Tagged Repeal And Replace Watch

In Deep-Blue State, Millions in Reddish Heartland Are Counting On Medicaid

FRESNO, Calif. — In 2012, when Jerry Goodwin showed up at a clinic with intense pain and swelling in his legs, doctors called for an ambulance even though the hospital was across the street. That generated a $900 bill — just the beginning of a nearly three-year ordeal for Goodwin, who was uninsured.

Diagnosed with cellulitis and an irregular heartbeat, Goodwin managed to get his emergency care costs covered through the hospital but then faced month after month of bills for follow-up care and medications.

Finally, in 2015, he was able to sign up for Medicaid coverage, which was expanded under the Affordable Care Act to cover many single adults without children. “That was a big relief,” said Goodwin, 64.

Now Goodwin and people like him are worried all over again.

Under Republican efforts to repeal, replace or reform the health law, many people on Medicaid — the nation’s single-largest insurer, with 72 million beneficiaries — could see their coverage slashed. The biggest chunk of them — 13.5 million — live in California. The state predicted Wednesday it could lose $24 billion in federal funding annually by 2027 under the current GOP proposal.

Among the hardest hit regions would be the Central Valley, the state’s agricultural heartland, stretching hundreds of miles from Redding to Bakersfield. Toward the south, in Fresno County, about half the population of 985,000 relies on Medi-Cal, as California’s Medicaid program is known. In adjacent Tulare County, 55 percent of the more than 466,000 residents were enrolled in Medi-Cal as of January 2016.

Much has been said about the plight of conservative voters in the Midwest who rely on Medicaid, a program the Trump administration and congressional Republicans are determined to shrink. But despite its reputation as a deep-blue state, California also has several red — or reddish — counties in its interior with millions of low-income people who depend heavily on Medicaid. Many live in congressional districts represented by Republicans who want to scrap or change the Affordable Care Act, also known as Obamacare.

J. Luis Bautista, an internist at Bautista Medical Center in Fresno, examines farm worker Jose Gonzalez in February. Gonzalez says he is not ready to retire and needs his insurance to stay healthy. (Heidi de Marco/KHN)

The current Republican bill, the American Health Care Act, would cut Medicaid funding by 25 percent by 2026, covering 24 million fewer people than today, according to the Congressional Budget Office.

“These are remarkable estimates,” said John Capitman, the executive director at the Central Valley Health Policy Institute and a professor at California State University, Fresno, referring to the CBO projections. “The level of cuts are devastating, and for California and the Central Valley, this represents a huge loss.”

The bill faces opposition from the left and right and is undergoing last-minute changes in the run-up to a House floor vote Thursday. Despite several protests in the valley and around the state, at least half of Republican lawmakers in the state appear poised to support it; several others are noncommittal.

U.S. Rep. Devin Nunes, whose congressional district includes portions of Tulare and Fresno counties, likes the proposal, saying it will improve care for everyone, including current Medi-Cal participants.

“Medi-Cal is a broken healthcare system that’s been completely mismanaged by the State of California,” Nunes said in a recent statement.

Capitman said Medi-Cal is vital in the Central Valley because of its high poverty rate, uneven access to care and pockets with very poor health outcomes. Many of these communities also depend on the Prevention and Public Health Fund, which was established by the ACA to fight chronic diseases and also is in peril, he said.

The valley suffers high rates of diabetes, obesity and heart disease. The area has some of the country’s dirtiest air, triggering epidemic levels of asthma. Wage stagnation and high unemployment contribute to stress and poor mental health.

Some areas are far better off than others. Within 10 miles, Capitman said, you can find up to a 20-year difference in life expectancy. On average, life is much shorter for residents in Southwest Fresno, for instance, where heavy industry soils the air, homeless people camp on sidewalks, and fences cage in lots overgrown with grass and weeds.

Not far away, Petra Martinez, a former fieldworker, recently waited to see a doctor at a crowded downtown clinic. At 86, she receives coverage from both Medi-Cal and Medicare, the federal insurance program for the elderly. She needs medication for arthritis, epilepsy and diabetes, all of which is paid for her through her dual coverage.

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Though the proposed House bill seemingly would not shrink spending on people with dual coverage, she is wary of what lies down the road.

“I’d like to think that we [seniors] will be OK, that maybe we won’t be affected by whatever changes are coming, but who knows?” Martinez said. “I don’t want to have to ask my children for money to go to the doctor.”

Dr. J. Luis Bautista, an internist at the clinic, estimates he’s seen a 20 percent increase in patient visits since the rollout of the ACA in 2014. The majority of his patients are on Medi-Cal.

“These are the people who usually wait until they’re very sick to come,” Bautista said. “We’ve seen people with high blood pressure who come in when they already have eye problems and heart problems. … They waited too long.”

But since the ACA rolled out, he said, preventive visits seem to have increased.

Luis Bautista, an internist at Bautista Medical Center in Fresno, examines Kathy Macias, 53, while her mother, Connie Hernandez, 72, waits to be seen last month. Bautista says the majority of his patients are afraid of losing the health insurance they received under the Affordable Care Act. (Heidi de Marco/KHN)

Fifteen miles outside the city of Fresno is Sanger, a largely Latino town of 25,000 where almost a quarter of residents live in poverty, according to the U.S. Census.

Here a neighborhood of newer houses with commuter residents isn’t far from another that lacks sidewalks and is strewn with aging or abandoned businesses and chain stores.

On a recent day, a hairstylist was tending to a client in a downtown salon nestled among boutiques, cafes and other small businesses. The stylist said she and her two teenagers are on Medi-Cal — and so are most of the people she knows. A single mother, she said she works six days a week but can’t afford to buy health coverage.

The salon’s owner interjected that she doesn’t oppose greater restrictions on who gets Medi-Cal — but plans on the state’s insurance exchange should be more affordable, so people will be drawn to buying coverage.

The women asked that they and the business not be identified.

Less than an hour southeast of Fresno, Iliana Troncoza lives in the city of Tulare, part of a heavily agricultural county of the same name. The county has one of the lowest incomes per capita in California.

Troncoza, a 47-year-old homemaker who takes care of her ailing husband, gets her health care at Altura Centers for Health, which runs seven clinics in the city. The thought of Medi-Cal cutbacks fills her with anxiety. Both she and her daughter, a college freshman, rely on the program for coverage.

Iliana Troncoza, 47, of Tulare, said she had gone without health coverage for six years before qualifying for Medi-Cal under the expansion. Troncoza said that since qualifying for Medi-Cal, she has gone in for mammograms, ultrasounds and has been able to obtain medication for her depression and anxiety. “It’s horrible to think that our Medi-Cal depends on people who don’t understand our situation,” Troncoza said. (Heidi de Marco/KHN)

Troncoza had gone without coverage for six years before qualifying under the ACA expansion. She traveled to Jalisco, Mexico, to remove a breast cyst because couldn’t afford the procedure in the U.S. Now, in her city, she can receive mammograms and ultrasounds, and has been able to obtain medication for her depression and anxiety, she said.

“It’s horrible to think that our Medi-Cal depends on people who don’t understand our situation,” Troncoza said.

Graciela Soto, CEO of Altura clinic system, said 75 percent of its patients are on Medi-Cal and 9 percent of patients are uninsured, mostly because of their immigration status. It’s quite a difference from 2012, before the ACA was implemented, when 50 percent of patients were on Medi-Cal and 35 percent uninsured, she said.

“The Medicaid expansion was wonderful for our patients,” Soto said.

Through the ACA, Soto said, many young women were able to access free or affordable birth control. That’s important, she said, because Tulare County has among the highest teen pregnancy rates in the state.

The region has a large population of migrant farm workers, many of whom don’t qualify for Medi-Cal. But a substantial portion of Latinos do qualify, as do non-Hispanic whites like Goodwin.

Among whites, the need for mental health and substance abuse services is growing, research suggests. Drug overdoses, alcohol abuse and suicide have significantly contributed to rising death rates, according to a study out of the Center on Society and Health at Virginia Commonwealth University.

In Fresno County, for example, the rate at which middle-aged white adults are dying from accidental drug poisoning has tripled since 1990, according to the report.

Some residents have turned to activism in their efforts to preserve ACA coverage. In January, Greg Gomez, a councilman for the city of Farmersville in Tulare County, led a small-scale protest outside Nunes’ office in Visalia.

It wasn’t just about politics — it was personal. Three of Gomez’s children are covered by Medi-Cal.

“The monthly premium to get my whole family covered by my employer would be about $2,000,” said Gomez, a computer systems engineer for Tulare County and former president for the local chapter of the Service Employees International Union. “That is totally out of reach. That’s why we need Medi-Cal. And that’s the story of a lot of Tulare residents.”

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

Categories: California Healthline, Insurance, Multimedia, Repeal And Replace Watch, The Health Law

Texas Braces For Medicaid Cuts Under GOP Health Plan

Many in Texas are keeping a close eye on the Republican bid to replace the Affordable Care Act. One of the big changes is how it would affect low-income people, seniors and people with disabilities who all get help from Medicaid. And Texans on both sides of the political spectrum say the Lone Star State is not going to fare well.

As the GOP bill, the American Health Care Act, works its way through Congress, Anne Dunkelberg, with the left-leaning Center for Public Policy Priorities in Austin, said she’s a little stumped.

“I have worked on Medicaid and uninsured and health care access issues in Texas for well over 20 years,” she chuckled. She said this bill leaves the fate of some current funding streams unclear, and there’s one pot of money she’s particularly concerned about. Texas has struck deals with the federal government under something known as a 1115 waiver to help reimburse hospitals for the cost of caring for people who don’t have insurance. And Texas has more uninsured residents than any other state.

“About half of what Texas hospitals get from Medicaid today comes through payments that are outside from the regular Medicaid program,” she said, which adds up to $4 billion in federal funds every year.

But even if Texas gets to keep all that money, there’s another issue — the GOP plan will reduce how much the federal government pays for Medicaid. It will either cap how much money states get for Medicaid from the federal government for every person they cover. That’s called a per-capita cap, and the payments under that formula would start in 2020, but would be based on how much the state spends this year. Or, in line with this week’s modification of the GOP bill, it would let states choose a lump sum, or block grant, also likely to cut the federal support Medicaid gets.

Adriana Kohler with Texans Care for Children, an advocacy group based in Austin, said Texas already leaves too many people without care.

“Last legislative session there were cuts to pediatric therapies for kids with disabilities enrolled in Medicaid,” she said. The cuts caused some providers to shut their doors, which left some children without services, she said. “That’s why these cuts coming down from the ACA repeal bill are very concerning to us.”

In Texas, she said, children, pregnant women, seniors and people with disabilities will bear the brunt of any belt-tightening. These populations make up 96 percent of people on Medicaid in Texas. That’s why, Dunkelberg said, the program as is should not be the baseline for years to come.

“They could lock Texas into a lot of historical decisions that were strictly driven by a desire to write the smallest budget possible,” she said.

Some on the right agree Texas is getting a raw deal. Dr. Deane Waldman, with the right-leaning Texas Public Policy Foundation, said there are things he likes in the bill. But in general, he said, “it’s bad deal for Texas. It’s a bad deal for the American people.”

He said it was the right thing for Texas not to expand Medicaid, but this bill punishes Texas for it. Under the GOP bill, states that expanded Medicaid would get more money. And because the initial Republican bill left the door open for states to expand Medicaid before 2020, he worried more states would do that to get in on the deal.

“It’s going to be a huge rush — an inducement to drag in as many people as they can drag in, because the more they can drag in, the more federal dollars they can get,” he said. The GOP’s latest plan, however, makes it impossible for any new states to expand Medicaid and cuts off funding for Medicaid expansion states earlier.

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

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

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Repeal Of Health Law Could Force Tough Decisions For Arizona Republicans

Connie Dotts is a big fan of her insurance.

“I like that we can choose our own doctors,” said the 60-year-old resident of Mesa, Ariz. “They also have extensive mental health coverage.”

Dotts isn’t on some pricey plan, either. She’s among the nearly 2 million people enrolled in Medicaid in Arizona and one of the more than 400,000 who have signed up since the Republican-led state expanded Medicaid in 2014.

Her eight prescription drugs are cheap, Dotts said, and she has no copays or premiums. The Medicaid benefits have helped her manage her emphysema, depression and osteoarthritis.

But taking care of other problems has to be delayed: “I have torn ligaments in my ankles, and I can’t take the time off work to go to physical therapy or surgery.”

Dotts works in retail and lives paycheck to paycheck. Without Medicaid, she said, she wouldn’t be able to afford to see a doctor. “It’s just barely above what they consider livable income. Any extensive medical issues would put an excessive burden on me,” she said.

The replacement health plan the GOP leaders are pushing in Congress would gradually cut off the federal funding for Medicaid that expanded eligibility. The bill also bars any additional states from expanding Medicaid immediately.

Swapna Reddy, a professor at Arizona State University’s School for the Science of Health Care Delivery, said that as Congress overhauls the health care law, a state like Arizona might particularly suffer.

Unlike some states that expanded Medicaid, Arizona saw a rush of people joining the rolls, Reddy says, because it had a “high-need, uninsured” population.

The Republican bill would continue to pay the higher federal rates that the ACA’s Medicaid expansion offered people like Dotts, Reddy said — but only if they’re already enrolled in Medicaid, and their personal income stays about the same.

“What we know about the Medicaid population is that they kind of fall in and out of eligibility on a regular basis,” she said, because the amount of money they earn tends to fluctuate.

“So it has the real potential of eradicating Medicaid expansion over a period of time,” Reddy says.

The states and the federal government share the cost of Medicaid. Instead of an open-ended entitlement, the bill making its way through Congress right now would cap the federal government’s contribution or turn it into a block grant.

Putting a fixed limit on the federal government’s contribution is unlikely to allow Arizona Medicaid to keep up with the growing cost of covering people, Reddy said.

“The states will have to come up with the remaining money to cover these folks,” she said.

The Republican health plan would eventually cost Arizona nearly half a billion dollars a year, according to calculations by the state, to keep the adults with the lowest income in the expansion population insured. It’s a group that Arizona voters actually required the state to cover in 2000 through a ballot initiative. But during the recession in later years, financial pressure led state lawmakers to freeze enrollment for those adults.

Scaling back Medicaid could be a particularly risky proposition for Arizona, according to the state program’s administrators, because Arizona is already one of the most efficient, lean programs in the country.

Getting locked in at the current funding rates would give other states a leg up, said Tom Betlach, who runs Medicaid in Arizona.

“If they are able to achieve improved outcomes and reduced costs, they are able to capture those savings,” Betlach said. “Versus we actually get penalized for being a good steward of taxpayer funds.”

Betlach said Arizona needs more control than it currently has over who and what types of treatments and procedures are covered if the federal government intends to give Arizona only a fixed amount of cash.

The federal fight over health care puts the state’s Republican governor, Doug Ducey, in a tricky situation. Ducey has said he would like the ACA repealed, but he has also said he doesn’t want hundreds of thousands of people to lose coverage. He has expressed concern that the GOP bill doesn’t give the state enough flexibility.

And it wasn’t even on Ducey’s watch that Arizona expanded Medicaid. The expansion happened under Jan Brewer, Arizona’s former governor and an ally of President Donald Trump. To pull that off, Brewer had to band together with Democrats and buck some of her fellow Republicans in the state Legislature, who then sued her over the expansion. In their lawsuit, the legislators claimed that the way the state pays its share — a fee on hospitals — is unconstitutional.

At a recent court hearing for that long-running lawsuit, Brewer defended her controversial decision to accept the ACA’s expansion funding.

“I think it was the right thing to do,” she said in an interview outside the courtroom. “It saved lives. It insured more people. It brought money into the state. It kept rural hospitals from being closed down. And today there are tens of thousands of people that are very, very grateful.”

But some Republicans, like state Sen. Debbie Lesko, who was among the Arizona legislators who sued Brewer, figured the day would come when the feds would try to roll back the funding.

“I voted against Medicaid expansion, not because I don’t want people to get health coverage,” Lesko said, “but because I’m a realist and I know how much we can afford in our budget.”

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

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

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On The Air With KHN

Kaiser Health News reporters have gone on television and radio shows in recent weeks to help explain the politics and policy at stake in the debate over a Republican plan to replace the Affordable Care Act. Catch up here on all the chatter:

Congressional Budget Office score released: 24 million Americans may lose coverage, Congress’ official scorekeeper finds. Julie Rovner, chief Washington correspondent for Kaiser Health News, describes the practical impact of the Republicans’ health care plan to “On Point” host Tom Ashbrook. (March 14)

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Health savings accounts debate revived: A crucial element of the Republican proposal, health savings accounts come with considerable tax breaks but mostly benefit the healthy and wealthy, Rovner tells “Here & Now” host Meghna Chakrabarti on WBUR. (March 13)

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Some left behind by GOP bill: Who are the winners and losers of the GOP plan? KHN senior correspondent Mary Agnes Carey explains on “Politics Inside Out” on Sirius XM Radio. (March 10)

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House health care bill would hit low-income and elderly Californians hardest: Chad Terhune, a senior correspondent for Kaiser Health News and California Healthline, discussed the House bill and how it would work in California with A Martínez, host of the “Take Two” show on Southern California Public Radio (KPCC). (March 10)

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Seismic changes to Medicaid proposed: The American Health Care Act accomplishes a long-held Republican goal of scaling back Medicaid from all except the neediest poor, Rovner tells Judy Woodruff on “PBS NewsHour.” (March 9)

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What is the American Health Care Act? Carey talks to Michael Smerconish of “The Michael Smerconish Program” on SiriusXM. Smerconish asks Carey, whom he calls the “health care whisperer,” to help listeners break down the GOP bill. Listen here. (March 9)

GOP tax credits raise cost to the elderly: Rovner talks to Judy Woodruff on “PBS NewsHour” about the impact on the individual market if the GOP plan becomes law: The criteria for tax credits shifts, with age becoming a greater factor than income. (March 8)

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How the Republican health care plan could affect you: Two days after Republicans unveil their plan to repeal and replace the Affordable Care Act, Carey joins Politico’s Dan Diamond and Susan Dentzer of the Network for Excellence in Health Innovation to discuss how the GOP plan could affect Americans on WAMU’s “1A” with Joshua Johnson. Listen here. (March 8)

American Health Care Act introduced: The day after House Republicans unveiled the American Health Care Act, Rovner discusses the legal restraints guiding what Republicans can repeal, and how, with the National Constitution Center. (March 7)

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Categories: Repeal And Replace Watch, The Health Law

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GOP Health Plan Aims To Curb Medicaid, Expand State Options

For all its populist design, the House GOP’s latest proposal to overhaul federal Medicaid funding creates financial risks for states and could leave some enrollees worse off.

Dramatic changes in Medicaid are a big part of the House bill to partially repeal the Affordable Care Act that’s steaming toward a floor vote scheduled for Thursday.

Big revisions were made to the legislation this week to appeal to conservatives pushing to reduce federal Medicaid spending and shift more power to states. Advocates for the program fear those measures, if enacted, could lead to cuts in benefits and fewer enrollees in the state-federal health insurance program for low-income people.

“We could see a complete unwinding of the Medicaid program as we know it today,” said Donna Friedsam, a health policy expert at the University of Wisconsin.

One big change in the GOP’s current bill would immediately shut off federal money to allow any more states to expand Medicaid eligibility under the ACA, commonly known as Obamacare. During the past three years, 31 states plus the District of Columbia have taken advantage of the provision, adding about 11 million people to Medicaid, and Kansas is considering the option. States also would gain more latitude to determine Medicaid eligibility and benefits for their populations. And for the first time, states could require some enrollees to work as a condition for getting coverage.

The GOP’s original plan was to begin shifting Medicaid expansion funding away from states in 2020. In the revised bill, states could keep funds after 2020 but only as long as those adults who gained coverage in the expansion stay in the program. When they drop out or lose eligibility, their funding would vanish.

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Because of changes in jobs and incomes, many Medicaid enrollees on average lose eligibility within two years, according to Census data.

Regular Medicaid funding also gets an overhaul in the GOP bill.

Since Medicaid’s creation in 1965, everyone eligible has been guaranteed coverage. The federal government’s commitment to help states deal with costs is open-ended, meaning its costs rise as states spend more. The states’ obligation is to cover certain groups of people and to provide specific benefits. Children and pregnant women who meet a state’s income criteria must be protected, for example.

The GOP bill would end that federal commitment, limiting what the government gives states to fixed amounts per year. States could choose two options.

The first way, called a per-capita allotment, means that federal dollars would be allocated to states based on how many Medicaid enrollees they served in a prior year, with annual adjustments for inflation and enrollment increases.

The second way would be a block grant.

Under the revised GOP bill, the block grant option would be available for Medicaid spending only on children, non-elderly adults without disabilities and pregnant women — groups that account for most enrollees.

All states would cover their disabled and elderly populations under the per-capita system, which would get a higher annual inflation rate adjustment than the block grant system under the GOP bill.

The objective is to ensure that funding keeps pace with rising health care costs and the needs of a growing elderly population.

Children could fare badly in states that choose the block grant option, said Joan Alker, executive director of the Center for Children and Families at Georgetown University.

They would no longer be guaranteed access to a standard Medicaid benefit that Congress created in 1967 to ensure that children got access to preventive health care services, treatment and periodic screenings to catch developing health problems early, Alker said.

“That means the governor and/or the state legislature would decide what benefits a child would get, not the child’s pediatrician,” she said.

Of the two funding arrangements, Medicaid block grants also would be financially riskier for states during economic downturns, when unemployment rises and more people seek to enroll in the program. While per-capita caps rise as enrollment grows, block grants do not — and that could leave a state short of federal aid when demand is strongest.

Most states would likely choose a per-capita cap for that reason, said Bill Hammond, director of health policy at the conservative Empire Center for Public Policy in New York.

But some would take a block grant for the freedom they would gain to change benefits and eligibility standards. As a bonus, they would also get to keep any federal money they saved and use it for non-Medicaid spending, he said.

Jason Fichtner, a Medicaid expert at George Mason University in Fairfax, Va., said a block grant would be attractive only for states if they could get more money than under the per-capita option, at least in the short term.

The GOP proposal would allow states to opt out of block-granted funds after 10 years and return to a full per-capita allotment.

Regardless whether the government uses block grants or per-capita caps, the prospects for dramatic changes are already causing shudders among advocates for low-income people.

“Both are really bad options and neither is good for Kentucky and neither is better than what we have now,” said Emily Beauregard, executive director for Kentucky Voices for Health.

Kentucky has a pending request with the Centers for Medicare & Medicaid Services to drastically change its Medicaid program, including adding a requirement that some enrollees work as a condition for enrollment.

The Obama administration consistently rejected states’ requests for a work requirement on the grounds that they would thwart low-income people from getting health care. Studies have found that many Medicaid enrollees who aren’t disabled or elderly already hold jobs, though often in positions that don’t provide health insurance.

The changes in the GOP bill would give states the option starting in October 2017 to add a work requirement for non-disabled adults. Pregnant women and parents of disabled children or children under 6 would be exempt.

Republican leaders said the requirement is modeled on those applied to federal welfare recipients. Under the Kentucky waiver request, people could meet the job requirement by caring for a family member or volunteering.

The work requirement provision is almost certain to face a court challenge if adopted.

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

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How Millennials Win And Lose Under The GOP Health Bill

Designing skateboards is just one of Luke Franco’s gigs. On a recent afternoon, he had just enough time before his next shift to chat at a café in downtown Providence, R.I.

“I work at the YMCA Monday through Friday with kindergartners through fifth-graders. It’s split shift; 7 to 9, 2 to 6 daily,” he said. “With the rest of my day, I also work at a local pizza place. And in addition to that, I also own and operate a small skateboard company.”

But none of his jobs comes with an offer of health insurance. Does that worry him?

“Yes, especially being an avid skateboarder,” the 26-year-old said. “That’s constantly something in the back of my head now — before I try this trick, what happens if I get hurt?”

So he’s looking for a full-time job with benefits. Beyond that, Franco hasn’t fully explored his insurance options. He’s a member of the millennial generation. They represent more than a quarter of the nation’s population. These are people loosely defined as 18 to 34 years old, and they figure prominently in the health care debate. How they fare under the GOP health care bill going through Congress is complicated.

Franco doesn’t know whether he qualifies for Medicaid or a subsidy to buy coverage on the exchange set up under the Affordable Care Act, also called Obamacare.

“I’m assuming that paying full price for it [health care] would be completely unaffordable for me,” he said.

The GOP plan would offer Franco a tax credit of $2,000 a year — that’s the flat amount available to 26- to 29-year-olds to help them buy insurance. The amount goes up to $2,500 for those ages 30 to 39. But even if Franco could buy a plan for a few hundred dollars a month, he doesn’t want to. He would rather hold on to what little pocket money he has for dinner or drinks with friends.

Jen Mishory heads an organization called Young Invincibles, a tongue-in-cheek name for millennials who think they’re too healthy to need health insurance. But the organization is serious about advocating for young people. Mishory said the ACA helped this generation.

“You’re starting pre-ACA with an uninsurance rate of about 29 percent for young people. We see that uninsurance rate drop, over the course of the last five, six years to about 16 percent,” she said. That’s due to many factors, the expansion of Medicaid, for one, and children being able to stay on their parents’ insurance until age 26. That’s how Franco was insured until his last birthday.

But coverage on the exchange is still expensive for some millennials. Even with subsidies, they didn’t sign up for the ACA exchanges in the numbers insurers were hoping for.

Mishory points out the GOP proposal to roll back Medicaid expansion could hurt some young, single adults. The proposed tax credit might help others.

“For some young people, [the tax credit] may be more than what they received under the ACA,” she said. “But for a lot of the low-income young people, they could see reductions in that subsidy.”

What concerns Mishory most is the Republican provision that insurance companies could charge customers 30 percent more for a plan if their coverage lapses.

“Young people are the most likely to see gaps in coverage,” she said. That’s because young adults move and change jobs a lot. They also tend to have lower incomes [than their elders], so the penalty might discourage millennials, especially healthy ones, from enrolling in coverage again.

Molly Tracy, 25, is in a different category than Franco: She’ll buy insurance, penalty or not. But she worries the Republican model won’t be affordable.

“I’m not rich! I work in public education,” said Tracy, who works in a charter school. “So even if I do have coverage, having a $3,000 medical bill … that’s going to pose a significant challenge for me.”

Right now, Tracy is covered by her father’s health insurance. But her 26th birthday is coming soon, “so I’m trying to get a tonsillectomy before my insurance lapses. That’s one of the issues. The other issue is scheduling, having enough time to recover.”

When Tracy does get her own health insurance through work this fall, she wants to know what she will be getting. Will birth control remain affordable? Will mental health care be covered? A Congressional Budget Office analysis finds that people like Tracy might end up paying much more out-of-pocket for those benefits than they do now.

This story is part of a partnership that includes Rhode Island Public Radio, NPR and Kaiser Health News.

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

A Fact Check Finds Many Misleading Letters From Lawmakers On Health Care

When Louisiana resident Andrea Mongler wrote to her senator, Bill Cassidy, in support of the Affordable Care Act, she wasn’t surprised to get an email back detailing the law’s faults. Cassidy, a Republican who is also a physician, has been a vocal critic.

“Obamacare” he wrote in January, “does not lower costs or improve quality, but rather it raises taxes and allows a presidentially handpicked ‘Health Choices Commissioner’ to determine what coverage and treatments are available to you.”

There’s one problem with Cassidy’s ominous-sounding assertion: It’s false.

The Affordable Care Act, commonly called Obamacare, includes no “Health Choices Commissioner.” Another bill introduced in Congress in 2009 did include such a position, but the bill died — and besides, the job as outlined in that legislation didn’t have the powers Cassidy ascribed to it.

As the debate to repeal the law heats up in Congress, constituents are flooding their representatives with notes of support or concern, and the lawmakers are responding. We decided to take a closer look at these communications after finding misleading statements in an email Sen. Roy Blunt (R-Mo.) sent to his constituents and asked readers to send us communications they had received.

The resulting review of more than 200 such missives by ProPublica and its partners at Kaiser Health News, Stat and Vox found dozens of errors and mischaracterizations about the ACA and its proposed replacement. The legislators have cited wrong statistics, conflated health care terms and made statements that don’t stand up to verification.

It’s not clear if this is intentional, or if the lawmakers and their staffs don’t understand the current law or the proposals to alter it. Either way, the issue of what is wrong — and right — about the current system has become critical as the House prepares to vote on the GOP’s replacement bill Thursday.

“If you get something like that in writing from your U.S. senator, you should be able to just believe that,” said Mongler, 34, a freelance writer and editor who is pursuing a master’s degree in public health. “I hate that people are being fed falsehoods, and a lot of people are buying it and not questioning it. It’s far beyond politics as usual.”

Cassidy’s staff did not respond to questions about Mongler’s letter.

Political debates about complex policy issues are prone to hyperbole and health care is no exception. And to be sure, many of the assertions in the lawmakers’ letters are at least partially based in fact.

Democrats, for instance, have been emphasizing to their constituents that millions of previously uninsured people now have medical coverage thanks to the law. They say insurance companies can no longer discriminate against patients with pre-existing conditions. And they credit the law with allowing adults under age 26 to stay on their parents’ health plans. All true.

For their part, Republicans criticize the law for not living up to its promises. They say former President Barack Obama pledged that people could keep their health plans and doctors, and premiums would go down. Neither has happened. They also say that insurers are dropping out of the market and that monthly premiums and deductibles (the amount people must pay before their coverage kicks in) have gone up. All true.

But elected officials in both parties have distorted evidence and left out important context. Some statements were simply disingenuous. Others were whoppers. And while more Republicans fudged than Democrats, both had their moments.

“Do most people pay that much attention to what their congressman says? Probably not,” said Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, who served as an assistant Health and Human Services secretary from 2010 to 2012. “But I think misinformation or inaccurate information is a bad thing, and not knowing what you’re voting on is a really bad thing.”

We reviewed the emails and letters sent by 51 senators and 134 members of the House within the past few months. Here are some of the most-glaring errors and omissions:

Rep. Pat Tiberi, R-Ohio, incorrectly cited the number of Ohio counties that had only one insurer on the Affordable Care Act insurance exchange.

What he wrote: “In Ohio, almost one third of counties will have only one insurer participating in the exchange.”

What’s misleading: In fact, only 23 percent (less than one quarter) had only one option, according to an analysis by the Kaiser Family Foundation.

His response: A Tiberi spokesperson defended the statement. “The letter says ‘almost’ because only 9 more counties in Ohio need to start offering only 1 plan on the exchanges to be one third.”

Why his response is misleading: Ohio has 88 counties. A 10 percent difference is not “almost.”

Rep. Kevin Yoder, R-Kan., said that the quality of health care in the country has declined because of the ACA, offering no proof.

What he wrote: “Quality of care has decreased as doctors have been burdened with increased regulations on their profession.”

Why it’s misleading: Some data show that health care has improved since the passage of the ACA. Patients are less likely to be readmitted to a hospital within 30 days after they have been discharged, for instance. Also, payments have been increasingly linked to patients’ outcomes rather than just the quantity of services delivered. A 2016 report by the Commonwealth Fund, a health care nonprofit think tank, found that the quality care has improved in many communities following the ACA.

His response: None.

Rep. Anna Eshoo, D-Calif., misstated the percentage of Medicaid spending that covers the cost of long-term care, such as nursing home stays.

What she wrote: “It’s important to note that 60 percent of Medicaid goes to long-term care and with the evisceration of it in the bill, this critical coverage is severely compromised.”

What’s misleading: Medicaid does not spend 60 percent of its budget on long-term care. The figure is closer to a quarter, according to the Center on Budget and Policy Priorities, a liberal think tank. Medicaid does, however, cover more than 60 percent of all nursing home residents.

Her response: Eshoo’s office said the statistic was based on a subset of enrollees who are dually enrolled in Medicaid and Medicare. For this smaller group, 62 percent of Medicaid expenditures were for long-term support services, according to the Kaiser Family Foundation.

What’s misleading about the response: Eshoo’s letter makes no reference to this population, but instead refers to the 75 million Americans on Medicaid.

Rep. Chuck Fleischmann, R-Tenn., pointed to the number of uninsured Americans as a failure of the ACA, without noting that the law had dramatically reduced the number of uninsured.

What he wrote: “According to the U.S. Census Bureau, approximately thirty-three million Americans are still living without health care coverage and many more have coverage that does not adequately meet their health care needs.”

Why it’s misleading: The actual number of uninsured in 2015 was about 29 million, a drop of 4 million from the prior year, the Census Bureau reported in September. Fleischmann’s number was from the previous year.

Beyond that, reducing the number of uninsured by more than 12 million people from 2013 to 2015 has been seen as a success of Obamacare. And the Republican repeal-and-replace bill is projected to increase the number of uninsured.

His response: None.

Rep. Joseph P. Kennedy III, D-Mass., overstated the number of young adults who were able to stay on their parents’ health plan as a result of the law.

What he wrote: The ACA “allowed 6.1 million young adults to remain covered by their parents’ insurance plans.”

What’s misleading: A 2016 report by the U.S. Department of Health and Human Services, released during the Obama administration, however, pegged the number at 2.3 million.

Kennedy may have gotten to 6.1 million by including 3.8 million young adults who gained health insurance coverage through insurance marketplaces from October 2013 through early 2016.

His response: A spokeswoman for Kennedy said the office had indeed added those two numbers together and would fix future letters.

Rep. Blaine Luetkemeyer, R-Mo., said that 75 percent of health insurance marketplaces run by states have failed. They have not.

What he said: “Nearly 75 percent of state-run exchanges have already collapsed, forcing more than 800,000 Americans to find new coverage.”

What’s misleading: When the ACA first launched, 16 states and the District of Columbia opted to set up their own exchanges for residents to purchase insurance, instead of using the federal marketplace, known as Healthcare.gov.

Of the 16, four state exchanges, in Oregon, Hawaii, New Mexico, and Nevada, failed, and Kentucky plans to close its exchange this year, according to a report by the House Energy and Commerce Committee.  While the report casts doubt on the viability of other state exchanges, it is clear that three-quarters have not failed.

His response: None.

Rep. Dana Rohrabacher, R-Calif., overstated that the ACA “distorted labor markets,” prompting employers to shift workers from full-time jobs to part-time jobs.

What he said: “It has also, through the requirement that employees that work thirty hours or more be considered full time and thus be offered health insurance by their employer, distorted the labor market.”

What’s misleading: A number of studies have found little to back up that assertion. A 2016 study published by the journal Health Affairs examined data on hours worked, reason for working part time, age, education and health insurance status. “We found only limited evidence to support this speculation” that the law led to an increase in part-time employment, the authors wrote. Another study found much the same.

In addition, PolitiFact labeled as false a statement last June by Donald Trump in which he said, “Because of Obamacare, you have so many part-time jobs.”

His response: Rohrabacher spokesman Ken Grubbs said the congressman’s statement was based on an article that said, “Are Republicans right that employers are capping workers’ hours to avoid offering health insurance? The evidence suggests the answer is ‘yes,’ although the number of workers affected is fairly small.”

We pointed out that “fairly small” was hardly akin to distorting the labor market. To which Grubbs replied, “The congressman’s letter is well within the range of respected interpretations. That employers would react to Obamacare’s impact in such way is so obvious, so nearly axiomatic, that it is pointless to get lost in the weeds,” Grubbs said.

Rep. Mike Bishop, R-Mich., appears to have cited a speculative 2013 report by a GOP-led House committee as evidence of current and future premium increases under the ACA.

What he wrote: “Health insurance premiums are slated to increase significantly. Existing customers can expect an average increase of 73 percent, while the average change due to Obamacare for those purchasing a new plan will be a 96 percent increase in premiums. The average cost for a new customer in the individual market is expected to rise $1,812 per year.”

What’s misleading: The figures seem to have come from a report issued before the Obamacare insurance marketplaces launched and before 2014 premiums had been announced. The letter implies these figures are current. In fact, premium increases by and large have been moderate under Obamacare. The average monthly premium for a benchmark plan, upon which federal subsidies are calculated, increased about 2 percent from 2014 to 2015; 7 percent from 2015 to 2016; and 25 percent this year, for states that take part in the federal insurance marketplace.

His response: None

Rep. Dan Newhouse, R-Wash., misstated the reasons why Medicaid costs per person were higher than expected in 2015.

What he wrote: “A Medicaid actuarial report from August 2016 found that the average cost per enrollee was 49 percent higher than estimated just a year prior — in large part due to beneficiaries seeking care at more expensive hospital emergency rooms due to difficulty finding a doctor and long waits for appointments.”

What’s misleading: The report did not blame the higher costs on the difficulty patients had finding doctors. Among the reasons the report did cite: patients who were sicker than anticipated and required a raft of services after being previously uninsured. The report also noted that costs are expected to decrease in the future.

His response: None

Sen. Dick Durbin, D-Ill., wrongly stated that family premiums are declining under Obamacare.

What he wrote: “Families are seeing lower premiums on their insurance, seniors are saving money on prescription drug costs, and hospital readmission rates are dropping.”

What’s misleading:  Durbin’s second and third points are true. The first, however, is misleading. Family insurance premiums have increased in recent years, although with government subsidies, some low- and middle-income families may be paying less for their health coverage than they once did.

His response:  Durbin’s office said it based its statement on an analysis published in the journal Health Affairs that said that individual health insurance premiums dropped between 2013 and 2014, the year that Obamacare insurance marketplaces began. It also pointed to a Washington Post opinion piece that said that premiums under the law are lower than they would have been without the law.

Why his response is misleading:  The Post piece his office cites states clearly, “Yes, insurance premiums are going up, both in the health-care exchanges and in the employer-based insurance market.”

Rep. Susan Brooks, R-Ind., told constituents that premiums nationwide were slated to jump from 2016 to 2017, but failed to mention that premiums for some plans in her home state actually decreased.

What she wrote: “Since the enactment of the ACA, deductibles are up, on average, 63 percent. To make matters worse, monthly premiums for the “bronze plan” rose 21 percent from 2016 to 2017. … Families and individuals covered through their employer are forced to make the difficult choice: pay their premium each month or pay their bills.”

What’s misleading:  Brooks accurately cited national data from the website HealthPocket, but her statement is misleading. Indiana was one of two states in which the premium for a benchmark health plan — the plan used to calculate federal subsidies — actually went down between 2016 and 2017. Moreover, more than 80 percent of marketplace consumers in Indiana receive subsidies that lowered their premium costs. The HealthPocket figures refer to people who do not qualify for those subsidies.

Her response: Brooks’ office referred to a press release from Indiana’s Department of Insurance, which took issue with an Indianapolis Star story about premiums going down. The release, from October, when Vice President Mike Pence was Indiana’s governor, said that the average premiums would go up more than 18 percent over 2016 rates based on enrollment at that time. In addition, the release noted, 68,000 Indiana residents lost their health plans when their insurers withdrew from the market.

Why her response is misleading: For Indiana consumers who shopped around, which many did, there was an opportunity to find a cheaper plan.

Sen. Ron Wyden, D-Ore., incorrectly said that the Republican bill to repeal Obamacare would cut funding for seniors in nursing homes.

What he wrote: “It’s terrible for seniors. Trumpcare forces older Americans to pay 5 times the amount younger Americans will — an age tax — and slashes Medicaid benefits for nursing home care that two out of three Americans in nursing homes rely on.”

What’s misleading: Wyden is correct that the GOP bill, known as the American Health Care Act, would allow insurance companies to charge older adults five times higher premiums than younger ones, compared to three times higher premiums under the existing law. However, it does not directly slash Medicaid benefits for nursing home residents. It proposes cutting Medicaid funding and giving states a greater say in setting their own priorities. States may, as a result, end up cutting services, jeopardizing nursing home care for poor seniors, advocates say, because it is one of the most-expensive parts of the program.

His response: Taylor Harvey, a spokesman for Wyden, defended the statement, noting that the GOP health bill cuts Medicaid funding by $880 billion over 10 years and places a cap on spending. “Cuts to Medicaid would force states to nickel and dime nursing homes, restricting access to care for older Americans and making it a benefit in name only,” he wrote.

Why his response is misleading: The GOP bill does not spell out how states make such cuts.

Rep. Derek Kilmer, D-Wash., misleadingly said premiums would rise under the Obamacare replacement bill now being considered by the House.

What he wrote: “It’s about the 24 million Americans expected to lose their insurance under the Trumpcare plan and for every person who will see their insurance premiums rise — on average 10-15 percent.”

Why it’s misleading: First, the Congressional Budget Office did estimate that the GOP legislation would cover 24 million fewer Americans by 2026. But not all of those people would “lose their insurance.” Some would choose to drop coverage because the bill would no longer make it mandatory to have health insurance, as is the case now.

Second, the budget office did say that in 2018 and 2019, premiums under the GOP bill would be 15 to 20 percent higher than they would have been under Obamacare because the share of unhealthy patients would increase as some of those who are healthy drop out. But it noted that after that, premiums would be lower than under the ACA.

His response: None.

Have you corresponded with a member of Congress or senator about the Affordable Care Act? We’d love to see the response you received. Please fill out our short form.

Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization based in New York City.

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

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By Decade’s End, California Estimates It Would Lose $24 Billion Annually Under GOP Health Plan

California would lose $24.3 billion annually in federal funding by 2027 for low-income health coverage under the current Republican plan to replace the Affordable Care Act, according to a state analysis released Wednesday.

The bill, up for a vote in the House on Thursday, represents a “massive and significant fiscal shift” from the federal to state governments by setting caps on Medicaid spending, reducing the amount of money available for new enrollees and eliminating other funding for hospitals and Planned Parenthood, the analysis said.

“It’s really devastating,” said Mari Cantwell, state Medicaid director with the California Department of Health Care Services, who co-wrote the analysis. “It raises some serious questions about whether we can continue to operate the program the way we do today.”

Her boss, department director Jennifer Kent, went further:  “It’s challenging to see how it would not … jeopardize the entire program.”

The analysis, based on internal cost, utilization and enrollment data, was done by the health care services department and the Department of Finance and was shared with California’s congressional delegation.

In 2020 alone, the analysis estimated, the state would lose $6 billion; by 2027, the annual loss would reach $24.3 billion.

Kent said that when faced with shortfalls in the past, the state has made cuts to optional benefits such as adult dental care. The state also could set lower provider rates, or restrict who is eligible. “These are all decisions that California and other states would have to grapple with in the future if this were to be adopted as it is proposed today,” she said.

The impact would vary, of course, depending on the state’s fiscal health.

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The Republican bill, called the American Health Care Act, would dramatically change funding for the Medicaid program, known as Medi-Cal in California. Since its inception, Medicaid funding to states has been open-ended, based on need. Under the new bill, federal money would be capped either through block grants or fixed per-capita amounts.

The Affordable Care Act allowed states to expand their Medicaid programs in 2014 to low-income childless adults, and the federal government is paying nearly all the costs for those new beneficiaries. The new bill would scale the expansion back.

Sally Pipes, president of the San Francisco-based Pacific Research Institute, said the expansion of Medicaid was too costly and should have never been included in the ACA. “These programs are not sustainable, unless you are going to tremendously increase taxes on the middle class,” she said.

Pipes said Medicaid funding should be converted from entitlements into block grants and states should be left to decide how to structure their programs. “More and more people are thinking they are entitled to this and entitled to that and these programs are expensive and not efficient,” she said.

The cuts to Medi-Cal and the restructuring of the program will be better for the California economy, Pipes said.

Meanwhile, Gov. Jerry Brown, who was attending an anniversary celebration for the Affordable Care Act in Washington, D.C., had sharp words Wednesday for President Donald Trump and what he called his “fake health care bill.”

“In California, we’re not talking about a few thousand – we’re talking about millions of real people getting hurt – getting diseases that will not be cured – having heart attacks, not being able to go to a hospital or get a doctor,” the governor said in his prepared remarks.

California was among the most aggressive states in the nation in implementing the Affordable Care Act, and the majority of new enrollees came through Medi-Cal.

Medi-Cal now provides coverage to 13.5 million low-income residents, about half of California’s children and a third of the adults. About 3.7 million people of those became newly eligible for the publicly funded health coverage through the Medcaid expansion. That helped reduce the state’s uninsurance rate from 17 percent in 2013 to about 7 percent in 2016, according to the UC Berkeley Labor Center for Education and Research.

The Medicaid program is funded jointly by California and the federal government and provides health, dental, mental health, long-term care and other services.

The bill could put hospitals, clinics and other providers in a tenuous financial position by forcing them to live within the cost limits while at the same time seeing more uninsured patients, the analysis said.

The California Hospital Association did its own analysis and concluded that at least three million people would lose coverage under the GOP plan, and hospitals could see their bad debt and charity care increase by $3 billion per year.

“As more people lose coverage, they are still going to have health issues, and the hospital is the only place in the health care system required under federal law to provide care,” said Jan Emerson-Shea, vice president of external affairs for the association.

Health officials estimated that Medi-Cal costs would exceed per-capita caps by nearly $680 million in 2020, with the gap growing to $5.28 billion by 2027. That spending limit could have a “devastating and chilling effect” on any increases in provider payments or plan rates, according to the analysis.

The state also expects an additional $3.3 billion in costs in 2020, growing to $13 billion by 2027, because of a change that reduces federal funds for new enrollees and for people who have a break in coverage. The bill would require certain beneficiaries to renew coverage every six months rather than once a year, which state officials say will cause many to lose their coverage.

According to the analysis, the state would face additional losses from other federal cuts, including to a program that pays for in-home care for elderly and disabled residents. In addition, the proposed freeze on federal funding to organizations that provide abortions would make the state responsible for $400 million in payments to Planned Parenthood, which serves more than 600,000 people in Medi-Cal and a state family planning program.

A new study by UC Berkeley’s Labor Center released Wednesday also warned of dramatic cuts in federal Medi-Cal funding that would threaten coverage for low-income adults. The center estimated that the state would have to increase spending by $10 billion each year to maintain coverage for those who became eligible for coverage under the Affordable Care Act. Without that funding, the researchers wrote, 3.7 million people could lose coverage by 2027.

Ken Jacobs, chair of the center, said the Republican plan would also result in job losses because of reduced federal funding. Jacobs said both the center’s and the state’s calculations point to a significant financial impact on California if the GOP bill becomes law.

“It’s hard to see where else in the state budget this could be pulled from,” he said. “This would be a very big hit on the budget, the health system and the economy of California. … And the implications for people’s health are serious.”

 

This story was updated.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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Medicaid Caps Pitched By GOP Could Shrink Seniors’ Benefits

Before nursing home patient Carmencita Misa became bedridden, she was a veritable “dancing queen,” says her daughter, Charlotte Altieri.

“Even though she would work about 60 hours a week, she would make sure to go out dancing once a week — no matter what,” Altieri, 39, said. “She was the life-of-the-party kind of person, the central nervous system for all her friends.”

A massive stroke in March 2014 changed all that. It robbed Misa, 71, of her short-term memory, her eyesight and her mobility — and it left her dependent on a feeding tube for nourishment. Altieri, who has two small children, is unable to provide the 24-hour care her mother now gets at a Long Beach, Calif., nursing home three miles away — all of it paid by Medi-Cal, California’s version of the Medicaid program for low-income people.

But advocates for the elderly now worry that Misa and other low-income seniors who receive long-term care in facilities or at home could see their benefits shrink or disappear under Republican-proposed legislation to cap federal Medicaid contributions to states. The proposal is part of a broader GOP plan to repeal and replace former President Barack Obama’s Affordable Care Act.

“My mom is getting the basic of basic care,” Altieri said. “If they cut it, I don’t know what to do.”

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Nationwide, Medicaid provides long-term care and support to more than 2 million low-income seniors. The program, funded jointly by the federal government and the states, pays more than half of all long-term care in the country — “more than Medicare, private long-term care insurance and out-of-pocket spending combined,” said Matt Salo, executive director of the National Association of Medicaid Directors.

And, he said, it’s the only public program that offers such care on an ongoing basis. The Medicare program — for people 65 and older — provides only limited long-term care to those who need it after being hospitalized.

The GOP bill, scheduled for a vote on the floor of the House on Thursday, would transform Medicaid from an open-ended system, in which the federal government matches state spending, to one in which it provides a fixed amount to each state, either through a lump-sum payment or on a per-capita basis.

In an attempt to overcome opposition to the bill among some Republicans, GOP leaders agreed Monday to add the option of a lump-sum payment, known as a block grant.

They also amended the bill to allocate additional money for elderly and disabled people on Medicaid. But Eric Carlson, a directing attorney in the Los Angeles office of the nonprofit group Justice in Aging, said such an allocation would not offset the wide funding gap created by caps on federal spending.

“It doesn’t matter whether it’s a block grant or per-capita cap,” Carlson said. “Either way the federal government is setting a hard limit on federal funding available, and states are going to be forced to make due with whatever is sent to them, and it’s not going to be enough.”

Carlson is co-author of a paper released by Justice in Aging that says capping federal Medicaid spending, with either per-capita funding or block grants, would harm older Americans, in part by forcing states to cut services for them “to the bone.”

“Federal payment for Medicaid would drop sharply, resulting in fewer services for everyone who relies on Medicaid, including older adults who account for over 22 percent of all Medicaid spending,” the report predicted.

In 2015, Medicaid spending topped $552 billion nationwide, including more than $85 billion spent on Medi-Cal enrollees, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Under the GOP proposal, nursing care in a facility would remain a guaranteed Medicaid benefit, though states could reduce how much they spent on it if they were forced to economize. And Republicans might well attempt to loosen or undo federal program requirements with subsequent legislation that would give states more control.

Such a shift would “decimate Medicaid’s current guarantee of adequate and affordable care,” according to the Justice in Aging paper.

In the meantime, states could do away with benefits not guaranteed under federal law, which include at-home nursing, personal care — which Medi-Cal covers for qualified beneficiaries — and even inpatient and nursing care in mental health facilities for the elderly.

A report released last week by the nonpartisan Congressional Budget Office suggests states might cut provider payments or eliminate some of their optional services to fill the funding gap left by the restricted flow of federal money.

Oren Cass, a senior fellow with the Manhattan Institute who specializes in anti-poverty law, doesn’t believe that means the GOP plan would necessarily harm elderly Medicaid beneficiaries.

“A state that wants to continue the spending it does on the elderly can do that if it would rather make cuts elsewhere,” he said. “Or it can put up more of its own money.”

Cass said that having more flexibility might appeal to California legislators and health care leaders.

“If you ask California today whether it would rather have Donald Trump run its Medicaid program or run it itself, I think most people there, especially liberal people, would say they would rather have the state making the rules,” he said.

For now, however, the debate over the GOP bill is largely speculative, since there may be enough Republicans with serious concerns about the legislation to sink or significantly amend it.

The CBO report shows the bill would reduce federal budget deficits by a cumulative $337 billion over a decade. The CBO also projected that the bill, if passed, would leave 14 million more people uninsured next year than under current law and 24 million more by 2026.

The cost savings may not be enough to overcome the reluctance of many conservative Congress members who call the bill “Obamacare Lite” because it retains some of the most popular features of the Affordable Care Act.

As the debate heats up in Washington, Charlotte Altieri of Long Beach remains hopeful that her mother’s nursing home care will be spared any cuts.

“We’re not at some grandiose nursing home right now,” she said, “Where are we going to find one that costs less than this one?”

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

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

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A Young Man With Parkinson’s Frets Over The Affordability Of GOP Health Plan

Many millennials have their hands full as they launch into adulthood — jobs, homes and partners. But Ford Inbody, 33, already thinks about a time when he won’t be able to work. He has Parkinson’s disease.

Every night after work, he and his wife, Cortney, walk their two dogs through their Overland Park, Kan., neighborhood. For now, going out for an evening’s stroll is easy. But many of their evening conversations revolve around a time they know is coming — when these walks will prove difficult.

Inbody was diagnosed with young-onset Parkinson’s disease three years ago. When he was 25, he started noticing confusing health symptoms like joint stiffness, tremors and loss of smell. He said initially he was relieved to get a definitive diagnosis.

But, he said, “I then started doing more research about it; that’s when it became a little bit scary. There is no cure. There is no way to slow the progression of the disease. There’s nothing really except just symptom management.”

Since the diagnosis, the couple has had to dramatically rethink their future.

“We had to very much start considering life planning,” he said. “We had to make sure, you know, are we going to have enough income?”

They’re not planning to have kids and are bracing for a much more modest lifestyle than they once imagined. They live now with Ford’s grandmother, to save money for the day when the degenerative disease will eventually force him to stop working.

For now he gets health insurance through his job at a law firm, training attorneys on corporate policies. But Ford and Cortney worry about how his condition will progress and how they’ll pay for health care when he can no longer work.

Cortney works in the human resources department for a chocolatier. It is possible Ford could go on her insurance, but when they first ran the numbers, that was prohibitively expensive. So they thought Ford would get private insurance at a reasonable price despite his condition on the Affordable Care Act exchange; then he’d probably transition to Medicaid when his condition gets bad enough. That’s been his plan.

Ford, now 33, was diagnosed with young-onset Parkinson’s disease three years ago. He and Cortney savor his relatively good health today. But the disease is degenerative, which means they’ll likely need an individual health policy one day soon and will eventually turn to Medicaid. (Alex Smith/KCUR)

But ever since the election, he’s been preoccupied with the developments of repeal and replace.

It’s a constant concern, he said — “reading the news every day, checking out all the different stories that are going on.”

Inbody read every word of the original GOP replacement plan, released March 6. He was somewhat relieved to see that, at least so far, it includes the requirement that insurance companies cover preexisting conditions in every plan on the exchange.

“It’s not like a complete ‘all is lost’ situation,” he said. “And I certainly am not jumping from the roof and concerned that Republicans are trying to doom me to a life of no care.”

But he does have questions about how the overhaul of the health law will play out, in terms of his situation. Chris Sloan, a senior manager with the research and consulting firm Avalere Health, said it’s true Inbody would be able to get some sort of insurance policy, regardless. But there’s a big difference between how the new tax credits he’d get under the GOP plan would compare with the ACA subsidies to help pay for insurance costs.

“The changes to the tax credits and to the subsidies available could mean that he’s going to have to pay more,” Sloan said. “Depending on his finances, some of those changes could mean that he has to pay a lot more to get coverage on the individual market.”

Today, the annual ACA subsidies are based on income and the cost of coverage in each region. Under the GOP proposal, Inbody and his wife would, instead, get a flat $5,000 per year to help pay for health insurance coverage for them both. So when Inbody stops working and the couple’s income is much lower, they won’t get extra help in the GOP plan to pay for monthly health insurance premiums.

That’s not all. Sloan explains that, under the GOP plan, some extra help for out-of-pocket costs will disappear.

“With this new proposal, that just doesn’t exist anymore,” he said.

Sloan said there’s also nothing in the new plan to stop another problem — many exchange policies cover fewer medications than employer-based plans, and the networks of doctors and hospitals are getting narrower.

The bill also proposes drastic changes to Medicaid. Inbody could very well end up on Medicaid — it’s the insurance many people with disabilities rely on.

The Republican plan would limit how much money states get for each Medicaid recipient. And though that amount would go up each year, the increase would be based on overall inflation, not the increase in medical costs. So eventually, Sloan said, the federal government would be giving states a lot less money, relative to the cost of health care.

“Then the state has to make a decision. In Kansas’ case, they’ll have to say, ‘How do we make up that difference?’” Sloan said. “They can say, ‘You know what, we’re just going to reduce eligibility. Previously, we gave Medicaid to people up to this income. Now we’re going to take that — a little bit — because we need the money. So we’ll save money by not covering these people.’”

For example, consider Inbody’s case. Restricting eligibility for Medicaid, under the GOP plan, could mean it will be harder for Inbody to get that coverage, Sloan said. Then, “even if he gets Medicaid down the line, how generous are the benefits? Do they cover everything that he needs for his Parkinson’s condition?”

Inbody has hope that whatever legislation is ultimately passed will help him and others with their health problems. But the politics frustrates him.

“The Republicans, they want it their way,” Inbody said. “And the Democrats are going to do everything they can to refuse a Republican victory. And really, what that means in the end is something completely ineffectual that doesn’t really help anybody is going to get passed — and nobody’s really going to be happy about it.”

For now, Inbody said, he’s enjoying the health he has. He and Cortney headed out last weekend on a Colorado road trip.

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

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

GOP Recycles Controversial 2003 Bill To Boost Small-Business Insurance

In a bid to improve the health insurance purchasing clout of small businesses, Republicans have dusted off a piece of controversial legislation more than a decade old and reintroduced it as part of their effort to remake the market after they throw out the Affordable Care Act.

The earlier bill, which passed the House in 2003 but didn’t advance, was widely panned by groups representing consumers, providers, the health insurance industry and state officials. At the time, they argued that it would do little to enhance the coverage options or control costs of many small businesses, especially those that employ older, sicker workers, while at the same time weakening consumer protections against plan insolvency and fraud.

Health policy experts say there’s no reason to change that assessment now.

“It was a bad idea in 2003, and it’s a worse idea today,” said Timothy Jost, an emeritus professor at Washington and Lee University School of Law in Virginia who is an expert on the health law.

Michelle AndrewsInsuring Your Health

The bill would allow the establishment of nationwide “association health plans” that could be offered by professional or trade groups, chambers of commerce and the like. Small businesses could buy coverage through these associations, in theory gaining strength in numbers to enhance their bargaining leverage with insurers, leading to cheaper, better coverage and lower administrative costs.

The Small Business Health Fairness Act of 2017 is slated to head to the House floor this week. Speaker Paul Ryan (R-Wis.) has expressed enthusiasm for association health plans and said he intends to move the legislation in tandem with the reconciliation bill that would unwind budget-related provisions of Obamacare, another name for the ACA.

Several business groups, including the National Retail Federation and the U.S. Chamber of Commerce, support the bill, hoping that it will encourage more small businesses to offer their employees coverage.

“We don’t think it’s going to be the panacea to solve all our members’ issues, but we view it as a valuable option,” said Kevin Kuhlman, director of government relations for the National Federation of Independent Business, a trade group and supporter of the bill. NFIB members, he said, “want a little more ability to design their own options and less responsibility to conform to federal requirements.”

The idea isn’t new. Association health plans have existed for decades. But they often escaped close supervision because neither states nor the federal government had clear regulatory authority over them. In the 1970s and ’80s, there were cases of fraud and insolvency that raised concerns about the model. Some multiple-employer purchasing groups went belly up and left consumers and providers with millions in unpaid claims.

So Congress amended federal law to allow states to regulate these plans. When the ACA passed in 2010, the Obama administration required that association health plans meet the new small-group standards: They had to cover the 10 essential health benefits, for example, and couldn’t charge older people premiums that were more than three times higher than those of younger people.

The new bill would change all that. It would eliminate most state regulation of association health plans and put oversight in the hands of the federal Department of Labor, which would certify them.

The ACA requirements that apply to all plans, like the prohibition on lifetime and annual coverage limits, would apply to association health plans as well, said Kevin Lucia, a research professor at Georgetown University’s Center on Health Insurance Reforms. But the ACA’s small-group requirements would not. Plans could offer stripped-down coverage and would have more latitude in setting premiums than regular plans in the small-group market. They could operate in multiple states and generally avoid state-mandated benefits and other state insurance rules.

Under the Republican bill, association health plans still couldn’t discriminate against individuals based on their health, but they could charge higher premiums to companies with sicker workers. So association health plans would likely appeal to employers with younger, healthier workers who would qualify for lower rates and not be troubled by skimpier coverage. That could draw those businesses away from state-regulated health plans, which would be left with sicker, costlier enrollees, creating an uneven playing field and a segmented market.

“If you’re a healthy small employer and you’re allowed to escape all these rules, you may be able to have lower premiums, until someone in your group gets sick,” said Lucia.

Solvency is a real concern as well, say experts, since the federal standards in the bill are generally less rigorous than state rules.

The flexibility that GOP lawmakers see in the bill might not serve workers well, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

“Right now there’s a fairly consistent set of rules of what a small group or individual plan has to look like in terms of benefits, costs and coverage,” she said. “If we’re talking about a world where none of that exists anymore or an association health plan is outside of those standards, then as a consumer you’re dealing with a very confusing situation.”

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

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

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Low-Income AIDS Patients Fear Coverage Gains May Slip Away

When Tami Haught was diagnosed with HIV, she was one day shy of her 25th birthday. The diagnosis did not come as a shock since doctors had determined her fiancé was dying of AIDS several weeks earlier.

In the two decades since, Haught, 48, has turned to expensive prescription drugs to keep the deadly infection in check. In 2005, she began receiving help purchasing her medications through the AIDS Drug Assistance Program (ADAP), a federally funded network of programs in each state that assist low-income HIV and AIDS patients. Since the Affordable Care Act was implemented, ADAP instead has helped her buy an insurance policy to cover a wide assortment of her health care needs.

Nationally, more than 139,000 clients were served by ADAPs in June 2015, according to the latest report from the National Alliance of State and Territorial AIDS Directors (NASTAD), a coalition of state officials responsible for administering HIV and hepatitis programs. About half of those clients were getting help purchasing insurance through the federal health law’s marketplaces or elsewhere, a switch from the program’s historical role of paying primarily for expensive prescriptions.

Advocates fear Republican plans to overhaul the health law could cause such upheaval in the individual insurance market that the program could not afford to continue the premium assistance and would be forced to turn primarily back to subsidizing medication.

“We are at a pivotal point in HIV where people are talking about the end of the epidemic,” said Ann Lefert, senior director of the prevention and care program and policy at NASTAD. “It’s hard to imagine that, if the health care coverage changes dramatically — it would be hard to get there in the same speed.”

According to the AIDS directors’ report, in June 2015, about 72,000 got help paying for their insurance, including nearly 4,000 who also received assistance to purchase medication. That’s more than twice as many as got insurance help in 2010, when the health law was passed.

Tami Haught, who was infected with HIV 23 years ago, now gets help paying for her insurance through the AIDS Drug Assistance Program. She worries that changes in the health law could cut back that help. (Courtesy of Tami Haught)

To qualify for ADAP assistance, prospective clients must meet standards determined by the state. Individuals must prove their residency and recertify every six months. NASTAD reported more than 70 percent of clients served by ADAP in June 2015 reached viral load suppression, or undetectable levels of HIV in the blood. By comparison, only 3 of 10 people living with HIV in the U.S. reached suppression in 2011, the Centers for Disease Control and Prevention reported.

ADAP is required to choose the most cost-effective way to assist clients. Currently, that option often is financial assistance for purchasing an insurance plan that covers broad health expenses. But before the ACA, when insurance companies could legally exclude customers with preexisting conditions or charge them very high premiums, buying insurance was difficult for HIV patients.

Consequently, the program focused primarily on helping patients buy the pricey drugs they needed. It struggled to meet that demand, however, often using waiting lists to determine which low-income clients could be helped. At its peak, 9,278 individuals waited to access ADAP services, according to NASTAD. The program eventually eliminated the waiting list in 2013.

For many of those low-income patients, it was the only help available, given they weren’t eligible in many states for Medicaid, which generally limited eligibility to children, very-low-income families and people with debilitating conditions.

“Most people had to be disabled in order to get access to Medicaid services, even though the treatments that became available in the 1990s prevented you from being disabled,” said Jeffrey Levi, a health management and policy professor at George Washington University in Washington, D.C.

But the ACA’s provisions — principally, the Medicaid expansion undertaken by 31 states and the District of Columbia; subsidies for low-income people buying plans on the insurance marketplace; and consumer insurance protections —enabled ADAP to spend less on purchasing drugs and use its funds more efficiently to help clients buy coverage. They could use the assistance to pay the portion of premiums not covered by federal tax subsidies and expenses not picked up by their plans, such as deductibles and copayments.

The NASTAD report also found that ADAP paid an average of $1,678 per client for medications in June 2015. In contrast, the program contributed an average $444 to health plans for clients. Some insured clients, however, also received help paying for medication.

While Lefert said she doesn’t anticipate waiting lists returning to ADAP if the health law is partially repealed, other experts worry about how far existing funds can be stretched.

“Now you’re going to have a bunch of people rushing back to the [ADAP] pool with not enough dollars to cover them all,” said Matthew Rose, policy and advocacy manager for the National Minority AIDS Council.

Changes to the health law could interrupt treatment and lead to gaps in care, said Erin Loubier, senior director for health and legal integration and payment innovation at the Whitman-Walker Health clinic in Washington, D.C. And without protections from discrimination based on preexisting conditions, she said, people could shirk screening for fear of losing their jobs or health insurance.

Haught, of Nashua, Iowa, now works as a training coordinator for the SERO Project, an advocacy group fighting against HIV criminalization laws around the nation. Haught said she’s surprised that she’s lived 23 years past her diagnosis, which allowed her to see her son graduate and spend time with her grandson, Chase. Taking her medication is critical.

“I will die if I don’t have access to my medication and treatment, and it’s not pretty,” she said. “I’ve seen it. It’s not an easy death.”

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

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I Do … Take You To Be My Lawfully Covered Health Care Dependent

“This is a first for me,” said Rabbi Andy Dubin, as he sat down on a collapsible chair opposite Ann Justi and Don Boyer.

The trio was in the compact living room of Boyer’s apartment in Yonkers, N.Y., standing between the sofa, TV and writing desk. Dubin was in his socks, having shed his snow-caked boots in the hallway.

Boyer and Justi were getting married. Never mind the blizzard-like conditions that kept one set of friends home, and a bad cold that waylaid another. They were determined to tie the knot that afternoon. So they recruited their landlord from downstairs and a public radio reporter to be witnesses.

Why the rush? Boyer and Justi had been listening to the news. They were planning to get married in the fall, but it occurred to them that there’s no knowing what could happen to health insurance if the Trump administration and congressional Republicans dismantle the Affordable Care Act.

Justi has several preexisting conditions — osteoporosis, asthma, allergies and vitamin B-12 malabsorption — and the insurance she carried over from her previous job will expire this summer. She had employer-based insurance for more than a decade but was laid off last year.

Justi and Boyer knew they could wait until the spring to get married, and she then could go on the health plan he receives as a concierge for a residential building — it’s a union job, and the health insurance is good. But Boyer worries about Republicans unspooling crucial Obamacare safeguards.

“There’s so much uncertainty as far as what’s going to be law tomorrow, what’s going to be law next month,” he said. “Nobody really knows, unfortunately.”

Much of the focus in the “repeal and replace” debate has been on the 20 million Americans who have received coverage via state and federal health insurance exchanges and Medicaid expansion. But most Americans still get coverage from employers, and their plans now have protections that could also be rolled back.

Under the Affordable Care Act, private insurers can no longer reject people with preexisting conditions, or charge them more for their insurance. As of now, the GOP plan moving through Congress also would require that people with preexisting conditions be able to get health insurance.

But there are other factors that could make that insurance much more expensive — such as the applicant’s age and the lack of a mandate, under the GOP plan, that everyone have health insurance. If you get rid of the mandate, many health care analysts say, it’s likely that the people buying that insurance would mostly be sick — further driving up the cost of the insurance, and driving out of the insurance pool the healthy, younger people who tend to bring down the cost of the insurance.

Justi’s current situation of having temporary insurance with an expiration date — instead of being on a stable health plan that can’t kick her off — takes her back to an earlier, uglier time in her life.

“Before the Affordable Care Act, I went from one employer to another, and the new employer’s insurance didn’t cover my preexisting conditions for a year, and that nearly bankrupted me,” she said.

So Justi and Boyer decided to get legally married as soon as possible, and have a more ceremonial, celebratory wedding in the fall. They found Rabbi Dubin online, on a list of licensed local wedding officiants. They warmed to his profile, even though neither is Jewish.

The service in their living room proved relaxed but formal. Dubin wore a suit, and both bride and groom were fashionably attired in black. Boyer sported a white rose boutonnière. Justi held a bouquet of white roses and calla lilies, their stems wrapped in silk. Dubin talked about marriage and commitment and faith. And he nodded to their need to protect themselves.

“Every marriage is important — but it’s also important because you are living in times, as we all are, when sometimes we have to take things into our own hands to make sure we come out all right on the other side,” he said.

For about 20 minutes, they discussed the journey behind the couple and the one ahead. Boyer and Justi read vows they’d written to each other, and then gave each other rings. Dubin declared, “By the authority vested in me by the state of New York, I now pronounce you, Don and Ann, husband and wife.”

They kissed, then signed some paperwork, raised a toast of sparkling water, took some smartphone pictures and embraced the rabbi.

They were beaming like newlyweds — albeit very practical newlyweds who were already planning next steps.

“As quickly as possible, I want to get you and this form down to the union headquarters tomorrow,” Boyer said.

And that was it. The landlord headed back downstairs. The rabbi and I headed out into the snow. And Justi and Boyer bundled up for a one-night honeymoon in a White Plains, N.Y., hotel. They said they’re prepared to face whatever comes next together — in sickness and in health.

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

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

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In Deep-Red Western N.C., Revered Congressman Leads Charge Against GOP Bill

HIGHLANDS, N.C. — In this corner of Appalachia, poverty takes a back seat to art galleries, country clubs, golf course communities, five-star restaurants and multimillion-dollar houses.

From this perch, Rep. Mark Meadows, a real estate entrepreneur who capitalized on the area’s transformation into a prosperous retirement and vacation community, rose to political power quickly. Now the conservative Republican leads the House Freedom Caucus, controlling between 30 and 40 votes in Congress and showing few qualms about endangering his party’s best chance to repeal the Affordable Care Act.

“I am willing to invest the political capital to get it right,” Meadows, who has called the GOP replacement “Obamacare Lite,” said Thursday on MSNBC. “The next week is critical.”

And on Saturday, Meadows went to President Donald Trump’s Mar-a-Lago Club in Florida to negotiate over the bill with Trump aides, along with with Sen. Ted Cruz (R-Texas) and Sen. Mike Lee (R-Utah).

Meadows’ confidence is warranted.

His gerrymandered district covers 17 counties, spanning 150 miles across western North Carolina. The populous liberal bastion of Asheville is mostly carved out of his district like a bite from a cookie. What’s left is a retiree-rich constituency of 750,000 people that is heavily Republican, mostly white and lives mainly in small, rural towns amid pockets of extreme wealth. Its survival could hinge on a Supreme Court ruling expected this year in a case alleging racial bias in the state Legislature’s 2011 redrawing of North Carolina’s congressional map.

Elected in 2012, Meadows, 57, has rebelled against the establishment Republican Party — helping shut down the government in 2013 and ousting Speaker John Boehner in 2015.

While Democrats and even moderate Republicans decry House Speaker Paul Ryan for cutting federal aid to help get people insured in the GOP bill, Meadows says the cuts don’t go deep enough. He vows to oppose any ACA replacement that does not bring down health costs for people and government. No such plan that actually controls costs is on the table, however.

Meadows wants to cut off all 10 million Americans who today get federal subsidies to buy health coverage, which he says the country can ill afford. With enough support, Meadows could either block the House leadership from passing its plan or force it to approve a more conservative replacement that would face little chance of getting through the more moderate Senate.

Meadows’ potential role as “Trumpcare” spoiler — is stirring concern in the White House and Congress. By Thursday, Meadows seemed to have gotten that message.

“The last thing I want is for the president to be mad at me,” Meadows told Politico. “He asked me to negotiate in good faith, so I have been working around the clock.”

A lake in Highlands, N.C., is pictured. (Phil Galewitz/KHN)

Meadows was absent, though, from a Friday meeting in the Oval Office with members of the Republican Study Committee, another group of conservative representatives, where Trump said he had secured enough votes to pass the House bill.

Meadows’ hard line doesn’t bother most folks back in western North Carolina, where Obamacare is unpopular. Only about 5 percent of those in his district receive government-subsidized health plans made available by the law.

Meadows, who now lives in West Asheville, moved to North Carolina from Tampa to raise a family in the 1980s. The proprietor of a small sandwich shop here in Highlands before he shifted to real estate, Meadows is revered by his constituents.

Even the local hospital industry — which typically opposes any effort to scale back the health law — remains firmly in Meadow’s corner.

“We are big fans of Mark. He’s a man of integrity and he has the heart,” said Jimm Bunch, CEO of Park Ridge Health, a 103-bed hospital in Hendersonville, N.C. He heaps praise on Meadows even as the congressman fights to eviscerate the law that helped the hospital achieve one of its best financial years ever. As more patients got insurance, Park Ridge gained $600,000 a year in funding it used to provide free care to other patients.

Jimm Bunch, CEO of Park Ridge Hospital in Fletcher, N.C. says the hospital made more money as a result of Obamacare subsidies but won’t bash the Meadows plan to take them away. (Phil Galewitz/KHN)

Because North Carolina did not expand Medicaid under Obamacare, many poor adults remained uninsured. The state’s uninsured rate fell from 20.4 percent in 2013 to 13.6 percent in 2016, 2.5 points higher than the national average, according to Gallup.

Small-business owners, who provide most jobs in the district, are reluctant to take on Meadows., who is seeking to eliminate their government assistance to get health coverage.

At Sanctuary Brewing in Hendersonville, co-owner Joe Dinan said the Obamacare coverage he bought this year helped him get skin cancer surgery on his head. “I don’t want to see the subsidy end,” Dinan said. He won’t say anything critical about Meadows though, demurring that Hendersonville is a small town.

Meadows insists no one will get left behind.

He wants to allow people to buy less-expensive policies with fewer benefits than now required under the ACA. His tax help would be in the form of deductions people take at the end of the year or a break on their payroll taxes — different than both the current law and the Trumpcare plan working its way through Congress now.

It worries Rachel Lewicki, 30, who works at the local tea and spice shop on Main Street in Highlands.

Lewicki recently had surgery for a uterine tumor, paid for by a subsidized health plan she bought under Obamacare that costs her less than $100 a month. Now she fears her good fortune will end. “It’s not fair,” she said. “The way things are going, I’m scared and so are a lot of people who need this help.”

Kent Loy, a volunteer at a thrift store in Hendersonville, speaks of Meadows in harsher, personal terms.

“It’s an attack on the poor and how someone who claims to be a Christian can take this behavior is beyond me,” said Loy, 71. “This should disqualify him from office.”

Joe Dinan, co-owner of Sanctuary Brewing in Hendersonville, used Obamacare subsidies to get coverage and deal with skin cancer this year. (Phil Galewitz/KHN)

But it won’t, said Chris Cooper, professor of political science at Western Carolina University. Meadows has little to worry about in his heavily Republican district where he took 65 percent of the vote in November. “Taking out Asheville turned the district from being the most competitive district in the state to the most conservative,” Cooper said.

The political climate is challenging for cultivating grass-roots opposition, according to Susan Kimball, of Waynesville, N.C., who is part of Progressive Nation WNC, a group pushing to retain the ACA.

She said she has sought to meet Meadows in his district office several times to complain about his Obamacare stance, but to no avail.

Critics like her have recently pushed Meadows to hold a town hall meeting to hear their views, as many members of Congress did in the past month. His office said Meadows arranges such meetings only in August.

“I just feel like he doesn’t care,” Kimball said.

A cancer survivor, Kimball, 62, has benefited from Obamacare’s mandate that insurers provide coverage to people with preexisting health conditions. For $237 a month, Kimball has a subsidized Blue Cross plan that pays for visits to doctors and tests when she needs them.

She moved to Waynesville from South Florida four years ago, and the area’s conservatism has been an eye-opener.

“We were just moving to the mountains, and we didn’t know the region would become Tea Party central,” Kimball said.

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

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KHN On Call: Answers To Questions On Tax Credits, Penalties And Age Ratings

For years, Republicans in Congress have promised to repeal and replace the Affordable Care Act, claiming that its requirement for nearly everyone to buy insurance or pay a fine is burdensome and costly, and that it doesn’t give people enough flexibility to get the coverage they need.

Now that they’re in charge, the bill they’ve released as an alternative (the American Health Care Act) would effectively eliminate the requirement to buy coverage and might open up more health care choices. It’s also under fire because it may cause millions of people to lose their coverage. According to the nonpartisan Congressional Budget Office, up to 24 million more people could be without insurance by 2026 if it passes.

So what are the differences between the ACA and the GOP alternative, and what does it all mean to you and your health care? We put some of your questions from our Twitter chat (#ACAchat) earlier this month to Alison Kodjak, NPR health policy correspondent, and Julie Rovner, chief Washington correspondent for Kaiser Health News.

Many questions came in about the elimination of the requirement to buy insurance, known as “the mandate,” and how the lack of one might affect the health insurance market.

Is the mandate in the GOP bill? It won’t work if people sign up only when they are sick.

Kodjak: The mandate is technically still written into the law, but since no one will enforce it under this new bill, it’s unlikely to have any impact. In fact, the Internal Revenue Service has already issued some guidance that suggests it may not enforce the mandate very actively even now, before this bill becomes law. The result? People who think insurance is too expensive and don’t expect to need it are unlikely to sign up for a health plan.

Rovner: It’s true that the GOP bill technically preserves the mandate, but it eliminates the penalties. Instead, the bill would require those with a lapse in insurance of more than 63 days to pay an insurance premium that’s 30 percent higher for one year. Analysts say that could actually serve as a disincentive for healthy people to purchase insurance if they’ve had a break.

Can someone wait until they are sick to buy insurance, knowing that they would have to pay a 30 percent fine?

Rovner: Not exactly. There will still be standardized open enrollment periods once a year, and you will only be able to buy insurance outside of those windows if you have a life change, like moving or losing a job. But if you’re willing to wait as long as 11 months, then, yes, you can wait and buy insurance after you get sick.

Kodjak: It’s not without risk. The Department of Health and Human Services has already proposed regulations that would reduce that open enrollment period to six weeks from the current three months. So a patient may incur some health care costs while awaiting the open enrollment, and then face the 30 percent penalty when they do buy a health plan. However, if the individual has a health issue where treatment can wait, then they certainly can enroll at the correct time and then seek medical care.

We also got a lot of questions about the GOP bill’s new tax credits to help people buy insurance, and how different they would be from the structure of purchasing help in the ACA.

Explain the difference between tax credits and subsidies, and will tax credits be distributed quarterly or at the end of the year?

Kodjak: Both the ACA and the AHCA use advanceable, refundable tax credits. That means the government each month sends the tax credit amount to your insurance company.

We refer to the Obamacare financial assistance as a “subsidy” in part because the amount fluctuates and is based on your income — the idea is to limit your health costs to a specific percentage of your income. In addition, under the ACA, there are payments to insurers to help cover the copayments and deductibles of lower-income people.

Rovner: The tax credits differ in how large they are and how they are calculated. The ACA tax credits are based on income and how much insurance costs in a given area. The GOP credits, by contrast, are based primarily on age and do not vary according to the cost of insurance in an area, so in low-cost parts of the country they will go further than in very high-cost areas.

In addition, the ACA has a series of subsidies that help those with low incomes (under 250 percent of poverty; about $50,000 for a family of three) pay their deductibles and other out-of-pocket expenses in addition to the tax credits to help pay for premiums.

Why does the GOP bill provide age-based tax credits instead of income-based ones?

Kodjak: The basis for age-based tax credits is that people who are younger tend to have fewer health costs, so insurance policies are likely to be lower-priced for them than for older people.

Republicans prefer the fixed credits in part because they are cheaper, and more predictable, than the income-based credits under the Affordable Care Act. That’s because those ACA credits rise as premiums rise, giving insurers little incentive to keep their premiums low. Republicans hope that by restraining the government’s financial help to patients, insurance companies will offer cheaper policies that better match the cost of the tax credits.

Rovner: Younger adults, on average, need less health care than older adults. The ACA limited the differential in premiums for older adults to three times more than the amount charged to younger adults. The GOP bill would change that so older adults could be charged five times more. The change would make insurance less expensive for younger people, likely enticing more of them to enroll, and lowering premiums for all, at least marginally, according to the Congressional Budget Office. But it would dramatically increase premiums for older adults, particularly those aged 55-64, just under the age to qualify for Medicare.

Which brings us to this question, which represents several we received about how the AHCA appears to disproportionately penalize people ages 55-64.

Do I face a penalty for waiting to buy health insurance until I’m eligible for Medicare in three years? I’m concerned that I’ll be stuck with an expensive plan.

Kodjak: No 30 percent penalty if you wait for Medicare, but remember, if you get sick while you’re waiting, you could be in financial trouble.

Rovner: That is correct. Also, remember, if you fail to sign up for Medicare when you first become eligible at age 65, you would also pay a premium penalty. It’s 10 percent per year, forever.

Got more questions? We’ll keep answering them as the GOP bill moves through Congress. Send them to us via Twitter at #ACAchat or via email at KHNHelp@kff.org.

Categories: Repeal And Replace Watch, The Health Law

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GOP Bill’s Unheralded Changes In Rules Could Undermine Health Of Neediest

An under-the-radar provision in the Republican proposal to replace the Affordable Care Act would require the millions of Medicaid enrollees who signed up under the Obamacare expansion to renew their coverage every six months — twice as often as under current law.

That change would inevitably push many people out of coverage, at least temporarily, experts say, and help GOP leaders phase out Medicaid expansion — a key goal of the pending legislation.

“That’s designed to move people off those rolls as soon as possible,” said Ken Jacobs, chairman of the University of California, Berkeley, Center for Labor Research and Education.

The proposal to cut renewal time in half is among other changes that seem only procedural but could have a profound effect on Medicaid enrollees’ health, pocketbooks and ability to get — and keep — coverage.

Another proposal would eliminate the ability of new Medicaid enrollees to request retroactive coverage for up to three months before the month they apply, which they can do under the current law — assuming they were eligible during that previous period.

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Health care experts and advocates fear that could potentially saddle people on Medicaid with unaffordable medical bills, shortchange providers and raise costs throughout the health care system.

“These are changes to fundamental pieces of the Medicaid program,” said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California in Sacramento, which represents human services directors from the state’s 58 counties.

“They could result in people delaying their health care or having to pay out-of-pocket and not having any hope for reimbursement at all,” she said.

But Michael Cannon, director of Health Policy Studies at the libertarian Cato Institute, said some of these changes would prevent fraud and keep ineligible people from obtaining benefits, thus saving taxpayer money.

“It’s so hard to eliminate fraud in Medicaid, because someone always benefits from it,” he said. “They don’t want to give that up.”

The expansion of Medicaid — the federal-state health care program for people with low incomes, known as Medi-Cal in California — would be phased out under the Republicans’ plan starting in 2020.

The expansion, adopted by 31 states and the District of Columbia, added more than 11 million people to the rolls, including about 3.7 million in Medi-Cal. The federal government picks up a much higher proportion of the cost for this population than for traditional Medicaid enrollees.

In the GOP plan, people already covered under the expansion would continue to be funded by the federal government after Jan. 1, 2020, but if states opted to sign up new enrollees under the expansion criteria after that date, they wouldn’t receive the more generous federal funding for them.

And those who remained in the program after 2020 but later lost eligibility would not draw the more generous federal funding for expansion enrollees if they became eligible again and re-enrolled at a later date.

In California, the potential loss of federal dollars caused by the rollback of the expansion would be massive. The state Legislative Analyst’s Office estimated last month that the Golden State is slated to receive more than $17 billion from the federal government for the Medi-Cal expansion in 2017-18.

“We’re talking about a big shift in costs to the state of California and potentially a major loss in coverage,” said UC Berkeley’s Jacobs.

The GOP legislation, which is scheduled for a vote on the House floor on Thursday, would impose the new renewal requirement on expansion enrollees starting Oct. 1.

“They’re saying to states that do the expansion, ‘We’ll cover people who are continuously in the program, but we’ll make it really hard for people to be continuously in the program,’” Jacobs said.

Wolf Faulkins, a resident of Mariposa, Calif., who enrolled in Medi-Cal in 2014 as a result of the expansion, said the proposed rule change regarding renewal would add one more layer to Medi-Cal’s already considerable bureaucratic requirements, none of them logical or simple.

“If I were more of a senior citizen than I am now, I would be overwhelmed” by it, Faulkins, 61, said. “I would not be a happy camper.” But he would complete the extra paperwork, he added, because his Medi-Cal coverage keeps him alive: Among other things, he has a heart condition and high blood pressure as well as knee and hand ailments.

Senderling-McDonald said the new paperwork will lead some enrollees to drop out for two reasons: Either they’re no longer eligible, or they’re eligible but the new bureaucratic hurdle stops them.

Faulkins agreed. Even though he would jump through the necessary hoops to keep his coverage, some others probably wouldn’t, he guessed. “There are people who are just going to say, ‘It’s important, but it’s too overwhelming. There’s no one to advocate for me. There’s no one to help me figure this out, ” he said. “People are just going to get frustrated and say no.”

The new renewal time frame has a precedent in California, which adopted a semiannual reporting requirement in 2003 for some enrollees that lasted about a decade. Though it was less cumbersome than the regular annual renewals, it nonetheless resulted in people dropping from the rolls, Senderling-McDonald said.

But the Cato Institute’s Cannon believes six-month renewals are reasonable. “The savings from removing ineligible people would justify the paperwork involved,” he said.

The paperwork imposed by these changes could be the least of the headaches for Medicaid beneficiaries.

Retroactive benefits, for example, are extremely valuable for new Medicaid enrollees who face medical bills during a gap in coverage, and losing them could cause financial pain.

“If they have had health expenses, like having to pay for a prescription out-of-pocket or a doctor’s visit, or a woman goes into labor uninsured, they can say to the county, ‘I had medical bills. Can you see if I was eligible during that time?’” said Senderling-McDonald.

Pregnant women are among the most frequent beneficiaries because they often don’t know that they’re pregnant right away, she added.

The GOP bill would end this, and would allow coverage to begin only the month in which enrollees apply. This provision would affect all Medicaid applicants and, like the change in renewal time, would begin Oct. 1.

Some experts believe the proposed change would increase medical debt for consumers hit with massive bills, and for providers who ultimately won’t get paid for their services.

The three-month retroactive rule is “a big deal for hospitals as well as people, because it keeps them from being saddled with medical debt,” said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington, D.C.

Senderling-McDonald warned that as more consumers racked up medical debt, the cost of it would shift to other people. “If someone has to declare bankruptcy when they are hit with bills they can’t pay, everybody else takes the hit for it,” she said. “They’re going to raise insurance rates or costs of care for everybody. People who have coverage through employers or the private market could see their rates go up.”

Cannon agreed that providers will get hit with more unpaid bills, but said that this provision would save the federal government money. “States have taxing authority and can fund these benefits themselves if they want to,” he said. “If they don’t, that should tell us something — that they don’t value these benefits that much.”

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

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

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On Medicaid Money, GOP Has Win-Or-Lose Proposition For States

New England’s bucolic countryside looks much the same on either side of the Connecticut River separating Vermont from New Hampshire.

But Medicaid beneficiaries are far better off in Vermont.

Vermont generously funds its Medicaid program. It provides better benefits, such as dental care, and pays doctors more than New Hampshire’s program does. That brings more doctors into the program, giving enrollees more access to care.

New Hampshire has twice Vermont’s population, but Vermont spends almost as much on Medicaid and covers more enrollees. Under the complicated formulas that set federal funding, Vermont’s substantial investment helps it capture nearly as much aid from the government as New Hampshire gets.

States’ policies differ about who or what to cover in Medicaid, and those decisions have led to historical variances in how much federal money they receive. House Republicans’ effort to shrink federal Medicaid spending would lock in the differences in a way that favors those already spending high amounts per enrollee.

“Republicans are finding out why changing Medicaid is so hard and why the easiest thing to do is to do nothing given the substantial variation in federal spending across states,” said John Holahan, a health policy expert with the nonpartisan Urban Institute.

Here’s why.

Medicaid, the national health program for low-income people that covers about 1 in 5 Americans, is 60 percent funded by the federal government and 40 percent by states. Total spending in 2015 was about $532 billion, according to the latest official data.

Federal funding is open-ended, which means the government guarantees states it will pay a fixed rate of their Medicaid expenses as spending rises.

Those matching rates are tied to average personal incomes and favor the lowest-income states. Mississippi has the highest Federal Matching Assistance Percentage — 76 — while 14 wealthy states, including New York and California, get the minimum 50 percent from the federal government.

But state Medicaid spending varies significantly, too, and that influences how much federal money each receives to fund its program. State policies about how generous benefits should be and how much to pay doctors and hospitals account for those differences.

GOP leaders want to give states a set amount of money each year based on the number of Medicaid enrollees they had in 2016, a formula known as per-capita caps.

A per-capita system would benefit high-spending states already receiving relatively rich allotments from the government, the Urban Institute said in a paper last September.

According to its estimates, if the system were in effect this year, Vermont would receive $6,067 per enrollee — one of the highest allotments in the country — while New Hampshire would get the least, just $3,084 per enrollee.

Per-capita caps would limit the government’s Medicaid spending because it would no longer be on the hook to help cover states’ rising costs. But caps also would shift costs and financial risks to the states and could force them to cut benefits or eligibility to manage their budgets.

“It would present a huge problem,” said Adam Fox, a spokesman for the Colorado Consumer Health Initiative, an advocacy group.

Under the GOP bill, federal Medicaid funding to states would be adjusted annually based on a state’s enrollment and medical inflation. But that would not be enough to keep up with rising Medicaid spending per enrollee, which would force states to put up more of their money or scale back the program, the nonpartisan Congressional Budget Office said March 13.

Other analyses of the GOP plan have reached the same conclusion.

Since 1999, however, the average annual growth rate in Medicaid spending per enrollee has risen more slowly than medical inflation, according to MACPAC, the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Republicans argue that overhauling federal Medicaid spending as they propose would hold down federal costs while giving states more leeway to run their programs as they see fit. “This incentive would help encourage efficiencies and accountability with taxpayer funds,” House Speaker Paul Ryan wrote last June in his white paper, “A Better Way.”

Rep. Greg Walden (R-Ore.), chairman of the powerful House Energy and Commerce Committee, which has oversight of health care matters, sounded a similar note at a press conference in Washington, D.C., when the GOP plan was announced. “I think it’s really important to empower states and to put Medicaid on a budget,” he said.

But Fox argued the opposite would happen under a per-capita system — instead of gaining more control over their Medicaid programs, states would not be able to meet their needs because they’d have fewer dollars to decide how to spend, he said.

Bill Hammond, director of health policy for the nonpartisan Empire Center for Public Policy in New York, said House leaders’ decision to tie future Medicaid funding to medical inflation could help mute concerns that funding wouldn’t keep up with rising costs, but would not address the fairness issue of giving some states higher per-capita amounts than others.

“If a low-spending state decides it wants to spend more money on paying hospitals and doctors or adding more benefits, they would have a harder time doing that without breaking the federal cap,” he said.

Medicaid advocates in New Hampshire are worried because their state has few alternatives to make up for a loss in federal funding. New Hampshire lacks an income or sales tax.

“There is a tremendous amount of fear among families here as Republicans try to dismantle the ACA,” said Martha-Jean Madison, co-director of New Hampshire Family Voices.

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

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Report: Fired U.S. Attorney Was Probing Tom Price’s Stock Trades

Preet Bharara, a former top federal prosecutor in Manhattan, was investigating stock trades by Health and Human Services Secretary Tom Price prior to Bharara’s ouster last week by President Donald Trump,  ProPublica reported Friday.

The report, attributed to an unnamed person familiar with the U.S. Attorney’s Office of the Southern District of New York, revived questions about the propriety of Price’s investments in numerous health care companies that stood to benefit from legislation he voted for and sponsored as a Georgia congressman. Those concerns have dogged the former congressman since Trump nominated him to head HHS last November.

Preet Bharara

Preet Bharara was asked to step down as U.S. attorney for the Southern District of New York by the Trump Administration. (Peter Foley/Bloomberg via Getty Images)

It also brought fresh dramatic flair to the little that is known about how one of the nation’s most prominent U.S. attorneys lost his job. Bharara, whose jurisdiction included Wall Street, gained fame prosecuting financial corruption cases over eight years on the job.

When the Trump administration asked 46 U.S. attorneys, including Bharara, to step down, he refused the request.  Afterward, Bharara tweeted that he had been fired.

The U.S. attorney’s office declined to comment on ProPublica’s report.

Price, previously a member of the House Ways and Means Committee, came under fire during his confirmation hearings for his health industry stock trades and promised to divest himself of holdings within 90 days of taking office. An HHS spokesman said Friday that Price met that requirement but declined to release details.

Among Price’s stock purchases that garnered the most scrutiny: his investment in Innate Immunotherapeutics.

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While Price sat on the Ways and Means health subcommittee, he bought shares of the Australian biotech in a private placement at a discounted rate — $0.18 cents per share. A new private placement announced Friday will offer shares for $0.72 per share. Innate’s trading on the Australian Stock Exchange was suspended while the company raises capital.

Four other Republican congressmen invested too, even as scrutiny surrounding the company increased. A report from ethics watchdog CREW (Citizens for Responsibility and Ethics in Washington) Friday found that Reps. Mike Conaway (R-Texas), Doug Lamborn (R-Colo.), Billy Long (R-Mo.) and Markwayne Mullin (R-Okla.) all bought shares of Innate in January 2017. Mullin and Long both sit on the health subcommittee with Collins.

“Congressman Long did not learn of Innate Immunotherapeutics through a colleague, but rather through the news in January when the company became a daily topic in the news,” Long’s press secretary Hannah Smith said in an email.

Democrats in January called for an investigation into the extent of Price’s holdings and asked the Securities and Exchange Commission to determine whether he used insider information. Earlier that month Public Citizen, a nonprofit watchdog group, submitted a letter of inquiry to the Office of Congressional Ethics requesting closer scrutiny of investments by Price and Collins in the foreign company.

The offices of Mullin, Conaway and Lamborn did not immediately return requests for comment.

Categories: Health Industry, Repeal And Replace Watch

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GOP’s 3-Bucket Strategy To Repeal And Replace Health Law Is Springing Leaks

Republicans in Washington working to overhaul the Affordable Care Act say their strategy consists of “three buckets.” But it appears that all three may be leaking.

The plan to dismantle and replace Obamacare emerged after the Republican congressional retreat in late January. The first bucket is a fast-track budget bill that needs only a simple majority to pass the Senate. Because of congressional rules, however, it can only address parts of the health law that have immediate impact on federal spending.

The second consists of changes to regulations and other policies put in place by the Obama administration that could theoretically be undone by new Health and Human Services Secretary Tom Price. And the third is separate legislation that would do things Republicans have been advocating for many years, such as imposing caps on medical malpractice damages and selling health insurance across state lines.

All three are proving problematic at this point — among Republicans.

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“There is no three-phase process, there is no three-step plan,” Sen. Tom Cotton (R-Ark.) told radio host Hugh Hewitt Tuesday. “That is just political talk. It’s just politicians engaging in spin.”

“Anyone who believes in the three-step process is believing in a fantasy,” said Rep. Raul Labrador (R-Idaho) at a press conference Thursday.

The first part, the so-called budget “reconciliation” bill, is already drawing fire within the GOP, not to mention among Democrats. Conservatives, like Sen. Rand Paul (R-Ky.), derisively refer to it as “Obamacare Lite” and oppose the bill’s tax credits to help people buy insurance as a new entitlement. Moderates have been shaken by the estimate from the Congressional Budget Office that 24 million people could lose their health coverage if the bill passes.

The bill has passed through several committees, but members of the conservative House Freedom Caucus say they might be able to stop the bill from passing the House, in spite of heavy pressure from Republican leaders and the Trump administration.

“The question is: ‘Am I OK losing my election because I did the thing I promised I would do?’” said Freedom Caucus co-founder Labrador, referring to his promise to repeal the entire law. He said the answer to that question is yes: “I can live with myself if I do the things I promised I would do.”

Complaints about the bill from a several Republican senators suggest that there are more than enough GOP “no” votes in that chamber to block its passage.

Conservatives also question exactly how much of the law the administration can dismantle.

Price said at a CNN Town Hall Wednesday that he is ready to plunge into the “hundreds” of regulations and “thousands” of guidance letters issued by the Obama administration to implement the health law.

“If they hurt patients, they need to go away,” he said. “If they drive up costs, then they need to go away.”

But undoing all those rules comes with its own set of dangers.

“Step two requires us to believe that Tom Price is going to go outside the law,” Labrador said. He noted that conservatives often complain when an administration takes on authority not granted in legislation when devising rules.

“And we think the courts are not going to stop him from doing that?” Labrador asked. Reversing policy on existing law can open up new rules and regulations to lawsuits.

Cotton, in his radio interview, noted that whatever changes Price proposes are “going to be subject to court challenge, and therefore, perhaps the whims of the most liberal judge in America.”

Finally, while Republicans tend to agree on step three, the legislation that would implement their preferred policies for the nation’s health care system, there is one big hurdle: It would need 60 votes to pass a filibuster in the Senate, and getting eight Democrats to join seems highly unlikely.

“It’s not going to happen if you need 60 votes in the Senate,” said Sen. Lindsey Graham (R-S.C.) on MSNBC Wednesday.

Cotton agreed. “If we had those Democratic votes, we wouldn’t need three steps,” he said. “We would just be doing that right now on this legislation.”

Categories: Repeal And Replace Watch, The Health Law

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Do You Speak ‘Repeal and Replace’?

Have questions about the terminology being used in the debate over health care legislation? Click on the bubbles above to learn more. (Illustration by Lynne Shallcross; photo by Mandel Ngan/AFP/Getty Images)

President Donald Trump and many congressional Republicans campaigned on repealing the Affordable Care Act and replacing it with their own plan to overhaul the nation’s health care system. As the GOP develops its offering, its representatives are tossing around wonky health policy terms to describe their core strategies.

Want to know what it all means? See below for a tipsheet, then click on the thought bubbles above for easy-to-understand translations.

MEDICAID BLOCK GRANTS AND PER-CAPITA CAPS: The federal government gives states a set amount of money to pay for coverage for Medicaid recipients. This would be a shift from the current Medicaid program, where the federal government matches state Medicaid spending on a percentage basis. Learn more.

HEALTH SAVINGS ACCOUNTS: Also known as HSAs, these allow consumers to put money away on a tax-free basis as long as they use it for medical expenses. Learn more.

BUDGET RECONCILIATION: Legislative process that allows measures to pass with a simple majority in Congress. Budget reconciliation bills can’t be filibustered but must focus on provisions that have a budgetary impact. Learn more.

ESSENTIAL HEALTH BENEFITS: ACA-mandated categories of benefits that health plans must cover. They include emergency services, hospitalization and maternity care. Learn more.

INDIVIDUAL MARKET: Where people who do not have health coverage through the government or their employer purchase a plan directly from an insurer. It is sometimes called the non-group market. Learn more.

TAX CREDITS/SUBSIDIES: Financial assistance to help consumers purchase health insurance. Learn more.

HIGH-RISK POOLS: Insurance groups that cover individuals with high health insurance costs, such as people who have a past serious illness or a chronic condition. Learn more.

Visit Repeal & Replace Watch for more KHN coverage of the health law debate.

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A Health Reporter Walks Into Reagan National Airport …

Flying out of Reagan National Airport on Wednesday, I was expecting a short reprieve from the issue that has consumed my work in health journalism for eight years — the Affordable Care Act and, lately, Republican efforts to replace it.

The voyage turned into anything but, with some unexpected close encounters.

Media-accessible Sen. Chuck Grassley (R-Iowa) keeps his pulse on the news and stays in touch with the public at Reagan National Airport outside Washington, D.C., on March 15. (Phil Galewitz/KHN)

Awaiting my flight and in search of any outlet to plug in my phone, I recognized Sen. Chuck Grassley heading back to his home state of Iowa. Always one of the more media-accessible senators, he didn’t hesitate to chat when my reporter’s instincts kicked in to curbside him with some questions on the ACA repeal. It was Grassley who initially helped turn public tide against Obamacare when he (wrongly) claimed the legislation had “death panels.”

Grassley, 83, chairman of the Senate Judiciary Committee and one of longest-serving members of Congress, told me the GOP leadership bill — the American Health Care Act — doesn’t go far enough to help older Americans, those ages 55-64, get coverage. He said a plan is circulating in the Senate to extend more government subsidies to help this age group, which a recent report by the non-partisan Congressional Budget Office (CBO) noted would be hit particularly hard.

But, reflecting Republican divisions, he acknowledged that subsidies — even if directed at low-income baby boomers — would be tricky given opposition from conservatives such as House Freedom Caucus Chairman Mark Meadows (R-N.C.). Much of the party’s hard right is opposed to subsidies, including former presidential candidate Ted Cruz.

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Then Grassley moved on to two points on which his party is united. He said the Republicans must deal with Obamacare before it adjourns for Easter/Passover recess on April 6. That’s because Republicans still must leave time to deal with tax reform and infrastructure bill before summer break. “It’s now or never,” he said.

I asked if he would support any GOP bill, even if it increased cost for some Americans or led to more joining the ranks of uninsured. Grassley grew a bit angry. “Anything is better than Obamacare and what we have now,” he said with his outstretched fingers nearly touching me.

This is a common but increasingly contentious talking point in GOP circles. The CBO report found that 24 million more Americans would lose coverage under the GOP plan by 2026.

No sooner had I shaken hands with the senator and boarded my American Airlines flight to South Florida, I spotted none other than Sen. Ted Cruz, himself, the conservative fireball from Texas, sitting in the row ahead of me. I watched the flight crew comp his glass of red wine — I paid $7 for my Sam Adams beer — and hesitated to disturb him in flight as he played a computer basketball game on his tablet.

But once landed, I couldn’t resist introducing myself as a reporter. I told him I had just read his op-ed in The Wall Street Journal explaining his own opposition to the GOP leadership plan, and the need to freeze Medicaid expansion immediately rather than by 2020 and provide tax credits only for working Americans to help them get health coverage.

Sen. Ted Cruz (R-Texas) flies coach — in the row that offers extra legroom — on a March 15 flight to South Florida. (Phil Galewitz/KHN)

As we deplaned in West Palm Beach, Cruz told me that he didn’t think Medicaid should help non-disabled adults because it would give them an incentive not to work and would make them dependent on government handouts. He said Medicaid was meant to help children, pregnant women and the disabled — and money spent to help others would take away from those who were more deserving.

He noted that states that expanded Medicaid have long waits for care for disabled Medicaid beneficiaries needing home and community-based care. I cover Medicaid and felt compelled to point out that the longest Medicaid waiting lists were in states that did not expand Medicaid.

Cruz, 46, mentioned that he wants the federal government to offer straight lump-sum grants to states for Medicaid — different from today’s open-ended federal funding and the GOP leadership’s plan that ties funding to the number of patients enrolled.

He said a block grant would give states more motivation to “innovate” to find ways to provide care for less money. I asked how states would innovate during time of economic downturns. “States have faced tough time before and would find a way,” he said.

Cruz, who was in Florida for a conference, discussed Obamacare changes in a thoughtful and mild manner that I did not expect, given the prevailing tone in Washington, D.C., these days.

As we searched for our rides, after midnight, outside the terminal, he took my business card.

My close encounters with two influential voices in the Republican Senate during one journey underlined the deep divisions the party faces as it seeks to replace the ACA.

It was time to put Obamacare to bed — at least for the night.

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

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Many Californians Could Be Priced Out Of Exchange Coverage, Analysis Finds

The average 40 percent drop in subsidies proposed under the GOP health care bill would put coverage out of reach for many Californians on the state exchange, according to a preliminary analysis released Tuesday.

People living in pricey cities like San Francisco, as well as the elderly and those with low incomes, would be most seriously affected, the Covered California analysis shows. That’s because the Affordable Care Act takes into account income and location, whereas the Republican bill offers flat-rate tax credits based only on age (up to $75,000 in income for an individual).

The Covered California analysis provides some stark comparisons:

  • Under the ACA, also known as Obamacare, a 62-year-old living in San Francisco making $20,000 a year would pay $84 a month with a tax credit for silver plan coverage (the second-least-costly plan). Under the GOP plan, that person would pay $668.
  • A San Francisco family of four earning $41,000 a year would pay $346 more in premiums per month under the GOP plan for coverage similar to an Obamacare silver plan.
  • A 27-year-old making $30,000 a year in San Francisco would pay $9 per month less under the GOP plan than for Obamacare coverage. A 62-year-old would pay $460 more.

In Los Angeles, many people would pay less under the GOP plan vs. Obamacare, especially young people and families, according to the analysis. That’s because health care there is much less expensive. All beneficiaries making at least $50,000 a year would pay much less in premiums under the GOP plan, because it offers tax credits to more affluent people who don’t qualify for them under Obamacare.

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The analysis came a day after the Congressional Budget Office released a report saying that the GOP’s plan, the American Health Care Act, would cut government subsidies for older and low-income consumers and cause an estimated 24 million Americans to lose their coverage by 2026.

Covered California has approximately 1.5 million enrollees, who benefited from $4.2 billion in premium subsidies last year, said Peter V. Lee, Covered California’s executive director, at Tuesday’s monthly board meeting. Ninety percent of exchange enrollees receive subsidies to help them cover the costs of their premiums.

Covered California’s calculations show that in 2016 the average subsidy for an individual was worth $3,500. Meanwhile, households received an average of $5,300 per year in subsidies. Twelve percent of households got subsidies worth about $10,000.

“That [$10,000] wasn’t a gift, it wasn’t extra money,” Lee said in a media call Tuesday. “It was given to them because without it they would have not been able to afford coverage.”

Ignoring income and geography means poor people would be worse off, Lee said.

Since 2014, the ACA has helped lower California’s uninsured rate from almost 17 percent to 7.1 percent, through both Covered California and an expansion of Medi-Cal, the state’s Medicaid program.

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

Categories: California Healthline, Repeal And Replace Watch, The Health Law

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Obamacare Pushed Nonprofit Hospitals To Do Good Beyond Their Walls. Now What?

For the past six years, Mardi Chadwick has run a violence prevention program at Boston’s Brigham and Women’s Hospital. The program’s goal is to address broader, community-based health issues and social problems that make people ill or prone to repeated injury from gunshots, stabbings or environmental causes.

In Chadwick’s view, this endeavor — almost from its inception — made a big difference in nearby neighborhoods. But its profile in the eyes of hospital administrators got a boost from an Affordable Care Act provision that required nonprofit hospitals to conduct triennial assessments of local health needs and devise strategies, updated yearly, to address them. Falling short would trigger a financial penalty.

“Everyone, all of a sudden, cares about the social determinants of health,” she said. “Our expertise is being brought in. … We have a bigger seat at the table.”

But will programs like this one continue to get such attention? As the GOP-controlled Congress works to scrap Obamacare, the answer is uncertain.

Requiring this “community health needs assessment” was part of a broader package of rules included in the health law to ensure that nonprofit hospitals justify the tax exemption they receive. Another directive was that these facilities establish public, written policies about financial assistance available for medically necessary and emergency care and that they comply with limits on what patients who qualify for the aid can be charged.

These requirements add to the ongoing controversy about whether all nonprofit hospitals do enough to deserve a tax break. People on one side of the issue view the assessment rule, for instance, as an undue, unfunded burden while others say it doesn’t do enough. So far, though, the community health assessment requirement hasn’t exactly been a hot topic in the repeal-and-replace debate and was not addressed by the House Republicans’ health plan unveiled March 6.

Sen. Chuck Grassley (R-Iowa), who has long urged that more scrutiny be applied to nonprofit hospitals’ tax status, championed the provision. His spokeswoman said he will continue to advocate that it remains in effect in whatever new health policy plans emerge. Regardless, the financial uncertainty of any overhaul of the health law could undermine some hospitals’ efforts.

The decades-old nonprofit tax status, granted by the Internal Revenue Service to institutions that meet the “community benefit” standard, spares hospitals from paying federal taxes and is collectively worth billions of dollars. Nonprofit hospitals have generally cited the uncompensated or “charity” care they provide, as well as initiatives they undertake to promote public health, as sufficient proof that they earn their tax exemption. But for-profit hospitals, which do pay taxes, cry foul, saying they make similar contributions.

There’s no question the Affordable Care Act required us
to bump up
our game.

 Joan Quinlan, vice president
for community health at
Massachusetts General Hospital

The new requirements overall were meant to hold nonprofits to a higher standard — and penalize those that didn’t deliver. Under the law, hospitals that fail to complete the assessment and implementation strategy face a $50,000 fine — which can seem small next to their overall operating budgets. But down the line, the penalties can accumulate and ultimately could jeopardize their valuable tax exemption.

Meanwhile, federal data show that as recently as 2011 nonprofit hospitals targeted less than 10 percent of their operating expenses to benefit the community — this includes charity care, unreimbursed costs from Medicaid and other government programs and medical research and education. Less than 1 percent went to community health improvement services like Chadwick’s.

Advocates hoped the health law would change this. The idea was to push nonprofit hospitals to invest more in public health initiatives that do not directly earn them money — giving such programs more value on the balance sheet. But it’s hard to gauge whether that’s happened.

“You can find hospitals that have done this. But … are we seeing a real shift in the hospital community? Or are these a few hospitals that are outliers?” said Gary Young, director of the Center for Health Policy and Healthcare Research at Northeastern University. “We’ve asked them to make a sea change in how they’re doing things. And that can’t happen overnight.”

Sen. Chuck Grassley (R-Iowa) has long urged that more scrutiny be applied to nonprofit hospitals’ tax status. (Courtesy of the Congressional Pictorial Directory)

Part of the problem, analysts say, is that the underlying idea — reaching into the community to help people navigate the social and economic factors that can influence health — goes beyond what hospitals have traditionally viewed as their mission. Despite the potential for long-term payoff, administrators tend to focus on the immediate questions: How many beds are full? What medical services are being provided? How are they doing with their operating budget?

“It’s a new world out there in terms of the hospital not being the center of the universe,” said Lawrence Massa, president of the Minnesota Hospital Association, the state’s hospital trade group, which has been tracking hospital response to the health assessment requirement.

Initially, they found the money nonprofit hospitals put toward “community needs” went up after the assessment requirement: from about $355 million in 2011 to $459 million in 2013, according to an analysis by the association. (The needs assessment requirement took effect in between, for the tax year starting after March 2012.) But the increase leveled off in 2014 — the most recent year for which data are available.

Massa’s conclusion: Caring for the health of people before they come into the hospital is unfamiliar territory. Not everyone took naturally to it. “We saw some communities that embraced this, and did a nice job. … In other communities, there’s been friction between public health and the acute setting — and lack of understanding.”

With continued time and sustained emphasis, that could have changed, said Sara Rosenbaum, a professor of health law and policy at George Washington University.

But now? Even if the community benefit requirements remain intact, she and others fear this accountability effort could take a hit. Repeal of the health care law is likely to create fresh financial challenges for hospitals. For instance, although the House GOP’s American Health Care Act would restore some of the uncompensated-care funding cuts hospitals absorbed under the ACA, the coverage changes proposed in Republicans’ plan could mean tens of millions more uninsured people.

That scenario, policy experts and trade groups say, would increase the amount of free care nonprofit hospitals provide, creating new budget pressures that could lead them to tamp down on efforts to promote community health work.

“We could be right back in a situation where there is a fair amount of charity care, and that could become a large component of how hospitals are justifying their nonprofit status,” said Ken Fawcett, a physician who runs a community health worker initiative at Spectrum Health in Grand Rapids, Mich.

Meanwhile, the health assessment’s impact has been evident at Boston-based Massachusetts General Hospital. There, administrators used it to devise an intervention strategy around drug abuse — partnering, for instance, with local schools and community organizations, and hiring former addicts to help patients navigate recovery.

“There’s no question the Affordable Care Act required us to bump up our game,” said Joan Quinlan, its vice president for community health. If people lose coverage, she added, hospitals will increasingly argue that’s enough reason for a tax break. It could stifle efforts to promote more substantial community benefit.

“If the ranks of the uninsured or underinsured grow, then charity care will increase. And the ability to do some of these more creative downstream efforts will be hampered,” she said. “There might be heightened awareness. But if there aren’t resources to address them, it’s going to be hard.”

Categories: Repeal And Replace Watch, The Health Law

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Once Nearly Buried By Medical Bills, Farmer Braces For Insurance Drought

Darvin Bentlage’s health insurance plan used to be the same as all the other cattle farmers in Barton County, Mo., he said: to stay healthy until he turned 65, then get on Medicare. But when he turned 50, things did not go according to plan.

“Well, I had a couple of issues,” he said.

That’s putting it mildly.

Over two years, he dealt with hepatitis C and diverticulitis. That was on top of his persistent kidney stones, diabetes and other health problems.

“I had to go back and refinance the farm,” he said. “By the time the two years was up, I had run up between $70,000 and $100,000 in hospital bills.”

He does not want to end up in that situation again, so he is paying close attention to what Republican health care bill working its way through Congress might mean for him.

He racked up those medical bills in 2007. Bentlage said that given his preexisting conditions, health insurance became impossibly expensive — a problem because he needed more health care. So when the Affordable Care Act exchanges opened in 2013, he said, “I was probably one of the first ones to get online with it and walk through it.”

About a quarter of the people on the exchanges are between 55 and 64, and they have more health problems than younger people do. So they have a lot on the line if the Affordable Care Act gets replaced. Under the GOP plan, older people’s insurance cost could rise dramatically, but the subsidies would be capped at $4,000. That’s less than half of what Bentlage is getting now under the ACA.

“And my estimated income is less than $20,000. So I’d have to go back to Plan A and hope I make it to 65, you know?” he chuckled.

Insurance premiums tend to be higher in rural areas where the population tends to be older, poorer and sicker than elsewhere. And Maggie Elehwany of the National Rural Health Association said there’s another issue: 80 rural hospitals have closed across the country since 2010.

“We’ve got an access crisis going on,” she said. “What this House bill does is nothing — nothing to address the rural hospital closure crisis. You’ve got to understand that so much of that is linked to not only the health, but to the economic vitality of the community. If a hospital closes in a rural area, it closes for good.”

One reason for these hospital closures is that 19 states, including Missouri, chose not to expand Medicaid, which left poor rural patients uninsured. The GOP proposal would cut Medicaid more over time.

Bentlage said his county recently increased property taxes to keep its hospital open.

“It falls on the farmers,” he said. “My property tax on the hospital went from about $80 to about $400. And it’s still in trouble.”

Missouri’s Republican congressional delegation has said Obamacare has failed. And Bentlage, whose positive experience with the health law once was featured in a healthcare.gov video, said the ACA does need work.

“There’s problems with it,” he said, “but I don’t think it’s worth scrapping.” All you need to do, he said, is look at how it’s helped him.

This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News.

Categories: Aging, Cost and Quality, Public Radio Partnership, Repeal And Replace Watch, The Health Law

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Health Exchange Enrollment Misses Obama Administration’s Goal, But Stays Steady

An estimated 12.2 million people signed up for health insurance through the Affordable Care Act for 2017, federal officials reported Wednesday, down slightly from the 12.7 million who signed up for 2016.

It was also fewer than the 13.8 million people the Obama administration predicted would sign up last fall.

But supporters of the law argue that final enrollment was held down by Republicans when they took over the White House in January. They also maintain that the law is not in danger of collapse, as both President Donald Trump and GOP leaders in Congress claim.

The administration had no immediate comment on the enrollment numbers.

“I think the discrepancy from last year is almost entirely explained by the lack of a final push in marketing and outreach and promotion,” said Topher Spiro, vice president for health policy at the liberal-leaning Center for American Progress. “We were on track to exceed enrollment,” he said, referring to a late rush to sign up in December for coverage that began Jan. 1.

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However, the Trump administration, which took over just 10 days before the end of the three-month enrollment period for the health law, immediately canceled the final round of ads encouraging people to sign up. In each of the health law’s previous enrollment periods, a huge rush came at the end, particularly among the younger, healthier adults whom insurers covet. That did not happen this year.

Still, enrollment among those ages 18 to 34 held basically steady, at 27 percent, down from 2016’s 28 percent.

Despite that, enrollment remained strong in states that were already doing well under the program, including California, which signed up more than 1.5 million people for coverage. Even Arizona, which had some of the largest premium increases in the nation, saw enrollment drop only slightly, from 203,000 in 2016 to 196,000 this year.

As in previous years, the vast majority of those who signed up on the health exchanges — 83 percent — had incomes low enough to qualify for tax credits to help them pay their premiums. More than half — 58 percent — got additional subsidies to help cover deductibles and other out-of-pocket costs.

Even before the numbers were released, the Congressional Budget Office, in its report on the Republican replacement for the bill, found that the individual market “would probably be stable in most areas under either current law or the [GOP] legislation.”

Spiro said he agrees with that but worries that the continual dire predictions being made by Trump and Republican leaders could become “a self-fulfilling prophecy” by creating so much uncertainty for both insurance companies and consumers.

“You have to ask how many more would have enrolled if there weren’t this cloud hanging over the law and if the president was not saying that the markets are imploding or collapsing. If you’re a consumer, that does not sound like something you want to be a part of,” he said.

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

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