Category Archives: Medicaid Expansion

What Trump and the GOP have planned for healthcare

Posted on by • Posted in ACA, Congressional Budget Office (CBO), Health Insurance Coverage Adequacy, Health Insurance Denial, Health Insurance Industry, Health Policy, Health System, Healthcare Reform, Hospital, Hospital Industry, Medicaid, Medicaid Block Grants, Medicaid Eligibility, Medicaid Expansion, Medicaid Work Requirements, Medicare, Medicare 340B Drug Discount Program, Medicare Advantage, Medicare Cuts, Medicare Denials, Medicare Hospital Fund, Medicare Payment, Medicare Payment Advisory Commission (MedPAC), Medicare Reimbursement, Medicare Site Neutral Payment, Project 2025, State of the Union, Tax Exempt Debt, Tax Exempt Status • Leave a comment
https://www.healthcarefinancenews.com/news/what-trump-and-gop-have-planned-healthcare?leadId=1234536&mkt_tok=NDIwLVlOQS0yOTIAAAGYKMuOSDpr4HmVgwoir-sctcWYrTCmAMidk2ElOKJYQgYV2OewZexaTT7OGNmdoOgJX4esGPrurXZW_6oPMprQ0Mc5ph-PR7Pcrbc3LivGTNmd

Health systems are rightly concerned about Republican plans to cut Medicaid spending, end ACA subsidies and enact site neutral payments, says consultant Michael Abrams, managing partner of Numerof, a consulting firm.

“Health systems have reason to worry,” Abrams said shortly after President Donald Trump was inaugurated on Monday. 

While Trump mentioned little about healthcare in his inauguration speech, the GOP trifecta means spending cuts outlined in a one-page document released by Politico and another 50-pager could get a majority vote for passage.

Of the insurers, pharmaceutical manufacturers and health systems that Abrams consults with, healthcare systems are the ones that are most concerned, Abrams said.

At the top of the Republican list targeting $4 trillion in healthcare spending is eliminating an estimated $2.5 billion from Medicaid. 

“There’s no question Republicans will find savings in Medicaid,” Abrams said.

Medicaid has doubled its enrollment in the last couple of years due to extended benefits made possible by the Affordable Care Act, despite disenrolling 25 million people during the redetermination process at the end of the public health emergency, according to Abrams.

Upward of 44 million people, or 16.4% of the non-elderly U.S. population are covered by an Affordable Care Act initiative, including a record high of 24 million people in ACA health plans and another 21.3 million in Medicaid expansion enrollment, according to a KFF report. Medicaid expansion enrollment is 41% higher than in 2020.

The enhanced subsidies that expanded eligibility for Medicaid and doubled the number of enrollees are set to expire at the end of 2025 and Republicans are likely to let that happen, Abrams said. Eliminating enhanced federal payments to states that expanded Medicaid under the ACA are estimated to cut the program by $561 billion.

If enhanced subsidies end, the Congressional Budget Office has estimated that the number of people who will become uninsured will increase by 3.8 million each year between 2026 and 2034. 

The enhanced tax subsidies for the ACA are set to expire at the end of 2025. This could result in another 2.2 million people losing coverage in 2026, and 3.7 million in 2027, according to the CBO.

WHY THIS MATTERS

For hospitals, loss of health insurance coverage means an increase in sicker, uninsured patients visiting the emergency department and more uncompensated care.

“Health systems are nervous about people coming to them who are uninsured,” Abrams said. “There will be people disenrolled.”

The federal government allowed more people to be added to the Medicaid rolls during the public health emergency to help those who lost their jobs during the COVID-19 pandemic, Numerof said. Medicaid became an open-ended liability which the government wants to end now that the unemployment rate is around 4.2% and jobs are available.

An idea floating around Congress is the idea of converting Medicaid to a per capita cap and providing these funds to the states as a block grant, Abrams said. The cost of those programs would be borne 70% by the federal government and 30% by states.

This fixed amount based on a per person amount would save money over the current system of letting states report what they spent.

Another potential change under the new administration includes site neutral Medicare payments to hospitals for outpatient services.

The HFMA reported the site neutral policy as a concern in a list it published Monday of preliminary federal program cuts totaling more than $5 trillion over 10 years. The 50-page federal list is essentially a menu of options, the HFMA said, not an indication that programs will actually be targeted leading up to the March 14 deadline to pass legislation before federal funding expires.

Other financial concerns for hospitals based on that list include: the elimination of the tax exemption for nonprofit hospitals, bringing in up to $260 billion in estimated 10-year savings; and phasing out Medicare payments for bad debt, resulting in savings of up to $42 billion over a decade.

Healthcare systems are the ones most concerned over GOP spending cuts, according to Abrams. Pharmacy benefit managers and pharmaceutical manufacturers also remain on edge as to what might be coming at them next.

THE LARGER TREND

President Donald Trump mentioned little about healthcare during his inauguration speech on Monday.

Trump said the public health system does not deliver in times of disaster, referring to the hurricanes in North Carolina and other areas and to the fires in Los Angeles.

Trump also mentioned giving back pay to service members who objected to getting the COVID-19 vaccine.

He also talked about ending the chronic disease epidemic, without giving specifics.

“He didn’t really talk about healthcare even in the campaign,” Abrams said.

However, in his consulting work, Abrams said, “The common thread is the environment is changing quickly,” and that healthcare organizations need to do the same “in order to survive.”

Advocates roll out efforts to shield Medicaid

Posted on by • Posted in ACA, Advocacy, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Block Grants, Medicaid Childrens Health Insurance Program (CHIP), Medicaid Eligibility, Medicaid Expansion, Medicaid Redeterminations, Medicaid Retroactive Eligibility, Underinsured, Uninsured • Leave a comment

https://nxslink.thehill.com/view/6230d94bc22ca34bdd8447c8msmrk.ngi/32c5cdf6

Liberal advocacy groups are ramping up efforts to protect the Medicaid program from potential cuts by Republican lawmakers and the new Trump administration. 

The Democratic group Protect Our Care launched Tuesday an eight-figure “Hands off Medicaid” ad campaign targeting key Republicans in the House and Senate, warning of health care being “ripped away” from vulnerable Americans. 

The lawmakers include GOP Sens. Bill Cassidy (La.), Chuck Grassley (Iowa), Lisa Murkowski (Alaska) and Susan Collins (Maine), as well as Reps. David Schweikert (Ariz.), Mike Lawler (N.Y.) and David Valadao (Calif.). 

The campaign will also include digital advertising across platforms targeting the Medicaid population in areas around nursing homes and rural hospitals, ads on streaming platforms as well as billboards and bus stop wraps. 

Medicaid covers 1 in 5 Americans, and the group wants to highlight that includes “kids, moms, seniors, people of color, rural Americans, and people with disabilities.” 

“The American people didn’t vote in November to have their grandparents kicked out of nursing homes or health care ripped away from kids with disabilities or expectant moms in order to give Elon Musk another tax cut,” Protect Our Care chair Leslie Dach said in a statement.  

House Republicans have expressed openness to making some drastic changes in the Medicaid program to pay for extending President Trump’s signature tax cuts, including instituting work requirements and capping how much federal money is spent per person. The ideas have been conservative mainstays since they were included as part of the 2017 Obamacare repeal effort.  

Separately, advocacy group Families USA led a letter with more than 425 national, state and local organizations calling on Trump to protect Medicaid.  

The groups noted that if the Trump administration wants to trim health costs, “there are many well-vetted, commonsense and bipartisan proposals” that don’t involve slashing Medicaid. 

“In 2017, millions upon millions of Americans rose up against proposed cuts and caps and made clear how much they valued Medicaid as a critical health and economic lifeline for themselves, their families, and their communities. The American people are watching once again, and we urge you to take this opportunity to choose a different path,” they wrote.  

Musk’s DOGE could leave millions uninsured

Posted on by • Posted in ACA, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, High Deductible Health Plans, Medicaid, Medicaid Block Grants, Medicaid Eligibility, Medicaid Expansion, Medicaid Redeterminations, Medicaid Retroactive Eligibility, Medicaid Section 1115 Waiver, Medicaid Unwinding, Medicaid Work Requirements, Medical Debt, Out of Pocket Expenses, State of the Union, Underinsured, Uninsured, Unnecessary Deaths • Leave a comment

https://www.linkedin.com/pulse/musks-doge-could-leave-millions-uninsured-robert-pearl-m-d–xl8dc/?trackingId=7TewioXWRzScafytDRqrQQ%3D%3D

As Donald Trump begins his second term, America’s healthcare system is in crisis: medical costs are skyrocketing, life expectancy has stagnated, and burnout runs rampant among healthcare workers.

These problems are likely to become worse now that Trump has handed the federal budget over to Elon Musk. The world’s richest man now co-heads the Department of Government Efficiency (DOGE), a non-government entity tasked with slashing $500 billion in “wasteful” spending.

The harsh reality is that Musk’s mission can’t succeed without gutting healthcare access and coverage for millions of Americans.

Deleting dollars from American healthcare

Since Trump’s first term, the country’s economic outlook has worsened significantly. In 2016, the national debt was $19 trillion, with $430 billion allocated to annual interest payments. By 2024, the debt had nearly doubled to $36 trillion, requiring $882 billion in debt service—12% of federal spending that is legally untouchable.

Add to that another 50% of government expenditures that Trump has deemed politically off-limits: Social Security ($1.35 trillion), Medicare ($848 billion) and Defense ($1.13 trillion). That leaves just $2.6 trillion—less than 40% of the $6.75 trillion federal budget—available for cuts.

In a recent op-ed, Musk and DOGE co-chair Vivek Ramaswamy proposed eliminating expired or misused funds for programs like Public Broadcasting and Planned Parenthood, but these examples account for less than $3 billion total—not even 1% of their target.

This shortfall will require Musk to cut billions in government healthcare spending. But where will he find it?

With Medicare off limits to DOGE, the options for major reductions are extremely limited. Big-ticket healthcare items like the $300 billion in tax-deductibility for employer-sponsored health insurance and $120 billion in expired health programs for veterans will prove politically untouchable. One will raise taxes for 160 million working families and the latter will leave veterans without essential medical care.

This means DOGE will have to attack Medicaid and the ACA health exchanges. Here’s how 20 million people will likely lose coverage as a result.

1. Reduced ACA exchange funding

Since its enactment in 2010, the Affordable Care Act (ACA) has provided premium subsidies to Americans earning 100% to 400% of the federal poverty level. For lower-income families, the ACA also offers Cost Sharing Reductions, which help offset deductibles and co-payments that fund 30% of total medical costs per enrollee. Without CSRs, a family of four earning $40,000 could face deductibles as high as $5,000 before their insurance benefits apply.

If Congress allows CSR payments to expire in 2026, federal spending would decrease by approximately $35 billion annually. If that happens, the Congressional Budget Office expects 7 million individuals to drop out of the exchanges. Worse, without affordable coverage alternatives, 4 million families would lose their health insurance altogether.

2. Slashing Medicaid coverage and tightening eligibility

Medicaid currently provides healthcare for over 90 million low-income Americans, including children, seniors and individuals with disabilities. To meet DOGE’s $500 billion goal, several cost-cutting strategies appear likely:

  • Reversing Medicaid expansion: The ACA expanded Medicaid eligibility to those earning up to 138% of the federal poverty level, reducing the uninsured rate from 16% to 8%. Undoing this expansion would strip coverage from millions in the 40 states that adopted the program.
  • Imposing work requirements: Proponents argue this could encourage employment, but most Medicaid recipients already work for employers that don’t provide insurance. In reality, work requirements primarily create bureaucratic barriers that disqualify millions of eligible individuals, reducing program costs at the expense of coverage.
  • Switching to block grants: Unlike the current Medicaid system, which adjusts funding based on need, less-expensive block grants would provide states with fixed allocations. This will, however, force them to cut services and reduce enrollment.

Medicaid currently costs $800 billion annually, with the federal government covering 70%. Reducing enrollment by 10% (9 million people) could save over $50 billion annually, while a 20% reduction (18 million people) could save $100 billion.

Either outcome would devastate families by eliminating access to vital services including prenatal care, vaccinations, chronic disease management and nursing home care. As states are forced to absorb the financial burden, they’ll likely cut education budgets and reduce infrastructure investments.

The first 100 days

The numbers don’t lie: Musk and DOGE could slash Medicaid funding and ACA subsidies to achieve much of their $500 billion target. But the human cost of this approach would be staggering.

Fortunately, there are alternative solutions that would reduce spending without sacrificing quality. Shifting provider payments in ways that reward better outcomes rather than higher volumes, capping drug prices at levels comparable to peer nations, and leveraging generative AI to improve chronic disease management could all drive down costs while preserving access to care.

These strategies address the root causes of high medical spending, including chronic diseases that, if better managed, could prevent 30-50% of heart attacks, strokes, cancers, and kidney failures according to CDC estimates.

Yet, in their pursuit of immediate budgetary cuts, Musk and DOGE have omitted these kinds of reform options. As a result, the health of millions of Americans is at major risk.

GOP Eyes Medicaid Overhaul

Posted on by • Posted in Health Policy, Healthcare Reform, Medicaid, Medicaid Expansion, Medicaid Work Requirements, Safety Net Hospitals, Safety-Net Providers • Leave a comment
https://www.axios.com/newsletters/axios-vitals-b7e6f780-a872-11ef-8351-d77555a9e21b.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Congressional Republicans are beginning to discuss overhauling Medicaid using a process that would allow the Senate to bypass the required 60-vote threshold to pass certain priorities, according to GOP lawmakers.

Why it matters: 

The changes could significantly reshape a safety net program that covers more than 70 million people, reducing federal spending and potentially leading to significant coverage losses.

Driving the news: 

Perhaps the most likely Medicaid change would be imposing work requirements for recipients, according to GOP sources.

  • That idea was discussed as part of last year’s debt ceiling talks and is familiar to GOP lawmakers.
  • House Majority Leader Steve Scalise (R-La.) told Axios that Medicaid work requirements “potentially” could be included in a legislative package brought up under the fast-track budget procedure known as reconciliation.
  • Asked about other Medicaid spending changes, Scalise said members “have a lot of internal conversations to have about all the things that will be included.”

Yes, but: 

It’s not clear how much, if any, health policy will be packed into a reconciliation bill, since the overriding focus of the package would be on extending major provisions of the Trump 2017 tax law.

  • There has been less recent enthusiasm for controversial health policy changes among Republicans, who’d prefer to focus on taxes, energy and immigration.
  • However, a health package could generate valuable savings to help pay for some of the tax cuts, and Medicaid is a large pot of money, costing over $800 billion per year.
  • Congressional scorekeepers previously estimated work requirements would save over $100 billion over 10 years — and 600,000 people would become uninsured.

What they’re saying: 

Rep. Brett Guthrie (R-Ky.), one of two leading contenders to be chair of the House Energy and Commerce Committee in the next Congress, told Axios he is interested in capping Medicaid spending on each enrollee, known as a “per capita cap” or allotment.

  • This would be a revival of a proposal from the 2017 Affordable Care Act repeal-replace plan.
  • “We offered Medicaid reform in reconciliation in the repeal-and-replace package, and it was per capita allotments, which didn’t cut Medicaid but it does limit the growth,” Guthrie said.
  • “I do think it has to be discussed as part of the package” next year, he said, adding he hadn’t discussed the idea with leadership yet.

Between the lines: 

Another potential change is reducing the federal share of spending on the Medicaid expansion population, currently at 90%, so that it matches the lower federal share for the traditional Medicaid population.

  • “It makes no sense for federal policy to pay states more for able-bodied enrollees than for disabled people, children and pregnant women on the program,” said Brian Blase, president of the Paragon Health Institute and a former Trump administration health official.
  • The flip side is that a cash crunch in the states could lead some to drop the Medicaid expansion altogether. Forty states have expanded their programs.

The big picture: 

The first Trump administration approved Medicaid waivers for conservative-led states that imposed work and reporting requirements. But courts struck down many of the approvals.

  • Republicans could be wary of political blowback from efforts to reshape the entitlement program this time around.
  • Protests against Medicaid cuts, as well as possible resistance from some Republican governors, helped doom the repeal-replace effort in 2017.
  • Democrats also are sure to portray any Medicaid cuts as penalizing the poor to help lower taxes on the wealthy.

Rep. Morgan Griffith (R-Va.), an Energy and Commerce Committee member, acknowledged “people get scared” when Medicaid work requirements are discussed, but he noted the possibility of exemptions for people with disabilities or those in school.

  • There have been “some private conversations” though “nothing formal” in the committee about Medicaid changes, he said.

The bottom line: 

“It’s hard to make adjustments to reduce federal spending without touching people who rely on the program,” said Robin Rudowitz, director of the Program on Medicaid and the Uninsured at KFF.

Campaign 2024 and US Healthcare: 7 Things we Know for Sure

Posted on by • Posted in 2024 Election Issues, Abortion, Abortion Pill, Abortion Rights, ACA, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Health System, Healthcare Reform, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Hospital, Hospital Industry, Medicaid, Medicaid Eligibility, Medicaid Expansion, Medicaid Funding, Medical Debt, Medicare, Medicare Advantage, Roe v. Wade • Leave a comment
Campaign 2024 and US Healthcare: 7 Things we Know for Sure

Over the weekend, President Biden called it quits and Democrats seemingly coalesced around Vice President Harris as the Party’s candidate for the White House. While speculation about her running mate swirls, the stakes for healthcare just got higher. Here’s why:

A GOP View of U.S. Healthcare

Republicans were mute on their plans for healthcare during last week’s nominating convention in Milwaukee. The RNC healthcare platform boils down to two aims: ‘protecting Medicare’ and ‘granting states oversight of abortion services.  Promises to repeal and replace the Affordable Care Act, once the staple of GOP health policy, are long-gone as polls show the majority (even in Red states (like Texas and Florida) favor keeping it. The addition of Ohio Senator JD Vance to the ticket reinforces the party’s pro-capitalism, pro-competition, pro-states’ rights pitch.

To core Trump voters and right leaning Republicans, the healthcare industry is a juggernaut that’s over-regulated, wasteful and in need of discipline. Excesses in spending for illegal immigrant medical services ($8 billion in 2023), high priced drugs, lack of price transparency, increased out-of-pocket costs and insurer red tape stoke voter resentment. Healthcare, after all, is an industry that benefits from capitalism and market forces: its abuses and weaknesses should be corrected through private-sector innovation and pro-competition, pro-consumer policies.

A Dem View of Healthcare

By contrast, healthcare is more prominent in the Democrat’s platform as the party convenes for its convention in Chicago August 19. Women’s health and access to abortion, excess profitability by “corporate” drug manufacturers, hospitals and insurers, inadequate price transparency, uneven access and household affordability will be core themes in speeches and ads, with a promise to reverse the Dobb’s ruling by the Supreme Court punctuating every voter outreach.

Healthcare, to the Democratic-leaning voters is a right, not a privilege.

Its majority think it should be universally accessible, affordable, and comprehensive akin to Medicare. They believe the status quo isn’t working: the federal government should steward something better.

Here’s what we know for sure:

  1. Foreign policy will be a secondary focus. The campaigns will credential their teams as world-savvy diplomats who seek peace and avoid conflicts. Nationalism vs. globalism will be key differentiator for the White House aspirants but domestic policies will be more important to most voters.
  2. Healthcare reform will be a more significant theme in Campaign 2024 in races for the White House, U.S. Senate, U.S. House of Representatives and Governors. Dissatisfaction with the status quo and disappointment with its performance will be accentuated.
  3. The White House campaigns will be hyper-negative and disinformation used widely (especially on healthcare issues). A prosecutorial tone is certain.
  4. Given the consequence of the SCOTUS’ Chevron ruling limiting the role and scope of agency authority (HHS, CMS, FDA, CDC, et al), campaigns will feature proposed federal & state policy changes and potential Cabinet appointments in positioning their teams. Media speculation will swirl around ideologues mentioned as appointees while outside influencers will push for fresh faces and new ideas.
  5. Consumer prices and inflation will be hot-button issues for pocketbook voters: the health industry, especially insurers, hospitals and drug companies, will be attacked for inattention to affordability.
  6. Substantive changes in health policies and funding will be suspended until 2025 or later. Court decisions, Executive Orders from the White House/Governors, and appointments to Cabinet and health agency roles will be the stimuli for changes. Major legislative and regulatory policy shifts will become reality in 2026 and beyond. Temporary adjustments to physician pay, ‘blame and shame’ litigation and Congressional inquiries targeting high profile bad actors, excess executive compensation et al and state level referenda or executive actions (i.e. abortion coverage, price-containment councils, CON revisions et al) will increase.
  7. Total healthcare spending, its role in the economy and a long-term vision for the entire system will not be discussed beneath platitudes and promises. Per the Congressional Budget Office, healthcare as a share of the U.S. GDP will increase from 17.6% today to 19.7% in 2032. Spending is forecast to increase 5.6% annually—higher than wages and overall inflation. But it’s too risky for most politicians to opine beyond acknowledgment that “they feel their pain.”

My take:

Regardless of the election outcome November 5, the U.S. healthcare industry will be under intense scrutiny in 2025 and beyond. It’s unavoidable.

Discontent is palpable. No sector in U.S. healthcare can afford complacency. And every stakeholder in the system faces threats that require new solutions and fresh voices.

Stay tuned.

The CBO Health Insurance Status Report: Four Reasons it’s Overly Optimistic

Posted on by • Posted in 2024 Election Issues, Congressional Budget Office (CBO), Health Insurance Coverage Adequacy, High Cost of Living, High Cost Therapies, High Premiums, High Prices, Medicaid, Medicaid Eligibility, Medicaid Expansion, Medical Debt, Medicare, Out of Pocket Expenses, Underinsured, Uninsured • Leave a comment
The CBO Health Insurance Status Report: Four Reasons it’s Overly Optimistic

In the Congressional Budget Office’ latest report on the status of health insurance coverage from the 2023 National Health Interview Survey released last week, a cautiously optimistic picture of coverage is presented:

  • “In 2023, 25.0 million people of all ages (7.6%) were uninsured at the time of interview. This was lower than, but not significantly different from 2022, when 27.6 million people of all ages (8.4%) were uninsured. Among adults ages 18 64, 10.9% were uninsured at the time of interview, 23.0% had public coverage, and 68.1% had private health insurance coverage.
  • The percentage of adults ages 18-64 who were uninsured in 2023 (10.9%) was lower than the percentage who were uninsured in 2022 (12.2%).
  • Among children ages 0–17 years, 3.9% were uninsured, 44.2% had public coverage, and 54.0% had private health insurance coverage.
  • The percentage of people younger than age 65 with exchange-based coverage increased from 3.7% in 2019 to 4.8% in 2023.”

That represents the highest level of coverage in modern history. Later, it adds important context: The percentage of adults ages 18–64 who were uninsured decreased between 2019 and 2023 for all family income groups shown except for adults in families with incomes greater than 400% FPL. Notably, a period in which the Covid-19 pandemic prompted federal government’s emergency funding so households and businesses could maintain their coverage.

  • “Among adults with incomes below 100% FPL, the percentage who were uninsured in 2023 (20.2%) was lower than, but not significantly different from, the percentage who were uninsured in 2022 (22.7%).
  • Among adults with incomes 100% to less than 200% FPL, the percentage who were uninsured decreased from 22.3% in 2022 to 19.1% in 2023.
  • Among adults with incomes 200% to 400% FPL, the percentage who were uninsured decreased from 14.2% in 2022 to 11.5% in 2023.
  • No significant difference was observed in the percentage of adults with incomes above 400% FPL who were uninsured between 2022 (4.1%) and 2023 (4.3%).”
  • In 2023, among adults ages 18–64, the percentage who were uninsured was highest among health insurance coverage of any type was higher for those with higher household income but decreased coverage in 2023 correlated to ethnicity, non-expansion of state Medicaid programs: From 2019 to 2023.”
  • And decreases in the ranks of the uninsured were noted across all ethnic groups:
    • Among Hispanic adults, from 29.7% to 24.8%
    • Among Black non-Hispanic adults, from 14.7% to 10.4% in 2023
    • Among White non-Hispanic adults, decreased from 10.5% to 6.8%
    • Among Asian non-Hispanic adults, from 8.8% to 4.4% in 2023.

The New York Times noted “The drops cut significantly into gaps between ethnic groups. The uninsured rate among Black Americans, for example, was almost 8% higher than for white Americans in 2010, and was only 4%higher in 2022. The data points to the broad effects of the Affordable Care Act, the landmark law President Barack Obama signed in 2010 that created new state and federal insurance marketplaces and expanded Medicaid to millions of adults. National uninsured rates have continued to drop in recent years, hitting a record low in early 2023.”

But the report also flags a reversal of the trend: “The uninsured share of the population will rise over the course of the next decade, before settling at 8.9% in 2034, largely as a result of the end of COVID-19 pandemic–related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022. The largest increase in the uninsured population will be among adults ages 19–44. Employment-based coverage will be the predominant source of health insurance, and as the population ages, Medicare enrollment will grow significantly. After greater-than-expected enrollment in 2023, Marketplace enrollment is projected to reach an all-time high of twenty-three million people in 2025.”

My take:

A close reading of this report suggests its forecast might be overly optimistic. it paints a best-case picture of health insurance coverage that under-estimates the realities of household economics and marketplace trends and over-estimates the value proposition promoted by health insurers to their customers. My conclusion is based on four trends that suggest coverage might slip more than the report suggests:

  1. The affordability of healthcare insurance is increasingly problematic to lower- and middle-income households who face inflationary prices for housing, food, energy and transportation. The CBO report verifies that household income is key to coverage and working age populations are most-at risk of losing its protections. Subsidies to fund premiums for those eligible, employer plans that expose workers to high deductibles and increased non-covered services are likely to push fewer to enroll as premiums become unaffordable to working age adults and unattractive to their employers. As outlined in a sobering KFF analysis, half of the adult population is worried about the affordability of their healthcare—and that includes 48% who have health insurance. And wages in the working age population are not keeping pace with prices for food, shelter and energy, leaving healthcare expenses including their insurance premiums and out-of-pocket obligations at greater risk.
  2. The value proposition for health insurance coverage is eroding among employers, consumers and lawmakers. To large employers that provide employee insurance, medical costs are forcing benefits reduction or cessation altogether. Insurance has not negated their medical costs. To small employers, it’s an expensive bet to recruit and keep their workforce. To government sponsors (i.e. Medicare, Medicaid, VHA, et al), insurance is a necessary but increasingly expensive obligation with growing dependence on private insurers to administer their programs. State and federal regulators are keen to limit public spending and address disparities in their public insurance programs. All recognize that private insurers play a necessary role in the system and all recognize that confidence in health insurance protections is suspect. Thus, increased regulation of private insurers is likely though unwelcome by its members.
  3. Public funding for government payers will be increasingly limited increasing insurer dependence on private capital for sustainability and growth. Funding for Medicare, Medicaid, Veterans and Military Health, Public Health et al are dependent on appropriations and tax collections. All are structured to invite private insurer participation: all are seeing corporate insurers seize market share from their weaker competitors. The issues are complex and controversial as evidenced by the ongoing debates about fairness in Medicare Advantage and administration of Medicaid expansion among others. And polls indicate widespread dissatisfaction with the system and lack of confidence in its insurers, hospitals, physicians or the government to fix it.
  4. Access to private capital for private health insurers is shrinking enabling corporate insurers to play bigger roles in financing and delivering services. Private investments in healthcare services (i.e. hospitals, physicians, clinics) has slowed and momentum has shifted from sellers to buyers seeking less risk and higher returns. Capital deployment by corporate insurers i.e. UHG, HUM et al has resulted in vertically-integrated systems of health inclusive of physician services, drug distribution, ASCs and more. And funding for AI-investments that lower their admin costs and increase their contracting leverage with providers is a strategic advantage for corporate insurer that operate nationally at scale. Unless the federal government bridles their growth (which is unlikely), corporate insurers will control national coverage while others fail.

Thus, no one knows for sure what coverage will be in 2034 as presented in the CBO report. Its analysis appropriately considers medical inflation, population growth and an incremental shift to value-based purchasing in healthcare, but it fails to accommodate highly relevant changes in the capital markets, corporate insurer shareholder interests and voter sentiment.

P.S. This is an important week for healthcare: Today marks the two-year anniversary of the Supreme Court’s Dobbs decision that overturned Roe v. Wade, ending the constitutional right to an abortion that pushed reproductive rights to states.

And Thursday in Atlanta, President Joe Biden and former President Donald Trump will make history in the first presidential debate between an incumbent and a former president.

Reproductive rights will be a prominent theme along with immigration and border security as wedge issues for voters.

The economy and inflation are the issues of most consequence to most voters, so unless the campaigns directly link healthcare spending and out of pocket costs to voter angst about their household finances, not much will be said.

Notably, half of the U.S. population have unpaid medical bills and medical debt is directly related to their financial insecurity. Worth watching.

Why a deep-red state could be on the verge of expanding Medicaid

Posted on by • Posted in ACA, Financial Strength, Financial Viability, Financially Distressed, Health Insurance Coverage Adequacy, Health Policy, Medicaid Expansion, Medicaid Work Requirements • Leave a comment

https://www.axios.com/2024/04/11/mississippi-medicaid-expansion-republicans-obamacare

Mississippi, one of the country’s poorest and least healthy states, could soon become the next to expand Medicaid.

Why it matters: 

It’s one of several GOP-dominated states that have seriously discussed Medicaid expansion this year, a sign that opposition to the Affordable Care Act coverage program may be softening among some holdouts 10 years after it became available.

  • A new House speaker who strongly backs expansion and growing fears that the state’s rural hospitals can’t survive without it have kept up momentum in Mississippi’s legislature this year.
  • As many as 200,000 low-income adults could gain coverage if lawmakers clinch a deal in the closing weeks of the Mississippi session.

State of play: 

Mississippi’s House and Senate this week began hashing out differences between two very different plans passed by each chamber.

  • The House bill is the traditional ACA expansion, extending coverage to adults earning 138% of the federal poverty level, or about $21,000.
  • The Senate’s version, which leaders have dubbed “lite” expansion, covers people earning up to the poverty line and wouldn’t bring in the more generous federal support available for full expansion.
  • Both plans include a work requirement, but only the House version would still allow expansion to take effect without it. The Biden administration opposes work rules, but former President Trump could revive them in a second term.

Zoom out: 

State lawmakers in Alabama and Georgia gave serious consideration to Medicaid expansion this year, though they ultimately dropped it. Kansas’ Gov. Laura Kelly, a Democrat, is trying again to expand Medicaid, but the GOP-run legislature remains opposed.

  • Shuttering rural hospitals and an acknowledgement that the ACA is unlikely to be repealed have made Republicans more willing to take a closer look at expansion, Politico reported earlier this year.
  • The fact that the extra federal funding from the ACA expansion could lift state budgets as pandemic aid dries up has also piqued states’ interest, said Joan Alker, executive director of the Georgetown University Center on Children and Families.

Zoom in: 

Mississippi’s expansion effort has advanced further than other states this year largely because new House Speaker Jason White has made it a priority. Lt. Gov. Delbert Hosemann, who presides over the Senate, has also pushed the issue.

  • “We see an unhealthy population that’s uncovered. And we see this as the best way” to insure them, White told Mississippi Today this week.
  • “I just think it’s time for us to realize that there’s not something else coming down the pipe.”

The state’s crumbling health infrastructure has also made expansion more urgent, said Democratic state Sen. Rod Hickman. More than 40% of the state’s 74 rural hospitals are at risk of closing, a report last summer found.

  • “The dire need of our hospital systems and the state finally recognizing that Medicaid expansion could assist in those issues is what has kind of brought that to the forefront,” he told Axios.

Yes, but: 

Republican Gov. Tate Reeves has reportedly pledged to oppose any Medicaid expansion deal that may emerge before the legislature adjourns in early May, so lawmakers would likely need a veto-proof majority to approve an expansion.

  • Austin Barbour, a Republican strategist who works in Mississippi politics, said he expects lawmakers will reach a deal.
  • But if they don’t, “I know this will be an issue that’ll pop right back up next session,” he said.

Michael Dowling: The most pressing question to start the year

Posted on by • Posted in Addiction, Board, Civility, Community Benefit, Community Hospital, Community-Based Services, Gun Violence, Integrity, Leadership, Leadership Commitment, Leadership Investment, Leadership Values, Leadership Vision, Medicaid Expansion, Mental Health, Mission, Respect, Social Determinants of Health, Under Served Populations • Leave a comment
https://www.beckershospitalreview.com/hospital-management-administration/michael-dowling-the-most-pressing-question-to-start-the-year.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=2893H2397267F7G

The new year is always an ideal time for healthcare leaders to reflect on the state of our industry and their own organizations, as well as the challenges and opportunities ahead.

As the CEO of a large health system, I always like to reflect on one basic question at the end of each year: Are we staying true to our mission? 

Certainly, maintaining an organization’s financial health must always be a priority but we should also never lose sight of our core purpose. In a business like ours that has confronted and endured a global pandemic and immense financial struggles over the past several years, I recognize it’s increasingly difficult to maintain our focus on mission while trying to find ways to pay for rising labor and supply costs, infrastructure improvements needed to remain competitive and other pressures on our day-to-day operations. 

After all, the investments we need to make to promote community wellness, mental health, environmental sustainability and health equity receive little or no reimbursement, negatively impacting our financial bottom lines. During an era of unprecedented expansion of Medicaid and Medicare, we get less and less relief from commercial insurers, whose denial and delay tactics for reimbursing medical claims continue to erode the stability of many health systems and hospitals, especially those caring for low-income communities. 

Despite those enormous pressures, it’s imperative that we continue to support underserved communities, military veterans struggling with post-traumatic stress, and intervention programs that help deter gun violence and addiction. 

The list of other worthy investments goes on and on: charity care to uninsured or underinsured patients who can’t pay their medical bills, funding for emergency services that play such a critical role during public health emergencies, nutritional services for families struggling to put food on the table, programs that combat human trafficking and support women’s health, the LGBTQIA+ community and global health initiatives that aid Ukraine, the Middle East and other countries torn apart by war, famine and natural disasters. 

We must also recognize the key role of healthcare providers as educators. School-based mental health programs are saving lives by identifying children exhibiting suicidal behaviors, anger management issues and other troublesome behaviors. School outreach efforts have the added benefit of helping health systems and hospitals address their own labor shortages by introducing young people to career paths that will help shape the future healthcare workforce. 

Without a doubt, the “to-do” list of community health initiatives that support our mission is daunting. We can’t do it all alone, but as the largest employers in cities and towns across America, health systems and hospitals can serve as a catalyst to get all sectors of our society — government, businesses, schools, law enforcement, churches, social service groups and other community-based organizations — to recognize that “health” goes far beyond the delivery of medical care. 

The health of individuals, families and communities hinges on the prevalence of good-paying jobs, decent and affordable housing, quality education, access to healthy foods, medical care, transportation, clean air and water, low prevalence of crime and illicit drugs, and numerous other variables that typically depend on the zip codes where we live. Those so-called social determinants of health are the driving factors that enable communities and the people who live there to either prosper or struggle, resulting in disparities that are the underlying cause of why so many cities and towns across the country fall into economic decay and become havens for crime and hotbeds for gun violence, which shamefully is now the leading cause of death for children and adolescents. 

To revive these underserved communities, many of which are in our own backyards, we have to look at all of the socioeconomic issues they struggle with through the prism of health and use the collective resources of all stakeholders to bring about positive change. 

Health is how we work together to build a sense of community. Having a healthy community also requires everyone doing what they can to tone down the political rhetoric and social media-fueled anger that is polarizing our society. Health is bringing back a sense of civility and respect in our public discourse, and promoting the values of honesty, decency and integrity. 

As healthcare providers and respected business leaders, we should all make a New Year’s resolution to stay true to our mission and do what we can within our communities to bring oxygen to hope, optimism and a healthier future. 

ACA enrollment continues at a record pace 

Posted on by • Posted in 2024 Election Issues, ACA, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid Expansion, Medical Loss Ratio (MLR), Out of Pocket Expenses, Preexisting Conditions, Underinsured, Uninsured • Leave a comment

https://nxslink.thehill.com/view/6230d94bc22ca34bdd8447c8k3p6r.11v6/ce256994

Affordable Care Act (ACA) enrollment appears poised to reach record levels once again as signups grew by more than a third of what they were this time last year, a fact the White House is using to continue to draw attention to former President Trump’s threats to try again to repeal the law.  

More than 15 million people have signed up for plans in states that use HealthCare.gov, representing a 33 percent increase from last year. The Biden administration estimates 19 million will sign up for plans by the Jan. 16 deadline.  

On Dec. 15, the deadline for coverage starting Jan. 1, more than 745,000 people selected a plan through HealthCare.gov — the most in a day in history, the Department of Health and Human Services said.  

For 2023 plans, more than 16.3 million people signed up through HealthCare.gov last year, another record. Of those who enrolled for this year, 22 percent were new to the marketplace. 

This year’s enrollment had some unusual factors that may have played a part in boosting enrollment. Those who were disenrolled from Medicaid this year during the “unwinding” period were allowed to sign up for ACA plans earlier than normal. 

There was also stronger insurer participation in the program this year, providing significantly more options for customers to choose from. 

“Thanks to policies I signed into law, millions of Americans are saving hundreds or thousands of dollars on health insurance premiums,” President Biden said on Wednesday. 

“Extreme Republicans want to stop these efforts in their tracks,” he added. “At every turn, extreme Republicans continue to side with special interests to keep prescription drug prices high and to deny millions of people health coverage.” 

The US doesn’t have universal health care — but these states (almost) do

Posted on by • Posted in ACA, Health Policy, Healthcare Reform, Medicaid, Medicaid Eligibility, Medicaid Expansion, Out of Pocket Expenses, Underinsured, Uninsured, Universal Coverage, Universal Healthcare System • Leave a comment

https://www.vox.com/policy/23972827/us-aca-enrollment-universal-health-insurance

Ten states have uninsured rates below 5 percent. What are they doing right?

Universal health care remains an unrealized dream for the United States. But in some parts of the country, the dream has drawn closer to a reality in the 13 years since the Affordable Care Act passed.

Overall, the number of uninsured Americans has fallen from 46.5 million in 2010, the year President Barack Obama signed his signature health care law, to about 26 million today. The US health system still has plenty of flaws — beyond the 8 percent of the population who are uninsured, far higher than in peer countries, many of the people who technically have health insurance still find it difficult to cover their share of their medical bills. Nevertheless, more people enjoy some financial protection against health care expenses than in any previous period in US history.

The country is inching toward universal coverage. If everybody who qualified for either the ACA’s financial assistance or its Medicaid expansion were successfully enrolled in the program, we would get closer still: More than half of the uninsured are technically eligible for government health care aid.

Particularly in the last few years, it has been the states, using the tools made available by them by the ACA, that have been chipping away most aggressively at the number of uninsured.

Today, 10 states have an uninsured rate below 5 percent — not quite universal coverage, but getting close. Other states may be hovering around the national average, but that still represents a dramatic improvement from the pre-ACA reality: In New Mexico, for instance, 23 percent of its population was uninsured in 2010; now just 8 percent is.

Their success indicates that, even without another major federal health care reform effort, it is possible to reduce the number of uninsured in the United States. If states are more aggressive about using all of the tools available to them under the ACA, the country could continue to bring down the number of uninsured people within its borders.

The law gave states discretion to build upon its basic structure. Many received approval from the federal government to create programs that lower premiums; some also offer state subsidies in addition to the federal assistance to reduce the cost of coverage, including for people who are not eligible for federal aid, such as undocumented immigrants. A few states are even offering new state-run health plans that will compete with private offerings.

I asked several leading health care experts which states stood out to them as having fully weaponized the ACA to reduce the number of uninsured. There was not a single answer.

“I don’t think any state has taken advantage of everything,” said Larry Levitt, executive vice president at the KFF health policy think tank. “No state has put all the pieces together to the full extent available under the ACA.”

But a few stood out for the steps they have taken over the last decade to strive toward universal health care.

Massachusetts (and New Mexico): Streamlined enrollment and state subsidies

Massachusetts has the lowest uninsured rate of any state: Just 2.4 percent of the population lacks coverage. It had a head start: The law provided the model for the ACA itself, with its system of government subsidies for private plans sold on a public marketplace that existed prior to 2010.

But experts say it still deserves credit for the steps it has taken since the Massachusetts model was applied to the rest of the country. Matt Fiedler, a senior fellow with the Brookings Schaeffer Initiative on Health Policy, said two policies stood above any others in expanding coverage: integrating the enrollment process for both Medicaid and ACA marketplace plans and offering state-based assistance on top of the law’s federal subsidies.

Massachusetts was among the first states to do both.

“The former can do a lot to reduce the risk that people lose their coverage when incomes change,” Fiedler told me, “while the latter directly improves affordability and thereby promotes take-up.”

Integrated enrollment means that, for the consumer, they can be directed to either the ACA’s marketplace (where they can use government subsidies to buy private coverage) or to the state Medicaid program through one portal. They enter their information and the state tells them which program they should enroll in. Without that integration, people might have to first apply to Medicaid and then, if they don’t qualify, separately seek out marketplace coverage. The more steps that a person must take to successfully enroll in a health plan, the more likely it is people will fall through the cracks.

The state assistance, meanwhile, both reduces premiums for people and makes it easier for them to afford more generous coverage, with lower out-of-pocket costs when they actually use medical services. Nine states including Massachusetts now have state assistance, with interest picking up in the past few years.

New Mexico, for example, only recently converted to a state-based ACA marketplace and started offering additional aid in 2023. Having already seen some dramatic improvements, it remains to be seen how much more progress the state can make toward universal coverage with that policy in place.

Minnesota and New York: The Basic Health Plan states

The basic structure of the ACA was this: Medicaid expansion for people living in or near poverty and marketplace plans for people with incomes above that. But the law included an option for states to more seamlessly integrate those two populations — and so far, the two states that have taken advantage of it, Minnesota and New York, are also among those states with the lowest uninsured rates. Just 4.3 percent of Minnesotans and 4.9 percent of New Yorkers lack coverage today.

They have both created Basic Health Plans, the product of one of the more obscure provisions of the health care law. This is a state-regulated health insurance plan meant to cover people up to 200 percent of the federal poverty level (about $29,000 for an individual or $50,000 for a family of three). Those are people who may not technically qualify for Medicaid under the ACA but who can still struggle to afford their monthly premiums and out-of-pocket obligations with a marketplace plan.

In both states, the Basic Health Plans offered insurance options with lower premiums and reduced cost-sharing responsibilities than the marketplace coverage that they would otherwise have been left with. In New York, for example, people between 100 percent and 150 percent of the federal poverty level pay no premiums at all, while people between 150 percent and 200 percent pay just $20 per month.

There is good evidence that the approach has increased coverage: In New York, for example, enrollment among people below 200 percent of the poverty level increased by 42 percent when the state adopted its BHP in 2016, compared to what it had been the year before when those people were relegated to conventional marketplace coverage.

State interest in Basic Health Plans has been limited so far, but Minnesota and New York provide a model others could follow. Fiedler said part of the basic plans’ success in those states has been using Medicaid managed-care companies to administer the plan: Those insurers already pay providers lower rates than marketplace plans do and the savings give the states money to reduce premiums and cost-sharing.

Colorado and Washington: Public options and assistance for the undocumented

These states have been inventive in myriad ways. They are both early adopters of a public option, a government health plan that competes with private plans on the marketplace, a policy also being tested in Nevada.

There is another policy that unites them, one that addresses a sizable part of the remaining uninsured nationwide: They both provide some state subsidies to undocumented immigrants.

Most uninsured Americans are already technically eligible for some kind of government assistance, whether Medicaid or marketplace subsidies. But there is a large chunk of people who are not: About 29 percent of the US’s uninsured are ineligible for government aid, among them the people who are in the country undocumented. Those people bear the full cost of their medical bills and may avoid care for that reason (among others, of course).

Starting this year, Washington is allowing undocumented people with incomes that would make them eligible for Medicaid expansion to enroll in that program, and making state subsidies available to people with higher incomes no matter their immigration status. Colorado has set aside a small pool of money annually to provide state aid to about 11,000 undocumented people. (After that threshold is hit, those folks can still enroll in a health plan but they must pay the full price.)

Interest has been robust: Last year, Colorado hit the enrollment limit after about a month. This year, enrollment capped out in just two days, suggesting the state may need to put more money behind the effort.

It is difficult to imagine insurance subsidies for undocumented people nationwide any time soon, given the fraught national politics of immigration. But states are finding ways to make inroads on their own: California has made undocumented people eligible for Medicaid.

Through these and other means, they are helping the US inch toward universal health care.