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

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

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

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

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

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

Among the takeaways from this week’s podcast:

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

Association health plan proposal: Experts wary of weak consumer protections, oversight issues

https://www.fiercehealthcare.com/regulatory/association-health-plans-consumer-protections-tim-jost?mkt_tok=eyJpIjoiTjJRNU5qUXlZVEJqWmpjNCIsInQiOiJOR2V2bEp4NkdoeVB3VndhZE43TVBjZXdaTGJcLzk1Z3hBd1wvZ05teDMrcjZ5UzJhb0tzUkpQbWlaSmVvUmJFazVDcERmajBTREhCTXJxR3BBaGtoY1MrZlVtQW5xeXRSbFwvYVhPOE44VE9uYUhNZWNnbGtoR3c3S0xHUlp5SlwvS2kifQ%3D%3D&mrkid=959610

stethoscope, coins and calculator

The new proposal to expand association health plans promises to provide more affordable insurance options for small-business owners and employees. But some experts aren’t convinced that this is the right solution.

For one, the proposal’s promises of consumer protections aren’t as strong as they seem, said Timothy Jost, a Washington and Lee University professor emeritus who closely follows the ACA.

Association health plans can’t charge higher premiums or deny coverage based on health status, according to the Department of Labor (DOL). But because AHPs would be subject to large-employer market rules, they wouldn’t have to cover the list of essential health benefits that the Affordable Care Act mandates.

The upshot, Jost told FierceHealthcare, is that insurers could legally weed out those with costly conditions while still complying with regulations that bar them from denying those individuals coverage or hiking their premiums.

“If you can’t exclude someone because they have cancer, it’s easy to just not cover chemotherapy,” he said. “Or if you can’t exclude people who have mental illness, it’s easy to just not cover mental health care.”

And Larry Levitt, senior vice president of the Kaiser Family Foundation, pointed out in a Twitter post that insurers could still hike premiums based on factors other than health status:

 The association health plan regulation prohibits variation in premiums based on health. It does not prohibit premium variation based on any other factor, such as gender, age, industry or occupation, or business size.
 Cherry-picking enrollees

Association health plans are also likely to be marketed toward the healthiest, youngest individuals, Jost noted.

“I doubt anybody is going to be out there writing association coverage for occupations that are predominantly people who are older or have chronic health problems,” he said.

The problem, then, is that AHPs would siphon more low-risk consumers out of the individual marketplaces—thus skewing that risk pool and likely causing insurers to raise premiums.

“I think everybody understands that this is going to undermine the market for ACA-compliant plans,” Jost said.

Andy Slavitt, the former Centers for Medicare & Medicaid Services acting administrator, laid out his own criticisms in a Twitter thread—including pointing out that breaking up risk pools goes against the proposal’s stated purpose of giving small businesses more clout:

 The regulation aims to push the idea of what can be considered an association.

Someone I talked to today referred to it as being able to create an “air breathers association.” Essentially, making it as rude-less as possible.

 Many of the premises of AHPs have been shown not to work in the past.

For example, the rule says AHPs will create “increased buying power”. Breaking up pools does exactly the opposite.

Instead, a “Runners’ Association” just sends a clear signal that these are healthy people.

Limited impact

Merrill Matthews, Ph.D., a resident scholar at the right-leaning Institute for Policy Innovation, praised the new proposed rule, noting that it allows small businesses to do what large employers have long been able to: self-insure.

“Self-insured employers have been able to avoid many of the state and federal mandates imposed on the small group and individual markets, which helped employers keep down the cost of coverage,” he said.

But even Matthews acknowledged that the impact of the proposed policy changes is likely to be limited, as it will only apply to small employers and possibly some self-employed individuals. Since the proposed changes are “unlikely to provide much relief” for those affected by high premiums in the individual market, he said, “Congress still needs to repeal the Affordable Care Act.”

Questions about oversight

Perhaps the biggest issue that Jost saw with the new proposal was the fact that AHPs have had past issues with insolvency, bankruptcy and even fraud.

“There’s just a long history of association health plans being formed that are thinly capitalized, that pay large salaries and expenses for their owners, and disappear when the going gets rough,” he said.

For its part, the DOL said it will “closely monitor these plans to protect consumers.” But Jost pointed out that the agency has experienced staff and budget cuts that might undermine that goal.

Even the DOL itself said in the proposed rule that “the flexibility afforded AHPs under this proposal could introduce more opportunities for mismanagement or abuse, increasing potential oversight demands on the department and state regulators.”

Ultimately, what plays out will largely be decided by how states respond to the new regulations once they are implemented, Jost added.

“In states that try to take an aggressive approach to regulating them, there won’t be that much activity,” he said. “And in states that take a hands-off approach and let anything go, there will be probably quite a bit of activity until [AHPs] start going belly up.”

 

AP-NORC Poll: Health Care Is the Issue That Won’t Go Away

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As President Donald Trump completes his first year in office, Americans are increasingly concerned about health care, and their faith that government can fix it has fallen.

A new poll by The Associated Press-NORC Center for Public Affairs Research finds that 48 percent named health care as a top problem for the government to focus on in the next year, up 17 points in the last two years.

The poll allows Americans to name up to five priorities and found a wide range of top concerns, including taxes, immigration and the environment. But aside from health care, no single issue was named by more than 31 percent.

And 7 in 10 of those who named health care as a top problem said they had little to no confidence that government can improve matters. The public was less pessimistic in last year’s edition of the poll, when just over half said they lacked confidence in the problem-solving ability of lawmakers and government institutions.

“We are way up there on the cost, and as far as giving good health care, we are way down,” said Rebekah Bustamante of San Antonio, a retired medical imaging technician. “Now in health care, you’re a number.”

Bustamante said she voted for Trump, but “he’s learning on the job, and he’s got a long way to go.”

Trump initially promised his own plan that would deliver “insurance for everybody” and “great” health care, “much less expensive and much better.” But the White House never released a health care proposal from the president.

GOP legislation to repeal and replace former President Barack Obama’s health care law failed in Congress, although the tax bill scraps the Obama requirement that most people get health insurance. Bloodied on both sides, Republicans and Democrats seem to have battled to an uneasy draw on health care.

Meanwhile, conflicting policy signals from Washington, including an abrupt White House decision to cancel insurer subsidies, roiled insurance markets. Premiums on health plans purchased by individuals jumped by double digits. Progress reducing the number of uninsured stalled, and one major survey found an uptick this year.

“There is zero bipartisanship, and it’s frustrating,” said Eric Staab, a high school teacher from Topeka, Kansas. “It seems like we have thrown everything at this dartboard, and nothing is improving the coverage.”

Rumblings of discontent have political repercussions for next year’s midterm elections and the presidential contest in 2020, said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health, who follows opinion trends on health care.

“It’s the issue that won’t go away,” said Blendon. “Given the news cycle, taxes should be first, the economy should be second, and this health care thing should be buried.”

Three in 10 Americans listed taxes among their top priorities, about double the percentage who said that last year. About a quarter mentioned immigration, and just under 2 in 10 mentioned environmental issues and education. Meanwhile, concerns about unemployment plunged to 14 percent, about half the mentions as last year.

Health care was by far the top issue mentioned by Democrats and independents. Republicans were about equally likely to mention immigration, health care and taxes.

Democrats were more likely than Republicans to say they have little to no confidence that the government will make progress on health care, 84 percent to 57 percent.

The reason health care doesn’t fade away is that costs aren’t getting any more manageable, said some people who took part in the AP-NORC survey.

Bustamante said she is planning a trip to Mexico for some dental work, because she can obtain quality service for much less there. “Thank God I live in Texas, where getting to Mexico isn’t that far away,” she said. “But everybody doesn’t have that option.”

ShyJuan Clemons of Merrillville, Indiana, said he’s currently uninsured because his previous health plan was costing too much money for the benefit he got from it. He faced his insurance plan’s annual deductible when he went to the doctor, so he’d wind up paying out-of-pocket for visits, on top of premiums.

“You are not constantly worried about taxes, but you are constantly worried about health care — be it major or minor,” said Clemons, a personal care attendant who works with disabled people. “You catch a cold, and you just think about it in passing — ‘I hope it doesn’t develop into a problem.'”

Clemons, a Democrat, said he’s disappointed that Trump and Republicans in Congress seem to be trying to tear down “Obamacare” instead of building on it. “I would like to see them make the thing run smoothly so we can do better, instead of just trying to cripple it,” he said.

The lack of confidence in the ability of government to find pragmatic solutions extended to other problems in the AP-NORC poll, including climate change, immigration, and terrorism.

Just 23 percent said that Trump has kept the promises he made while running for president, while 30 percent said he’s tried and failed, and 45 percent said he has not kept his promises at all.

Nearly 2 in 3 said they were pessimistic about the state of politics in the U.S. About half were downbeat about the nation’s system of government, and 55 percent said America’s best days are behind.

 

Out-of-pocket health spending in 2016 increased at the fastest rate in a decade

https://www.washingtonpost.com/news/wonk/wp/2017/12/06/out-of-pocket-health-spending-in-2016-increased-at-the-fastest-rate-in-a-decade/?utm_term=.42b85bdeba98

U.S. health care spending increased to $3.3 trillion in 2016, with out-of-pocket health care costs borne directly by consumers rising 3.9 percent — the fastest rate of growth since 2007.

The findings, published Wednesday by Health Affairs, are considered the authoritative breakdown of American health care spending and are prepared each year by the Centers for Medicare and Medicaid Services.

The overall rate of increase in health care spending experienced a slight slowdown over the previous year, driven in part by the expected moderation in growth after the expansion of insurance coverage through the Affordable Care Act. There was also a sharp decrease in the growth of prescription drug expenditures, as hepatitis C treatment costs have declined and fewer patients are receiving them.

The slowdown in spending growth — a 4.3 percent increase in 2016, following a 5.8 percent growth the previous year — stemmed from changes in a broad array of health care sectors.

That ranged from slower growth in Medicaid spending after the surge in enrollment caused by the Affordable Care Act expansion, to a marked slowdown in prescription drug spending growth that had been pushed higher by the approval of a new, expensive treatment for hepatitis C in 2013.

A shift toward insurance plans that transfer more of the burden of health care costs onto patients helped fuel the rise in out-of-pocket costs. In 2016, 29 percent of people who receive insurance through employers were enrolled in high-deductible plans, up from 20 percent in 2014. The size of the deductibles also increased over this time period, a 12 percent increase in 2016 for individual plans, compared with a 7 percent increase in 2014.

Out-of-pocket spending grew the most on medical equipment and supplies and decreased slightly for prescription drugs, according to the analysis.

The most noticeable change was a big slowdown in prescription drug spending growth, which made up 10 percent of the total spending, or $328.6 billion. (That spending number does not include drugs administered by physicians or hospitals.)

That decrease highlights the effect that expensive new treatments used by large numbers of people can have on national spending. A new generation of expensive hepatitis C drugs drove national drug spending 12.4 percent higher in 2014 and 8.9 percent higher in 2015. In 2016, the prescription drug spending increased by 1.3 percent, closer to the rates in the years before the new drugs were approved.

The authors of the report attributed that trend not just to hepatitis C drugs. There were also fewer new, brand name drugs approved in 2016 — 22 new drugs, compared with 45 the previous year. Another factor was a slowdown in the growth of spending on insulin, a lifesaving drug for people with diabetes, in Medicare.

Insulin prices have been under intense scrutiny as drugmakers have increased the list prices of insulin while claiming the true cost to patients has remained flat due to discounts and rebates

Health care spending has been buffeted by unusual changes during the past decade. There was a historic slowdown in growth due to the Great Recession, and then the Affordable Care Act’s expansion of health insurance coverage fueled spending.

The authors said this year’s trend of slower growth could be a sign that things were returning to normal.

“Future health expenditure trends are expected to be mostly influenced by changes in economic conditions and demographics, as has historically been the case,” the authors wrote.

 

Ryan eyes push for ‘entitlement reform’ in 2018

http://thehill.com/homenews/house/363642-ryan-pledges-entitlement-reform-in-2018?utm_source=&utm_medium=email&utm_campaign=12524

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House Speaker Paul Ryan (R-Wis.) on Wednesday said House Republicans will aim to cut spending on Medicare, Medicaid and welfare programs next year as a way to trim the federal deficit.

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an interview on Ross Kaminsky’s talk radio show.

Health-care entitlements such as Medicare and Medicaid “are the big drivers of debt,” Ryan said, “so we spend more time on the health-care entitlements, because that’s really where the problem lies, fiscally speaking.”

Ryan said he’s been speaking privately with President Trump, who is beginning to warm to the idea of slowing the spending growth in entitlements.

During his campaign, Trump repeatedly promised not to cut Medicare, Medicaid or Social Security.

“I think the president is understanding choice and competition works everywhere, especially in Medicare,” Ryan said.

House and Senate Republicans are currently working on their plans for tax reform, which are estimated to add more than $1 trillion to the deficit. Democrats have voiced concerns that the legislation could lead to cuts to the social safety net.

Ryan is one of a growing number of GOP leaders who have mentioned the need for Congress to cut entitlement spending next year.

Last week, House Ways and Means Committee Chairman Kevin Brady (R-Texas) said that once the tax bill was done, “welfare reform” was up next.

Sen. Marco Rubio (R-Fla.), last week, said “instituting structural changes to Social Security and Medicare for the future” will be the best way to reduce spending and generate economic growth.

Rep. Jeb Hensarling (R-Texas), chairman of the House Financial Services Committee, told Bloomberg TV that “the most important thing we can do with respect to the national debt, what we need to do, is obviously reform current entitlement programs for future generations.”

Ryan also mentioned that he wants to work on changing the welfare system, and Republicans have in the past expressed a desire to add work requirements to programs such as food stamps.

Speaking on the Senate floor while debating the tax bill last week, Senate Finance Committee Chairman Orrin Hatch (R-Utah) said he had a “rough time wanting to spend billions and billions and trillions of dollars to help people who won’t help themselves, won’t lift a finger and expect the federal government to do everything.”

His comments were echoed by Ryan.

“We have a welfare system that’s trapping people in poverty and effectively paying people not to work,” Ryan said Wednesday. “We’ve got to work on that.”

 

AARP to Congress: Don’t Cut Medicare

https://www.aarp.org/politics-society/advocacy/info-2017/medicaid-medicare-tax-reform-fd.html?cmp=EMC-DSO-NLC-WBLTR—MCTRL-120817-F1-2613065&ET_CID=2613065&ET_RID=33152417&mi_u=33152417&mi_ecmp=20171208_WEBLETTER_Member_Control_Winner_251100_391403&encparam=rGtTYC48LtlDepUYFPD2E6KmzkAw6WgcgwvDlv37DZs%3D

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The tax bill would trigger an automatic funding cut in the vital program.

AARP Chief Executive Officer Jo Ann Jenkins called on congressional leaders Thursday to keep their promise to America’s seniors and prevent a large cut to Medicare that the tax bill now being debated on Capitol Hill would trigger.

The tax measure would result in a $1.5 trillion increase in the federal deficit over the next decade, according to the nonpartisan Congressional Budget Office (CBO). Such a deficit would prompt an automatic $25 billion cut to Medicare as soon as January because of the “pay-as-you-go” law, commonly referred to as PAYGO.

The law was designed to keep the deficit in check by requiring the administration to reduce spending in many mandatory federal programs if Congress enacts a law that increases the deficit but doesn’t provide offsetting revenue.

In a letter to Senate Majority Leader Mitch McConnell, Minority Leader Charles Schumer, House Speaker Paul Ryan and Minority Leader Nancy Pelosi, Jenkins reminded McConnell and Ryan that they had recently issued a statement promising that “we will work to ensure these spending cuts are prevented.”

In their statement, the Republican leaders pointed out that the PAYGO law has never been enforced since it was passed in 2010 and “we have no reason to believe that Congress would not act again” to forestall the cuts PAYGO would require.

Medicaid, Social Security, food stamps and some other social safety net programs are exempt from the PAYGO law. But Medicare and programs like federal student loans, agricultural subsidies and the operations of U.S. Customs and Border Protection are not exempt.

The law caps how much the government can trim from Medicare at 4 percent. That’s $25 billion the first year, according to CBO. The amount could be higher in subsequent years, depending on the size of the deficit and Medicare’s budget.

The reduction would affect the payments that doctors, hospitals and other health care providers receive for treating Medicare patients. Individual benefits would not be directly cut, but the reduction could have implications for the care beneficiaries receive.

“The sudden cut to Medicare provider funding in 2018 would have an immediate and lasting impact, including fewer providers participating in Medicare and reduced access to care for Medicare beneficiaries,” Jenkins wrote. Health care providers might stop taking Medicare patients, she added, even as 10,000 older adults are enrolling in the health program each day.

In addition, Medicare Advantage plans and Part D prescription drug plans may compensate for the cuts by charging higher premiums or shifting more costs to beneficiaries in future years.

“Our members and other older Americans are counting on you to preserve their access to Medicare services, including their doctors and hospitals,” Jenkins wrote.

Challenges Abound For 26-Year-Olds Falling Off Parental Insurance Cliff

Challenges Abound For 26-Year-Olds Falling Off Parental Insurance Cliff

Marguerite Moniot felt frustrated and flummoxed, despite the many hours she spent in front of the computer this year reading consumer reviews of health insurance plans offered on the individual market in Virginia. Moniot was preparing to buy a policy of her own, knowing she would age out of her parent’s plan when she turned 26 in October.

Marguerite Moniot recently purchased health insurance on the open market with the help of a health navigator. She and her parents began searching for a policy several months ago, but the details of each plan became too complicated for the family. (Courtesy of Marguerite Moniot)

She asked her parents for help and advice. But they, too, ran into trouble trying to decipher which policy would work best for their daughter. The family had relied on her father’s employer-sponsored plan through his work as an architect for years, so no one had spent much time sifting through policies.

“Honestly, my parents were just as confused as I was,” said Moniot, a restaurant server in Roanoke.

In defeat, just before Thanksgiving, she went with her mother to meet a certified health insurance navigator, buying a policy that allowed her to keep her current doctors.

A new crop of young people like Moniot are falling off their parents’ insurance plans when they turn 26 — the age when the Affordable Care Act stipulates that children must leave family policies.

They were then expected to be able to shop relatively easily for their own insurance on Obamacare marketplaces. But with Trump administration revisions to the law and congressional bills injecting uncertainty into state insurance markets, that task of buying insurance for the first time this year is anything but simple.

The shortened sign-up period, which started Nov. 1, runs through Dec. 15. That window is half as long as last year’s, hampering those who wait until the last minute to obtain insurance.

Reminders and help are scarcer than before: The federal government cut marketing and outreach funds by $90 million, and federal funding to groups providing in-person assistance was whacked by 40 percent.

“I think it’s definitely going to be difficult. There’s just additional barriers with [less] in-person help, just fewer resources going around,” said Erin Hemlin, director of training and consumer education for Young Invincibles, an advocacy group for young adults.

Emily Curran, a research fellow at Georgetown University’s Health Policy Institute, said those actions combined with the Trump administration’s vigorous criticism of the health law could further handicap the uphill battle to entice young people to enroll. As of Dec. 2, more than 3.6 million people had enrolled through the federal marketplace, according to the Centers for Medicare & Medicaid Services. The data were not sorted by age.

“There’s already a barrier where young adults are having difficulty understanding what the value of insurance is,” she said. “Coming out … and saying prices are going up, choice is going down and this law is a mess doesn’t really get at the young adult population.”

Trouble Attracting Young Adults 

Before the Affordable Care Act, young adults had the highest uninsured rate of any age group.

The ACA made coverage more affordable and accessible. It allowed states to expand Medicaid to cover single, childless adults. Tax credits to help pay for premiums made plans on the individual market more affordable for people whose incomes fell between 100 and 400 percent of the federal poverty level (between $12,060 and $48,240 for an individual). And young adults were allowed to stay on their parents’ plan until their 26th birthday.

If the Trump administration’s moves dampen enrollment, insurers could face additional challenges in attracting healthy adults to balance those with illnesses, who drive up costs.In all, the uninsured rate dropped to roughly 15 percent among 19- to 34-year-olds in 2016. Still, young adults have not joined the individual market in the numbers as expected. About a quarter of marketplace customers in 2016 were ages 18-34, according to the Department of Health and Human Services. But that age group makes up about 40 percent of the exchanges’ potential market, according to researchers and federal officials.

“When you’re relatively healthy, it’s not something that you’re thinking about,” said Sandy Ahn, associate research professor at Georgetown University’s Health Policy Institute.

But illness does not recognize age. Dominique Ridley, who turned 26 on Dec. 6, knows this all too well.

Ridley has asthma. She always carries an inhaler and sees a doctor when she feels her chest tighten. The student at Radford University in Virginia relies on her mother’s employer-sponsored plan for coverage.

Ridley started peppering her parents with questions about health insurance as soon as she started seeing ads for this year’s open enrollment.

“I don’t want to just go out there and apply for health insurance, and it be all kinds of wrong and I can’t afford it,” she said.

Her parents didn’t have the answers, but her mother linked up Ridley with a friend that runs a marketing company tailored to promoting the Affordable Care Act. Ridley then connected with a broker who signed her up for a silver plan that will cost her less than $4 per month, after receiving a premium subsidy of more than $500 a month.

“If you don’t have health insurance, you don’t have anything,” Ridley said.

A Digital Campaign 

The Obama administration relied in part on partnerships to attract young enrollees to sign up. Last year, it collaborated with national organizations like Planned Parenthood Federation of America and Young Invincibles on a social media campaign called #HealthyAdulting. Emails, according to Joshua Peck, former chief marketing officer for healthcare.gov, were particularly effective for recruitment.

The Centers for Medicare & Medicaid Services, which oversees the marketplaces, said it will focus this year’s resources on “digital media, email and text messages.”

“But obviously we can’t make up for $90 million in advertising” that’s been cut, said Hemlin.Hemlin said the government has not asked Young Invincibles to assist in marketing. Her group will use its own resources to pay for targeted ads on social media to reach the target demographic, she said.

One factor that might compensate is that 20-somethings are facile at shopping online, said Jill Hanken, director of Enroll! Virginia, a statewide navigator program.

“Our job is to make sure they understand to look at provider networks and drug formularies if they have health concerns. But they’re able to do the mechanics of enrollment on their own very often.”

James Rowley, a 26-year-old entrepreneur from Fairfax, Va., is among those who signed up without help. He started his own company two years ago while covered under his father’s health plan. When he turned 26, he signed up for health insurance on his own through a special enrollment period this year. After general enrollment opened this fall, he once again picked a plan.

“I might not 100 percent need it now, but there will come a time where health insurance is important,” said Rowley.