Tagged U.S. Congress

GOP Health Plan Aims To Curb Medicaid, Expand State Options

For all its populist design, the House GOP’s latest proposal to overhaul federal Medicaid funding creates financial risks for states and could leave some enrollees worse off.

Dramatic changes in Medicaid are a big part of the House bill to partially repeal the Affordable Care Act that’s steaming toward a floor vote scheduled for Thursday.

Big revisions were made to the legislation this week to appeal to conservatives pushing to reduce federal Medicaid spending and shift more power to states. Advocates for the program fear those measures, if enacted, could lead to cuts in benefits and fewer enrollees in the state-federal health insurance program for low-income people.

“We could see a complete unwinding of the Medicaid program as we know it today,” said Donna Friedsam, a health policy expert at the University of Wisconsin.

One big change in the GOP’s current bill would immediately shut off federal money to allow any more states to expand Medicaid eligibility under the ACA, commonly known as Obamacare. During the past three years, 31 states plus the District of Columbia have taken advantage of the provision, adding about 11 million people to Medicaid, and Kansas is considering the option. States also would gain more latitude to determine Medicaid eligibility and benefits for their populations. And for the first time, states could require some enrollees to work as a condition for getting coverage.

The GOP’s original plan was to begin shifting Medicaid expansion funding away from states in 2020. In the revised bill, states could keep funds after 2020 but only as long as those adults who gained coverage in the expansion stay in the program. When they drop out or lose eligibility, their funding would vanish.

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Because of changes in jobs and incomes, many Medicaid enrollees on average lose eligibility within two years, according to Census data.

Regular Medicaid funding also gets an overhaul in the GOP bill.

Since Medicaid’s creation in 1965, everyone eligible has been guaranteed coverage. The federal government’s commitment to help states deal with costs is open-ended, meaning its costs rise as states spend more. The states’ obligation is to cover certain groups of people and to provide specific benefits. Children and pregnant women who meet a state’s income criteria must be protected, for example.

The GOP bill would end that federal commitment, limiting what the government gives states to fixed amounts per year. States could choose two options.

The first way, called a per-capita allotment, means that federal dollars would be allocated to states based on how many Medicaid enrollees they served in a prior year, with annual adjustments for inflation and enrollment increases.

The second way would be a block grant.

Under the revised GOP bill, the block grant option would be available for Medicaid spending only on children, non-elderly adults without disabilities and pregnant women — groups that account for most enrollees.

All states would cover their disabled and elderly populations under the per-capita system, which would get a higher annual inflation rate adjustment than the block grant system under the GOP bill.

The objective is to ensure that funding keeps pace with rising health care costs and the needs of a growing elderly population.

Children could fare badly in states that choose the block grant option, said Joan Alker, executive director of the Center for Children and Families at Georgetown University.

They would no longer be guaranteed access to a standard Medicaid benefit that Congress created in 1967 to ensure that children got access to preventive health care services, treatment and periodic screenings to catch developing health problems early, Alker said.

“That means the governor and/or the state legislature would decide what benefits a child would get, not the child’s pediatrician,” she said.

Of the two funding arrangements, Medicaid block grants also would be financially riskier for states during economic downturns, when unemployment rises and more people seek to enroll in the program. While per-capita caps rise as enrollment grows, block grants do not — and that could leave a state short of federal aid when demand is strongest.

Most states would likely choose a per-capita cap for that reason, said Bill Hammond, director of health policy at the conservative Empire Center for Public Policy in New York.

But some would take a block grant for the freedom they would gain to change benefits and eligibility standards. As a bonus, they would also get to keep any federal money they saved and use it for non-Medicaid spending, he said.

Jason Fichtner, a Medicaid expert at George Mason University in Fairfax, Va., said a block grant would be attractive only for states if they could get more money than under the per-capita option, at least in the short term.

The GOP proposal would allow states to opt out of block-granted funds after 10 years and return to a full per-capita allotment.

Regardless whether the government uses block grants or per-capita caps, the prospects for dramatic changes are already causing shudders among advocates for low-income people.

“Both are really bad options and neither is good for Kentucky and neither is better than what we have now,” said Emily Beauregard, executive director for Kentucky Voices for Health.

Kentucky has a pending request with the Centers for Medicare & Medicaid Services to drastically change its Medicaid program, including adding a requirement that some enrollees work as a condition for enrollment.

The Obama administration consistently rejected states’ requests for a work requirement on the grounds that they would thwart low-income people from getting health care. Studies have found that many Medicaid enrollees who aren’t disabled or elderly already hold jobs, though often in positions that don’t provide health insurance.

The changes in the GOP bill would give states the option starting in October 2017 to add a work requirement for non-disabled adults. Pregnant women and parents of disabled children or children under 6 would be exempt.

Republican leaders said the requirement is modeled on those applied to federal welfare recipients. Under the Kentucky waiver request, people could meet the job requirement by caring for a family member or volunteering.

The work requirement provision is almost certain to face a court challenge if adopted.

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

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A Fact Check Finds Many Misleading Letters From Lawmakers On Health Care

When Louisiana resident Andrea Mongler wrote to her senator, Bill Cassidy, in support of the Affordable Care Act, she wasn’t surprised to get an email back detailing the law’s faults. Cassidy, a Republican who is also a physician, has been a vocal critic.

“Obamacare” he wrote in January, “does not lower costs or improve quality, but rather it raises taxes and allows a presidentially handpicked ‘Health Choices Commissioner’ to determine what coverage and treatments are available to you.”

There’s one problem with Cassidy’s ominous-sounding assertion: It’s false.

The Affordable Care Act, commonly called Obamacare, includes no “Health Choices Commissioner.” Another bill introduced in Congress in 2009 did include such a position, but the bill died — and besides, the job as outlined in that legislation didn’t have the powers Cassidy ascribed to it.

As the debate to repeal the law heats up in Congress, constituents are flooding their representatives with notes of support or concern, and the lawmakers are responding. We decided to take a closer look at these communications after finding misleading statements in an email Sen. Roy Blunt (R-Mo.) sent to his constituents and asked readers to send us communications they had received.

The resulting review of more than 200 such missives by ProPublica and its partners at Kaiser Health News, Stat and Vox found dozens of errors and mischaracterizations about the ACA and its proposed replacement. The legislators have cited wrong statistics, conflated health care terms and made statements that don’t stand up to verification.

It’s not clear if this is intentional, or if the lawmakers and their staffs don’t understand the current law or the proposals to alter it. Either way, the issue of what is wrong — and right — about the current system has become critical as the House prepares to vote on the GOP’s replacement bill Thursday.

“If you get something like that in writing from your U.S. senator, you should be able to just believe that,” said Mongler, 34, a freelance writer and editor who is pursuing a master’s degree in public health. “I hate that people are being fed falsehoods, and a lot of people are buying it and not questioning it. It’s far beyond politics as usual.”

Cassidy’s staff did not respond to questions about Mongler’s letter.

Political debates about complex policy issues are prone to hyperbole and health care is no exception. And to be sure, many of the assertions in the lawmakers’ letters are at least partially based in fact.

Democrats, for instance, have been emphasizing to their constituents that millions of previously uninsured people now have medical coverage thanks to the law. They say insurance companies can no longer discriminate against patients with pre-existing conditions. And they credit the law with allowing adults under age 26 to stay on their parents’ health plans. All true.

For their part, Republicans criticize the law for not living up to its promises. They say former President Barack Obama pledged that people could keep their health plans and doctors, and premiums would go down. Neither has happened. They also say that insurers are dropping out of the market and that monthly premiums and deductibles (the amount people must pay before their coverage kicks in) have gone up. All true.

But elected officials in both parties have distorted evidence and left out important context. Some statements were simply disingenuous. Others were whoppers. And while more Republicans fudged than Democrats, both had their moments.

“Do most people pay that much attention to what their congressman says? Probably not,” said Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, who served as an assistant Health and Human Services secretary from 2010 to 2012. “But I think misinformation or inaccurate information is a bad thing, and not knowing what you’re voting on is a really bad thing.”

We reviewed the emails and letters sent by 51 senators and 134 members of the House within the past few months. Here are some of the most-glaring errors and omissions:

Rep. Pat Tiberi, R-Ohio, incorrectly cited the number of Ohio counties that had only one insurer on the Affordable Care Act insurance exchange.

What he wrote: “In Ohio, almost one third of counties will have only one insurer participating in the exchange.”

What’s misleading: In fact, only 23 percent (less than one quarter) had only one option, according to an analysis by the Kaiser Family Foundation.

His response: A Tiberi spokesperson defended the statement. “The letter says ‘almost’ because only 9 more counties in Ohio need to start offering only 1 plan on the exchanges to be one third.”

Why his response is misleading: Ohio has 88 counties. A 10 percent difference is not “almost.”

Rep. Kevin Yoder, R-Kan., said that the quality of health care in the country has declined because of the ACA, offering no proof.

What he wrote: “Quality of care has decreased as doctors have been burdened with increased regulations on their profession.”

Why it’s misleading: Some data show that health care has improved since the passage of the ACA. Patients are less likely to be readmitted to a hospital within 30 days after they have been discharged, for instance. Also, payments have been increasingly linked to patients’ outcomes rather than just the quantity of services delivered. A 2016 report by the Commonwealth Fund, a health care nonprofit think tank, found that the quality care has improved in many communities following the ACA.

His response: None.

Rep. Anna Eshoo, D-Calif., misstated the percentage of Medicaid spending that covers the cost of long-term care, such as nursing home stays.

What she wrote: “It’s important to note that 60 percent of Medicaid goes to long-term care and with the evisceration of it in the bill, this critical coverage is severely compromised.”

What’s misleading: Medicaid does not spend 60 percent of its budget on long-term care. The figure is closer to a quarter, according to the Center on Budget and Policy Priorities, a liberal think tank. Medicaid does, however, cover more than 60 percent of all nursing home residents.

Her response: Eshoo’s office said the statistic was based on a subset of enrollees who are dually enrolled in Medicaid and Medicare. For this smaller group, 62 percent of Medicaid expenditures were for long-term support services, according to the Kaiser Family Foundation.

What’s misleading about the response: Eshoo’s letter makes no reference to this population, but instead refers to the 75 million Americans on Medicaid.

Rep. Chuck Fleischmann, R-Tenn., pointed to the number of uninsured Americans as a failure of the ACA, without noting that the law had dramatically reduced the number of uninsured.

What he wrote: “According to the U.S. Census Bureau, approximately thirty-three million Americans are still living without health care coverage and many more have coverage that does not adequately meet their health care needs.”

Why it’s misleading: The actual number of uninsured in 2015 was about 29 million, a drop of 4 million from the prior year, the Census Bureau reported in September. Fleischmann’s number was from the previous year.

Beyond that, reducing the number of uninsured by more than 12 million people from 2013 to 2015 has been seen as a success of Obamacare. And the Republican repeal-and-replace bill is projected to increase the number of uninsured.

His response: None.

Rep. Joseph P. Kennedy III, D-Mass., overstated the number of young adults who were able to stay on their parents’ health plan as a result of the law.

What he wrote: The ACA “allowed 6.1 million young adults to remain covered by their parents’ insurance plans.”

What’s misleading: A 2016 report by the U.S. Department of Health and Human Services, released during the Obama administration, however, pegged the number at 2.3 million.

Kennedy may have gotten to 6.1 million by including 3.8 million young adults who gained health insurance coverage through insurance marketplaces from October 2013 through early 2016.

His response: A spokeswoman for Kennedy said the office had indeed added those two numbers together and would fix future letters.

Rep. Blaine Luetkemeyer, R-Mo., said that 75 percent of health insurance marketplaces run by states have failed. They have not.

What he said: “Nearly 75 percent of state-run exchanges have already collapsed, forcing more than 800,000 Americans to find new coverage.”

What’s misleading: When the ACA first launched, 16 states and the District of Columbia opted to set up their own exchanges for residents to purchase insurance, instead of using the federal marketplace, known as Healthcare.gov.

Of the 16, four state exchanges, in Oregon, Hawaii, New Mexico, and Nevada, failed, and Kentucky plans to close its exchange this year, according to a report by the House Energy and Commerce Committee.  While the report casts doubt on the viability of other state exchanges, it is clear that three-quarters have not failed.

His response: None.

Rep. Dana Rohrabacher, R-Calif., overstated that the ACA “distorted labor markets,” prompting employers to shift workers from full-time jobs to part-time jobs.

What he said: “It has also, through the requirement that employees that work thirty hours or more be considered full time and thus be offered health insurance by their employer, distorted the labor market.”

What’s misleading: A number of studies have found little to back up that assertion. A 2016 study published by the journal Health Affairs examined data on hours worked, reason for working part time, age, education and health insurance status. “We found only limited evidence to support this speculation” that the law led to an increase in part-time employment, the authors wrote. Another study found much the same.

In addition, PolitiFact labeled as false a statement last June by Donald Trump in which he said, “Because of Obamacare, you have so many part-time jobs.”

His response: Rohrabacher spokesman Ken Grubbs said the congressman’s statement was based on an article that said, “Are Republicans right that employers are capping workers’ hours to avoid offering health insurance? The evidence suggests the answer is ‘yes,’ although the number of workers affected is fairly small.”

We pointed out that “fairly small” was hardly akin to distorting the labor market. To which Grubbs replied, “The congressman’s letter is well within the range of respected interpretations. That employers would react to Obamacare’s impact in such way is so obvious, so nearly axiomatic, that it is pointless to get lost in the weeds,” Grubbs said.

Rep. Mike Bishop, R-Mich., appears to have cited a speculative 2013 report by a GOP-led House committee as evidence of current and future premium increases under the ACA.

What he wrote: “Health insurance premiums are slated to increase significantly. Existing customers can expect an average increase of 73 percent, while the average change due to Obamacare for those purchasing a new plan will be a 96 percent increase in premiums. The average cost for a new customer in the individual market is expected to rise $1,812 per year.”

What’s misleading: The figures seem to have come from a report issued before the Obamacare insurance marketplaces launched and before 2014 premiums had been announced. The letter implies these figures are current. In fact, premium increases by and large have been moderate under Obamacare. The average monthly premium for a benchmark plan, upon which federal subsidies are calculated, increased about 2 percent from 2014 to 2015; 7 percent from 2015 to 2016; and 25 percent this year, for states that take part in the federal insurance marketplace.

His response: None

Rep. Dan Newhouse, R-Wash., misstated the reasons why Medicaid costs per person were higher than expected in 2015.

What he wrote: “A Medicaid actuarial report from August 2016 found that the average cost per enrollee was 49 percent higher than estimated just a year prior — in large part due to beneficiaries seeking care at more expensive hospital emergency rooms due to difficulty finding a doctor and long waits for appointments.”

What’s misleading: The report did not blame the higher costs on the difficulty patients had finding doctors. Among the reasons the report did cite: patients who were sicker than anticipated and required a raft of services after being previously uninsured. The report also noted that costs are expected to decrease in the future.

His response: None

Sen. Dick Durbin, D-Ill., wrongly stated that family premiums are declining under Obamacare.

What he wrote: “Families are seeing lower premiums on their insurance, seniors are saving money on prescription drug costs, and hospital readmission rates are dropping.”

What’s misleading:  Durbin’s second and third points are true. The first, however, is misleading. Family insurance premiums have increased in recent years, although with government subsidies, some low- and middle-income families may be paying less for their health coverage than they once did.

His response:  Durbin’s office said it based its statement on an analysis published in the journal Health Affairs that said that individual health insurance premiums dropped between 2013 and 2014, the year that Obamacare insurance marketplaces began. It also pointed to a Washington Post opinion piece that said that premiums under the law are lower than they would have been without the law.

Why his response is misleading:  The Post piece his office cites states clearly, “Yes, insurance premiums are going up, both in the health-care exchanges and in the employer-based insurance market.”

Rep. Susan Brooks, R-Ind., told constituents that premiums nationwide were slated to jump from 2016 to 2017, but failed to mention that premiums for some plans in her home state actually decreased.

What she wrote: “Since the enactment of the ACA, deductibles are up, on average, 63 percent. To make matters worse, monthly premiums for the “bronze plan” rose 21 percent from 2016 to 2017. … Families and individuals covered through their employer are forced to make the difficult choice: pay their premium each month or pay their bills.”

What’s misleading:  Brooks accurately cited national data from the website HealthPocket, but her statement is misleading. Indiana was one of two states in which the premium for a benchmark health plan — the plan used to calculate federal subsidies — actually went down between 2016 and 2017. Moreover, more than 80 percent of marketplace consumers in Indiana receive subsidies that lowered their premium costs. The HealthPocket figures refer to people who do not qualify for those subsidies.

Her response: Brooks’ office referred to a press release from Indiana’s Department of Insurance, which took issue with an Indianapolis Star story about premiums going down. The release, from October, when Vice President Mike Pence was Indiana’s governor, said that the average premiums would go up more than 18 percent over 2016 rates based on enrollment at that time. In addition, the release noted, 68,000 Indiana residents lost their health plans when their insurers withdrew from the market.

Why her response is misleading: For Indiana consumers who shopped around, which many did, there was an opportunity to find a cheaper plan.

Sen. Ron Wyden, D-Ore., incorrectly said that the Republican bill to repeal Obamacare would cut funding for seniors in nursing homes.

What he wrote: “It’s terrible for seniors. Trumpcare forces older Americans to pay 5 times the amount younger Americans will — an age tax — and slashes Medicaid benefits for nursing home care that two out of three Americans in nursing homes rely on.”

What’s misleading: Wyden is correct that the GOP bill, known as the American Health Care Act, would allow insurance companies to charge older adults five times higher premiums than younger ones, compared to three times higher premiums under the existing law. However, it does not directly slash Medicaid benefits for nursing home residents. It proposes cutting Medicaid funding and giving states a greater say in setting their own priorities. States may, as a result, end up cutting services, jeopardizing nursing home care for poor seniors, advocates say, because it is one of the most-expensive parts of the program.

His response: Taylor Harvey, a spokesman for Wyden, defended the statement, noting that the GOP health bill cuts Medicaid funding by $880 billion over 10 years and places a cap on spending. “Cuts to Medicaid would force states to nickel and dime nursing homes, restricting access to care for older Americans and making it a benefit in name only,” he wrote.

Why his response is misleading: The GOP bill does not spell out how states make such cuts.

Rep. Derek Kilmer, D-Wash., misleadingly said premiums would rise under the Obamacare replacement bill now being considered by the House.

What he wrote: “It’s about the 24 million Americans expected to lose their insurance under the Trumpcare plan and for every person who will see their insurance premiums rise — on average 10-15 percent.”

Why it’s misleading: First, the Congressional Budget Office did estimate that the GOP legislation would cover 24 million fewer Americans by 2026. But not all of those people would “lose their insurance.” Some would choose to drop coverage because the bill would no longer make it mandatory to have health insurance, as is the case now.

Second, the budget office did say that in 2018 and 2019, premiums under the GOP bill would be 15 to 20 percent higher than they would have been under Obamacare because the share of unhealthy patients would increase as some of those who are healthy drop out. But it noted that after that, premiums would be lower than under the ACA.

His response: None.

Have you corresponded with a member of Congress or senator about the Affordable Care Act? We’d love to see the response you received. Please fill out our short form.

Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization based in New York City.

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

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Trump’s Promise To Rein In Drug Prices Could Open Dam To Importation Laws

With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.

Congress came close to allowing importation through the Medicare Modernization Act in 2003, but added one firm precondition that has proved a nonstarter. The secretary of Health and Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.

“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard — guaranteeing that no imported prescriptions posed a threat — has kept any secretary of HHS from condoning it.

In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan and Andrew von Eschenbach, who headed the FDA at various times between 2002 through 2016.

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The recent proposal, from Sen. Bernie Sanders (I-Vt.) and such Democrats as Cory Booker from New Jersey and Bob Casey from Pennsylvania, drops that requirement. Instead, it sets up a regulatory system where Canadian pharmacies who purchase their supply from manufacturers inspected by the Food and Drug Administration would be licensed to sell to customers across the border. The bill allows not only individuals but drug wholesalers and pharmacies to buy from Canada.

After two years, HHS could allow importation from other countries that meet standards comparable to those of the U.S.

(Another bill in Congress, proposed in January by John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.) focuses solely on allowing individuals to purchase from such pharmacies.)

Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with Elijah Cummings, Peter Welch (D-Vt.) and the head of Johns Hopkins Hospital, Redonda Miller, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cummings told reporters later that Trump said he supports Medicare price negotiation as well as the Sanders bill.

PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.

“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.

Surveys indicate that up to 8 percent of Americans have bought medicines outside the U.S. even though the practice is technically illegal and imported pills are subject to confiscation.

Around 45 million Americans — 18 percent of the adult population — said last year they did not fill a prescription due to cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of PharmacyChecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company comparing prices offered in Canada to those in New York, shows drugs are frequently three times or more as costly in the U.S. as over the border.

For example, a simple Proventil asthma inhaler costs $73.19 in the U.S. vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in the U.S. but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.

Many previous bills to allow importation or to allow Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77 percent of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.

To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A General Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings and regulatory expenses.

Allowing people to legally import medications wouldn’t totally solve the problem of high prescription drugs, advocates say, but would be a step in the right direction. Said Levitt: “The best way for Americans to afford their meds is to enact polices here to bring the prices down here.”

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, Pharmaceuticals

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In Deep-Red Western N.C., Revered Congressman Leads Charge Against GOP Bill

HIGHLANDS, N.C. — In this corner of Appalachia, poverty takes a back seat to art galleries, country clubs, golf course communities, five-star restaurants and multimillion-dollar houses.

From this perch, Rep. Mark Meadows, a real estate entrepreneur who capitalized on the area’s transformation into a prosperous retirement and vacation community, rose to political power quickly. Now the conservative Republican leads the House Freedom Caucus, controlling between 30 and 40 votes in Congress and showing few qualms about endangering his party’s best chance to repeal the Affordable Care Act.

“I am willing to invest the political capital to get it right,” Meadows, who has called the GOP replacement “Obamacare Lite,” said Thursday on MSNBC. “The next week is critical.”

And on Saturday, Meadows went to President Donald Trump’s Mar-a-Lago Club in Florida to negotiate over the bill with Trump aides, along with with Sen. Ted Cruz (R-Texas) and Sen. Mike Lee (R-Utah).

Meadows’ confidence is warranted.

His gerrymandered district covers 17 counties, spanning 150 miles across western North Carolina. The populous liberal bastion of Asheville is mostly carved out of his district like a bite from a cookie. What’s left is a retiree-rich constituency of 750,000 people that is heavily Republican, mostly white and lives mainly in small, rural towns amid pockets of extreme wealth. Its survival could hinge on a Supreme Court ruling expected this year in a case alleging racial bias in the state Legislature’s 2011 redrawing of North Carolina’s congressional map.

Elected in 2012, Meadows, 57, has rebelled against the establishment Republican Party — helping shut down the government in 2013 and ousting Speaker John Boehner in 2015.

While Democrats and even moderate Republicans decry House Speaker Paul Ryan for cutting federal aid to help get people insured in the GOP bill, Meadows says the cuts don’t go deep enough. He vows to oppose any ACA replacement that does not bring down health costs for people and government. No such plan that actually controls costs is on the table, however.

Meadows wants to cut off all 10 million Americans who today get federal subsidies to buy health coverage, which he says the country can ill afford. With enough support, Meadows could either block the House leadership from passing its plan or force it to approve a more conservative replacement that would face little chance of getting through the more moderate Senate.

Meadows’ potential role as “Trumpcare” spoiler — is stirring concern in the White House and Congress. By Thursday, Meadows seemed to have gotten that message.

“The last thing I want is for the president to be mad at me,” Meadows told Politico. “He asked me to negotiate in good faith, so I have been working around the clock.”

A lake in Highlands, N.C., is pictured. (Phil Galewitz/KHN)

Meadows was absent, though, from a Friday meeting in the Oval Office with members of the Republican Study Committee, another group of conservative representatives, where Trump said he had secured enough votes to pass the House bill.

Meadows’ hard line doesn’t bother most folks back in western North Carolina, where Obamacare is unpopular. Only about 5 percent of those in his district receive government-subsidized health plans made available by the law.

Meadows, who now lives in West Asheville, moved to North Carolina from Tampa to raise a family in the 1980s. The proprietor of a small sandwich shop here in Highlands before he shifted to real estate, Meadows is revered by his constituents.

Even the local hospital industry — which typically opposes any effort to scale back the health law — remains firmly in Meadow’s corner.

“We are big fans of Mark. He’s a man of integrity and he has the heart,” said Jimm Bunch, CEO of Park Ridge Health, a 103-bed hospital in Hendersonville, N.C. He heaps praise on Meadows even as the congressman fights to eviscerate the law that helped the hospital achieve one of its best financial years ever. As more patients got insurance, Park Ridge gained $600,000 a year in funding it used to provide free care to other patients.

Jimm Bunch, CEO of Park Ridge Hospital in Fletcher, N.C. says the hospital made more money as a result of Obamacare subsidies but won’t bash the Meadows plan to take them away. (Phil Galewitz/KHN)

Because North Carolina did not expand Medicaid under Obamacare, many poor adults remained uninsured. The state’s uninsured rate fell from 20.4 percent in 2013 to 13.6 percent in 2016, 2.5 points higher than the national average, according to Gallup.

Small-business owners, who provide most jobs in the district, are reluctant to take on Meadows., who is seeking to eliminate their government assistance to get health coverage.

At Sanctuary Brewing in Hendersonville, co-owner Joe Dinan said the Obamacare coverage he bought this year helped him get skin cancer surgery on his head. “I don’t want to see the subsidy end,” Dinan said. He won’t say anything critical about Meadows though, demurring that Hendersonville is a small town.

Meadows insists no one will get left behind.

He wants to allow people to buy less-expensive policies with fewer benefits than now required under the ACA. His tax help would be in the form of deductions people take at the end of the year or a break on their payroll taxes — different than both the current law and the Trumpcare plan working its way through Congress now.

It worries Rachel Lewicki, 30, who works at the local tea and spice shop on Main Street in Highlands.

Lewicki recently had surgery for a uterine tumor, paid for by a subsidized health plan she bought under Obamacare that costs her less than $100 a month. Now she fears her good fortune will end. “It’s not fair,” she said. “The way things are going, I’m scared and so are a lot of people who need this help.”

Kent Loy, a volunteer at a thrift store in Hendersonville, speaks of Meadows in harsher, personal terms.

“It’s an attack on the poor and how someone who claims to be a Christian can take this behavior is beyond me,” said Loy, 71. “This should disqualify him from office.”

Joe Dinan, co-owner of Sanctuary Brewing in Hendersonville, used Obamacare subsidies to get coverage and deal with skin cancer this year. (Phil Galewitz/KHN)

But it won’t, said Chris Cooper, professor of political science at Western Carolina University. Meadows has little to worry about in his heavily Republican district where he took 65 percent of the vote in November. “Taking out Asheville turned the district from being the most competitive district in the state to the most conservative,” Cooper said.

The political climate is challenging for cultivating grass-roots opposition, according to Susan Kimball, of Waynesville, N.C., who is part of Progressive Nation WNC, a group pushing to retain the ACA.

She said she has sought to meet Meadows in his district office several times to complain about his Obamacare stance, but to no avail.

Critics like her have recently pushed Meadows to hold a town hall meeting to hear their views, as many members of Congress did in the past month. His office said Meadows arranges such meetings only in August.

“I just feel like he doesn’t care,” Kimball said.

A cancer survivor, Kimball, 62, has benefited from Obamacare’s mandate that insurers provide coverage to people with preexisting health conditions. For $237 a month, Kimball has a subsidized Blue Cross plan that pays for visits to doctors and tests when she needs them.

She moved to Waynesville from South Florida four years ago, and the area’s conservatism has been an eye-opener.

“We were just moving to the mountains, and we didn’t know the region would become Tea Party central,” Kimball said.

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

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A Health Reporter Walks Into Reagan National Airport …

Flying out of Reagan National Airport on Wednesday, I was expecting a short reprieve from the issue that has consumed my work in health journalism for eight years — the Affordable Care Act and, lately, Republican efforts to replace it.

The voyage turned into anything but, with some unexpected close encounters.

Media-accessible Sen. Chuck Grassley (R-Iowa) keeps his pulse on the news and stays in touch with the public at Reagan National Airport outside Washington, D.C., on March 15. (Phil Galewitz/KHN)

Awaiting my flight and in search of any outlet to plug in my phone, I recognized Sen. Chuck Grassley heading back to his home state of Iowa. Always one of the more media-accessible senators, he didn’t hesitate to chat when my reporter’s instincts kicked in to curbside him with some questions on the ACA repeal. It was Grassley who initially helped turn public tide against Obamacare when he (wrongly) claimed the legislation had “death panels.”

Grassley, 83, chairman of the Senate Judiciary Committee and one of longest-serving members of Congress, told me the GOP leadership bill — the American Health Care Act — doesn’t go far enough to help older Americans, those ages 55-64, get coverage. He said a plan is circulating in the Senate to extend more government subsidies to help this age group, which a recent report by the non-partisan Congressional Budget Office (CBO) noted would be hit particularly hard.

But, reflecting Republican divisions, he acknowledged that subsidies — even if directed at low-income baby boomers — would be tricky given opposition from conservatives such as House Freedom Caucus Chairman Mark Meadows (R-N.C.). Much of the party’s hard right is opposed to subsidies, including former presidential candidate Ted Cruz.

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Then Grassley moved on to two points on which his party is united. He said the Republicans must deal with Obamacare before it adjourns for Easter/Passover recess on April 6. That’s because Republicans still must leave time to deal with tax reform and infrastructure bill before summer break. “It’s now or never,” he said.

I asked if he would support any GOP bill, even if it increased cost for some Americans or led to more joining the ranks of uninsured. Grassley grew a bit angry. “Anything is better than Obamacare and what we have now,” he said with his outstretched fingers nearly touching me.

This is a common but increasingly contentious talking point in GOP circles. The CBO report found that 24 million more Americans would lose coverage under the GOP plan by 2026.

No sooner had I shaken hands with the senator and boarded my American Airlines flight to South Florida, I spotted none other than Sen. Ted Cruz, himself, the conservative fireball from Texas, sitting in the row ahead of me. I watched the flight crew comp his glass of red wine — I paid $7 for my Sam Adams beer — and hesitated to disturb him in flight as he played a computer basketball game on his tablet.

But once landed, I couldn’t resist introducing myself as a reporter. I told him I had just read his op-ed in The Wall Street Journal explaining his own opposition to the GOP leadership plan, and the need to freeze Medicaid expansion immediately rather than by 2020 and provide tax credits only for working Americans to help them get health coverage.

Sen. Ted Cruz (R-Texas) flies coach — in the row that offers extra legroom — on a March 15 flight to South Florida. (Phil Galewitz/KHN)

As we deplaned in West Palm Beach, Cruz told me that he didn’t think Medicaid should help non-disabled adults because it would give them an incentive not to work and would make them dependent on government handouts. He said Medicaid was meant to help children, pregnant women and the disabled — and money spent to help others would take away from those who were more deserving.

He noted that states that expanded Medicaid have long waits for care for disabled Medicaid beneficiaries needing home and community-based care. I cover Medicaid and felt compelled to point out that the longest Medicaid waiting lists were in states that did not expand Medicaid.

Cruz, 46, mentioned that he wants the federal government to offer straight lump-sum grants to states for Medicaid — different from today’s open-ended federal funding and the GOP leadership’s plan that ties funding to the number of patients enrolled.

He said a block grant would give states more motivation to “innovate” to find ways to provide care for less money. I asked how states would innovate during time of economic downturns. “States have faced tough time before and would find a way,” he said.

Cruz, who was in Florida for a conference, discussed Obamacare changes in a thoughtful and mild manner that I did not expect, given the prevailing tone in Washington, D.C., these days.

As we searched for our rides, after midnight, outside the terminal, he took my business card.

My close encounters with two influential voices in the Republican Senate during one journey underlined the deep divisions the party faces as it seeks to replace the ACA.

It was time to put Obamacare to bed — at least for the night.

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

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Deciphering CBO’s Estimates On The GOP Health Bill

The Congressional Budget Office is out with its estimate of what effects the Republican health bill, “The American Health Care Act,” would have on the nation’s health care system and how much it would cost the federal government. The GOP plan is designed to partially repeal and replace the Affordable Care Act passed during the Obama administration.

Here are some of the CBO highlights:

• $337 billion reduction in the deficit. That’s CBO’s estimate over the next decade, taking into account both decreased government spending in the form of less help to individuals to purchase insurance and lower payments to states for the Medicaid program. It also includes decreased revenue from the repeal of the taxes imposed by the ACA to pay for the new benefits.

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• 24 million more people without insurance in a decade. The federal budget experts estimate that people will lose insurance and that the drop will kick in quickly. In 2018, they say 14 million more people would join the ranks of the uninsured. It would reach the 24 million by 2026, when “an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”

• 15 to 20 percent increase in 2018 premiums, but relief would follow. Monthly costs for insurance would go up at first, due to the elimination of the requirement for most people to have insurance or else pay a tax penalty. After 2018, CBO estimates that average premiums would actually drop by 10 percent by 2026 compared to current law. That is because the lower prices for younger people would encourage more to sign up. By contrast, the law would “substantially [raise] premiums for older people.”

• $880 billion drop in federal Medicaid spending over the decade. That comes primarily by imposing, for the first time, a cap on federal contributions to the program for those with low incomes.

• 14 million fewer Medicaid enrollees by 2026. That’s 17 percent fewer than projected under current law. The projection includes people who are currently eligible and would lose coverage, as well as people who might have become eligible if more states, as expected, expanded coverage under the ACA. CBO projects that is unlikely to happen now.

• 95 percent of people who are getting Medicaid through the health law’s expansion would lose that enhanced federal funding. The CBO estimates that only 5 percent of enrollees in the expansion program would remain eligible for the higher federal payments by 2024, since the bill would phase out those payments to states as patients cycle in and out of eligibility.

• 15 percent of Planned Parenthood clinic patients would “lose access to care.” These patients generally live in areas without other sources of medical care for low-income people. The Republican bill would cut out Medicaid funding for Planned Parenthood for a year.

Categories: Insurance, Medicaid, Public Health, The Health Law

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KHN On Call: How Will People Who Are Already Sick Be Treated Under A New Health Law?

Many people are worried about how potential changes to the federal health law might affect them. But few are as concerned as those with preexisting health conditions.

The Affordable Care Act made it illegal for insurers to deny or charge people more money because of a history of illness. That’s a pretty big deal because an estimated 52 million American adults have such conditions — ranging from serious ailments like diabetes and HIV to more minor maladies like acne or seasonal allergies. Before the ACA, people with these conditions were often denied insurance. If they were offered insurance, it could cost more or didn’t include coverage of their condition.

Republicans insist they want to continue to allow people with preexisting conditions to maintain their coverage in any replacement for the health law, and the current draft of the American Health Care Act retains that provision.

“We are protecting those patients living with preexisting conditions,” said House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) at the start of his committee’s consideration of the bill March 8.

But it is not yet clear how they will be able to do it, which leads to our listener question this week.

Rich Renner of Collingswood, N.J., asks, if the law is repealed and whatever replaces it does not include a preexisting conditions provision, are there any programs in place at the state level that would step in to help?”

In a word, no. But it’s complicated.

First, a little background. People who get their insurance on the job have been protected against discrimination for preexisting conditions since 1996, when Congress passed the Health Insurance Portability and Accountability Act (HIPAA). They can go from one job-based policy to another job-based policy, or, in some cases, to an individual policy, as long as they remain covered without a break of more than 63 days.

But insurance companies in the individual market were afraid that if sick people could buy insurance, it would drive costs up, and healthy people wouldn’t bother to buy coverage or would be priced out. That could lead to an insurance “death spiral,” where there are no healthy people left to help spread out the costs of the sick.

The compromise in the ACA was to require healthy people to have insurance or else pay a fine. That wasn’t popular, and it’s the number one item Republicans say they want to repeal.

In the bill introduced by Republican leaders, however, the requirement for insurers to sell to those with preexisting conditions remains intact. That’s not because they don’t want to repeal it, but because they can’t under the budget rules that govern the bill.

But that doesn’t guarantee people with preexisting conditions will still be able to get insurance.

The GOP bill says that people who experience a gap in coverage will pay a fine to the insurance company of 30 percent higher premiums for a year.

But analysts say that could actually deter healthy people from signing up until they need care.

And if that happens and there are still too many sick people signing up, more insurers will stop selling coverage until there’s nothing left to buy.

So in the end you could have a guarantee but no way to buy coverage. Obviously there’s much more to be worked out here.

Got more questions about what’s happening to the ACA? I’ll be back next week with even more answers. Just tweet @MorningEdition using the hashtag #ACAchat.

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

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