Tag Archives: Health Policy

The driving force of health care fear

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https://www.axios.com/driving-force-health-care-fear-c90adaf6-e5f8-4c11-816d-d3893b5d1374.html

Stethoscope

Insurers are afraid of a deteriorating market for individual coverage, fueled by the repeal of the Affordable Care Act’s individual mandate as well as regulatory changes from the Trump administration.

What to watch: Over the course of the spring, they’ll be deciding whether it makes sense to simply quit offering ACA coverage in some parts of the country. Rural areas will likely be the first to see insurers leave.

Pharma fears Washington after a couple of surprising defeats on Capitol Hill have shown the industry may not be as bulletproof as it seems.

  • What to watch: The Trump administration is eager to show progress on drug prices, and its early efforts have largely steered clear of drug companies themselves. But Health and Human Services secretary Alex Azar is open to reining in some of the industry’s patent tricks — a move that could cost drugmakers billions of dollars.

Everyone fears Amazon. Just the possibility that it might enter the pharmacy business has accelerated a trend of health care mega-mergers, as the old guard looks to lock in as much market power as it can.

And the public fears the cost of health care. That’s part of the reason the industry, which profits from those costs, is right to worry about what’s ahead.

 

The politics of ACA rate hikes will be 2016 in reverse

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https://www.axios.com/politics-aca-rate-hikes-2016-in-reverse-63e401ef-03b7-4c11-a2b3-7410e1322c63.html

Protester holds sign saying "ACA Saves Lives"

We are about to see a replay of the 2016 election fight over premium increases, but this time in reverse. Last time, it was the Republicans hammering Democrats for the rate hikes. This time, it will be Democrats accusing Republicans of driving up premiums by sabotaging the Affordable Care Act.

What to watch: It’s going to be a balancing act for the Democrats. They can (and will) score political points by blaming Republicans for the coming premium increases, but another campaign debate about rising premiums could also undermine the ACA by focusing on its continuing problems.

In 2016, fear of rising premiums jumped the individual market, and a majority of Americans came to believe that rising premiums were somehow affecting them when only a small share of the public was impacted. That undermined the ACA and may have affected the election.

This time, Democrats will be on the offensive, buttressed by polling that shows the public sees Republicans and President Trump owning the ACA’s problems. Democrats are sure to call out Republicans and the administration for steps they have taken to undermine the law.

These include:

  • Eliminating the penalty for not buying insurance.
  • Failing to pass stabilization legislation.
  • Developing regulations to allow the sale of short-term policies and the wider sale of association health plans.

Taken together, these actions provide more options for the healthy, but will drive up rates overall.

Reality check: Last year, far more Americans came to believe they were affected by premiums increases than the relatively small number of unsubsidized people in the non-group market who were actually affected.

Our August 2017 tracking poll showed that fully 60% of the American people believed they were negatively affected by the premium increases, when in reality, just a sliver of the public — the unsubsidized people in the individual health insurance market — were actually affected.

The numbers that matter, per Kaiser Family Foundation estimates:

  • Affected: 6.7 million
  • Unaffected: 319 million

No doubt the broader public’s fears about rising premiums fueled cynicism about the ACA. Some political scientists say it contributed to the Republican victory in 2016.  In fact, premiums for most Americans with private coverage have been growing at a 3% clip, a historically moderate level.

The bottom line: As the midterms approach, Republicans’ first impulse may be to attack the law to rev up their base as they have done before. The tradeoff they face is that they now own the ACA in the eyes of the public, including the problem of rising premiums which they will have helped to create.

And Democrats now have a chance to score political points on the ACA for the first time — but the risk is a disproportionate public reaction, much like in 2016, that undermines the law they worked so hard to pass.

 

 

Consumers are paying less for ACA plans, even as premiums continue to rise

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https://www.fiercehealthcare.com/payer/consumer-satisfaction-exchange-enrollment-up-but-premiums-continue-to-rise?mkt_tok=eyJpIjoiWlRReU4yTXdZelF5TUdJMyIsInQiOiJqbDN6cndBd1YwOHFvQkV3NGNvXC9xVWh3bVpNYzJ0djZyaXJOakFGaU5nQWdETG0wWE1nWDhTck5XK2JIVTZkanFidU85clo2akpIT0VvXC9MWjFjOExsUm5kUEpRZk9IQ0tYNWFQeGJaQmhJMWNTdnkweFBtTGRJME1KNzJvaTRFIn0%3D&mrkid=959610

Healthcare.gov site on computer

The Centers for Medicare & Medicaid Services (CMS) proclaimed its 2018 open enrollment period a success, citing relatively stable enrollment on reduced costs of outreach and a tightened enrollment period.

The agency’s final report on 2018 enrollment data provides insight on the 11.8 million individuals who enrolled or renewed coverage through the exchanges in 2018. That number includes approximately 8.7 million who signed up through HealthCare.gov, where the average premium rose 30% from $476 last year to $621 this year. A solid majority of consumers opted for the middle-tier silver plans, with 29% choosing bronze plans and only 7% purchasing gold plans.

CMS Administrator Seema Verma lauded the agency’s efforts on Twitter, but pointed to the 30% jump in premiums as an indication that “more affordable options are needed,” particularly for those that don’t qualify for tax credits.

Despite delivering the most successful consumer experience to date, Americans continue to experience skyrocketing premiums and limited choice on http://Healthcare.gov .

Despite higher premiums, consumers that qualified for the tax credit actually saw a 16% decline in their final cost, with average monthly costs dropping from $106 in 2017 to $89 in 2018.

“The reduction in price that consumers paid was staggering,” Josh Peck, co-founder of Get America Covered and former chief medical officer of Healthcare.gov under President Barack Obama, told FierceHealthcare.

“To be totally honest, enrollment would have been far higher had they tried,” he added.

While the total number of enrollees dipped slightly year over year, they remained relatively stable given the shortened time frame rolled out by the Trump administration. Verma also pointed to consumer satisfaction scores of 90%, up from 85% last year, as proof the agency had met its primary goal of ensuring “a seamless experience” for consumers.

Critics, however, lashed out at CMS for doing little to educate the public about open enrollment options.

Lori Lodes@loril

Really weird (and gobsmacking) to see @SeemaCMS take credit for 11.8 million people signing up for health care when she refused to do anything to educate people about Open Enrollent. https://twitter.com/SeemaCMS/status/981250136344088576 …

The agency also touted the cost effectiveness of the enrollment period, after CMS slashed its advertising spending from approximately $11 per enrollee last year to just over $1 per enrollee in 2018. Those cuts spurred increased advertising dollars from private insurers in an attempt to make up the gap.

The majority of consumers using the exchanges continues to rely on premium subsidies. The age mix among consumers trended older, as enrollees aged 55 and over ticked up two percentage points to 29%, while the share of those aged 18-34 declined slightly.

Final Exchange Enrollment Report also shows most consumers on the Exchanges relied on premium subsidies. Approximately 83% of consumers nationwide had their premiums reduced by tax credits.

In a statement, Verma said she was pleased with the rise in customer satisfaction, but expressed concerns about the future. “Even with the success of this year’s open enrollment, the individual market continues to see premiums rise and choices diminish,” she said.

 

 

Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries

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Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries

Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits offered to Medicare beneficiaries who choose private sector health plans, when new federal rules take effect next year.

On Monday, the Centers for Medicare & Medicaid Services (CMS) expanded how it defines the “primarily health-related” benefits that private insurers are allowed to include in their Medicare Advantage policies. And insurers would include these extras on top of providing the benefits traditional Medicare provides.

“Medicare Advantage beneficiaries will have more supplemental benefits, making it easier for them to lead healthier, more independent lives,” said CMS Administrator Seema Verma.

Of the 61 million people enrolled in Medicare last year, 20 million opted for Medicare Advantage, the privately run alternative to the traditional government program. Advantage plans limit members to a network of providers, and similar restrictions may apply to the new benefits. In California, 40 percent of Medicare beneficiaries have joined Medicare Advantage.

Many Medicare Advantage plans already offer some health benefits not covered by traditional Medicare, such as eyeglasses, hearing aids, dental care and gym memberships. However, the new rules, which the industry sought, will expand that list significantly, adding more items and services that are not directly medical.

CMS said the insurers will be permitted to provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness and injuries, or reduce the need for emergency medical care.

Addressing a patient’s health and social needs outside the doctor’s office isn’t a new concept. In California, for example, the Institute on Aging, a nonprofit, offers social, psychological and health-related services for seniors and adults with disabilities. It has helped people in San Francisco and Southern California move from nursing homes back to their own homes, and it provides a variety of services and goods — from kitchen supplies to wheelchair ramps — that help improve their quality of life.

“By taking a more integrated approach to address people’s social and health needs, we have seen up to a 30 percent savings in health care costs compared to the costs of the same individuals before they joined our program,” said Dustin Harper, the institute’s vice president for strategic partnerships. The agency serves 20,000 Californians a year, including former nursing home residents who qualify for Medicare, the federally funded health insurance program for seniors, or Medicaid, the federal-state program for low-income people — or both.

The institute also provides a number of other innovative services. Volunteers and staff members answer calls to its toll-free, ’round-the-clock Friendship Line (800-971-0016), which is intended to combat social isolation and loneliness. In partnership with the city and county of San Francisco, the institute also offers subsidized home care for a small group of low- and middle-income people who don’t qualify for other assistance and could not otherwise afford it.

The organization also runs one of California’s 38 Multipurpose Senior Service Program sites, providing Medicaid-funded, home-based care. Some 33 social service organizations are MSSP providers, including the Partners in Care Foundation in Los Angeles, which operates four sites. About 2 million older adults and people with disabilities rely on Medicaid for home-based services to live at home for as long as possible.

Although Medicare Advantage insurers are still in the early stages of designing their 2019 policies, some companies have ideas about what they might include. In addition to transportation to doctors’ offices or better food options, some health insurance experts said additional benefits could include simple modifications inside beneficiaries’ homes, such as installing grab bars in the bathroom, or aides to help with daily activities, including dressing, eating and other personal care needs.

“This will allow us to build off the existing benefits that we already have in place that are focused more on prevention of avoidable injuries or exacerbation of existing health conditions,” said Alicia Kelley, director of Medicare sales for Capital District Physicians’ Health Plan, a nonprofit serving 43,000 members in 24 upstate New York counties.

Although a physician’s order or prescription is not necessary, the new benefits must be “medically appropriate” and recommended by a licensed health care provider, according to the new rules.

Many beneficiaries have been attracted to Medicare Advantage because of its extra benefits and the limit on out-of-pocket expenses. However, CMS also cautioned that new supplemental benefits should not be items provided as an inducement to enroll.

The new rules “set the stage to continue to innovate and provide choice,” said Cathryn Donaldson, of America’s Health Insurance Plans, a trade group.

“CMS is catching up with the rest of the world in terms of its understanding of how we keep people healthy and well and living longer and independently, and those are all positive steps,” said Ceci Connolly, chief executive officer of the Alliance of Community Health Plans, which represents nonprofit health insurance plans. Some offer non-emergency medical transportation, low-cost hearing aids, a mobile dental clinic and a “grocery on wheels,” to make shopping more convenient, she said.

UnitedHealthcare, the largest health insurer in the U.S., also welcomes the opportunity to expand benefits, said Matt Burns, a company spokesman. “Medicare benefits should not be one-size-fits-all, and continued rate stability and greater benefit design flexibility enable health plans to provide a more personalized health care experience,” he said.

This is one of several vans that provides door-to-door service for seniors and adults with disabilities going to medical appointments and programs at the Institute on Aging in San Francisco.

But patient advocates including David Lipschutz. senior policy attorney at the Center for Medicare Advocacy, are concerned about those who may be left behind. “It’s great for the people in Medicare Advantage plans, but what about the majority of the people who are in traditional Medicare?” he asked. “As we tip the scales more in favor of Medicare Advantage, it’s to the detriment of people in traditional Medicare.”

The details of the 2019 Medicare Advantage benefit packages must first be approved by CMS and will be released in the fall, when the annual open enrollment begins. It’s very likely that all new benefits will not be available to all beneficiaries since there is “tremendous variation across the country” in what plans offer, said Gretchen Jacobson, associate director of the Kaiser Family Foundation’s Program on Medicare Policy. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

In addition to next year’s changes in supplemental benefits, CMS also noted that a new federal law allows Medicare Advantage plans to offer benefits that are not primarily health-related for Medicare Advantage members with chronic illnesses. The law and the agency’s changes are complementary, CMS officials said. They promised additional guidance in the coming months to help plans differentiate between the two.

 

Hospitals are germy, noisy places. Some acutely ill patients are getting treated at home instead.

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https://www.washingtonpost.com/national/health-science/hospitals-are-germy-noisy-places-some-acutely-ill-patients-are-getting-treated-at-home-instead/2018/03/30/5fcb5006-2155-11e8-badd-7c9f29a55815_story.html?utm_term=.e3db8d812c05

Phyllis Petruzzelli spent the week before Christmas struggling to breathe. When she went to the emergency department on Dec. 26, the doctor at Brigham and Women’s Faulkner Hospital near her home in Boston said she had pneumonia and needed hospitalization. Then the doctor proposed something that made Petruzzelli nervous. Instead of being admitted to the hospital, she could go back home and let the hospital come to her.

As a “hospital-at-home” patient, Petruzzelli learned, doctors and nurses would come to her home twice a day and perform any needed tests or bloodwork.

A wireless patch would be affixed to her skin to track her vital signs and send a steady stream of data to the hospital. If she had any questions, she could talk via video chat anytime with a nurse or doctor.

Hospitals are germy and noisy places, putting acutely ill, frail patients at risk for infection, sleeplessness and delirium, among other problems. “Your resistance is low,” Petruzzelli said the doctor told her. “If you come to the hospital, you don’t know what might happen. You’re a perfect candidate for this.”

So Petruzzelli, who is now 71, agreed. That afternoon, she arrived home in a hospital vehicle. A doctor and nurse were waiting at the front door. She settled on the couch in the living room, with her husband, Augie, and dog, Max, nearby. The doctor and nurse checked her IV, attached the monitoring patch to her chest, and left.

When David Levine, the doctor, arrived the next morning, he asked Petruzzelli why she had been walking around during the night. Far from feeling uncomfortable that her nocturnal trips to the bathroom were being monitored, “I felt very safe and secure,” Petruzzelli said. “What if I fell while my husband was out getting me food? They’d know.”

After three uneventful days, she was “discharged” from her hospital-at-home stay. “I’d do it again in a heartbeat,” Petruzzelli said.

Brigham Health is one of a slowly growing number of health systems that encourage selected acutely ill emergency department patients to opt for hospital-level care at home.

In the couple of years since Brigham Health started testing this type of care, hospital staff who were initially skeptical have generally embraced it, Levine said. “They very quickly realize that this is really what patients want, and it’s really good care.”

This approach is quite common in Australia, Britain and Canada, but it has faced an uphill battle in the United States.

A key obstacle, clinicians and policy analysts agree, is getting health insurers to pay for it. At Brigham Health, the hospital can charge an insurer for a physician house call, but the remainder of the hospital-at-home services are covered by grants and other funding, Levine said.

Insurers don’t have a position on hospital-at-home programs, said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry trade group.

“Overall, health insurance providers are committed to ensuring patients have access to care they need, and there are Medicare Advantage plans that do cover this type of at-home care,” Donaldson said in a statement.

Levine, a clinician-investigator at Brigham and Women’s Hospital and an instructor at Harvard Medical School, was the lead author of a recently published study comparing patients who received either hospital-level care at home or in the hospital in 2016.

The 20 patients analyzed in the trial had one of several conditions, including infection, heart failure, chronic obstructive pulmonary disease and asthma. The trial found that while there were no adverse events in the home-care patients, their treatment costs were significantly lower — about half that of patients treated in the hospital.

Why? For starters, labor costs for at-home patients are lower than for patients in a hospital, where staff must be on hand around the clock. Home-care patients also had fewer lab tests and visits from specialists.

The study found that both groups of patients were about equally satisfied with their care, but the home-care group was more physically active.

Brigham Health is conducting further randomized controlled trials to test the at-home model for a broader range of diagnoses.

Bruce Leff began exploring the hospital-at-home concept more than 20 years ago, conducting studies that found fewer complications, better outcomes and lower costs in home-care patients.

Hospitals, accustomed to the traditional business model that emphasizes filling hospital beds in a bricks-and-mortar facility, have been slow to embrace the idea, however.

There are practical hurdles, too.

“It’s still easier to get Chinese food delivered in New York City than to get oxygen delivered at home,” said Leff, a professor of medicine and director of Johns Hopkins Medical School’s Center for Transformative Geriatric Research.

Since the seven-hospital Mount Sinai system in New York launched its hospital-at-home program, more than 700 patients have chosen it. And they have fared well on a number of measures.

The average length of stay for acute care was 5.3 days in the hospital vs. 3.1 days for home-care patients, while 30-day readmission rates for home-based patients were about half of those who had been hospitalized: 7.8 percent vs. 16.3 percent.

Begun with a $9.6 million federal grant in 2014, Mount Sinai’s program initially focused on Medicare patients with six conditions, including congestive heart failure, pneumonia and diabetes. Since then, the program has expanded to include dozens of conditions, including asthma, high blood pressure and serious infections such as cellulitis, and is now available to some privately insured and Medicaid patients.

Mount Sinai has also partnered with Contessa Health, a company with expertise in home care, to negotiate contracts with insurers to pay for hospital-at-home services.

Among other things, insurers are worried about the slippery slope of what it means to be hospitalized, said Linda DeCherrie, clinical director of the mobile acute care team at Mount Sinai.

Insurers “don’t want to be paying for an admission if this patient really wouldn’t have been hospitalized in the first place,” DeCherrie said.

 

Five Worrisome Trends in Healthcare

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https://www.medpagetoday.com/publichealthpolicy/healthpolicy/72001?xid=fb_o_

healthcare; insurance; drugs; drug companies; Government-run Insurance Program Sure to Backfire | iHaveNet.com

A reckoning is coming, outgoing BlueCross executive says.

A reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.

Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:

1. The effects of the recently passed tax bill. “If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.

Burrell noted that 74 million people are currently covered by Medicaid, 60 million by Medicare, and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”

2. The increasing obesity problem. “Thirty percent of the U.S. population is obese; 70% of the total population are either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”

3. The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”

To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”

Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue on quality but there is a profound issue on costs.”

4. The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.

5. The lackluster performance of new payment models. “Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.

“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect accessibility of care.”

“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”

Veterans Affairs Shake-Up Stirs New Fears of Privatized Care

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President Trump’s dismissal of David J. Shulkin, the secretary of veterans affairs — and the nomination of a Navy doctor with no known policy views to take his place — has brought renewed focus to an increasingly contentious debate over whether to give veterans the option of using the benefits they earned through military service to see private doctors rather than going to government hospitals and clinics.

The issue, which has pitted almost every major veterans group against Concerned Veterans for America, an advocacy group funded by the billionaire conservative brothers Charles G. and David H. Koch, and its allies, has been at the center of months of intrigue at the sprawling Department of Veterans Affairs, which is charged with caring for the United States’ 20 million veterans.

But Mr. Shulkin’s departure and the abrupt elevation of Dr. Ronny L. Jackson, the White House physician, to the department’s top job on Wednesday have raised new fears among Democrats and groups like the Veterans of Foreign Wars and the American Legion. They worry that the Trump administration will push for a major change in veterans’ health care that they have bitterly opposed.

The groups say the end result would be disastrous, effectively bleeding to death a network of 1,700 hospitals and clinics that has taken decades to build.

Dr. Shulkin, who was dismissed Wednesday evening by presidential tweet, argued in an op-ed article in The New York Times and in a subsequent interview on Thursday that such radical restructuring of veterans’ health care would not work.

He said that a middle path that he had tried to pursue — investing in the department’s own health care system while offering veterans more, though not unfettered, access to private doctors — had been rejected by Trump administration officials interested in rewarding private individuals and companies with a windfall in government money.

“They saw me as an obstacle to privatization who had to be removed,” he wrote in one of the most forceful statements offered yet by a fired Trump administration official.

Senior White House officials offered a different rationale for his firing that was based more on a damaging report about Dr. Shulkin’s use of government funds on a trip to Europe released last month than on a dispute over policy.

Lindsey Walters, a deputy White House press secretary, told reporters aboard Air Force One on Thursday that the nomination of Dr. Jackson should not be interpreted as a signal that Mr. Trump wants to privatize veterans’ health care.

But Mr. Trump seemed to renew those concerns just a short time later, promising in a speech in Ohio that he was going to ensure that veterans “have choice,” harkening back to a campaign promise to enact something like the Koch-backed plan.

Veterans advocates are especially concerned that Dr. Jackson, a rear admiral in the Navy who has no real management or political experience in a large bureaucracy, will be pushed around or, worse, simply co-opted by officials in the administration set on drastically expanding private care.

“We don’t know what his agenda is. We don’t know what his views are,” said Verna L. Jones, the executive director of the American Legion. “No one has had an opportunity to talk to him.”

“Of course we are nervous,” she added.

Leaders of the older, congressionally chartered veterans groups like the Legion are not categorically opposed to easing restrictions on private care, particularly in cases where veterans are facing long wait times and subpar facilities. About 30 percent of veterans’ appointments are currently made with private health providers for those reasons.

But the groups prefer tweaking programs already in place while at the same time addressing the problems that made private care necessary.

John Hoellwarth, the communications director for Amvets, said he thought the first response of most veterans groups to Dr. Jackson was to search for him online.

Dr. Shulkin said that he had been friendly with Dr. Jackson for several years — both men also served in the Obama administration — and encouraged him to go through the interview process to lead the department’s health system this year. Still, he said that he thought concerns about Dr. Jackson’s résumé were justified.

“There is no question about it, but I can’t imagine any job that prepares you for this type of job,” Dr. Shulkin said.

By most accounts, Dr. Shulkin’s rapid fall began as he increasingly butted heads with other Trump administration official over how to approach the expansion of private care. The officials — who included the department’s press secretary and assistant secretary for communications — came to consider Dr. Shulkin as an obstacle and repeatedly tried to have him removed.

Many of those officials, several of whom have ties to the Concerned Veterans group, are still in the administration and are likely to have increased sway in the department. But the ultimate decision about the structure of the department’s health care most likely resides on Capitol Hill, where lawmakers have been struggling for almost a year with the issue.

“I think that there was a miscalculation that if you could get rid of the secretary who is a moderate that things will fall in place, and I just don’t think that is going to happen,” Dr. Shulkin said.

Dan Caldwell, the executive director of Concerned Veterans for America, strenuously disputed Dr. Shulkin’s analysis and said the secretary was using privatization as a “straw man” to distract from his own ethical lapses.

“The president has said he supports full V.A. choice,” Mr. Caldwell said. “The president would not have selected Admiral Jackson if he did not believe he supports his full agenda.”

Mr. Caldwell was referring to a damning report released in February by the department’s inspector general that found “serious derelictions” related to a trip Dr. Shulkin took last year to Britain and Denmark. It concluded that he had spent much of the trip, which cost more than $122,000, sightseeing and that he had improperly accepted Wimbledon tickets as a gift.

Dr. Shulkin has continued to deny any wrongdoing, and on Thursday blamed his political opponents in the department for the investigation itself.

“This is 100 percent about the politics and this is the way that people fight their battles in Washington rather than having intellectually honest discussions,” he said.

The White House did not view it that way. Senior officials came to believe that Dr. Shulkin had misled them in the run-up to the report’s release. His public declarations of innocence only further aggravated top officials, who felt he had too openly aired internal politics with news outlets and had repeatedly opened the White House to criticism.

The exact circumstances surrounding Dr. Shulkin’s firing, and exactly how much the White House chief of staff, John F. Kelly, was aware of it, remained unclear.

One person with direct knowledge of the events said Dr. Shulkin had called Mr. Kelly around 10:30 a.m. Wednesday, asking if he were about to be fired. Mr. Kelly told that him he did not know, and that he would get back to him.

A White House official would not discuss the details of what took place, beyond saying that Mr. Kelly had called Dr. Shulkin to accept his resignation, and that the secretary gave it.

Dr. Shulkin declined to discuss the episode in detail, but said he did speak on the phone with Mr. Trump on Wednesday about the progress of various policy initiatives at the department and implied that his job status did not come up.

A few hours later, he was at home on the phone with his wife when she broke the news: the president had fired him in a tweet.

 

What The Health? VA Secretary Out, Privatization In?

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https://khn.org/news/podcast-khns-what-the-health-va-secretary-out-privatization-in/

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David Shulkin, the secretary of Veterans Affairs, was fired Wednesday night by President Donald Trump. To replace him, Trump will nominate his White House physician, naval Rear Adm. Ronny Jackson. Shulkin, however, is not going quietly. He took to The New York Times op-ed page to claim he was pushed out by those who want to privatize VA health services for profit.

Meanwhile, two more states, Iowa and Utah, passed legislation that would sidestep some of the requirements of the Affordable Care Act. Iowa wants to allow the sale of health plans that cover fewer benefits — or restrict coverage for people with preexisting health conditions. Utah wants to expand Medicaid to those higher up the income scale — but not as high as prescribed by the ACA.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Sarah Kliff of Vox.com and Alice Ollstein of Talking Points Memo.

Among the takeaways from this week’s podcast:

  • If Shulkin is right that the administration is keen on privatizing the VA, would it move to something akin to the Medicaid managed-care systems that many states have set up?
  • Veterans groups haven’t yet shown their cards on whether they think Jackson is a suitable choice to replace Shulkin.
  • Iowa is poised to allow farmers groups to offer health plans that could sidestep some of the consumer protections in the federal Affordable Care Act, such as requiring that preexisting conditions be covered. Tennessee has a program similar to what Iowa is implementing, and some consumer groups have complained it pulls healthy individuals out of the ACA marketplace and drives up premiums for those who remain.
  • Utah’s request for a federal waiver so that it can offer a Medicaid expansion program to people earning up to 100 percent of the federal poverty level — and not the 138 percent included in the ACA — will show whether the Trump administration has a different standard than the Obama administration. Obama officials rejected partial Medicaid expansion requests.
  • Sen. Elizabeth Warren (D-Mass.) introduced a bill that offers provisions to help middle-income customers buying insurance on the ACA marketplace. But it suggests Democrats are still not sure what is the best health care strategy heading into the midterm elections.

 

State and Federal Contraceptive Coverage Requirements: Implications for Women and Employers

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State and Federal Contraceptive Coverage Requirements: Implications for Women and Employers

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Contraceptive Coverage under the Affordable Care Act (ACA) has made access to the full range of contraceptive methods affordable to millions of women. Since it was first issued in 2012, this provision has been controversial and has been the focus of two major cases that have reached the Supreme Court. Following the Hobby Lobby ruling, the Obama Administration took the stand that almost all women had an entitlement to the contraceptive benefit and developed an “accommodation” to assure they would still get coverage, even if their employer had religious objections to contraception. The Trump Administration, in contrast, has prioritized the rights of employers, and in October 2017, issued regulations that significantly broadened the exemption to nearly any employer with a religious or moral objection. The new regulations have been challenged by 8 states and have been blocked from being implemented pending the outcome of the litigation.

Before the ACA was passed, many states had enacted contraceptive equity laws that required plans to treat contraceptives in the same way they covered other services. In addition, since the ACA was passed, a number of states have enacted laws that basically codify in state legislation the ACA benefit rules (requiring all plans to cover, without cost-sharing each of the 18 FDA approved contraceptive methods). This issue brief provides an update on the status of the continuing litigation on the federal contraceptive requirement and explains the interplay between the federal and state contraceptive coverage laws and the implications for employers and women.

Background on State and Federal Contraceptive Coverage Requirements

Before the ACA, coverage for prescription contraceptives was generally widespread in the private and public sectors, but not universal, and certainly not free of cost-sharing. In 2000, a ruling by the Employment Equal Opportunity Commission found that employers that covered preventive prescription drugs and services but did not cover prescription contraceptives were in violation of the Civil Rights Act.1 Currently, 29 states and DC2 require insurance plans to cover contraceptives, with a wide range of coverage and cost-sharing requirements, and exemptions among these mandates (Appendix A). State laws, however, do not have authority over all plans; they only apply to state regulated (fully-insured) plans, but not self-funded plans under ERISA where 60% of covered workers are insured.3

The ACA is the first law to set preventive coverage requirements for health insurance across all markets – individual, small group, large group and self-insured plans. Starting in 2012, all new private plans were required to cover, without cost-sharing, the full range of contraceptive services and supplies approved by the Food and Drug Administration (FDA) as prescribed for women. Only employers that were classified as a “house of worship” were exempted from this requirement. While a number of states had contraceptive equity laws that required plans to cover some or all methods, cost-sharing typically applied. Fully-insured plans must comply with both state and federal laws. For some health services, the federal law may require a higher level of benefits, and for other services the state law may require a higher level of benefits.

Conclusion

The outcome of the litigation challenging the Trump Administration’s new regulations is not clear. Currently, the federal government is blocked from enforcing the new regulations. The new regulations would substantially expand the exemption to nonprofit and for-profit employers, as well as to private colleges or universities with religious or moral objections to contraceptive coverage. If the new regulations become effective, for women enrolled in fully-insured employer plans, the scope of their contraceptive benefits would depend on the coverage policies and exemptions established by state laws. Employers who qualify for the exemption under federal law would still need to comply with the state contraceptive requirement. Depending on the state law, employers may still have to provide no-cost coverage for some or all methods of contraception or a narrower set of contraceptive benefits. For women covered by fully-insured plans issued for employers with religious or moral exemptions, their choice of contraceptive methods would be determined by the scope of benefits and exemptions allowed by state law where they live.

 

 

State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting the Risk to the Individual Market

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http://www.commonwealthfund.org/publications/fund-reports/2018/mar/state-regulation-coverage-options-outside-aca?omnicid=EALERT1377329&mid=henrykotula@yahoo.com

Abstract

  • Issue: Certain forms of individual health coverage are not required to comply with the consumer protections of the Affordable Care Act (ACA). These “alternative coverage arrangements” — including transitional policies, short-term plans, health care sharing ministries, and association health plans — tend to have lower upfront costs and offer far fewer benefits than ACA-compliant insurance. While appealing to some healthy individuals, they are often unattractive, or unavailable, to people in less-than-perfect health. By leveraging their regulatory advantages to enroll healthy individuals, these alternatives to marketplace coverage may contribute to a smaller, sicker, and less stable ACA-compliant market. The Trump administration recently has acted to reduce federal barriers to these arrangements.
  • Goal: To understand how states regulate coverage arrangements that do not comply with the ACA’s individual health insurance market reforms.
  • Methods: Analysis of the applicable laws, regulations, and guidance of the 50 states and the District of Columbia.
  • Findings and Conclusions: No state’s regulatory framework fully protects the individual market from adverse selection by the alternative coverage arrangements studied. However, states have the authority to ensure a level playing field among coverage options to promote market stability.

Background

Recent federal actions have created the potential for instability in the individual health insurance market, through which approximately 18 million Americans currently purchase their health insurance coverage.1 In October 2017, President Trump issued an executive order to encourage the sale of health insurance products that do not comply with the consumer protections of the Affordable Care Act (ACA).2 In December, Congress repealed, effective in 2019, the tax penalty for individuals who can afford to maintain health insurance coverage but decline to do so (the individual mandate penalty).3

Prior to health reform, insurers in the individual market had wide latitude to deny coverage, charge an unaffordable premium, or limit benefits based on a person’s medical history. As a consequence, individual market health insurance routinely proved inadequate for consumers’ health and financial needs and was often inaccessible to those with even minor health problems.4 The ACA established numerous consumer protections designed to make it easier for consumers in the individual market to access affordable, adequate health insurance. The law requires insurers that sell individual health insurance to offer coverage to all individuals regardless of health status, requires coverage of preexisting conditions, and prohibits insurers from charging higher premiums based on a person’s medical history or gender. It also includes limits on cost-sharing and requires insurers to cover a minimum set of essential health benefits, including coverage for mental and behavioral health care, prescription drugs, and maternity services.

For these consumer protections to work as intended and to keep premiums affordable, they need to be paired with policies that encourage a broad and balanced risk pool. To promote continuous enrollment by the sick and healthy alike, the ACA imposes an individual mandate and provides financial assistance to make coverage more affordable for those with lower and moderate incomes. Importantly, the ACA also defines what types of coverage were sufficiently protective for purposes of satisfying the individual mandate. To prevent cherry-picking of individuals who are low health risks, it also requires all individual market insurers to play by the same rules.

In many ways, the ACA’s regulatory approach to the individual market has proven successful. During the most recent open enrollment period, approximately 11.7 million Americans signed up for coverage through the ACA marketplaces (also called exchanges), most of whom are eligible for subsidies to help with the cost of coverage.5 In turn, improved access to comprehensive individual health insurance under the ACA, along with the expansion of Medicaid, has helped to reduce the uninsured rate by a third, as of 2018, and lower consumers’ average out-of-pocket costs.6 And, despite insurers’ continued uncertainty over the possible repeal of the health law and the Trump administration’s approach to implementing the ACA, analysis showed that, on average, states’ individual markets were stabilizing, with some insurers reaching profitability.7

However, challenges remain. In the past two years, the individual market in most states has seen significant increases in premiums, coupled with decreases in the number of participating insurers.8 While the ACA’s premium subsidies insulate many consumers from these price hikes, many millions of consumers are not eligible for subsidies, and those individuals identify the cost of coverage as a significant barrier to care.9 And though marketplace sign-ups remain stable despite federal policy uncertainty and Trump administration actions seen as undermining the ACA, enrollment remains well below early expectations.10

These challenges are interrelated and can be attributed to many factors. Still, the availability of coverage options that are not compliant with the ACA’s rules, as well as confusion over them, likely has played an important contributing role.

Policy Implications

Although states’ approaches to implementing the ACA can sharply differ, the law’s consumer protections operate nationwide, and nearly all states have taken responsibility for enforcing these reforms in their jurisdictions. The insurance exchanges in most states have proven resilient in the face of significant change and uncertainty, with millions of Americans now able to depend on individual health insurance to protect them both medically and financially.

However, maintaining a stable individual market will become more challenging, thanks to an environment in which healthy consumers are not required to maintain insurance and federal regulations are loosened to promote coverage arrangements likely to weaken insurance risk pools and raise premiums. These developments may incline healthy individuals to look increasingly outside the compliant market for coverage, leaving those who remain to face higher costs and fewer plan choices.68

Based on our review of state laws and standards, it appears that no state maintains a regulatory environment that fully protects its individual health insurance market from being undermined by the alternative coverage options we have identified. However, states continue to be the primary regulators of private health insurance. Although the ACA set a federal floor of consumer protections for insurers that operate in the individual market, it did not curtail states’ power to regulate above these minimum standards and to exercise full authority over coverage arrangements that fall outside the scope of federal insurance law.

How We Conducted This Study

This analysis is based on a review of applicable laws, regulations, and guidance enacted or promulgated prior to February 1, 2018, by each of the 50 states and the District of Columbia. This review was supplemented by correspondence with state regulators in 48 states and the District of Columbia.

A number of states have taken steps to limit the availability of non-ACA-compliant products and protect against adverse selection. Massachusetts and New York promptly discontinued transitional coverage and effectively prohibit underwritten short-term policies, while several other states tightly restrict the duration of such plans. Significantly, Massachusetts also has its own individual mandate, requiring state residents to maintain coverage that meets minimum standards.69 Other states have begun to explore enactment of similar policies in anticipation of the federal mandate’s 2019 repeal.

On many fronts, states face a federal regulatory approach to the individual market that is significantly different from what was originally envisioned under the Affordable Care Act. In light of these changed circumstances, there may be value for states in considering regulatory options for protecting their individual insurance markets and their insured beneficiaries from the detrimental effects of non-ACA-compliant policies. The decisions states make will likely have a significant impact on their residents’ access to adequate and affordable coverage and on the stability of their individual health insurance markets.