Tagged The Health Law

A Busy Week For Health: Budget Cuts, CBO Scores And Mitch McConnell’s Cryptic Signal

https://kaiserhealthnews.files.wordpress.com/2017/05/052617_khn_hoth.mp3

It was a hectic week for people who follow news about health politics. Kaiser Health News’ veteran reporters Mary Agnes Carey and Julie Rovner sat down to discuss some of the major developments.

MARY AGNES CAREY: Hello, and thanks for joining us. I’m Mary Agnes Carey, partnerships editor and a senior correspondent for Kaiser Health News. Julie Rovner, KHN’s chief Washington correspondent, is here with me to talk about a very busy week in health care: Medicaid cuts in President [Donald] Trump’s budget plan and a new Congressional Budget Office analysis of the House passed ACA overhaul. We’ll also look at what Senate Republicans have in mind for their ACA replacement bill. Julie, let’s get started.

JULIE ROVNER: OK.

MARY AGNES CAREY: First the budget. President Trump released his fiscal 2018 budget plan this week. Federal spending on Medicaid and the Children’s Health Insurance Program would be cut. Can you take us through those changes.

JULIE ROVNER: Yes these Medicaid changes would be on top of what’s in the House-passed health care bill, which would be about $800 billion. What the administration says is that they’re going to let the amount that Medicaid goes up every year go up by less. So that would result in even more cuts. There’s a roughly 20 percent cut to the Children’s Health Insurance Program.

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This budget also includes big cuts to the public health infrastructure. It cuts the Centers for Disease Control and Prevention by about 17 percent. It would cut the National Institutes of Health by nearly 18 percent. It would completely eliminate the Agency for Healthcare Research and Quality and fold that into the NIH. So there’s been a lot of uproar from the medical and scientific community, although we should point out that this budget is unlikely to happen. Presidents’ budgets are mostly wish lists — that goes back decades. Congress basically decides who gets how much money.

MARY AGNES CAREY: Because they control the purse, right.

JULIE ROVNER: Absolutely.

MARY AGNES CAREY: All right. Let’s move on to the ACA. The Congressional Budget Office, or the CBO as we like to call it, released a new score or analysis for the House Republicans’ plan to replace the Affordable Care Act. What were the top takeaways for you?

JULIE ROVNER: Well, a lot of attention was paid to, you know, that sort of top line — that it would result in 23 million more people not having insurance after 10 years and then overall it would save about $119 billion from the deficit.

But what most of us were really looking at is what would happen as a result of that last-minute compromise that actually got the bill passed in the House. That was this amendment that would let states waive some of the requirements in the bill, like having a set of benefits and not charging people with preexisting conditions more. And interestingly, the CBO said that either under the Affordable Care Act or under the original House bill the market for individual insurance would probably be stable. But in those states that decided to take those waivers, it might well become unstable.

And the CBO didn’t say which states that would be, but they estimated that about one-sixth of Americans lived in states where that might happen. In those cases, people with preexisting conditions might be completely priced out of being able to get policies and even people who could get insurance might have to pay many, many thousands of dollars more because some benefits that they might need, like maternity care or mental health care, would no longer be covered. So it was not a ringing endorsement of that last-minute compromise.

MARY AGNES CAREY: And there’s also a big differential between if you’re younger or older, right?

JULIE ROVNER: That’s absolutely right. This is in sort of the original House bill. They would change the way tax credits are provided for people to help pay their premiums. Right now, they’re basically based on your income and how much insurance costs, so it doesn’t matter in different parts of the country if you’re sure insurance costs more. You only have to pay a set percent of your income.

The Republicans would change that, and they would link the tax credits more to age so older people would get more. Younger people would get less, but people would get less help overall. So for older people, premiums would spike dramatically. Sometimes you know more than $10,000 or $12,000. Some younger people, healthy younger people, would see a decrease, but it would not be nearly as large as the increase for older people.

MARY AGNES CAREY: So what does this CBO score mean for Senate Republicans as they try to draft their ACA replacement.

JULIE ROVNER: Well it certainly doesn’t help. The Senate had to wait for the Congressional Budget Office to deliver this score. That’s one of the requirements of the budget process that they’re using. But Senate Majority Leader Mitch McConnell did a couple of interviews this week where he basically said that they’re working hard on health care, but he doesn’t see a path to 50 votes, which is what they need to get this bill passed. That’s assuming Vice President [Mike] Pence could break a tie.

What we’re starting to see are conservatives saying they need to have these waivers — the ones that the CBO just said might destabilize the insurance market. Then you’ve got more moderates saying no we want fewer or no waivers. It’s hard to see where they’re going to come together. We’re told that staff is going to try to draft something next week while Congress is out for the Memorial Day break. But there’s no real anticipated timeline for this yet.

MARY AGNES CAREY: So Julie, why do you think Mitch McConnell would send such a public signal that he’s having a problem getting to 50 votes?

JULIE ROVNER: I really don’t know. I thought it was kind of curious. One of the things that it might be is that he wants to, you know, light a fire under his caucus, who are having all this disagreement, saying you know this whole thing could, you know, just dissolve if you don’t actually start coming to the table and compromising. Why else do you think he might do it?

MARY AGNES CAREY: Well you talk about how the calendar is working against him if he wants to get to tax reform. We’re at Memorial Day, and typically tax reform takes a lot of work, a heavy lift, maybe he just wants to move onto that.

JULIE ROVNER: So basically abandon the whole health reform idea?

MARY AGNES CAREY: I mean it sounds a little nutty. And obviously it’s a campaign promise they’ve all made. But also, as we’ve seen, there are problems in the marketplace. You do see insurers leaving over uncertainty. Perhaps they want to let that play out. I’m not sure.

JULIE ROVNER: Neither am I.

MARY AGNES CAREY: All right, well there you go. Thank you, Julie Rovner of Kaiser Health News.

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

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Different Takes: The Politics Of Repeal, Replace And Reform

Editorial pages across the country include thoughts about the political risks in play as Congress and states confront efforts to dismantle Obamacare.

Bloomberg: Exposing The Obvious About The GOP Health-Care Bill
The gory details of the Congressional Budget Office’s report on the House legislation to “repeal and replace” Obamacare are, in many ways, superfluous. The bill’s flaws, substantive and otherwise, have long been evident. Less clearly understood, though equally disturbing, is the larger political context. (5/25)

Roll Call: A GOP Guide To Running For Cover On Health Care
Most of the news coverage highlighted the CBO’s estimate that 23 million fewer Americans would have health coverage in 2026 under the bill. But in 2026, most current House Republicans will be lobbyists and strategic consultants — and some future Congress would get the blame. In political terms, the scariest CBO number was that 14 million fewer Americans would be without health insurance next year. And many of these suddenly uninsured people just might remember whom to blame when they cast their 2018 ballots. (Walter Shapiro, 5/26)

Los Angeles Times: Die Hard: Republican Healthcare Bill Has No Problem Throwing You Off A Building
Glendale resident David Cannizzaro has had asthma since he was 7. Prior to Obamacare, his healthcare strategy was to see the doctor as little as possible so his insurer wouldn’t notice his preexisting condition and decide to raise his rates or drop his coverage. Now that Republican lawmakers are advancing a bill that would repeal the Affordable Care Act and potentially allow insurers to jack up premiums for people with preexisting conditions, Cannizzaro, 49, said he’s once again living in fear. “It’s very, very scary,” he told me. (David Lazarus, 5/26)

The Washington Post: Senate Republicans Who Are Gunning For Obamacare Are Caught In A Trap
Republican senators who are being asked today about the brutal Congressional Budget Office score of the health-care plan that passed the House have a ready answer: That doesn’t have anything to do with us. Numerous senators released statements saying that the CBO score just shows that the American Health Care Act (AHCA) is a radioactive fungus, which is why they’re starting over on their own bill. (Paul Waldman, 5/25)

The Washington Post: Don’t Blame The CBO For Problems In The House Health-Care Bill
The new Congressional Budget Office score of the American Health Care Act is devastating. In 2026, 23 million fewer Americans would be insured with it than without it. The response of the secretary of health and human services and other defenders of the Republican bill? Attack the Congressional Budget Office. I had the honor of running the CBO a decade ago and will be the first to admit it’s not perfect. But it’s also far better than the alternatives, and most of the critiques are off base. (Peter Orszag, 5/25)

Los Angeles Times: If You Plan On Having A Baby Under Trumpcare, You Better Start Saving Now
Seventeenth century playwright William Congreve famously wrote that hell has no fury like a woman scorned. House Republicans may feel some of that heat once their constituents find out the healthcare bill they passed could make maternity coverage vastly more expensive and harder to obtain. It’s widely known that the House GOP’s proposed American Health Care Act would bar federal funding for Planned Parenthood, which provides many reproductive and maternal health services to lower-income women across the country. Less well understood is that an amendment to the AHCA would also allow states to lift the mandate that insurers include maternity coverage in all the policies they sell to people in the individual and small-group markets (i.e., everyone not covered by a large company health plan). (Jon Healey, 5/25)

Tribune News Service: Obamacare Replacement Would Give Women Better Options, Lower Costs
Women make the majority of decisions about care and insurance for our families, and we generally consume more healthcare than men. As a result, women have a lot at stake when it comes to the laws that govern American healthcare and insurance. In 2010, the Affordable Care Act — Obamacare — made it illegal for insurers to charge women more than men and mandated that insurance plans cover women’s preventive care, including birth control, with no copay. Therefore, some now suggest repealing the Affordable Care Act would be detrimental for women’s health. But the opposite is true: Repeal will afford women greater choice and lower costs when it comes to insurance plans, doctors and care. (Hadley Heath Manning, 5/25)

Detroit Free Press: Who Will Play Fred Upton In Senate Sequel To House Health Care Farce?
Fred Upton is a 16-term congressman who may or may not be interested in becoming Michigan’s next U.S. senator. But there are almost certainly some Republican U.S. senators interested in becoming the next Fred Upton. A grandson of Whirlpool Corp. co-founder Frederick Upton, Rep. Upton is among the wealthiest members of Congress. Until 2016, he served as chair of the House Committee on Energy and Commerce. (Brian Dickerson, 5/25)

Sacramento Bee: California Democrats Did Far More Than Flip Off Trump 
California Democrats now number more than 8 million for the first time, hold every constitutional office, and command a supermajority in the Legislature because we reflect the values of the citizens of our state.But we are not resting on our laurels, far from it. While President Donald Trump and Republicans in Congress are talking about slashing health care for 23 million Americans, California Democrats re-emphasized their belief that health care is a right, not a privilege, as we pursue Medicare for all with Senate Bill 562. (Eric Bauman, 5/25)

Des Moines Register: Privatized Medicaid Was Supposed To Save Money?
Iowa is now 14 months into its experiment with privatized Medicaid management. … Privatization is a slow-motion train wreck, with providers across the state closing up shop or taking out loans to make payroll because the checks from Medicaid are slow to arrive and patient services are being paid at a lower rate. At the same time, the managed care organizations that Iowa hired to administer Medicaid say they are losing millions, and need an enormous increase in funding in order to make ends meet. This was not only predictable, it was predicted. (5/25)

St. Louis Post-Dispatch: Western Missouri Becomes A Canary In Obamacare Coal Mine
In what could be a disturbing portent, Blue Cross Blue Shield of Kansas City on Wednesday announced it was pulling out of the Obamacare health exchanges in 2018. The decision will leave 67,000 people in 25 Missouri counties and two Kansas counties with no option for private insurance, subsidized or not, under the Affordable Care Act. Blue Cross Blue Shield announced it had lost nearly $100 million on Obamacare policies since 2014; only last year did it take in more premium money than it paid out, and overhead costs pushed the Blues into the red. (5/25)

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

Research Roundup: Early Hospital Discharges; Missed Vaccinations; Growth In Spending

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

JAMA Surgery: Costs And Consequences Of Early Hospital Discharge After Major Inpatient Surgery In Older Adults
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? … 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., 5/17)

Annals of Internal Medicine: Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations
40 810 adult travelers were included [in an observational study in U.S. pretravel clinics]; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). (Hyle et al., 5/16)

Urban Institute/Robert Wood Johnson Foundation: The Evidence On Recent Health Care Spending Growth And The Impact Of The Affordable Care Act
Conventional wisdom holds that health care cost growth is high and the Affordable Care Act (ACA) has done little to address the problem. However, overall increases in national health expenditures (NHE) since the law passed have been lower than anticipated, premiums and premium growth in the ACA’s health insurance marketplaces are high in some states but quite low in others, and growth in Medicare and Medicaid spending per enrollee has been very modest. NHE are still high, now at 18.3 percent of gross domestic product …. In this brief, we attempt to address several misconceptions about recent spending increases; these misconceptions are centered in three areas: the recent and projected growth in NHE the levels and recent growth of ACA marketplace premiums the recent and projected spending growth in the Medicaid program. (Holahan et al., 5/25)

Urban Institute: Medicaid/CHIP Participation Rates Rose Among Both Children And Parents In 2015
Using the 2013-2015 American Community Survey, this brief finds improvements for both parents and children in uninsurance, Medicaid/CHIP participation, and the number who are eligible for Medicaid/CHIP but not enrolled. Uninsurance fell nationally and in nearly every state, and the number of eligible but uninsured children fell to 2.1 million – declining by over half since 2008. Children’s participation reached 93.1 percent in 2015 (exceeding 90 percent in 36 states), while participation among parents rose to 80.2 percent, with larger gains between 2013 and 2015 in expansion states than nonexpansion states. Participation grew among every subgroup of children and parents examined. (Kenney et al., 5/17)

The Kaiser Family Foundation: Financing Family Planning Services For Low-Income Women: The Role Of Public Programs
Medicaid, the Title X Family Planning Program, and Section 330 of the Public Health Service Act (PHSA) are the leading sources of federal funding for the over 10,000 safety-net clinics across the country that provide reproductive health services to low-income women, men, and teens. The Trump administration and the Republican leadership of the 115th Congress have proposed to block federal Medicaid funds from going to Planned Parenthood …. Changes to these programs and funding to the clinics that provide family planning services could limit the availability of contraceptive services, STI screenings and treatment, and preventive cancer screenings, along with other primary care services to low-income women. … One in three low-income women reported that they obtained birth control from a family planning clinic such as Planned Parenthood or another health center or public health clinic. (Ranji et al., 5/11)

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

‘Health Care’ = Fighting Words In Montana

There was likely good reason why Greg Gianforte, successful Republican candidate for Congress from Montana, lost his cool on the eve of the election — scuffling with a reporter, breaking the man’s glasses and ending up with a misdemeanor assault charge:

He, like many Republicans these days, walks a perilous line when talking health care.

Ben Jacobs, a reporter for The Guardian, approached the candidate armed with an audio recorder and persistent, pesky questions about a Congressional Budget Office (CBO) report, which found that the GOP’s American Health Care Act would leave 23 million more Americans uninsured over 10 years and would effectively price out from coverage millions with preexisting conditions.

Though the AHCA passed muster in the House of Representatives, disapproval of the Republican plan has been high among voters — by ratios of more than 2-to-1 among men and more than 3-to-1 among women, according to a Quinnipiac University poll. Over 50 percent of Republicans opposed cutting federal funding for Medicaid, a component of the bill.

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Torn between conflicting impulses, the GOP candidate for Montana’s only seat in the House of Representatives had already stepped into the health care muck twice — on opposite sides of the issue. He told reporters he would not have voted for the Obamacare repeal bill passed by the House earlier this month, but a tape surfaced of him saying he was “thankful” for that same bill during a fundraising call with D.C. lobbyists. No wonder he wasn’t eager to respond to Jacobs’ question.

On the other side of the political divide, Democratic challenger Rob Quist tried to seize the moment, making opposition to the AHCA a campaign issue. On the final weekend before Thursday’s vote, Quist made a major buy of political ads that pinned the erosion of preexisting condition protections on his opponent. He confided his own preexisting condition — related to “a botched gall bladder surgery” — and noted that about half of all Montanans have a preexisting condition. Approximately 52 million Americans have a health history that could make them uninsurable in the future, if laws don’t guard against the practice.

According to the CBO report, “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”

Quist’s health narrative also dissolved one of Gianforte’s most potent attacks on him: financial problems that led to bankruptcy. Medical bills caused that bankruptcy, Quist said, and indeed, as a folk singer for most of his life, Quist was someone who had to buy health insurance on the unstable and discriminatory individual market. At 69, he can now rely on Medicare.

Gianforte, at 56, is in the age range of those who can be charged five times more than younger people for insurance under the House-passed bill. But, like President Donald Trump, Gianforte is a wealthy businessman, who likely has not had to focus deeply on the high costs of health coverage.

The altercation may not have affected the election. The seat has been occupied by a Republican for more than two decades, and nearly two-thirds of the expected turnout had already cast a ballot by mail. Montana also has same-day voter registration. Reporters from Montana Public Radio heard from brand-new voters Thursday — some who were appalled and compelled by Gianforte’s behavior and others who thought Jacobs was in the wrong.

It’s hard to say how much health care influenced Gianforte’s 6 percentage point win over Quist. The use of public lands had been the central issue in the election, and both candidates had avoided the topic of health care for much of the race, which replaces the seat vacated by Interior Secretary Ryan Zinke.

But Gianforte’s election eve scuffle may signal how tense and explosive health care will be politically for the 2018 election cycle.

Eric Whitney of Montana Public Radio contributed to this report.

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

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Strategies To Defend Unpopular GOP Health Bill: Euphemisms, False Statements And Deleted Comments

Earlier this month, a day after the House of Representatives passed a bill to repeal and replace major parts of the Affordable Care Act, Ashleigh Morley visited her congressman’s Facebook page to voice her dismay.

“Your vote yesterday was unthinkably irresponsible and does not begin to account for the thousands of constituents in your district who rely upon many of the services and provisions provided for them by the ACA,” Morley wrote on the page affiliated with the campaign of Rep. Pete King (R-N.Y.). “You never had my vote and this confirms why.”

The next day, Morley said, her comment was deleted and she was blocked from commenting on or reacting to King’s posts. The same thing has happened to others critical of King’s positions on health care and other matters. King has deleted negative feedback and blocked critics from his Facebook page, say several of his constituents who shared screenshots of comments that are no longer there.

“Having my voice and opinions shut down by the person who represents me — especially when my voice and opinion wasn’t vulgar and obscene — is frustrating, it’s disheartening, and I think it points to perhaps a larger problem with our representatives and maybe their priorities,” Morley said in an interview.

King’s office did not respond to requests for comment.

As Republican members of Congress seek to roll back the Affordable Care Act (ACA), commonly called Obamacare, and replace it with the American Health Care Act (AHCA), they have adopted various strategies to influence and cope with public opinion, which, polls show, mostly opposes their plan. ProPublica, with our partners at Kaiser Health News, Stat and Vox, has been fact-checking members of Congress in this debate and we’ve found misstatements on both sides, though more by Republicans than Democrats. The Washington Post’s Fact Checker has similarly found misstatements by both sides.

Today, we’re back with more examples of how legislators are interacting with constituents about repealing Obamacare, whether online or in traditional correspondence. Their more controversial tactics seem to fall into three main categories: providing incorrect information, using euphemisms for the impact of their actions and deleting comments critical of them. (Share your correspondence with members of Congress with us.)

Incorrect Information

Rep. Vicky Hartzler (R-Mo.) sent a note to constituents this month explaining her vote in favor of the Republican bill. First, she outlined why she believes the ACA is not sustainable — namely, higher premiums and few choices. Then she said it was important to have a smooth transition from one system to another.

“This is why I supported the AHCA to follow through on our promise to have an immediate replacement ready to go should the ACA be repealed,” she wrote. “The AHCA keeps the ACA for the next three years then phases in a new approach to give people, states, and insurance markets plenty of time to make adjustments.”

Except that’s not true.

“There are quite a number of changes in the AHCA that take effect within the next three years,” wrote ACA expert Timothy Jost, an emeritus professor at Washington and Lee University School of Law, in an email to ProPublica.

The current law’s penalties on individuals who do not purchase insurance and on employers who do not offer it would be repealed retroactively to 2016, which could remove the incentive for some employers to offer coverage to their workers. Moreover, beginning in 2018, older people could be charged premiums up to five times more than younger people — up from three times under current law. The way in which premium tax credits would be calculated would change as well, benefiting younger people at the expense of older ones, Jost said.

“It is certainly not correct to say that everything stays the same for the next three years,” he wrote.

In an email, Hartzler spokesman Casey Harper replied, “I can see how this sentence in the letter could be misconstrued. It’s very important to the Congresswoman that we give clear, accurate information to her constituents. Thanks for pointing that out.”

Other lawmakers have similarly shared incorrect information after voting to repeal the ACA. Rep. Diane Black (R-Tenn.) wrote in a May 19 email to a constituent that “in 16 of our counties, there are no plans available at all. This system is crumbling before our eyes and we cannot wait another year to act.”

Black was referring to the possibility that, in 16 Tennessee counties around Knoxville, there might not have been any insurance options in the ACA marketplace next year. However, 10 days earlier, before she sent her email, BlueCross BlueShield of Tennessee announced that it was willing to provide coverage in those counties and would work with the state Department of Commerce and Insurance “to set the right conditions that would allow our return.”

“We stand by our statement of the facts, and Congressman Black is working hard to repeal and replace Obamacare with a system that actually works for Tennessee families and individuals,” her deputy chief of staff Dean Thompson said in an email.

On the Democratic side, The Washington Post Fact Checker has called out representatives for saying the AHCA would consider rape or sexual assault as preexisting conditions. The bill would not do that, although critics counter that any resulting mental health issues or sexually transmitted diseases could be considered existing illnesses.

Euphemisms

A number of lawmakers have posted information taken from talking points put out by the House Republican Conference that try to frame the changes in the Republican bill as kinder and gentler than most experts expect them to be.

An answer to one frequently asked question pushes back against criticism that the Republican bill would gut Medicaid, the federal-state health insurance program for the poor, and appears on the websites of Rep. Garret Graves (R-La.) and others.

“Our plan responsibly unwinds Obamacare’s Medicaid expansion,” the answer says. “We freeze enrollment and allow natural turnover in the Medicaid program as beneficiaries see their life circumstances change. This strategy is both fiscally responsible and fair, ensuring we don’t pull the rug out on anyone while also ending the Obamacare expansion that unfairly prioritizes able-bodied working adults over the most vulnerable.”

That is highly misleading, experts say.

The Affordable Care Act allowed states to expand Medicaid eligibility to anyone who earned less than 138 percent of the federal poverty level, with the federal government picking up almost the entire tab. Thirty-one states and the District of Columbia opted to do so. As a result, the program now covers more than 74 million beneficiaries, nearly 17 million more than it did at the end of 2013.

The GOP health care bill would pare that back. Beginning in 2020, it would reduce the share the federal government pays for new enrollees in the Medicaid expansion to the rate it pays for other enrollees in the state, which is considerably less. Also in 2020, the legislation would cap the spending growth rate per Medicaid beneficiary. As a result, a Congressional Budget Office review released Wednesday estimates that millions of Americans would become uninsured.

Sara Rosenbaum, a professor of health law and policy at the Milken Institute School of Public Health at George Washington University, said the GOP’s characterization of its Medicaid plan is wrong on many levels. People naturally cycle on and off Medicaid, she said, often because of temporary events not changing life circumstances — seasonal workers, for instance, may see their wages rise in summer months before falling back.

“A terrible blow to millions of poor people is recast as an easing off of benefits that really aren’t all that important, in a humane way,” she said.

Moreover, the GOP bill actually would speed up the “natural turnover” in the Medicaid program, said Diane Rowland, executive vice president of the Kaiser Family Foundation, a health care think tank. (Kaiser Health News is an editorially independent project of KFF.)

Under the ACA, states were permitted only to recheck enrollees’ eligibility for Medicaid once a year because cumbersome paperwork requirements have been shown to cause people to lose their coverage. The American Health Care Act would require these checks every six months — and even give states more money to conduct them.

Rowland also took issue with the GOP talking point that the expansion “unfairly prioritizes able-bodied working adults over the most vulnerable.” At a House Energy and Commerce Committee hearing earlier this year, GOP representatives maintained that the Medicaid expansion may be creating longer waits for home- and community-based programs for sick and disabled Medicaid patients needing long-term care, “putting care for some of the most vulnerable Americans at risk.”

Research from the Kaiser Family Foundation, however, showed that there was no relationship between waiting lists and states that expanded Medicaid. Such waiting lists predated the expansion and they were worse in states that did not expand Medicaid than in states that did.

“This is a complete misrepresentation of the facts,” Rosenbaum said.

Graves’ office said the information on his site came from the House Republican Conference. Emails to the conference’s press office were not returned.

The GOP talking points also play up a new Patient and State Stability Fund included in the AHCA, which is intended to defray the costs of covering people with expensive health conditions. “All told, $130 billion dollars would be made available to states to finance innovative programs to address their unique patient populations,” the information says. “This new stability fund ensures these programs have the necessary funding to protect patients while also giving states the ability to design insurance markets that will lower costs and increase choice.”

The fund was modeled after a program in Maine, called an invisible high-risk pool, which advocates say has kept premiums in check in the state. But Sen. Susan Collins (R-Maine) says the House bill’s stability fund wasn’t allocated enough money to keep premiums stable.

“In order to do the Maine model — which I’ve heard many House people say that is what they’re aiming for — it would take $15 billion in the first year and that is not in the House bill,” Collins told Politico. “There is actually $3 billion specifically designated for high-risk pools in the first year.”

Deleting Comments

Morley, 28, a branded content editor who lives in Seaford, N.Y., said she moved into Rep. King’s Long Island district shortly before the 2016 election. She said she did not vote for him and, like many others across the country, said the election results galvanized her into becoming more politically active.

Earlier this year, Morley found an online conversation among King’s constituents who said their critical comments were being deleted from his Facebook page. Because she doesn’t agree with King’s stances, she said she wanted to reserve her comment for an issue she felt strongly about.

A day after the House voted to repeal the ACA, Morley posted her thoughts. “I kind of felt that that was when I wanted to use my one comment, my one strike as it would be,” she said.

By noon the next day, it had been deleted and she had been blocked.

“I even wrote in my comment that you can block me but I’m still going to call your office,” Morley said in an interview.

Some negative comments about King remain on his Facebook page. But King’s critics say his deletions fit a broader pattern. He has declined to hold an in-person town hall meeting this year, saying, “to me all they do is just turn into a screaming session,” according to CNN. He held a telephonic town hall meeting but answered only a small fraction of the questions submitted. And he met with Liuba Grechen Shirley, the founder of a local Democratic group in his district, but only after her group held a protest in front of his office that drew around 400 people.

“He’s not losing his health care,” Grechen Shirley said. “It doesn’t affect him. It’s a death sentence for many, and he doesn’t even care enough to meet with his constituents.”

King’s deleted comments even caught the eye of Andy Slavitt, who until January was the acting administrator of the Centers for Medicare and Medicaid Services. Slavitt has been traveling the country pushing back against attempts to gut the ACA.

Since the election, other activists across the country who oppose the president’s agenda have posted online that they have been blocked from following their elected officials on Twitter or commenting on their Facebook pages because of critical statements they’ve made about the AHCA and other issues.

Have you corresponded with a member of Congress or senator about the Affordable Care Act? Or has your comment on an elected official’s Facebook page been deleted? We’d love to hear about it. Please fill out our short form or email charles.ornstein@propublica.org.

Categories: Repeal And Replace Watch, The Health Law

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Ominous Conclusions From The CBO Analysis Of The GOP Health Plan: ‘Fatal Flaws,’ ‘A Train Wreck’

Opinion writers use the Congressional Budget Office’s recent analysis of the updated American Health Care Act to pan the House Republican’s repeal-and-replace measure.

The Washington Post: The CBO Report Proves The GOP Health-Care Bill Is No Rescue Plan
Republicans sold the American Health Care Act (AHCA), the Obamacare repeal-and-replace plan that the House passed last month, with a number of untruths, chief among them that Obamacare is collapsing and the GOP effort is nothing short of a rescue plan. The Congressional Budget Office, Congress’s official scorekeeper, found Wednesday that the Republicans’ bill is no such thing. Not only would it result in 23 million more people lacking health insurance in a decade, but it would destabilize some states’ individual health-care insurance markets for all but relatively healthy people. (5/24)

The New York Times: C.B.O. Report Reveals Trumpcare’s Fatal Flaws
The Congressional Budget Office’s analysis of the House health care bill is a devastating indictment.The new report shows that millions of Americans would lose health insurance and the quality of insurance for millions more would deteriorate. The savings from that carnage — to borrow a favorite word of President Trump’s — would pay for tax cuts for the wealthy. (David Leonhardt, 5/24)

The New York Times: Republicans, Get Ready For The Trumpcare Headlines
In promising to repeal and replace the Affordable Care Act, many Republicans cited headlines from last year such as “Obamacare Premiums to Soar 22 Percent” and “As Obamacare Choices Dwindle, Feds Face Consumer, Political Backlash.” Yet based on a new analysis by the nonpartisan Congressional Budget Office, headlines would be even worse under the health care bill to repeal Obamacare, which was passed by the House this month. (Jeanne Lambrew, 5/24)

Los Angeles Times: CBO On GOP Obamacare Repeal: Still A Train Wreck
The Congressional Budget Office has spoken: The Obamacare repeal bill passed by the House GOP earlier this month could destroy the individual insurance markets in states where one-sixth of the population resides. It would cost 23 million people their insurance coverage within 10 years. And in many states it would be terrible for any but the most healthy Americans. That’s the CBO’s score of the latest version of the House bill, which only passed after it was amended to allow individual states to eviscerate consumer protections written into the Affordable Care Act. The CBO’s bottom line is that the bill is still a train wreck that will cost millions of Americans their coverage and sharply raise costs for millions more. (Michael Hiltzik, 5/24)

The New York Times: C.B.O. Has Clear Message About Losers In House Health Bill
The Senate now has a clearer sense of who would win and lose under the health bill the House sent them. It also got a startlingly direct message from government analysts about how destabilizing one of the House ideas could be. The Congressional Budget Office published its assessment of the House health bill on Wednesday, and warned that a last-minute amendment made to win conservative votes would result in deeply dysfunctional markets for about a sixth of the population. In those places, insurance would fail to cover important medical services, and people with pre-existing illnesses could be shut out of coverage, the budget office said. (Margot Sanger-Katz, 5/24)

The Washington Post: The CBO Confirms: The Republican Health-Care Bill Is Rotten Legislation
When the Congressional Budget Office finally released its scoring of the American Health Care Act, it seemed anti-climactic, if not irrelevant. The Senate is not bothering to take up the AHCA at all. The CBO score, to the delight of Democrats, does remind us how counterproductive is the GOP House bill, which every member will have to defend in 2018. (Jennifer Rubin, 5/24)

Huffington Post: 23 Million Fewer People Would Have Coverage Under Obamacare Repeal Bill, CBO Confirms
[T]he reasons why health insurance would be less expensive for some aren’t much to cheer about, the budget report makes clear. Prices would come down for healthy people because those who are sick or have illness in their medical histories would have less access to coverage ― and the policies available on the market would tend to be a lot less comprehensive. In other words, the price for lower premiums would be some combination of higher out-of-pocket costs, fewer covered services, and coverage that would be harder to get for the people who need it most. (Jonathan Cohn and Jeffrey Young, 5/24)

RealClear Health: CBO And America’s AHCA Headache
The much-anticipated Congressional Budget Office (CBO) score of the American Health Care Act (AHCA), the GOP’s effort to dismantle the Affordable Care Act (ACA) released yesterday, indicates that the bill would cause 23 million people to become uninsured while reducing the federal deficit by $119 billion. In that sense, there is little change from their assessment of the original version of AHCA. (Billy Wynne, 5/25)

USA Today: Republican Health Care Bill Indicted, Again
Now we know why House Republicans were so quick to ram through an Obamacare repeal-and-replace bill last month, not waiting for an estimate of its impact or holding any public hearings. On Wednesday the non-partisan Congressional Budget Office got around to “scoring” the bill, and the results are not pretty. By next year, 14 million fewer people would have health insurance. Within a decade, 23 million fewer people would be covered. (5/24)

USA Today: Republican Health Care Bill Fails The Jimmy Kimmel Test. Again.
Every so often a “national moment” takes us out of our day-to-day and helps shape our national thinking. The Exxon Valdez oil spill helped forge our national opinion about environmental responsibility. Terry Schiavo’s life-support case made the public contemplate a dignified death. Someday, when we look back on the current health care debate, we may see how a national moment helped us articulate a new consensus when late night TV host Jimmy Kimmel told the poignant story of the birth of his son Billy. (Andy Slavitt, 5/24)

Los Angeles Times: Trumpcare Will Make It Even Harder For Millions Of California’s Kids To Graduate And Get Jobs
he latest report from the Congressional Budget Office once again exposes the sharp and bitter truth about the House Republican efforts to “repeal and replace” President Obama’s Affordable Care Act. The American Health Care Act — now in the hands of the Senate — represents a glaring transfer of wealth, security and opportunity from low-income to high-income individuals. Should the AHCA or anything close to it become law, the students we serve in the California State University system and California Community Colleges system will be among the hardest hit. (Zelman Epstein, 5/24)

Modern Healthcare: An Extremist Attack On Public Health
Anyone who knows anything about healthcare didn’t need a Congressional Budget Office scorecard to understand the disastrous consequences of the American Health Care Act. That legislation, now before the Senate, passed the House in early May in a straight party-line vote without hearings or a CBO score. Now we know the score. 23 million would lose their health insurance over the next decade, including 14 million by the end of next year. (Merrill Goozner, 5/24)

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

Different Visions: Are Republicans Trying ‘To Starve’ Obamacare To Death; Analyzing The State Of ACA Insurance Markets And Premiums

Opinion writers offer a variety of thoughts on health policy issues, including whether the health law is “collapsing under its own weight,” some ominous predictions about the individual insurance markets, the importance of the public option and a range of other ideas.

The New York Times: How The G.O.P. Sabotaged Obamacare
Obamacare is not “collapsing under its own weight,” as Republicans are so fond of saying. It was sabotaged from the day it was enacted. And now the Republican Party should be held accountable not only for any potential replacement of the law, but also for having tried to starve it to death. The Congressional Budget Office on Wednesday released its accounting of the House Republicans’ replacement bill for the Affordable Care Act, and the numbers are not pretty: It is projected to leave 23 million more Americans uninsured over 10 years, through deep cuts to insurance subsidies and Medicaid. The report underscores how the bill would cut taxes for the rich to take health care away from the less well-off. (Abbe R. Gluck, 5/25)

The Wall Street Journal: How To Read An ObamaCare Prediction
The political world waited with rapt attention Wednesday for the oracles at the Congressional Budget Office to release their cost-and-coverage predictions for the revised House health reform bill, which arrived late in the afternoon. But while Washington stood by, two reports emerged from the real world that are far more consequential. (5/24)

Los Angeles Times: Trump’s Team Issues A Stunningly Dishonest Study Of Obamacare Rate Increases
The Department of Health and Human Services seemed mightily pleased with a statistic it issued Tuesday. The agency’s figures showed that premiums on the Affordable Care Act exchanges “doubled” from 2013 through this year. This might not sound like good news for the people buying their coverage on those exchanges, but to HHS it was vindication. “This report is a sobering reminder of why reforming our healthcare system remains a top priority of the Trump administration,” agency spokesperson Alleigh Marré said. (Michael Hiltzik, 5/24)

Kansas City Star: Should A Limited Public Option Be Part Of Health Care Reform? 
Weren’t we focused on health care reform just a few weeks ago? Yes we were. And as it turns out, while we’re all looking at other things, lawmakers in Washington are still working on a rewrite of the Affordable Care Act. There were two important developments over the last two weeks we should think about. (Dave Helling, 5/24)

Stat: Native Americans’ Health Threatened By Denial Of Medicaid Expansion
America has broken several centuries worth of promises to its indigenous people. And we’re poised to do it again. … The Affordable Care Act provided a way to improve the health of thousands of Native Americans through Medicaid expansion. It provided a much-needed injection of funding to the long-neglected Indian Health Service and tribal health facilities by raising the income level needed for eligibility. With the poverty rate at 28 percent among Native Americans, this group disproportionately benefited from Medicaid expansion. (Kevin Duan and Aaron Price, 5/25)

Milwaukee Journal Sentinel: Health Care Reform The Wisconsin Way
Wisconsin has been a leader in covering its residents with high-quality health care and providing community supports so people with disabilities and frail elders can stay in their homes and communities and out of costly facilities. The American Health Care Act poses a particularly dangerous threat to our state’s residents, in part because we have done so much right. (Barbara Beckert, 5/24)

Lexington Herald Leader: Calling Dr. Paul: Seriously, You Don’t Think The U.S. Can Afford Health Care?
The United States spends more per person on health care than any other country, but our health outcomes are far from the best. Simply put, the challenge facing Congress is how to get more value for all that money. Yes, the details are complex, but we’re a big, complex country with a big, complex economy. Our elected leaders should engage that complexity and produce practical reforms and solutions that inspire confidence in the future. That is a reasonable expectation. (5/24)

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Citing CBO Report, Critics Decry GOP Bill’s Potential Fallout In California

Though the budget analysis released Wednesday on the GOP health care bill didn’t address California specifically, both the state’s Medicaid program and its individual market could be seriously harmed if the legislation passes, according to legislators, consumer advocates and other critics.

“I feel like I am in a bad dream,” said Sen. Ed Hernandez, the West Covina Democrat who chairs the state Senate Health Committee.

The Congressional Budget Office confirmed what Hernandez expected — that large numbers of people would lose coverage and poorer, older Californians would pay significantly more for coverage under the American Health Care Act.

The Republican bill passed the House of Representatives earlier this month with no Democratic support and is now in the hands of the Senate, which is working on its own version.

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Hernandez said he’s especially concerned about the changes to the Medicaid program, known as Medi-Cal in California. “The state budget is not going to be able to absorb this,” he said. “We are going to have a real problem.”

All 14 members of California’s Republican delegation in the House voted for the GOP bill. Like their counterparts nationally, several have said that President Obama’s signature health law was failing and that the new legislation would offer consumers more choice and better care at better prices.

But critics said the law would roll back much of what California had achieved when it heartily embraced the Affordable Care Act, which brought the state’s uninsured rate to record lows.

Nationally, the $119 billion in savings projected by the CBO over a 10-year period doesn’t seem worth the anticipated cost of adding 23 million to the rolls of the uninsured, said John Baackes, CEO of LA Care Health Plan.

In California, Baackes said, the cuts to Medi-Cal “will create a huge gap that the state would have to fill.” And he said it could end the Medicaid expansion ushered in by the Affordable Care Act. Since the law took effect, about 5 million more people enrolled in Medi-Cal, including 3.7 million who became newly eligible under the expansion.

An earlier analysis of the House bill by the California Department of Health Care Services, which oversees the state’s Medicaid program, estimated that the state would lose more than $24 billion annually by 2027 compared to what it would have received under the ACA.

Covered California officials declined to comment on the budget analysis Wednesday but have said in the past that the GOP legislation would make coverage unaffordable for many Californians, especially those who have lower incomes and live in pricier areas.

Even assuming California keeps the 10 essential benefits spelled out under the ACA and continues to prohibit higher premiums for those with preexisting conditions, the individual market in the state would be destabilized, said Laurel Lucia, a health care researcher at the University of California-Berkeley Labor Center.

For many people, the Republican proposal also would reduce premium subsidies for Covered California plans, which Lucia said would make coverage less affordable. And proposed caps on federal Medicaid spending would tightly squeeze the California program, she said.

“Overall there would be substantial loss of coverage for low- and middle-income Californians, especially older Californians,” Lucia said.

Jen Flory, a policy advocate at the Western Center on Law & Poverty in California, said the CBO report shows that “drastic cuts to Medicaid are largely offsetting tax cuts for wealthy Americans.”

Flory said she also feared that that optional Medi-Cal benefits under the law — such as prescription drugs and nursing home care — would be at risk. “The state would be faced with some really tough choices,” Flory said.

Carmela Castellano-Garcia, CEO of CaliforniaHealth+ Advocates, said the CBO score is “devastating.”

“It will impact millions in the state of California,” she said.

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

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

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Millions Of Ill People May Face ‘Extremely High Premiums’ Under House Bill, CBO Says

The Republican overhaul of the federal health law passed by the House this month would result in slightly lower premiums and slightly fewer uninsured Americans than an earlier proposal. But it would leave as many as one-sixth of Americans living in states where older and sicker people might have to pay much more for their health care or be unable to purchase insurance at all, the Congressional Budget Office said Wednesday.

In some states, said the report, “less healthy people would face extremely high premiums, despite the additional funding that would be available” in the bill to help offset those increases.

The report incorporates the changes to the bill made just before it narrowly passed the House on May 4. Those changes included an amendment offered by Rep. Tom MacArthur (R-N.J.) that would let states waive some key provisions of the health law, including requirements to cover “essential health benefits” and to offer insurance to people with preexisting conditions at no extra cost.

CBO said the current version would result in savings of $119 billion over 10 years and 23 million more uninsured people than would be expected under the current law.

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According to the estimate, premiums would be slightly lower than under the Affordable Care Act, but mostly because “the insurance, on average, would pay for a smaller proportion of health care costs.”

Prior to the changes, the CBO estimated that the bill would result in savings of $150 billion over the next decade and grow the number of uninsured Americans by 24 million. That dollar figure was a considerable change from the original version of the bill that CBO said would have saved $337 billion, but lawmakers decided to spend back some of those savings on help for those likely to be cut off from insurance.

The two earliest versions of the bill could not muster enough support for the House leadership to bring them to a vote on the floor. Later, MacArthur and leaders of the conservative Freedom Caucus negotiated changes that they said should help bring down premium costs for consumers. That is the bill approved and now evaluated by CBO.

The CBO also estimated that in states deciding to take the option to waive requirements related to charging sicker people more, “the nongroup market would start to become unstable.” In particular, said the report, “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”

And in states that chose to waive the requirements for essential benefits, even people with insurance “would experience substantial increases in what they would spend on health care,” because their policies might no longer cover expensive treatments like those for maternity care or mental health and substance abuse.

Despite repeated claims from President Donald Trump and congressional Republicans that the Affordable Care Act is collapsing, the CBO specifically said that the market would continue “to be stable in most areas” under current law. It predicted the same for the original version of the House bill.

In fact, the only place the CBO specifically said the individual insurance market might become unstable is in states that decide to waive the ACA’s coverage requirements. It did not guess which states might do that, but the report says that one-sixth of the population could be subject to that instability.

“What is clear is that these waivers make life much, much worse for people with preexisting conditions, for older people, for sicker people,” said Aviva Aron-Dine, a senior fellow at the Center on Budget and Policy Priorities and former Obama administration health staffer.

The savings in the bill are mostly the result of capping federal funding to states for the Medicaid program for those with low incomes and scaling back the tax credits that help some people with low and modest incomes pay for private insurance. An estimated 14 million of the 23 million people who would no longer have insurance would otherwise have obtained it through Medicaid.

The bill would also repeal nearly all the taxes imposed in the ACA to pay for the new benefits, including taxes on wealthy individuals and much of the health industry.

Reaction to the new estimate fell mostly along predictable party lines.

“CBO continues to find that through our patient-focused bill, premiums will go down and that our reforms will help stabilize the market,” said a statement from House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) and its health subcommittee chairman, Michael Burgess (R-Texas).

By contrast, Rep. Steny Hoyer (D-Md.) said the new estimate shows “TrumpCare will kick millions of Americans off their insurance coverage and force consumers to pay more for less.”

But the reaction was not completely partisan. Sen. Bill Cassidy (R-La.), a key swing vote in the Senate, said that “Congress’s focus must be to lower premiums with coverage which passes the Jimmy Kimmel test,” referring to the late-night host’s tearful monologue about the health problems of his newborn son. The House-passed bill, he said, “does not. I am working with Senate colleagues to do so.”

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

CBO Score Of Revised GOP Health Bill: Over Next Decade, 23M Would Be Left Uninsured, Deficit Reduced By $119B

May 24 2017

The nonpartisan Congressional Budget Office issues its latest report on the American Health Care Act.

The New York Times: C.B.O. Projects Dismantling Obamacare Increases Uninsured By 23 Million In A Decade
A bill to dismantle the Affordable Care Act that narrowly passed the House this month would increase the projected number of people without health insurance by 14 million next year and by 23 million in 2026, the Congressional Budget Office said Wednesday. That 10-year figure is slightly less than originally estimated. It would reduce the federal deficit by $119 billion over a decade, less than the $150 billion in savings projected in late March for an earlier version of the bill. And in states that seek waivers from rules mandating essential health coverage, the new law could make insurance economically out of reach for some sick consumers. (Pear, 5/24)

NPR: CBO: Republicans’ AHCA Would Leave 23 Million More Uninsured
The deficit reduction in the latest version of the bill represents a decline from previous versions. When the CBO first scored the AHCA, it said the plan would save $337 billion over 10 years. Later revisions reduced those savings to $150 billion. By far the biggest savings would come from Medicaid, which serves low-income Americans. That program would face $884 billion in cuts. Cutbacks in subsidies for individual health insurance would likewise help cut $276 billion. But those are offset in large part by bigger costs, including the repeal of many of Obamacare’s taxes. (Kurtzleben, 5/24)

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Millones de personas enfermas enfrentarían primas altísimas, según nuevo informe

El informe de la Oficina de Presupuesto del Congreso (CBO) conocido el miércoles 24 de mayo indicó que, bajo el proyecto de salud republicano aprobado por la Cámara Baja a principios de mes, millones de personas tendrían que pagar mucho más por su atención médica, o incluso no podrían siquiera solventarla.

En algunos estados, dijo el informe, “las personas menos saludables se enfrentarían a primas muy altas, a pesar de la financiación adicional que estaría disponible” bajo el proyecto de ley para ayudar a compensar esos aumentos.

El informe incorporó los cambios al proyecto hechos justo antes de aprobarse el 4 de mayo. Esos cambios incluyeron una enmienda ofrecida por el representante Tom MacArthur (republicano de New Jersey) que permitiría a los estados renunciar a algunas disposiciones claves de la ley de salud, incluyendo los requisitos para cubrir los “beneficios esenciales de salud” y para ofrecer seguro a las personas con condiciones preexistentes sin costo adicional.

La CBO dijo que la nueva versión del proyecto de ley resultaría en un ahorro de $119 mil millones en 10 años y que habría 23 millones de personas más sin seguro, comparado con las estimaciones bajo la ley actual.

Según la estimación, las primas serían ligeramente más bajas que las de la Ley de Cuidado de Salud Asequible (ACA), en especial porque “el seguro, en promedio, pagaría una proporción menor de los costos de atención médica”.

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Antes de los cambios, la CBO había estimado que el proyecto de ley daría lugar a ahorros de $150 mil millones en la próxima década y aumentaría el número de estadounidenses sin seguro médico en 24 millones. Esa cifra en dólares fue un cambio considerable respecto a la versión original del proyecto de ley que la CBO dijo que habría ahorrado $337 mil millones, pero los legisladores decidieron gastar parte de esos ahorros en ayuda para aquellos que podrían no poder afrontar el costo de un seguro de salud.

Las dos primeras versiones del proyecto de ley no pudieron reunir suficiente apoyo para que los representantes de la Cámara Baja los sometieran a votación. Más tarde, MacArthur y los líderes del Freedom Caucus negociaron los cambios que, dijeron, deberían ayudar a bajar los costos de las primas (lo que se paga por mes por tener cobertura de salud) para los consumidores. Ese es el proyecto aprobado y que ahora evaluó la CBO.

La CBO también estimó que en los estados que decidan tomar la opción de renunciar a los requisitos relacionados con pagar por las personas más enfermas, “el mercado de los asegurados individuales sería inestable”. En particular, dijo el informe, “las personas menos saludables (con condiciones médicas preexistentes o enfermedades recién diagnosticadas) no podrían, en última instancia, comprar un seguro de salud integral con primas comparables a las de la legislación vigente”.

Y en los estados que optaran por renunciar a los requisitos para los beneficios esenciales, incluso las personas con seguro “experimentarían aumentos sustanciales en lo que gastarían en la atención de la salud”, porque sus planes ya no podrían cubrir tratamientos costosos como cuidados de maternidad, salud mental o abuso de sustancias.

A pesar de las repetidas declaraciones del presidente Donald Trump y de los republicanos del Congreso de que ACA se está derrumbando, la CBO dijo específicamente que el mercado continuaría “siendo estable en la mayoría de las áreas” bajo la ley actual. Predijo lo mismo para la versión original del proyecto de ley de la Cámara Baja.

De hecho, la CBO dijo específicamente que el único lugar en el que el mercado de seguros individual puede llegar a ser inestable es en los estados que decidan renunciar a los requisitos de cobertura de ACA. No predijo qué estados podrían hacer eso, pero el informe dice que una sexta parte de la población podría verse afectada por esa inestabilidad.

“Lo que está claro es que estas exenciones hacen la vida mucho, mucho peor para las personas con condiciones preexistentes, para las personas mayores, para las personas más enfermas”, dijo Aviva Aron-Dine, experta senior del Center on Budget and Policy Priorities y ex miembro del equipo de salud de la administración de Barack Obama

Los ahorros en el proyecto de ley surgen principalmente de limitar la financiación federal a los estados para el Medicaid, el programa que ofrece atención de salud a los más pobres, y de reducir los créditos fiscales que ayudan a algunas personas con ingresos bajos y modestos a pagar por un seguro privado. Un estimado de 14 millones de los 23 millones que ya no tendrían seguro lo habrían podido obtener a través del Medicaid.

El proyecto de ley también derogaría casi todos los impuestos que dispuso ACA para pagar los nuevos beneficios, incluyendo los impuestos a los individuos ricos y a gran parte de la industria de la salud.

La reacción a la nueva estimación fue predecible.

“La CBO continúa encontrando que, a través de nuestro proyecto enfocado en el paciente, las primas bajarán y que nuestras reformas ayudarán a estabilizar el mercado”, dijo en un comunicado el presidente del Comité de Energía y Comercio de la Cámara de Representantes, Greg Walden (republicano de Oregon) y el presidente del subcomité de salud, Michael Burgess (republicano de Texas).

Por el contrario, el representante Steny Hoyer (demócrata de Maryland) dijo que la nueva estimación muestra que “el Trumpcare expulsará a millones de estadounidenses de su cobertura de seguros y obligará a los consumidores a pagar más por menos”.

Pero la reacción no fue completamente partidaria. El senador Bill Cassidy (republicano de Louisiana), un votante clave en el Senado, dijo que “el enfoque del Congreso debe ser primas bajas con cobertura que supere la prueba Jimmy Kimmel”, refiriéndose al emocional monólogo que el conductor de TV hizo sobre los problemas de salud de su hijo recién nacido. El proyecto de ley aprobado por la Cámara, dijo, “no pasa la prueba. Estoy trabajando en eso con los colegas del Senado”.

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

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Viewpoints: The Rule Of Law And Subsidies; Anticipating CBO’s Score On The GOP Health Plan

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

Bloomberg: Rule Of Law Actually Applies To Democrats, Too
Yes. Congress can mandate subsidies without also mandating a funding source. Medicaid is another example. This is crazy, but there it is. For once the Constitution is admirably clear on how the executive branch should handle this quandary: “No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law; and a regular Statement and Account of the Receipts and Expenditures of all public Money shall be published from time to time.” The law appropriated no money for these cost-sharing reduction payments. But the Obama administration went ahead and paid them anyway. (Megan McArdle, 5/23)

The New York Times: How To Read The C.B.O. Score Of The Health Bill Like An Expert
Today, the Congressional Budget Office will issue important numbers about the House-passed version of the American Health Care Act, the Republican bill to repeal and replace portions of the Affordable Care Act. Although the budget office had analyzed an early version of the bill, the House on May 4 took the unusual step of voting before the budget office could gauge how several last-minute amendments might affect the deficit or the number of uninsured. (Margot Sanger-Katz, 5/24)

RealClear Health: Why Nutrition Standards And Policies Should Continue
The U.S. Department of Agriculture said recently it will delay the implementation of school lunch rules aimed at lowering the amount of sodium and raising the whole grain content of meals served to kids. At the same time, the Food and Drug Administration announced it will delay for one year the implementation of Obama administration rules to require calorie labels on menus and prepared food displays. (Deborah A.Cohen, 5/24)

WBUR: America’s Food Access Problem Starts On The Farm 
Given that we’re tangled in knots over how to pay for health care, it’s remarkable that food and farm policy isn’t more in the public’s mind. Heads of hunger programs and food banks have begun to grasp the obvious; as one told WBUR, “food is medicine, food is health,” with good health impossible in the absence of nutritious eating. (Rich Barlow, 5/23)

San Jose Mercury News: Single-Payer Detracting From Big Medi-Cal Fight
Sen. Ricardo Lara’s single-payer legislation was a non-starter in California from day one, even before it was given an eye-popping $400 billion price tag. … It’s merely an exercise in politics, which is all well and good except that it detracts from a far more important California health care issue: Can the state fight off President Trump’s inhumane effort to slash the nation’s Medicaid budget by more than $880 billion through 2026? (5/23)

Stat: Risk Scores For Preventing Heart Disease, Stroke Must Take The Long View
Back in 1998, researchers with the legendary Framingham Heart Study created the first heart risk calculator. Using answers to questions about age, cholesterol and blood pressure levels, tobacco use, and the presence of diabetes, it estimated an individual’s risk of having a heart attack or stroke over the next 10 years. Since then, this calculator has been revised and many others have been developed, including ones that extend the time horizon out to an individual’s lifetime. Yet much to our surprise, the use of these single-point-in-time risk calculators does little to reduce the risk of heart attack or stroke compared with not using such calculators. ( Kunal N. Karmali and Mark Huffman, 5/23)

On the Ground: Our Teeth Are Making Us Sick
The left side of Jacquelyn Garcia’s face throbbed fiercely. She had tried taking Tylenol and Excedrin for the pain, but threw them up. On a Monday morning straight after working the night shift as a custodian, she rushed to the N.Y.U. emergency dental clinic. Here a student delivered the verdict: decay so deep it had reached the nerve. The tooth needed to be pulled. (Zoe Greenberg, 5/23)

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New Hampshire Governor Supports Moving State To High-Risk Pool Model

Meanwhile, the state’s conservatives speak out against reported rate increases for next year. “The latest premium increases under Obamacare will break many families’ budgets,” says New Hampshire Republican State Committee Chairman Jeanie Forrester.

New Hampshire Union Leader: Sununu Proposes Return Of High-Risk Pool
Gov. Chris Sununu and the state’s top insurance official on Monday backed a revision in state law that would allow officials to waive some of the provisions of Obamacare — including provisions addressing pre-existing conditions. In a joint statement, Sununu and New Hampshire Insurance Commissioner Roger Sevigny endorsed an amendment to House Bill 469, which they said would authorize Sevigny to seek federal waivers if they would keep insurance affordable and available in the state. On Sunday, the New Hampshire Sunday News reported about a document that details a potential premium increase of 44 percent next year on the Obamacare Exchange. (Hayward, 5/23)

New Hampshire Union Leader: NH Conservative Groups Critical Of Possible Obamacare Rate Increases 
Granite State conservative groups weighed in Monday on a report in the New Hampshire Sunday News that health insurance policies through the Affordable Care Act could see high rate increases in the coming year. “The latest premium increases under Obamacare will break many families’ budgets. The law is obviously failing working people and is doing far more harm than good. Republicans in Congress are actively working to reform our nation’s healthcare system with a plan that lowers premiums while ensuring folks have access to quality coverage,” said New Hampshire Republican State Committee Chairman Jeanie Forrester. (5/22)

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$2M Ad Blitz In Support Of GOP Health Plan Targets Vulnerable Republicans’ Districts

The group launching the campaign, the American Action Network, is aligned with House Speaker Paul Ryan (R-Wis.).

The Hill: Ryan-Allied Group Launches $2M Ad Campaign Ahead Of Healthcare CBO Score 
An outside GOP group aligned with Speaker Paul Ryan (R-Wis.) unveiled a $2 million TV ad blitz on Tuesday defending the legislation to replace ObamaCare ahead of the highly anticipated Congressional Budget Office analysis of its effects. American Action Network’s ad will run in 21 House districts and nationally on MSNBC’s “Morning Joe” to tout the GOP’s bill, known as the American Health Care Act. (Marcos, 5/23)

Los Angeles Times: Conservative Group Runs Ads Thanking California GOP For Health Care Vote
A conservative advocacy group will run television ads thanking six California Republicans for voting for the GOP bill to roll back the Affordable Care Act. All 14 Republicans in California’s congressional delegation voted for the bill, called the Affordable Health Care Act, when it passed the House without Democratic support last month. Democrats have pledged to make it a campaign issue. (Wire, 5/22)

And in other election-related news —

Kaiser Health News: Health Debate Heats Up In Montana For This Week’s Special Election
Montana’s one and only seat in the House of Representatives is up for grabs, and in the final weekend before Thursday’s special election, the underdog Democrat was hammering the Republican health care bill in TV ads. The ads open with Democrat Rob Quist asking, “Did you know half of all Montanans have a preexisting condition?” He then attacks Republican challenger Greg Gianforte for supporting the House-passed American Health Care Act, which would allow states to drop preexisting conditions protections. (Whitney, 5/23)

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

Disagreement Over Preexisting Conditions Reveals Deep Intra-Party Divide Over Health Law

The push-and-pull between moderate and conservative Republicans is not limited to the House debates. Cracks in the Senate are showing as well.

The Hill: Divisions Emerge In The Senate On Pre-Existing Conditions 
Senate Republicans are showing early divisions over what to do about ObamaCare’s protections for people with pre-existing conditions. Some conservatives, including Sen. Mike Lee (R-Utah), want to simply repeal those provisions and other ObamaCare regulations and leave them up to the states. But advocates of a more centrist approach, like Sen. Bill Cassidy (R-La.), are speaking out in favor of pre-existing condition protections and endorsing a “Jimmy Kimmel test” for the bill, where no one can be denied coverage.  (Sullivan, 5/23)

Nashville Tennessean: Senate Republicans Consider ‘Two-Step’ Process For Obamacare Replacement
Republican senators working to craft their own bill to replace the Affordable Care Act are looking at possibly phasing out the requirement that Americans buy health insurance instead of ending it abruptly. Sen. Lamar Alexander, who chairs the committee that oversees health care issues, said Monday a “two-step” process for ending the insurance mandate and other provisions is something that senators have been discussing. (Collins and Whetstone, 5/22)

The Hill: Conservative Groups Press Senate On ObamaCare Repeal 
Two conservative groups are seeking to influence the Senate’s healthcare bill with a list of recommendations aimed at keeping the bill to the right. Americans for Prosperity and Freedom Partners detailed their requests in a letter sent Monday to Senate Majority Leader Mitch McConnell (R-Ky.), who has convened a working group of senators to examine what ObamaCare repeal-and-replace bill can pass the chamber. (Roubein, 5/22)

Kaiser Health News: GOP’s Health Bill Could Undercut Some Coverage In Job-Based Insurance
The American Health Care Act that recently passed the House would fundamentally change the individual insurance market, and it could significantly alter coverage for people who get coverage through their employers too. The bill would allow states to opt out of some of the requirements of the Affordable Care Act, including no longer requiring plans sold on the individual market to cover 10 “essential health benefits,” such as hospitalization, drugs and maternity care. (Andrews, 5/23)

Meanwhile, back in the House —

Politico Pro: House Panel To Start Work On ‘Third Bucket’ Obamacare Bills 
House Republicans on Wednesday plan to start work on three Obamacare replacement bills they’re hoping to pass with bipartisan support, sources familiar with the matter said. These bills are part of the so-called third bucket of the GOP repeal and replace strategy — legislation that doesn’t fit the fast-track budget reconciliation procedure being used to get Obamacare repeal through the Senate, but which further advances the Republican vision of reshaping health care. (Haberkorn and Everett, 5/22)

And, a look at how many people have gained coverage under the Affordable Care Act —

The New York Times: Nearly 20 Million Have Gained Health Insurance Since 2010
The number of Americans without health insurance has fallen drastically in recent years, according to new data from the National Center for Health Statistics. In 2016, there were 28.6 million Americans without health insurance, down from more than 48 million in 2010. Some 12.4 percent of adults aged 18 to 24 were uninsured, 69.2 percent were covered by private plans and 20 percent had public coverage. (Bakalar, 5/22)

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Head Of CMS Accused Of Offering Insurers Quid Pro Quo For Support Of GOP Health Bill

According to a Los Angeles Times investigation, during a meeting with industry officials, Centers for Medicare and Medicaid Services head Seema Verma linked payment of the insurers’ subsidies to providers’ support of the American Health Care Act.

The Hill: Dems Demand Answers On Report That Admin Tried To Trade ObamaCare Payments 
Top Democrats are demanding answers from the Trump administration about whether a top healthcare official offered insurance companies a quid pro quo to get their support for the GOP’s ObamaCare repeal bill. Centers for Medicare & Medicaid Services Administrator Seema Verma sought political support from insurance companies for the American Health Care Act (AHCA) by offering a deal to continue funding congressionally mandated cost-sharing reduction (CSR) payments, the Los Angeles Times reported. (Weixel, 5/22)

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

GOP’s Health Bill Could Undercut Some Coverage In Job-Based Insurance

This week, I answer questions about how the Republican proposal to overhaul the health law could affect job-based insurance and what the penalties for not having continuous coverage mean. Perhaps anticipating a spell of uninsurance, another reader wondered if people can rely on the emergency department for routine care.

Q: Will employer-based health care be affected by the new Republican plan?

The American Health Care Act that recently passed the House would fundamentally change the individual insurance market, and it could significantly alter coverage for people who get coverage through their employers too.

Michelle AndrewsInsuring Your Health

The bill would allow states to opt out of some of the requirements of the Affordable Care Act, including no longer requiring plans sold on the individual market to cover 10 “essential health benefits,” such as hospitalization, drugs and maternity care.

Small businesses (generally companies with 50 or fewer employees) in those states would also be affected by the change.

Plans offered by large employers have never been required to cover the essential health benefits, so the bill wouldn’t change their obligations. Many of them, however, provide comprehensive coverage that includes many of these benefits.  

But here’s where it gets tricky. The ACA placed caps on how much consumers can be required to pay out-of-pocket in deductibles, copays and coinsurance every year, and they apply to most plans, including large employer plans. In 2017, the spending limit is $7,150 for an individual plan and $14,300 for family coverage. Yet there’s a catch: The spending limits apply only to services covered by the essential health benefits. Insurers could charge people any amount for services deemed nonessential by the states.

Similarly, the law prohibits insurers from imposing lifetime or annual dollar limits on services — but only if those services are related to the essential health benefits.

In addition, if any single state weakened its essential health benefits requirements, it could affect large employer plans in every state, analysts say. That’s because these employers, who often operate in multiple states, are allowed to pick which state’s definition of essential health benefits they want to use in determining what counts toward consumer spending caps and annual and lifetime coverage limits.

“If you eliminate [the federal essential health benefits] requirement you could see a lot of state variation, and there could be an incentive for companies that are looking to save money to pick a state” with skimpier requirements, said Sarah Lueck, senior policy analyst at the Center on Budget and Policy Priorities.

Q: I keep hearing that nobody in the United States is ever refused medical care — that whether they can afford it or not a hospital can’t refuse them treatment. If this is the case, why couldn’t an uninsured person simply go to the front desk at the hospital and ask for treatment, which by law can’t be denied, such as, “I’m here for my annual physical, or for a screening colonoscopy”?

If you are having chest pains or you just sliced your hand open while carving a chicken, you can go to nearly any hospital with an emergency department, and — under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) — the staff is obligated to conduct a medical exam to see if you need emergency care. If so, they must try to stabilize your condition, whether or not you have insurance.

The key word here is “emergency.” If you’re due for a colonoscopy to screen for cancer, unless you have symptoms such as severe pain or rectal bleeding, emergency department personnel wouldn’t likely order the exam, said Dr. Jesse Pines, a professor of emergency medicine and health policy at George Washington University, in Washington, D.C.

“It’s not the standard of care to do screening tests in the emergency department,” Pines said, noting in that situation the appropriate next step would be to refer you to a local gastroenterologist who could perform the exam.

Even though the law requires hospitals to evaluate anyone who comes in the door, being uninsured doesn’t let people off the hook financially. You’ll still likely get bills from the hospital and physicians for any care you receive, Pines said.

Q: The Republican proposal says people who don’t maintain “continuous coverage” would have to pay extra for their insurance. What does that mean? 

Under the bill passed by the House, people who have a break in their health insurance coverage of more than 63 days in a year would be hit with a 30 percent premium surcharge for a year after buying a new plan on the individual market.

In contrast, under the ACA’s “individual mandate,” people are required to have health insurance or pay a fine equal to the greater of 2.5 percent of their income or $695 per adult. They’re allowed a break of no more than two continuous months every year before the penalty kicks in for the months they were without coverage.

The continuous coverage requirement is the Republicans’ preferred strategy to encourage people to get health insurance. But some analysts have questioned how effective it would be. They point out that, whereas the ACA penalizes people for not having insurance on an ongoing basis, the AHCA penalty kicks in only when people try to buy coverage after a break. It could actually discourage healthy people from getting back into the market unless they’re sick.

In addition, the AHCA penalty, which is based on a plan’s premium, would likely have a greater impact on older people, whose premiums are relatively higher, and those with lower incomes, said Sara Collins, a vice president at the Commonwealth Fund, who authored an analysis of the impact of the penalties.

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

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

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Health Debate Heats Up In Montana For This Week’s Special Election

Montana’s one and only seat in the House of Representatives is up for grabs, and in the final weekend before Thursday’s special election, the underdog Democrat was hammering the Republican health care bill in TV ads.

The ads open with Democrat Rob Quist asking, “Did you know half of all Montanans have a preexisting condition?” He then attacks Republican challenger Greg Gianforte for supporting the House-passed American Health Care Act, which would allow states to drop preexisting conditions protections.

The latest polls put the race within a single-digit margin, surprising in a mostly red state where the previous two Democrats running for the seat lost by 15 points or more. Republicans have held Montana’s statewide seat in the House since the 1996 election. It became vacant in March when Rep. Ryan Zinke resigned it to become secretary of Interior.

Quist, a political neophyte, is a Montana-famous folk singer, who has written and performed Western-themed songs across the state for four decades.

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Republican Gianforte is a software entrepreneur whose only political experience is failing to unseat Montana’s Democratic governor in November, getting the fewest votes of any Republican statewide candidate in 2016. Donald Trump won Montana by 20 points.

A last-minute TV ad for Gianforte, funded by $2.5 million that the national Republican Congressional Leadership Fund has poured into the race, pairs a photo of Quist with Nancy Pelosi and says Quist supports her agenda, including “government-run health care.”

Montana resident Jim Lynch plans to vote for Gianforte. Lynch is a member of the Glacier Country Pachyderm Club. Members get together once a month in Kalispell, Mont., to talk about advancing Republican values.

Lynch says health care is a top issue for him. He hates the Affordable Care Act. He’s 63 and says his job provided good health insurance coverage throughout the Obama administration and continues to do so. But, he said, “there’s a lot of people in my shoes who aren’t that lucky. I do know, personally, that they’ve seen huge increases in health care costs, to the point that they don’t even have it anymore.”

Indeed, people who are 55 to 64 can be charged as much as three times what a younger person can be charged for ACA health insurance. Subsidies are available based on income, but older people may earn more than young people just starting their careers.

Under the GOP bill passed by the House, however, older people can be charged five times as much as younger people, and the subsidies are decreasing in aggregate.

Lynch said he doesn’t think the House health care bill is perfect, but he’s confident that, as President Trump shepherds it through Congress, it will be modified into something much better than the Affordable Care Act.

About a hundred miles south in Missoula, Mont., restaurant owner Molly Galusha dreads the idea of Obamacare being repealed. She said the current health care law’s subsidies have made it possible for her employees to afford health coverage on the wages she can afford to pay them.

Galusha is 62 and gets her health coverage through her husband’s job. She says she doesn’t know what they’d do if their insurance went away.

“We’re old and broken,” she said with a laugh.

The Affordable Care Act’s protections for people with preexisting conditions are also likely to affect older people, because the likelihood of having a preexisting condition increases with age.

“We are uninsurable as a couple, so we’re very grateful,” Galusha said.

Republican candidate Gianforte said he won’t vote for a health care bill that doesn’t work for Montana.

“I need to know that, in fact, it’ll bring premiums down, preserve rural access and protect people with preexisting conditions,” he said.

He also said he would have voted against the House health care bill if he’d already been in Congress, because there wasn’t enough time to read the bill and understand it before the House voted.

Democrats, however, accused Gianforte of being disingenuous. They point to a recording of a phone call he had with lobbyists on the day the House bill passed, which was leaked to The New York Times. On the tape he said, “Sounds like we just passed a health care thing, which I’m thankful for, that we’re starting to repeal and replace.”

Quist pounced on those words. Quist needs Republican votes to win, so he’s trying to convince Republicans that their candidate will sell out the state’s interests on health care.

“Montanans want a congressman who’ll shoot straight, not a dishonest politician who says one thing to Montanans and another to the millionaires behind closed doors,” he said. Quist said he wants to build on the ACA and thinks the country should eventually move to a single-payer health insurance system.

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

Categories: Repeal And Replace Watch, The Health Law

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Thoughts On Health Reform: Decision On Subsidies Due Today; Protect Kids In Medicaid

Opinion writers reflect on changes for the nation’s health care system.

Los Angeles Times: The Entire Healthcare Industry Is Panicking That Trump Is About To Blow Up Obamacare
Organizations representing most of the healthcare industry — along with attorneys general from 15 states and the District of Columbia — took desperate steps Friday in a last-ditch attempt to keep President Trump from blowing up the Affordable Care Act. … Monday is a crucial deadline. On that day, the Trump administration has to tell a federal appeals court whether it will continue to defend the ACA against a legal attack by the House of Representatives. (Michael Hiltzik, 5/20)

The Hill: Keep Kids Off The Negotiating Table In Medicaid Reform
Discussions around repealing the Affordable Care Act are now taking place in the Senate, and Medicaid will once again be in the spotlight. That could spell trouble for the nation’s children. There will be new ideas, extended discussions and ultimately negotiations that try to improve our healthcare system. But while we applaud discourse and debate, and encourage our elected officials to weigh the pros and cons of all proposals, we have a simple request — as you debate Medicaid, protect children. (Irwin Redlener and Dennis Walto, 5/20)

San Antonio Express-News: Who Has Absolute Health Care Moral Authority?
As ever, absolute moral authority only belongs to those who preach civility and compassion for others — while ramming their own policy preferences and values down our throats. Millions of us who wanted our individual market health insurance plans left alone were branded selfish or liars for the past eight years. Our stories were stifled; our cancellation notices derided; our accounts of skyrocketing health insurance costs and diminished access to doctors mocked. (Michelle Malkin, 5/20)

Richmond Times-Dispatch: Better, Less Expensive Health Care Requires That We Reframe The Debate 
The divisive debate over federal health care legislation incorrectly assumes that health care is like a balloon — squeeze one side and the air pops out someplace else… It is possible to reduce spending by increasing medical practice that is guided by evidence-based medicine, by both increasing high-value care and reducing the considerable amount of care that evidence shows us is often of no or low value. (Beth A. Bortz, 5/19)

Miami Herald: ‘With Friends Like This, I Could Get Myself Unelected!’
An oddly timed political commercial has been appearing on West Palm Beach television stations, aimed at voters in Florida’s 18th congressional district. The ad urges people to call Rep. Brian Mast and thank him for courageously standing with President Trump and working to repeal Obamacare. … Obviously, the last thing Brian Mast needs right now is for everyone living in his district to be reminded over and over that he voted for a healthcare law that would bankrupt lots of sick people and abandon others. So it made perfect sense that the Democrats would launch the “thank Brian Mast” commercials, just to punk the freshman congressman. Not so. Incredibly, the ads are real. (Carl Hiaasen, 5/19)

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

Georgia Appears To Dodge A Bullet As Blue Cross Doesn’t Signal Plans To Pull Back Operations

In its initial filings with the state, the company says it will continue to sell individual policies in all 159 counties. In other news, a New Hampshire paper reports indications that premiums could go up significantly and California Healthline examines which companies are enticing customers on that exchange.

Atlanta Journal-Constitution: Blue Cross Blue Shield May Stay In Georgia Obamacare Market
Blue Cross Blue Shield of Georgia, the only remaining company to serve all 159 counties in the state, has filed its annual plans for next year’s insurance market exchange under the Affordable Care Act. In its initial filing, it filed plans for the entire state, said spokeswoman Debbie Diamond. The decision can still change. Negotiations between insurers and the state will continue for several months. (Hart, 5/19)

NH Union Leader: Obamacare Rate Could See Big Spike In NH Next Year 
Some Obamacare exchange premiums could increase an average of 44 percent next year in New Hampshire due in large part to Medicaid expansion and the opioid and mental health crises, according to a document obtained by the New Hampshire Union Leader. The document — stamped “Confidential” and marked “Draft Only” and “not for distribution” — hints that New Hampshire soon could be hit with health-care premium increases it has not experienced since Obamacare coverage started in January 2014. Provided by a government official, the document appears to be written by an insurance carrier to explain the expected double-digit increase. (Hayward, 5/20)

California Healthline: Blue Shield Has Highest Share Of Enrollees In Covered California
Blue Shield of California has the largest number of enrollees in the Covered California health insurance exchange, widening its lead over rivals Anthem Blue Cross and Kaiser Permanente, according to recently released data. The data, from Covered California, show that Blue Shield had 389,480 enrollees in the exchange as of December 2016, about 31 percent of the market. Anthem was next with 310,690 members, for a 25 percent share. Kaiser Permanente was third with 297,030 exchange enrollees, or 24 percent. Health Net and Molina Healthcare were fourth and fifth, respectively. (Terhune and Bazar, 5/22)

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

Republicans Race The Clock On Health Care — But The Calendar Is Not Helping

Back in January, Republicans boasted they would deliver a “repeal and replace” bill for the Affordable Care Act to President Donald Trump’s desk by the end of the month.

In the interim, that bravado has faded as their efforts stalled and they found out how complicated undoing a major law can be. With summer just around the corner, and most of official Washington swept up in scandals surrounding Trump, the health overhaul delays are starting to back up the rest of the 2018 agenda.

One of the immediate casualties is the renewal of the Children’s Health Insurance Program. CHIP covers just under 9 million children in low- and moderate-income families, at a cost of about $15 billion a year.

Funding for CHIP does not technically end until Sept. 30, but it is already too late for states to plan their budgets effectively. They needed to know about future funding while their legislatures were still in session, but, according to the National Conference of State Legislatures, the local lawmakers have already adjourned for the year in more than half of the states.

“If [Congress] had wanted to do what states needed with respect to CHIP, it would be done already,” said Joan Alker of the Georgetown Center for Children and Families.

“Certainty and predictability [are] important,” agreed Matt Salo, executive director of the National Association of Medicaid Directors. “If we don’t know that the money is going to be there, we have to start planning to dismantle things early, and that has a real human toll.”

In a March letter urging prompt action, the Medicaid directors noted that while the end of September might seem far off, “as the program nears the end of its congressional funding, states will be required to notify current CHIP beneficiaries of the termination of their coverage. This process may be required to begin as early as July in some states.”

CHIP has long been a bipartisan program — one of its original sponsors is Sen. Orrin Hatch (R-Utah), who chairs the Finance Committee that oversees it. It was created in 1997, and last reauthorized in 2015, for two years. But a Finance hearing that was intended to launch the effort to renew the program was abruptly canceled this month, amid suggestions that Republicans might want to hold the program’s renewal hostage to force Democrats and moderate Republicans to make concessions on the bill to replace the Affordable Care Act.

“It’s a very difficult time with respect to children’s coverage,” said Alker. Not only is the future of CHIP in doubt, but also the House-passed health bill would make major cuts to the Medicaid program, and many states have chosen to roll CHIP into the Medicaid program.”

“We’ve just achieved a historic level in coverage of kids,” she said, referring to a new report finding that more than 93 percent of eligible U.S. children now have health insurance under CHIP. “Now all three legs of that coverage stool — CHIP, Medicaid and ACA — are up for grabs.”

But it’s not just CHIP at risk due to the congested congressional calendar. Congress also can’t do the tax bill Republicans badly want until lawmakers wrap up the health bill.

That is because Republicans want to use the same budget procedure, called reconciliation, for both bills. That procedure forbids a filibuster in the Senate and allows passage with a simple majority.

There’s a catch, though. The health bill’s reconciliation instructions were part of the fiscal 2017 budget resolution, which Congress passed in January. Lawmakers would need to adopt a fiscal 2018 budget resolution in order to use the same fast-track procedures for their tax changes.

And they cannot do both at the same time. “Once Congress adopts a new budget resolution for fiscal year 2018,” said Ed Lorenzen, a budget-process expert at the Committee for a Responsible Federal Budget, that new resolution “supplants the fiscal year 2017 resolution and the reconciliation instructions in the fiscal year 2017 budget are moot.”

That means if Congress wanted to continue with the health bill, it would need 60 votes in the Senate, not a simple majority.

There is, however, a loophole of sorts. Congress “can start the next budget resolution before they finish health care,” said Lorenzen. “They just can’t finish the new budget resolution until they finish health care.”

So the House and Senate could each pass its own separate budget blueprint, and even meet to come to a consensus on its final product. But they cannot take the last step of the process — with each approving a conference report or identical resolutions — until the health bill is done or given up for dead. They could also start work on a tax plan, although, again, they could not take the bill to the floor of the Senate until they finish health care and the new budget resolution.

At least that’s what most budget experts and lawmakers assume. “There’s no precedent to go on,” said Lorenzen, because no budget reconciliation bill has taken Congress this far into a fiscal year. “So nobody really knows.”

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

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Perspectives On Health Debate: GOP Disregard Of ACA Maintenance; Miss USA’s Health Stand

Even as other issues are overtaking the air waves, some opinion writers keep an eye on the health debate.

The New York Times: Trumpcare Is Already Hurting Trump Country
The mere threat that Obamacare will be dismantled or radically changed — either by Congress or by President Trump himself — has persuaded several big insurance companies to stop selling policies or significantly raise premiums. The practical effect is that some lower-income and middle-class families may have no good options for insurance and will have to spend more on health care. (5/19)

Los Angeles Times: Miss USA Spoke For Many Americans When She Said Healthcare Isn’t A Right
[W]e probably shouldn’t be surprised that the person who has most clearly articulated America’s core philosophical belief when it comes to healthcare is our newly crowned Miss USA, Kara McCullough. She was asked at this week’s celebration of swimsuits, evening gowns and womanhood whether she thought “affordable healthcare for all U.S. citizens is a right or a privilege.” “I’m definitely going to say it’s a privilege,” the 25-year-old answered without hesitation. … Miss USA initially was voicing a position common to many Americans, mostly conservatives — a stance that has prevented the United States from joining all other developed countries in providing its citizens with universal coverage. (David Lazarus, 5/19)

Morning Consult: Despite What You’ve Read, Many Small Businesses Support Obamacare
Now, the latest round of stories on the Republican attempt to repeal and replace the Affordable Care Act give the impression that America’s small businesses will be glad to see the ACA go if and when Congress manages to repeal it. While most small business owners agree there are portions of the ACA that can and should be improved, polling shows that a majority of small businesses actually prefer the current law over the GOP replacement plan, and that key provisions of the ACA are helping entrepreneurs succeed. (John Arensmeyer, 5/19)

Medscape: Is Medicaid Only For Those Who ‘Deserve’ It?
I am irritated today. Why? Because we keep getting proposals from Washington that suggest that people ought to work if they want to be eligible for Medicaid. What bothers me about this is that it is a reversion to 19th-century thinking, that the people who deserve healthcare are only those who earn it. This was the attitude when Charles Dickens wrote Oliver Twist, which was a bit biographical in that his own dad was hauled off to debtor’s prison when the author was a child. He bemoaned the idea that only the “deserving” poor should get our aid. (Art Caplan, 5/18)

The New York Times: The Best Replacement For Obamacare Is Medicaid
In defending their efforts to repeal the Affordable Care Act, Republican leaders in Congress argue that the insurance marketplaces created by the law are failing. They aren’t completely wrong. Trouble began with faulty websites during the rollout in 2013. Since then, enrollment continues to be below expectations. Obamacare plans often have higher premiums and out-of-pocket expenses than expected. Some markets, mainly in rural areas, may not attract a single insurer in 2018. And insurers that stay are likely to impose double-digit premium increases. (Michael S. Sparer, 5/18)

Louisville (Ky.) Courier-Journal: A Country Of The Well, A Country Of The Sick
I am alarmed at many of the ideas underlying the House Republican health care plan and the administration’s proposed budget. Each seems to be driven by an idea that there is an “us” (rich, healthy, young) and a “them” (poor, sick, old). The winners and the losers, each residing in their unchanging, indisputable categories. This cold-blooded social Darwinism is poised to deprive millions of health care, while millions more will find insurance prices prohibitive and go without basic health care, or the astronomical cost of insurance and health care will bankrupt them. According to the logic of this health care plan, it is their own fault for having pre-existing conditions, or being old, or poor. (Sara T. Baker, 5/18)

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: A Grandmother’s Abortion; Exploding Obamacare; And Doctors In China

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

The New Yorker: My Grandmother’s Desperate Choice
Some friends and I had got into a long after-school discussion about abortion, prompted by the gruesome posters that a protester had staked in front of the Planned Parenthood in our Vermont town. I had already begun reading my mother’s Ms. magazines cover to cover, but this was the first time I’d encountered a pro-life position. When I hopped into my mom’s car after school, I was buzzing with new ideas. I had almost finished repeating one friend’s pro-life argument when I saw the look on Mom’s face. That’s when she told me: the “household accident” that had killed her mother had, in fact, been a self-induced abortion. (Kate Daloz, 5/14)

Vox: What Does It Look Like When Obamacare Explodes? This Interactive Graphic Explains.
The biggest risk when health insurance plans quit Obamacare is that some areas could end up with no plans at all. This would mean that, while the law was still technically standing, people there would not have access to the program. They’d have no place to use the financial help the government provides to buy coverage on Healthcare.gov. (Sarah Kliff and Sarah Frostenson, 5/15)

The Economist: Shod, But Still Shoddy: China Needs Many More Primary-Care Doctors
Queues at Chinese hospitals are legendary. The acutely sick jostle with the elderly and frail even before gates open, desperate for a coveted appointment to see a doctor. Scalpers hawk waiting tickets to those rich or desperate enough to jump the line. The ordeal that patients often endure is partly the result of a shortage of staff and medical facilities. But it is also due to a bigger problem. Many people who seek medical help in China bypass general practitioners and go straight to hospital-based specialists. In a country once famed for its readily accessible “barefoot doctors”, primary care is in tatters. (5/11)

WIRED: The WannaCry Ransomware Hackers Made Some Major Mistakes
The WannaCry Ransomware Attack has quickly become the worst digital disaster to strike the internet in years, crippling transportation and hospitals globally. But it increasingly appears that this is not the work of hacker masterminds. Instead, cybersecurity investigators see in the recent meltdown a sloppy cybercriminal scheme, one that reveals amateur mistakes at practically every turn. (Andy Greenberg, 5/15)

The Atlantic: Does Depression Contribute To Opioid Abuse?
It can sometimes seem strange how so much of the country got hooked on opioids within just a few years. Deaths from prescription drugs like oxycodone, hydrocodone, and methadone have more than quadrupled since 1999, according to the CDC. But pain doesn’t seem to be the only culprit: About one-third of Americans have chronic pain, but not all of them take prescription painkillers for it. Of those who do take prescription opioids, not all become addicted. (Olga Khazan, 5/15)

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

Research Roundup: Medicaid Wellness Programs; Preexisting Conditions; Changes In Subsidies

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

Health Affairs: Iowa’s Medicaid Expansion Promoted Healthy Behaviors But Was Challenging To Implement And Attracted Few Participants
As part of Iowa’s Medicaid expansion, the Healthy Behaviors Program was designed to provide members with incentives to complete specified healthy activities in return for waiving monthly premiums. We used claims data and interviews to document the first year (2014) of the program’s implementation. Healthy activities completion rates did not exceed 17 percent. Interviews with members and clinic managers revealed low levels of awareness of the program’s existence, deficits in knowledge about how the program works, and a variety of barriers to activity completion. … The results suggest that efforts by federal and state governments to reform Medicaid by shifting responsibility onto program members for healthy behaviors are unlikely to succeed. (Askelson et al., 5/2)

JAMA: Trends And Patterns Of Geographic Variation In Cardiovascular Mortality Among US Counties, 1980-2014
In this study of small area estimation models applied to death records from the National Center for Health Statistics, the difference between county-level mortality rates declined substantially over the past 35 years for both ischemic heart disease and stroke; however, large differences remained in 2014. The largest concentration of counties with high cardiovascular disease mortality extended from southeastern Oklahoma along the Mississippi River Valley to eastern Kentucky, and several cardiovascular disease conditions were clustered substantially outside the South, including atrial fibrillation (Northwest), aortic aneurysm (Midwest), and endocarditis (Mountain West and Alaska). (Roth et al., 5/16)

The New England Journal of Medicine: Aerobic Or Resistance Exercise, Or Both, In Dieting Obese Older Adults
In this clinical trial involving 160 obese older adults, we evaluated the effectiveness of several exercise modes in reversing frailty and preventing reduction in muscle and bone mass induced by weight loss. Participants were randomly assigned to a weight-management program plus one of three exercise programs — aerobic training, resistance training, or combined aerobic and resistance training — or to a control group (no weight-management or exercise program). … Of the methods tested, weight loss plus combined aerobic and resistance exercise was the most effective in improving functional status of obese older adults. (Villareal et al., 5/18)

JAMA Internal Medicine: Perceived Discrimination Experienced By Physician Mothers And Desired Workplace Changes
In a large cross-sectional survey of physician mothers, we found that perceived discrimination is common, affecting 4 of 5 respondents, including about two-thirds of the respondents who reported discrimination based on gender and more than a third who reported maternal discrimination. The overlap of groups reporting gender and maternal discrimination was less than half, suggesting that they are somewhat different phenomena. (Adesoye et al., 5/8)

International Journal of Health Services: Availability Of Outpatient Mental Health Care By Pediatricians And Child Psychiatrists In Five U.S. Cities
The authors sought to assess the availability of outpatient mental health care through pediatrician and child psychiatrist offices in the United States and to characterize differences in appointment availability by location, provider type, and insurance across five cities. To do so, the authors posed as parents of a 12-year-old child with depression, gave a predetermined insurance type, and asked to make the first available appointment with the specified provider. They called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield, one of the largest private insurers in the United States. Appointments were obtained with 40% of the pediatricians and 17% of the child psychiatrists. The mean wait time for psychiatry appointments was 30 days longer than for pediatric appointments. (Cama et al., 5/9)

The Kaiser Family Foundation: Gaps in Coverage Among People With Pre-Existing Conditions
The American Health Care Act (AHCA), which has passed the House of Representatives, contains a controversial provision that would allow states to waive community rating in the individual insurance market. In this brief we estimate the number of people with pre-existing conditions who might be affected by such a policy. … Using the most recent National Health Interview Survey (NHIS), we estimate that 27.4 million non-elderly adults nationally had a gap in coverage of at least several months in 2015. This includes 6.3 million people (or 23% of everyone with at least a several-month gap) who have a pre-existing condition that would have led to a denial of insurance in the pre-ACA individual market and would lead to a substantial premium surcharge under AHCA community rating waiver. (Levitt et al., 5/17)

Urban Institute: Premium Tax Credits Tied To Age Versus Income And Available Premiums: Differences By Age, Income, And Geography
This paper compares tax credits offered through the Affordable Care Act (ACA) with those in the American Health Care Act (AHCA). They examined the premium levels in 10 cities, five of which have relatively low premiums and five of which have relatively high premiums. The authors find that younger people typically receive larger insurance premium tax credits under the AHCA, while older adults typically receive larger premium tax credits under the ACA. The analysis also shows that lower-income older adults currently receive higher tax credits under the ACA than they would under the AHCA regardless of where they live. (Holahan, Blumberg and Wengle, 5/17)

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

Secret Sauce In Maine’s Successful High-Risk Pool: Enough Money

As the GOP health care bill moves from the U.S. House of Representatives to the Senate, many consumers and lawmakers are especially worried that people with preexisting conditions won’t be able to find affordable health coverage.

There are a number of strategies under consideration, but one option touted by House Republicans borrows an idea that Maine used just before the Affordable Care Act went into effect. It’s called an “invisible high-risk pool” — invisible because people in it didn’t even know they were.

The Maine pool earned higher marks than most state high-risk pools because it had a key ingredient: enough money.

“The problem is that in order to do the Maine model — which I’ve heard many House people say that is what they’re aiming for — it would take $15 billion in the first year, and that is not in the House bill,” Sen. Susan Collins (R-Maine) told Politico. “There is actually $3 billion specifically designated for high-risk pools in the first year.”

Here’s how the Maine model worked: When a resident applied for health insurance, they had to fill out a questionnaire. If they had certain medical conditions known to be costly, their application was flagged for the high-risk pool. To consumers, it was seamless: They paid regular premiums and got the same sort of coverage as any other enrollee in their chosen health plan.

What was different was how their medical bills were paid. The state set up a nonprofit entity — the Maine Guaranteed Access Reinsurance Association, or MGARA. Mitchell Stein, an independent health policy consultant, explained that the money to pay for these high-cost patients came from two sources: the insurance policy premiums paid by patients within that high-risk pool and a $4-a-month surcharge on all policyholders in the state.

This “invisible high-risk pool” was just one part of a larger health reform law in Maine, Stein said, and that makes a straight-up assessment of how well the strategy worked difficult. But it’s “a great theory,” he said, “and can be an appropriate way to handle these things.”

Eric Cioppa, superintendent of Maine’s Bureau of Insurance, agrees with Stein. “In Maine, for the period of time it was operating, it worked very well,” Cioppa said.

It was active from 2012 through 2013, as 2014 marked the advent of the Affordable Care Act’s marketplace insurance exchanges. Though in effect only for a brief period, Cioppa said, the invisible high-risk pool did keep costs down in the individual market, where Anthem was the largest insurer.

Without the invisible high-risk pool, Cioppa said, Anthem would have increased rates more than 20 percent, based on estimates the insurer had to make. Instead, the rates went up less than 2 percent.

But Steve Butterfield, policy director of the Maine-based advocacy group Consumers for Affordable Health Care, cautioned that one crucial component that made Maine’s high-risk pool work was that it was well-funded. The strategy proposed in the House Republicans’ American Health Care Act is not, he said.

“An analysis that was done on what this program would need showed that it would need $15 billion to $20 billion per year to have any kind of reasonable impact on premiums,” Butterfield said.

The GOP bill does allocate about $15 billion to $20 billion — but that is supposed to last almost a full decade, not per year.

“One of our concerns,” Butterfield said, “is if the feds are going to put this in place and only kick in a token amount of money, is it going to be up to the states to pick up the slack and pay into this thing to make it work?”

Furthermore, Butterfield said, as the law stands now, under the Affordable Care Act, there’s no need for high-risk pools of any sort. The idea to use invisible high-risk pools is a solution to a problem that the GOP health care bill creates. Right now people can buy insurance regardless of their health status, whether or not they have a preexisting condition. It’s the GOP bill that would allow states to opt out of that Obamacare rule.

“I don’t understand,” Butterfield said, “why it would be a good idea to, on the one hand, say, ‘Well, we’re worried about preexisting conditions, so we’re going to throw not enough money at a problem we’re creating. At the same time, we’re going to allow insurance companies to charge sick people more.’ ”

And the invisible high-risk pool, said consultant Stein, is just one small proposal within the larger health bill.

“There’s nothing inherently wrong with it,” Stein said, “but it doesn’t really fix all the other problems of the bill.”

Which, he said, include cuts to Medicaid and potential changes to what are, under Obamacare, guaranteed “essential benefits.”

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

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

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