Tagged Repeal And Replace Watch

Safe Under The ACA, Patients With Preexisting Conditions Now Fear Bias

Cheasanee Huette, a 20-year-old college student in Northern California, is worried. Two years ago, knowing she was protected by the Affordable Care Act’s guarantees of coverage for preexisting conditions, she decided to find out if she carried the same genetic mutation that eventually killed her mother.

She tested positive for one of the cancer-related mutations referred to as Lynch syndrome.

Now, as congressional Republicans advance proposals to overhaul the health law’s consumer protections, she frets that her future health insurance and employment options will be defined by that test — and that the mutation documented in her medical records and related screenings could rule out individual insurance coverage.

“Once I move to my own health care plan, I’m concerned about who is going to be willing to cover me and how much will that cost,” said Huette, who now has coverage under her father’s policy.

With the protections of Obamacare in place, physicians in recent years have urged patients to be screened for a variety of diseases and predisposition to illness, feeling confident it would not affect their future insurability. Being predisposed to an illness — such as carrying BRCA gene mutations associated with breast and ovarian cancer — does not mean a patient will come down with the illness. And it may allow them to take steps to prevent its development.

But the results recorded on patients’ charts could haunt them, experts say.

Dr. Kenneth Lin, associate professor of family medicine at Georgetown University School of Medicine in Washington, D.C., said that doctors might become reluctant to screen for widespread conditions such as prediabetes. The Centers for Disease Control and Prevention and the American Medical Association have urged primary care doctors to screen patients at risk for the condition with a blood test. It is one of the screening tests covered under the ACA at no-cost to those patients.

If the changes being proposed by the GOP become law, Lin wrote in an email, “you can bet that I’ll be even more reluctant to test patients or record the diagnosis of prediabetes in their charts.” Such a notation might mean hundreds of dollars a month more in premiums for individuals in some states under the new bill, according to Lin.

It is a concern expressed by many patient-advocacy groups, who say members could be penalized or face the possible loss of the guarantee of coverage.

Huette is sharing her story publicly, since — come what may — her genetic mutation is already on the record — her medical record.

But genetics experts and patient advocates worry that people are already shying away from testing as the health law’s future becomes more uncertain. Their underlying concern: What if a positive result is added to their medical record, along with related screening and other preventive procedures that might further flag them to future insurers?

There have been “panicked expressions of concern,” said Lisa Schlager, vice president of community affairs and public policy at the nonprofit group Facing Our Risk of Cancer Empowered (FORCE). “Somebody who had cancer even saying, ‘I don’t want my daughter to test now.’ Or ‘I’m going to be dropped from my insurance because I have the BRCA mutation.’ There’s a lot of fear.”

These fears, which come in an era of accelerating genetics-driven medicine, rest upon whether a gap that was closed by the ACA will be reopened.

A law passed in 2008, the Genetic Information Nondiscrimination Act (GINA), bans health insurance discrimination if someone tests positive for a mutation. But that protection stops once the mutation causes “manifest disease,” jargon for a diagnosable health condition.

That means “when you become symptomatic,” although it’s not clear how severe the symptoms must be to constitute having the disease, said Mark Rothstein, an attorney and bioethicist at the University of Louisville School of Medicine in Kentucky, who has written extensively about GINA.

The ACA, passed two years later, closed that gap by barring health insurance discrimination based on preexisting conditions, Rothstein said.

On paper, the legislation unveiled by Senate Majority Leader Mitch McConnell (R-Ky.) last week wouldn’t permit higher rates to be charged to people with preexisting conditions, but health policy analysts said it could effectively exclude such patients from coverage because it allows states to offer insurance that carved out coverage for certain maladies. The bill that passed the House last month has a provision that allows states to waive preexisting protections for people buying their own insurance if they have a gap in coverage of 63 days or longer during the prior year.

A genetic predilection for a certain disease is “not black-and-white,” said Dr. Robert Green, a medical geneticist who directs the Genomes2People (G2P) Research Program at Brigham and Women’s Hospital and Harvard Medical School in Boston. Once someone tests positive for a mutation, the recommended screening to catch disease at an earlier point could over time identify clinical or laboratory data “that are suggestive, but not definitive,” he said.

Green was involved with a study published this week in the Annals of Internal Medicine, which found that even seemingly healthy individuals can carry — unbeknownst to them — mutations for rare diseases. Of the 50 healthy patients who agreed to undergo whole-genome sequencing, 11 tested positive. Subsequently, two of the 11 were found to have related symptoms; the rest showed no signs of disease.

Lisa Salberg, chief executive officer of the Hypertrophic Cardiomyopathy Association, has cardiomyopathy, a condition that can make the walls of the heart thick and rigid. She was recovering from a heart transplant earlier this year when her phone and social media accounts blew up over the preexisting waivers in the House bill. “We finally got to a place where people understood the value [of genetic testing],” she said. “Now, because we’re turning health care on its head, people are becoming more paranoid again.”

When members of a Lynch syndrome-related social media group were asked about their views on testing, with assurance of no direct attribution without prior consent, slightly more than two dozen men and women responded.

Nearly all of those who posted said they were delaying action for themselves or suggesting that family members, and particularly children, should hold off. (Lynch syndrome refers to a cluster of mutations that can boost the risk of a wide range of cancers, particularly colon and rectal.)

Huette was the only one who agreed to speak for attribution.

She had witnessed the impact that worries about insurance coverage before the ACA had on patients. Her mother, a veterinarian, had wanted to run her own practice but instead took a federal government job for the guarantee of health insurance. She died at age 57 in 2011 of pancreatic cancer, one of six malignancies she had been diagnosed with over the years.

Huette said she doesn’t regret getting tested. Without that result, Huette pointed out, how was she going to persuade a doctor to give her a colonoscopy in her 20s? She added: “Ultimately, my health is more important than my bank account.”

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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Drop In Sudden Cardiac Arrests Linked To Obamacare

If 22 million Americans lose their health care coverage by 2026 under the GOP Senate’s plan to repeal and replace the Affordable Care Act, how many people could die? The question is at the heart of the debate raging in Washington, D.C., but has been difficult to answer.

“Show me the data on lives saved by Obamacare, please,” conservative political scientist Charles Murray requested in a recent tweet.

A pilot study published Wednesday in the Journal of the American Heart Association may provide an answer: Researchers found that the rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in Multnomah County, Ore., after the Affordable Care Act expanded insurance coverage.

The study analyzed sudden cardiac arrest data from the emergency medical system in 2011-12 before the ACA, and compared the data from 2014-15, after insurance coverage expanded. During that time, the percentage of people in Multnomah County with Medicaid coverage nearly doubled, from 7 percent to 13.5 percent.

Cardiac arrest can serve as an early indicator to show how an increase in health insurance coverage under the ACA might affect mortality.

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Each year, about 350,000 people in the United States have a sudden cardiac arrest, in which the heart unexpectedly stops beating. It is one of the most deadly types of heart attacks — only 1 in 10 patients survive it. “It speaks to the importance of predicting and preventing [cardiac arrest], because once it happens, it’s much too late,” said Dr. Sumeet Chugh, medical director of the Heart Rhythm Center of the Cedars-Sinai Heart Institute in California and one of the authors of the study.

The good news is that nearly half of patients experience warning symptoms, offering an opportunity for intervention, said Chugh. Cholesterol and blood pressure medication, diet and exercise, and surgical interventions can all help stave off sudden cardiac arrest. But patients without health insurance might ignore their symptoms and avoid seeing a doctor.

“Imagine that you’re someone with a warning symptom. If you had insurance or access to health care that was relatively easy, you might be more inclined to see a provider. If you didn’t,you might let it go for a while,” said Chugh.

Chugh cautions that the study population was small and did not examine other factors that could have led to a decline in cardiac arrests. Still, it is consistent with other studies that found a link between Medicaid expansion and a decline in mortality. Chugh and fellow author Eric Stecker of the Oregon Health & Science University plan follow-up studies to narrow in on the causes in Multnomah County.

J. Michael McWilliams of the Department of Health Care Policy at Harvard Medical School, who was not involved in the study, questioned the large reduction in cardiac arrests seen in the study, saying it “seems too good to be true.”

Still, he said assessing the effects of health insurance on clinical outcomes like cardiac arrest is notoriously difficult, and there is good evidence that health insurance improves access to care and diagnosis of important conditions.

“I think when we focus on the lack of consensus evidence on the effects of coverage on hard outcomes like mortality, and use that as an argument against covering the uninsured, I think we let perfect be the enemy of good,” McWilliams said.

James Frank (Courtesy of James Frank)

Take James Frank, 64, of Lancaster, Calif., who was uninsured several years ago when he first started experiencing the symptoms of heart disease.

“I couldn’t catch my breath, I was wheezing,” Frank recalled. “I felt like I had like a chest cold. My feet were tingling. I was getting the sweats.” In 2013, Frank had a heart attack and was taken to the emergency room.

He signed up for coverage under Covered California, the state’s health insurance exchange, which opened in 2013 for coverage that began in January 2014. His doctor put him on a statin and blood pressure medication to prevent another heart attack, and he started watching his weight religiously.

Frank was quick to add that the coverage he gained under the ACA has not been perfect — his premium and deductibles are high, and he thinks that Congress should repair it. Still, he believes the health law saved his life. “I had the same heart attack that killed my mother,” he said. “Had it not been for Obamacare, I probably would have had another one.”

Categories: Public Health, Repeal And Replace Watch, The Health Law

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Calif. Officials Sound Alarm, Envisioning $114B Hit To Medi-Cal Under U.S. Senate Bill

California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday.

The reductions in the nation’s largest Medicaid program would start at $3 billion in 2020 and would escalate to $30.3 billion annually by 2027, according to an analysis released by the state departments of finance and health care services.

“It is not Medicaid reform,” Jennifer Kent, director of the state Department of Health Care Services, said in an interview. “It is not entitlement reform. It is simply a huge funding reduction in the Medicaid program. We are deeply concerned what that means for the long-term viability of the program as it stands today.”

Medicaid covers a staggering 13.5 million low-income Californians — children, people with disabilities, nursing home residents and others. About 3.8 million of them, many of whom are chronically ill, became eligible for coverage under the Affordable Care Act, informally known as Obamacare.

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California would face the biggest losses of any state, according to a report issued Wednesday by the consulting firm Avalere Health. Federal funding would drop by 26 percent over 10 years, the report said. Many states, including Alabama, Georgia, Texas and Florida, would face a drop of less than 10 percent.

The Senate bill to repeal and replace the ACA would be a “massive and significant fiscal shift” of responsibility from the federal government to states, according to the analysis. It would force difficult decisions about who and what to cover and how much to pay doctors, hospitals and clinics, the report said.

In addition to expanding its Medicaid population early and vigorously under Obamacare, the state began covering undocumented immigrant children last year. California’s program, known as Medi-Cal, also provides dental care and other services that are optional under federal Medicaid rules.

The state’s Medicaid director, Mari Cantwell, said Republican proposals present a fundamental problem that can’t be solved by making cuts around the edges.

“Nothing is safe — no population, no services,” Cantwell said. “It is really disheartening and honestly horrifying to think about the world under this Senate bill and what it would mean.”

The losses are more than what was predicted under the House bill. The analysis said that’s because the cost shift increases over time under the Senate proposal.

Ken Bascom, 62, was diagnosed with kidney cancer after becoming eligible for Medi-Cal in 2014. Bascom is now cancer-free but said that without insurance, “more likely than not, I would’ve been dead.” (Anna Gorman/KHN)

GOP leaders in Congress have been trying to repeal the ACA for seven years, deeming it disastrous public policy that costs too much and leaves consumers with rising premiums and too few choices for care.

The Senate bill would overhaul Obamacare in several ways. Besides revamping the Medicaid program, it would dramatically change the system of tax credits used to help low-income Americans get health coverage. The Congressional Budget Office concluded that the bill would cut the federal deficit by $321 billion over the next decade while leaving 22 million more Americans without health insurance.

Unable to lock down the support he needs in the Senate, Majority Leader Mitch McConnell on Tuesday postponed a vote on the bill until after the July Fourth holiday. Its fate remains uncertain as senators head back to their districts for a weeklong recess.

Under the legislation, the federal government would pay a fixed amount to states for Medicaid expenditures, a per capita rate, instead of paying for a share of all expenses incurred.

State health leaders predict that the state’s costs would outpace the federal government’s allocation, meaning California would have to come up with an additional $37.3 billion between 2020 and 2027.

“Whether it’s drugs or cost of living going up or new technologies in health care, there are costs we can’t control,” Cantwell said. “And if you have a trend factor that doesn’t really reflect the reality of what health care looks like, the state is always going to be in a place of not being able to bring the costs within that target.”

The proposed financial caps would have a “devastating and chilling effect” on spending in the Medicaid program and would pinch providers further, the analysis said. California already ranks near the bottom for how much it pays Medicaid providers.

The Senate’s overhaul of Obamacare would also force hospitals and clinics serving the poor and uninsured to live within the new financial limits, leading to “uncompensated care in the hundreds of millions, if not billions annually,” according to the analysis.

In addition, the Senate bill would phase out funding for the expansion of Medicaid, which enabled 3.8 million single, childless adults and others in the state to qualify. Under the Affordable Care Act, the federal government pledged to pay for 90 percent of their costs. But the Senate bill would reduce that to 50 percent beginning in 2024.

Without the promised federal funds, California would have to spend five times more than previously estimated to continue covering those newly eligible. By 2027, the cumulative cost to California would be $74.1 billion, according to the analysis.

California leaders vowed Tuesday to fight the bill, known as the Better Care Reconciliation Act. “Simply stated, this is a terrible bill and we must defeat it,” said Democratic Sen. Dianne Feinstein in a call with reporters.

Sen. Kamala Harris, also a Democrat, added that the most vulnerable populations are the ones who have most to lose: children, people with disabilities, seniors. “This bill is nothing short of a disaster, and it’s no wonder they did it in secret because they have nothing to be proud of,” said Harris, who aims to kill the bill before it hits the Senate floor.

The fallout would be particularly bad in Los Angeles County, home to 1 of every 20 Medicaid recipients in the nation, county officials said Tuesday.

“L.A. County will be ground zero for the plan’s deadly consequences,” said county Supervisor Sheila Kuehl during a press conference. “This is not just about money. … This is about the people who count on us for health care.”

During the conference, several Los Angeles County residents and union members held up signs that read “Healthcare is a Human Right” and, in Spanish, “SALUD para todos,” or “Health for everyone.”

Ken Bascom, 62, who lives in Venice, Calif., and attended the gathering, said he lost his job and his employer-based insurance during the recession. Soon after Bascom became eligible for Medi-Cal in 2014, he was diagnosed with kidney cancer. Now cancer-free, Bascom said he often thinks about what would have happened if he hadn’t been able to get health care.

“More likely than not, I would’ve been dead,” said Bascom, who gets care at Venice Family Clinic. “It’s very scary.”

Also in attendance was Steven Martin, 27, who said he depends on insurance he got through Obamacare to pay for his leukemia treatment. Martin, who has private insurance through Covered California, the state’s exchange, said his medication costs tens of thousands of dollars each year.

“Without insurance, I’m not going to have access to my medication,” he said.

Los Angeles County Health Agency Director Mitch Katz said the ACA made a “huge difference” in the county — dramatically cutting the uninsured rate, reducing wait times at emergency rooms and helping connect patients to primary care doctors.

“The emergency rooms themselves often had two- and three-day waits,” he said. “Because of the ACA, that is no longer the case. … The emergency room now is back to what is should be — for emergencies.”

Katz said he feared all of that would change if the Republicans succeed in overhauling the health law.

Ana Ibarra contributed to this report.

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

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


For Millennials, Both Good And Bad News In Senate’s GOP Health Bill

Darlin Kpangbah receives free health insurance through Medicaid and is grateful for the coverage in case of accidents, such as when she tore a ligament in her leg a few years ago. “I feel like I’m injury-prone,” said Kpangbah, 20, who lives in Sacramento, Calif. Without insurance, she said, the injury “would’ve been huge to pay for.”

Young adults like Kpangbah were among the biggest beneficiaries of Obamacare, which helped reduce the rates of uninsured millennials to record lows and provided millions of Americans with access to free or low-cost insurance as well as maternity care, mental health treatment and other services.

Now, Senate Republicans have proposed overhauling the Affordable Care Act — a move that could help some young adults by lowering the cost of their premiums in the private insurance marketplaces but could hurt others who gained insurance through a massive expansion to Medicaid. A Congressional Budget Office analysis of the bill released Monday estimated that 22 million Americans could lose coverage under the Senate bill, which could change significantly before an expected vote before July 4.

The proposed legislation also would retain a popular Obamacare provision that allowed young adults up to age 26 to stay on their parents’ insurance. But the bill in its current form also could dramatically reduce health coverage and care for other young adults, according to the bill’s many critics, which include the American Medical Association and the American Hospital Association.

“Don’t be fooled,” said Jen Mishory, executive director of the advocacy organization Young Invincibles. “This is going to be a bad deal, particularly for the most vulnerable young people.”

Mishory said one of the biggest concerns is that states could opt out of requiring insurers to provide benefits such as maternity care, mental health care and prescription drugs — all commonly used among young adults. “You will see a lot of young people not getting the kind of coverage they need,” she said.

The proposed changes in the marketplaces, however, could make coverage more attractive to young people. The Congressional Budget Office reports that the Senate bill would result in a larger number of younger people paying lower premiums to buy private plans. The proposal would allow insurers to charge older people up to five times more than others, which could mean lower premiums for younger people.

At the same time, the Senate bill shifts the amount people who qualify for subsidies must pay toward their own premiums, meaning that people under age 40 might pay a smaller portion of their income toward coverage than they do under Obamacare.

But young adults could face other cost increases because of larger deductibles and less help with out-of-pocket expenses. Some no longer would qualify for subsidies at all, because the bill would reduce the income threshold for eligibility.

Millions of young adults have enrolled in coverage through the insurance exchanges, in part because of a coordinated push to get as many healthy, young people into the marketplace to balance out older, sicker consumers who were eager to sign up right away.

About 27 percent of the 12.2 million consumers who enrolled in health insurance through the exchanges across the nation in 2017, were 18 to 34 years old. In California, 37 percent of 2017 enrollees were in that age group, according to Covered California, the state’s insurance exchange.

Steven Orozco, who lives in Los Angeles, is among them. He, his wife and 2-year-old daughter have a plan through Covered California. Orozco, who is a real estate agent, said they are all healthy so they don’t use it often, but he has it just in case of broken arms or other unexpected health needs.

Orozco, 32, said that he is concerned about what could happen in Washington and how that might affect his coverage, which currently costs about $450 a month.

Despite potential benefits to young adults in the private marketplace, the most damaging changes under the Senate proposal would be for young adults covered by Medicaid, said Walter Zelman, chairman of the public health department at Cal State-Los Angeles.

In addition to phasing out the expansion of Medicaid, the Senate bill also would result in reduced funding for the program, he said.

“The biggest impact on young people is the dismantling of Medicaid,” Zelman said.

Since the Affordable Care Act took effect, about 3.8 million young adults have gained coverage through the expansion of Medicaid, according to Young Invincibles.

In California alone, Zelman said, hundreds of thousands of young people won’t be able to access Medi-Cal, California’s version of Medicaid, if the expansion is phased out. Zelman, who worked to enroll California State University students into health coverage under Obamacare, said that historically the highest percentages of uninsured people have been young adults, low-income residents, part-time workers and Latinos.

“Those are my students,” he said. “And, more generally, those are young people overall. … Anything that threatens [their] access to health is bad for them,” he said.

It’s unclear whether the proposed Republican overhaul would result in more or fewer young enrollees.

Uninsured Sacramento resident Sydney Muns, 27, works at a nonprofit that doesn’t offer health coverage, and she earned too much money to qualify for Medi-Cal or receive Obamacare subsidies. Muns said she hopes premiums and out-of-pocket costs will decline in the future so she can get coverage.

“It’s just not affordable,” said Muns, who faces $50,000 in college loan debt. “I don’t know anyone my age who has insurance.”

Carly Carpenter, left, and Chyneise Dailey are each on their parents’ health insurance plans, but say they will purchase their own when they have to. (Kellen Browning/California Healthline)

But Chyneise Dailey, 24, said she plans to purchase health care whether or not she is required to do so. Dailey, who works at Sacramento State, remains on her parents’ Blue Cross health insurance plan, but knows she has only a couple of years before she has to buy her own coverage.

“You never know what can happen. You get into a car accident, you’re in the ER — do you want to pay full rate or do you want to pay your copay?” Dailey said. “I’d just rather be safe than sorry.”

Under both the Senate and House plans to overhaul Obamacare, young women who go to Planned Parenthood for reproductive health and other medical services could be hurt because of a provision to ban federal funding of the organization for a year.

That concerns Niki Kangas, 35, who frequently visits Planned Parenthood clinics even though she has job-based coverage from Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.) Kangas, of Sacramento, said she is “pissed off” that the Senate’s proposed bill would impose a one-year ban on federal funding to the organization, which is a frequent target for conservatives.

“I’ve used Planned Parenthood a lot, either in between jobs or sometimes it’s just more convenient than going out to Kaiser, like if I just need birth control,” said Kangas, a project manager at a design agency. “I think for people who don’t have insurance through their work that it’s a resource they depend on.”

Mary Agnes Carey, Julie Appleby and Barbara Feder Ostrov contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

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

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Scenes From Capitol Hill: Doubts, Dissent Over Health Care Bill Rescue July 4 Holiday

WHEN Senate Majority Leader Mitch McConnell broke the news Tuesday afternoon, all the nervous buildup around the Senate health care bill vanished faster than a sticky, summer day in Washington, D.C. after a thunderstorm. Could McConnell really push the bill through the Senate before senators left town for the holiday? How many senators were balking now? Those and other questions disappeared — for now — when McConnell announced the Better Care Reconciliation Act would get no floor vote until after July 4.

GOP senators were just leaving their Tuesday afternoon policy lunch about 2 p.m. ET as word about a delay circulated before McConnell confirmed it. Many wanted nothing to do with the sea of reporters that waited outside the room where the senators meet for lunch. Sen. John Cornyn (R-Texas) slipped quickly into an elevator, taking no questions. Sen. Rob Portman (R-Ohio) — head down, shoulders hunched — practically sprinted past microphones into the Senate chamber.

ONE of the few who stopped to talk was Sen. Marco Rubio (R-Fla.), who expressed hope that a bill would get through the Senate and the House before the August recess. Reporters showered him with attention.

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Once Republican leadership emerged to explain why the vote was being delayed, they defaulted to a familiar script: bashing the Affordable Care Act. “The schedule may have changed a little bit, but one thing that hasn’t is that Obamacare is collapsing,” said Sen. John Thune (R-S.D.), the Republican Conference chairman. McConnell told reporters the delay wasn’t an indictment of the bill, but the outcome of more discussions and senators asking for more time. “It’s complicated,” he said.

MINORITY Leader Chuck Schumer, looking visibly annoyed that reporters were still in a scrum around Thune and not at his mic, said Democrats aren’t counting the delay as a victory. “No matter what tweaks they may add in the next week and a half, no matter how the bill changes around the edges, it is fundamentally flawed at the center,” he said.

LATER in the afternoon, three dozen or so people stood on the grass outside the Capitol, chanting, banging drums, delivering speeches and waving signs that read, “AHCA=Death” and “Survival of the Richest.” The group represented LGBTQ and HIV/AIDS advocacy groups. Though their tone was happy and elevated in the wake of the health care bill vote’s delay, it wasn’t victorious. “We got complacent with the House bill,” one speaker said. Organizers announced phone banks and letter writing campaigns every week in opposition to the Senate proposal.

THEY say picture is worth a thousand words and Senate Democrats tried out that advice in in a media photo op on the Capitol steps early Tuesday afternoon. About two dozen senators held foam posters decorated with large photos of constituents who had reported they would be hurt by Trumpcare. What the cameras didn’t show were the posters’ backsides where the name of the senator who was supposed to be holding that poster was written in marker. Many also had their constituent’s story printed out and taped on the back. As each senator left the second floor of the Capitol building to descend the stairs to waiting cameras, staffers handed out the posters and quickly prepped their bosses, almost like stage parents reminding a child how to perform a dance routine before a recital. As one lawmaker darted through the double doors to join the others, a staffer handed him his poster and said, “Here’s your constituent, senator, isn’t she a beauty?”

Categories: Repeal And Replace Watch, The Health Law


Analysis: Mitch McConnell Plans to Hide Trumpcare’s Pain Until After Midterms

Senate Majority Leader Mitch McConnell is well aware of the political peril of taking health benefits away from millions of voters. He also knows the danger of reneging on the pledge that helped make him the majority leader: to repeal Obamacare.

Caught between those competing realities, McConnell’s bill offers a solution: go ahead and repeal Obamacare, but hide the pain for as long as possible. Some of the messaging on the bill seems nonsensical (see: the contention that $772 billion squeezed out of Medicaid isn’t a cut). But McConnell’s timetable makes perfect sense — if you are looking at the electoral calendar.

Here are a few key dates in McConnell’s “Better Care Reconciliation Act” (BCRA) that seem aimed more at providing cover for lawmakers than coverage for Americans:

2019: First major changes and cuts to the Affordable Care Act exchanges happen after the 2018 midterm cycle, allowing congressional Republicans to campaign on a “fixed” health system, even though Obamacare is still largely in place next year.

2019: States share $2 billion in grants to apply for waivers under a much looser process through this fiscal year. These waivers could allow insurers to sell skimpy plans that have low price tags but don’t take adequate care of people with preexisting conditions. None of those waivers has to go into effect, however, until after 26 Republican governors face re-election in 2018.

2020: Stabilization cash that makes the markets more predictable and fair for insurers flows through the congressional midterm cycle and the 2020 presidential cycle. Then it disappears. Medicaid expansion funds hold steady through this crucial political window, too.

2024: States enjoy their last few sips of Medicaid expansion cash at the end of 2023 — just as, perhaps, a second Republican presidential term is ending.

2025: The bill changes the formula for the entire Medicaid budget (not just the Obamacare expansion), dramatically reducing federal funding over time. That starts eight years and two presidential election cycles from now.

McConnell insists everything about the bill has been aboveboard and transparent.

“Nobody’s hiding the ball here. You’re free to ask anybody anything,” McConnell said on June 13.

But he and his working group did literally hide the bill from Democrats and most Republicans, crafting it behind closed doors until there was just a week left before his goal to secure a vote on it. (That timing was thrown off Tuesday with the announcement the vote was delayed, but the dealmaking is just beginning.)

Meanwhile, at least two policy details in the bill may obscure the effects for several years and make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.

One is a stipulation that compels the federal government, for two years, to pay the cost-sharing reduction payments to insurance companies that President Donald Trump has threatened to end. The payments are part of the Affordable Care Act, and they flow to insurers on behalf of low-income marketplace customers to cover their out-of-pocket health expenses. Republicans had sued to stop the payments, adding considerable instability to ACA marketplaces next year. McConnell ends that uncertainty for two years.

On top of that cash infusion, the BCRA proposes a “Short-Term Stabilization Fund” that would also aim to help lower premium costs and could attract a few more insurers into counties that are sparsely covered now. It would dish out $50 billion to insurers — $15 billion per year in 2018 and 2019 and $10 billion per year in 2020 and 2021.

The money would make up for the billions that the Republican-led Congress has refused to appropriate for insurance companies under the ACA’s risk corridors program. Risk corridors aimed to offset losses for insurers whose costs were more than 103 percent of expected targets. Congress has so far paid only 12.6 cents on the dollar of those obligations and faces lawsuits from insurers that were stiffed.

In short, the two pots of money would go a long way toward addressing the instability in Obamacare created by the Republican-led Congress, but only through the next presidential cycle in 2020.

Beyond timing, the legislation’s features allow senators to make truthful arguments that disguise negative effects.

Perhaps the key claim is that the Senate bill would increase access to insurance. It might, in that insurance companies in states that waive standards would be free to offer much cheaper plans. But those plans would be cheaper because they wouldn’t cover essential health benefits or adequately cover preexisting conditions. Lower-income Americans might be able to buy a plan — possibly a $6,000 deductible for someone who makes less than $12,000 a year.

A spokesman for McConnell did not answer a request for comment. But Democrats are keenly aware of the electoral machinations in the bill.

“Everything about this legislation, from the process to the effective dates of many of the provisions, is driven by political expediency,” said Brian Fallon, a Democratic consultant and former lead spokesman for Hillary Clinton’s campaign. “Mitch McConnell only cares about getting the ‘win,’ not about the substance of the bill.”

Senate Democratic aides who spoke on background were not sure that the steps the bill takes to shore up markets for the next two elections would work when insurance companies can see what lies ahead. But they agreed the timing and short-term fixes might help McConnell twist the arms of reluctant Republican senators.

“I think it will be enormously helpful to McConnell in a room with a moderate Republican who wants to be told, ‘Hey, a lot of this stuff that’s going to happen in this bill that you’re hearing about, that’s worrisome is past your re-elect, it’s past 2018, it’s past 2020,’” one senior aide said. “‘Just vote for it, it’ll be fine, we’ll figure the rest out later.’”

Democrats said McConnell’s hide-the-ball strategy will not work with voters, and they want Republican senators to know that before they vote.

“The polling already shows that, based on the fact that they control every aspect of government, Trump and the Republicans own everything that happens from now on in the health care system,” Fallon said.

Sen. Patty Murray (D-Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee who has the task of leading the arguments against the GOP bill, thinks senators will imperil their political futures if they buy McConnell’s arguments.

“Sen. McConnell is doing everything he can to persuade Senate Republicans that Trumpcare won’t be devastating for the people they serve, but the facts are that Trumpcare is going to cause families to pay more, gut Medicaid, and take coverage away from millions of people,” Murray said. “Any Senate Republican who votes for Trumpcare and believes patients and families won’t hold them accountable is being sold a bill of goods.”

Still, McConnell knows how to work a legislative calendar. Expect a July full of closed-door dealmaking with reluctant senators, leading up to maximum leverage before the August recess.

Categories: 2018 Elections, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

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CBO Deals Blow To Senate Health Bill With Estimate Of 22M More Uninsured

Senate Republicans’ legislation to overhaul the Affordable Care Act would leave an additional 22 million people without health care coverage over the next decade and cut the federal deficit by $321 billion, according to a Congressional Budget Office analysis released late Monday.

By 2026, an estimated 49 million people would be uninsured, compared with about 28 million who would lack coverage under current law.

The Senate’s bill — the Better Health Care Act, which GOP leaders hope to put to a vote later this week, comes nearly two months after the House passed its plan to overhaul the Affordable Care Act. That measure would cut about $834 billion from Medicaid and leave an additional 23 million people without coverage in 2026, according to CBO. It would reduce the federal deficit by $119 billion.

Earlier in the day, before the nonpartisan budget office’s score was released, Senate Majority Leader Mitch McConnell (R-Ky.) described the GOP plan as preserving “access to care for patients with preexisting conditions.” He also said it would “strengthen Medicaid,” give “Americans more power to control and reduce their medical costs and out-of-pocket expenses” and give “states significant new tools to drive down premiums.”

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Yet it was unclear if Republicans, who have a razor-thin Senate majority, could garner the 50 votes necessary for the measure to pass. The budget office’s findings added to this uncertainly.

Sen. Susan Collins (R-Maine), a moderate who has been on the fence about the bill, tweeted late this afternoon that she could not support the current bill based on the CBO score. “I want to work with my GOP and Democratic colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won’t do it. I will vote no,” on bringing the bill to the Senate floor, she announced.

Senate Democrats were also swift to react.

“The CBO report should be the end of the road for Trumpcare,” tweeted Senate Minority Leader Chuck Schumer (D-N.Y.). And, in a statement, Sen. Ron Wyden (R-Ore.) said it was “abundantly clear [Republicans] are going in the wrong direction.”

Sen. Bernie Sanders (I-Vt.) pointed to the analysis and said the GOP plan was “a cynical and immoral proposal.”

Detailing The Medicaid Numbers

Under the GOP measure, federal spending on Medicaid would drop by 26 percent over current spending projections, or $772 billion, over the next decade, according to the analysis.

The drop in spending would occur mainly because the Senate plan phases out federal funds for states to expand Medicaid and it puts annual caps on federal Medicaid dollars to states. Currently, federal Medicaid matching payments to states are open-ended.

By 2026, the budget office predicted, 15 million fewer people would be enrolled in Medicaid than projected under the ACA. Currently, more than 74 million low-income and disabled people are Medicaid beneficiaries.

How Medicaid beneficiaries are affected by these caps depends on how states respond to them, the CBO notes.

“With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes,” according to the analysis.

The Medicaid funding provisions are a key reason several influential health groups say they cannot support the bill.

“Access to care for some of the most vulnerable members of our society — including those who require treatment for opioid-use disorder — would be endangered by the Senate proposal’s arbitrary, unsustainable, and shortsighted formula for funding Medicaid,” David Barbe, president of the American Medical Association, said in a statement posted on the organization’s website.

And even before the CBO report was issued, the National Association of Medicaid Directors were on record with their concerns. “The Senate bill does formalize several critical administrative and regulatory improvements, such as giving Medicaid Directors a seat at the table in the development of regulations that impact how the program is run, and the pathway to permanency for certain waiver programs,” the group said. “However, no amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill.”

Other organizations, such as Families USA and the American Public Health Association, said the CBO’s findings show the Senate proposal did “devastating harm” and would “seriously jeopardize the health of America.”

Cost And Coverage

The budget scorekeepers also concluded that, for the individual insurance market, premium costs would go down under the Senate plan, but so would the amount of coverage provided.

Because these plans “would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law,” CBO said.

In 2017, an estimated 12 million people bought health coverage through the ACA’s marketplaces. Most bought silver-level plans, which covered 70 percent of health care costs.

Under the Senate’s plan, the average premiums for an individual in 2020 would be about 30 percent lower. But these policies would cover about 58 percent of costs on average.

According to the CBO, “a combination of factors would lead to that decrease – most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.”

The CBO also analyzed the Senate bill provision that would allow states to use waivers to modify the health law’s essential health benefits that include items like prescription drugs, maternity coverage, mental health and substance abuse. In states where such waivers were granted, consumers could experience substantial cost increases for supplemental premiums or out-of-pocket spending, or choose to forgo services. Nearly half the population, the CBO estimates, would reside in states that seek these waivers.

In addition, the ACA’s ban on lifetime and annual limits on covered benefits would no longer apply to health benefits not defined as essential in a state.

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law


Senate And House Take Different Plans To Scrap Individual Mandate

Update: This story was originally published March 21, 2017. It was updated on June 26, 2017 with details of the Senate health care bill.

The Affordable Care Act’s tax penalty for people who opt out of health insurance is one of the most loathed parts of the law, so it is no surprise that Republicans are keen to abolish it. But the penalty, called the individual mandate, plays a vital function: nudging healthy people into the insurance markets where their premiums help pay for the cost of care for the sick. That has required Republican lawmakers to come up with alternatives, which were included in the House bill that passed in May and updates to the Senate draft bill released Monday.

The GOP approach is called a “continuous coverage”  or “creditable coverage” penalty. It would apply to people who buy insurance if they have gone 63 consecutive days without a policy during the past 12 months. In the Senate bill, they would have to wait six months before they could buy insurance. The bill that passed the House took a different tack: it did not include a waiting period but required insurers to increase  premiums by 30 percent, and that surcharge would last for a year. While the ACA assesses a fine for each year people don’t buy insurance, the GOP plan would punish those who decide to purchase it after not being in the market.

Much is at stake. If the GOP’s approach fails to prod enough healthy people into buying insurance, rates for everyone else in the insurance pool will rise, destabilizing promises by President Donald Trump and GOP leaders to make their Obamacare replacement more affordable. The nonpartisan Congressional Budget Office projects that millions fewer people will buy insurance if the individual mandate is repealed and replaced with a continuous coverage surcharge as the House proposed.

The budget office expects that the Senate’s six-month waiting period would “slightly increase the number of people with insurance. ” Nonetheless, CBO projects that at least 22 million people will lose insurance under either the House or Senate bill because both proposals scale back government assistance to people buying insurance and limit Medicaid coverage.

Why do people allow their insurance to lapse?

Some simply can’t afford the premiums, like Sheila Swartz. She and her husband, Don, who has a heart condition, dropped their policy in December after learning monthly premiums were going to increase by about $140 to $530. “You can’t get blood out of a turnip,” said Swartz, who lives outside Nashville, Tenn., and works as a house cleaner. “If you can’t afford that premium, you can’t afford that premium.”

Others stop paying premiums when they lose a job or are hit with unexpected costs in other areas, such as major home or car repairs. “If you have to pay rent or health insurance, you are probably not going to choose health insurance,” said Bruce Jugan, a health insurance broker in Montebello, Calif.

Some people try to game the system, taking the calculated risk of going without insurance until they get sick or know they need expensive medical care, such as for maternity or an elective surgery.

Both the Affordable Care Act and the GOP proposal include a deterrent by limiting people from enrolling anytime they want. People must wait for annual enrollment periods, usually in the final weeks of the year, meaning that some people might have to wait months before getting coverage. (People still can get insurance during special enrollment periods if they lose a job, get divorced or have another specified major life change.)

How tough is the GOP penalty compared with the individual mandate?

Under the ACA, the average individual mandate penalty in 2015 was $442, according to the Internal Revenue Service.  The House penalty would vary based on cost of premiums but generally would be more expensive than paying the mandate’s penalty. A 40-year-old with annual premiums of $4,328 would pay an extra $1,298 because of the House surcharge.

“It’s got teeth,” said Cheryl Damberg, a Rand Corp. economist. “In some ways, it’s a more punishing penalty, and it’s going to hit people who are least capable of financially affording it.”

Seth Chandler, a law professor at the University of Houston Law Center who has been critical of the Affordable Care Act’s insurance markets, said he is skeptical the House surcharge is high enough to make people enroll. “I am concerned that the Republicans are succumbing to the same softness of heart as the Democrats succumbed too when they set the individual mandate [fine],” he said. “If you start to see insurance companies object or drop out of the markets, that’s a sign this thing is miscalculated.”

Two conservative economists at the American Enterprise Institute, Joseph Antos and James Capretta, argue the penalty is “far too small” to be effective. “Healthy consumers are likely to take their chances,” they wrote. “With the repeal of the individual mandate, and the retention of the ACA’s insurance rules, the overall effect would be significant market turbulence, starting immediately in 2017.”

The CBO predicted that there would be a brief increase in the number of people holding insurance in 2018, as roughly 1 million people buy coverage to avoid the surcharge. In most years afterward, however, about 2 million fewer people would buy policies, either because of the surcharge or because of the requirement they provide documentation proving they had been insured. The CBO said healthy people in particular would be more likely to avoid buying policies.

The House plan has some parallels to Medicare’s late enrollment penalty, which is applied to premiums for people who did not sign up upon turning 65. But Christopher Koller, a former Rhode Island health insurance commissioner, doubts the GOP penalty would be as effective. “Medicare is an entitlement with the force of government behind it,” said Koller, now president of the Milbank Memorial Fund, a foundation in New York that focuses on healthy populations. “You get lots of notices about what your obligations are as you approach that age.”

What about people who can’t afford premiums?

The House surcharge contains no hardship exemptions, unlike the individual mandate, which allowed people to escape paying a penalty if premiums would have eaten up too much of their income (8.16 percent in 2017).

In 2015, 5.6 million people paid the individual mandate penalty, but another 11 million claimed a hardship exemption, according to the IRS.

Lower-income people are going to have even more trouble buying — and keeping — coverage under either of the GOP plans, experts said. The ACA’s premium subsidies are based on income, and millions of people on the poorer end of the spectrum do not have to pay anything for premiums if they choose the cheapest plan. The House plan would offer a flat tax credit that adjusts only for age. The penalties would make some even more reluctant to buy insurance — especially if they are relatively healthy. The Senate plan retained income-based subsidies, but they are smaller than those under the ACA and are tied to plans with higher co-payments and deductibles.

“I think we would just end up with a lot more uninsured people, and they would clearly be the type of people who are less able to navigate and less able to afford insurance,” said Geoffrey Joyce, director of health policy for the University of Southern California Schaeffer Center for Health Policy & Economics.

Republican lawmakers say their plan rightly places the responsibility on individuals. It is a view shared by some health insurance brokers like Helena Ruffin, a broker in Playa Vista, Calif. She said that a continuous coverage requirement like the one proposed by the House would “limit those people who are not playing by the rules.”

“I am favor of the penalties,” she said. “Whether or not people are going to pay attention is another story.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Categories: Health Industry, Insurance, Repeal And Replace Watch, The Health Law, Uninsured

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‘Coverage Gap’ For Poor May End, But Many Will Still Have Trouble Affording Plans

Having long decried the failings of the Affordable Care Act, Senate Republicans are purporting to fix one of its loopholes with their newly unveiled health plan. The so-called coverage gap left more than 2.5 million people living below the poverty line of $11,880 for an individual ineligible for Medicaid or financial assistance to buy insurance — even as higher earners got subsidy checks to buy theirs.

But experts say the fix, which looks fine on paper, is a mirage.

In fairness, the loophole was essentially created by Republicans and others when a Supreme Court decision meant that states were no longer required to expand Medicaid.

The Affordable Care Act offered help paying premiums to people earning between 100 to 400 percent of the poverty line, under the assumption that those under the poverty line would be covered by Medicaid.

So when 19 states decided not to expand Medicaid, millions of Americans were left in the coverage gap because they didn’t qualify for Medicaid and couldn’t afford private insurance.

As a remedy, the Senate bill would offer federal tax credits to help pay for insurance premiums for anyone earning between 0 and 350 percent of the poverty level (up to about $42,000 for an individual) starting in 2020. (Note that the upper ceiling is somewhat lower than that stipulated by the ACA.)

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But health law experts caution that this coverage gap fix for these very low earners would likely be largely undercut by two other changes in the bill.

First, the Senate’s plan would shift the calculation for subsidies. The ACA required that premium subsidies be linked to the price of a category of health insurance that was a kind of minimum standard for Obamacare and covered 70 percent of health costs on average — called a silver plan under Obamacare nomenclature. The Senate would instead tie the subsidy to the more bare-bones bronze plans, which cover on average only 60 percent of health costs.

Although low earners might qualify for subsidies to buy insurance, making coverage an option, they would likely have a hard time using the plans because bronze plans generally have higher deductibles and copayments.

In addition, the legislation in 2019 would discontinue a second ACA subsidy — the cost-sharing reductions offered to anyone earning less than 250 percent of the poverty level. These payments help cover out-of-pocket expenses. So even if marketplace customers got subsidies to help cover their premiums, their out-of-pocket costs could be too expensive and would likely keep them from using or buying coverage.

Gary Claxton, director of the Health Care Marketplace Project at the Kaiser Family Foundation, said expanding subsidies doesn’t mean the poor will find affordable coverage. “It will give people plans that are very difficult to use at their income levels,” he said, noting the coverage will likely have deductibles of over $6,000 a year. (Kaiser Health News is an editorially independent program of the foundation.)

Another factor that experts noted is the Senate plan would phase out the Medicaid expansion.

Theoretically, people affected by the end of that program could get federal subsidies to buy coverage under the Senate plan.

But experts say the benefits would likely not be as good. That’s because Medicaid typically provides services such as transportation to medical appointments and home health care, said Chiquita Brooks-LaSure, an insurance expert with the consulting firm Manatt Health.

Andy Slavitt, who oversaw the health law for the final years of the Obama administration, said that despite the fix, options for very-low-income people would be worse under the measure announced Thursday, eliminating Medicaid and moving people to bare-bones plans, with skimpier benefits.

“That’s the aim,” he said.

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

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Deep Cuts To Medicaid Put Rural Hospitals In The Crosshairs

For the hundreds of rural U.S. hospitals struggling to stay in business, health policy decisions made in Washington, D.C., this summer could make survival a lot tougher.

Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding.

“A lot of hospitals like [ours] could get hurt,” says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.

The GOP’s repeal of the Affordable Care Act calls for deep cuts to Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities. The House version of the repeal law cuts Medicaid by $834 billion over 10 years, and the Senate revision of that bill cuts the program even more on a different timetable. The Congressional Budget Office has not yet scored the Senate version of the bill, but it said the House version would result in 23 million more people being uninsured in the next 10 years.

Loss of coverage is a problem for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for most health indicators, including premature deaths, quality of life and adult smoking rates. Closing the county’s hospital could make those much worse.

And a rural hospital closure goes beyond people losing health care. Jobs, property values and even schools can suffer. Pemiscot County already has the state’s highest unemployment rate. Losing the hospital would mean losing the county’s largest employer.

“It would be devastating economically,” Noble said. “Our annual payrolls are around $20 million a year.”

All of that weighs on Noble’s mind when he ponders the hospital’s future. Pemiscot’s story is a lesson in how decisions made by state and federal lawmakers have put these small hospitals on the edge of collapse.

Back in 2005, things were very different. The hospital was doing well, and Noble commissioned a $16 million plan to completely overhaul the facility, which was built in 1951.

“We were going to pay for the first phase of that in cash. We didn’t even need to borrow any money for it,” Noble said, while thumbing through the old blueprints in his office at the hospital.

But those renovations never happened. In 2005, the Missouri legislature passed sweeping cuts to Medicaid. More than 100,000 Missourians lost their health coverage, and this had an immediate impact on Pemiscot Memorial’s bottom line. About 40 percent of their patients were enrolled in Medicaid at the time, and nearly half of them lost their insurance in the cuts.

Pemiscot Memorial had plans for expansion and improvements that the county hospital was ready to make — and pay for — in 2005, before the state legislature slashed Medicaid rolls. (Bram Sable-Smith/Side Effects Public Media)

Those now-uninsured patients still needed care, though, and as a public hospital, Pemiscot Memorial had to take them in.

“So we’re still providing care, but we’re no longer being compensated,” Noble said.

And as the cost of treating the uninsured went up, the hospital’s already slim margins shrunk, and it went into survival mode.

The Affordable Care Act was supposed to help with the problem of uncompensated care. It offered rural hospitals a potential lifeline by giving states the option to expand Medicaid to a larger segment of their populations. In Missouri, that would have covered about 300,000 people.

“It was the fundamental building block [of the ACA] that was supposed to cover low-income Americans,” said Sidney Watson, a St. Louis University health law professor.

In Missouri, Kerry Noble and Pemiscot Memorial became the poster children for Medicaid expansion. In 2013, Noble went to the state Capitol to make the case for expansion on behalf of the hospital.

“Our facility will no longer be in existence if this expansion does not occur,” Noble told a crowd at a press conference.

“Medicaid cuts are always hard to rural hospitals,” Watson said. “People have less employer-sponsored coverage in rural areas and people are relying more on Medicaid and on Medicare.”

But the Missouri legislature voted against expansion.

For now, the doors of Pemiscot Memorial are still open. The hospital has cut some costly programs — like obstetrics — outsourced its ambulance service and has skipped upgrades.

“People might look at us and say, ‘See, you didn’t need Medicaid expansion. You’re still there,’” Noble said. “But how long are we going to be here if we don’t get some relief?”

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

The Association of Health Care Journalists and The Commonwealth Fund are supporting a yearlong series of stories on rural health care by Side Effects Public Media and KBIA.

Categories: Cost and Quality, Medicaid, Repeal And Replace Watch, States, The Health Law, Uninsured

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Poll: Most Americans Unaware GOP Plans Would Make Deep Funding Cuts To Medicaid

Congress is moving fast toward repealing the Affordable Care Act, with an eye on revamping Medicaid, the health insurance program for low-income people. But most Americans say the program — which Republicans call a “broken system” — is working well on the national level and within their states.

That’s according to a monthly tracking poll released Friday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent project of the foundation.) That support, the poll suggests, holds true across the political spectrum, though support was strongest among Democrats.

While almost three-fourths of Americans have a favorable view of Medicaid, only about four in 10 — 38 percent — are aware that the House-passed American Health Care Act would make major funding reductions and structural changes to the program. About a fourth of respondents said the bill made “minor reductions” to Medicaid, and 13 percent didn’t realize there were any proposed cuts. (The poll was conducted before the Senate released its legislation on June 22.)

The nonpartisan Congressional Budget Office estimates the House bill would cut the program by $834 billion over a decade. The Senate measure has not yet been scored — that analysis is expected next week — but its cuts to Medicaid are steeper. Congressional Republicans argue their plans gives states more flexibility, so they can run efficient programs that make up the difference. Critics worry the size of the funding cuts would mean states ultimately scale back benefits and limit who’s eligible for the program. Traditionally, states and the federal government have jointly funded the program, and its budget isn’t capped.

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The proposed Medicaid changes were not initially a major point of discussion surrounding consideration of the House bill, the KFF poll notes, which may partly explain why many respondents were unaware of its effect.

Since then, the program has become a sticking point in the Senate. Many moderate Republicans — particularly those whose states expanded the program under the ACA — have expressed concern about scaling back eligibility or funding. The cuts have also spurred criticism from industry groups — particularly hospitals and medical associations — along with organizations treating mental illness and drug addiction, which often rely on Medicaid dollars.

Respondents did express support for some program changes. Seventy percent thought states should be allowed to have work requirements for people on Medicaid — meaning able-bodied beneficiaries must have or be seeking a job to qualify for the program and 64 percent supported letting states drug test people before letting them get Medicaid. This support held up across party lines.

Other proposed changes were less popular. For example:

  • About 36 percent of respondents favored letting states limit how long people can qualify for Medicaid, the same as supported cutting federal funds for the program’s expansion.
  • Thirty-five percent back limiting the amount of federal funding states can receive.
  • Thirty percent support stopping Medicaid payments to Planned Parenthood for a year — another change included in the Senate bill and seen by many as a way to win conservative backing.
  • Twenty-one percent favored limits on Medicaid coverage for long-term care for seniors and people with disabilities.

Republicans were more likely to support all of those policies.

When it comes to possible changes to the health insurance system, respondents generally favored more federal regulations on insurance plans. Across party lines, a majority said the government should ban insurance companies from charging more to cover people with preexisting health conditions. They also said the all plans should be required to meet a certain standard of coverage, known as “essential health benefits.” The House bill would let states apply through waivers to let insurance carriers offer skimpier plans.

The poll also marked the first time a majority of respondents — 51 percent — indicated they viewed the ACA favorably. KFF has tracked the law’s popularity since it passed in 2010.

At the same time, public support for House Republicans’ health bill declined. About 55 percent of respondents viewed the bill in a negative light — the same as a month before — but disapproval had grown among Republicans. Previously, 67 percent of Republican respondents supported the measure. This time, only 56 percent did. Among respondents who supported President Donald Trump, 55 percent approved of the Republican bill, compared with 69 percent in May.

Regardless of party, a minority thought repealing the law should be the White House’s top concern. But the political implications are still unclear — respondents were split in answering whether they would support lawmakers who voted for repeal. About half of Democrats would be more likely to vote against such a lawmaker, while just over 60 percent of Republicans would be more likely to support one. About 35 percent of independents would view a vote for repeal negatively, and 30 percent would view one favorably.

This month’s poll was conducted by telephone, between June 14 and 19, using a nationally representative random sample of about 1,200 adults. The margin of error is +/- 3 percentage points for the full sample.

Categories: Cost and Quality, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

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Promises Made To Protect Preexisting Conditions Prove Hollow

Senate Republicans praised the Affordable Care Act replacement bill they presented Thursday as preserving coverage for people with cancer, mental illness and other chronic illness.

But the legislation may do no such thing, according to health law experts who have read it closely.

Built into the bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.

Depending on what states do, plans sold to individuals might exclude coverage for prescription drugs, mental health, addiction and other expensive benefits, lawyers said. Maternity coverage might also be dropped.

Somebody with cancer might be able to buy insurance but find it doesn’t cover expensive chemotherapy. A plan might pay for opioids to control pain but not recovery if a patient became addicted. People planning families might find it hard to get childbirth coverage.

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“The protection your insurance provides could depend a lot on where you live,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. In some states, “over time, [patients with chronic illness] might find it increasingly difficult to find insurance companies that will offer plans that cover their needs.”

The Senate provisions aren’t expected to affect job-based health plans or Medicare for seniors. It would mainly affect the kind of insurance sold to individuals through the Affordable Care Act’s online exchanges, which cover about 10 million people.

Obamacare overhauls in both the House and Senate would also limit spending on Medicaid for low-income people, which analysts say would cause coverage losses for millions.

The Senate legislation, expected to be voted on next week, follows a widely criticized House bill that would also overhaul the Affordable Care Act, in its case giving states the option of denying coverage or raising premiums for those with preexisting illness.

On Thursday Republican Senators touted their bill as avoiding those features.

“I feel comfortable that no one is going to be denied coverage because they’ve been sick before,” said Sen. Lindsey Graham (R-S.C.) The bill “doesn’t change [protections for] preexisting illnesses, which is good,” he said.

Not explicitly. But it still gives insurers a potential way to shrink coverage for the chronically ill, albeit less obviously, said health law scholars.

“There’s nothing in the Senate bill that specifically would allow withdrawal of coverage for a person with a preexisting condition,” said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform. “What it does do is allow states to get waivers” allowing exceptions to rules requiring comprehensive coverage, he said.

The Affordable Care Act required carriers to offer “essential health benefits” covering a wide range of services including hospitalization, maternity, prescription drugs and mental health.

Both the Republican House bill and the Senate bill would let states change that rule. Under those measures, states could set their own standards that might not be as generous, allowing insurers to exclude benefits for those with preexisting illness.

“The Senate bill guarantees people with preexisting conditions access to insurance at the same rate as healthy people, but there is not a guarantee that the benefits they need will be covered by insurance,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Obamacare, too, allows states to make exceptions for essential health benefits — but with strict limits. Coverage must be at least as comprehensive as the federal standard, for one thing. The Senate bill contains no such safeguard.

“As long as they can show that it’s budget neutral, states would have a lot of latitude” to cut essential benefits, said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner.

Insurance plans for individuals might again start to look as they did in the days before Obamacare, when they typically excluded coverage for maternity, mental health and substance abuse, the health policy expert said.

For their part, insurers may heavily pressure states to make such changes, analysts said.

Unlike the Affordable Care Act and the House bill, the Senate bill contains no incentives or inducements for healthy people to maintain medical coverage. That could result in a disproportionately sick group of people buying individual insurance, driving up carriers’ costs and prompting them to seek ways to trim coverage and cut claims.

“If the only people motivated to buy insurance are going to be the ones who really need it, insurers are really going to have a strong incentive to use their benefit design to deter enrollment for the sickest people,” said Corlette.

Categories: Cost and Quality, Insurance, Mental Health, Repeal And Replace Watch, States, The Health Law

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Winners And Losers: 40 Is Old In Senate GOP Health Plan’s Subsidy Structure

People getting subsidies to help buy health insurance would see at least three sharp changes — tied to both age and income — that could dramatically affect how much they pay for coverage if the Senate Republican health plan becomes law.

The Senate bill released Thursday would reduce the income thresholds that determine eligibility, change the amount people who receive help pay toward their insurance premiums and peg subsidies to less generous coverage.

About 85 percent of the nearly 10 million consumers who enrolled in coverage last year through federal and state marketplaces received tax credit subsidies and other types of financial assistance. Under the Senate plan, some could pay less in premium costs, but many, particularly older Americans, could see their share of payments go up. And let’s be clear — you’re old at about 40.

Incomes Eligible For Help Fall To 350 Percent Of Poverty

The Affordable Care Act provides tax credit subsidies on a sliding scale for people earning up to 400 percent of the federal poverty level — an amount that equals about $47,520 this year for individuals. Starting in 2020, the Senate bill would drop that to 350 percent, which is now an annual income of about $41,580. As a result, fewer people would qualify. To be sure, some enrollees who exceed that new income limit might lose only a small subsidy because of the way the current law is structured, but older enrollees could lose substantial amounts. The Center on Budget and Policy Priorities estimated Thursday that a 60-year-old earning just above the cutoff would lose at least $3,000 annually in subsidies.

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Age Matters

Tax credits are just one part of the picture. Under the ACA, subsidy-eligible enrollees must pay a percentage of their annual household income toward premiums, ranging from about 2 percent to just over 9.5 percent for those with higher incomes. Those amounts go up over time. The Senate bill would adjust those percentages based on age, keeping the lower limit at around 2 percent, but exceeding 16.2 percent at the highest income and age group. So if you are 39 or younger, you generally would pay smaller percentages of your income when compared with what you pay under the ACA, ranging from about 2 percent to 8.9 percent.

But once you hit 40, things change. Let’s say you earn $41,580 — 350 percent of poverty — you would pay more than 12.5 percent of your income, or $5,197, under the Senate plan. That compares with $4,029, or 9.69 percent currently under the ACA. At that same income level, percentages rise to 15.8 for those ages 50 to 59 and up to 16.2 percent of income for those 60 and up.

Aiming For Bronze: Subsidies Tied To Less Generous Coverage

The Senate would link the subsidies to plans with less generous coverage than the ACA. Subsidies under current law are pegged to a benchmark “silver” plan, which covers an average of about 70 percent of medical expenses. The Senate would peg the subsidy to the median price of a policy that covers about 58 percent of health costs, roughly equivalent to today’s “bronze” plans. Consumers pay the rest of the cost, usually through deductibles and copayments. This year, average deductibles for bronze plans were more than $6,000, while silver plans averaged $3,500, according to consumer website HealthPocket. People could still use subsidies to buy more generous plans, but the premiums would be higher.

Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, said the changes might prompt more people to buy insurance, noting that subsidies will be available to those who are under the federal poverty level, which they aren’t under current law. Younger people also might benefit by paying less toward coverage, helping boost their enrollment.

To make that happen, however, he said, the formula had to be adjusted so older people at the higher-income end of subsidy eligibility pay more.

“The current ACA discourages younger people from getting in,” said Condeluci, who expects “the older-age lobby will continue to criticize this type of proposal.”

While getting people under the poverty level covered by insurance would be a good thing, it should be done by expanding Medicaid, said Sabrina Corlette, who studies the individual insurance market as research professor at Georgetown University’s Health Policy Institute.

“It’s much more expensive for the federal government to subsidize private insurance than provide a Medicaid benefit,” said Corlette, who also doubts that many people earning less than $12,000 a year have enough saved to cover the cost of a deductible in the types of plans the Senate proposal would subsidize.

In total, the changes proposed in the Senate bill mean, Corlette said, “the subsidy buys you less and the older you are, the more you will be asked to pay.”

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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Proyecto de salud del Senado cambiaría Medicaid y limitaría apoyo para las primas

Los republicanos en el Senado de los Estados Unidos revelaron el jueves 22 de junio un proyecto de ley que transformaría dramáticamente el programa Medicaid, haría cambios significativos a los créditos tributarios de la ley federal de salud que ayudan a las personas de bajos ingresos a comprar cobertura, y permitiría a los estados cambiar algunas de las garantías de la ley.

El proyecto de ley también deroga los impuestos que financiaron los beneficios de la Ley del Cuidado de Salud Asequible (ACA), lo que resultará en cientos de miles de millones de dólares en recortes de impuestos para los más ricos y para la industria de la salud.

La mayoría de los senadores obtuvieron su primer vistazo a la ley cuando fue publicada el jueves por la mañana, ya que fue elaborada en secreto durante las últimas semanas. El líder de la mayoría del Senado, Mitch McConnell (republicano de Kentucky), está buscando que el proyecto de ley se vote antes que el Congreso empiece la próxima semana el receso del 4 de julio.

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Los senadores habían prometido que su propuesta de reemplazo del ACA sería muy diferente de la versión que aprobó la Cámara Baja en mayo. Sin embargo, el proyecto de ley siguió la dirección de la Cámara en muchos aspectos.

A la velocidad de la luz y con poco más de una semana para una revisión más amplia, el proyecto de ley de los republicanos podría influir en la atención médica y el seguro de salud de cada estadounidense. Al invertir el curso de algunas de las disposiciones más populares de la Ley del Cuidado de Salud Asequible (ACA), amenaza con dejar a decenas de millones de estadounidenses de bajos ingresos sin seguro, y, una vez más, a aquellos con condiciones médicas crónicas o costosas en una posición financiera vulnerable.

Al igual que la medida de la Cámara de Representantes, el proyecto de ley del Senado, que se denomina un “borrador de discusión”, no derogaría completamente ACA, pero anularía muchas de las disposiciones clave de la ley. Ambos proyectos de ley también limitarían -por primera vez en la historia- el financiamiento federal para el programa Medicaid, que cubre a más de 70 millones de estadounidenses de bajos ingresos. Desde su creación en 1965, el gobierno federal ha igualado el gasto estatal para Medicaid. El nuevo proyecto de ley transferiría gran parte de esa carga a los estados.

El proyecto de ley también reconfigura cómo los estadounidenses con ingresos ligeramente altos, que no califican para el Medicaid, obtendrían créditos fiscales para ayudar a pagar las primas de sus seguros, y elimina las sanciones para aquellos que no logran obtener cobertura y para los empleadores que no proporcionan beneficios de salud. También la ley facilita que los estados puedan renunciar a las protecciones de los consumidores establecidas por ACA, que requieren que las compañías de seguros cobren las mismas primas a las personas enfermas y a las saludables, y a proporcionar un conjunto específico de beneficios.

“Acordamos en la necesidad de liberar a los estadounidenses de los mandatos del Obamacare, y las políticas contenidas en el borrador de discusión anularán el mandato individual para que los estadounidenses ya no se vean obligados a comprar seguros que no necesitan o no pueden pagar; también derogará el mandato del empleador para que los estadounidenses ya no vean sus salarios recortados por esta razón”, dijo McConnell en la sala del Senado después de dar a conocer el proyecto de ley. Agregó que el proyecto ayudaría a “estabilizar los mercados de seguros que también están colapsando bajo el Obamacare”.

No está claro si el proyecto de ley pasará la barrera del pleno del Senado. El Senado (como la Cámara) está operando bajo un conjunto especial de reglas presupuestarias que le permiten aprobar esta medida con sólo una mayoría simple, impidiendo que los demócratas pueden alargar el debate cabildeando. Pero el proceso de “reconciliación presupuestaria” se debe realizar bajo reglas estrictas, incluyendo el requisito de que todas las disposiciones del proyecto de ley impacten principalmente en el presupuesto federal, ya sea añadiendo o restando del gasto federal.

Por ejemplo, la legislación que se publica incluye una prohibición de un año de financiación del Medicaid a Planned Parenthood. Esa es una demanda clave de los grupos contra el aborto y algunos conservadores del Congreso, porque Planned Parenthood realiza abortos con fondos no federales. Pero aún no está claro si el parlamentario del Senado permitirá que esa disposición sea incluida en el proyecto de ley.

También todavía está entre signos de preguntas una disposición del proyecto de ley del Senado que permitiría a los estados renunciar a las regulaciones de seguros impuestas por el Obamacare. Muchos expertos en presupuesto dicen que se opone a las reglas del presupuesto del Senado porque el impacto de la financiación federal es “meramente incidental” para la política.

Redactar el proyecto de ley del Senado ha sido una danza delicada para McConnell. Con sólo 52 republicanos, y los demócratas unidos oponiéndose a cambiar la ley de salud, McConnell puede permitirse el lujo de perder sólo dos votos y seguir aprobando la ley con un voto de desempate del vicepresidente Mike Pence. McConnell ha liderado un pequeño grupo de trabajo de senadores -todos hombres- pero incluso algunos de ellos se han quejado de que no pudieron participar plenamente de la configuración del proyecto, que parece haber sido en gran medida escrito por el propio personal de McConnell.

Hasta ahora, McConnell había estado recibiendo quejas de las alas más moderadas y más conservadoras de su partido. Y el proyecto que ha surgido parece tratar de aplacar a ambos.

Por ejemplo, según lo que buscan los moderados, el proyecto de ley reduciría gradualmente la expansión del Medicaid de 2020 a 2024, algo más lentamente que el proyecto de ley de la Cámara de Representantes. Pero finalmente terminaría. El proyecto de ley del Senado también se aparta de los créditos de impuestos fijos de la Cámara para ayudar a pagar los seguros, lo que habría agregado miles de dólares a las primas de las personas más pobres y mayores que aún no son elegibles para el Medicare.

Se espera a principios de la próxima semana un informe de la Oficina de Presupuesto del Congreso (CBO) que estima el impacto del proyecto de ley del Senado sobre las personas y el presupuesto federal. De acuerdo con la CBO, el proyecto de ley de la Cámara Baja,  resultaría en 23 millones de estadounidenses menos con seguro de salud a lo largo de 10 años.

Para los conservadores, sin embargo, el proyecto de ley del Senado impactaría aún más en el Medicaid en años posteriores. El tope impuesto por la Cámara crecería más lentamente que el gasto del Medicaid, pero el tope del Senado crecería aún más lentamente que el de la Cámara. Eso dejaría a los estados con pocas opciones, aparte de aumentar los impuestos, reducir la elegibilidad o reducir los beneficios para mantener sus programas.

Los defensores de la actual ley de salud reaccionaron rápidamente.

El senador Ron Wyden (demócrata de Oregon) se quejó de los cambios en las garantías de cobertura en ACA.

“También quiero hacer una nota especial sobre la disposición estatal de renuncia. Los republicanos han retorcido y abusado de una parte de la Ley de Cuidado de Salud Asequible que escribí para promover la innovación estatal, y la están usando para dar a las compañías de seguros el poder de asediar a las personas”, dijo en un comunicado emitido poco después de que se publicara la ley. “Esto equivale a ocultar un ataque a las garantías básicas de atención de la salud detrás de renuncias estatales, y voy a luchar contra ella en cada oportunidad”.

“El desalmado proyecto de ley de salud del Senado hace que la atención de la salud sea peor para todos: eleva los costos, reduce la cobertura, debilita las protecciones y reduce aún más los fondos para el Medicaid que el odioso proyecto de la Cámara”, dijo en un comunicado Protect Our Care, un grupo de defensa que se opone a los cambios republicanos a la ley de salud. “Ellos escribieron su plan en secreto y se apresuran a votar la semana que viene porque saben el daño que su proyecto de ley les hará a millones de personas”.

Categories: Medicaid, Noticias En Español, Repeal And Replace Watch, The Health Law

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Senate Health Bill Would Revamp Medicaid, Alter ACA Guarantees, Cut Premium Support

Republicans in the U.S. Senate on Thursday unveiled a bill that would dramatically transform the nation’s Medicaid program, make significant changes to the federal health law’s tax credits that help lower-income people buy insurance and allow states to water down changes to some of the law’s coverage guarantees.

The bill also repeals the tax mechanism that funded the Affordable Care Act’s benefits, resulting in hundreds of billions of dollars in tax cuts for the wealthy and health care industry.

Most senators got their first look at the bill as it was released Thursday morning. It had been crafted in secret over the past several weeks. Senate Majority Leader Mitch McConnell (R-Ky.) is seeking a vote on the bill before Congress leaves next week for its Fourth of July recess.

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Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.

At lightning speed and with a little over a week for wider review, the Republicans’ bill could influence health care and health insurance of every American. Reversing course on some of the more popular provisions of the Affordable Care Act, it threatens to leave tens of millions of lower-income Americans without insurance and those with chronic or expensive medical conditions once again financially vulnerable.

Like the House measure, the Senate bill, which is being called a “discussion draft,” would not completely repeal the ACA but would roll back many of the law’s key provisions. Both bills would also — for the first time — cap federal funding for the Medicaid program, which covers more than 70 million low-income Americans. Since its inception in 1965, the federal government has matched state spending for Medicaid. The new bill would shift much of that burden back to states.

The bill would also reconfigure how Americans with slightly higher incomes who don’t qualify for Medicaid would get tax credits to help pay insurance premiums, eliminate penalties for those who fail to obtain insurance and employers who fail to provide it, and make it easier for states to waive consumer protections in the ACA that require insurance companies to charge the same premiums to sick and healthy people and to provide a specific set of benefits.

“We agreed on the need to free Americans from Obamacare’s mandates, and policies contained in the discussion draft will repeal the individual mandate so Americans are no longer forced to buy insurance they don’t need or can’t afford; will repeal the employer mandate so Americans no longer see their hours and take-home pay cut by employers because of it,” McConnell said on the floor of the Senate after releasing the bill. He also noted that the bill would help “stabilize the insurance markets that are collapsing under Obamacare as well.”

It is not clear that the bill will make it through the Senate, however, or that all of it will even make it to the Senate floor. The Senate (like the House) is operating under a special set of budget rules that allow it to pass this measure with only a simple majority vote and block Democrats from dragging out the debate by using a filibuster. But the “budget reconciliation” process comes with strict rules, including the requirement that every provision of the bill primarily impact the federal budget, either adding to or subtracting from federal spending.

For example, the legislation as released includes a one-year ban on Medicaid funding for Planned Parenthood. That is a key demand of anti-abortion groups and some congressional conservatives, because Planned Parenthood performs abortions with non-federal funding. But it is not yet clear that the Senate parliamentarian will allow that provision to be included in the bill.

Also still in question is a provision of the Senate bill that would allow states to waive insurance regulations in the Affordable Care Act. Many budget experts say that runs afoul of Senate budget rules because the federal funding impact is “merely incidental” to the policy.

Drafting the Senate bill has been a delicate dance for McConnell. With only 52 Republicans in the chamber and Democrats united in opposition to the unraveling of the health law, McConnell can afford to lose only two votes and still pass the bill with a tie-breaking vote from Vice President Mike Pence. McConnell has been leading a small working group of senators — all men — but even some of those have complained they were not able to take part in much of the shaping of the measure, which seems to have been largely written by McConnell’s own staff.

So far, McConnell has been fielding complaints from the more moderate and more conservative wings of his party. And the draft that has emerged appears to try to placate both.

For example, as sought by moderates, the bill would phase down the Medicaid expansion from 2020 to 2024, somewhat more slowly than the House bill does. But it would still end eventually. The Senate bill also departs from the House bill’s flat tax credits to help pay for insurance, which would have added thousands of dollars to the premiums of poorer and older people not yet eligible for Medicare.

A Congressional Budget Office report estimating the Senate bill’s impact on individuals and the federal budget is expected early next week. The House bill, according to the CBO, would result in 23 million fewer Americans having health insurance over 10 years.

For conservatives, however, the Senate bill would clamp down even harder on Medicaid in later years. The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s. That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs.

Defenders of the health law were quick to react.

Sen. Ron Wyden (D-Ore.) complained about changes to coverage guarantees in the ACA.

“I also want to make special note of the state waiver provision. Republicans have twisted and abused a part of the Affordable Care Act I wrote to promote state innovation, and they’re using it to give insurance companies the power to run roughshod over individuals,” he said in a statement issued shortly after the bill was released. “This amounts to hiding an attack on basic health care guarantees behind state waivers, and I will fight it at every turn.”

“The heartless Senate health care repeal bill makes health care worse for everyone — it raises costs, cuts coverage, weakens protections and cuts even more from Medicaid than the mean House bill,” said a statement from Protect Our Care, an umbrella advocacy group opposing GOP changes to the health law. “They wrote their plan in secret and are rushing forward with a vote next week because they know how much harm their bill does to millions of people.”

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

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Longer Looks: Obamacare’s 6-Year-Old Lobbyist; Mental Illness In Prison; And Antibiotic Resistance

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

The Guardian: She Was The Town’s Leading Heroin Dealer. She Was 19 Years Old
Breanne McUlty knew about Dr Rajan Masih long before she met him.McUlty was still a teenager, hooked on whiskey and methamphetamine and soon to be dealing heroin, when she first heard about the doctor. Masih was a respected, prosperous family man running a hospital emergency room.But McUlty knew from those of her friends who preferred to get high on painkillers – effectively heroin in a legal pill – that Masih was the go-to doctor for illicit opioid prescriptions in Grant County, West Virginia. (Chris McGreal, 6/19)

The Atlantic: Even With Insurance, Americans Can’t Afford Their Medical Bills
A chance trip to Long Island’s Adventureland amusement park just might have saved Cassidy McCarthy’s life. After Cassidy—whose family calls her Cassie—then 4, complained about pain and nausea following a ride on the Ladybug rollercoaster, her dad, Daniel, a registered nurse, felt her stomach and discovered a small bump. A CT scan ordered up at a local hospital’s emergency room revealed a kidney tumor. (Helaine Olen, 6/18)

The New York Times: Psychologists Open A Window On Brutal C.I.A. Interrogations
Fifteen years after he helped devise the brutal interrogation techniques used on terrorism suspects in secret C.I.A. prisons, John Bruce Jessen, a former military psychologist, expressed ambivalence about the program. He described himself and a fellow military psychologist, James Mitchell, as reluctant participants in using the techniques, some of which are widely viewed as torture, but also justified the practices as effective in getting resistant detainees to cooperate. (Fink and Risen, 6/21)

Huffington Post: Cerebral Palsy Didn’t Stop This College Junior. Obamacare Repeal Might.
Justin Martin, 21, is in many respects a typical junior at Kenyon College. He lives in an off-campus apartment, which he shares with six other guys. He’s majoring in English, helps run a student improv group, and last semester he took five courses instead of the usual four ― a “terrible idea,” he now concedes. Sometimes he pulls all-nighters to write papers or study for exams, drawing sustenance from soda and chocolate-covered almonds. And sometimes he stays up late just to have long arguments with his roommates ― like over whether it’s OK to ban campus speeches by white supremacists (Martin says no) or whether the seventh Harry Potter novel was the worst (Martin says yes). (Jonathan Cohn, 6/17)

Vogue: Cecile Richards On Planned Parenthood, The Resistance, And Galvanizing The Next Generation Of Activists
Cecile Richards strides into the University of Nevada, Las Vegas, student union in a hot-pink dress and a black cardigan. As she walks past me I notice that her toenails are also pink—a color that precisely matches the “I stand with Planned Parenthood” pins and signs and T-shirts that are all around the room. She is uncharacteristically late this morning, and before she arrived I was a little worried: There was only a smattering of local media, and the energy was muted. But as soon as she walked in, the air crackled—as if, in her presence, every atom gained an electron. (Jonathan Van Meter, 6/19)

Vox: Americans Should Be More Afraid Of HPV
Lee Tomlinson wasn’t a smoker. He wasn’t a drinker. He was a longtime professional tennis player and marathoner based in Los Angeles, “the healthiest guy anyone knew,” he says.That’s why, in 2012, at the age of 62, he was shocked to learn that he had stage-three throat cancer. (Julia Belluz, 6/15)

The Atlantic: Could The Answer To The Antibiotic-Resistance Crisis Be Found On A Toilet Seat?
There was a time when all of our antibiotics came from natural sources. That is how the antibiotic era began, in 1928: Sir Alexander Fleming reputedly left a window open in his London laboratory, and discovered weeks later that specks of the mold Penicillium, blown in on the breeze, excreted a chemical that killed the bacterium Staphylococcus. That chemical became the first antibiotic, penicillin. It was followed by chloramphenicol, made by a bacterium found in compost in Venezuela, and chlortetracycline, excreted by a bacterium found in a field at the University of Missouri, a test plot for growing hay. (Maryn McKenna, 6/20)

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

Meet The Republican Men Secretly Reshaping Your Health Care

Who are the GOP senators working on the American Health Care Act behind closed doors? You’ve likely heard they are all white men chosen by Majority Leader Mitch McConnell. Here are some of their vital stats that may influence the outcome.

Sources: Census Bureau; CMS.gov; CNN; Gallup; Kaiser Family Foundation; Medicaid.gov; Senate.gov

Contributors: Phil Galewitz, Doug Carroll, Caitlin Hillyard, Lynne Shallcross and Terry Byrne

Categories: Multimedia, Repeal And Replace Watch, The Health Law


Ear To The Door: 5 Things Being Weighed In Secret Health Bill Also Weigh It Down

Anyone following the debate over the “repeal and replace” of the Affordable Care Act knows the 13 Republican senators writing the bill are meeting behind closed doors.

While Senate Majority Leader Mitch McConnell (R-Ky.) continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill.

Spoiler: No one knows what the final Senate bill will look like, including those writing it.

“It’s an iterative process,” Senate Majority Whip John Cornyn (R-Texas) told Politico, adding that senators in the room are sending options to the Congressional Budget Office to try to figure out in general how much they would cost. Those conversations between senators and the CBO — common for lawmakers working on major, complex pieces of legislation — sometimes prompt members to press through and other times to change course.

Although specifics, to the extent there are any, have largely stayed secret, some of the policies under consideration have slipped out, and pressure points of the debate are fairly clear. Anything can happen, but here’s what we know so far:

1. Medicaid expansion

The Republicans are determined to roll back the expansion of Medicaid under the Affordable Care Act. The question is, how to do it. The ACA called for an expansion of the Medicaid program for those with low incomes to everyone who earns less than 133 percent of poverty (around $16,000 a year for an individual), with the federal government footing much of the bill. The Supreme Court ruled in 2012 that the expansion was optional for states, but 31 have done so, providing new coverage to an estimated 14 million people.

The Republican bill passed by the House on May 4 would phase out the federal funding for those made eligible by the ACA over two years, beginning in 2020. But Republican moderates in the Senate want a much slower end to the additional federal aid. Several have suggested that they could accept a seven-year phaseout.

Keeping the federal expansion money flowing that long, however, would cut into the bill’s budget savings. That matters: In order to protect the Senate’s ability to pass the bill under budget rules that require only a simple majority rather than 60 votes, the bill’s savings must at least match those of the House version. Any extra money spent on Medicaid expansion would have to be cut elsewhere.

2. Medicaid caps

A related issue is whether and at what level to cap federal Medicaid spending. Medicaid currently covers more than 70 million low-income people. Medicaid covers half of all births and half of the nation’s bill for long-term care, including nursing home stays. Right now, the federal government matches whatever states spend at least 50-50, and provides more matching funds for less wealthy states.

The House bill would, for the first time, cap the amount the federal government provides to states for their Medicaid programs. The CBO estimated that the caps would put more of the financial burden for the program on states, who would respond by a combination of cutting payments to health care providers like doctors and hospitals, eliminating benefits for patients and restricting eligibility.

The Medicaid cap may or may not be included in the Senate bill, depending on whom you ask. However, sources with direct knowledge of the negotiations say the real sticking point is not whether or not to impose a cap — they want to do that. The hurdles: how to be fair to states that get less federal money and how fast the caps should rise.

Again, if the Senate proposal is more generous than the House’s version, it will be harder to meet the bill’s required budget targets.

3. Restrictions on abortion coverage and Planned Parenthood

The senators are actively considering two measures that would limit funding for abortions, though it is not clear if either would be allowed to remain in the bill according to the Senate’s rules. The Senate Parliamentarian, who must review the bill after the senators complete it but before it comes to the floor, will decide.

The House-passed bill would ban the use of federal tax credits to purchase private coverage that includes abortion as a benefit. This is a key demand for a large portion of the Republican base. But the Senate version of the bill must abide by strict rules that limit its content to provisions that directly impact the federal budget. In the past, abortion language in budget bills has been ruled out of order.

4. Reading between the lines

A related issue is whether House language to temporarily bar Planned Parenthood from participating in the Medicaid program will be allowed in the Senate.

While the Parliamentarian allowed identical language defunding Planned Parenthood to remain in a similar budget bill in 2015, it was not clear at the time that Planned Parenthood would have been the only provider affected by the language. Planned Parenthood backers say they will argue to the Parliamentarian that the budget impact of the language is “merely incidental” to the policy aim and therefore should not be allowed in the Senate bill.

5. Insurance market reforms

Senators are also struggling with provisions of the House-passed bill that would allow states to waive certain insurance requirements in the Affordable Care Act, including those laying out “essential” benefits that policies must cover, and those banning insurers from charging sicker people higher premiums. That language, as well as an amendment seeking to ensure more funding to help people with preexisting conditions, was instrumental in gaining enough votes for the bill to pass the House.

Eliminating insurance regulations imposed by the ACA are a top priority for conservatives. “Conservatives would like to clear the books of Obamacare’s most costly regulations and free the states to regulate their markets how they wish,” wrote Sen. Mike Lee (R-Utah), who is one of the 13 senators negotiating the details of the bill, in an op-ed in May.

However, budget experts suggest that none of the insurance market provisions is likely to clear the Parliamentarian hurdle as being primarily budget-related.

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

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Longer Looks: Prescription Heroin; Smartphone Psychiatry; And Obamacare Repeal

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

Vox: The Case For Prescription Heroin
A clinic where patients use heroin may sound shocking and irresponsible, particularly now, as a deadly and devastating opioid epidemic ravages North America. But this approach is meant to treat the victims of that epidemic. The idea is this: If some people are going to use heroin no matter what, it’s better to give them a safe source of the stuff and a safe place to inject it, rather than letting them pick it up on the street — laced with who knows what — and possibly overdose without medical supervision. Patients can not only avoid death by overdose but otherwise go about their lives without stealing or committing other crimes to obtain heroin. (German Lopez, 6/12)

The Atlantic: The Smartphone Psychiatrist
Sometime around 2010, about two-thirds of the way through his 13 years at the helm of the National Institute of Mental Health (NIMH)—the world’s largest mental-health research institution—Tom Insel started speaking with unusual frankness about how both psychiatry and his own institute were failing to help the mentally ill. Insel, runner-trim, quietly alert, and constitutionally diplomatic, did not rant about this. It’s not in him. You won’t hear him trash-talk colleagues or critics. (David Dobbs, 6/8)

FiveThirtyEight: Facts Alone Won’t Convince People To Vaccinate Their Kids
Measles is a highly contagious and potentially deadly viral infection. Although the MMR vaccine that prevents it is quite effective, some children — including those with pre-existing health conditions, like cancer or compromised immune systems, and those who are younger than 6 months old — cannot receive it. These vulnerable populations rely on herd immunity to protect them. When vaccination levels reach a critical threshold — 83 percent to 94 percent for measles — the high concentration of immune people squelches the spread of the disease, preventing it from reaching large numbers of unprotected people. (Erin Hare, 6/12)

Vox: “This Is Red Alert”: Inside The Left’s Game Plan For Beating The GOP Health Bill
Progressive activists and Senate Democrats are trying to mount an all-out campaign to sink a Republican health care bill that Senate Majority Leader Mitch McConnell wants to pass before Congress’s July 4 recess. … There’s just one key problem with this effort: Nobody on the left knows exactly what they’re fighting against, because Senate Republicans haven’t yet released their bill. (Jeff Stein, 6/14)

The Guardian: One Community Garden At A Time: How New Yorkers Are Fighting For Food Justice
As part of New York mayor Bill de Blasio’s Building Healthy Communities initiative, the city recently upped the number of GreenThumb gardens in underserved neighborhoods with limited access to healthy food. The new grants include gardens in East Harlem and Bedford-Stuyvesant and the H.E.A.L.T.H for Youths garden on police department property.But even as community food production programs gain in number, the overall picture is darkening. (Edward Helmore, 6/12)

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

Descent Into Secrecy: Senate Health Talks Speak To Steady Retreat From Transparency

Congress struggling to finish a huge budget reconciliation bill. A GOP president pushing a major overhaul of federal payments for health insurance that could transform the lives of sick patients.

Sound familiar? The year was 1986. I was a rookie health reporter on Capitol Hill and watched a Medicare bill move from introduction, to hearings, to votes in subcommittees, to full committees and then to the entire House — an operation that took months and was replicated in the Senate, before the two chambers got together to iron out their differences for final passage. Everything was published in the official Congressional Record in almost excruciating detail for everyone to see — as long as they could read really tiny type.

Since then, in three decades of reporting, I’ve had a front-row seat to Congress’ slow, stuttering retreat from such step-by-step transparency, a process known as “regular order.”

It has now culminated in the Senate GOP leadership’s top-secret process to try to write a health bill that could change the formula for nearly one-fifth of the nation’s economy, with a vote they want to cast by July 4. In fact, a GOP Senate aide told the news site Axios on Monday that no details would be forthcoming until the bill is finished, adding, “We aren’t stupid.” That means bypassing the debate that traditionally went into lawmaking, in order to achieve consensus.

The extreme secrecy is a situation without precedent, at least in creating health law. Still, it’s not hard to see how we got here — and there is plenty of bipartisan blame to go around.

Since 1986, I have chronicled the passage (and repeal) of the Medicare Catastrophic Coverage Act, the fight over President Bill Clinton’s health proposal, passage of the Medicare prescription drug bill and passage of the Affordable Care Act, in addition to a dozen budget reconciliation measures that altered health care, often in fundamental ways.

Despite promises from incoming Democratic and Republican leaders over the past decade to restore a time-honored process, regular order has not returned. In fact, not only has it become increasingly rare, but the legislative process itself has become ever-more truncated, with Congress skipping steps it deemed inconvenient to partisan ends, particularly as leaders have “end run” the committees that are supposed to do the lion’s share of legislative work.

So long as there is bipartisan agreement, regular order can still prevail. A major bill completed in 2015 to reconfigure how Medicare pays doctors was the product of 15 months of work by Democrats and Republicans in the House and Senate, and passed three committees in open session by unanimous roll call votes.
But it has become progressively — and distressingly — more acceptable to set transparency aside in lawmaking over the years.

In the 1980s, Rep. Bill Natcher (D-Ky.) routinely closed the subcommittee markup of the spending bill to fund the Departments of Labor, Health and Human Services, and Education, even when there was no particular controversy to avoid. Reporters got to see the bill for the first time at the full Appropriations Committee markup.

Markups at the House Ways and Means Committee under Chairman Dan Rostenkowski (D-Ill.) also were frequently closed to the press and public, mostly for tax bills. Still, once I personally held up a health subcommittee markup for nearly a half-hour because the vote to close the session required a majority of members present. I refused to leave until a couple of committee members could be located and brought to the room to vote in person and kick me out.

Even meetings open to the press were sometimes less than revealing. In House-Senate conference meetings, members would frequently refer to what they were talking about using numbers on notes that were not shared with the audience, including reporters. So they basically spoke in code, and if you didn’t have the key you were just out of luck.

Of course, today there are fewer and fewer formal conference committees, places the two sides hammer out their differences in the public eye. Often the final versions of contentious bills are worked out behind closed doors, often without all of the members of the conference committee. In 2003, House Ways and Means Committee Chairman Bill Thomas (R-Calif.) retreated with all the Republican conferees and two of seven Democrats into his Capitol hideaway office in a group he called “the coalition of the willing.” They wrote the final bill in secret while reporters and lobbyists stood outside in the hall for weeks on end. (Sitting in the Capitol is considered civil disobedience and is strictly forbidden.) We were there so long and got to know one another so well that on my birthday someone got all the conferees in the room to sign a birthday card for me.

The final version of that bill was the one that passed the House in the dead of night – Republicans purposely scheduled the vote to begin at 1 a.m. (on the theory it would be easier to get wavering members to vote yes if only to go home to bed). The vote didn’t end until nearly 6 a.m., after President George W. Bush reportedly got the last few members to switch, via phone calls.

In 2009, creation of the Affordable Care Act was both open and closed. There were hundreds of hearings and markups that lasted days, or, in the case of the Senate Health, Education, Labor and Pensions Committee, months. But the unsuccessful effort by Senate Finance Committee Chairman Max Baucus (D-Mont.) to bring Republicans into the fold consisted of weeks of closed-door discussions, and the Senate bill that would ultimately become the foundation of the ACA was written in Senate Majority Leader Harry Reid’s office before being debated on the Senate floor for almost a month.

We got a sneak preview of how the GOP might shepherd its health bill through in 2015, when Republicans — who by then controlled Congress — orchestrated a “dress rehearsal” ACA repeal bill that was vetoed (as they knew it would be) by President Barack Obama. The bill was prewritten by leadership, approved by the relevant House committees, passed by the House and sent to the Senate. The Senate passed it with small changes (and without committee consideration). Rather than having a conference, the amended Senate bill was then simply approved by the House and sent to Obama for his veto.

That secretive process is being reiterated now. Only this time a Republican, Donald Trump, is president and the potential for change is real. People are outraged over the lack of transparency and the loss of regular order. But both Democrats and Republicans have laid the track on which this train is rolling.

Categories: Cost and Quality, Insurance, Repeal And Replace Watch, The Health Law

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