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Pre-existing conditions drive moderates’ concern over repeal bill

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http://www.politico.com/story/2017/04/27/healthcare-repeal-pre-existing-conditions-moderates-237713?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=51306136&_hsenc=p2ANqtz-_Kd2qUCppTF1-MJzmxXc-yctQ3aukhBU3TjgUBmQorQj2jnFsKpRFmI9jaf7tldE1bHi7_7v6CLiebqofmJrqHhkUGzA&_hsmi=51306136

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Moderate Republicans are largely withholding their support for the Obamacare repeal bill, arguing it would hurt people with pre-existing conditions

House Republican leaders hoped that the House Freedom Caucus’s endorsement of the latest Obamacare repeal bill would light a fire under enough moderates to get their whip count to the 216 votes needed to pass the measure. Instead, the holdouts are digging in, saying that the latest changes only moved the bill to the right and could put more Americans at risk of losing their health insurance.

“My concern has always been and what a lot of us talked about: people with pre-existing conditions, the elderly,” said Rep. Mario Díaz-Balart (R-Fla.). “How this makes the original bill better? Where is the part that is better for the folks I’m concerned about it? I’m not seeing it at this stage.”

Protections for people with pre-existing conditions have only been in effect for seven years, but proven to be one of the most popular and well-known features of the Affordable Care Act. Moderate Republicans are worried about stripping the safeguards without a reliable replacement. If the resistance from moderates holds, it would be enough to block Obamacare repeal in the House — or send the effort back to square one.

GOP leaders have been buttonholing moderates for two days, arguing that the latest changes — drafted by Rep. Tom MacArthur (R-N.J.) with consultation from the House Freedom Caucus — would ensure people with pre-existing conditions wouldn’t be priced out of a reconfigured market, pointing to high-risk pool requirements in state that choose to opt out of Obamacare provisions.

Backers of the repeal measure say the bill protects people with pre-existing conditions, arguing that people with coverage, for instance, can’t be priced out if they maintain it.

But buying into the plan would pose big political risks for centrists in swing districts. Voicing concerns about pre-existing conditions could prevent a tough vote on an issue that Democrats would surely spotlight in the 2018 election.

 

Several Republican sources say at least some moderates have climbed aboard, but they’re not inclined to say so publicly. House Appropriations Chairman Rodney Frelinghuysen (R-N.J.), who was widely panned by fellow Republicans for not supporting an earlier version of the repeal bill given his high-profile post, is expected to now support it, according to several sources.

Other than Frelinghuysen, there are no moderates who have publicly flipped to support the bill.

Republicans can absorb no more than 22 defections (depending on how many members are seated when the vote is held) from the 238-member Republican conference. The leaders still need fewer than 10 votes, according to several sources.

Rep. Ryan Costello (R-Pa.) said the latest changes to the bill didn’t bring him to a yes.

“Protections for those with pre-existing conditions without contingency and affordable access to coverage for every American remain my priorities for advancing healthcare reform, and this bill does not satisfy those benchmarks for me,” he said in a statement.

Rep. Barbara Comstock (R-Va.), one of the most vulnerable Republicans in 2018, said she is still a no. Rep. Carlos Curbelo of Florida is undecided— he’s still talking with leadership but claims no one is twisting his arm.

“They know better than to pressure me,” he said.

It’s not just traditional moderates who have qualms. Rep. Chris Smith (R-N.J.), who is very conservative on most social issues, is still a no.

Rep. Pete King (R-N.Y.) doesn’t want Obamacare’s Medicaid expansion repealed under the latest GOP plan, but told POLITICO he would vote to move the bill forward and assumes the Senate would restore Medicaid expansion. If the bill were to come back with Medicaid repealed, “it would be a problem,” he said.

The latest changes may have even eroded the support of moderates who backed the earlier repeal bill that was pulled in March. Rep. Adam Kinzinger of Illinois said he’s undecided. Rep. Steve King of Iowa, one of the House’s most conservative members, told reporters he’s undecided now, too.

Rep. Jim Renacci (R-Ohio), who supported the original repeal bill, is undecided but inclined to move the process forward.

“My biggest concern is that we’re changing things based on amendments written in backrooms and not everyone knows what is said and what’s part of the deal,” he said.

Some Republicans just don’t want to talk about it.

Rep. Darrell Issa of California paused to hear a reporter’s question on his vote, then kept walking.

4 key questions surrounding Obamacare repeal

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http://www.politico.com/story/2017/04/27/will-obamacare-be-repealed-237696?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=51306136&_hsenc=p2ANqtz-91DD9raN2n1umqmo9b8-k4OlgLXPyEkzYPXWWRbdIcAe7dVIMt6R7ki08jRw6FoDweDXiNFAYwLxupQZu-Acb4cLNFKQ&_hsmi=51306136

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House Republicans are mounting yet another effort to tear down Obamacare and remake the health care system — but the path to delivering on one of the GOP’s longest-standing priorities remains complicated and fraught with uncertainty.

House GOP leadership is working furiously to rally support for its Obamacare repeal bill amid threats of a government shutdown, rebellion within its ranks and dire warnings about the consequences for the nation’s most vulnerable Americans. The Trump administration and Republican leaders contend they’re drawing closer to a deal. Still, the situation is more fluid than ever. Here’s where things stand on the biggest outstanding questions:

Give it to us straight: Is the House going to vote on Obamacare repeal this week?

The official answer is no — at least not yet. The Republican leaders are working behind the scenes to win over enough lawmakers to get the 216 votes they need. They’re not there, and there’s little expectation that enough holdouts will flip in time for a Friday vote.

“We’re going to go when we have the votes,” Speaker Paul Ryan said this morning. “It takes time to do that.”

Republicans can only absorb 22 defections — and preliminary counts suggest there are more than that number either opposed to the bill or still undecided. Most are moderate Republicans still wary of provisions in the bill that would roll back Obamacare’s expansion of Medicaid and give states new opportunities to opt out of some of the health law’s core provisions.

The bill has changed a lot since it was first introduced. What would the latest version actually do?

The core elements of the GOP’s original American Health Care Act remain intact — the measure would eliminate big parts of Obamacare, such as its requirement that everybody purchase health insurance, and it would replace the law’s subsidies with a new set of tax credits to help pay for coverage. Those credits would be less generous than what’s offered under Obamacare, and the amount people would receive is based on their age.

The legislation also would overhaul Medicaid, rolling back its expanded coverage and capping its federal funding.

Originally, Republicans planned to keep several other major Obamacare provisions intact. But the changes proposed by the new Tom MacArthur amendment would let states apply for waivers to opt out of federal requirements that insurance plans cover a minimum set of benefits, and reopen the door to charging more based on a person’s health status under certain circumstances. States that take advantage of that flexibility would have to set up a high-risk pool or some other program to ensure that people would not be priced out of the market.

Those changes were essential to winning support from conservatives who complained that the original bill didn’t go far enough to repeal Obamacare. But that shift also threatens to alienate moderates, who were already nervous about leaving more people uninsured.

Who are these moderates? And what will it take to get them on board?

Many of the Republican holdouts belong to the Tuesday Group, the caucus of some 50 centrist House members. Their opposition was key to the GOP’s last-minute decision to abandon a planned vote on Obamacare repeal last month, and they’re still standing in the way. The moderates’ objections vary, but they essentially have one concern: That the repeal bill would leave far more people uninsured than there are with Obamacare.

So far, it looks like that concern hasn’t yet been addressed. The latest version of the bill would retain the phase-out of Obamacare’s Medicaid expansion and wouldn’t make the tax credits more generous. On top of that, the new state waivers could result in more people seeing higher premiums and fewer benefits. The AHCA’s proponents disagree, maintaining that the legislation would incentivize states to customize the health care system to residents’ needs. But it’s not clear that the argument has won over many centrists.

Exactly how many more uninsured are we talking about under the AHCA?

That’s not clear, and won’t be without an updated estimate from the nonpartisan Congressional Budget Office. The agency’s evaluation of the original bill predicted that 24 million more people would end up without coverage over a decade, than there are with Obamacare — losses that would come largely as a result of the restructuring of Medicaid.

But the legislation has changed several times since then, and the CBO hasn’t had an opportunity to take a second look. In fact, it may not do so until after the House votes, assuming that Republicans bring the bill to the floor in the next couple of weeks. The CBO told lawmakers’ offices that it won’t have time to fully reevaluate the revised bill, according to Democrats, and Republicans already under pressure to show progress on the bill don’t seem worried about plowing ahead without a new score.

How To Ease The Financial Pain Of High-Deductible Health Plans

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How To Ease The Financial Pain Of High-Deductible Health Plans

No matter what happens to Obamacare, one health care trend is fairly certain to continue: A growing number of you will have high-deductible health plans, whether you’re insured through your employer or buy on the private market.

A high-deductible health plan is just what it sounds like: In exchange for a lower premium, you pay more of your own money for medical care until your insurance coverage kicks in.

The IRS defines a high-deductible plan as one with a deductible of at least $1,300 a year for an individual or $2,600 for a family.

Many deductibles are higher. For instance, Covered California, the state health insurance exchange, offers bronze-level plans this year with a $6,300 individual and $12,600 family deductible, plus a separate deductible for prescription medications.

How many of you have that kind of money lying around?

A series of columns answering consumers’ questions about California’s changing medical landscape.

Send questions for Emily to AskEmily@kff.org

The most important thing you can do to lower your costs is to choose the right plan for yourself and your family during open enrollment (assuming you have a choice).

“A high-deductible plan will work better for younger, healthier people who don’t expect to have a lot of medical expenses,” says Walter Zelman, a health policy professor at California State University-Los Angeles. “If you know you’re going to use a reasonable amount of health care in a given year, the high-deductible plan is to be avoided.”

But since most of you are stuck with your plans until the next open enrollment period, here are some simple steps you can take now to control costs.

The Basics

Under the Affordable Care Act, most health plans must offer certain preventive services for free, including mammograms, colonoscopies and routine vaccinations.

Taking advantage of them can prevent more expensive coverage down the line, says Elizabeth Abbott, director of the state’s Office of the Patient Advocate.

“Get your flu shot,” she says. “If you keep up with all of your preventive services, you will save yourselves a fair amount of money because you’re less likely to get sick and won’t have to get invasive procedures.”

No matter what kind of appointment or procedure you’re scheduling, choose in-network providers whenever possible, says Betsy Imholz, special projects director for Consumers Union. “If you stay in network, your costs are going to be lower,” she says.

Cross-check with both your provider and your insurer to confirm network status.

And don’t forget — as I often do — that you may be able to avoid a doctor’s visit by calling your insurance company’s nurse advice line, Zelman says.

Prescription Drugs

Unless you take only specialty drugs to treat serious or rare conditions, these steps can probably save you money:

— Over-the-counter and generic drugs: If your doctor prescribes a brand-name drug, ask if there’s an over-the-counter or generic option you can try first. Generics cost a fraction of the brand-name version, says David Collum, assistant clinical professor for the Department of Pharmacy Practice at University of the Pacific in Stockton, Calif.

— Shop around: Many pharmacies (both chains and independents) offer discount programs for common generic drugs, charging $4 for a 30-day supply and $10 for a 90-day supply.

Don’t be afraid to switch pharmacies or buy drugs from different places, Abbott says. “If you’re taking five drugs, price those all out,” she says. “Don’t assume a particular pharmacy offers the best price for every drug.”

Consumers Union generally finds the best drug prices at Costco or by using GoodRx’s online search tool, Imholz says.

— Patient-assistance programs: Ask your pharmacist or doctor if they know of programs that can help you afford your prescription.

Groups such as the Patient Advocate Foundation and NeedyMeds also have compiled links to organizations — and even drug companies — that provide financial aid.

— Shorter initial prescription: If your doctor prescribes a pricey drug you haven’t taken before, ask her to write the prescription for a few days or a week and monitor the results, Collum suggests.

If the drug works for you, request a new prescription for a longer period. If it’s ineffective, at least you won’t be out for the cost of a full month of medication.

Comparison Shopping

Most of us wouldn’t buy a car or plane tickets without comparison shopping. So why not shop around for medical care, whose prices can vary wildly from provider to provider?

You could save hundreds or thousands of dollars.

First, ask your doctor for the specific medical code, called a CPT code, for the procedure or test that you need, says Jeanne Pinder, CEO of ClearHealthCosts, which aims to make medical prices more transparent.

Simply asking about the cost of a lower-back MRI won’t be sufficient. “You’ll want to call and say ‘How much does an MRI of the lower back, without contrast, CPT code 72148, cost?’” she says.

Armed with the code, reach out to different providers and your insurance company. Ask both how much the procedure would cost you, and whether the provider is in your plan’s network.

Along the way, consider bypassing your insurance for a particular treatment or prescription.

“You might be better off, as an insured person, paying cash,” Pinder says. “Many people don’t reach their deductible by the end of the year, anyway.”

If you go this route, don’t call your insurance plan. Just call providers (who don’t have to be in your network) and ask them “How much will this cost me?” and “What’s your cash price?” Pinder counsels.

If the provider asks whether you have insurance, repeat that you want to be a cash customer.

“Just keep saying, ‘I’m looking for the cash price. I’m a cash customer.’ If they ask if you have insurance, repeat that you’d like to pay cash,” Pinder says.

Take detailed notes, including the name of the person who gives you the quote, Pinder adds. Better yet, get it in writing.

Pinder took her own advice recently when a family member needed an MRI, which can cost thousands of dollars. She found one for $450 cash.

“We need to get used to having this conversation and asking those questions in that fashion,” she says. “By the time you start doing it, it doesn’t hurt anymore.”

California Senate Health Committee approves universal healthcare bill: 5 things to know

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http://www.beckershospitalreview.com/payer-issues/california-senate-health-committee-approves-universal-healthcare-bill-6-things-to-know.html

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A California single-payer healthcare bill is one step closer to passage after approval from the Senate Health Committee, according to a Los Angeles Times report.

Here are five things to know.

1. The bill in question, SB 562, would create a government-run healthcare plan, covering people living in America illegally and all other California residents, according to the report.

2. California would foot the bill for all medical expenses, according to the report. The measure, the report notes, states the program would be paid for by “broad-based revenue,” although exact details on how the program would be funded were not included.

3. Lawmakers had a few ideas on how to implement the single-payer system, including the use of EHRs and securing federal waivers to administer Medicaid and Medicare monies, according to the report.

4. Among the bill’s supporters are labor groups, such as the California Nurses Association, as well as consumer groups and the grassroots group Our Revolution, reports the Los Angeles Times. Opposing groups cited in the report include insurers, manufacturers and the California Chamber of Commerce.

5. One of the bill’s co-authors, Sen. Ricardo Lara, D-Bell Gardens, said a detailed financial study would be completed next month, according to the report.

Florida Blocked From Enforcing Medicaid Reimbursement Law

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Florida can’t enforce a state law that allowed the state’s Medicaid agency to seek reimbursement from patients who received third-party settlements ( Gallardo v. Dudek , 2017 BL 128992, N.D. Fla., No. 4:16-cv-116, 4/18/17 ).

Judge Mark E. Walker of the U.S. District Court for the Northern District of Florida ruled that Florida’s Medicaid reimbursement statute was preempted by the federal Medicaid Act. The court barred the state from using the statute to satisfy any payment lien against a Medicaid patient whose settlement includes payment for both past and future medical bills.

The court’s decision represents a tension that many states face when dealing with Medicaid reimbursement. The Medicaid Act requires the state to attempt to recover money paid for medical expenses to patients whose injuries are caused by third parties. However, the states are prevented from seeking to obtain the entire amount of a third party settlement and are limited to the amounts set aside for medical expenses.

The court cited a U.S. Supreme Court decision from 2006, Ark. Dept. of Health & Human Servs. v. Ahlborn , 547 U.S. 268 (U.S. 2006), which interpreted the anti-lien provisions of the Medicaid Act as limiting a state to a proportional reimbursement, representing that portion of any settlement or judgment that represents past medical bills. However the provision that the supreme court interpreted in that case and that the court relied on in this case could be changing as of Oct. 1.

At least one practitioner told Bloomberg BNA that the change, which has been delayed repeatedly, could result in this Florida statute suddenly becoming legal.

One Size Doesn’t Fit All

At issue in this case was Florida’s recovery law, which established a formula for determining how much of a third party settlement can be sought by the state Agency for Health Care Administration. Under that law, the AHCA can seek either 37.5 percent of the settlement, or the actual amount paid for medical expenses, whichever is less.

The case was brought by the family of Gianinna Gallardo, a 13-year-old girl who was hit by a car and ended up in a persistent vegetative state as a result of her injuries. The AHCA paid about $800,000 for her medical treatments. Gallardo’s parents sued the individual responsible for her injuries in a suit that they valued at $20 million. They settled for 4 percent of the estimated value of the suit, or $800,000

Following its formula, the AHCA instituted a lien on the settlement of $300,000, which represented 37.5 percent of the total amount. The Gallardos challenged the lien, claiming it didn’t reflect a proportional reimbursement and it accessed funds in the settlement, which had been set aside for Gianinna’s future medical bills.

The court agreed with the Gallardos. According to the court, the law’s “one-size-fits-all” formula didn’t match with the supreme court’s decision in Ahlborn and was thus improper. The court said the Medicaid Act only permitted the AHCA to recoup a portion of a settlement that had been designated to cover past medical bills.

Floyd Faglie of Staunton & Faglie in Monticello, Fla., who represented the Gallardo family in the litigation, said his clients were very pleased with the court’s ruling.

“This is a tremendous benefit to the Gallardo family, to Gianinna Gallardo in particular,” he told Bloomberg BNA. “What the court has done is leveled the playing field for people to challenge Medicaid liens asserted against tort settlements and made it fair.”

A representative for the AHCA declined to comment on the ongoing litigation.

 

Essential Facts About Health Reform Alternatives: Eliminating Cost-Sharing Reductions

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http://www.commonwealthfund.org/publications/explainers/2017/apr/cost-sharing-reductions?omnicid=EALERT1202020&mid=henrykotula@yahoo.com

How do cost-sharing reductions work?

Americans with low or moderate incomes can get their out-of-pocket health care expenses reduced if they have purchased a silver plan in the Affordable Care Act’s (ACA) health insurance marketplaces. The ACA’s cost-sharing reductions (CSRs) mean lower copayments and deductibles for people in households earning between 100 percent and 250 percent of the federal poverty level (about $12,000 to $30,000 for an individual, and about $24,000 to $60,750 for a family of four).1 The federal government reimburses insurers for providing the subsidies, which in 2016 totaled $7 billion.2

Those who use health care the most see the largest savings. A 2016 Commonwealth Fund analysis of marketplace plans in 38 big-city markets found that without CSRs, a 40-year-old man with a silver plan who is a high health care user and earns $35,000 a year—too much to qualify—might face up to $6,500 in out-of-pocket expenses.3 But for someone earning $17,000 who is also a high user of care, projected out-of-pocket spending would be no higher than $650—a savings of nearly $6,000 compared to the average silver plan. In other words, instead of potentially spending more than a third of his income on health care expenses, he spends no more than 3.8 percent of his income with CSRs.

What’s the backstory?

In 2017, 7 million people qualified for CSRs—58 percent of all marketplace enrollees.4 But the subsidies face challenges on several fronts. In 2014, Republicans in the U.S. House of Representatives sued the Obama administration, alleging that the U.S. Department of Health and Human Services’ payments to insurers were unlawful because Congress had not appropriated funds to pay for them.5 A May 2016 ruling by a federal judge in favor of the GOP would have stopped payment of the subsidies, but the Obama administration appealed. The case, now known as House v. Price, has been paused since the November election.

The Trump administration has indicated that, at least for now, it will continue making payments to insurers.6 And some congressional Republicans, wishing to preserve the subsidies, are willing to appropriate the necessary funds.7 However, the GOP’s recent health care reform proposal—the American Health Care Act—would eliminate cost-sharing reductions entirely.

How would eliminating cost-sharing reductions affect consumers?

If the Trump administration decides at some point to stop defending the lawsuit to end cost-sharing reductions and Congress fails to appropriate funds for them, payments to insurers would end. While insurers have signed contracts with federal and state regulators to offer health coverage, some might seek to terminate them early because of the loss of payments. Doing so would throw consumers off their coverage midyear.8

Insurance costs would rise as well, as companies opting to remain in the market would be forced to increase premiums to make up for the lost government payments. Analysts say that marketplace insurers across the country would likely raise premiums for silver plans by anywhere from 9 percent to 27 percent.9 This also would increase federal spending above what the CSRs cost, since higher premiums mean larger premium tax credits.10

How would eliminating cost-sharing reductions affect insurance markets?

Eliminating cost-sharing reductions could destabilize insurance markets. The insurers relying most heavily on cost-sharing reduction payments could see their current 7 percent profit margins turn into 25 percent losses, on average.11 Since marketplace insurers would need to substantially raise premiums, there is a risk of further market instability as healthy individuals earning too much to be eligible for the ACA’s tax credits decide to drop out of the market entirely.12

Given the magnitude of their prospective losses, many insurance companies may opt to exit the ACA marketplaces altogether. Ending the cost-sharing reductions also would discourage insurers from participating in future years. Carriers must decide before June 21, 2017, whether they will sell plans on the marketplaces in 2018. Uncertainty surrounding the payment of cost-sharing reductions is already dissuading some insurers from participating.13

Ultimately, insurers might sue the federal government to recover cost-sharing reduction payments promised under the ACA. Such litigation would be expensive and time-consuming, with the legal costs likely passed on to consumers in the form of higher premiums and out-of-pocket costs.14

Anthem loses Cigna takeover appeal

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http://www.healthcaredive.com/news/anthem-cigna-merger-over/441551/

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Dive Brief:

  • The U.S. Court of Appeals on Friday upheld a decision to block the $54 billion merger between insurance giants Anthem and Cigna.
  • A federal judge ruled in February that the combined company would result in reduced competition in the national health insurance market, agreeing with the U.S. Department of Justice, which brought the antitrust case last July. Anthem filed an appeal to reverse the decision later that month.
  • In a 2-1 decision, the court ruled Anthem had failed to “show the kind of extraordinary efficiencies necessary to offset the conceded anticompetitive effect of the merger.”

Dive Insight:

Unless Anthem takes it to the Supreme Court, this is the end of the deal after several months of contentious debates and infighting among the two health insurance giants.

The healthcare industry has been closely watching the case. The American Medical Association was quick to issue a statement applauding the decision from the Court of Appeals. “The appellate court sent a clear message to the health insurance industry: a merger that smothers competition and choice, raises premiums and reduces quality and innovation is inherently harmful to patients and physicians,” said AMA President Andrew W. Gurman.

Cigna has been wanting to end the merger plans for months. After the merger was first blocked, Cigna filed a lawsuit against Anthem seeking at least $14 billion in damages, which is a lot more than the $1.85 billion contractual breakup fee. It also asked for a statement that Cigna had lawfully terminated the deal.

Anthem was granted a temporary restraining order against Cigna shortly thereafter. The infighting certainly did not help support Anthem-Cigna’s argument that it would effectively implement the claimed efficiencies that would benefit consumers.

Earlier this week, Anthem filed a motion with the Delaware Court of Chancery for a preliminary injunction that would block Cigna from terminating the deal on April 30, which is the contractual deadline.

Anthem and Cigna could soon end their plan to merge. Once it’s over, it will be “harder for either Anthem or Cigna to do another deal that involves a combination of another large insurer,” Mitchell Raup, an antitrust attorney from Polsinelli, told Healthcare Dive. “They would have to convince the Department of Justice or perhaps a court that the next deal is not like this deal, that the judge’s opinion about this deal doesn’t apply to the next deal.”

Also this week, Anthem released first quarter 2017 earnings showing it beat projections with $1 billion in net income. It also said it would cautiously begin work on 2018 rates for the Affordable Care Act exchanges. Anthem and other payers, however, are still anxiously awaiting word from the President Donald Trump administration on whether it will continue the cost-sharing reduction subsidies.

Healthcare Dive requested comments from both payers. Anthem has not yet sent a statement. Cigna, through a company lawyer, said it has no comment at this time. An 8-K Cigna filed earlier today just states that it “continues to work through the litigation process in the pending Delaware Court of Chancery matter involving Cigna and Anthem, including the preliminary injunction hearing scheduled for May 8, 2017.”