Tag Archives: ACA

Lawsuit filed against ObamaCare insurer over coverage

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Lawsuit filed against ObamaCare insurer over coverage

Lawsuit filed against ObamaCare insurer over coverage

The insurance carrier Centene misled enrollees about the benefits of its ObamaCare exchange plans and offered far skimpier coverage than promised, according to a class-action lawsuit filed Thursday.

The lawsuit, filed in federal court in Washington state, claims customers who bought Centene’s ObamaCare plans had trouble finding in-network doctors or hospitals and often found that doctors who were advertised as in-network actually were not.

ObamaCare requires plans to meet certain minimum requirements.

Centene covers about 10 percent of the ObamaCare individual market and is one of the largest insurance carriers that participates on the exchanges.

As many other insurers have pared back their ObamaCare exchange plans, or completely left the market, Centene has expanded. In some areas of the country, Centene is the only insurer offering plans for ObamaCare customers.

Centene markets its signature product — its three-tiered Ambetter plans — in at least 15 states, and covers more than 1.4 million customers.

According to the lawsuit, Centene targets low-income customers who qualify for substantial government subsidies “while simultaneously providing coverage well below what is required by law and by its policies.”

A spokeswoman for the company told The Hill they have not been served papers and only learned of the lawsuit Thursday morning.

“We believe our networks are adequate. We work in partnership with our states to ensure our networks are adequate and our members have access to high quality health care,” Marcela Manjarrez Hawn said in an email.

Narrow networks — insurance plans that limit which doctors and hospitals customers can use — are not uncommon, as they are cheaper than more expansive plans. But the lawsuit says Centene went far beyond the norm.

“Centene misrepresents the number, location and existence of purported providers by listing physicians, medical groups and other providers — some of whom have specifically asked to be removed — as participants in their networks and by listing nurses and other non-physicians as primary care providers,” the lawsuit claims.

According to the lawsuit, customers found the provider network Centene said was available was “largely fictitious. Members have difficulty finding — and in many cases cannot find — medical providers who will accept Ambetter insurance.”

The suit was filed on behalf of two Centene customers, but seeks class-action status to represent all customers who purchased Centene plans on the ObamaCare exchange.

 

ObamaCare repeal fades from GOP priorities list in new year

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ObamaCare repeal fades from GOP priorities list in new year

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The chances of repealing ObamaCare this year are fading further, with top Republicans saying they hardly discussed repeal of the law during a Camp David retreat last weekend focused on their 2018 agenda.

Meanwhile, Republicans say talk of welfare or entitlement reform this year is also narrowing down to an emphasis on things like job training, not the broad overhaul of Medicare, Medicaid and other entitlements that Democrats have warned against.

While some conservative groups and select lawmakers are pushing for ObamaCare repeal in 2018, President Trump and GOP leaders have signaled a desire to move on, at least for now, after unsuccessful repeal efforts sucked up months of the legislative calendar in 2017. Trump also declared after signing the GOP tax overhaul in December, which did away with the mandate that most people buy health insurance or face a tax penalty, that Republicans had “essentially repealed ObamaCare.”“There’s some work we need to do on the health-care front, but I would hope we’re in a position to do things on a bipartisan basis,” said Sen. John Cornyn (R-Texas), one of the GOP leaders who huddled with Trump at Camp David to discuss the 2018 agenda.

Asked if ObamaCare repeal was discussed in the meetings over the weekend, Cornyn — the Senate’s No. 2 Republican — replied flatly, “No.”

A source familiar with the conversations at Camp David confirmed that ObamaCare repeal was hardly discussed, except for Senate Majority Leader Mitch McConnell (R-Ky.) saying that he did not want to do a partisan bill like ObamaCare repeal or entitlement reform through the fast-track process of reconciliation this year.

ObamaCare repeal has largely fallen off the GOP agenda for 2018, in part due to the realities of a narrower Senate majority than one that already failed to pass a repeal bill. Reopening the divisive issue in an election year would also be tough.

McConnell’s office pointed to his comments at a press conference at the end of December. The GOP leader said then that he wanted to focus on areas of bipartisan agreement in 2018.

When asked about trying to repeal ObamaCare again, McConnell responded that 51-49 is a “pretty tight majority” and noted that “the sensitivity of entitlements is such that you almost have to have a bipartisan agreement in order to achieve a result.”

Democrats have also pointed to comments Speaker Paul Ryan (R-Wis.) made late last year about reining in entitlement spending to warn that Republicans could try to cut Medicare and Medicaid in 2018.

But the source familiar with the Camp David meetings said any welfare or entitlement push this year would likely not be through the fast-track reconciliation process aimed at preventing a Democratic filibuster in the Senate.

Instead, the push would be narrower and focus on areas like job training that could potentially get bipartisan support, not Medicare or Medicaid changes.

“It was a little different than what I anticipated,” Cornyn said of the Camp David discussions on welfare reform. “In other words, it’s not Medicare, Social Security, entitlement reform; it is more, workforce training.”

Ryan outlined this emphasis in a press conference on Tuesday, where he made no mention of ObamaCare, Medicare or Medicaid in talking about an agenda for 2018.

Instead, Ryan said, “We’ve got more work to do to work on people, getting them the skills they need so they can get the careers that they want so they can get the lives that they deserve.”

Trump likewise pushed aside the idea of partisan welfare reform in a press conference at Camp David, which was dominated by the president lashing out at a new, critical book about his young administration.

“We’ll try and do something in a bipartisan way, otherwise we’ll be holding it for a little bit later,” Trump said when asked about welfare reform.

It is still possible, though, that some Republican lawmakers could push to bring back ObamaCare repeal this year. Sen. Lindsey Graham (R-S.C.), for example, pushed back against McConnell last month when McConnell suggested moving on from repealing the law.

“To those who believe — including Senate Republican leadership — that in 2018 there will not be another effort to Repeal and Replace Obamacare — you are sadly mistaken,” Graham said on Twitter last month.

Kevin Bishop, a spokesman for Graham, said on Tuesday that those comments still stand.

Conservative groups are also pressuring Republicans to try again on ObamaCare repeal this year. A range of leading groups, including Heritage Action, Club for Growth and Americans for Tax Reform, wrote to Trump last week urging him to push for ObamaCare repeal this year.

The groups want the fast-track reconciliation process, which is needed to avoid Democrats blocking a bill with a filibuster, to be used for ObamaCare repeal. That is essentially the only way to give repeal a chance of passing.

However, it is in doubt whether the reconciliation process can even be used for anything this year. Using the process requires first adopting a budget, which would be hard for Republicans to agree on, especially in an election year.

With ObamaCare repeal out of focus for 2018, most of the law, including its Medicaid expansion and subsidies to help people buy coverage, remains in place.

Republicans have hailed their victory in repealing ObamaCare’s individual mandate as part of the tax bill, which takes out a central feature of the law and one of the most unpopular parts. Still, some experts have warned that removing the mandate will destabilize markets and cause premium increases.

It is possible that Congress could pass measures aimed at stabilizing ObamaCare in the coming weeks, though House conservatives are opposed to those bills.

Trump Likes Drug Price Negotiations; His Nominee for Health Secretary Doesn’t

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 Alex M. Azar II, President Trump’s nominee for secretary of health and human services, said Tuesday that he was wary of proposals for the government to negotiate drug prices for Medicare beneficiaries, an idea endorsed by Mr. Trump in the 2016 campaign.

But Mr. Azar said that in some situations, he was willing to look at proposals to negotiate prices for a limited number of medicines.

He made the comments at a Senate confirmation hearing on Tuesday, where he tried to allay the concerns of some Democrats who asserted that he would be biased in favor of pharmaceutical companies because he had worked for a decade as a top executive at Eli Lilly, the company in Indiana that sells drugs for diabetes, erectile dysfunction and schizophrenia, among other conditions.

Mr. Azar’s remarks on drug price negotiations were carefully circumscribed and somewhat ambiguous — an approach that allowed him to get through the hearing largely unscathed.

If Medicare negotiates drug prices, he said, patients might have less access to some medicines because the government would probably establish a list of preferred products.

“For the government to negotiate there, we would have to have a single national formulary that restricted access to all seniors for medicines,” Mr. Azar told the Senate Finance Committee. “I don’t believe we want to go there in restricting patient access.”

At the same time, Mr. Azar said, “it’s worth looking at” proposals to allow price negotiations for drugs in Part B of Medicare. Under this part of the program, patients receive cancer drugs and other medications, often by infusion or injection, in doctor’s offices and hospital outpatient clinics.

Mr. Azar, who worked for six years in the administration of President George W. Bush, is expected to win confirmation, with support from Republicans and perhaps a few Democrats, who view him as a pragmatic problem solver rather than an ideologue. He would take charge of a cabinet department that spends more than a trillion dollars a year providing health insurance to more than 130 million Americans.

Senator Bill Nelson, Democrat of Florida, asked Mr. Azar whether he would support cuts in Medicare, Medicaid or Social Security to offset increases in the federal budget deficit that would be caused by the recently passed tax legislation.

“The president has stated his opposition to cuts to Medicare, Medicaid or Social Security,” Mr. Azar replied. “He said that in the campaign, and I believe he remains steadfast in his views on that. He’s made that commitment. I will live up to that if I’m confirmed.”

But like many Republicans, Mr. Azar said that cuts in the growth of federal benefit programs were not really cuts if federal spending on the programs continued to increase.

Democrats kept returning to the question of drug prices. Mr. Azar said that the expertise he acquired in the pharmaceutical industry would help him rein in drug costs as a federal official.

“Across the board,” he said, “drug prices are too high. Insulin prices are too high. All drug prices are too high in this country.”

Democrats were generally skeptical, based on Lilly’s record during Mr. Azar’s time at the company.

“The price of Lilly’s bone-growth drug Forteo, used to treat osteoporosis, more than doubled on Mr. Azar’s watch,” said Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee. In the same period, Mr. Wyden said, the company more than doubled prices for other drugs including Humalog, used to treat diabetes, and Strattera, for attention deficit hyperactivity disorder.

Mr. Wyden asked Mr. Azar if, as head of Lilly’s operations in the United States, he had ever approved a reduction in the price of a Lilly drug.

Mr. Azar avoided a direct answer and blamed “the system.”

“I don’t know that there is any drug price of a branded product that has ever gone down from any company on any drug in the United States because every incentive in this system is toward higher prices,” Mr. Azar said, adding: “No one company is going to fix that system. That’s why I want to be here working with you.”

Mr. Azar said he saw no need for the government to negotiate prices for drugs covered by Part D of Medicare, which pays for pills and other products that patients can give themselves and purchase from neighborhood drugstores and mail-order pharmacies.

Medicare’s Part D drug benefit is delivered entirely by private companies under contract with the government. These companies and their agents, known as pharmacy benefit managers, negotiate with drug manufacturers, and Mr. Azar said he did not believe the government could get lower prices by negotiating directly with drug companies.

A 2003 law prohibits the Department of Health and Human Services from interfering in negotiations between drug manufacturers and insurers that provide drug coverage under Part D of Medicare. “You would not get better pricing by removing” that prohibition, Mr. Azar said.

In the 2016 campaign and since taking office, Mr. Trump has said that Medicare could save large sums by negotiating directly with drug companies. But drug companies adamantly oppose that idea, and Mr. Trump has not taken steps to translate that into practice.

Asked specifically if Medicare should negotiate drug prices, Mr. Azar said: “In Part D, we do significant negotiation through pharmacy benefit managers that get the best rates of any commercial payers. We don’t do that in Part B, which is where we have physician-administered drugs. We basically pay sales price plus 6 percent or some other number.”

As an alternative, Mr. Azar said he supported proposals to link the pricing of prescription drugs to an assessment of how well they work for patients. Under such arrangements, known as value-based pricing, insurers would pay more for medicines that were highly effective and less for those that did not work well.

Mr. Azar also said he supported an agency created by the Affordable Care Act to test novel ways of delivering and paying for health care. And he said that some of the experiments could require doctors and hospitals to participate. Republicans in Congress have generally opposed mandatory participation.

Podcast: ‘What The Health?’ While You Were Celebrating …

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https://khn.org/news/podcast-what-the-health-while-you-were-celebrating/?utm_campaign=KFF-2018-The-Latest&utm_source=hs_email&utm_medium=email&utm_content=59811229&_hsenc=p2ANqtz–JERFINvucriGGpU1rflJEeJxuQPVDm8Wxcl7b-PGXeAoVUch8Oz-J5zdRyTzl09wIqr9zHKJO6Lrp-P6xvIdaGh3oKQ&_hsmi=59811229

Image result for Podcast: ‘What The Health?’ While You Were Celebrating …

The year in health policy has already begun: The Trump administration Thursday released a long-awaited regulation aimed at making it easier for small businesses and others to form “association health plans.” Now advocates and opponents will be able to weigh in with more specific recommendations.

Meanwhile, in December, the health policy focus was on the tax bill and its repeal of the Affordable Care Act’s “individual mandate” penalty for most people who don’t have health insurance. But some recent key court decisions could reshape the benefits millions of people receive as part of their health coverage.

This week’s “What the Health?” guests are Julie Rovner of Kaiser Health News, Paige Winfield Cunningham of The Washington Post, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

They discuss these topics, as well as the prospects for pending health legislation on Capitol Hill.

Among the takeaways from this week’s podcast:

  • The Trump administration’s decision to expand association health plans faces a number of obstacles, including the lack of good oversight in many states and the poor track record of many past plans.
  • Consumer advocates fear that growth of association plans could leave many consumers without adequate benefits because some plans will not cover the same essential benefits that Obamacare plans guarantee. They also are concerned that healthy customers will migrate to the new plans and leave the ACA’s marketplace plans with an abundance of enrollees who are ill.
  • The prospects of the bill to stabilize the individual insurance market sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) appear to be dimming.
  • Two federal judges have ruled against the Trump administration rule to change the ACA’s contraception mandate. The decisions, though, are not based on the policy but on faulty rule-making.
  • In another highly watched court case, a federal judge has ruled that the Equal Employment Opportunity Commission has until 2019 to set new rules on what employers can require of workers in their wellness programs.

Credit rating agency, researchers give vote of confidence to health insurance sector

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Health insurance, pen and stethoscope

Two new reports offer evidence that policy uncertainty aside, the health insurance industry is doing just fine.

In one report, A.M. Best explains why it decided to change its outlook for the health insurance sector from negative to stable. The credit rating agency said the change “reflects a variety of factors that have led to improvement in earnings and risk-adjusted capitalization.”

While insurers have experienced losses in the individual exchange business, this market segment has improved in 2016 and 2017—in part due to consecutive years of high rate increases, a narrowing of provider networks and a stabilizing exchange population, the report said.

A.M. Best also predicted that Congress won’t make repealing and replacing the Affordable Care Act a high priority in 2018. And even if it does, health insurers will have time to make adjustments, since legislative changes won’t take effect for two or more years.

The rating agency’s findings about the individual market echo those of a new report from the Kaiser Family Foundation, which examined insurers’ financial data from the third quarter of 2017.

It found that insurers saw significant improvement in their medical loss ratios, which averaged 81% through the third quarter. Gross margins per member per month in the individual market segment followed a similar pattern, jumping up to $79 per enrollee in the third quarter of 2017 from a recent third-quarter low of $10 in 2015.

One caveat is that KFF’s findings reflect insurer performance only through September—before the Trump administration stopped reimbursing insurers for cost-sharing subsidies. “The loss of these payments during the fourth quarter of 2017 will diminish insurer profits, but nonetheless, insurers are likely to see better financial results in 2017 than they did in earlier years of the ACA marketplaces,” KFF said.

As promising as these observations about the individual market are, A.M. Best pointed out that this market segment is just a small portion of most health insurers’ earnings and revenues. In fact, health plans largely owe their overall profitability to the combined operating results of the employer group, Medicaid and Medicare Advantage lines of business.

Looking ahead, the agency predicted that Medicare and Medicaid business lines will remain profitable for insurers—though margins will likely compress for both. It said the employer group segment will also remain profitable, but noted that membership will continue to be flat.

 

Don’t read too much into health care’s high poll rankings

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https://www.axios.com/dont-read-too-much-into-health-cares-high-poll-rankings-2521856369.html

Image result for ap/norc poll healthcare

An AP/NORC poll published late in December found that health care ranked number one on the list of the public’s priorities for government. It’s a well done and well reported poll, and as the head of a health policy and journalism organization, I suppose I should be happy that health ranked number one.

Yes, but: Having conducted and watched health care polling for decades, I’d caution readers not to over-interpret health care’s first place finish, which may not mean very much for upcoming elections. They are unlikely to be about health care and are much more likely to be about the candidates and President Trump.

Between the lines: For one thing, health care has been in the news and hotly debated. So when given a list of issues to choose from on a poll, or asked to name issues on their mind in an open ended question, the public is more likely to pick health care.

The economy is doing well, and health care’s other major competitor on a polling list of issues, the tax legislation, has not grabbed the public yet and may not until people begin paying their taxes.

The catch: When a topic like health care ranks high on a list of issues, it doesn’t mean voters will vote on that issue. In many races, they are more likely to vote on the basis of how they feel about the candidate overall than on issues. These upcoming elections are also likely to become a referendum on President Trump, as the race in Virginia largely was.

We also cannot assume that when the public picks “health” or “health care” on a poll they always mean the Affordable Care Act, whether that’s repealing it for Republicans or protecting it for Democrats.

  • People will give you a typically partisan view of the ACA if you ask for it. But most Americans are not covered by the ACA, and our own polling at the Kaiser Family Foundation shows that the public is mostly concerned their own health care costs.
  • Other health concerns also creep into the mix on various polls, such as CHIP funding and opioids.

What to watch: In the AP/NORC poll, Republicans placed a lower priority on health than Democrats and Independents did; they were about equally likely to pick immigration and taxes as health care. But we know from other polling that Democratic intensity about the ACA has increased, while Republican intensity is flat.

For that reason, Democrats are likely to put forward a variety of health care plans in 2018 and 2020, which will keep health care on the agenda. Health care could be for Democrats what it has been for Republicans in recent elections — a jump starter for the base. This could be the main way in which it plays a role in the election.

The bottom line: It’s always good to remember that the top issues in polls are not often the top factors in elections, especially in a year when, one way or another, Donald Trump will be on every ballot.

https://www.apnews.com/d0d4166afad649ac994e60f8d0b0da48

 

13 healthcare M&A deals that made headlines in 2017

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handshake

Analysts rightly predicted that 2016 would be a big year for healthcare industry mergers, but 2017 is on pace to top it, with a number of blockbuster mergers between big-name health systems headlining the year in M&A.

Kaufman Hall reported that 87 hospital mergers had been recorded through the third quarter of 2017, compared to 102 overall in 2016. By that point, eight transactions had included hospitals with $1 billion or more in revenue, twice as many big-ticket mergers as in all 2016.

“These transactions are driven primarily by strategic imperative and less so by financial drivers,” said Anu Singh, managing director of Kaufman Hall.

M&A activity wasn’t restricted to hospitals and health systems, as a number of deals in the payer sphere could also significantly impact the industry.

However, though the industry’s merger mania continued throughout 2017, a number of major deals were abandoned or put on hold, as the Federal Trade Commission continued to keep a close eye on merger activity.

Here’s a recap of some of the biggest healthcare industry mergers that were announced last year:

Aetna and Humana

These two payer giants announced merger plans in 2015 but abandoned the deal in February after a judge blocked it on antitrust grounds.

The Department of Justice and several states sued to block the merger in the summer of 2016, and a judge ruled that merger would unlawfully weaken competition in the Medicare Advantage market.

Anthem and Cigna

If Aetna and Humana parted ways on what one might consider good terms, the same was not true for Anthem and Cigna. This insurance megamerger was also blocked by a federal judge on antitrust grounds, but what followed was a protracted legal dispute between Anthem and Cigna over ending the deal. Anthem finally agreed to end the deal in May after a judge ruled Cigna was free to walk away.

NorthShore University HealthSystem and Advocate Health Care

A potential deal between NorthShore and Advocate was first announced in 2014, but a federal judge blocked it in early March. The two Illinois systems then agreed to abandon the merger in response.

PinnacleHealth and UPMC

PinnacleHealth revealed in March that it would merge with UPMC, the largest integrated health system in Pennsylvania, and would acquire four new hospitals in an effort to expand its reach in the central part of the state. Pinnacle previously pursued a merger with Penn State Hershey.

Partners HealthCare and Care New England Health System

Care New England had been aligned with Partners since 2009, but Partners announced in April that it would acquire the system, which is the second largest in Rhode Island.

Steward Health Care System and IASIS Healthcare LLC

Steward’s purchase of IASIS, which was finalized in October after being announced in May, established the system as the largest private hospital operator in the U.S. With the purchase, Steward now operates 36 hospitals across 10 states and is projected to have revenue in excess of $8 billion in 2018.

Ascension and Presence Health

Ascension, the largest Catholic health system in the U.S., announced plans to purchase Illinois’ largest Catholic system, Presence Health.

If the deal is finalized, Presence will operate under Ascension’s AMITA Health venture.

UNC Health Care and Carolinas HealthCare System

A final deal between UNC and Carolinas would create one of the largest nonprofit health systems in the U.S. The two providers said the alignment would increase rural access to healthcare, allow each to negotiate better with payers and potentially save millions of dollars in healthcare costs.

Centene and Fidelis Care

Centene spent much of 2017 expanding its reach in the Affordable Care Act’s marketplaces, but it announced in September that it would acquire New York-based Fidelis Care for $3.75 billion. Centene said purchasing the 1.6 million-member insurer would benefit shareholders and allow it to continue to reach underserved areas.

CVS and Aetna

Though Aetna’s merger with Humana failed earlier in 2017, it was snapped up later in the year by pharmacy giant CVS in a deal worth $69 billion.

The purchase had been rumored since October and could impact hospitals or health systems that operate urgent clinics, as gaining Aetna’s 22 million members would be a significant boon to CVS’ MinuteClinics.

Dignity Health and Catholic Health Initiatives

These two massive Catholic systems signed a deal to create a new nonprofit system, the name of which has yet to be announced. The merger would unite 139 hospitals and 700 care sites across 28 states under the same umbrella. Dignity and CHI had a combined $28.4 billion in revenue in 2017.

Providence St. Joseph Health and Ascension

A deal between these two systems has not officially been announced, but sources told The Wall Street Journal that Providence and Ascension were deep in merger talks. If these two systems were to align, it would create the largest hospital operator in the U.S., with 191 hospitals across 27 states and a combined annual revenue of $44.8 billion.

Humana and Kindred Healthcare

Following its failed merger with Aetna, Humana seemed a ripe target for acquisition by another insurer. Instead, it was revealed in mid-December that it, alongside two private equity firms, would purchase Kindred in a deal worth $4.1 billion. The Kindred deal won’t kill talk that Humana could be acquired, however.

 

Push for return to ACA repeal

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Affordable Care Act highlighted

While lawmakers’ most pressing priority right now is to prevent a government shutdown, it’s not too early to start asking: Is the push to repeal the Affordable Care Act over?

The answer to that question, however, depends upon which Republican you ask.

Senate Majority Leader Mitch McConnell has said that while he wants to unwind more of the healthcare law, he’s doubtful that Republicans will have enough votes to do so now that their majority has gotten even slimmer.

But others on the right are pushing to keep the repeal effort alive. Majority Whip Steve Scalise, R-La., said Tuesday that one of the GOP’s major goals this year is to tackle welfare reform, but “then we’re going to have to work on healthcare again.”

“Look, I’m for repealing and replacing Obamacare,” he said during an interview with Fox & Friends, later adding, “So let’s get back to work on some of those things—like what we passed in the House, that almost passed in the Senate—so that we can get our healthcare system working again [and] rebuild the private marketplace.”

The GOP is also facing external pressure. A collection of conservative groups known as the “Repeal Coalition” sent a letter Tuesday to President Donald Trump, saying that now that he’s reformed the tax code, he now must “deliver on the rest of the promises made to the American people to free them from the shackles of Obamacare.”

Thus, the letter said, healthcare reform must be the focus of lawmakers’ budget reconciliation instructions for 2019. The Trump administration must also help the Senate and the House “design a bill that can muster the votes needed for passage of true health reform,” it added.

Whichever path that Republicans choose to take regarding the ACA this year, however, they will do so without a veteran senator who has played a major role in healthcare policymaking. Sen. Orrin Hatch, R-Utah, announced Tuesday that he will not run for an eighth term.

Hatch, who chairs the Senate Finance Committee, has opposed the ACA and criticized a bill drafted by Republican Sen. Lamar Alexander and Democratic Sen. Patty Murray that was designed to stabilize the law. In fact, he floated an alternative to the Alexander-Murray bill that would both temporarily fund cost-sharing reduction payments and ax the individual and employer mandates. Ultimately, he helped repeal the individual mandate via the GOP’s tax reform package.

Hatch also has a history of bipartisanship, however. He was often forced to work with Democratic Sen. Ted Kennedy when they led what is now known as the Health, Education, Labor and Pensions Committee, according to The Salt Lake Tribune. One of their biggest achievements was creating the Children’s Health Insurance Program—though that program is now on shaky ground since Congress let federal funding for it lapse last fall and has since failed to reauthorize it.

 

 

Payer Roundup—Mississippi gets 10-year Medicaid waiver extension; A third of Americans believe ACA is repealed

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Medicaid

CMS approves 10-year Medicaid waiver extension for Mississippi

Last week, the federal government approved its first 10-year extension of a Section 1115 Medicaid demonstration program.

The Mississippi program provides family planning services for people ages 13-44 with income of up to 194% of the federal poverty level. To get approval for its 10-year extension, the state agreed to submit monitoring reports and participate in calls with CMS every year.

The lengthy waiver extension, according to CMS Administrator Seema Verma, lets Mississippi administer its Medicaid program “without the inconvenience of obtaining routine approvals from CMS.” The action also shows the agency’s “continuing commitment to giving states the flexibility they deserve to meet the unique needs of their people,” she said.

Alabama won’t freeze CHIP enrollment or stop coverage—for now

Because of the temporary funding for the Children’s Health Insurance Program included in Congress’ year-end spending bill, Alabama officials canceled their plans to freeze CHIP enrollment on Jan. 1.

The state will also not follow through with its plan to terminate coverage for current CHIP enrollees by Feb. 1, according to AL.com. But Cathy Caldwell, director of the Alabama Bureau of Children’s Health Insurance, told the publication that “we desperately need Congress to act, hopefully in January.”

Federal funding for CHIP expired Sept. 30, and Congress’ effort to reauthorize funding have been bogged down by partisan disputes. The short-term spending bill passed before the holiday break set aside $2.85 billion to temporarily tide states over.

One-third of Americans believe ACA has been repealed

President Donald Trump was not correct when he said that the GOP tax bill repealed the Affordable Care Act, but a new poll indicates a sizable chunk of Americans believe it nonetheless.

According to the poll (PDF), conducted by The Economist/YouGov, 31% of respondents indicated that Trump has delivered on his promise to repeal the healthcare law. Forty-nine percent said that he didn’t, and 21% were unsure.

The sweeping overhaul to the tax code that Republicans passed before the holiday break did repeal the ACA’s individual mandate, a key part of its insurance market reforms. But experts disagree on how big of an impact that will have, and other core components of the law—like premium subsidies—remain intact.

ACA expert to stop blogging for Health Affairs

Timothy Jost, who has chronicled nearly every Affordable Care Act-related development over the past 8½ years, will no longer contribute to the Health Affairs Blog’s “Following the ACA” series.

Jost, a Washington and Lee University professor emeritus, wrote more than 600 blog posts about the adoption and implementation of the healthcare law, plus the omnipresent political battles surrounding it. Jost wrote in his final post that “I am getting older and believe it is time to slow down.” He will continue to write a monthly “Eye on Reform” column for Health Affairs, however.

Katie Keith, a health policy expert with a law degree from Georgetown University and a master of public health from Johns Hopkins University, will take the helm as the author of the Health Affairs blog series on the ACA.

 

From premiums to politics: 5 predictions for the health insurance industry in 2018

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Businessman uses a crystal ball

After the demise of two major insurer mergers and multiple Affordable Care Act repeal attempts, few could argue that 2017 wasn’t an eventful year for the health insurance industry.

But 2018 is shaping up to be just as interesting—complete with more political wrangling, M&A intrigue and evidence that, despite all this uncertainty, insurers are pushing ahead and embracing innovation.

Read on for our predictions about what’s in store for the industry in the coming months.

1. The CVS-Aetna deal will have a domino effect in the healthcare industry

While the lines between payer, provider and pharmacy benefits manager have been blurring for a while now, CVS’ $69 billion deal to purchase Aetna is undoubtedly a game-changer.

The move was likely motivated by a desire to compete with UnitedHealth’s thriving Optum subsidiary, which has its own PBM and an increasing presence in care delivery. So it stands to reason that other major insurers will try to strike deals of their own that mimic that scale and level of diversification.

Already, Humana has made a bid to purchase part of hospice- and home-health giant Kindred Healthcare. There’s also been speculation that it is preparing to be acquired—possibly by Cigna, or in a deal that would mimic CVS-Aetna, Walmart or Walgreens.

Other insurers may also seek to build PBM capabilities, following in the footsteps of UnitedHealth, a combined CVS-Aetna and Anthem, which announced in October that it would team up with CVS to create an in-house PBM called IngenioRx.

It’s certainly possible, however, that CVS’ purchase of Aetna will not pass regulatory muster. While it would require less divestment than the ill-fated Anthem-Cigna and Aetna-Humana deals, the DOJ’s decision to block another vertical deal—between AT&T and Time Warner—doesn’t bode well for its chances.

2. Republicans and Democrats will be forced to work together on ACA fixes

With one less Republican senator—thanks to Alabama’s election of Democrat Doug Jones—the GOP likely won’t have the votes to pass a repeal bill without bipartisan support. Senate Majority Leader Mitch McConnell acknowledged as much before Congress’ holiday recess, though he clarified the next day that he would be happy to pass an ACA repeal bill if there are enough votes for it.

McConnell also owes Sen. Susan Collins, R-Maine, as he had promised her he’d pass her reinsurance bill and a bill that would fund cost-sharing reduction payments this year. While Collins held up her end of the bargain—voting for the GOP tax bill—the ACA fixes didn’t make it into the stopgap spending bill Congress passed on Dec. 21.

Democrats, meanwhile, will also be motivated to reach across the aisle. The repeal of the individual mandate will likely put the ACA on more unstable footing, lending more urgency than ever to the task of shoring up the exchanges.

Both parties will also likely face pressure from the healthcare industry’s biggest lobbying groups to get some sort of ACA fix passed. The push to do so, however, will be complicated by the full slate of legislative priorities Congress is facing in the new year, including reauthorizing funding for the Children’s Health Insurance Program.

3. There will be more premium hikes and insurer exits in the individual market

The individual mandate is now gone, and arguments about its effectiveness aside, that was one of the mechanisms that encouraged healthy people to buy insurance and stay covered. Even if the effect on coverage levels is minimal, the move is probably going to be enough to push risk-averse insurers to raise rates and even exit more rating areas in 2019.

There is also little indication that large insurers that have exited will come back anytime soon. After all, why invest resources in an unstable market when there are far more steady and lucrative markets like Medicare Advantage?

Adding to the policy uncertainty for the remaining insurers, there is no guarantee that Congress will authorize short-term funding for cost-sharing reduction payments. Many insurers raised their 2018 rates to account for the possibility of them disappearing—which turned out to be a wise move—so it stands to reason they’d have to do the same for 2019.

Perhaps the best harbinger of what’s to come came from a study conducted in November, which noted that the actions insurers and state regulators took to fill in “bare counties” on the ACA exchanges are “temporary and unsustainable without long-term federal action.” And with Republicans in charge, federal action to patch up the exchanges is unlikely.

4. Federal agencies will start to carry out Trump’s executive order—and states will push back

Although it was overshadowed by all the repeal-and-replace drama, Trump’s healthcare-focused executive order has huge implications for the industry. Put simply, it paves the way for expanded use of association health plans, short-term health plans and employer-based health reimbursement arrangements.

In 2018, we’re likely to see the relevant agencies start issuing rules to implement the order, which could dramatically change the individual market as we know it—and not for the better. Such rulemaking would also set the stage for a power struggle between the federal government and left-leaning states.

In fact, a coalition of healthcare organizations have urged state insurance commissioners to take steps to override any rules resulting from the executive order. For example, states could restore the three-month limit on short-term health plans if agencies unwind that Obama-era rule on the federal level.

Since only certain states are likely to heed these suggestions, the upshot of Trump’s executive order will be to create a patchwork of individual market rules across the country. If that sounds strangely like what the individual insurance markets were like before the ACA, well, that’s precisely the point.

5. Payers’ move to value-based payment models will continue, with or without the feds leading the way

On the one hand, the Trump administration clearly wants to scale back the federal government’s role in pushing payers and providers away from fee-for-service payment models. The surest sign was CMS’ announcement late last year that it would endmandatory bundled payment models for hip fractures and cardiac care.

Some have worried that moving away from those mandatory programs would be a setback for the move to value-based payments, given that the feds play a powerful role in galvanizing the industry to change. In addition, the administration wants to take the Center for Medicare and Medicaid Innovation in a “new direction”—one that CMS Administrator Seema Verma said would “move away from the assumption that Washington can engineer a more efficient healthcare system from afar.”

But even if the federal government will take a lighter touch in the move from volume to value, it’s not likely that the private sector will take that as a cue to reverse course. On the payer side, especially, too many industry-leading companies have invested heavily in alternative payment models to turn back now. And they have compelling business reasons to keep investing in those models, given their potential to lower costs and improve care quality.