Tag Archives: Health Policy

Illinois hospital will have to meet constitutional charity standards, judge rules

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https://www.beckershospitalreview.com/finance/illinois-hospital-will-have-to-meet-constitutional-charity-standards-judge-rules.html?origin=cfoe&utm_source=cfoe

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An Illinois judge has ruled that the operator of Carle Foundation Hospital in Urbana must meet constitutional standards for charitable organizations in order to receive tax exemptions, The News-Gazette reports.

The Carle Foundation is seeking retroactive property tax exemptions for 2004-2011 and a refund for taxes it paid to local authorities during that time. However, Champaign County Judge Randy Rosenbaum agreed with the recent Illinois Supreme Court ruling that hospitals seeking tax exemptions must not only offer as much charity care as they would have paid in taxes; they also must extend charity care to an indefinite number of people and not create any barriers to it.

Hospitals looking for a tax exemption  also must show they do not have any capital, stock or shareholders. Carle Foundation attorneys  have argued that they need only show that the hospital complies with the terms of the hospital tax-exemption law.

John Colombo, a retired law professor at the University of at Illinois Urbana-Champaign, said that the ruling is important for the Carle Foundation’s upcoming trial, but does not clearly define charitable use for the future of Illinois hospitals.

“The Illinois Supreme Court is going to have to say at some point, ‘Here’s what it takes for an Illinois hospital to be tax-exempt,'” said Mr. Colombo.

 

 

Number of uninsured children increases for first time in a decade

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https://thehill.com/policy/healthcare/418884-number-of-uninsured-children-increased-for-first-time-in-a-decade-during

Number of uninsured children increases for first time in a decade

The number of uninsured children in the U.S. increased for the first time in a decade, according to a new report that puts much of the blame on policies spearheaded by Republicans.

An estimated 3.9 million children did not have health insurance in 2017, an increase of 276,000 compared to the previous year, according to the Georgetown University Center for Children and Families.

No state made statistically significant progress on children’s coverage last year, despite an improving economy and low unemployment rate, according to the report, which noted that the District of Columbia made substantive gains in 2017.

Researchers said the rising number for states was due to a variety of factors, though they said GOP-led states refusing to expand Medicaid played a major role, as well as Republican efforts in Congress to repeal ObamaCare and cap federal Medicaid funding.

Three-quarters of the children who lost coverage between 2016 and 2017 live in states that have not expanded Medicaid coverage to parents and other low-income adults, the report found. The uninsured rates for children in non-expansion states increased at almost triple the rate as states that have expanded Medicaid.

The report also noted that Congress eliminated the health law’s individual mandate and the Trump administration dramatically cut ObamaCare outreach and enrollment grants while shortening the open enrollment period.

“All of these changes in the national political and policy realm mark a sharp reversal after many years of successful efforts to reduce the uninsured rate for children and families,” the researchers wrote.

The report’s prognosis for the future was not encouraging.

“Barring new and serious efforts to get back on track, there is every reason to believe the decline in coverage is likely to continue and may get worse in 2018,” researchers concluded.

The number of uninsured children in the U.S. was particularly high in Florida and Texas, the two largest states that have not expanded Medicaid, according to the report.

Texas had an estimated 80,000 more children uninsured in 2017 than in 2016, and Florida had 37,000 more.

Researchers also pointed to President Trump‘s recent crackdown on immigration as a reason why the number of uninsured kids is rising.

One quarter of all children under 18 living in the United States have a parent who is an immigrant, according to the report. Several policies targeting immigrant communities, like the administration’s “public charge” proposal, are likely deterring parents from enrolling their eligible children in Medicaid or the Children’s Health Insurance Program, despite the fact that most of these children are U.S. citizens.

 

 

340B FINAL RULE WILL LAUNCH ON JANUARY 1, 2019

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https://www.healthleadersmedia.com/340b-final-rule-will-launch-january-1-2019

HHS shortens the 340B final rule implantation by six months after determining that it would not ‘interfere’ with the departments ‘comprehensive policies’ to address high drug costs.

KEY TAKEAWAYS

PhRMA says the ‘overly burdensome’ final rule fails to address hospital abuse of the program.

The new rule provides drug pricing information to 340B participants through a closed website.  

Proponents scoff at drug makers’ claims that more time is needed before the oft-delayed final rule is implemented.

After several delays, hundreds of public comments, a lawsuit, and an eight-year-old Congressional mandate, the federal government on Thursday bumped up the starting date of its 340B drug pricing final rule by six months.

In a notice published this week in the Federal Register, the Department of Health and Human Services said the final rule—which is designed to protect hospitals from being overcharged by drug manufacturers—would take effect on January 1, 2019, instead of July 1, 2019.

The final rule was supposed to take effect on January. 5, 2017, but HHS delayed implementation because it said it was in the midst of “developing new comprehensive policies to address the rising costs of prescription drugs.”

Hospitals got tired of waiting and filed suit, asking a federal judge to order the Trump Administration to launch the final rule on January 1, 2019. The hospitals allege that the delays are causing significant financial harm to the nearly 2,500 hospitals nationwide that participate in the 340B Drug Pricing Program.

In late October, the Trump Administration said it was considering accelerating implementation.

In bumping up the final rule implantation by six months, HHS said it “has determined that the finalization of the 340B ceiling price and civil monetary penalty rule will not interfere with HHS’s development of these comprehensive policies.”

Under the new rule, federal regulators will provide pricing information to 340B hospitals through a closed website, which proponents of the rule say is essential for ceiling price enforcement.

As expected, hospitals praised the action, and drug makers expressed disappointment.

“This rule is good for patients and for essential hospitals, which rely on 340B savings to make affordable drugs and health care services available to vulnerable people and underserved communities,” said America’s Essential Hospitals President and CEO Bruce Siegel, MD.

“It also ends years of delay for much-needed measures to hold drug companies accountable for knowingly overcharging covered entities in the 340B program,” Siegel said.

Maureen Testoni, interim president and CEO of 340B Health, called the announcement “a big step toward stopping drug companies from overcharging 340B hospitals, clinics, and health centers.”

“The next step toward ensuring true 340B drug maker transparency is for the administration to launch its ceiling price website so hospitals, clinics, and health centers can ascertain that they are paying the correct amounts for 340B medications,” Testoni said.

“We are encouraged that HHS says it will release that pricing reporting system shortly and that the department will communicate additional updates through its website,” she said.

PhRMA said it was “disappointed the Administration did not issue new proposals for this rule as it repeatedly stated it would.”

The pharmaceutical industry advocates said HHS “ignored the numerous concerns raised by stakeholders on the proposed ceiling price calculations, offset policy and civil monetary penalty provisions.”

Drug makers allege that hospitals have been scamming the 340B program, and PhRMA said Thursday that the final rule’s “flawed policies are not in line with the 340B statute and fail to address root problems in the 340B program that have enabled private 340B hospitals to generate record profit without commensurate benefit to patients.”

“Not only is the final rule itself overly burdensome in its requirements, but moving up its effective date also leaves manufacturers with very little time to make operational changes to systems and procedures,” PhRMA said.

Testoni scoffed at claims that more time was needed.

“The regulation now will be going into effect more than eight years after Congress mandated it—and only after a lawsuit filed by 340B Health and other hospital organizations to stop repeated administrative delays to the effective date,” Testoni said.

“As today’s final rule notes, these delays have given drug makers ‘more than enough time to prepare for its requirements.'”

“THESE DELAYS HAVE GIVEN DRUG MAKERS MORE THAN ENOUGH TIME TO PREPARE FOR ITS REQUIREMENTS.”

 

 

New insurance guidelines would undermine rules of the Affordable Care Act

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https://www.washingtonpost.com/national/health-science/new-insurance-guidelines-would-undermine-rules-of-the-affordable-care-act/2018/11/29/ff467f46-f357-11e8-aeea-b85fd44449f5_story.html?utm_term=.c279fcb895a6&wpisrc=al_news__alert-hse–alert-national&wpmk=1

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The Trump administration is urging states to tear down pillars of the Affordable Care Act, demolishing a basic rule that federal insurance subsidies can be used only for people buying health plans in marketplaces created under the law.

According to advice issued Thursday by federal health officials, states would be free to redefine the use of those subsidies, which began in 2014. They represent the first help the government ever has offered middle-class consumers to afford monthly premiums for private insurance.

States could allow the subsidies to be used for health plans the administration has been promoting outside the ACA marketplaces that are less expensive because they provide skimpier benefits and fewer consumer protections. In an even more dramatic change, states could let residents with employer-based coverage set up accounts in which they mingle the federal subsidies with health-care funds from their job or personal tax-deferred savings funds to use for premiums or other medical expenses.

If some states take up the administration’s offer, it would undermine the ACA’s central changes to the nation’s insurance system, including the establishment of nationwide standards for many kinds of health coverage sold in the United States.

Another goal of the ACA, the sprawling 2010 law that was President Barack Obama’s preeminent domestic accomplishment, was to concentrate help on the individual insurance market serving people who do not have access to affordable health benefits through a job. Prices were often out of control and discrimination against unhealthy people was more prevalent before the ACA imposed required benefits, prohibited insurers from charging more to people with preexisting conditions and created a federal health exchange and similar state-run marketplace in which private insurance companies compete for customers.

The ACA health plans have been the only ones for which consumers can use the subsidies, designed to help customers with incomes up to the middle class — 400 percent of the federal poverty line — afford the premiums.

The new advice, called “waiver concepts” because they are ideas for how states could get federal permission to deviate from the law’s basic rules, stray from both of those goals. And it would allow states to set different income limits for the subsidies — higher or lower than the federal one.

The day before they were released by Seema Verma, administrator of the Department of Health and Human Services’ Centers for Medicare and Medicaid Services, an analysis by the Brookings Institution questioned the legality of the content and method of these concepts. The analysis by Christen Linke Young, a Brookings fellow and HHS employee during the Obama administration, contends that “there are serious questions” about whether the changes are allowable under the law and that “at the very least, it is likely invalid” for CMS to issue the advice to states without going through the formal steps to change federal regulations.

In a statement Thursday, HHS Secretary Alex Azar said: “The Trump administration is committed to empowering states to think creatively about how to secure quality, affordable healthcare choices for their citizens.” He said the four recommendations issued Thursday, including new accounts in which consumers could pool federal subsidies and other funds, are intended to “show how state governments can work with HHS to create more choices and greater flexibility in their health insurance markets, helping to bring down costs and expand access to care.”

In a midday speech before a gathering of the conservative American Legislative Exchange Council, Verma delivered a broadside against the health-care law in explaining the rationale for freeing states to rework health policies on their own. “It was such a mistake to federalize so much of health care in the ACA,” said Verma, who worked as a consultant to states before becoming one of Trump’s senior health-care advisers. While the law sought to make health coverage more available and affordable, she said, “the insurance problem has not been solved. For many Americans it’s even been made worse.”

In urging states to consider the changes, CMS is renaming a provision of the law, known as 1332, which until now has mainly been used to give states permission to create programs to ease the burden on insurers of high-cost customers. CMS is switching the name to “State Relief and Empowerment Waivers,” emphasizing the administration’s desire to hand off health-care policies to states.

The changes go beyond a variety of other steps Trump administration health officials have taken in the past year to weaken the ACA, which the president has opposed vociferously.

Until now, they have focused on bending the ACA’s rules for health plans themselves. The administration has rewritten regulations to make it easier for Americans to buy two types of insurance that is relatively inexpensive because it does not contain all the benefits and consumer protections that the ACA typically requires.

The new steps go further by undercutting the basic ACA structure of the individual insurance marketplaces created for those who cannot get affordable health benefits through a job.

During a conference call with journalists, Verma said that no state would be allowed to retreat from a popular aspect of the ACA that protects people with preexisting medical conditions from higher prices or an inability to buy coverage.

She said that, in evaluating states’ proposals, CMS would focus on several considerations, including whether changes would foster comprehensive coverage and affordability and would not increase the federal deficit. She said federal officials would favor proposals that help, in particular, low-income residents and people with complex medical problems.

Verma reiterated an administration talking point that insurance rates have escalated since the ACA was passed and that health plan choices within ACA marketplaces have dwindled. However, the current ACA enrollment period, lasting until mid-December, is different from the previous few because prices for the most popular tier of coverage have stabilized in many places and more insurers are taking part in the marketplaces.

 

JAMA Forum: Medicaid as a Safeguard for Financial Health

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JAMA Forum: Medicaid as a Safeguard for Financial Health

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Home insurance doesn’t make a home less flammable. It protects homeowners against financial disaster should something happen to their home. The same holds true for auto insurance, for life insurance, and for disability insurance. And though we often talk about health insurance in terms of making people healthier, its true goal is the same as with other insurance: to safeguard the financial health of beneficiaries in the face of undesirable circumstances.

Even in that respect, the Medicaid expansion appears to be working.

Many articles have focused on the positive effects of Medicaid on health and well-being of recipients. A recent National Bureau of Economic Research working paper highlighted instead the effect of Michigan’s Medicaid expansion on Medicaid recipients’ financial health.

You’re still here? I said go read it at the JAMA Forum!

https://www.nber.org/papers/w25053

Click to access w25053.pdf

 

 

 

 

 

 

 

Healthcare Triage: Medicare for All and Administrative Costs

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Healthcare Triage: Medicare for All and Administrative Costs

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Political talk is getting more and more serious around Medicare for All in the United States. The argument, as usual comes down to costs. One of the advantages that proponents always bring up are the very low administrative costs of Medicare. Are those low costs for real? Would they hold up if everyone was in the system? Healthcare Triage looks at the facts.

 

 

ACA Slow Enrollment as Uninsured Rate Remains Steady

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https://www.healthaffairs.org/do/10.1377/hblog20181120.831184/full/

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In most states across the country, the open enrollment period for 2019 began on November 1 and will end on December 15, 2018. As we near the halfway point for enrollment—at least for the states with a federal marketplace—recent federal data suggests that enrollment in Affordable Care Act (ACA) marketplace plans is lagging relative to last year.

In its “week 2” enrollment snapshot, the Centers for Medicare and Medicaid Services (CMS) announced that nearly 1.2 million consumers selected a plan between November 1 and November 10 in the 39 states that use HealthCare.gov. Of these consumers, about 275,000 were new consumers while about 901,000 were renewing their coverage from last year. This reflects a significant increase from the first three days of open enrollment when about 371,000 consumers selected a plan.

“Week 2” plan selections are down by about 302,000 consumers relative to last year. This can be read as between an 8 to 13 percent decline in plan selections compared to last year, when a total of 11.8 million consumers in all 50 states and DC selected or were automatically reenrolled in a marketplace plan. Enrollment remained largely stable from 2017 to 2018 despite a shortened open enrollment period and significant cuts to advertising and navigator funding.

This year, however, brings additional changes that could be contributing to what is, at least so far, depressed enrollment through HealthCare.gov. These changes include repeal of the individual mandate penalty; 2019 is the first year that consumers will no longer pay a penalty for being uninsured under the ACA. In addition, new federal rules are enabling expanded access to non-ACA plans (such as short-term, limited-duration insurance and association health plans). These non-ACA plans typically have a much lower premium than ACA plans and could lure consumers away from the marketplace.

It is too early to tell if the reduced enrollment trend will hold and if this pattern will continue. Enrollment may increase significantly before the December 15 deadline, and millions of Americans will enroll in coverage before the end of the year.

The declines are, however, significant. The former chief marketing officer for HealthCare.gov recently noted that the data “should be a wake-up call to everyone who cares about people having health care … on the need to step up efforts to raise awareness.” CMS intends to release enrollment snapshots on a weekly basis. Each snapshot also includes point-in-time estimates of call center activity and visits to HealthCare.gov and CuidadoDeSalud.gov, among other data.

The new open enrollment data comes at a time when the uninsured rate continues to remain steady. Data from the National Center for Health Statistics—in reports both from late August and November—shows that the uninsured rate of about 8.8 percent for 2018 remains largely unchanged from 2017. Although there was not a significant shift from 2017 to 2018, there has been a sizable drop in the uninsured rate since the ACA was enacted in 2010. Between 2010 and the first six months of 2018, the uninsured rate dropped from 16 percent (48.6 million people) to 8.8 percent (28.5 million people).

 

 

Five controversial health actions on Trump’s agenda

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Five controversial health actions on Trump’s agenda

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The Trump administration is expected to push ahead with a range of controversial health policies next year despite Democrats retaking the House.

Democrats captured the House majority in part on their health-care message. But despite that there are a slew of actions where the administration is moving ahead on its own agenda.

Here are five controversial moves Trump officials are expected to make on health care.

 

Roll back transgender protections

A new policy from the Trump administration could limit or completely eliminate federal protections for transgender individuals.

The move would narrow the definition of gender under a federal civil rights law to either male or female, as defined by a person’s sex at birth.  It’s being spearheaded by the Department of Health and Human Services and reportedly being pushed across multiple agencies.

The potential change has alarmed activists and medical professionals. The American Medical Association, the country’s largest physician lobbying group, said it will “oppose efforts to deny an individual’s right to determine their stated sex marker or gender identity.”

The new policy could be related to a broader proposed rule that’s been under review by the White House Office of Management and Budget since April, that opponents say would make it easier for doctors and hospitals to deny treatment to transgender patients and women who have had abortions.

That rule is expected to roll back a controversial anti-discrimination provision buried within ObamaCare, which prohibits health care providers and insurers who receive federal money from denying treatment or coverage to anyone based on sex, gender identity, or termination of pregnancy, among other conditions.

Religious providers say they expect the Trump administration’s rule would merely reinforce their right not to provide treatment that’s against their beliefs.

 

Limit abortion providers from getting federal money

The administration is expected to finalize regulations in January that would make it harder for Planned Parenthood and other abortion providers to receive federal family planning money.

The rule would ban clinics that receive Title X family planning funds from referring women for abortions while also removing a requirement that clinics counsel women on abortion as an option.

It would also require Title X grantees have a physical and financial separation from abortion providers.

Anti-abortion groups, like the Susan B. Anthony List, have pushed the Trump administration to implement these rules as a way to cut Planned Parenthood and other abortion providers from the program.

Title X funds organizations offering family planning services, like birth control and pregnancy tests, to low-income women and men.

Similar regulations were issued under former President Ronald Reagan, and later upheld by the Supreme Court, but never went into effect due to a lengthy legal battle.

The regulations are expected to be in effect for the next batch of Title X grants, which begin in April.

 

Approve more state Medicaid work requirements

The Department of Health and Human Services is committed to allowing states to impose work requirements on Medicaid beneficiaries.

The administration has approved work requirements in five states so far, and several more are expected in the coming months.

Just this week, the administration reapproved a plan in Kentucky to charge premiums, impose work requirements and remove people from the Medicaid program if they don’t comply.

The initial effort was blocked by a federal judge, but by re-approving it with only technical changes, the administration showed its commitment to forge ahead despite criticism.

Opponents say the requirements are a way to punish poor people. They argue the requirements are only meant to kick people off Medicaid and save states money.

Arkansas was the first state to implement a work requirement, and more than 12,000 people have lost health coverage as a result.

The administration insists work requirements are empowering, and help people lift themselves out of poverty and government dependence.

Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma sounded a defiant tone when she announced the administration’s approval of Wisconsin’s work requirements at the end of October.

“We will not retreat from this position,” Verma said. “Community engagement requirements in Medicaid are not a blunt instrument. This is a thoughtful and reasonable policy, and one that is rooted in compassion.”

 

Indefinitely detain migrant families

The Trump administration is seeking to indefinitely jail migrant children with their families, a policy that would overturn 20 years of protections for immigrant children.

The administration is expected to issue final regulations that would terminate and replace the Flores agreement, which has governed the detention of migrant children since 1997.

The plan, which was issued in September, would allow immigration officials to keep children and their parents detained together for the entire length of their court proceedings, which could take months in some cases.

Comments on the proposal were due earlier this month, and the rule could be made final next year.

The Flores rules are the result of a settlement in a federal class-action lawsuit over the physical and emotional harm done to children held in jail-like settings for extended periods. The settlement was only meant to be temporary, until it could be written into federal law.

Multiple administrations have challenged the rules and attempted to extend the time migrant children can be detained, but the federal judge overseeing the case has rejected those attempts.

The Trump administration is trying something novel; no administration has attempted to replace the Flores agreement with new regulations. It’s not a guarantee of success, and advocates have promised a challenge as soon as the final rules are announced.

 

Loosen nursing home emergency preparedness rules

Senate Democrats are decrying a move by the Trump administration to change safety rules for nursing homes.

The administration says the proposal would reduce a regulatory burden and save money for providers. But critics say that instead of making nursing homes safer, the proposal would put seniors at risk.

Sen. Ron Wyden (D-Ore.), ranking member of the Senate Finance Committee, said the administration is moving in the opposite direction of what they should be doing in the wake of hurricanes last year that left dozens of people dead across multiple states.

Last year, 12 people died when a Florida nursing home lost power in the wake of Hurricane Irma. In Texas, multiple facilities decided not to evacuate after Hurricane Harvey, despite warnings about the threat of catastrophic flooding.

The original emergency preparedness requirements went into effect just last year, more than a decade after the Department of Health and Human Services (HHS) Office of Inspector General first called for reform in the wake of hurricanes Katrina and Rita.

A report from Senate Finance Committee Democrats included 18 recommendations to improve nursing home safety during natural disasters. But Wyden said the administration is ignoring them in order to “pad the pockets of medical providers.” 

 

Can a Divided Congress Fix Health Care?

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KFF Health Tracking Poll – November 2018: Priorities for New Congress and the Future of the ACA and Medicaid Expansion

The Kaiser Family Foundation’s latest tracking poll finds that costs and affordability are the health care issues Americans most want Congress to address — though the public remains highly skeptical that Democrats and Republicans can actually work together to do anything on health care.

The poll also finds that the favorability of the Affordable Care Act has risen to 53 percent and that 59 percent of people living in states that have not expanded Medicaid under the ACA want such an expansion.

Key Findings:

  • The November KFF Health Tracking Poll, conducted the week after the 2018 midterm election, finds a majority of the public wants the new Democratic majority in the U.S. House of Representatives to work with Republicans on legislation to address the major problems facing the country as well as conduct oversight of the Trump administration’s actions on policies such as health care. Yet, few Americans are “very confident” (6 percent) that Republicans and Democrats in Congress will be able to work on bipartisan legislation to address the health care issues facing the country.
  • The midterm elections brought Medicaid expansion to three additional states, bringing the total number of states that have expanded their Medicaid programs to cover more low-income uninsured adults to 37 (including Washington, D.C.). Those living in states that have not expanded their Medicaid programs continue to hold a favorable view of Medicaid expansion and most would like to see their state expand their Medicaid program. And as a possible indicator of how some other states may expand their Medicaid programs in the future, most of those living in a non-expansion state say that if their state government chooses not to expand, voters themselves should be able to decide if their state expands their Medicaid program.
  • The new Democratic majority in the House all but guarantees the Affordable Care Act (ACA) will remain the law of the land for at least the next two years. The most recent tracking poll finds a slight uptick – largely driven by Democrats – in the overall favorability of the law (53 percent) and many of the ACA’s provisions continue to be quite popular with a majority of the public. But the poll also finds the public is largely unaware about the law’s sixth open enrollment period, and four in ten 18-64 year olds who buy their own insurance or are currently uninsured say they will choose to go without coverage in 2019.

    Most Americans say it is “very important” to keep the ACA provisions barring insurers from denying coverage or charging more (62%) to people with pre-existing conditions, even after hearing that these may have increased costs for some healthy people

  • A divided Congress does not mean that the coming year will not see any changes to the country’s health care system. There is an impending lawsuit, Texas v. United States, which may end the ACA’s protections for people with pre-existing medical conditions as well as the Trump administration’s recent actions allowing employers to be exempt from covering the full cost of birth control for their employees if they oppose to it due to religious or moral reasons, which could lead to substantial changes to health coverage for many Americans. This month’s tracking poll examines the public’s support for these proposed changes and examines the malleability of these opinions.

The Public’s Priorities for Next Congress

With Democratic gains in the U.S. House of Representatives during the 2018 midterm election, Democrats and Republicans will split control of Congress next year. These results will mean that President Trump will have a divided Congress for the first time in his presidency. About half of the public (53 percent) say oversight of the Trump administration’s actions on policies such as health care, education, and the environment should be a “top priority” for House Democrats in the coming year. This is similar to the share (55 percent) who say that working to enact new laws to address the major problems facing the country should be a “top priority” for House Democrats in the coming year and substantially larger than the share who say investigating corruption within President Trump’s administration should be a “top priority” (36 percent).

Majority of The Public Say Working To Enact New Legislation And Oversight Are Top Priorities For Democrats

Figure 1: Majority of The Public Say Working To Enact New Legislation And Oversight Are Top Priorities For Democrats

Unsurprisingly, the share of partisans who say each of these should be a “top priority” for Democrats in the U.S. House of Representatives varies drastically; majorities of Democrats saying conducting oversight (77 percent), working to enact legislation (67 percent), and investigating corruption (58 percent) should all be top priorities for the coming year. A majority of independents (54 percent) say working to enact legislation should be a “top priority,” while less than half of Republicans say any of these – including working to enact legislation – should be “a top priority” for House Democrats.

Figure 2: Most Democrats Say New Legislation, Oversight, and Investigating Corruption Are Top Priorities For House Democrats

Figure 2: Most Democrats Say New Legislation, Oversight, and Investigating Corruption Are Top Priorities For House Democrats

Immigration and Health Care Top Public’s Priorities

Similar to the issues driving voters in the 2018 midterm elections, the most recent KFF Health Tracking Poll finds immigration and health care as the top issues the public want to see the next Congress act on in 2019 with the issues offered largely driven by party identification. Overall, about one-fifth of voters offer immigration or border security (21 percent) when asked to say in their own words the issue Congress should work on next year. This is similar to the share of the public who offer health care (20 percent) as the top issue they want to see the next Congress work on. Fewer offer gun control/legislation (8 percent), tax reform (4 percent), or education (4 percent) as the issues they want to see Congress act on in 2019.

Four times as many Republicans (41 percent) offer immigration/border security as the issue they would most like the next Congress to act on in 2019 as Democrats (10 percent). On the other hand, health care is the top issue for Democrats. One-fourth of Democrats (27 percent) say health care is the issue they would most like to see the next Congress act on, compared to 11 percent of Republicans who say the same. Independents are divided across the top two issues, with similar shares offering immigration/border security (22 percent) and health care (21 percent) as the issues they want to see Congress work on.

Table 1: Immigration and Health Care Top Public’s Priorities for Next Congress
Thinking about next year, which issue would you most like the next Congress to act on in 2019? (open-end) Total Democrats Independents Republicans
Immigration/Border security 21% 10% 22% 41%
Health care 20 27 21 11
Gun control/legislation 8 13 4 8
Tax reform 4 2 7 8
Education 4 7 2 –
Note: Only top five responses shown. Question asked of half sample.
COST AND AFFORDABILITY CONTINUES TO DOMINATE HEALTH CARE PRIORITIES

When asked which health care issue they would most like to see the next Congress act on in 2019, more Americans offer issues around health care affordability and cost (19 percent) than other health care issues including the 2010 Affordable Care Act (ACA) (10 percent) or Medicare (6 percent). Health care affordability and cost are also the most frequently mentioned health care issues by Democrats (14 percent), independents (25 percent), and Republicans (17 percent). The ACA is the second most frequently mentioned health care issue among partisans, with Democrats saying they want to see Congress “protecting or improving the ACA” while Republicans say they want to see the next Congress “repealing the ACA.” Independents are divided on this issue, with similar shares saying they want to see Congress repealing and protecting the 2010 health care law.

Figure 3: Cost And Affordability Top Public’s Health Care Priorities For Next Congress

Figure 3: Cost And Affordability Top Public’s Health Care Priorities For Next Congress

While there appears to be consensus among the public on what health care issue they want to see Congress work on next year, not quite one-third are confident that Democrats and Republicans in Congress will be able to work together on bipartisan legislation to address the health care issues facing the country. In fact, seven in ten say they are either “not very confident” (34 percent) or “not at all confident” (35 percent) that Congress will be able to work on such bipartisan legislation, while fewer are confident, either “very confident” (six percent) or “somewhat confident” (24 percent), in Congress being able to work together.

Figure 4: Less Than One-Third Are Confident Congress Can Work Together To Address Health Care Issues Facing The Country

Figure 4: Less Than One-Third Are Confident Congress Can Work Together To Address Health Care Issues Facing The Country

Democrats are slightly more confident in the ability of Democrats and Republicans in Congress to be able to work together on bipartisan health care legislation (41 percent) compared to independents (27 percent) and Republicans (19 percent); yet, a majority across party identification say they are either “not very confident” or “not at all confident” (58 percent, 72 percent, and 79 percent, respectively).

The Future of the Affordable Care Act and Medicaid Expansion

The 2018 midterm elections have major implications for both the future of the 2010 health care law known as the Affordable Care Act (ACA) as well as one of its most popular provisions – individual state’s expansion of the Medicaid program for low-income people.

The Affordable Care Act

With Democrats regaining a majority in the U.S. House of Representatives for the first time since 2010, and without continued efforts among Republicans to repeal the ACA, the latest KFF Tracking Poll finds a slight uptick in the public’s view of the law with 53 percent saying they view law favorably compared to four in ten who have an unfavorable view of the law. This slight shift is largely driven by Democrats with about eight in ten saying they have a favorable opinion of the law, including about half (48 percent) who have a “very favorable” view. Similarly, three-fourths of Republicans (76 percent) continue to view the law unfavorably with more than half (54 percent) saying they have a “very unfavorable” opinion of the law.

Figure 5: Post-Election Tracking Poll Finds Slight Uptick in ACA Favorability, Largely Driven By Democrats

Figure 5: Post-Election Tracking Poll Finds Slight Uptick in ACA Favorability, Largely Driven By Democrats

AMERICANS CONTINUE TO HOLD FAVORABLE OPINIONS OF ACA PROVISIONS

Similar to previous KFF Tracking Polls, many of the ACA’s provisions continue to be quite popular, even across party lines. A majority of the public – regardless of party identification – hold favorable views of all of the ACA’s provisions with one exception (fewer than half of Republicans say they have a favorable opinion of the Medicare payroll tax increases on earnings for upper-income Americans).

Table 2: Americans’ Opinions of ACA Provisions
Percent who say they have a FAVORABLE opinion of each of the following provisions of the law: Total Democrats Independents Republicans
Allows young adults to stay on their parents’ insurance plans until age 26 82% 90% 82% 66%
Creates health insurance exchanges where small businesses and people can shop for insurance and compare prices and benefits 82 91 78 71
Provides financial help to low- and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage 81 92 82 63
Gradually closes the Medicare prescription drug “doughnut hole” so people on Medicare will no longer be required to pay the full cost of their medications 81 85 82 80
Eliminates out-of-pocket costs for many preventive services 79 88 78 68
Gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults 77 91 77 55
Requires employers with 50 or more employees to pay a fine if they don’t offer health insurance 69 88 61 56
Prohibits insurance companies from denying coverage because of a person’s medical history 65 70 66 58
Increases the Medicare payroll tax on earnings for upper-income Americans 65 77 69 42
Note. Some items asked of half samples.

In previous KFF Health Tracking Polls, one of the ACA’s provisions – the individual mandate which required nearly all Americans have health insurance or pay a fine – was consistently viewed unfavorably by a majority of the public. As part of the federal tax bill passed in 2017, Congress zeroed out the dollar amount and percentage of income penalties imposed by the individual mandate. Overall, three in ten Americans (31 percent) are aware that Congress has gotten rid of the penalty for not having health insurance, while four in ten (38 percent) incorrectly say Congress has not gotten rid of this penalty and an additional three in ten (31 percent) are unsure. The results are similar among those under 65 years old who either buy their own insurance or are currently uninsured with three in ten (31 percent) aware Congress has gotten rid of the penalty for not having health insurance.

Figure 6: Most Americans Are Not Aware Congress Has Gotten Rid Of The Penalty For Not Having Health Insurance

Figure 6: Most Americans Are Not Aware Congress Has Gotten Rid Of The Penalty For Not Having Health Insurance

Medicaid Expansion

Three states (Idaho, Nebraska, and Utah) voted during the 2018 election to expand their Medicaid program to cover more low-income residents, bringing the total number of states that have expanded their Medicaid programs to 37 states including Washington, D.C. Overall, about three-fourths of the public – including 77 percent of those living in non-expansion states – have a favorable view of the ACA’s provision that gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults. In addition, a majority (59 percent) of those living in non-expansion states would like to see their state expand Medicaid to cover more low-income uninsured people while one-third (34 percent) say they want to see their state keep Medicaid as it is today. A majority of Democrats and Democratic-leaning independents say they want to see their state expand Medicaid (84 percent) while most Republicans and Republican-leaning independents want to see their state keep Medicaid as it is today (65 percent).

Figure 7: Majority Of Residents In Non-Expansion States Want Their State To Expand Their Medicaid Programs

Figure 7: Majority Of Residents In Non-Expansion States Want Their State To Expand Their Medicaid Programs

Among those living in states without Medicaid expansion who want to see their state expand their Medicaid program, nearly nine in ten (51 percent of all residents living in non-expansion states) say that if their governor and state government choose not to expand Medicaid, voters themselves should be able to decide if their state expands Medicaid.

The ACA’s 2019 Open Enrollment Period

The ACA’s sixth open enrollment period for individuals who purchase health plans on their own began on November 2, 2018 and closes in most states on December 15, 2018.1 According to the Centers for Medicare and Medicaid Services, as of November 21, 2018, 1.9 million people have signed up for insurance through the federal marketplace, which is slightly less than in previous years.2

The most recent KFF Tracking Poll finds a majority of the group most directly affected by open enrollment (those 18-64 years old who either purchase their own insurance or are currently uninsured) are unaware of the current open enrollment deadlines. About one-fourth (24 percent) of this group is aware of the current deadline to buy insurance for 2019 while six in ten (61 percent) say they “do not know” the deadline and 16 percent either offer the wrong date, incorrectly say there is no deadline or that the deadline has passed, or refuse to answer the question.

Figure 8: About One-Fourth Of Those Who Buy Their Own Insurance Or Are Uninsured Know Current Open Enrollment Deadline

Figure 8: About One-Fourth Of Those Who Buy Their Own Insurance Or Are Uninsured Know Current Open Enrollment Deadline

Slightly less than half (45 percent) of those 18-64 who either purchase their own insurance or are currently uninsured, say they have heard or seen any ads in the past thirty days from an insurance company attempting to sell health insurance. Fewer – about three in ten (31 percent) say they have heard or seen any information about how to get health insurance under the health care law.

IT IS STILL UNCLEAR HOW TWO MAJOR CHANGES TO ACA MARKETPLACES WILL AFFECT OPEN ENROLLMENT

This year’s open enrollment period has two major changes brought about by Republicans and President Trump’s administration: the removal of the penalty for not having health insurance and the introduction of short-term health insurance plans. About half of 18-64 year olds who buy their own insurance or are currently uninsured say they plan to buy their own insurance in 2019, despite the elimination of the fine for people who don’t have health insurance, while four in ten (42 percent) say they will choose to go without coverage in 2019.

Figure 9: Unclear How Changes To Individual Mandate Penalty And New Short-Term Plans May Affect Open Enrollment

Figure 9: Unclear How Changes To Individual Mandate Penalty And New Short-Term Plans May Affect Open Enrollment

One option available to those who buy their own insurance that would not have satisfied the ACA individual mandate in previous years are short-term health insurance plans. These plans cost significantly less than ACA-compliant plans but provide fewer benefits and may not pay for care for some pre-existing medical conditions.3 About one-fifth (21 percent) of those under the age of 65 who buy their own insurance or are currently uninsured say that if they had the opportunity, they would want to purchase a short-term plan. Seven in ten say they would either continue going without coverage or keep the plan they have now.

Public Support Trump Administration’s Actions on Prescription Drug Advertisements, Divided on Actions Aimed at Women’s Health and Pre-Existing Coverage

In recent months, the Trump administration has announced several actions aimed at different aspects of the U.S. health care system. The most recent KFF Tracking Poll finds the public supports the Trump administration’s proposed actions on prescription drug advertisements, even after hearing counter-arguments. The public is more divided on the administration’s actions on women’s health and protections for people with pre-existing conditions.

PRESCRIPTION DRUG ADVERTISEMENTS

Earlier this year, President Trump announced a series of ideas aimed at lowering the price of prescription drugs. One of its key elements is to require drug manufacturers to publish list prices for their prescription drugs in television advertisements. About three-fourths (77 percent) favor the federal government requiring prescription drug advertisements to include a statement about how much the drug costs. In a rare instance of bipartisanship, this policy proposal is supported by a majority of Democrats (80 percent), independents (74 percent) and Republicans (77 percent).

Figure 10: Large Shares, Regardless Of Party, Favor Requiring Prescription Drug Advertisements To Include Pricing Information

Figure 10: Large Shares, Regardless Of Party, Favor Requiring Prescription Drug Advertisements To Include Pricing Information

After President Trump announced this proposal, there was some debate about how this could be implemented with opponents saying that since people often pay different prices for the same drug based on the type of insurance they have, including a price in a drug advertisement could be confusing to consumers. About one-fifth of those who originally supported this proposal change their minds after hearing this counter-argument, leaving a slight majority of the public (53 percent) continuing to support this proposal. On the other side of the debate, nearly half of those (7 percent of total) who originally opposed this proposal change their minds after hearing that putting the price of a drug in an advertisement would put pressure on drug companies to lower their prices.

Figure 11: Majority Of The Public Continue To Favor Putting Prices In Drug Advertisements Even After Hearing Counter-Arguments

Figure 11: Majority Of The Public Continue To Favor Putting Prices In Drug Advertisements Even After Hearing Counter-Arguments

EMPLOYER EXEMPTION FROM COVERING BIRTH CONTROL

On November 15, 2018, the Trump Administration issued final regulations expanding the types of employers that may be exempt from the Affordable Care Act’s (ACA) contraceptive coverage requirement to all nonprofit and closely-held for-profit employers with objections to contraceptive coverage based on religious beliefs or moral convictions, including private institutions of higher education that issue student health plans.4 Overall, six in ten (57 percent) of the public, including most women, oppose allowing employers to be exempt from the requirement to cover the full cost of prescription birth control in their plans if they object to it for religious or moral reasons.

Figure 12: Majorities Across Groups – Except For Republicans – Oppose Allowing Employers To Be Exempt From Covering Birth Control

Figure 12: Majorities Across Groups – Except For Republicans – Oppose Allowing Employers To Be Exempt From Covering Birth Control

Few individuals, on either side of the debate, change their minds about employers being exempt from covering the cost of prescription birth control for religious or moral reasons after hearing counter-arguments. About one-fourth (9 percent of total) change their minds and now oppose employer exemptions after hearing that this means some women would not be able to afford birth control. On the other side of the argument, one in eight (7 percent of total) now favor this exemption if they heard that some business owners feel like they are being forced to pay for a benefit that violates their religious or moral beliefs.

Figure 13: Few, On Either Side Of Debate, Change Minds About Employer Birth Control Coverage After Hearing Counter-Arguments

Figure 13: Few, On Either Side Of Debate, Change Minds About Employer Birth Control Coverage After Hearing Counter-Arguments

PROTECTIONS FOR PEOPLE WITH PRE-EXISTING MEDICAL CONDITIONS

In June 2018, President Trump’s administration announced – as part of a lawsuit known as Texas v. United States, brought by 20 Republican state attorneys general – it will no longer defend the ACA’s protections for people with pre-existing medical conditions. These provisions prohibit insurance companies from denying coverage based on a person’s medical history (known as guaranteed issue), and prohibit insurance companies from charging those with pre-existing conditions more for coverage (known as community rating). The impending suit, Texas v. United States, will decide, among other things, whether both of these protections are unconstitutional and if they will be deemed invalid beginning on January 1, 2019.

The majority of the public say it is “very important” to them that the ACA’s provisions protecting those with pre-existing conditions remain law even after hearing that these protections may have led to increased insurance costs for some healthy people. Sixty-five percent of the public say it is “very important” to them that the provision that prohibits health insurance companies from denying coverage because of a person’s medical history remains law. An additional fifth (22 percent) say it is “somewhat important” this provision remains law. Similarly, about six in ten say it is “very important” that the provision that prohibits health insurance companies from charging sick people more remains law, while an additional one in five (22 percent) say it is “somewhat important.”

Figure 14: Majorities Say Pre-Existing Condition Protections Are Very Important To Them

Figure 14: Majorities Say Pre-Existing Condition Protections Are Very Important To Them

If the judge ruling on Texas v. United States decides the ACA’s protections for people with pre-existing conditions are unconstitutional, a majority of the public – including 87 percent of Democrats, 67 percent of independents, and about half of Republicans – say they would want their state to establish protections for people with pre-existing health conditions, even if this means some healthy people may pay more for coverage.

Figure 15: Majorities Say They Would Support State Action If ACA’s Pre-Existing Condition Protections Are Ruled Unconstitutional

Figure 15: Majorities Say They Would Support State Action If ACA’s Pre-Existing Condition Protections Are Ruled Unconstitutional

 

 

Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks

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The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.

The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.

With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.

From hundreds of letters sent to the government by health care executives and lobbyists in the last few weeks, some themes emerge: Federal laws prevent insurers from rewarding Medicare patients who lose weight or take medicines as prescribed. And they create legal risks for any arrangement in which a hospital pays a bonus to doctors for cutting costs or achieving clinical goals.

The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries. The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.

Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.

“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.

Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.

These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.

Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.

The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.

The Trump administration is calling its effort a “regulatory sprint to coordinated care.”CreditSarah Silbiger/The New York Times.

Health care providers can be fined if they offer financial incentives to Medicare or Medicaid patients to use their services or products. Drug companies have been found to violate the law when they give kickbacks to pharmacies in return for recommending their drugs to patients. Hospitals can also be fined if they make payments to a doctor “as an inducement to reduce or limit services” provided to a Medicare or Medicaid beneficiary.

Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”

Almost every week the Justice Department files another case against health care providers. Many of the cases were brought to the government’s attention by people who say they saw the bad behavior while working in the industry.

“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

But the laws are complex, and the stakes are high. A health care provider who violates the anti-kickback or self-referral law may face business-crippling fines under the False Claims Act and can be excluded from Medicare and Medicaid, a penalty tantamount to a professional death sentence for some providers.

Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community.

Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.

AstraZeneca, the drug company, said that older Americans with drug coverage under Part D of Medicare “often face prohibitively high cost-sharing amounts for their medicines,” but that drug manufacturers cannot help them pay these costs. For this reason, it said, the government should provide legal protection for arrangements that link the cost of a drug to its value for patients.

Even as health care providers complain about the broad reach of the anti-kickback statute, the Justice Department is aggressively pursuing violations.

A Texas hospital administrator was convicted in October for his role in submitting false claims to Medicare for the treatment of people with severe mental illness. Evidence at the trial showed that he and others had paid kickbacks to “patient recruiters” who sent Medicare patients to the hospital.

The owner of a Florida pharmacy pleaded guilty last month for his role in a scheme to pay kickbacks to Medicare beneficiaries in exchange for their promise to fill prescriptions at his pharmacy.

The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million.

The line between patient assistance and marketing tactics is sometimes vague.

This month, the inspector general of the Department of Health and Human Services refused to approve a proposal by a drug company to give hospitals free vials of an expensive drug to treat a disorder that causes seizures in young children. The inspector general said this arrangement could encourage doctors to continue prescribing the drug for patients outside the hospital, driving up costs for consumers, Medicare, Medicaid and commercial insurance.