Tagged The Health Law

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! If you’ve been able to tear your attention away from the soap opera that is the ever-escalating (and public and messy!) feud between HHS Secretary Alex Azar and CMS Administrator Seema Verma, you’re a better person than I. (But hey, I’m not alone — the White House itself is apparently riveted by the drama).

The week kicked off with reports that Verma had filed a claim for $47,000 worth of jewelry and other property that was stolen while she was on a work trip. Then came the accusations that HHS leaked the story and then came more accusations that Verma leaked the info that eventually brought down former HHS Secretary Tom Price.

They were both called to a meeting at the White House and told to make nice. (Oh, to have been a fly on that wall …). Because as fun as it is to watch the drama unfold, the feud seems to be derailing President Donald Trump’s health agenda during a time when that is a less-than-ideal thing to happen.

The Washington Post: Infighting Between Alex Azar, Seema Verma Stymies Trump Health Agenda

OK, onward to the rest of the news of the week before I risk turning into a Page Six gossip column.

House Democrats passed a sweeping drug-pricing bill that would allow Medicare to negotiate drug prices, among other things. Like most bills these days, its purpose is more political than anything else — it will live a full life on the 2020 campaign trail long after it’s killed in the Senate.

The New York Times: House Votes to Give the Government the Power to Negotiate Drug Prices

Stat: Drug Pricing Bill Is a Sneak Peek at Democrats’ 2020 Campaign Message

It was all around not a great weak for drugmakers. The industry was spitting mad at what they deemed was an “unforced error” from Trump that “was a reflection of the weakness of the negotiating skills of the president.” The error? Trump stripped a 10-year exclusivity provision for biologics from the new trade deal with Mexico and Canada.  The blow to pharma is just the latest reminder that they can’t assume any wins just because a Republican is in the White House.

Stat: With New Trade Deal, Trump Deals a Blow to Drug Makers

The government’s word was on trial at the Supreme Court this week when the justices heard arguments over the health law’s “risk corridor” program. It was a slice of the financial carrot to get insurers to participate in the risky marketplaces, but then Congress stripped the funds from the budget. Insurers — who say they’re owed $12 billion — were less than pleased. The justices seemed sympathetic to the insurers, with Justice Stephen Breyer summing it up well: “Why doesn’t the government have to pay its contracts just like everybody else?”

Reuters: U.S. Supreme Court Justices Lean Toward Insurers on $12 Billion Obamacare Claims

And speaking of the health law, the IRS inadvertently ran an experiment on the importance of health coverage when it sent a letter to the nearly 4 million people who were fined because they didn’t have insurance. The letter prompted people to enroll and thus that little letter saved about 700 lives.

The New York Times: The I.R.S. Sent a Letter to 3.9 Million People. It Saved Some of Their Lives.

Back to the Supreme Court: The justices decided to leave in place a Kentucky law that requires physicians to show and describe ultrasounds to patients seeking abortions. The law requires the physicians to continue with the process even if the patient objects and shows signs of distress.

Reuters: U.S. Supreme Court Leaves in Place Kentucky Abortion Restriction

Side note: The story below is less about abortion and more about congressional committees and their inner workings, but I found it a fascinating read (at least for all you wonkish types out there).

Politico: Impeachment Committee’s Rancor Forged by Decades of Abortion Battles

South Carolina is the latest state to be granted a waiver to add work requirements to its Medicaid program. It’s the 10th one so far, but the move is still notable. That’s because, unlike other states, South Carolina never expanded the Medicaid to begin with. That means that the work-age population on its Medicaid rolls is made up almost entirely by poor mothers. Research also suggests that research found the population subject to the new requirements is disproportionately black.

The New York Times: South Carolina Is the 10th State to Impose Medicaid Work Requirements

What a roller-coaster ride this year has been for surprise medical bills. It seemed like low-hanging fruit that even in this particular Congress everyone could agree was bad. But alas, we can always find something to argue about, and progress stalled when lawmakers couldn’t agree on how to solve the problem. Then after months of stagnation, a new deal emerged (which the White House backs). How did they manage that? They actually *gasp* compromised between two of the strategies.

Bills under $750 would be paid at a default price; ones over that could be brought to arbitration, and the final price decision would be binding.

But wait, the ride isn’t over. The House Ways and Means Committee released its own version that would at first let insurers and doctors try to work out payment on their own before an arbitration system kicked in. However it all shakes out, it’s certainly not the easy bipartisan win that was expected.

The Associated Press: White House Backs Emerging Deal on Consumer Health Costs

The Hill: Ways and Means Committee Announces Rival Surprise Medical Billing Fix

South Bend, Ind., Mayor Pete Buttigieg released a list of clients he worked with during his tenure at McKinsey, a powerhouse consulting firm that has drawn fire lately for its work with the Trump administration’s immigration plans. One of Buttigieg’s clients was Blue Cross Blue Shield of Michigan, which eventually went on to lay off about 10% of its workforce. Buttigieg defended his work for the insurer, saying he was focused on administrative costs and cutting overhead expenses.

The New York Times: How Pete Buttigieg Spent His McKinsey Days: Blue Cross, Best Buy, U.S. Agencies

There was nothing particularly notable about Dr. Stephen Hahn’s confirmation process, but I’d be remiss if I didn’t include the fact that the Senate approved him as the new FDA commissioner. Hahn during his hearing sidestepped lawmakers’ attempts to pin him down on e-cigarettes, but any concerns about how he’d handle the epidemic weren’t enough to sink his ship.

The Associated Press: Senate OKs Trump’s FDA Nominee Despite Unclear Vaping Agenda

The FCC approved switching to a three-digit number (988) for the National Suicide Prevention Lifeline. Considering how clunky the old one (800-273-TALK ) was, the change has advocates celebrating. It was interesting that the FCC report had to note that the increase in costs associated with the presumed increase in calls would be offset by avoiding medical expenses such as hospitalizations or emergency department visits.

CNN: FCC Unanimously Approves Proposal for New 3-Digit Number As Suicide Prevention Hotline

A group of doctors carried out a three-day protest in front of a Border Patrol regional headquarters in San Diego. They were demanding that the agency offer flu vaccines to detained migrants — an issue made even more relevant by the fact that three children have died in U.S. custody because of the illness. But Border Patrol says it doesn’t make sense to vaccinate all the people who move through the system.

The Associated Press: Doctors End Protest to Demand Flu Vaccines for Migrants

That’s it from me! Have a great weekend.

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As Health Law Enrollment Deadline Nears, Remember The Insurance That Looks Too Good To Be True Probably Is

Californians Without Health Insurance Will Pay A Penalty — Or Not

Californians, be warned: A new state law could make you liable for a hefty tax penalty if you do not have health insurance next year and beyond.

But some of you need not worry: The law contains several exemptions that will allow certain people to avoid the penalty, among them prisoners, low-income residents and those living abroad.

“It will be really important that people get clear guidance and instruction to make sure they don’t inadvertently pay a penalty when they are eligible for an exemption,” says Laurel Lucia, director of the Health Care Program at the University of California-Berkeley’s Center for Labor Research and Education.

California’s penalty is modeled on the one originally in the federal Affordable Care Act. Congress eliminated the federal penalty, effective this year.

The Golden State will join Massachusetts, New Jersey, Rhode Island, Vermont and Washington, D.C., in requiring their residents to have health coverage and dinging those without it.

Most types of insurance, including Medi-Cal, Medicare and employer-sponsored coverage, will satisfy California’s coverage requirement. People who purchase insurance for themselves and their families, either through Covered California, the state’s health insurance exchange, or the open market, will have until Jan. 31 to buy a health plan for 2020.

If you aren’t covered and owe a penalty for 2020, it will be due when you file your tax return in 2021. The penalty will amount to $695 for an adult and half that much for dependent children. Some people with higher incomes instead will have to pay 2.5% of their income, which could make their penalty quite a bit heftier.

Penalty payments are expected to raise $317 million in the first year they are collected, according to the state Legislative Analyst’s Office. The money will help pay for new state subsidies intended to make insurance more affordable for some people.

You won’t have to pay the penalty if you are uninsured for three consecutive months or less during the year, or if you are incarcerated or are Native American. Likewise, if you are in the U.S. illegally.

General hardship exemptions also are available if you are facing personal or family difficulties, including homelessness, domestic violence, bankruptcy, eviction or the consequences of a natural disaster.

And you’re off the hook if your household income is below the threshold for filing a tax return. This was the most common exemption from the federal penalty, according to Internal Revenue Service data based on 2016 returns. It might be even more popular under the California law, since the state’s filing threshold is higher than the federal one, Lucia says.

You can also claim an exemption if you would have to spend more than 8.24% of your income on insurance premiums in 2020. This so-called affordability exemption was also among the most common under the federal law.

How you claim an exemption depends on the type you are seeking.

Covered California will handle three types of exemptions: religious conscience, general hardship and affordability. Each will require filling out a different application, and the applications will be available starting in January, says James Scullary, an exchange spokesman.

For other exemptions, you’ll need to apply when you file your 2020 return with the Franchise Tax Board in early 2021. A tax board spokeswoman promises that “our tax forms and instructions will include information for all exemptions claimed on the tax return.”

You can also apply to the tax board for an affordability exemption when you file your return.

Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research, says the 8.24% threshold to qualify for the affordability exemption is too high and pushes many middle-class families to pay a penalty even when they are hard-pressed to buy insurance.

Steven Morelock, a resident of Los Angeles, paid hundreds of dollars in federal penalties for several years because he felt too financially stressed to plunk down $250 a month for a high-deductible health plan. He was already shelling out nearly half of his $2,500-a-month salary in rent alone.

“I would have had to change my habits very dramatically,” says Morelock, 41, a labor organizer. “It would have cut the amount of money I had for non-fixed costs by about half.” He finally got employer-sponsored insurance late last year.

Another exemption that has stirred some debate is for membership in a health care sharing ministry — an association of religiously like-minded people, primarily Christians, who cover one another’s medical costs.

Legislators and others who opposed including this exemption in California’s law argued that the ministries are subject to little regulatory scrutiny, the coverage they offer is limited, and it’s not guaranteed. More recently, concerns have arisen about sham ministries engaged in deceptive business practices.

Dr. Dave Weldon, president of the Alliance of Health Care Sharing Ministries, acknowledges some of the limitations and says the organizations he represents “all counsel their members that this is not insurance, there’s no contract, there’s no obligation to pay.”

Bob Stedman, pictured with his wife, Teresa Stedman, and four of their five children, says his family was exempt from the federal tax penalty because of their membership in a health care sharing ministry. He plans to take the same exemption under the new California law. (Courtesy of Bob Stedman)

Bob Stedman, 55, says he and his family were exempt from the federal penalty every year because of their membership in Samaritan Ministries International. The Lake Forest, Calif., resident plans to take the same exemption under the California law.

Stedman figures he’s saving about $1,000 to $1,500 a month in premiums compared with regular insurance, and was pleased when the $50,000 bill he received following a stroke was heavily discounted by the hospital and then almost entirely covered by other ministry members. And knowing his money is not being used to finance abortions, which most commercial health plans in California are required to cover, gives him “the benefit of a clear conscience,” he says.

Weldon says the exemption is warranted on those grounds alone. “This nation has a long history of religious accommodation,” he says.

If you’re not sure whether you might qualify for an exemption, you can get more information from Covered California or the tax board.

Contact Covered California at www.coveredca.com or by phone: 800-300-1506. For the tax board, log on to www.ftb.ca.gov or call 800-852-5711.

But don’t limit yourself to those two agencies. Insurance agents and tax preparers across the state are trying to master the details of the new law, and they can help.

For a list of insurance agents whose help is free, log on to the Covered California website and click on “find help” or go to the website of the National Association of Health Underwriters (www.nahu.org) and hit “find an agent.” The California Society of Tax Consultants (https://www.cstcsociety.org/) and the California Society of CPAs (www.calcpa.org) can help you find a tax preparer.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Some Rejoice Over New California Health Insurance Subsidies. Others Get Shut Out.

Syd Winlock bought one of the cheapest health insurance policies he could find for himself and his wife, Lisa, this year: a high-deductible plan with lousy coverage and a $1,500-per-month price tag.

For coverage next year, the Elk Grove, Calif., resident qualifies for new state-funded health insurance subsidies totaling about $870 per month. This aid allows him to buy a better plan with a lower deductible for about $1,200 per month.

That’s still high, he said, but any help is welcome.

“It made a huge difference,” said Winlock, 61, a small-business owner who provides accounting and point-of-sales systems to other businesses. “We were thinking that in 2020 we wouldn’t be able to keep our plan,” let alone afford an upgrade, he said.

Heather Altman, an independent environmental consultant in Long Beach, also hoped to qualify for the new state financial aid. But, after checking with a health insurance agent, she learned she won’t get anything. “At first I thought it might be a mistake,” she said. “It was disappointing.”

Starting Jan. 1, California will offer financial aid to some consumers who buy health coverage through Covered California, the state’s Affordable Care Act insurance exchange.

Some of the subsidies will go to people who already qualify for the federal tax credits available to some Covered California consumers, primarily those with low incomes. But the assistance will also be extended to middle-income people such as Winlock who make too much money to qualify for the federal tax credits and have had to bear the entire cost of their premiums. California will be the first state to offer such help to middle-class consumers.

With open enrollment for Covered California going full steam — sign-ups for 2020 coverage end Jan. 31 — consumers are eagerly trying to determine whether they might qualify for the new aid and, if so, how much.

The results are mixed.

“It’s brought higher-income earners to call me, but most still earn too much” to qualify, said Kevin Knauss, a Sacramento-area insurance agent who also has clients in Los Angeles and the Bay Area. “Others are picking up $15 to $25.”

More than 486,000 people have already qualified for the new state subsidies, with more expected as open enrollment continues, Covered California announced Thursday. This includes about 23,000 middle-income enrollees who make too much to qualify for federal tax credits, said Covered California Executive Director Peter Lee.

Lee added that new enrollment is up by 16% compared with this time last year, largely due to the new state financial aid and insurance requirement.

This “is a small slice of who will sign up,” he said. “We’re optimistic there will be many, many more people covered by these state subsidies for the middle class.”

Earlier this year, Gov. Gavin Newsom signed a 2019-20 state budget that includes nearly $429 million for the subsidies. To help pay for them, the state is imposing a tax penalty starting next year on people who don’t have health insurance — similar to the federal penalty the Republican-controlled Congress eliminated effective this year.

Covered California has estimated that nearly 1 million Californians could benefit from the new state money.

Some of the aid will go to low- and moderate-income people who earn between 200% and 400% of the federal poverty level, or roughly $25,000 to $50,000 for an individual and $51,500 to $103,000 for a family of four, based on 2019 figures. This group also qualifies for federal tax credits. The average household state subsidy in this category would be $21 a month, Covered California estimates.

The majority of the state assistance, however, will go to people whose incomes are between 400% and 600% of the poverty level — too high for federal aid but still low enough to make health care financially challenging. That’s between about $50,000 and $75,000 a year for an individual and $103,000 to $154,500 for a family of four. The average state assistance for this group will be about $460 a month, according to Covered California.

But falling into this income bracket doesn’t guarantee subsidies, as Altman learned.

She estimated she will make $60,000 next year, which puts her within the income range to qualify as an individual, but she won’t be getting any aid, and she doesn’t quite understand why.

Besides income, household size, location and age play a role in eligibility for the subsidies, Covered California’s Lee explained. For example, older people who live in areas with high health care costs have a higher chance of getting help, he said.

Altman, 47, who has severe asthma and is on multiple medications, said she can’t go without coverage, so she will pay $640 every month for a health plan next year, up $70 from this year.

“I was just glad that it was only an 11% increase,” she said. “In previous years, I’ve seen a 20-something percent increase.”

Winlock said he feels grateful he qualified for the state financial aid because it allowed him to buy a better plan. Now he can seek care that he has been avoiding.

“We’re pretty healthy, and I’m very active, but I do have an issue with arthritis that I haven’t been pursuing because just testing alone is very expensive,” he said.

Evette Tsang, an insurance agent in Sacramento, said that while news of financial aid is driving some customers to her office, the new insurance requirement — and the accompanying tax penalty — are ultimately motivating most people to sign up.

People who don’t have insurance in 2020 will have to pay the penalty when they file their state tax returns in 2021. The penalty will amount to $695 for an adult and half that much for dependent children. Some people with higher incomes instead will have to pay 2.5% of their income, which could make their penalty quite a bit heftier.

Tsang saw clients drop their coverage when the federal penalty was eliminated. “Now they’re coming back,” she said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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KHN’s ‘What The Health?’: Legislate-A-Palooza

Can’t see the audio player? Click here to listen on SoundCloud.

The House overwhelmingly passed a 2020 National Defense Authorization that included a provision that would give 12 weeks of paid parental leave for federal workers. The measure is expected to pass the Senate, and President Donald Trump has said he would sign the measure ― a priority for his daughter and special adviser Ivanka Trump ― into law.

Meanwhile, the bipartisan leadership of key health care committees on Capitol Hill announced compromise legislation to address “surprise” medical bills, but a deal on a final package is far from clear. The House passed Speaker Nancy Pelosi’s package to lower prescription drug costs, but the measure is dead on arrival in the Senate, where a bipartisan proposal from leaders of the Senate Finance Committee is pending.

This week’s panelists are Mary Agnes Carey from Kaiser Health News, Kimberly Leonard of the Washington Examiner, Joanne Kenen of Politico and Emmarie Huetteman of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • The House passed a defense measure that includes 12 weeks of paid parental leave — which represents the biggest change to family leave policy since the Clinton administration. It also highlights a rare case of bipartisanship. The measure is on track to clear the Senate, and Trump has said he would sign it into law. The legislation would put parental leave benefits for federal employees more in line with those for military personnel. Federal employees’ benefits are more narrow, though.
  • There has been lots of talk and now maybe some Capitol Hill movement on the topic of surprise medical bill legislation. Earlier this week, the bipartisan leadership of the House Energy and Commerce Committee and the Republican leader of the Senate Health, Education, Labor and Pensions Committee (HELP) announced a compromise measure to curb these often-high unexpected bills. Midweek, the House Ways and Means Committee also announced that it had come to terms on an approach. These are clear signs of progress. What is not clear is when all the parties will coalesce. Key players, such as HELP ranking member Patty Murray (D-Wash.) and Senate Minority Leader Chuck Schumer, have yet to sign on. If a plan doesn’t crystallize in the immediate future, Congress will likely tackle it during the first few months of 2020.
  • Even as the podcast was being taped, the House was taking up H.R. 3, the drug-pricing bill backed by Pelosi. The measure is expected to pass the House easily with Democratic support. But Senate Majority Leader Mitch McConnell has said it will not get a vote on the Senate floor. This is an interesting issue because the problem of the high cost of prescription drugs has the attention of Democrats, Republicans and the White House. House passage could create momentum in the Senate to address the issue through another measure, this one drafted by Senate Finance Committee Chairman Chuck Grassley (R-Iowa) and ranking member Ron Wyden (D-Ore.).
  • The feud between Centers for Medicare & Medicaid Services Administrator Seema Verma and Health and Human Services Secretary Alex Azar continues. The two officials were called this week for White House meetings, but the battle has been open, public and vituperative, and policy areas ― such as the administration’s plan for an Affordable Care Act replacement as well as for high drug costs ― have been affected.
  • Open enrollment for coverage under the Affordable Care Act, or ACA, expires Sunday. So far this year, enrollment is a bit behind last year’s pace. Important reminders: There is automatic enrollment for people who don’t opt for another plan and, if history holds, there will be a last-minute enrollment rush before the deadline.

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

Mary Agnes Carey: The Washington Post’s “A Stunning Indictment of the U.S. Health-Care System, in One Chart,” by Christopher Ingraham

Joanne Kenen: Politico’s “Impeachment Committee’s Rancor Forged by Decades of Abortion Battles,” by Alice Miranda Ollstein

Kimberly Leonard: Undark’s “Wheelchairs on Planes: Why Can’t Passengers Use Their Own Onboard?” by Michael Schulson. The story appeared on NPR Shots.

Emmarie Huetteman: The New York Times’ “The I.R.S. Sent a Letter to 3.9 Million People. It Saved Some of Their Lives.” by Sarah Kliff

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Supreme Court Seems Sympathetic To Insurers In Obamacare Case

No clear split between conservative and liberal Supreme Court justices emerged Tuesday as justices heard arguments over whether the federal government could renege on Congress’ promise to pay health insurance companies billions to motivate them to participate in the Obamacare marketplaces.

Health insurers hope to recoup $12 billion they believe is owed to them from that Affordable Care Act incentive program.

During the hour of oral arguments, six justices appeared to favor the insurers’ argument — Chief Justice John Roberts, plus justices Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, Elena Kagan and Brett Kavanaugh. Samuel Alito seemed to side with the Trump administration. Neither Clarence Thomas nor Neil Gorsuch spoke during the session.

The Trump administration argues it doesn’t have to pay the money because a Republican-controlled Congress stripped away most of the funding in 2014 and only Congress can appropriate money under the law.

The so-called risk-corridor payments were designed to help health plans recover some losses in the first three years of the Obamacare marketplaces. Congress gave the incentive because of the uncertainty insurers faced regarding how sick or costly this previously uninsured population would be.

Insurers that made large profits were to pay some of it back to the government to share with money-losing insurers. But the money taken in under the program fell billions short of the amount owed to insurers. The Obama administration told insurers it would make up the difference with funds from the Centers for Medicare & Medicaid Services’ budget. But in late 2014 ― after insurers began selling policies to millions of Americans with the expectation that the safeguard would back them up ― Congress barred the federal government from using that funding stream.

Kagan noted how the profitable insurers are still obligated to pay money into the risk-corridor program even though the federal government says it no longer has to pay out.

“You pay in, that’s obligatory. We commit ourselves to paying out. It turns out, if we feel like it. What, what kind of, what kind of a statute is that?” she asked.

No justice was more critical of the administration’s position than Breyer. He questioned why the 2010 health law promised money to insurers who lost money but later took it away after the insurers began covering millions of customers.

“My hat’s on the flagpole. If you bring it down, I’ll pay you $10. You bring it down. I owe you $10. Now how does this differ?”

Deputy Solicitor General Edwin Kneedler, who was arguing the case for the Justice Department, responded that insurers had many reasons to participate in the Obamacare marketplaces beyond the promised risk-corridor payments, most notably that they are the only places millions of people could get federal subsidies to lower their health insurance premiums.

Roberts interjected: “It’s a good business opportunity for them because the government promised to pay.”

Kavanaugh, the newest and one of most conservative justices, suggested to Kneedler that a high court ruling against the insurers could set a precedent to not fund other federal programs with no specific appropriation amount. “If we were to rule for you, everyone will be on notice going forward, private parties and Congress itself, that “shall pay” doesn’t obligate actual payments.”

A ruling on the case, Maine Community Health Options v. United States, is expected in the spring.

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Obamacare Back At The High Court — With Billions For Insurers On The Line

More than $12 billion is at stake for the nation’s health insurers Tuesday when the Supreme Court hears another Affordable Care Act case.

For the federal government, the potential damages could be far greater, as its reputation as a reliable partner to private businesses is on the line.

Unlike earlier Obamacare cases before the high court — where the entire 2010 law and health coverage for millions of Americans was at risk — the latest case has largely flown under consumers’ radar.

The case revolves around a temporary Obamacare provision — called the “risk-corridor” program — that was designed to help health plans recover some losses in the first three years of the health law marketplaces.

The Republican-controlled Congress in late 2014 stripped most of the money out of the program in a budget bill signed by President Barack Obama. This occurred a year after insurers began selling policies to millions of Americans with the expectation that the safeguard would back them up.

Republicans led by Sen. Marco Rubio (R-Fla.), who were determined to repeal the ACA, called the original provision an insurer “slush fund.” But researchers later found that the loss of the risk-corridor program was largely responsible for soaring premiums in 2016 and 2017, and contributed to several startup insurers going out of business.

Dozens of insurers have cried foul and sued the government. Lower courts were split on whether the government should be forced to make the payments.

Here are five reasons you should pay attention to the case:

The integrity of the federal government is at stake.

Health insurers say the government’s decision on the risk-corridor program amounts to a bait-and-switch. The health plans took a chance with the new marketplaces, where they had little knowledge of how sick or expensive new enrollees would be. They said they expected the risk-corridor funding would back them up.

The latest data shows the government owes insurers more than $12 billion in payments to cover losses on the insurance exchanges between 2014 and 2016.

“This case warrants comparison to Lucy Van Pelt pulling the football away from Charlie Brown — with our nation’s government cast as the capricious bully,” the Association for Community Affiliated Plans, an industry group representing nonprofit health plans, wrote in an amicus brief to the Supreme Court. “If the Federal Circuit’s rule stands, then from now on no business can trust a statutory promise of payment from the government.”

The risk-corridor program was one of several ACA safeguards for insurers. The law called for insurers that made large profits to pay some of it back to the government to share with money-losing plans.

But the money taken in under the program fell billions short of the amount owed to insurers. The Obama administration told insurers that it would make up the difference with funds from the Centers for Medicare & Medicaid Services’ budget. The General Accountability Office, the investigative arm of Congress, supported that decision for 2014.

The Trump administration argued the federal government never had power under the law to make the payments out of the CMS budget. The December 2014 budget deal confirmed that, according to the administration.

The federal government’s top lawyer rejects insurers’ notion that the risk-corridor money was ever guaranteed to them.

Congress did not “lure private parties into expensive undertakings with clear promises, only to renege after private parties have relied to their detriment and incurred actual losses,” Solicitor General Noel Francisco argued in court briefs.

Obamacare consumers may benefit if the court sides with the insurers.

The Supreme Court case combined suits from four insurers: Moda Health Plan of Oregon, Maine Community Health Options, Blue Cross Blue Shield of North Carolina and Land of Lincoln Mutual Health Insurance, a now-defunct health plan from Illinois. But dozens of other insurers also have filed lawsuits. If the court rules in favor of insurers, it could force the federal government to pay them $12 billion.

Experts say that could have a marginal effect on those insurers in setting future premiums. It could also force some plans to make rebate payments to customers based on another ACA provision that plans pay money back to members if they spend more than 20% of their premium dollars on administration, marketing and profits.

Meg Murray, CEO of the Association for Community Affiliated Plans, said the government owes $627 million to about 20 of her organization’s plans. “The money would help them going forward in paying back debts or investing their plans or reducing premiums,” she said.

The co-ops have been stymied.

When the Affordable Care Act was nearing its final votes, Democrats removed a controversial provision that would have set up a government-operated plan that would be a “public option for consumers. It was replaced with federal money to start new, nonprofit insurers to bring more competition into many markets, which lawmakers hoped would help hold down premium costs. There were 23 new health cooperatives that started enrolling members in 2014. Today, just four are still in business.

More than other insurers, the co-ops were most at risk when the money was eliminated because they operated on the smallest budgets.

“This was a huge factor in the failure of the co-ops,” said Timothy Jost, a retired law professor at Washington and Lee University in Lexington, Va., who has studied the ACA.

Kevin Lewis, CEO of Maine Community Health Options, said his company is owed $59 million. Without that money, his plan had to withdraw from New Hampshire and raise premiums in areas it still serves. Community Health Options is one of three health plans on the marketplace in Maine and has 38,000 members.

Lewis said that, while many factors caused the demise of the co-ops, the loss of risk-corridor money is high among them.

The U.S. Chamber of Commerce — a leading opponent of Obamacare — is defending the risk-corridor provision.

The chamber has spent nearly a decade and millions of dollars fighting to overturn the Affordable Care Act. That’s why its amicus brief supporting insurers’ fight to restore its risk-corridor funding is so notable.

In its brief, the chamber said the health law promised funding to private insurers, and when the government reversed its commitment, “it pulled the rug out from under them.”

The court’s ruling would reverberate well beyond just the health insurance industry if it does not reverse lower court rulings, according to the chamber.

“If allowed to stand, the decision will chill the business community from working with the federal government in the future,” the chamber said.

A ruling could influence another big Obamacare case.

If the justices rule in favor of the insurers on this case, they may strengthen the industry’s argument in a separate ACA lawsuit working its way through lower courts.

Insurers have sued the federal government for $2.3 billion in unpaid “cost-sharing reduction” payments after the Trump administration stopped making the payments in 2017. Six insurers — in front of three different federal judges — have succeeded in their challenges over unpaid payments.

These ACA payments were intended to compensate insurers for reducing deductibles, copayments and coinsurance mandated by the ACA for marketplace enrollees with low incomes.

Some lawsuits from insurers have been stayed, pending the court’s ruling on risk corridors.

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It’s Not Just You: Picking Health Insurance Is Hard. Here’s How To Be Smart About It.

Science has proved, no kidding around: Picking health insurance is extremely hard.

It’s open enrollment — time to pick next year’s insurance — for folks who buy it on their own and for many of us in our jobs. Lots of us aren’t sure we know how to pick, and research shows: We’re not wrong.

A group of economists found that most people will not make the best choice among the plans in front of them.

And it’s not just average people who have trouble. One of the economists who did that research — George Loewenstein of Carnegie-Mellon University — told me he was personally dreading the process of helping his adult son pick a plan.

“I have no confidence that I’m going to make the right decision,” he said.

So, it’s not just you.

Most of us, Loewenstein and his colleagues found, have two main problems: We don’t understand all the terms, and we have a hard time doing the math.

The good news is, you can avoid some of the worst mistakes. That can mean saving thousands, or even tens of thousands of dollars.

Here’s what you’re aiming for.

Set Realistic Goals

You’ve seen the stats, like how most bankruptcies involve medical debt, and you’ve seen the horror stories, like the guy whose first month of dialysis threatened to stick him with a half-million-dollar bill.

The goal in my family is simple: Avoid disaster.

That may mean paying a little more every month. A health insurance payment — the monthly premium — is very annoying for most of us, especially since we often still have to shell out to see a doctor, even with insurance.

But getting that monthly payment as close to zero as possible? Probably not your best move. Not if it puts you at risk of a horror story you could avoid.

So: Be very careful with plans that don’t comply with Obamacare rules. They’re sometimes marketed as “Trumpcare” — which is not actually a thing — and although they do tend to have lower premiums, they could leave you vulnerable in unexpected ways.

Just ask the woman in Philadelphia who had her foot amputated. Her insurance plan’s response: “Nope! Not covered.”

Understand The Terms

Quick: What’s a deductible? What’s a copay? What is coinsurance? What does out-of-network mean? What does OPX stand for?

And those are just the basics. If you’ve got them down cold, you can skip to the next section, but otherwise here’s a quick rundown:

  • The deductible is how much you shell out before your insurance covers much of anything. The amount can be absurdly high. If your plan has a $7,000 deductible, ask yourself, “Where would I get hold of seven grand?”
  • Copay is how much you pay for an office visit with a doctor. Usually a flat amount: $20 or $30 … or more.
  • Coinsurance is your share of other medical expenses — stuff that can get pricey, like a hospital stay. Usually expressed as a percentage: 10%, 20%, etc. (Of course, serious medical stuff gets so expensive super quickly, so 10% of a LOT is … a lot.)
  • The network is the set of providers — doctors, hospitals, clinics — that accept your insurance. Anybody who doesn’t take your insurance may be able to charge you … whatever they want.
  • OPX stands for out-of-pocket maximum, and it’s a key number: It puts a cap on how much you could pay (beyond your premium) in a given year.

If you could use more detail, here are some resources:

Do The Math And The Research

For the math, you’re going to want to make a spreadsheet. Maybe open yourself a beer first.

To evaluate an insurance plan, you’re solving for two things:

1. What does this plan cost me in a normal year?

If you’re superhealthy, maybe that means you don’t go to the doctor at all. If you’ve got some conditions that mean you know you’ll need a provider, or you’re going to need access to meds, figure out what those copays and coinsurance fees might add up to.

2. How much might this plan protect me — and how much would I still have to pay — if, God forbid, I got hit by a bus or something?

That’s really what insurance is for, and you want to know the answer to this one. It’s usually the same as the answer to “What’s my out-of-pocket maximum?” — assuming you’ve done the research.

The research? This is where you study the network.

This step is especially important if there are things you know you will — or could — need next year: Might you or your partner get pregnant? Have you reached the age where docs say you should get a colonoscopy? Is there a funny rash you’re starting to worry about?

You get the idea.

If so, definitely make sure you’re OK with whichever providers are in the network for a given plan.

Because remember that key term, “out-of-pocket maximum”? Well, in a lot of plans — including everything on the Obamacare exchanges — this threshold applies only for in-network providers.

With out-of-network providers, not only are they free to charge whatever they want, your insurance is not there to put any limits on what you might have to pay.

For details about making your spreadsheet: Check out this first-person account by Zachary Tracer, the health care editor at Business Insider — which is illustrated with a photo of him working his spreadsheet, beer close at hand.

About the research: It’s not easy, especially if you’re going to the hospital for something like surgery or childbirth. A reporter from Bloomberg who writes about health care recently posted to Twitter asking for advice.

Get Help, The Best You Can Find

Here’s why my economist source was dreading this process. Getting to the bottom line taxes the average person’s spreadsheet mojo.

I thought I could figure it out on my own. When I said that to Lynn Quincy, who runs the nonprofit Health Care Value Hub, she laughed.

“Your plan could have different deductibles,” she said. “It could have a general deductible, it could have a pharmaceutical deductible, it could have a hospital deductible.”

She was basically saying, How’s your spreadsheet looking now, smart guy?

Of course, the answer was: Looking pretty sad.

For instance, here’s part of an actual quote my insurance agent sent this fall: $200 IP $150 OP

I was, like: What do IP and OP even stand for? Just getting the answer to that required a couple of tries-and-misses with Google on my part — and I report on this stuff full time. (Answer: “inpatient” and “outpatient.” But even now that I’ve got that answer … how could those numbers affect my bottom line?)

There are automated services that can help — basically, databases that do the math for you — but we don’t all have access to them. Some employers offer this kind of thing as a benefit.

Check with your HR department, and if it’s an option, jump on it. And if it isn’t, well: Ask your HR folks all the best questions you can. And ask if they’ll consider adding a service like that next year.

In some states, the Obamacare exchanges offer a similar service, developed by a nonprofit called Consumers Checkbook. Here’s the list of states where that’s available.

For the rest of us, here’s a place to find actual human beings near you whose job it is to explain this stuff. Note that you’ll find two types of folks listed:

  • “Assisters,” who can help you navigate the Obamacare marketplace or see if you qualify for programs like Medicaid. They’re obligated to be on your side, paid by government grants.
  • “Agents/brokers” can also help you navigate … but they’re generally paid by insurance companies. And not all states require them to act in your best interest.

OK, there it is — and, of course, it’s not entirely pretty.

Just remember: It’s not just you.

And this: This is not an SAT question. There’s no one right answer.

Especially: It’s not realistic ― and probably not a good idea ― to shoot for a game plan where you end next year having spent the absolute least amount of money possible on health care and insurance. Life is kind of a crapshoot that way.

But with a little patience ― and maybe a stiff drink ― you can reduce the risk that you’ll go broke. And that’s worth doing.

Dan Weissmann is the host of “An Arm and a Leg,” a podcast about the cost of health care, now in its third season. It is co-produced by Kaiser Health News.

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Hope everyone had a lovely, restful Thanksgiving. And here’s your periodic (and I’m sure very appreciated and not at all tiresome) reminder not to be one of the nearly 40 percent of Americans who plan to skip their flu shot.

Now on to our jam-packed week of news! Here’s what you might have missed.

There seems to be some conflicting narrative around what exactly a new health care spending analysis means, but one thing is clear—we are now spending $11,172 per person and that is… uh… a lot, to say the least. Spending on health care grew at a slower pace than the economy overall. But the spending didn’t increase because people were going to the doctor more. Instead, price hikes made up for the slower usage growth found by the HHS analysis.

If you want a good plain-English breakdown of what this means, check out this Axios summary of it all; they do a better job than I could. (No one told me there’d be math!) Or listen to KHN’s “What The Health” podcast by our fabulously knowledgeable Julie Rovner.

The New York Times: Health Spending Grew Modestly, New Analysis Finds

Axios: Health Care Spending Grew At A Faster Rate In 2018

KHN: ‘What The Health?’: We Spend HOW MUCH On Health Care?

Speaking of outrageous hospital prices, in a move that shocked no one, hospitals officially filed a suit against the Trump administration rule that would compel them to share secretly negotiated prices for procedures.

The New York Times: Hospitals Sue Trump To Keep Negotiated Prices Secret

There has been an absolute flood of news out of the Trump administration this week, so buckle up.

Nearly 700,000 Americans are slated to lose their food stamp benefits under a new rule that tightens the work requirements in the Supplemental Nutrition Assistance Program (commonly known as SNAP). The move will purportedly save the government $5.5 billion over five years. The Agriculture Department defended the decision to crack down on waivers that extend the amount of time a beneficiary can receive aid as essentially, if not now (when the economy is good) then when? 

Critics were quick to point out the economic and moral pitfalls of this kind of decision, among them being: most beneficiaries work and many of the ones who don’t usually have a reason beyond wanting the $1.83 per meal that they receive under SNAP; it’s been shown that SNAP spending helps cushion the economy during a recession; and the people being cut off are among the most vulnerable in the society.

The Associated Press: 668,000 Will Lose Food Stamp Benefits Under New Work Rules

As part of the administration’s goal to eradicate the HIV epidemic, HHS announced that uninsured Americans can now get free HIV-prevention drugs. While PrEP has been shown to be wildly successful, many people who are at high-risk of contracting the virus aren’t taking the drug for one reason or another.

(I wonder if this is all a bit awkward considering that HHS and PrEP’s-maker are locked in a bitter patent battle.)

The New York Times: 200,000 Uninsured Americans To Get Free H.I.V.-Prevention Drugs

Attorney General William Barr made waves when he suggested that communities upset with police brutality might lose protections from the cops they’re protesting. The remarks — which seemed to encourage abandonment as a form of retribution for those seeking criminal justice reform — were quickly condemned as dangerous.

The New York Times: Barr Says Communities That Protest The Police Risk Losing Protection

A new investigation from Reuters found that the FDA ignored warning bells about the dangers of talc from as early as the 1970s. The agency for decades deferred to the industry over outside experts’ advice.

Reuters: FDA Bowed To Industry For Decades As Alarms Were Sounded Over Talc

And a disturbing video obtained by ProPublica contradicts the Border Patrols’ account of the death of a sick 16-year-old who was being held in U.S. custody. The video shows the boy staggering to the toilet and collapsing on the floor, where he remained in the same position for the next four-and-a-half hours. According to ProPublica “The video shows the only way CBP officials could have missed Carlos’ crisis is that they weren’t looking.” Border Patrol also said it was agents who found his body — but in reality it was a cellmate who alerted them to his death.

ProPublica: Inside The Cell Where A Sick 16-Year-Old Boy Died In Border Patrol Care

Meanwhile, new documents reveal how a powerhouse consulting firm proposed money-saving methods for the detention centers that included proposed cuts in spending on food for migrants, as well as on medical care and supervision of detainees.

ProPublica: How McKinsey Helped The Trump Administration Detain And Deport Immigrants

Over on the presidential campaign trail, “Medicare for All” continues to trip up the candidates, including Sen. Elizabeth Warren (D-Mass.) whose fate seems to have become tied to the proposal that wasn’t even hers to start with. Politico takes us all the way back to a town hall in 2017 hosted by Sen. Kamala Harris (D-Calif.) to figure out how we got to where we are today.

Politico: Medicare For All: The Most Consequential Moment Of The 2020 Primary

The Washington Post: How A Fight Over Health Care Entangled Elizabeth Warren — And Reshaped The Democratic Presidential Race

Meanwhile, some Dems in the race are touting a “public option” as a moderate alternative to “Medicare for All,” but don’t let that fool you. That kind of shift could still send an earthquake through the health care landscape.

The New York Times: Why The Less Disruptive Health Care Option Could Be Plenty Disruptive

Gains made by the anti-abortion movement in recent years are often attributed to a well-executed ground game by the right. But there have also been crucial missteps on the other side of the abortion wars. Critics say the national abortion rights movement lost touch with the ways access was steadily eroding in Republican strong-holds, and that leaders grew overconfident during President Barack Obama’s term. As one director of a clinic in Atlanta told The New York Times: “We were screaming at the top of our lungs, everything is not fine, please pay attention.”

The New York Times: How A Divided Left Is Losing The Battle On Abortion

There’s been a ton of buzz around the first major gun case the Supreme Court took up in nearly a decade. But will it all be for naught? Arguments in the case that centers around a NYC hand gun ordinance focused on the fact that the city got rid of the contested limits in July.

Reuters: U.S. Supreme Court Justices Debate Whether To Dismiss Major Gun Case

I have to say I did not expect to read the phrase, “we are feared as a tiger with claws, teeth and balls,” when I kicked off my workweek, but here we are. As seems to be the case every time we get unsealed documents dealing with the Sackler family, the newest ones reveal how deeply involved Richard Sackler was in the aggressive push to market OxyContin.

Stat: Purdue’s Richard Sackler Proposed Plan To Play Down OxyContin Risks, And Wanted Drug Maker Feared ‘Like A Tiger,’ Files Show

So often opioid news focuses on the big players and court cases these days. But in this article people who were high school kids at the time the epidemic was really starting to brew talk about how their lives have been irrevocably changed by the crisis.

The New York Times: The Class Of 2000 ‘Could Have Been Anything.’ Until Opioids Hit.

Despite the fact that it seems warnings are everywhere about the dangers of vaping, a new survey reveals that nearly one in three teens have used a tobacco product recently. What’s more is that many students said they did not consider intermittent smoking of any product to be harmful.

The New York Times: Nearly A Third Of Teens Use One Or More Tobacco Products

In the miscellaneous file for the week:

•  In Rhode Island, 11 patients over a two-and-a-half year time span died because of a misplaced breathing tube (something that’s supposed to never happen in emergency medicine). The state is the only one in New England to allow responders other than the most highly trained paramedics place the tubes. But advocates say if they tighten those rules, it will cost even more lives because fewer patients will have access to the equipment.

ProPublica: EMS Crews Brought Patients To The Hospital With Misplaced Breathing Tubes. None Of Them Survived.

• Every once in a while we’re hit with a story that reminds us that relying on technology — especially when it comes to health care — is a dangerous game despite the benefits it brings. This time it was a glitch with diabetes monitors.

Stat: A Glitch In Diabetes Monitors Serves As A Cautionary Tale For Health Tech

• Patients who are desperate for a miracle are being given tips by stem cell clinics on how to raise enough money to afford unproven, and sometimes dangerous, treatments. There’s always GoFundMe, the clinics say when met with the patients’ financial barriers.

The Washington Post: Clinic Pitches Unproven Treatments To Desperate Patients, With Tips On Raising The Cash

That’s it from me! Have a great weekend.

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Va. Governor Wants To Hit Pause On Medicaid Work Requirements That Were Crucial To Expansion Deal With GOP

Viewpoints: Public Charge Policy Is Great At Stoking Fear, Preventing Millions From Getting Health Care; Don’t Believe Nonsense About Being Able To Keep Your Health Plan

Different Takes: Medicaid Expansion Is Becoming Irresistible, Even In Deep Red States; In Texas, Scrooge Still Rules, Deprives Thousands Of Care

Candidates Are Betting Big On Health. Is That What Voters Really Want?

The one thing we know about health care in the 2020 Democratic presidential primary race is that it’s a top issue for voters.

The latest Tracking Poll from the Kaiser Family Foundation found 24% of Democrats and Democratic-leaning independents said they want to hear the candidates discuss health care. That’s twice the total for the next top issue, climate change; and four times the total for immigration, the No. 3 issue. (Kaiser Health News is an editorially independent program of the foundation.)

The big question, though, is whether that interest will reward a candidate who backs a sweeping, “Medicare for All”-type plan, or a more modest plan like a public option, in which a person can voluntarily join a government health insurance plan.

Polling doesn’t make that clear. On the one hand, Democrats and Democratic-leaning respondents in the KFF poll say when it comes to health care, the candidate they trust most is Sen. Bernie Sanders of Vermont (who initially pushed a Medicare for All plan).

Yet those same people say they prefer a public option (of the sort supported by former Vice President Joe Biden) to Sanders’ Medicare for All plan. That bears out in a separate Quinnipiac poll released last week, in which 36% of respondents say Medicare for All is a good idea while 52% say it is a bad idea. An NBC/Wall Street Journal poll from September found similar results: 67% of respondents said they would support allowing people under age 65 to “buy their health coverage through the Medicare program,” while only 41% favored “adopting Medicare for All, a single payer health care system in which private health insurance would be eliminated.”

So, what the candidates now face is a question of strategy and tactics. Sanders remains all-in on Medicare-for-All. “I wrote the damn bill,” he keeps reminding reporters. Biden and the rising-in-the-polls Pete Buttigieg, the mayor of South Bend, Ind., are firmly in favor of a more moderate approach. “We take a version of Medicare. We let you access it if you want to. And if you prefer to stay on your private plan, you can do that, too,” Buttigieg said at the Democrats’ October debate. “That is what most Americans want.”

Sen. Elizabeth Warren of Massachusetts looks like she is trying to have it both ways. She has unveiled a far more detailed version of Medicare for All than Sanders or other backers of the concept in Congress. And her campaign has unveiled a “first-term” health plan that could be implemented quickly, moving to a broader Medicare for All system later in her first term. (Even Warren’s transitional plan is more expansive than either Biden’s or Buttigieg’s plan.)

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Who’s right? There’s no good way to tell until voters go to the polls. But it might surprise people that the last time a health overhaul was a major issue in the Democratic presidential primary race ― in 2008 ― it wasn’t the candidate with the most sweeping plan who emerged as the winner.

Then-Sen. Hillary Clinton had a more sweeping plan for health care than her Senate colleague Barack Obama did. Clinton called for a cap on out-of-pocket medical expenses, and an “individual mandate,” the requirement (repealed by Republicans in 2017) that people either prove they have coverage or pay a fine.

Obama resisted many of those specifics, particularly the mandate. “In order for you to force people to get health insurance, you’ve got to have a very harsh stiff penalty,” he said at a debate in February 2008. Eventually he called for a mandate that all children have coverage. Obama did not fully embrace the mandate that would become part of the Affordable Care Act until mid-2009, during the congressional debate.

But Democratic primary voters have moved significantly to the left since 2008, Medicare for All proponents say.

That is clearly the case. But if Democrats are to keep control of the House of Representatives, they will need to keep the loyalty of those independent voters in districts that are far more moderate than those represented by left-leaning lawmakers like Alexandria Ocasio-Cortez (D-N.Y.) and Ilhan Omar (D-Minn.), who are pressing for major changes including the passage of a Medicare for All plan.

The key to all this, of course, is threading the political needle in a way that keeps the enthusiasm of the Democrats’ Medicare for All base, while not scaring away voters in swing areas who fear such major changes. So far, not one of the presidential candidates has found that perfect spot. The one who does could well be the next president.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

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Perspectives: Explosive Health Care Spending Keeps Chipping Away At Poor And Middle Class; Warren’s ‘Medicare For All’ Has Major Benefits For Businesses