Tagged Repeal And Replace Watch

Support For Health Law Grows, Leaving Republicans In A Bind

Republican members of Congress are at home this week, with many of them getting an earful from anxious constituents about their plans to “repeal and replace” the Affordable Care Act. A poll out Friday gives those lawmakers something to be anxious about, too.

The monthly tracking poll from the Kaiser Family Foundation finds overall support for the health law ticked up to 48 percent in February, the highest point since shortly after it passed in 2010. That was a 5-point increase since the last poll in December. (Kaiser Health News is an editorially independent project of the foundation.)

In addition, 6 in 10 people said they did not favor current GOP proposals for turning control of Medicaid, the federal-state program for low-income residents, over to the states or changing the federal funding method. More than half said Medicaid is important to them or family members.

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The increase in the law’s popularity is almost entirely due to a spike in support among independents, whose approval of the law has risen to 50 percent, compared with 39 percent unfavorable. Continuing a trend that dates to the passage of the law, the vast majority of Democrats approve of it (73 percent), while the vast majority of Republicans disapprove (74 percent).

Poll respondents are also concerned about the way Republicans say they will overhaul the measure. While they are almost evenly divided between wanting to see the law repealed (47 percent) or not repealed (48 percent), very few (18 percent) of those favoring repeal support the idea of working out replacement details later. More than half of the repeal supporters (28 percent of the sample) say the repeal and the ACA’s replacement should come simultaneously.

Interestingly, even among Republicans, fewer than a third (31 percent) favor an immediate repeal, while 48 percent support simultaneous repeal and replacement, and 16 percent don’t want the law repealed at all.

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Simultaneous repeal and replacement, which is what President Donald Trump has promised, could prove difficult since Republicans have not agreed to a plan. They are using a special budget procedure, called reconciliation, that allows them to move legislation with only a simple majority in the Senate, but that bill is limited in what it can remove from the law and what can be added to it. Other bills would likely have to overcome a filibuster by Democrats in the Senate, which requires 60 votes. Republicans currently have a 52-48 majority in that chamber.

When asked about the Republican plans to overhaul the Medicaid program, nearly two-thirds of those polled prefer the current Medicaid program to either a “block grant” that gives states more flexibility but would limit Medicaid’s currently unlimited budget, or a “per capita cap,” which would also limit spending to states but would allow federal funding to rise with enrollment increases.

Respondents also strongly favor letting states that expanded Medicaid under the Affordable Care Act continue to receive federal funding. The Supreme Court in 2012 made that expansion optional; 31 states (plus Washington, D.C.) adopted it. Eighty-four percent said letting the federal funds continue was very or somewhat important, including 69 percent of Republicans, and 80 percent of respondents in states that did not expand the program.

Republicans are counting on savings from capping Medicaid to pay for other health care options they are advocating.

The national telephone poll was conducted Feb. 13-19 with a sample of 1,160 adults. The margin of error is plus or minus 3 percentage points for the full sample.

Categories: Medicaid, Repeal And Replace Watch, Syndicate, The Health Law

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Threat Of Obamacare Repeal Leaves Community Health Centers In Limbo

Treating people for free or for very little money has been the role of community health centers across the U.S. for decades. In 2015, 1 in 12 Americans sought care at one of these clinics; nearly 6 in 10 were women, and hundreds of thousands were veterans.

The community clinics — now roughly 1,300-strong — have also expanded in recent years to serve people who gained insurance under the Affordable Care Act. In 2015, community health centers served 24.3 million people — up from 19.5 million in 2010. Most of the centers are nonprofits with deep roots in their communities and they meet the criteria to be a federally qualified health center. That means they can qualify for federal grants and a higher payment rate from Medicaid and Medicare.

The ACA was a game changer for these clinics — it has enabled them to get reimbursement for much more of the care they provided, because more of their patients now had private insurance or were on Medicaid. Revenue at many clinics went up overall, and many of the health centers used federal funding available under the law to expand their physical facilities and add more services, such as dentistry, urgent care or mental health care.

With repeal of the ACA looming, clinic directors said they stay up at night wondering what’s next. We spoke with four, who all say their clinics are in a holding pattern as Congress debates the health law’s future.

Saban Community Clinic, Los Angeles

Julie Hudman, the CEO of Saban Community Clinic in Los Angeles, Calif., said there’s a lot at stake for her patients.

“A lot of the folks that we see are single adults,” she explained. “They’re maybe more transitional. They’re homeless patients. They have behavioral health challenges. They’re really, to be honest, some of the most vulnerable and poorest patients of all.”

Before the ACA went into effect, eligibility for Medi-Cal, as Medicaid is known in California, depended on a variety of factors, including income, household size, family status, disability and others. Under Obamacare, according to the California Department of Health Care Services, people can now qualify for Medi-Cal on the basis of income alone if their household makes less than 138 percent of the federal poverty level — that’s $16,395 for an individual and $33,534 for a family of four.

Prior the ACA, about half of the Saban clinic’s 18,000 patients were uninsured, Hudman said. They paid little for treatment — maybe a copay of $5 or $10. Almost all of those patients qualified for Medi-Cal after the health law expanded eligibility, she said, and that’s made a big difference for the clinic’s bottom line: Medi-Cal pays the clinic around $200 per patient visit.

These days, more than half of Saban’s revenue comes from health insurance. The possibility of losing some of that money, Hudman said, is forcing some hard decisions. She had been looking to lease or buy a fourth facility, she said, but now that plan is on hold; as are her hopes of expanding free help for the homeless.

“I’m not willing to move forward and take some of those risks,” she said. “I need to make sure that we’re able to pay our bills and pay our staff.”

Before the last election, Hudman said, “we had a lot of momentum moving forward. And now we’ve just sort of stalled.” — Rebecca Plevin, KPCC, Los Angeles

Jordan Health, Rochester, N.Y.

In the last few years, funding has been on the rise at Jordan Health, in Rochester, N.Y., and so has the extent of the clinic’s services.

The boost in funding has partly come from higher reimbursement rates the ACA authorizes, and from the increased number of patients at the clinic who have insurance. But Jordan Health, which has 10 locations in the area, has also benefited from the federal government’s pumping of more money into what are known as section 330 grants that enable expansion of services and facilities.

Janice Harbin, CEO of Jordan Health in Rochester, N.Y. says section 330 grants have allowed Jordan Health to hire more health practitioners. (Karen Shakerdge/WXXI)

Janice Harbin, CEO of Jordan Health in Rochester, N.Y. says section 330 grants have allowed Jordan Health to hire more health practitioners. (Karen Shakerdge/WXXI)

The 330 grant money gives qualified clinics the option of offering services that aren’t billable to insurance plans. At Jordan Health, the funds enabled the hiring of some different types of health practitioners who were not previously part of the team — dietitians, behavioral health specialists and care coordinators. And that, in turn, said Janice Harbin, president and CEO of Jordan Health, means patients can increasingly get the different kinds of care they need in one place.

Almost 90 percent of Jordan’s patients are considered a racial or ethnic minority, and over 97 percent live at or below 200 percent of the federal poverty line, according to data gathered by the federal Health Resources & Services Administration.

“When you’re dealing with a situation of concentrated poverty,” Harbin said, “your patient needs more than just ‘OK, let me give you a checkup, and pat you on the back and say now go out and do all these things I told you to do.’”

Jordan Health received an increase of about $1 million since 2013, according to its grant coordinator, Deborah Tschappat.

Tschappat said she expects Jordan will get about the same annual award in 2017, assuming federal funding for the 330 program stays about the same. If federal funding is cut significantly, they would potentially lose some services.

For now, Jordan Health plans to “expand services judiciously, while increasing efficiency and productivity,” Tschappat said.

In the coming months Harbin and her colleagues will be lobbying lawmakers in Albany and Washington, D.C., to renew Jordan’s funding — including the 330 grant, which is set to end in September.

“We’re used to doing a lot with a little, but we increasingly know that we do need to have financial support,” Harban said. “And that’s keeping us up at night.” — Karen Shakerdge, WXXI, Rochester

Adelante Healthcare, Phoenix

Adelante Healthcare has been part of the health safety net in Phoenix for nearly four decades — when its doctors began helping farm workers in the city’s surrounding fields. But the Affordable Care Act enabled Adelante to expand like a brand new business.

“Adelante has grown by 35 percent in the last 12 months,” said Dr. Robert Babyar, Adelante’s assistant chief medical officer. “We’ve increased our provider staffing — almost doubled our providers. And the number of services we provide has doubled.”

Adelante operates nine clinics throughout the Phoenix metro area. The one where Babyar met with me includes play areas for children and a dental office.

Most of their 70,000 patients are low-income and about half are covered by either Medicaid or KidsCare — Arizona’s version of the Children Health Insurance Program. In 2014, Arizona became one of the Republican-led states that expanded Medicaid under the ACA. That brought more than 400,000 people onto the state’s Medicaid rolls and created big demand for Adelante. Low-income patients who did not have insurance before the expansion had relied on Adelante’s sliding fee schedule. Much of that population now has health coverage, either through the ACA marketplace or the state.

“That opened up more options for our patients, more specialists they could see, procedures they could have done,” Babyar said.

As Congress moves to repeal and replace the health care law, Adelante is in a holding pattern. It has delayed the groundbreaking of a new site until later this year because of the uncertainty. A full repeal of the ACA — without a replacement that keeps its patients covered — would limit any future growth, and strain the new staff and resources it has added. It wouldn’t be the first time Adelante had to scale back its services because of changes to Medicaid. In 2010 and 2011, Arizona lawmakers froze enrollment for its CHIP program and for childless adults in Medicaid. Then, in 2012, Adelante lost more than a million dollars.

Babyar said it has taken several years to get their new patients into the system and working with doctors consistently to manage their conditions.

“All the progress we made with those patients to stay and be healthy — that can fall apart really quick,” said Babyar. — Will Stone, KJZZ, Phoenix

Denver Health, Denver

Denver’s Federico F. Peña Southwest Family Health Center is part of Denver Health — the safety-net system that takes care of low-income people.

“Definitely this clinic has benefited from Obamacare,” said Dr. Michael Russum, who practices family medicine for Denver Health and helps lead the clinic. “And this population has benefited from Obamacare by the expansion of Medicaid.”

That’s what helped make the economics work as Denver Health put a new $26 million clinic in a high poverty neighborhood in 2016, said Dr. Simon Hambidge, Denver Health’s CEO of Community Health Services. With the ACA in place, he said, the health system was able to count on the new clinic having a population of paying patients with insurance that could help support it.

Hambidge predicted the hospital will weather the storm if Obamacare is repealed and there are serious cuts to safety-net programs, like Medicaid and Medicare, as some Republicans have suggested. But it will probably be harder to open new clinics in other high-need neighborhoods, he conceded.

“We’ll survive,” Hambidge said. “We may not be able to be as expansive, because we would be back to less secure times.” — John Daley, Colorado Public Radio

This story is part of NPR’s reporting partnership with local member stations and Kaiser Health News.

Categories: Medicaid, Public Radio Partnership, Repeal And Replace Watch, States, Syndicate, The Health Law

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KHN On Call: What’s Next For The ACA?

“KHN On Call” is a new regular feature, a product of our ongoing partnership with NPR. Each week, Julie Rovner, KHN’s chief Washington correspondent, will answer a few audience questions about the new administration’s effort to revamp U.S. health care — to “repeal and replace” the Affordable Care Act. Which changes are real and imminent? What can the president do without congressional agreement? How will policy changes affect patient lives? Tell us what you’d like to know. The segment will air on Morning Edition and we’ll repost the audio and a story here. You can submit questions via Twitter @MorningEdition #ACAchat or @KHNews #KHNOnCall.

Health care under the Affordable Care Act is poised to change — again. The Republican-led Congress has vowed to “repeal and replace” the health law known as Obamacare.

That has left many people anxious and confused about what will happen and when. So NPR’s Morning Edition asked listeners to post questions on Twitter and Facebook, and we will be answering some of them here and on the radio in the weeks ahead.

Many of the questions or comments that have come in so far have to do with timing. For example, Steva Stowell-Hardcastle of Lewisburg, Pa., said, “I’m confused about what parts of the ACA have been repealed and when those changes take place.”

First, while some parts of the huge health law have been altered since it passed in 2010, nothing substantive has been repealed in 2017.

In January, Republicans in Congress passed a budget resolution that called for major changes to the law to be made in a subsequent bill, called budget reconciliation. That will allow the bill to pass the Senate with only a majority of votes, rather than the 60 votes needed to overcome a filibuster by Democrats. Congressional leaders have yet to unveil what they plan to put in that second bill.

Whatever they include, however, they cannot repeal the entire law in reconciliation. That’s because the budget process limits changes to those that directly affect the federal budget. Put simply, they can modify money but not rules. While there is some debate over how that will look, most people believe the rule that requires insurers to cover people with preexisting conditions could not be repealed through a budget bill.

The Trump administration has taken a few actions, but none making concrete changes — yet. In January, Trump signed an executive order calling for federal agencies to “waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the act” that would “impose a fiscal burden” on states, individuals, healthcare providers, and others in the health industry.

But so far the only federal action in response to that order has come from the IRS, which decided not to more strictly enforce the “individual mandate” that requires most Americans to have health insurance. The IRS, however, noted that the requirement is still law.

A related question comes from Kathryn Henry of Iowa City, Iowa. She asks, “If it is repealed, what happens to people like me who currently have insurance through it and when?”

Both President Trump and GOP congressional leaders have insisted that they want a smooth transition from the current system to a new one, particularly for the 11 million or so people who purchased coverage on the federal or state health insurance exchanges.

“We don’t want to pull the rug out from under people while we’re replacing this law,” said House Speaker Paul Ryan (R-Wis.) in January. Trump has insisted that repealing the law and replacing it be done “essentially simultaneously,” so as not to leave people without insurance.

Unless something unexpected happens, people who purchased insurance for 2017 should be covered through the remainder of the year.

The bigger question is what happens in 2018. The uncertainty alone is prompting some insurers to get out of the individual insurance market, which is the most affected by the health law.

Insurance company Humana has already said it won’t participate in the health insurance exchanges next year, and the CEO of Aetna told reporters that his company might drop out, too. If Congress deadlocks over how to overhaul the health law, that exodus could accelerate.

Insurers were supposed to tell the federal government whether they planned to participate in the insurance exchanges by May 3, but the Trump administration has now given them until the end of June.

Categories: Repeal And Replace Watch, The Health Law

Longer Looks: A K Street Renegade; Dismantling Obamacare & Opioids In Sierra Leone

Each week, KHN’s Shefali Luthra finds interesting reads from around the Web.

The Wall Street Journal: The Rise And Fall Of A K Street Renegade
Few outside Washington had ever heard of Evan Morris. Yet in the capital of wheeling and dealing, he was one of its most gifted operators. From his start as an intern in the Clinton White House, he made powerful friends and at age 27 became a top Washington lobbyist for Roche Holding AG of Switzerland, one of the world’s largest pharmaceutical companies. (Brody Mullins, 2/13)

Vox: No Limits 
Timmy Morrison was delivered by emergency C-section, weighing in at 3 pounds, 9 ounces. Doctors put him under anesthesia within a week and into surgery within a month. Parts of his stomach sometimes made their way to his lungs. Workers in the intensive care unit frequently needed to resuscitate him. He arrived seven weeks premature — but, in a way, just at the right time. (Sarah Kliff, 2/15)

The Dallas Morning News: Severely Disabled Kids’ Lives At Risk, Parents Say, As Texas Enacts Medicaid Cost-Savings Plan
Amy Pratt drove her severely disabled son, Quinten, four-plus hours to Children’s Medical Center Dallas only to learn the insurance company that Texas hired to care for him had suddenly denied payment for an important procedure, one that could potentially save the 9-year-old’s life. In El Paso, 11-year-old Rudy Smith lost most of the therapy services that helped him cope with cerebral palsy and a severe form of epilepsy, which plagues him with 50 to 100 seizures a day. His mother says she’s having trouble getting prescriptions filled, and the insurance company keeps sending her incorrect or faulty medical supplies. (J. David McSwane, 2/13)

The New York Times: Will Obamacare Really Go Under The Knife?
Six days after he was sworn in as America’s 45th president, Donald J. Trump traveled to Philadelphia to address Republican lawmakers at their annual retreat. Standing behind a lectern emblazoned with the presidential seal, Trump predicted, “This Congress is going to be the busiest Congress we’ve had in decades.” Being Trump, he could not resist ad-libbing a superlative: “Maybe ever. Maybe ever. Think of that.” (Robert Draper, 2/14)

The Atlantic: Universal Health Care And The Future Of The Affordable Care Act 
The Senate confirmed Tom Price as secretary of health and human services at 2 a.m. on Friday. After a contentious confirmation process, the Trump administration and the Republican-controlled Congress had finally installed one of the leading generals in its war on Obamacare in the department that oversees its programs. Price is a titan in the GOP camp that wants to repeal the health law, and is perhaps one of the few Republican lawmakers with both the vision and the experience needed to begin the daunting task. (Vann Newkirk, 2/14)

The New Yorker: Another Planned Parenthood Protest Showdown
In January, 1993, the New York City Council moved unanimously to erect a sign at the intersection of Bleecker and Mott streets designating the small corner on the eastern edge of the West Village as Margaret Sanger Square. The bill, introduced by Kathryn Freed, noted that Sanger had opened America’s first birth-control clinic, in Brooklyn, in 1916, and that when she was arrested and jailed on obscenity charges she had taught her fellow-inmates about contraception. Her second birth-control clinic eventually became part of Planned Parenthood in New York City, which now serves more than fifty thousand patients each year and has been headquartered at the corner of Bleecker and Mott since 1992. (Jia Tolentino, 2/13)

Vox: How Repealing Obamacare Could Splinter Neighborhoods
Sure, it was billed as a policy that would make individual people healthier — and it ended up insuring 20 million people. But it also made neighborhoods healthier. It meant communities no longer had to fight over local tax dollars to care for the uninsured. It also meant there were fewer uninsured people who felt cast out and dehumanized by their communities. It lifted up our poorest and most vulnerable neighbors. (Alvin Chang, 2/13)

Al Jazeera: Opioids: Sierra Leone’s Newest Public Health Emergency
The dark street corner would have been silent if not for the grumble of a motorbike. It was nearing midnight, but for Ibrahim Sesay – a 27-year-old motorbike taxi driver in Freetown – the evening had just begun. He pulled four small pills from his breast pocket, gulped them down without water and set off into the night. (Cooper Inveen, 2/13)      

The Wall Street Journal: Computers Turn Medical Sleuths And Identify Skin Cancer
When it comes to melanoma, early detection is a matter of life and death. But it takes a trained eye to distinguish a harmless blemish from cancer, and many people around the world lack ready access to a dermatologist.Scientists have been seeking a solution for some time. In the latest sign that they’re succeeding, researchers at Stanford University have found a way to get a computer to identify skin cancer as reliably as board-certified dermatologists can. The hope is that, eventually, scientists can get this to happen on a smartphone anywhere in the world. (Daniel Akst, 2/10)

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

For California’s Smallest Businesses, Obamacare Opened The Door

If Republicans in Congress scrap the Affordable Care Act, Carmina Bautista-Ortiz might have to go back to Mexico for health care. But she’d rather spend the time running the printing shop she and her husband own in Jurupa Valley, a city about 50 miles east of Los Angeles.

For at least 10 years, before the Affordable Care Act made it possible for them to get insurance, Bautista-Ortiz and her husband Roger had been uninsurable — she because of a heart condition known as tachycardia, he because of high cholesterol.

Bautista-Ortiz crossed the border to get tests and specialty care for her rapid heartbeat. Her husband was slapped with a $20,000 hospital bill, which Carmina spent two years negotiating down until the hospital dismissed the debt.

Three years ago, the couple was finally able to buy subsidized health coverage through the state’s Obamacare exchange, Covered California, and Bautista-Ortiz said they now spend less time worrying about how to get care.

“Our health is … basically the most important thing that we have,” said Bautista-Ortiz. “If you’re not feeling well, you’re not going to do your job the right way.”

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Under Republican-led plans to repeal the Affordable Care Act, hundreds of thousands of self-employed people in California are at risk of losing their ability to buy affordable insurance. Some business owners welcome the rollback of the law, but the smallest of California businesses — entrepreneurs and contract workers who buy insurance on their own through Covered California — have the most to lose under a repeal.

That worries small business advocates who favor the Affordable Care Act. They say putting health care coverage out of reach of the self-employed could threaten Americans’ entrepreneurial spirit and burden people who create jobs and take on financial risk.

“When you’re providing a benefit that allows folks to take that risk with a little more of a safety net … that allows more entrepreneurs to take the plunge,” said Mark Herbert, California Director for Small Business Majority, an advocacy organization that opposes repeal.

Nationally, California has one of the highest rates of small business owners who get their coverage through a health insurance exchange — 16 percent — according to a U.S. Department of the Treasury analysis of 2014 data. And Covered California officials say nearly a quarter of enrollees — 377,000 people — declared themselves “self-employed” as of December. Enrollees receive an average of $440 a month in tax credits to help offset insurance premium costs, a spokesperson for the exchange said.

Herbert said rolling back subsidized health care and the no-exclusion policy for preexisting conditions could lead entrepreneurs to abandon their endeavors for more secure jobs, or prevent them from setting up shop in the first place.

“Uncertainty is very scary,” Herbert said. “There are enough variables and challenges that small business owners face,” said Herbert.

Other self-employed people say the looming repeal of Obamacare may not make them change careers, but it would change their relationship to health care.

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Charlie Murphy, a sewer pipe inspector in San Rafael, Calif., signed up for health insurance through Covered California last year. He recently lost 20 pounds after a doctor’s check-up. (Courtesy of Charlie Murphy)

Charlie Murphy, a sewer pipe inspector in Marin County, says if the hefty government subsidies that help him pay his monthly premium disappeared, he’d drop his coverage, or get a skeletal policy instead.

“My focus would be more [on] something catastrophic, than [a plan that supports] health maintenance,” said Murphy, 54, who pays a fraction of a monthly premium of roughly $500. The rest is subsidized with federal money.

When Murphy signed up for health care last year, he decided it was time for a check-up, the first in seven years. He barely interacted with doctors during the previous fifteen years, which he spent uninsured.

He was surprised to hear that his blood sugar and blood pressure were higher than they should be.

“I thought I was in better health than I was,” Murphy said.

The doctor’s visit — and a break up with a girlfriend — inspired Murphy to lose 20 pounds this past year. He cut down on smoking and drinking alcohol, and learned he can “survive without cookies and pie.”

He got some mental health treatment for anxiety, too, which improved his “outlook,” he said.

Although Obamacare may have made a notable impact on his health, he said he wouldn’t pay more for insurance or abandon his career to keep the same health care access he has now.

“I like working for myself, it’s nice … Driving around with the dog,” said Murphy, who performs site visits on homes for sale, inspecting sewage systems.

Just as each individual experiences the health care system differently, small business owners’ perspectives on Obamacare also vary widely and are influenced by ideological views and how much care costs.

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Sunder Ramani, owner of Westwind Media in Burbank, Calif., pays the health care premiums for roughly a dozen employees who opt into his employer-sponsored plans. He says premiums he have been steadily increasing in recent years. (Courtesy of Sunder Ramani)

Sunder Ramani, who owns Westwind Media, a post-production company in Burbank, Calif., offers small group coverage to roughly a dozen employees, even though he’s not legally required to. He pays 100 percent of their premiums.

“I’ve been paying higher and higher premiums, but for what appears to be packages that are less and less attractive,” said Ramani. He is a member of the California Leadership Council of the National Federation of Independent Business, a conservative small business association which opposes the Affordable Care Act and sued to overturn the law when it was first passed.

Ramani said if his business revenue hadn’t grown over the past several years, he might have shifted more of the health cost burden onto his employees. While Obamacare may not be solely responsible for health cost increases, Ramani said, the law didn’t bring them down as much as it could have.

In California, premiums in the small group market have been going up, but recent premium hikes have been smaller than in previous years, according to data from one of California’s two insurance regulators, the California Department of Managed Health Care. Premiums grew by almost 10 percent for small employer plans in 2011, whereas this year, they rose less than 6 percent, according to the data.

Businesses with 50 or more workers have greater legal responsibilities under the Affordable Care Act. The health reform law requires them to offer employees affordable coverage or pay a penalty.

That employer mandate has created an administrative “headache” for small business owners, say the insurance agents who help them comply with new required paperwork.

What’s more, the new requirement on employers hasn’t increased the rate of people with job-based coverage, because most employers of that size already offered employee health care before Obamacare, according to researchers at the Urban Institute.

But to the individuals who run the smallest of California’s enterprises, the law gave them benefits that didn’t exist before — the guaranteed availability of insurance, and the financial support to pay for it.

The promised repeal of the federal health law, as well as other policy changes under President Donald Trump, is complicating Carmina Bautista-Ortiz’s decisions to hire more employees or offer health care to the two she currently has.

Right now, those two employees, hired late last year, are responsible for their own health care. One is covered through her husband, and Carmina suggested to the other that he find a policy on the open market.

Bautista-Ortiz plans to look into a group health policy and help her employees pay for coverage. But right now, she says, those decisions are on hold.

She’s not sure how a repeal of Obamacare would affect her business yet, but she knows it will affect her personally.

“We’re ready for the worst, and hoping for the best,” she said.

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

Categories: California, California Healthline, Covered California, Insurance, Repeal And Replace Watch, Syndicate, The Health Law, Uninsured

New Rules Try To Shore Up Individual Health Insurance Market In 2018

While Congress continues to struggle with how to “repeal and replace” the Affordable Care Act, the Trump administration today unveiled its first regulation aimed at keeping insurers participating in the individual market in 2018.

“These are initial steps in advance of a broader effort to reverse the harmful effects of Obamacare, promote positive solutions to improve access to quality, affordable care and ensure we have a health system that best serves the needs of all Americans,” Tom Price, secretary of the Department of Health and Human Services said in a Twitter message.

But the new rule, which had been widely expected, was actually begun by the outgoing Obama administration. In part, it is an effort to address complaints by insurers that consumers were “gaming” the system to purchase coverage only when they were sick and then dropping it when they were healthy.

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To combat that, the regulation makes it harder for patients to sign up outside of annual open enrollment periods and would allow insurers to collect past-due premiums before starting coverage for a new year. It would also shorten the annual enrollment period by half, from three months to 45 days, ending right between Thanksgiving and Christmas. And it would give insurers more flexibility in the types of plans they offer and return regulation of the size and adequacy of health care provider networks to the states.

But it remains unclear whether the action will be too little, too late to ensure insurance is available next year. That would be necessary to keep congressional Republicans’ promises that people “do not get the rug pulled out from under them” during the transition to a new program, as House Speaker Paul Ryan (R-Wis.) says frequently.

On Tuesday, Humana announced it would stop selling policies in the health exchanges at the end of this year, and on Wednesday Mark Bertolini, the CEO of Aetna, suggested his firm might follow suit, repeating GOP charges that the individual market exchanges are in a “death spiral” where only sick people buy coverage.

While Humana was not a major player in the state exchange market — it only sold policies in 11 states for 2017 — its exit could leave at least 16 counties in Tennessee, including Knoxville, with no insurance company offering policies on the health exchange, according to data from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

That alarmed Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, who has been one of the leading voices in Congress advocating a slower repeal and replace strategy.

“Yesterday’s news from Humana should light a fire under every member of Congress to work together to rescue Americans trapped in the failing Obamacare exchanges before they have no insurance options next year,” Alexander said in a statement.

Last year Aetna’s Bertolini also cited losses in the market as the reason for the company’s scaling back participation in the exchanges, although in an unrelated case, a judge’s ruling later said the decision had at least as much to do with pushing federal officials to allow Aetna to merge with Humana. On Monday that merger was officially called off after being blocked by a judge.

The new rules were greeted with cautious optimism by insurance industry trade groups.

“While we are reviewing the details, we support solutions that address key challenges in the individual market, promote affordability for consumers, and give states and the private sector additional flexibility to meet the needs of consumers,” Marilyn Tavenner, president and CEO of America’s Health Insurance Plans, said in a statement.

The Alliance of Community Health Plans, which represents nonprofit insurers, called the regulation “a promising first step.” But in a statement, president and CEO Ceci Connolly warned that the rule “does not resolve all of the uncertainty for plans and patients alike. Without adequate funding it will be extremely difficult to provide high-quality, affordable coverage and care to millions of Americans.”

Groups representing patients, however, were less happy with the changes. They argue that the rules could result in higher out-of-pocket costs.

Ron Pollack, executive director of the consumer group Families USA, said the new administration “is deliberately trying to sabotage the Affordable Care Act, especially by making it much more difficult for people to enroll in coverage.”

Sick people are likely to jump through any hoops required to get coverage, but healthy people are less inclined to sign up when it is more difficult. So by making it harder for healthy people to enroll, said Pollack, “they are creating their own death spiral that would deter young adults from gaining coverage, thereby driving up costs for everyone.”

And the American Cancer Society said that the new rules could hurt cancer patients in particular — for example, when they need to purchase new coverage after becoming too sick to work or moving to be closer to health providers. The proposed changes “would require documentation that is often challenging to quickly obtain,” and could “delay a patient’s treatment and jeopardize a person’s chance of survival,” said a statement from Chris Hansen, president of the society’s Cancer Action Network.

Unless the new administration changes the date, insurers must decide by May 3 if and where they will sell insurance for next year on the state exchanges.

Meanwhile, the Republican-led Congress remains in a deadlock between conservatives in the House, who want to repeal the health law as soon as possible, and moderates in the Senate like Alexander, who want to wait until there is agreement on what will replace it.

“We should just do what we said we would do,” Rep. Raul Labrador (R-Idaho) told reporters on Tuesday.

Conservatives say, at a minimum, Congress should pass the partial repeal bill it passed in 2015 that President Barack Obama vetoed. That measure would eliminate the expansion of the Medicaid program, financial help for people to purchase insurance, the penalties for not having coverage, and all the taxes that pay for the program, among other things.

“Why would it be difficult to get [the Senate] to vote for something they already voted for?” asked Rep. Mark Meadows (R-N.C.).

But congressional budget scorekeepers in January said that bill, which has no replacement provisions, could result in a doubling of premiums and 32 million more people without insurance.

And Republicans in the Senate, as well as President Donald Trump, continue to say that repeal and replace should take place simultaneously.

“I thought we were embarked on an effort to replace it,” said Sen. John McCain (R-Ariz.).

Categories: Insurance, Repeal And Replace Watch, Syndicate, The Health Law

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Individual Insurance Primer: Long Troubled Market At Center Of Drive For Repeal

As the country braces for a possible overhaul of the Affordable Care Act, consumers and patients are raising concerns that the more than 10 million people who purchased plans through the law’s insurance marketplaces could lose coverage. Some are also nervous that changes unleashed by any revamping of the law could throw insurance purchased by individuals outside of the marketplaces into jeopardy.

This individual insurance market has long been troubled with chronic problems, which helped propel efforts to pass Obamacare in 2010. Yet, consumers’ complaints about the resulting coverage have helped drive the Republicans’ arguments to dismantle the ACA.

Here is a primer on the individual insurance market and the potential consequences of repealing portions of the sweeping health law.

What is the individual insurance market?

It is used by people who do not have health coverage through the government or their employer when they purchase a plan directly from an insurer. It is sometimes called the non-group market.

These plans can be offered either on or off of the ACA marketplace, with the exception of the District of Columbia, which provides insurance solely through that marketplace.

What’s the difference between individual plans sold on the health exchanges and those sold outside the exchanges?

Plans sold on the health exchanges, also called marketplaces, provide several benefits to consumers. Enrollees earning up to 400 percent of the federal poverty level — about $47,500 for an individual and $97,200 for a family of four — qualify for a tax credit to offset the cost of the premiums. Additionally, many of the online portals allow consumers to compare plans side by side, helping buyers find a plan that fits their needs.

In contrast, plans purchased off the exchange do not qualify for the subsidies and are generally more expensive. However, the off-marketplace plans often offer broader benefits, particularly access to providers who are not part of the insurers’ networks. More than half of off-exchange plans gave customers some sort of out-of-network coverage, according to a Robert Wood Johnson Foundation analysis on the Health Affairs website, whereas just 36 percent of marketplace plans offered the same benefit.

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How many people use these individual insurance plans?

The number is relatively small — roughly 8 percent of the U.S. population in 2015 — but it has been growing since the health law made such coverage more accessible and barred insurers from denying coverage to people with pre-existing health conditions. Among the people who might turn to an individual plan are self-employed business owners, someone taking early retirement, an unemployed worker who loses his access to job-based insurance and young adults who no longer qualify for coverage under a parent’s plan.

According to the latest data, 10.4 million people purchased an individual plan through the marketplace in the first half of last year.

It is harder to pinpoint the number of people buying insurance off the marketplaces. The Department of Health and Human Services last October estimated that total at 6.9 million. In that same report, HHS estimated that 2.5 million of these consumers could have qualified for tax credits available if they had purchased marketplace policies.

How do you buy these plans?

Plans on the federal or state marketplace online can be purchased online and often through insurance brokers. Some areas also provide enrollment assistance through trained personnel, often referred to as health care navigators.

Off-exchange programs can be purchased directly through the insurer or a broker.

How much do these plans cost?

Insurers offering any plans on or off the marketplaces can set prices based solely on five factors: age, location, tobacco use, individual-versus-family enrollment and the plan’s category, which denotes how much of the medical expenses, on average, the plan covers. Plans are categorized by metal tiers, with bronze plans covering 60 percent of costs, silver plans 70 percent, gold plans 80 percent and platinum plans 90 percent.

On average, plans on the marketplace are generally less expensive than those sold off of it. According to the Robert Wood Johnson analysis, the average premium for off-exchange plans in 2016 was 13 percent more expensive and had higher deductibles than on-exchange policies.

According to the federal Centers for Medicare & Medicaid Services, which oversees the health law marketplaces, 84 percent of marketplace shoppers qualified for premium tax credits in October 2016. And those earning less than 250 percent of poverty ($29,700 for an individual) who purchase a silver plan also qualify for subsidies that help cover deductibles, copayments and other out-of-pocket expenses.

What are the concerns?

Prior to the ACA, consumers often found it difficult to get comprehensive coverage on the individual market, especially since insurers could refuse to sell to customers who had pre-existing conditions. About 18 percent of applicants were denied coverage because of those health problems, according to one study. A 2011 report by HHS found half of non-elderly Americans lived with a condition that could have barred them from obtaining insurance.

Insurers could also include exclusion riders. These provisions cut out coverage for treatments related to specific diseases.

Because of those problems, many people turned to poor quality plans that had limited coverage, sometimes without realizing that their policies wouldn’t provide adequate insurance. Those who had comprehensive insurance often found it to be expensive. In addition, in some areas few plans were offered.

Although the health law standardized the benefits that policies must offer, it did not solve some of this market’s problems. Insurers complained that they were losing money because the market was attracting too many sick people and not enough healthy ones to stabilize their risk pools, which help spread the costs among health and sick customers. Some companies exited the exchanges, cutting down on competition and consumer choice. This year, 89 insurers have left the marketplace, according to a November analysis by consulting firm McKinsey and Co.

Others increased their premiums, reduced their provider networks and set higher deductibles that patients had to pay out of pocket before their coverage kicked in. The price for the silver marketplace plans on which subsidies are pegged increased an average of 22 percent nationwide in 2017, according to HHS. Several states experienced sharper hikes, including Minnesota, where premiums increased 50 to 67 percent.

What happens if the ACA is repealed?

Most political observers believe that Republicans cannot repeal the entire law since they don’t have the 60 votes needed in the Senate to avoid a filibuster. As a result, GOP leaders are working to repeal portions of the law through a complicated process known as budget reconciliation, which requires a 51-vote majority. Provisions in a reconciliation bill can deal only with federal spending, so it might affect parts of the law such as those that set up the financial subsidies for exchange customers, the Medicaid expansion and the tax penalty for those who don’t get coverage.

The Republicans, however, have not yet come together on a plan for replacing those provisions with their alternatives, an effort that would be separate from the repeal legislation.

Many analysts suggest that the upheaval could push enough healthy individuals out of the marketplace plans to upset insurers’ risk pools. The change could also erode the exchanges by driving more insurers out of the marketplace. According to a report by the Congressional Budget Office, a Republican repeal plan vetoed last year by President Barack Obama would have resulted in 32 million Americans losing coverage by 2026.

An Urban Institute report found that if lawmakers go forward with their partial repeal and do not have adequate safeguards to help insurers keep healthy customers, “significant market disruption would occur,” including the loss of some insurers quickly.

But the shocks could also cause enough chaos that insurers would pull out of the entire market, said Paul Ginsburg, a professor of health policy and management at the University of Southern California.

“That would not only wipe out the coverage that the subsidies underwrote,” he said in reference to a partial repeal through reconciliation, “it would also wipe out the rest of individual market.”

Categories: Insurance, Repeal And Replace Watch, Syndicate, The Health Law

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Obamacare Came To Montana Indian Country And Brought Jobs

The Affordable Care Act created new health coverage opportunities more than half a million Native Americans and Alaska Natives — and jobs have followed on its coattails.

In Montana, this is playing out at the Blackfeet Community Hospital. It’s the only hospital on the Blackfeet reservation, and has been mostly funded — and chronically underfunded — by the Indian Health Service, which has been in charge of Native American health care since its founding in the 1950s. But now, many Native Americans have been able to afford health insurance on the Obamacare exchange, and last year, Montana expanded Medicaid. Now, about one in seven reservation residents gets Medicaid.

Blackfeet Community Hospital needed to build an infrastructure to deal with the byzantine bureaucracy that comes with taking Medicaid and private insurance. The tribe’s community college started a new curriculum to help meet the growing demand for people in Indian country to process insurance claims.

Blackfeet tribal member Gerald Murray took the courses. “I got a contract before I graduated in April, and then the day of graduation in May it became permanent so I applied for it,” he said.

Murray’s experience is an example of the health care law’s transformative power in Native American communities, said Montana’s director of American Indian Health, Mary Lynn Billy-Old Coyote.

“To me, there’s opportunity there to not only build health care, but to build your entire community and build jobs,” said Billy-Old Coyote.

Unemployment on most of Montana’s Indian reservations is at least double the rest of the state. And people who are working don’t always get health insurance with their jobs. So ACA subsidies that bring down the cost of insurance premiums are a big deal, Billy-Old Coyote said. Most Montanans, Native or not, can now get policies for about $75 a month. It is a big change for the reservation communities where people are accustomed to the underfunded IHS, which often didn’t pay for care unless someone was in immediate danger of losing life or limb.

(Courtesy of Mary Lynne Billy-Old Coyote)

(Courtesy of Mary Lynne Billy-Old Coyote)

“Now you’ve got an opportunity for American Indian people to truly have access to private insurance,” she said. “You have access to greater networks of providers and specialists, and all the things we generally don’t see you have access to.”

Medicaid expansion had a lot to do with the number of health care jobs in Montana growing by 3 percent last year, according to state statistics. And schools in Montana, including tribal colleges, are offering more classes in health care fields.

At Blackfeet Community College, 23-year-old Leroy Bearmedicine is working toward certification as an emergency medical technician.

“I’d like to become a registered nurse at some point, maybe even work my way up to flight nurse — something to get the adrenaline going,” he says.

Native American leaders have seen the Affordable Care Act as a means to remedy a series of broken promises by the federal government to care for them. They now fear that promise, too, will fade. One estimate suggests Montana will lose 3,000 health care jobs if the Affordable Care Act is repealed.

This story is part of a reporting partnership with NPR, Montana Public Radio and Kaiser Health News.

Categories: Medicaid, Public Radio Partnership, Repeal And Replace Watch, Reporting Consortium, Syndicate

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El secretario de Salud Tom Price podría cambiar rápido 5 temas clave de salud

Después de un proceso accidentado, el Senado confirmó la madrugada del 10 de febrero al representante republicano por Georgia, Tom Price, para dirigir el Departamento de Salud y Servicios Humanos (HHS), por un voto de 52 a 47.

Como secretario, Price tendrá una autoridad significativa para reescribir las reglas de la Ley de Cuidado de Salud Asequible (ACA), popularmente conocida como Obamacare, algunas de las cuales ya están casi listas para poner en acción.

Pero ahora, Price tiene una influencia de muy largo alcance, como jefe de una agencia con un presupuesto de más de $ 1 billón para el año fiscal actual. Puede interpretar las leyes de formas diferentes a las de sus predecesores y reescribir las regulaciones y las guías, que definen cómo se ponen en marcha legislaciones importantes.

“Virtualmente, la forma en que se administra el HHS afecta todo lo que la gente hace todos los días”, dijo Matt Myers, presidente de la Campaign for Tobacco-Free Kids. Las responsabilidades del departamento de salud incluyen: seguridad de alimentos y medicamentos, investigación biomédica, prevención y control de enfermedades, así como supervisión de todo, desde laboratorios médicos hasta hogares de ancianos.

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Price, un médico de Georgia que se opone a ACA, al aborto y a la financiación de Planned Parenthood, entre otras cosas, podría tener un impacto rápido, incluso sin una orden presidencial o un acto del Congreso

Algunos que lo apoyan están entusiasmados con esa posibilidad. “Con el doctor Price tomando el timón de la política de salud de los Estados Unidos, los médicos y los pacientes tienen razones sólidas para esperar un cambio bienvenido y esperado desde hace mucho tiempo”, dijo Robert Moffit, miembro de la Heritage Foundation, en un comunicado, cuando se anunció la nominación de Price.

Otros son menos entusiastas. Cuando se le preguntó sobre qué políticas podría promulgar, Topher Spiro, del Center for American Progress, dijo en ese momento: “No sé si quiero pensar en las malas ideas que podría llevar a cabo”.

Las siguientes son cinco acciones que el nuevo secretario del HHS podría tomar, según los defensores de ambas partes, que perturbarían las políticas de salud actualmente vigentes:

Cobertura de métodos de control de la natalidad: bajo ACA, la mayoría de los planes de las aseguradoras deben proporcionar a las mujeres cualquier forma de anticoncepción aprobada por la Administración de Alimentos y Drogas (FDA) sin costo adicional. Esto ha sido particularmente polémico en lo que respecta a los empleadores religiosos quienes se oponen a la anticoncepción artificial, lo que ha llevado a alteraciones en las reglas, y ha resultado en dos decisiones separadas de la Corte Suprema, una sobre los derechos de las firmas privadas de tener objeciones religiosas y otra sobre los hospitales religiosos sin fines de lucro y escuelas.

Como secretario, Price tendría dos opciones principales. Podría ampliar la exención de este requisito a todo empleador con objeciones religiosas. O, porque la inclusión específica del control de la natalidad se estableció a través de una regulación y no por la ley en sí, podría simplemente eliminar la cobertura anticonceptiva sin copago de la lista de beneficios que los planes de seguro deben ofrecer. (Esto supone la continuación de la existencia de la ley de salud, al menos en el corto plazo.)

Cambios en el pago de Medicare: la ley de salud creó una agencia dentro del Medicare, llamada el Center for Medicare and Medicaid Innovation, cuya tarea es explorar nuevas formas de pagar a médicos y hospitales, que reducirían los costos y mantendrían la calidad. El secretario del HHS puede obligar a que los médicos y los hospitales participen en los experimentos y en los nuevos modelos de pago. Algunos de ellos han demostrado ser poco populares, en particular la idea de pagar a los proveedores por paquetes de atención, en lugar de permitirles facturar artículo por artículo.

Uno de estos paquetes cubre reemplazos de cadera y rodilla, desde el momento de la cirugía hasta la rehabilitación postquirúrgica. Price, como ex cirujano ortopédico, probablemente actuaría para reducir, retrasar o cancelar ese proyecto, ya que “ha sido un crítico en el pasado”, dijo Dan Mendelson, CEO de Avalere Health, una firma consultora con sede en Washington.

Financiamiento de Planned Parenthood: los republicanos han estado movilizándose literalmente por décadas para sacarle a Planned Parenthood su financiamiento federal. El Congreso tendría que cambiar la ley del Medicaid para quitarle este financiamiento de manera permanente al grupo de salud de la mujer, que también realiza abortos (con fondos no federales) en muchos de sus sitios. Pero un secretario del HHS tiene muchas herramientas a su disposición para hacerle la vida miserable a la organización.

Por ejemplo, durante las administraciones de Ronald Reagan y George H.W. Bush, se impusieron reglas, eventualmente confirmadas por la Corte Suprema, que prohibían al personal de clínicas de planificación familiar financiadas por el gobierno federal ofrecer consejería o referir a mujeres con un embarazos no deseados que buscaran un aborto. La subsiguiente administración de Bill Clinton abolió las reglas, pero podrían regresar bajo el liderazgo del nuevo secretario.

Price también podría arrojar el peso del departamento en las investigaciones en curso sobre los vínculos de Planned Parenthood con firmas que supuestamente vendían tejido fetal con fines de lucro.

Regulación del tabaco: después de años de discordia, el Congreso finalmente acordó, en 2009, otorgar a la FDA una autoridad (limitada) para regular los productos de tabaco. “La autoridad central está permitida”, dijo Matt Myers de la Campaign for Tobacco-Free Kids, quien abogó por la ley. Eso significa que el Congreso tendría que actuar para eliminar muchos de sus cambios. Pero una Secretaría que se oponga a la ley (Price votó en contra de ella en ese momento) podría debilitar su aplicación, dice Myers. O podría reescribir y anular algunas reglas, incluyendo las recientes que afectan a los cigarros y a los cigarrillos electrónicos.

“El secretario tiene una autoridad discrecional muy amplia para no aplicar, o implementar vigorosamente el estatuto de una manera agresiva”, dijo Myers.

Protecciones de conciencia: al final del gobierno de George W. Bush, el HHS publicó reglas destinadas a aclarar que los profesionales de la salud no tenían que participar en la realización de abortos, esterilizaciones u otros procedimientos que violaran una “creencia religiosa o convicción moral”.

Los opositores a las reglas se quejaron, sin embargo, de que eran tan vagas y extensas que podían aplicarse no sólo a los opositores al aborto, sino también a aquéllos que no quieren proporcionar control de la natalidad a las mujeres solteras, o tratamiento del VIH a los homosexuales.

El gobierno de Barack Obama revisó exhaustivamente las reglas, ante la continua consternación de los conservadores. Estaban entre los pocos artículos relacionados con el tema incluidos en la sección de salud del sitio web del presidente electo antes de que la página fuera retirada. Decía: “La Administración actuará para proteger la conciencia individual en el cuidado de la salud”. Muchos esperan que las reglas vuelvan a su forma original.

Categories: Capitol Desk, Noticias En Español, Public Health, Repeal And Replace Watch, Syndicate, The Health Law

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