Cartoon – Axis of Evil II
Category Archives: Uncategorized
Cartoon – Primary vs Secondary Funding
Medicaid Has A Bull’s-Eye On Its Back, Which Means No One Is Entirely Safe
When high levels of lead were discovered in the public water system in Flint, Mich., in 2015, Medicaid stepped in to help thousands of children get tested for poisoning and receive care.
When disabled children need to get to doctors’ appointments — either across town or hundreds of miles away — Medicaid pays for their transportation.
When middle-class older Americans deplete their savings to pay for costly nursing home care, Medicaid offers coverage.
The United States has become a Medicaid nation.
Although it started as a plan to cover only the poor, Medicaid now touches tens of millions of Americans who live above the poverty line. The program serves as a backstop for America’s scattershot health care system, and as Republicans learned this year in their relentless battle to replace the Affordable Care Act, efforts to drastically change that can spur a backlash.
The latest Republican proposal — by Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) — is being pummeled by doctors, insurers, hospitals and patient advocates because it would scrap the health law’s Medicaid expansion and reduce federal funding for Medicaid. Senate leaders are trying to get a vote before Sept. 30, when special budget rules would allow the package to pass with only 50 votes.
Today, Medicaid is the nation’s largest health insurance program, covering 74 million, or more than 1 in 5 Americans. Over the next weeks, Kaiser Health News will explore the vast reach of the program. Twenty-five percent of Americans will be on Medicaid at some point in their lives — many are just a pink slip away from being eligible.
Medicaid funding protects families from having to sell a home or declare bankruptcy to pay for the care of a disabled child or elderly parent. It responds to cover disaster relief, public health emergencies and programs in schools that lack other sources of funding.
Millions of women who don’t qualify for full Medicaid benefits each year obtain family planning services paid for by Medicaid. These women have incomes as high as triple the federal poverty rate, or over $36,000 for an individual. And thousands of women, who otherwise don’t qualify for the program, get treated each year for breast and cervical cancers through Medicaid.
“Instead of cutting Medicaid, [lawmakers] increased public awareness of its value and made it even harder to cut in the future,” said Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill and a supporter of the federal health law. The Medicaid cuts passed the House, but the ACA overhaul legislation fell short in the Senate in July.
Medicaid is the workhorse of the health system, covering:
- 39 percent of all children.
- Nearly half of all births in the country.
- 60 percent of nursing home and other long-term care expenses.
- More than one-quarter of all spending on mental health services and over a fifth of all spending on substance abuse treatment.
Unlike Medicare beneficiaries, who keep that insurance for life, most Medicaid enrollees churn in and out of the program every few years, depending on their circumstances.
Such numbers underline the importance of Medicaid, but also provoke alarm among conservatives and some economists who say the U.S. cannot afford the costs over the long run.
Bill Hammond, director of health policy of the fiscally conservative Empire Center for Public Policy in Albany, N.Y., said Medicaid has been a big help for those it was designed to cover — children and the disabled. But it has grown so big that the cost hurts state efforts to pay for other necessary public services, such as education and roads. “I can’t think of any other anti-poverty program that reaches so many people. … It’s too expensive a benefit.”
“We need to transition people to get coverage in the private sector,” he said, noting how millions on the program have incomes above the federal poverty level.
It May Be The Person Down The Block
Joana Weaver, 49, of Salisbury, Md., who has cerebral palsy, has been on and off Medicaid since birth. For the past few years, it’s paid for home nursing services for six hours a day to help her get dressed, bathed and fed. That’s kept her out of a nursing home and enabled her to teach English part time at a local community college.
“For me, Medicaid has meant having my independence,” Weaver said.
Like Weaver, many people getting Medicaid today are not easily typecast. They include grandmothers — one-quarter of Medicaid enrollees are elderly people or disabled adults.
Or the kid next door. About half of Medicaid enrollees are children, many with physical or mental disabilities.
Many of the rest — about 24 million enrollees — are adults under 65 without disabilities who earn too little to afford health insurance otherwise. About 60 percent of non-disabled adult enrollees have a job. Many of those who don’t work are caregivers.
“It’s the mechanic down the street, the woman waiting tables where you go for breakfast and people working at the grocery store,” said Sara Rosenbaum, a health policy expert at George Washington University in Washington, D.C.
While all states rely on Medicaid, it’s used more in some places than others because of varying state eligibility rules and poverty rates. As of August, about 44 percent of New Mexico residents are insured by Medicaid. In West Virginia and California, the rate is nearly 1 in 3.
peak or walk. It also covers costs for his wheelchair, walker and home health care. (Nick Krug/Lawrence Journal-World)
Jane and Fred Fergus, in Lawrence, Kan., said Medicaid has been a cornerstone in their lives since their son, Franklin, was born eight years ago with a severe genetic disability that left him unable to speak or walk. He is blind and deaf on one side of his body.
Although the family has insurance through Fred’s job as a high school history teacher, Franklin was eligible for Medicaid through an optional program that states use to help families let their children be cared for at home, rather than moving to a hospital or nursing home. Medicaid pays all his medical bills, including monthly transportation costs to Cincinnati Children’s Hospital, where for the past 18 months he has been receiving an experimental chemotherapy drug to help shrink tumors blocking his airway, Jane Fergus said. It also covers his wheelchair, walker and daily nursing care at home.
“We have such great health care for him because of Medicaid,” his mother said.
Jane Fergus was never politically active until this year, when she feared that the GOP plans to cut Medicaid funding would reduce services for her son.
“If there is a silver lining in all this debate, it’s that we have been given a voice, and people in power are being educated on the role of Medicaid,” she said.
Moving Beyond Its Roots
Medicaid was born in a 1965 political deal to help bring more support for President Lyndon Johnson’s dream of Medicare, the national health insurance program for the elderly.
Over the past 40 years and in particular since the 1980s, Medicaid expanded beyond its roots as a welfare program. In 1987, Congress added coverage for pregnant women and children living in families with incomes nearly twice the federal poverty level (about $49,200 today for a family of four).
In 1997, Congress added the Children’s Health Insurance Program to help cover kids from families with incomes too high for Medicaid.
And since September 2013, Obamacare allowed states to expand the program to anyone earning under 138 percent of poverty (or $16,394 for an individual in 2016), adding 17 million people.
In addition, more than 11 million Medicare beneficiaries also receive Medicaid coverage, which helps them get long-term care and pay for Medicare premiums.
“Medicaid is plugging the holes in our health system,” said Joan Alker, executive director of the Georgetown University Center for Children and Families, “and our health system has a lot of holes.”
But that comes at a steep price.
A Blessing And A Curse
With increasing enrollments and health costs steadily rising, the cost of Medicaid has soared. Federal and state governments spent about $575 billion combined last year, nearly triple the level of 2000.
Those dollars have become both a blessing and a curse for states.
The federal government matches state Medicaid spending, with Washington paying from half to 74 percent of a state’s costs in 2016. Poorer states get the higher shares.
The funding is provided on an open-ended basis, so the more states spend the more they receive from Washington. That guarantee protects states when they have sudden enrollment spikes because of downturns in the economy, health emergencies such as the opioid crisis or natural disasters such as Hurricane Katrina.
The program is the largest source of federal funding to states. And Medicaid is often the biggest program in state budgets, after public education.
“Medicaid is the elephant in the room for health care,” said Jameson Taylor, vice president for policy for the Mississippi Center for Public Policy, a free-market think tank. He said states have become dependent on the federal funding to help fill their state budget coffers. While the poorest states, such as Mississippi, get a higher percentage of federal Medicaid dollars, that still often isn’t enough to keep up with health care costs, he said.
Extensive Benefits
Medicaid provides significant financing for hospitals, community health centers, physicians, nursing homes and jobs in the health care sector.
But the revenue stream flows further. Billions in annual Medicaid spending goes to U.S. schools to pay for nurses; physical, occupational and speech therapists; and school-based screenings and treatment for children from low-income families, as well as wheelchairs and buses to transport kids with special needs.
Medicaid also often covers services that private health insurers and Medicare do not — such as non-emergency transportation to medical appointments, vision care and dental care. To help people with disabilities stay out of expensive nursing homes, Medicaid pays for renovations to their homes, such as wheelchair ramps, and personal care aides.
Rena Schrager, 42, of Jupiter, Fla., who has severe vision problems, has relied on Medicaid for more than 20 years. Although she often has difficulty finding doctors who will accept Medicaid’s reimbursements — which are often lower than private insurance and Medicare — she is grateful for the coverage. “When you do not have anything else, you are glad to have anything,” Schraeger said.
As it’s grown, Medicaid has become more popular, another reason why politicians are cautious to curtail benefits or spending.
A recent survey by the Kaiser Family Foundation showed three-fourths of the public, including majorities of Democrats (84 percent) and Republicans (61 percent), hold a favorable view of Medicaid. That’s nearly as high as Americans’ views on Medicare. (Kaiser Health News is an editorially independent program of the foundation.)
But it may still have a bull’s-eye on its back.
“The fact that the House passed a bill to cut $800 billion from Medicaid and it came one vote short to passing the Senate shows Medicaid is stronger than maybe many Republican leaders anticipated,” said Oberlander. “But politically it is still in a precarious position.”
A closer look at how the revised health bill would benefit key senators’ states
The revised Republican health-care bill that senators unveiled Monday would partly even out wide gaps between states that would win and lose financially, providing more generous funding to states of some reluctant GOP lawmakers, but would give states less freedom to unwind federal health insurance rules.
The new version of the Cassidy-Graham legislation eliminates what had been one of the measure’s most controversial features, which would have enabled states to get federal permission to let insurers charge higher prices to customers with preexisting medical conditions. In addition, states now would not be able to allow health plans to impose annual or lifetime limits on coverage, as the original bill would have done.
Yet for the health-care standards that the bill would let states ignore if they wanted, the latest legislative language no longer would require states to get formal permission from the government through a waiver process. Instead, states would simply have to explain to federal officials what they intend to do. The standards that could be sidelined include the benefits that health plans sold to individuals and small businesses must cover and limits on how much more plans may charge older customers than younger ones.
While still giving states block grants for their programs and much more freedom to create their own rules than under the Affordable Care Act, this second draft of the plan would be less punitive financially than the first one for states that have most significantly expanded their residents’ access to insurance under the 2010 law. At the same time, the figures provide no indication that the bill’s chief sponsors have abandoned their plan to make steep cuts to Medicaid through a per-capita cap. Such a move would end up cutting federal funding by billions of dollars by 2026.
The plan update emerged late Sunday after its primary sponsors, GOP Sens. Bill Cassidy (La.) and Lindsey O. Graham (S.C.), worked through the weekend on changes designed to both bolster support on the right and win over a handful of centrists who have been balking.
The latest version would steer more money to states with key senators in a few ways.
One provision would direct $500 million in funding to states like Alaska — whose senior senator, Lisa Murkowski (R), is viewed as a crucial potential holdout — that have been granted waivers under a specific part of the ACA. Section 1332 aims to give states more flexibility in implementing the law, in order to set up a reinsurance program to help lower premiums on a state’s individual insurance market. With this provision included, Alaska will get to keep the federal funds it has been slated to receive.
Another part of the revised bill would give one-fourth of a $6 billion contingency fund to states with the lowest-density population — Alaska among them.
Separately, the law provides $750 million for states that expanded Medicaid after Dec. 31, 2015. That language means additional financial assistance for Montana and Cassidy’s home state of Louisiana.
Another addition to the plan, perhaps intended to appeal to another skeptical Republican, Maine Sen. Susan Collins, would require states to demonstrate that their health-care rules meet several federal standards, including parity for mental health care, reconstructive surgery after mastectomies and minimal hospital stays for newborns, among others.
To even out the checkerboards of winners and losers among states, the bill’s new version substantially revises the formula that would determine the allotment of money through block grants starting in 2020. Among other changes, the revision would spread the change over a decade, rather than the original half-dozen years.
Two of the states that now would fare the worst, Oregon and Minnesota, would lose 17 percent and 15 percent, respectively, of their federal funding between 2020 and 2026 relative to the current law. The two states have only Democrats in the Senate and in the governor’s mansion. It is a topic that is likely to come up on Monday during a Senate Finance Committee hearing on the bill; Sen. Ron Wyden (D-Ore.) is the panel’s ranking member.
The revised Cassidy-Graham legislation doesn’t change the total sum the federal government would spend on the block grants from 2020 to 2026. Instead, it tries to smooth over the formula of how the money would be distributed in an effort to put the states on a more equal footing.
Independent analysts had estimated a wide variation in block grant funding that states could get under the initial version of Cassidy-Graham: Mississippi would get 148 percent more relative to current law, while New York would get 35 percent less, according to an analysis by the Kaiser Family Foundation.
The range in state funding would now be narrower. South Dakota would see the largest funding increase at 88 percent, Oregon the greatest decrease.
The latest version notably retains more funding for states represented by key holdout senators. Kaiser had estimated that Maine would get 8 percent more under the initial Cassidy-Graham; it would get 43 percent more under the revised bill, according to the state-by-state summary.
But the state funding estimates don’t take into consideration the bill’s additional cuts to regular Medicaid spending. If those were considered, states like Alaska would still be losing out on federal funds overall. And the GOP estimates also assume that states would slash their own funding for coverage and then factor that into the final number as “state savings.”
Cartoon – Reason for High Drug Prices
Everyone Says We Must Control Exorbitant Drug Prices. So, Why Don’t We?
Of all the promises President Donald Trump made for the early part of his term, controlling stinging drug prices might have seemed the easiest to achieve.
An angry public overwhelmingly wants change in an easily vilified industry. Big pharma’s recent publicity nightmare included thousand-percent price increases and a smirking CEO who said, “I liken myself to the robber barons.” Even powerful members of Congress from both parties have said that drug prices are too high.
But any momentum to address prescription drug costs — a problem that a large number of Americans now believe government should solve — has been lost amid rancorous debates over replacing Obamacare and stalled by roadblocks erected via lobbying and industry cash.
“There is a very aggressive lobby that is finding any and all means to thwart any reform to a system that has produced very lucrative profits,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School who follows drug legislation. “Everything that’s coming out is being hit and hit hard — even stuff that’s commonsensical.”
Those in Congress concerned with health policy have spent much of the year advancing proposals to overhaul the Affordable Care Act, none of which would affect pharmaceutical pricing. The latest Republican proposal, by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, is no different.
Meanwhile, more than two dozen bills aimed at curbing drug costs have been introduced in this or the previous Congress, according to the Drug Pricing Lab, a Memorial Sloan Kettering Cancer Center program that has catalogued ideas for reducing prices. Many have bipartisan support.
Proposals include importation from other developed countries, where regulations keep prices down; allowing government to negotiate the price of Medicare-covered drugs; speeding approval of cheaper generics; requiring notification before raising drug prices; and restricting consumer drug ads.
GOP Health Bill’s Changes Go Far Beyond Preexisting Conditions
The latest GOP effort to “repeal and replace” the Affordable Care Act is getting a lot of attention, even if its passage seems unlikely. But there is far more to the measure than its changes to rules regarding preexisting health conditions.
In fact, the bill proposed by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) would disrupt the existing health system more than any of the measures considered so far this year, according to supporters and critics.
For backers of the bill, that disruption is a good thing. But others are appalled. As insurance industry analyst Robert Laszewski put it in a note to clients this week, “Would you rather lose your Republican Senate seat because you couldn’t pass an Obamacare repeal-and-replace plan or because you blew up the health insurance system?”
Some of those alterations have generated little discussion but would have major impacts. Here are four unheralded changes:
— The Bill Caps Federal Funding To Medicaid
Much focus has been placed on the bill’s funding formula, which would take money from states that expanded the Medicaid program for the poor. Less notice has been paid to the fact that this bill, like some other GOP options over the summer, would, for the first time, cap overall federal Medicaid funding. The federal government has provided an open-ended funding match since the program’s creation in 1965 — meaning the federal government has provided its share of whatever states spend to care for low-income children, pregnant women, seniors and people with disabilities. More than 70 million people are covered by Medicaid, including those added as a result of the ACA.
Republicans have been pushing unsuccessfully to limit the federal government’s funding of Medicaid to states since the 1980s.
State Medicaid directors — including both Republicans and Democrats — are alarmed at the idea that something of such magnitude could be done with so little debate or consideration. “Graham-Cassidy would completely restructure the Medicaid program’s financing, which by itself is three percent of the nation’s Gross Domestic Product and 25 percent of the average state budget,” said a statement from the group.
The Congressional Budget Office estimated in June that an earlier version of the cap would reduce federal Medicaid spending 35 percent by 2036. As a result, said CBO, states would “need to … decide whether to commit more of their own resources, cut payments to health care providers and health plans, eliminate optional services, restrict eligibility for enrollment, or adopt some combination of those approaches.”
“There won’t be enough money to do what’s authorized under current law,” said Jessica Schubel of the left-leaning think tank the Center on Budget and Policy Priorities.
— The Bill Gives Unprecedented Power To The Secretary Of Health And Human Services
Republicans complained bitterly about the power delegated by Congress to the secretary of Health and Human Services in the ACA. But conservative analyst Chris Jacobs pointed out that the Graham-Cassidy bill gives the HHS secretary more power still.
The bill creates a dizzyingly complex formula for the funds now being spent on the ACA, which is intended to draw money away from wealthier states (that mostly expanded Medicaid under the health law) toward poorer ones (that mostly did not). But there is a huge loophole, noted Jacobs. The bill gives the HHS secretary authority to change the formula on his or her own.
“That’s a trillion-dollar loophole that leaves HHS bureaucrats with the ultimate say over how much money states will receive,” Jacobs wrote.
And, he said, it’s the opposite of “federalism,” or giving states more authority, which the bill’s sponsors claim to be advancing.
“Draining the swamp shouldn’t involve distributing money from Washington out to states, whether under a simple formula or executive discretion,” he wrote. “It should involve eliminating Washington’s role in doling out money entirely.”
— The Bill Cuts Off All ACA Funding After 2026
The bill would lump together all funds being spent under the health law to help people pay premiums, out-of-pocket health costs and expand Medicaid to non-disabled adults and redistribute those funds to the states in the form of block grants. States could then use that money for almost anything health-related.
What few people have noticed, however, is that those block grants end abruptly after 2026. Originally, many thought this was because of congressional budget rules that limit new programs to no more than 10 years.
In fact, those rules only say that a program cannot add to the deficit after 10 years. The block grant is paid for by ongoing taxes generated from the ACA, so there is no budget requirement to end the block grant.
The reason seems to be a desire to require Congress to come back and revisit the program. A spokesman for Cassidy said the program “just has to be reauthorized in 2026 just like the CHIP program.” CHIP is the Children’s Health Insurance Program, also created in a budget bill in 1997. Congress was supposed to reauthorize that program by the end of September, although it looks as if lawmakers will miss that deadline, despite bipartisan support.
Others, however, worry that cutting the money off after 2026 means Congress could no longer use the current funding mechanism. Instead, lawmakers would have to come up with massive cuts to other programs or new tax increases if they wanted to continue providing the money for health care.
— The Bill Could Roil The Individual Insurance Market In Some States By Banning Abortion Coverage In Private Health Plans.
In keeping a promise to anti-abortion lawmakers, the bill would prohibit all private insurance plans receiving any federal funds from providing abortion coverage.
As part of a delicate compromise that got the ACA enacted in 2010, states were given the option to ban abortion coverage in plans on their health exchanges. Half of them did.
But some states, notably California, New York and Oregon require plans they regulate to offer coverage of elective abortions.
The problem is that the deadline for insurers to opt into coverage under the ACA is next Wednesday. If Congress were to pass the bill after that, it is unclear what would happen to those plans. In California, the requirement for abortion coverage is based on the state’s Constitution, so it would be possible that no plans could be offered to people who are eligible for federal help.
“There aren’t clear answers” to what would happen if the bill becomes law in its current form and takes effect in January, said Debra Ness, president of the National Partnership for Women and Families, a reproductive rights advocacy group. “I think it’s going to create chaos.”
GOP facing likely failure on ObamaCare repeal
Congressional Republicans are facing the prospect of failing this week — perhaps for a final time — in their bid to repeal ObamaCare.
Senate Republicans have yet to throw in the towel, but it seems more than likely their nine-month odyssey will be unsuccessful, with Sens. John McCain (R-Ariz.) and Rand Paul (R-Ky.) opposed to the measure and Sen. Susan Collins (R-Maine) leaning strongly against it.
Republicans can lose just two votes and still muscle the bill through the Senate in the face of unanimous Democratic opposition.
They also face a Sept. 30 deadline. After this week, they will lose the ability to use special budgetary rules on ObamaCare repeal that prevent a Democratic filibuster.
GOP Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.), aiming to keep their bill alive, made last-minute changes to the legislation over the weekend, including directing more funding toward states of holdout senators.
Collins told CNN’s “State of the Union” on Sunday that she had “a number of serious reservations” about Cassidy and Graham’s bill, which would end ObamaCare’s expansion of Medicaid and repeal much of the law, replacing it with block grant funding for states.
Her comments did nothing to assuage GOP fears that there is little chance of winning her vote.
Separately, Sen. Ted Cruz (R-Texas) said that as the bill now stood, he would be a no vote, as would fellow conservative Sen. Mike Lee (R-Utah). Cruz said the duo wants changes made that they believe would lower premium costs.
While some believed Cruz and Lee can be won over, it’s harder to see Republicans convincing Paul, Collins and McCain to reverse course. And a fourth GOP senator, Lisa Murkowski of Alaska, voted against the “skinny” repeal bill earlier this summer and may also be a no vote.
It’s a surprise position for the GOP, which had high hopes about repealing ObamaCare after President Trump won the White House, leaving Republicans in control of both ends of Pennsylvania Avenue.
Nearly a year later, the consensus among Republican lawmakers, aides and strategists is that the job of dismantling ObamaCare turned out to be a lot tougher than they ever expected.
“I think they confused sloganeering with planning and they fell more in love with the slogan than actual governing,” said John Weaver, a Republican strategist.
“We never repealed an entitlement program in this country. Why they thought this would be something simple, easy or even appropriate is beyond me,” he added.
Paul and Collins both expressed irritations over the GOP’s effort in their separate Sunday show appearances.
“When we’re dealing with a sixth of our economy and millions of people, you can’t do sound health insurance policy this way,” Collins said Sunday on CBS’s “Face the Nation.”
“You need to have extensive hearings. The Democrats must come to the table,” said Collins, echoing complaints McCain made when he issued a statement on Friday afternoon opposing the bill.
Republicans face a difficult balancing act in trying to win over McCain, Murkowski and Collins as they also face complaints from the right.
Paul warned Sunday on NBC’s “Meet the Press” that if Republicans vote for a replacement plan that keeps core elements of ObamaCare in place, “the Republican name will be on health care and this isn’t going to work.”
“You’re going to end up having Republicans absorb the blame for a terrible health-care system,” he said.
Senate Majority Leader Mitch McConnell (R-Ky.) has come under enormous pressure to make progress on ObamaCare repeal from Trump, who was furious when McCain voted no on a slimmed-down version of repeal in July.
Trump and McConnell also have plenty of stake this week in Alabama, where Sen. Luther Strange (R) is facing a tough primary challenge from conservative Roy Moore, a former state Supreme Court chief justice. Moore has been ahead in polls despite Trump and McConnell’s backing of Strange. Voters go to the polls for the primary runoff on Tuesday.
A Strange defeat coupled with another loss on ObamaCare threatens to sink the Trump-McConnell relationship to a new low — which just adds to the pressure of the week.
As Republicans near what might be a decisive defeat on health care, some in the GOP argue their party made a mistake in tackling the decisive issue as the first order of business instead of tax cuts, which is more of a GOP specialty and more popular politically.
“We should have started with taxes,” said one Senate GOP aide. “It’s not easy for Republicans to coalesce around health care. We know how to cut taxes.”
No matter what happens this week on health care, tax reform is the next item on the Trump-GOP agenda.
But the effort will go forward on a whimper if the party suffers yet another disappointment on health care this week.
Cartoon – We’re in Good Shape
Cartoon – Consolidation is tearing us apart
HENRY KOTULA 