Tag: The Health 202

Biden’s Got a New Set of Orders for Obamacare. Is It His Last?

The Biden administration has issued its latest official wish list for Obamacare insurance plans, potentially one of the last major Affordable Care Act health policy efforts in the president’s first term.

Changes on tap for 2025? For one, the administration wants states that run their own ACA marketplaces to crack down on what’s called “network adequacy” — how many doctors, hospitals and other providers Obamacare insurers include in their covered networks.

The regulatory proposal, known in Washington as the payment parameters notice, came out on Nov. 15. Arriving in the run-up to a presidential election, the proposed rules could be finalized in the spring and would take effect in January 2025, not long before Inauguration Day.

Should President Biden fail to fend off his likely Republican challenger, former president Donald Trump, Obamacare and the insurance markets it created could start to look a lot different. Biden, of course, has been a staunch supporter of the ACA and has taken steps to expand the program through both rulemaking and legislation, including measures that increased premium subsidies. Enrollment has hit records under his watch.

But over Thanksgiving weekend, Trump posted on his Truth Social site that the GOP’s failure to repeal the ACA in his first term was “a low point for the Republican Party.”

He’s “seriously” considering alternatives, Trump added — harking back to his presidency, when he repeatedly promised he was about to reveal an Obamacare replacement plan. Spoiler alert — he never did.

That’s a softball for Democrats. Obamacare has grown to be largely popular with Americans, according to KFF, which has long tracked public opinion of the law. Trump’s failed attempt to repeal it helped cost his party control of the House in 2018, exit polls indicated.

Biden seized on Trump’s posts, saying Monday at the White House that “my predecessor once again called for cuts that could rip away health insurance for tens of millions of Americans.” 

Behind the back and forth between the men, however, is a reality: Many of the changes made during Biden’s term, especially those in regulations, could be altered if there’s a new administration elected next year — just as Biden did when he took office, and Trump before him.

Trump, for example, rolled back ACA actions by his predecessor, President Barack Obama, including sharply reducing funding for enrollment assistance, shortening the annual sign-up period and loosening rules so less expensive short-term plans could be sold for longer periods.

Biden’s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans, which don’t cover many benefits required by the ACA and are called “junk insurance” by critics.

But the latest payment parameters notice from Health and Human Services is a modest set of tweaks that, in part, aims to address concern about whether ACA insurers cover enough doctors and hospitals to meet demand. The network adequacy provision would require states to set numerical standards, such as  the maximum time or distance patients might have to travel to access in-network care, that are at least as tough as the rules the feds impose on insurers in its exchange. A quarter of states running their own marketplaces don’t have any such quantitative standards, according to CMS.

In addition, the payment rule would:

  • Seek to expand access to routine adult dental coverage by allowing states to add the care to essential benefits in their benchmark plans. That’s currently not allowed.
  • Standardize open enrollment periods across all states to start Nov. 1 and run at least through Jan. 15. Most states already do that, although Idaho currently opens Oct. 15 and ends Dec. 15.

“If the past is any guide, and the next administration is different, the first thing they will do is roll things back,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

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Desantis, Newsom to Tangle Over Hot-Button Health Issues

Florida’s Republican presidential hopeful, Ron DeSantis,and Democratic firebrand Gavin Newsom of California square off today in a contest of governors that can best be described as the debate to determine ¿quién es más macho? — who is more manly — about protecting your freedoms. 

Both men have led their respective states since 2019, and they’ve lately been engaged in an escalating feud. While Newsom isn’t running for president himself — yet — he’s a key surrogate for President Biden. Fox News is playing up the faceoff, which it’ll host, as “The Great Red Vs. Blue State Debate.” 

The debate promises to put America’s culture wars front-and-center. Abortion. Homelessness. Transgender health care. The coronavirus pandemic response. Health coverage for undocumented immigrants. Even drag shows, DEI and Disney’s First Amendment rights.

Though conservative TV host Sean Hannity is moderating the 90-minute showdown in Alpharetta, Ga., seemingly a home-field advantage for DeSantis, Newsom is relishing the confrontation after goading Florida’s governor into going head-to-head. 

Both men use each other’s states as punching bags. DeSantis portrays Newsom as too liberal for America, presiding over a failed state where homelessness and crime are rampant, citizens are forced to mask up and get vaccinated, and access to abortion and public assistance like Medicaid is too easy, breaking society morally and financially.

In a fundraising video for his presidential campaign, DeSantis called California “the petri dish for American leftism,” adding that “everything Biden is doing — they would accelerate and they would cause this country to collapse. That is not the future that we need. Florida shows a model for revival, a model based on freedom.”

Newsom has blasted DeSantis as a “small pathetic man” and argues that small-d democracy itself is at stake in the presidential election. His political operation paid for an ad on Florida’s airwaves this year in which Newsom told Sunshine State residents: “Freedom — it’s under attack in your state.”

He has knocked DeSantis’s education policies that restrict teaching gender and sexuality to schoolchildren as well as laws the Florida governor pushed through the legislature banning abortion after six weeks and limiting gender transition-related health care. 

“Your Republican leaders, they’re banning books, making it harder to vote, restricting speech in classrooms,” Newsom said in his ad. “Even criminalizing women and doctors. Join us in California, where we still believe in freedom.”

Newsom’s health and education policies are largely the opposite of DeSantis’s. He’s expanded access to gender-affirming care for children and adults, and is expanding Medicaid beginning Jan. 1 to cover lower-income undocumented immigrants. Backed by the Democratic-controlled state legislature, Newsom led an effort in 2022 to enshrine the right to abortion in the state constitution, and he’s fought to block local school districts from restricting access to certain books.

While DeSantis directs resources to the presidential campaign, where he’s struggling to maintain his second-place standing in the GOP primary behind front-runner Donald Trump, Newsom struck again this month with another Florida ad buy, this time centered on reproductive health and abortion access. 

The ad alleges that DeSantis has criminalized doctors and women seeking an abortion after six weeks and argues that they could be arrested “by order of Governor Ron DeSantis.”

Both men face a monumental test in their debate. Newsom must demonstrate his loyalty to Biden, the Democratic Party leader and the actual candidate next November, while scoring points against DeSantis.

DeSantis, a wooden public speaker who struggles to connect with his audiences, has faced some criticism in Republican circles for a lackluster campaign. He’s got to persuade GOP voters that he’s a formidable option to Trump, without any major gaffes. 

The proxy battle could shape not only next year’s presidential contest, but the 2028 field of White House contenders as well.

One other hot-button issue we’re watching for is homelessness, considering nearly one-third of all homeless Americans live in California. Expect DeSantis to hammer Newsom over Californians fleeing for cheaper living elsewhere — including to Florida. Newsom, meanwhile, will play up the unprecedented investment he’s spearheaded to combat the humanitarian crisis (without clear results as of yet).

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Hospitals and Doctors Are Fed up With Medicare Advantage

Medicare Advantage plans are pretty popular with both lawmakers and ordinary Americans — they now enroll about 31 million people, representing just over half of everyone in Medicare, by KFF’s count.

But among doctors and hospitals, it’s a different story.

Across the country, provider grumbling about claim denials and onerous preapproval requirements by Advantage plans is crescendoing. Some hospitals and physician practices are so fed up they’re refusing to accept the plans — even big ones like those offered by United Healthcare and Humana.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

Last week, the industry’s largest lobbying group, the American Hospital Association, fired off a letter to the Centers for Medicare and Medicaid Services warning that some insurers seem intent on circumventing new rules put in place by the Biden administration aimed at reining in some prior authorization and claim denials.

It isn’t like we’ve never seen disputes between insurers and providers before, especially in negotiations with employer-sponsored plans.

But the focus now on Medicare Advantage “seems different,” said David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy, who says hospitals and doctors are becoming “much more vocal” about their frustrations with some of the insurers’ cost-control efforts.

Baptist Health in Louisville, for example, has threatened that all of its nine hospitals, along with its clinics and physician groups, will cut ties with Advantage plans offered by UnitedHealthcare and WellCare Health Plans Inc. beginning in January unless they can come to terms.

The plans “routinely deny or delay approval or payment for medical care recommended by your physician,” the system wrote in a message to patients posted on its website.

The system’s medical group, with nearly 1,500 physicians and other providers, left Humana’s network in September.

And in San Diego, more than 30,000 people are looking for new doctors after two large medical groups affiliated with Scripps Health said they would no longer contract with any Medicare Advantage insurers. Revenue “is not sufficient to cover the cost of patient care we provide,” they said in a statement.

Lipschutz thinks providers are feeling emboldened following a study by the Health and Human Services Department’s inspector general published last year that found some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules.

The Biden administration’s new rules, set to take effect in January, are in part a response to the OIG report. Enrollment for Medicare Advantage plans, supplemental plans for traditional Medicare coverage and stand-alone Medicare drug plans is open until Dec. 7.

While the insurance industry likes to boast that a huge majority of Congress supports the plans, there’s increasing scrutiny at the Capitol, too.

Prior approval is a big point of friction. Virtually all Medicare Advantage enrollees are in plans that require the insurer to sign off in advance for at least some care, according to KFF. Insurers say that process ensures treatments are coordinated and appropriate.

In 2021, more than 35 million requests for prior approval were submitted for Medicare Advantage enrollees, according to KFF, and over 2 million of them were denied. For the small minority of patients who appeal (11 percent), a whopping 82 percent won a full or partial overturning of the insurers’ decision.

To be sure, commercial plans covering people with job-based insurance or those who buy their own through the Affordable Care Act also engage in prior approval, and there’s lots of complaints about them, too.

The difference with Medicare, though, is that beneficiaries can choose the traditional, government-run program, where prior approval and claim denials are much more limited. Doctors and hospitals have plenty of gripes about how much traditional Medicare pays them, but from their point of view, they spend less time fighting over medical decisions.

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Medicaid’s ‘Unwinding’ Can Be Especially Perilous for Disabled People

Earlier this year, Beverly Likens thought she’d done everything she needed to do to keep her Medicaid. Then came an unwelcome surprise: Ahead of surgery to treat chronic bleeding, the hospital said her insurance was inactive, jeopardizing her procedure.

Likens had just been diagnosed with severe anemia and given a blood transfusion at the emergency room. “I was just ready to fall to pieces,” she said. The Kentucky resident, 48 at the time, experienced a coverage gap that she and a lawyer who tried to help say never should have happened. 

The situation highlights a complication with what’s known as the Medicaid “unwinding.” States are reviewing the eligibility of millions of Americans who remained enrolled in the safety-net health program through the pandemic — but the process has been messy and caused chaos all over the country, as KFF Health News has reported.

In part, that’s because people are being asked to reapply when they shouldn’t need to, or outright dropped when they still qualify. According to consumer advocates and legal aid attorneys, some states aren’t following federal rules that require them to consider all the ways people might qualify for Medicaid before concluding that they’re ineligible and terminating their coverage. That’s what happened to Likens.

Before she lost her coverage, Likens qualified for Medicaid because she had Supplemental Security Income, a program for people with little to no income or assets who are blind, disabled or at least 65 years old. After she lost her SSI benefits in the spring because she had assets whose cash value exceeded federal limits, Kentucky’s Medicaid agency sent a notice in April that she’d automatically lose her health coverage but could reapply.

The state didn’t assess whether Likens qualified another way. She did: Even without SSI, her income was low enough. And when she tried to reapply herself, she experienced technical issues with Kentucky’s enrollment system — another common problem around the country.

“There undoubtedly are people who are eligible in another category, but they’re falling through the cracks,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Medicaid eligibility is complicated. Often, someone who qualifies initially for one reason can remain eligible even when their life circumstances change, as long as their income remains below certain thresholds. But those income thresholds can vary — both state by state and even within a single state.

At least 11.1 million people have been disenrolled from Medicaid this year, as of Monday, according to KFF’s unwinding tracker, while 20.7 million had their coverage renewed. During the pandemic, when states were banned from disenrolling people, Medicaid enrollment grew by 22.6 million, data from the Centers for Medicare and Medicaid Services shows. 

Certain Medicaid beneficiaries are more likely to run into problems maintaining enrollment, said Jennifer Tolbert, associate director of KFF’s program on Medicaid and the uninsured. They include pregnant women whose eligibility for the program would change after delivery, kids who age out of eligibility or someone who had been receiving disability benefits but isn’t anymore — like Likens. There were 7.7 million SSI recipients as of 2021, according to the Social Security Administration.

But if a state’s Medicaid eligibility system works correctly, it “should automatically” assess all the ways an applicant may qualify, Tolbert said. “It should be built into the system.”

Likens, who doesn’t have children and isn’t working, was eventually reinstated and had her surgery. But she knows that other people aren’t as fortunate. “We are entitled to health care,” she said.

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Nikki Haley (And Her Opponents) Struggle With a Vaccine Message

Former South Carolina governor Nikki Haley portrays herself as a voice of reason in the Republican Party. “Let’s find consensus,” she said about abortion during the first GOP primary debate. “Let’s treat this like a respectful issue.”

It’s talk like that — and strong polling in a hypothetical matchup against President Biden — that has helped position Haley to potentially overtake Florida Gov. Ron DeSantis as the GOP’s “plan B” presidential candidate.

But an examination of her record on vaccination shows how she’s also tuned her positions to the views of the Republican base. 

Many of the GOP presidential candidates have struggled to fine-tune their message on vaccination, my colleague Daniel Chang and I have reported, as their voters grow increasingly skeptical of shots that most doctors will tell you are vital for public health. Former president Donald Trump, for example, has tried to simultaneously claim credit for his “Operation Warp Speed” program to accelerate development of coronavirus vaccines and also bash DeSantis for promoting vaccination to Floridians.

Forty percent of Republicans believe that parents should be able to opt out of required childhood vaccines — about double the rate in 2019, according to a September survey from KFF. Support for vaccination among Democrats has remained stable, by comparison, with 84 percent saying they should be required for public school students.

It’s an especially tricky subject for Haley as she tries to hold herself out as the sensible GOP candidate. Her basic message: Covid vaccines are good but shouldn’t be required. 

During the height of the pandemic, Haley praised the Trump administration’s efforts to expedite vaccine development — and even touted Microsoft co-founder Bill Gates’s donations for vaccine manufacturing plants.

But she’s since declared her opposition to vaccine mandates, saying in a November 2021 interview with the Christian Broadcasting Network: “Mandates are not what America does.” And she’s encouraged some anti-vaccine themes. 

“Did I get it, did my family get it? Yes,” she said in the CBN interview. “But if you ask a woman who wants to get pregnant, and she’s worried about it, or you ask a parent whose child might be compromised, and they’re worried about it, that’s a personal family decision.”

The idea that the coronavirus vaccine may interfere with fertility is a common fear stoked by anti-vaccine activists. The Centers for Disease Control and Prevention says on its website that there is “no evidence that any vaccines, including COVID-19 vaccines, cause fertility problems.”

Early in her political career as a state legislator, Haley co-sponsored a bill mandating vaccinations for HPV — a common sexually transmitted virus, some variants of which can cause cervical and other cancers as well as genital warts.

The benefits of HPV vaccination are hard to dispute. One 2020 study tracking nearly 1.7 million Swedish girls and women over 11 years found a nearly 90 percent reduction of risk for cervical cancer for those who began vaccination before age 17, compared with the unvaccinated. HPV vaccination can also help protect boys against some cancers.

But Haley, and the rest of the South Carolina legislature, faced a lobbying blitz by evangelicals, who feared that the vaccine would encourage children to have sex. Support for the bill cratered; Haley kept her name on as co-sponsor but later voted against the legislation. As governor, Haley vetoed a bill that would have encouraged — not mandated — HPV shots.

Haley’s primary positioning on vaccines is less extreme than that of some of her rivals; biotech entrepreneur Vivek Ramaswamy, for example, has said he regrets getting the covid shot. 

But her long history on vaccination issues looks today like a premonition. Megan Weis, a faculty member at the University of South Carolina’s Arnold School of Public Health, said of the state’s struggle over the HPV vaccine: “In retrospect, that was the beginning of some of the vaccine misinformation movement.”

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Biden Administration Nibbles at the Maternal Health Crisis

Choosing where to give birth typically comes down to what hospital is most convenient to your home, where your obstetrician practices and your insurance company’s provider network.

Now, the Biden administration has given expectant parents another factor to consider: whether their hospital has won the government’s new “birthing friendly” designation.

But don’t worry — a birthing-friendly hospital won’t be hard to find: Most U.S. facilities that deliver babies won the designation, according to Centers for Medicare and Medicaid Services and March of Dimes data. And that raises some questions about the rigor of the administration’s tests for the designation. “I guess this is a good first start, but it’s a quite weak standard,” said Kathleen Simpson, editor in chief of the American Journal of Maternal/Child Nursing.

In the D.C. area, most major hospitals and health systems that offer maternity care made the list, including Georgetown University Hospital, George Washington University Hospital, Howard University Hospital, Sibley Memorial, MedStar Washington Hospital Center and Inova Health System.

The U.S. has far higher maternal and infant mortality rates than similar large and wealthy countries, especially for people of color — and the problem has gotten worse in recent years. In addition, the Supreme Court’s decision in 2022 to overturn Roe v. Wade has increased barriers to abortion in many states, putting even more pressure on the feds to improve maternal and infant health. The White House has made the crisis a priority, with Vice President Harris leading the government’s response. 

While the administration has said it’s attacking the problem on several fronts, the birthing-friendly designation is one of the more visible efforts for consumers.

The Biden administration has also successfully pushed states to offer pregnant women continuous coverage under Medicaid, the insurance program for low-income people, for up to a year after delivery. So far, the administration has approved postpartum coverage extensions for 39 states and D.C. Medicaid pays for about 4 in 10 U.S. births.

To get the birthing-friendly designation, announced Nov. 8, hospitals merely had to attest they participate in a state or national quality collaborative and attest to adhering to “evidence-based care.”

“That is the lowest bar that they could have set,” Simpson said.  “It doesn’t measure anything.”

Simpson had hoped CMS would use nurse staffing ratios in maternity or neonatal units to help consumers differentiate among hospitals.

“I’m pleased to see things happening but the designation is not something that is going to make a difference,” she said.

Erin Jones, director of legislative and strategic counsel at the March of Dimes, called the birthing designation a “positive first step.” 

She said that persuading hospitals to participate in quality-improvement collaboratives isn’t always easy. The designation, she said, may put pressure on hospitals that aren’t engaged in quality improvement in maternity care to get started.

A CMS spokesperson said 66 percent of about 3,100 hospitals that report data to a federal quality review program won the designation. But the spokesperson couldn’t say how many of the 3,100 provide obstetric care. Some hospitals nationwide — especially in rural areas — have recently shuttered their labor and delivery units.

“It looks like every hospital got the designation, or very close to it,” Simpson said.

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