Category Archives: ACA

November jobs report: US economy adds 245,000 jobs, unemployment rate falls to 6.7%

Posted on by • Posted in ACA, Chronic Care Management, Chronic Conditions, Chronic Diseases, Coronavirus, Crisis, Crisis Management, Deferred Healthcare, Economic Crisis, Economic Recovery, Employee Furlough, Employee Hiring Freeze, Employee Layoffs, Employee Pay Cuts, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Job, Job Loss, Job Market, Job Search, Job Security, Out of Pocket Expenses, Pandemic, Preexisting Conditions, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

https://finance.yahoo.com/news/november-2020-jobs-report-labor-market-coronavirus-pandemic-unemployment-183714326.html

The 245,000 new jobs added last month is smallest since U.S. recovery began in May - MarketWatch

The U.S. economy added back the smallest number of jobs in seven months in November, as the labor market endured mounting pressure from the coronavirus pandemic while businesses wait for a vaccine to be distributed next year.

The U.S. Department of Labor released its monthly jobs report Friday morning at 8:30 a.m. ET. Here were the main results from the report, compared to Bloomberg consensus data as of Friday morning:

  • Change in non-farm payrolls: +245,000 vs. +460,000 expected and a revised +610,000 in October
  • Unemployment rate: 6.7% vs. 6.7% expected and 6.9% in October
  • Average Hourly Earnings month-over-month: 0.3% vs. +0.1% expected and +0.1% in October
  • Average Hourly Earnings year-over-year: 4.4% vs. +4.2% expected and a revised +4.4% in October

During November, a plethora of new stay-in-place measures and curfews swept the nation as COVID-19 cases, hospitalizations and deaths swelled to record levels. These renewed restrictions weighed on the rate of the recovery in the labor market, which had already been slowing after a record surge in rehiring followed the initial wave of lockdowns in the spring.

To that end, job gains in November sharply missed expectations. Non-farm payrolls grew by just 245,000 during the month for the smallest number since April’s record, virus-induced decline. October’s payroll gain was downwardly revised to 610,000 from the 638,000 reported earlier, while September’s gain was raised to 711,000 from 672,000.

A third straight month of declining government employment served as a drag on the headline payrolls figure, as another 93,000 temporary workers hired for the 2020 Census were let go.

In the private sector, retail trade industries shed nearly 35,000 jobs following a gain of 95,000 in October. Leisure and hospitality employers added just 31,000 jobs during November, declining by nearly 90% from October. And in goods-producing industries, manufacturing jobs rose by only 27,000 for the month, falling short of the 40,000 expected.

But a handful of other industries added more jobs in November from October: Transportation and warehousing jobs grew by 145,000 to more than double October’s advance, and growth in wholesale trade positions also doubled to 10,400.

November’s unemployment rate also improved just marginally to 6.7% from the 6.9% reported in October. While down from a pandemic-era high of 14.7% in April, the jobless rate remains nearly double that from before the pandemic.

Other employment reports this week underscored the decelerating trend. Private-sector hiring fell to the lowest level in four months in November, according to data tracked by ADP. New weekly jobless claims began rising again around the 12th of the month, when the Labor Department conducts its surveys for its monthly jobs report. And in the Federal Reserve’s November Beige Book, the central bank noted that nearly all districts reported rising employment, “but for most, the pace was slow, at best, and the recovery remained incomplete.”

The U.S. economy still has a ways to go before fully making up for the drop in payrolls induced by the pandemic. Even with a seventh straight month of net job gains, the economy remains about 9.8 million jobs short of its pre-pandemic level in February. The U.S. economy lost more than 22 million jobs between March and April.

And worryingly, the number of the long-term unemployed has kept climbing. Those classified as “permanent job losers” totaled 3.7 million in November, eclipsing the number of individuals on temporary layoff for the second time since the start of the pandemic. Permanent job losers have increased by 2.5 million since February, before the pandemic meaningfully hit the U.S. economy.

In Washington, congressional lawmakers have for months been at a stalemate over the size and scope of another stimulus package, which could help provide funds for businesses to help keep workers employed, and offer extended unemployment benefits for those the pandemic has kept out of work. Federal unemployment programs authorized under the CARES Act in the spring are poised to expire at the end of the month. These include the Pandemic Emergency Unemployment Compensation and Pandemic Unemployment Assistance programs, which together provide benefits for more than 13 million Americans.

“The only thing that matters about today’s NFP [non-farm payrolls] report is whether it increases the likelihood of a stimulus deal getting done during the lame duck session,” Peter Tchir, head of macro strategy for Academy Securities, said in an email Friday morning. “While the unemployment rate shrunk and wages ticked up nicely, the headline number dropped significantly, was well below average expectations, and included some downward revisions to last month (and upward revisions to 2 months ago) – all of which point to a less robust job market.”

Aliera ordered to pay $1 million for selling illegal health insurance

Posted on by • Posted in ACA, Consumer Protection, Consumer Trust, Essential Health Benefits, Fraud and Abuse, Health Insurance Benefit Design, Health Insurance Coverage Adequacy, Health Insurance Industry, Healthcare Sharing Ministry, Preexisting Conditions, Unlicensed • Leave a comment

https://www.insurance.wa.gov/news/aliera-ordered-pay-1-million-selling-illegal-health-insurance

Aliera Ordered To Pay $1 Million for Selling Illegal Health Insurance - Dailyfly.com Lewis-Clark Valley Community - colleent

Insurance Commissioner Mike Kreidler’s action against Aliera Healthcare, Inc. (Aliera) ordering the company to stop selling health insurance illegally was upheld on Nov. 13 after the company appealed.  Today, Aliera was ordered to pay a $1 million fine. It has 90 days to appeal. 

Kreidler took action against Aliera and its partner, Trinity Healthshare, Inc. (Trinity) in May 2019 after an investigation revealed that since August 2018, the companies sold 3,058 policies to Washington consumers and collected $3.8 million in premium. Trinity agreed to Kreidler’s order. 

“Aliera and Trinity promised to provide people with coverage when they needed it only to leave consumers with huge medical bills,” said Kreidler. “I’m taking action today to send a message to all scam artists – if you harm our consumers, you will pay heavily.

“Shopping for health insurance can be very stressful – especially if you have to worry about being ripped off. True insurance companies have to meet rigorous standards before they can sell coverage to consumers. These companies are hiding behind a federal and state exemption that exists for legitimate health care sharing ministries and using it to rake in profit across the country on the backs of vulnerable consumers.”

Aliera, an unlicensed insurance producer in Washington, administered and marketed health coverage on behalf of Trinity HealthShare. Trinity represents itself as a health care sharing ministry. Such ministries are exempt from state insurance regulation only if they meet statutory requirements.  If so, they do not have to meet the same consumer protections guaranteed under the Affordable Care Act. This includes providing coverage for anyone with a pre-existing medical condition.  

A legal health care sharing ministry is a nonprofit organization whose members share a common set of ethical or religious beliefs and share medical expenses consistent with those beliefs. 

Kreidler’s office has received more than 20 complaints from consumers. Some believed they were buying health insurance without knowing they had joined a health care sharing ministry. Many discovered this when the company denied their claims because their medical conditions were considered pre-existing under the plan.

“Real health care sharing ministries can offer a valuable service to their members,” Kreidler said. “Unfortunately, we’re seeing players out there trying to use the exemptions for legitimate ministries to skirt insurance regulation and mislead trusting consumers. I want these outfits to know we’re on to them and we will hold them accountable.”

Kreidler’s investigation found Aliera:

  • Sold insurance without a Washington insurance producer license. 
  • Represented an unauthorized insurer, Trinity.  
  • Operated an unlicensed discount plan organization. 

Kreidler’s investigation into Trinity found that it failed to meet key federal and state requirements:

Trinity was formed on June 27, 2018, without any members.  Federal and state laws require that health care sharing ministries be formed before Dec. 31, 1999, and their members to have been actively sharing medical costs. 

Affordable Care Act market for 2021 sees strong insurer participation

Posted on by • Posted in ACA, Chronic Care Management, Chronic Conditions, Chronic Diseases, Deferred Healthcare, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Out of Pocket Expenses, Preexisting Conditions, Supreme Court, Uncompensated Care, Underinsured, Uninsured • Leave a comment

https://www.healthcarefinancenews.com/news/ffordable-care-act-market-2021-sees-strong-insurer-participation

Insurer Participation on the ACA Marketplaces, 2014-2021 | KFF

Some 30 insurers are entering the individual market, and an additional 61 are expanding their service area within states, a KFF report says. 

Insurer participation in the Affordable Care Act marketplace in 2021 is seeing a third straight year of growth as several insurers are entering the market or expanding their service area, according to a recent Kaiser Family Foundation report.

For instance, in 2020, UnitedHealthcare, the nation’s largest insurer, became a new entrant in five states, according to the report: Arizona, Maryland, North Carolina, Tennessee and Virginia. Twenty states had new entrants to the market.

For 2021, 30 insurers are entering the individual market, and an additional 61 are expanding their service area within states. 

There will be an average of five insurers per state in 2021, up from a low of 3.5 in 2018, but still below the peak of six in 2015. Only 10% of counties will have a single insurer offering in 2021, down from 52% of counties in 2018, the report said. Rural areas tend to have fewer insurers in the ACA market.

Often, when there is only one insurer participating on the exchange, that company is a Blue Cross Blue Shield or Anthem plan, the report said. Before the ACA, state individual markets were often dominated by a single Blue Cross Blue Shield plan.

WHY THIS MATTERS

Despite uncertainties surrounding the ongoing pandemic, the end of the individual mandate and the question of whether the Supreme Court will rule next year to invalidate the entire ACA, the numbers show that insurers appear bullish on participation.

Insurers remained profitable during the pandemic due to decreases in healthcare utilization and claims costs. They are on track yet again to owe substantial rebates to consumers based on low medical loss ratios in 2021.

Even with the lack of a mandate, individuals continue to enroll in ACA plans, with enrollment this year more than keeping pace with last year’s figures. Premiums for 2021 are 1-4% below the average.

THE LARGER TREND

The enrollment numbers continue a trend of rising insurer participation in the ACA going into the 2020 market, and lower premiums.

Insurer participation next year equals the average participation levels at the outset of the marketplaces in 2014, according to the KFF report. 

Since 2014, the number of insurers participating on the exchanges has been in flux. Going into the 2018 plan year, many insurers left the market or reduced their footprint due to losses in the market.

How a conservative Supreme Court could save the ACA

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Individual Mandate, Lawsuit, Preexisting Conditions, Severability, Supreme Court • Leave a comment

https://www.axios.com/supreme-court-amy-coney-barrett-health-care-3d67ac28-0be7-424e-b687-253fe0356e4c.html

How a conservative Supreme Court could save the ACA - Axios

Even a solidly conservative Supreme Court could find a pretty easy path to preserve most of the Affordable Care Act — if it wants to.

The big picture: It’s too early to make any predictions about what the court will do, and no ACA lawsuit is ever entirely about the law. They have all been colored by the bitter political battles surrounding the ACA.

  • Even so, a handful of factors — the specifics of this case, the court’s recent precedents, even a few threads from Amy Coney Barrett’s Supreme Court confirmation hearings — can at least help draw a roadmap for a conservative ruling that would leave most of the ACA intact.

How it works: There are two steps to the current ACA case. First, the justices will have to decide whether the law’s individual mandate has become unconstitutional. If it has, they’ll then have to decide how many other provisions have to fall along with it.

  • The real action is in the second step — whether the mandate is “severable” from the rest of the law.

“If you picture severability being like a Jenga game — it’s kind of, if you pull one out, can you pull it out while it all stands? Or if you pull two out, will it still stand?” Barrett explained during Wednesday’s questioning.

  • “The presumption is always in favor of severability,” she said.

Severability is a question of congressional intent — whether Congress still would have passed the rest of a law if it knew it couldn’t have the piece the courts are striking down. And conservative judges make a point of relying only on a law’s text when determining congressional intent.

  • That should make the current case easy, the blue states defending the ACA argue: Congress zeroed out the mandate and left the rest of the law intact — a pretty clear sign that it intended for the rest of the law to operate in the absence of the mandate.
  • “It is abundantly clear that Congress wanted to keep the hundreds of other ACA provisions … without an enforceable minimum coverage provision, because that is the scheme Congress created,” Democratic attorneys general said in a brief.

The other side: The red states challenging the law, on the other hand, get further away from straight textualism.

  • They say the courts should instead look to Congress’ initial belief, when it passed the ACA in 2010, that the mandate was inextricably tied to protections for pre-existing conditions.

What we’re watching: Barrett acknowledged in this week’s hearings that the law has changed since it was first passed — a potentially encouraging sign, if you’re an ACA defender hoping the conservative justices will look at legislative text Congress wrote in 2017 instead of expert statements from 2010.

  • “Congress has amended the statute since” the 2012 Supreme Court ruling upholding the ACA, Barrett said Wednesday. “It has zeroed out the mandate, so now California v. Texas involves a different provision.”

A case from earlier this year — tied to another big-ticket Obama policy — might also help illuminate the current court’s approach to severability.

  • The court’s conservative majority ruled in June that the leadership structure of the Consumer Financial Protection Bureau was unconstitutional.
  • But a combination of four liberals and three conservatives then held that the whole agency didn’t have to be struck down because of it.

Yes, but: None of this means that the threat to the entire ACA, or to its protections for people with pre-existing conditions, has been exaggerated.

  • The Republican attorneys general who brought the case are asking the court to invalidate the entire statute. So is the Justice Department.
  • A federal judge ruled that the entire law had to fall. An appeals court couldn’t decide how much to strike, but said it would probably need to be more than just the mandate — and protections for pre-existing conditions would be next in line.

The bottom line: The ACA’s allies may not be able to save the remains of the individual mandate, but that’s a loss they can live with. And there is at least a clear path to a ruling, even from a conservative court, that would leave the rest of the law intact.

Key conservative justices express openness to preserving ObamaCare’s protections

Posted on by • Posted in ACA, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Individual Health Insurance, Individual Mandate, Preexisting Conditions, Severability, Supreme Court, Underinsured, Uninsured • Leave a comment

https://thehill.com/policy/healthcare/525293-key-conservative-justices-express-openness-to-preserving-obamacares

Key conservative justices express openness to preserving ObamaCare's protections | TheHill

Two conservative justices on the Supreme Court appeared prepared to preserve at least some of the major components of ObamaCare, including its protections for people with preexisting conditions, as they heard arguments Tuesday in a suit challenging the law.

Chief Justice John Roberts and Justice Brett Kavanaugh seemed to express the view that if the court were to strike down the provision of the law mandating the purchase of health insurance, the rest of the law should be allowed to survive.

“Looking at our severability precedents, it does seem fairly clear that the proper remedy would be to sever the mandate provision and leave the rest of the act in place, the provisions regarding preexisting conditions and the rest,” Kavanaugh said.

ACA heads to Supreme Court Nov. 10: 5 things to know

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Individual Health Insurance, Individual Mandate, Lawsuit, Medicaid, Medicaid Expansion, Out of Pocket Expenses, Preexisting Conditions, Severability, Supreme Court, Texas v. United States, Uncompensated Care, Underinsured, Uninsured • Leave a comment

https://www.beckershospitalreview.com/hospital-management-administration/aca-heads-to-supreme-court-nov-10-5-things-to-know.html?utm_medium=email

What to know as ACA heads to Supreme Court — again | National | insightnews.com

The U.S. Supreme Court is set to hear a case questioning the legality of the ACA on Nov. 10.

Five things to know:

1. At the center of the case is whether the health law should be struck down. In a brief filed June 25 in Texas v. United States, the Trump administration argues the entire ACA is invalid because in December 2017, Congress eliminated the ACA’s tax penalty for failing to purchase health insurance. The administration argues the individual mandate is inseverable from the rest of the law and became unconstitutional when the tax penalty was eliminated; therefore, the entire health law should be struck down.

2. The administration’s brief was filed in support of a group of Republican-led states seeking to undo the ACA. Meanwhile, California Attorney General Xavier Becerra is leading a coalition of more Democratic states to defend the ACA before the Supreme Court. 

3. The case goes before the Supreme Court days after media outlets projected Joe Biden as the next president of the U.S. President-elect Biden has said he seeks to expand government-subsidized insurance coverage and wants to the bring back the ACA’s tax penalty for failing to purchase health insurance, according to The Wall Street Journal. If a change regarding the tax penalty did occur, the publication notes that Republicans’ argument on severability would no longer apply.

4. The case also goes before the Supreme Court about two weeks after the Senate voted Oct. 26 to confirm Amy Coney Barrett to the Supreme Court. Ms. Barrett previously criticized Chief Justice John Roberts’ 2012 opinion sustaining the law’s individual mandate, The New York Times reported, but she said during her confirmation hearings in October that “the issue in the case is this doctrine of severability, and that’s not something that I have ever talked about with respect to the Affordable Care Act.”

5. According to the Journal, the Supreme Court is not expected to make a decision in the case until the end of June.

What healthcare executives can expect under Biden presidency

Posted on by • Posted in ACA, Asymptomatic Transmission, Centers for Disease Control & Prevention (CDC), Clinical Research, Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Dept of Health and Human Services (HHS), Employer-Based Health Insurance, Essential Health Benefits, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Health System, Hospital, Hospital Industry, Infection Control, Infection Control Plan, Infectious Virus, Interoperability, Leadership Alignment, Leadership Cares, Leadership Commitment, Leadership Intent, Market Consolidation, Market Power, Market Trends, Medicaid, Medicaid Expansion, Medicare, Medicare Advantage, Mergers & Acquisitions, Mortality, National Strategy, Pandemic, Pharmaceutical Industry, Preexisting Conditions, Price Transparency, Public Health, Public Opinion, Public Option, Public Perception, Public Safety, Public Trust, Quarantine, Scientists, Social Distancing, Supply Chain, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Value Creation, Value-Based Contracting, Value-Based Healthcare, Workforce Strategy, World Health Organization (WHO) • Leave a comment

https://www.beckershospitalreview.com/hospital-management-administration/pwc-what-healthcare-executives-can-expect-under-biden-presidency.html?utm_medium=email

https://www.pwc.com/us/Biden2020healthagenda

President-elect Joe Biden’s healthcare agenda: building on the ACA, value-based care, and bringing down drug prices.

In many ways, Joe Biden is promising a return to the Obama administration’s approach to healthcare:

  • Building on the Affordable Care Act (ACA) through incremental expansions in government-subsidized coverage
  • Continuing CMS’ progress toward value-based care
  • Bringing down drug prices
  • Supporting modernization of the FDA

Bolder ideas, such as developing a public option, resolving “surprise billing,” allowing for negotiation of drug prices by Medicare, handing power to a third party to help set prices for some life sciences products, and raising the corporate tax rate, could be more challenging to achieve without overwhelming majorities in both the House and the Senate.

Biden is likely to mount an intensified federal response to the COVID-19 pandemic, enlisting the Defense Production Act to compel companies to produce large quantities of tests and personal protective equipment as well as supporting ongoing deregulation around telehealth. The Biden administration also will likely return to global partnerships and groups such as the World Health Organization, especially in the area of vaccine development, production and distribution.

What can health industry executives expect from Biden’s healthcare proposals?

Broadly, healthcare executives can expect an administration with an expansionary agenda, looking to patch gaps in coverage for Americans, scrutinize proposed healthcare mergers and acquisitions more aggressively and use more of the government’s power to address the pandemic. Executives also can expect, in the event the ACA is struck down, moves by the Biden administration and Democratic lawmakers to develop a replacement. Healthcare executives should scenario plan for this unlikely yet potentially highly disruptive event, and plan for an administration marked by more certainty and continuity with the Obama years.

All healthcare organizations should prepare for the possibility that millions more Americans could gain insurance under Biden. His proposals, if enacted, would mean coverage for 97% of Americans, according to his campaign website. This could mean millions of new ACA customers for payers selling plans on the exchanges, millions of new Medicaid beneficiaries for managed care organizations, millions of newly insured patients for providers, and millions of covered customers for pharmaceutical and life sciences companies. The surge in insured consumers could mirror the swift uptake in the years following the passage of the ACA.

Biden’s plan to address the COVID-19 pandemic

Biden is expected to draw on his experience from H1N1 and the Ebola outbreaks to address the COVID-19 pandemic with a more active role for the federal government, which many Americans support. These actions could shore up the nation’s response in which the federal government largely served in a support role to local, state and private efforts.

Three notable exceptions have been the substantial federal funding for development of vaccines against the SARS-CoV-2 virus, Congress’ aid packages and the rapid deregulatory actions taken by the FDA and CMS to clear a path for medical products to be enlisted for the pandemic and for providers, in particular, to be able to respond to it.

Implications of Biden’s 2020 health agenda on healthcare payers, providers and pharmaceutical and life sciences companies

The US health system has been slowly transforming for years into a New Health Economy that is more consumer-oriented, digital, virtual, open to new players from outside the industry and focused on wellness and prevention.  The COVID-19 pandemic has accelerated some of those trends.  Once the dust from the election settles, companies that have invested in capabilities for growth and are moving forcefully toward the New Health Economy stand to gain disproportionately.

Shortages of clinicians and foreign medical students may continue to be an issue for a while

The Trump administration made limiting the flow of immigrants to the US a priority. The associated policy changes have the potential to exacerbate shortages of physicians, nurses and other healthcare workers, including medical students. These consequences have been aggravated by the pandemic, which dramatically curtailed travel into the US.

  • Healthcare organizations, especially rural ones heavily dependent on foreign-born employees, may find themselves competing fiercely for workers, paying higher salaries and having to rethink the structure of their workforces.
  • Providers should consider reengineering primary care teams to reflect the patients’ health status and preferences, along with the realities of the workforce on the ground and new opportunities in remote care.

Focus on modernizing the supply chain

Biden and lawmakers from both parties have been raising questions about life sciences’ supply chains. This focus has only intensified because of the pandemic and resulting shortages of personal protective equipment (PPE), pharmaceuticals, diagnostic tests and other medical products.

  • Investment in advanced analytics and cybersecurity could allow manufacturers to avoid disruptive stockouts and shortages, and deliver on the promise of the right treatment to the right patient at the right time in the right place.

Drug pricing needs a long-term strategy

Presidents and lawmakers have been talking about drug prices for decades; few truly meaningful actions have been implemented. Biden has made drug pricing reform a priority.

  • Drug manufacturers may need to start looking past the next quarter to create a new pricing strategy that maximizes access in local markets through the use of data and analytics to engage in more value-based pricing arrangements.
  • New financing models may help patients get access to drugs, such as subscription models that provide unlimited access to a therapy at a flat rate.
  • Companies that prepare now to establish performance metrics and data analytics tools to track patient outcomes will be well prepared to offer payers more sustainable payment models, such as mortgage or payment over time contracts, avoiding the sticker shock that comes with these treatments and improving uptake at launch.
  • Pharmaceutical and life sciences companies will likely have to continue to offer tools for consumers like co-pay calculators and use the contracting process where possible to minimize out-of-pocket costs, which can improve adherence rates and health outcomes.

View interoperability as an opportunity to embrace, not a threat to avoid or ignore

While the pandemic delayed many of the federal interoperability rule deadlines, payers and providers should use the extra time to plan strategically for an interoperable future.

  • Payers should review business partnerships in this new regulatory environment.
  • Digital health companies and new entrants may help organizations take advantage of the opportunities that achieving interoperability may present.
  • Companies should consider the legal risks and take steps to protect their reputations and relationships with customers by thinking through issues of consent and data privacy.

Health organizations should review their policies and consider whether they offer protections for customers under the new processes and what data security risks may emerge. They should also consider whether business associate agreements are due in more situations.

Plan for revitalized ACA exchanges and a booming Medicare Advantage market

The pandemic has thrown millions out of work, generating many new customers for ACA plans just as the incoming Biden administration plans to enrich subsidies, making more generous plans within reach of more Americans.

  • Payers in this market should consider how and where to expand their membership and appeal to those newly eligible for Medicare. Payers not in this market should consider partnerships or acquisitions as a quick way to enter the market, with the creation of a new Medicare Advantage plan as a slower but possibly less capital-intensive entry into this market.
  • Payers and health systems should use this opportunity to design more tailored plan options and consumer experiences to enhance margins and improve health outcomes.
  • Payers with cash from deferred care and low utilization due to the pandemic could turn to vertical integration with providers as a means of investing that cash in a manner that helps struggling providers in the short term while positioning payers to improve care and reduce its cost in the long term.
  • Under the Trump administration, the FDA has approved historic numbers of generic drugs, with the aim of making more affordable pharmaceuticals available to consumers. Despite increased FDA generics approvals, generics dispensed remain high but flat, according to HRI analysis of FDA data.
  • Pharmaceutical company stocks, on average, have climbed under the Trump administration, with a few notable dips due to presidential speeches criticizing the industry and the pandemic.
  • Providers have faced some revenue cuts, particularly in the 340B program, and many entered the pandemic in a relatively weak liquidity position.  The pandemic has led to layoffs, pay cuts and even closures. HRI expects consolidation as the pandemic continues to curb the flow of patients seeking care in emergency departments, orthopedic surgeons’ offices, dermatology suites and more.

Lawmakers and politicians often use bold language, and propose bold solutions to problems, but the government and the industry itself resists sudden, dramatic change, even in the face of sudden, dramatic events such as a global pandemic. One notable exception to this would be a decision by the US Supreme Court to strike down the ACA, an event that would generate a great deal of uncertainty and disruption for Americans, the US health industry and employers.

2021 Healthcare Reform

Posted on by • Posted in 2020 Election Issues, ACA, Asymptomatic Transmission, Centers for Disease Control & Prevention (CDC), Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economic Recovery, Economic Stimulus, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Health Insurance Coverage Adequacy, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Leadership, Leadership Alignment, Mortality, National Strategy, Pandemic, Personal Protective Equipment (PPE), Public Health, Public Opinion, Public Perception, Public Safety, Public Trust, Quarantine, Scientists, Social Distancing, Supreme Court, Vaccine, World Health Organization (WHO) • Leave a comment
https://gisthealthcare.com/gist/gist-alert-biden-elected/
Healthcare Reform in the US Should Be Left to a Panel of Healthcare MBAs - The Leader Newspaper

After an exhausting and contentious election campaign, and a vote count that was prolonged by enormous voter turnout and record-breaking use of early and mail-in voting, the major news networks have now made their calls. Joseph R. Biden, Jr. will be the 46th President of the United States, and Kamala D. Harris will be the first woman, and first person of color, to become Vice President. Securing an electoral victory by achieving razor-thin victories in a number of battleground states, President-elect Biden received the largest number of votes of any candidate in American history. Although the Trump campaign vowed to pursue legal challenges to the validity of the election, Biden’s win appeared to be secure.

The election results came in the midst of a dramatic acceleration of the coronavirus pandemic. Over the last week, the average number of new cases per day in the US surpassed 96,000, up 54 percent from just two weeks earlier. On Friday the nation recorded a pandemic-high 132,700 new cases, along with at least 1,220 COVID deaths. Hospitalizations were up in most states, hospital bed and workforce capacity are strained, and public health experts warned that the coming weeks and months will bring even worse news. Unsurprisingly, the pandemic was a top issue on the minds of voters. According to exit polls, however, the electorate was deeply divided on the issue: 82 percent of Biden voters cited the pandemic itself as one of the most important issues in determining their vote, with only 14 percent of Trump voters agreeing. Conversely, 82 percent of Trump voters said the economy was the most important issue on their minds, as opposed to Biden voters, only 17 percent of whom listed the economy as their top issue. Based on that data, it appears that at least one important split among the electorate was “lives” versus “livelihoods”—whether the pandemic response, or its impact on the economy, was of greatest concern.

In the coming weeks, attention is likely to turn in earnest to addressing both aspects of the issue during the lame duck period. Senate Majority Leader Mitch McConnell (R-KY) has signaled that he intends to resume negotiations on a stimulus package with Democrats in the House, whose majority was diminished in the election. At this writing, it appears likely that control of the Senate will come down to the results of two runoff elections in Georgia, and McConnell will undoubtedly want to make the case that Senate Republicans have taken decisive action to bolster the economic recovery. It’s also possible that, as part of the Trump administration’s Operation Warp Speed, a coronavirus vaccine will be granted approval by the end of the year. Health officials at both federal and state levels must continue to work closely together to tackle the complex logistics of distributing and administering the vaccine, and it will be critical for the incoming administration to seek ways to collaborate with the Trump team to ensure a smooth transition of this vital work.

The outcome of the Senate runoffs in Georgia will determine whether the Biden administration must work with divided Congress, or an evenly split Senate in which Vice President-elect Kamala Harris casts the deciding vote. In either case, given the political realities underscored by the electoral result, it’s very unlikely than any of the more sweeping proposals in the Biden campaign platform—lowering the eligibility age for Medicare, establishing a government-run “public option” insurance plan, extending premium subsidies to middle-income workers—will advance very far. Rather, as we’ve discussed before, we’d expect a Biden administration’s first actions to focus on an enhanced federal response to managing the pandemic, including issuing a national mask mandate, enhancing efforts to augment and coordinate personal protective equipment (PPE) supply, and rejoining the World Health Organization.

As we look to the next two years, most healthcare policy changes are likely to come in the form of regulatory reform, such as reversing waivers for Medicaid programs to establish work requirements and withdrawing flexibility for short-term plans that fail to comply with the Affordable Care Act (ACA). Other Trump-era regulatory changes might continue. There’s broad bipartisan support for efforts to make value-based Medicare payment reforms more successful, to increase price transparency, and to address the issues of surprise billing and the cost of prescription drugs. But even in if Democrats beat the odds and win back control of the Senate, we believe the Biden administration will have other legislative priorities that will supersede any attempt to dramatically overhaul healthcare coverage—voting reforms, climate change legislation, immigration reform, and long-overdue infrastructure investments.

Unless, that is, the Supreme Court throws a spanner in the works by overturning the ACA. Should the Court rule that the individual mandate is not severable from the rest of the law, and that the entire ACA is unconstitutional, the new administration would be forced to take quick action to protect coverage and insurance protections for millions of Americans. In that event, healthcare would rocket to the top of the agenda. Either the Biden team would be forced to find a compromise solution that could pass a divided Congress, or (if Harris is the tie-breaking vote) find a way to use the budget reconciliation process to address coverage. That potential drama lies months in the future, as we won’t know the outcome of the case until next spring. We’ll monitor the oral arguments in the ACA case closely, and let you know what we hear, and what we think it means for the future of the case.

In the coming weeks, we’ll be watching for answers to some of the big healthcare questions that lie ahead: How will the Trump administration handle the worsening pandemic situation in the 75 days between now and Inauguration Day? Will any new stimulus package include additional economic relief for healthcare providers? When and how will a COVID vaccine become widely available? And perhaps most importantly, what toll will the “third wave” of the pandemic take on a nation already exhausted by a difficult year, and a bitter political fight? Surely one reason to be optimistic is that, having turned out to vote in the largest numbers in a century, Americans are more engaged than ever in finding a way forward amid the problems that confront us. Let’s hope our political leaders from across the ideological spectrum will rise to the occasion, and meet this difficult moment with positive, constructive solutions.

Dr. Philip Lee Is Dead at 96; Engineered Introduction of Medicare

Posted on by • Posted in ACA, Access & Quality of Healthcare, Chronic Care Management, Chronic Conditions, Chronic Diseases, Civil Rights, Deferred Healthcare, Desegregation, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Medicare, Medicare for All, Out of Pocket Expenses, Preexisting Conditions, Senior Care, Social Determinants of Health, Underinsured, Uninsured • Leave a comment

https://us.newschant.com/business/dr-philip-lee-is-dead-at-96-engineered-introduction-of-medicare/

Dr. Philip Lee Is Dead at 96; Engineered Introduction of Medicare - The New York Times

Dr. Philip R. Lee, who as a number one federal well being official and fighter for social justice below President Lyndon B. Johnson wielded authorities Medicare money as a cudgel to desegregate the nation’s hospitals within the Sixties, died on Oct. 27 in a hospital in Manhattan. He was 96.

The trigger was coronary heart arrhythmia, his spouse, Dr. Roz Lasker, mentioned.

From his workplace at the Department of Health, Education and Welfare, because the assistant secretary for well being and scientific affairs from 1965 to 1969, Dr. Lee engineered the introduction of Medicare, which was established for older Americans in 1965, one 12 months after Johnson had bulldozed his landmark civil-rights invoice via Congress.

“To Phil, Medicare wasn’t just a ‘big law’ expanding coverage; it was a vehicle to address racial and economic injustice,” his nephew Peter Lee, the manager director of Covered California, which runs the state’s well being care market below the Affordable Care Act, was quoted as saying in a tribute by the University of California, San Francisco. Dr. Lee was the college’s chancellor from 1969 to 1972, after leaving the Johnson administration.

Dr. Lee’s use of Medicare funding to desegregate hospitals “changed the economic lives of millions of seniors,” Mr. Lee added.

Provisions within the Medicare laws subjected 7,000 hospitals nationwide to guidelines barring discrimination towards sufferers on the premise of race, creed or nationwide origin. The regulation required equal remedy throughout the board — from medical and nursing care to mattress assignments and cafeteria and restroom privileges — and barred discrimination in hiring, coaching or promotion.

Before the regulation took impact in 1966, fewer than half the hospitals within the nation met the desegregation commonplace and fewer than 25 p.c did within the South.

“I remember during one of my visits,” Dr. Lee instructed the journal of the American Society on Aging in 2015, “a cardiologist at Georgia Baptist Hospital told me, ‘Well, you know, Dr. Lee, if I put a nigger in with one of my white patients, it would kill the patient. My patient would die of a heart attack.’”

By February 1967, a 12 months or much less after many of the regulation’s provisions had taken impact, 95 p.c of hospitals have been compliant, Dr. Lee mentioned.

“He was largely responsible for that effort,” mentioned Professor David Barton Smith of Drexel University and writer of “The Power to Heal: Civil Rights, Medicare and the Struggle to Transform America’s Health System” (2016).

Dr. Lee hailed from a household of physicians — his father and 4 siblings have been medical doctors — and whereas working within the Palo Alto Medical Clinic (now the Palo Alto Medical Foundation), which his father based, he noticed firsthand the consequences on the poor and the aged of insufficient well being care and the shortage of insurance coverage protection.

As early as 1961, he was a guide on growing older to the Santa Clara Department of Welfare in California, and as a member of the American Medical Association and a Republican at the time, he defied each the A.M.A. and his celebration in testifying earlier than Congress on behalf of a precursor to Medicare that might have helped pay for hospital and nursing dwelling care via Social Security for sufferers over 65.

Dr. Lee was branded a socialist and a Communist (irrespective of that he had served as a physician within the Korean War).

In 1987, after main the University of California, San Francisco, and heading well being coverage and analysis packages there as a professor of social drugs, he additional riled fellow physicians when, as chairman of Congressional fee, he really helpful a standardized nationwide restrict on how a lot medical doctors enrolled within the Medicare program, with an enormous pool of sufferers obtainable to them, might cost above a set schedule.

He was referred to as again to Washington in 1993, once more to be an assistant secretary, this time of the renamed Department of Health and Human Services below the Clinton administration. Serving till 1997, he suggested the White House on its in the end failed effort on well being care reform.

In 2015 he endorsed the Obama administration’s Affordable Care Act and steered that the nation might go even additional in guaranteeing common well being care.

“In 1967, President Johnson said we would continue to work until equality of treatment is the rule,” Dr. Lee wrote in Generations: Journal of the American Society on Aging. “By making Medicare an option for all Americans, the kind of care I receive could be available to everyone.”

Philip Randolph Lee was born in San Francisco on April 17, 1924, to Dr. Russell Van Arsdale Lee, who had lobbied for nationwide medical insurance as a member of a fee appointed by President Harry S. Truman, and Dorothy (Womack) Lee, an newbie musician.

His curiosity in drugs, he instructed Stanford Medicine Magazine in 2004, “began with house calls with my dad from the age of 6 or 7.”

He earned his bachelor’s and medical levels at Stanford University in 1945 and 1948. As a member of the Naval Reserve, he was on lively responsibility as a physician at the top of World War II and once more from 1949 to 1951, through the Inchon invasion in Korea. He obtained a grasp of science diploma from the University of Minnesota in 1955 and had fellowships at the Rusk Institute of Rehabilitation Medicine in New York and the Mayo Clinic.

“Phil moved from clinical medicine to health policy and then devoted his life to addressing issues at the nexus of civil rights, social justice and health,” Dr. Lasker, his spouse, mentioned in an e-mail.

His distinguished function in shaping Medicare and different federal well being insurance policies was preceded by a stint, 1963-65, as director of well being for the Agency for International Development. As chancellor of the University of California, San Francisco, he was credited with rising racial variety amongst its workers, college and pupil physique.

In 2007, the college named its Institute for Health Policy Studies, which he based in 1972, in his honor.

He was additionally lauded for his aggressive function in confronting the AIDS epidemic because the president of the newly-formed Health Commission of the City and County of San Francisco from 1985 to 1989.

The writer of a half-dozen books, Dr. Lee was an early critic of the pharmaceutical trade in “Pills, Profits and Politics” (1974, with Milton Silverman).

More Than Politics On The Line For Voters With Preexisting Conditions

Posted on by • Posted in 2020 Election Issues, ACA, Bad Debt Expense, Chronic Care Management, Chronic Conditions, Chronic Diseases, Deferred Healthcare, Election, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Medicaid, Medicaid Expansion, Medicare, Out of Pocket Expenses, Preexisting Conditions, Short Term Health Insurance, Skinny Health Plans, Supreme Court, Uncompensated Care, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment
https://www.npr.org/sections/health-shots/2020/11/02/928237198/more-than-politics-on-the-line-for-voters-with-pre-existing-conditions?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202020-11-03%20Healthcare%20Dive%20%5Bissue:30622%5D&utm_term=Healthcare%20Dive
More Than Politics On The Line For Voters With Preexisting Conditions | WAMU

In swing states from Georgia to Arizona, the Affordable Care Act — and concerns over protecting preexisting conditions — loom over key races for Congress and the presidency.

“I can’t even believe it’s in jeopardy,” says Noshin Rafieei, a 36-year-old from Phoenix. “The people that are trying to eliminate the protection for individuals such as myself with preexisting conditions, they must not understand what it’s like.”

In 2016, Rafieei was diagnosed with colon cancer. A year later, her doctor discovered it had spread to her liver.

“I was taking oral chemo, morning and night — just imagine that’s your breakfast, essentially, and your dinner,” Rafieei says.

In February, she underwent a liver transplant.

Rafieei does have health insurance now through her employer, but she fears whether her medical history could disqualify her from getting care in the future.

“I had to pray that my insurance would approve of my transplant just in the nick of time,” she says. “I had that Stage 4 label attached to my name and that has dollar signs. Who wants to invest in someone with Stage 4?”

“That is no way to feel,” she adds.

After doing her research, Rafieei says she intends to vote for Joe Biden, who helped get the ACA passed in this first place.

“Health care for me is just the driving factor,” she says.

Even 10 years after the Affordable Care Act locked in a health care protection that Americans now overwhelmingly support — guarantees that insurers cannot deny coverage or charge more based on preexisting medical conditions — voters once again face contradicting campaign promises over which candidate will preserve the law’s legacy.

A majority of Democrats, independents and Republicans say they want their new president to preserve the ACA’s provision that protects as many as 135 million people from potentially being unable to get health care because of their medical history.

President Trump has pledged to keep this in place, even as his administration heads to the U.S Supreme Court the week after Election Day to argue the entire law should be struck down.

“We’ll always protect people with preexisting,” Trump said in the most recent debate. “I’d like to terminate Obamacare, come up with a brand new, beautiful health care.”

And yet the Trump administration has not unveiled a health care plan or identified any specific components it might include. In 2017, the administration joined with congressional Republicans to dismantle the Affordable Care Act, but none of the GOP-backed replacement plans could summon enough votes. The Republicans’ final attempt, a limited “skinny repeal” of parts of the ACA, failed in the Senate because of resistance within their own party.

In an attempt to reassure wary voters, Trump recently signed an executive order that asserts protections for preexisting conditions will stay in place, but legal experts say this has no teeth.

“It’s basically a pinky promise, but it doesn’t have teeth,” says Swapna Reddy, a clinical assistant professor at Arizona State University’s College of Health Solutions. “What is the enforceability? The order really doesn’t have any effect because it can’t regulate the insurance industry.”

Since the 2017 repeal and replace efforts, the health care law has continued to gain popularity.

Public approval is now at an all-time high, but polling shows many Republicans still don’t view the ACA as synonymous with its most popular provision — protections for preexisting conditions.

Democrats hope to change that.

“If you have a preexisting condition — heart disease, diabetes, breast cancer — they are coming for you,” said Biden’s running mate, California Sen. Kamala Harris, during her recent debate with Vice President Pence.

Voters support maintaining ACA’s legal protections

In key swing states, many voters say protecting preexisting conditions is their top health concern.

Rafieei, the Phoenix woman with colon cancer, still often has problems getting her treatments covered. Her insurance has denied medications that help quell the painful side effects of chemotherapy or complications related to her transplant.

“During those chemo days, I’d think, wow, I’m really sick, and I just got off the phone with my pharmacy and they’re denying me something that could possibly help me,” she says.

Because of her transplant, she will be on medication for the rest of her life, and sometimes she even has nightmares about being away and running out of it.

“I will have these panic attacks like, ‘Where’s my medicine? Oh my god, I have to get back to get my medicine?'”

Election season and talk of eliminating the ACA has not given Rafieei much reassurance, though.

“I cannot stomach politics. I am beyond terrified,” she says.

And yet she plans to head to the polls — in person — despite having a compromised immune system.

“It might be a long day. But you know what? I want to fix whatever I can,” she says.

A few days after she votes, she’ll get a coronavirus test and go in for another round of surgery.

A key health issue in political swing states

Rafieei’s home state of Arizona is emblematic of the political contradictions around the health care law.

The Republican-led state reaped the benefits of the ACA. Arizona’s uninsured rate dropped considerably since 2010, in part because it expanded Medicaid.

But the state’s governor also embraced the Republican effort to repeal and replace the law in 2017, and now Arizona’s attorney general is part of the lawsuit that will be heard by the Supreme Court on Nov. 10 that could topple the entire law.

Depending on how the Supreme Court rules, ASU’s Reddy says any meaningful replacement for preexisting conditions would involve Congress and the next president.

“At the moment, we have absolutely no national replacement plan,” she says.

Meanwhile, some states have passed their own laws to maintain protections for preexisting conditions, in the event the ACA is struck down. But Reddy says those vary considerably from state to state.

For example, Arizona’s law, passed just earlier this year, only prevents insurers from outright denying coverage — consumers with preexisting conditions can be charged more.

“We are in this season of chaos around the Affordable Care Act,” says Reddy. “From a consumer perspective, it’s really hard to decipher all these details.”

As in the congressional midterm election of 2018, Democrats are hammering away at Republican’s track record on preexisting conditions and the ACA.

In Arizona, Mark Kelly, the Democratic candidate running for Senate, has run ads and used every opportunity to remind voters of Republican Sen. Martha McSally’s votes to repeal the law.

In Georgia, Democratic challenger Jon Ossoff has taken a similar approach.

“Can you look down the camera and tell the people of this state why you voted four times to allow insurance companies to deny us health care coverage because we may suffer from diabetes or heart disease or have cancer in remission?” Ossoff said during a debate with his opponent, Republican Sen. David Purdue.

Republicans have often tried to skirt health care as a major issue this election cycle because there isn’t the same political advantage to pushing the repeal and replace argument, says Mark Peterson, a professor of public policy, political science and law at UCLA.

“It’s political suicide, there doesn’t seem to be any real political advantage anymore,” says Peterson.

But the timing of the Supreme Court case — exactly a week after election day — has somewhat obscured the issue for voters.

Republicans have chipped away at the health care law by reducing the individual mandate — the provision requiring consumers to purchase insurance — to zero dollars.

The premise of the Supreme Court case is that the ACA no longer qualifies as a tax because of this change in the penalty.

“It is an extraordinary stretch, even among many conservative legal scholars, to say that the entire law is predicated on the existence of an enforced individual mandate,” says Peterson.

The court could rule in a very limited way that does not disrupt the entire law or protections for preexisting conditions, he says.

Like many issues this election, Peterson says there is a big disconnect between what voters in the two parties believe is at stake with the ACA.

“Not everybody, particularly Republicans, associates the ACA with protecting preexisting conditions,” he says. “But it is pretty striking that overwhelmingly Democrats and Independents do — and a number of Republicans — that’s enough to give a significant national supermajority.”