Tag Archives: Health Policy

The Union That Roars: Nurses Aren’t Giving Up On California’s Single-Payer Push

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The Union That Roars: Nurses Aren’t Giving Up On California’s Single-Payer Push

To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, extreme.

Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.

To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.

Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.

Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly.

Dramatic and, to some, offensive, tactics are nothing new for this California union of about 100,000 registered nurses, which has made a name for itself in the state and nationally as a progressive and aggressive political powerhouse. Its reach has only broadened with the advent of social media. Leader DeMoro counts more than 29,000 Twitter followers, and CNA’s operation has a knack for mobilizing protesters and drawing crowds.

“The politicians are afraid of these angry intense grass-roots activists” mobilized by the union, said Mike Madrid, a Republican and principal at the public affairs firm Grassroots Lab, who believes the tactics could backfire. “Using fear and intimidation as a tactic in the legislature usually doesn’t get you too far.”

Others are impressed with the union’s drive and creativity, recalling how in 2005 CNA members taunted California’s then-governor, Arnold Schwarzenegger, trailing him wherever he went to protest his attempts to roll back hard-won nurse-to-patient requirements in hospitals. Activists dressed up as the Republican leader and staged theatrical protests at baseball games, rock concerts and even the San Francisco Ritz-Carlton.

In the single-payer fight, the union has shown it will go just as fervently after Democratic leaders in a heavily Democratic legislature. While the union isn’t responsible for everything freelance activists do in a campaign, the Assembly Democratic caucus has condemned the “bullying tactics” and violent rhetoric in the CNA-led effort.

Though not always admired for its approach, the CNA often gets results — or works up a sweat trying. It counts among its legislative successes the 1999 passage of the strict nurse-to-patient ratios, the nation’s first such mandate to bolster staffing in hospitals. It has fended off attempts to overturn that law, worked to protect employee pensions and pushed for campaign financing reform. And it lent its considerable political muscle to Bernie Sanders’ presidential campaign.

Historically, the nurses have had the upper hand in labor negotiations, says Joanne Spetz, director of the Health Workforce Research Center at UC-San Francisco. That’s partly because in some areas of California it represents most or all of the registered nurses, including many thousands who work for the managed-care giant Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Members of the California Nurses Association Board of Directors, Martha Kuhl (left) and Nancy Casazza, show their support for a 1994 state proposition to implement single-payer health care in California. (Courtesy of the California Nurses Association)

The union, founded in 1903, has always “punched above its weight,” said Thad Kousser, chair of the political science department at University of California-San Diego.

Sherry Bebitch Jeffe, a professor of public policy communication at the University of Southern California, agreed.

“I’m not sure we would be discussing single-payer if not by the push of the nurses’ association,” Jeffe said.

The union, which is affiliated with National Nurses United, makes no apologies for its approach, saying it is determined to hold lawmakers accountable. And it has no intention of backing off its campaign for a single-payer system in the state, an effort that would put the California government in charge of funding health care.

“We’re going to demand that the legislature legislate and move this bill,” said Michael Lighty, director of public policy at California Nurses Association/National Nurses United. The group on Tuesday plans to stage a “people’s assembly health committee” mock hearing in Sacramento.

Lighty said that the rallies reflect Californians’ desperation and fear about losing health coverage under Republican proposals to repeal Obamacare more than anything else.

Although Lighty said the union’s elected nurse leaders collectively decide on its actions, supporters and critics alike see DeMoro as setting the tone and agenda.

People focus on DeMoro because she “pushes the parameters of the politically possible” and that rubs “defenders of the status quo” the wrong way, Lighty said. DeMoro, on vacation, was unavailable for comment.

Former state senator Sheila Kuehl, who attempted several times to pass a single-payer bill, said the California Nurses Association has always been “very aggressive for the things they believed in.”

Former state senator Sheila Kuehl, who authored single-payer legislation in the 2000s, participates in a 2008 rally in San Francisco. (Courtesy of the California Nurses Association)

A smaller health consumer advocacy group persuaded Kuehl to carry the bill for the first time in 2003-04, Kuehl recalled, but the California Nurses Association brought more visibility and credibility when they joined her effort. Eventually, it became a co-sponsor.

“CNA, as fierce and progressive as they are, gave the idea a real boost,” said Kuehl, now a Los Angeles County supervisor.

Two of her bills passed through the legislature, but both were vetoed by then-Gov. Schwarzenegger.

Kuehl doesn’t buy the argument that the union’s in-your-face strategies may hurt their chances of passing single-payer later. Union members made nasty comments about Schwarzenegger at their rallies and that didn’t hurt the CNA’s reputation, she said.

Madrid, the Republican political consultant in Sacramento, says the CNA’s aggressive advocacy for a single-payer health system reflects the intense political polarization seen around the country right now — as well as conflicts among members of left-leaning causes.

More mainstream Democrats, including Assembly Speaker Anthony Rendon — the recipient of online death threats — say the legislature’s priority is to defend California against a GOP-proposed repeal of the Affordable Care Act and massive cuts to Medicaid, the state and federal health plan for the poor.

Rendon also said the single-payer bill, though approved by the state Senate, was “woefully incomplete” and needed to be recast. Among other problems, it carried a $400 billion annual price tag , according to an analysis by the state Senate Appropriations Committee.

But the CNA sees an opportunity for broader change and believes single-payer can move forward even as the state fights the Republican proposals in Washington.

If the single-payer bill stays idle in the legislature this year, the group vows to try again next year, making it a campaign issue in the 2018 elections.

“The best way to fight the GOP is to have an alternative,” Lighty said.

Here’s What a Bipartisan Health Care Deal Might Look Like

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https://www.thefiscaltimes.com/2017/07/08/Here-s-What-Bipartisan-Health-Care-Deal-Might-Look

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Practically overnight, Senate Majority Leader Mitch McConnell (R-KY) placed the once-unthinkable notion of a bipartisan deal with the Democrats to salvage the Affordable Care Act well within the realm of possibility.

For months, McConnell, House Speaker Paul Ryan (R-WI) and President Trump vowed to move with alacrity to repeal and replace Obamacare with a far superior GOP health insurance plan that would bring down premium costs , provide tax relief for wealthier Americans and the health care industry, and phase out expanded Medicaid coverage for millions of poor and disabled people.

But with the Senate’s 52 Republicans still badly divided over how best to proceed and time running out before a long August recess, McConnell said Thursday during a speech in Kentucky that if his party cannot muster at least 50 votes to rewrite the Obamacare law, it would have no choice but to work with the Democrats to produce a more modest bill to support the law’s existing insurance market.

“No action is not an alternative ,” McConnell said during a speech at a Rotary Club lunch in Glasgow, Kentucky. “We’ve got the insurance markets imploding all over the country, including in this state.”

The Republicans have long argued that Obamacare is in a “death spiral,” with premiums going through the roof and more and more major health care insurers pulling out of the market after incurring huge losses on the ACA exchanges. The Trump White House, the Department of Health and Human Services (HHS) and the Internal Revenue Service have also taken executive actions that have undercut enrollment and insurer participation.

But the veteran Senate majority leader has begun facing up to the harsh political reality that as many as a dozen conservative and moderate Republicans currently oppose a bill that McConnell almost single-handedly drafted behind closed door. Now it will take a herculean effort to muster a minimum of 50 votes needed to pass the bill under expedited budget reconciliation rules that were designed to avert a filibuster.

Douglas Holtz-Eakin, a former Congressional Budget Office director and Republican economic adviser, said on Friday that McConnell “has done the [political] arithmetic right” and that there may be no choice but to cut a deal with Senate Minority Leader Chuck Schumer (D-NY).

“We know that the exchanges are melting down under current law,” Holtz-Eakin, president of the American Action Forum, said in an interview. “We know that the cost-sharing money [to subsidize insurers] has to come from somewhere or they will continue to melt down, and insurers will leave, and premiums will continue to skyrocket.”

However, he warned that such an agreement would have serious political ramifications for the GOP and could touch off a conservative backlash, especially in the House. “It’s going to be a really bad deal for Republicans, and House Republicans are going to have to eat it.”

Michael F. Cannon, director of health policy at the libertarian Cato Institute, said McConnell might have raised the idea of working with Democrats to force recalcitrant Republicans into line. However, he said it was high risk for a party that for the past seven years has promised to repeal and replace Obamacare.

“If he does pursue a bill with Democrats to bail out the exchanges, then it will cause a rift in his own party much bigger than the rift he sees right now,” Cannon cautioned.

Schumer on Thursday called McConnell’s comments encouraging, and that his caucus is “eager to work with Republicans to stabilize the markets and improve the law.” The minority leaders have said for weeks that the Democrats were ready to bargain with the GOP and the White House on virtually any issue provided the Republicans abandoned their effort to repeal former President Barack Obama’s signature program.

According to several policy experts, here are five areas where a bipartisan health care compromise might be struck:

  1. Cost sharing — One of the pillars of the Obamacare markets is the $7 billion a year in federal cost-sharing subsidies to insurance companies that allow them to help offset the cost of the monthly premiums and copayments of low and moderate income Americans who make between $12,000 and $48,000 a year. House Republicans challenged the constitutionality of those subsidies in court, and Congress and the Trump administration have agreed to continue the payments pending a final outcome of the case.
    But without more certainty of the future of those subsidies, many major insurance companies have begun pulling out of markets throughout the country. If both parties are concerned about stabilizing the Obamacare insurance markets and making sure they don’t go under, making the cost-sharing subsidies permanent would be a good place to start.
  2. Reviving Risk Corridors –Before the Republicans succeeded in turning off the spigot, an Obamacare reinsurance program or so-called “risk corridors” funneled billions of dollars to insurers to offset the unforeseen costs of their most expensive enrollee.
    Republicans led by Sen. Marco Rubio (R-FL) led an effort to kill off the program, arguing that it constituted an unjustifiable “bailout” of the insurance industry. But Republican and Democratic negotiators would likely have to reconsider reviving the program – and tax revenue to pay for it – to further stabilize the insurance market.
  3. Tax Repeal – The Senate GOP plan includes a tax cut of $700 billion over the coming decade, which would be achieved by repealing all the tax hikes in Obamacare passed to help finance the health insurance program. The cost of that massive tax relief for mainly wealthy Americans and the pharmaceutical, health care and insurance industries, would be offset by deep cuts in Medicaid for millions of poor and disabled Americans.
    Democrats are adamant about blocking wholesale cuts in Medicaid. However, they might be open to some horse trading to repeal some of the Obamacare taxes while preserving others, in order to prevent massive cuts in Medicaid.
  4. Medicaid Spending– The Senate GOP bill would allow 31 states that expanded Medicaid to millions of childless, able-bodied, low-income adults to continue receiving bonus federal funding through 2013, before beginning to reduce it between 2021 and 2024.
    Democrats would be insistent on preserving expanded Medicaid even longer and would have considerable leverage in order to achieve that goal. Moreover, there is virtually no interest on their part in transforming Medicaid from an open-ended entitlement to a per-capita-cap block grant to the states. But amid growing concern about the long-term impact of growing entitlements on the debt, Democratic negotiators might be open to reforms to slow the rate of growth of Medicaid.
  5. Lowering premiums – There is little disagreement between the two parties on the need to bring down premiums and copayments that have literally priced many families out of the market, even with tax subsidies. Yet finding a compromise that satisfies the Democrats demands to preserve Obamacare levels of benefits – including a ban on insurers discriminating against people with preexisting medical conditions — and GOP insistence on allowing skimpier, less expensive policies for younger and healthier people – will be hard to do.
    “All of this adds up to huge new spending, but the Democrats would be in charge, and McConnell knows it,” Joe Antos, a health care expert with the conservative-leaning American Enterprise Institute, said. “They won’t get everything, but I don’t expect any compromise to look like a Republican bill. Nonetheless, if the Democrats aren’t too greedy, such a bill could pass in the Senate, but would be rejected in the House.”

AHCA could mean 725K fewer healthcare jobs by 2026

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http://www.healthcaredive.com/news/ahca-could-mean-725k-fewer-healthcare-jobs-by-2026/445131/

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Dive Brief:

  • The American Health Care Act (AHCA), as it was passed in the House, would result in the loss of 924,000 jobs over 10 years and spark economic downturns in every state, according to research by the George Washington University Milken Institute School of Public Health and The Commonwealth Fund.
  • The healthcare sector would be hit the hardest, with 725,000 jobs lost by 2026. There would be fewer healthcare jobs immediately in 17 states. The states that would be most affected overall include New York, Pennsylvania and Florida.
  • The primary cause of the job disappearances and state economic downturns would be cuts to healthcare funding, such as more than $800 billion to Medicaid, and lower premium subsidies.

Dive Insight:

The analysis is of the House version of the bill, and the Senate is expected to make changes when it brings its own version up for a vote. But with those negotiations going on behind closed doors, there is not enough information to makes estimates based on the Senate bill.

The report is a warning call to the healthcare industry and another black mark on the increasingly unpopular AHCA. The bill is already opposed by most major industry groups. They balk at the huge cuts to Medicaid and the Congressional Budget Office estimates up to 23 million people would lose coverage.

The threat of jobs losses could become another rallying cry. In fact, healthcare executives shaken by the potential for repeal of the Affordable Care Act (ACA) are already scaling back hiring and new projects in the face of uncertainty. Former CMS Administrator Andy Slavitt said a poll he conducted found nearly 40% of executives said they are slowing hiring and 31% are cutting capital expenses.

Healthcare job growth spiked after the passage of the ACA, which the AHCA seeks to replace. The ACA helped create about 240,000 jobs in the industry, and employment increased from an average of 1.7% in 2010 to 2.5% from 2014 to 2016. But that trend has tempered. Healthcare has averaged 22,000 job gains a month so far this year. The average monthly gain in 2016 was 32,000.

The AHCA phases out Medicaid expansion, which has been an economic boon for states that decided to expand. The authors of the latest report said those states would be hit hardest in financial terms by the bill.

“Hospitals, health systems, clinics and pharmacies might be forced to close or lay off staff as federal funding for healthcare is cut and the number of uninsured patients grows,” the researchers wrote.

House narrowly passes malpractice reform legislation

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http://www.healthcaredive.com/news/house-narrowly-passes-malpractice-reform-legislation/446208/

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Dive Brief:

  • Lawmakers in the House voted 218-210 this week to pass the Protecting Access to Care Act of 2017, paving the way for the potential of major tort reforms this year.
  • H.R. 1215 would cap noneconomic damages in malpractice litigation at $250,000 and limit the fees lawyers can charge in healthcare lawsuits. It also protects providers from liability in product liability lawsuits involving an FDA-approved drug or medical device.
  • Sponsored by Rep. Steve King (R-Iowa), the bill would apply to lawsuits where a patient’s coverage was provided through a federal program, subsidy or tax benefit. That includes patients insured under the Affordable Care, veterans, service members, civil servants and Medicare and Medicare beneficiaries.

Dive Insight:

The bill is designed to protect providers from superfluous lawsuits and unnecessary costs and would preempt state laws with higher limits on damages or no limits at all. According to a Congressional Budget Office analysis, the measure would save taxpayers $50 billion over the next 10 years.

American Medical Assocation President Dr. David Barbe praised the House action, calling H.R. 1215 “an important first step toward fixing” a broken medical liability system, adding, “By redirecting healthcare spending from defensive medicine, additional dollars can go to patient care, safety and quality improvements, and to health information technology systems that would help improve care and outcomes.”

Republicans in Congress are eyeing 2017 as a major year for tort reform. Though clinicians will likely champion H.R. 1215, some have questioned whether the reform is necessary. According to Doctors Company, a major malpractice insurer, the rate of malpractice has been halved since 2003. Tort reform has been on the mind of HHS Secretary Tom Price for 20 years so a Republican-controlled Congress allows for such reforms to be made.

President Donald Trump’s administration also expressed his support for the legislation. His fiscal year 2018 budget proposal includes a provision that would alter the collateral source rule to allow evidence of a plaintiff’s income from other sources to be introduced at trial.

In addition to H.R. 1215, three other tort reform bills are under review. H.R. 720, the Lawsuit Abuse Reduction Act, would discourage the filing of frivolous claims by requiring mandatory sanctions on those who do and eliminating the ability of plaintiffs and their lawyers to avoid sanctions by withdrawing claims after a motion to sanction.

Another bill, the Fairness in Class Action Litigation Act, H.R. 985, would make it more difficult for plaintiffs’ attorneys to file class action lawsuits by requiring that all claimants in the class experienced the same type and degree of injury.

Finally, the Innocent Party Protection Act, H.R. 725, would let defendants sued in state courts remove the case to the federal level if the plaintiff and defendant are from different states and more than $75,000 in damages is on the line.

https://www.washingtonpost.com/news/to-your-health/wp/2016/12/30/top-republicans-say-theres-a-medical-malpractice-crisis-experts-say-there-isnt/?utm_term=.6d703b176017

 

Healthcare Triage News: The Senate’s BCRA Bill – High Premiums, Huge Deductibles, AND Massive Medicaid Cuts

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Healthcare Triage News: The Senate’s BCRA Bill – High Premiums, Huge Deductibles, AND Massive Medicaid Cuts

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GOP pessimism rising on ObamaCare repeal

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GOP pessimism rising on ObamaCare repeal

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Senate Republicans are returning to Washington increasingly pessimistic about their plan to repeal and replace ObamaCare.

They’ve had to put off plans for a vote next week, and they’ve seen loyal members either double down on their opposition to the bill, or at least question whether they will back it.

Sen. Jerry Moran (R-Kansas)—a “no” vote that took many in Washington by surprise—distanced himself the closed-door process used to draft the Senate bill.

“It takes two parties who want to come together. Not just Republicans. Not just Democrats,” he said during a polite, but pointed, meeting with constituents in rural Kansas.

Asked if he could support the bill, Sen. Chuck Grassley (R-Iowa) told constituents that “I don’t know if we’re even going to get a bill up,” according to the Des Moines Register.

Sen. John Hoeven (R-N.D.), who normally aligns with leadership, also came out as “no” over the recess break.

Even Senate Majority Leader Mitch McConnell (R-Ky.) appeared to suggest that Republicans might need to move to plan B involving stabilizing insurance markets if they can’t pass their bill.

“If my side is unable to agree on an adequate replacement, then some kind of action with regard to private health insurance markets must occur,” he said at a Rotary Club meeting in Kentucky.

The gloomy outlook highlights why McConnell had sought to finish work on the repeal-and-replace legislation before the July 4 recess.

McConnell didn’t want his members to face additional pressure over the break, and he also wasn’t keen on spending more time on healthcare. His conference now faces a marathon three-week session to take action on the issue.

The caucus remains deeply divided with rank-and-file members signaling they don’t believe they are close to a deal that could capture 50 votes.

“We’re still several weeks away from a vote, I think,” Sen. Pat Toomey (R-Pa.) said a televised Q & A event, while dozens of protesters urged him to oppose the Senate bill.

Moran added that there wasn’t “significant consensus” on how to fix healthcare.

“[It’s] almost impossible to try to solve when you’re trying to do it with 51 votes in the United States Senate, in which there is not significant consensus on what the end result ought to be,” he said.

Leadership held a flurry of closed-door negotiations before the recess as they tried to reach deals that would win over undecided lawmakers, including adding more money for opioid treatment.

With a slim 52-seat majority, McConnell can only afford to lose two GOP senators and still let Vice President Pence break a tie. With Hoeven’s defection there are roughly 10 GOP senators publicly opposed to the bill.

“Compared to how optimistic I was the week before now … I’m very pessimistic,” Grassley told constituents in Mount Pleasant, Iowa, before adding that he thinks Congress will get something done even if repeal now and replace later.

Republicans have campaigned for years on repealing and replacing ObamaCare, arguing the Affordable Care Act is “failing” and in a “death spiral,” and insisting that the law is not fixable.

McConnell’s staff were quick to note that the GOP leader’s comments are similar to remarks he made after a closed-door meeting with Senate Republicans and Trump at the White House. But the pivot comes as McConnell is trying to wrangle his caucus behind his legislation even as conservatives appear to be digging in for a fight.

If the warning was meant to be a signal to unruly Republicans that it was either the Senate bill or working with Democrats, there was no sign they had an immediate impact.

A few hours after McConnell’s comments, Sen. Rand Paul (R-Ky.), a conservative opponent of the Senate bill who believes it would leave too much of ObamaCare in place, held a press conference to tout his proposal to loosen rules on association healthcare plans.

He said he’d heard no feedback from leadership.

“No, none. We’ve reached out to Senate Republican leadership,” Paul told reporters. “We’ve described some of the things with the association plans…and we have not gotten any feedback. Now I talked to the president about it, and he was very receptive.”

Conservatives are also demanding an amendment from Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that don’t meet ObamaCare regulations.

But the demand has riled GOP aides and other members of the caucus, who are accusing Cruz of making unrealistic demands that can’t get 50 votes. GOP leadership has sent two versions of their bill to the CBO, one that would include Cruz’s proposal and one without.

Just hours after McConnell’s comments, Cruz became the latest GOP senator to call for simply repealing ObamaCare without a replacement plan as a plan B.

“We have had – for seven years – we have promised to do that,” Cruz said. “Repealing Obamacare was the single biggest factor producing a Republican House, a Republican Senate and, I think, ultimately a Republican president.”

The move would either require Republicans to get 60 votes for a replacement plan or use the fiscal year 2018 budget as a vehicle, scrapping their plans for tax reform.

Senate GOP leadership has signaled the idea is a non-starter even after it got the backing of Trump and a growing number of senators.

Sen. Ben Sasse (R-Neb.) told local reporters that he was willing to see if McConnell could “get the ball across the finish line” by the time lawmakers return to Washington, but if not he supported separating repeal and replace.

“If we can’t get this done instead of walking away from either repeal or replace … I don’t want that to happen,” he said. “So I think it would be a more prudent legislative step to unbundle repeal and replace.”

Section 1332 State Innovation Waivers: Current Status and Potential Changes

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Section 1332 State Innovation Waivers: Current Status and Potential Changes

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Section 1332 of the Affordable Care Act (ACA) authorizes states to waive key requirements under the law in order to experiment with different health coverage models. As Republicans in Congress debate repeal and replacement of the ACA, renewed attention is being paid to these waivers as a mechanism for giving states flexibility to restructure their health care markets. The waiver authority is generally broad, though certain process and outcome standards must be satisfied. State interest in 1332 waivers to date has been limited; however, changes to the statutory waiver requirements included in the Senate Better Care Reconciliation Act of 2017 (BCRA) or other signals from the Trump administration could spark increased state action. This brief describes current 1332 waiver activity and raises questions regarding the future of these waivers, particularly in the context of proposed changes under discussion.

What Does Section 1332 Allow?

Beginning in 2017, states can request 5-year waivers of certain ACA provisions through Section 1332. States may seeks waivers of requirements related to the essential health benefits (EHBs) and metal tiers of coverage (bronze, silver, gold, and platinum) along with the associated limits on cost sharing for covered benefits. They may alter the premium tax credits and cost-sharing reductions, including requesting an aggregate payment of what residents would otherwise have received in premium tax credits and cost-sharing reductions. States may also modify or replace the marketplaces and change or eliminate the individual and/or employer mandates (See Appendix A for more detail on these provisions).

The ACA includes guardrails limiting how 1332 waivers can be used by states. The current statutory language requires that state waiver applications must demonstrate that the innovation plan will:

  • Provide coverage that is at least as comprehensive in covered benefits;
  • Provide coverage that is at least as affordable (taking into account premiums and excessive cost sharing);
  • Provide coverage to at least a comparable number of state residents; and
  • Not increase the federal deficit.

Additionally, while states can submit ACA innovation waivers in conjunction with Medicaid waivers (under Sec. 1115 of the Social Security Act), innovation waivers cannot be used to change Medicaid program requirements.

In 2012, the Department of Health and Human Services (HHS) issued final regulations outlining the procedures for state innovation waiver applications. In 2015, HHS and the Treasury Department issued guidance on how they would interpret the law’s requirements for waivers to provide for comparable coverage, comprehensiveness, affordability, and budget neutrality. Unlike regulations and statutes, guidance is not legally-binding, and therefore, can be more easily changed by subsequent administrations.1 On his first day in office, President Trump issued an executive order suggesting that states would be given increased flexibility with regard to ACA implementation.

The 2015 guidance offered a fairly strict interpretation of the statutory guardrails for 1332 waivers. It emphasized the need to protect access to care and affordability for vulnerable populations, including the poor, the elderly, and those with high health needs and risks, noting that impacts on these populations would be considered in assessing whether any waiver met the statutory guidelines. The guidance also specified that coverage and affordability would be measured annually as well as over the life of the waiver and that comprehensiveness of coverage would evaluate coverage under all ten essential health benefit (EHB) categories and under any one EHB category. In calculating deficit neutrality, states cannot use savings from a separate 1115 waiver to offset spending under a 1332 waiver, and any changes in the cost of Medicaid that might result from a waiver would also be measured. Finally, with respect to waiver administration, the guidance noted that to the extent waiver programs envision new methods for determining eligibility for or delivering subsidies, states would need to build their own systems and could not rely on IRS or HHS to customize operations of healthcare.gov or the federal tax system to accommodate individual state programs.

The unexpected political power of dentists

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https://www.washingtonpost.com/politics/the-unexpected-political-power-of-dentists/2017/07/01/ee946d56-54f3-11e7-a204-ad706461fa4f_story.html?utm_term=.d637119c01a6

As the cost of dental care rises beyond the reach of millions of Americans, the dental lobby is coming under increasing scrutiny. Critics say the ADA has worked to scuttle competition that could improve access to dental care in underserved areas and make routine checkups and fillings more affordable.

The Federal Trade Commission has battled dentists in state after state over anti-competitive conduct. In 2007, the FTC successfully settled a complaint over a South Carolina dental board requirement that dentists examine children in school clinics before hygienists can clean their teeth, adding greatly to the cost. In 2015, the FTC won a Supreme Court ruling against the North Carolina dental board, which tried to block teeth-whitening businesses from operating in malls.

This year, the FTC publicly commented on a growing campaign to improve access to dental care by creating a category of mid-level practitioners, or “dental therapists,” to provide some routine services. In a letter to the Ohio lawmakers considering such a measure, FTC officials said therapists “could benefit consumers by increasing choice, competition, and access to care, especially for the underserved.”

More than a dozen states are considering similar proposals, despite fierce resistance from the ADA and its state affiliates. During the Maine debate, so many dentists flooded the statehouse in Augusta that besieged lawmakers taped up signs declaring their offices a “Dental Free Zone.”

The dentists had a unique way to get around the blockade: the regular checkup. While the bill was pending, some lawmakers found themselves getting an earful when they stretched out and opened wide for an oral exam.

“I’m certainly a captive audience when I am in the dental chair,” said Brian Langley (R), a Maine state senator who also got calls from four other dentists in his district and ended up siding with them.

Former lobsterman Michael Hanson, 54, says the American dental system is broken. (Linda Davidson/The Washington Post)

The bill establishing a new provider type ultimately passed, but “it was brutal, very brutal,” recalled David Burns, a Republican state senator who retired after supporting the measure. Afterward, Burns said, he got a call from his dentist, who vowed never to treat him again, saying, “This relationship is over.”

Most of the 200,000 dentists in America work solo, in offices that are essentially small businesses. They are known for projecting a remarkably unified voice on issues relating to their livelihood. The ADA says 64 percent of dentists belong to the association. By comparison, only 25 percent of physicians belong to the American Medical Association.

 

Podcast: What The Health? Why Is This Stuff So Complicated?

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Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Paige Winfield Cunningham of The Washington Post discuss the latest on the Senate’s effort to “repeal and replace” the Affordable Care Act, and why it is so difficult to make popular changes, such as requiring insurers to cover people with preexisting health conditions.

What Are the Implications for Medicare of the American Health Care Act and the Better Care Reconciliation Act?

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What Are the Implications for Medicare of the American Health Care Act and the Better Care Reconciliation Act?

 

An important question in the debate over proposals to repeal and replace the Affordable Care Act (ACA) is what might happen to the law’s many provisions affecting the Medicare program. The American Health Care Act (AHCA), which was passed by the House of Representative on May 4, 2017, and the Better Care Reconciliation Act (BCRA), released by Senate Republicans on June 22, 2017, would leave most ACA changes to Medicare intact, including the benefit improvements (no-cost preventive services and closing the Part D coverage gap), reductions to payments to health care providers and Medicare Advantage plans, the Independent Payment Advisory Board, and the Center for Medicare and Medicaid Innovation.

However, both bills would repeal the Medicare payroll surtax on high-income earners that was added by the ACA, effective January 2023. That provision, which took effect in 2013, provides additional revenue for the Part A trust fund, which pays for hospital, skilled nursing facility, home health and hospice benefits. The Part A trust fund is financed primarily through a 2.9 percent tax on earnings paid by employers and employees (1.45 percent each). The ACA increased the payroll tax for a minority of taxpayers with relatively high incomes—those earning more than $200,000/individual and $250,000/couple—by 0.9 percentage points.

In addition to repealing the ACA’s Medicare payroll surtax, both bills would repeal virtually all other tax and revenue provisions in the ACA, including the annual fee paid by branded prescription drug manufacturers, which would decrease revenue to the Part B trust fund. The bills would also reinstate the tax deduction for employers who receive Part D Retiree Drug Subsidy (RDS) payments, which would increase Medicare Part D spending.

According to the Congressional Budget Office, the provision in the AHCA and the BCRA to repeal the Medicare payroll surtax would reduce revenue for Part A benefits by $58.6 billion between 2017 and 2026. Proposed changes to the ACA’s marketplace coverage provisions and to Medicaid financing in both bills would also increase the number of uninsured, putting additional strain on the nation’s hospitals to provide uncompensated care. As a result, Medicare’s “disproportionate share hospital” (DSH) payments would increase, leading to higher Part A spending between 2018 and 2026 of more than $40 billion, according to CBO.

Altogether, changes to Part A spending and financing in the AHCA and BCRA would weaken Medicare’s financial status by depleting the Part A trust fund two years earlier than under current law, moving up the projected insolvency date from 2028 to 2026, according to Medicare’s actuaries (Figure 1).