Tagged The Health Law

March Madness Vasectomies Encourage Guys To Take One For The Team

Doctors say it all started eight years ago, when a urology clinic in Oregon ran an ad promoting the benefits of scheduling a vasectomy in March.

“You go in for a little snip, snip and come out with doctor’s orders to sit back and watch nonstop basketball,” the voice-over promised. “If you miss out on this, you’ll end up recovering during a weekend marathon of ‘Desperate Housewives’!”

Copycat ads followed. Now a sports radio show in Washington, D.C., has an annual Vasectomy Madness contest, where the prize is a free vasectomy.

Here’s how it works: Three guys come on the air to make their cases for getting snipped. The announcers ruthlessly roast them, and then listeners vote on their favorite.

“All right, let’s bring in our next contestant,” a host said. “I believe it’s Abe from Warrenton, Va. So tell us your story. Why are you here?”

Abe has three kids, ages 9, 6 and 3.

“Another one — surprise! Due in July,” Abe said. “I was shopping after the third for a vasectomy and, like a dope, dragged my feet.”

There’s Mike, also expecting his fourth child — also a surprise.

“My wife and I have had enough,” he pleaded. “We need help to stop the flow.”

And then there’s Charles.

“Four kids. Three different women,” Charles said, inspiring a roar of jeers from the hosts.

Procrastination can be so common with the “Big V” that it takes a panel of sports jocks offering a free procedure for some guys to finally let a doctor take a scalpel to their nether regions.

That may be one reason vasectomy rates are low: About 5 percent of women rely on their partner’s vasectomy for contraception, unchanged from a decade ago. The Centers for Disease Control and Prevention’s National Survey of Family Growth compares that to 20 percent of women who have had a sterilization procedure, even though women’s surgery is more invasive and more expensive.

“Men are culturally the providers. It’s hard for them to seek care,” said Dr. Paul Turek, a California urologist. “They don’t know how to be a patient.”

Turek has clinics in San Francisco and Beverly Hills. He sees an uptick in vasectomy visits during March Madness, and he’s also noticed more guys coming in together.

“One group came in from a tech company in a limousine,” he said.

Last year, five college buddies scheduled a group vasectomy in March. They live all over the U.S. now, and one of them had an idea to reunite in San Francisco and undergo the outpatient procedure together.

“I gave ’em a deal,” Turek said. “I closed the doors. We had sports TV on. They were having fun.”

As each guy returned to the waiting room, he was greeted with fist bumps and high-fives. Then the men hobbled back to their hotel to bet on the games and yell at the television together.

Turek made an interesting observation during that bro basketball weekend: The friends seemed to recover faster than his typical patients.

“They had no complaints,” he said. “They were back at work sooner. They took fewer pain pills. It was the best anesthesia, having their buddies with them.”

Turek gives all his vasectomy patients a certificate of honor for “uncommon bravery and meritorious performance.”

There is another theory about why vasectomies aren’t more popular: the cost. The Affordable Care Act requires insurers to cover contraceptives without charging out-of-pocket costs. But vasectomies weren’t included in the rule. The procedure costs about $500, but some doctors charge up to $1,000.

That’s why Charles subjected himself to the free vasectomy contest at the D.C. radio station. His insurance covers a portion of the procedure, “but I’d still have to pay my deductible, which is, like, a thousand bucks.”

Vasectomy was overlooked in Obamacare because, under the law, birth control was considered a women’s health service.

“Right now the policy says to a couple: Your insurance will cover birth control without any out-of-pocket costs on your end, as long as it’s the woman who’s using it,” says Adam Sonfield, senior policy manager at the Guttmacher Institute.

Last year, 12,000 people signed a petition asking regulators to cover vasectomy without cost sharing. Doctors’ groups even drafted language to this effect to add to the regulations.

But when the Trump administration took over, it told the groups to stop trying, according to Aaron Hamlin, executive director of the Male Contraception Initiative.

“The birth control benefit has been under pretty much continual political attack since the ACA was enacted,” said Sonfield.

So for now that leaves guys like Charles, Mike and Abe vying for a free March Madness vasectomy. The winner in the end?

Abe — one of the guys expecting his fourth child.

His prize came with a catch, though. He will have to let one of the sportscasters come to his appointment, to broadcast a “play-by-play.”

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

Categories: Cost and Quality, Health Industry, Public Health, The Health Law


On The Air With KHN: What’s Next For The Affordable Care Act?

On Friday, House Republican leaders failed to secure enough support to pass their plan to repeal and replace the Affordable Care Act. Reporters with Kaiser Health News and California Healthline (produced by KHN) have appeared on numerous radio and television shows in recent days to assess what’s next for the health law. Listen to what they had to say below.

National Media

NPR’s All Things Considered with Mary Agnes Carey (March 25):

CNN’s Smerconish with Mary Agnes Carey (March 25):

WBUR’s On Point with Mary Agnes Carey (March 27):


WAMU’s 1A with Julie Rovner (March 27):

Click here to listen to the segment.

WBUR’s Here & Now with Julie Rovner (March 27):


PBS NewsHour with Mary Agnes Carey (March 27):

[embedded content]

California Media

KCRW’s The Mixer with Anna Gorman (March 24):


KQED’s The California Report with Pauline Bartolone (March 27):


KPCC’s Air Talk with Chad Terhune (March 27):


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

Perspectives On What Happens Now: Can Obamacare Be Fixed Or Will It Be Left To ‘Explode’?

Opinion writers offer their thoughts on this question, outline ways the health law can be spared and examine the direction in which the political winds could send the ongoing debate.

The Washington Post: Obamacare Is The Law Of The Land. But It’s Still Vulnerable.
House Speaker Paul D. Ryan’s (R-Wis.) decision to pull legislation to reconfigure the nation’s health-care system is a major setback to President Trump and the GOP. For seven years, Republicans promised to repeal and replace Obamacare. Their failure to deliver on this promise exposes intraparty divisions that will not be easily healed. (Eric Patashnik and Jonathan Oberlander, 3/27)

Los Angeles Times: Can Trump Be Stopped From Making Obamacare ‘Explode’?
Supporters of the Affordable Care Act may have celebrated prematurely at the demise last week of the House Republicans’ proposal for its repeal. Yes, the most immediate threat to the future of Obamacare is dead, for now. And in the wake of the House fiasco, President Trump as well as some Senate Republicans have made noises about reaching out to Democrats to shore up the health insurance program. But the Trump White House and congressional Republicans still have it within their power to damage the prospects of health coverage for millions of Americans, whether by actively undermining the Affordable Care Act by administrative fiat or by letting it wither by neglect. (Michael Hiltzik, 3/27)

The Atlantic: Obamacare Won’t Explode Unless Trump Wants It To
The scope of Obamacare’s problems is small, but significant. While health-care costs have been going up less than normal in recent years and premiums for people insured by their employers have also been fairly stable, people who buy their own insurance through the Obamacare marketplaces saw premiums spike by an average of about 25 percent this year. Also, several insurers pulled out of the Obamacare exchanges in the past year, leaving 21 percent of exchange enrollees with just one insurance option and people in Knoxville, Tennessee with potentially no insurers at all. (Olga Khazan, 3/28)

The New York Times: Pushing Obamacare Over The Cliff 
After Republicans pulled their legislation to repeal and replace the Affordable Care Act last Friday, President Trump told The Washington Post, “The best thing politically is to let Obamacare explode.” Or he could light a match. Republicans may have conceded defeat in their legislative effort to get rid of Obamacare, but their guerrilla war to achieve its demise remains underway. (Steven Rattner, 3/28)

The Washington Post: Why Trump Won’t ‘Let Obamacare Explode’
As President Trump licked his wounded ego Friday, he told The Post in an interview, “The best thing politically is to let Obamacare explode.” His Office of Management and Budget director, Mick Mulvaney, echoed that sentiment on “Meet the Press.” (Jennifer Rubin, 3/27)

The Des Moines Register: It’s Time To Embrace And Fix Affordable Care Act
“I have to tell you, it’s an unbelievably complex subject,” President Donald Trump told governors during a meeting last month. “Nobody knew that health care could be so complicated.” Nobody except everyone else. That is why the 2009 Democratic-controlled Congress spent a year debating and ironing out the details of what eventually became the Affordable Care Act. The two-part law and regulations total thousands of pages. Before passage, lawmakers met with insurers, hospitals, physicians and patient advocacy groups to build a consensus for what they all understood was a labyrinthine endeavor. (3/27)

The New York Times: Republicans For Single-Payer Health Care
Without a viable health care agenda of their own, Republicans now face a choice between two options: Obamacare and a gradual shift toward a single-payer system. The early signs suggest they will choose single payer. That would be the height of political irony, of course. Donald Trump, Paul Ryan and Tom Price may succeed where left-wing dreamers have long failed and move the country toward socialized medicine. And they would do it unwittingly, by undermining the most conservative health care system that Americans are willing to accept. (David Leonhardt, 3/28)

Atlanta Journal-Constitution: Post-AHCA, How Health Reform Can Move Forward In Georgia
When Roswell’s Tom Price moved from Congress to the executive branch as secretary of health and human services, he instantly gained the power to reshape much of the way health care works in this country, regardless of what becomes of Obamacare. Ironically, it’s Obamacare that gives him that ability… It also gives Price’s department the authority to grant the states waivers to the law’s requirements for health plans offered on their insurance exchanges, and that’s where this gets interesting. (Kyle Wingfield, 3/27)

WBUR: Can Gov. Charlie Baker Fix Health Care In America?
Republicans have long hyped the need for a replacement bill by sowing the fear that Obamacare is imploding. Yet they hypocritically ignore their own complicity in creating the conditions for failure. Now that their bill has collapsed, the new mantra is to practice saying “I told you so,” in the event their self-fulfilling prophecy comes to fruition. (Lauren Stiller Rikleen, 3/28)

The Washington Post: Why Trump And The GOP Could Fail On Tax Reform, Too
There are many lessons to be learned from the failure of the GOP health-care effort. An important one is that being a businessman, even a successful one, does not prepare you for the complexities of governing, any more than being a successful software engineer means you could easily become a great carpenter. (Paul Waldman, 3/27)

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

Different Takes On Who’s To Blame For The Demise Of The House GOP Health Plan

Editorial pages across the country offer their thoughts on the blame game as well as the policies and politics that led to last week’s dramatic outcome.

Los Angeles Times: Healthcare Debacle Results From Republicans Believing Their Own Myths
Donald Trump and congressional Republicans created a political debacle for themselves by believing a set of scare stories about Obamacare that came back to haunt them. It is an object lesson in how false realities ultimately pop like soap bubbles when pricked by plain old truth. There are five fatal fibs the GOP sold to supporters and to themselves. (David Horsey, 3/27)

Boston Globe: In Donald Trump’s Oval Office, The Buck Stops Elsewhere
Since US House Speaker Paul Ryan scrapped last week’s vote on the Republican proposal to replace Obamacare, Trump has blamed different people for its demise, depending on the day. From the Oval Office on Friday, Trump blamed Democrats. On Saturday, Trump asked people to watch a Fox News Channel show on which the host proclaimed, “Paul Ryan needs to step down as speaker of the House.” (Pindell, 3/27)

The Wichita Eagle: Trump’s Ego Costs Him Opportunity On Health Care
When President Trump’s first major governing challenge unexpectedly crystallized last week, his failure to meet it was preordained by his personality. Because he considers himself the center of every universe, an opportunity to step toward greatness was invisible to him. His primary failure wasn’t his inability to persuade the hard-liners in his party to go along with a cobbled-together, cynical and desperate attempt to repeal and replace the Affordable Care Act. Solomon could not have salvaged that wreck. (Davis Merritt, 3/28)

Los Angeles Times: Who’s To Blame For Trump’s Failures? Must Be Paul Ryan
Paul Ryan did it. That’s the argument many of the louder voices on the right are shouting. In the story they tell, the speaker of the House is fully responsible for the GOP’s failure to pass an Obamacare repeal-and-replace bill last week. President Trump should walk across a Havana ballroom like Michael Corleone in “The Godfather Part II,” kiss Ryan on the mouth and say, “I know it was you, Paul. You broke my heart.” (Jonah Goldberg, 3/27)

The Washington Post: This Is Why The Freedom Caucus Called The Shots On Trump’s Health-Care Bill
The Republicans’ failed strategy to repeal and replace the Affordable Care Act is puzzling. Knowing that a more conservative health-care bill would be dead on arrival in the Senate, why did President Trump and House Speaker Paul D. Ryan (R-Wis.) seek the votes of the House Freedom Caucus (HFC), a group of about 30 of the chamber’s most conservative members? Desperate to secure a majority, the White House offered significant last-minute policy concessions to the group — turning off the more centrist members of the Tuesday Group, failing to secure Freedom Caucus votes and dooming the bill. (Ruth Bloch Rubin, 3/27)

The Wall Street Journal: The GOP Entitlement Caucus
The full dimensions of the GOP’s self-defeat on health care will emerge over time, but one immediate consequence is giving up block grants for Medicaid. This transformation would have put the program on a budget for the first time since it was created in 1965, and the bill’s opponents ought to be held accountable for the rising spending that they could have prevented. (3/27)

The Washington Post: The Freedom Caucus Blows Its Chance To Govern
A few days before the House Freedom Caucus brought down the American Health Care Act, Rep. Mark Meadows laid out the stakes for his group: “This is a defining moment for our nation, but it’s also a defining moment for the Freedom Caucus.” The North Carolina Republican was right. The vote was indeed a defining moment — a test in which the Freedom Caucus had to decide: Would it remain a minoritarian opposition bloc whose only role was to defend truth without compromise? Or could it become something bigger, transforming itself into a majoritarian governing force that could lead Congress toward achievable conservative victories and have a lasting impact on the direction of our country? (Marc A. Thiessen, 3/27)

Huffington Post: The Death Of Trumpcare Is The Ultimate Proof Of Obamacare’s Historic Accomplishment
Somehow, despite the intense political forces arrayed against it, and the mind-boggling policy problems it tries to solve, the 2010 health care law keeps defying efforts to wipe it out. That says something about the people who wrote it ― and what they have achieved. Obamacare has never been hugely popular, and it has never worked as well as its architects hoped. Millions of Americans don’t like it and, even now, there are parts of the country where the markets are struggling to survive. But the program has provided security and access to care for millions of others. More importantly, it has shifted the expectations of what government should do ― and of what a decent society looks like. (Jonathan Cohn, 3/26)

Los Angeles Times: The Original Mistake That Distorted The Health Insurance System In America
A World War II-era mistake distorted the U.S. health insurance system. Reformers tried to fix the problem with patchwork solutions until Obamacare dumped yet another layer of misguided policy onto what was already a mess. Now the tangle is so perplexing that a Republican Congress, under a Republican president, could not even bring a health-insurance reform bill to a vote last week. But legislators will no doubt try to tackle the issue again, and when they do, they should consider erasing the original error instead of merely papering it over. (Myron Magnet, 3/28)

RealClear Health: Five Lessons From The AHCA’s Demise
While the keyhole of history has had insufficient time to bring the failed launch of the American Health Care Act (AHCA) into focus, it’s not too soon to begin learning some of the lessons it can teach us. Legislative efforts have a lifespan but our health care system does not. So whether we are still rejoicing or recriminating, let’s take a look at some timeless principles we can apply to the ongoing effort to improve health care in the United States. (Billy Wynne, 3/27)

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

McAuliffe Says Health Bill’s Collapse In Congress Signals Need For Virginia To Expand Medicaid

But the state’s Republican lawmakers, who have consistently opposed such a move, appear unlikely to accept the governor’s suggestion. News outlets also examine a proposal in Georgia to revamp Medicaid, a look at how the program for low-income Americans has evolved since the 1960s and a request from Wisconsin to add drug tests for eligibility.

The Washington Post: McAuliffe: If Obamacare Is Here To Stay, Then It’s Time To Expand Medicaid
The failure of Congress to repeal and replace Obamacare has emboldened Gov. Terry McAuliffe (D) to renew his stalled crusade to expand Medi­caid in Virginia. On Monday, he proposed an amendment to state budget language to give him power to set an expansion in motion, and called on the Republican-controlled General Assembly to immediately begin making plans. But Republican legislators were unmoved by the plea, saying they would reject the amendment and that they stood firm against expanding Medicaid. (Schneider, 3/27)

CNN: McAuliffe Pushes Virginia Medicaid Expansion After GOP’s Failure To Repeal Obamacare
Virginia’s Democratic governor is using President Donald Trump’s failure to repeal Obamacare to heap pressure on Republican state lawmakers to expand Medicaid. Gov. Terry McAuliffe — who has long supported the Affordable Care Act’s Medicaid expansion, but has been stymied by GOP legislators in extending the coverage to more than 400,000 Virginians — announced the push Monday. (Bradner, 3/27)

Atlanta Journal-Constitution: Georgia Eyes New Medicaid Options After Trump Health Bill Fails 
Gov. Nathan Deal said Monday his administration is exploring changes to Georgia’s Medicaid program after a sweeping Republican overhaul of the Affordable Care Act was scuttled in a stunning rebuke to Donald Trump and Congressional leaders. The Republican governor said there are limits to what the state can request “as long as mandates under the basic Obamacare legislation stand in place.” But he said the state would review healthcare options that could include changes to “mandated minimum coverage” provisions that require the state Medicaid program to cover a range of health services to recipients. (Bluestein, 3/27)

The Associated Press: Georgia Governor Says State Will Explore Health Care Changes
Trump’s administration has signaled a willingness to let states experiment with Medicaid funds using waivers. Former Georgia congressman Tom Price now leads the Department of Health and Human Services under Trump. Deal said Monday that he wants the state to look into the options but didn’t discuss details. He also added that his administration hasn’t developed a proposal so far. (Foody, 3/27)

The New York Times: In Health Bill’s Defeat, Medicaid Comes Of Age
When it was created more than a half century ago, Medicaid almost escaped notice. Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills. (Zernike, Goodnough and Belluck, 3/27)

Milwaukee Journal Sentinel: With Congress Gridlocked, Scott Walker Wants Trump To OK Drug Tests For State Health Coverage
With the GOP’s repeal of Obamacare stymied in Congress, Gov. Scott Walker is still rejecting the federal law and instead asking the Trump administration to let Wisconsin drug test applicants for state coverage. Even though federal money remains available for providing health care to more Wisconsin residents, the GOP governor says he’s not reconsidering his decision to skip that and forgo hundreds of millions of dollars from federal taxpayers. (Stein, 3/27)

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

Taking Stock: After The Smoke Clears, The Health Insurance Issues Remain

Premium costs, essential benefits, Medicaid expansion and the fact that the health industry has a huge impact on the financial markets are among the thoughts on which opinion writers continue to focus.

Bloomberg: Market Impact Of Republicans’ Insurance Debacle Far From Clear
Having stiff-armed political risk for quite a while, market participants now have to think a lot more about the issue in general — and specifically, about how much the Trump administration’s legislative agenda will suffer on account of Republicans’ last-minute decision on Friday to pull their health-care bill from an imminent vote on the floor of the House of Representatives. Some may be inclined to predict other failures that would impact forthcoming economic bills, given the erosion of Republicans’ political capital and the Washington blame game that’s sure to play out. But the situation on the ground is a lot more complicated than that. (Mohamed A. El-Erian, 3/24)

RealClear Health: The Root Cause Of Health Care Dysfunction
Before the Affordable Care Act (ACA) passed in March 2010, President Obama repeatedly promised that the typical family’s health premiums would go down by (sometimes “up to” but frequently “on average”) $2,500. That decline did not occur because the ACA strengthened the control that insurance companies—as opposed to patients—have over health care spending. In fact, Americans’ increasing dependence on health insurance over the last seven decades has been a major contributor to exploding health costs. (John R. Graham, 3/27)

Modern Healthcare: Some Insurance Benefits Are Essential
The House of Representatives last week postponed voting to gut Obamacare after new provisions weakening the essential benefits guarantee failed to win the support from right-wing Republicans, who are opposed to any form of subsidized health insurance. Suffice it to say that the last-minute maneuvering clarified how far the modern Republican Party is willing to go in undermining health insurance, and the healthcare system along with it. (Merrill Goozner, 3/25)

Forbes: More States To Expand Medicaid Now That Obamacare Remains Law
More states will pursue expansion of Medicaid health benefits for poor Americans under the Affordable Care Act after Republicans failed to repeal and replace the law. … At least two states – Kansas and North Carolina – are already working toward becoming the 32nd and 33rd states to expand Medicaid under the ACA. (Bruce Japsen, 3/26)

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

What Happens Next?: How To Move Forward On Fixing The Nation’s Health Care

Opinion writers speculate on what will happen now for the future of Obamacare.

The New York Times: How To Build On Obamacare
“Nobody knew that health care could be so complicated.” So declared Donald Trump three weeks before wimping out on his promise to repeal Obamacare. Up next: “Nobody knew that tax reform could be so complicated.” Then, perhaps: “Nobody knew that international trade policy could be so complicated.” And so on. (Paul Krugman, 3/27)

USA Today: Here’s The Bipartisan Path Forward On Health Care: Andy Slavitt
The failure of Trumpcare last week can be seen as a rejection of policies that Americans judged would move the country backwards. But it also presents the opportunity to end the divisiveness that hampered the Obamacare era and move forward in a bipartisan direction that focuses not on destructive rhetoric, but squarely on reducing premiums and expanding access for all Americans. (Andy Slavitt, 3/26)

USA Today: Trump’s New Health Care Opportunity: Our View
President Trump says he has a new strategy to address problems with the Affordable Care Act. He is going to wait “to let Obamacare explode” and then wait some more to let the Democrats “come to us” so we can “make one beautiful deal for the people.” (3/26)

Chicago Tribune: Moving On: Who’ll Fix Obamacare Now?
This week in Washington, a staggered president and his party dig out from the rubble of their failed Obamacare replacement effort. As House Speaker Paul Ryan says, there’s no sugarcoating this. The politics of the Republicans’ failure to pass, or even vote on, the American Health Care Act was ugly. House conservatives in the Freedom Caucus sought a full repeal without an effective replacement, guaranteeing the smoldering political debris in Washington. Why be greedy? Millions of Americans gained coverage via Obamacare. You can’t replace something, no matter how gravely flawed, with nothing. (3/26)

USA Today: The Health Care War Is Far From Over
After eight years of fear-mongering and spreading outright lies about the Affordable Care Act, Republicans finally got the chance to step to the plate and give it their best swing. And they whiffed. Hard. (Neera Tanden, 3/27)

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

State Reviews Of The GOP’s Health Plan Implosion

Editorial pages examine who dodged the bullets in their states and detail what went wrong with the American Health Care Act.

Kansas City Star: Americans Want Health Care That Works For All 
I continue to believe that most Americans think everyone should have health care. And while the current law is far from perfect and would benefit from some bipartisan improvements, it is by any measure — coverage, cost, continuity of care — vastly superior to the law Republicans proposed and then couldn’t pass last week. (Kathleen Sebelius, 3/25)

Cleveland Plain Dealer: Collapse Of Trumpcare A Victory For Republicans Who Pushed Back To Protect States Like Ohio
The dramatic collapse today of efforts by House Speaker Paul Ryan and President Donald Trump to force House Republicans to pass Ryan’s jury-rigged repeal of Obamacare was a victory not just for common sense but also for those Republicans who stood up to Trump. Among them: Sen. Rob Portman of Ohio, who, along with several other Republican senators, sent a letter to Majority Leader Mitch McConnell earlier this month outlining the plan’s likely harm to the millions of Americans covered by Medicaid expansion, in Ohio and other states — and to the states themselves. (3/24)

Miami Herald: Healthcare Bill, And GOP, Fail Miserably
But, and pardon the tortured mix of metaphor, Republicans had the ball in their court, for seven years now, and fumbled it — most spectacularly on Friday. That’s when their controversial bill to replace the Affordable Care Act, failed to win the necessary 216 votes to pass. House Speaker Paul Ryan recommended pulling it. President Trump, the biggest loser, agreed. The bill, a cornerstone of Trump’s campaign and that of scores of new Republican lawmakers, went down. Obamacare rules — until Republicans get serious. That’s great news for millions of Americans, and Floridians especially. The bill would have left almost 2 million state residents without health insurance and forced many others to pay thousands more for coverage. Republican Rep. Ileana Ros-Lehtinen told her local constituents she would vote No, while her more cowed Miami colleagues kept mumbling about having to study the situation. (3/25)

The Kansas City Star: Congratulations, Republicans. This Health Care Defeat Is Really A Win.
Cheer up, Republicans. Sometimes, what looks and feels like a loss is really a win. Usually it takes a while for the all-for-the-best benefits of a short-term defeat to sink in. But the health care bill that the Republicans pulled at the last minute on Friday would have quickly made the GOP nostalgic for the days when they could take bows for show votes repealing the Affordable Care Act for the umpteenth time. Had the bill passed, Republicans would have lost both politically and in human terms as the bill devastated many of the very voters who believed President Donald Trump’s campaign promise that “everybody’s going to be taken care of much better than they’re taken care of now.” (3/24)

Chicago Tribune: Why Health Care Can’t Be Fixed
Bill Clinton tried to fix America’s health care problems and was shot down by Congress. Barack Obama got his solution enacted only to find most people didn’t like it. Republicans who voted repeatedly to repeal Obamacare and replace it with something far better have found it fiendishly hard to agree on how. (Steve Chapman, 3/24)

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

Perspectives From Monday Morning Quarterbacks: How The Health Bill Unraveled

Opinion writers analyze what happened last week in Congress when the House GOP’s health law replacement plan came undone.

The Wall Street Journal: The ObamaCare Republicans
House Republicans pulled their health-care bill shortly before a vote on Friday, and for once the media dirge is right about a GOP defeat. This is a major blow to the Trump Presidency, the GOP majority in Congress, and especially to the cause of reforming and limiting government. (3/24)

The Wall Street Journal: High Anxiety Over Health-Care Reform
What politicians, those hardy folk, don’t understand about health care is how anxious it makes their constituents. Not suspicious, not obstinate, but anxious. Because unlike such policy questions as tax reform, health care can be an immediate life-or-death issue for you. It has to do with whether, when, and where you can get the chemo if you’re sick, and how long they’ll let you stay in the hospital when you have nobody, or nobody reliable and nearby, to care for you. To make it worse, the issue is all hopelessly complicated and complex and pits you as an individual against huge institutions—the insurance company that doesn’t answer the phone, the hospital that says “I’m afraid that’s not covered”—and you have to make the right decisions. (Peggy Noonan, 3/24)

The Washington Post: The Lessons Trump And Ryan Failed To Learn From History
If President Trump and House Speaker Paul D. Ryan (R-Wis.) had paid attention to Mitt Romney, they could have avoided the fiasco of their now dead and unmourned health-care bill. They would not now face a situation in which both of them are being blamed because they both deserve to be. And the Republican Party would not be engulfed in a festival of recriminations. (E.J. Dionne Jr., 3/26)

The New York Times: The G.O.P.’s Existential Crisis
Give Donald Trump this: His travel ban enraged only half the country. The House Republicans’ attempt to replace the Affordable Care Act, meanwhile, has alienated everyone, including members of the Republican Party itself. The bill was supposed to go to a vote on Friday, but the leadership, facing a likely defeat, was forced to pull it when it became clear it didn’t have the necessary support. It was perhaps better off dead: Already a rushed, Rube Goldberg solution in search of a problem, by the time it neared the House floor it had so many compromises woven into it to win votes that, even if it passed, it would have probably gone down in defeat in the Senate. (Corey Robin, 3/24)

The Washington Post: Republicans’ Dangerous Health-Care Delusions
The jaw-dropping spectacle in which their party holds the White House and majorities in both houses of Congress and yet failed on its first, and arguably most significant, agenda item should disabuse Republicans of a number their deeply held, inaccurate beliefs. (Jennifer Rubin, 3/26)

USA Today: Colossal GOP Failure And Not Just On Health
The plan to replace Obamacare with a new bill crafted by House Speaker Paul Ryan has failed, and embarrassingly so. And that failure is part and parcel of a larger failure of the Republican-led Congress to push an agenda in the new administration. (Glenn Harlan Reynolds, 3/26)

Bloomberg: A Republican Fiasco Years In The Making
We should pause and realize what a big deal this is. The number one agenda item for years, the one that most House Republicans campaigned on when first elected, and they couldn’t manage to even get an initial bill out of the House. Not only that, but it was clear this week that even though most of them were willing to vote for it, practically no one was enthusiastic about what they had produced. It also polled terribly, and conservative health care wonks hated the bill. (Jonathan Bernstein, 3/24)

Los Angeles Times: Trump Discovers That Legislating Is Complicated As The GOP Healthcare Bill Goes Down In Flames
Having recently learned that healthcare is complicated, President Trump has now discovered that legislating is complicated too. Trump’s attempt to force a half-baked bill to “repeal and replace” Obamacare down the throats of reluctant House Republicans failed, as House leaders were simply unable to satisfy the conflicting demands from the two wings of their party. In the end, it wasn’t a case of savvy dealmakers coming up with an offer that buyers couldn’t refuse; it was a case of buyers looking at the offer and saying, “No thanks.” (3/24)

Los Angeles Times: Boy, These Washington Big Shots Ate Well While Their Healthcare Bill Was Blowing Up
One can always count on this feature in the aftermath of any great event that has taken place behind closed doors: the journalistic “inside story.” It’s known in the trade as a “tick-tock.” And the implosion of the House Republicans’ Obamacare repeal bill has thrown off its fair share of examples, notably in the New York Times, Politico, the Washington Post and at CNN. They’re full of scenes of heightened drama from the last week, all described in cinematic detail, replete with the interior monologues of participants at the White House, the Capitol and other locations around town. (Michael Hiltzik, 3/26)

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Not A Done Deal: Ryan Pulls Back Bill To Replace Obamacare

Despite days of intense negotiations and last-minute concessions to win over wavering GOP conservatives and moderates, House Republican leaders Friday failed to win enough support to pass their plan to partially repeal and replace the Affordable Care Act.

House Speaker Paul Ryan made the announcement at the Capitol after rushing to the White House to meet with President Donald Trump. The decision came after a fluid 24 hours of negotiation among Republican leaders and different factions of the party. The leadership had hoped to have a vote on their bill Thursday but put that off after it was clear they didn’t have enough “yes” votes. Trump issued an ultimatum to House members Thursday night, saying he was done with concessions and they needed to vote Friday to get the legislation moving. But the gambit did not change enough votes to push the bill through the House.

Story is developing. Check back here for more details shortly.

Categories: Repeal And Replace Watch, The Health Law


Insurers May Notch Bigger Profits From Fewer Customers In ‘Trumpcare’

The House GOP’s embattled health care bill has plenty of detractors: Democrats, hospitals, the American Medical Association and the House Freedom Caucus all oppose it. But the insurance industry is not on that list — even though it stands to lose millions of customers.

One reason the industry has been hanging back: Insurers’ profits are expected to fatten under the bill.

The House Republicans’ replacement plan would likely attract more younger, healthier consumers to the individual market than the Affordable Care Act did, according to Standard & Poor’s, the corporate credit rating firm. The ACA tilted the opposite way, offering more options for older, sicker Americans whose health care claims eroded insurers’ profits.

“Profitability will likely improve, as the replacement plan can result in an improved risk pool in the individual market,” S&P said in a report on the House leadership’s initial plan.

A vote on the GOP “Trumpcare” bill is expected Friday, but by late Thursday it remained unclear whether there were enough votes to pass it. The Trump administration has said if the measure doesn’t pass Friday, it will abandon the effort to replace Obamacare.

Under the current health law, an insurer is allowed to charge a 64-year-old consumer a premium that’s three times what it charges a 21-year-old. The House bill allows insurers to charge older consumers premiums that are five times higher.

That change would reduce premiums for younger consumers but boost them significantly for people in their 50s and 60s – even with tax credits that increase for older people under the GOP plan.

Not all insurers are enthusiastic about what’s in the House bill. Those that are also mainly in the business of managing Medicaid services to enrollees under contract with states — such as Molina Healthcare — oppose the bill because of the expected sharp reductions in Medicaid if the House measure is enacted.

In a new analysis of the House bill that was released Thursday, the Congressional Budget Office predicted 9 million people would fall off Medicaid rolls by 2020 and 14 million by 2026. Overall, 52 million Americans under 65 would be uninsured by 2026 compared with 28 million that year under current law, the CBO said.

America’s Health Insurance Plans (AHIP), which has expressed concerns about the bill but hasn’t taken a formal position for or against the bill, has said the legislation’s provisions would give short-term relief to insurers that have been mostly losing money since the exchanges started in 2014.

Those include giving states $100 billion over 10 years to start high-risk pools and stabilization funds to help insurers deal with higher-risk customers.

One of the most significant positives for insurers in the GOP bill is the elimination of a tax that all insurers paid under the ACA. The industry paid $8 billion in 2014 and is expected to pay $14.3 billion in 2018. Congress temporarily suspended the fee for this year.

Insurers’ opposition to the tax was one of the main reasons why the insurance industry chose not to support the ACA when it was approved in 2010. However, the insurance industry built support for the law by throwing its weight behind a requirement preventing insurers from refusing coverage to consumers with preexisting conditions in exchange for a mandate that most Americans have health coverage.

Although many conservative Republicans favor ending the individual mandate, the GOP bill as originally proposed would instead require that Americans keep continuous health coverage or pay a 30 percent penalty when they do buy private coverage.

Many of the nation’s largest insurers, such as UnitedHealthcare, Cigna and Aetna, were never large players in the health law’s exchanges or they have pulled out citing steep financial losses. For them, the elimination of the health insurer tax makes the GOP bill look appealing, said Ana Gupte, a health analyst with Leerink, an investment bank. “The GOP bill is a net positive” for those insurers, she said.

Even insurers with many customers on ACA policies now will be better off financially in the GOP bill, Gupte said. “They will make a bigger [profit] margin on a smaller number of people,” she said.

Anthem, a larger player in the Obamacare marketplaces, has said the GOP bill would benefit insurers and individuals by ensuring that remaining insurers stay in the market to provide choices for consumers.

Health insurers’ cautious optimism about the bill contrasts with the rest of the health industry. Lobbying groups representing doctors, hospitals and nurses have objected vehemently to the legislation. AHIP spokeswoman Kristine Grow said the group remains concerned about the long term stability of the Medicaid health plan market because the GOP bill would kill the Medicaid expansion and reduce federal Medicaid funding to states. She also said it’s too early to know how insurers’ 2018 premiums would be affected under the GOP bill.

A big uncertainty for insurers is whether the Trump administration will continue to allow a key program under Obamacare that helps low-income individuals with out-of-pocket health costs. House Republicans suspended a lawsuit that claimed the $7 billion federal funding of the program was illegal.

The program’s future is of concern to Dr. J. Mario Molina, CEO of Molina Healthcare, which has 3 million Medicaid members and nearly 1 million customers on Obamacare exchange plans. The Long Beach, Calif.-based company operates in about a dozen states.

But Molina said his biggest concern is the GOP bill will return the country to the broken individual market system in place before 2014. “The main thing I am worried about is this bill will cause millions of people to lose insurance coverage,” he said.

Regardless of what Congress and the Trump administration decide to do with Medicaid’s federal funding, Molina predicted more states will shift Medicaid recipients into managed care plans to control costs. “In the short term, we will still grow,” he said.

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

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Essential Health Benefits Reviewed: ‘Galling’ Return To Bad Old Days; Lowering Premiums

Some opinion writers urge caution before jettisoning insurance guarantees, but premium costs appear to be at the heart of the argument to get rid of the health law’s essential health benefits.

Los Angeles Times: Remember When You Couldn’t Get Insurance With A Preexisting Condition? Those Days Are Probably Coming Back
Raise your hand if you want to go back to the days when you couldn’t get health insurance because you’d been sick or injured. That’s one of the galling possibilities raised by the evolving version of the American Health Care Act, the House GOP leadership’s plan to repeal and replace Obamacare. The blame lies with the changes that President Trump and House leaders reportedly pledged to make in the bill to win the support of members of a group of far-right House members, the Freedom Caucus. (Jon Healy, 3/23)

Forbes: Bring GOP Right-Wingers And Pragmatists Together On Obamacare — By Making Premiums Affordable
Thursday, March 23 was a wild day in Republicans’ quest to repeal and replace Obamacare, with vote cancellations, last-minute amendments, CBO analyses, and Presidential ultimatums. But the most surprising development of all was this: a way has emerged to get both hard-line and pragmatic conservatives to support the American Health Care Act. … The GOP’s right wing came to a surprisingly pragmatic realization. While refundable tax credits were not their favored approach to health reform, there were too many Republicans who believed otherwise; stubbornness on this point would jeopardize the success of any bill to replace Obamacare. So, congressional hard-liners reoriented their efforts toward repealing most, if not all, of Obamacare’s insurance regulations. (Avik Roy, 3/24)

The New York Times: Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy But Not Chemotherapy
Why should that 60-year-old man have to pay for maternity benefits he will never use? If 60-year-old men don’t need to pay for benefits they won’t use, the price of insurance will come down, and more people will be able to afford that coverage, the thinking goes. … But there are two main problems with stripping away minimum benefit rules. One is that the meaning of “health insurance” can start to become a little murky. The second is that, in a world in which no one has to offer maternity coverage, no insurance company wants to be the only one that offers it. (Margot Sanger-Katz, 3/23)

Huffington Post: Spicer Denies That Ending Maternity Care Guarantee Would Mean Women Pay More For Health Care He’s Wrong.
White House press secretary Sean Spicer on Thursday defended the idea of taking away guaranteed maternity coverage in health insurance, denying that it would mean women must pay relatively more for their health care. He’s wrong about that. Ending the guarantee could mean slightly lower premiums for individual men and much older women, but it would just as surely drive up premiums for women of child-bearing age and their families ― unless it left them paying the full cost of prenatal care and delivery, typically many thousands of dollars, out of their own pockets. (Jonathan Cohn, 3/23)

The New York Times: Yes, Senator, You Wouldn’t Want To Lose Your Mammograms — Or Women Voters
Republicans seem to have an evil genius for tone-deafness when it comes to women. On Thursday, a photograph that was widely circulated on Twitter showed a room packed with white men cutting a deal to eliminate maternity care and mammograms from the package of essential benefits that insurers are required to provide in the Republican bill to replace the Affordable Care Act. There were some women out of camera range, including Kellyanne Conway, the White House counselor. Earlier in the day, Senator Pat Roberts, Republican of Kansas, made an ill-judged quip that he quickly had to apologize for: “I wouldn’t want to lose my mammograms,” he said to a reporter from Talking Points Memo. (Susan Chira, 3/23)

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Health Debate Opinions: Crisis Is Not Trump’s Or Ryan’s Fault; GOP Failed Its Voters’ Needs

As consideration of the Republican health bill stalls on Capitol Hill, opinion writers find many faults.

The Wall Street Journal: The Freedom-From-Reality Caucus
The delay is said to be a defeat for President Trump and Speaker Paul Ryan, but both men have done about as much as they can. They’ve listened to different points of view across a diverse coalition of Members and 33 Governors, and the House bill is a realistic compromise …. No one has offered a better policy alternative to the American Health Care Act that could pass the House and Senate. The real obstacle to progress has been the 29 or so Members of the House Freedom Caucus, who have the power to deny Mr. Ryan a majority of 216 with a mere 22-vote margin of error. (3/23)

The New York Times: The Trump Elite. Like The Old Elite, But Worse!
Legislation can be crafted bottom up or top down. In bottom up you ask, What problems do voters have and how can they be addressed. In top down, you ask, What problems do elite politicians have and how can they be addressed? The House Republican health care bill is a pure top-down document. It was not molded to the actual health care needs of regular voters. It does not have support from actual American voters or much interest in those voters. It was written by elites to serve the needs of elites. Donald Trump vowed to drain the swamp, but this bill is pure swamp. (David Brooks, 3/24)

Politico: The Health Care Albatross
The lesson of Obamacare is that passage of a major health care law never puts health care behind you, only in front of you. For Republicans, their replacement bill will — one way or the other, pass or fail — loom large in 2018 and presumably 2020, if not beyond. (Rich Lowry, 3/22)

The Washington Post: A Postponed Health-Care Vote, A Big GOP Embarrassment And No Good Options Ahead
Legislative sausage-making is never pretty, but what has been happening all week with the signature legislative priority of the GOP seems beyond the norms. Faced with possible defeat on the floor, House Republican leaders postponed a scheduled vote until Friday, hoping that another day of negotiations could produce what seven years of talking have failed to produce, which is a consensus bill that all factions of the party can support. The difficulties Republicans are confronting are entirely of their own making. (Dan Balz, 3/23)

The Wall Street Journal: The Big Health Fix Bruises Ryan And Trump
Former President Barack Obama tried the big fix in health care and he came away with the scars to show for it. Now, House Speaker Paul Ryan and President Donald Trump are trying for the big health-care fix, and they are coming away with the scars to show for it. Maybe there is a lesson in there. (Gerald F. Seib, 3/23)

Bloomberg: Paul Ryan Is Trying To Save Himself
The basic problem is that Republicans have spent years building up expectations for repealing Obamacare without coming up with two crucial parts of their solution: An alternative that they agree on, and the votes in the Senate to impose whatever they want– if they could agree on what they want. (Jonathan Bernstein, 3/23)

The New England Journal of Medicine: The Mirage Of Reform — Republicans’ Struggle To Dismantle Obamacare
[A]s its potential demise draws nearer, the popularity of the ACA, now part of the status quo, is growing. In the Republican imagination, Obamacare has been a disaster. The GOP’s problem is that in reality Obamacare has substantially expanded health coverage, with 20 million Americans gaining insurance. Rolling back the ACA means making insurance less affordable for low-income Americans, increasing the uninsured population, and taking vast funds away from states and medical providers. The GOP health plan neither fully repeals the ACA nor provides a compelling replacement. Instead, in my opinion, it offers only a mirage of reform. (Jonathan Oberlander, 3/22)

The Wall Street Journal: Here’s How 51 Senators Can Reduce Premiums
As this week’s jousting between Speaker Paul Ryan and the Freedom Caucus makes clear, the Republican Party’s conservative and pragmatic wings don’t always agree. But there’s consensus on this: The American Health Care Act, the GOP’s bill to repeal and replace ObamaCare, doesn’t do enough to make insurance more affordable. … The trouble is the Senate’s rules. Republican leaders are counting on passing the AHCA through the budget reconciliation process, which requires only 51 votes, bypassing a filibuster. But for a bill to go through reconciliation, every provision must be budget-related, with clear relevance to either taxing or spending. GOP leaders expect the Senate parliamentarian to rule that repealing ObamaCare’s regulations through the AHCA would have only incidental fiscal consequences. (Avik Roy, 3/23)

USA Today: Obamacare Is Broken, And Republicans Can Fix It
When President Obama signed the Affordable Care Act seven years ago, he saddled Americans with a healthcare system that put the ultra-liberal agenda ahead of our best interests. We were promised that Obamacare would bring down healthcare costs with increased competition between insurance providers. We were promised we could keep our healthcare plans. We were promised that Obamacare would not raise middle class taxes. Instead, the law brought the American people rising premiums, unaffordable deductibles, fewer insurance choices and higher taxes. We were let down. (Ronna McDaniel, 3/23)

The Washington Post: Republicans Have Met The Enemy On Health Care. It’s Them.
The legislation may pass — either Friday or over the weekend. (It almost certainly won’t pass without changes.) But House Republicans had to be feeling a sense of deja vu as it became clear Thursday that despite the efforts of President Trump and Speaker Paul D. Ryan, the votes simply weren’t there to pass the legislation. Republicans — led by then-Speaker John A. Boehner — failed time and time again to rally votes behind proposals, from the fiscal cliff in 2012 to the farm bill in 2013 to the debt ceiling in 2014. (Chris Cillizza, 3/23)

Politico: Trump’s No-Win Health Care Debacle
Now it is Trump who needs wavering members of his party to come to his rescue. … [B]y 2018, the impact of “Trumpcare” will be start to be felt; and if the analyses of the Congressional Budget Office, the Kaiser Family Foundation and others are correct, the impact will be felt most sharply among older, less affluent, working-class Americans … in other words, Trump’s base. If that prospect ripens into reality, what would be celebrated as a legislative triumph may wind up as an epic disaster. (Jeff Greenfield, 3/22)

Georgia Health News: ACA Repeal Is Too Great A Chance To Take 
People in Georgia are relying on the ACA. If it is repealed, Georgia would lose much of the federal funding that helps sustain its health care system, which has struggled to pay for uncompensated care. Additionally, repeal of the ACA would cost many Georgia jobs. Policymakers are rushing to repeal or restrict the ACA even though that could cause many Georgians to lose their coverage. (Karuna Ramachandran, 3/23)

Arizona Republic: Ducey Not (Yet) Deserting 400,000 Arizonans
The House Republican plan to replace the Affordable Care Act would be huge step back, even for those of us who have insurance (for now). It would be a complete disaster, and in some cases, a death sentence, for Arizona’s most needy citizens. Gov. Doug Ducey knows this. (EJ Montini, 3/23)

Des Moines Register: Branstad Cheerfully Ignores Threat To Medicaid Expansion
Health and Human Service Secretary Thomas Price and Centers for Medicare and Medicaid Service Administrator Seema Verma have sent a letter to Branstad and the governors of 30 other states who expanded Medicaid …. They’re also urging the governors to pursue changes in Medicaid, such as charging beneficiaries higher premiums and requiring beneficiaries to pay for emergency-room visits to discourage such visits. … Apparently, the governor’s enthusiasm for Medicaid expansion has been supplanted by his enthusiasm for a CMS director determined to scuttle that effort. Could it be “the health needs of our state” are less of a priority than the president’s political agenda? (3/23)

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Research Roundup: Ads And Testosterone Use; Home Monitoring With Apps; Per Capita Caps

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA: Association Between Direct-To-Consumer Advertising And Testosterone Testing And Initiation In The United States, 2009-2013
Question: Is there an association between televised direct-to-consumer testosterone advertising and testosterone testing and initiation in the United States? Findings: In this ecological study of 75 US designated market areas, each exposure to a testosterone advertisement was associated with monthly relative increases in rates of new testosterone testing of 0.6%, new initiation of 0.7%, and initiation without a recent baseline test of 0.8%. (Layton et al., 3/21)

JAMA Surgery: Effect Of Home Monitoring Via Mobile App On The Number Of In-Person Visits Following Ambulatory Surgery
Question: For patients undergoing ambulatory surgery, can follow-up care via a mobile app avert in-person visits compared with conventional, in-person follow-up care during the first 30 days after the operation? Findings: In this randomized clinical trial of 65 patients, those who used the mobile app attended fewer in-person visits for follow-up care during the first 30 days after the operation than patients in the in-person follow-up care group. This difference was statistically significant. (Armstrong et al., 3/22)

JAMA Surgery: Costs And Consequences Of Early Hospital Discharge After Major Inpatient Surgery In Older Adults
Question: Do fast-track discharge protocols and shorter postoperative length of stay after major inpatient surgery reduce overall surgical episode payments, or are there unintended increased costs because of postdischarge care? Findings: In a cross-sectional cohort study of 639 943 risk and postoperative complication–matched Medicare beneficiaries undergoing colectomy, coronary artery bypass grafting, or total hip replacement, hospitals with shortest routine postoperative length of stay achieved lowest overall surgical episode payments and did not offset shorter hospital stays with greater postdischarge care spending. (Regenbogen et al., 3/22)

JAMA Internal Medicine: Patient Mortality During Unannounced Accreditation Surveys At US Hospitals
Question: What is the effect of heightened vigilance during unannounced hospital accreditation surveys on the quality and safety of inpatient care? Findings: In an observational analysis of 1984 unannounced hospital surveys by The Joint Commission, patients admitted during the week of a survey had significantly lower 30-day mortality than did patients admitted in the 3 weeks before or after the survey. This change was particularly pronounced among major teaching hospitals; no change in secondary safety outcomes was observed. (Barnett, Olenski and Jena, 3/20)

The Kaiser Family Foundation: Health Insurance Premiums Under The ACA Vs. AHCA: County-Level Data
These maps compare county-level estimates of premiums and tax credits under the Affordable Care Act (ACA) in 2020 with what they’d receive under the American Health Care Act as unveiled March 6 by Republican leaders in Congress. The maps were updated on March 21, 2017 to show estimates of how much a person buying their own insurance would have to pay under both the ACA and the House replacement bill. The maps include premium tax credit estimates by county for current ACA marketplace enrollees at age 27, 40, or 60 with an annual income of $20,000, $30,000, $40,000, $50,000, $75,000, or $100,000. (3/22)

Urban Institute: The Impact Of Per Capita Caps On Federal And State Medicaid Spending
In this paper, we analyze the effect of two per capita cap approaches: that in the AHCA and that in Speaker of the House Paul Ryan’s “Better Way” health care plan, released in June 2016. We estimate the effect of each of these per capita caps on federal and state spending from 2019 to 2028. We estimate that between 2019 and 2028, the Better Way proposal would reduce federal Medicaid spending by $841 billion, or 18.1 percent. The AHCA would reduce federal spending by $457 billion, or 9.8 percent. Assuming the bulk of states that expanded coverage under the ACA dropped eligibility for their expansion populations, we estimate that 8 million enrollees would lose Medicaid coverage, and federal savings would increase to $735 billion between 2019 and 2028. (Holahan, Buettgens and Wang Pan, 3/20)

The Kaiser Family Foundation: What Could A Medicaid Per Capita Cap Mean For Low-Income People On Medicare?
Policymakers are giving serious consideration to proposals, such as the American Health Care Act (AHCA), that would fundamentally change the structure and financing of Medicaid – the federal-state program that provides health coverage for 70 million low-income Americans, including one in five people on Medicare. Federal financing for Medicaid would be converted to a per capita cap model (such as under the AHCA) or block grant, both of which aim to limit and make more predictable federal spending on Medicaid and provide states more flexibility in their management of Medicaid spending. Such a change could affect low-income people on Medicare because Medicaid help cover Medicare’s premiums and cost-sharing, and pays for services not covered by Medicare, such as nursing home care. (Jacobson, Neuman and Musumeci, 3/20)

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Trump, A Self-Avowed Dealmaker, Faces High Stakes In Outcome Of Friday’s House Vote

As the GOP health plan became mired in intense negotiations this week, the ability to secure the measure is increasingly viewed as a major test for President Donald Trump. Meanwhile, news outlets also report that the process has caused him doubts about choosing to pursue Obamacare replacement as first item on his agenda.

The New York Times: Trump The Dealmaker Projects Bravado, But Behind The Scenes, Faces Rare Self-Doubt
President Trump, the author of “The Art of the Deal,” has been projecting his usual bravado in public this week about the prospects of repealing the Affordable Care Act. Privately he is grappling with rare bouts of self-doubt. Mr. Trump has told four people close to him that he regrets going along with Speaker Paul D. Ryan’s plan to push a health care overhaul before unveiling a tax cut proposal more politically palatable to Republicans. (Thrush and Haberman, 3/23)

Politico: Delayed Vote A Setback For Trump The Dealmaker
Most Republicans appeared comfortable with the delay, taking the lumps of a single negative news cycle, so long as the legislation eventually passes. But some worried that if Trump can’t muscle the first major bill he’s backed through a single chamber in a Republican-controlled Congress, it could devastate his agenda and weaken his authority moving forward. “This is a reputational deal,” said Scott Reed, the chief strategist for the U.S. Chamber of Commerce. “We have a lot riding on this.” (Goldmacher, Dawsey and Palmeri, 3/23)

The Hill: Report: Trump Regrets Backing Health Plan Before Pushing For Tax Reform 
President Donald Trump regrets throwing his support behind Speaker Paul Ryan’s healthcare proposal before his administration could propose a tax reform plan that more Republicans would favor, according to a Thursday New York Times report. Trump reportedly questioned his decision to several allies, saying he should’ve prioritized tax reform after seeing the immediate Republican fallout from the GOP healthcare proposal. (Beavers, 3/23)

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Clearing The House Is Just The First Step; GOP Plan Faces Significant Hurdles In The Senate

In the upper chamber, Republicans only claim a 52-48 majority, and many senators have already expressed their dismay at parts of the House’s American Health Care Act. Democrats also see opportunities to snag parts of the GOP plan. Meanwhile, Sen. Rand Paul (R-Ky.), who argues that the measure does not go far enough to repeal Obamacare, is among those who has raised constitutional issues.

Politico: Trump’s Obamacare Repeal Concessions Likely Can’t Pass Senate
Democrats say they are certain they can kill any language in the repeal bill that erases Obamacare’s mandate for minimum benefits in insurance plans. And top Republicans are making no promise that the last-ditch changes to win over conservatives will fly in the more centrist Senate, which is beginning to write its own health care plan. (Everett and Haberkorn, 3/23)

The Hill: Senate GOP Hedges On ObamaCare Repeal Timeline 
Senate Republicans are starting to publicly hedge on when they’ll be able to repeal and replace ObamaCare as their House counterparts struggle to find a deal. On Thursday afternoon, the House delayed a vote on the bill that was originally scheduled for later that day. Sen. Bill Cassidy (R-La.), who has been skeptical of the House bill, said after a caucus launch that he was told that senators would have “more time” to consider a repeal and replace bill and that the House might not vote until next week.  (Carney, 3/23)

CQ Magazine: Even If The GOP Passes A Health Care Bill, Some Wonder If It’ll Be Constitutional
If Republicans rescind the Affordable Care Act mandate that everyone buy health insurance, will their bill be constitutional? GOP Sen. Rand Paul of Kentucky is raising that question, citing the reasoning of Chief Justice John G. Roberts Jr., who wrote the 2012 opinion that upheld the individual mandate penalties in the 2010 health care overhaul. In his opinion in NFIB v. Sebelius, Roberts said the health care law essentially violated the Constitution’s Commerce Clause that gives Congress the power to regulate interstate commerce because it forced people to buy health insurance. But he wrote the requirement that individuals pay a penalty for not obtaining health insurance “may be reasonably characterized as a tax” and let it slide. (Lesniewski, 3/27)

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High Stakes Of GOP Health Bill Leaves Divisions Among Representatives, Many State Officials

News outlets around the country report on how their local congressional delegations — and state officials — are leaning on the Republican plan to dismantle Obamacare.

Chicago Tribune: Health Care Vote Delay Leaves Illinois GOP Delegation Uncertain 
After House Republicans suffered a setback Thursday in their bid to overhaul health care, some GOP lawmakers from Illinois refused to commit to future revisions of the GOP plan and expressed skepticism about quick action moving forward. …While saying Obamacare is in a “death spiral,” [Rep. Randy] Hultgren said it’s important for House and Senate Republicans “get a replacement that works.” He said he could not predict “whether that can happen today or tomorrow or over the weekend or next week” and added: “I really feel like it’s unknown right now how this ends.” (Skiba, 3/23)

Atlanta Journal-Constitution: In Tom Price’s Backyard, A Republican Split Over Health Plan
Even in Tom Price’s home turf, there’s a sharp divide over the embattled GOP health plan among the Republicans racing to replace him. Several of the top Republicans in the April 18 special election to succeed Price, Donald Trump’s health secretary, say the plan needs broader changes before they can accept it. Others, including those running as Trump loyalists, say they would vote for it in a flash. (Bluestein, 3/23)

The Wall Street Journal: House GOP Super PAC Pulls Support From Iowa Congressman Who Opposes GOP Health Bill
The super PAC overseen by House Speaker Paul Ryan and the House GOP leadership is yanking support from a House Republican who pledged to oppose the health-care legislation pushed by President Donald Trump and House GOP leadership. The Congressional Leadership Fund is pulling staff from and closing an office it opened last month in Iowa Rep. David Young’s Des Moines-based district. (Epstein, 3/23)

Texas Tribune: Gohmert, Weber Among Holdouts As House Postpones Health Bill Vote
The process got somewhat easier on Thursday when two Republicans, U.S. Rep. Joe Barton of Ennis and Michael McCaul of Austin moved into the affirmative column. The Dallas Morning News reported McCaul’s change of heart from undecided to yes. “I don’t have a comment other than I am glad Donald Trump got elected president so that we have a chance to bring an end to Obamacare,” said the fiercest GOP holdout of the delegation, U.S. Rep. Louie Gohmert of Tyler. (Livingston, 3/23)

The Philadelphia Inquirer: Where Philly-Area Representatives Stand On The Health-Care Bill
One local Republican – Rep. Patrick Meehan, whose district mostly covers Delaware County – has yet to decide whether he would support his party’s long-promised plan to repeal and replace Obamacare. The stance of another local GOP representative, Ryan Costello of Chester County, remains unclear. Like Meehan, Costello supported the bill in committee but has not committed to voting for the final measure. (Tornoe and Babay, 3/23)

The Baltimore Sun: Rep. Andy Harris Remains A ‘No’ On GOP Health Care Bill 
Rep. Andy Harris, a Baltimore County Republican and member of the conservative Freedom Caucus, said Thursday that last-minute changes to the Republican plan to replace Obamacare are not yet enough to win his support. Harris, who ran his first campaign for Congress on a vow to repeal the Affordable Care Act, joined about three dozen Republicans who announced opposition to the legislation. Because of that opposition, GOP leaders pulled the measure from a scheduled vote Thursday — dealing a blow to President Donald Trump. (Fritze, 3/23)

St. Louis Post Dispatch: One St. Louis-Area Republican’s Shuttle Diplomacy In The Health-Care Quicksand Of Repeal And Replace 
Rep. Rodney Davis thought he was about to cast a long-anticipated vote to begin repealing and replacing Obamacare on Thursday. Instead, he took another trip to the White House, part of the extraordinary and sometimes confusing shuttle diplomacy that was going on inside the Republican Party on health care reform this week. Davis, R-Taylorville, and Rep. Ann Wagner, R-Ballwin, are among a small group of Republican vote-counters in the U.S. House on the Republicans’ American Health Care Act. They’re “whips” in the parlance of what is often called legislative sausage making. (Raasch, 3/24)

The CT Mirror: As GOP Health Care Plan Falters, CT Dems Watch And Wait 
President Donald Trump and House Republicans are making both threats and promises to try to salvage the GOP health care bill – but the deal-making is all on the Republican side of the aisle, with Connecticut’s all-Democratic congressional delegation sitting on the sidelines… While Democrats are not sitting at the negotiating table, that doesn’t mean Connecticut’s lawmakers were idle. (Radelat, 3/23)

The CT Mirror: CT GOP Legislative Leaders Urge Delay On Obamacare Replacement 
The Republican leaders of the Connecticut House and Senate politely distanced themselves Thursday from the push by President Trump and U.S. House Speaker Paul Ryan for the immediate passage of an alternative to the Affordable Care Act. In a letter to the president and speaker, Sen. Len Fasano of North Haven and Rep. Themis Klarides of Derby said they shared the national Republican leaders’ concerns about Obamacare, but urged Trump and Ryan to avoid passage of a bill still being digested by state officials and members of Congress. (Pazniokas, 3/23)

Kansas City Star: Brownback, Greitens Sign Letter In Support Of GOP Health Care Bill 
Kansas Gov. Sam Brownback and Missouri Gov. Eric Greitens have both signed a letter in support of a controversial bill that would repeal the Affordable Care Act. Brownback’s office released the letter after U.S. House Speaker Paul Ryan delayed a vote on the American Health Care Act because of a lack of support for the bill. The letter from eight GOP governors thanks Ryan, a Wisconsin Republican, and U.S. Senate Majority Leader Mitch McConnell of Kentucky for their efforts to repeal the ACA, also known as “Obamacare.” (Lowry, 3/23)

The Associated Press: Walker: Up To 45K Alaskans Could Lose Coverage With GOP Bill
Gov. Bill Walker says as many as 45,000 Alaskans could lose health care coverage under a Republican bill proposed in the U.S. House. Walker says that includes 30,000 Alaskans covered by the expanded Medicaid program and roughly two-thirds of the Alaskans with individual plans on the federally facilitated insurance marketplace. About 19,000 Alaskans have individual plans. Walker said about 13,000 could lose coverage. (Bohrer, 3/24)

WBUR: Mass. Democrats Denounce GOP Health Care Bill
Gov. Baker has estimated the state would lose about $1 billion in federal reimbursement, starting in 2020, should the American Health Care Act pass. On Tuesday, Baker said, “I think our hope and our expectation is that the issues that are raised not just by people here in Massachusetts but by people in other states who have similar concerns can help affect the nature of the debate and the discussion.” Today also marks the seventh anniversary of the Affordable Care Act. (Bologna, Bruzek and Chakrabarti, 3/23)

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

Majority Of Americans Oppose Republicans’ Replacement Bill, New Poll Finds

Only 17 percent surveyed by Quinnipiac University support the American Health Care Act. And as former President Barack Obama makes a rare statement about the debate regarding his signature health care legislation, Democrats mobilize to use the vote against vulnerable Republicans.

The Hill: Poll: Just 17 Percent Of Voters Back ObamaCare Repeal Plan 
A majority of American voters oppose the Republicans’ plan to repeal and replace ObamaCare, while very few voters support it, a new poll finds. A poll published Thursday by Quinnipiac University found that 56 percent of voters disapprove of the GOP healthcare plan, while just 17 percent support it. Even among Republicans, only 41 percent support the American Health Care Act, while 24 percent oppose it. And 58 percent of Democratic voters disapprove of the plan. (Firozi, 3/23)

Politico: As Repeal Vote Nears, Obama Pleads To Preserve Affordable Care Act
Former President Barack Obama, who has remained on the sidelines for much of the contentious debate surrounding the Trump administration’s plan to repeal and replace the Affordable Care Act, urged lawmakers Thursday to preserve and build on his signature legislative achievement. The lengthy statement … celebrated the merits of Obamacare and described the legislation as a watershed moment in determining that health care is “not just a privilege for a few, but a right for everybody.” (Sutton, 3/23)

Bloomberg: Democrats Aim To Weaponize Health Bill Against House Republicans 
Democrats seized on the House health-care vote as an opportunity to inflict political damage on vulnerable Republicans.The Democratic National Committee has begun blanketing the districts of roughly 50 House Republicans with targeted emails and robocalls about the bill, urging recipients to call the lawmakers to express opposition to the bill…It’s the first time the DNC has carried out this kind of campaign since Perez became chair of the party last month and reflects the committee’s efforts to be a hub of anti-Trump activity. (Epstein, 3/23)

Meanwhile, protests against the GOP bill and in support of Planned Parenthood take place in cities like Los Angeles, Chicago, Phoenix and Detroit —

Reuters: Obamacare Supporters Rally Against Congressional Repeal Efforts
Supporters of Obamacare staged rallies across the country on Thursday denouncing efforts by President Donald Trump and Republican congressional leaders to repeal the landmark law that has extended medical insurance coverage to some 20 million Americans. Hundreds of demonstrators turned out in Washington, Chicago and Los Angeles marking the seventh anniversary of enactment of Obamacare, as the Affordable Care Act (ACA) has become widely known. (Simpson, 3/23)

Los Angeles Times: Crowd In Downtown L.A. Protests Obamacare Repeal
Crowds marched through Downtown Los Angeles Thursday afternoon to protest efforts by Republican lawmakers to overhaul the Affordable Care Act. In a rally that occupied a portion of Temple Street outside of the Roybal Federal Building, speakers addressed a crowd of healthcare providers and advocates. (Kohli, 3/23)

Chicago Sun Times: Hundreds Rally, March Downtown To Decry American Health Care Act 
Hundreds of protesters rallied and march through downtown Thursday afternoon, denouncing plans — since delayed — to repeal and replace the Affordable Care Act on the seventh anniversary of the bill becoming law. Rallying in Federal Plaza before heading north on Dearborn, eventually stopping across the Chicago River from Trump Tower, the crowd cheered as they learned that a vote on the American Health Care Act would not be held Thursday, as was originally planned. (Charles, 3/24)

Arizona Republic: Planned Parenthood Advocates Rally In Phoenix Against ‘Obamacare’ Repeal
As wrangling continued in Washington, D.C., on Thursday over a bill to repeal the Affordable Care Act, Planned Parenthood supporters gathered in Phoenix and cities across the nation to oppose what they call the “worst piece of legislation for women in a generation.” In Phoenix, about 50 people gathered outside the Arizona State Capitol to rally against the health bill. (Newman, 3/23)

Detroit Free Press: Detroit Protesters Stage ‘Funeral’ For Obamacare
Ahead of today’s unsure vote on Republican changes to former President Barack Obama’s signature health care reform, protesters in downtown Detroit staged a mock funeral of the Affordable Care Act, saying its replacement would leave millions without coverage. Among the protesters was Ed Weberman, a lawyer from White Lake Township whose 24-year-old son, Alex, is in remission from stage 4 non-Hodgkin’s lymphoma. Weberman said his son’s recovery was possible only because he could keep him on his insurance up to age 26 under Obamacare. (Helms, 3/23)

KQED: As House Vote Approaches, Protesters Of GOP Health Care Bill Get Creative 
Wearing white coats and surgical scrubs, a small group of political activists passed out pink fliers in downtown Oakland Wednesday. They wore toy stethoscopes and shiny, circular mirrors on their heads. They’re not really doctors, but they dressed the part to grab the attention of pedestrians and warn them about the political efforts to dismantle the Affordable Care Act. (Klivans, 3/23)

California Healthline: From ‘Stressed Out’ To Hopeful, Five Californians Weigh In On GOP Bill
[T]he GOP proposal could have a big impact on the nearly 14 million Californians — about one-third of the state’s population — who are covered by Medicaid, the health program for low-income people, known as Medi-Cal in California. The GOP plan would also likely scramble the health care calculations of people who buy their own coverage, especially if they do so through Covered California, the state’s insurance exchange, and get federal help with their premiums. (Gorman and Bazar, 3/23)

San Jose Mercury News: Bay Area Voters Not Surprised By GOP Health Care Vote Delay
Yet no matter where they got the news, and regardless of their political leaning, several people on the Bay Area News Group’s 25-member voters’ panel — assembled to evaluate President Donald Trump’s first 100 days in office — said they weren’t surprised that the dismantling of Obamacare had gotten so gummed up in the nation’s capital that the GOP plan appeared to be going nowhere for now. (Seipel, 3/23)

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

GOP House Leaders Are On Edge With Gamble On Health Bill Vote

The vote — which was scheduled in response to demands by President Donald Trump — is dicey for the majority and highlights the continuing factions within the Republican caucus as well as their hesitancy to negotiate and compromise.

The Associated Press: House Sets Risky Health Care Vote After Trump Demands It
In a gamble with monumental political stakes, Republicans set course for a climactic House vote on their health care overhaul after President Donald Trump claimed he was finished negotiating with GOP holdouts and determined to pursue the rest of his agenda, win or lose. House Speaker Paul Ryan set the showdown for Friday, following a nighttime Capitol meeting at which top White House officials told GOP lawmakers that Trump had decided the time for talk was over. (Fram and Alonso-Zaldivar, 3/24)

USA Today: Damn The Torpedoes: GOP Sets Friday Vote On Health Care Despite Opposition
Rep. Chris Collins, R-N.Y., told reporters at the Capitol that Mulvaney’s message was: “The president needs this, the president has said he wants a vote tomorrow. If for any reason (it fails) we’re just going to move forward with additional parts of his agenda. This is our moment in time but the president is insisting on a vote one way or the other.” Collins said the message from the administration — Stephen Bannon, Reince Priebus and Kellyanne Conway also attended the meeting — was that negotiations were over and it was time to act. (Kelly, Collins and Shesgreen, 3/23)

Roll Call: House GOP Heads Into Health Care Vote ‘Between A Rock And A Hard Place’
The outcome of Friday’s House vote to partially repeal and replace the 2010 health care law is not certain, but one thing is: All parties to the Republican negotiations will walk away with some losses. … the chips in this case are a group of conservative hardliners and moderate majority-makers (members leadership typically relies on to help pass bills) that have stood in opposition to bill before the latest round of changes. While at least a dozen of those Republicans have said since the final plan was announced Thursday evening that they remain “no” votes, several others appear to be wavering. (McPherson, 3/24)

News outlets note that the difficulties GOP leaders have confronted during this week’s negotiations are similar to the ones that dogged them during the Obama administration –

The Wall Street Journal: In Health-Law Fight, GOP Leaders Struggle To Reconcile Factions’ Needs
After years of making the repeal of the Affordable Care Act a signature issue, Republicans are struggling to deliver on the promise, floundering amid warring factions that neither President Donald Trump nor House Speaker Paul Ryan have been able to whip into line. … They are confronting a thorny challenge that required two things in short supply among today’s Republican rank and file: a willingness to compromise or to defer to leadership. (Hook and Epstein, 3/23)

The Associated Press: New Congress, All-GOP, Same Political Divisions
With control of the White House and Senate and a commanding majority in the House, Republicans were supposed to brush off any challenge from the hardline Freedom Caucus and work their will with impunity. But something happened on the way to governing. Now, House Republican leaders are struggling with the same divisions that plagued them under President Barack Obama. (Ohlemacher, 3/24)

Politico: Trump Vs. The Freedom Caucus
The House Freedom Caucus has threatened to tank the House GOP Obamacare replacement bill unless they get what they want. But Trump is now calling their bluff. White House officials told members of the group on Thursday they have one shot: If they help defeat the American Health Care Act, the Trump administration is going to move on — meaning the Freedom Caucus could be pinned with actually saving Obamacare. The White House is betting that they will cave, given that saving Obamacare is something these conservative Republicans will never be able to stomach. (Bade and Bresnahan, 3/23)

And some tips on how to salvage the repeal-and-replace effort if the bill fails –

Politico: How The GOP Could Still Salvage The Obamacare Repeal
House Republican leaders scrambling to buck up wavering members had portrayed the vote as the only shot to eliminate the GOP’s longtime boogeyman — and as an essential show of support for President Donald Trump. But in fact, they have several options to salvage the repeal effort after they couldn’t muster 215 votes. (Cancryn, 3/23)

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

Popular Guarantee For Young Adults’ Coverage May Be Health Law’s Achilles’ Heel

The Affordable Care Act struck a popular chord by allowing adult children to obtain health coverage through a parent’s plan until their 26th birthday.

Now, seeking broad support for their efforts to repeal and replace the ACA, House Republicans have kept that guarantee intact. But it’s not clear whether that provision will be successful or a destabilizing force in the insurance marketplace.

The policy has proven to be a double-edged sword for the ACA’s online health exchanges because it has funneled young, healthy customers away from the overall marketplace “risk pool.” Insurers need those customers to balance out the large numbers of enrollees with chronic illnesses who drive up insurers’ costs — and ultimately contribute to higher marketplace premiums.

Joseph Antos, a health economist with the American Enterprise Institute, a Washington, D.C.-based conservative think tank, said the ability for young adults to stay on family plans represents a “critical mistake” within the health law, cutting off insurers from a large, healthy demographic that likely would be able to afford a health care plan.

“This is essentially an ideal group for an insurance company,” he said. “They’re not going to use many services, and they’re going to pay their bills.”

The young-adult provision went into effect in September 2010 and families put it to use quickly, with many young adults leaving their own insurance plans. A report published by the Centers for Disease Control and Prevention in 2013 found the percentage of adults ages 19 to 25 with personal plans fell from nearly 41 percent in 2010 to just over 27 percent in 2012, while the ratio of those covered through a family member’s plan rose by 14 percentage points.

And the Department of Health and Human Services said last year that final 2016 marketplace enrollment numbers showed more than 6 million people ages 19 to 25 gained insurance through the health law, including 2.3 million who went onto their family health plan between September 2010 and when online marketplaces began operating in 2014.

Cara Kelly, a vice president of the health care consulting firm Avalere Health, said the provision’s effect must be understood in the context of the law’s implementation. Affordability and the selection of plans available in the marketplace also could have influenced the decision among young adults to buy or shirk insurance, Kelly said. Even if the provision had not been included in the law, she said, one can’t assume that the young adults would have signed up for coverage.

A little more than a quarter of marketplace customers in 2016 were adults ages 18 to 34, according to data from the Department of Health and Human Services. But federal officials and insurers had hoped for higher rates, noting that the group made up about 40 percent of the potential market.

Public support for the young-adult provision makes it difficult to take away. A survey conducted by the Kaiser Family Foundation in December 2016 found that 8 in 10 Republicans and 9 in 10 Democrats favored the benefit. (Kaiser Health News is an editorially independent program of the foundation.)

The young-adult provision went into effect in September 2010 and families put it to use quickly, with many young adults leaving their own insurance plans. (Centers for Disease Control and Prevention)

“It has been extremely popular,” said Al Redmer Jr., the Maryland insurance commissioner and chairman of the health insurance and managed care committee within the National Association of Insurance Commissioners. “So with that being the case, I don’t know if politically there’s an appetite to unwind it.”

Republicans have opted for different measures than the ACA to attract increased numbers of healthy, young customers and make the risk pools vibrant. To keep prices lower for these customers, the bill allows insurers to charge older people up to five times more than young adults. Under the ACA, that difference is 3-to-1, and Republicans say that made prices too expensive for younger customers.

It would also replace the health law’s individual mandate — the requirement that almost everyone have health insurance or face a penalty — with a 30 percent surcharge on their premium for late enrollment or allowing your insurance to lapse for more than 63 days within a year.

The overall effect, according to an analysis conducted by the Congressional Budget Office, would be a more stable market with a larger number of healthy enrollees. The report also estimated the bill could result in 24 million more people being uninsured.

But the bill also has disincentives for those young people. To help pay for premiums, low-income people will get tax credits based on age and household income. Older people would get $4,000 per year, twice as much as younger customers.

Insurers have reacted cautiously. The insurer Blue Cross Blue Shield Association released a statement this month expressing its support for increasing affordability for younger enrollees. But it also raised concerns about the Republicans’ tax credit proposal. A benefit based on age alone “does not give healthy people enough incentive to stay in the market, especially in the absence of an individual mandate.”

The insurance trade group America’s Health Insurance Plans sent a letter to House Republican committee chairmen voicing support for the 5-to-1 age-band rating and tax credits based on age.

“We have stated previously that there is no question that younger adults are under-represented in the individual market,” the letter said. “Recalibrating and reforming the way in which the premium assistance is structured will encourage younger Americans to get covered.”

KHN reporter Mary Agnes Carey contributed to this article.

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

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Late Move To Dump ‘Essential’ Benefits Could Strand Chronically Ill

A last-minute attempt by conservative Republicans to dump standards for health benefits in plans sold to individuals would probably lower the average consumer’s upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act.

But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care.

For example, a woman who had elected not to have maternity coverage could face financial ruin from an unintended pregnancy. A healthy young man who didn’t buy drug coverage could be bankrupted if diagnosed with cancer requiring expensive prescription medicine. Someone needing emergency treatment at a non-network hospital might not be covered.

What might be desirable for business would leave patients vulnerable.

“What you don’t want if you’re an insurer is only sick people buying whatever product you have,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner. “So the way to get healthy people is to offer cheaper products designed for the healthy people.”

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The proposed change could give carriers wide room to do that by eliminating or shrinking “essential health benefits” including hospitalization, prescription drugs, mental health treatment and lab services from plan requirements — especially if state regulators don’t step in to fill the void, analysts said.

The Affordable Care Act requires companies selling coverage to individuals and families through online marketplaces to offer 10 essential benefits, which also include maternity, wellness and preventive services — plus emergency room treatment at all hospitals. Small-group plans offered by many small employers also must carry such benefits.

Conservative House Republicans want to exclude the rule from any replacement, arguing it drives up cost and stifles consumer choice.

On Thursday, President Donald Trump agreed after meeting with members of the conservative Freedom Caucus to leave it out of the measure under consideration, said White House Press Secretary Sean Spicer. “Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included,” Spicer told reporters.

Pushed by Trump, House Republican leaders agreed late Thursday to a Friday vote on the bill but were still trying to line up support. “Tomorrow we will show the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families,” said House Speaker Paul Ryan (R-Wis.). “And tomorrow we’re proceeding.” When asked if he had the votes, Ryan didn’t answer and walked briskly away from the press corps.

But axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed, said Gary Claxton, a vice president and insurance expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“They’re not going to offer benefits that attract people with chronic illness if they can help it,”said Claxton, whose collection of old insurance policies shows what the market looked like before.

One Aetna plan didn’t cover most mental health or addiction services — important to moderate Republicans as well as Democrats concerned about fighting the opioid crisis. Another Aetna plan didn’t cover any mental health treatment. A HealthNet plan didn’t cover outpatient rehabilitative services.

Before the ACA most individual plans didn’t include maternity coverage, either.

The House replacement bill could make individual coverage for the chronically ill even more scarce than a few years ago because it retains an ACA rule that forces plans to accept members with preexisting illness, analysts said.

Before President Barack Obama’s health overhaul, insurers could reject sick applicants or charge them higher premiums.

Lacking that ability under a Republican law but newly able to shrink benefits, insurers might be more tempted than ever to avoid covering expensive conditions. That way the sickest consumers wouldn’t even bother to apply.

“You could see even worse holes in the insurance package” than before the ACA, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “If we’re going into a world where a carrier is going to have to accept all comers and they can’t charge them based on their health status, the benefit design becomes a much bigger deal” in how insurers keep the sick out of their plans, she said.

Michael Cannon, an analyst at the libertarian Cato Institute and a longtime Obamacare opponent, also believes dumping essential benefits while forcing insurers to accept all applicants at one “community” price would weaken coverage for chronically ill people.

“Getting rid of the essential health benefits in a community-rated market would cause coverage for the sick to get even worse than it is under current law,” he said. Republicans “are shooting themselves in the foot if they the offer this proposal.”

Cannon favors full repeal of the ACA, allowing insurers to charge higher premiums for more expensive patients and helping consumers pay for plans with tax-favored health savings accounts.

In an absence of federal requirements for benefits, existing state standards would become more important. Some states might move to upgrade required benefits in line with the ACA rules but others probably won’t, according to analysts.

“You’re going to have a lot of insurers in states trying to understand what existing laws they have in place,” Koller said. “It’s going to be really critical to see how quickly the states react. There are going to be some states that will not.”

Mary Agnes Carey and Phil Galewitz contributed to this story.

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

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Viewpoints: Ryan Says Vote Will Fulfill GOP Promise; Small Business Sees Relief; Vote No On ‘Skinflint’ Bill

A selection of opinions on the health care debate in Congress from around the country.

The Wall Street Journal: Keeping Our Promise To Repeal ObamaCare
The election of Donald Trump and a Republican Congress provides an opportunity: We can immediately halt the leftward drift of American social policy, while renewing prosperity through market-based, state-driven solutions that empower people instead of bureaucrats. This is the stuff of conservative dreams. But it will become reality only if Republicans keep the promises we have made. (House Speaker Paul Ryan, 3/22)

Los Angeles Times: A Healthcare Test We’re Hoping Republicans Will Flunk
On Thursday, House Republicans and President Trump face their first big test since the election that put the GOP in complete control of the federal government. The House will be voting on a bill to repeal much of the healthcare reform law Democrats pushed through Congress in 2010, replacing it with a skinflint alternative that’s projected to leave 24 million more people uninsured in a decade. It’s a horrible proposal, and the main hope for the country is that dissident Republicans will kill it because it’s not awful enough for them. (3/22)

Huffington Post: Mental Health, Maternity Care Guarantees In Jeopardy As GOP Wrangles For Votes
Someone with bipolar disease might have no way to pay for a psychiatrist to monitor his condition. A couple might have to fork over $15,000 to have a baby. These are just two of the possible consequences of a deal now under discussion in the U.S. House as Republican leaders working with the Trump administration try furiously to round up the votes they need to win approval for their bill to repeal the Affordable Care Act. (Jonathan Cohn, 3/23)

Los Angeles Times: Eliminating Essential Health Insurance Benefits Is A Stupid Idea That Won’t Save Money. Here’s Why.
David Anderson of Duke points us to a recent paper by Milliman, the preeminent cost-analysis firm in healthcare, about how much these essential benefits actually add to the cost of health insurance and the consequences of removing the mandates. The paper finds that eliminating the most vulnerable mandates, such as maternity care, will reduce average premiums somewhat but drive costs for people who need those services sky-high and transfer much of the cost to other public programs. The net gain for society is almost invisible. To put it another way, the savings are an illusion. In fact, eliminating the mandates might even cost the federal government more money. (Michael Hiltzik, 3/22)

USA Today: Vote ‘No’ On Ryancare: Our View
During the presidential campaign, Donald Trump repeatedly promised to repeal Obamacare and replace it with “something terrific.” There are many words for the House Republicans’ latest health care plan, embraced by Trump and scheduled for a vote on Thursday. “Terrific” is not among them. (3/22)

USA Today: Repair Damage From Obamacare: Opposing View
For decades, the National Federation of Independent Business (NFIB) has asked small business owners to rank the top challenges. For more than 30 years, their No. 1 problem has been the high cost of health care. Obamacare turned this concern into a crisis for small businesses. It fails to deliver on its main promise to make health care more affordable. For small business owners, the law has made insurance more complicated, more restrictive and more expensive. (Juanita Duggan, 3/22)

Los Angeles Times: The GOP Healthcare Bill Would Be Good For Small Business
The Affordable Care Act, or Obamacare, was perfectly misnamed. It failed entirely to make insurance affordable for small business owners and millions of other Americans. On the contrary, Obamacare has driven up costs for small business owners, who are hit with higher payroll taxes, taxes on health insurance products, the employer and individual mandate penalties, and the so-called Cadillac tax on expensive health insurance plans. (Tom Scott, 3/23)

Richmond Times-Dispatch: Obamacare Stinks. Small Businesses Need Something Better. 
Eight years ago, small-business owners were given many promises about the Affordable Care Act: that it would drive down costs; that small-business owners could take advantage of new tax credits; and that new exchanges would give owners and employees new options to purchase coverage. By the time President Obama signed the bill, it was abundantly clear that the law would do more to harm small businesses than help them. (Nicole Riley, 3/22)

The Washington Post: The GOP’s Health-Care Plan Goes In The Exact Wrong Direction
There’s a lot not to like about America’s fragmented, inefficient health-insurance system. If you had to identify its fundamental flaw, however, it would probably be this: People need medical care whether they have a job or not, yet the U.S. system is built on a linkage between health insurance and employment. (Charles Lane, 3/22)

Los Angeles Times: The GOP’s Tax Cut For Healthcare CEO Pay Is A Bigger Ripoff Of Taxpayers Than It First Seemed
As the House of Representatives prepares to vote Thursday to repeal the Affordable Care Act, there’s a new estimate of the cost of one of its hidden provisions, a rollback of rules designed to restrain executive pay at health insurance companies. Here’s the bottom line: Rolling back the provision will result in an even bigger ripoff of the American taxpayer than previously calculated. (Michael Hiltzik, 3/22)

Boston Globe: Health Bill Isn’t Reform; It’s A Tax Cut For The Wealthy 
Under Barack Obama, the Affordable Care Act adapted the Massachusetts model, and it now covers 22 million formerly uninsured Americans. But congressional Republicans are attacking national health reform and are seeking to destroy the ACA, not reform it. If they succeed, a moderate Republican governor and a liberal state legislature will soon face the choice of undoing coverage or once again leading the country on health reform. (Jon Kingsdale, 3/22)

Boston Globe: Romney’s Health Care Legacy Under Attack, Just Like Obama’s
Romneycare, as it came to be known, provided the conceptual foundation for Obamacare. And President Trump’s commitment to repealing President Obama’s signature accomplishment — the Affordable Care Act — also puts Romney’s signature accomplishment at great risk. Governor Charlie Baker is warning that the Republican plan to repeal the ACA would reduce federal funding to Massachusetts by as much as $1.1 billion to $1.9 billion. (Joan Vennochi, 3/22)

Forbes: In Amended Health Care Bill, GOP Doubles Down On Tax Breaks For The Rich, Reduced Medicaid Funding
Yesterday, the GOP released amendments to its health care bill, and in response to the shortcomings highlighted by the CBO report, the changes to the bill would add more tax breaks for the rich and further slash Medicaid funding. Yup, you read that right. But as counterintuitive as it may seem, there is a method to the GOP’s madness, as yesterday’s changes 1) make it more likely the bill will pass the House and potentially, the Senate, and 2) it brings within reach the bigger prize being sought by Republican leaders: tax reform. (Tony Nitti, 3/22)

The Washington Post: Health-Care Reform Is A Lot Harder Than Tax Cuts. So Why Are The Republicans Trying To Do It First?
Today, the House Republicans are voting on what I consider their awful health-care replacement plan for the Affordable Care Act. I’ve already explained my negativity about the highly regressive American Health Care Act. If you think the problem is that the wealthy don’t have enough after-tax income and the poor have too much health care, this is the plan for you. … Why are Republicans making their lives harder by starting with a complicated health-care replacement plan, one that itself conflates health policy with tax cuts? The answer, as tax analyst Chye Ching Huang points out in a new piece, is that “passing the health package first facilitates deeper tax cuts for the wealthy and corporations in subsequent tax legislation.” (Jared Bernstein, 3/22)

Bloomberg: Republicans Want To Repeal Medicaid, Too 
Under the AHCA, each state would instead be given a capped allowance, and that amount would rise each year with medical inflation. It would not account for any unforeseen expenses. Over time, as the rise in per-patient costs outstripped the rise in general medical inflation — as the Congressional Budget Office assumes they will — the federal share of funding would decline. Hundreds of billions in costs would be shifted from the federal government to the states. In response, states would need to either raise their own spending on Medicaid — or more likely, offer fewer services to fewer people. (3/22)

Seattle Times: Medicaid Is A Lifeline For Our Children
As discussions continue to swirl around the future of our nation’s health-care system and the American Health Care Act (AHCA), it’s vital we do not forget about the well-being of those who represent the future of our nation — our children. Medicaid is the most critical health care program for our country’s youth, and we at Seattle Children’s are deeply alarmed about the proposed changes to Medicaid that would disproportionately impact our children. (Jeff Sperring, 3/22)

The New York Times: Why Medicaid Work Requirements Won’t Work
Paul Ryan’s plan to replace Obamacare is headed to the House floor on Thursday for a vote that, even now, could go either way. That may sound surprising since Republicans have a sizable majority in the House. But if you’ve been following the debate over their replacement plan, the American Health Care Act, you know that, as harsh as it is, it’s not draconian enough for some members of Speaker Ryan’s party. In an attempt to win over those lawmakers, the Republican leadership has offered ideas to restrict coverage even further. One of the worst is a Medicaid work requirement. (Jared Bernstein and Ben Spielberg, 3/22)

Cincinnati Enquirer: America Needs A Clean Repeal Of Obamacare
There is no question that former President Barack Obama’s signature legislation – Obamacare – has been a massive failure with deadly consequences. The law, which requires Americans to buy insurance from private companies, also manages to increase premiums drastically. … Democrats have been stunningly comfortable playing politics with the life and death consequences of health insurance coverage. … Now is the chance to repeal Obamacare, and it is not a minute too soon. (Ken Blackwell, 3/22)

Cincinnati Enquirer: Insurance Has No Place In Medicine
No fiscal conservatives make health care policy or legislation. Nothing about today’s health care system is fiscally conservative. Insurance is a “needless markup” in the healthcare industry. The management and control of the medical/industrial/Congressional complex must be returned to physicians. Doctors receive only 10 percent of the monies that flow through this system, so they are not the cost problem. (James Baker, 3/22)

The Washington Post: Would The GOP Benefit If Its Obamacare Replacement Failed?
House Republicans plan to vote Thursday on an Obamacare replacement plan, called the American Health Care Act. On Tuesday, Post Opinions writer Jennifer Rubin and Alice Stewart, former spokeswoman for Sen. Ted Cruz’s 2016 presidential campaign, discussed how passage of the bill would affect the GOP’s political fortunes. The email discussion was moderated by Post Opinions digital editor James Downie and has been edited for style and clarity. (3/22)

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

Longer Looks: Explaining The GOP Health Bill, Utah’s Teen Suicide Spike And Election Anxiety

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

FiveThirtyEight: How The GOP Bill Could Change Health Care, In 8 Charts
After years of trying to repeal and replace the Affordable Care Act, aka Obamacare, Republicans finally got their chance with the election of President Trump. The House GOP made haste coming up with a bill, releasing the American Health Care Act on March 6. It’s a partial repeal of Obamacare — it includes substantial changes to the law, but when it comes to health insurance coverage and how people get it, the GOP bill largely works within the framework set up by the Affordable Care Act. (Anna Maria Barry-Jester and Charlie Smart, 3/20)

Vox: “If It Wasn’t For Insurance, I Wouldn’t Be Here”: How Obamacare’s End Would Worsen The Opioid Crisis
[Jessica] Goense is one of the hundreds of thousands of Americans who rely on the Affordable Care Act (“Obamacare”) and particularly Medicaid, which Obamacare expanded, for addiction care. By expanding not just access to health insurance but also enforcing requirements that insurers cover mental health and addiction services, Obamacare and the rules tied around it have dramatically expanded access to addiction coverage. By one estimate, the law gave potentially life-saving coverage to 2.8 million Americans with drug use disorders. (German Lopez, 3/21)

The New York Times: Coming Out In Droves For Free Health Care
A nonprofit sets up temporary clinics that provide free medical services to people in rural areas of the United States. For the hundreds that showed up in Cookeville, Tenn., this was a chance to get a checkup, dental treatment or eye care. Video. (Chris Carmichael, Niko Koppel and Kaitlyn Mullin, 3/22)

The Atlantic: The Silent Victims Of The GOP Health-Care Proposal
This is a 21st-century success story, one that health-care policy experts attribute to the Affordable Care Act, Medicaid, and the Children’s Health Insurance Program. Since 2008, the number of uninsured kids in the country has been cut in half. Since 2014, when the ACA was implemented, uninsurance among children dropped 20 percent. The bad news is that the significant gains in coverage for kids in recent years appear poised for a reversal. (Adrienne Lafrance, 3/20)

The Economist: Donald Trump Has Not Faced A Challenge Like Fixing American Health Care Before
On the campaign trail, [now-President Donald] Trump pledged to abolish what he called the “disaster” that is the ACA, and to “come up with a new plan that’s going to be better health care for more people at a lesser cost.” He promised to scrap things that the public dislikes about Obamacare, starting with its government mandate to buy health insurance or pay a penalty, while keeping things that are popular, such as protections for people with pre-existing conditions. (3/16)

Vox: “I See My Son In Every One Of Them”: With A Spike In Suicides, Parents Of Utah’s Queer Youth Fear The Worst
In recent years, suicide has become the leading cause of death in Utah among adolescents between the ages of 10 and 17, whereas national rates of youth suicide are considerably lower. According to the Centers for Disease Control and Prevention, suicide is the third leading cause of death among teenagers across the US each year. Hard data on the youth suicide rate is difficult to come by for 2016 because the year has only recently drawn to a close. (Nico Lang, 3/20)

FiveThirtyEight: Did The Election Stress Americans Out? If It Did, We Didn’t See Our Doctors About It
A wealth of anecdotes, and some research, supports the idea that the turbulence and hostility of the current political environment, along with many Americans’ fear that they will be adversely affected by changes in policy, could be bad for our mental health. After the election, for example, the National Suicide Prevention Lifeline reported a surge in calls for help. Recent research has also found that Google searches for “presidential election” are associated with searches for anxiety and depression. And a new report from the American Psychological Association found that 57 percent of Americans say the current political climate is a “very” or “somewhat” significant source of stress and that 59 percent of Republicans and 76 percent of Democrats are stressed about the future of the country. (Anupam Jena, Josh Gray, Stewart Richardson and Dhruv Khullar, 3/16)

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

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