Tagged Medicaid

Majority Of Iowa’s Medicaid Recipients Left With Only One Provider

Majority Of Iowa’s Medicaid Recipients Left With Only One Provider Choice

Preliminary Report Finds Oregon Mismanaged $78M In Medicaid Funds

Puertorriqueños desplazados enfrentan obstáculos para tener seguro médico

El gobierno federal otorgó a las personas afectadas por los devastadores huracanes que impactaron en los estados costeros y en Puerto Rico este verano 15 días adicionales para inscribirse y obtener cobertura médica bajo la Ley de Cuidado de Salud Asequible (ACA).

Sin embargo, los puertorriqueños que se han instalado en los Estados Unidos continental después que sus casas o negocios fueran destruidos enfrentan problemas más complejos que esa fecha límite.

Muchos de estos estadounidenses tienen preguntas complicadas sobre si su cobertura del Medicaid o Medicare de Puerto Rico puede modificarse (o incluso no funcionar) en sus nuevos hogares. Y para aquellos que buscan seguro privado, usar los mercados de ACA probablemente sea una experiencia nueva, ya que la ley federal de salud no se estableció en la isla.

Los miembros del Congreso de Florida dijeron el miércoles 15 de noviembre que les preocupa que muchos de estos recién llegados, así como las aseguradoras y los navegadores que ayudan a los consumidores con la inscripción, estén confundidos. El grupo envió una carta a Seema Verma, directora de los Centros de Servicios de Medicare y Medicaid (CMS), exigiendo que los funcionarios federales envíen una hoja informativa para “proporcionar la claridad necesaria y aliviar la confusión” entre los puertorriqueños que se han trasladado a los Estados Unidos.

Para la mayoría de las personas, el período abierto de inscripción para obtener cobertura a través de los mercados de la ley de salud termina el 15 de diciembre. Ante las dificultades causadas por las tormentas de agosto y septiembre, los residentes de las zonas más afectadas de Texas, Florida y Georgia tienen un período de gracia de 15 días extra para inscribirse, hasta el 31 de diciembre. Pero retrasar la inscripción significa que el inicio de su cobertura tendría que esperar hasta el 1 de febrero.

Muchos puertorriqueños expulsados ​​de sus hogares, sin embargo, están enfrentando un proceso más complicado. Además de aquellos que están aprendiendo cómo usar los mercados de seguros privados, algunos están aplicando para obtener una nueva cobertura del Medicare. En Puerto Rico, casi tres cuartas partes de los beneficiarios del Medicare tienen planes privados Advantage. Muchos tienen preguntas sobre si seguirán cubiertos por esos planes en el continente.

Además, el programa del Medicaid para residentes de bajos ingresos en Puerto Rico cubre casi a la mitad de los residentes de la isla, una tasa más alta que cualquier otro estado, por lo que las personas que se mudan a Estados Unidos continental pueden no calificar. Esto es especialmente cierto si su nuevo estado no expandió el Medicaid bajo ACA para todos los adultos que ganan hasta el 138 por ciento del nivel de pobreza federal (alrededor de $16,000 para un individuo). Tal es el caso de Florida.

Como mínimo, los nuevos residentes que deseen cobertura del Medicaid deberán volver a presentar una solicitud. Generalmente, la forma más efectiva de hacerlo es a través de los mercados de ACA. Ese proceso les mostrará si son elegibles para el Medicaid o tal vez para un subsidio federal con el cual podrían comprar un plan privado.

Según un memo de los CMS publicado en septiembre, los desplazados por los huracanes pueden llamar a la línea de ayuda de cuidadodesalud.gov (1-800-318-2596) y presentar una solicitud. La nota, que no proporciona detalles sobre qué documentación se necesita, también dice: “las personas pueden experimentar eventos que califican debido a un huracán que los hace elegibles para un período de inscripción especial (SEP)” para acceder a otro plan de salud. Por ejemplo, las personas que se mudaron temporalmente a Florida debido a un huracán y ahora están fuera del área de cobertura de su plan de salud podrían ser elegibles para un período especial de inscripción debido a la mudanza.

Después de las tormentas en agosto y septiembre, la Agencia Federal para el Manejo de Emergencias (FEMA) designó a todos los condados en Florida y Georgia, y 53 en Texas, para recibir “asistencia individual” o “asistencia pública”. En Puerto Rico, esta categoría fue otorgada a 31 de los 78 municipios de la isla.

Aun así, Anne Packham, directora del proyecto de mercado de seguros en Covering Central Florida, una organización con sede en Orlando, dijo que la atención debe enfocarse en alentar a los consumidores a registrarse antes del 15 de diciembre, el último día en que la gente puede inscribirse para la cobertura que comienza el 1 de enero.

“Todo es ya muy confuso, y creemos que decirles a los consumidores que pueden registrarse hasta el 31 de diciembre durante un período especial es agregar confusión”, dijo. “Estas personas necesitan un seguro en este momento, el 1 de enero, no en febrero”.

Después del huracán, más de 140,000 puertorriqueños llegaron a la zona central de Florida, según la oficina del gobernador Rick Scott, para quedarse durante meses, o para establecerse y comenzar una nueva vida. Buscar seguro y atención médica ha sido arduo.

Marni Stahlman, presidenta y CEO de Shepherd’s Hope Inc., una organización con sede en Orlando que ayuda a las personas a encontrar cobertura y servicios, recordó a una pareja de puertorriqueños que la pasó mal.

“El hombre tenía Medicare, y ella, quien es maestra retirada, tiene seguro de salud a través de su sindicato. Ambos se encontraron con obstáculos”, contó Stahlman. “El plan de Medicare del esposo no era aplicable en el continente y tampoco el plan privado de la esposa. Ambos han tenido que comenzar de nuevo. Él volvió a solicitar el Medicare y ella tuvo que presentar una solicitud por primera vez en un mercado de seguros. En este momento todavía están sin cobertura, algo que nunca tuvieron que enfrentar”.

Maria Gotay y sus hijos, Edwin Rodriguez (izq.) y Cristian Rodriguez. Los tres llegaron a Orlando, Fla., dos semanas después de la tormenta y tuvieron que realizar el proceso para tener cobertura de salud. (Foto: cortesía María Gotay)

Para muchas familias, la falta de documentos y suministros complica la situación. Los huracanes no solo devastaron vidas, hogares y se llevaron la electricidad, también arrasaron con medicinas, recetas, tarjetas de seguro médico y copias de declaraciones de impuestos.

“La ayuda para todos, pero para los puertorriqueños en particular, tiene que ser integral porque estas personas solo llegan con sus pasaportes”, dijo Jean Zambrano, vicepresidenta de operaciones médicas de Shepherd’s Hope.

Entre los recién llegados a Florida, hay al menos 18,000 niños y adolescentes que necesitan atención médica inmediata, debido a que se les exige exámenes de vista y audición, y presentar sus vacunas, para asistir a la escuela. Stahlman y Zambrano dijeron que no hay un esfuerzo coordinado a nivel estatal para allanarles el camino.

La articulación de estos procesos entre los territorios y Estados Unidos continental no es un mecanismo aceitado, y la atención médica puede pasarse por alto, lo que significa que el último recurso para muchos que necesitan un doctor es la sala de emergencias.

Aquellos que llegan con sus documentos importantes tienen el éxito un poco más asegurado. María Gotay, de 51 años, llegó a Orlando desde Bayamón, Puerto Rico, con sus dos hijos, Cristian, de 17, y Edwin, de 22, 10 días después que el huracán María devastara la isla.

“Guardamos nuestros documentos en un lugar seguro”, dijo, por lo que los tuvo listos cuando solicitó cobertura de salud para sus hijos.

La navegadora Doris Allen, de Covering Central Florida, la ayudó a inscribir a su hijo menor en el Programa de Seguro de Salud Infantil (CHIP) y al mayor en un plan privado por $33 al mes después de un subsidio. Maria Gotay ya estaba cubierta por el Medicare: tiene un status de discapacidad ya que sufre de fibromialgia.

“Fuimos muy afortunados de conocer a personas que nos apoyaron”, dijo Gotay. Recordó haber llegado al centro de salud y haber caído en los brazos de Allen llorando desconsoladamente. “Nunca quise salir de Puerto Rico, nunca imaginé estar al borde de la muerte”.

“Durante el huracán, todos estábamos juntos, nuestra casa se dañó e inundó, pero resistió el ataque de María”, dijo Gotay.

La mujer trajo a sus hijos a Orlando porque sus dos hijas ya viven allí. Su esposo se quedó en la isla cuidando a su padre, que muestra signos de Alzheimer.

Gotay dijo que vive con estrés y miedo desde el huracán, y que ha estado viendo a un psiquiatra en Orlando que la está ayudando a superarlo. A pesar de todo, regresará a Puerto Rico este mes, mientras que sus hijos se quedarán en Florida y comenzarán una nueva vida.

Esta historia fue producida por Kaiser Health News, un programa editorialmente independiente de la Kaiser Family Foundation.

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Massachusetts Grabs Spotlight By Proposing New Twist On Medicaid Drug Coverage

In the absence of new federal policies to tame break-the-bank drug prices, Massachusetts’ state Medicaid program hopes to road-test an idea both radical and market-driven. It wants the power to negotiate discounts for the drugs it purchases and to exclude drugs with limited treatment value.

“This is a serious demonstration proposal,” said Sara Rosenbaum, a health policy expert and professor at George Washington University. “They’re not simply using [this idea] as an excuse to cut Medicaid. They’re trying to take a step toward efficiency.”

If the Department of Health and Human Services approves the Bay State’s plan, others will likely take similar action. According to the most recent federal data, Medicaid spending on prescription drugs increased about 25 percent in 2014 and nearly 14 percent in 2015.

Currently, state Medicaid programs are required to cover almost all drugs that have received Food and Drug Administration approval, including multiple drugs from different manufacturers used for the same purpose and in the same category. In exchange, manufacturers must discount those drugs — typically based on a set percentage of the list price, specified by federal law. The idea is Medicaid’s vulnerable beneficiaries get medications they need and the state doesn’t go broke paying for them.

As drug prices soar, states say, those fractional rebates no longer suffice to defray the burden of rising costs.

Take, for instance, the hepatitis C cures released in recent years. The price tags come in tens or even hundreds of thousands of dollars and — even after rebates — have cost Medicaid billions. In turn, some states tried to restrict access, so only the sickest patients could get the drugs. Advocates filed suit in response and won based on the argument that such limits violated Medicaid’s statutory drug benefit.

State officials contend that the current Medicaid rebate system may encourage drug price inflation, since a set percentage of a higher price yields a greater profit. Also, the legal requirement to cover most prescriptions leaves little wiggle room to negotiate a better price.

So, Massachusetts wants to go a different route, requesting a federal exemption known as a Section 1115 waiver, which is meant to let states test ways of improving Medicaid. It wants to pick which drugs it covers based on most beneficiaries’ medical needs and which medicines demonstrate the highest rates of cost effectiveness.

It says it will be able to negotiate better prices as a result, saving public dollars while maintaining patients’ access to needed therapies.

The federal Centers for Medicare & Medicaid Services, which will ultimately approve or reject Massachusetts’ proposal, has no deadline for its decision. A Massachusetts spokeswoman said officials are pushing for an answer by year’s end.

Already, though, the pitch is turning heads.

“This is absolutely something a lot of other states are looking very closely at,” said Matt Salo, executive director of the National Association of Medicaid Directors.

If the request is approved, agreed Jane Horvath, a senior policy fellow at the National Academy for State Health Policy, other states would follow suit “in about five minutes.”

Critics worry this change could make it harder for low-income people to get needed medications, without necessarily providing them an alternative. In the past decade, though, it has become commonplace for people with commercial insurance to have limited drug choices — meaning only those medicines listed on a plan’s formulary are covered.

The Pharmaceutical Research and Manufacturers of America (PhRMA), the drug industry’s trade group, has already lodged its displeasure, saying this would limit consumer access and is unnecessary on top of the rebates Medicaid programs receive.

“The pharmaceutical industry has a reputation for being litigious. This would be a big deal for them,” said Andy Schneider, a Medicaid expert at Georgetown University, who worked at CMS under the Obama administration. If CMS approves the waiver, analysts said, the industry would likely sue, though PhRMA wouldn’t comment on potential legal action.

But federal approval is no sure thing.

On one hand, the Trump administration has encouraged states to test changes that would run Medicaid more like a private insurance plan. Through that frame, Massachusetts’ approach seems a logical fit. Though a formal strategy has not been released, President Donald Trump has said his administration intends to bring drug prices “way down.”

On the other hand, analysts said, CMS’ decision-making regarding waivers has proven unpredictable. The agency declined to comment beyond confirming it was reviewing Massachusetts’ request.

It’s clear why states are interested. On average, between 25 and 30 percent of state budgets go to Medicaid, and program directors across the country identify rising drug costs as a major contributor to spending increases, according to a recent survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

In Massachusetts, Medicaid accounts for about 40 percent of the state’s budget. Prescription-drug spending has in the past seven years more than doubled — from about $917 million in 2010 to about $1.94 billion last year, according to figures provided by the state health department.

If the waiver is approved, the state’s Medicaid program would cover at least one medication per therapeutic class — that is, per specific medical need.

It also would have an appeals process for people to get their off-formulary drugs covered, if they’re medically necessary.

Number crunchers say it’s hard to estimate what this would save. It depends on how the state negotiates, how industry responds and what the program covers. The potential result is significant, though.

“You’d have to be foolish not to consider this,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School, who studies drug pricing and related legislation.

But consumer groups worry about Medicaid’s low-income beneficiaries, even as they acknowledge that rising drug costs are unsupportable for state budgets.

“The Medicaid population is different from the commercially insured — they’re more vulnerable and have a lot more going on in their lives, and are generally poorer. So they have fewer resources to try to get the services and prescription drugs they need,” said Suzanne Curry, associate director of policy and government relations at Health Care For All, a Massachusetts-based advocacy group.

Although Massachusetts, a state with a long history of innovation, has committed to making sure patients get needed medicine, “you have to ask what will real-world implementation looks like,” said Benjamin Sommers, an associate professor of health policy and economics at Harvard’s public health school. Appeals processes, he noted, can be onerous or restrictive.

And even if Massachusetts receives federal approval, it still couldn’t challenge the cost of certain expensive drugs that are the only offering in their therapeutic class. For instance, Spinraza, which treats the rare but debilitating disease of spinal muscular atrophy, has a price tag of $750,000 for an initial year of treatment. With no therapeutic equivalent, it would still have to be covered.

But states are desperate to push back in new ways and however they can. “We have seen in the past year … drugs that have almost bankrupted state budgets,” Sarpatwari said. “There will be many other states that will be interested in following this lead.”

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

Related Topics

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Displaced Puerto Ricans Face Obstacles Getting Health Care

The federal government has granted people affected by the devastating hurricanes that wracked coastal states and Puerto Rico 15 extra days to sign up for health coverage under the Affordable Care Act.

But Puerto Ricans who fled to the mainland after the destruction face problems well beyond timing.

Many of those Americans have complicated questions about whether the Medicaid or Medicare coverage they had in Puerto Rico will shift with them to their new locations. And for those seeking private coverage, using the ACA’s insurance marketplaces will likely be a new experience because the federal health law didn’t establish those marketplaces in the U.S. territory.

Members of Congress from Florida said Wednesday they are concerned that many of these recent arrivals, as well as insurance companies and navigators, are confused. They sent a letter to Seema Verma, the director of the Centers for Medicare & Medicaid Services (CMS), requesting that federal officials put out a fact sheet to “provide much-needed clarity and alleviate confusion” among Puerto Ricans who have relocated to the States.

Insurance enrollment on the health law’s marketplaces ends for most people Dec. 15. In a bow to the hardships caused by the August and September storms, residents living in hard-hit areas of Texas, Florida and Georgia are allowed to sign up as late as Dec. 31. But waiting until those final 15 days means that the start of their coverage is delayed until Feb. 1.

Many Puerto Ricans driven from their homes, however, are negotiating layers of red tape. In Puerto Rico, nearly three-quarters of Medicare beneficiaries are in private Advantage plans. Many have questions about whether those plans will cover them stateside.

Also, the Medicaid program for low-income residents in Puerto Rico covers nearly half of the island’s residents  — a rate higher than any state — but it’s not clear that people moving stateside will continue to qualify because they may not meet the tighter eligibility standards. That is especially true if their new home state did not expand Medicaid under the ACA to all adults earning up to 138 percent of the federal poverty level (about $16,000 for an individual).

At the very least, they will have to reapply for Medicaid coverage. Often the most effective route is through the ACA marketplaces. That process will show them whether they are eligible for Medicaid or perhaps a federal subsidy to purchase a private plan.

According to a CMS memo released in September, they can call the healthcare.gov help line (1-800-318-2596) for help. The memo, which doesn’t provide details about what documentation is needed, also says that “individuals may experience qualifying events due to a hurricane that makes them eligible for a special enrollment period (SEP)” to access another health plan. For example, individuals who temporarily relocated to Florida due to a hurricane and are now out of their health plan coverage area could be eligible for a special enrollment period because of the move.

After the storms hit, the Federal Emergency Management Agency (FEMA) designated all counties in Florida and Georgia, and 53 in Texas, to receive “individual assistance” or “public assistance.” In Puerto Rico, this category was granted to 31 of the island’s 78 municipalities.

Still, Anne Packham, director of the insurance marketplace project at Covering Central Florida, an organization based in Orlando, said the focus should be on encouraging consumers to register before Dec. 15, the last day most people can sign up for coverage that begins Jan. 1.

“Everything is already very confusing, and we think that telling consumers that they can register until Dec. 31 during a special period is adding confusion,” she said. “These people need insurance right now, on Jan. 1, not February.”

Since the storms, more than 140,000 Puerto Ricans have arrived in the central area of ​​Florida, according to Gov. Rick Scott’s office. They may stay only for a few months or settle to start a new life. Seeking insurance and medical attention has proven arduous.

Marni Stahlman, president and CEO of Shepherd’s Hope Inc., an organization based in Orlando that helps people find coverage and services, recalled one Puerto Rican couple that had a tough time.

He had Medicare and she was a retired teacher who had insurance through her union, Stahlman said. “The husband’s Medicare policy was not applicable on the mainland and the wife’s was not honored either,” she said. “Both have had to start over. He with reapplying for Medicare and she had to apply for the very first time in a marketplace. They are at this time still ‘uninsured,’ something that they have never had to encounter.”

Maria Gotay and her sons, Edwin Rodriguez (left) and Cristian Rodriguez. They came to Orlando, Fla., two weeks after Hurricane Maria hit Puerto Rico. Having important papers helped them through the process to obtain health care. (Courtesy of Maria Gotay)

Complicating the situations for many families is the lack of records and supplies. The hurricanes not only devastated lives, homes and power, but they also took medicines, prescriptions, insurance cards and copies of tax returns.

“Help for everybody, but for Puerto Ricans in particular, it has to be integral because these people only arrive with their passports,” said Jean Zambrano, vice president of medical operations at Shepherd’s Hope.

Among the newcomers to Florida, there are at least 18,000 children and adolescents who need medical attention quickly because they are required to get vision, hearing and immunization screenings to attend school. Stahlman and Zambrano said there is no coordinated effort at the state level to pave the way for them.

Maneuvering between the territories and the States is not a well-oiled machine, and health care can fall through the cracks — which means the last resort for many needing medical attention is the emergency room.

Those who arrive with their important papers help ensure success. María Gotay, 51, arrived in Orlando from Bayamón, Puerto Rico, with her two boys, Cristian, 17, and Edwin, 22, 10 days after Hurricane Maria ravaged the island.

“We keep our documents in a safe place,” she said, so she had them ready when applying for coverage for her children.

Navigator Doris Allen, from Covering Central Florida, helped sign up Gotay’s younger son for the Children’s Health Insurance Program (CHIP) and the older one in a private insurance plan for $33 a month after a subsidy. Maria Gotay was already covered by Medicare because she has a disability from fibromyalgia.

“We were very fortunate to meet such supportive people,” said Gotay. She recalled arriving at the health center and falling in Allen’s arms crying hysterically. “I never wanted to leave Puerto Rico, I never imagined being at the edge of dying.”

“During the hurricane, we were all together, our house was damaged and flooded, but it withstood Maria’s onslaught,” said Gotay.

She brought her sons to Orlando because her two daughters were already living there. Her husband stayed on the island, caring for his father who shows signs of Alzheimer’s, she said.

She said she has enormous stress and fear following the hurricane, and has been seeing a psychiatrist in Orlando to get help. However, she will return to Puerto Rico this month, while her boys stay in Florida to begin a new life.

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Medicaid Expansion Takes A Bite Out Of Medical Debt

As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state Legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

Since graduating from college more than 20 years ago, Wilson has mostly had to pay out-of-pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson said.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with a deeply discounted rate from a nearby hospital, she couldn’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson said. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as an illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past-due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th-highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golberstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7-percentage-point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points from 2012 to 2015.

Medicaid, as opposed to private insurance, is the key, said the Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, they aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell said.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head of the Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma said that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what we’re seeing in our paper,” Caswell said. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she said, she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she said.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson said. “It’s hard losing your dreams.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

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Trump Administration Plan to Add Medicaid Work Requirement Stirs Fears

The Trump administration’s recent endorsement of work requirements in Medicaid and increased state flexibility is part of broader strategy to shrink the fast-growing program for the poor and advance conservative ideas that Republicans failed to get through Congress.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, laid out her vision for the state-federal program in two appearances last week, saying her new course give states wide latitude over eligibility and benefits.

In a speech Nov. 7 to state Medicaid directors, Verma said the program needs to give people “hope that they can achieve a better future for themselves and their families, hope that they can one day break the chains of generational poverty and no longer need public assistance.”

She has noted other government assistance programs such as food stamps, have similar requirements.

But her outline scares advocates who see the changes as a way for states to kick millions of adults off the program and undermine its mission of providing health coverage to the poor. They note most nondisabled adults on Medicaid already work. Many who don’t are either too sick, go to school or care for relatives.

“Medicaid coverage is not something that should be earned,” said Robert Doherty, senior vice president at the American College of Physicians. “Medicaid is not a welfare program. It is a health care entitlement program, and anyone who meets the requirements should be able to have coverage.”

Verma’s plan to greenlight work requirements is only just the beginning of dramatic changes, these advocates said. They expect that she would allow more states to charge monthly premiums, as Indiana has proposed; approve drug testing of enrollees, as Wisconsin has requested; and putting a time limit on coverage, as Arizona has asked.

Katherine Howitt, associate director of policy at the Community Catalyst, a consumer health advocacy group that backs the federal health law and  expansion of Medicaid, said Verma has thrown open the door to allowing states to add more restrictions on coverage.

“This new approach is not really about promoting work or improving care or improving state flexibility,” she added. “At the end of the day, it is making it harder for low-income people to access health coverage.”

Nearly 75 million people are covered by Medicaid, including 16 million added since 31 states and the District of Columbia expanded their programs under the Affordable Care Act.

Verma said her goal for Medicaid is to move people out of the program by getting them into jobs that offer coverage or provide enough income so they buy it on their own.

“Her comments show she doesn’t understand the reality that many low-wage jobs don’t offer benefits,” Howitt said.

Several states, including Arkansas, Kentucky and Maine, have asked CMS to allow them to require Medicaid recipients to work or do volunteer work as a condition of enrollment. The Obama administration turned down such proposals.

Even some right-leaning pundits say work requirements could backfire because taking away health coverage could make individuals sicker and less likely to hold down jobs.

“This could run counter to the goal of Republicans to help put people to work,” said Jason Fichtner, a health policy expert at the conservative Mercatus Center at George Mason University in Fairfax, Va.

But Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said he was encouraged by Verma’s approach.

“I think the intent of the program depends on different populations it serves,” he said. “For someone in a nursing home, it’s a health program. But for people in the Medicaid expansion, it is more like a welfare program where able-bodied people are expected to move back into the workforce.”

Congress, with the blessing of President Donald Trump, tried earlier this year to make substantial changes to Medicaid as part of the bills to replace the ACA. Those efforts stalled.

The changes included offering states more flexibility, but federal funding would not be as generous. The nonpartisan Congressional Budget Office said millions fewer people would eventually be covered.

Verma, a former health consultant who helped Indiana expand Medicaid in 2015 under Obamacare, said the law should never have allowed so-called able-bodied adults into the program. That’s because Medicaid already had too many problems, including not enough doctors and wait lists for some people seeking coverage, she said.

Before the ACA, Medicaid mainly covered children, disabled people and pregnant women.

The health law broadened Medicaid to all low-income people, opening up the program to cover nondisabled adults without children with incomes up to 138 percent of the federal poverty level (about $16,600 for an individual).

“We put people on the Medicaid program — able-bodied individuals — in a program that is essentially designed for people that are going to be on the program for the rest of their lives,” Verma said Nov. 9 at an event sponsored by The Wall Street Journal.

Two-thirds of people on Medicaid are disenrolled within three years, according to a U.S. Census Bureau report.

Verma’s pointed criticism of Medicaid, the Affordable Care Act’s expansion and even state officials who helped implement that effort drew rebukes from state Medicaid directors.

Critics said her remarks were misguided and showed she doesn’t understand the program she runs.

Doherty said that by law Medicaid allows states to conduct experiments in how they run the program, but not by making it harder for people to get covered.

Nothing stops states, he added, from offering job training and other programs to help people on Medicaid get back to work. “But we can’t deny them access to health care just because they happen to be poor,” he said.

Robin Rudowitz, a Kaiser Family Foundation policy analyst, said Verma appears willing to let states experiment as never before.

“Some proposals [like work requirements] could create barriers to coverage for eligible beneficiaries and result in losses of coverage for Medicaid enrollees,” she said. (Kaiser Health News is an editorially independent program of the foundation.)

Some health experts said they see many contradictions in Verma’s approach. They said she wants Medicaid to focus only on the most needy — but she has been unwilling to criticize Congress for failing to reauthorize the Children’s Health Insurance Program (CHIP) that covers 9 million children. Federal CHIP funding ran out Sept. 30.

Verma also questioned why some states spend significantly more per enrollee than other states on Medicaid. But the reason, these experts note, is because states have flexibility to vary their benefits, eligibility rules and payments to providers.

As Medicaid has grown to cover more than 1 in 5 Americans, it has become more popular among beneficiaries, health care providers and even among some Republican governors who agreed to expand it. Howitt said the Trump plan would take Medicaid back to the 1980s when it was often linked to cash assistance welfare and carried a stigma.

Joan Alker, director of the Georgetown University Center for Children and Families, said backing work-requirement proposals helps the Trump administration further its ideological message that Medicaid is a welfare program and not a health program.

Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities, which supports the ACA, said Verma’s vision is simple: to undo the health law’s coverage gains.

“In 2010, Congress decided to expand Medicaid as the vehicle for low-wage workers to have coverage as part of health reform,” she said. “That is still the law and she [Verma] doesn’t get to disagree with that, she has to follow the law not sabotage it.”

Related Topics

Medicaid States The Health Law

Policy Thoughts: Weighing The Wisdom Of Using The ACA To Pay For Tax Cuts; Have Efforts To Scrap Obamacare Made It Stronger?

Opinion writers offer their thoughts on a range of health policy topics, including future congressional efforts to move on the Alexander-Murray bill, the importance of access to health insurance and the latest on Medicaid from Ohio and Iowa.

Los Angeles Times: Sabotage Obamacare To Finance More Tax Cuts For The Rich? No Thanks
As Republicans try to rush a tax bill through Congress, some lawmakers want to use the measure to kill a key piece of the Affordable Care Act. Doing so would free up more dollars for tax cuts, but in the most shortsighted and cynical way: by inducing fewer low- and moderate-income Americans to sign up for health insurance. Oh and yes, it would cause premiums to rise even faster for those who get their insurance coverage through Obamacare. (11/14)

CT Mirror: Everyone Should Be Entitled To Health Insurance, Even The Middle Class
The Affordable Care Act, more commonly known as Obamacare, is a perverse twist on the Robin Hood tale. Rather than steal from the rich, Obamacare has taken from the middle class. Prior to ACA, the self-employed middle class had many options for comprehensive insurance. They were largely able to afford their premiums and deductibles, and out of pocket costs were manageable. Most importantly, they were free to choose their own doctors and hospitals from a nationwide provider network. (Martin H. Klein, 11/13)

Cincinnati Enquirer: Medicaid Cuts Will Hurt Hospitals, Patients
Ohio hospitals have long been committed to being part of the solution to curtailing health care costs while ensuring quality health care can be delivered efficiently; ultimately leading to a healthier Ohio for all citizens. But hospitals now are facing hundreds of millions of dollars in new Medicaid cuts. Ultimately, patients will be affected. (Dr. Kevin Webb, 11/13)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Policy Thoughts: Weighing The Wisdom Of Using The ACA To Pay For Tax Cuts; Have Efforts To Scrap Obamacare Made It Stronger?

Opinion writers offer their thoughts on a range of health policy topics, including future congressional efforts to move on the Alexander-Murray bill, the importance of access to health insurance and the latest on Medicaid from Ohio and Iowa.

Los Angeles Times: Sabotage Obamacare To Finance More Tax Cuts For The Rich? No Thanks
As Republicans try to rush a tax bill through Congress, some lawmakers want to use the measure to kill a key piece of the Affordable Care Act. Doing so would free up more dollars for tax cuts, but in the most shortsighted and cynical way: by inducing fewer low- and moderate-income Americans to sign up for health insurance. Oh and yes, it would cause premiums to rise even faster for those who get their insurance coverage through Obamacare. (11/14)

CT Mirror: Everyone Should Be Entitled To Health Insurance, Even The Middle Class
The Affordable Care Act, more commonly known as Obamacare, is a perverse twist on the Robin Hood tale. Rather than steal from the rich, Obamacare has taken from the middle class. Prior to ACA, the self-employed middle class had many options for comprehensive insurance. They were largely able to afford their premiums and deductibles, and out of pocket costs were manageable. Most importantly, they were free to choose their own doctors and hospitals from a nationwide provider network. (Martin H. Klein, 11/13)

Cincinnati Enquirer: Medicaid Cuts Will Hurt Hospitals, Patients
Ohio hospitals have long been committed to being part of the solution to curtailing health care costs while ensuring quality health care can be delivered efficiently; ultimately leading to a healthier Ohio for all citizens. But hospitals now are facing hundreds of millions of dollars in new Medicaid cuts. Ultimately, patients will be affected. (Dr. Kevin Webb, 11/13)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Some States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor — And For Hospitals

If you’re poor, uninsured and fall seriously ill, in most states if you qualify for Medicaid — but weren’t enrolled at the time — the program will pay your medical bills going back three months. It protects hospitals, too, from having to absorb the costs of caring for these patients.

But a growing number of states are rescinding this benefit known as “retroactive eligibility.” On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed. Each state had to secure approval by the federal government.

Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.

Michelle AndrewsInsuring Your Health

All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — have expanded Medicaid under the health law, which allowed states to include adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person. So, in theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.

The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.

State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll. It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and leave hospitals to absorb more uncompensated care when patients can’t pay. Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children under age 1. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.

“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child & Family Policy Center in Des Moines, whose organization opposed the change.

When someone has a traumatic health event, the initial focus is to get them stabilized, not figure out how to pay for it, said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Patients may neglect to apply immediately for Medicaid, leaving them financially responsible for days or months of care they received before they got in their application, even though they may have been eligible for Medicaid all along.

That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassesed every year.

“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.

In addition, complications can arise for people who might need Medicaid coverage for long-term care services. “The criteria are complicated. For a layperson to find those criteria and figure out if they’re eligible” is challenging and they may need extra time, said Musumeci. Once patients have secured coverage, they may already have accrued hefty expenses.

Maybe so, but some people argue that a 90-day retroactive eligibility guarantee is counterproductive.

“We’re trying to get people to behave more responsibly, not less responsibly,” said Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky said.

In contrast to Iowa, the waivers in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)

Kentucky has a request pending that, like Iowa, would eliminate retroactive Medicaid eligibility except for pregnant women and children under 1, according to KFF.

Under federal law, officials can waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years. Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, said Bonnyman.

“There was no reason for anybody to be uninsured except undocumented immigrants,” said Bonnyman. “It didn’t seem to have the potential for harm.”

But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.

Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah, according to the Kaiser Family Foundation.

Bonnyman said his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family, one or two days in the hospital is enough to ruin you financially,” he said.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insurance, Insuring Your Health, Medicaid

Viewpoints: Arguments For Finding Tax Relief By Repealing Individual Mandate; Should Gov’t Help Pharma Rehab From Painkiller Marketing?

A selection of opinions on health care from around the country.

The Wall Street Journal: ObamaCare Tax Relief
Republicans in Congress are plowing ahead on tax reform, and one obstacle is the complexity of Senate budget rules that limit how much taxes can be cut. The good news is that for once Washington’s fiscal fictions could be deployed to improve policy by repealing ObamaCare’s individual mandate as part of tax reform. The Senate Finance Committee on Thursday released the details of its tax proposal, which includes a permanent 20% corporate rate and more. Senators Pat Toomey and Bob Corker cut a budget deal to allow for $1.5 trillion in net tax cuts over 10 years without accounting for faster economic growth (and more revenues) as a result of reform. (11/12)

The Wall Street Journal: The Individual Mandate Is The Worst Tax Ever
If you were deliberately trying to design the most arbitrary, painful and pointless tax possible, how would you go about it? First, you would structure it to inflate the cost of an essential product. Then, you’d create exemptions so vast that only 5% of taxpayers were subject to it. You might even ensure that it hit people only when they were particularly vulnerable—like when they’d lost a job. Finally, you would use it to drive enrollment in entitlements, so that it increased the federal deficit by $338 billion. (Chris Pope, 11/12)

The New York Times: The Insanity Of Taxpayer-Funded Addiction
The pharmaceutical industry was listed as one of the “Contributors to the Current Crisis” in the final report of President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis. The report cites decades of aggressive marketing and industry-sponsored physician “conferences” aimed at expanding opioid use by minimizing the dangers of addiction. Lawsuits by state attorneys general, counties and local jurisdictions allege that the industry fostered the epidemic by overpromoting its products, while raking in billions as Americans became addicted and overdosed. “To this day,” the commission says, “the opioid pharmaceutical industry influences the nation’s response to the crisis.” (11/10)

Richmond Times-Dispatch: Medicaid’s Costs Continue To Soar
Over the past decade, Medicaid spending has grown at an annual rate of 8.9 percent — far faster than the budget as a whole (although that has grown plenty, too). …Officials hope a new approach will keep it from hitting one-fourth of the budget. They intend to shift thousands of beneficiaries from the traditional fee-for-service model to a managed-care system conducted through private insurance companies. (11/11)

The Wall Street Journal: The Hype Of Virtual Medicine
Will “virtual medicine” transform the American health-care system? Will the latest computer-based technologies—apps, wearables, remote monitors and other high-tech devices—make Americans healthier? That’s the promise made by tech gurus, who see a future in which doctors and patients alike track health problems in real time, monitor changing conditions and ensure both healthy habits and compliance with drug and therapy regimens. (Ezekiel J. Emanuel, 11/10)

WBUR: The Cost Of Assuming Your Doctor Knows Best
Most doctors are not geniuses, but even geniuses make mistakes. As a diagnostician myself, I’d like to believe I’ve made some good, even great, diagnoses in my day. But patients need to spend more time focusing on a more important issue — physician error. (Vinita Parkash, 11/13)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Maine Gears Up For Funding Fight Next Year Over Medicaid Expansion

The governor says he won’t implement the expansion approved by voters in a referendum this month unless lawmakers fully fund it. Elsewhere in the news, other states consider the Maine experience while considering their own voter referendums on expansion, one family in Iowa bemoans the experiences trying to get specialized care for their son from his Medicaid managed care plan, West Virginia officials consider work requirements for Medicaid enrollees and health care jobs are at stake as Ohio cuts reimbursement rates.

The Hill: Maine Governor’s Refusal To Expand Medicaid Sets Off New Battle
Maine Gov. Paul LePage’s (R) steadfast opposition to abide by overwhelming voter support of expanding Medicaid is likely to set off a funding battle when the state legislature meets early next year. Estimates over the expansion cost differ wildly, and the governor has said he won’t approve a plan if it involves raising taxes or raiding the state’s rainy day fund. (Weixel, 11/10)

NPR: Medicaid Expansion Takes A Bite Out Of Medical Debt
As the administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger. On Tuesday, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018. … A study from the Urban Institute may shed some light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid. (Smith, 11/10)

Des Moines Register: Troubled Iowa Teen’s Progress Stalled Again By Private Medicaid Manager
In his worst moments, Logan Polly kicked holes in walls, beat himself and attacked others. He threatened to kill his mother, filled his school locker with hoarded food, ran away often and stopped eating for days at a time. Back in April, the 14-year-old adopted teen’s prospects of a productive future seemed dim and getting dimmer. His hard-to-find treatment, funded by Medicaid, was at risk of being cut short. AmeriHealth Caritas, one of three firms Iowa hired to manage Logan’s care, was trying to rein in the cost of his care, Tina Polly said. (Rood, 11/10)

California Healthline: Wary Of Exchanges, Insurers Are Wooed By Expanded Medicaid Program
In California and much of the country, it’s a tale of two programs under the Affordable Care Act: state insurance exchanges and expanded Medicaid. Many health insurers, citing financial losses or the uncertainty of federal funding, have left the government exchanges where consumers buy subsidized coverage. The nation’s largest health insurer, UnitedHealth, exited the Covered California marketplace at the end of last year, and for 2018 Anthem will stop selling exchange policies in about half of California’s counties. (11/10)

Charleston (W.Va.) Gazette-Mail: DHHR Considering Work Requirements For Medicaid Recipients
The West Virginia Department of Health and Human Resources is considering adding work requirements to the Medicaid program. Jeremiah Samples, deputy secretary of the state DHHR, said Friday that state officials are considering whether to add work requirements for about 170,000 West Virginians covered by Medicaid expansion. He said the requirement, if enacted, would focus on able-bodied people. (Beck, 11/12)

Crain’s Cleveland Business: State Medicaid Cuts Could Run Deep In Northeast Ohio
A proposed cut to the state Medicaid reimbursement rate could mean a loss of up to 2,500 health care jobs in Northeast Ohio, advocates say. The Ohio Department of Medicaid has proposed a rate cut of 5% over the biennium for the care provided to Medicaid recipients. The Center for Health Affairs, an advocacy group representing Northeast Ohio hospitals, estimates that would result in a loss of $160 million over fiscal years 2018 and 2019 for the region’s hospitals, leaving them with few options to make up those costs. (Coutré, 11/12)

Hillary Clinton raises concerns about the delay in funding for children’s health coverage —

The Hill: Clinton: Congress Playing ‘Roulette’ With Children’s Health Funding
Hillary Clinton says Congress is playing “roulette” over extending funding for the Children’s Health Insurance Program (CHIP). … As first lady, Clinton was a champion of CHIP when it first made its way through Congress during former President Bill Clinton’s first term in office. Funding for the program, which covers 9 million children, technically expired at the end of September, but the first states aren’t expected to run out of funding until the end of the year. (Hellmann, 11/10)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Trump Administration Chips Away At Initiatives That Base Payments On Quality Over Quantity

Experts have said that paying doctors for quality care instead of just the number of appointments they take would help rein in burgeoning medical costs. But the Trump administration wants to slow efforts to shift toward that model.

The New York Times: Trump Health Agency Challenges Consensus On Reducing Costs
For several decades, a consensus has grown that reining in the United States’ $3.2 trillion annual medical bill begins with changing the way doctors are paid: Instead of compensating them for every appointment, service and procedure, they should be paid based on the quality of their care. The Obama administration used the authority of the Affordable Care Act to aggressively advance this idea, but many doctors chafed at the scope and speed of its experiments to change the way Medicare pays for everything from primary care to cancer treatment. Now, the Trump administration is siding with doctors — making a series of regulatory changes that slow or shrink some of these initiatives and let many doctors delay adopting the new system. (Goodnough and Zernike, 11/12)

In other news —

The Wall Street Journal: Fewer Return Visits To The Hospital, But Higher Rates Of Death, Study Finds
The Affordable Care Act required Medicare to penalize hospitals with high numbers of heart failure patients who returned for treatment shortly after discharge. New research shows that penalty was associated with fewer readmissions, but also higher rates of death among that patient group. The researchers said the study results, being published in JAMA Cardiology, can’t show cause and effect, but “support the possibility that the [penalty] has had the unintended consequence of increased mortality in patients hospitalized with heart failure.” (Evans, 11/12)

Modern Healthcare: Redesigning Hospitals With Patient Experience In Mind
The clinics are flanked by an atrium, a cafe and a library with an outdoor deck. Their main concourses are dotted with furnished alcoves. One thing they don’t have: designated waiting rooms. That’s because patients at the clinics in the Health Transformation Building at Dell Medical School, part of UT Health Austin, can either go straight to their rooms, if available, or if they arrive early, to any of those decidedly non-institutional spaces, where in the future they’ll be buzzed via a smartphone app. (Arndt, 11/11)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Podcast: ‘What The Health?’ We Have Numbers!

Democrats won some unexpectedly large victories in Tuesday’s off-off-year elections, putting health care squarely back on the political map. Meanwhile, enrollment was unexpectedly high in the insurance exchanges’ opening days, according to the Department of Health and Human Services.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of Vox.com, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the potential political impact of Tuesday’s voting, including the success in Maine of a referendum to expand the Medicaid program, as well as the latest news from Washington, D.C.

Among the takeaways from this week’s podcast:

— Voters in exit polls cited health care as a major voting issue — and in Virginia the vast majority of those who said health care was a top issue voted for the Democrat. But some Republicans continue to insist that voters are angry that they did not repeal the Affordable Care Act and are doubling down on efforts to make that happen before the congressional midterm elections in 2018.

— Tuesday’s results in the Maine Medicaid referendum might prompt voters in other states that have yet to expand the program to try the direct-ballot route. But Maine’s governor has said he will continue to try to block implementation, which could lead to lawsuits.

— Despite the Trump administration’s efforts to undermine the Affordable Care Act, open enrollment for 2018 has seen a spike in sign-ups in the first few days. Some suggest one reason is that many people who qualify for tax credits are getting an unexpected windfall this year because of the way states have addressed federal cuts in subsidies for low-income enrollees. People who earn just over the cutoff for federal help, however, are facing frequently unaffordable rates.

— Federal Medicaid chief Seema Verma this week suggested the Trump administration will be approving state requests to require Medicaid recipients to work or perform community service in exchange for their benefits. Work requirements would be a major change for the program, and one several states are seeking.

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

Julie Rovner: Kaiser Health News and Climate Central, “Breathing Fire: Health Is A Casualty Of Climate-Fueled Blazes,” by John Upton and Barbara Feder Ostrov.

Sarah Kliff: Kaiser Health News, “Liquid Gold: Pain Doctors Soak Up Profits By Screening Urine For Drugs,” by Fred Schulte and Elizabeth Lucas.

Joanne Kenen: The New Yorker, “Faces of an epidemic,” by Philip Montgomery and Margaret Talbot.

Alice Ollstein: Reuters, “Exclusive: FBI agents raid headquarters of major U.S. body broker,” by John Shiffman and Brian Grow.

To hear all our podcasts, click here.

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

Categories: Medicaid, Multimedia, The Health Law

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Viewpoints: Veterans Day Thoughts On Vets’ Health Care; GOP’s Tax-Reform Secret: Success Is Tied To Medicare Cuts

A selection of opinions on health care from around the country.

USA Today: On Veterans Day, A VA Doctor Shares Praise And Hope
Perhaps this is the inevitable conclusion for someone only reading news headlines about the Department of Veterans Affairs, but I am honored to be a VA doctor. The other day, I was in a Lyft car (I am writing from San Francisco, after all.) chatting with the driver when I mentioned I work at the VA. He immediately opened up and shared that he was an Iraq War veteran and told me all about his primary care doctor at the VA and the support he received as he transitioned back to civilian life. He thanked me for my service to the veterans. I thanked him for his service to our country. This is the VA that I know, the VA that our country should be proud of. (Megha Garg, 11/10)

JAMA: Transforming The Military Health System
The Military Health System (MHS) is one of the largest health systems in the United States, delivering health services to 9.4 million eligible patients in nearly 700 military hospitals and clinics around the world as well as through the TRICARE health plan. … The National Defense Authorization Act for Fiscal Year 2017 directs changes to existing management structures, enabling the MHS to collectively transform into an integrated system of readiness and health. … This Viewpoint describes the strategic logic of a transformation that Sen John McCain (R, Arizona) stated was the “Most sweeping overhaul of the [MHS] in a generation.” (David J. Smith, Raquel C. Bono and Bryce J. Slinger, 11/9)

Reuters: For U.S. Republicans, Tax Reform Math Hinges On Cutting Medicare
A 2018 budget blueprint approved by Congress late last month would reduce Medicare spending by $473 billion over 10 years compared with the current baseline projection, and proposes $1.3 trillion in cuts to Medicaid, various Affordable Care Act (ACA) tax credits and cost sharing subsidies and other health spending. Republicans need the spending reductions to make room for $1.5 trillion in tax cuts, mostly for corporations and wealthy households. The budget plan does not include the specifics on how these cuts will be achieved. (Mark Miller, 11/9)

The New England Journal Of Medicine: Explaining Sluggish Savings Under Accountable Care
Despite aggressive targets set by Medicare for the spread of value-based payment arrangements and widespread agreement on the importance of delivery-system reform, progress toward lower spending growth and a transformed delivery system has been slow. Accountable care organizations (ACOs) are a prime example: nearly 1000 organizations operate as ACOs, but they have generated limited savings. Even in the third year of Medicare ACO contracts, fewer than half of ACOs received a bonus for reducing spending. To guide policy and help providers succeed, it would be useful to understand why so few ACOs are achieving savings. Data-driven empirical work on ACO performance has yielded few insights into the specific characteristics of ACOs that lead to success. We believe it would be helpful to consider how economic and organizational theories might explain early results from the ACO experiment. (Valerie A. Lewis, Elliott S. Fisher and Carrie H. Colla, 11/8)

Axios: How The Elections Could Put The Brakes On Anti-ACA Plans
The most important issue in an election is sometimes, but seldom, the factor that actually determines the outcome of the election. That’s what we saw happen in Virginia this week. Health was the top issue in the Virginia race, according to exit polls, but it was only one of many factors that drove the election. The bottom line: The election may have been more of a referendum on President Trump than health care — but the results in Virginia and in the Maine referendum on Medicaid expansion will still have a practical impact on what happens next, including the appetite for Affordable Care Act repeal and for cutting Medicaid to pay for tax cuts. (Drew Altman, 11/10)

The New York Times: Medicaid Is Great, but Rural Maine Needs Hospitals, Too
This week Maine voted to become the 32nd state to expand Medicaid despite opposition by Gov. Paul LePage, who had vetoed five previous expansion bills passed by the state legislature and has now threatened to block the results of the ballot initiative. Unless Mr. LePage succeeds, about 80,000 more Mainers will be eligible for coverage, a victory in an unsettling year for health care in America. With the Affordable Care Act under constant threat from the Trump administration and out-of-pocket costs rising faster than wages, health care topped the list of the most important issues facing Americans this year. (Zak Ringelstein, 11/9)

Lexington Herald Leader: Em’s Dead. Read This And You Won’t Feel So Hot Either.
But he eventually succumbed to that final straw that broke his back. Em was dead. And when I gave my best friend his last good-bye and spoke his eulogy, we all missed those days of doing what a patient needed, rather than what a bureaucrat wanted. We knew, if Em could speak, he might regret that phrase.“Joe, that’s just the way life is.” Em died. We lost him in a blizzard of records, finances, trivialities, computerized slowdowns with decreased productivity, and the fact that our patient/friends had now just become patients. For Em, you see, was the first letter of my beloved . . . Medicine. (Joseph P. Bark, 11/10)

The New England Journal Of Medicine: Health Care Professionals And Law Enforcement
Health care professionals generally have a respectful, sometimes even friendly, attitude toward law enforcement. We may feel we’re on the same team as the police when we’re treating victims of crime, and police may be called to protect us from people who seek to harm us in the hospital. Some health care professionals in emergency departments or intensive care units may have frequent interactions with police officers who are investigating alleged crimes. But the relationship may be profoundly tested when health care professionals refuse demands from law enforcement that conflict with what we understand to be our professional obligations. These conflicts may arise when law-enforcement officers prevent clinicians from having confidential discussions with patients, demand inappropriate restraints for patients that severely impede examination and treatment, or demand that health care personnel draw specimens from patients or retrieve evidence in an invasive manner from those who refuse or are unable to consent because they lack decision-making capacity due to delirium, confusion, or unconsciousness. (Arthur R. Derse, 11/8)

The Des Moines Register: After Four DUIs And Two Prison Stays, Now-Sober Lawyer Fights For Her Practice
As a student in the 1980s, Sandra Suarez was president of the Brody Middle School “Just Say No” club. It was named for former First Lady Nancy Reagan’s admonition to reject drugs and alcohol. It made perfect sense to the young Cuban-American girl, who had an alcoholic father and had witnessed what she calls “some of the ugliest things that no child should have to see.” She was so keen to get far away that she chose a college in Washington state. Her father stopped drinking after she left. Rekha Basu, 11/9)

The New York Times: Facebook Is Ignoring Anti-Abortion Fake News
Last year, just weeks before the election, an article from a site called Mad World News began circulating around Facebook. The headline read “Before Applauding Hillary’s Abortion Remarks, Know the One Fact She Ignored.” In the article, the writer says she wants to expose Hillary Clinton’s lies about late-term abortions. She argues that a baby never needs to be aborted to save a mother’s life but doesn’t cite any sources or studies, and presents anecdotes and opinion as fact. Midway through the story, she shares an illustration of what she calls a “Partial-Birth Procedure” — a procedure banned in the United States. In it, she describes how a doctor “jams scissors into the baby’s skull” and how “the child’s brains are sucked out.” (Rossalyn Warren, 11/10)

The New England Journal Of Medicine: The Promise, Growth, And Reality Of Mobile Health — Another Data-Free Zone
The use of mobile communication technologies to improve the health of individuals and populations — dubbed “mobile health,” or “mHealth” — has grown dramatically since 2008, when the term mHealth became widely used. The excitement over the use of mHealth technology especially in low- and middle-income countries (LMICs) stems from the recognition that mobile phones have penetrated the market like no other technology. There are more than 5 billion wireless communication subscribers, and more than 70% of them are in LMICs1 (though the subscription rate in low-income countries is 60% overall, and much lower in rural areas). Moreover, commercial wireless signals reach 85% or more of the world’s population, extending much farther than the electrical grid. (Amira Roess, 11/8)

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Federal Medicaid Chief Again Raises Concerns About Effect Of Expansion

Seema Verma, who heads up the Centers for Medicare & Medicaid Services, says the federal health law should not have opened Medicaid to nondisabled adults because it “stretched the safety net” and imperils care for those who need it.

The Wall Street Journal: Trump Official Says Medicaid Expansion Not Sustainable Without Changes
Medicaid, the federal-state health-insurance program, was never designed for low-income but able-bodied adults and is unsustainable without major changes, a top Trump administration health official said Thursday. “One of the major fundamental flaws in the Affordable Care Act was putting in able-bodied adults into a program that was designed for disabled people,” said Seema Verma, the Centers for Medicare and Medicaid Services administrator, who oversees Medicaid as well as implementation of the ACA, popularly known as Obamacare. “It stretched the safety net and it jeopardizes care for the individuals that the program was originally intended for.” (Radnofsky, 11/9)

CQ: West Virginia Could Close Children’s Health Program
West Virginia could close its Children’s Health Insurance Program as early as February if Congress does not act soon to renew federal funds for the program. The state’s CHIP board of directors voted Wednesday to close enrollment on Feb. 28, 2018, if funds are not provided before then. If needed, notifications with additional information will be sent to families and providers in early January, but benefits would continue as usual until the end of February. (Raman, 11/9)

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