Opioid Commission Unveils Blueprint To Fight Crisis, But Passes Funding Buck To Congress

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The group’s 56 recommendations include tightening prescription practices and expanding drug courts, prevention efforts, treatment access and law enforcement tactics.

President Trump’s bipartisan commission on the opioid crisis made dozens of final recommendations on Wednesday to combat a deadly addiction epidemic, ranging from creating more drug courts to vastly expanding access to medications that treat addiction, including in jails.

The commissioners did not specify how much money should be spent to carry out their suggestions, but they pressed Congress to “appropriate sufficient funds” in response to Mr. Trump’s declaration last week of a public health emergency.

The 56 recommendations — which covered opioid prescribing practices, prevention, treatment, law enforcement tactics and funding mechanisms — did not so much advocate a new approach as expanding strategies already being used.

Reaction from treatment advocates was mixed, with many expressing frustration that the commission had not called for a specific level of funding. Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health, which represents treatment providers, said that his group agreed with many of the recommendations, but that the report “starves the country for the real resources it needs to save American lives.”

Although the commission did not put a dollar amount on its recommendations, it had specific ideas for how federal money should be funneled to states. Its top recommendation was to streamline “fragmented” federal funds for addiction prevention and treatment into block grants that would require each state to file only a single application instead of seeking grants from dozens of programs scattered across various agencies.

The commission also appealed to the Trump administration to track more carefully the huge array of interdiction, prevention and treatment programs it is funding and to make sure they are working. “We are operating blindly today,” its report said.

Regina LaBelle, who was chief of staff in the White House Office of National Drug Control Policy under President Barack Obama, said the recommendations recognized “the importance of proper and appropriate treatments” for addiction, particularly medications that help people avoid cravings and symptoms of withdrawal. But, she added, “There needs to be more funding for this.”

The head of the commission, Gov. Chris Christie of New Jersey, a Republican, suggested in a television interview Sunday that Mr. Trump would soon ask Congress to allocate far more money for fighting the nation’s addiction problem. “I would say that you’re going to see this president initially ask for billions of dollars to deal with this,” he said on ABC’s “This Week.”

The White House issued a statement thanking the commission and saying it would review the recommendations.

It is hard to determine how much money is truly needed. When Senate Republicans added $45 billion in addiction treatment funds to an Obamacare repeal bill that ultimately failed, Gov. John Kasich of Ohio, a Republican, said that amount was akin to “spitting in the ocean.”

Richard Frank, a health economics professor at Harvard Medical School who worked in the Obama administration, estimated that it could cost roughly $10 billion a year to provide medication and counseling to everyone with opioid use disorder who is not already in treatment. Treating opioid-dependent newborns, meeting the needs of children in foster care because of their parents’ addiction and treating hepatitis C and other illnesses common among opioid addicts would cost “many billions more,” Mr. Frank said.

Mr. Frank also cautioned that block grants would not work if the administration decided to include federal Medicaid funding for addiction treatment in them. “When one starts to carve out certain services as grants, as opposed to insurance funding, one undermines the insurance,” he said. “It is a method of killing Medicaid with 1,000 nicks.”

Some of the commission’s other recommendations included making it easier for states to share data from prescription drug monitoring programs, which are electronic databases that track opioid prescriptions, and requiring more doctors to check the databases for signs of “doctor shopping” before giving a patient opioids.

The commission encouraged the federal Centers for Medicare and Medicaid Services to review policies that it claimed discouraged hospitals and doctors from prescribing alternatives to opioids, especially after surgery. According to the commission’s report, C.M.S. pays a flat, “bundled” payment to hospitals after patients undergo surgery, which includes treatment for pain. Because they get a flat fee, hospitals are encouraged to use cheap products – and most opioid medications are generic and inexpensive.

“Purchasing and administering a non-opioid medication in the operating room increases the hospital’s expenses without a corresponding increase in reimbursement payment,” the report said.

More broadly, the report said the federal government as well as private insurers should do a better job of covering a range of pain-management and treatment services, such as non-opioid medicationsphysical therapy and counseling. And it recommended that the Department of Health and Human Services and other federal agencies eliminate any reimbursement policies that limit access to addiction medications and other types of treatment, including prior authorization requirements and policies that require patients to try and fail with one kind treatment before getting access to another.

One prevention measure the commission did not embrace is expanding syringe exchange programs, which public health experts say save money and lives by reducing the spread of H.I.V. and hepatitis C with contaminated syringes.

“I was hoping to see that in this report,” Ms. LaBelle said.

The commission’s members – Mr. Christie, Gov. Charlie Baker of Massachusetts, a Republican; Gov. Roy Cooper of North Carolina, a Democrat; Pam Bondi, the Republican attorney general of Florida; Patrick Kennedy, a former Democratic congressman from Rhode Island and Bertha Madras, a Harvard professor – all voted for the final recommendations, which came about a month later than expected.

His voice quaking with emotion, Mr. Kennedy said during the commission’s meeting Wednesday that Congress needed to appropriate sufficient funds for the initiative, suggesting at least $10 billion.

”This town doesn’t react unless it hears from real people“ who will vote in the next election, he said, nodding to guests who had testified about their families’ searing experiences with addiction, stigma, lack of treatment options and the refusal of insurance companies to cover treatment.

Mr. Kennedy also noted that insurance coverage is crucial to fighting addiction; in another commission meeting earlier this year, he took Republicans to task for working to repeal the Affordable Care Act and cut Medicaid.

 

Trump suggests repealing ObamaCare mandate in tax bill

Trump suggests repealing ObamaCare mandate in tax bill

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President Trump on Wednesday suggested using the GOP tax bill to repeal ObamaCare’s individual mandate.

“Wouldn’t it be great to Repeal the very unfair and unpopular Individual Mandate in ObamaCare and use those savings for further Tax Cuts,” Trump tweeted.

The idea is being pushed by Sen. Tom Cotton (R-Ark.) and also has the backing of House Freedom Caucus Chairman Mark Meadows (R-N.C.).

Meadows said Wednesday he supports repealing the mandate in tax reform and thinks “ultimately” it will be included because he is going to push for it. He said he has been talking to Cotton about it.

A Cotton spokeswoman told The Hill that Cotton and Trump spoke by phone about the idea over the weekend and “the President indicated his strong support.”

Senate Finance Committee Chairman Orrin Hatch (R-Utah) this week said that he wouldn’t rule out including repeal of the mandate in the tax legislation.

But other top Republicans have rejected the idea, including House Ways and Means Committee Chairman Kevin Brady (R-Texas), Senate Majority Whip John Cornyn (R-Texas) and Sen. John Thune (R-S.D.). They fear adding the ObamaCare change would jeopardize tax reform.

“Look, I want to see that individual mandate repealed,” Brady said during an interview with radio host Hugh Hewitt on Tuesday. “I just haven’t seen, no one has seen, 50 votes in the Senate to do it.”

Brady added that he would be open to adding a repeal of the mandate to the House bill if the Senate passed it first.

Asked Wednesday about the president’s tweet, Senate Majority Whip John Cornyn (R-Texas) threw cold water on the idea.

“I think tax reform is complicated enough without adding another layer of complexity,” Cornyn told The Hill.

Thune, meanwhile, said mandate repeal is “not currently a part of our deliberations.”

But Thune added that some members have expressed interest in the idea and said he was “somewhat” interested in it because of the revenue implications.

Sen. Mike Rounds (R-S.D.) on Tuesday also dismissed adding a repeal of the mandate to tax reform.

“If there was a way to do it, I’d be open to it, but I’m not going to pitch it because I want to focus on taxes in the tax reduction plan,” Rounds told reporters.

The Congressional Budget Office has estimated that repealing the mandate would save the government $416 billion over a decade.

The mandate requires people, with some exceptions, to pay a fine to the IRS if they do not have health insurance.

Experts have said repealing the mandate would result in massive premium spikes and a major increase in the number of uninsured people.

It could also send ObamaCare exchanges into a “death spiral” because it would discourage healthy younger individuals to sign up for insurance.

Asked about it on Wednesday after Trump’s tweet, Hatch again did not rule out the move, but cautioned that he wants to keep health care separate from tax reform, a point echoed by GOP aides.
“I think we ought to do tax reform. If they want to do something on health care they can do that separate,” Hatch said. It was not clear who “they” referred to.
“I’d have to really look at all sides of that. I’ve never been very excited about the individual mandate,” Hatch said.

CMS to allow states to define essential health benefits

http://www.modernhealthcare.com/article/20171027/NEWS/171029872/cms-to-allow-states-to-define-essential-health-benefits

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The CMS proposed a rule late Friday aimed at giving states more flexibility in stabilizing the Affordable Care Act exchanges and in interpreting the law’s essential health benefits as a way to lower the cost of individual and small group health plans.

In the 365-page proposed rule issued late Friday, the agency said the purpose is to give states more flexibility and reduce burdens on stakeholders in order to stabilize the individual and small-group insurance markets and improve healthcare affordability.

The CMS said the rule would give states greater flexibility in defining the ACA’s minimum essential benefits to increase affordability of coverage. States would play a larger role in the certification of qualified health plans offered on the federal insurance exchange. And they would have more leeway in setting medical loss ratios for individual-market plans.

“Consumers who have specific health needs may be impacted by the proposed policy,” the agency said. “In the individual and small group markets, depending on the selection made by the state in which the consumer lives, consumers with less comprehensive plans may no longer have coverage for certain services. In other states, again depending on state choices, consumers may gain coverage for some services.”

However, the CMS acknowledged it’s unclear how much money the new state flexibility will save. States are not required to make any changes under the policy.

The CMS urged states to consider the so-called spillover effects if they choose to pick their own benefits. These include increased use of other services, such as increased used of emergency services or increased use of public services provided by the state or other government entities.

The agency in 2017 proposed standardized health plan options as a way to simplify shopping for consumers on the federally run marketplaces. The CMS said it would eliminate standardized options for 2019 to maximize innovation. “We believe that encouraging innovation is especially important now, given the stresses faced by the individual market,” the proposed rule states.

The CMS proposes to let states relax the ACA requirement that at least 80% of premium revenue received by individual-market plans be spent on members’ medical care. It said states would be allowed to lower the 80% medical loss ratio standard if they demonstrate that a lower MLR could help stabilize their individual insurance market.

The CMS also said it intended to consider proposals in future rulemaking that would help cut prescription drug costs and promote drug price transparency.

The Trump administration hopes to relax the ACA’s requirements and provide as much state flexibility as possible through administrative action, following the collapse of congressional Republican efforts this year to make those changes legislatively.

The proposed rule comes after months of calls from health insurers and provider groups for the federal administration to help stabilize the struggling individual insurance market. The fifth ACA open enrollment is slated to begin Nov. 1, and experts have predicted fewer sign-ups in the wake of a series of actions by the Trump administration to undercut the exchanges.

In the proposed rule, the CMS also proposes to exempt student health insurance from rate reviews for policies beginning on or after Jan. 1, 2019. The CMS said student health insurance coverage is written and sold more like group coverage, which is already exempt from rate review, and said the change would reduce regulatory burden on states and insurance companies.

The ACA requires that insurers planning to increase premiums by 10% or more submit their rates to regulators for review. The CMS proposed to increase the rate review threshold to 15% “in recognition of significant rate increases in the past number of years.”

The rule also tweaks a requirement that enrollees need to have prior coverage before attempting to get coverage via special enrollment after moving to a new area. Under the proposal, a person who lived in an area with no exchange qualified health plans will be able to obtain coverage.

Trump tells Senate to fix taxes — not Obamacare

https://www.politico.com/story/2017/10/24/trump-obamacare-taxes-senate-republicans-244124

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The bipartisan effort to stabilize insurance markets gets pushed to the end of the year.

President Donald Trump on Tuesday steered Senate Republicans toward tax reform and away from health care, pushing off any deal to fund controversial Obamacare subsidies to the end of the year at best.

Trump joined Senate Republicans at their weekly policy lunch but gave no direction on what he wants to see in a health care bill. He praised Sen. Lamar Alexander’s (R-Tenn.) work on a bipartisan deal meant to stabilize the Obamacare markets, but his emphasis on taxes led senators in the room to believe Trump doesn’t want a stand-alone Obamacare vote anytime soon.

“There isn’t anything else other than taxes,” said Sen. John Cornyn (R-Texas).

A filibuster-proof majority backs the bipartisan deal Alexander brokered with Sen. Patty Murray (D-Wash.), but conservatives and the White House oppose it, meaning it won’t even come up for a vote in the Senate.

Without a clear directive from the president, Republicans are still debating whether to work with Democrats to fund Obamacare’s “cost-sharing” program, which helps low-income people pay their out-of-pocket medical bills. Trump abruptly cut off the subsidies — the subject of a court battle — earlier this month. Insurers still have to make the payments, and many boosted their premiums for 2018 to take those costs into account.

Alexander’s stabilization bid got even more muddled when a pair of top Republicans said they would release a different bill — rivaling the bipartisan proposal — to fund the subsidies. But their version would neuter the individual mandate for five years, a nonstarter for Democrats who would be needed to get a bill through the Senate.

The new version “proves that we should be focused on tax reform right now, because obviously we haven’t gotten our act together on health care,” said Sen. John Thune (R-S.D.).

Republicans are increasingly confident that the subsidies will get rolled into a large, year-end bill to fund the government and raise the nation’s debt limit. But there is no agreement on what exactly that will look like, and leadership-level negotiations on the year-end bill are weeks away.

The lack of clarity left Senate Republicans with enough wiggle room to interpret Trump’s Obamacare comments as they see politically fit.

Cornyn saw a “shoutout” by Trump to Alexander as encouragement for his bill. “He wasn’t specific, but that’s the way I interpreted it,” he said.

But Sen. Ted Cruz (R-Texas) — an Alexander-Murray skeptic — said Trump didn’t offer any clear support for the proposal over the GOP’s competing ideas.

“There was not significant discussion on Alexander-Murray,” Cruz said.

Sen. Orrin Hatch (R-Utah), another foe of Alexander-Murray, walked away with the same conclusion.

“He didn’t get into that in great depth — put it that way,” Hatch said. “All I can say is that he wasn’t too definitive.”

During the lunch meeting, Trump focused more on getting tax reform done so that the GOP can take another shot at repealing Obamacare in the future, instead of what should be done to stabilize the health care law in the interim.

“If we get taxes done, we’ll have momentum for health care,” said Sen. Lindsey Graham (R-S.C.), summing up Trump’s position. “He talked a lot about doing health care again.” Trump has repeatedly stated recently that the GOP now has the votes for repeal in the Senate — but senators say that’s not the case, that no one has flipped.

The meeting marked Trump’s first visit to the Senate GOP’s weekly policy lunch as president, and it came amid a rift with Sen. Bob Corker (R-Tenn.) and growing concern within the GOP that lawmakers will go into the 2018 midterm election without a legislative accomplishment. That’s amped up the pressure in the GOP to do tax reform.

But many Republican senators said after the lunch meeting that there was no discussion of petty politics and that Trump was focused on notching some GOP wins.

“It was the complete opposite of what I thought it would be — the atmosphere in the room and his complete focus,” said one senator.

The conservative Obamacare bill introduced Tuesday came from Hatch, the chairman of the Senate Finance Committee, and House Ways and Means Chairman Kevin Brady.

That bill, which would fund the cost-sharing program for two years, is designed to appeal to Republicans who want to fund the Obamacare program but feel that Alexander didn’t get enough conservative concessions in his negotiations with Murray.

It would eliminate Obamacare’s individual mandate penalties through 2021 and expand the use of health savings accounts. The Hatch-Brady bill would also exempt businesses from the employer mandate for 2015 through 2017 and apply certain “pro-life protections” to the cost-sharing funding.

“We must include meaningful structural reforms that provide Americans relief,” Hatch said. “This agreement addresses some of the most egregious aspects of Obamacare.”

Some of the provisions in the proposal — like the expansion of HSAs and employer mandate exemption — mirror the changes that the White House requested be made to the Alexander-Murray bill.

Alexander said he was encouraged by a growing consensus Congress should fund the payments to insurers for two more years.

“We’ve gone from a position where everybody was saying we can’t do cost sharing to responsible voices like Sen. Hatch and Chairman Brady saying we should,” he said.

But any cost-sharing bill will need 60 votes to get through the Senate, meaning Republicans will have to get at least eight Democrats to sign on. Undoing the mandates in the future would be a nonstarter for many Democrats.

“If it were just a matter of getting Republicans to agree with each other, we would have repealed and replaced Obamacare by now,” said a Senate GOP aide.

How Premiums Are Changing In 2018

How Premiums Are Changing In 2018

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The premiums for 2018 Marketplace plans were recently released to give consumers a chance to look at their plan options before open enrollment begins on November 1. Premiums are rising significantly in many counties across the country, in part due to the decision of the Trump Administration to cease payments to insurers for cost-sharing reductions. Insurer participation also declined in many areas, leaving more counties with only one insurer, which likely contributed to the high rate of premium growth.

The map below illustrates how premiums changed for 2018 by looking at the change in the lowest-cost bronze, silver and gold plans by county in states participating in the federal Marketplace. Results are shown for a 40-year-old paying the full premium and for a 40-year old with an income of $25,000 (207% of poverty), $30,000 (249% of poverty), $35,000 (290% of poverty), and $40,000 (332% of poverty), who would be eligible for a premium tax credit.

Percent Change in Lowest-Cost Metal Plan Before and After Tax Credit, 2017-2018

Nationally, the unsubsidized premium for the lowest-cost bronze plan in the federal Marketplace is increasing an average of 17% between 2017 and 2018, the lowest-cost silver plan is increasing an average of 35%, and the lowest-cost gold plan is increasing an average of 19% (Table 1). These average increases are weighted by the number of plan selections by county in 2017 (see Methods). Premiums for silver plans are rising much more than those for bronze or gold plans because in many states insurers loaded the cost from the termination of the cost-sharing reduction payments entirely on the silver tier.

For consumers who receive premium tax credits, the amounts that they will have to pay will often be lower in 2018 (Table 2). The particularly large increase in premiums for silver plans means that tax-credit-eligible Marketplace enrollees will see much higher premium tax credits (which are calculated based on the second-lowest-cost silver plan in each area). These large credits make gold plans more easily attainable and make bronze plans much cheaper (or even available at no additional premium). In fact, after these increases, the lowest-cost gold premium is lower than the lowest-cost silver premium in 459 counties.

For example, a 40-year-old individual making $35,000 (249% of poverty) and eligible for a tax credit will on average pay 39% less in 2018 for their share of the premium for the lowest-cost bronze plan, 7% less for the lowest-cost silver plan, and 13% less for the lowest-cost gold plan. The savings are greater for subsidized enrollees with lower incomes and less for those with higher incomes (Table 2). The premiums for bronze plans may be particularly attractive to many people eligible for premium tax credits. For example, the tax credit for a 40-year-old individual making $25,000 covers the full cost of the premium for the lowest-cost bronze plan in 1,540 counties.

Counties Where the Lowest-Cost Bronze Plan Premium Costs Zero Dollars After the Tax Credit in 2018

The map below shows counties where the unsubsidized premium for the lowest-cost gold plan has a lower or comparable premium to the lowest-cost silver plan in 2018.

Counties Where the Lowest-Cost Gold Plan Costs Less than the Lowest-Cost Silver Plan

Discussion

The differences in premium changes across plan types and the peculiar effect these differences have on plan costs for both unsubsidized and subsidized enrollees makes it important that consumers shop around and carefully consider their options. Although CMS will no longer be paying insurers for reducing the cost sharing for lower-income enrollees, insurers remain obliged to provide the reduced cost sharing policies to eligible Marketplace enrollees. These policies generally have higher actuarial values than gold plans for enrollees with incomes below 200% of poverty so consumers will need to carefully consider whether it makes sense to switch even though gold-plan premiums may be comparable or less than silver plans. Consumers eligible for cost sharing reductions also will need to weigh the much lower premiums they would pay for a bronze plan with the much higher cost sharing they could encounter if they need care.

The individual market will thrive in the long run

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Not since the first year of the Affordable Care Act has there been so much uncertainty at the start of an open enrollment period. How many Americans will sign up for health coverage? As experts weigh the uncertain impact of the Trump administration’s last-minute policy moves, estimates from the Congressional Budget Office and Urban Institute range from nearly one million fewer Americans with coverage to at least 600,000 more.
As co-founders of Oscar Health, an insurance startup that will be signing up Americans for individual plans across six states this year, we anticipate the Trump administration’s actions will simultaneously aid and undermine enrollment, thanks to the mixed impact of its political and policy changes.
The bottom line: It will be hard — after four years where tens of millions of Americans have gained access to health insurance — for the administration to erase the virtues of an individual market where consumers choose their health plan and no one is discriminated against based on health status. In fact, we project that Oscar will enroll significantly higher membership across our six states this year.

Here’s why we believe the administration’s actions will both help and hurt enrollment:

  • Plans will be more affordable for millions of Americans due to the seesaw impact of cuts to cost-sharing reduction subsidies, which will actually increase subsidies for many low-income consumers. And for the first time, the IRS will be aggressively enforcing the individual mandate.
  • On the other hand, the administration’s cuts to outreach and sporadic lip service to repealing the ACA do nothing to stanch growing confusion among shoppers.
The biggest threat to a strong open enrollment period is consumer confusion. That’s why our outreach this year, themed “Get Covered,” is so focused on educating Americans on the importance of health insurance. We were the first to launch our open enrollment ads six weeks ago. And when HealthCare.gov is down for maintenance every Sunday, Oscar will be up — consumers in our states will be able to get subsidized coverage on our website.
The big picture: Our optimism about the individual market, both this year and beyond, stems from our conviction that the near-term regulatory turbulence will pass and that the individual market will thrive in the long run.
That’s because health care costs are spiraling out of control across the board, even for Americans who get coverage through their jobs. This year, premium contributions for workers increased by 8.2%, while the employer’s share increased hardly at all: 1.4%.
But Americans see the full sticker price of care in the individual market alone. To ensure that consumers who are paying out of their own pockets can still afford coverage, it’s actually the insurers and providers in the individual market who are working hardest to control costs.
The details: Indeed, we are seeing signs that sustainable strategies to keep health care costs down for all Americans are being accelerated and proven out in the individual market.
  • Our health care system, for example, must move away from expensive emergency room visits and embrace virtual care. Prices to treat many of the same exact conditions in emergency rooms — where half of all care is delivered in the U.S. — can be orders of magnitude higher than telemedicine. In the first year of the ACA, Oscar introduced the first health insurance plan in the country with free, 24/7 access to telemedicine — and today, one in four Oscar members use it.
  • The individual market has also accelerated the shift away from big hospital networks in health insurance plans that drive prices up for all Americans. Narrow networks — which most ACA plans have — can result in lower premiums for consumers without impacting their quality of care.
  • The true innovation unlocked by the smaller networks, however, is one of integration by design. By making the insurer and hospital more dependent on each other, we can finally begin to remove the friction between your doctor and insurer to result in better, more coordinated care. For example, more than one third of all first-time doctor visits for our members are routed through our Oscar app and Concierge teams, to doctors that we partner with.
  • Hospitals are now looking to become your insurance company, too. Indeed, the Cleveland Clinic, a world-renowned hospital, is offering its own jointly-run plan with Oscar next year — in the individual market.
What’s next: There is no doubt that the individual market under the ACA has stumbled out of the gate, and is in need of some fixes. But America has seen rocky private insurance markets recover before.
Between 1998 and 2002, the number of private Medicare+Choice plans — what are now known as Medicare Advantage plans — was cut in half, to less than 150. After a legislative fix in 2003, the market recovered and matured, and seniors this year will have over 3,000 Medicare Advantage plans to choose from.
We’re confident the same can and will happen with the individual market.

What’s next for the ACA after Trump’s executive order

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President Trump couldn’t get Congress to repeal the Affordable Care Act, so he signed an executive order to encourage cheaper, less regulated insurance options — a change that critics fear will remove patient protections and undermine insurance markets. In response, Senators Lamar Alexander and Patty Murray have put forward a bipartisan bill designed to stabilize the ACA markets.

With the future of the ACA so fiercely contested, what impact will Trump’s executive order have on health insurance, and what action should Congress now take?

We asked five experts:

CBO: Alexander-Murray Bill Would Trim Deficit, Keep Americans Insured

http://www.healthleadersmedia.com/health-plans/cbo-alexander-murray-bill-would-trim-deficit-keep-americans-insured?spMailingID=12228675&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1262308916&spReportId=MTI2MjMwODkxNgS2#

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Is the Senate’s bipartisan compromise a workable fix or a ‘futile’ stopgap?

The bipartisan Alexander-Murray bill aimed at propping up the Affordable Care Act long enough for more substantial changes to be made is receiving a mixed response from lobbying groups and legislators, with some saying the bill only extends the life of a system that should be allowed to die.

Supporters say the bill would stabilize a volatile healthcare insurance market and preserve coverage for millions of Americans by continuing the cost sharing reduction (CSR) payments that health plans say are essential to helping them survive the ACA.

The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) released an assessment Wednesday of the measure, finding that the deal would reduce the deficit by $3.8 billion over the next decade “without substantially changing the number of people with health insurance coverage, on net.” By contrast, earlier proposals to overhaul the ACA lost steam this year after CBO scores indicated that they would likely drive down the number of insured Americans by tens of millions.

“This nonpartisan analysis shows that our bill provides savings and ensures that funding two years of cost-sharing payments will benefit taxpayers and low-income Americans, not insurance companies,” Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA) said Wednesday in a joint statement.

The CSR payments are intended to compensate insurers for providing coverage to lower-income consumers at below cost, and many say losing those payments will drive premiums higher and force some insurers to leave certain markets.

The compromise

Alexander and Murray developed the compromise bill in a bid to maintain the CSR subsidies that the Trump administration announced October 12 it would halt. The White House argues the CSRs were never authorized by Congress.

California is leading the charge in a legal challenge of President Trump’s stated intention to stop the payments, and the American Hospital Association, along with several other groups representing hospitals and other healthcare organizations, has filed a brief in support of the CSRs. But a federal judge in California sided Wednesday with the White House, ruling that the government doesn’t have to continue making the payments while states challenge the move in court, Reuters reported.

A bipartisan coalition of 24 senators—12 Republicans and 12 Democrats—have signed on to the healthcare legislation as cosponsors. Preserving the CSRs was a major priority of the Democrats, who compromised by agreeing to the Republican push to allow states to seek waivers of ACA requirements in their own states.

Ending the subsidies is expected to result in healthcare plans raising premiums even higher than otherwise planned. But the Alexander-Murray bill would authorize the CSR payments for two years and tie them to the changes in the ACA that give states more flexibility to seek waivers from the law’s requirements.

The proposed legislation also would allow insurance companies to sell less comprehensive plans to all consumers. Republican leaders say the allowance would make more affordable plans available, which, in turn, would encourage more people to buy coverage and help the insurers remain profitable.

“This is a first step: Improve it, and pass it sooner rather than later. Our purpose is to stabilize and then lower the cost of premiums in the individual insurance market for the year 2018 and 2019,” Alexander said.

Bill opposition

The Association of American Physicians and Surgeons (AAPS) opposes the bill, saying it seeks to stabilize the insurance marketplace by forcing taxpayers to pay insurers to lower out-of-pocket costs for certain plan members.

Jane M. Orient, MD, executive director of AAPS, says the ACA actually makes insurance unaffordable.

“The deceitfully named Affordable Care Act did not just destabilize the individual insurance market; it destroyed it by outlawing genuine, voluntary insurance,” Orient says. “ACA-compliant plans are not true insurance, but coercive prepayment schemes for a federally dictated package that might be rejected by most subscribers.”

Orient says the bill being considered should be seen as an inappropriate form of legislative life support.

“Resuscitating Obamacare with Alexander-Murray would only prolong its dying process, but at great expense,” Orient says.

“Instead of running a futile Code Blue on Obamacare, we should be attending to American medicine and the American economy,” she adds.

Bill ‘provides critical stability’

American College of Emergency Physicians (ACEP) President Becky Parker, MD, FACEP, disagrees.

She says ACEP supports the Alexander-Murray legislation because it will provide critical stability for the individual health insurance marketplace, ensuring that millions of Americans have continued access to the health coverage they need and deserve.

“This legislation is a good-faith bipartisan effort that will help limit increases in health insurance premiums and preserve important consumer protections, such as the Essential Health Benefits package that includes emergency services, while also providing additional flexibility for states to implement innovative approaches to coverage,” Parker says.

Insurance and device taxes back on the chopping block

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It’s time once again for the insurance and medical device industries to ramp up their lobbying against the ACA’s taxes on their products. Congress has frozen both taxes, but both are set to kick in again next year.

  • A trio of Senate Democrats — Heidi Heitkamp, Jeanne Shaheen and Joe Donnelly — introduced a bill last week to delay the insurance tax for another two years. House Republicans are also hoping to find some bipartisan support for a similar measure, though they also still need to finalize the policy details.
  • Opposition to the device tax is also bipartisan, and heating up. More than 175 House members, including 43 Republicans, signed on to a letter yesterday urging Speaker Paul Ryan to bring up a bill fully repealing the device tax.

Reality check: Both industries, but especially insurers, are more likely to win another delay than see their taxes repealed.

And though there will be public pushes here and there for stand-alone bills, or for inclusion in tax reform, getting onto Congress’ massive end-of-year package is their best bet. Measures to delay the insurance or device taxes could be added to Alexander-Murray, if it comes up, as a way to win more Republican votes without losing Democrats.

Republicans go toe-to-toe, again, with competing ACA bills

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Now the Senate has two competing plans to fund the ACA’s cost-sharing subsidies — which could mean it won’t be able to pass either one. Senate Finance chair Orrin Hatch and House Ways and Means chair Kevin Brady outlined a new proposal yesterday as an alternative to the bipartisan ACA bill led by Sens. Lamar Alexander and Patty Murray.

The details: It’s hard to call these competing ACA stabilization bills. Although they’d both fund cost-sharing reduction (CSR) subsidies for two years, Hatch-Brady would also waive the law’s individual mandate for five years — effectively replacing one source of rising premiums with another.

  • Conservatives are not happy with Alexander-Murray. They’ve argued that if they’re going to keep the law’s cost-sharing payments flowing, they should be able to extract severe regulatory reforms in exchange.
  • Hatch-Brady is definitely more conservative than Alexander-Murray. The big unknown is whether its presence will stop more Republicans from accepting Alexander-Murray as “The Bill” — especially in the House, where its standing is weaker than in the Senate.
  • What they’re saying: “Sad attempt at relevancy by health care staff on Finance who are upset that their boss is entirely focused on tax reform, as he should be,” a senior GOP aide told my colleague Caitlin Owens.

The odds: 100% of the available evidence, from the entire Trump administration to date, suggests very strongly that Republicans are not capable of passing a health care bill on their own. They couldn’t do it with 50 votes in the Senate, and either one of these bills would need 60.

  • Alexander-Murray has 60 votes in the Senate.
  • Hatch-Brady would have an extremely hard time getting there. Waiving the individual mandate will be too much to ask from most, if not all, Democrats.
  • Leadership will likely face a choice between passing Alexander-Murray, with only minor modifications; or not passing anything at all.
  • All of this still probably comes down to December, when lawmakers have to deal with a host of thorny must-pass bills.