Tagged Trump Administration

Must-Reads Of The Week From Brianna Labuskes

We’re barreling toward November, folks. (How is it mid-October already?) As you might expect, election stories made up the bulk of the health care news this week. Other great gems and intriguing developments surfaced, though, so let’s get right to it.

Republicans on the campaign trail have been hammered by attack ads over their stance on the health law, with “preexisting conditions protections” — insurance safeguards for patients diagnosed with chronic illness — becoming a catch-all phrase for the most popular parts of the Affordable Care Act. Even the law’s most vocal opponents have been reading tea leaves and softening their stances. That’s why statements from GOP leadership this week that Congress could revisit their “repeal” fight post-midterms may have landed with a thunk.

The New York Times: Republican Candidates Soften Tone on Health Care As Their Leaders Dig In

The Washington Post: Trump Says ‘All Republicans’ Back Protections for Preexisting Conditions, Despite Repeated Attempts to Repeal Obamacare

Democrats are pulling out a tried-and-true talking point that seemed perfectly timed for them as news of the federal deficit reignited Republican talk about cutting entitlement programs. Dems (who have been playing defense over Medicare) seized the opportunity to accuse Republicans of putting the beloved program on the chopping block.

The Associated Press: Dems Shift Line of Attack, Warning of GOP Threat to Medicare

As the parties duke it out on the trail, voters seem to agree on one thing: Our health care system is broken and someone needs to fix it. “It’s crippling people. It’s crippling me,” one voter says in Politico’s deep read that takes us to a Pennsylvania county where the “margins of electoral victories traditionally are as slim as the spectrum of political opinion is vast.”

Politico Magazine: The Great American Health Care Panic

On the state level, a Missouri Democrat opposed to abortion struggles to find her place in the party. And Georgia becomes a preview of the growing political clout of home health aides.

The New York Times: Is It Possible to Be an Anti-Abortion Democrat? One Woman Tried to Find Out

Politico: Home Health Aides Test Political Clout in Georgia Governor’s Race


The Trump administration this week proposed a requirement that pharma add drug prices to TV ads — triggering skepticism. One problem is that ad prices wouldn’t reflect what most people end up paying for a drug at the pharmacy counter.

Politico: Trump Set to Force Drugmakers to Post Prices in Ads

What I found surprising, considering how common those ads are, is that just a few dozen drugmakers run any at all — nearly half are put out by five companies. Those manufacturers would bear the brunt of the new rules.

Stat: Five Drug Makers Will Be Hit Hardest By Trump’s New Proposal on Drug Ads

Trying to think outside the box to rein in high drug prices, several states are considering treating pharma as they would a public utility — with rate-setting bodies to review, approve or adjust medication prices.

Stat: A Growing Number of States Consider Legislation to Treat Pharma As a Utility

And keep an eye on this battle: Minnesota became the first state to sue drugmakers over the price of insulin, but I don’t think it will be the last. The “life-or-death” drug has gotten a lot of attention recently, synthesizing the human toll of high costs into a digestible talking point.

Stat: Minnesota Becomes First State to Sue Major Insulin Makers Over Price-Gouging


Another 4,100 Arkansas beneficiaries were dropped from the state’s Medicaid rolls, and 4,800 more are at risk next month (on top of the original 4,353 people dropped last month) — all because of the state’s new work requirements. For critics of the restrictions, their worst fears are realized, while state and national officials focus on what they call positive outcomes. It’s unclear why so many workers are failing to report their hours, but experts suggest limited internet access and lack of knowledge about the requirements as possibilities.

Modern Healthcare: 4,100 More Arkansans Lose Medicaid Over Work Requirements


Anthem was slammed this week with a $16 million settlement over its massive data breach. (Remember the biggest known health care hack in U.S. history?) That penalty is nearly three times the previous record paid over such a case.

The Associated Press: Insurer Anthem Will Pay Record $16M for Massive Data Breach


I’m not sure whether it’s because I saturate myself in health care stories, but I detect a serious reckoning in the field of medical research. The latest call for retractions involves a prominent cardiologist.

The New York Times: Harvard Calls for Retraction of Dozens of Studies by Noted Cardiologist


In the miscellaneous must-read file:

• A mysterious polio-like illness that causes sudden paralysis is hitting children in states across the country. The wave of cases is similar to one officials saw in 2014 and 2016, but experts are baffled.

Los Angeles Times: What Is AFM? Everything You Need to Know About the Polio-Like Virus Suddenly Affecting Children Across the U.S.

• I have to admit, this is the headline that most piqued my interest this week. Gene editing is such a hot field, but in the racially charged landscape of the country, scientists are worried their research into genes and genetic diversity will be twisted by hate groups to support their views.

The New York Times: Why White Supremacists Are Chugging Milk (And Why Geneticists Are Alarmed)

• Why hasn’t #WhyIStayed caught on fire like #MeToo? Stigma, for one. But also the #MeToo movement has shown how powerful multiple accusations can be, amplified to the point they can’t be ignored. In a domestic violence situation, it’s often only one survivor speaking out.

The New York Times: Domestic Violence Awareness Hasn’t Caught Up With #MeToo. Here’s Why.

• Viruses don’t always have to be a scary thing. This therapy uses bacteriophages — literally, eaters of bacteria — that inject themselves into germs and cause them to explode. (As this delightful image from the Stat article describes: The viruses can “pop bacteria the way middle schoolers pop zits.”)

Stat: How The Navy Brought a Once-Derided Scientist Out of Retirement — and Into the Virus-Selling Business

• “Pregnant? Don’t want to be? Call Jane.” That’s how a clandestine underground abortion network advertised during the years leading up to Roe v. Wade, according to this retro report from the NYT.

The New York Times: Code Name Jane: The Women Behind a Covert Abortion Network


It turns out, it is now scientifically supported that daylight helps kill germs indoors. So make sure to let the sun in this weekend! And have a good one.

Must-Reads Of The Week From Brianna Labuskes

We’re barreling toward November, folks. (How is it mid-October already?) As you might expect, election stories made up the bulk of the health care news this week. Other great gems and intriguing developments surfaced, though, so let’s get right to it.

Republicans on the campaign trail have been hammered by attack ads over their stance on the health law, with “preexisting conditions protections” — insurance safeguards for patients diagnosed with chronic illness — becoming a catch-all phrase for the most popular parts of the Affordable Care Act. Even the law’s most vocal opponents have been reading tea leaves and softening their stances. That’s why statements from GOP leadership this week that Congress could revisit their “repeal” fight post-midterms may have landed with a thunk.

The New York Times: Republican Candidates Soften Tone on Health Care As Their Leaders Dig In

The Washington Post: Trump Says ‘All Republicans’ Back Protections for Preexisting Conditions, Despite Repeated Attempts to Repeal Obamacare

Democrats are pulling out a tried-and-true talking point that seemed perfectly timed for them as news of the federal deficit reignited Republican talk about cutting entitlement programs. Dems (who have been playing defense over Medicare) seized the opportunity to accuse Republicans of putting the beloved program on the chopping block.

The Associated Press: Dems Shift Line of Attack, Warning of GOP Threat to Medicare

As the parties duke it out on the trail, voters seem to agree on one thing: Our health care system is broken and someone needs to fix it. “It’s crippling people. It’s crippling me,” one voter says in Politico’s deep read that takes us to a Pennsylvania county where the “margins of electoral victories traditionally are as slim as the spectrum of political opinion is vast.”

Politico Magazine: The Great American Health Care Panic

On the state level, a Missouri Democrat opposed to abortion struggles to find her place in the party. And Georgia becomes a preview of the growing political clout of home health aides.

The New York Times: Is It Possible to Be an Anti-Abortion Democrat? One Woman Tried to Find Out

Politico: Home Health Aides Test Political Clout in Georgia Governor’s Race


The Trump administration this week proposed a requirement that pharma add drug prices to TV ads — triggering skepticism. One problem is that ad prices wouldn’t reflect what most people end up paying for a drug at the pharmacy counter.

Politico: Trump Set to Force Drugmakers to Post Prices in Ads

What I found surprising, considering how common those ads are, is that just a few dozen drugmakers run any at all — nearly half are put out by five companies. Those manufacturers would bear the brunt of the new rules.

Stat: Five Drug Makers Will Be Hit Hardest By Trump’s New Proposal on Drug Ads

Trying to think outside the box to rein in high drug prices, several states are considering treating pharma as they would a public utility — with rate-setting bodies to review, approve or adjust medication prices.

Stat: A Growing Number of States Consider Legislation to Treat Pharma As a Utility

And keep an eye on this battle: Minnesota became the first state to sue drugmakers over the price of insulin, but I don’t think it will be the last. The “life-or-death” drug has gotten a lot of attention recently, synthesizing the human toll of high costs into a digestible talking point.

Stat: Minnesota Becomes First State to Sue Major Insulin Makers Over Price-Gouging


Another 4,100 Arkansas beneficiaries were dropped from the state’s Medicaid rolls, and 4,800 more are at risk next month (on top of the original 4,353 people dropped last month) — all because of the state’s new work requirements. For critics of the restrictions, their worst fears are realized, while state and national officials focus on what they call positive outcomes. It’s unclear why so many workers are failing to report their hours, but experts suggest limited internet access and lack of knowledge about the requirements as possibilities.

Modern Healthcare: 4,100 More Arkansans Lose Medicaid Over Work Requirements


Anthem was slammed this week with a $16 million settlement over its massive data breach. (Remember the biggest known health care hack in U.S. history?) That penalty is nearly three times the previous record paid over such a case.

The Associated Press: Insurer Anthem Will Pay Record $16M for Massive Data Breach


I’m not sure whether it’s because I saturate myself in health care stories, but I detect a serious reckoning in the field of medical research. The latest call for retractions involves a prominent cardiologist.

The New York Times: Harvard Calls for Retraction of Dozens of Studies by Noted Cardiologist


In the miscellaneous must-read file:

• A mysterious polio-like illness that causes sudden paralysis is hitting children in states across the country. The wave of cases is similar to one officials saw in 2014 and 2016, but experts are baffled.

Los Angeles Times: What Is AFM? Everything You Need to Know About the Polio-Like Virus Suddenly Affecting Children Across the U.S.

• I have to admit, this is the headline that most piqued my interest this week. Gene editing is such a hot field, but in the racially charged landscape of the country, scientists are worried their research into genes and genetic diversity will be twisted by hate groups to support their views.

The New York Times: Why White Supremacists Are Chugging Milk (And Why Geneticists Are Alarmed)

• Why hasn’t #WhyIStayed caught on fire like #MeToo? Stigma, for one. But also the #MeToo movement has shown how powerful multiple accusations can be, amplified to the point they can’t be ignored. In a domestic violence situation, it’s often only one survivor speaking out.

The New York Times: Domestic Violence Awareness Hasn’t Caught Up With #MeToo. Here’s Why.

• Viruses don’t always have to be a scary thing. This therapy uses bacteriophages — literally, eaters of bacteria — that inject themselves into germs and cause them to explode. (As this delightful image from the Stat article describes: The viruses can “pop bacteria the way middle schoolers pop zits.”)

Stat: How The Navy Brought a Once-Derided Scientist Out of Retirement — and Into the Virus-Selling Business

• “Pregnant? Don’t want to be? Call Jane.” That’s how a clandestine underground abortion network advertised during the years leading up to Roe v. Wade, according to this retro report from the NYT.

The New York Times: Code Name Jane: The Women Behind a Covert Abortion Network


It turns out, it is now scientifically supported that daylight helps kill germs indoors. So make sure to let the sun in this weekend! And have a good one.

Podcast: KHN’s ‘What The Health?’ Republicans’ Preexisting Political Problem

Ensuring that people with preexisting health conditions can get and keep health insurance has become one of the leading issues around the country ahead of this fall’s midterm elections. And it has put Republicans in something of a bind — many either voted to repeal these coverage protections as part of the 2017 effort in Congress or have signed onto a lawsuit that would invalidate them.

Meanwhile, the Trump administration, eager to show progress regarding high prescription drug costs — another issue important to voters — has issued a regulation that would require prices to be posted as part of television drug advertisements.

Also this week: an interview with California Attorney General Xavier Becerra, a former member of Congress who is using his current post to pursue a long list of health initiatives.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Stephanie Armour of The Wall Street Journal and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Congress passed a package of bills addressing the nation’s opioid epidemic on a rare note of bipartisanship. Many of the measures are designed to help prevent opioid addiction but are short on treatment options.
  • Democrats have made health care — especially the protections for people with preexisting conditions — their central strategy in midterm campaigns. It’s an issue that the GOP did not want to be campaigning on.
  • Republicans say that despite their moves to destroy the federal health law, they would work to preserve coverage options for people with preexisting conditions. But they don’t lay out what those options would be and earlier efforts have major loopholes, Democrats point out.
  • The announcement by federal health officials this week that they want drug prices added to advertisements about the products is expected to have marginal effects because pricing is so complicated. If the federal government requires drugmakers to post their prices on ads, the manufacturers are widely expected to sue based on First Amendment issues.
  • Open enrollment for Medicare began this week and runs until Dec. 7. Medicare Advantage, the private-plan option for enrollees, is becoming increasingly popular and now covers more than a third of Medicare beneficiaries.
  • But while Medicare Advantage offers many benefits the traditional program does not — frequently including dental and foot care — a recent report from the inspector general at the Department of Health and Human Services finds that some of these plans may be wrongly denying care to Medicare patients. At the same time, Medicare beneficiaries who choose to use Medicare Advantage plans may be in for a shock if they later decide to switch back to the traditional form of Medicare. They may not be eligible at that point to buy a Medigap plan to help cover their cost sharing.

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’ “Is Medicare for All the Answer to Sky-High Administrative Costs?” by Austin Frakt

Stephanie Armour: The Associated Press’ “Study: Without Medicaid Expansion, Poor Forgo Medical Care,” by Ricardo Alonso-Zaldivar

Rebecca Adams: The New Yorker’s “Rural Georgians Want Medicaid, But They’re Divided on Stacey Abrams, the Candidate Who Wants to Expand It,” by Charles Bethea

Joanne Kenen: Seven Days Vermont’s “Obituary: Madelyn Linsenmeir, 1988-2018.”

To hear all our podcasts, click here.

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

Podcast: KHN’s ‘What The Health?’ Republicans’ Preexisting Political Problem

Ensuring that people with preexisting health conditions can get and keep health insurance has become one of the leading issues around the country ahead of this fall’s midterm elections. And it has put Republicans in something of a bind — many either voted to repeal these coverage protections as part of the 2017 effort in Congress or have signed onto a lawsuit that would invalidate them.

Meanwhile, the Trump administration, eager to show progress regarding high prescription drug costs — another issue important to voters — has issued a regulation that would require prices to be posted as part of television drug advertisements.

Also this week: an interview with California Attorney General Xavier Becerra, a former member of Congress who is using his current post to pursue a long list of health initiatives.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Stephanie Armour of The Wall Street Journal and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Democrats have made health care — especially the protections for people with preexisting conditions — their central strategy in midterm campaigns. It’s an issue that the GOP did not want to be campaigning on.
  • Republicans say that despite their moves to destroy the federal health law, they would work to preserve coverage options for people with preexisting conditions. But they don’t lay out what those options would be and earlier efforts have major loopholes, Democrats point out.
  • The announcement by federal health officials this week that they want drug prices added to advertisements about the products is expected to have marginal effects because pricing is so complicated. If the federal government requires drugmakers to post their prices on ads, the manufacturers are widely expected to sue based on First Amendment issues.
  • Open enrollment for Medicare began this week and runs until Dec. 7. Medicare Advantage, the private-plan option for enrollees, is becoming increasingly popular and now covers more than a third of Medicare beneficiaries.
  • But while Medicare Advantage offers many benefits the traditional program does not — frequently including dental and foot care — a recent report from the inspector general at the Department of Health and Human Services finds that some of these plans may be wrongly denying care to Medicare patients. At the same time, Medicare beneficiaries who choose to use Medicare Advantage plans may be in for a shock if they later decide to switch back to the traditional form of Medicare. They may not be eligible at that point to buy a Medigap plan to help cover their cost sharing.

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’ “Is Medicare for All the Answer to Sky-High Administrative Costs?” by Austin Frakt

Stephanie Armour: The Associated Press’ “Study: Without Medicaid Expansion, Poor Forgo Medical Care,” by Ricardo Alonso-Zaldivar

Rebecca Adams: The New Yorker’s “Rural Georgians Want Medicaid, But They’re Divided on Stacey Abrams, the Candidate Who Wants to Expand It,” by Charles Bethea

Joanne Kenen: Seven Days Vermont’s “Obituary: Madelyn Linsenmeir, 1988-2018.”

To hear all our podcasts, click here.

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

Medicare For All? CMS Chief Warns Program Has Enough Problems Already

The Trump administration’s top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.

“We only have to look at some of Medicare’s major problems to know it’s a bad idea,” Verma told health insurance executives at a meeting in Washington.

CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can’t take steps used by private insurers to control costs.

“We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population,” she added.

Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn’t add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.

Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.

Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. “That is ridiculously low,” she said.

Verma also lamented the traditional Medicare program’s limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.

Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that “Medicare is not always nimble, particularly in adjusting benefits,” and officials have long complained that Congress micromanages the program. Still, he added, “with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes.”

Verma for months has spoken out against the “Medicare-for-all” proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America’s Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.

Proponents of “Medicare-for-all” are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program’s existing challenges of controlling costs and improving care.

“But their solution is literally to do more of what’s not working,” she added. “It’s like the man who has a pounding headache, who then takes a hammer to his head to make it go away.”

Verma’s comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.

“In payment reform, Medicare has a record of being a leader and innovator,” he said. “For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare’s price regulation has produced substantial savings.”

Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.

More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan’s network of providers.

“Medicare Advantage represents value for our beneficiaries and taxpayers,” Verma said.

She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.

It is “one of the most significant changes made to the Medicare program” and “will have a major impact” on improving health for plan members, she said.

But the private plans have taken a cautious approach to adding those benefits.

About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.

At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.

“We are operating in a vacuum of good evidence,” said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.

Verma did not mention a report last month by the Department of Health and Human Services’ inspector general that found many Advantage plans were improperly denying claims from patients and doctors.

Administration critics were quick to note that omission.

“Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly” — is “striking,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is “her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored.”

Medicare For All? CMS Chief Warns Program Has Enough Problems Already

The Trump administration’s top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.

“We only have to look at some of Medicare’s major problems to know it’s a bad idea,” Verma told health insurance executives at a meeting in Washington.

CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can’t take steps used by private insurers to control costs.

“We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population,” she added.

Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn’t add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.

Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.

Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. “That is ridiculously low,” she said.

Verma also lamented the traditional Medicare program’s limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.

Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that “Medicare is not always nimble, particularly in adjusting benefits,” and officials have long complained that Congress micromanages the program. Still, he added, “with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes.”

Verma for months has spoken out against the “Medicare-for-all” proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America’s Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.

Proponents of “Medicare-for-all” are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program’s existing challenges of controlling costs and improving care.

“But their solution is literally to do more of what’s not working,” she added. “It’s like the man who has a pounding headache, who then takes a hammer to his head to make it go away.”

Verma’s comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.

“In payment reform, Medicare has a record of being a leader and innovator,” he said. “For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare’s price regulation has produced substantial savings.”

Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.

More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan’s network of providers.

“Medicare Advantage represents value for our beneficiaries and taxpayers,” Verma said.

She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.

It is “one of the most significant changes made to the Medicare program” and “will have a major impact” on improving health for plan members, she said.

But the private plans have taken a cautious approach to adding those benefits.

About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.

At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.

“We are operating in a vacuum of good evidence,” said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.

Verma did not mention a report last month by the Department of Health and Human Services’ inspector general that found many Advantage plans were improperly denying claims from patients and doctors.

Administration critics were quick to note that omission.

“Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly” — is “striking,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is “her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored.”

Trump Administration, Pharma Exchange Verbal Volleys On Drug-Price Transparency

The Trump administration and drugmakers are squaring off over a proposal to show drug prices in television ads.

“Putting list prices in isolation in the advertisements themselves would be misleading or confusing,” argued Stephen Ubl, CEO of the Pharmaceutical Researchers and Manufacturers of America, known as PhRMA, the major trade group for branded drugs.

Ubl issued his statement hours before Health and Human Services Secretary Alex Azar was scheduled to speak about drug prices and what the Trump administration plans to do to lower them. He went on the offensive, questioning the legality and practicality of showing list prices of drugs in TV ads.

Instead, Ubl, whose trade group represents the largest pharmaceutical manufacturers on the globe, promised that pharma companies would direct consumers to websites that include a drug’s list price and estimates of what people can expect to pay, which can vary widely depending on coverage.

Drug manufacturers will voluntarily opt in to this disclosure starting next spring, he said.

Within an hour of PhRMA’s announcement, Azar fired back with a statement of his own, characterizing PhRMA’s strategy as still “resistant to providing real transparency around their prices” but a “small step in the right direction.”

He promised the White House “will go further” in requiring drug price transparency. Its proposal comes weeks before midterm elections, in which health care is a top voter concern. Polling from the Kaiser Family Foundation suggests most voters support forcing price transparency in drug advertisements. (Kaiser Health News is an editorially independent program of the Foundation.)

The White House’s plan for direct-to-consumer advertising, which was teased in President Donald Trump’s blueprint this summer, has won praise from insurance groups and the American Medical Association. Sens. Chuck Grassley (R-Iowa) and Dick Durbin (D-Ill.) also proposed the plan in the Senate last month, but it failed to garner enough support. Experts pointed out a host of complications, suggesting that neither PhRMA’s approach nor the White House’s would fully explain to consumers what they’ll actually pay for drugs.

That’s because a drug’s list price — the metric HHS wants to emphasize — often bears little relationship to what a patient actually pays at the drugstore. Insurance plans and pharmacy benefit managers often negotiate prices that are below the list price. Some patients qualify for other discounts. And often patients pay only what their copay or deductible require at any given time.

Other consumers could be stuck paying the full price tag, depending on how their insurance plan is designed, or if they don’t have coverage.

“The system is very opaque, very complicated and, importantly, there isn’t a huge relationship between list prices for drugs and what patients will expect to pay out-of-pocket,” said Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice who researches drug marketing.

But the industry’s strategy, she said, also appeared lacking.

Under PhRMA’s plan, drugmakers would not standardize how they display their information. Where consumers go could vary on Pfizer’s website versus Merck’s to learn about the list price and the range of out-of-pocket costs. That, Faerber argued, would make it difficult for people to unearth relevant information.

PhRMA also announced it is partnering with patient advocacy groups to create a “patient affordability platform,” which could help patients search for costs and insurance coverage options.

Ubl cast their proposal as a way to address more effectively the government and public concern about drug price transparency.

Pharmaceutical manufacturers rely heavily on national advertising and now represent the third-highest spender in national television advertising, according to Michael Leszega, a manager of market intelligence at consulting firm Magna.

At certain times of day, pharmaceutical ads make up more than 40 percent of TV advertisements. And those commercials stand out  because they are generally longer, with their long list of side effects and warnings the pharmaceutical industry must tag on at the end.

Those disclaimers highlight another challenge for the administration: legal action.

There is a body of Supreme Court decisions that dictates how disclaimers and disclosures can be required, said constitutional law expert Robert Corn-Revere. He filed a “friend of the court” brief in a 2011 U.S. Supreme Court case related to commercial speech and the pharmaceutical industry.

Generally, the administration’s requirement must meet the standards of being purely factual, noncontroversial and not burdensome, Corn-Revere said.

On the question of whether requiring drug prices be listed in advertising violates the First Amendment’s free-speech guarantee, Corn-Revere said it “all comes down to the specifics.”

Ubl, when asked Monday morning about a potential lawsuit, didn’t rule out the possibility. “We believe there are substantial statutory and constitutional principles that arise” from requiring list-price disclosure, Ubl said, adding: “We do have concerns about that approach.”


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

Trump Administration, Pharma Exchange Verbal Volleys On Drug-Price Transparency

The Trump administration and drugmakers are squaring off over a proposal to show drug prices in television ads.

“Putting list prices in isolation in the advertisements themselves would be misleading or confusing,” argued Stephen Ubl, CEO of the Pharmaceutical Researchers and Manufacturers of America, known as PhRMA, the major trade group for branded drugs.

Ubl issued his statement hours before Health and Human Services Secretary Alex Azar was scheduled to speak about drug prices and what the Trump administration plans to do to lower them. He went on the offensive, questioning the legality and practicality of showing list prices of drugs in TV ads.

Instead, Ubl, whose trade group represents the largest pharmaceutical manufacturers on the globe, promised that pharma companies would direct consumers to websites that include a drug’s list price and estimates of what people can expect to pay, which can vary widely depending on coverage.

Drug manufacturers will voluntarily opt in to this disclosure starting next spring, he said.

Within an hour of PhRMA’s announcement, Azar fired back with a statement of his own, characterizing PhRMA’s strategy as still “resistant to providing real transparency around their prices” but a “small step in the right direction.”

He promised the White House “will go further” in requiring drug price transparency. Its proposal comes weeks before midterm elections, in which health care is a top voter concern. Polling from the Kaiser Family Foundation suggests most voters support forcing price transparency in drug advertisements. (Kaiser Health News is an editorially independent program of the Foundation.)

The White House’s plan for direct-to-consumer advertising, which was teased in President Donald Trump’s blueprint this summer, has won praise from insurance groups and the American Medical Association. Sens. Chuck Grassley (R-Iowa) and Dick Durbin (D-Ill.) also proposed the plan in the Senate last month, but it failed to garner enough support. Experts pointed out a host of complications, suggesting that neither PhRMA’s approach nor the White House’s would fully explain to consumers what they’ll actually pay for drugs.

That’s because a drug’s list price — the metric HHS wants to emphasize — often bears little relationship to what a patient actually pays at the drugstore. Insurance plans and pharmacy benefit managers often negotiate prices that are below the list price. Some patients qualify for other discounts. And often patients pay only what their copay or deductible require at any given time.

Other consumers could be stuck paying the full price tag, depending on how their insurance plan is designed, or if they don’t have coverage.

“The system is very opaque, very complicated and, importantly, there isn’t a huge relationship between list prices for drugs and what patients will expect to pay out-of-pocket,” said Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice who researches drug marketing.

But the industry’s strategy, she said, also appeared lacking.

Under PhRMA’s plan, drugmakers would not standardize how they display their information. Where consumers go could vary on Pfizer’s website versus Merck’s to learn about the list price and the range of out-of-pocket costs. That, Faerber argued, would make it difficult for people to unearth relevant information.

PhRMA also announced it is partnering with patient advocacy groups to create a “patient affordability platform,” which could help patients search for costs and insurance coverage options.

Ubl cast their proposal as a way to address more effectively the government and public concern about drug price transparency.

Pharmaceutical manufacturers rely heavily on national advertising and now represent the third-highest spender in national television advertising, according to Michael Leszega, a manager of market intelligence at consulting firm Magna.

At certain times of day, pharmaceutical ads make up more than 40 percent of TV advertisements. And those commercials stand out  because they are generally longer, with their long list of side effects and warnings the pharmaceutical industry must tag on at the end.

Those disclaimers highlight another challenge for the administration: legal action.

There is a body of Supreme Court decisions that dictates how disclaimers and disclosures can be required, said constitutional law expert Robert Corn-Revere. He filed a “friend of the court” brief in a 2011 U.S. Supreme Court case related to commercial speech and the pharmaceutical industry.

Generally, the administration’s requirement must meet the standards of being purely factual, noncontroversial and not burdensome, Corn-Revere said.

On the question of whether requiring drug prices be listed in advertising violates the First Amendment’s free-speech guarantee, Corn-Revere said it “all comes down to the specifics.”

Ubl, when asked Monday morning about a potential lawsuit, didn’t rule out the possibility. “We believe there are substantial statutory and constitutional principles that arise” from requiring list-price disclosure, Ubl said, adding: “We do have concerns about that approach.”


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

Must Reads Of The Week From Brianna Labuskes

Just in case our ever-decreasing anonymity in this tech-driven world hasn’t scared you enough, new studies find that within a few years 90 percent — 90 percent! — of Americans of European descent will be identifiable from their DNA. If you fall into that group, it doesn’t even matter whether you’ve given a DNA sample to one of the popular gene-testing sites (like 23andMe). Enough of your distant relatives have, so there’s a good chance you’re in the system.

Take your mind off that by checking out what you may have missed in health care this week.

The biggie, of course, was President Donald Trump’s opinion piece in USA Today about “Medicare-for-all.” (And the rebuttal from Vermont Sen. Bernie Sanders.)

Fact checkers came out in droves to comb through Trump’s arguments and found that nearly every paragraph contained a misleading statement or falsehood.

The Washington Post: Fact-Checking President Trump’s USA Today Op-Ed on ‘Medicare-for-All’

More than shedding any kind of light on the complicated topic, the back-and-forth highlights how much of a role health care is playing in the upcoming midterm elections. Each side has doubled down on its respective talking points (read: preexisting conditions and Medicare-for-all — I warned you you’d get tired of me saying that). In fact, health care is featured so heavily in ads that it trumps the topics of jobs or taxes.

The Wall Street Journal: Health Care Crowds Out Jobs, Taxes in Midterm Ads

(Side note: If you do want some light shed on Medicare-for-all and single-payer systems, check out these great pieces from KHN’s own Shefali Luthra.)

Speaking of midterms, the Democrats’ attempt to block the administration’s expansion of short-term plans (very predictably) failed, with only Maine Republican Sen. Susan Collins joining the Democrats. It was never about winning, though. What it did was force Republicans to go on record with a vote that is potentially politically dangerous in the current landscape.

Politico: Senate Democrats Fail to Block Trump’s Short-Term Health Plans

In stark contrast to the sharply partisan discourse, Trump signed two bipartisan health care measures into law this week. The bills banned “gag clauses” on pharmacists, which had prohibited them from offering consumers cheaper options. The legislation won’t directly affect drug prices, but it might mean people will pay less at the register.

The New York Times: Trump Signs New Laws Aimed at Drug Costs and Battles Democrats on Medicare


For the first time, premiums for the most popular level of insurance sold in the health law marketplaces have gone down. The numbers are the latest sign that the marketplace is stabilizing. (Centene’s expansion into new states is another from this week.) CMS Administrator Seema Verma touted the success, saying the news counters any accusations of sabotage. Health experts, however, said those price tags would have been even lower if not for the administration’s actions over the past year.

The Washington Post: Premiums for Popular ACA Health Insurance Dip for the First Time


The Justice Department approved CVS’ $69 billion merger with Aetna, and although the deal still needs approval from state regulators, the green light is a major hurdle cleared. The merger would reshape the health landscape and mark the end of an era for free-standing pharmacy benefit managers. The potential consolidation is just one of many in recent years in a fast-evolving industry — a trend critics worry will lessen competition and drive up prices for consumers.

The New York Times: CVS Health and Aetna $69 Billion Merger Is Approved With Conditions


Hospitals scrambled to ensure patient safety as Hurricane Michael battered Florida and Georgia this week. “It was like hell,” said one doctor who rode out the storm at Bay Medical Center in Panama City, Fla. The hurricane brought with it memories of last year’s power outages that came with Hurricane Irma and were linked to the deaths of several nursing home residents.

The New York Times: Hospitals Pummeled by Hurricane Michael Scramble to Evacuate Patients


Now that the Brett Kavanaugh battle is over and he’s taken a seat on the Supreme Court, Planned Parenthood has gone into planning mode in case anything happens to Roe v. Wade. A key component of the organization’s plan is to shore up networks in states where abortion would likely remain legal (with longer hours for clinics, for example). On the other side, abortion-rights opponents are getting primed for a new high court that’s likely friendlier to them by strategizing what cases would be best to move forward with.

NPR: With Kavanaugh Confirmed, Both Sides of Abortion Debate Gear Up for Battle

How do you fight measures to expand abortion rights in progressive states? Make it about money. A battle in Oregon illustrates a strategy that — although unlikely to be successful — gives opponents of the bills at least a hope of winning.

Politico: Oregon’s Unlikely Abortion Fight Hinges on Taxes


Holes in the court system have allowed state judges to grant full custody of migrant children to American families — without notifying their parents. Federal officials say it should never happen, but oversight of the problem is scattershot and challenging because states handle adoption proceedings differently.

The Associated Press: Deported Parents May Lose Kids to Adoption

Democrats have been vocal about what they don’t like when it comes to immigration policy. But they have a problem: a lack of cohesion within the party about the correct way forward.

The New York Times: The Democrats Have an Immigration Problem


In the miscellaneous, must-read file:

• A gripping piece takes you into the bowels of a Philadelphia neighborhood dubbed the “Walmart of heroin.” “Drug tourists” come from all over to buy the cheap, pure heroin flowing through the veins of the streets, and some never make it out. (Warning: Make sure you have some time before you start, it will suck you in completely.)

The New York Times: Trapped by the ‘Walmart of Heroin’

• Why were nursing home residents getting extremely pricey therapy in the last weeks of their lives? Bloomberg takes a closer look at these cash-strapped facilities and the questionable decisions made about patients’ rehab.

Bloomberg: Nursing Homes Are Pushing the Dying Into Pricey Rehab

• In good news from the segment of people who were too old to take advantage of the HPV vaccine, the Food and Drug Administration just approved its use for those up to age 45.

The Associated Press: FDA Expands Use of Cervical Cancer Vaccine up to Age 45


As an office of ardent dog lovers, we were distressed to hear the news that therapy dogs in hospitals are little germ machines, leaving behind happiness but also superbugs.

Have a great (hopefully superbug-free) weekend!

Podcast: KHN’s ‘What The Health?’ Falling Premiums And Rising Political Tensions

The Trump administration announced that, for the first time, the average premium for a key plan sold on the federal health law’s insurance marketplaces will fall slightly next year. Federal officials said that changes they have made helped facilitate the reduction, but others argue that it was because more plans are moving back into those federal exchanges and making money.

The news is likely to further inflame the political debate on health care in the run-up to the midterm elections. Democrats and Republicans are battling over which party is more attuned to consumers’ needs on protections for people with preexisting conditions and affordable health care.

Meanwhile, President Donald Trump signed two bills this week that would ban efforts to keep pharmacists from telling customers that their prescriptions would be cheaper if they paid in cash, rather than using their insurance. And the Food and Drug Administration this week announced it will ease the process for drugmakers to bring some products to market.

This week’s panelists for KHN’s “What the Health?” are Mary Agnes Carey of Kaiser Health News, Rebecca Adams of CQ Roll Call, Anna Edney of Bloomberg News and Julie Appleby of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • The drop in the average price for ACA plans follows a recent analysis that found insurers are regaining profitability in the individual market.
  • Democrats this week were unsuccessful in their effort to get the Senate to reverse a new policy that eased rules for short-term health plans. The administration argues that these plans help provide a more affordable option for many people, but Democrats complain that they are junk insurance because they don’t have many of the protections offered through the ACA.
  • Trump and members of Congress celebrated a rare moment of bipartisanship on health care when the president signed the two bills restricting gag orders on pharmacists. Despite the goodwill, the much-touted aim of the administration to constrain drug prices has not made much progress.
  • Health care has been a key issue in midterm campaigns, with Democrats hitting hard at their opponents to charge that the GOP would not guarantee ACA protections for people with preexisting conditions. But Republicans are fighting back with personal stories of their own health concerns — and an op-ed by the president on concerns about some Democrats’ plans to expand Medicare.
  • The new policy announced by the FDA this week will apply to complex drugs, which are drugs that are coupled with a device, such as patches or auto-injectors. The agency said it would be more flexible in reviewing materials for approving those devices.

To hear all our podcasts, click here.

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

Obamacare Premiums Dip For First Time. Some Call It A Correction

After two years of double-digit price hikes, the average premium for individual health coverage on the federal health law’s insurance marketplace will drop by 1.5 percent for 2019, the Trump administration said Thursday.

The announcement marked the first time average premiums have fallen since the exchanges created by the Affordable Care Act went into effect in 2014.

It also comes during a bitter midterm congressional campaign season in which health care is a central issue following last year’s efforts by Republicans to repeal the ACA.

Administration officials claimed credit for the price drop, saying it was due to their actions to make changes to the law. Health policy experts said it was a reaction to insurers’ huge profits following hefty premium increases on plans offered this year.

The federal exchange covers about 9 million people in 39 states. The other states and the District of Columbia have their own online marketplaces and were not included in the report.

The analysis by federal officials looked at the price of the second-lowest silver plan for a 27-year-old nonsmoker on the marketplaces. Those silver plans are used by the ACA to set subsidies.

Open enrollment for 2019 runs from Nov. 1 through Dec. 15.

Charles Gaba, a Michigan-based blogger who tracks ACA sign-ups, noted that the numbers released by the administration were just one snapshot of the marketplace.

He said premiums next year will “still be a whopping 30% higher than they were in 2017, with the vast bulk of that due specifically to sabotage actions taken by the Trump Administration and Congressional Republicans.”

Before the 2010 health law passed, it was typical for individual health insurance rates to increase yearly, largely because people needing the insurance had above-average health risks.

The health law’s marketplace was designed to allow shoppers to easily compare rates for policies that had to meet federal benefit requirements, such as covering mental health and pregnancy care.

Under President Barack Obama, insurance rates on the marketplace rose 1 percent for plans available in 2015 and 8 percent in 2016. But, just as Obama was leaving office, rates rose 20 percent for 2017 plans. Premiums for plans in 2018 soared 34 percent, following changes made by the Trump administration that included dropping subsidies paid to insurers to help cover the cost of out-of-pocket expenses they shoulder for low-income customers.

“Premiums would have dropped more on average if not for harmful Trump administration actions,” said Sarah Lueck, senior policy analyst for the left-leaning Center on Budget and Policy Priorities. She cited decisions to expand the use of plans that don’t provide all ACA patient protections and the dramatic cut in outreach and enrollment assistance for consumers.

The vast majority of consumers buying on the exchange have been shielded from rate hikes because their incomes are low enough to qualify for federal subsidies. But the marketplace price hikes have become a political lightning rod — bolstering the arguments from Trump and congressional Republicans to repeal the health law.

Administration officials said a decision they made allowing seven states to set up reinsurance programs helped insurance companies lower premiums.

Seema Verma, administrator of the federal Centers for Medicare & Medicaid Services, also pointed to new regulations allowing insurers to sell short-term policies. These policies can be renewed for up to three years and don’t have to meet federal minimum benefit rules. She said that caused carriers to drop rates on the exchange to be more competitive.

Those new plans are not yet available and are not included in the marketplace rates.

Despite the drop in prices, Verma said, premiums are still high. “To open the markets to more Americans … as well as the millions who are priced out of the market, the law needs to change,” she said.

Verma, like Trump, has repeatedly called for the health law to be repealed, but she did not repeat that call on Thursday.

During a briefing with reporters, she was asked about policy experts who say flat or declining rates for 2019 come mainly because insurers raised premiums so much in 2018 in response to Trump administration actions. She replied, “We heard a lot of predictions that didn’t turn out to be true.”

Cynthia Cox, who monitors the marketplaces for the Kaiser Family Foundation, wrote on Twitter: “One big reason insurers are lowering premiums: Individual market insurers are currently so profitable it would be hard for many companies to justify a rate increase.”

Those profits are also driving new companies into the Obamacare marketplace in several states, she said. (Kaiser Health News is an editorially independent program of the foundation.)

Cox said some efforts by the Trump administration have made the marketplace more attractive to insurers, such as cutting in half the open-enrollment period and approving some states’ reinsurance plans. That green light allows states to help insurers pay for extremely costly patients so that premiums for the overall patient pool can remain relatively modest.

Rates still vary dramatically by state. For example, average premiums are dropping 26 percent in Tennessee but rising 16 percent in Delaware.

The drop in rates is good news for people buying unsubsidized coverage — those with incomes over 400 percent of the federal poverty level, or about $49,000 for an individual.

Consumers will get less assistance this fall in shopping for exchange plans. The Trump administration cut millions of dollars in funding to the program that pays groups to work with people needing help selecting coverage.

Nonetheless, Verma said the falling premiums show the administration has been defying its critics.

“While some have publicly been accusing us of sabotage, the reality is we have been working hard to mitigate damage caused by Obamacare,” she said. “Our actions have succeeded.”

Fact-Check: Who’s Right On Protections For Preexisting Conditions? It’s Complicated

Ensuring that people with preexisting health conditions can get and keep health insurance is the most popular part of the Affordable Care Act. It has also become a flashpoint in this fall’s campaigns across the country.

And not only is the ACA, which mostly protects people who buy their own coverage, at risk. Also potentially in the crosshairs are preexisting conditions protections that predate the federal health law.

Democrats charge that Republicans’ opposition to the ACA puts those protections in peril, both by their (unsuccessful) votes in Congress in 2017 to “repeal and replace” the law, and via a federal lawsuit underway in Texas.

“800,000 West Virginians with preexisting conditions in jeopardy of losing their health care,” claimed Sen. Joe Manchin (D-W.Va.).

Republicans disagree. “Preexisting conditions are safe,” President Donald Trump declared at a rally in West Virginia for Manchin’s GOP opponent, Patrick Morrisey. Morrisey, West Virginia’s attorney general, is one of a group of state officials suing to overturn the ACA.

Who is right? Like everything else in health care, it’s complicated.

What is clear, however, is that voters want protections. Even majorities of Republicans told pollsters this summer that it is “very important” that guarantees of coverage for preexisting conditions remain law.

Here are some key details that can help put the current political arguments in perspective.

Preexisting conditions are common.

Preexisting conditions are previous or ongoing medical issues that predate health insurance enrollment. The problem is that the term is a grab bag whose limits have never been defined. It certainly applies to serious ongoing conditions such as cancer, heart disease and asthma. But insurers also have used it to apply to conditions like pregnancy or far more trivial medical issues such as acne or a distant history of depression.

The Kaiser Family Foundation estimated in 2016 that more than a quarter of adults younger than 65 — about 52 million people — have a preexisting health condition that likely would have prevented them from purchasing individual health insurance under the pre-ACA rules. (Kaiser Health News is an editorially independent program of the foundation.)

Protections vary by what kind of insurance you have.

But what protections people with preexisting conditions have depends on how they get their coverage. For that reason, it’s not right to say everyone with health problems is potentially at risk, as Democrats frequently suggest.

For example, Medicare, the federal health program for seniors, and Medicaid, the federal-state health plan for low-income people, do not discriminate in either coverage or price on the basis of preexisting conditions. The two programs together cover roughly 130 million Americans — nearly a third of the population.

The majority of Americans get their coverage through work. In 1996, Congress protected people with preexisting conditions in employer-based coverage with the passage of the Health Insurance Portability and Accountability Act, known as HIPAA.

HIPAA was intended to eliminate “job lock,” or the inability of a person with a preexisting condition (or a family member with a preexisting condition) to change jobs because coverage at the new job would likely come with a waiting period during which the condition would not be covered.

HIPAA banned those waiting periods for people who had maintained “continuous” coverage, meaning a break of no more than 63 days, and the law limited waiting periods to one year for those who were previously uninsured. In addition, it prohibited insurers from denying coverage to or raising premiums for workers based on their own or a family member’s health status or medical history.

HIPAA was less successful in protecting people without job-based insurance. It sought to guarantee that people with preexisting conditions leaving the group market could buy individual coverage if they had remained continuously covered. But the law did not put limits on what individual insurers could charge for those policies. In many cases, insurers charged so much for these “HIPAA conversion” policies that almost no one could afford them.

The Affordable Care Act, passed in 2010, built on those 1996 protections, and specifically sought to help people buying their own coverage. It barred all health insurers from excluding people due to preexisting conditions, from charging them higher premiums and from imposing waiting periods for coverage of that condition.

While the protections were mostly aimed at the individual insurance market, where only a small portion of Americans get coverage, the ACA also made some changes to the employer market for people with preexisting conditions, by banning annual and lifetime coverage limits.

Will protections on preexisting conditions become collateral damage?

In 2017, the GOP-controlled House and Senate voted on several versions of a bill that would have dramatically overhauled the ACA, including its protections on preexisting conditions. Under the last bill that narrowly failed in the Senate, states would have been given authority to allow insurers to waive some of those protections, including the one requiring the same premiums be charged regardless of health status.

In February, 18 GOP attorneys general and two GOP governors filed suit in federal court in Texas. They charge that because Congress in its 2017 tax bill eliminated the ACA’s penalty for not having insurance, the entire federal health law is unconstitutional. Their argument is that the Supreme Court upheld the ACA in 2012 based only on Congress’ taxing power, and that without the tax, the rest of the law should fall.

The Trump administration, technically the defendant in that case, said in June that it disagreed that the entire law should fall. But it is arguing that the parts of the law addressing preexisting conditions are so tightly connected to the tax penalty that they should be struck down.

Clearly, if the lawsuit prevails in either its original form or the form preferred by the Trump administration, preexisting protections are not “safe,” as the president claimed.

Even more complicated, the protections written into HIPAA were rewritten and incorporated into the ACA, so if the ACA in whole or part were to be struck down, HIPAA’s preexisting conditions protections might go away, too.

Republicans in Congress have introduced a series of proposals they say would replicate the existing protections. But critics contend none of them covers as many situations as the ACA does. For example, a bill unveiled by several Republican senators in August would require insurers to offer coverage to people with preexisting health conditions, but not require coverage of the conditions themselves.

That hasn’t stopped Republicans from claiming that they support protections for preexisting conditions.

“Make no mistake about it: Patients with preexisting conditions should be covered,” said Wisconsin GOP Senate candidate Leah Vukmir, who is running to unseat Democratic Sen. Tammy Baldwin. Health care has been a major issue in that race, as well as many others. Yet Vukmir was recently hailed by Vice President Mike Pence as someone who will vote to “fully repeal and replace Obamacare.”

Meanwhile, Democrats who are chastising their Republican opponents over the issue are sometimes going a bit over the top, too.

An example is Manchin’s claim about the threat to coverage for 800,000 people in West Virginia. West Virginia’s population is only 1.8 million and more than a million of those people are on Medicare or Medicaid. That would mean every other person in the state has a preexisting condition. A recent study found West Virginia has a relatively high level of preexisting conditions among adults, but it is still less than 40 percent.

Doctors Give Medicare’s Proposal To Pay For Telemedicine Poor Prognosis

The Trump administration wants Medicare for the first time to embrace telemedicine across the country by paying doctors $14 for a five-minute “check-in” phone call with their patients.

But many physicians say the proposed reimbursement will cover a service they already do for free. And the Medicare reimbursement — intended to motivate doctors to communicate with patients outside the office — could have a chilling effect on patients because they would be required to pay a 20 percent cost-sharing charge.

Medicare said the call would be used to help patients determine whether they need to come in for an appointment. But doctors and consultants said the virtual sessions could cover a broad array of services, including monitoring patients starting a new medicine or those trying to manage chronic illnesses, such as diabetes. The Medicare Payment Advisory Commission, which provides guidance to Congress, panned the proposal last month, saying it could lead to excess spending without benefiting patients.

“Direct-to-consumer telehealth services … appear to expand access, but at a potentially significant cost and without evidence of improved quality,” the commission’s chairman, Dr. Francis Crosson, said in a letter to the Centers for Medicare & Medicaid Services (CMS). “Due to their greater convenience, these services are at risk of misuse by patients or provider.”

Congress has shied away from expanding the use of telemedicine in Medicare — even as it has become commonplace among private insurers — because of concerns about higher spending. Budget hawks worry that rather than replace comparatively expensive in-person visits, extra telemedicine billings would add to them.

Lack of coverage — except in rare circumstances — means fewer than 1 percent of the 50 million Medicare beneficiaries use telemedicine services each year.

Federal law forbids Medicare from paying for telemedicine services that replace in-person office visits, except in certain rural areas. That’s why CMS called the new benefit a check-in using “virtual” or “communications technology,” said Jacob Harper, who specializes in health issues at the law firm Morgan, Lewis & Bockius.

In addition to the check-in call, CMS has proposed starting to pay physicians to review photos that patients text or email to them to evaluate skin and eye problems, as well as and other conditions. It also has proposed paying physicians an unspecified fee for consulting electronically or by phone with other doctors.

“Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly,” said CMS Administrator Seema Verma when announcing the proposal.

CMS said it hopes to enact the changes in 2019. Officials will announce their final rule after evaluating public comments on the plan.

Verma and other CMS officials say they believe the change would end up saving Medicare money by reducing unnecessary office visits and catching health problems early, before they become more costly to treat.

But in its detailed proposal, CMS acknowledges the telehealth service will increase Medicare costs. CMS said the telehealth will result in “fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the [Medicare physician pay schedule] by about 0.2 percent,” or eventually about $180 million per year. Because the change must be budget-neutral, CMS is paying for this by decreasing some other Medicare physician payments.

CMS doesn’t expect rapid adoption of the telehealth service, partly because doctors can get paid from $35 to $150 for an in-person visit. “Because of the low payment rate relative to that for an office visit, we are assuming that usage of these services will be relatively low,” CMS said in its proposal.

The virtual check-in can be conducted by physicians or nurse practitioners or physician assistants working with a doctor.

Only patients who have established relationships with a doctor would be eligible for the service. Doctors also would not be allowed to bill for the check-in service if it stems directly from an in-person visit or is followed by an appointment with the doctor, according to the CMS proposal.

Dr. Michael Munger, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, said many doctors routinely check on patients by phone. Still, he applauded the effort to increase physician pay.

“Anytime you can tie payment to what many of us are already doing is good,” he said.

Mercy, a large hospital system in St. Louis, has been offering telehealth services even without reimbursement because it helps patients access care and lowers costs in the long run, said Dr. J. Gavin Helton, president of clinical integration at Mercy Virtual.

“We are already on this path, and this will help to continue to grow our programs and make them financially sustainable,” he said.

Still, Helton said the “check-in” fee from Medicare won’t be enough to motivate providers to start telehealth services.

He said the new reimbursement signals that Medicare wants to pay for services to keep patients well rather than just treat them while they are sick.

Other physicians were more skeptical, particularly while Medicare has also proposed reducing some fees for in-person office visits.

In a letter to CMS, Dr. Amy Messier, a family medicine doctor in Wilmington, N.C., raised concerns about the effect this could have on patients’ expenses.

“I worry about implementation of this from the patient perspective now that we are charging patients for this previously free service and they have to pay their portion of the charge,” she said.

“Patients will be less likely to engage their physician outside of the office visit and more likely to seek care face-to-face at more expense, when perhaps that visit could have been avoided with a phone call which they will no longer make because it comes with a charge,” she said.

Dr. Todd Czartoski, chief executive of telehealth at Providence St. Joseph Health in Renton, Wash., predicts most doctors won’t use the proposed telehealth service.

“It’s still easier for a doctor to go room to room with patients lined up,” he said. “It’s a step in the right direction, but I don’t think it will open the floodgates for virtual care.”


KHN’s coverage of these topics is supported by
John A. Hartford Foundation
and
The SCAN Foundation

No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices

For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off.

When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret.

President Donald Trump was expected to sign two bills Wednesday that ban “gag order” clauses in contracts between pharmacies and insurance companies or pharmacy benefit managers — those firms that negotiate prices for employers and insurers with drugstores and drugmakers. Such provisions prohibit pharmacists from telling customers when they can save money by paying the pharmacy’s lower cash price instead of the price negotiated by their insurance plan.

The bills — one for Medicare and Medicare Advantage beneficiaries and another for commercial employer-based and individual policies— were passed by Congress in nearly unanimous votes last month. A spokesman for Sen. Susan Collins (R-Maine) said her office had been told the president would sign the bills Wednesday. The White House declined to comment.

“Americans deserve to know the lowest drug price at their pharmacy, but ‘gag clauses’ prevent your pharmacist from telling you!” Trump wrote on Twitter three weeks ago, shortly before the Senate voted on the bills. “I support legislation that will remove gag clauses.” The change was one of the proposals included in Trump’s blueprint to cut prescription drug prices issued in May.

Ronna Hauser, vice president of payment policy and regulatory affairs at the National Community Pharmacists Association, said many members of her group “say a pharmacy benefit manager will call them with a warning if they are telling patients it’s less expensive” without insurance. She said pharmacists could be fined for violating their contracts and even dropped from insurance networks.

According to research published in JAMA in March, people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013. Copayments in those plans were higher than the cash price for nearly 1 in 4 drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.

Yet some critics say eliminating gag orders doesn’t address the causes of high drug prices. “As a country, we’re spending about $450 billion on prescription drugs annually,” said Steven Knievel, who works on drug price issues for Public Citizen, a consumer advocacy group. The modest savings gained by paying the cash price “is far short of what needs to happen to actually deliver the relief people need.”

After the president signs the legislation affecting commercial insurance contracts, gag order provisions will immediately be prohibited, said a spokesman for Collins, who co-authored the bill. The bill affecting Medicare beneficiaries wouldn’t take effect until Jan. 1, 2020.

But there’s a catch: Under the new legislation, pharmacists will not be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask.

The Pharmaceutical Care Management Association, a trade group representing pharmacy benefit managers, said gag orders are increasingly rare. The association supported the legislation. Some insurers have also said their contracts don’t include these provisions. Yet two members of Congress have encountered them at the pharmacy counter.

At a hearing on the gag order ban, Collins said she watched a couple leave a Bangor, Maine, pharmacy without their prescription because they couldn’t afford the $111 copayment and the pharmacist did not advise them about saving money by paying directly for the medicine. When she asked him how often that happens, he said every day.

“Banning gag clauses will make it easier for more Americans to afford their prescription drugs because pharmacists will be able to proactively notify consumers if a less expensive option may be available,” she said last week.

When Rep. Debbie Dingell (D-Mich.) went to a Michigan pharmacy to pick up a prescription recently, she was told it would cost $1,300. “After you peeled me off the ceiling, I called the doctor and screamed and talked to the pharmacist,” she recalled during a hearing last month. “I’m much more aggressive than many in asking questions,” she admitted, and ended up saving $1,260 after she learned she could get an equivalent drug for $40.

While the legislation removes gag orders, it doesn’t address how patients who pay the cash price outside their insurance plan can apply that expense toward meeting their policy’s deductible.

But for Medicare beneficiaries there is a little-known rule — not found in the “Medicare & You” handbook or on its website —that helps people with Medicare Part D or Medicare Advantage coverage. If they pay the lower cash price for a covered drug at a pharmacy that participates in their insurance plan and then submit the proper documentation to their plan, insurers must count it toward patients’ out-of-pocket expenses.

The total of those expenses are important because that amount affects the drug coverage gap commonly called the “doughnut hole.” (This year, the gap begins after the plan and beneficiary spend $3,750 and ends once the beneficiary has spent a total of $5,000.)

And beneficiaries don’t have to wait until the gag order ban takes effect in two years.

The Medicare rule also says that if a senior asks about a lower price for a prescription, the pharmacist can answer.

Rep. Buddy Carter (R-Ga.), a pharmacist who sponsored the Medicare gag order bill, said he wasn’t surprised by the bipartisan support for the legislation. “High prescription drug costs affect everyone,” he said.


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

The Feds’ Termination Of A Tiny Contract Inflames Bitter Fight Over Fetal Tissue

Federal health officials announced late last month they had terminated their contract with a company that supplies human fetal tissue for medical research and were checking that similar contracts, as well as studies conducted with that tissue, comply with federal law.

The seemingly innocuous release about a tiny government contract, which came out as Americans focused on Judge Brett Kavanaugh’s nomination to the Supreme Court, belied the big stakes and contentious issue behind it. Government officials are considering pulling federal funding for a decades-old form of research that has yielded a number of medical advances, including the polio vaccine.

The Department of Health and Human Services has faced mounting pressure from conservative lawmakers and abortion opponents, who strongly supported President Donald Trump’s candidacy, to halt the use of tissue obtained from aborted fetuses.

“The federal government must find ethical alternatives as soon as possible, and should end all association with those who participate in any trafficking or procurement of aborted baby organs,” 45 leaders from groups, including Susan B. Anthony List and the Family Research Council, wrote in a recent letter to HHS.

But a letter to congressional leaders, signed by 64 medical and scientific institutions including the American Academy of Pediatrics and Johns Hopkins University, said interfering in fetal tissue research would be “devastating.” The letter cited its impact in understanding viruses like Zika and HIV, as well as ongoing clinical trials to find treatments for spinal cord injuries.

“Fetal tissue research has been critical for scientific and medical advances that have saved the lives of millions of people,” they wrote.

The supplier whose contract was terminated, a California-based company called Advanced Bioscience Resources, came under fire in 2015 when it was identified in videos that surreptitiously captured Planned Parenthood officials discussing how fetal tissue is provided to researchers.

The videos were part of a controversial sting operation by activists who alleged Planned Parenthood was unlawfully profiting from the sale of fetal tissue, including to Advanced Bioscience Resources. Planned Parenthood officials condemned the videos, which they said were deceptively edited. After its own investigation, a Texas grand jury declined to indict anyone from Planned Parenthood, instead indicting two of the activists responsible for the videos.

HHS vowed to look into the research “in light of the serious regulatory, moral, and ethical considerations.”

The announcement also comes weeks before Election Day, giving Republicans an opportunity to employ a potent talking point — their rigid opposition to Planned Parenthood — as they urge their supporters to vote.

Here’s what you need to know to understand the debate.

Where does fetal tissue come from, and how is it used in research?

Tissue from human fetuses is frequently used to make cell cultures, which allow researchers to examine biological processes in a laboratory setting.

The tissue comes from elective abortions, with the written consent of the woman donating the tissue. Health facilities where the abortion occurred may provide it directly to researchers or transfer it to a supplier, such as Advanced Bioscience Resources.

It is unclear how many suppliers there are. A 2015 report from the Congressional Research Service identified just a few known suppliers, citing a New York Times story that said many researchers go to just two companies: Advanced Bioscience Resources and another California-based company called StemExpress.

Researchers have used fetal tissue to study genetic diseases and development disorders like Down syndrome, as well as to test the toxicity of medications taken by pregnant women and the efficacy of vaccines. The measles vaccine, for example, was developed with the help of fetal tissue.

Fetal tissue also has been transplanted into patients in attempts to treat various disorders, injuries and illnesses, including Parkinson’s disease.

Why is HHS reviewing compliance with federal law? Isn’t this research legal?

It is legal to conduct research using fetal tissue, subject to laws and regulations addressing issues such as consent from the woman undergoing the abortion. Researchers in the United States have used fetal tissue since the 1930s, and the federal government has funded such research since the 1950s, according to the Congressional Research Service.

Things get thorny when it comes to acquiring the tissue. A 1993 law made it illegal “to knowingly acquire, receive, or otherwise transfer any human fetal tissue for valuable consideration if the transfer affects interstate commerce.” In other words, you can neither sell nor purchase fetal tissue in the United States.

But the ban comes with a caveat: Companies that supply researchers with fetal tissue can charge to cover their costs for things like storage, preservation and transportation.

Republican lawmakers and abortion opponents have accused Advanced Bioscience Resources, as well as StemExpress and another supplier that has since gone out of business, of inflating their costs to turn a profit.

After the release of the sting videos in 2015, House and Senate Republicans launched lengthy investigations into fetal tissue acquisition and research, culminating in a pair of reports that accused the suppliers, Planned Parenthood and a handful of its affiliates of illegal sales and purchases.

In late 2016, Republican lawmakers asked the Justice Department to investigate the matter, and several news outlets reported last December that it appeared to be doing so. (The Justice Department typically does not confirm the existence of ongoing investigations.)

So, why is HHS doing this now?

In August, the conservative news outlet CNSNews.com reported the Food and Drug Administration had signed a one-year, nearly $16,000 contract with Advanced Bioscience Resources to acquire fetal tissue for transplantation in mice in federal research labs.

It was not the government’s first contract with the supplier. Records show the FDA contracted with Advanced Bioscience Resources in 2015 and 2016.

In September, 85 House Republicans sent a letter to Scott Gottlieb, the head of the FDA, noting that lawmakers had found evidence the supplier may have violated federal law during their investigations.

“We urge you to cancel this contract immediately and utilize alternative, modern scientific techniques that do not contribute to the trafficking in baby body parts,” the lawmakers wrote. 

Has fetal tissue research been an issue in the past?

Yes. In 1988, in fact, HHS banned funding for research on fetal tissue transplantation while an advisory panel reviewed the issue. While divided in their views on abortion, most panel members supported the conclusion that, since abortion was legal and the research could yield significant medical discoveries, this research was “acceptable public policy.”

The George H.W. Bush administration rejected the panel’s conclusion, concerned the research would create incentives for women to have abortions, and the ban stood until President Bill Clinton eliminated it in 1993, shortly after being sworn in.

Democrats in Congress seized on the safeguards recommended by the panel and soon passed the 1993 law that, among other things, banned the sale and purchase of fetal tissue.

A similar fight over stem cells erupted in 2001, when President George W. Bush severely restricted research on embryonic stem cells, which are taken from human embryos donated by couples undergoing in vitro fertilization. President Barack Obama later lifted the restrictions.


KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.