Tagged The Health Law

Feds Urge States To Encourage Cheaper Plans Off The Exchanges

For those who make too much money to qualify for health insurance subsidies on the individual market, there may be no Goldilocks moment when shopping for a plan. No choice is just right.

A policy with an affordable premium may come with a deductible that’s too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

The guidance is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don’t incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall to plans sold on the individual market. It was a response to the Trump administration’s announcement that it would no longer pay the companies for the “cost-sharing reduction” subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. “Silver loading,” as it’s called, added an estimated 10 percent to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

“It encourages states to encourage silver loading only on the exchange,” said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they’re unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS’ endorsement of the strategy removes doubts states may have had, said David Anderson, a research associate at Duke University’s Margolis Center for Health Policy who has tracked the issue.

Eighty-three percent of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was 16 percent lower than the monthly premium the year before.

For people who don’t qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year’s total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, federal rules require that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges nearly two-thirds of people bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan,” she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it’s possible that they’ll also be selling plans off the exchange.

But that’s not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they’re considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

“Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans,” said Anderson.

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

Feds Urge States To Encourage Cheaper Plans Off The Exchanges

For those who make too much money to qualify for health insurance subsidies on the individual market, there may be no Goldilocks moment when shopping for a plan. No choice is just right.

A policy with an affordable premium may come with a deductible that’s too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

The guidance is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don’t incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall to plans sold on the individual market. It was a response to the Trump administration’s announcement that it would no longer pay the companies for the “cost-sharing reduction” subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. “Silver loading,” as it’s called, added an estimated 10 percent to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

“It encourages states to encourage silver loading only on the exchange,” said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they’re unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS’ endorsement of the strategy removes doubts states may have had, said David Anderson, a research associate at Duke University’s Margolis Center for Health Policy who has tracked the issue.

Eighty-three percent of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was 16 percent lower than the monthly premium the year before.

For people who don’t qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year’s total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, federal rules require that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges nearly two-thirds of people bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan,” she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it’s possible that they’ll also be selling plans off the exchange.

But that’s not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they’re considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

“Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans,” said Anderson.

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

Must-Reads Of The Week From Brianna Labuskes

The next time I even hint that we’re drifting into a slow news period, feel free to remind me not to jinx things: This week was bursting with industry moves, health law attacks, midterm strategizing, and, oh yeah — an indictment.

A quick programming note before we dive into all that: The Breeze is going on hiatus as I breeze out of town for a bit. But I’ll be back Aug. 31, just as we really start heading into midterm season, so look for me again then.

Now for the news you may have missed:

This week’s swipe at the health law focused on accountable care organizations (shorthand explanation: a program that took a carrot-and-stick approach to getting hospitals, doctors and other providers to coordinate, with the end result of higher-quality, more efficient care). They were supposed to save the government billions of dollars, but data show they’ve failed to measure up to the promise, so the program is being overhauled.

The Washington Post: Trump Administration Proposes Further Dismantling of Affordable Care Act Through Medicare

Rep. Chris Collins (R-N.Y.) was charged with fraud in connection to alleged insider trading after an investigation into his ties with Innate Immunotherapeutics, an Australian biotech firm.

Politico: GOP Rep. Chris Collins Charged With Securities Fraud

If that all sounded vaguely familiar, it’s because back when then-HHS secretary nominee Tom Price was being vetted for any possible ethics violations, his connection to both Innate and Collins was put in the spotlight. And just a small plug: KHN did deep reporting on this, and you can read the stories here.

Medicare Advantage got some leverage to curb drug costs this week by way of “step therapy” (or, as it’s known to critics, “fail first”). Essentially, the private plans will be able to require that patients try cheaper versions of drugs before moving on to more expensive ones. To be clear: This is a pretty distant cry from campaign promises to let Medicare negotiate drug prices, and there’s no guarantee patients will actually see any savings from this move.

Stat: Private Medicare Plans Will Be Able to Use a New Tool to Lower Drug Costs

Would a Netflix model work for drugs? That’s what Louisiana wants to find out. Under the proposal, the state would pay a subscription-type fee to be able to cover all of its Medicaid patients who need hepatitis C treatment. Beyond the click-baity notion, though, experts warn that because drug prices are such a moving target (with some costs coming down quickly) the state may not actually save money.

Stat: Louisiana Explores a ‘Netflix’ Subscription Model for Buying Hepatitis C Drugs

For even some moderate Democrats, “Medicare-for-all” is a pipe dream involving all sorts of politically unpopular complications like trillions of dollars in government spending (the current point of contention). But on the trail, it’s a rallying cry. Gubernatorial candidates, especially, are embracing it, suggesting their states become early testing grounds for universal coverage plans that have been more rhetoric than action so far.

The Washington Post: Tossing Aside Skepticism, Democratic Candidates for Governor Push for State-Based Universal Health Care

The Hill: Ocasio-Cortez: ‘Medicare for All’ Is ‘Not a Pipe Dream’

Apart from “Medicare-for-all,” Democrats could have a winning health issue with drug prices. The problem? They can’t really coalesce behind a plan, all these “concessions” as of late are making it harder to attack the administration, and, uh, there may be a lack of interest in cutting off campaign cash this close to the elections.

Stat: Drug Prices Could Be a Winning Issue for Democrats — If Only They Had a Plan

The idea to penalize legal immigrants’ use of Medicaid has been rumbling around for a bit now, but it picked up some speed in recent days. Though it could be a winning issue for Republicans on the trail, the argument isn’t really backed up by the data. It turns out that legal immigrants are likely subsidizing native-born Americans’ health care.

The New York Times: Plan to Punish Immigrants for Using Welfare Could Boost G.O.P. Candidates

The Hill: Study: Immigrants Have Lower Health-Care Costs Than People Born in US

Buckle up, there were industry moves galore this week. I’ll try to keep it quick:  Billionaire Carl Icahn came out against Cigna’s attempts to acquire Express Scripts, saying it is (in my favorite vocab usage of the week) a “$60 billion folly”;  Rite Aid called off its (unpopular) merger with Albertsons; the American Medical Association came out against CVS’ deal with Aetna; and GM signed an exclusive deal with a health system to provide care for its workers.

The Wall Street Journal: Carl Icahn Publicly Opposes $54 Billion Cigna-Express Scripts Deal

The Wall Street Journal: Rite Aid, Albertsons Call Off Merger Amid Investor Opposition

Reuters: American Medical Association Opposes Merger of CVS and Aetna

The Wall Street Journal: GM Cuts Different Type of Health-Care Deal

If that wasn’t enough news for you, here’s my miscellaneous file: A billionaire and his PTSD clinics have become entangled in the fierce debate over VA privatization; a look at how Zika babies are faring as they grow up is sobering in the breadth of damage the virus has done; an app can warn those recovering from addiction when they’re in neighborhoods or with acquaintances that could trigger a relapse; and a medical examiner is writing to doctors personally each time one of their patients dies from an overdose — and it’s working.

ProPublica: Steve Cohen Is Spending Millions to Help Veterans. Why Are People Angry?

The Washington Post: 1 In 7 Babies Exposed to Zika in U.S. Territories Have Birth Defects, Nervous System Problems

Stat: Can An App’s Warnings to Avoid Triggers Prevent Opioid Addiction Relapses?

Los Angeles Times: Coroner Sent Letters to Doctors Whose Patients Died of Opioid Overdoses. Doctors’ Habits Quickly Changed

 —

And don’t miss one of my favorite long reads of the week (which I got sucked into while on deadline, thank you very much) about an Appalachian odyssey and a hunt for ALS genes.

Stat: Appalachian Odyssey: Hunting for ALS Genes Along a Sprawling Family Tree

Have a great weekend, all!

Medicare To Overhaul ACOs But Critics Fear Fewer Participants

Accountable care organizations were among the key initiatives of the Affordable Care Act, designed to help control soaring Medicare costs.

ACOs were expected to save the government nearly $5 billion by 2019, according to the Congressional Budget Office.

It hasn’t come anywhere close.

On Thursday, the Trump administration proposed an overhaul to the program, which was designed to encourage doctors and hospitals to work together to coordinate care by reducing unnecessary tests, procedures and hospitalizations. The move could dramatically scale back the number of participating health providers.

Administration officials say ACOs have led to higher Medicare spending.

The announcement was just the latest in a steady drumbeat of moves by Trump administration officials to unwind health policies set in place by the Obama administration.

Medicare ACOs began in 2012 and today enroll more than 10 million beneficiaries. If they provide care for less than certain cost targets — while meeting quality of care standards — then they get to share in any of the savings. Commercial insurers and Medicaid have also adopted ACOs in the past decade.

About 82 percent of the 561 Medicare ACOs are set up so that they are not at risk of losing money from Medicare. They can share in any savings they achieve. The rest are in a model where they can gain a higher share of savings, but also risk paying back money to Medicare if they do not meet their savings targets. Those ACOs have been more successful in saving money, Medicare officials said.

The Medicare program said it would phase out its no-risk model beginning in 2020.

A recent industry-sponsored survey showed 70 percent of ACOs would rather quit than assume such financial risk.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said it’s wrong to have ACOs that can only make profits but not risk any losses. “We want to put the accountability back into Accountable Care Organizations,” she said during a briefing with reporters.

Existing ACOs will have one year to switch to a model accepting financial risk. New ACOs will have two years.

Currently, ACOs have up to six years to shift to a model where they share in financial risk.

These and other proposed changes would save Medicare $2.2 billion over the next decade, Verma said.

The proposal drew rare praise from a former Obama administration official. Andy Slavitt, who once headed CMS, tweeted: “CMS is proposing changes to Medicare pay for value (ACO) models. … At first look, they look positive to me.”

CMS estimated that its new policy would lead to a drop of about 100 ACOs by 2027.

Industry observers say that prediction seems modest at best.

“That does not seem too realistic,” said Ross White, manager of the Center for Health Care Regulatory Insight at KPMG, a large consulting firm. “This is going to come as quite a shock to a lot of current participants, although the administration has been sending these signals for several months. … It definitely seems like they are trying to ratchet down and squeeze the dollar savings out and not have participants in it for the wrong reasons.”

Clif Gaus, the CEO of the National Association of ACOs, blasted the proposal, saying it will “upend the ACO movement” and introduces “many untested and troubling policies.”

CMS is “pulling the rug out from ACOs by redoing the program in a short timeframe,” he said.

He added that the “likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value.”

Tom Nickels, executive vice president of the American Hospital Association, also criticized the new ACO rules. “The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task; it requires significant investments of time, effort and finances.”

Under the new plan, CMS also wants to require doctors in ACOs to inform their patients that they are in an ACO. That has not occurred previously, because unlike HMOs, ACOs do not restrict which providers they can see.

Verma, who has repeatedly said unleashing the free market principles will help control costs and improve quality, said ACOs are driving more hospitals and doctors into mergers, which leads to higher costs.

“We want to work with ACOS that are serious about delivering value. We can no longer run a program that is losing money for taxpayers,” she said.

Podcast: KHN’s ‘What The Health?’ Coming Soon: ‘Long-Term Short-Term’ Plans

The Trump administration’s new rule allowing “short-term” insurance plans to be used for up to three years has touched off a big reaction in health policy circles. Supporters of the change say those who can no longer afford comprehensive health insurance will have the ability to purchase lesser but cheaper plans. But opponents worry that consumers who fail to read the fine print will end up with plans that won’t cover care they need.

Reaction is similarly divided over an administration rule change that will make it easier for managed-care plans participating in Medicare to negotiate the price of drugs provided in doctors’ offices or hospitals. Insurance groups call it a small but positive step; patient groups worry it will make it harder for those with serious medical problems to get the medication their doctors recommend.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Margot Sanger-Katz of The New York Times and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • The Trump administration says its promotion of short-term health plans is designed to help people who don’t get government subsidies find more affordable health coverage and will provide some help to people who are not going to buy a plan on the federal health insurance marketplaces anyway. But the policies tend to limit many types of care, such as maternity expenses, prescription drugs and mental health issues.
  • In addition to concerns that these plans will destabilize the Affordable Care Act marketplaces, some consumer advocates say people looking at the plans don’t realize the extent to which they lack patient protections. For example, one may not cover hospital expenses if a patient is admitted over a weekend or pay for care needed for injuries if the patient was drunk.
  • As part of the administration’s effort to meet President Donald Trump’s promise to curb prescription costs, federal officials announced this week that private Medicare Advantage plans can require patients being prescribed drugs from a doctor or in a hospital to first try the cheapest drug options. But some patient advocates object, saying consumers and their doctors should be able to decide what is the best therapy.
  • The federal indictment announced this week against Rep. Chris Collins (R-N.Y.) renews questions about why a member of Congress with a large role in a biotech company was allowed to be a member of a House committee that oversees health issues. After the indictment, House Speaker Paul Ryan stripped Collins of his seat on the Energy and Commerce Committee.
  • New York Gov. Andrew Cuomo, a Democrat, surprised many people with his announcement that insurers would not be able to factor in to premium prices the expectation that fewer people will buy marketplace plans because the health law’s coverage penalties expire in 2019.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: NPR’s “Doctors With Disabilities Push For Culture Change In Medicine,” by Elana Gordon

Anna Edney: The Atlantic’s “Women More Likely to Survive Heart Attacks If Treated by Female Doctors,” by Ed Yong

Margot Sanger-Katz: ProPublica’s “The Shadow Rulers of the VA,” by Isaac Arnsdorf

Kimberly Leonard: The Washington Post’s “A Huge Clinical Trial Collapses, and Research on Alcohol Remains Befuddling,” by Joel Achenbach

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Democrats Tout $2 Trillion In Savings From ‘Medicare For All,’ But Author Of Cost Analysis Cries Foul

The Washington Post fact checks the notion that a recent working paper supports the idea that the proposal by Sen. Bernie Sanders (I-Vt.) would save $2 trillion in health care spending. To get to that number, one would need to make unrealistic assumptions, the report’s author says.

Once Its Greatest Foes, Doctors Are Embracing Single-Payer

When the American Medical Association — one of the nation’s most powerful health care groups — met in Chicago this June, its medical student caucus seized an opportunity for change.

Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated — older physicians warned their pay would decrease, calling younger advocates naïve to single-payer’s consequences. But this time, by the meeting’s end, the AMA’s older members had agreed to at least study the possibility of changing its stance.

“We believe health care is a human right, maybe more so than past generations,” said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”

The ins and outs of the AMA’s policymaking may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.

Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats — ranging from candidates to established Congress members — are putting forth proposals that would vastly increase the government’s role in running the health system. These include single-payer, Medicare-for-all or an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus.

Organized medicine, and previous generations of doctors, had for the most part staunchly opposed to any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents.

But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.

Many younger physicians are “accepting of single-payer,” said Dr. Christian Pean, 30, a third-year orthopedic surgery resident at New York University.

In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence — running practices with minimal government interference, said Dr. Steven Schroeder, 79, a longtime medical professor at the University of California-San Francisco.

In his 50 years of teaching, students’ attitudes have changed: “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” said Schroeder. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’”

Though “single-payer” health care was long dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea — though it is not clear people know what the term means.

A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. Medicare-for-all, a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)

Meanwhile, lots of countries achieve universal health care — everyone is covered somehow — but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.

American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.

“Few really understand what you mean when you say single-payer,” said Dr. Frank Opelka, the medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’”

But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.

Recent surveys through LinkedIn, recruiting firm Merritt Hawkins and trade publication NEJM Catalyst indicate growing support. In the March NEJM survey, 61 percent of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.

Delving further, that survey data shows support is stronger among younger physicians, said Dr. Namita Mohta, a hospitalist at Brigham and Women’s Hospital and clinical editor at NEJM Catalyst.

But it’s unclear whether these findings reflect young doctors’ feelings about the policy or whether they are tapping in to broader frustrations with the American health system.

Much like the general public, doctors often use terms like single-payer, Medicare-for-all and universal health care interchangeably.

“Our younger generation is less afraid to come out and say we want universal health care,” said Dr. Anna Yap, 26, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. “But how? It’s different in what forms we see.”

Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.

“Medical students, I would say, are very interested in public health and improving social determinants of health — one of them being access to health insurance,” said Dr. Jerome Jeevarajan, 26, a neurology resident at the University of Texas-Houston, referring to non-medical factors that improve health, such as food or housing.

Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting individual practices. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.

The debate is, at this point, still theoretical. Republicans — who control all branches of the federal government — sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado and New York have fallen flat.

Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests — including private insurance, the drug industry and hospital trade groups — have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.

But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.

“There’s tremendous potential … to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable,” Pean said.

Medicaid Expansion Making Diabetes Meds More Accessible To Poor, Study Shows

Low-income people with diabetes are better able to afford their medications and manage their disease in states that expanded Medicaid under the Affordable Care Act, a new study suggests.

The Health Affairs study, released Monday afternoon, found a roughly 40 percent increase in the number of prescriptions filled for diabetes drugs in Medicaid programs of the 30 states (including Washington, D.C.) that expanded eligibility in 2014 and 2015, compared with prior years.

By contrast, states that didn’t embrace the Medicaid expansion saw no notable increase.

“Gaining Medicaid insurance would have significantly reduced out-of-pocket spending for insulin for previously uninsured patients, thereby facilitating uptake of the medication,” the Health Affairs study said.

Diabetes, characterized by abnormally high blood sugar, is a chronic disease thfat requires expensive and ongoing medical care.

In the long run, preventing diabetic complications not only saves lives, but it improves public health and saves public money,” said Dr. Michael Bush, an endocrinologist in Beverly Hills, Calif., and president of the California chapter of the American Association of Clinical Endocrinologists.

Bush and other experts said the Health Affairs study shows that the Medicaid expansion can help patients manage their health and also limit unnecessary spending. An analysis by the Centers for Disease Control and Prevention cited by the study shows that each diabetic patient who is treated for the condition can lead to a $6,394 reduction in health care costs (in 2017 dollars) because of fewer hospital admissions.

In California, roughly 3.9 million people gained coverage when the state expanded eligibility for Medi-Cal, the state’s version of the federal Medicaid program. In all, about 13.5 million people — more than one-third of Californians — are enrolled in Medi-Cal.

By 2016, about 12 million people had enrolled in Medicaid nationwide as a result of the expansion, according to the Kaiser Family Foundation. The foundation estimates that more than 2 million people who live in non-participating states would have qualified for Medicaid had their states chosen to expand. (Kaiser Health News is an editorially independent program of the foundation.)

“It’s not particularly surprising that extending Medicaid opened up this door for lots of other people to be able to fill prescriptions and be able to take advantage of managing a chronic disease like diabetes,” said Flojaune Cofer, director of state policy and research at Public Health Advocates, a nonprofit organization based in Davis, Calif., that seeks to eliminate health inequalities in California.

But Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Medicaid expansion may not mean good news for everyone.

Medicaid pays a fraction of a drug’s list price, so pharmaceutical companies may hike prices for everyone if they don’t feel they’re being compensated fairly, he said. That, in turn, could drive up everyone’s premium costs or lead those with private insurance to pay more out-of-pocket.

“You have to look at not just the immediate effects of a policy, but all of the effects of a policy,” Cannon said. “As prices rise, fewer people will be able to afford diabetic medications.”

Last year, nearly 900,000 Californians with Medi-Cal were known to have diabetes, according to state figures.

One of them is James Warden, 62, a retired rancher near Fresno, Calif., who said he was forced to stop working because of a back injury several years ago.

Warden enrolled in Medi-Cal in 2016 and was diagnosed with diabetes last year after a urinary condition landed him in the hospital, he said. Without the coverage, he said, he wouldn’t have the insulin his body needs.

“Medi-Cal saved me,” he said. “I wouldn’t have the money to be able to pay, or go to the doctor or anything.”

The researchers found that people in groups with a higher prevalence of diabetes before the ACA became law, such as those ages 55–59, showed larger increases in filling their diabetes prescriptions after the Medicaid expansions.

The price of insulin, a staple medication for many diabetes patients, rose almost 200 percent from 2002 to 2013, according to the study.

And nearly 40 percent of insulin users who responded to the American Diabetes Association’s 2018 insulin affordability survey reported that they had faced a price increase in the past year. As a result of the price hikes, many said, they took less of the medication, missed doses or switched to a cheaper drug.

In states that didn’t expand Medicaid after 2014, such as Texas and Florida, the number of diabetes prescriptions filled remained relatively flat, the study found. In these states, low-income and uninsured diabetics must rely on a “patchwork of options” to get insulin and other medications to treat their disease, according to the American Diabetes Association. Patients may need to seek help through drug company patient assistance programs or charities, the group said.

The study also showed a surge in filled prescriptions for newer, pricier diabetes drugs that have fewer side effects and control diabetes more effectively. And there was an increase in prescriptions for metformin, a generic drug that is often used as a first line of treatment for new Type 2 diabetes patients.

The rise in metformin prescriptions suggests the federal health law also led to more people being diagnosed with the disease, the authors said.

The study, conducted by University of Southern California pharmaceutical and health economists, was based on an analysis of filled prescriptions before and after the state Medicaid expansions began in 2014. The number of states that expanded Medicaid has since grown to 33 states and Washington, D.C.

The prescriptions analyzed cover the period from 2008 to 2015. About 15 percent of retail pharmacies did not share their information, and the data did not include prescriptions filled by health clinics or via mail-order, which could have led to underestimates of the total effect, the authors said.

Bush, the Beverly Hills endocrinologist, acknowledged that providing diabetes drugs to Medicaid patients is costly to taxpayers. But he said it’s money well spent.

“This is clearly a disease where if you take care of it now, you can prevent complications that occur later,” he said.


KHN’s coverage of these topics is supported by
California Health Care Foundation
and
Laura and John Arnold Foundation

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

Must-Reads Of The Week From Brianna Labuskes

A slow health news week wrapped up with a flurry of movement over the Affordable Care Act in the past few days. As we drift into August, there are definitely a few stories to keep an eye on.

Here’s what you might have missed:

The Trump administration issued a final rule on short-term plans. (The highlights: Coverage can go for 12 months and be renewed for a max of 36 months; it doesn’t have to cover essential benefits; and there aren’t preexisting conditions protections.) Officials were surprisingly candid (“We make no representation that it’s equivalent coverage”) in acknowledging the skimpiness of these plans — which were only ever supposed to act as three-month stopgaps for people between jobs.

The New York Times: ‘Short Term’ Health Insurance? Up to 3 Years Under New Trump Policy

For Democrats in the Senate, there’s a silver lining: The move gives them an opportunity to try to force Republicans — just months before midterm elections, mind you — to go on record voting against those popular provisions that short-term plans strip away. There’s no chance such a measure would pass the House (much less be signed by President Donald Trump), but it puts their colleagues across the aisle in a tough spot.

The Associated Press: Dems Will Try Forcing Senate Vote Against Trump Health Plan

The latest attempt to unmoor the ACA is just one in a series of grenades the administration has lobbed at the health law. But premiums aren’t spiking as much this year, insurers are joining the marketplace instead of fleeing it, and public support for Obamacare is skyrocketing. Has the war been already won?

Politico: Trump’s Losing Fight Against Obamacare

And, that wasn’t the only hubbub over the health law this week. Four major cities are suing Trump, saying his multiple attempts to “sabotage” the legislation is a failure of his constitutional duty to enforce the laws of the land. (Spoiler: They’re unlikely to be successful.)

Reuters: Four U.S. Cities Sue Over Trump ‘Sabotage’ of Obamacare

Passion over HHS’ decision to separate children at the border continues to boil. The government is now making the argument that the burden of reuniting deported parents with their children should actually fall on the American Civil Liberties Union. The ACLU fired back saying that the government is the one that made the mess, and officials shouldn’t be able to foist it off now that it needs cleaning up.

Politico: Trump Administration Tells ACLU to Find Deported Parents

An eye-popping price tag for a “Medicare-for-all” proposal dominated headlines early this week, but experts are saying there’s more to that $32.6 trillion than it might seem. Essentially, the plan would actually save money in overall national health care spending, but shift it over to the government — which means higher taxes.

Modern Healthcare: Libertarian Think Tank: Providers Would Pay for Medicare for All

Rebates are being painted as the new villain in the blame game that is the conversation around lowering high drug prices. Here’s a primer on what they are — but don’t get too attached, they might not be around for long.

The New York Times: Meet the Rebate, the New Villain of High Drug Prices

Bloomberg: Secret Drug Price Rebates Will Go Away, Pfizer CEO Predicts

If that’s not enough news for you, my miscellaneous file is chock-full: New VA Secretary Robert Wilkie is planning on reassigning the officials who have been at the heart of the morale crisis plaguing the agency; Medicare could save nearly $3 billion in a single year if it were able to negotiate drug prices as other agencies can; the FDA put the companies that were selling a dangerous class of opioids in charge of monitoring abuse of said opioids — and then did little to intervene over poor prescribing practices; and the drug industry is pumping millions in charity money into those very towns that are suing the companies over their role in the opioid crisis.

The Washington Post: New Veterans Affairs Chief Plans to Reassign, Sideline Trump Loyalists Now in Power

Stat: Medicare Could Save $2.8 Billion in a Single Year if Prices Could Be Negotiated

The New York Times: F.D.A. Did Not Intervene to Curb Risky Fentanyl Prescriptions

Bloomberg: Facing Wave of Opioid Lawsuits, Drug Companies Sprinkle Charity on Hard-Hit Areas

And as if childbirth wasn’t hard enough, this woman says she had to have a C-section without anesthesia.

Have a great weekend!

WATCH: What You Should Know About The New Rule On Short-Term Health Plans

Kaiser Health News senior correspondent Julie Appleby explains on “PBS NewsHour” how the Trump administration’s approach to short-terms plans could make this form of health coverage more widely available.

But the plans also could cause premium increases for those consumers who opt for more comprehensive insurance through the Affordable Care Act marketplaces.

Listen: Why Red States Challenging ACA Tread Precariously On A Popular Protection

States seeking to overturn the Affordable Care Act must do a delicate dance. That’s because most of them have higher-than-average rates of residents with preexisting conditions — a group specifically protected under the ACA. The 2010 health law prohibits insurers from charging more or denying coverage for such conditions, and that provision remains popular across the country and party lines.

Twenty GOP state attorneys general and governors filed a challenge to the constitutionality of the ACA in February. Last month, the Department of Justice under Attorney General Jeff Sessions sided with them and decided not to defend key portions of the ACA, including the preexisting conditions provision.

Nine of the 11 U.S. states with the highest rates of preexisting conditions have signed on to the lawsuit, according to an analysis published by California Healthline on July 17.

The challengers to the law have said they support protections for people with histories of illness but that the law is unconstitutional and that there are other ways to provide those protections.

Most experts don’t expect any immediate changes, since the lawsuit will take a considerable amount of time to work its way through the courts. Should the GOP-led states ultimately prevail, the impact of losing the protection for preexisting conditions would vary by state. In some states, there is no similar protection to replace the federal one afforded by the ACA. Other states do have such protections.

In California, for example, where more than 5 million people have preexisting conditions, state rules would protect them for 12 months if the ACA were struck down. Some consumer advocates in the state believe that would give lawmakers enough time to pass a law offering longer-term protection.

California Attorney General Xavier Becerra is leading the defense of the ACA in the case, joined by 16 other Democratic attorneys general.

California Healthline reporter Harriet Rowan spoke to Tonic editor Susan Rinkunas on “The VICE Guide to Right Now” podcast about how the outcome of the lawsuit could affect people’s health.

Listen to the conversation at vice.com.


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

Administration Loosens Restrictions On Short-Term Plans, But The Coverage Comes With A Lot Of Fine Print

The administration released the final rule on Wednesday expanding the amount of time people can be covered under the plans. But they’re less expensive for a reason. “We make no representation that it’s equivalent coverage,” said James Parker, a senior adviser to Health and Human Services Secretary Alex Azar. Insurers and analysts are worried that the plans will attract healthier consumers, driving premiums up for the rest of the marketplace.

Trump Administration Loosens Restrictions On Short-Term Health Plans

Insurers will again be able to sell short-term health insurance good for up to 12 months under final rules released Wednesday by the Trump administration.

This action overturns an Obama administration directive that limited such plans to 90 days. It also adds a new twist: If they wish, insurers can make the short-term plans renewable for up to three years.

The rule will “help increase choices for Americans faced with escalating premiums and dwindling options in the individual market, said James Parker, a senior adviser to Health and Human Services Secretary Alex Azar.

But the plans could also raise premiums for those who remain in the Affordable Care Act marketplace — and the short-term coverage is far more limited.

“We make no representation that it’s equivalent coverage,” Parker said.

The Trump administration’s approach is expected to please brokers and the insurers that offer the coverage.

“To restore these to 364 days — as originally drafted — is exactly what we are looking for,” said Jan Dubauskas, general counsel for the IHC Group, speaking before the final rule was released. The IHC Group is an organization of insurance carriers headquartered in Stamford, Conn.

She said she expects IHC to offer 12-month versions as soon as the rule goes into effect, which will be 60 days after it is published.

Administration officials estimate plan premiums could be half the cost of the more comprehensive ACA insurance. They predict about 600,000 people will enroll in a short-term plan in 2019, with 100,000 to 200,000 of those dropping ACA coverage to do so.

Just over 14 million people are enrolled in ACA plans this year.

Short-term plans are less expensive because, unlike their ACA counterparts, which cannot bar people with preexisting health conditions, insurers selling these policies can be choosy — rejecting people with illnesses or limiting their coverage.

Short-term plans can also set annual and lifetime caps on benefits, and cover few prescription drugs.

Most exclude benefits for maternity care, preventive care, mental health services or substance abuse treatment.

Some policy experts, including those from the Center on Health Insurance Reforms at Georgetown University, warn that allowing increased use of the skimpier coverage offered by short-term plans could leave some patients in financial or medical difficulty.

“If you get cancer, your plan will not cover oncology drugs, which can cost an average of $10,000 a month” and “if you are pregnant, you will have to find another way to pay for the cost,” averaging about $32,000 for prenatal care and delivery, the center said in a recent post.

Allowing short-term plans to last longer is the latest move to change regulations issued by the Obama administration. In June, the administration released final rules on association health plans, which grants greater leeway to small businesses and sole proprietors to join together to purchase insurance that doesn’t have to meet all the ACA’s requirements, although AHP plans are more robust than short-term plans.

Those changes to Obama-era rules, and other congressional actions, are expected to impact the cost of coverage for individuals in the ACA marketplace.

Premiums for the average benchmark ACA plan rose by 34 percent this year, according to a recent Congressional Budget Office report.

Factors driving the increase include medical inflation, but the CBO also cited the administration’s decision last fall to drop payments to insurers for lowering deductibles for certain low-income policyholders.

That same report expects premiums for ACA plans to increase 15 percent next year, in part because many consumers may be less likely to buy coverage without the threat of a tax penalty. The tax bill approved last year by Congress stops this financial penalty as of 2019.

Short-term plans, if they appeal to many consumers, could also play a role.

By drawing younger or healthier consumers out of the ACA marketplace, the short-term plan expansion will add up to a 1.7 percent increase to premiums next year, according to the industry lobbying group America’s Health Insurance Plans.

Short-term plans have been around for decades, meant as a stopgap for job changers, students and others who found themselves without coverage.

Under the Trump administration directive, insurers also can renew the short-term coverage for the same amount of time as the original plan — maxing out at 36 months.

HHS officials said current law allows the plans to have this longer shelf life, although critics are likely to argue that — when you factor in the renewal option — a plan that lasts three years cannot be considered short-term.

Supporters of the new rules say the short-term plans won’t affect the ACA market as much as critics fear because the plans will mainly appeal to those consumers already sitting on the sidelines, or those who don’t get a subsidy.

Already the vast majority of people who buy ACA coverage through federal or state exchanges qualify for premium subsidies.

Brokers will likely be pushing the plans, as they often pay higher commissions than do ACA plans.

And, for insurers, profit margins tend to be higher for short-term plans compared with ACA coverage. The plans have limits on coverage. Also, insurers are not held to the ACA requirement that they spend at least 80 percent of premium revenue on plan members’ medical care.

Both supporters and critics of short-term plans say consumers who do develop health problems while enrolled could, in theory, hang on until the next open-enrollment period and buy an ACA plan during the sign-up period because the ACA bars insurers from rejecting people with preexisting conditions.

That part of the law is under threat, however, in a case brought by Texas and 19 other states that seeks to declare that provision and two other parts of the ACA unconstitutional.

In early June, the Department of Justice said it would not defend the law against the Texas case, which is on appeal and may eventually end up at the Supreme Court.