Tag Archives: ACA

The Commonwealth Fund’s Top 10 for 2018

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

https://www.commonwealthfund.org/publications/2018/dec/commonwealth-funds-top-10-2018?omnicid=CFC%25%25jobid%25%25&mid=%25%25emailaddr%25%25

top 10

In 2018, the Commonwealth Fund’s centennial year, we continued our efforts to advance health care for all. When viewed through the lens of the most popular publications, it has been a year dedicated in large part to showing how Americans covered through the Affordable Care Act have fared as the law has come under attack from Congress and the White House. 

In the last year, we also released our latest state scorecard of health system performance and updated our analysis of the rise in deaths attributable to drugs, alcohol, and suicide. Another top report demonstrated how states can sustain investments in social supports for people in Medicaid managed care.

Please join us as we look back over the year. Here they are: the 10 most-read Commonwealth Fund publications released in 2018.

 

 

 

10 Notable Health Care Events of 2018

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , , , , • Leave a comment

https://www.commonwealthfund.org/blog/2018/10-notable-health-care-events-2018?omnicid=CFC%25%25jobid%25%25&mid=%25%25emailaddr%25%25

2018

Between the fiercely competitive midterm elections and ongoing upheaval over the Trump administration’s immigration policies, 2018 was no less politically tumultuous than 2017. The same was true for the world of health care. Republicans gave up on overt attempts to repeal and replace the Affordable Care Act (ACA) through legislation, but the administration’s executive actions on health policy accelerated. Several states took decisive action on Medicaid and some of the struggles over the ACA made their way to the courts. Drug prices remain astronomically high, but public outrage prompted some announcements to help control them. At the same time, corporate behemoths made deeper inroads into health care delivery, including some new overtures from Silicon Valley. Here’s a refresher on some of the most notable events of the year.

1. The ACA under renewed judicial assault

Texas v. Azar, a suit brought by Texas and 19 other Republican-led states, asked the courts to rule the entire ACA unconstitutional because Congress repealed the financial penalty associated with the individual mandate to obtain health insurance that was part of the original law. District Judge Reed O’Connor ruled in favor of the plaintiffs, creating confusion at the end of the ACA’s open enrollment period, and setting up what may be a years-long judicial contest (yet again) over the constitutionality of the ACA. To learn more about the legal issues at stake, see Timothy S. Jost’s recent To the Point post.

2. Turnout for open enrollment in health insurance marketplaces surged at the end of the sign-up period

The federal and state-based marketplaces launched their sixth enrollment season on November 1 for individuals seeking to buy health coverage in the ACA’s individual markets for 2019. Insurer participation remained strong and premiums fell on average. While some states have extended enrollment periods, HealthCare.gov, the federal marketplace, closed on December 15. After lagging in the early weeks, enrollment ended just 4 percent lower this year than in 2017.

3. The administration continues efforts to hobble ACA marketplaces

While the reasons behind lower enrollment cannot be decisively determined, executive action in 2018 may have contributed. The Trump administration dramatically cut back federal investments in marketplace advertising and consumer assistance for the second year in a row. The federal government spent $10 million on advertising for the 34 federally facilitated marketplaces this year (the same as last year but an 85 percent cut from 2016) and $10 million on the navigator program (down from $100 million in 2016), which provides direct assistance to hard-to-reach populations.

4. Insurers encouraged to sell health plans that don’t comply with the ACA

Another tactic the Trump administration is using to undercut the ACA is increasing the availability of health insurance products, such as short-term health plans, that don’t comply with ACA standards. Short-term plans, previously available for just three months, can now provide coverage for just under 12 months and be renewed for up to 36 months in many states. These plans may have gaps in coverage and lead to costs that consumers may not anticipate when they sign up. By siphoning off healthy purchasers, short-term plans and other noncompliant products segment the individual market and increase premiums for individuals who want to — or need to — purchase ACA-complaint insurance that won’t discriminate against people with preexisting conditions, for example.

5. Medicaid expansion in conservative states

Few states have expanded Medicaid since 2016, but in 2018, a new trend toward expansion through ballot initiatives emerged. Following Maine’s citizen-initiated referendum last year, Idaho, Nebraska, and Utah passed ballot initiatives in November to expand Medicaid. Other red states may follow in 2019. Medicaid expansion not only improves access to care for low-income Americans, but also makes fiscal sense for states, because the federal government subsidizes the costs of newly eligible Medicaid enrollees (94 percent of the state costs at present, dropping to 90 percent in 2020).

6. Red states impose work requirements for Medicaid

A number of states submitted federal waivers to make employment a requirement for Medicaid eligibility. Such waivers were approved in five states — Arkansas, Kentucky, Wisconsin, New Hampshire, and Indiana — and 10 other states are awaiting approval. At the end of 2018, lawsuits are pending in Arkansas and Kentucky challenging the lawfulness of work requirements for Medicaid eligibility. About 17,000 people have lost Medicaid in Arkansas as a result of work requirements.

7. Regulatory announcements respond to public outrage over drug prices

Public outrage over prescription drug prices — which are higher in the U.S. than in other industrialized countries — provided fodder for significant regulatory action in 2018 to help bring costs under control. Of note, the Food and Drug Administration announced a series of steps to encourage competition from generic manufacturers as well as greater price transparency. The U.S. Department of Health and Human Services in October announced a proposed rule to test a new payment model to substantially lower the cost of prescription drugs and biologics covered under Part B of the Medicare program.

8. Corporations and Silicon Valley make deeper inroads into health care

Far from Washington, D.C., corporations and technology companies made their own attempts to alter the way health care is delivered in the U.S. Amazon, Berkshire Hathaway, and J.P. Morgan Chase kicked 2018 off with an announcement that they would form an independent nonprofit health care company that would seek to revolutionize health care for their U.S. employees. Not to be outdone, Apple teamed up with over 100 health care systems and practices to disrupt the way patients access their electronic health records. And CVS Health and Aetna closed their $69 billion merger in November, after spending the better part of the year seeking approval from state insurance regulators. In a surprise move, a federal district judge then announced that he was reviewing the merger to explore the potential competitive harm in the deal.

9. Growth in health spending slows

The annual report on National Health Expenditures from the Centers for Medicare and Medicaid Services estimates that in 2017, health care spending in the U.S. grew 3.9 percent to $3.5 trillion, or $10,739 per person. After higher growth rates in 2016 (4.8%) and 2015 (5.8%) following expanded insurance coverage and increased spending on prescription drugs, health spending growth has returned to the same level as between 2008 to 2013, the average predating ACA coverage expansions.

10. Drug overdose rates hit a record high

Continuing a tragic trend, drug overdose deaths are still on the rise. The Centers for Disease Control and Prevention reported 70,237 fatalities in 2017. Overdose deaths are higher than deaths from H.I.V., car crashes, or gun violence, and seem to reflect a growing number of deaths from synthetic drugs, most notably fentanyl. 2018 was the first year after President Trump declared the opioid crisis a public health emergency. National policy solutions have so far failed to stem the epidemic, though particular states have made progress.

As we slip into 2019, expect health care issues to remain front and center on the policy agenda, with the administration continuing its regulatory assault on many key ACA provisions, Democrats harassing the executive branch with House oversight hearings, both parties demanding relief from escalating pharmaceutical prices, and the launch of health care as a 2020 presidential campaign issue.

 

 

OUTLOOK ‘STABLE’ FOR HEALTH INSURERS IN 2019 DESPITE ACA UNCERTAINTY

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , • Leave a comment

https://www.healthleadersmedia.com/finance/outlook-stable-health-insurers-2019-despite-aca-uncertainty

A robust job market bolstering employer-sponsored plans, Baby Boomers transitioning to Medicare Advantage, and ACA exchanges attracting new payers are good signs for health plans in the coming year.

KEY TAKEAWAYS

Consolidations among larger payers makes it harder for smaller players to enter the market or sustain a presence.

Payment reforms around the ACA will continue to drive more cross-sector collaboration among payers and providers.

Despite the uncertainty over the future of the Affordable Care Act, the U.S. health insurance sector remains stable heading into 2019, according to a new analysis by S&P Global Ratings.

“A combination of still-favorable business conditions, financial factors, and diminished near-term legislative uncertainty balances our concerns relating to merger and acquisition activity, elevated policy risk, and re-emergent legal overhang,” said S&P analyst Joseph Marinucci.

Strong job growth is bolstering commercial markets, aging Baby Boomers are driving Medicare Advantage growth, states are shifting their high acuity populations into managed Medicaid, and the ACA exchanges are stabilizing and attracting new competitors, S&P said.

“We assess capital and liquidity as strong or better for most of our rated U.S. health insurers, which supports balance-sheet strength,” Marinucci said. “U.S. health insurers’ operating performance reflects sustained earnings strength and improved earnings quality.”

However, Marinucci said that profitability could moderate somewhat this year.

M&As remain a key rating factor, especially with larger transaction sizes, raising concerns about financial leverage, integration, and cultural compatibility. Consolidations, joint ventures, and partnering among larger insurers are defragmenting the sector, allowing the big insurers to build scale, “and create more touch points as the trend toward consumerism gains traction.”

“This is making it harder for newer and smaller players to enter the market or sustain their presence,” S&P said. “As a result, we continue to see larger health insurers taking a bigger share of the marketplace, and smaller players being displaced or struggling to achieve profitable growth as the competitive gap widens.”

“Although the mid-term elections removed a good deal of legislative uncertainty for the industry, policy risk remains elevated given the administration’s preference for ACA alternatives,” S&P said.

In addition, S&P says that payment and delivery reforms mandated in the ACA around value-based care will continue to drive greater cross-sector collaboration among payers and providers.

“A COMBINATION OF STILL-FAVORABLE BUSINESS CONDITIONS, FINANCIAL FACTORS, AND DIMINISHED NEAR-TERM LEGISLATIVE UNCERTAINTY BALANCES OUR CONCERNS RELATING TO MERGER AND ACQUISITION ACTIVITY, ELEVATED POLICY RISK, AND RE-EMERGENT LEGAL OVERHANG.”

 

 

 

HOW SEN. ORRIN HATCH CHANGED AMERICA’S HEALTH CARE

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , • Leave a comment

https://www.healthleadersmedia.com/strategy/how-sen-orrin-hatch-changed-americas-health-care?utm_source=silverpop&utm_medium=email&utm_campaign=ENL_190103_LDR_BRIEFING_resend%20(1)&spMailingID=14894079&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1560203883&spReportId=MTU2MDIwMzg4MwS2

How Sen. Orrin Hatch Changed America's Health Care

Utah’s Orrin Hatch is leaving the Senate, after 42 years. The Republican led bipartisan efforts to provide health care to more kids and AIDS patients. He also thrived on donations from the drug industry.

https://www.npr.org/player/embed/673851375/681125070

Sen. Orrin Hatch, the Utah Republican retiring from 42 years in the Senate as a new generation is sworn in, leaves a long list of achievements in health care. Some were more controversial than others.

Hatch played key roles in shepherding the 1983 Orphan Drug Act to promote drug development for rare diseases, and the 1984 National Organ Transplant Act, which helped create a national transplant registry. And in 1995, when many people with AIDS were still feeling marginalized by society and elected leaders, he testified before the Senate about reauthorizing funding for his Ryan White CARE Act to treat uninsured people who have HIV.

“AIDS does not play favorites,” Hatch told other senators. “It affects rich and poor, adults and children, men and women, rural communities and the inner cities. We know much, but the fear remains.”

Hatch, now 84, co-sponsored a number of bills with Democrats over the years, often with Sen. Ted Kennedy of Massachusetts. The two men were sometimes called “the odd couple,” for their politically mismatched friendship.

In 1997, the two proposed a broad new health safety net for kids —the Children’s Health Insurance Program.

“This is an area the country has made enormous progress on, and it’s something we should all feel proud of — and Senator Hatch should too,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

Before CHIP was enacted, the number of uninsured children in America was around 10 million. Today, it’s under half that.

Hatch’s influence on American health care partly came from the sheer number of bills he sponsored — more than any other living lawmaker — and because he was chairman of several powerful Senate committees.

“History was on his side because the Republicans were in charge,” said Dr. David Sundwall, an emeritus professor in public health at the University of Utah and Hatch’s health director in the 1980s.

When Ronald Reagan was elected president in 1981, the Senate became Republican-controlled for the first time in decades. Hatch was appointed chairman of what is now known as the Health, Education, Labor and Pensions Committee. The powerful legislative group has oversight of the Food and Drug Administration, Centers for Disease Control and Prevention and the National Institutes of Health.

“He was virtually catapulted into this chairmanship role,” Sundwall said. “This is astonishing that he had chairmanship of an umbrella committee in his first term in the Senate.”

In 2011, Hatch was appointed to the influential Senate Finance Committee, where he later became chairman. There he helped oversee the national health programs Medicare, Medicaid and CHIP.

Hatch’s growing influence in Congress did not go unnoticed by health care lobbyists. According to the watchdog organization Center for Responsive Politics, in the past 25 years of political campaign funding, Hatch ranks third of all members of Congress for contributions from the pharmaceutical and health sector. (That’s behind Democratic senators who ran for higher office — President Barack Obama and presidential nominee Hillary Clinton).

“Clearly, he was PhRMA’s man on the Hill,” said Dr. Jeremy Greene, referring to the trade group that represents pharmaceutical companies. Green is a professor of the history of medicine at Johns Hopkins University School of Medicine. Though Hatch did work to lower drug prices, Greene said, the senator’s record was mixed on the regulation of drug companies.

For example, an important piece of Hatch’s legislative legacy is the 1984 Hatch-Waxman Act, drafted with then-Rep. Henry Waxman, an influential Democrat from California. While the law promoted the development of cheaper, generic drugs, it also rewarded brand-name drug companies by extending their patents on valuable medicines.

The law did spur sales of cheaper generics, Greene said. But drugmakers soon learned how to exploit the law’s weaknesses.

“The makers of brand-name drugs began to craft larger and larger webs of multiple patents around their drugs,” aiming to preserve their monopolies after the initial patent expired, Greene said.

Other brand-name drugmakers preserved their monopolies by paying makers of generics not to compete.

“These pay-for-delay deals effectively hinged on a part of the Hatch-Waxman Act,” Greene said.

Hatch also worked closely with the dietary supplement industry. The multibillion-dollar industry specializing in vitamins, minerals, herbs and other “natural” health products, is concentrated in his home state of Utah.

“There was really no place for these natural health products,” said Loren Israelsen, president of the United Natural Products Alliance and a Hatch staffer in the late 1970s.

As the industry grew, there was a debate over how to regulate it: Should it be more like food or like drugs? In 1994, Hatch sponsored the Dietary Supplement Health and Education Act, known as DSHEA, which treats supplements more like food.

“It was necessary to have someone who was a champion who would say, ‘All right, if we need to change the law, what does it look like,’ and ‘Let’s go,'” Israelsen said.

Some legislators and consumer advocacy groups wanted vitamins and other supplements to go through a tight approval process, akin to the testing the Food and Drug Administration requires of drugs. But DSHEA reined in the FDA, determining that supplements do not have to meet the same safety and efficacy standards as prescription drugs.

That legislative clamp on regulation has led to ongoing questions about whether dietary supplements actually work and concerns about how they interact with other medications patients may be taking.

DSHEA was co-sponsored by Democrat Tom Harkin, then a senator from Iowa.

While that kind of bipartisanship defined much of Hatch’s career, it has been less evident in recent years. He was strongly opposed to the Affordable Care Act, and in 2018 called supporters of the heath law among the “stupidest, dumb-ass people” he had ever met. (Hatch later characterized the remark as “a poorly worded joke.”)

In his farewell speech on the Senate floor in December, Hatch lamented the polarization that has overtaken Congress.

“Gridlock is the new norm,” he said. “Like the humidity here, partisanship permeates everything we do.”

 

 

Older Americans worried about insurance coverage, health costs as they approach retirement

Posted on by • Posted in Uncategorized • Tagged , , , , , , , • Leave a comment

https://www.fiercehealthcare.com/payer/older-americans-worried-about-insurance-coverage-and-health-costs-as-they-approach-retirement?mkt_tok=eyJpIjoiTXpGak0yVmtNamN6TnpkaCIsInQiOiJtQnVtUmFtN0RYbHMzb2hyM1wvXC93N1kwRDJ6RmlNSjg5Q2VsYkFFSTJpZlptKzc2b1ByYTcrVzNxNUtcL3BwVWVIbzJBWThSWmY4ZXpHK1RBUWdWODhqdkxYMXZQRnJtNWV4TWc4aFJqVUdiXC9sWWh0MEdJK2NPckNzVDQ3ZlhoUEgifQ%3D%3D&mrkid=959610&utm_medium=nl&utm_source=internal

A sizable percentage of Americans between the ages of 50 and 64 are worried about their healthcare coverage as they head toward retirement, according to a new poll from the University of Michigan.

Although some of these concerns include things people can’t directly control, such as policy changes, many are focused on maintaining current coverage provided through an employer while reducing personal healthcare expenses.

“The ACA’s insurance coverage expansion was intended, in part, to reduce ‘job lock’ and allow individuals to change or leave their job without concern about becoming uninsured,” the report says. “However, data from this poll suggest that many adults age 50–64 still worry about maintaining employer-sponsored health insurance and keeping a job for that reason.”

About a quarter (27%) of respondents fear they won’t be able to afford their insurance over the next year, and nearly half (45%) expressed little to no confidence in being able to afford their insurance when they retire.

Meanwhile, 13% of those surveyed postponed medical care within the last year due to cost concerns. Another 15% postponed procedures until they could change their plan the following coverage year—so it would be covered, to incur lower out-of-pocket costs or to see a specific doctor in-network. Additionally, 8% of respondents between the ages of 60 and 64 reported delaying a procedure until they could get Medicare.

Nearly 1 in 5 (19%) said they were keeping a job, delaying retirement or considering delaying retirement to keep their employer-sponsored insurance. With that in mind, 71% of retirees were confident in their ability to afford insurance—a much higher percentage than those who were working (54%) or not working (49%).

Men were more confident than women that they could afford insurance at retirement (61% vs. 50%). Those in “excellent” health were more confident than those in “good” or “fair/poor” health (62% vs. 54% and 42%), as were those with a college degree compared to those without.

Nearly 8 in 10 respondents (79%) said they were very confident in their ability to navigate the health insurance landscape, though about 3 in 10 (29%) indicated little or no confidence that they could determine the out-of-pocket costs associated with a prospective service.

The study indicates Americans are closely watching and responding to challenges to the Affordable Care Act, such as a ruling by a federal judge in Texas striking down the law. Over the weekend, the judge issued a stay on the ruling, saying the healthcare law should remain in effect as appeals weave their way through the courts.

Half of those surveyed said they closely follow news about the ACA, Medicare or Medicaid, and 68% said they are worried about how their coverage may change due to federal policies.

“Regardless of potential federal policy changes, patients and their health care providers should discuss the out-of-pocket costs of health care, such as medical procedures, tests, or medications. Such discussions can help inform decisions about their health insurance options and the timing, choice, and appropriateness of health care services,” it concluded.

 

 

 

Proposed Changes to Medicare Part D Would Benefit Drug Manufacturers More Than Beneficiaries

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , • Leave a comment

https://www.commonwealthfund.org/blog/2019/proposed-changes-medicare-part-d-would-benefit-drug-manufacturers-more-beneficiaries?omnicid=EALERT1538445&mid=henrykotula@yahoo.com

senior opens medications

As part of the Bipartisan Budget Act of 2018 (BBA), Congress made changes to the Medicare prescription drug benefit program, or Part D, to lower spending for both beneficiaries and the federal government. Specifically, the BBA increased the size of the discount on brand-name drugs that manufacturers are required to offer beneficiaries who are in the Part D coverage gap, or “donut hole,” from 50 percent to 70 percent. (The donut hole, in which Medicare beneficiaries who have spent over a certain amount on prescription drugs must pay all drug costs out of pocket, was designed to help contain federal costs.) By increasing the size of the manufacturer discount, Congress was able to shrink the share of spending in the donut hole covered by Part D plan sponsors and beneficiaries.

Pharmaceutical manufacturers have continued to put pressure on Congress to make two changes: 1) roll back the discount from manufacturers from 70 percent to 63 percent (and increase Part D plan-sponsor liability) and 2) block an increase in the total amount beneficiaries must spend out of pocket on their prescription drugs before catastrophic coverage kicks in.

According to our analysis, these proposals would financially benefit drug manufacturers more than Medicare beneficiaries: while beneficiaries’ spending in the coverage gap would be slightly reduced, manufacturers’ spending would be reduced far more. Moreover, Medicare spending under Part D would increase to cover the savings to beneficiaries and manufacturers.

Key Definitions Under Part D

Donut Hole: The third phase of Medicare Part D coverage in which beneficiaries pay all drug costs out of pocket.

TrOOP (True Out-of-Pocket) Threshold: The total amount beneficiaries need to spend out of pocket before reaching catastrophic coverage.

Part D Plan Sponsors: Typically insurance companies and pharmacy benefit managers

Part D Coverage Gap Discount: A program established by the ACA that requires drug manufacturers and Part D plan sponsors to give beneficiaries price discounts on brand-name drugs when beneficiaries reach the coverage gap. It also reduces the share of spending that Part D plan sponsors cover.

Original Medicare Part D Design

When the Medicare Part D program was created in 2003, Congress required all Part D plan sponsors — typically insurance companies and pharmacy benefit managers — to establish a standard benefit package with four phases of coverage that beneficiaries move through depending on their drug spending. In the first phase, the federal government covers 100 percent of cost-sharing until beneficiaries reach their deductible. In the second phase, the federal government covers 25 percent of cost-sharing. In the third phase, known as the coverage gap or donut hole, beneficiaries pay all drug costs out of pocket. In the final phase, catastrophic coverage is reached and beneficiaries cover just 5 percent of cost-sharing.

The amount beneficiaries need to spend out of pocket before reaching catastrophic coverage is called the TrOOP (“True Out-of-Pocket) threshold; it was $5,000 in 2018. The TrOOP threshold increases each year to account for growth in Medicare per-beneficiary spending under Part D, which includes prescription drug prices.

Filling the Part D “Donut Hole”

As part of the Affordable Care Act (ACA), Congress included two changes to Part D to help fill the donut hole. First, Congress established the Part D Coverage Gap Discount Program that requires participating drug manufacturers and Part D plan sponsors give beneficiaries price discounts on brand-name drugs when beneficiaries reach the coverage gap. Between 2011 and 2020, this program reduces beneficiary cost-sharing in the gap from 100 percent to 25 percent. The discounts were phased in and scheduled to fill the coverage gap by 2020.

Second, Congress slowed the annual update to the TrOOP threshold through 2019 by basing the update on the consumer price index (CPI) plus 2 percentage points rather than drug spending growth. The purpose was to give certainty to the size of the donut hole during the phase-in of the manufacturer discount program. Because the CPI has grown far less rapidly than drug prices under Part D, this change has kept the size of the donut hole smaller, enabling beneficiaries to reach the catastrophic benefit sooner than they would have under the original Part D benefit. This also helps manufacturers, who don’t have to offer as many discounts when people are in the coverage gap for a shorter period of time. And once the federal government is covering more costs under catastrophic coverage, manufacturers no longer have to provide discounts at all.

While Congress slowed growth in the TrOOP threshold through 2019, under the ACA, the threshold amount reverts back to the pre-ACA calculation in 2020. When the threshold is based on drug price spending growth again, the amount a beneficiary must spend in the coverage gap will jump from $5,100 to $6,350. (If manufacturer price growth had been at or close to CPI growth in recent years, there would be no increase in 2020.) But if Congress wants to block the spike in the TrOOP amount, it must take action no later than June 2019, the deadline for Part D plans bidding to offer coverage in 2020.

Effect of the Bipartisan Budget Act of 2018 on the Coverage Gap

In February 2018, the BBA made changes to the Part D Coverage Gap Discount Program to help fill the donut hole in 2019 (a year earlier than the ACA provision) by increasing the manufacturer discount for beneficiaries from 50 percent to 70 percent and reducing the share that Part D plan sponsors cover. This change will require manufacturers to offer a larger discount and reduce beneficiaries’ out-of-pocket drug costs in the donut hole. By reducing the share that insurance companies or pharmacy benefit managers are responsible for, Congress intended to lower premiums, which in turn will save the federal government on premiums subsidies.

The Financial Impact of the New Proposals

While Congress established the Part D Coverage Gap Discount Program at the same time it slowed growth in the TrOOP threshold — and both relate to the donut hole — the two policies function independently and need not be conflated in terms of making changes to them in statute.

Moreover, the financial implications of proposals to change these components differ markedly. Beneficiaries spend an average of $1,321 on cost-sharing in the coverage gap today and would spend $1,156 in 2020 — or $165 less — if Congress amends the BBA and blocks the TrOOP increase as proposed by the pharmaceutical industry.

However, manufacturers would save even more under these proposed policies. Brand-name manufacturer discounts in the donut hole would fall from $3,698 per beneficiary today to roughly $2,998 — a reduction of $785 per beneficiary. Part D plan sponsors would spend $555 per beneficiary in the coverage gap or $291 more if both policies were addressed.

Understanding the implications of these proposals beyond their impact on Medicare spending and the federal budget is important. Even if Congress were only to block the increase in the TrOOP threshold — and not undo the increase in manufacturer discounts — beneficiary spending would be slightly lower (as a lower limit on TrOOP spending would enable beneficiaries to get out of the donut hole and into the most generous level of federal coverage more quickly) but manufacturers would still come out far ahead of both Part D plan sponsors and beneficiaries. Given the financial implications of these two policies, Congress may want to consider broader changes to Part D that would lower drug prices, provide more cost savings to beneficiaries, and avoid higher spending under the Medicare program.

 

 

 

Short-Term Health Plans Hold Savings For Consumers, Profits For Brokers And Insurers

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , • Leave a comment

https://www.thelundreport.org/content/short-term-health-plans-hold-savings-consumers-profits-brokers-and-insurers?mc_cid=87537ae734&mc_eid=1d14ffb322

Sure, they’re less expensive for consumers, but short-term health policies have another side: They’re highly profitable for insurers and offer hefty sales commissions.

Driven by rising premiums for Affordable Care Act plans, interest in short-term insurance is growing, boosted by Trump administration actions to ease Obama-era restrictions and possibly make federal subsidies available to consumers to purchase them.

That’s good news for brokers, who often see commissions on such policies hit 20 percent or more.

On a policy costing $200 a month, for example, that could translate to a $40 payment each month. By contrast, ACA plan commissions, which are often flat dollar amounts rather than a percentage of premium, can range from zero to $20 per enrollee per month.

“Customers are paying less and I’m making more,” said Cindy Holtzman, a broker in Woodstock, Ga., who said she gets 20 percent on short-term plan commissions.

Large online brokers also are eagerly eyeing the market.

Ehealth, one such firm, will “continue to shift our focus to selling short-term plans and non-ACA insurance packages,” CEO Scott Flanders told investors in October. The firm saw an 18 percent annual jump in enrollment in short-term plans this year, he added.

Insurers, too, see strong profits from plans because they generally pay out very little toward medical care when compared with the more comprehensive ACA plans.

Still, some agents like Holtzman have mixed feelings about selling the plans, because they offer skimpier coverage than ACA insurance. One 58-year-old client of Holtzman’s wanted one, but he had health problems. She also learned his income qualified him for an ACA subsidy, which currently cannot be used to purchase short-term coverage.

“There’s no way I would have considered a short-term plan for him,” she said. “I found him an ACA plan for $360 a month with a reduced deductible.” (A federal district court judge in Texas issued a ruling Dec. 14 striking down the ACA, which would among other things impact the requirements of ACA coverage and subsidies. The decision is expected to face appeal.)

Short-term plans can be far less expensive than ACA plans because they set annual or lifetime payment limits. Most exclude people with medical conditions, they often don’t cover prescription drugs, and policies exclude in fine print some conditions or treatments. Injuries sustained in school sports programs, for example, often are not covered. (These plans can be purchased at any time throughout the year, which is different than plans sold through the federal marketplaces. The open enrollment period for those ACA plans in most states ends Dec. 15.)

Consequently, insurers providing short-term plans don’t have to pay as many medical bills, so they have more money left over for profits. In forms filed with state regulators, Independence American Insurance Co. in Ohio shows it expects 60 percent of its premium revenue to be spent on its enrollees’ medical care. The remaining 40 percent can go to profits, executive salaries, marketing and commissions.

A 2016 report from the National Association of Insurance Commissioners showed that, on average, short-term plans paid out about 67 percent of their earnings on medical care.

That compares with ACA plans, which are required under the law to spend at least 80 percent of premium revenue on medical claims.

Short-term plans have long been sold mainly as a stopgap measure for people between jobs or school coverage. While exact figures are not available, brokers say interest dropped when the ACA took effect in 2014 because many people got subsidies to buy ACA plans and having a short-term plan did not exempt consumers from the law’s penalty for not carrying insurance.

But this year it ticked up again after Congress eliminated the penalty for 2019 coverage. At the same time, the premiums for ACA plans rose on average more than 30 percent.

“If I don’t want someone to walk out of the office with nothing at all because of cost, that’s when I will bring up short-term plans,” said Kelly Rector, president of Denny & Associates, an insurance sales brokerage in O’Fallon, a suburb of St. Louis. “But I don’t love the plans because of the risk.”

The Obama administration limited short-term plans to 90-day increments to reduce the number of younger or healthier people who would leave the ACA market. That rule, the Trump administration complained, forced people to reapply every few months and risk rejection by insurers if their health had declined.

This summer, the administration finalized new rules allowing insurers to offer short-term plans for up to 12 months — and gave them the option to allow renewals for up to three years. States can be more restrictive or even bar such plans altogether.

Administration officials estimate short-term plans could be half the cost of the more comprehensive ACA insurance and draw 600,000 people to enroll in 2019, with 100,000 to 200,000 of those dropping ACA coverage to do so.

And recent guidance to states says they could seek permission to allow federal subsidies to be used for short-term plans. Currently, those subsidies apply only to ACA-compliant plans.

Granting subsidies for short-term plans “would mean tax dollars are not only subsidizing commissions, but also executive salaries and marketing budgets,” said Sabrina Corlette of Georgetown University Center on Health Insurance Reforms.

No state has yet applied to do that.

For now, brokers are focusing on getting their clients into some kind of coverage for next year. Commissions on both ACA and short-term plans are getting their attention.

After several years of declining commissions for ACA plans — with some carriers cutting them altogether a couple of years ago — brokers say they are seeing a bit of a rebound.

Among Colorado ACA insurers, “it’s gone from about $14 to $16 per enrollee [a month] to $16 to $18,” said Louise Norris, a health policy writer and co-owner of an insurance brokerage.

Rector, in Missouri, said an insurer that last year paid no commissions has reinstated them for 2019 coverage. For her, that doesn’t really matter, she said, because once carriers started reducing or eliminating commissions, she began charging clients a flat rate to enroll.

Norris noted that some states changed their laws so brokers could do just that.

At least one state, Connecticut, ruled that insurers had to pay a commission, which she thinks is protective for consumers.

“Insurance regulators need to step in and make sure brokers are getting paid,” said Norris, or some brokers, “out of necessity,” might steer people to higher-commission products, such as short-term plans, that might not be the best answer for their clients.

Her agency does not sell short-term or some other types of limited-benefit plans.

“I don’t want to have a client come back and say I’ve had a heart attack and have all these unpaid bills,” she said.

 

 

 

Policy upheaval, tech giant disruption and megamergers: Healthcare Dive’s 10 best stories of 2018

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , • Leave a comment

https://www.healthcaredive.com/news/policy-upheaval-tech-giant-disruption-and-megamergers-healthcare-dives-1/543390/

Mobile health records and nurse protests also grabbed readers this year.

This year in healthcare was marked by sweeping changes, including seemingly constant vertical and horizontal consolidation, led by the $69 billion CVS grab of Aetna and Cigna’s $67 billion acquisition of Express Scripts.

As 2018 wound down, a federal judge took an ax to the Affordable Care Act as the Trump administration kept up its efforts to undermine the law, with CMS expanding short-term health plans many say are built to subvert the ACA. Elimination of the individual mandate penalty, Medicaid expansion and rising premiums all likely contributed to declined enrollment on ACA exchanges as well.

The administration encouraged states to use waivers to expand controversial Medicaid work requirements and proposed site-neutral payments, rattling health systems of all sizes that were already struggling under ferocious operating headwinds. Hospitals cut back on services and invested heavily in lucrative outpatient facilities in an attempt to reclaim volume.

Tech companies Apple and Amazon pushed further into the space, with the former focusing on mobile health apps and the latter focusing on, well, almost everything.

But that’s just scratching the surface. Here is a curated list of Healthcare Dive’s top stories from the last year.

    1. Optum a step ahead in vertical integration frenzy

      After a 2017 marked by failed horizontal mergers, vertical consolidation came into vogue during the year, led by CVS-Aetna, Cigna-Express Scripts and Humana-Kindred.

      Some smart observers saw a predecessor to these unions in UnitedHealth Group’s Optum: a pharmacy benefit manager plus a care services unit that employs over 30,000 physicians, using data analytics to capitalize on consumerism and value-based care.

      Our piece on Optum’s solid foothold in the space, and its likelihood of staying ahead of the nascent competition, was Healthcare Dive’s most-read article in 2018. Read More »

    2. New Medicare Advantage rules hold big potential for pop health

      A novel Medicare Advantage rule giving payers more flexibility to sell supplemental benefits to chronically ill enrollees sparked a fair amount of interest in our readers.

      The rule offered up a slate of new opportunities for insurers such as UnitedHealthcare and Humana that can now work with rideshare companies to provide transportation to medical appointments, air conditioners for beneficiaries with asthma and other measures around issues like food insecurity in a broad shift to recognizing social determinants of health. Read More »

    3. Apple debuts medical records on iPhone

      Outside players such as Apple, Amazon and Google moved forward in their bids to disrupt healthcare in 2018. Apple rang in the New Year with its announcement that customers would now be able to access their medical records on the Health app following months of speculation and buzz.

      The move looks to put access to personal, sensitive data back in the patients’ hands, an objective a lot of the entrenched healthcare ecosystem can get behind as well. Heavy hitters on the EHR side (Epic, Cerner, athenahealth) and the provider side (Johns Hopkins, Cedars-Sinai, Geisinger) are taking place in the initiative. Read More »

    4. At least 14 states have legislation addressing safe staffing currently, but California is the only one to implement a strict ratio at one nurse per every five patients. Looking to 2019, in Pennsylvania voters elected a governor who has voiced support for state legislation. Read More »

    5. More employers go direct to providers, sidestepping payers

      Employers ramped up their cost-containment creativity in 2018. One method? Cutting out the middleman and forging direct relationships with providers themselves, whether it’s contracting with an accountable care organization to manage an entire employee population or a simple advocacy role to fight for payment reform.

      Aside from some correlated CMS interest, big names forging inroads in the arena include General Motors, Walmart, Whole Foods, Boeing, Walt Disney and Intel, all with various levels of investment.

      Although only 6% of employers are doing so currently, 22% are considering solidifying some sort of provider relationship for next year according to a Willis Towers Watson survey. It’s also likely the Amazon-J.P. Morgan-Berkshire Hathaway venture will look at direct contracting in its (still vague) mission to lower employer costs. Read More »

    6. Amazon Business’ medical supply chain ambitions: 4 things to know

      Amazon’s B2B purchasing arm reached out and grabbed the healthcare supply chain this year, shaking a once-predictable business model.

      Under intense operating headwinds, supply chain professionals looked to trim the fat from traditional distribution and supplier models in 2018. Some looked to Amazon Business, which generated more than a billion dollars in sales its first year alone by relying on its marketplace model, streamlined ordering and a “tail spend” strategy.

      1. Healthcare Dive discussed this and more with global healthcare leader at Amazon Chris Holt in an exclusive interview that drove a lot of interest. Read More »

GE, Medtronic among those linking with hospitals for value-based care

Value-based care was a buzzword over the past year, with providers, payers and healthcare execs across the board looking (or saying they’re looking) for ways to cut costs and improve quality.

Although legal barriers stemming from the Anti-Kickback Statute and Stark Law persist, medical technology companies jumped on the bandwagon, with big names like GE, Philips and Medtronic coupling with hospitals to promote VBC initiatives. Read More »

  1. How Amazon, JPM, Berkshire Hathaway could disrupt healthcare (or not)

The combination of the e-commerce giant, a 200-year-old multinational investment bank and Warren Buffet’s redoubtable holding company joining forces to take on healthcare costs spooked investors in traditional industry players. The venture added a slew of big names to its C-suite, including Atul Gawande and Jack Stoddard for CEO and COO, respectively. Read More »

 

 

 

States in the Obamacare lawsuit are biting the hand that feeds them

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , • Leave a comment

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/12/20/the-health-202-states-in-the-obamacare-lawsuit-are-biting-the-hand-that-feeds-them/5c1a559e1b326b2d6629d4f8/?utm_term=.48253007006e

Image result for biting the hand that feeds them

Obamacare is precarious yet entrenched as 2019 approaches. Even many of the GOP-led states seeking to knock it down in court would be in a real bind should they succeed.

Of the 20 states involved in a high-profile Texas-led lawsuit arguing the Affordable Care Act is unconstitutional, nearly half have already accepted its extra dollars to expand their Medicaid programs or are moving that direction. States don’t have to expand Medicaid under a 2012 Supreme Court decision, but most have found it advantageous because the federal government foots most of the bill.

These states — nine in total — would suddenly be facing a much larger expense for hundreds of thousands of low-income earners newly enrolled in Medicaid under the ACA, should last week’s decision by U.S. District Judge Reed O’Connor rolling back the entire health-care law ultimately stand.

They include Louisiana, North Dakota and West Virginia, along with Arizona, Arkansas and Indiana, three states that expanded Medicaid but with some modifications. In three other states — Maine, Nebraska and Utah — voters approved ballot initiatives adopting expansion.

Yet these states are asking the courts to overthrow not just Obamacare’s protections for people with preexisting conditions – the part of the lawsuit that has gotten the most attention — but also the entire sweeping law, which is now firmly a part of the country’s health-care ecosystem eight years since its passage. More than 12 million people have become eligible for Medicaid since ACA passage, while another 11 million have enrolled in the ACA’s federally subsidized private marketplaces.

“God help us all, because the dark age is not that far from us again,” said Sen. Joe Manchin (D-W.Va.). “It will be worse than before because there won’t be the money to help rural clinics and hospitals.”

Developments in the past week — including the court ruling and slightly lagging marketplace enrollment figures released yesterday by the Trump administration — underscore the political divides dogging Obamacare even though Republicans in Congress and at the state level have embraced some of its major components.

Nearly 8.5 million people signed up for 2019 plans in the 39 states using the HealthCare.gov website (the other states run their own marketplaces), per figures from the Centers for Medicare and Medicaid Services. Enrollment was just 4 percent less than a year ago, due to a last-minute rush that suggests consumers were undeterred by the court ruling, our Washington Post colleague Amy Goldstein reports.

“After lagging by about 11 percent most of the six weeks of open enrollment — a shortened period adopted by the Trump administration a year ago — the more than 400,000 who selected coverage during the final week actually exceeded the year before,” Amy writes.

CMS Administrator Seema Verma seemed unperturbed by the reduced enrollment numbers, saying they merely show new GOP and administration policies to roll back some ACA requirements on insurers and consumers are working.

But if the entire law gets scrapped by the Supreme Court ( we should note, the case still has a long way to go in the legal system), it will quickly become clear the ACA — for whatever its faults — has extended benefits to Americans they’ve now come to expect. Despite their persistent rhetoric against the law, Republicans have found it politically necessary to embrace big parts of it, including its protections for people with preexisting conditions — and, in some states, its Medicaid expansion.

Case in point: West Virginia. Its Republican attorney general, Patrick Morrisey, has joined the lawsuit against Obamacare even though the state embraced its Medicaid expansion, growing its enrollment in the program by nearly one-third.The federal government covers more than 90 percent of the cost of the newly eligible enrollees.

When I asked Morrisey’s office about what striking the ACA would mean for Medicaid recipients, his office provided a statement praising O’Connor’s ruling and discussing premium hikes in the marketplaces — but didn’t mention Medicaid.

“Our nation must move beyond Obamacare, innovate, provide more choices to consumers, and attack the skyrocketing premiums that have caused such pain and hardship on West Virginian and American families,” the statement said.

In some cases, the decisions by state attorneys general to join the anti-ACA lawsuit has put them at odds with their governor. Louisiana’s Democratic governor, John Bel Edwards, moved quickly to expand Medicaid when he took office in 2016. Nearly half a million people have enrolled in Medicaid since then, growing the state’s program by 27 percent.

Edwards hasn’t hidden his disdain for Louisiana Attorney General Jeff Landry (R), who has called the law an “unconstitutional overreach.” Edwards issued a critical statement after last Friday’s decision.

“This was a short-sighted lawsuit, to say the least,” Edwards said in a statement. “I intend to vigorously pursue legislation to protect individuals with pre-existing conditions from losing their health insurance and ensuring the working people of our state aren’t penalized because of this decision.”

 

Conservatives Are Using the Courts to Attack Health Care for All Americans

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , • Leave a comment

https://www.americanprogress.org/issues/healthcare/news/2018/12/20/464562/conservatives-using-courts-attack-health-care-americans/

A doctor in Milton, Massachusetts, wheels his patient into his office, February 2018.

Conservative state officials, in conjunction with the Trump administration, have launched an all-out attack on health care in the United States. They have brought a suit to overturn the entirety of the Affordable Care Act (ACA), which would have serious consequences for nearly every American who has health coverage, whether through their employer, the individual market, Medicare, or Medicaid. And they found a partisan judge who, last Friday, proved willing to ignore the rule of law and help them advance their political agenda through the courts.

For now, the ACA remains the law of the land. But if the partisan decision in Texas v. United States is upheld, the consequences could be devastating. The Urban Institute estimates that overturning the ACA would result in 17 million more Americans being uninsured in 2019—in addition to coverage reductions that would occur due to the elimination of the individual mandate penalty. Millions of American families could be left without access to health care—and without the financial safety and peace of mind that health insurance provides. Overturning the law would also have serious negative effects on public health and drug development and would shorten the life of the Medicare trust fund. Moreover, it would provide a major tax break to the wealthiest Americans, insurance companies, and drug manufacturers.

Supporters of the decision have talked about this as an effort to end “Obamacare,” which may cause some people to mistakenly believe it only affects those who obtain coverage through the individual marketplace. Nothing could be further from the truth: Virtually no American’s health care coverage would be safe from the effects of this decision. Here are just some of the impacts that this decision, if upheld, would have.

Risks for people who obtain coverage through their employer

  • Lifetime and annual limits on coverage: Polling shows that without the ACA’s ban on lifetime and annual caps on benefits, firms would choose to reinstate limits on coverage. Tens of millions of workers and dependents could face annual or lifetime limits.
  • Loss of coverage for young adult children: The ACA requires employer plans that cover dependents to include young adults up to age 26. More than 2 million young adults have gained coverage under the ACA’s dependent coverage provision.
  • Loss of free preventive services, including contraception: The ACA requires preventive services—such as immunizations; screenings for cancer, diabetes, and depression; and well-child visits—to be available at no cost to the patient. Womensave about $250 annually thanks to the lack of cost sharing for contraception.
  • Elimination of rebates to cover excessively high premiums: The ACA requires insurers to provide rebates if they overprice premiums relative to actual medical costs. Under the ACA’s medical loss ratio provision, insurance companies paid back $344 million in 2016 to people with employer coverage.

Risks for people who receive coverage through Medicare

  • Increases in premiums and out-of-pocket costs: Elimination of the ACA would increase some beneficiaries’ premiums, deductibles, and copayments in Medicare Part A and Part B; overturning the law would eliminate Medicare savings, and premiums are based on program spending.
  • Cost sharing for preventive services such as mammograms: Under the ACA, Medicare provides preventive services and covers a yearly wellness visit at no cost to the patient.
  • Possibility of falling back into the prescription drug coverage gap: The ACA narrowed the Part D coverage gap and was on track to completely fill it by 2020. Without the ACA, many seniors could face higher costs for prescription medications.

Risks for people who receive coverage through Medicaid

  • Loss of coverage under the Medicaid expansion: About 12 million people are covered under the Medicaid expansion, which was funded mostly by the federal government under the ACA.
  • Higher costs for preventive services such as children’s vaccines: The ACA provided a financial incentive for states to provide preventive services to Medicaid beneficiaries free of charge, which a number of states currently utilize.
  • Fewer options to receive care in homes and communities: The ACA provided new options to states to allow elderly enrollees and enrollees with disabilities to receive care in their homes. If the law is overturned, more enrollees will be forced into institutional care.

Risks for people who buy insurance on their own

  • Loss of tax credits that make coverage affordable: Nearly 9 in 10 enrollees in the ACA marketplaces receive premium tax credits. Without the ACA, enrollees would lose financial assistance toward monthly premiums, as well as funding that helps lower deductibles and copayments.
  • Increased costs or denial of coverage due to pre-existing conditions: Without the ACA, individual market insurers would be allowed to charge more, exclude coverage benefits, or turn away people based on medical history. More than 133 millionAmericans with pre-existing conditions could be subject to discrimination if they ever needed individual market coverage.
  • Increased costs for older enrollees: The ACA limits how much more insurance companies can charge older people for coverage relative to younger ones. Without the ACA’s protections, the elderly and near-elderly would see their premiums rise

The legal reasoning behind the lower court’s decision to overturn the ACA is so poor that it has been decried by even some of the most strident conservative legal critics of the law—including those who have backed the previous efforts to overturn it through the courts. Congress has tried and failed to repeal the ACA, and voters in the midterm elections made it clear that they care about keeping protections for pre-existing conditions. Yet the court’s ruling has been approvingly cited by conservative political officials, including President Donald Trump. As such, the decision is best understood not as a legal opinion but instead as a policy preference pursued through the U.S. judiciary. That preference could not be clearer: to give the country’s wealthy and special interests massive taxes cuts—and pay for them with everyone else’s health care.