Category Archives: Medicaid Expansion

Drug pricing, most Medicare expansions are out of Biden’s economic bill

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https://www.washingtonpost.com/politics/2021/10/28/drug-pricing-most-medicare-expansions-are-out-biden-economic-bill/

The FDA could greenlight a vaccine for kids as soon as Friday and more workers now have vaccine mandates. But first: 

Democrats are ditching progressives’ health priorities in their economic bill

The White House says Democrats have clinched a deal. 

The $1.75 trillion framework for Biden’s massive social spending bill temporarily funds several of the party’s health care ambitions. But it includes big misses on health care, such as significantly paring back progressives’ goal of adding new benefits to Medicare — instead including only coverage for hearing services — and excluding Democrats’ plan aimed at lowering the sky-high prices of prescription drugs. 

Will all Democrats get on board? Senior administration officials projected confidence that they would, and characterized the framework as the biggest expansion of health care in a decade. Yet, it includes major defeats for the party’s more liberal members, who have been reticent to draw red lines on what they would or wouldn’t support.

It’s a critical day. President Biden is heading to huddle privately with House Democrats this morning. House Speaker Nancy Pelosi announced plans for the chamber’s Rules Committee to hold a hearing, although legislative text hasn’t yet been released. And before leaving for his trip overseas, Biden will speak publicly about the path forward for his legislative agenda, per a White House official. 

Early this morning, senior administration officials spoke to reporters on the condition of anonymity to detail the framework. 

What’s in and what’s out

Prescription drug negotiation: OUT

Democrats campaigned on reducing prices of prescription drugs — and letting Medicare directly force lower prices is a key plank of that effort. But the party couldn’t overcome fierce divisions amid a lobbying storm.

  •  “At the end of the day, there are not yet enough votes to get something across the line to deliver what the American people need and expect on prescription drugs,” a senior administration official said. “We’re going to keep fighting to get this done and deliver lower drug prices.”

The House’s signature drug proposal faced resistance from a trio of House moderates who instead backed more limited drug negotiation. On the other side of the Capitol, Sen. Kyrsten Sinema had raised objections and other senators had concerns with a bill as sweeping as the one the House passed in 2019. The industry’s main trade group has been working furiously to keep the proposal out of Democrats’ economic package.

  • Of note: The framework includes fully repealing a Trump-era ban on prescription drug rebates as a way to offset the cost of the package. The administration anticipates that would save $145 billion.

Medicare expansion: mostly OUT

Sen. Bernie Sanders (I-Vt.) and the House Congressional Progressive Caucus have been bullish on two main health policies: allowing the federal government to negotiate drug prices, and using those savings to expand Medicare to cover dental, vision and hearing.

The framework only creates a new Medicare benefit for hearing. 

  • Rep. Pramila Jayapal (D-Wash.), the chair of the CPC, has repeatedly said her 96 members aren’t drawing red lines. But here’s how she characterized the CPC’s thoughts yesterday: “For a lot of members, it’s like what are we doing for seniors? How do we make sure we get some benefits for seniors in here?”
  • Sanders is the person to watch here. He’s long championed expanding Medicare, and has already come down on his ambitions for a wide-ranging $6 trillion bill.

Closing the Medicaid coverage gap: IN 

The framework extends coverage for 2.2 million adults in the dozen, mostly GOP-led states that have refused Obamacare’s Medicaid expansion. They’ll get tax credits to receive premium-free health coverage on the Obamacare health exchanges through 2025. 

Earlier this week, Manchin raised concerns with allowing the federal government to pay for health coverage for 2.2 million adults in the dozen, mostly GOP-led states refusing Obamacare’s Medicaid expansion. His own colleagues — such as Georgia Sens. Raphael Warnock and Jon Ossoff — lobbied heavily to change his mind.

Obamacare subsidies: IN

The framework would extend more generous financial help to Obamacare consumers through 2025, building on an effort that began in Biden’s coronavirus relief bill passed this spring. 

In-home care: IN 

Biden has pushed for a $400 billion investment in home care for seniors and the disabled. It’s been clear for weeks that his ask will be significantly pared back. Administration officials said funding for home and community-based services is included in the framework, but didn’t detail how much money would go toward the program helping keep seniors and those with disabilities out of institutional settings.   

Democrats’ risky health care play

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https://www.axios.com/democrats-health-care-coverage-medicaid-affordable-care-act-4758a48b-fc65-4ca4-8c1e-888c882e759f.html

Some Democrats say it’s possible that pieces of their social policy agenda end up being enacted or extended for only a year or two, including major Affordable Care Act and Medicaid provisions.

Why it matters: Limited terms may be the only way Democrats can strike a deal within their budget. But the risk is that Republicans will be able to undo these temporary programs if they’re able to regain control of Congress through next year’s midterms.

  • There also aren’t many policy areas that Republicans are less excited about than the ACA and Medicaid expansion.

What they’re saying: Extending programs for only a year or two is a “possibility,” Senate Majority Whip Dick Durbin (D-Ill.) told Axios.

  • Extending enhanced ACA subsidies and closing the Medicaid coverage gap were measures that “we wanted … to be permanent,” said Sen. Ben Cardin D-Md.). “Clearly there’s a lot of pressure to get as much in as we can, [which] means shorter periods.”
  • “I think all of the programs are being considered for shorter periods. There are some that are of greater importance to get as long as possible,” Cardin added. He said it’s also possible that an extension of the child tax credit would also last only a year.

The big picture: Political, budgetary and practical factors are all at play as Democrats try to figure out what’s in and what’s out of their reconciliation bill.

  • But one giant consideration when it comes to the health care provisions — particularly the ACA and Medicaid ones — is that Republicans may not feel compelled to extend these programs should they gain power.
  • “I expect Republicans would be glad to take back the mantle of the child tax credit but Democrats should not fool themselves into thinking Republicans will feel any real pressure to extend these health care policies,” said Brendan Buck, a longtime aide to former Republican House Speaker Paul Ryan.

The other side: Republicans may encounter political pressures similar to the ones they did in 2017, when they struggled — and ultimately failed — to repeal and replace the ACA.

  • Declining to extend Democrat-enacted coverage policies in the next couple of years would be somewhat similar, in that the result would be millions of low-income people would lose their health coverage or see its cost skyrocket.
  • Also, most of the states that haven’t expanded Medicaid are ruby-red.
  • “Remember what happened with the Affordable Care Act — they said that they didn’t like these things, but then they couldn’t repeal them because they didn’t have another option,” said Sen. Tina Smith, (D-Minn.)

Yes, but: But inaction is different from voting to end a benefit, Buck said.

  • Some Democrats are skeptical, too.
  • “The modern Republican party isn’t for much other than the destruction of government. So the idea that Republicans are going to want to hold onto programs even if they benefit the middle class runs a bit contrary to the recent history of the party,” said Sen. Chris Murphy (D-Conn.).

The bottom line: At this point, Democrats will take any party-wide agreement they can get. And temporary health coverage expansions may have their upside.

  • “It’s an easy way to slim costs,” said one Democratic strategist, adding that it allows both Sen. Bernie Sanders (I-Vt.) and Sen. Joe Manchin (D-W.Va.) to claim victory.
  • “If I’m [Majority Leader] Chuck Schumer, I do it for a year and make Republicans vote on it in October,” right before the midterm elections, the strategist added.

Democrats’ moral Medicaid dilemma

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https://www.axios.com/democrats-medicaid-medicare-dilemma-68bfff7e-48f9-41ff-8664-a923d7f5280b.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Democrats’ push to extend health coverage to millions of very low-income people in red states has a lot working against it: It’s expensive, it’s complicated, it may invite legal challenges, and few national Democrats stand to gain politically from it.

Yes, but: The policy is being framed as a test not only of Democrats’ commitment to universal health coverage, but also their commitment to racial equity.

The big picture: Democrats are still figuring out how much money they have to spend in their massive social policy legislation, but there’s already intense competition among policies — including between health care measures.

  • Progressives are adamant about expanding Medicare to cover dental, vision and hearing benefits. But a handful of prominent Democrats are making the case that closing the Medicaid coverage gap is equally, if not more, important.
  • The gap exists in 12 Republican-controlled states that have refused to accept the Affordable Care Act’s Medicaid expansion, the majority of which are in the South.

What they’re saying: Closing the coverage gap is “very, very important to people of color. The majority of Black people in this country still live in the South,” said Rep. Jim Clyburn, one of the leading proponents of the measure.

  • More than 2 million adults are in the coverage gap, and 60% of them are people of color, according to the Center on Budget and Policy Priorities.
  • “What is the life expectancy of Black people compared to white people? I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people,” Clyburn added. “If we took care of Medicaid, maybe Black people would live longer.”

Between the lines: In terms of raw politics, it’s pretty easy to see why many Democrats would prioritize Medicare expansion over closing the Medicaid gap: Seniors live in every district and state in the U.S.

  • Only three Democratic senators represent non-expansion states, and in 2020, only ine of the 41 battleground House seats identified by Ballotpedia were in non-expansion states.

Yes, but: Sens. Jon Ossoff and Raphael Warnock, both from Georgia, are the reason that Democrats are able to consider their social policy legislation at all. Warnock is up for re-election next year.

  • “This is about people in this country, and I wish we’d stop this red state and blue state stuff,” Clyburn said. “Warnock and Ossoff won a runoff that nobody gave them a chance to win by promising they would close this gap.”

The catch: States that have already expanded Medicaid are covering a small portion of those costs themselves, and may question the fairness full federal funding for the holdout states.

  • That could create an incentive for existing expansion states to drop the ACA’s Medicaid expansion and pick up the new program instead. And any effort Congress makes to stop them could invite legal challenges.
  • “The case law in this domain is a bit of a moving target, and as we’ve seen over the past decade, there’s an awful lot of litigation over things pertaining to health reform,” said Nick Bagley, a professor at the University of Michigan Law School.

The bottom line: Like Democrats’ other proposed health policies, filling the coverage gap could cost hundreds of billions of dollars.

  • But “if your goals are relieving health care cost burdens or expanding access to care, then it’s hard to do better on a dollar-for-dollar basis than buying coverage for uninsured people below the poverty line,” said Brookings’ Matt Fiedler.

What we’re watching: “I don’t see Medicaid as being on the radar of some of my friends in the caucus who seem to feel it’s more important to do Medicare,” Clyburn said. “I’m trying to get Medicaid on their agenda.”

  • “I’m tired of my party perpetuating … inequity,” he added. “Treating people according to their needs is what breaks the cycle.”

America’s major medical debt problem

Posted on by • Posted in Health Insurance Coverage Adequacy, Health Policy, Hidden Fees, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Medicaid Expansion, Medical Debt, Out of Network, Out of Pocket Expenses • Leave a comment

https://mailchi.mp/d953ea288786/newsletter031821-4639518?e=ad91541e82

Concerns Mount Over Looming Surge in Bankruptcy as COVID Medical Debt Soars

Medical debt can be a crushing burden for families, and it is a major problem in the United States. The nonprofit RIP Medical Debt says it’s wiped out debt for 2.7 million patients since 2014, totalling more than $4.5 billion. One of the most famous health policy studies ever conducted — the Oregon Health Insurance Experiment — found that having Medicaid coverage reduced a person’s likelihood of having an unpaid medical bill sent to collection by 25%. Now a study published last month in JAMA offers new evidence on the relationship between Medicaid and medical debt, and the scale of the country’s medical debt problem.

Using a subset of credit reports from one major U.S. credit agency for every year between 2009 and 2020, researchers Raymond Kluender, Neale Mahoney, Francis Wong and Wesley Yin looked at the total amount of medical debt and new medical debt each year. They found that while both measures of medical debt have decreased almost every year since 2014, nearly 1 in 5 Americans were under collections for medical debt as of early 2020. They also found that since 2014, medical debt has been the largest source of debt for Americans, surpassing all other types of debt — credit cards, personal loans, utilities and phone bills — combined. And the medical debt was not evenly distributed around the country. Approximately, 1 in 4 individuals in the South were under collection for medical debt in 2020, but only 1 in 10 in the Northeast.

To assess the impact of Medicaid coverage on medical debt, Kluender and colleagues compared the total amount of new debt accrued by people living in states that expanded Medicaid and those that have not between 2009 and 2020, allowing them to confirm that any trends they identified didn’t pre-date Medicaid expansion in 2014. They found that between 2013 and 2020 the average amount of new medical debt decreased 34 percentage points more in states that expanded in 2014 compared to non-expansion states, and the drops were most prominent in the lowest income zip codes. The analysis can’t prove a causal relationship between medical debt and Medicaid expansion, but interestingly, the authors found no statistically significant difference in nonmedical debt between expansion and non-expansion states. This lack of an effect on nonmedical debt supports the association between Medicaid and reductions in medical debt.

The article does have limitations: It doesn’t include debts paid on a credit card or through payment plans; it doesn’t reflect the impact of COVID-19; and it can’t account for unobservable changes in policy or circumstance that might have coincided with Medicaid expansion and impacted medical debt. But it does add evidence to support the value of Medicaid coverage — a particularly timely finding, with more than 11 million people joining Medicaid since the start of the pandemic and Democrats in Congress looking to cover the more than 2 million people in the so-called coverage gap in the 12 non-expansion states.

Missouri’s Medicaid expansion is back on

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https://mailchi.mp/b5daf4456328/the-weekly-gist-july-23-2021?e=d1e747d2d8

Missouri Supreme Court reverses Medicaid expansion decision

On Thursday, the Missouri Supreme Court unanimously reversed a lower court ruling that held that the state’s $1.9B Medicaid expansion, approved by voters in a 2020 ballot initiative, was unconstitutional.

The ruling clears the way for the state’s Department of Social Services to begin implementation of the expansion, which is expected to cover 275,000 low-income Missouri residents. Under the Affordable Care Act (ACA), the federal government will pay 90 percent of the cost to cover the newly eligible Medicaid beneficiaries, along with an additional bump in federal funding for Missouri’s Medicaid program, thanks to a provision in the American Rescue Plan Act passed earlier this year. 

Missouri voters approved the expansion by a 53-47 margin last year, but the ballot initiative was held to be unconstitutional because it did not include a source of funding for the portion of coverage costs to be paid for by the state (and the state legislature refused to allocate money for the expansion, despite currently running a surplus). Five other states have turned to ballot initiatives to expand Medicaid under the ACA, seeking to work around state legislatures that have resisted the change. In all, a dozen states, mostly in the Southeast, have  chosen not to expand their Medicaid programs, even despite the additional incentives Congress voted into law this year. 

Democrats on Capitol Hill are considering legislative alternatives to provide new coverage to low-income residents in those states, as part of the $3.5T reconciliation package currently being negotiated. Numerous studies have shown the positive impact of expanding Medicaid on health and financial well-being, but state-level politics have proven to be a challenge, especially in deep-red states. Meanwhile, tax dollars continue to flow from those states to fund Medicaid expansion elsewhere—now, including Missouri.

Healthcare and the Proposed Infrastructure Legislation

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Click to access Industry_Insights_7.21.21.pdf

Senate Democrats Agree on $3.5 Trillion Infrastructure Bill | Barron's

One of the most important initiatives for President Biden since
taking office in 2021 has been to pass a sweeping infrastructure
bill to improve roads, bridges, water systems, and to make
affordable housing more available to Americans in need, to name a few key
components. While a bill has not yet been passed, initial estimates range from $2.5 –
3.5 Trillion in total spending across all sectors. How will the proposed infrastructure bill
affect healthcare for Americans? Healthcare remains the largest component of
household spending in the U.S. In 2019, Americans spent approximately $3.8 Trillion on
healthcare, or about 18% of the Gross Domestic Product. More importantly, we learned
from the pandemic that healthcare service providers are a critical infrastructure support
network to our nation. What does the infrastructure bill provide to assist with this going
forward?
The largest healthcare components in the infrastructure bill are estimated to be:

  • $400 Billion for Home and Community Based care for the disabled and elderly.
    According to census, an estimated 20% of the U.S. population will be over 65 by
  1. Caring for elderly relatives or living independently will become a top concern
    for most Americans. Home care is projected to grow by 22.6% in the next decade.
  • Lowering the Medicare eligibility age from 65 to 60. If it passes, this will increase the
    participants in the Medicare program by an estimated 20 million.
  • $18 Billion for needed upgrades to VA hospitals. The average age of a VA hospital is
    58 years. The private-sector hospitals median age is 11 years old. There are 1,700
    VA hospitals and clinics with 69% are more than 50 years old. Additionally, nearly
    100 VA sites, mostly in the western part of the country, need seismic correction.
    Other President Biden Healthcare Priorities
    There are several other healthcare topics that President Biden has added to his Agenda.
    • Expand coverage to Medicaid at the state level to provide access to almost 5
    million additional individuals
    • Lowering drug costs for consumers by requiring drug companies to negotiate
    with Medicare, limiting drug price increases and import drugs to save costs
    • Ending surprise billing
  • Expand funding for mental health care through the ACA and bring parity between mental health and other healthcare services
  • Tax credits for eligible families who enroll in coverage through the Marketplace
  • Unfortunately, while these estimates may continue to change between now and when a final bill is passed, healthcare is not a meaningful part of the infrastructure bill. Given our recent experience during the pandemic with hospital capacity being overloaded, one would have thought that the infrastructure bill would have addressed this critical shortfall.

Americans’ medical debt tops $140B, study finds

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https://www.beckershospitalreview.com/finance/americans-medical-debt-tops-140b-study-finds.html?utm_campaign=bhr&utm_source=website&utm_content=latestarticles
What Are The Best Ways to Clear Medical Debt?

Collection agencies held $140 billion in unpaid medical debt in 2020, according to a study published July 20 in JAMA.

Researchers examined a nationally representative panel of consumer credit reports between January 2009 and June 2020. Below are four other notable findings from their report.

  1. An estimated 17.8 percent of Americans owed medical debt in June 2020. The average amount owed was $429.
  2. Over the time period studied, the amount of medical debt became progressively more concentrated in states that don’t participate in the Affordable Care Act’s Medicaid expansion program.
  3. Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in the average flow of medical debt that was 34 percentage points greater than the average medical debt flow in states that didn’t expand Medicaid.
  4. In the states that expanded Medicaid, the gap in the average medical debt flow between the lowest and highest ZIP code income levels decreased by $145, while the gap increased by $218 in states that did not expand Medicaid.

Senate Democrats strike a $3.5T spending deal

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https://mailchi.mp/26f8e4c5cc02/the-weekly-gist-july-16-2021?e=d1e747d2d8

Senate Democrats aim to include Medicare drug price negotiation authority in $3.5T infrastructure deal | FierceHealthcare

Senate Democrats announced a compromise budget framework to fund President Biden’s social spending plans to the tune of $3.5T, including substantial money for some of the administration’s key healthcare priorities. The framework sends instructions to several Senate committees, including the Budget and Finance panels, to craft legislative language around the central components of the deal, with the goal of passing a spending package before next month’s recess.

Many specifics remain to be ironed out in negotiations among the party’s progressive and moderate camps, but some of the main elements of the deal became clear this week. The plan includes extending the enhanced subsidies for purchasing individual coverage on the healthcare marketplaces, which were implemented earlier this year as part of the American Rescue Plan Act. It would also seek to close the so-called “Medicaid coverage gap”, by providing new coverage options for low-income adults in states that did not expand Medicaid under the Affordable Care Act (ACA).

New investments would be made in home- and community-based services for long-term care, along the lines of the $400B proposed in President Biden’s American Families Plan. And the budget deal envisions expanding benefits in the Medicare program to include dental, vision, and hearing services. Given the budgetary concerns of moderate Democratic lawmakers like Sen. Joe Manchin (WV), one critical question will be how the $3.5T deal will be paid for. One likely source of funding for the deal will be reforming the way Medicare purchases prescription drugs, making that long-time Democratic policy objective a probable part of any final package.
 
Notably absent from the healthcare spending proposals: lowering the eligibility age for Medicare from 65 to 60. No final decision has been reached on whether to incorporate such a move; rather, the question will be sent to the Senate Finance Committee for consideration. Given the urgency of passing as much of the Biden administration’s legislative agenda as possible before the midterm campaign season begins in earnest, we think it’s unlikely that Democrats will be willing to cross the Rubicon of Medicare expansion at this point.

The prospect of having to gain support from all 50 Democratic senators—as zero Republicans are expected to support the package—will likely temper any appetite for picking a fight with the influential hospital and physician industries, which have strongly opposed Medicare expansion.

One longer-term implication of the apparent decision to favor expansion of Medicare benefits over lowering the Medicare eligibility age now: a richer package of services in traditional Medicare might make Medicare Advantage (MA) a less attractive alternative for potential enrollees and could undermine any future efforts to create an “MA buy-in” for coverage expansion.

Expect lobbying and negotiations to reach a furious pace over the next several weeks, as lawmakers work out the final details of the $3.5T spending plan.

‘It’d be catastrophic’: Dallas-area hospitals could lose $1.1B annually without Medicaid waiver, healthcare group warns

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https://www.beckershospitalreview.com/finance/it-d-be-catastrophic-dallas-area-hospitals-could-lose-1-1b-annually-without-medicaid-waiver-healthcare-group-warns.html?origin=CFOE&utm_source=CFOE&utm_medium=email&utm_content=newsletter&oly_enc_id=2893H2397267F7G
Original map. Location of hospitals in Dallas, TX. Source: North... | Download Scientific Diagram

Hospitals in the Dallas-Fort Worth region could collectively lose $1.1 billion in funding each year without a Medicaid waiver extension, a healthcare group warned, according to CBS Local.

The group, Texas Essential Healthcare Partnerships, represents 72 hospitals in the Dallas-Fort Worth region, including those operated by Dallas-based Tenet Healthcare and Houston-based Baylor Scott & White Health. 

In April, CMS rescinded approval for a Section 1115 waiver to extend reimbursement to Texas hospitals for uncompensated care through September 2030. President Joe Biden’s CMS said that under the previous administration, CMS and Texas failed to adhere to public comment period requirements in the approval process, so it should be rescinded.  

Don Lee, Texas Essential Healthcare Partnerships, told CBS he’s concerned about CMS’ decision to rescind the waiver next year and that hospitals could begin feeling the effects in just three months. 

“There’s about $330 million of very important mental healthcare funding for mental healthcare services for the poor that will be lost starting in September of this year,” Mr. Lee told CBS Local. 

Texas plans to resubmit its application to extend the 1115 waiver soon, according to the report. However, if the new application is not approved, Mr. Lee said that some hospitals in the North Texas region may be forced to close. 

“We believe it’d be catastrophic, not just for the hospitals, but for all Texans,” Mr. Lee told CBS Local.