On Health Care, Dems Go From Running to Baby Steps

https://www.rollcall.com/news/policy/health-care-democrats-congress-baby-steps?utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters&utm_content=102918&bt_ee=laxMKcbLquOQ38r3vgGpAMJX0zq6rDqxygOXbPDfSwKSHMjaEgq8JGZkmOJJy/1x&bt_ts=1542196035790&utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters&utm_content=102918&bt_ee=tH6eZI6YXwNy2ZGbobMIrH2ZCUu8d3EvTOK0U9Cxlbepc1ICeXiBfznzGL6Gj8mS&bt_ts=1542196035723

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Incremental measures will dominate action on the health law in a largely gridlocked Congress.

The midterm elections all but ended the Republican push to repeal the 2010 law known as Obamacare, but as a defining issue for Democrats in their takeover of the House, health care will likely remain near the top of lawmakers’ policy and political agenda.

Newly emboldened Democrats are expected to not only push legislation through the House, but use their majority control of key committees to press Trump administration officials on the implementation of the health law, Medicaid work requirements, and insurance that does not have to comply with Obamacare rules.

Both parties are looking to address issues that voters prioritized, such as lowering prescription drug prices, though different approaches by Republicans and Democrats could mean incremental changes stand a better chance of enactment than any major bill.

Early on, lawmakers may find themselves dealing with the fallout of a court ruling that could overturn the law’s mandate that health insurance cover pre-existing conditions, putting Congress on the spot in the face of widespread voter support for those protections.

All of these issues, which dominated this year’s elections, will play out against the backdrop of the next congressional and presidential contests.

“In a lot of ways, the purpose of legislation in this Congress for the Democrats is going to be to set the agenda for the 2020 election,” said Dan Mendelson, the founder of the consulting firm Avalere.

Drug prices

Lowering drug prices is a top priority for House Democrats and President Donald Trump. Leaders of both parties identified this issue last week as a possible area for bipartisanship.

But Democrats’ more ambitious plans, like allowing Medicare to negotiate drug prices, aren’t expected to advance in the Republican Senate. Instead, issues like increasing transparency or speeding up approvals for new treatments could be ones where both parties can find agreement.

Texas Democratic Rep. Lloyd Doggett, a contender to lead the Ways and Means Health Subcommittee, is pushing a measure that would require HHS to negotiate prices for drugs covered by the Medicare Part D program. While most Democrats say they back price negotiations, there will likely be debate within the party about the details, particularly if they seem to be close to the government setting prices.

“When you start getting into anything that looks like price controls, you might get some bipartisan support for, but you also might get bipartisan support against,” said Ben Isgur, the leader of PwC’s Health Research Institute.

Democrats’ other focal points center on price-gouging for pharmaceuticals, which gained significant attention in recent years. The House Democrats’ “Better Deal” legislative agenda envisions a “price-gouging” enforcer, which would be a Senate-confirmed position to lead a new agency focused on stopping significant price increases for prescription drugs. Democrats also hope to require drug manufacturers to provide data to justify significant price increases.

Their plan would require drugmakers to justify price increases of certain amounts at least 30 days before they take effect.

Leaders in both parties have said since the election that drug pricing will be on the agenda, but have appeared skeptical of whether their efforts would yield a successful outcome.

“The jury’s out in my mind,” Democratic Rep. Pramila Jayapal said in a call with reporters last week. “If he is serious about taking on those pharmaceutical drug companies and ensuring that we can really get prescriptions filled for our seniors and negotiate prices for our pharmaceutical drugs the way we do for our VA, then we might have something we can work on.”

Mendelson predicted that even if a major bipartisan agreement to lower prices doesn’t advance in the next Congress, the Trump administration will keep taking steps that could eventually lower prices. Food and Drug Commissioner Scott Gottlieb has earned bipartisan praise for speeding new drug approvals, for instance.

The Trump administration could try to stay in command of drug pricing politics ahead of the 2020 election, he added, although Democrats will also seek to control the issue.

“There could well be significant progress over the next year or two because the administration has a lot of authority and they will use it to neutralize the issue before the 2020 election,” said Mendelson, a former Clinton administration official.

Health care law

The electrifying election-year issue of pre-existing condition protections is likely to win a House vote as Democrats seek to prove their commitment to that popular part of the law.

Both parties are bracing for a ruling from U.S. District Court Judge Reed O’Connor of Texas in a lawsuit filed by 20 state officials seeking to overturn the 2010 law. O’Connor heard oral arguments in September, although the Trump administration asked to delay a ruling until after the open enrollment period ends on Dec. 15.

If O’Connor strikes down all or part of the health care law, Democrats expect a group of state attorneys general defending the law to seek an immediate injunction and appeal the decision. Legal scholars on both sides of the aisle question the arguments of those attempting to kill the law, but the case could reach the Supreme Court.

House Democrats plan to consider a bill by Rep. Jacky Rosen of Nevada who won a Senate bid last week, that would allow the House to intervene in the case and defend the health law, aides say.

Across the Capitol, 10 Senate Republicans introduced a bill this summer to guarantee coverage of pre-existing conditions, which GOP aides say could be part of a response to the lawsuit.

Democrats have criticized the Senate GOP bill because it doesn’t require insurers to cover certain services for patients with pre-existing conditions. Republicans like North Carolina Sen. Thom Tillis, who sponsored the measure, defend it.

“If they do strike down large parts of the legislation, Sen. Tillis’ bill could be one important part of a larger health care legislative effort,” said Adam Webb, a spokesman for Tillis.

Senate Majority Leader Mitch McConnell of Kentucky declined to reveal after the election how the chamber would respond to a ruling striking down parts of the law, but called for bipartisan fixes to the health law.

A draft bipartisan stabilization bill, which has been at an impasse for nearly a year, could re-emerge in the next Congress, but it’s not clear if lawmakers can resolve a fight over abortion restrictions that blocked an agreement or how that measure could change a year later.

“The first thing we need to do is stop Republican attacks on coverage of pre-existing conditions, stop any movement toward extending these short-term plans,” Iowa Rep.-elect Cindy Axne, who defeated Rep. David Young, said in a call with reporters last week.

Top Democrats — Frank Pallone Jr.Richard E. Neal of Massachusetts, and Robert C. Scott of Virginia, who are expected to chair the Energy and Commerce, Ways and Means, and Education and Workforce committees, respectively — introduced legislation this year to shore up the health law. It would increase the size of the tax credits that help people pay their premiums and expand eligibility. It would also block Trump administration rules to expand health plans that don’t meet the 2010 law’s requirements.

Aides caution the bill could see minor changes next year based on developments since it was introduced in March and say it could be tied into a stabilization debate.

Since falling short in their efforts to overhaul the law last year, Senate Republicans pivoted to rising health care costs, a focus that will likely extend into next year. Several senators showed interest in legislation to prevent surprise medical bills, but it’s not clear what other topics could lead to bipartisan agreement, which will still be needed in the Senate even with a larger Republican majority.

Oversight

Oversight of the health care law will dominate House action on the health law in a largely gridlocked Congress. House Democrats plan to bring administration officials to Capitol Hill to explain what critics call “sabotage” of the law’s insurance exchanges.

“We’ll be looking at what they’re doing administratively to undermine the operations of the Affordable Care Act and what consequences they may have caused to literally millions of people,” Minority Whip Steny H. Hoyer told reporters in September.

Oversight could touch on issues such as Trump’s funding cuts to outreach and advertising for the exchanges, reductions in enrollment help and the effects of repealing the law’s mandate to get coverage.

Maryland Rep. Elijah E. Cummings, who is expected to lead the House Oversight Committee, will likely rev up an investigation into drug companies high prices that he has been conducting as ranking member and could bring executives in to testify before the panel.

In a post-election press conference, the presumed incoming House speaker, Nancy Pelosi of California, highlighted the Energy and Commerce Committee as another “big oversight committee” that will be active.

“We do not intend to abandon or relinquish our responsibility … for accountability, for oversight and the rest,” said Pelosi. “This doesn’t mean we go looking for a fight, but it means that if we see a need to go forward, we will.”

 

Dems Won on Health Care. Now What?

 

Democrats rode a health care message to their Election Day takeover of the House. Now that the election is (mostly) over, how will they follow through on that campaign focus?

The party is still figuring out its next steps on health care, and Nancy Pelosi and her colleagues will have a lot of decisions to make and details to sort out. “The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare,” writes Dylan Scott at Vox. “But Democrats are less certain about an affirmative health care agenda.”

Some big-picture agenda items are clear, though. “The top priorities for Ms. Pelosi, the House Democratic leader, and her party’s new House majority include stabilizing the Affordable Care Act marketplace, controlling prescription drug prices and investigating Trump administration actions that undermine the health care law,” reports Robert Pear in The New York Times.

House Democrats also plan to vote early next year on plans to ensure patients with preexisting medical conditions are protected when shopping for insurance, Pear reports. And they’ll likely vote to join in the defense of the Affordable Care Act and its protections for those with pre-existing conditions against a legal challenge now before a Texas federal court.

Here are a few areas where House Democrats will likely look to exercise their newly won power.

Stabilizing Affordable Care Act markets: “I’m staying as speaker to protect the Affordable Care Act,” Pelosi said in an interview with CBS’s “Face the Nation,” calling that her “main issue.” And Vox’s Scott says that “a bill to stabilize the Obamacare insurance markets would be the obvious first item for the new Democratic majority’s agenda,” adding that a bill put forth by Reps. Richard Neal (MA), Frank Pallone (NJ) and Bobby Scott (VA) is the likely starting point. Democrats may look to provide funding for the Obamacare “cost-sharing reduction” subsidy payments to insurers that President Donald Trump ended in October 2017. And they may look to restore money for Affordable Care Act outreach and enrollment programs after the Trump administration slashed that funding by 84 percent, to $10 million, Pear says. “Another idea is for the federal government to provide money to states to help pay the largest medical claims,” he adds. “Such assistance, which provides insurance for insurance carriers, has proved effective in reducing premiums in Alaska and Minnesota, and several other states will try it next year.”

Investigating the Trump administration ‘sabotage’: “Administration officials who have tried to undo the Affordable Care Act — first by legislation, then by regulation — will find themselves on the defensive, spending far more time answering questions and demands from Congress,” Pear writes.

Reining in prescription drug prices: Trump, Pelosi and Senate Majority Leader Mitch McConnell have all pointed to this as an area of potential cooperation, But Vox’s Scott calls this “another area where Democrats know they want to act but don’t know yet exactly what they can or should do.” Some options include pushing to let Medicare negotiate drug prices directly with manufacturers and requiring makers of brand-name medications to provide samples to manufacturers of generics, potentially speeding the development of less expensive competitors.

“There are a lot of levers to pull to try to reduce drug prices: the patent protections that pharma companies receive for new drugs, the mandated discounts when the government buys drugs for Medicare and Medicaid, existing hurdles to getting generic drugs approved, the tax treatment of drug research and development,” Scott writes. But it’s not clear just what policy mix would really work to bring down drug prices, and the pharmaceutical industry lobby is likely to push back hard on such efforts. Democrats may also be hesitant to give President Trump a high-profile win on the issue ahead of the 2020 election.

Medicare for all: Much of the Democratic Party may be gung-ho for some sort of Medicare-for-all legislation, but don’t expect significant progress over the next two years. “House Democratic leaders probably don’t want to take up such a potentially explosive issue too soon after finally clawing back a modicum of power in Trump’s Washington,” Scott writes. And Democrats have to forge some sort of internal consensus on just what kind of plan they want to push in order to further expand health insurance coverage.

MID-TERM MESSAGE: DON’T MESS WITH MY HEALTHCARE!

https://www.healthleadersmedia.com/mid-term-message-dont-mess-my-healthcare

Tired of the partisanship and dithering in Congress, voters took matters into their own hands Tuesday and largely embraced initiatives and politicians who vowed to expand Medicaid and protect coverage for pre-existing conditions.


KEY TAKEAWAYS

You can’t undo an entitlement.

‘Repeal and replace’ is dead. Drug pricing reforms a likely area of bipartisan consensus.

Democrats can push Medicare For All at their own peril.

For healthcare economist Gail Wilensky, the big message that voters sent to their elected officials during Tuesday’s mid-term elections was straightforward and simple.

“Don’t mess with my healthcare,” says Wilensky, a senior fellow at Project HOPE and a former MedPAC chair.

“It’s as clear as that. There were no subtleties involved here,” she says. “That includes protections for pre-existing conditions and added coverage under Medicaid.”

Consider what happened on Tuesday:

  • Overall, Democrats wrested control of the House from Republicans in an election where healthcare was seen as the single biggest issue. Democrats ceaselessly hammered Republicans with the claim that the GOP would eliminate protections for pre-existing conditions.
  • Ballot initiatives in three bright-red Republican states all passed with healthy margins. A similar ballot initiative in Montana failed, but observers blamed the failure on an unpopular $2-per-pack tax on cigarettes that would have paid for the expansion.
  • Wisconsin Attorney General Brad Schimel, a lead plaintiff in a Texas v. Azar, was ousted by Democrat Josh Kaul, who promised to withdraw Wisconsin from the suit.
  • Three-term Wisconsin Gov. Scott Walker lost a re-election bid to Democrat Tony Evers, likely scuttling that state’s recent waiver approval for Medicaid work requirements. Evers also pledged to expand Medicaid.
  • Phil Weiser, Colorado’s Democratic Attorney General-elect, and a former Obama administration staffer, told Colorado Public Radio that one of his first actions would be to join the 17 Democratic attorneys general intervening to defend the ACA in Texas v. Azar.  

Wilensky says the mid-terms results reinforce one of the oldest truisms in politics: Once an entitlement is proffered, there’s no going back.

“There is no precedent that I’m aware of in American political history where a benefit can be taken away,” she says. “Once granted, it can be modified, it can be increased, it can be augmented in some way, but there’s no taking it away after it’s been in place.”

When Democrats took control of the House, Wilensky says, they drove a stake through the heart of the “repeal and replace” movement.

“Republicans couldn’t even get that done when they control both houses of Congress, she says. “It’s a non-issue, in part because a lot of Republicans support major provisions of the Affordable Care Act.”

With repealing the ACA off the table, Democrats and Republicans might find common ground on issues such as drug pricing.

“That’s clearly is the most obvious, in general, but the specifics of what you want to do become much more challenging,” Wilensky says. “Typically, Democrats want to use administered pricing the way that we use administer pricing in parts of Medicare. I don’t know how much Republican support there is for that.”

The two parties could reach some sort of bipartisan agreement on Medicare Part B drugs, Wilensky says, because it’s a smaller program and the drugs are generally much more expensive.

“Most members of Congress are not talking about messing around with Part D, the ambulatory prescription drug coverage,” Wilensky says. “So it really has to do either with the expensive infusion drugs that are administered in the physician’s office or maybe something about drug advertising. Even then, it’s going to be hard lift when you actually get down to the specifics.”

Besides, Wilensky says, it’s not the cost of drugs that’s at the heart of voter agitation.

“You have to unpack what they’re saying to figure out what they’re actually pushing for,” she says. “People couldn’t care less about drug prices. They only care about what it costs them. So when they talk about drug prices they mean, ‘I want to spend less for the drugs I want, and I don’t want any constraints about what I can order.’

More likely, she says, common ground could be found in arcane areas such as mandating greater transparency for pharmacy benefits managers, and changing PBMs’ rebate structure.

Wilensky warns that giddy Democrats should learn from the mistakes of Republicans in the mid-terms and not attempt to force a Medicare-For-All solution on a wary public.

“First of all, they’re going to have to define what it means,” she says. “But, you have to be very careful because historically there’s not been warm and fuzzy response to taking away people’s employer-sponsored insurance.”

“Again, historically, when candidates mess around with employer-sponsored insurance they have gotten themselves into trouble,” she says. “Most people would like to keep what they have, because keeping what you have is much safer than going with something as yet to be defined.”

“DON’T MESS WITH MY HEALTHCARE. IT’S AS CLEAR AS THAT. THERE WERE NO SUBTLETIES INVOLVED HERE,”

 

What the 2018 Midterm Elections Means for Health Care

https://www.healthaffairs.org/do/%2010.1377/hblog20181107.185087/full/?utm_source=Newsletter&utm_medium=email&utm_content=What+the+Midterms+Mean+For+Health+Care%3B+%22Stairway+To+Hell%22+Of+Health+Care+Costs%3B+Patient+Safety+In+Inpatient+Psychiatry&utm_campaign=HAT%3A+11-07-18

Whatever you want to call the 2018 midterm elections – blue wave, rainbow wave, or purple puddle – one thing is clear: Democrats will control the House.

That fundamental shift in the balance of power in Washington will have substantial implications for health care policymaking over the next two years. Based on a variety of signals they have been sending heading into Tuesday, we can make some safe assumptions about where congressional Democrats will focus in the 116th Congress. As importantly, there were a slew of health care-related decisions made at the state level, perhaps most notably four referenda on Medicaid expansion.

In this post, I’ll take a look at which health care issues will come to the fore of the Federal agenda due to the outcome Tuesday, as well as state expansion decisions. And it should of course be noted that, in addition to positive changes Democrats are likely to pursue over the next two years, House control will allow them to block legislation they oppose, notably further GOP efforts to repeal the Affordable Care Act (ACA).

Drug Pricing

Democrats have long signaled they consider pharmaceutical pricing to be one of their highest priorities, even after then-candidate Trump adopted the issue as part of his campaign platform and maintained his focus there through his tenure as President.

While aiming to use the issue to drive a wedge between President Trump and congressional Republicans, who have historically opposed government action to set or influence prices, Democrats will also strive to distinguish themselves by going further on issues like direct government negotiation of Medicare Part D drug reimbursement.

Relevant House committee chairs, perhaps especially likely Oversight and Investigations chair Elijah Cummings (D-MD), will also take a more aggressive tack in investigating manufacturers and other sector stakeholders for pricing increases and other practices. Democratic leaders believe it will be easier to achieve consensus on this issue than on more contentious issues like single payer (more detail below) among their diverse caucus, which will include dozens more members from “purple” districts as well as members on the left flank of the party

Preexisting Condition Protections

If you live in a contested state or district, you have probably seen political ads relating to protecting patients with preexisting conditions. As long as a Republican-supported lawsuit seeking to repeal the ACA continues, Democrats believe they can leverage this issue to demonstrate the importance of the ACA and their broader health care platform.

A three-legged stool serves under current law to protect patients with chronic conditions: (1) the ban on preexisting condition exclusions; (2) guaranteed issue; and (3) community rating. Democrats will likely seek to bolster these protections with measures to shore up the ACA exchange markets. In the same vein, they will likely strive to rescind Trump Administration proposals to expand association-based and short-term health plans, which put patients with higher medical costs at risk by disaggregating the market.

Opioids

Congressional Democrats believe that there were some stones left unturned in this year’s opioid-related legislation, especially regarding funding for many of the programs it authorized. This is a priority for likely Ways & Means Committee Chair Richie Neal (D-MA) and could potentially be a source of bipartisan compromise.

Medicare for All

While this issue could become a bugaboo for old guard party leaders, the Democratic base will likely escalate its calls for action on Medicare for All now that the party has taken the House. Because the details of what various camps intend by this term are still vague (some believe it is tantamount to single payer, others view it as a gap-fill for existing uninsured, etc.), we will likely see a variety of competing proposals arise in the coming two years. Expect less bona fide committee action and more of a public debate aired via the presidential primary season that will kick off about, oh, right now.

Surprise Bills

The drug industry is not the only health care sector that can expect heightened scrutiny of their pricing practices now that Democrats control the people’s chamber. Most notably, the phenomenon of surprise bills (unexpected charges often stemming from a hospital visit) has risen as a salient issue for the public and thus a political winner for the party. Republicans have shown interest in this issue as well, so it could be another source of bipartisanship next year.

Regulatory Oversight

Democrats believe they are scoring well with the public, and certainly their base, every time they take on President Trump. The wide range of aggressive regulation (and deregulation) the Administration has pursued will be thoroughly investigated and challenged by Democratic committee leaders, especially administration efforts to dismantle the ACA and to test the legal bounds of the hospital site neutrality policy enacted in the Bipartisan Budget Act (BBA) of 2015.

Extenders

While it instituted permanent policies for Medicare physician payments and some other oft-renewed ‘extenders’, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 left a variety of policies in the perennial legislative limbo of needing to be repeatedly extended. While the policies in the Medicare space have dwindled to subterranean, though not necessarily cheap, affairs like the floor on geographic adjustments to physician payments, a slew of Medicaid-related and other policies are up for renewal in 2019.

For example, Medicaid Disproportionate Share Hospital (DSH) payments face a (previously delayed) cliff next year. That and the most expensive extender, ACA-initiated funding for community health centers, alone spring the cost of this package into the high single digit billions at least, driving a need for offsetting payment cuts and creating a vehicle for additional policy priorities.

A likely addition to this discussion will be the fact that Medicare physician payments, per MACRA, are scheduled to flatline for 2020-2025 before beginning to increase again, albeit in divergent ways for doctors participating in the Merit-Based Incentive Payment Program (MIPs – 0.25 percent/year) and Advanced Alternative Payment Models (APMs – 0.75 percent/year). The AMA assuredly noticed this little wrinkle in the celebrated legislation but hundreds of thousands of doctors probably did not.

Medicaid Expansion

Of the variety of state-level health policy decisions voters made on Tuesday, perhaps the most significant related to Medicaid expansion. In there states where Republican leaders have blocked expansion under the ACA – Nebraska, Idaho, and Utah – voters endorsed it via public referenda. Increasing the Medicaid eligibility level in those three states to the ACA standard will bring coverage to approximately 300,000 people.

Notably, voters in Montana rejected a proposal to continue funding the Medicaid expansion the state enacted temporarily in 2015 by an increase to the state’s tobacco tax. Their expansion is now scheduled to lapse in July 2019 if the legislature doesn’t act to maintain it. If they do not act, about 129,000 Montanans will lose Medicaid coverage.

Finally, Democratic gubernatorial wins in Maine, Kansas, and Wisconsin will make Medicaid expansion more likely in those states.

As they say, elections have consequences. While the Republican-controlled Senate and White House can block any Democratic priorities they oppose, the 2018 midterm elections assure a busy two years for health care stakeholders.

 

 

Health Care Is on Agenda for New Congress

https://www.scripps.org/blogs/front-line-leader/posts/6546-ceo-blog-health-care-is-on-agenda-for-new-congress

After months of polls, mailbox fliers, debates and seemingly endless commercials, the mid-term elections are over and the results are in. As predicted by many, the Democrats have won back the majority in the U.S. House of Representatives, while the Republicans have expanded their majority in the Senate.

This means that for the first time since 2015 we have a divided Congress, which leaves me pondering the possible consequences for Scripps Health and the broader health care sector.

Without a doubt, health care will be on the agenda for both parties over the coming months. That became apparent during pre-election campaigning as voters on both sides of the political spectrum voiced concerns about a wide range of health care-related issues.

Exit polls found that about 41 percent of voters listed health care as the top issue facing the country, easily outpacing other issues such as immigration and the economy.

That’s really no surprise. Health care affects all of us, whether we’re young or old, poor or well off, or identify as more conservative or more liberal. And despite all of the division around the country, most Americans seem to agree on at least a few things – health care costs too much, more needs to be done to rein in those costs, everyone should have access to health insurance, and pre-existing condition shouldn’t be a disqualifier for getting coverage.

When the new Congress convenes on Jan. 3, a wide range of health care issues will be on the agenda.

Here are a few of the issues that I’ll be watching as our lawmakers adjust to the reshuffled political dynamics in Washington.

  • Repealing elements of the Affordable Care Act (ACA) is likely off the table now that Democrats control the House. Previously, House Republicans had voted to change a number of ACA provisions that required health insurance policies to cover prescription drugs, mental health care and other “essential” health benefits. But even before the election, Republicans had reassessed making changes to measures that protect people with pre-existing conditions as that issue gained traction with voters.
  • Efforts to expand insurance coverage and achieve universal health care will likely increase. A number of newly elected Democrats vowed to push for a vote on the single-payer option, but other less politically polarizing options such as lowering the eligibility age for Medicare and expanding Medicaid likely will draw more support.
  • While Republicans used their majority in the House to reduce the burden of government regulations in health care and other industries, Democrats might use their new-found power to initiate investigations on a wide range of matters such as prescription drug costs.

We could see some significant changes take place at a more local level as well. On Tuesday, voters in three states approved the expansion of Medicaid, the government program that provides health care coverage for the poor.

And here in California, we will be watching newly elected Governor Gavin Newsom to see what plans he will put forward for expanding health care coverage in this state.

At Scripps, we believe everyone should have access to the health care services that they need, and we have worked hard in recent years to do all that we can to bring down the costs of delivering that care to our patients.

In this new world of divided government, gridlock likely will prevail and President Trump’s initiatives will struggle in the Democrat-controlled House. Everyone will be focused on positioning themselves and their party for the next presidential and congressional elections in two years.

Compromise and bipartisanship are clearly the best options for addressing the health care challenges we now face in ways that have the best chance to win wide public support.

If Democrats in the House fail to reach across the aisle to Republicans or try to make too many changes too quickly, they surely will face many of the same pitfalls that confronted Republicans over the last two years.

 

 

THE RACES AND ISSUES HEALTHCARE LEADERS NEED TO WATCH ON ELECTION NIGHT

https://www.healthleadersmedia.com/strategy/races-and-issues-healthcare-leaders-need-watch-election-night

The 2018 midterm elections will decide the fate of numerous healthcare-related ballot measures as well as which leaders will shape health policy in the coming years.


KEY TAKEAWAYS

Issues to watch: Medicaid expansion in 4 states, a healthcare bond initiative in California, and the debate over preexisting condition protections.

Candidates to watch: Wisconsin Gov. Scott Walker, former Gov. Phil Bredesen, former HHS Secretary Donna Shalala, and others.

Healthcare has been an overarching issue for voters in the 2018 midterm election cycle, with many focusing on the future of the Affordable Care Act when it comes to national health policy but also taking stock of state and local ballot initiatives as well.

Several traditionally Republican states will decide whether to expand Medicaid under the ACA; staffing requirements for nurses are a hot-button topic in Massachusetts; and a major children’s hospital bond is on the table in California. 

Beyond the issues are the candidates, including many Republican leaders on Capitol Hill in tight races to defend their seats after voting to repeal and replace the ACA. At the state level, Republican governors and their attorneys general are having their healthcare records put to the test as Democrats make protecting preexisting conditions and rejecting Medicaid work requirements key parts of the campaign.

Here are the key issues and candidates healthcare leaders will be watching as results begin rolling in Tuesday evening, with voters determining the direction of healthcare policymaking for years to come.

MEDICAID EXPANSION IN 4 RED STATES

One year after voters approved Medicaid expansion in Maine, the first state to do so through a ballot initiative, four other states have the opportunity to join the Pine Tree State.

Montana: The push to extend Medicaid expansion in Montana before the legislative sunset at the end of the year is tied to another issue: a tobacco tax hike. The ballot measure, already the most expensive in Montana’s history, would levy an additional $2-per-pack tax on cigarettes to fund the Medicaid expansion which covers 100,000 persons.

Nebraska: Initiative 427 in traditionally conservative Nebraska, could extend Medicaid coverage to another 90,000 people. The legislation has been oft-discussed around the Cornhusker State, earning the endorsement of the Omaha World-Herald editorial board.

Idaho: Medicaid expansion has been one of the most talked about political items in Idaho throughout 2018. Nearly 62,000 Idahoans would be added to the program by Medicaid expansion, some rural hospitals have heralded the move as a financial lifeline, and outgoing Gov. Bruce Otter, a Republican, blessed the proposal last week.

Utah: Similar to Montana’s proposal, Utah’s opportunity to expand Medicaid in 2018 would be funded by a 0.15% increase to the state’s sales tax, excluding groceries. The measure could add about 150,000 people to Medicaid if approved by voters, who back the measure by nearly 60%, according to a recent Salt Lake Tribune/Hinckley Institute poll.

4 MORE BALLOT INITIATIVES

In addition to the four states considering whether to expand Medicaid, there are four others considering ballot initiatives that could significantly affect the business of healthcare.

Massachusetts mulls nurse staffing ratios. Question 1 would implement nurse-to-patient staffing ratios in hospitals and other healthcare settings, as Jennifer Thew, RN, wrote for HealthLeaders. The initiative has backing from the Massachusetts Nurses Association.

Nurses have been divided, however, on the question, and public polling prior to Election Day suggested a majority of voters would reject the measure, which hospital executives have actively opposed. The hospital industry reportedly had help from a major Democratic consulting firm.

California could float bonds for children’s hospitals. Proposition 4 would authorize $1.5 billion in bonds to fund capital improvement projects at California’s 13 children’s hospitals, as Ana B. Ibarra reported for Kaiser Health News. With interest, the measure would cost taxpayers $80 million per year for 35 years, a total of $2.9 billion, according to the state’s Legislative Analyst’s Office.

Proponents say children’s hospitals would be unable to afford needed upgrades without public assistance; opponents say the measure represents a fiscally unsound pattern. (California voters approved a $750 million bond in 2004 and a $980 million bond in 2008.)

Nevada nixing sales tax for medical equipment? Question 4 would amend the Nevada Constitution to require the state legislature to exempt certain durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax. The proposal, which passed a first time in 2016, would become law if it passes again.

Bennett Medical Services President Doug Bennett has been a key proponent of the measure, arguing that it would bring Nevada in line with other states, but opponents contend the measure is vaguely worded, as the Reno Gazette Journal reported.

Oklahoma weighs Walmart-backed optometry pitch. Question 793 would add a section to the Oklahoma Constitution giving optometrists and opticians the right to practice in retail mercantile establishments.

Walmart gave nearly $1 million in the third quarter alone to back a committee pushing for the measure. Those opposing the measure consist primarily of individual optometrists, as NewsOK.com reported.

INCUMBENTS, PLAINTIFFS, PREEXISTING CONDITIONS

It’s been more than two months since Republican attorneys general for 20 states asked a federal judge to impose a preliminary injunction blocking further enforcement of the Affordable Care Act, including its coverage protections for people with preexisting conditions. Some see the judge as likely to rule in favor of these plaintiffs, though an appeal of that decision is certain.

Amid the waiting game for the judge’s ruling, healthcare policymaking—especially as it pertains to preexisting conditions—rose to the top of voter consciousness in the midterms. That explains why some plaintiffs in the ACA challenge have claimed to support preexisting condition protections, despite pushing to overturn them.

The lawsuit and its implications mean healthcare leaders should be watching races in the 20 plaintiff states in the Texas v. Azar lawsuit: Alabama, Arizona, Arkansas, Florida, Georgia, Indiana, Kansas, Louisiana, Maine Gov. Paul LePage, Mississippi Gov. Phil Bryant, Missouri, Nebraska, North Dakota, South Dakota, South Carolina, Tennessee, Texas, Utah, West Virginia, and Wisconsin. Thirteen of those plaintiff states have active elections involving their state attorneys general, and several have races for governor in which the ACA challenge has been an issue, including these noteworthy states:

  • Texas: Attorney General Ken Paxton, a Republican representing the lead plaintiff in the lawsuit, is facing a challenge from Justin Nelson, a Democrat, and the race seemed to be competitive, as The Texas Tribune reported. Gov. Greg Abbott was expected to win against Democratic challenger Lupe Valdez.
  • Florida: Attorney General Pam Bondi, a Republican, is term-limited, so she’s not running for reelection. Ashley Moody, a Republican, and Sean Shaw, a Democrat, are facing off for Bondi’s position. Moody expressed support for Florida’s participation in the ACA challenge, while Shaw said he would pull the state out, calling the case a “partisan stunt,” as the Tampa Bay Times reported. Bondi has campaigned, meanwhile, for Republican gubernatorial candidate Ron DeSantis, who’s facing off with Democrat Andrew Gillum. Gillum said he would back a state law to protect people with preexisting conditions, while DeSantis said he would step in if federal action removed the ACA’s preexisting condition protections, as the Miami Herald reported. Gillum and DeSantis are vying to succeed term-limited Gov. Rick Scott, a Republican who’s running for U.S. Senate.
  • Wisconson: Attorney General Brad Schimel, a Republican, is facing a challenge from Josh Kaul, a Democrat who has slammed Schimel’s participation in the ACA challenge, as The Capital Times reported. Gov. Scott Walker, a Republican, said he supports preexisting condition protections, despite authorizing his state’s participation in the lawsuit. Democratic challenger Tony Evers accused Walker of “talking out of both sides of his mouth,” as the Milwaukee Journal Sentinel reported.

PROPONENTS OF MEDICAID WORK REQUIREMENTS

Five states have received approvals from the Centers for Medicare and Medicaid Services to institute Medicaid work requirements: Kentucky, Indiana, Wisconsin, New Hampshire, and Arkansas. (Only four have active approvals, however, since a federal judge blocked Kentucky’s last summer.)

Three incumbent governors who pushed for work requirements are running for reelection:

New Hampshire: After receiving approval for New Hampshire’s Medicaid work requirements, Republican Gov. Chris Sununu said the government is committed to helping Granite Staters enter the workforce, adding that it is critical to the “economy as a whole.” Despite spearheading a controversial topic in a politically centrist state, Sununu has not trailed against his Democratic opponent Molly Kelly in any poll throughout the midterm elections.

Arkansas: Similarly, Arkansas Gov. Asa Hutchinson, is running in a race where he has held a sizable lead over his Democratic challenger Jared Henderson. Since enacting the work requirements over the summer, the state has conducted two waves where it dropped more than 8,000 enrollees.

Wisconsin: The most vulnerable Republican governor of a state with approved Medicaid work requirements is Wisconsin Gov. Scott Walker, who has been neck and neck with Democratic nominee Tony Evers. While the Badger state only received approval for its Medicaid work requirements last week, healthcare has been a central issue of the campaign as Walker, a longtime opponent of the ACA, works to address premium costs in the state and defend his record on preexisting conditions.

Indiana and Kentucky: Indiana Gov. Eric Holcomb and Kentucky Gov. Matt Bevin are not on the ballot this year.

When HealthLeaders issued its first list in April of the healthcare leaders running for public office during the primaries, there were more than 60 candidates with relevant healthcare backgrounds out on the campaign trail.

Now, for the general election, that list has nearly been halved, with 35 candidates still remaining. 

This collection of healthcare leaders includes registered nurses, former insurance company executives, physicians, and former government health policy leaders.

U.S. Senate: Running for the Senate are Florida Gov. Rick Scott, former Tennessee Gov. Phil Bredesen, former Celgene CEO Bob Hugin, and State Sen. Leah Vukmir.

U.S. House: Among those aiming to join the House are Lauren Underwood, RN, former HHS Secretary Donna Shalala, and Dr. Kim Schrier.

 

 

How Will the Midterm Elections Impact Healthcare?

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With the midterms less than a week away,  a new poll published October 18th by the non-partisan Kaiser Family Foundation got a lot of attention. Over seventy percent of voters say health care is a very important issue in deciding who to vote for. 

But exactly what happens to key healthcare initiatives, especially the Affordable Care Act including expansion of Medicaid in many states—which tends to be more popular among Democratic lawmakers than Republicans–depends on whether it’s the Democrats or Republicans who get control of the House, says Eric Feigl-Ding, MPH, Ph.D., a health economist and visiting scientist at the Harvard Chan School of Public Health in Cambridge, Mass.

Based on multiple polls, the New York Times reported on October 23 that a likely outcome is that Democrats will gain the majority in the House of Representatives and the Republicans will keep the majority in the Senate. But the Times and many other news outlets continually point out that many factors including the news of each day make it difficult to predict the outcome.

Feigl-Ding says having opposing parties in the House, Senate and White House could make it harder to pass national legislation. Changes can still happen to the ACA, however, because the President can continue to make certain executive level decision such as ending the penalty for not having health insurance which he did last year. That change takes effect in 2019.

In terms of new legislation, Feigl-Ding says a split Congress and White House means that passing legislation will be difficult because what comes from the House side, if most members are Democrats in the next sessions, could be more liberal and the corresponding bills from the Senate, likely to remain Republican, could be more conservative. So, says Feigl-Ding, either a bill won’t pass at all, or there will have to be much more of a compromise. “And assuming they would get to compromise is a big assumption, that then requires the president to agree to sign that legislation,” adds Feigl-Ding.

A report this week by strategy and policy group Manatt Health, based in Washington, DC lists the health care issues the firm thinks will dominate in states and the federal government after the elections:

  • The role of Medicaid as either a welfare program or health insurance for low-income Americans: While Democrats generally support continued expansion of Medicaid with no cost or work requirements for low-income adults, Republican governors in a number of states—with the approval of the Trump administration– have introduced premiums, work requirements, increased paperwork and penalties for falling off on requirements those that can keep many adults from applying for or remaining on Medicaid.
  • Differences in states about expanding and stabilizing the Affordable Care Act (ACA) Marketplace or promoting non-ACA coverage: The ACA allows states to open their own health insurance marketplaces or simply offer access to the federal marketplace. According to 2017 data from the National Academy for State Health Policy, more consumers sign up for health care coverage in states that run their own marketplaces
  • Drug prices: According to the Organization for Economic Development, an international forum with 36-member countries, consumers in the U.S. spend just over $1,100 on prescription drugs each year, more than consumers in any other country. President Trump has promised to help lower drug prices and on October 25 he released a plan that would tie some drug prices for patients on Medicare to an index based on international prices. Those prices are often far lower than Americans pay. PhRMA, the largest drug trade association announced its opposition to the plan the same day it was announced.

According to the report what states do will depend on the election outcomes for governors in more than a dozen states and many of those races are as impossible to predict as the Congressional races.

Other important health care issues for 2019-20120 include:

Pre-Existing Conditions 

Listening to ads for some Republicans candidates for Congress makes it appears protecting pre-existing conditions will be a top priority for some Republicans, even among some who voted against them previously. But Feigl-Ding says keeping coverage for preexisting conditions in health insurance plans also requires figuring out how to pay for it. Under the original ACA legislation, the hope was that a financial penalty for not having health coverage would keep more healthy people in the plans—along with the prohibition against letting insurers “cherry pick” only healthy consumers. But that penalty is now gone. “Take that away and you probably can’t sustain the preexisting conditions, says Feigl-Ding.

Medicaid Work Requirements and Other Conditions of Eligibility.

Legal challenges in several states could impact the implementation of work requirements. Some governors have said they’ll cut the number of state Medicaid beneficiaries to save money if work requirements are overturned.

ACA Repeal. Twenty states are challenging the constitutionality of the ACA in Texas v. The U.S., a case that could make it to the Supreme Court.

Association Health Plans and Short-Term Plans. Several Democratic state attorneys general have filed a lawsuit against the administration’s rule promoting association health plans that allow individuals and small businesses to join to purchase health care coverage and short-term plans. The suit argues that the new rules for both avoid protection for people with pre-existing conditions, according to Manatt.

No one has a crystal ball for what will happen, but everyone has hindsight. According to the Manatt report, in 2010 Republicans replaced Democratic governors in eleven states, and all but one of those states ended plans to establish a state-based health insurance marketplace (SBM). In five states where Democrats replaced Republicans, all those states set up those marketplaces.

And whatever the outcome of the 2018 elections, their impact on healthcare may only be short lived. At a foundation briefing on the midterm elections earlier this week Mollyann Brody, Executive Director, Public Opinion and Survey Research at the Kaiser Family Foundation reminded the crowd that “the day the 2018 elections are over the 2020 campaign starts.”

Still the end of the week also brought a glimmer of hope. In response to President Trumps remarks on October 25thabout his administration’s plan to test new drug pricing models in Medicare Part B help to lower drug prices Frederick Isasi, executive director of FamiliesUSA, a liberal leaning health insurance advocacy group, released a statement that said, in part, “I hope this is a serious policy that will be formally proposed and finalized by the Trump administration. If so, it is an important step forward for our nation’s seniors and taxpayers.”