Often Missing From The Current Health Care Debate: Women’s Voices

Posted on August 19, 2017 by henrykotula • Posted in Uncategorized • Tagged Abortion, Birth Control, Essential Health Benefits, Health Policy, Out of Pocket Expenses, Planned Parenthood, Women's Health Advocacy, Women's Health Issues, Womens Health • Leave a comment

http://www.npr.org/sections/health-shots/2017/08/16/543723927/often-missing-from-the-current-health-care-debate-womens-voices?utm_campaign=KFF%3A%20The%20Latest&utm_source=hs_email&utm_medium=email&utm_content=55441015&_hsenc=p2ANqtz-9nhXUhC_zqpJNwIaw0vOuF3PfAn3PBrmE3HVyeYM_l7-5vAx-FPWjwuS3F0Ac1H67HXbfu9Hfyvmuf37WeEGpqXqf-Sw&_hsmi=55441015

Women have a lot at stake in the fight over the future of health care.

Not only do many depend on insurance coverage for maternity care and contraception, they are struck more often by autoimmune conditions, osteoporosis, breast cancer and depression. They are more likely to be poor and depend on Medicaid, and to live longer and depend on Medicare. And it commonly falls to them to plan health care and coverage for the whole family.

Yet in recent months, as leaders in Washington discussed the future of American health care, women were not always invited. To hammer out the Senate’s initial version of a bill to replace Obamacare, Majority Leader Mitch McConnell appointed 12 colleagues, all male, to closed-door sessions – a fact that was not lost on female Senators. Some members of Congress say they don’t see issues like childbirth as a male concern. Why, two GOP representatives wondered aloud during the House debate this spring, should men pay for maternity or prenatal coverage?

As the debate over health care continues, one of the challenges in addressing women’s health concerns is that they have different priorities, depending on their stage in life. A 20-year-old may care more about how to get free contraception, while a 30-year-old may be more concerned about maternity coverage. Women in their 50s might be worried about access to mammograms, and those in their 60s may fear not being able to afford insurance before Medicare kicks in at 65.

To get a richer sense of women’s varied viewpoints on health care, we asked several women around the country of different ages, backgrounds, and political views to share their thoughts and personal experiences.

Patricia Loftman, 68, New York City

Loftman spent 30 years as a certified nurse-midwife at Harlem Hospital Center and remembers treating women coming in after having botched abortions.

Some didn’t survive.

“It was a really bad time,” Loftman says. “Women should not have to die just because they don’t want to have a child.”

When the Supreme Court ruled that women had a constitutional right to an abortion in 1973, Loftman remembers feeling relieved. Now she’s angry and scared about the prospect of stricter controls. “Those of us who lived through it just cannot imagine going back,” she says.

A mother and grandmother, Loftman also recalls clearly when the birth control pill became legal in the 1960s. She was in nursing school in upstate New York and glad to have another, more convenient option for contraception. Already, women were gaining more independence, and the Pill “just added to that sense of increased freedom and choice.”

To her, conservatives’ attack on Planned Parenthood, which has already closed many clinics in several states, is frustrating because the organization also provides primary and reproductive health care to many poor women who wouldn’t be able to get it otherwise.

Now retired, Loftman sits on the board of the American College of Nurse-Midwivesand advocates for better care for minority women. “There continues to be a dramatic racial and ethnic disparity in the outcome of pregnancy and health for African-American women and women of color,” she says.

Terrisa Bukovinac, 36, San Francisco

Bukovinac calls herself a passionate pro-lifer. As president of Pro-Life Future of San Francisco, she participates in marches and protests to demonstrate her opposition to abortion.

“Our preliminary goal is defunding Planned Parenthood,” she says. “That is crucial to our mission.”

As much as the organization touts itself as being a place where people get primary care and contraception, “abortion is their primary business model,” Bukovinac says.

She said the vast majority of abortions are not justifiable and that she supports a woman’s right to an abortion only in cases that threaten her life. “We are opposed to what we consider elective abortions,” she says.

Bukovinac says she also tries to help women in crisis get financial assistance so they don’t end their pregnancies just because they can’t afford to have a baby. She supports women’s access to health insurance and health care, both of which are costly for many. “Certainly, the more people who are covered, the better it is” for both the mother and baby.

Bukovinac herself is uninsured because she says the premiums cost more than she would typically pay for care. Self-employed, Bukovinac has a disorder that causes vertigo and ringing in the ear and spends about $300 per month on medication for that and for anxiety.

She doesn’t know if the Affordable Care Act is to blame, but she said that before the law “I was able to afford health insurance and now I’m not.”

Irma Castaneda, 49, Huntington Beach, Calif.

Castaneda is a breast cancer survivor. She’s been in remission for several years but still sees her oncologist annually and undergoes mammograms, ultrasounds, and blood tests.

The married mom of three, a teacher’s aide to special education students, is worried that Republicans may make insurance more expensive for people like her with pre-existing conditions. “They could make our premiums go sky high,” she says.

Her family previously purchased a plan on Covered California, the state’s Obamacare exchange. But there was a high deductible, so she had to come up with a lot out-of-pocket money before insurance kicked in. “I was paying medical bills up the yin yang,” she says. “I felt like I was paying so much for this crappy plan.”

Then, about a year ago, Castaneda’s husband got injured at work and the family’s income dropped by half. Now they rely on Medicaid. At least now they have fewer out-of-pocket expenses for health care.

Whatever the coverage, Castaneda says, she needs high-quality health care. “God forbid I get sick again,” she says. And she worries about her daughter, who is transgender and receives specialized physical and mental health care.

“Right now she is pretty lucky because there is coverage for her,” Castaneda says. “With the Trump stuff, what’s going to happen then?”

Celene Wong, 39, Boston

The choice was agonizing for Wong. A few months into her pregnancy, she and her husband learned that her fetus had chromosomal abnormalities. The baby would have had severe special needs, she said.

“We always said we couldn’t handle that,” Wong recalls. “We had to make a tough decision, and it is not a decision that most people ever have to face.”

The couple terminated the pregnancy in January 2016, when she was about 18 weeks pregnant. “At the end of the day, everybody is going to go away except for your husband and you and this little baby,” she says. “We did our research. We knew what we would’ve been getting into.”

Wong, who works to improve the experience for patients at a local hospital, says she is fortunate to have been able to make the choice that was right for her family.

“If the [abortion] law changes, what is going to happen with that next generation?” she wonders.

Lorin Ditzler, 33, Des Moines, Iowa

Ditzler is frustrated that her insurance coverage may be a deciding factor in her family planning. She quit her job last year to take care of her 2-year-old son and was able to get on her husband’s plan, which doesn’t cover maternity care.

“To me it seems very obvious that our system isn’t set up in a way to support giving birth and raising very small children,” she says.

While maternity benefits are required under the Affordable Care Act, her husband’s plan is grandfathered under the old rules, which is not uncommon among employers that offer coverage. Skirting maternity coverage might become more common if Republicans in Congress pass legislation allowing states to drop maternity coverage an “essential benefit.”

Ditzler looked into switching to an Obamacare plan that they could buy through the exchange, but the rates were much higher than what she pays now.

If she goes back to work, she could get on a better insurance plan that covers maternity care. But that makes little sense to her. “I would go back to a full-time job so I could have a second child, but if I do that, it will be less appealing and less feasible to have a second child because I’d be working full time.”

Ashley Bennett, 34, Spartanburg, S.C.

Bennett describes herself as devoutly Christian. She is grateful that she was able to plan her family the way she wanted, with the help of birth control. She had her daughter at 22 and her son two years later.

“I felt free to make that choice, which I think is an awesome thing,” she says. She’s advised her 12-year-old daughter to wait for sex until marriage but has also been open with her about birth control within the context of marriage.

But she draws the line at abortion. “I just feel like we’re playing God. If that conception happens, then I feel like it was meant to be.”

Bennett had apprehensions about Trump but voted for him because he was the anti-abortion candidate. “That was the deciding factor for me, [more than] him yelling about how he’s going to build a wall.”

For her, opposition to abortion must be coupled with support for babies once they are born. She supports adoption and is planning to become a foster parent.

She also is concerned about the mental and physical well-being of young women. Bennett teaches seventh-grade math and coaches the school’s cheerleading and dance teams.

She watches the girls take dozens of photos of themselves to get the perfect shot, then add filters to add makeup or slim them down.

“There’s going to be an aftermath that we haven’t even thought about,” she says. “I worry we’re going to have more and more kids suffering from depression, eating disorders and even suicide because of the effects of the social media.”

Maya Guillén, 24, El Paso, Texas

When Guillén was growing up, her family spent years without health insurance. They crossed the border into Juárez, Mexico, for dental care, doctor appointments, and optometry visits.

Guillén is now on her parents’ insurance plan under a provision of the Affordable Care Act that allows children to stay on until they turn 26. She’s been disheartened by Republicans’ proposed changes to contraception and abortion coverage, she says.

In high school, Guillén received abstinence-only sex education. She watched her friends get pregnant before they graduated.

When it came time to consider sex, she thought she’d be able to count on Planned Parenthood, but the clinic in El Paso closed, as have 20 other women’s health clinics in Texas. She worries that if Republicans defund Planned Parenthood, more young girls, especially those in predominantly Hispanic communities like hers, will not be able to get contraceptives.

Jaimie Kelton, 39, New York City

When Jaimie Kelton’s wife gave birth to their baby 3½ years ago, she thought the country was finally becoming more open-minded toward gays and lesbians.

“Now I am coming to realize that we are the bubble and they are the majority and that’s really scary,” says Kelton, now pregnant with her second child.

Kelton says it seems as though Republicans have launched a war against women in general, with reproductive rights and maternity care at risk.

“It is crazy to think that most of the people making these laws are men,” she said. “Why do they feel the need to take away health care rights from women?”

Would your plan cover John McCain’s treatment?

Posted on July 25, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Cost Sharing Reduction Payments, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, Limited Benefit Plans, Medicaid, Out of Pocket Expenses, Preexisting Conditions, Short Term Health Insurance Coverage, Underinsured, Uninsured • Leave a comment

https://www.healthinsurance.org/blog/2017/07/25/would-your-plan-cover-john-mccains-treatment/

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The Arizona Senator’s health plan will ensure top-notch glioblastoma treatment, but how would Americans with other health coverage fare?

Last week, we heard the sad news that Senator John McCain has been diagnosed with glioblastoma. McCain had surgery at Phoenix’s Mayo Clinic in mid-July, and it’s expected that he’ll also receive chemotherapy and radiation, along with other potential treatments. Senator McCain has proven time and again that he’s tough as nails, and appears to be facing this latest battle head-on. One thing that he likely has on his side is top-notch health insurance.

McCain is 80, which means he’s presumably been on Medicare for 15 years. Currently serving federal lawmakers are able to obtain employer-subsidized coverage in the Washington DC small-business exchange, and they can have this coverage in addition to Medicare.

How good is McCain’s coverage?

McCain hasn’t said publicly exactly what insurance he has, and his office has not responded to my inquiry. But the most likely scenario is that he has Medicare plus employer-sponsored coverage through the DC exchange – a very comprehensive benefits package.

There are certainly lots of other people who have similar coverage arrangements – either because they’re still working after turning 65, like McCain, or because they receive generous retiree health benefits that supplement their Medicare coverage. For those who don’t, there are private Medicare supplements available that cover virtually all of the out-of-pocket costs associated with Medicare.

But health coverage in the United States is a bit of a mixed bag, with some people having much better coverage than others. A serious illness tends to shine a spotlight on the flaws that exist in some health plans, so let’s take a look at how the average American facing a glioblastoma diagnosis would fare under various health plans.

Employer-sponsored health insurance

Most employer-sponsored health insurance plans provide pretty solid health coverage. According to a 2016 Kaiser Family Foundation analysis, the average deductible for covered workers was about $1,500, and that doesn’t count the 17 percent of covered workers whose plans had no deductible at all.

In addition, the average employer paid more than two-thirds of the total premiums. And the tax exclusion of employer-sponsored insurance premiums amounts to a subsidy that cost the federal government $250 billion in fiscal year 2016.

However, employer-sponsored health insurance is, by definition, linked to employment. A person going through a serious illness like glioblastoma might not be able to continue working, depending on the specifics of the treatment.

As long as the employer has at least 20 employees, the employee will be able to continue the coverage under COBRA for 18 months, even if he or she is unable to work. But COBRA is expensive, as the employer contribution to the premiums and the tax exclusion of the premiums are eliminated. (COBRA premiums are counted as a medical expense for the purpose of itemized medical deductions, but only expenses that exceed 10 percent of your income can be deducted this way.)

Although most employer-sponsored plans provide good coverage, that’s due in part to the ACA. It was not uncommon – particularly in low-wage, high turnover industries – for employers to offer “mini-meds” before the ACA, with exceedingly low benefit caps. (The ACA’s ban on lifetime and annual benefit limits means that these plans are no longer offered to employees.)

A mini-med with a $2,000 or $5,000 annual benefit maximum would not have done much in the face of glioblastoma. Vox reported that just the initial craniotomy to remove a blood clot above Senator McCain’s eye would likely have been billed at more than $76,000. And that was before the cancer diagnosis.

ACA-compliant individual market coverage

The pre-ACA individual market included plenty of solid plans. But dubious coverage also abounded, and regulations varied considerably from one state to another.

The ACA imposed a bevy of regulations on the individual health insurance market, bringing all new (as of 2014) plans up at least a basic minimum standard. Individual major medical coverage can no longer be sold without the ACA’s essential health benefits.

And for those benefits, insurers cannot limit how much they’ll pay during a year or over the course of an insured’s lifetime. (Sadly, another Arizona resident with cancer, Arijit Guha, died in 2013 at age 32. Guha’s health insurance plan had a $300,000 lifetime cap – which is no longer allowed, thanks to the ACA – and his treatment, including chemotherapy that cost $11,000 per session, quickly exceeded that limit.)

Individual-market plans also cannot discriminate against people with pre-existing conditions, either by charging them higher prices or declining their applications (both of those were standard practice in nearly every state prior to 2014). Notably, Senator McCain has a history of melanoma, which would have virtually guaranteed a declined application in the individual market pre-ACA if he had been in need of non-group coverage for some reason.

A person with ACA-compliant individual market coverage would have solid coverage for glioblastoma. The maximum out-of-pocket costs during 2017 would be $7,150, although most plans have out-of-pocket maximums below that threshold. And 57 percent of people who enrolled through the exchanges in 2017 have cost-sharing subsidies, which further reduce the out-of-pocket costs.

The American Cancer Society explains in more detail how the ACA improves access to care for people with cancer. But the short story is that a person facing glioblastoma with a 2017 individual health insurance policy has a much more secure financial safety net than someone with the same diagnosis a decade ago.

Medicaid

Medicaid provides comprehensive coverage. Although the benefits available under traditional Medicaid vary from one state to another, Medicaid expansion coverage is required to include the ACA’s essential health benefits. (The Senate’s Better Care Reconciliation Act – BCRA – would eliminate this requirement after 2019.)

Medicaid has minimal cost-sharing, limited to no more than 5 percent of a family’s annual income.

It’s true that compared with private health insurance and Medicare, fewer medical providers accept Medicaid. But the majority do work with Medicaid. (According to a Kaiser Family Foundation analysis, about 69 percent of office-based physicians accept new Medicaid patients, while about 85 percent accept new privately-insured patients.)

Short-term health insurance

The ACA implemented regulations that apply to virtually all types of health insurance. But some plans are not regulated by the law, including short-term health insurance.

As evidenced by the name, short-term plans are limited in their duration. As of 2017, a short-term plan can last no more than three months, although people who remain healthy can purchase a second short-term plan after the first one ends.

Short-term plans do not cover pre-existing conditions. So if you were to be diagnosed with glioblastoma while covered under a short-term plan, the first thing the insurer would do is go back through your medical records to make sure that you didn’t have any symptoms prior to enrolling in the plan.

Assuming you were healthy before you enrolled, your short-term plan would start to cover your treatments. But you would be facing a looming and inflexible coverage termination date, along with annual and lifetime benefit maximums. Short-term plans vary considerably in quality – some have lifetime benefit maximums of $250,000 or less, while others provide benefits well in excess of a million dollars. In the case of a glioblastoma diagnosis, coverage would end when the policy reached its predetermined end date, or when you hit your benefit maximum – whichever happened first.

Either way, you’d want to hope that you had other coverage already lined up and ready to go at that point. The cancer diagnosis would make it impossible to obtain another short-term policy.

And since a short-term plan is not considered minimum essential coverage, the termination of the short-term policy would not trigger a special enrollment period for individual or employer-sponsored insurance. You would still be able to enroll in a regular individual-market plan, or an employer plan if you’re eligible for one, during regular annual open enrollment. But you might experience a significant gap in coverage, which can be disastrous in the middle of cancer treatment.

A limited-benefit plan

Limited-benefit plans are another category of coverage that’s not regulated by the ACA (despite attempts by the Obama Administration to place some regulations on certain types of fixed indemnity coverage).

Fixed indemnity means that the plan pays a specific dollar amount if the insured has a covered claim. For example, the plan might pay $1,000 per day for hospitalization, or $50 for a doctor visit. There’s no cap on how much the patient has to pay, and these plans often have very low annual and lifetime benefit limits.

So imagine a plan that will pay $2,000 per day for hospitalization, for up to 25 days. It will also pay $2,500 for an outpatient surgical procedure and $2,500 for an inpatient surgical procedure. And it will pay $625 for anesthesia, but it does not cover prescriptions (these numbers are from a real plan currently available in the limited benefit market).

Remember that McCain’s craniotomy – before the glioblastoma was even diagnosed – likely cost $70,000. He was home very soon after the surgery, so if he was hospitalized at all, it wasn’t more than a day or two. A limited benefit plan like the one described above would have paid $2,000 for each day in the hospital (which amounts to zero dollars if the procedure didn’t result in an inpatient stay), $2,500 for the surgery, and $625 for the anesthesia. That would leave a sizeable chunk of the $70,000 bill as the patient’s responsibility.

And all of that is before the treatment for the glioblastoma even begins.

A Cruz Amendment plan

In mid-July, Senator Ted Cruz introduced an amendment to the BCRA aimed at reducing regulations on health insurance plans. The Cruz Amendment, if included in the BCRA, would allow insurers to offer non-ACA-compliant plans as long as they also offered at least one Silver plan, one Gold plan, and one plan that complies with the BCRA’s benchmark standards (58 percent actuarial value).

The non-compliant plans would likely range from decent to terrible, since they would have wide latitude in terms of the consumer protections they’d be able to waive. Essentially, it would be a return to the pre-ACA days when there was more of an “anything goes” approach to health insurance. Plans would be available without essential health benefits, would not have to cover pre-existing conditions, and could be offered with higher out-of-pocket limits than ACA compliant plans.

These plans would likely appeal to healthy people, as they would be less expensive than ACA compliant plans. But a person who seems perfectly healthy can be diagnosed with glioblastoma, at which point the holes in the coverage become glaringly apparent.

What about those who lack McCain’s coverage

In glioblastoma, Senator McCain is facing a fierce battle, and our hearts go out to him and his family. But thanks to McCain’s health coverage, he won’t have to worry about how to pay for his treatment. I’m glad he has that health coverage.

Senator McCain is not alone in his battle. There are more than 12,000 Americans who will be diagnosed with glioblastoma this year. Unfortunately, many of them do not have the level of health coverage that McCain has. Even with the best health insurance, the diagnosis plunges each family into an immensely challenging situation. With lesser – or no – coverage, the challenge becomes even more insurmountable.

Nobody deserves cancer. And nobody deserves to have to fight cancer with less-than-adequate health insurance. With our current medical know-how, we can’t keep everyone from getting cancer. But we can make sure that as many people as possible are covered by high-quality health insurance. We owe it to all the lesser-known John McCains out there to work towards that goal.

That means pushing back against any sort of “reform” that would result in fewer people with insurance. It also means rejecting proposals that would allow junk insurance plans to flood the market, lulling consumers into a false sense of security – until they’re diagnosed with brain cancer.

Wondering Which Health Bill the Senate Will Vote On? Here’s Your Scorecard

Posted on July 23, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Cost Sharing Reduction Payments, Essential Health Benefits, Health Policy, Punt to the States • Leave a comment

https://www.thefiscaltimes.com/2017/07/21/Wondering-Which-Health-Bill-Senate-Will-Vote-Here-s-Your-Scorecard

There h Image result for health bill scorecard ave been times when congressional leaders decided to roll the dice and send major legislation to the floor with no certainty of the outcome because the odds of passage were a toss-up. Former House Speaker John Boehner (R-OH) did that more than once in trying to break a deadlock between far-right Freedom Caucus members and more moderate members of his party.

But rarely has a leader from either party asked his members to vote on a controversial bill – one with huge political implications for them — with no advanced warning of what was in the legislation.

Senate Majority Leader Mitch McConnell, a 32-year veteran lawmaker who some consider a “Master of the Senate” because of his wily ability to overcome legislative log-jams, is about to do just that next Tuesday, when he seeks to bring up health care reform legislation that for now remains a mystery to most of his own members, let alone the Democrats and the public.

McConnell spent months in secret backroom negotiations with a select group of Republican senators and Trump administration officials devising an alternative to a House-passed version of the legislation. But when the emerging plan was met with hostility from senators who thought it didn’t go far enough in gutting Obamacare or went too far in cutting Medicaid funding, McConnell engaged in an intense round of deal making to try to buy off opponents. But that didn’t work either.

Now, seemingly baffled by how to proceed, McConnell appears determined to seek closure on his party’s seven-year crusade to repeal and replace the Affordable Care Act. Unable to muster a minimum 50-vote Republican majority around any of a half-dozen competing plans to scrap and replace Obamacare, McConnell is considering a smorgasbord of choices next week to see which – if any—can win approval on the Senate floor in a wide-open showdown.

The options would range from an outright repeal of the ACA while delaying the effective date for two years to give Congress more time to devise a replacement, to simultaneously repealing and replacing Obamacare, to essentially punting on the issue by allowing states to decide for themselves whether to stick with the increasingly popular Obamacare program.

McConnell’s tactic is nearly unprecedented and would mark an extraordinary abdication of leadership responsibility in the drafting of historic health care reform legislation affecting one sixth of the economy, the health and well-being of 20 to 30 million Americans, and the long-term debt.

President Trump vowed throughout the 2016 presidential campaign that he and Republican lawmakers would repeal and replace the national health insurance program practically overnight once he took office. But for months, Trump was largely AWOL from the early talks and lobbying efforts that led to the narrow passage of a plan in the House in early May to the current deadlock in the Senate. Now Trump is making eleventh-hour demands that the Senate stay in town and pass some version of a GOP health bill, leaving McConnell caught between a rock and a hard place.

Steve Bell, a senior official at the Bipartisan Policy Center who spent 32 years on Capitol Hill as a Republican budget and economic adviser, said in an interview Friday, “I have never seen anything like this on an issue of this magnitude.”

Bell, who took part in past congressional deliberations over Social Security reform, deficit reduction deals and nuclear disarmament, added that “In all my years I’ve never seen a major issue that has been as mishandled as this.”

When Senate Majority Whip John Cornyn (R-TX) was asked by reporters whether senators would know in advance precisely what they would be voting on next week, he replied: “That’s a luxury we don’t have.”

There are several possible scenarios for how this political melodrama will play out on Tuesday, provided McConnell can persuade the majority to even proceed with a debate, which is far from a given. Here are the likely choices:

Repeal and Delay

Called the Obamacare Repeal and Reconciliation Act, this version of the bill is perhaps the simplest, if only because it does the least. Over the course of two years, the ORRA would eliminate many elements of the ACA entirely. The mandates would disappear, as would the tax increases, the new regulations regarding what insurance policies must cover, the subsidy payments to keep insurance affordable, and much more. What ORRA would not do is replace the ACA with a different structure meant to prevent the insurance markets from imploding.

The idea behind the ORRA is that, by giving lawmakers two years before the full impact of the law will be felt, there will be ample opportunity to craft a replacement. And because the alternative is so terrible, the argument goes, it follows that lawmakers will do just that.

This is not, to be clear, a sure thing at all. Congressional leaders used the same logic in 2011, putting the prospect of budget sequestration in place to force themselves to craft an alternative. They failed, and the country has been dealing with a policy that even its authors believed was terrible ever since.

CBO reviewed the ORRA earlier this week and determined that it would reduce federal deficits by $473 billion over a decade. But that reduction would come at the cost of 32 million fewer Americans with health care and premium costs for those who remain increasing 100 percent.

Repeal and Replace (I)

The Better Care Reconciliation Act is a sort of half-measure when it comes to doing away with the ACA. It would eliminate much of the law, including the hated individual mandate and many of the related taxes and regulations. However, it would leave much of the law’s structure in place, including subsidies paid to low- and -middle-income Americans. It would also leave many of the requirements related to what insurance policies must cover in place.

Those subsidies, however, would be smaller, and the policies they would buy would generally be worse in terms of coverage. The law changes the benchmark insurance policy from one that covers 70 percent of the expected costs of an individual’s average health care expenses to one that covers about 58 percent. While premiums would come down, the law would also cause deductibles to increase, in some cases by very large amounts. The CBO on Thursday found that the bill would result in Americans living near the poverty line being obligated to spend nearly their entire annual income in deductibles before full coverage kicked in.

CBO found that this version of the GOP repeal effort would save the Treasury $20 billion over a decade. That would come at the cost of about 22 million more Americans without insurance than would have it under current law.

Repeal and Replace (II)

This is an alternative version of the BCRA, restructured to make conservatives who felt the first draft of the bill left too much of the ACA intact. Championed by Texas Sen. Ted Cruz, it contains a provision that would allow insurance companies to offer policies that do not comply with the ACA coverage mandates. This would be conditional on them also offering plans that do comply, at the same time.

The CBO has not scored the BCRA with the Cruz amendment yet, and it is unclear that it will be able to do so before Senate leadership tries to reach an endgame on the health care reform process next week. But while there is no official tallying of the impact, experts have weighed in to warn that the Cruz amendment would have a serious negative effect on people with pre-existing medical conditions.

By allowing young and healthy people to choose bare-bones insurance policies, it will drain the risk pool for more substantial policies, leaving only older and sicker people covered under them. Because this means the insurers will face considerably more risk, they will, in turn, raise premiums and create a vicious cycle that could eventually price many Americans out of the market entirely.

Punt to the States

Some members of the Senate appear to have had their fill of attempting to restructure the health insurance industry in the US and are ready just to hand off the task to the states. Last week, on the same day that McConnell introduced the latest version of the BCRA, South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy announced that they would be offering their own alternative bill devolving much of the responsibility for structuring health care markets to the states.

“There’s about $500 billion in money; rather than trying to run health care from Washington, we’re going to block grant it to the states,” Graham said on CNN last week. “And here’s what will happen. If you like Obamacare, you can reimpose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced. It will be up to the governors. They’ve got a better handle on this than any bureaucrat in Washington.”

The bill has not been scored by CBO and has received relatively little attention from the media. However, it offers senators two things that many of them would like very much. First is the ability to say that they brought the health care debate to a conclusion that included the demise of the ACA. Second is that it gives the opportunity to claim that they had a role in funneling billions of dollars back into their states’ economies. While it’s unlikely to come up for a vote next week, given the confused state of play in the GOP conference, it would be unwise to rule it out completely.

GOP wrestles with soaring deductibles in healthcare bill

Posted on July 23, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Out of Pocket Expenses, Underinsured, Uninsured • Leave a comment

GOP wrestles with soaring deductibles in healthcare bill

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Senate Republicans have run into another problem in passing their ObamaCare replacement bill: It could increase deductibles by thousands of dollars, potentially alienating moderates who are already skeptical of the bill.

An analysis released Thursday by the nonpartisan Congressional Budget Office (CBO) concluded that a single policyholder purchasing a standard benchmark plan under the GOP bill could face a deductible of $13,000 in 2026.

Under current law, an individual making $56,800 would have a deductible of $5,000, while someone making $26,500 would have an $800 deductible.

A higher deductible is the tradeoff Republicans made when they decided that lowering premiums would be a top priority for their legislation; plans with lower premiums generally have higher deductibles.

“The way we come together, the way we bring together senators all across the ideological spectrum, is focusing on lowering premiums,” Sen. Ted Cruz (R-Texas) said on Fox News on Friday.

“If we’re lowering premiums, that’s a win for everyone.”

Deductibles could become so high under the GOP plan, the CBO said, that many low-income people might decide not to purchase a health insurance plan, even if the premiums were low.

That could be an issue for moderates who have worried about coverage losses, especially for those who gained coverage through ObamaCare’s Medicaid expansion.

The Republican legislation ends the expansion by 2023, and those people will be eligible for tax credits to buy insurance under the GOP plan.

Under the Senate bill, the tax credits for purchasing coverage are tied to ObamaCare’s less generous “bronze” plans that have lower premiums and higher deductibles.

Another factor driving the higher deductibles under the Republican proposal, according to the CBO, is the elimination of ObamaCare insurer payments known as cost sharing reduction subsidies. These payments reimburse insurers for giving discounted deductibles to low-income people.

In an attempt to address the issue, the White House is trying to win over moderates by proposing to allow states to use some Medicaid funding to help low-income people pay for their deductibles.

Higher deductibles for low-income people are a concern, said Sen. Bill Cassidy (R-La.), but he hopes the new White House proposal will fix that.

Senate Republican leaders are also considering offering $200 billion to states that expanded Medicaid, which would be funded by leaving in two of ObamaCare’s taxes on high earners.

That money would come in addition to $132 billion the revised bill already sets aside for a long-term state innovation fund and $45 billion to treat opioid addiction.

“If there’s enough to make it real that someone who is lower-income can get the assistance they need to afford insurance, then that matters,” Cassidy told reporters Thursday.

Sen. Mike Rounds (R-S.D.) said the purpose of leaving those taxes in was to “redistribute” that money to people facing higher costs under the bill.

“What we’re trying to do is allow more local control in some areas so individual states can do some things to help people based on what their needs are,” he said.

“That’s why we kept some of that tax revenue in place. So we can redistribute some of that money to help them because they have no place else to go.”

But some lawmakers question whether the additional funding would make a difference.

While the proposal would add $200 billion in funding, the legislation would cut $756 billion from Medicaid over the next decade, which includes the rollback of the expansion.

“As long as we are fundamentally changing Medicaid and taking some $700 billion out of the program, I do not see myself supporting a bill that does that,” Sen. Susan Collins (R-Maine) told reporters Thursday.

The CBO noted in its score that funding provided to states for stabilization would likely be used to reduce premiums, not deductibles, though the analysis did not include the additional $200 billion.

“The CBO expects that most of these funds would be used to lower premiums. There’s not a lot of money left over for cost-sharing,” said Cynthia Cox, an insurance expert with the Kaiser Family Foundation.

Small Missouri Town Went For Trump, Now Some Fear Health Care Overhaul

Posted on July 22, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, High Drug Costs, Out of Pocket Expenses, Preexisting Conditions, Rural Health, Underinsured, Uninsured • Leave a comment

http://kcur.org/post/small-missouri-town-went-trump-now-some-fear-health-care-overhaul-0#stream/0

The closest emergency room is 20 miles east on the highway. That’s why it isn’t unusual for people experiencing heart attacks, blood clots and strokes to show up at Dr. Rodney Yager’s clinic on Main Street in Monroe City, Missouri.

Yager, who grew up in the area, can handle the fast pace of a small-town clinic. What worries him more is how federal health care policies being shaped in Washington, D.C., could affect his patients.

The most recent proposal by Senate Republicans would cut taxes for the wealthy and leave 22 million more U.S. residents uninsured by 2026, compared to current law.

But voter frustrations with the Affordable Care Act’s rollout in communities like Monroe City helped fuel the elections of candidates who promised to dismantle it.

“Honestly, I can see the Republican side of wanting to make budget cuts and try to eliminate waste,” Yager said.”But at the same time, they’re hurting a lot of people.”

This town of almost 2,500 people sprang up about 130 miles northwest of St. Louis, along the railroad in the 1850s. Monroe City, which is just west of Hannibal, was once a Democratic stronghold in northeast Missouri. In the last decades, voters have shifted to favor conservative Republican candidates and their policies. In the most recent presidential election, Monroe, Marion, and Ralls counties voted for Republican Donald Trump over Hillary Clinton, his Democratic rival, by a 3 to 1 margin.

Nevertheless, Democratic U.S. Sen. Claire McCaskill received a warm welcome at the Monroe City Senior Nutrition Center last week, where she held her eighth of 10 town halls during the Senate’s July 4 recess. Her Republican counterpart, Sen. Roy Blunt, held none, a decision that drew protests in the St. Louis area. Members of Blunt’s staff said he met with constituents one-on-one throughout the week.

McCaskill is in a tough spot. Her six-year term will be up at the end of 2018, and she’s running for re-election in an increasingly red state. But in Monroe City, about 60 people listened as she vowed to vote against the latest Republican plan to gut the Affordable Care Act, and reiterated a call for Republican senators to accept amendments proposed by Democrats.

“It’s really a big tax break for wealthy folks, paid for by cutting the Medicaid program,” McCaskill said. “So I’m hoping it doesn’t pass. And then we can sit down together and try and fix what we have, repair what we have.”

It took just three questions before someone asked whether health insurance should be the basis of a health care system at all. Nearly everyone in the room raised their hands when McCaskill asked who would favor extending Medicare coverage to everyone, of any age. The idea of a single-payer system for American health care is a non-starter for conservative lawmakers and think tanks, but has grown in popularity among the general public. A recent Politico poll found that 44 percent of respondents would support a federal health care program for everyone.

“Even though more of you are for ‘Medicare for all,’ I’m worried that we can’t afford it right now,” McCaskill told the crowd. “It’s very expensive.”

Like many small towns in the United States, Monroe City’s population is aging. While voters are more likely to cast their ballot for Republican candidates, they are disproportionately affected by cuts in public spending for health care programs.

Medicaid Changes in Better Care Reconciliation Act (BCRA) Go Beyond ACA Repeal and Replace

Posted on July 22, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Block Grant Medicaid, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Medicaid, Medicaid DSH Payments, Medicaid Per Capita Spending, Planned Parenthood, Underinsured, Uninsured • Leave a comment

Medicaid Changes in Better Care Reconciliation Act (BCRA) Go Beyond ACA Repeal and Replace

Medicaid Changes in Better Care Reconciliation Act (BCRA) Go Beyond ACA Repeal and Replace

The Senate released an updated discussion draft of legislation called the Better Care Reconciliation Act of 2017 (BCRA) on July 20, 2017. For Medicaid, the overall framework is very similar to earlier versions of the bill in the Senate as well as the American Health Care Act (AHCA) that passed in the House. Both the BCRA and the AHCA go beyond repeal and replacement of the Affordable Care Act (ACA) to make fundamental changes to Medicaid by setting a limit on federal funding through a per capita cap or block grant. The BCRA also includes additional changes that would further reduce federal spending for states with high per enrollee spending, limit state financing mechanisms, allow states to impose work requirements, and make other eligibility changes. The revised draft of the BCRA leaves many provisions up to HHS Secretary discretion, creating further uncertainty for states about how implementation of the legislation would proceed. Across the board, these changes would have significant implications for the 74 million people covered by the Medicaid program and for states that jointly finance and administer the program.

The Congressional Budget Office estimates that under current draft of the BCRA, federal Medicaid spending related to the coverage provisions would decline by $756 billion over the 2017-2026 period or $739 billion accounting for all Medicaid provisions in the bill. According to CBO’s longer-term projections, the BCRA would reduce federal Medicaid spending by 35% in 2036 (Figure 1). These reductions would leave states with difficult choices about how to fill in the gaps in federal funding or cut back on Medicaid eligibility, benefits, or reimbursement rates (Figure 2). This brief explains the five most significant Medicaid changes in the BCRA as well as additional Medicaid changes that could have major implications for states, providers, and beneficiaries.

5 Most Significant Medicaid Financing Changes in the BCRA

1. Phase out the enhanced federal financing for the ACA Medicaid expansion.

Under the BCRA, for states that adopted the expansion as of March 1, 2017, the enhanced federal match would phase-out from 90% in CY 2020, to 85% in 2021, 80% in 2022, 75% in 2023 and then to the regular state match rate in 2024 and beyond. Thirty-one states plus DC have implemented the Medicaid expansion (Figure 3). On average, expansion enrollees account for 20% of all Medicaid enrollees (as of early 2016) and federal expansion financing accounts for about 21% of all Medicaid funding (for FY 2015). However, these shares are much higher in some states, placing them at higher risk for facing challenges in responding to the reduction in the federal match. Multiple states are likely to eliminate or scale back their expansion coverage due to the increased cost if federal funding is reduced, including eight expansion states (AR, AZ, IL, IN, MI, NH, NM, and WA) that have legislation requiring them to reduce or eliminate the expansion if the federal match rate is reduced. Given the magnitude of estimates of how much it would cost states to replace federal expansion funds, it appears that it is unrealistic to suggest that expansion states would be able to replace those funds and continue their expansion programs at current levels without the enhanced expansion match rate. Reports suggest that waivers or additional grant funding may be offered to states in place of the enhanced funding for the expansion, however, it is unlikely that such amounts would fully offset federal funding reductions in the BCRA tied to the expansion.

2. Limit federal Medicaid funding through a per capita, or per enrollee, cap on financing.

Under current law, Medicaid provides a guarantee of coverage for individuals who are eligible for the program and a guarantee to states of federal matching dollars for spending on Medicaid services. Beginning in FY 2020, the BCRA would limit federal Medicaid funding to each state based on the sum of the costs per enrollee for five beneficiary groups – elderly, blind and disabled adults,¹ children, expansion adults, and other adults – multiplied by the number of enrollees in the group and the state’s federal match rate. The proposed legislation specifies a uniform national inflation factor for the federal financing growth rate. Under both AHCA and BCRA, the per enrollee amounts would increase annually at slower rates than projected growth for Medicaid.

The caps are estimated to result in large reductions in federal Medicaid spending over time. Under BCRA, the caps would initially grow by the Consumer Price Index for medical care (CPI-M) for adults and children and by the CPI-M plus one percentage point for elderly and disabled groups. Starting in 2025, per enrollee amounts for all groups would increase by the historically lower CPI for urban consumers (CPI-U). All of these rates are lower than projected growth for private health insurance spending per enrollee. Reductions in federal Medicaid funding from the caps are expected to grow over time, especially after 2025 when the inflation factor is limited to CPI-U. Current projections have CPI-M growing at 3.7% and CPI-U at 2.4% annually; however, the rate of growth for these indices can vary and fluctuate over time which could cause uncertainty and instability in state budgeting.

3. Provides Secretary discretion to adjust per enrollee spending down for states with per enrollee spending 25% higher than the national average.

The BCRA also includes a provision not included in the AHCA, which would direct the HHS Secretary to adjust target per enrollee amounts under the per capita cap to bring states closer to national average spending. Specifically, the Secretary would adjust a state’s target per enrollee amounts by 0.5% to 2% for states spending 25% or more either above or below the national average per enrollee expenditures beginning in 2020. These adjustments are applied to overall per enrollee spending in 2020 and 2021 and then for each enrollment group in subsequent years. Adjustments are to be budget neutral to the federal government (meaning they would not result in a net increase of federal payments under the per capita caps for the fiscal year). Certain states with population densities less than 15 individuals per square mile (currently: AK, MT, ND, SD, and WY) would be exempt from this provision. Data for 2014 show that the number of states with high per capita spending that face tighter caps exceeds the number of states that would experience relief for having low spending overall and for each eligibility group (Table 1). Secretary discretion and actual spending patterns will make it difficult for states to estimate the effect of this provision.

4. Allow states the option to choose block grant financing for non-expansion Medicaid adults.

Beginning in FY 2020 under the BCRA, states could elect to receive federal financing for nonelderly/non-disabled traditional adults (low-income parents and pregnant women) and/or adults eligible through the ACA Medicaid expansion in the form of block grant instead of per capita cap funding. The block grant amount that states would receive from the federal government is initially based on the state’s target per capita spending amount for the fiscal year multiplied by the number of adult enrollees and the federal average Medicaid matching rate. The amount would grow annually by CPI-U even prior to 2025 when the per capita cap amounts would grow by the higher CPI-M inflation factor. States have a maintenance of effort (MOE) requirement—essentially, a minimum amount states must spend each year—that is the state share of the enhanced CHIP match rate (without the 23 percentage point increase provided under the ACA) multiplied by the block grant amount. If a state fails to meet the MOE requirement in a given year, its federal block grant amount for the following year would be reduced. States that meet MOE and continue to elect the block grant option can rollover unused block grant funds into the next fiscal year.

Under the block grant option, states could impose conditions of eligibility and not comply with key provisions in current law like comparability and state-wideness. Under the block grant option, states would be required to cover low-income parents and pregnant women at current federal minimum income levels and provide certain benefits. However, states could set conditions of eligibility for groups beyond these federal minimum groups, including for ACA expansion adults. Additionally, states electing the BCRA block grant option would not have to comply with other federal requirements, including comparability (the requirement that Medicaid-covered benefits be provided in the same amount, duration, and scope to all enrollees), state-wideness (the requirement that bars Medicaid programs from excluding enrollees or providers because of where they live or work in the state), and freedom of choice of provider (that allows beneficiaries to be permitted to choose among any provider participating in Medicaid). Like per capita caps, Medicaid block grants fail to account for changes in health care costs over time. Block grants also carry additional risk for states, providers, and beneficiaries because they do not account for changes in Medicaid enrollment (which could increase during an economic downturn).

5. Provides the HHS Secretary discretion to allocate funds to address the opioid crisis and public health emergencies.
The BCRA appropriates $45 billion for FY 2018 through FY 2026 for grants to states to support substance use disorder treatment and recovery support services with significant discretion to the HHS Secretary to allocate the funds. The BCRA also provides the HHS Secretary with discretion to exclude from a state’s per capita cap or block grant limit a total of $5 billion across all states for Medicaid spending in response to a public health emergency from January 2020 through December 2024. This exclusion would only apply during a period in which the HHS Secretary has declared a public health emergency in a state or region and also deemed an exclusion appropriate. Under current law, states can increase spending with a guaranteed federal match or seek waivers (like in Flint, MI or for states hit by hurricane Katrina) to address public health emergencies.

Other Significant BCRA Medicaid Changes

Other BCRA Medicaid changes with significant implications for states, providers, and beneficiaries include the following:

Limiting states’ ability to use provider taxes to finance their share of Medicaid by lowering the provider tax safe harbor threshold² from 6.0% to 5.0% of net patient revenues over 5 years, beginning in 2021. All states except for Alaska currently use provider taxes to finance the state share of Medicaid, and in 2016, 28 states had at least one tax exceeding 5.5% of net patient revenues. The proposed BCRA change could shift additional costs to states or result in additional reductions in Medicaid payment rates, services, or eligibility.

Creating a state option to require work as a condition of eligibility for nondisabled, nonelderly Medicaid adults as of October 1, 2017 (with some exemptions for certain groups including pregnant women or the sole caretaker of a child under age 6 or a child with a disability). Depending on how they are implemented, work requirements could increase administrative burdens on states and adversely affect some people, who are unable to comply due to their health, family caregiving obligations, or other reasons, by preventing them from accessing needed health coverage through Medicaid.³

Cancelling scheduled disproportionate share hospital (DSH) payment reductions for non-expansion (but not for expansion) states. The BCRA would exempt non-expansion states from the DSH reductions that were included in the ACA. During FY 2020-FY 2023, the BCRA would also provide a DSH payment increase to non-expansion states with per capita FY 2016 DSH allotment amounts (the FY 2016 DSH allotment divided by the number of uninsured individuals in the state for the fiscal year) that are below the national average per capita amount. A state qualifies as a non-expansion state if it is not covering expansion adults on or after January 1, 2021. This means that current expansion states that discontinue their expansions by the end of 2020 could qualify for increased DSH funds after their expansion ends. In addition, the BCRA would provide certain non-expansion states with $10 billion over 5 years (FY 2018-FY 2022) for safety-net funding.

Changing eligibility and enrollment processes with new requirements for eligible individuals to obtain and maintain Medicaid coverage. Changes include: repealing the requirement for states to cover Medicaid benefits retroactively for three months prior to the month of an individual’s enrollment in the program except for enrollees who are eligible based on old age or disability only); prohibiting hospitals from temporarily enrolling individuals in Medicaid if they are likely to be eligible under a state’s Medicaid eligibility rules (a policy known as “hospital presumptive eligibility”); removing a presumptive eligibility option that includes health care providers other than hospitals for expansion adults; and giving states the option to renew eligibility of Medicaid expansion adults every six months (or more frequently) compared to the current 12 month redetermination period.

Prohibiting federal Medicaid funding for Planned Parenthood for one year (beginning on the date of enactment). The Hyde Amendment already prevents the use of federal funds for abortion services,⁴ so the effect of this proposed policy would be to limit Planned Parenthood’s capacity to provide preventive care and other services to women (such as clinical breast exams or birth control).

Repealing the enhanced federal match rate available under the ACA for the Community First Choice (CFC) state plan option, as of January 1, 2020. The ACA established the CFC option to allow states to provide home and community-based attendant services and supports to Medicaid enrollees who would otherwise require an institutional level of care. States taking up the option currently receive a 6% increase in their federal match rate for CFC services, and without this additional funding states may eliminate the option. The BCRA also creates a demonstration that would provide 100% federal matching funds for certain states selected by the HHS Secretary providing home and community-based services (HCBS) for seniors or adults with disabilities under a Section 1915 (c) or (d) waiver or Section 1915 (i) state plan authority, limited to $8 billion over four years, from 2020 through 2023. The Secretary would select participating states with priority given to the 15 states with the lowest population density. Unlike CFC, the authority for this new demonstration is time-limited, all states likely could not participate, and federal funding is capped. The $8 billion allocated to the new demonstration is less than half of the cost of the elimination of CFC funding, estimated by the CBO at $19 billion over 10 years.

Increasing the federal match rate for Medicaid services provided to American Indians by non-Indian Health Services (IHS) providers. Under existing law, the federal government covers 100% of the costs of Medicaid-covered services provided to American Indians through an IHS or Tribally-operated facility, and the BCRA would expand this 100% match rate to apply to all Medicaid-covered services delivered by all Medicaid providers to Medicaid-eligible members of an Indian tribe.

Repealing the essential health benefit requirement in Medicaid alternative benefit plans, beginning in 2020. The alternative benefit plans are required for expansion adults and a state option for benefit package design for certain other populations. While the Medicaid benefit package for children under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is comprehensive, states have flexibility to design benefit packages for adults, and many services for adults are offered at state option. If the essential health benefits requirement were repealed, there would be no federal minimum requirement in Medicaid to ensure that adults have coverage in certain areas such as mental health and substance use disorder treatment.

CBO: ObamaCare repeal without replace would cost 32 million insurance

Posted on July 19, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Cost Sharing Reduction Payments, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Medicaid, Preexisting Conditions, Underinsured, Uninsured • Leave a comment

CBO: ObamaCare repeal without replace would cost 32 million insurance

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Repealing ObamaCare without a replacement would result in 32 million people losing their insurance in the next 10 years, according to the Congressional Budget Office.

The bill, much of which would take effect in 2020, would also massively increase insurance premiums. According to the CBO, average premiums would increase by about 25 percent in 2018 alone. The increase would reach about 50 percent in 2020, and premiums would increase nearly 100 percent by 2026, CBO said.

Senate Republicans said this week they would consider voting on repeal only, after it appeared their replacement legislation had failed. However, negotiations attempting to revive repeal and replace continue and senators are scheduled to huddle Wednesday night to discuss if there’s a path forward.

The unfavorable score of the repeal-only bill could help jumpstart discussions about returning to the repeal-and-replace legislation.

A previous CBO score of the Senate’s repeal-and-replace bill estimated that 22 million people would lose insurance over the next decade.

The CBO hasn’t released a score on the most recent revision, which includes a controversial amendment from Sen. Ted Cruz (R-Texas).

The Senate will vote next week on a motion to proceed, though it’s not clear which bill Majority Leader Mitch McConnell (R-Ky.) wants to move to — a straight repeal or the repeal-and-replace legislation that seemed dead just days ago.

Both the House and Senate passed the “repeal-only” bill in 2015 that was vetoed by President Obama. Among other provisions, the “repeal only” bill would eliminate: ObamaCare’s individual and employer mandates, the Medicaid expansion, and subsidies for low-income individuals.

It would retain the requirements that protect people with pre-existing conditions from discrimination and would continue to require insurers to offer specific benefits.

According to the CBO “eliminating the penalty associated with the individual mandate and the subsidies for insurance while retaining the market regulations would destabilize the nongroup market, and the effect would worsen over time.”

Republicans have argued that they need to repeal and replace ObamaCare to “rescue” the growing number of people who live in counties with no insurers on the healthcare exchanges. But according to the CBO, repeal-only would make the problem worse.

The repeal-only bill would cause insurers to begin dropping out of the marketplace as soon as next year, the CBO said. It would also leave about half of the nation’s population without any ObamaCare insurers by 2020, a figure that would increase to about three-quarters of the population by 2026.

Here are the hidden items in the Senate GOP’s new Obamacare repeal bill

Posted on July 17, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Essential Health Benefits, Health Policy, Medicaid, Senate Exempts Themselves from Loss of Consumer Protections • Leave a comment

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The Senate GOP hid the meanest things very deeply in its Obamacare repeal bill. We found them

Senate Republicans unveiled a new, “improved” version of their Affordable Care Act repeal bill Thursday, so the treasure hunt is on: the search for provisions so horrifically inhumane that they’ve had to be concealed deep in the measure’s legislative language and procedural maze.

We’ve found quite a few, with the help of professional spelunkers Andy Slavitt, David Anderson, Larry Levitt and others. Here are some of the provisions in the so-called Better Care Reconciliation Act, or BCRA, that the Senate GOP really doesn’t want you to know about.

—The measure kills the birth control and women’s health screening requirements. The Affordable Care Act advanced women’s healthcare rights immensely by mandating that health plans cover contraceptives, as well as a range of preventive screenings, without deductibles or co-pays. Conservatives have been trying to roll back those guarantees since the ACA’s enactment. The new Senate bill eliminates them.

That action is part of the Cruz Amendment, on which more below. It allows states to authorize the sale of health plans that don’t include the women’s health provisions. Observes Dawn Laguens of Planned Parenthood, “Insurance companies would once again be allowed to refuse to cover basic preventive healthcare, as well as charge women co-pays for birth control, immunizations and cancer screenings.” She calls this “a major step backward for women.”

—HHS Secretary Tom Price gets enormous new power over healthcare standards and even state budgets. The essence of the amended bill’s bait-and-switch structure is the creation of several slush funds to moderate the costs to states of various repeal provisions, especially the drastic cutback in Medicaidfunding.

Those slush funds, however, would come under the control of Health and Human Services Secretary Tom Price. A known enemy of Medicaid and of expanding healthcare services for women and the needy, Price would have the authority to apportion those funds as he wishes, favoring some states over others because of their politics and policies, for example.

As former Medicare/Medicaid chief Andy Slavitt observes, there are no rules or standards guiding Price’s hand — he could dole out all the money to red states or pull funding from others at will. The money doesn’t have to go to services for low-income people or to replace lost Medicaid funding. He could shortchange states that require health plans to cover abortion — such as California and New York.

“The bill is a giant ‘Trust Tom Price’ bill,” Slavitt tweeted. And even if the money is apportioned responsibly, it’s not enough: The total in the slush funds, Slavitt calculates, would restore barely 10% of the cuts in Medicaid.

—The bill still cuts taxes for the wealthy. One widely noticed change from the original Senate bill is the retention of two taxes the ACA imposes on high-income taxpayers — those earning more than $200,000, or $250,000 for couples. These are a 3.8% surcharge on capital gains and dividends and a 0.9% increase in the Medicare tax for those taxpayers. The original Senate bill would have repealed those taxes, handing over an estimated $346-billion windfall to the rich over 10 years.

But don’t cry for the wealthy just yet. The amendment expands another windfall — health savings accounts, which are tax-preferred accounts that can be used to pay for out-of-pocket medical expanses. Under the amended bill, HSAs also can be used to pay premiums, which effectively renders premiums in the individual market tax-deductible for the first time.

HSAs sound good in principle, but in practice they’re geared to higher-income taxpayers. Although some employers help their workers fund HSAs, for the most part the accounts have to be funded out of disposable income, which many middle- and working-class families may find hard to come by. A study released this month by the Employee Benefit Research Institute found that, although the maximum annual contribution is $6,750 for families and $3,450 for individuals, the average total account contribution was $2,922 in 2016.

The Tax Policy Center says that more than 16% of all households with $200,000 in income or more have HSAs — but fewer than 2% of households earning less than $30,000 do.

The Republican repeal bills would raise the maximum contributions to $6,550 for individuals and $13,100 for families — but since most families can’t even max out their HSAs now, they plainly wouldn’t be helped by this change. Rich families would be helped, however.

—The senators exempt themselves from the loss of consumer protections. A convoluted provision in the amended measure exempts Congress and its staff members from the loss of guarantees for those with preexisting conditions and other consumer protections.

You won’t find the words “Congress” and “exemption” next to each other anywhere in the bill. You have to know that “1312(d)(3)(D)” is the provision of the Affordable Care Act requiring members of Congress and their staffs to obtain coverage through the Obamacare exchanges, and then notice, on Page 167 of the Senate bill, that the elimination of consumer protections is “non-applicable” to that section.

Senate leaders say the exemption is necessary for procedural purposes, and imply that they’ll remove it in subsequent legislation. We’ll see.

—The opioid money is a Band-Aid. Opioid addiction has emerged as perhaps the worst public health crisis in the nation. As much as 40% of the cost of treatment of addicts has been covered by Medicaid. The harsh cuts in that program imposed by the Senate and House repeal bills would force more of that expense onto states that simply can’t afford it. Meanwhile, the projected loss of medical coverage by as many as 23 million Americans under repeal will keep many victims of the epidemic from finding treatment.

The cost of fighting the epidemic and treating the secondary health problems of its victims, such as HIV and hepatitis C, has been estimated at as much as $183 billion over 10 years. The original Senate measure included only a one-year, $2-billion appropriation for the purpose. The revised bill provides $45 billion over 10 years. Interestingly, that’s exactly what was requested by GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia. So the appropriation won’t be adequate as a solution to the opioid crisis, but it might be enough to bring those two potential holdouts on board.

—The “Murkowski Mollification.” The Senate bill has a craftily-worded handout for Sen. Lisa Murkowski (R-Alaska). She’s been a holdout on the Senate bill because of its massive cuts to Medicaid, an important healthcare program in her state.

The amended measure guarantees at least $1.3 billion, or 1% of a $132-billion, 10-year bailout fund, to any state where premiums are 75% higher than the national average. Only one state qualifies: Alaska.

It’s not unusual for such provisions to be buried in legislation that appears to have broader application. Indeed, the Affordable Care Act included a so-called “Cornhusker Kickback” to benefit Nebraska and secure the vote of then-Sen. Ben Nelson. In this case, the provision means Alaska, a state with 0.2% of the nation’s Medicaid enrollment, would get a disproportionate windfall. As of this writing, Murkowski hasn’t said if she’ll take the bait. But as Slavitt observes, the payoff sets the stage for demands by senators from other states.

“If I’m WV, TN, AZ, WY, I want to know where mine is,” Slavitt tweeted. In any event, the money wouldn’t be enough to cover Alaska’s losses from the Medicaid rollback, and it would still be subject to cancellation at any time by Price.

—The Cruz Amendment is a disaster for health insurance buyers. We’ve written before about the amendment crafted by Sen. Ted Cruz (R-Texas). It would effectively destroy the healthcare market nationwide.

The amendment would allow states to authorize any insurer to offer bare-bones policies as long as they also offered at least one ACA-compliant policy in that state. This opens the door to bifurcating the insurance market. Younger, healthier buyers, especially males, might sign up for cheap policies without coverage for hospitalization, substance abuse, prescriptions, maternity or preexisting conditions. That would force everyone else to buy a fully compliant plan; since such a plan would be filled with customers with potentially risky and costly conditions, its premium would soar. As it became progressively less affordable, all but the sickest buyers would leave, making it even more costly.

This is the definition of a “death spiral” that Republicans claim they want to avoid. It makes a mockery of their promise to protect people with preexisting conditions, since the cost of insurance for them would soon be stratospheric.

—Buyers of cheap Cruz plans would be locked out of the insurance market if they get sick. A little-noticed aspect of the Cruz proposal is that the cheap plans it allows would not qualify as legitimate insurance coverage under the GOP’s “continuous coverage” rules.

Those rules, embodied in both the House and Senate GOP repeal bills, guarantee coverage for preexisting conditions as long as the buyer maintains insurance coverage without a break of longer than two months. Under the Senate bill, anyone with such a lapse would face a six-month waiting period for new insurance before the preexisting condition guarantee would be effective.

That means that individuals who get sick and discover that their Cruz plan won’t cover their illness wouldn’t be able to buy full coverage for at least six months. It’s a classic bait-and-switch, but you won’t hear it being bragged about by Senate Republicans. They don’t really want you to know.

The Congressional Budget Office, which determined last month that the original Senate bill would cost 22 million Americans their insurance by 2026 compared with the current law, hasn’t weighed in on the amended version. It’s unlikely that the CBO will think much more highly of the amendments.

For that reason, Senate GOP leaders have been hinting that they’ll skip, or ignore, any CBO analysis and rely instead on one prepared by Price’s HHS. What are the chances the HHS will deliver a credible analysis? Probably nil

In Senate Health Care Bill, A Few Hidden Surprises

Posted on July 16, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Block Grant Medicaid, CBO, Essential Health Benefits, Federal Matching Fund for Medicaid, Health Policy, Health System, Hospital, Medicaid, Medicaid Retroactive Eligibility, Mental Health, Rev Cycle, Substance Abuse Disorders, Uncompensated Care • Leave a comment

http://healthaffairs.org/blog/2017/07/13/in-senate-health-care-bill-a-few-hidden-surprises/

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A low-income person, eligible for Medicaid but not enrolled, is hit by a car or a bullet. Gravely injured, she arrives at the hospital unconscious. Thanks to expert, intensive care that lasts for days or weeks, she gradually recovers. Eventually, her health improves to the point where she can complete the paperwork needed to apply for Medicaid.

Such a hospital can be paid today, thanks to Medicaid’s “retroactive eligibility.” Even if the combination of medical problems and bureaucratic delays prevents an application from being filed and completed for several months, Medicaid will cover the care if the patient was eligible when services were provided.

The newest version of the Senate health bill—the Better Care and Reconciliation Act, or BCRA—would end this longstanding feature of the Medicaid program for beneficiaries who are neither elderly nor people with disabilities. If services are received in one calendar month and the application is completed the following month, the hospital would be denied all payment, even if the patient was eligible and the services were both essential and costly.

It does not matter if the state is led by a governor who understands the devastating impact of this change on hospital infrastructure, especially in rural areas where many hospitals are hanging on by a thread. Today, states have the flexibility to seek waivers that limit retroactive eligibility. Under the BCRA, that flexibility would disappear, as states are forced to end retroactive coverage, whether they like it or not.

Almost certainly, this provision would come as a surprise to most senators who are being asked to support the BCRA. It is only one of many unpleasant surprises lurking largely undiscovered throughout the bill. Following are other selected examples.

A Massive Expansion In Federal Power Over State Budgets

The BCRA grants the federal government startling new power over state Medicaid programs and state budgets. Federal dollars per person would be capped, based on state data about prior spending. But in setting the initial cap for each state, the secretary of Health and Human Services (HHS) could change the amount to rectify what the secretary views as problems in the “quality” of state data. In later years, many states could have their caps adjusted up or down by as much as 2 percent per year. That may sound like a small number, but when applied to billions of federal Medicaid dollars going to a state, it could make or break a state’s entire budget. Medicaid costs triggered by a public health emergency are exempt from the cap, but only if “the Secretary determines that such an exemption would be appropriate.” No statutory limits bound the Secretary’s use of this decision-making authority, which can have an extraordinary fiscal impact on states experiencing an epidemic or other public health crisis.

These provisions would give HHS remarkable new leverage over states, which current or future administrations could use to compel state policy changes in any desired direction. The aggressive use of available leverage has been an unfortunate feature of past administrations’ relationships to state Medicaid programs, but it could become substantially more pronounced with the increased federal authority granted by the Senate bill.

Adding To Uncertainties Surrounding State Expenditures

One recurring theme in Medicaid’s history involves state efforts to claim federal matching funds without spending the requisite state dollars. The Senate bill appears to increase this risk. Under Section 207 in the Senate bill, new opportunities emerge for states desperate to counteract the loss of billions of federal dollars. The bill authorizes unprecedented waivers involving federal funding for tax credits that help consumers buy private health insurance. So long as officials complete a form explaining how the waiver’s replacement of federal safeguards would provide an “alternative means” of increasing “access to comprehensive coverage, reducing average premiums, and increasing enrollment,” a state arguably could convert some or all of this federal money into so-called “pass-through” funds that can be used for purposes unrelated to health care. Unlike the Senate bill’s new public health emergency provisions, which require federal audits of state expenditures, states’ use of pass-through dollars has no statutory audit requirement. A state could convert subsidies meant for health insurance to other uses, or simply use the money to close a budget shortfall. As the Congressional Budget Office (CBO) explained about the virtually identical prior version of this section, the Senate health care bill would “substantially reduce the number of people insured” if states “reduced subsidies, received pass-through funds, and used those funds for purposes other than health insurance coverage.”

Medicaid Treatment For Mental Health And Substance Use Disorders

The bill repeals the current requirement that Medicaid programs must cover all “essential health benefits,” including treatment of mental health and substance use disorders. CBO found that, as the per capita limits in the Senate bill grow progressively tighter, federal Medicaid funding would eventually decline by more than a third, compared to current law. States facing such an enormous drop in federal support may see themselves as having no alternative but to cut services classified as optional, which the Senate bill redefines to include mental health and substance abuse treatment.

A Disordered Process

These problems could have been averted had the legislative process followed regular order, with hearings, legislative staff explaining the bill’s provisions, expert testimony, a public markup, and opportunities to address policy and drafting anomalies. Embedded in a measure with underlying policy goals that the authors of this blog post find fundamentally questionable, the picture that emerges is extraordinarily troubling—a legislative effort to divert more than a trillion dollars away from health care for people who are sicker, poorer, older, and indigent, while leaving states with such massive funding deficits and federal leverage that some states may attempt to stem their losses in ways that harm their vulnerable residents even more.

Even people sympathetic to the bill’s core aims, however, have good reason to oppose the Senate making such consequential decisions without taking the elementary legislative steps needed to detect and avoid terrible mistakes. Continuing to shun all the protections of regular order, the Senate appears poised to act on a bill that almost certainly includes additional unpleasant surprises going beyond those discussed here. With legislation that governs one-sixth of the US economy and that directly affects the health and economic security of millions of constituents, Senators are being asked to vote largely in the dark.

The massive Senate GOP shift on pre-existing conditions

Posted on July 13, 2017 by henrykotula • Posted in Uncategorized • Tagged ACA, ACA Repeal, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Insurance Individual Market, Health Policy, Preexisting Conditions, Underinsured, Uninsurable Pre-Existing Condition, Uninsured • Leave a comment

https://www.axios.com/the-massive-senate-gop-shift-on-pre-existing-conditions-2458798705.html

Over the past several weeks, senior GOP aides have repeatedly said that if the Senate bill touches pre-existing conditions in any way, it will lose around a third of the caucus. Today, a provision that could cause sick people to pay much higher premiums than they currently do has not caused any Republicans to say they’ll vote against the GOP health bill.

When Senate GOP leaders first presented their plan to the caucus in a PowerPoint presentation, it explicitly said that pre-existing conditions wouldn’t be touched, aides say.
As recently as two weeks ago, aides said members were surprised and angry to learn that Sen. Ted Cruz’s Consumer Freedom Option would allow plans that didn’t include the Affordable Care Act’s pre-existing conditions protections. (They could only be sold by insurers that also offered plans with the protections.)
Sen. Bob Corker: “I think people understand that’s got to be protected, and people understand what happened when the House dealt with it and opened it up, and it’s just not something that senators are wishing to do.”
Sen. Shelley Moore Capito over recess: “I think that reopens an issue that I can’t support, that it would make it too difficult for people with pre-existing conditions to get coverage.”
Sen. Chuck Grassley last week: “There’s a real feeling that that’s subterfuge to get around pre-existing conditions.”

Now, that resistance is “melting away,” as one Senate Republican aide put it today. “No one wants to be bad guy.”

Indeed, almost seven hours after the revised bill — including the Cruz provision — had been released, no Republican senator had threatened to vote against the bill unless the provision is removed. In fact, Republicans had surprisingly little to say about it.

What the Consumer Freedom Option does:

It allows insurers that offer ACA-compliant plans to also sell plans that do not comply with ACA regulations, including the law’s essential health benefits and its pre-existing conditions protections.
Advocates of the bill say that while this could sort sick and healthy people into two different marketplaces, causing premiums to skyrocket for sick people, they’ll be insulated from these costs by premium subsidies and the bill’s stabilization fund.
Members “don’t realize we are basically creating single payer for sick people,” the GOP aide told me, saying that Republicans’ support is growing because people with pre-existing conditions can still get exchange plans.
The problem: “If there were hearings, everyone would have a lot more information about Cruz. Right now, Cruz is the only seller of the amendment and he’s the only one with information about the amendment,” said one well-connected GOP lobbyist, who said Cruz’s sales pitch seems to be convincing members to support his idea.

What insurers and experts are saying:

America’s Health Insurance Plans: “Patients with pre-existing conditions … would potentially lose access to comprehensive coverage and/or have plans that were far more expensive.”
Scott Serota, president and CEO of the Blue Cross Blue Shield Association: “The ‘Consumer Freedom Option’ is unworkable as it would undermine pre-existing condition protections, increase premiums and destabilize the market.”
Kaiser Family Foundation: 1.5 million people with pre-existing conditions could have higher premiums under the Cruz amendment.

Yes, but: The conservative groups love it, as it addresses the ACA regulations that weren’t fully addressed in the previous version of the bill. They believe those regulations are driving up the cost of insurance. Stripping the provision could lose these groups’ support.

And Michael Cannon of the libertarian Cato Institute says the provision “would make access to healthcare more secure for patients who develop expensive conditions” — because it would free insurers to introduce a wider variety of health plans and make them less likely to leave the markets.

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HENRY KOTULA

A Healthcare Leadership Blog

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