Tagged The Health Law

A Tale Of Two States: California, Texas And The Latest ACA Repeal Bid

The GOP’s latest attempt to repeal the Affordable Care Act wobbled on Friday as Sen. John McCain (R-Ariz.) said he could not support it. But the bill known as Graham-Cassidy isn’t dead yet. And whatever its fate, the long-held Republican goal it embodies — to fundamentally change how the government funds Medicaid — will survive.

Graham-Cassidy would dramatically redistribute federal funds to states. And, generally, states that expanded Medicaid — like California — stand to lose billions of dollars as that money is doled out to states that didn’t — like Texas.

“For a state like California or a Massachusetts or a New York — exactly the states that might be most motivated to at least try to preserve the ACA coverage gains — those are the states that would face the deepest cuts to their federal resources,” said Aviva Aron-Dine, a senior fellow with the Center on Budget and Policy Priorities.

The bill’s authors said their plan gives states more flexibility to build their own health systems. But health officials in California released a strongly worded analysis on Friday, predicting dire consequences if the measure were to pass.

Simply stated, this proposal is the most devastating of the three federal health care proposals that we have evaluated this year,” top officials from the state Department of Health Care Services wrote, emphasizing their words in italics.

They cited the significant shift in costs from the federal government to the states, forcing California to pay nearly $4.4 billion more in 2020 to maintain current coverage levels. In 2027, when the federal block grants would end, the state’s additional burden would grow to $53.1 billion, according to the analysis.

All told, from 2020 through 2027, “the impact would total $138.8 billion in federal funding cuts,” the officials wrote.

“If this amendment is adopted and becomes law, California will be faced with tens of billions of dollars in new costs, [which] will require difficult decisions regarding the populations and benefits we choose to cover and how much we pay providers and plans for the services they provide,” the health officials said.

California’s overall uninsured rate dropped by more than half since the ACA’s coverage expansion.

Meanwhile, Texas looks like one of the bill’s big winners. It gets a windfall of more than $35 billion to help replace Obamacare exchanges and other programs, more than any other state. State officials get to decide how they want to spend that money.

But experts in the state said that could present its own set of problems.

“Regardless of the size of the block grant, there’s just no assurance that it would translate into good coverage or coverage that’s [as] affordable as what we have today,” said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin.

Texas has replaced California as the state with the highest number of uninsured people. Pogue said the state doesn’t have the infrastructure in place to expand coverage to more people. It didn’t expand Medicaid, and the state didn’t set up its own Obamacare exchange.

To sell ACA policies, Texas uses healthcare.gov, which will cease to exist if Graham-Cassidy passes.

“There’s no planning and no thought put into how would we create affordable coverage for low-income Texans,” Pogue said. “Texas would be starting from scratch.”

For comparison, it took Massachusetts four years to set up its pre-Obamacare insurance market.

Pogue said the political will needed to expand health insurance to more Texans has been lacking among state lawmakers for years. In order to get the block grant, states would need to create something workable by 2020.

Another issue is how the grants would be calculated. The federal government would pay a fixed amount up to a cap for each Medicaid enrollee.

“We have very low per capita costs already, and we [would] get locked into that forever,” said Stacy Wilson, president of the Children’s Hospital Association of Texas. “We are very concerned.”

The Texas Public Policy Foundation, a conservative group, also said it was not happy about the bill. Its concern is that it doesn’t go far enough to repeal Obamacare.

“In the end, this rushed legislation will not lead to the creation of a functioning free market,” said Drew White, a senior policy analyst with the group.

This story is part of a partnership with NPR, local member stations and Kaiser Health News.

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


HHS To Close Insurance Exchange For 12 Hours On Sundays During Enrollment

The Trump administration plans to shut down the federal health insurance exchange for 12 hours during all but one Sunday in the upcoming open enrollment season. The shutdown will occur from 12 a.m. to 12 p.m. ET on every Sunday except Dec. 10.

The Department of Health and Human Services will also shut down the federal exchange — healthcare.gov — overnight on the first day of open enrollment, Nov. 1. More than three dozen states use that exchange for their marketplaces.

HHS officials disclosed this information Friday during a webinar with community groups that help people enroll.

The Trump administration has come under attack from critics who say that it is intentionally undermining the Affordable Care Act, through regulatory actions. It shortened the enrollment period, withdrew money for advertising and cut the budget for navigators to help people shop for plans.

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The fact that HHS is now closing the site for a substantial portion of each weekend, supposedly for maintenance, seemed the last straw. Many working patients — the prime target group for ACA insurance — might be shopping at just that time.

“The Department of Health & Human Services is actively trying to prevent people from signing up for healthcare coverage,” Rep. Don Beyer (D-Va.) tweeted. “This is outrageous.”

“Argh” was the reaction of Shelli Quenga, program director at the Palmetto Project in South Carolina, a nonprofit group that received about $1 million to help with outreach and enrollment in the past 12 months. This month, HHS cut her budget in half for this year’s open enrollment.

Open enrollment season this year runs from Nov. 1 to Dec. 15, less than half the time people have had to sign up during the first four years of the exchanges created under the Affordable Care Act.

More than 12 million people enrolled on the state and federal marketplaces for 2017 coverage, including more than 9 million on the federal exchange. Some customers give up coverage over the course of the year.

Advocates were already nervous that fewer people would sign up during the shortened period this time around.

“I could see this really impacting the ability of people to complete an application sign-up in a single sitting, which is so important,” said Jason Stevenson, spokesman for the Utah Health Policy Project, an Obamacare navigator group. He noted that 10 p.m. Mountain Time is often a relatively popular time for people to enroll online.

“Health insurance is complicated, and in the past couple of years we had an administration that made it easier to sign up, but that has really changed in the past six months, with more hurdles not only for consumers but for those whose job it is to help them,” he said.

A spokesman for the federal Centers for Medicare & Medicaid Services, which oversee the exchanges, said the shutdowns should not cause too many problems.

“Maintenance outages are regularly scheduled on healthcare.gov every year during open enrollment. This year is no different,” the official said. “The maintenance schedule was provided in advance this year in order to accommodate requests from certified application assisters. System downtime is planned for the lowest-traffic time periods on HealthCare.gov including Sunday evenings and overnight.”

Categories: Insurance, The Health Law

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GOP Health Bill’s Changes Go Far Beyond Preexisting Conditions

The latest GOP effort to “repeal and replace” the Affordable Care Act is getting a lot of attention, even if its passage seems unlikely. But there is far more to the measure than its changes to rules regarding preexisting health conditions.

In fact, the bill proposed by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) would disrupt the existing health system more than any of the measures considered so far this year, according to supporters and critics.

For backers of the bill, that disruption is a good thing. But others are appalled. As insurance industry analyst Robert Laszewski put it in a note to clients this week, “Would you rather lose your Republican Senate seat because you couldn’t pass an Obamacare repeal-and-replace plan or because you blew up the health insurance system?”

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Some of those alterations have generated little discussion but would have major impacts. Here are four unheralded changes:

The Bill Caps Federal Funding To Medicaid

Much focus has been placed on the bill’s funding formula, which would take money from states that expanded the Medicaid program for the poor. Less notice has been paid to the fact that this bill, like some other GOP options over the summer, would, for the first time, cap overall federal Medicaid funding. The federal government has provided an open-ended funding match since the program’s creation in 1965 — meaning the federal government has provided its share of whatever states spend to care for low-income children, pregnant women, seniors and people with disabilities. More than 70 million people are covered by Medicaid, including those added as a result of the ACA.

Republicans have been pushing unsuccessfully to limit the federal government’s funding of Medicaid to states since the 1980s.

State Medicaid directors — including both Republicans and Democrats — are alarmed at the idea that something of such magnitude could be done with so little debate or consideration. “Graham-Cassidy would completely restructure the Medicaid program’s financing, which by itself is three percent of the nation’s Gross Domestic Product and 25 percent of the average state budget,” said a statement from the group.

The Congressional Budget Office estimated in June that an earlier version of the cap would reduce federal Medicaid spending 35 percent by 2036. As a result, said CBO, states would “uneed to … decide whether to commit more of their own resources, cut payments to health care providers and health plans, eliminate optional services, restrict eligibility for enrollment, or adopt some combination of those approaches.”

“There won’t be enough money to do what’s authorized under current law,” said Jessica Schubel of the left-leaning think tank the Center on Budget and Policy Priorities.

— The Bill Gives Unprecedented Power To The Secretary Of Health And Human Services

Republicans complained bitterly about the power delegated by Congress to the secretary of Health and Human Services in the ACA. But conservative analyst Chris Jacobs pointed out that the Graham-Cassidy bill gives the HHS secretary more power still.

The bill creates a dizzyingly complex formula for the funds now being spent on the ACA, which is intended to draw money away from wealthier states (that mostly expanded Medicaid under the health law) toward poorer ones (that mostly did not). But there is a huge loophole, noted Jacobs. The bill gives the HHS secretary authority to change the formula on his or her own.

“That’s a trillion-dollar loophole that leaves HHS bureaucrats with the ultimate say over how much money states will receive,” Jacobs wrote.

And, he said, it’s the opposite of “federalism,” or giving states more authority, which the bill’s sponsors claim to be advancing.

“Draining the swamp shouldn’t involve distributing money from Washington out to states, whether under a simple formula or executive discretion,” he wrote. “It should involve eliminating Washington’s role in doling out money entirely.”

— The Bill Cuts Off All ACA Funding After 2026

The bill would lump together all funds being spent under the health law to help people pay premiums, out-of-pocket health costs and expand Medicaid to non-disabled adults and redistribute those funds to the states in the form of block grants. States could then use that money for almost anything health-related.

What few people have noticed, however, is that those block grants end abruptly after 2026. Originally, many thought this was because of congressional budget rules that limit new programs to no more than 10 years.

In fact, those rules say that a program cannot add to the deficit after 10 years and don’t affect the length of the program. The block grant is paid for by continuing taxes from the ACA, so there is no budget need to cut it off.

The reason seems to be a desire to require Congress to come back and revisit the program. A spokesman for Cassidy said the program “just has to be reauthorized in 2026 just like the CHIP program.” CHIP is the Children’s Health Insurance Program, also created in a budget bill in 1997. Congress was supposed to reauthorize that program by the end of September, although it looks as if lawmakers will miss that deadline, despite bipartisan support.

Others, however, worry that cutting the money off after 2026 means Congress could no longer use the current funding mechanism. Instead, lawmakers would have to come up with massive cuts to other programs or new tax increases if they wanted to continue providing the money for health care.

— The Bill Could Roil The Individual Insurance Market In Some States By Banning Abortion Coverage In Private Health Plans.

In keeping a promise to anti-abortion lawmakers, the bill would prohibit all private insurance plans receiving any federal funds from providing abortion coverage.

As part of a delicate compromise that got the ACA enacted in 2010, states were given the option to ban abortion coverage in plans on their health exchanges. Half of them did.

But some states, notably California, New York and Oregon require plans they regulate to offer coverage of elective abortions.

The problem is that the deadline for insurers to opt into coverage under the ACA is next Wednesday. If Congress were to pass the bill after that, it is unclear what would happen to those plans. In California, the requirement for abortion coverage is based on the state’s Constitution, so it would be possible that no plans could be offered to people who are eligible for federal help.

“There aren’t clear answers” to what would happen if the bill becomes law in its current form and takes effect in January, said Debra Ness, president of the National Partnership for Women and Families, a reproductive rights advocacy group. “I think it’s going to create chaos.”

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

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Policy Implications: The GOP Bill’s Math Problems; The Importance Of Funding CHIP

Editorial pages include policy analysis of the Graham-Cassidy health care bill and examine some of the key policies now in play.

The Washington Post: Tens Of Millions Of Americans Could Lose Obamacare Tax Credits Because Thousands Of Alaskans Won’t
American politics is always a math problem. If you have a group of x people, you need (x/2) + 1 votes to win the most votes. That holds true for most elections pitting two candidates against each other, and it holds true for passing legislation. In the case of Cassidy-Graham, the clumsily named bill that is the latest and last iteration of Republican efforts to gut the Affordable Care Act, also known as Obamacare, the x is 100 — the number of votes in the Senate. Thanks to two quirks of the process, the legislation would pass with just (x/2) votes, with the +1 being added by VPOTUS-ex-machina Mike Pence. (Philip Bump, 9/21)

Los Angeles Times: Believe It Or Not, Graham-Cassidy Socializes The Cost Of Health Insurance
There are plenty of things wrong with the Graham-Cassidy-Heller-Johnson proposal to overhaul Obamacare (and Medicaid, while it’s at it), from its cockamamie approach to helping people not insured by their employers to its blithe indifference to the rising cost of medical care. But give sponsoring Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.) credit for doing something remarkable: They got even the most conservative of their Republican colleagues to agree to socialize more of the cost of health insurance. (Jon Healey, 9/21)

The Washington Post: Republicans’ Brave New Strategy For Fixing The U.S. Health-Care System
Republicans have unveiled their brave new strategy for fixing the U.S. health-care system: Make someone else deal with it. Of all the god-awful Obamacare-repeal-and-replace plans that Republicans have proposed, Cassidy-Graham might be the god-awfulest. It’s definitely the most cowardly. Republicans spent nine months fighting over how to repeal Obamacare without shafting the poor and enraging voters, and they failed. So instead they’re passing the buck. (Catherine Rampell, 9/21)

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

Political Perspectives: Pleas For Truth Talk Regarding Graham-Cassidy; Does Panic On Left Suggest Progress On Right?

Opinion writers express outrage at the contents of the Senate GOP’s latest attempt to repeal and replace Obamacare and explore the political motivations for pursuing the measure’s passage.

The New York Times: Senator Cassidy, Please Stop Lying About Health Care
Here’s a giveway about how bad the new Senate health care bill is: Bill Cassidy, one of its authors, keeps trying to sell it by telling untruths. “The relatively new phenomenon of just ‘up is down’ lying about your bill’s impacts is jarring,” says Loren Adler of the USC-Brookings-Schaeffer Initiative on Health Policy. Most egregiously, Cassidy is claiming that the bill would not ultimately deprive sick people of health insurance. That’s false, as NPR calmly explained when Cassidy said otherwise. (David Leonhardt, 9/21)

The Wall Street Journal: The Panic Over Graham-Cassidy
Senate Republicans must be making progress on their latest attempt to reform health care, because the opposition is again reaching jet-aircraft decibel levels of outrage. The debate could use a few facts—not least on the claims that the GOP is engaging in an unfair process. Republicans are scrambling to pass Lindsey Graham and Bill Cassidy’s health-care bill before Sept. 30, when the clock expires on the budget procedure that allows the Senate to pass legislation with 51 votes. The bill would devolve ObamaCare funding to the states, which could seek waivers from the feds to experiment within certain regulatory boundaries, and it also repeals the individual and employer mandates and medical-device tax. (9/21)

The New York Times: Cruelty, Incompetence And Lies
Graham-Cassidy, the health bill the Senate may vote on next week, is stunningly cruel. It’s also incompetently drafted: The bill’s sponsors clearly had no idea what they were doing when they put it together. Furthermore, their efforts to sell the bill involve obvious, blatant lies.Nonetheless, the bill could pass. And that says a lot about today’s Republican Party, none of it good. (Paul Krugman, 9/22)

The Washington Post: This Republican Health-Care Bill Is The Most Monstrous Yet
Motivated by the cynical aims of fulfilling a bumper-sticker campaign promise and lavishing tax cuts on the wealthy, Republicans are threatening to pass a health-care bill they know will make millions of Americans sicker and poorer. Do they think we don’t see what they’re doing? Does Sen. Charles E. Grassley (R-Iowa) think we didn’t hear what he said Wednesday? “You know, I could maybe give you 10 reasons why this bill shouldn’t be considered,” he told reporters. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.” (Eugene Robinson, 9/21)

The Wall Street Journal: The Graham-Cassidy Show Is Like ‘Jaws’—And You’re The Swimmer
If you’ve been following the congressional health-care “debate”—an overly kind word, to be sure—you may now be getting an eerie feeling. It’s sort of like “Jaws.” You thought it was safe to go back into the health-care waters. The poor and the powerless seemed to be out of harm’s way. Sens. Lamar Alexander (R., Tenn.) and Patty Murray (D., Wash.) were reporting progress on a bipartisan compromise. Then the Graham-Cassidy bill came out of nowhere, like a great white shark, accompanied by a bit of ominous music. (Alan S. Blinder, 9/21)

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

Money-Saving Offer For Medicare’s Late Enrollees Is Expiring. Can They Buy Time?

Many older Americans who have Affordable Care Act insurance policies are going to miss a Sept. 30 deadline to enroll in Medicare, and they need more time to make the change, advocates say.

A lifetime of late enrollment penalties typically await people who don’t sign up for Medicare Part B — which covers doctor visits and other outpatient services — when they first become eligible. That includes people who mistakenly thought that because they had insurance through the ACA marketplaces, they didn’t need to enroll in Medicare.

Medicare officials are offering to waive those penalties under a temporary rule change that began earlier this year, but the deal ends Sept. 30.

On Wednesday, more than 40 groups, including consumer health advocacy organizations and insurers, asked Medicare chief Seema Verma to extend the waiver deadline through at least Dec. 31, because they are worried that many people who could be helped still don’t know about it.

They also say more time is needed because of application delays at some Social Security Administration (SSA) local offices, where beneficiaries request the waiver.

“We know there are people who can still benefit from it,” said Stacy Sanders, the federal policy director at the Medicare Rights Center, a Washington-based advocacy group that coordinated the request to Medicare. “We know there have been delays, and those are good reasons to extend it.”

Counselors at the Medicare Rights Center have helped seniors apply for the waiver in Arizona, California, Florida, Minnesota, Missouri, New Jersey and New York, she said.

Since the marketplaces opened in 2014, the focus has been on getting people enrolled, Sanders added. “There’s no reason to expect that people would understand how to move out of the marketplace into Medicare.”

The waiver offer applies not only to people over 65 who have kept their marketplace plans, but also to younger people who qualify for Medicare through a disability and chose to use marketplace plans.

The waiver also allows Medicare beneficiaries who earlier realized their mistake in keeping a marketplace plan and have switched to ask for a reduction or elimination of the penalty.

In all cases, people had to be eligible for Medicare after April 1, 2013.

Officials at the Centers for Medicare & Medicaid, which runs Medicare, would not provide details about the number of waivers granted or pending applications. Nor would they comment on the likelihood of an extension.

Barbara Davis said that when she initially applied, a Social Security representative didn’t know about the waiver. She eventually contacted the Medicare Rights Center, where a counselor interceded on her behalf in June. A day later, a Social Security representative told her she would not have a penalty.

“My advice would be, find out your rights before you apply,” said Davis, 68, who lives with her husband in rural western New York. “Because they don’t seem to want to give you information to help you, you have to know this on your own.”

A Social Security spokeswoman said the agency is processing waiver applications from “across the country” but does not keep track of the number. She declined to comment on whether SSA employees know about the waiver.

Sanders suggested that people applying for the waiver ask Social Security officials for it by using its official name: “time-limited equitable relief.”

Since Medicare’s Part A hospitalization benefit is usually free, some seniors who liked their marketplace coverage thought — incorrectly — that they had nothing to lose by signing up for Part A and keeping their marketplace plan.

Some people receiving Social Security retirement or disability benefits opted to keep their marketplace plan and drop Part B after the Social Security Administration enrolled them automatically in Medicare when they became eligible.

If the temporary waiver expires, the only other way for beneficiaries to get an exemption is by proving they declined Part B because a government employee misinformed them.

The groups writing Verma argue that keeping the waiver in place past Sept. 30 could also help many beneficiaries who may be surprised by a little-known rule that will affect 2018 marketplace policies.

For the first time, insurers will be prohibited from issuing a marketplace plan if they know the member is eligible for Medicare and the 2018 policy is significantly different.

Those who find themselves without a marketplace plan could be in for another surprise: They won’t have insurance for outpatient care until July 1 because Medicare imposes a waiting period before Part B coverage kicks in for latecomers.

Extending the deadline “would lessen a significant hardship for many people … [who] are unaware of the repercussions that could result from keeping their marketplace coverage,” said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry group.

For information on how to apply for the time-limited equitable relief waiver, go to the Medicare Rights Center’s Medicare Interactive webpage or call the center’s helpline at 1-800-333-4114.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation and coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Aging, Cost and Quality, Insurance, Medicare, The Health Law

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Uncertainty Over Health Care’s Future Hobbles Entrepreneurs

Stinson Dean is used to taking risks. The entrepreneur from Independence, Mo., says coping with the ups and downs of the market is an inevitable part of his business.

But when he started his company about a year and a half ago, he laid down a firm rule.

“One of the things I wasn’t willing to risk was the health of my family,” Dean said.

Dean is the proud father of three young children — two girls and a boy. Playing with them in the front yard before dinner, he and his wife, Stephanie, talk about the possibility of another.

Like many Americans, Dean has nervously watched this year’s national health care debate. He credits the Affordable Care Act for making it possible to start his business, which involves buying Canadian lumber and selling it to U.S. lumberyards. Now, uncertainty about the ACA’s future affects his business’s potential for growth.

In May 2016, Stephanie was pregnant with their daughter Julie, and Dean was working as a commodities risk consultant.

A few months before a baby’s due date is typically not the time for a big career move, but it happened to mesh with a once-in-a-lifetime opportunity in the lumber market to buy low and sell high.

Encouraged by the availability of affordable insurance through the ACA, the family took the plunge. Dean left his job and started his company. The move paid off, as new construction boosted Dean’s business far beyond what he imagined.

He’s now ready to expand and bring on three or four new people, but there’s a problem.

“There’s a huge unknown with the ACA and what that’s going to look like,” Dean said.

President Trump and many members of Congress campaigned with promises to repeal and replace the Affordable Care Act, and they’ve spent much of this year attempting to do so.

That’s meant hardship for Dean. He’s having trouble persuading people with steady jobs and great benefits to take a chance and work for him.

Repeal-and-replace efforts are again alive in the Senate, and the president has threatened to withhold certain payments to insurers. That strain, on top of already unstable insurance markets, has led Dean to worry about whether decent insurance coverage will be available in the long run for him, his family and potential new employees

“What that’s doing for me is preventing me [from luring] folks who are in a similar situation to where I was — a nice corporate job, making good money, with great benefits, with kids — convincing them to leave that to come work for me with no benefits,” he said. “They’re going to have to go on the individual marketplace, on healthcare.gov, just like I did, and pick a plan.”

Exactly how the ACA has affected entrepreneurs and job growth remains unclear, said Dean Baker, co-director of the left-leaning Center for Economic and Policy Research, based in Washington, D.C. But there’s been a sharp increase in entrepreneurial activity since 2013, when the insurance marketplaces started.

Baker says the ACA has helped entrepreneurs by leveling the playing field in the competition for hiring talent. Before the health law, entrepreneurs had been at a disadvantage compared with larger businesses, who were more likely to be able to afford to offer insurance.

“Once [an entrepreneur’s] workers are able to get insurance through the exchange, much of that disadvantage goes away,” Baker said.

Baker said uncertainty is poison for any business, but all the questions about the ACA’s future have made 2017 especially toxic for entrepreneurs.

“For a lot of small businesses, they are sitting there with some trepidation, saying, ‘OK, how does this work out? Where are we a year from now? Where are we two years from now?’ And presumably, at least some of them are going to be putting their plans on hold,” Baker said.

That’s the case for Stinson Dean. He sees big opportunities opening in his field again, but he may not be able to take advantage of them, even if the ACA survives this year.

“What about 2019, 2020?” Dean said. “These are the questions I’m being asked by these folks I’m trying to recruit, and I don’t have an answer for them.”

This story is part of a reporting partnership with NPR, KCUR and Kaiser Health News.

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

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State Perspectives: Outlooks Are Not Rosy Regarding The On-The-Ground Impact Of The Current GOP Repeal Plan

Newspapers offer their members of Congress a bleak picture of what would happen in their states if the Graham-Cassidy proposal were to become law.

The Kansas City Star: No, Sen. Pat Roberts, This Awful Health Care Bill Isn’t The Only Obamacare Alternative
The Category 5 Hurricane known as Graham-Cassidy is a man-made disaster that may yet be avoided. But if you’re asking why even the craziest storm chaser wouldn’t steer clear of the direct hit that this latest health care bill would amount to, well, talk to our own Sen. Jerry Moran, who remains undecided. Or better yet, listen to his fellow Kansas Republican, Sen. Pat Roberts, whose explanation of this final attempt to blow up the Affordable Care Act is daft but highly instructional. (9/20)

The Des Moines Register: Senate’s Latest Health Bill Offers No Lifeline For Iowa
Gov. Kim Reynolds jumped aboard the latest Republican effort to repeal most of Obamacare as if it were the last lifeboat off the Titanic. “You know, this can work and I believe right now, this is the only vehicle we have to address Obamacare, that’s failing,” she said Tuesday. She was talking about legislation co-sponsored by Republican U.S. Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. The bill would put states in charge of designing their own health-care systems, with federal money from existing Obamacare taxes. Expansion of the federal program for low-income Americans, Medicaid, would end in 2020 and states would get block grants instead. (Kathie Obradovich, 9/20)

Lexington Herald Leader: Latest GOP Bill Greatest Threat To Ky. Health Care Coverage
The latest attempt to repeal the Affordable Care Act is known as Cassidy-Graham, and it very well may be the greatest threat to Kentucky’s health care. The state’s success in getting people coverage, and even health-care gains achieved decades ago, are at risk of being undone with this legislation. The bill, sponsored by Sens. Bill Cassidy and Lindsey Graham, is perhaps the final attempt at tearing up the ACA and doing permanent damage to Medicaid. It’s being rushed through before policymakers and the public can understand its implications. That’s because after Sept. 30, the Senate can no longer pass a partisan repeal bill with only 51 votes, due to chamber rules. (9/19)

Kansas City Star: Cassidy-Graham Health Care Bill Would Hurt Kansans
Now, in a last ditch effort to repeal the ACA by September 30, the end of the federal fiscal year, Congress is back with another destructive bill. Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina have introduced legislation that, like its failed predecessors, will result in coverage losses, higher costs, and elimination of consumer protections. (Sandy Praeger, 9/20)

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

Parsing The Policies: Is This Just Another ‘Lousy’ Bill Or Does It Advance A ‘Great Idea’?

Editorial pages offer a variety of ideas about the Graham-Cassidy bill now pending in the Senate, with some saying it’s “poison” and others praising its intent to give states flexibility.

Los Angeles Times: Graham-Cassidy: Another Day, Another Lousy GOP Healthcare Bill
The latest proposal — by Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.) — suffers from the same fundamental problems as all of its predecessors. Aiming to lower insurance costs for the healthy, it would allow states to herd people with preexisting conditions or potentially expensive risks — say, women who might want maternity coverage — into insurance gulags with egregiously high premiums. (9/21)

USA Today: Last-Ditch Obamacare Repeal Would Be Poison
Given up as a lost cause this summer, the Republican effort to repeal and replace Obamacare is back, this time in the form of a last-ditch effort led by GOP Sens. Lindsey Graham, Bill Cassidy, Dean Heller and Ron Johnson. Like previous efforts, this measure would strip tens of millions of people of their health coverage. It would gut Medicaid, the program responsible for funding nearly half of baby deliveries and most of nursing home care. It would allow insurers in some states to deny coverage based on a previous medical condition. And it would allow insurers to skip coverage of essential services, including maternity care. (9/20)

USA Today: Let States Tailor Health Care Plans
Under Obamacare, insurance premiums in the individual market have more than doubled nationally, and without billions of additional taxpayer dollars, many of those markets are at risk of collapse. Obamacare was never designed to be patient-friendly. In fact, one of the key tenets of Obamacare is taking power away from patients and local officials. Obamacare gives this decision-making power to the federal government, allowing bureaucrats to call the shots. (Sen. Ron Johnson, 9/20)

The New York Times: Graham-Cassidy Has One Great Idea
In the timid sense, the proposal would keep much more of Obamacare’s taxes and spending in place than previous Republican plans this year. Yet Graham-Cassidy makes more sweeping changes by turning money currently used on insurance subsidies and the Medicaid expansion into block grants to states. This change would give states more flexibility to design their own health care systems. (Philip Klein, 9/20)

The Washington Post: Cassidy-Graham Is Attractive In Theory. But It Has A Giant Flaw.
A group of Republican senators, led by Bill Cassidy (La.) and Lindsay O. Graham (S.C.), have revived GOP efforts to repeal and replace Obamacare. Their bill has a number of attractive attributes: It would repeal Obamacare’s individual mandate, for example, and make important reforms to Medicaid. But Cassidy-Graham also has an important, albeit fixable, flaw — what we might call “asymmetric federalism.” (Avik Roy, 9/20)

Los Angeles Times: The Disastrous Impact Of The GOP’s Obamacare Repeal Plan, In Three Devastating Charts
The healthcare consulting firm Avalere on Wednesday released the latest in a series of independent analyses of Senate Republicans’ new effort to repeal the Affordable Care Act. The findings are beyond ugly. They show devastating cuts in healthcare funding for adults, children and the disabled — in effect, almost every population category in the U.S. other than seniors enrolled in Medicare. (Michael Hiltzik, 9/20)

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

Political Reverberations: How Graham-Cassidy Impacts The Health Care Debate

Editorial pages feature opinions praising this “last-chance” legislation or calling it “nonsense” and “cynical.” They also detail how, regardless of the outcome of the vote planned for next week, the GOP will own it.

The Wall Street Journal: Republicans Get One Last Chance On ObamaCare Reform
For seven years Republicans promised to repeal ObamaCare, and now they have one last chance to deliver. A bill recently introduced by Sens. Lindsey Graham, Bill Cassidy, Dean Heller and Ron Johnson would eliminate some of ObamaCare’s most unpopular provisions and enact reforms that would lower costs, expand choices, promote federal fiscal responsibility, and give power back to states and consumers. … The Graham-Cassidy bill’s biggest strength is the idea that states are uniquely equipped to design and implement health care programs that suit their residents. The bill would consolidate much of the federal funding given to states under ObamaCare’s coverage provisions—including money for its Medicaid expansion and subsidies to help people buy private insurance—into a single block grant, which states could use for a wide variety of health reforms. (Lanhee J. Chen, 9/20)

JAMA Forum: Republicans Will Own Whatever Happens To The ACA And Health Care Reform
As has become clear, “Repeal and Replace” of the Affordable Car Act (ACA), a mantra that provided such a unifying theme for Republicans when Democrats controlled the White House, has been much harder than Republicans expected when they achieved “full control” of the government. Republicans were barely able to pass a health care bill in the House despite their substantial majority over Democrats (240-194) and the Senate fell short of passing the so-called “skinny” repeal bill, HR 1628, which repealed only a limited portion of the ACA. (Gail Wilensky, 9/19)

The Washington Post: Lots Of Vulnerable House Republicans Come From States That Will Lose Under Cassidy-Graham
If the Senate passes Cassidy-Graham, its latest attempt to repeal Obamacare, the legislation will then go to the House for a vote. If that happens, Speaker Paul D. Ryan (R-Wis.) has vowed to engineer its quick passage in the lower chamber, too …. certain states are going to be hit with major losses if this bill becomes law. And it turns out that those states that would lose out happen to be heavy with incumbent House Republicans whose seats are vulnerable in 2018. Will those vulnerable House Republicans vote for a bill that drains their states of huge sums of money that could have been used to cover their own constituents? (Sarah Posner and Greg Sargent, 9/20)

The Wall Street Journal: The Republicans Who May Save ObamaCare
Like Lazarus, the Republican effort to repeal ObamaCare has risen from the dead. Pundits dutifully filled out the toe tag in July, after a repeal-and-replace bill failed to pass the Senate. Now comes new legislation championed by Sens. Lindsey Graham and Bill Cassidy, which just might get the 50 GOP votes needed for Vice President Mike Pence to break the tie and pass the bill. … Senate passage would clear the way to ending the individual and employer mandates, repealing the medical-device tax, and phasing out the ObamaCare exchanges and their highly prescriptive regulations. … The danger is that there are at least four Republican senators at risk of voting “no.” (Karl Rove, 9/20)

Bloomberg: Republicans Peddle Nonsense To Sell Health-Care Plan
Graham and Cassidy have sold this hastily assembled measure as a bipartisan compromise that, rather than cutting coverage, merely gives the states the funds and flexibility to determine their own health-care policies. None of that holds up. The bill is purely partisan—it’s being rushed through for the simple reason that it lacks any Democratic support. Graham, in press conferences, has hailed the plan as a middle-ground compromise between Obamacare and the coverage-slashing Republican proposals that collapsed in July. That’s nonsense. (Albert R. Hunt, 9/20)

Boston Globe: Yet Another Cynical GOP Ploy On Health Care
The latest Republican vehicle for repealing and replacing Obamacare is Graham-Cassidy, a bill that would dramatically cut federal health care spending and block-grant remaining monies to the states while not requiring those states to spend the money on expanding care. (Micheal Cohen, 9/20)

Bloomberg: How The Health-Care Debate Would Change If Graham-Cassidy Passes
What a difference a week makes. Last week, many commentators (including me) saw the Graham-Cassidy bill as a bit of Hail Mary legislating, a last desperate stand against Obamacare. This week, it started to look as if it might actually have some chance of passage. The legislative math remains daunting; the parliamentary obstacles high. But the status of Republican health-care efforts has moved from “flatline” to “still breathing, barely.” (Megan McArdle, 9/20)

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

Podcast: ‘What The Health?’ Zombie Repeal-And-Replace Bill Rises Again

Republican efforts to “repeal and replace” the Affordable Care Act are back, in a big way. And the “What the Health” podcast is focused on Capitol Hill’s debate on the bill by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.):

  • The impact of shifting billions in federal funding to states.
  • Sizing up the implications for the four wavering Republican senators.
  • The demise of bipartisan attempts to fix Obamacare.
  • And does the measure pass the Jimmy Kimmel test?

The White House and Congressional Republican leaders are lining up behind the Graham-Cassidy bill that in many ways would even more broadly remake the nation’s health system than the proposals that failed to pass in July.

It is still far from certain the Senate can muster the 50 votes necessary before a Sept. 30 budget deadline, which ends their ability to pass such sweeping legislation with a simple majority. But the push is on.

Meanwhile, the unexpected effort to repeal Obamacare has pushed to the backburner two other key health issues with late September deadlines.

Republicans and Democrats at the Health, Education, Labor, and Pensions Committee have – for now – abandoned plans for a bipartisan bill to stabilize the individual health insurance market. Health insurers must make final decisions about whether to participate in Affordable Care Act by Sept. 27. And Congress seems likely to let the Children’s Health Insurance Program expire on Sept. 30, at least temporarily.

In this week’s episode of “What the Health?” Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, and Margot Sanger-Katz of the New York Times discuss all these issues. Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

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

Julie Rovner: Politico’s “Prices’s private-jet travel breaks precedent,” by Dan Diamond and Rachana Pradhan.

Joanne Kenen: HuffPost’s “The Week My Husband Left And My House Was Burgled I Secured A Grant To Begin The Project That Became BRCA1,” by Mary-Claire King.

Margot Sanger-Katz: Stat News’ “Every time it’s a battle: In excruciating pain, sickle cell patients are shunted aside,” by Sharon Begley.

To hear all our podcasts, click here.

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

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Thoughts On Graham-Cassidy: ‘Bad Idea’; ‘Shoddiest’ Repeal Idea Yet; ‘Ideological Crusade’

Opinion writers offer dim views of the current measure being advanced by Senate Republicans to undo the Affordable Care Act.

The Washington Post: Another Execrable Health-Care Bill Proves Bad Ideas Never Die
Over the next week and a half, Republican senators may try one last time to repeal and replace Obamacare. The latest bill, from Sens. Bill Cassidy (La.), Lindsey O. Graham (S.C.), Dean Heller (Nev.) and Ron Johnson (Wis.), is about as execrable as the others that GOP lawmakers previously failed to approve. The process by which Republicans would pass it would be as sloppy and partisan as the one to which senators such as John McCain (R-Ariz.) objected earlier in the summer. The outcome would be no less destructive. The big difference now is the clock; the procedural window for passing a health-care bill along straight party lines will disappear at the end of the month, spurring Republicans to try one last time. That is a sad excuse to rush through — without even an attempt at bipartisanship and without a complete Congressional Budget Office assessment — a half-baked bill that would harm millions. (9/19)

Bloomberg: The Latest Obamacare Repeal Is The Shoddiest Yet
The new version, sponsored by Senators Lindsey Graham of South Carolina and Bill Cassidy from Louisiana, would do a number of things to a health care system that millions rely upon. A main selling point is giving states additional ability to act on their own — which means that virtually all of the popular protections of the Affordable Care Act, including on pre-existing protections, would be at risk — and also slashing health care funding. What exactly would it do? It’s not much clearer than that now and won’t get much clearer until next month. The Congressional Budget Office has announced they “will not be able to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks.” (Jonathan Bernstein, 9/19)

USA Today: Obamacare Repeal Is An Ideological Crusade Past Its Sell-By Date. Give It Up, GOP
Just when Democrats thought it was safe to either stop paying attention or go full Don Quixote on Medicare For All, Obamacare repeal is back. When an entire political party has campaigned and won for seven years on getting rid of a law that was about as popular as President Trump (as in not very), it’s hard to move on. We get that. And who would have thought the country would change its collective mind, just when Republicans won control of the whole government? (Jill Lawrence, 9/19)

Bloomberg: Graham-Cassidy Is Already Hurting Health Care 
This last-gasp bill — called Graham-Cassidy after the senators leading it — would be extremely disruptive to hospitals and government-focused insurers. The proposal ends individual and employer insurance mandates, gives states a big chunk of money and then largely leaves them to run their own health-care markets. It would likely lead to large cuts to Medicaid, destabilize the individual insurance market, and significantly reduce insurance coverage. (Max Nisen, 9/19)

The Washington Post: The Graham-Cassidy Health-Care Bill Puts Millions Of Americans At Risk
The Senate is on the verge of launching a dangerous experiment. Having failed for months to repeal and replace the Affordable Care Act, Republicans hope to dump onto the states the problem of providing low- and moderate-income Americans with access to health care. So long as they are determined to push forward without meaningful Democratic input, they have until Sept. 30 to act under Senate rules. The Graham-Cassidy bill — their last chance to meet this deadline — would simply hand the states block grants and abandon to them millions of Americans whom the ACA now helps. (Timothy Jost, 9/19)

Los Angeles Times: Repeal And Replace Is Back, And Scarier Than Ever
Like the villain in a slasher movie, Senate Republicans keep coming for the health insurance of tens of millions of Americans. After Sen. John McCain’s dramatic “no” vote seemed to finish off this year’s attempts to repeal the Affordable Care Act, a proposal by two senators with mostly unearned reputations for moderation — Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) — represents the latest threat to the many people who gained access to healthcare under President Obama. The scariest part is that it might just pass. (Scott Lemieux, 9/19)

St. Louis Post-Dispatch: Last-Ditch Graham-Cassidy Health Care Bill Is The Worst One Yet
Under cover of a fog of news, Senate Republicans have been trying to round up enough votes for yet another bid to repeal and replace the Affordable Care Act. The bill they have in mind is in many ways worse than any of the three bills that failed this summer. After a dramatic thumbs-down “no” vote by Sen. John McCain, R-Ariz., killed the GOP’s third ACA replacement bill, Senate Majority Leader Mitch McConnell, R-Ky., said it was time to move on. Congress went into recess until after Labor Day, and the nation’s attention turned to hurricanes, immigration, budget matters and rapprochement between President Donald Trump and Democrats. (9/19)

The New York Times: John McCain Faces A New Test Of His Principles
It looks as if John McCain’s Senate colleagues are going to test him once again. And the health insurance of millions of Americans depends on the outcome. This summer, when his party was trying to force a health bill with unprecedented haste — no hearings, no support from medical experts — McCain stood up for the idea of the Senate. By now, you’ve probably heard a line or two from his July 25 speech, shortly after learning he had aggressive brain cancer. But the full speech is worth reading. It’s McCain at his best, a defense of the imperfect but noble pursuit of democratic politics. (David Leonhardt, 9/19)

Roll Call: The Fatal Flaw For Republicans In Graham-Cassidy
The Republicans’ latest drive to repeal Obamacare is reminiscent of a poetry fragment from Tennyson’s “The Charge of the Light Brigade”: “Theirs not to make reply, theirs not to reason why.” Whatever happens with the bill likely slated to reach the Senate floor next week, it is hard to escape the feeling that this wild charge will end badly for the Republicans. (Walter Shapiro, 9/20)

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

Last-Ditch GOP Effort To Replace ACA: 5 Things You Need To Know

Republican efforts in Congress to “repeal and replace” the federal Affordable Care Act are back from the dead. Again.

While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), along with Sens. Dean Heller (R-Nev.) and Ron Johnson (R-Wis.)

They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.

An earlier attempt to replace the ACA this summer fell just one vote short when Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska) and John McCain (R-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.

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After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes ­— which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.

Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.

“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.

Here are five things to know about the latest GOP bill: 

1. It would repeal most of the structure of the ACA.

The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.

It would eliminate the tax on medical devices. 

2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.

Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.

3. It would fundamentally restructure the Medicaid program.

Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.

The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill. 

4. It’s getting mixed reviews from the states.

Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich (R-Ohio) and Bill Walker (I-Alaska).

On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letter to Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.

Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”

5. The measure would come to the Senate floor with the most truncated process imaginable.

The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.

Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.

Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”

That has outraged Democrats, who are united in opposition to the measure.

“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.

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In Stark Contrast To ACA Plans, Premiums For Job-Based Coverage Show Modest Rise

Family health insurance premiums rose an average 3 percent this year for people getting coverage through the workplace, the sixth consecutive year of small increases, according to a study released Tuesday.

The average total cost of family premiums was $18,764 for 2017, according to a survey of employers by the Kaiser Family Foundation and the Health Research & Educational Trust. That cost is generally divided between the employer and workers. (Kaiser Health News is an editorially independent program of the foundation.)

While overall premium increases remain modest, workers are picking up a greater portion of the tab — this year $5,714 for family coverage, about a third of total cost.

Employer-provided coverage for a single person rose on average 4 percent, to $6,690. Those individuals pay $1,213 on average.

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Still, the employer market looks remarkably stable compared to the price increases seen in the Affordable Care Act’s insurance marketplaces for people who buy their own coverage. Premiums on those plans spiked on average about 20 percent this year, and many insurers dropped out because of financial concerns.

For all the media attention and political wrangling over the  Obamacare exchanges, their share of the market is relatively small. They provide coverage to 10 million Americans while 151 million Americans get health insurance through their employer.

The continued slow rise of employer health premiums identified in the Kaiser survey surprised some analysts who have expected the trend to end as the economy picked up steam, leading to a jump in use of health services and health costs.

Drew Altman, CEO of the Kaiser Family Foundation, said it’s “health care’s greatest mystery” why health insurance costs have continued their slow pace even as the economy has picked up the past few years. “We can’t explain it.”

Another unexpected result was that workers’ deductibles — the health bills that workers must pay before their insurance coverage kicks in — remained stable this year at $1,221. Since 2010, as companies sought to keep premiums in check, deductibles have nearly doubled. Higher deductibles can limit premium increases because costs are shifted to workers and it gives them greater incentive to cut spending.

“Increasing deductibles has been a main strategy of employers to keep premiums down and we will have to watch if this plateauing is a one time thing … or if this portends a sharper increase in premiums in future years,” said Altman. “It could be deductibles are reaching their natural limit or could be the tighter labor market” that’s causing employers to back off, he added.

Meanwhile, a second employer survey released Monday by Mercer, a benefits consulting firm, suggests a modest increase in health costs coming next year, too. Employers said they expect their health costs to increase by an average 4.3 percent in 2018, according to the survey.

To deal with higher medical costs — notably big increases in the prices of prescription drugs — employers are using multiple strategies, including continuing to shift more costs to workers and paying doctors and hospitals based on the value of the services rather than just quantity of services.

Jeff Levin-Scherz, a health policy expert with benefits consultant Willis Towers Watson, said there is a limit on how much employers can shift costs to their workers, particularly in a tight labor market. “Single-digit increases doesn’t mean health care costs are no longer a concern for employers,” he said.

The 19th annual Kaiser survey also found that the proportion of employers offering health coverage remained stable last year at 53 percent. But the numbers have fallen over the past two decades.

The survey highlights that the amount workers pay can vary dramatically by employer size. Workers in small firms — those with fewer than 200 employees — pay on average $1,550 more annually for family premiums than those at large firms. The gap occurs because small firms are much more likely than large ones to contribute the same dollar amount toward a worker’s health benefits whether they’re enrolled in individual or family coverage.

More than one-third of workers at small employers pay at least half the total premium, compared with 8 percent at large employers.

That’s the case at Gale Nurseries in Gwynedd Valley, Pa., where health insurance costs rose 7.5 percent this year. Its 25 workers are paying nearly half the cost of the premium — at least $45 a week for those who choose the base coverage plan offered through Aetna. Employees also have deductibles ranging from $1,000 to $2,500.

A decade ago, the nursery paid the full cost of the premium.

“It’s crazy — we keep paying more and getting less,” said comptroller Candy Koons.

At the Westport (Conn.) Weston Family YMCA, health insurance premiums rose about 7 percent this year, leaving its 50 full-time employees to pay a $156 premium for individual coverage.

“It’s not problematic, but it’s one of our bigger costs associated with payroll,” said Joe Query, the human resources director.

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Bemoaning Budget Cuts, Navigators Say Feds Don’t Appreciate Scope Of The Job

The Trump administration says many of the organizations that help people enroll in health plans on the federal insurance marketplaces don’t provide enough bang for the buck, sometimes costing thousands of dollars to sign up each customer. So, it is cutting their funding, some by as much as 90 percent, the government told the groups last week.

But the navigators, as they’re called, say the government doesn’t understand the time involved in the effort or the complexity of the enrollment challenge. Nor do federal officials appreciate the variety of tasks that navigators are asked to handle, they say.

Some customers don’t know how to use a computer. Many don’t understand insurance lingo — what’s a deductible, anyway? — or how to pick the best plan for their needs. Consumers get confused about estimating income and determining household size to qualify for premium tax credits that are available for people with incomes up to 400 percent of the poverty level (about $98,000 for a family of four). What if you’re self-employed and have no idea how many hours of work you’ll get next year? If Grandma is a dependent, does she count as part of the household? What about mixed immigrant families, in which one member is undocumented and ineligible for health insurance? These are the types of vexing questions navigators routinely field, they say.

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In addition to helping people sign up, navigators often assist them throughout the year as their income or job status changes and offer community outreach and education services. Marketplace coverage is complicated and so are people’s lives, they argue, and finding the right plan can be tough.

“You can decide on the best policy, but people come from so many different backgrounds and experiences that it’s impossible to have a policy that can be applied uniformly,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. The center has run a technical assistance project for navigators in recent years and produced an online guide that addresses frequently asked questions.

Sandy Dimick is program director for Get Covered Tennessee, part of Family and Children’s Service, the state’s primary navigator grant recipient. She said one of the common issues that navigators there deal with is helping self-employed people estimate their income for the coming year to know if they can qualify for federal subsidies to help pay for their premiums.

“We’re in Nashville, Music City, and lots of musicians are contract workers,” she said. “They think they qualify for subsidized coverage, but by the time they deduct their expenses they may be in the Medicaid gap because we didn’t expand Medicaid here.” She was referring to people whose incomes are below 100 percent of the poverty level, the minimum amount to qualify for marketplace premium tax credits, but earn too much to qualify for Medicaid.

Navigators can also be instrumental in helping clients save money on out-of-pocket costs, she said, because the federal health law offers cost-sharing reduction subsidies for people earning up to 250 percent of the federal poverty level (about $30,000 for an individual in 2018). The subsidies may bring their deductibles down to zero, potentially saving them thousands of dollars in out-of-pocket costs, Dimick said. But many marketplace customers don’t know about the subsidy and don’t realize it’s available only if they buy a silver plan on the marketplace. Unless these people work with a navigator, they may miss out because those who are financially strapped lean toward purchasing the slightly cheaper bronze plan that doesn’t qualify for cost-sharing reductions.

Dimick said her group will lose 15 percent in federal funding on its $1.6 million grant, about the amount they had anticipated.

Helping people understand how the marketplace coverage works is an ongoing challenge, said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, New York’s largest navigator program. New York runs its own marketplace, and Benjamin said she doesn’t expect a funding cut.

“People are still struggling with the metal levels,” Benjamin said, referring to the bronze, silver, gold and platinum plan types offered on the marketplaces that pay from 60 to 90 percent of covered medical expenses. “They don’t understand that if they have premium tax credits and cost-sharing reductions they shouldn’t just lurch to the lowest-cost bronze plan.”

Erinn Garrison, a navigator in Ohio, sometimes travels to meet people at coffee shops or churches in the rural portions of the state.

“A lot of the people I work with have limited technological capability,” said Garrison, the health initiatives manager at the Ohio Association of Foodbanks in Columbus, which leads a statewide consortium of navigators. “They can’t work on a computer.”

The group’s navigator funding was cut by 71 percent for the coming year, to $485,967.

The Trump administration is taking a hard line, it says, because the navigator groups have not shown that they are providing good value. Last year, the groups received $62.5 million and enrolled 81,426 individuals. The administration said the new funding formula is based on how well each group did toward meeting its 2017 enrollment goal, but many navigator groups say there doesn’t appear to be a correlation.

The federal Centers for Medicare & Medicaid Services, which oversees the federal marketplaces, has a toll-free call center. When asked if it plans to increase staffing or undertake other enrollment activities this year, officials said, “CMS will continue to operate our year-round exchange call center to assist consumers with enrollment and as in past years we will ramp up staffing to support the higher call volume anticipated during open enrollment.”

If navigators are thin on the ground this fall, people can opt to sign up directly with insurers or brokers. The federal government plans to launch a “help on demand” tool on healthcare.gov that will connect consumers directly with agents and brokers, according to a blog post on the Health Affairs website by Timothy Jost, an emeritus professor at Washington and Lee University in Virginia and an expert on the health law. But advocates have expressed concerns that consumers may not get impartial advice from vendors who receive sales commissions for specific insurance products.

In addition to healthcare.gov, some groups have published detailed information aimed at navigators that may help intrepid consumers get answers to enrollment questions. The Georgetown navigator guide is available online, as is information from the Center on Budget and Policy Priorities.

The published CBPP information may be helpful to some individuals, but it’s not a substitute for navigators who help people one-on-one, said Judith Solomon, the center’s vice president for health policy. “It’s not boots on the ground,” she said.

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

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Different Takes: What To Do With CHIP; Deal With Threats To Obamacare Before Single Payer

News outlets examine a variety of pressing health policy issues, ranging from the reauthorization of the Children’s Health Insurance Program to what’s next for the Affordable Care Act.

Forbes: Children’s Health Insurance Program Demands Quick, Bipartisan Passage
CHIP was a shared vision of Republicans and Democrats alike. It seems like ancient history now, but, in 1997, I joined with members from both sides of the aisle to debate health care policy forcefully but productively. Led by Senators Ted Kennedy (D-MA) and Orrin Hatch (R-UT), we crafted the CHIP language. Bipartisan action, so crucial to the health of the country and the economy, was never more important than when it came to insuring America’s children. Now, two decades later, that progress is in jeopardy. CHIP is set to expire on September 30. (Bill Frist, 9/14)

National Review: Continue To Fund Children’s Health Care, But Coordinate The Programs Better
CHIP, which helps states provide health-care coverage to low-income kids, is better structured than Medicaid to ensure that funds are targeted to those who need assistance most. Now, after the Affordable Care Act has created an entitlement to subsidized coverage through the exchange, CHIP-eligible families are often torn between two programs that fit together poorly. If a few minor flaws in its design are fixed, however, CHIP can fill a gap and enhance the rest of America’s health-care safety net. (Chris Pope, 9/18)

The Washington Post: Before Tackling Single-Payer, Save Obamacare
Before supporters of universal health coverage get all wrapped up debating a single-payer system, they need to focus on a dire threat to the Affordable Care Act likely to come up for a vote in the Senate before the end of the month. The latest repeal bill is an offering from Republican Sens. Lindsey O. Graham (S.C.) and Bill Cassidy (La.) that would tear apart the existing system and replace it with block grants to the states. Block grants — flows of money for broad purposes with few strings attached — are a patented way to evade hard policy choices. All the tough decisions are kicked down to state capitals, usually with too little money to achieve the ends the block grant is supposed to realize. (E.J. Dionne, 9/17)

The New York Times: Complacency Could Kill Health Care
I haven’t yet read Hillary Clinton’s “What Happened,” but it seems pretty clear to me what did, in fact, happen in 2016. These days, America starts from a baseline of extreme tribalism: 47 or 48 percent of the electorate will vote for any Republican, no matter how terrible, and against any Democrat, no matter how good. This means, in turn, that small things — journalists acting like mean kids in high school, ganging up on candidates they consider uncool, events that suggest fresh scandal even when there’s nothing there — can tip the balance in favor of even the worst candidate imaginable. (Paul Krugman, 9/18)

Baltimore Sun: Medicaid Cuts Shift Burdens To States
Thanks to massive grassroots mobilization efforts, our state narrowly averted disaster when Congress failed to pass any version of Affordable Care Act (ACA) repeal that would have restructured Medicaid and left thousands of my constituents without health care coverage. Stopping health care repeal was a huge victory, but the fight is not over yet. Even deeper cuts to Medicaid have been proposed in the 2018 budget resolution, which would slash health care by $1.5 trillion over the next 10 years to pay for billions in tax breaks to the rich and corporations over that same period. (Rep. C.A. “Dutch” Ruppersberger, 9/17)

The New York Times: The Best Health Care System In The World: Which One Would You Pick?
“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats. This is often accompanied by calls to match the health care coverage of “the rest of the world.” But this overlooks a crucial fact: The “rest of the world” is not all alike. The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between. (Aaron E. Carroll and Austin Frakt, 9/18)

The Washington Post: A Century Ago, Women Fought For Access To Contraception. The Trump Administration Threatens To Undo Their Work.
Trump administration officials vow that they are going to take care of the health of moms and babies. But their pledge to cut funding to Planned Parenthood promises to do the opposite. The proposed cuts have focused not just on the procedure of legal abortion (which is, of course, another column), but also on eliminating access to contraceptives. These proposals ignore a fundamental truth: Access to birth control is central to women’s health. In fact, it always has been. (Lauren MacIvor Thompson, 9/15)

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

Ohio House Speaker Surveys Colleagues About Overriding Kasich’s Medicaid Expansion

Last summer, Ohio Gov. John Kasich vetoed the part of the state’s budget bill that would have frozen Medicaid expansion enrollment. Republicans in the House threatened to try to override the veto in July but eventually did not take a vote. Also in Medicaid news, Pennsylvania’s governor says that a cash shortfall is causing Medicaid payments to insurance companies to go out late.

The Associated Press: Ohio House Considers Overriding Gov. Kasich’s Medicaid Expansion Veto
The Ohio House is again weighing an override of Republican Gov. John Kasich’s veto protecting Medicaid expansion after scrapping the idea in July. A memo circulating among House Republicans said GOP Speaker Cliff Rosenberger “would just like to see” where his caucus members stand now that efforts to repeal the federal health care law in Washington appear indefinitely stalled. (9/17)

The Philadelphia Inquirer/Philly.com: With Budget Impasse, Gov. Wolf Delays More Than $1B In Medicaid Payments
With the state’s cash running low, Gov. [Tom] Wolf on Friday said he was forced to withhold nearly $1.2 billion in payments to Medicaid program providers. In a short statement, the governor said his administration will be unable for at least a week to make the payments to managed care organizations, the private health insurers that cover many of the state’s neediest children, elderly, and disabled residents. Insurance industry officials said Wolf’s move is unlikely to interrupt services for Medicaid recipients but could affect the business side. (Navratil and Couloumbis, 9/15)

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

Without Price Breaks, Rural Hospitals Struggle To Stock Costly, Lifesaving Drugs

MOUNTAIN VIEW, Ark. — Hospital pharmacist Mandy Langston remembers when Lulabelle Berry arrived at Stone County Medical Center’s emergency department last year.

Berry couldn’t talk. Her face was drooping on one side. Her eyes couldn’t focus.

“She was basically unresponsive,” Langston recalls.

Berry, 78, was having a severe ischemic stroke. Each passing second made brain damage more likely. So, Langston reached for the clot-busting drug Activase, which must be given within a few hours to work.

“If we don’t keep this drug [in stock], people will die,” Langston said.

Berry survived. But Langston fears others could die because of an unintended bias against rural hospitals built into the U.S. health law. An obscure Obamacare provision forces rural hospitals like Langston’s to pay full price for drugs that many bigger hospitals buy at deeply discounted rates.

For example, Langston’s 25-bed hospital pays $8,010 for a single dose of Activase — up nearly 200 percent from $2,708 a decade ago. Yet, just 36 miles down the road, a bigger regional hospital gets an 80 percent discount on the same drug.

White River Medical Center, a 235-bed facility in Batesville, Ark., buys Activase for about $1,600 per dose. White River participates in a federal drug discount program Congress approved in the early 1990s. The program offers significant price breaks on thousands of drugs to hospitals that primarily serve low-income patients. One federal report found the average discount ranged from 20 to 50 percent, though as illustrated with Activase, it can be much higher.

Rural hospitals have long wanted to be part of the so-called 340B program, too, but were blocked from participating until the Affordable Care Act of 2010. That historic health law added rural hospitals to the overall program. But, unlike bigger hospitals, rural hospitals can’t get discounts on expensive drugs that treat rare diseases because of a last-minute exclusion written into the ACA.

That seemingly minor detail in the law has left rural hospital pharmacists and health care workers struggling to keep medicines in stock, and wondering if they will be able to adequately care for patients.

Arkansas, for example, is in the “stroke belt,” where medical staff depend on Activase to help them battle one of the highest rates of stroke deaths in the country. When Langston went to restock Activase this year, it was so expensive she left a reorder unfilled for more than week, anxiously keeping only one dose of the clot-busting drug on hand.

“Usually strokes come in clusters,” Langston said. “I didn’t want two people to come in and we were going to [have to] choose which one we were going to treat.”

In Atlantic, Iowa, pharmacy director Crystal Starlin sparingly stocks oncology drugs at Cass County Memorial Hospital. Newly diagnosed cancer patients might have to wait a couple of days to start treatment.

“We just can’t keep the extra [drugs] on hand,” Starlin said.

In Vermont, North Country Hospital closed its infusion center this spring due to the soaring cost of medicines.

“That was one area we could not afford to be in,” said chief executive Claudio Fort. North Country is the only hospital in a two-county region along the Canadian border and its roughly dozen active chemotherapy patients now must drive 45 minutes away for treatment.

The rare-disease exclusion was not publicly debated before being added into the ACA. Rather, it was tucked into the law at the very end of the process. How it wound up in the law is a bit of a mystery.

Former PhRMA chief executive Billy Tauzin said he doesn’t recall negotiating the exclusion. But, he said, the industry has consistently raised concerns about the drug discount program’s reach.

“It’s a question of how deeply you can afford to discount drugs that are expensive,” said Tauzin, who abruptly stepped down just before the ACA passed.

After the health law passed, PhRMA battled for years — in federal court — to keep rural hospitals from getting discounts on rare-disease drugs.

Congressman Peter Welch, a Democrat from Vermont who represents North Country, said it is clear whom the law hurts and helps.

“The pharma lobbyists pay attention, and their lawyers pay attention to the fine print,” Welch said. The pharmaceutical industry changes that fine print … [and] many legislators don’t even realize [that it] will have this adverse impact on hospitals in their communities.”

The rare-disease exclusion means that certain types of hospitals — including critical access, sole community and rural referral centers — cannot get discounts on rare-disease drugs, or on drugs that are “designated” to treat a rare disease. (Rare-disease drugs are also known as orphan drugs, which is a federally approved category of drugs that treat a disease affecting fewer than 200,000 people. Often, they carry price tags of up to $100,000 a year or more.)

The Food and Drug Administration gives the designation as a first step when it agrees with a drugmaker’s request to study whether a drug can be used to treat a specific rare disease. This can happen even if a drug is already FDA-approved and on the market for use in treating a common condition. The next step — the ability to market the medicine as an orphan drug — comes once research confirms that the drug is safe and effective in treating a specific, less common condition.

The popular clot-buster Activase has not won final approval to treat a rare disease but, on two separate occasions in 2003 and 2014, the FDA has given it the orphan designation while research is ongoing.

About 450 orphan drugs have been approved by the FDA. But thousands of drugs are “designated” and more are identified every week.

The list includes generic drugs such as the hormone melatonin and the autoimmune drug abatacept. In other words, medicines used to treat everything from sleep troubles to arthritis have ended up “designated.”

The small town of Mountain View, Ark., known for its crafts and music scene, is about two hours north of Little Rock and nestled in the rolling Ozarks. Arkansas’ mountainous terrain makes it essential for local hospitals to stock lifesaving stroke drugs. The state reports some of the nation’s highest rates of stroke deaths. (Sarah Jane Tribble/KHN)

Some drugmakers, such as Janssen Pharmaceuticals, have voluntarily offered discounts to rural hospitals on all of their orphan drugs including Remicade, whether they’re approved or designated. In contrast, drugmaker Genentech sent letters to rural hospitals on Jan. 1 listing dozens of drugs that would not qualify for discounts, including Activase and cancer drug Avastin.

Susan Willson, a Genentech spokeswoman, said the company is “deeply committed to ensuring that people have access to the medicines they need.” But, she added, the company believes the federal drug discount program has “grown well beyond its original intent.”

Several federal reports in recent years from the Medicare advisory board, as well as the Government Accountability Office and the Office of Inspector General, have evaluated the federal drug discount program’s growth. About 40 percent of U.S. hospitals now participate in the program and House Republicans held a hearing this summer questioning the program’s growth.

But for Dana Smith, director of pharmacy at Dallas County Medical Center in Fordyce, Ark., the discount program’s growth and problems are a separate issue.

“Basically, Genentech is saying to me that rural health care and the patients in rural America are not as important as patients in urban areas,” Smith said, adding the pharmaceutical industry “knows we have less manpower to fight them.”

Back at Stone County, emergency room medical director Dr. Barry Pierce paused one recent afternoon at the nursing station and recalled those tense days with just one dose of Activase. Stone County now keeps two doses of the stroke drug on hand.

Pierce noted that Stone County is at least 45 minutes away from the next nearest hospital and, echoing Langston’s concern, he said: “If we don’t have the drugs we need, people will die.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

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

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Different Takes: Sanders And Single-Payer; One Last Try On Obamacare Repeal; Building On Victory

Opinion writers across the country examine the health proposal offered by Sen. Bernie Sanders (I-Vt.), where things stand for congressional Democrats and Republicans, how the Trump administration is quietly moving against the Affordable Care Act and why it’s time for politicians to get real.

The Washington Post: The Biggest Thing Single-Payer Has Going For It
The smartest, savviest people in Washington will tell you Bernie Sanders’s “Medicare for all” idea is dead on arrival, a waste of time and energy. But since those same smart, savvy people told you Donald Trump didn’t have a prayer of becoming president, I’d advise keeping an open mind. What the Vermont senator’s bill has going for it is simple: It’s the right thing to do. (Eugene Robinson, 9/14)

The Wall Street Journal: One Last ObamaCare Try
Senator Lindsey Graham admits that when a defense specialist like him feels compelled to roll out a health-care bill, something has gone wrong—and that’s an understatement for the Republican failure to repeal the Affordable Care Act. The question is whether a last-ditch effort by Sen. Graham and a few colleagues represents an improvement over the Obama Care status quo. The answer is yes. (9/14)

Bloomberg: Democrats Can Build On Their Health-Care Victory
The Republicans’ failure to repeal Obamacare has created a political opening. The American public, threatened with the withdrawal of health insurance from millions of people, has largely come to embrace the idea of universal coverage. At such a moment, Democrats are right to advance ideas for building on the gains accomplished by the Affordable Care Act. (9/14)

The Washington Post: How Trump Is Sabotaging The Affordable Care Act In Virginia
Since President Trump took office, he and his administration have expressed their intention to sabotage the Affordable Care Act by creating instability in state insurance markets. As governors and other leaders across the nation warned, the Trump administration’s actions could threaten the health care and indeed the lives of millions of people across our nation. Unfortunately, here in Virginia, we have seen many of those fears come to fruition. (Gov. Terry McAuliffe, 9/14)

The New York Times: Bernie’s Secret G.O.P. Allies
Bernie Sanders’s biggest ally in his push for single-payer health insurance may well be the Republican Party. Yes, Republicans criticized and mocked the “Medicare for all” bill that Sanders released yesterday, and I doubt any Congressional Republicans will support the bill in the foreseeable future. But I do think they are unwittingly helping his cause. (David Leonhardt, 9/14)

The Washington Post: Sanderscare Is All Cheap Politics And Magic Math
But the lesson the Democrats seem to have taken from the 2016 electoral trouncing is that they need to become more like Republicans. Meaning: Abandon thoughtful, detail-oriented bean-counting and attempts to come up with workable solutions grounded in (occasionally unpopular) reality, and instead chant virtue-signaling catchphrases. (Rampell, 9/14)

Milwaukee Journal Sentinel: The Magical Mystery Of Medicare For All
It’s admirable to stand up for what you believe and to try to persuade voters that the nation would be better off with single payer, a $15-an-hour minimum wage and free college. There are reasonable arguments for all three. But all three are political losers outside the liberal base — at least right now. (David D. Haynes, 9/14)

The Guardian: Universal Healthcare In America? Not A Taboo Now, Thanks To Bernie Sanders
Once radical and taboo in mainstream Democratic circles, endorsing universal healthcare coverage is now de rigueur for anyone who seriously wants to run for president on the Democratic side in 2020. Kamala Harris, the California senator who seemed to be taking the Clinton route to the nomination by courting her Hamptons donors, is now co-sponsoring Sanders’ Medicare for All bill. (Ross Barkan, 9/14)

The Charlotte Observer: Medicare For All? First, Some Big Questions
The United States has long needed a real debate about the possibility of the kind of universal healthcare system that has led to some better outcomes in other developed countries. Sen. Bernie Sanders effectively kicked off that debate Wednesday by revealing a “Medicare for All” plan, backed by 15 Democratic Senate colleagues. (9/14)

The New York Times: Politicians, Promises, And Getting Real
On Wednesday Donald Trump demanded that Congress move quickly to enact his tax reform plan. But so far he has not, in fact, offered any such plan. Not only is there no detailed legislative proposal, his administration hasn’t even settled on the basic outlines of what it wants. Meanwhile, 17 Senate Democrats — more than a third of the caucus — have signed on to Bernie Sanders’s call for expanding Medicare to cover the whole population. So far, however, Sanders hasn’t produced either an estimate of how much that would cost or a specific proposal about how to pay for it. I don’t mean to suggest that these cases are comparable: The distinctive Trumpian mix of ignorance and fraudulence has no counterpart among Democrats. Still, both stories raise the question of how much, if at all, policy clarity matters for politicians’ ability to win elections and, maybe more important, to govern. (Paul Krugman, 9/15)

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

Policy Points: Three GOP Senators ‘Bedside Miracle;’ Immigration As A Public Health Issue

Columnists offer their opinions on a range of health policy topics, including the Obamacare alternative being advanced by Sens. Lindsay Graham (R-S.C.), Bill Cassidy (R-La.) and Dean Heller (R-Nev.), the impact of immigration policy and how to make sense of issues during the upcoming open enrollment period.

Bloomberg: The Latest (Dim, Distant) Hope For Health-Care Reform
Health-care reform is like one of those ill people in a Victorian novel. They are pronounced close to death, with no possibility of a cure … and then they linger on for hundreds of pages of breathless plotting, while the reader wonders: “Is this it? Could they possibly live after all that suffering?” The latest bedside miracle is the Graham-Cassidy-Heller proposal, which would cut spending, cap spending, and shift spending away from states that expanded Medicaid to those that haven’t. (Megan McArdle, 9/13)

WBUR: Trump’s Aggressive Immigration Policies Have Created A Public Health Disaster
We are seeing only the tip of the iceberg of public health disasters stemming from the Trump administration’s aggressive detention and deportation policies. Lower birth weights have been reported in Latina mothers affected by immigration raids, and a spike in adverse mental health symptoms has been reported in many immigrant communities. (Dr. Sondra S. Crosby, Gilbert E. Benavidez and J. Astrian Horsburgh, 9/14)  

Los Angeles Times: Making Sense Of Covered California And Medicare During Open Enrollment
It’s that time of year when we all have to start thinking about health insurance plans and options. Not only do I need to figure out if my current plan will be offered again next year, and with what changes, but my husband is over 65, so I also have to research the latest Medicare plans as well. As a columnist, research is my thing, but this insurance stuff makes my head spin. (Barbara Venezia, 9/13)

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

Arizona High Court To Hear GOP Lawmakers’ Suit Challenging Expansion Of Medicaid

The legislators filed suit in 2013 seeking to stop then Gov. Jan Brewer’s decision to expand Medicaid under the federal health law. In other Medicaid news, Iowa officials are considering moving people with serious disabilities out of the state’s new managed care plan and a federal judge dismissed a lawsuit seeking to move more people out of nursing homes in Washington, D.C.

Des Moines Register: Disabled Iowans Could Be Exempted From Private Medicaid Management
Iowa might resume direct oversight of care for people with serious disabilities instead of having private Medicaid-management companies continue doing it, the state’s human-services director said Wednesday. Many of the most serious complaints about Iowa’s privatized Medicaid system have come from disabled Iowans and their families. Numerous families have reported having their services cut and their hassles multiplied by the management companies. Their plight has sparked a federal lawsuit against the state. (Leys, 9/13)

The Washington Post: Nursing Home Residents Lose Class-Action Suit To Secure Community-Based Services
A U.S. district court judge on Wednesday dismissed a class-action lawsuit that alleged that the District failed to comply with a federal mandate to move eligible and interested Medicaid recipients out of nursing homes and into the community. U.S. District Judge Ellen Segal Huvelle ruled that a single injunction could not remedy the problems experienced by the elderly and disabled nursing home residents because barriers to moving them back into the community extended beyond the system’s shortfalls with transition services. (Chandler, 9/13)

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Podcast: ‘What The Health?’ Health Plans Busting Out All Over

In a busy health week for Congress, Republicans and Democrats on the Senate Finance Committee agreed on a proposal to fund the Children’s Health Insurance Program for five more years, while Republicans and Democrats at the Health, Education, Labor and Pensions Committee continued to pursue a joint plan to stabilize the individual health insurance market.

Meanwhile, a growing group of Democrats, led by liberal standard-bearer Sen. Bernie Sanders (I-Vt.), unveiled a “Medicare for All” single-payer health care bill. But the apparent groundswell of support could overstate what might happen when details come out and people see who wins and loses. And Republicans continue to pursue one last-ditch effort to pass a bill to “repeal and replace” the Affordable Care Act in the Senate under rules that let the bill pass with a simple majority.

In this week’s episode of “What the Health?” Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Stephanie Armour of The Wall Street Journal discuss all these issues. Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: The New York Times’ “How Single-Payer Health Care Could Trip Up Democrats,” by Margot Sanger-Katz.

Joanne Kenen: Reuters’ “Doctors who take pharmaceutical money use Twitter to hype drugs,” by Ronnie Cohen.

Margot Sanger-Katz: Vox’s “Once Obamacare repeal is dead, the GOP has no Plan B,” by Dylan Scott.

Stephanie Armour: Vox’s “Single-payer isn’t the only progressive option on health care,” by Ron Pollack.

To hear all our podcasts, click here.

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

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Viewpoints: At HHS, ‘Waste Scores A Victory’; Home Care Costs; Misreading The Opioid Crisis

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

The Washington Post: Tom Price Decides He Doesn’t Want Medicare To Save Money
The coming crisis is as predictable as it is worrying. Nearly a fifth of every dollar spent in this country is spent on health care. Without reform, that number will only rise as the baby boomers retire. Younger generations will suffer, as money is taken from building roads and educating children to paying for Medicare to cover boomers’ health costs. … Yet waste scored a victory when Health and Human Services Secretary Tom Price decided to stop or scale back “bundled payment” experiments the Obama administration had begun. (9/12)

The Wall Street Journal: Why Home Care Costs Too Much
As baby boomers age into long-term care facilities, Medicaid costs will go through the roof. Americans already spend—counting both public and private money—more than $310 billion a year on long-term support services, excluding medical care, for the elderly and the disabled. Medicaid accounts for about 50% of that, according to a 2015 report from the Kaiser Commission on Medicaid and the Uninsured. Other public programs cover an additional 20%. … There’s an urgent need to find ways of providing good long-term care at a lower cost. One fix would be to deregulate important aspects of home care. (Paul Osterman, 9/12)

The Wall Street Journal: The Way We Pay Doctors Is Hurting Health Care
For several decades, specialists in the U.S. have been paid considerably more than primary-care physicians. On average, orthopedic surgeons, cardiologists, radiologists and plastic surgeons make about twice as much as internists, pediatricians and family medicine doctors. True, most specialists train for a longer period of time than primary-care providers, but the degree of divergence in compensation has little to do with market forces or input costs. The difference has consistently been tied to how we pay for care with our emphasis on volume, procedures and technology, rather than prevention, care coordination, evaluation expertise and outcomes. (Howard Forman, 9/12)

Los Angeles Times: The Great Medi-Cal Paper Waste
Remember the telephone book? That giant, multi-thousand-page behemoth that used to land on your doorstep once a year? Well, neither do we, barely. The heyday of the phone book is long gone, and yet communications with friends and businesses is easier than it’s ever been before. Can it be that California officials haven’t noticed that? A new federal rule that took effect in July allows health insurance plans to stop automatically printing and mailing lengthy Medi-Cal provider directories, some of which are the size of phone books, to all new enrollees and make the information available digitally. Anyone without online access or who preferred having a hard copy could still request one. (9/12)

The Washington Post: Poor, Middle Class Saw Solid Gains Last Year, But We’ll Need Better Policy To Keep It Going
Poverty fell, middle-class incomes rose, and the share of Americans without health coverage ticked down to a historical low last year, according to data released Tuesday morning by the Census Bureau. This trifecta of gains for poor and middle-income households, as well as the uninsured, shows that the seven-year expansion, along with the Affordable Care Act, has continued to lift the living standards of many American households. However, last year’s gains were even stronger for those at the top of the income scale, suggesting that the inequality of economic outcomes continues to grow in America. (Jared Bernstein, 9/12)

The Washington Post: The Media Gets The Opioid Crisis Wrong. Here Is The Truth.
Lawmakers and the media have devoted much of their attention recently to deaths from opioid overdoses, as well as to the broader “deaths of despair” that include suicides and deaths from alcoholic liver disease and cirrhosis. But despite the intense focus on the topic, misinformation about the epidemic runs rampant. By conventional wisdom, tackling this crisis would require extending Medicaid and improving how it functions, cracking down on prescription painkillers and getting more health-care resources into rural communities. (Anne Case and Angus Deaton, 9/12)

San Antonio Press-Express: ‘Bad Paper’ Denying Vets Needed Services
Like [Mike] Gerardo, thousands are discharged from the military though the behaviors that got them this attention are service connected. Suffering from PTSD, for instance, often means self-medicating with drugs and alcohol. These service members are deemed problems and are discharged without being provided the services other “wounded” vets are accorded. (9/12)

WBUR: How To Talk To Your College-Age Kids About Depression And Suicide
School’s back in session, and parents ushering kids to college for the first time will undoubtedly deliver some emotional nuggets of advice. But they should also have a potentially life-saving talk with their kids in the first semester of college to avert a possible tragedy — suicide. (Nancy Rappaport, 9/13)

The New York Times: The Nazis’ First Victims Were The Disabled
I sit facing the young German neurologist, across a small table in a theater in Hamburg, Germany. I’m here giving one-on-one talks called “The Unenhanced: What Has Happened to Those Deemed ‘Unfit’,” about my research on Aktion T4, the Nazi “euthanasia” program to exterminate the disabled. “I’m afraid of what you’re going to tell me,” the neurologist says. (Kenny Fries, 9/13)

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