Tagged States

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Before we dive in to the harder news, please join me in enjoying this story about scientists dosing a shy breed of octopus with ecstasy to see if the animal became cuddly and friendly while high. (I swear, it relates to health care: More studies are evaluating psychedelic drugs as outside-the-box treatments, especially for post-traumatic stress disorder in veterans.)

Now, here’s what else you may have missed:

Senators were busy bees this week on the Hill. In a rare bipartisan feat, the upper chamber passed a sweeping opioids package … but there’s some fine print. Lawmakers still have to iron out the (harder, more controversial) differences between the Senate and House versions of the legislation, and they probably won’t do that work until November — conveniently, after midterms. Until then, they have a talking point!

And you know that “doughnut hole” change (which forces drugmakers to pay more for medication used by Medicare beneficiaries) that pharma hates and has been pestering lawmakers about for ages? Congress might tuck a measure rolling that back into the opioid package.

The Associated Press: GOP, Dems Unite Behind Senate Bill Fighting Addictive Drugs

Stat: GOP Lawmakers Seeking to Use Opioids Bill to Deliver Drug Industry Major Victory

It’s not all roses for drugmakers, though: A Senate-passed bill would ban “gag clauses,” which currently keep pharmacists from talking to consumers about lower-cost options.

Stat: Senate Passes Bill That Would Ban ‘Gag Clauses’ Limiting Disclosures on Drug Prices

In a sharp divergence from the budget spectacles of years past, the Senate quietly OK’d a measure to avert a government shutdown. The measure included a big, 5 percent boost to the National Institutes of Health, which was the fourth-straight significant increase for the agency.

The Associated Press: Senate Backs Bill to Avert Shutdown, Boost Military Spending

There’s a real fear out there that we’re all one bad accident away from financial ruin. A bipartisan group of senators wants to protect patients from that worry with its proposed measure on surprise bills, otherwise known as “balance billing.” (Bonus: Check out the KHN story that Republican Sen. Bill Cassidy cited in his announcement.)

The Hill: Bipartisan Senators Unveil Proposal to Crack Down on Surprise Medical Bills


As the news continues to evolve over the sexual assault allegations against Supreme Court nominee Brett Kavanaugh, here’s a health tidbit you might have missed if you didn’t scan all the way to the bottom of today’s stories. Gov. Bill Walker of Alaska, an independent, and his lieutenant governor, Byron Mallott, both came out against Kavanaugh’s nomination — not because of the accusations, but because they’re worried he’s going to jeopardize Medicaid coverage. It will be interesting to see if that’s enough to sway Alaska Sen. Lisa Murkowski, a Republican, who is being watched closely as a possible swing vote.

The New York Times: Christine Blasey Ford Opens Negotiations on Testimony Next Week


Attorney general races are rarely the belles of the ball when it comes to elections. But as more of them use their position to try to check President Donald Trump’s policies (especially ones chipping away at the health law), the campaigns are drawing more eyes.

Politico: Obamacare Lawsuit Boosts Democrats in State AG Races

Preexisting conditions have been a bomb Republicans have been trying to defuse for weeks on the campaign trail, but even GOP strategists call it a losing battle. “What you have to do at this point is duck and cover,” said one in Politico’s coverage.

Politico: Republicans ‘Duck and Cover’ on Pre-Existing Conditions


A new, more detailed report has emerged of the slow-moving medical catastrophe that was Hurricane Maria. It’s also a grim insight into why counting a death toll becomes so complicated.

The Associated Press: Maria’s Death Toll Climbed Long After Rain Stopped

Meanwhile, an investigation has been launched into why two mentally ill women who were seeking care were taken from a safe hospital and driven into Florence’s floodwaters, where they both drowned.

The New York Times: They Were Seeking Mental Health Care. Instead They Drowned in a Sheriff’s Van.


In the miscellaneous, must-read file for the week:

  • The U.S. is the most dangerous place to have a baby in the developed world, yet states are doing little to address the issue. And the ones that are, often blame the moms.

USA Today: Maternal Deaths: What States Aren’t Doing to Save New Mothers’ Lives

  • We’re on the precipice of some amazing breakthroughs for cancer treatments, yet Native Americans and black patients are missing out because they’re underrepresented in clinical trials.

ProPublica/Stat: Black Patients Are Being Left Out of Clinical Trials for New Cancer Therapies

  • Personal health aides can be a lifeline for elderly patients. Inviting a stranger into your home, though, is inherently risky and there’s few regulations that exist to weed out predators.

Boston Globe: Stranger in the House

  • And a fascinating Alzheimer’s treatment called “reminiscence therapy” has seen success overseas and is gaining traction here. Check out this one facility that recreated a 1950s town square, complete with Buddy Holly on the jukebox and an old-fashioned diner.

The Wall Street Journal: To Help Alzheimer’s Patients, A Care Center Re-Creates The 1950s


As a newsroom that has a dedicated chocolate drawer and sweet treats brought in by colleagues a few times a week, this article on employers cutting down on sugary snacks sparked a bit of a debate here. To ban or not to ban, that is the question of the week.

Have a great weekend!

State Highlights: Safety Allegations Against Manchester VA Unfounded, Internal Draft Report Shows; Colorado’s Mental Health System Riddled With Failures, Advocates Say

Media outlets report on news from New Hampshire, Colorado, Florida, Illinois, Massachusetts, Maryland, Tennessee, Louisiana, Texas, Washington, Ohio, Connecticut, California, Minnesota and Kansas.

CHIP Coffers Are Habitually Raided To Finance Other Parts Of The Budget. Take A Look At How It Survives.

Funds for the Children’s Health Insurance Program are technically outside the jurisdiction of the Appropriations Committees and don’t count against annual discretionary caps, and the pool of “contingency money” dedicated to the program has been tapped sparingly. Medicaid news comes out of Alabama and Maine, as well.

America’s Drug Death Trends Are More Complex Than The Current Narrative About Opioid Overdoses

Overdose deaths are on a sharp upward trajectory, but the roles different drugs play in that overarching epidemic has been simplified to focus on opioids. A new study reveals the depth of the crisis in America over the past four decades, and offers a grim picture of the country’s future. In other drug-related news: hospitals and addiction treatment; the Trump administration’s efforts to curb the epidemic; information exchanges; and more.

Alex Azar Came To HHS Ready To Execute A Four-Point Health Plan. Then The Zero-Tolerance Crisis Happened.

HHS Secretary Alex Azar became the public face of the crisis because his agency is responsible for housing the migrant children that were separated from their parents. The Washington Post looks at how he handled the pressure. Meanwhile, Azar plans to shift millions from public health programs to help pay to house detained migrant children.

As States Try To Rein In Drug Spending, Feds Slap Down One Bold Medicaid Move

States serve as “laboratories of democracy,” as U.S. Supreme Court Justice Louis Brandeis famously said. And states are also labs for health policy, launching all kinds of experiments lately to temper spending on pharmaceuticals.

No wonder. Drugs are among the fastest-rising health care costs for many consumers and are a key reason health care spending dominates many state budgets — crowding out roads, schools and other priorities.

Consider Vermont, California and Oregon, states that are beginning to implement drug price transparency laws. In Nevada, the push for transparency includes the markup charged by pharmacy benefit managers (PBMs). In May, Louisiana joined a growing list of states banning “gag rules” that prevent pharmacists from discussing drug prices with patients.

State-based experiments may carry even greater weight for Medicaid, the federal-state partnership that covers roughly 75 million low-income or disabled Americans.

Ohio is targeting the fees charged to its Medicaid program by PBMs. New York has established a Medicaid spending drug cap. In late June, Oklahoma’s Medicaid program was approved by the federal Centers for Medicare & Medicaid Services to begin “value-based purchasing” for some newer, more expensive drugs: When drugs don’t work, the state would pay less for them.

But around the same time, CMS denied a proposal from Massachusetts that was seen as the boldest attempt yet to control Medicaid drug spending.

Massachusetts planned to exclude expensive drugs that weren’t proven to work better than existing alternatives. The state said Medicaid drug spending had doubled in five years. Massachusetts wanted to negotiate prices for about 1 percent of the highest-priced drugs and stop covering some of them. CMS rejected the proposal without much explanation, beyond saying Massachusetts couldn’t do what it wanted and continue to receive the deep discounts drugmakers are required by law to give state Medicaid programs.

The Medicaid discounts were established in 1990 law based on a grand bargain that drugmakers say guaranteed coverage of all medicines approved by the Food and Drug Administration in exchange for favorable prices.

The New England Journal of Medicine dives into the CMS decision regarding Massachusetts and its implications for other state Medicaid programs in a commentary by Rachel Sachs, an associate professor of law at Washington University in St. Louis, and co-author Nicholas Bagley. They dispute the Trump administration’s claim that Massachusetts’ plan would violate the grand bargain.

We talked with Sachs about Massachusetts’ proposal and the implications for the rest of the country. Her answers have been edited for length and clarity.

Q: Why do you think states, such as Massachusetts, should be allowed to exclude some drugs, a move the pharmaceutical industry has said would break the deal reached back in 1990?

In our view, there’s a way to frame it where the bargain has been broken and Massachusetts is simply trying to restore the balance. The problem is that the meaning of FDA approval has changed significantly over the last almost 30 years. Now we have a lot more drugs that are being approved more quickly, on the basis of less evidence — smaller trials, using surrogate endpoints — where the state has real questions about whether these drugs work at all, not only whether they are good value for the money.

Q: You suggest that Massachusetts could make a reasonable case if it chose to challenge the CMS denial. How?

CMS did not explain why it didn’t grant Massachusetts’ waiver. It needs to give reasons for denying something that Massachusetts, in our view, has the legal ability to do. CMS’ failure to give reasons in this case resembles their failure to give reasons in a number of other cases that have recently led courts to strike down actions by the Trump administration for failure to explain the actions that they were taking.

(Note: A spokeswoman for Health and Human Services in Massachusetts says the state is not going to challenge the CMS decision.)

Q: While CMS blocked the Massachusetts experiment, it has approved the value-based purchasing plan in Oklahoma, and New York has capped its Medicaid drug spending. Aren’t those signs of flexibility for states?

In some ways, yes, and in other ways, no. New York passed a cap on state Medicaid pharmaceutical spending. But once the state hits that cap, it doesn’t mean the state will stop paying for prescription drugs. It just means the state is empowered to negotiate with some of these companies and seek additional discounts. They didn’t need CMS approval for this. New York doesn’t have the ability to say “If you don’t take this deal, we’re not going to cover this product.”

Oklahoma is pursuing outcomes-based pricing, which is of interest. It’s the first state to express interest in doing so. However, there are a lot of observers who are skeptical that outcomes agreements of this kind will materially lower prices or if they just provide companies cover to charge higher prices in the first instance.

Q: So what options do you see ahead for states given what happened in Massachusetts with the Medicaid waiver?

Unfortunately, states are quite limited in what they’re able to do on their own, in terms of controlling prescription drug costs — both costs that are borne by the state in its capacity as a public employer and its capacity as an insurer for the Medicaid population. and then more generally for the many citizens who are on private insurance plans throughout the state.

This is a real problem, this concern of federal pre-emption where states’ ability to go beyond federal law is often limited. So what we’re seeing now is more states like Massachusetts and Vermont taking action that forces the federal government to do something or say something. States are increasingly putting pressure on the federal government because they know that their ability to act on this problem of drug pricing is limited.

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

Drug Companies Back New California Bill To Protect Integrity Of Research Data From Consumers

The legislation comes in reaction to a law that was geared toward protecting consumer privacy. Drug companies say, though, that it could inadvertently invalidate research, make it difficult to obtain funding and ultimately drive scientists from the state. In other industry news, companies in Massachusetts are being wooed by Maryland, and Europe signs off on another Humira copy.

Drug Companies Back New California Bill To Protect Integrity Of Research Data From Consumers

The legislation comes in reaction to a law that was geared toward protecting consumer privacy. Drug companies say, though, that it could inadvertently invalidate research, make it difficult to obtain funding and ultimately drive scientists from the state. In other industry news, companies in Massachusetts are being wooed by Maryland, and Europe signs off on another Humira copy.

Advocates Ask Trump Administration To Ignore Maine Governor’s Resistance And Approve State’s Medicaid Expansion

Due to a court order, Gov. Paul LePage requested approval last month to expand Medicaid in Maine. But the governor also wrote a letter to the administration urging officials to reject his application. Meanwhile, support for a program that helps people with disabilities move out of nursing homes gains support. Medicaid news comes out of Iowa, as well.

Advocates Ask Administration To Ignore Maine Governor’s Resistance And Approve State’s Medicaid Expansion

A court ordered Gov. Paul LePage to request approval for expanding Medicaid in Maine, but the governor also wrote a letter to the administration urging officials to reject the application. Meanwhile, support for a program that helps people with disabilities move out of nursing homes gains support. Medicaid news comes out of Iowa, as well.

Former Tennessee Governor Touts Deep Medicaid Cuts In Race For Senate Seat

Former Gov. Phil Bredesen (D-Tenn.) was facing a budget that advisers said was the toughest they’d seen in their careers. In a new campaign ad, Bredesen says he “saved TennCare,” but those fixes came at a cost and proved controversial for many at the time. Bredesen is running for the Senate against Rep. Marsha Blackburn (R-Tenn.) Medicaid news comes out Iowa and Michigan, as well.

Former Tennessee Governor Touts Deep Medicaid Cuts In Race For Senate Seat

While governor, Phil Bredesen (D-Tenn.) faced a budget that advisers said was the toughest they’d seen in their careers. In a new campaign ad, Bredesen says he “saved TennCare,” but those fixes came at a cost and proved controversial for many at the time. Bredesen is running for the Senate against Rep. Marsha Blackburn (R-Tenn.) Medicaid news comes out Iowa and Michigan, as well.

Paper Jam: California’s Medicaid Program Hits ‘Print’ When The Feds Need Info

In the shadow of Silicon Valley, the hub of the world’s digital revolution, California officials still submit their records to the feds justifying billions in Medicaid spending the old-fashioned way: on paper.

Stacks and stacks of it.

Stuck with decades-old technology, the nation’s largest Medicaid program forces federal officials to sift through thousands of documents by hand rather than sending electronic files. That’s one of the critical findings in a Sept. 5 report from the federal government’s chief watchdog citing inefficient and lax oversight of Medicaid nationwide.

To illustrate, the U.S. Government Accountability Office published a photo showing piles of records submitted for one three-month period. One folder was placed upright to show the height of the heap.

“It’s really amazing when you look at that picture,” said Carolyn Yocom, a health care director at the GAO who focuses on Medicaid, the federal-state health insurance program for low-income people. “For this type of reporting on expenditures, California really should be able to provide that electronically.”

California, with more than 13 million Medicaid enrollees, said it’s hamstrung because it uses 92 separate computer systems to run its Medicaid program — although it has plans underway to modernize its technology.

“Given system limitations and the magnitude of the supporting documentation, providing it electronically is currently not feasible,” the California Department of Health Care Services said in a statement.

The state’s Medicaid program, known as Medi-Cal, has struggled with technology for years. The state thought it had a solution in 2010 when it awarded a $1.7 billion contract to Xerox, which included $168 million for a new system. But after years of delay, the state scrapped the contract in 2016 and started from scratch, leaving the patchwork system in place a few more years.

Nationwide, despite industry buzz about electronic medical records, smartphone apps and artificial intelligence, a lot of paper is still being pushed across the health care system. Consider all those forms patients repeatedly fill out in the waiting room, the screeching sound of fax machines inside doctors’ offices and the bulging binders of patients’ records in file rooms.

Under Medicaid, states submit data quarterly to the federal government on their spending and include supporting documents such as invoices, cost reports and eligibility records. In California, reports on spending are shared electronically, but the copious supporting documentation required for federal review is not, according to the GAO.

When the Xerox venture failed, the company agreed to pay California more than $123 million as part of a settlement agreement, according to state officials.

Meantime, Conduent, the services unit of Xerox that was spun off into a separate company, was left to keep operating the system and process claims.

Last month, the state awarded a contract to DXC Technology of Tysons, Va., to take over some operations from Conduent. The state said the contract could be worth $698 million over 10 years.

Separately, California’s Medicaid officials are working on plans for a new system that would cost an estimated $500 million. Under the federal-state partnership on Medicaid, the federal government would cover 90 percent of those costs for design and implementation, and the state’s share would be about $50 million.

Pressure has been mounting on California to fix the situation. The Medicaid IT system “needs to be replaced, because it is more than 40 years old, its operations are inefficient, maintaining the system is difficult and there is a high risk of system failure,” state auditor Elaine Howle wrote in a June 26 letter to Gov. Jerry Brown and legislative leaders.

In her letter, Howle said the state was paying about $30 million annually to maintain the legacy system.

Overall, Medi-Cal serves 1 in 3 Californians. The annual Medicaid budget in California is about $104 billion, counting federal and state funds.

Beyond California, the GAO criticized the U.S. Centers for Medicare & Medicaid Services (CMS) more broadly. One complaint: Federal officials assign a similar number of staff to states for reviewing case files — even though some states, like California, pose a far bigger risk for enrollment errors and misspent money due to their size and complexity.

For instance, the report’s authors said, CMS reviewed claims for the same number of newly eligible Medicaid enrollees — 30 — in California as it did in Arkansas, even though California had 10 times the number of newly enrolled patients under the Affordable Care Act.

The report also said CMS devoted a similar number of staff to review both California, which represents 15 percent of federal Medicaid spending, and Arkansas, which accounts for 1 percent.

CMS “needs to step back and assess where are the biggest threats and vulnerabilities,” Yocom said. “If you aren’t looking, you don’t know what you aren’t catching.”

Overall, from fiscal years 2014 to 2018, federal Medicaid spending increased by about 31 percent, according to the GAO report. But the full-time staff at CMS dedicated to financial oversight declined by roughly 19 percent over the same period.

In a July 18 letter to the GAO, the U.S. Department of Health and Human Services agreed with the agency’s recommendations for improving oversight efforts.

HHS wrote that it “will complete a comprehensive national review to assess the risk of Medicaid expenditures reported by states and allocate resources based on risk.”


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