Category Archives: Health Insurance Coverage Adequacy

How a Medicare Buy-In or Public Option Could Threaten Obamacare

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Medicare, Medicare Buy-In, Medicare for All, Pharmaceutical Industry, Public Option • Leave a comment
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Some Democrats are proposing a government alternative to private insurance. But allowing people to choose such a plan may destabilize the A.C.A., some experts say.

It seems a simple enough proposition: Give people the choice to buy into Medicare, the popular federal insurance program for those over 65.

Former Vice President Joseph R. Biden Jr. is one of the Democratic presidential contenders who favor this kind of buy-in, often called the public option. They view it as a more gradual, politically pragmatic alternative to the Medicare-for-all proposal championed by Senator Bernie Sanders, which would abolish private health insurance altogether.

A public option, supporters say, is the logical next step in the expansion of access begun under the Affordable Care Act, passed while Mr. Biden was in office. “We have to protect and build on Obamacare,” he said.

But depending on its design, a public option may well threaten the A.C.A. in unexpected ways.

A government plan, even a Medicare buy-in, could shrink the number of customers buying policies on the Obamacare markets, making them less appealing for leading insurers, according to many health insurers, policy analysts and even some Democrats.

In urban markets, “a public option could come in and soak up all of the demand of the A.C.A. market,” said Craig Garthwaite, a health economist at the Kellogg School of Management at Northwestern University.

And in rural markets, insurers that are now profitable because they are often the only choices may find it difficult to make money if they faced competition from the federal government.

Some insurers could decide that a smaller and uncertain market is not worth their effort.

If the public option program also matched the rates Medicare paid to hospitals and doctors, “I think it would be really hard to compete,” Mr. Garthwaite said. Even leading insurers do not have the leverage to demand lower prices from hospitals and other providers that the government has.

Whether to implement a public option or Medicare buy-in has become a defining question among Democratic presidential candidates and is likely to be a contentious topic at this week’s debates.

On Monday, Senator Kamala Harris took an alternate route, unveiling a plan that would allow private insurers to participate in a Medicare-for-all scheme, akin to their role currently offering private plans under Medicare Advantage.

The recent spate of proposals reprises some of the most difficult questions leading up to the passage of the A.C.A., in many ways a compromise over widely divergent views of the role of the government in ensuring access to care.

After a shaky start, the federal and state Obamacare marketplaces are surprisingly robust, despite repeated attempts by Republicans to weaken them. They provide insurance to 11 million customers, many of whom receive generous federal subsidies to help pay for coverage.

The A.C.A. is now a solidly profitable business for insurers, with several expanding options after earlier threats to leave. For example, Centene, a for-profit insurer, controls about a fifth of the market, offering plans in 20 states. It is expected to bring in roughly $10 billion in revenues this year by selling Obamacare policies.

In spite of stock drops because of investors’ concerns over Medicare-for-all proposals, for-profit health insurers have generally thrived since the law’s passage.

But a buy-in shift in insurance coverage could profoundly unsettle the nation’s private health sector, which makes up almost a fifth of the United States economy. Depending on who is allowed to sign up for the plan, it could also rock the employer-based system that now covers some 160 million Americans.

In a recent ad, Mr. Biden features a woman who wants to keep her current coverage. “I have my own private insurance — I don’t want to lose it,” she said.

A spokesman for Mr. Biden argued that a public option can extend the success of the Affordable Care Act.

“Joe Biden thinks it would be an egregious mistake to undo the A.C.A., and he will stand against anyone — regardless of their party — who tries to do so,” said Andrew Bates, a spokesman for Mr. Biden, in an email.

Major insurers and hospital chains, pharmaceutical companies and the American Medical Association have joined forces to try to derail efforts like Medicare-for-all and the public option. Mr. Sanders denounced these powerful interests in a recent speech.

“The debate we are currently having in this campaign and all over this country has nothing to do with health care, but it has everything to do with the greed and profits of the health care industry,” he said.

Other critics of the public option, including Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, argue Democrats’ programs will lead to a “complete government takeover.”

“These proposals are the largest threats to the American health care system,” she said in a speech earlier this month.

Some experts predict that private insurers will adapt, while others warn that the government could wind up taking on the sickest customers with high medical bills, leaving the healthier, profitable ones to private insurers.

It’s uncertain whether hospitals, on the other hand, could thrive under some versions of the public option. If the nation’s 5,300 hospitals were paid at much lower rates by a government plan — rates resembling those of Medicare — they might lose tens of billions of dollars, the industry claims. Some would close.

One variant of the public option — letting people over 50 or 55 buy into Medicare — is often depicted as less drastic than a universal, single-payer program. But this option would also be problematic, experts said.

This consumer demographic is quite valuable to insurers, hospitals and doctors.

Middle-aged and older Americans have become the bedrock of the Obamacare market. Some insurers say this demographic makes up about half of the people enrolled in their A.C.A. plans and, unlike younger people who come and go, is a reliable and profitable source of business for the insurance companies.

The aging-related health issues of people in this group guarantee regular doctor visits for everything from rising blood pressure to diabetes, and they account for a steady stream of lucrative joint replacements and cardiac stent procedures.

The 55-to-64 age group, for example, accounts for 13 percent of the nation’s population, but generates 20 percent of all health care spending, according to the Kaiser Family Foundation.

Health Spending

People age 55–64 are responsible for one fifth of total health spending and account for a sizable share of the private insurance market. People 65 and older are eligible for Medicare and account for one third of total spending.

Several experts said that designing a buy-in program that is compatible with the existing public and private plans could be daunting.

“You’d have to do it carefully,” said Representative Donna Shalala, a Florida Democrat who served as the secretary of health and human services under President Bill Clinton.

Linda Blumberg, a health policy expert at the Urban Institute, a nonpartisan think tank, agreed. “The idea of Medicare buy-ins was taken very seriously before there was an Affordable Care Act,” she said. “In the context of the A.C.A., it’s a lot more complicated to do that.”

Many dismiss concerns about whether insurers can compete.

“Any time a market shrinks in America, insurers don’t like it,” said Andy Slavitt, the former acting Medicare administrator under President Obama and a former insurance executive. Mr. Slavitt noted that insurers raised similar concerns about the federal law when it was introduced. “They’ll figure it out,” he said.

In Los Angeles County, five private insurers that sell insurance in the A.C.A. market already compete with L.A. Care Health Plan, which views itself as a kind of public option, said John Baackes, the plan’s chief executive.

The insurer offers the least expensive H.M.O. plan in the county by paying roughly Medicare rates. “We’ve proved that the public option can be healthy competition,” he said.

But the major insurance companies, which were instrumental in defeating the public option when Congress first considered making it a feature of the A.C.A., are already flexing their lobbying muscle and waging public campaigns.

In Connecticut, fierce lobbying by health insurers helped kill a state version of the public option this spring. Cigna resisted passage of the bill, threatening to leave the state. “The proposal design was ill-conceived and simply did not work,” the company said in a statement.

Blue Cross plans could lose 60 percent of their revenues from the individual market if people over 50 are shifted to Medicare, said Kris Haltmeyer, an executive with the Blue Cross Blue Shield Association, citing an analysis the company conducted. He said it might not make sense for plans to stay in the A.C.A. markets.

Siphoning off such a large group of customers could also lead to a 10 percent increase in premiums for the remaining pool of insured people, according to the Blue Cross analysis. More younger people with expensive medical conditions have enrolled than insurers expected, and insurers would have to increase premiums to cover their costs, Mr. Haltmeyer said.

Tricia Neuman, a senior vice president at the Kaiser Family Foundation, which studies insurance markets, said a government buy-in that attracted older Americans could indeed raise premiums for those who remained in the A.C.A. markets, especially if those consumers had high medical costs.

But some experts countered that prognosis, predicting that premiums could go down if older Americans, whose health care costs are generally expensive, moved into a Medicare-like program.

“The insurance companies are wrong about opposing the public option,” Ms. Shalala said.

Dr. David Blumenthal, the president of the Commonwealth Fund, a foundation that funds health care research, said a government plan that attracted people with expensive conditions could prove costly.

“You might, as a taxpayer, become concerned that they would be more like high-risk pools,” he said.

Jonathan Gruber, an M.I.T. economist who advised the Obama administration during the development of the A.C.A., likes Mr. Biden’s plan and argues there is a way to design a public option that does not shut out the private insurers.

“It’s all about threading the needle of making a public option that helps the failing system and not making the doctors and insurers go to the mat,” he said.

Many experts point to private Medicare Advantage plans, which now cover one-third of those eligible for Medicare, as proof that private insurers can coexist with the government.

But the real value of a public option, some say, would stem from the pressure to lower prices for medical care as insurers were forced to compete with the lower-paying government plans, like Medicare.

Washington State recently passed the country’s first public option, capping prices as part of its plan to provide a public alternative to all residents by 2021.

“It’s couched in this language in expanding coverage, but it does it by regulating prices,” said Sabrina Corlette, a health policy researcher at Georgetown University.

The hospital industry would most likely fight just as hard to defeat any proposal that would convert a profitable group of customers, Americans who are privately covered at present, into Medicare beneficiaries.

Private insurers often pay hospitals double or triple what Medicare pays them, according to a recent study from the nonprofit Rand Corporation.

While Ms. Shalala supports a public option as an alternative to “Medicare for All,” she is clear about how challenging it will be to preserve both Obamacare and the private insurance market. “You can’t do it off the top of your head,” she said.

 

A small group of patients account for a whole lot of spending

Posted on by • Posted in Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Out of Pocket Expenses, Preexisting Conditions • Leave a comment

https://www.axios.com/drug-prices-health-care-costs-spending-employers-63a65abc-0148-4f98-bd39-b30e4d3c9caf.html

Illustration of a $100 bill going into a small pill bottle

A very small group of patients with major illnesses is responsible for an outsized share of health care spending, and new data show that prescription drugs are a big part of the reason their bills are so high.

The big picture: Among people who get their coverage from a large employer, just 1.3% of employees were responsible for almost 20% of overall health spending, averaging a whopping $88,000 per year.

Between the lines: “Persistently high spenders” are people who have accumulated big health care bills for at least 3 consecutive years.

  • They often have HIV, MS, cystic fibrosis, rheumatoid arthritis, diabetes, cancer and other serious conditions requiring frequent and often costly care.
  • Drugs are lifesavers for these patients, but also big offenders when it comes to costs.

By the numbers: Prescription drugs account for about 40% of this group’s costs, not counting rebates — compared with just 10% for the country as a whole.

  • Their bills just for prescription drugs average out to about $34,000 per year. That’s much more than the average premium for family coverage.

Why it matters: These are exactly the people our insurance system is failing. They have insurance and a major illness, but still struggle with their medical bills as deductibles and other out-of-pocket costs keep rising faster than wages.

One solution might be to exempt this small group of high spenders with serious illnesses from drug or other copays, and limit their deductibles.

  • Congress is also considering proposals to lower the cost of the most expensive drugs, which could make a dent in both employer and employee spending for this population.

The bottom line: I have had family members in the 1.3%.

  • I know from experience as well as the data that we should take care not to sacrifice needed care as we try to reduce spending for this small group of very high spenders with complicated medical needs.

 

 

 

Could States Do Single-Payer Health Care?

Posted on by • Posted in 2020 Election Issues, Health Insurance Coverage Adequacy, Health Policy, Single Payer Health System, Single Payer Healthcare System • Leave a comment

https://www.healthaffairs.org/do/10.1377/hblog20190717.466249/full/?utm_source=Newsletter&utm_medium=email&utm_content=Health+Spending+Briefing%3B+Single-Payer%3B+Drug+Prices%3B+Cannabis+Patients%3B+ACA%3B+Access+To+Antidiabetic+Drugs%3B+Skilled+Nursing+Facilities&utm_campaign=HASU

 

The Affordable Care Act (ACA) transformed the US health care system by increasing coverage, expanding federal involvement in private health insurance, and changing public expectations for access to affordable coverage. Yet, the ACA did not provide universal coverage and has proven unstable under political and legal attacks since its enactment in 2010. While proposals for replacing the ACA with single-payer health care have attracted national political attention, discussions of a federal single-payer system such as “Medicare for All” remain light on specifics. At the state level, however, state legislators have drafted and introduced dozens of detailed bills to implement single-payer systems. Our study of state single-payer proposals in the ACA era highlights the extent to which states must contort their health reforms to overcome federal legal hurdles—particularly the threat of preemption by the Employee Retirement Income Security Act (ERISA) of 1974—and prompts questions about whether states can actually implement single-payer health care.

State Single-Payer Proposals (2010–19)

We define state single-payer bills as legislative attempts to achieve universal health care coverage for all residents in a state by combining financing for health care services into a single, state-administered payer. Using this definition, we collected and coded bills introduced in state legislatures since 2010, identifying the number of unique proposals by excluding substantially similar legislation introduced in different chambers or with different designations in the same session. From 2010 through 2019, legislators in 20 states have proposed 59 unique single-payer bills (Exhibit 1).

Most, but not all, of the single-payer proposals come from states that expanded Medicaid under the ACA, leaving only a small fraction of the population uninsured. Thus, it appears that beyond achieving universal coverage, state single-payer bills also seek to control health spending through expansive rate-setting authority and streamlined administration, as well as to relieve individuals of their growing out-of-pocket expenses. These state single-payer bills share many common elements: They all provided universal eligibility for state residents, and most also included expansive provider eligibility, rate-setting for health care services and prescription drugs, low or no cost sharing for patients, comprehensive benefits, and limits on the ability of health insurers (but not employers) to offer coverage that duplicates the single-payer benefits.

Legal And Financial Hurdles For State Single-Payer Health Care

To finance these universal and comprehensive benefits, state single-payer bills use several strategies to capture health expenditures from the existing multipayer system, while navigating a number of financial and legal impediments. First, the state bills would consolidate federal funds from Medicare, Medicaid, and the ACA exchanges into the state single-payer plan using waiver provisions in those federal programs. The Department of Health and Human Services has considerable discretion to deny state applications for each of these federal waivers; however, and the state bills generally lack fallback plans for capturing federal funds should the agency deny the waivers. Nor do the state single-payer bills confront financial obstacles from state constitutional prohibitions on deficit spending, which constrain state plans when tax revenues fall during economic recession.

Second, but perhaps more crucially, state single-payer bills must find ways to redirect the employer-sponsored health plans that currently cover 49 percent of Americans—a daunting legal task under ERISA. ERISA preempts all state laws that “relate to” employer-sponsored benefits, so states cannot simply mandate that employers cease offering health benefits. States do retain broad power to regulate health care providers and health insurers, but ERISA preempts the application of state insurance regulations to employers’ self-funded health plans, which now comprise more than 60 percent of all employer-sponsored health benefits. ERISA challenges states’ abilities to capture employer health spending—a source of funding that would be critical to the viability of a single-payer system.

The labyrinth of ERISA preemption has inspired creative drafting of state single-payer bills to do indirectly what ERISA prohibits them from doing directly. Our survey revealed three strategies for state bills to capture employer expenditures and move employees into the state single-payer system: levy payroll taxes on employers and income taxes on employees; restrict providers from accepting private-insurer reimbursement; and allow the single-payer plan to pay for all eligible patients’ care, then recoup those payments from other coverage a patient may have. The taxes fund the single-payer plan’s coverage of resident employees and nudge employers to cease offering private coverage. The provider reimbursement restriction further encourages a shift to single-payer coverage by shrinking provider networks for private insurance. The pay-and-recoup provision enables those employers who wish to continue providing benefits to do so without fully eroding the administrative advantages of the single-payer system.

Nearly all states’ bills include one of these strategies; most include a combination of them. Vermont is the only state that has actually enacted single-payer legislation, before abandoning its implementation largely due to the cost of its payroll and income taxes.

The Unnecessary Uncertainty For State Single-Payer Health Care

To gird against the looming threat of ERISA preemption, state legislatures have resorted to elaborate measures that may dilute their broader aims of achieving universality, solidarity, and efficiency in health care coverage. There are strong legal arguments why provisions to capture employer health spending should survive ERISA preemption. States have wide latitude to levy taxes and regulate health care in general, and providers in particular. The bills’ provisions do not require employers to alter their employee benefit plans, they merely encourage a shift to the state’s health plan. But federal appellate courts have split over the extent to which states may use financial incentives to affect employers’ health benefit decisions. In short, state single-payer plans should survive ERISA preemption, but courts’ unpredictable applications of ERISA cast a pall of uncertainty over the viability of single-payer plans.

State single-payer proposals face formidable legal uncertainties that a federal single-payer plan would not. On the other hand, health reform of this scale presents an experiment well-suited to the laboratories of the states. States’ experimentation with single-payer care could test various models and inform federal health reform debates about the benefits of single-payer over more incremental reforms, or about structuring a single-payer system to minimize disruption for health care providers and patients. The road to reform often starts with the states. This was the path for the ACA, which was first modeled in Massachusetts, and for Canada’s single-payer system, which got its start in Saskatchewan. Significant health reforms tested at the state level may pave the road to better policy at the national level.

While ERISA preemption has bedeviled state health reforms for decades, this wave of state single-payer legislation highlights the depth of the problem. At a time when states are the engines of health policy innovation, ERISA continues to unnecessarily thwart state health reform efforts. Thus, any meaningful health reform should start with ERISA reform. For example, Congress could amend ERISA to narrow its preemption provisions or add a waiver provision similar to other federal health care statutes. While states may successfully contort their health reform efforts to avoid ERISA preemption, they should not have to do so. The time has come to remove ERISA’s obstructions and to unlock states’ capacities as laboratories of health reform.

Most, but not all, of the single-payer proposals come from states that expanded Medicaid under the ACA, leaving only a small fraction of the population uninsured. Thus, it appears that beyond achieving universal coverage, state single-payer bills also seek to control health spending through expansive rate-setting authority and streamlined administration, as well as to relieve individuals of their growing out-of-pocket expenses. These state single-payer bills share many common elements: They all provided universal eligibility for state residents, and most also included expansive provider eligibility, rate-setting for health care services and prescription drugs, low or no cost sharing for patients, comprehensive benefits, and limits on the ability of health insurers (but not employers) to offer coverage that duplicates the single-payer benefits.

 

 

Democrats are making Republican arguments about health care. Why?

Posted on by • Posted in 2020 Election Issues, ACA, Dignity, Health Insurance Coverage Adequacy, Health Policy, Medicare, Medicare Buy-In, Medicare for All, Respect, Single Payer Health System, Single Payer Healthcare System, Universal Healthcare System • Leave a comment

https://www.washingtonpost.com/opinions/2019/07/26/democrats-are-making-republican-arguments-about-health-care-why/?fbclid=IwAR1mA1uEcNMiO12elygl_lSLxDD12kvHhzfYOO78Z50u7HAEv56yEVGL2Pc&utm_term=.e2f83bcb12ec

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The Democratic argument over health care is beginning to get heated, which unfortunately means that things are becoming more problematic. In fact, the candidates making what is arguably the most sensible policy choice are justifying it with some absolutely abominable arguments — arguments that should warm the heart of the Republican Party.

Right now there’s a divide within the party, with some of the presidential candidates including Bernie Sanders and Elizabeth Warren supporting single payer (though Warren hasn’t been specific), and most of the others including Joe Biden, Amy Klobuchar and Pete Buttigieg suggesting some form of public option that would be voluntary, not Medicare For All but Medicare For All Who Want It.

I’ve come to believe that for all the benefits of a single payer system, trying to move immediately to one is a task with such overwhelming political obstacles and policy complications that it’s probably a better idea to achieve universal coverage through a dramatic expansion of public insurance while, for the moment, leaving substantial portions of the private system intact, even if that’s in many ways distasteful. I realize many readers will disagree with that, which is fine; we should continue to debate it.

But let’s at least grant that it’s a reasonable position to take. The problem with what’s happening now is that some advocates of the public option approach are sounding a lot like, well, Republicans.

Their most common talking point when defending their plan is some variation of “We can’t kick 150 million people off their insurance,” referring to the number of people who are covered by employer plans:

  • “We should have universal health care, but it shouldn’t be the kind of health care that kicks 150 million Americans off their health care,” says John Delaney.
  • Beto O’Rourke says Medicare-for-all “would force 180 million Americans off their insurance.”
  • “I am simply concerned about kicking half of America off their health insurance within four years, which is what [Medicare-for-all] would do,” says Amy Klobuchar.

The generous interpretation of this line is that it’s warning about widespread disruption; the other interpretation is that it’s meant to stoke the fear that if you now have coverage and single payer passes, you could be left with no insurance at all, which is just false. If we passed single payer, you’d move from your current plan to a different plan, one that depending on how it’s constructed would probably offer as good or better coverage at a lower cost.

The further danger is that that kind of talk inevitably leads one toward the promise that got Barack Obama into such trouble, “If you like your plan, you can keep it.” In fact, here’s O’Rourke saying that under his plan, “For those who have private, employer-sponsored insurance or members of unions who have fought for health care plans … they’ll be able to keep that.” And here’s Biden saying much the same thing: “If you like your health care plan, your employer-based plan, you can keep it. If in fact you have private insurance, you can keep it.”

Haven’t they learned anything?

While there may be political value in communicating to people that a public option would be voluntary, we have to tell them the truth, which is that if you’re going to open it to employers and not just individuals, some people will be moved to the public plan whether they want to or not, since their employers will make that choice for them. That’s how employer coverage works: What plan you’re on is seldom up to you, it’s a decision made by your employer.

And the broader truth is that no one, I repeat, no one gets to keep their plan if they like it even under the status quo. “If you like your plan, you can keep it” is a fantasy. If you have insurance through your employer, you’ve probably had the experience of your employer changing insurers or changing plans; many do it every year. Sometimes the new plan is better; often it’s not. But if you liked your plan, you didn’t get to keep it.

That’s even true of people on public insurance plans, though to a far lesser degree. Medicare and Medicaid go through changes, and benefits are added or taken away. It’s not up to you.

The trouble is that we have a situation where change is constant yet everyone is afraid of change, which makes it awfully tempting to encourage that fear. But the more we propagate the fiction that Americans, especially those with private insurance, aren’t vulnerable under the current system, the easier it will be to crush any reform effort.

Apart from the praise of the Affordable Care Act, this video could almost have been scripted by the Republican National Committee, with its paeans to private health insurance. Of particular note is the woman’s explanation of how she and her husband “earned” health coverage through decades of work, which implies that health care is not a right, as most Democrats believe, but a privilege one has to earn.

To top it off, Biden’s caption to the video says that “Because a union fought for their private health insurance plan, Marcy and her husband were able to retire with dignity and respect,” which is why Biden wants to let them stay on their existing insurance.

Let me suggest a crazy idea: What if retiring with dignity and respect wasn’t something you only got if you were lucky enough to be represented by a union (as a mere 1 in 10 American workers is, and 1 in 16 private sector workers), and only if that union happened to be successful in its fight to get you health benefits? What if everybody got dignity and respect? Isn’t that the world Joe Biden is trying to create?

You can make a strong case for both a single payer plan and one built around a public option. But please, Democrats, when you’re arguing for your preferred solution, don’t undermine the entire philosophical approach your party takes to health care. That only makes the job of reform more difficult.

 

 

Governors Weigh Health Care Plans as They Await Court Ruling

Posted on by • Posted in 2020 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Policy, Single Payer Health System, Single Payer Healthcare System, Universal Healthcare System • Leave a comment

https://www.usnews.com/news/business/articles/2019-07-25/governors-weigh-health-care-plans-as-they-await-court-ruling

The Associated Press

As they gather at a conference in Utah, governors from around the country are starting to think about what they would do if an appeals court upholds a lower court ruling overturning President Obama’s signature health care law.

More than 20 million Americans would be at risk of losing their health insurance if the 5th U.S. Circuit Court of Appeals agrees with a Texas-based federal judge who declared the Affordable Care Act unconstitutional last December because Congress had eliminated an unpopular tax it imposed on people who did not buy insurance.

The final word on striking down law will almost certainly come from the Supreme Court, which has twice upheld the 2010 legislation.

Nevada Gov. Steve Sisolak, a Democrat, signed a bill earlier this year prohibiting health insurers from denying coverage to patients due to pre-existing conditions, a pre-emptive move in case the Affordable Care Act were struck down.

He said this week in Salt Lake City at the summer meeting of the National Governors Association that he would ask his recently created patient protection commission to come up with recommendations for how to ensure patients don’t lose coverage if the law is overturned, which would impact about 200,000 people enrolled in Medicaid expansion in Nevada.

“To rip that away from them would be devastating to a lot of families,” Sisolak said.

Nevada is among a coalition of 20 Democratic-leaning states led by California that appealed the lower court ruling and is urging the appeals court to keep the law intact.

At a news conference Thursday, Democrats touted the protections they’ve passed to prevent people from losing health coverage.

New Mexico Gov. Michelle Lujan Grisham signed laws this year that enshrine provisions of the Affordable Care Act into state law, including guarantees to insurance coverage for patients with pre-existing conditions and access to contraception without cost-sharing. She said half of the state’s residents use Medicaid, prompting New Mexico officials to research creating a state-based health care system.

California Gov. Gavin Newsom said his state is already deep in contingency planning because five million people could lose health insurance if the law is struck down and the state doesn’t have enough money to make up for the loss of federal funds. He said the decision this year to tax people who don’t have health insurance, a revival of the so-called individual mandate stripped from Obama’s model, was the first step. That tax will help pay for an expansion of the state’s Medicaid program, the joint state and federal health insurance program for the poor and disabled.

Newsom said the state is looking at Massachusetts‘ state-run health care program and investigating if a single-payer model would work as possible options if the law is spiked.

“The magnitude is jaw-dropping,” Newsom said. “You can’t sit back passively and react to it.”

Arkansas Gov. Asa Hutchinson, a Republican, said states need Congress to be ready to quickly pass a new health care plan if the court overturns Obama’s law, since doing so would cut off federal funding for Medicaid expansion.

A court decision in March blocked Arkansas from enforcing work requirements for its Medicaid expansion program, which has generated seemingly annual debate in that state’s Legislature about whether to continue the program.

“Congress can’t just leave that out there hanging,” Hutchinson said.

The 2018 lawsuit that triggered the latest legal battle over the Affordable Care Act was filed by a coalition of 18 Republican-leaning states including Arkansas, Arizona and Utah.

Arizona Gov. Doug Ducey, a Republican, said he wants to see how the court rules before he makes any decisions about how his state would deal with the loss of Medicaid funds but that Arizona has backup funds available.

“They’re going to rule how they’re going to rule and we’ll deal with the outcome,” Ducey said. “The best plans are to have dollars available.”

It is unknown when the three-judge panel will rule.

The government said in March that 11.4 million people signed up for health care via provisions of the Affordable Care Act during open enrollment season, a dip of about 300,000 from last year.

Utah Gov. Gary Herbert, a Republican, said if the law is overturned, it would provide a perfect opportunity for Congress to try to craft a better program with support from both political parties.

He said his state, which rolled out its partial Medicaid expansion in April, probably will not start working on a contingency plan for people who would lose coverage until the appeals court rules.

“It’s been talked about for so long, people are saying ‘Why worry about it until it happens?'” Herbert said. “I think there’s a little bit more of a lackadaisical thought process going on.”

President Donald Trump, who never produced a health insurance plan to replace Obama’s health care plan, is now promising one after the elections.

Newsom warned Americans not to rely on that.

“God knows they have no capacity to deal with that,” Newsom said. “The consequences would be profound and pronounced.”

 

 

Judge upholds short-term plan expansion in Trump win against ACA

Posted on by • Posted in ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Short Term Health Insurance • Leave a comment

https://www.healthcaredive.com/news/judge-upholds-short-term-plan-expansion-in-trump-win-against-aca/559146/

Dive Brief:

  • A district judge ruled in favor of a controversial Trump administration policy expanding the sale of short-term health insurance Friday, advancing conservative efforts to weaken the Affordable Care Act.
  • Judge Richard Leon of the U.S. District Court for the District of Columbia rejected plaintiffs’ claims that the limited coverage unlawfully undermines the ACA, basing his decision partly on the elimination of the individual mandate tax penalty in 2017.
  • The plaintiffs, including the Association for Community Affiliated Plans, the National Alliance on Mental Illness and AIDS United, plan to appeal the decision, with ACAP CEO Margaret Murray slamming the policy as “arbitrary and capricious” in a statement following the ruling.

Dive Insight:

Originally intended as stopgap coverage while consumers transition between insurance plans, the Obama administration limited short-term health plans to three months. In a rule that took effect Oct. 2, the Trump administration expanded the length of the coverage to 12 months, renewable for up to three years.

Like many other Trump administration healthcare policies, that led to a lawsuit.

The plaintiffs had a hard skeptic in Leon, who seemed unmoved by their arguments in the case in late May. In a position backed up by outside research, the group maintained Trump’s expansion of the short-term health plans could lure healthier Americans away from the ACA exchanges, weakening the risk pool and raising premiums across the board.

Legal representation for the administration countered there was consumer demand for insurance more inexpensive than that offered through the ACA marketplace, and that there was no evidence the plans were attracting healthier people away.

“To be sure, the ACA’s various reforms are interdependent and were designed to work together as features of the individual exchange markets,” Leon wrote in his decision. “However, Congress clearly did not intend for the law to apply to all species of individual health insurance.”

It’s been a busy week for the judge. Leon is also overseeing the beleaguered CVS-Aetna settlement pact and will hear oral arguments on the merger Friday afternoon.

Despite Republican lawmakers’ highly public failure to repeal the ACA in 2017 and GOP attempts to declare the ACA unconstitutional in a case now in front of the Fifth Circuit Court of Appeals, the party is trying to rebrand itself as the party of healthcare going into the 2020 presidential election.

The limited coverage options, often decried as “junk plans” by critics, aren’t required to cover the 10 essential health benefits protected under the ACA or to cover pre-existing conditions. They also don’t have to pay out at least 80% of premium dollars to fund medical and preventive care.

In March, the House Energy and Commerce Committee launched an investigation into the marketing and business practices of the plans. Leading Democrats, led by Frank Pallone, D-N.J., requested documents and information from 12 companies that either sell, market or help consumers in purchasing the limited coverage, including market giants Anthem and UnitedHealth Group.

In many cases, consumers may not be aware they’re being peddled bare-bones coverage. Tampa, Florida-based Health Insurance Innovations is currently being sued by two policyholders that were left with tens of thousands of dollars in medical bills for care they thought was covered under their short-term plans.

Other attempts by the Trump administration to undermine the ACA have hit legal roadblocks.

In March, another federal judge struck down its attempt to allow small businesses to join together to create association health plans exempt from ACA rules, slamming it as an “end run” around the law.

The same month, another judge rejected Medicaid work requirements in Kentucky and Arkansas requiring low-income Americans to meet stringent work or education benchmarks to receive coverage under the program.

Shares of companies that sell short-term plans, including Health Insurance Innovations, spiked following news of the decision Friday.

 

 

 

Rising health insurance deductibles fuel middle-class anger and resentment

Posted on by • Posted in 2020 Election Issues, Health Insurance Coverage Adequacy, High Deductible Health Plans, Out of Pocket Expenses • Leave a comment

https://www.latimes.com/politics/la-na-pol-health-insurance-angry-patients-20190628-story.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

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The IRS rolled out new rules yesterday to help people who have chronic diseases, but are also on the hook for thousands of dollars of their medical bills.

How it works: The new rules allow insurers to cover treatment for chronic conditions, like diabetes and high blood pressure, before patients have met their deductibles.

  • This only applies to high-deductible plans that also offer a health savings account — which is an increasingly common arrangement.

My thought bubble: High-deductible plans and chronic disease are both pretty ubiquitous, and this will surely help sick people get the care they need.

  • As the Wall Street Journal notes, there’s a broad base of support for these new rules, including patients, insurers and policymakers from both parties.

But it’s hard to look at this change without asking some more fundamental questions about the rise of deductibles.

  • After all, making people pay for more of their own care is the whole point. High-deductible plans were designed to give people more “skin in the game.”
  • It only stands to reason that when you require people to pay a couple thousand dollars of their own bills before insurance kicks in, that’s primarily going to affect people who have a couple thousand dollars in health care bills.

Deductibles are a large and growing source of frustration for middle-class families, the L.A. Times’ Noam Levey writes.

  • Neither high deductibles nor health savings accounts have put a dent in health care prices, as their advocates thought they would.
  • And families with the highest deductibles are among the least satisfied with their employer coverage.

Go deeper: Workers’ health care costs just keep rising

 

 

Family of four faces $25,000 in average annual unsubsidized ACA costs in 2019

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, High Deductible Health Plans, Out of Pocket Expenses, Preexisting Conditions, Underinsured, Uninsured • Leave a comment

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Costs for two- and four-person families rose despite overall premiums being relatively flat compared to last year.

Average 2019 health insurance premiums are $1,403 per month for families of four who don’t qualify for subsidies under the Affordable Care Act, according to a report released today by eHealth.

The 2019 Health Insurance Index Report analyzes costs and trends among unsubsidized consumers who purchased individual and family coverage for the 2019 plan year at eHealth during the ACA’s most recent open enrollment period. eHealth, Inc. dba as eHealthInsurance, is a private online marketplace for health insurance.

The data and research is focused on ACA market consumers who earn too much per year to qualify for government subsidies that help to reduce what they spend on insurance premiums and out-of-pocket costs. The new report is based on individual and family health insurance applications submitted by unsubsidized eHealth consumers between November 1 and December 15, 2018.

WHAT’S THE IMPACT

While overall premiums were relatively flat compared to the 2018 open enrollment period, costs for two- and four-person families hit a couple of new milestones.

The first is that total combined annual premiums plus deductibles for a four-person family topped $25,000 for 2019. The second is that average premiums for two-person families broke $1,000 per month for the first time this year.

Deductibles marked their first significant decline since 2014, when the ACA took effect. he average individual deductible decreased 6% for 2019, while the average family deductible decreased 8%.

Plan selection trends for 2019 show that HMO plans continue to dominate the market, representing 56% of all plan selections, the same as in 2018.

Meanwhile, exclusive provider organization, or EPO plans reach 26% of all plan selections, up from 20% in 2018; and silver plans reach 35% of all plan selections, up from 30% over last year.

THE LARGER TREND

An estimated 87% of Healthcare.gov customers received subsidies. Their premium cost after subsidies is $87 a month, according to the report. But costs borne by the unsubsidized are significantly greater. At eHealth during the fourth quarter of 2018, which included the ACA’s 2019 open enrollment period, 64% of applications were for consumers purchasing ACA-compliant plans not eligible for use with subsidies.

Premiums for those with employer-sponsored health insurance plans have also been on the rise.

Between 2008 and 2018, such premiums increased 55 percent — twice as fast as workers’ earnings, according to a June report from Kaiser Family Foundation. And since 2006, the average health insurance deductible for covered workers soared by more than 200 percent — from an inflation-adjusted average of $379 to more than $1,300 today.

 

One State’s Big Leap to Reduce Medicare and Medicaid’s Out-of-Pocket Costs

Posted on by • Posted in Continuum of Care, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, Long-Term Healthcare, Out of Pocket Expenses, Payroll Tax • Leave a comment

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Washington state is going further than any other to cover aging Americans’ medical bills.

More than 15 percent of Americans have already reached the age of 65, and by 2030 that number will have risen to one in five as the last of the baby boomers reach retirement age. Despite these numbers, insurance options to cover the long-term health-care needs that many aging Americans will need are elusive. While Medicare pays for medical services in a nursing facility, it covers the cost of the stay itself only for short stints. And Medicaid typically covers long-term care only for those Americans with virtually no assets.

It’s an issue that state legislatures are continually revisiting, but overall there’s been little progress toward meeting the full health-care costs of the elderly. This year, however, the state of Washington passed legislation that will go further than any other state in closing coverage gaps for a large proportion of its residents.

The program will be funded by a wage tax of about 0.6 percent, which kicks in in 2022. Beginning in 2025, the state will offer a maximum lifetime benefit of $36,500 for a person to use for long-term care needs, with the benefit indexed to rise annually with inflation. The coverage isn’t universal: To use the money — up to $100 a day — a resident will need to have worked and paid into the program for at least three years in the past six or for a total of 10 years with five years of uninterrupted work. In addition to the standard stay in a nursing home, the benefit will cover items such as installing wheelchair ramps at home and providing services such as those offered at an assisted living facility or by in-home care.

A challenge for the state will be to make sure that as residents’ paychecks reflect the new wage tax, they understand where their money is going. “We need a backstock of resources, and that’s what this does,” says Jason McGill, health policy adviser to Gov. Jay Inslee. “They might not know what they’re paying into, and it’s our next step to communicate what that is and why it’s important.”

While Washington’s approach is broader than most, advocates say there are plenty of other ways to chip away at the unaffordability of health care for the elderly. “It’s not one thing or the other. It’s a series of policy changes that will change the landscape,” says Elaine Ryan, vice president for state advocacy and strategy integration at AARP.

Ryan lists helping with caregiver expenses as a good place to start, given that the average out-of-pocket cost for a caregiver is $7,000 a year. Hawaii took such a step in 2017 with legislation providing $70 a day for up to a year for caregiver expenses. A couple of other states are weighing tax credits for caregiving costs, and a bipartisan federal bill taking that approach is pending.

Another step that would lessen the burden of long-term health care costs would be to implement more flexible sick-leave policies that would make it easier for employees to care for aging relatives. “It’s hard to believe you don’t have that for anything other than your own health,” says Ryan.

Whatever approaches a state considers must be framed around the need for options across the continuum of a person’s life, in Ryan’s view. “We need these systems to be more contemporary,” she says. “That’s why when we communicate the need for these policies at the state level, we refer to them as a whole-family caregiving journey.”

 

The Battle for Health Care

Posted on by • Posted in 2020 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, Individual Mandate, Out of Pocket Expenses, Preexisting Conditions, Supreme Court, Underinsured, Uninsured • Leave a comment

https://www.newyorker.com/podcast/comment/the-health-care-defense?reload=true

The Battle for Health Care

The latest Republican effort to destroy the Affordable Care Act appears likely to reach the Supreme Court in the heat of the 2020 Presidential race.

One of the central questions of the 2020 Presidential campaign was posed last week before the Court of Appeals for the Fifth Circuit, in New Orleans, to a lawyer for the Trump Administration, who didn’t even pretend to have an answer. A three-judge panel was hearing the appeal of a ruling by Reed O’Connor, a Texas district-court judge, that the Affordable Care Act, or Obamacare, was unconstitutional in its entirety—an opinion that the Administration has endorsed. O’Connor had ordered that the government cease implementing or enforcing all aspects of the A.C.A., including its protections for people with preëxisting conditions, its ban on lifetime caps, its expansion of Medicaid and coverage for young adults on their parents’ plan, and its support for the treatment of addiction. The order could cost tens of millions of people all or much of their coverage, and throw the health-care system, which accounts for a fifth of the economy, into chaos. But O’Connor, in what Judge Jennifer Elrod, of the Fifth Circuit, described with no apparent irony as a “modest” act, had stayed his own order, pending appeals. Here, now, was the first appeal. So, if the stay is lifted, Elrod asked, “What’s the government planning to do?”

As the lawyer, August Flentje, struggled to answer (“This is a very complicated program—multifaceted, obviously”), it became clear that Republican opposition to the A.C.A. remains a project of blind destruction. One of President Trump’s few health-care initiatives, on drug prices, fell into disarray last week, with one measure defeated in court and another abandoned. Otherwise, he has mostly complained that Democrats want to extend care to, among others, undocumented people. His almost pathological need to undo President Obama’s legacy can be added to the mix; the restraint sometimes said to characterize conservatism can be subtracted. And there is a growing conviction among the A.C.A.’s opponents that the current Supreme Court, given the addition of Neil Gorsuch and Brett Kavanaugh, will back them up.

They may be right; the threat that this case, Texas et al. v. United States, presents to Obamacare should not be underestimated, especially as it is likely to reach the Court in the heat of the 2020 campaign. The case was brought by twenty states whose most distinct common quality is their redness. Maine and Wisconsin dropped out of the suit after the 2018 midterm elections, when their Republican governors were replaced by Democrats. When the Trump Administration declined to defend the law, a group of mostly blue states—currently twenty-one—got permission from the district court to do so. They were joined by a lawyer for the Democratic-controlled House of Representatives. When Kurt Engelhardt, another of the appeals judges, pointedly asked that lawyer why the Senate hadn’t sent someone to defend the law, he replied that the Senate “operates differently.” It is, after all, led by Mitch McConnell, not Nancy Pelosi.

The complaint concerns the so-called “individual mandate.” When the A.C.A. was enacted, in 2010, it directed every American to get insurance or face a penalty, which was calculated on a sliding scale (and dropped altogether for low-income people; other groups, such as prisoners, were exempt). The constitutionality of the mandate was the subject of an earlier challenge to the A.C.A., but Chief Justice John Roberts wrote an opinion classifying the penalty as a tax, which Congress has the power to levy. Trump’s 2017 tax package, however, reduced the penalty to zero. For the A.C.A.’s opponents, this led to a wild surmise: if the mandate had survived because the penalty was a tax, the absence of a tax might make the mandate unconstitutional. That point might seem academic—constitutional or not, the mandate is, for all practical purposes, already gone, now that there is no penalty for ignoring it. But Texas et al. makes a far more radical claim: The phantom mandate is not only unconstitutional but “inseverable” from the rest of the law. If it is invalid, then all nine hundred and six pages of Obamacare are also invalid.

This argument is as senseless as it is ruinous. It’s like saying that the 2017 tax bill was a stealth total repeal of the A.C.A., something that even leading Republicans denied at the time. And yet at least two of the judges, Elrod and Engelhardt, appeared inclined to accept it. The main issue for them seemed to be just how much of Obamacare to trash.

On that question, too, the Administration has been erratic. Initially, it argued that the court should invalidate only certain provisions, such as preëxisting-condition protections—a major feature that Trump has elsewhere claimed to like. Then, in March, the Administration said that it agreed with the Texas ruling: burn it all. Two months later, though, it argued that, while every word of the law was invalid, any relief that the lower court granted should be limited to damages suffered by Texas and the other states, without defining what those damages might be. This led to utter confusion in the oral arguments: Would there be different versions of the law for different states? Which provisions might the government want to keep? (“You would leave in place the calorie guides?” Judge Elrod asked.) Flentje, the Justice Department’s lawyer, told Elrod that, really, “things don’t need to get sorted out until there’s a final ruling”—that is, from the Supreme Court.

Obamacare has reduced the number of uninsured Americans by twenty million and, while the system is imperfect, premiums are more manageable than is often reported. But, as the Texas case suggests, it can still all be undone. And there is much more to do; the United States has not achieved universal coverage. All the Democratic Presidential front-runners share that goal, but they have what are sometimes sharply diverging proposals for getting there. Vice-President Joseph Biden, Mayor Pete Buttigieg, of South Bend, and former Representative Beto O’Rourke, of El Paso, want to build on the A.C.A. and make Medicare available to all as a public option, alongside private insurance. Senator Bernie Sanders, of Vermont, has a Medicare for All bill that aims to displace private insurance, and in most cases make it unlawful, leaving a public option as the only real option. Senators Elizabeth Warren and Kamala Harris have signed on to Sanders’s plan, although Harris has at times tried to downplay the impact on private insurance.

The next Democratic debates, which will be held on July 30th and 31st, may sharpen the candidates’ positions or further polarize them. The Democrats need a plan to protect Americans’ health coverage. And they need a plan to win in 2020. Those might even be the same thing. ♦