Tag Archives: Health Policy

Humana CMO: “As we improve the quality of healthcare, costs decrease”

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Humana CMO: “As we improve the quality of healthcare, costs decrease”

Dr. Roy Beveridge has served as CMO of Louisville, Kentucky-based Humana since 2013. Two years into his tenure, he opened the MedCity ENGAGE conference with a discussion calling for the democratization of healthcare.

In a recent phone interview, Beveridge discussed everything from value-based care to social determinants of health.

This exchange has been lightly edited.

What has been Humana’s biggest accomplishment in 2017?

From a physician and patient standpoint, we’re really moving quickly into value-based arrangements with MACRA and MIPS. There’s been a mind shift around physicians recognizing that in order to accomplish their goals of population health and value-based reimbursement, the whole discussion has changed around the need for analysis of data and a very different type of communication between the payer and the provider. Without that data, they can’t close gaps or improve the quality metrics that are becoming the norm.

A few years ago, I mistakenly thought value-based care was something that was going to be focused on the primary care physician and would not impact the specialist as much. But what you’re seeing is specialists recognize this value-based payment system is something they have to participate in.

From our standpoint, what that has resulted in is this continuous focus around community relationships. If payers like Humana are going to be successful, we need to be engaging our physicians’ patients. Services are needed for patients in the home. That’s the shift we have thought about and been successful at as we continue to recognize that an increasing amount of care will be in the home.

Why is it important to incorporate social determinants of health, and what work is Humana doing in this space?

When I was early in my practice and would see someone with diabetes, I remember having this belief that my role was to recognize what the patient’s diagnosis was and give a prescription for insulin. And then I thought I’d done a good job.

That was the mindset up until recently. Simply giving someone a prescription is the easy part. The more complicated part is explaining what their disease is and helping them take their medicine. We used to think that was a social worker’s problem. But if giving someone a prescription that they can’t fill doesn’t really help them.

As we look into the social determinants of health, transportation is big. Social isolation is a big one, and food insecurity goes hand in hand with diabetes and everything else.

I don’t think five years ago you’d be asking a question about social determinants of health. But at this point, the recognition of social determinant health issues is fundamentally linked to population health.

If you’re looking at a fee-for-service model, writing the prescription is all I need to do. If we shift the model to health outcomes, then you’re aligning everyone’s incentives to make sure people are thinking about these social determinants of health.

The other thing we have learned in the last year or two is that care really is local. We as a society have to recognize that what happens in South Florida is different than what happens in Texas or Minnesota or Massachusetts. There’s not one size that fits everything.

Humana recently released its inaugural value-based care report, which outlines numerous topics, including how Humana Medicare Advantage members affiliated with physicians in value-based models typically have healthier outcomes. Which finding from the report most surprised or shocked you?

I don’t think anything shocked me. There were parts of this that I think a couple years ago would have shocked people.

Five or 10 years ago, I would have said to you that in order to improve quality, you have to make an investment globally and that investment is going to cost the system more.

What’s pretty clear in the report is quality metrics do all the right things, yet at the same time, they lower the global cost of care. I don’t think that’s shocking, but it’s something that’s still hard for people to recognize and internalize. Fundamentally, as we improve the quality of healthcare, costs decrease.

News recently surfaced that Humana will acquire a 40 percent stake in Kindred Healthcare’s home care business for approximately $800 million. What does this mean for Humana?

We’ve only made the proposal. We haven’t gotten government approval for anything.

We’re thinking about, “How can we always get closer to the patient? How do we help improve someone’s health by being where someone is more of the time?” [Patients are] not in the hospital most of the time — they’re at home most of the time. We recognize we need to get closer to where people are if we’re going to help them in their destination of improving health.

What is your number one prediction for healthcare in 2018?

My number one prediction in healthcare is the pace of change within the system is going to continue to be fast.

CMS is pushing — and appropriately so — down a health orientation that moves from fee-for-service to quality-based outcomes.

My prediction for ’18 is that we’re going to hit an inflection point where the light bulb goes off because of the number of patients in the system who have moved from fee-for-service into this health outcomes model. Once it hits a certain amount of engagement within your hospital, then it becomes something everyone is aligned around.

 

Evidence-Based Health Policy

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http://www.nejm.org/doi/full/10.1056/NEJMp1709816?query=featured_home&

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In these times of heated rhetoric about what various health care reforms can and cannot accomplish, both hopeful and doomsday stories abound. Proponents and opponents of reforms often claim that their views are grounded in evidence, but it’s not always clear what they mean by that — particularly given the wide range of often incompatible views. Voters, physicians, and policymakers are left to wade through a jumble of anecdotes, aspirations, associations, and well-designed studies as they try to evaluate policy alternatives. Having a clear framework for characterizing what is, and isn’t, evidence-based health policy (EBHP) is a prerequisite for a rational approach to making policy choices, and it may even help focus the debate on the most promising approaches.

EBHP, we believe, has three essential characteristics (see table Illustrative Examples of Health Policies, Possible Goals, and Relevant Evidence Base.). First, policies need to be well-specified; a slogan is not sufficient. For example, “expand Medicaid” isn’t a policy. “Expand existing Medicaid benefits to cover all adults below the poverty line” is closer — but, of course, moving to a specific, implementable program requires vastly more detail. “Target population health” doesn’t qualify as a policy, let alone EBHP, because myriad policies fall under the population health banner, including influenza vaccination, smoking cessation, medication adherence, improving diets, increasing diabetes screening, addressing transportation barriers, and coordinating care. Slogans like “population health,” “single payer,” or “malpractice reform” may be an effective way to signify a political position or rally support (after all, who’s against population health?), but in avoiding specificity, they sidestep the hard work of assessing the relative effectiveness and implementation details of the policies included under their umbrella.

Second, implementing EBHP requires us to distinguish between policies and goals. This distinction is important in part because different people may have different goals for a particular policy. Consider the policy of implementing financial incentives for physicians to coordinate care. The evidence that such incentives would reduce health care spending (one potential goal) is quite weak, whereas the evidence that it might improve health outcomes (a different goal) is stronger.1 Claims that care coordination “doesn’t work” because it doesn’t save money miss the point that it may achieve other goals. Conversely, different policies may vary in their effectiveness at achieving a particular goal. If the goal is to reduce spending, then promoting competition or rate regulation may be more effective than care coordination.

Similarly, consider the policy of raising income limits for Medicaid eligibility. The evidence suggests that this policy is likely to achieve the goal of expanding access to care. On the other hand, evidence from a randomized trial indicates that it’s not likely to achieve the goal of reducing emergency department (ED) use (and even the broader evidence is mixed).2,3 If one favors expanding Medicaid to achieve the normative goal of redistribution from rich to poor and healthy to sick, it is tempting to suggest that expansion would also save money by reducing the use of expensive ED visits. But such claims are at best disingenuous and at worst counterproductive: if the evidence shows that Medicaid doesn’t achieve the stated objective of reducing ED use, that undermines the case for expansion even if the policy might achieve the unstated goal of redistribution. Being clear about goals is the only way to evaluate a policy’s effectiveness and the implied trade-offs between competing goals. These stylized examples are meant to illustrate the key components of the EBHP approach; evidence on each of these policies (and their many variants) is clearly much more nuanced than we can outline here.

Third, EBHP requires evidence of the magnitude of the effects of the policy, and obtaining such evidence is an inherently empirical endeavor. Introspection and theory are terrible ways to evaluate policy. In some instances, we have clear conceptual models that suggest the direction of the effect a policy is likely to have, but these models never tell us how big the effect is likely to be. For example, economic theory says that, all else being equal, when copayments or deductibles are higher, patients use less care (we’re pretty sure that demand slopes down), but this theory doesn’t tell us by how much. And often even the direction of the effect is unclear without empirical research, with different effects potentially going in opposite directions.

What makes for “rigorous enough evidence”? Professional medical societies have developed gauges of the strength of evidence to support clinical guidelines, and we should demand nothing less for health policy. No study is perfect, and important policy questions are rarely answered definitively by any one study. Nor does pointing to a large literature with similar results prove a point if those studies share a common weakness such as an inability to control for confounders. There is a crucial distinction between finding an association between a policy and an outcome (Do people who receive more preventive care spend less on health care? Often yes) and a causal connection (Does delivering more preventive care reduce health care spending? Overall, we think probably not).

There is also a key difference between “no evidence of effect” and “evidence of no effect.” The first is consistent with wide confidence intervals that include zero as well as some meaningful effects, whereas the latter refers to a precisely estimated zero that can rule out effects of meaningful magnitude. These nuances are often lost when “evidence” is deployed in policy debates.

The effect of a policy, of course, also depends on the design and implementation details and the program particulars (Medicaid varies from state to state, for example, and the effect of expansions to different populations may vary) — and evidence needs to speak to those particulars. It is also important to consider the full range of a policy’s effects — its costs and benefits, and how each of these evolves over time.4 An impartial assessment of the budgetary costs like those provided by the Congressional Budget Office (CBO) is a crucial but incomplete part of the picture because of the CBO’s statutory emphasis on the federal budget rather than lives or well-being.

Making health policy on the basis of evidence will always be a fraught and uncertain endeavor, and each component we outline here comes with challenges. For starters, we acknowledge that fully specifying a policy requires the kind of legislative and regulatory detail that is impractical for a high-level policy debate, but often the “policies” being discussed are so ill specified that it’s impossible to bring any evidence to bear.

In addition, just as the distinction between policies and goals is often muddied, interpretations of the evidence are often flavored by the implicit goals of the analyst.5 A given body of evidence can be used to support very different policy positions (depending on what one’s goals are — for example, how one weighs costs to taxpayers versus redistribution of health care resources), but different goals shouldn’t drive different interpretations of the evidence base.

Finally, even a rich body of evidence cannot guarantee that a policy will achieve its goals, and waiting for that level of certainty would paralyze the policy process. In health policy — as in any other realm — it is often necessary to act on the basis of the best evidence on hand, even when that evidence is not strong. Doing so requires weighing the costs of acting when you shouldn’t against those of not acting when you should — again, a matter of policy priorities.

Just because something sounds true doesn’t mean that it is, and magical thinking won’t improve our health care system. EBHP helps separate facts from aspiration. But as important as evidence is to good policy choices, it can’t tell us what our goals should be — that’s a normative question of values and priorities. Better policy requires being both honest about our goals and clear-eyed about the evidence.

 

Is M&A the Cure for a Failing Health Care System?

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https://hbr.org/2017/12/is-ma-the-cure-for-a-failing-health-care-system

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The U.S. health care system is begging for disruption. It costs way too much ($3.3 trillion last year) and delivers too little value. Hundreds of millions of Germans, French, English, Scandinavians, Dutch, Danish, Swiss, Canadians, New Zealanders, and Australians get comparable or better health services for half of what we pay. For most Americans, care is not only expensive but is also fragmented, inconvenient, and physically inaccessible, especially to the sickest and frailest among us.

It should come as no surprise, then, that when titans of our private, for-profit health care sector — like Aetna, CVS, UnitedHealth Group (UHG), and DaVita — strike out in new directions, stakeholders react with fascination and excitement. Could this be it? Is free-market magic finally bringing Amazon-style convenience, quality, and efficiency to health care? Are old-guard institutions, like hospitals and nursing homes, on the verge of extinction?

The answer, frustratingly, is that it depends. It depends above all on the results. To be the change that many desire, these new mergers and acquisitions, and the others that will likely follow, must produce a higher-quality product for consumers (and satisfy physicians and other health professionals) at an affordable price. The details are crucial, and the details in health care — as our political leaders have recently learned — are complicated.

Even a high level look at two apparently similar deals suggests the importance of getting under the hoods of these arrangements. Both CVS’s planned $69 billion acquisition of Aetna and UnitedHealth’s $4.9 billion deal to buy DaVita Medical Group, bring together a very large national insurer and a large provider of health care services. Combining an insurance function with a delivery system has ample precedent in health care. Some of the nation’s most innovative, high-performing non-profit health care organizations use this formula.  These include the Kaiser Health Plans, Intermountain Healthcare in Utah and Idaho, the Geisinger System in Pennsylvania, the Henry Ford Health System in Detroit, and HealthPartners in Minnesota and Wisconsin, among others.

The reason this formula works is that when care-delivery systems also act as insurers, they assume financial responsibility for the care they provide. This tends to focus doctors, nurses, and other health professionals on the value of what they do — finding the most cost-effective approach to managing their patients’ problems. The result can be a culture of economy and quality that is very hard to replicate in the prevailing fee-for-service environment, where health professionals get rewarded for the volume rather than the value of services.

So the big question is whether these bold new combinations of insurer and provider can generate promising partnerships similar to a Kaiser or an Intermountain, or find some other equally powerful formula for disruption. The answer is far from certain, and the uncertainties differ for the two mergers.

In the CVS-Aetna case, the care provider, a pharmaceutical retailer and pharmaceutical benefit manager, provides a very limited set of health services: drugs, drug purchasing, and selected, basic, routinized primary care at more than 1,100 local Minute Clinics  located in communities around the United States. To become a Geisinger or an Intermountain equivalent, Aetna-CVS would have to acquire — or develop — seamless relationships with legions of primary care and specialty physicians and hospitals. It would have to turn its stores into medical clinics, with exam rooms, diagnostic laboratories, and x-ray suites. And it would have to install and link electronic health records with other providers in its communities. Having done all this, CVS would have to excel at the very challenging task of managing physicians and other health professionals — something that daily confounds even the most experienced, long-time, care-delivery systems. The challenge would be unprecedented, the expense considerable, and the outcome uncertain.

The CVS-Aetna partnership seems likely, instead, to set off in a very different, and intriguing, direction: offering an augmented suite of preventive and population health services for high-cost chronically-ill patients through its convenient, community-based outlets. CVS staff will serve as local case managers and coordinators for patients who might otherwise skip needed preventive services, have trouble getting to their primary care physicians’ offices, or just need help taking their medicines. The hope is that this will reduce patients’ use of more expensive emergency, hospital, and specialty services, thereby reducing Aetna’s bills and making its product more competitive. Aetna would incent its clients to use CVS services by exempting these from the normal deductibles and copays that most insurers charge, thus incidentally, increasing CVS’s business more generally. This strategy could attract customers to both CVS and Aetna, add health care value, and even drive up profits.

But uncertainties remain. In addition to those I’ve mentioned, one of the biggest challenges will be coordinating with traditional care providers, both primary care and specialists. Seamless teamwork is critical to effective care of complex, high-cost patients. And by adding another player to our already-fragmented health care system, the CVS-Aetna project could actually undermine coordination of services. And while better care for complex patients is clearly part of the solution to our cost and quality problems, it may not be the systemic disruption that some are hoping for.

The UnitedHealth-DaVita deal, in contrast, seems more likely at first glance to accomplish the insurer-provider partnership that has characterized Kaiser-style organizations in the past. The DaVita Medical group employs 2,000 primary care and specialist physicians in nearly 300 medical clinics, 35 urgent-care centers, and six outpatient surgery centers in six states. Among the group’s divisions is the formerly independent HealthCare Partners, which, as this Commonwealth Fund case study makes clear, has a long history of accepting and managing financial risk, using advanced information systems, and promoting quality-improvement programs.

That said, no one should underestimate the challenge of growing the UnitedHealth acquisition of dispersed physician groups into a national system capable of disrupting our floundering health system. Health care is a very local affair, and the organizations providing it tend to be creatures of their localities and histories. It can take generations for a provider-insurer partnership to develop a culture of trust, collaboration, and value orientation that has made existing examples of these combinations so uniquely effective. If the new entity seeks to grow, it will find that recruiting and training physicians who can leave the fee-for-service mentality behind is a challenge, as is finding leadership that can gain and keep health professionals’ trust. Kaiser has failed in several attempts to spread to new locations. And though UnitedHealth’s Optum division, which will run the partnership, has some limited experience managing selected specialty health services, making this new enterprise work could prove daunting.

Even if the Aetna-CVS and UnitedHealth-DaVita ventures contain the seeds of transformative health system change, it will take time for those seeds to germinate. But Wall Street is not a patient audience. The involved companies will face short-term pressure to prove the profitability of the new arrangements. From this standpoint, it does not bode well that DaVita was anxious to sell its medical groups because they were not performing financially.

The excitement about these two bold new health care arrangements says as much about the desperation with our current health care systems as it does about the promise of the mergers themselves. They may have compelling short-term business value to shareholders — though that, too, remains to be proven. As fundamental health care disrupters, however, they face challenging and uncertain futures.

 

Tax bill has major downside for heavily indebted healthcare companies

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https://www.beckershospitalreview.com/finance/tax-bill-has-major-downside-for-heavily-indebted-healthcare-companies.html

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The Republicans’ tax overhaul plan, which is expected to become law soon, will cause many healthcare organizations to reassess their debt levels.

The tax bill will limit the tax deduction companies take for the interest they pay on their debt to 30 percent of earnings before interest, taxes, depreciation and amortization. This change will put pressure on healthcare companies with heavy debt loads. In 2022, interest expense deductions would be further reduced, which could cause companies’ tax bills to increase further, according to The Wall Street Journal.

Franklin, Tenn.-based Community Health Systems and Dallas-based Tenet Healthcare, which carry about $14 billion and $15 billion of debt, respectively, could be negatively affected by the tax bill’s limit on interest expense deductions. On Tuesday, Tenet said it expects the change to lower its 2018 earnings forecast, according to the report.

In a report issued earlier this month, Moody’s Investors Service said many speculative-grade companies across several sectors, including healthcare, would be negatively affected if deductibility were limited.

 

Moody’s: 3 ways the GOP tax bill will hurt nonprofit hospitals

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https://www.beckershospitalreview.com/finance/moody-s-3-ways-the-gop-tax-bill-will-hurt-nonprofit-hospitals.html

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The Republicans’ tax overhaul plan, which is expected to become law soon, has negative credit implications for nonprofit hospitals and health systems, according to Moody’s Investors Service.

Here are three ways the tax bill will hurt nonprofit hospitals and health systems.

1. The tax bill will repeal the ACA’s individual insurance mandate. This will cause the uninsured population to rise and raise uncompensated care costs, which will negatively affect healthcare organizations’ operating margins and cash flow, according to Moody’s.

2. The tax plan’s limits on tax-exempt refundings is negative for all issuers of tax-exempt debt, including nonprofit hospitals and health systems, as these financings have been used to reduce long-term borrowing costs and take advantage of lower interest rates, according to Moody’s.

3. The tax bill will slash the corporate tax rate to 21 percent from 35 percent. This change has negative implications for nonprofit hospitals and health systems, as it “makes tax-exempt bonds a less attractive investment for banks and other financial institutions, which will weaken demand, especially for direct bank loans and private placements,” according to Moody’s.

No, Trump Hasn’t ‘Essentially Repealed Obamacare’

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https://www.politico.com/magazine/story/2017/12/20/trump-obamacare-mandate-repeal-taxes-216125

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Killing the mandate doesn’t gut the health care law. Most likely, it will muddle along, because the rest of it is broadly popular.

In July and again in September, Republicans narrowly failed to repeal the Affordable Care Act. But their newly passed tax legislation included a provision getting rid of Obamacare’s mandate requiring Americans to buy insurance, and President Donald Trump immediately declared victory in the partisan health care wars. “When the individual mandate is being repealed, that means Obamacare is being repealed,” he crowed at a Cabinet meeting on Wednesday. “We have essentially repealed Obamacare.”

Well, no. The individual mandate is only part of Obamacare. It wasn’t even included in the original health care plan that Barack Obama unveiled during the 2008 campaign. The mandate did become an important element of Obamacare, and the only specific element that a majority of the public opposed. But the more generous elements of the program—like a major expansion of Medicaid, significant government subsidies for private insurance premiums, and strict protections for pre-existing conditions—are still popular, and still the law of the land.

“The death of Obamacare has been exaggerated,” says Larry Levitt, who oversees health reform studies at the Kaiser Family Foundation. “Eliminating the mandate creates uncertainty, but all the benefits for people remain in place.”

The Republican ecstasy and Democratic gloom over the death of the mandate reflects the most consistent misperception over the seven-plus years of Affordable Care Act debates, the incorrect assumption that the “Obamacare exchanges,” where Americans can buy private insurance, are synonymous with Obamacare. The vast majority of Americans who get their coverage through Medicare, Medicaid or their employers shouldn’t be affected. Yes, killing the mandate could cause problems for the remaining 6 percent of Americans who have to buy insurance on the open market, but nearly half will remain eligible for subsidies that would insulate them from any premium hikes.

Repealing the tax penalties for Americans who don’t buy insurance would not repeal Obamacare’s perks for Americans who do—like the ban on annual and lifetime caps that insurers previously used to cut off coverage for their sickest customers, or the provision allowing parents to keep their children on their plans until they turn 26. And it would not repeal Obamacare’s “delivery reforms” that are quietly transforming the financial incentives in the medical system, gradually shifting reimbursements to reward the quality rather than quantity of care. The growth of U.S. health care costs has slowed dramatically since the launch of Obamacare, and the elimination of the mandate should not significantly affect that trend.

In fact, during the 2008 campaign, Obama was the only Democratic candidate whose health plan did not include a mandate, because he was the only Democratic candidate who thought the main problem with health care was its cost. “It’s just too expensive,” he explained at an Iowa event in May 2007. Insurance premiums had almost doubled during the George W. Bush era, and Obama believed that was the reason so many Americans were uninsured. He doubted it would be worth the political heartburn to try to force people to buy insurance they couldn’t afford.

But Obama eventually embraced the argument that a mandate was necessary to ensure that young and healthy Americans bought insurance. The fear was that otherwise, insurance markets dominated by the old and sick (who would enjoy the law’s new protections for pre-existing conditions) would have produced even higher premiums, and might scare insurers away from serving Americans who don’t get coverage through their jobs or the government. Killing the mandate will be a step in that direction, boosting Trump’s heighten-the-contradictions effort to sabotage the functioning of Obamacare to build support for a more sweeping repeal.

That effort has already produced some damaging results for the exchanges. Insurers have increased their premiums for 2018, repeatedly citing uncertainty over Trump’s efforts to blow up Obamacare as well as his decision to cut off promised payments to insurers who cover lower-income families. Several insurers left the exchanges even before the elimination of the mandate, and others could follow.

But the widespread warnings that wide swaths of America would have no insurers on the exchanges were wrong; there are zero “bare counties” with no insurers for 2018. And a Kaiser review found the exchanges have gotten more profitable for insurers this year,despite Trump’s efforts to damage them. This year’s enrollment period appears to have gone fairly well even though the Trump administration shortened it by half and slashed its promotional budget.

The fear is that eliminating the mandate could produce a “death spiral” for the exchanges, where higher premiums scare away healthier customers, leading to even higher premiums and even sicker customers—until eventually,the insurers decide to bail. It could also encourage insurers to try to lure healthier customers with cheaper but skimpier plans that don’t provide protections for pre-existing conditions, since those customers would no longer have to pay a tax penalty.

But it is also possible that younger and healthier customers who initially bought insurance because they were required to do so will now buy insurance because they want to; surveys show that more than 75 five percent of Americans covered on the exchanges are happy with their coverage. And as a political matter, repealing the unpopular mandate could make it even harder for Republicans to pass legislation repealing insurance protections, Medicaid expansions and the rest of Obamacare, because the rest of Obamacare is popular. It’s not surprising that Republicans managed to kill the law’s vegetables, but it won’t be as easy to kill dessert.

Trump thinks congressional Democrats will soon be begging him to come up with a replacement for Obamacare, and even many Republicans who don’t embrace that fantasy believe the demise of the mandate will ratchet up pressure for a permanent solution to a seven-year political war. It could happen. But there hasn’t been a lot of bipartisanship in Washington lately, and after the Doug Jones upset in Alabama, it seems unlikely that a Senate with one fewer Republican will be more amenable to a Republican-only repeal bill.

The most likely outcome seems to be at least a few more years of Obamacare muddling through, and at least a few more years of Obamacare political warfare.

 

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

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https://www.nytimes.com/aponline/2017/12/21/us/politics/ap-us-ap-poll-health-care.html

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Despite Compressed Sign-Up Period, ACA Enrollment Nearly Matches Last Year’s

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https://khn.org/news/despite-compressed-sign-up-period-aca-enrollment-nearly-matches-last-years/

A day after President Donald Trump said the Affordable Care Act “has been repealed,” officials reported that 8.8 million Americans have signed up for coverage on the federal insurance exchange in 2018 — nearly reaching 2017’s number in half the sign-up time.

That total is far from complete. Enrollment is still open in parts of seven states, including Florida and Texas, that use the federal healthcare.gov exchange but were affected by hurricanes earlier this year. The numbers released Thursday by the Department of Health and Human Services also did not include those who signed up between midnight Dec. 15 and 3 a.m. ET on Dec. 16, the final deadline for 2018 coverage, as well as those who could not finish enrolling before the deadline and left their phone number for a call back.

And enrollment has not yet closed in 11 states — including California and New York — plus Washington, D.C., that run their own insurance exchanges. Those states are expected to add several million more enrollees.

The robust numbers for sign-ups on the federal exchange — 96 percent of last year’s total — surprised both supporters and opponents of the health law, who almost universally thought the numbers would be lower. Not only was the sign-up period reduced by half, but the Trump administration dramatically cut funding for advertising and enrollment aid. Republicans in Congress spent much of the year trying to repeal and replace the law, while Trump repeatedly declared the health law dead, leading to widespread confusion.

On the other hand, a Trump decision aimed at hurting the exchanges may have backfired. When he canceled federal subsidies to help insurers offer discounts to their lowest-income customers, it produced some surprising bargains for those who qualify for federal premium help. That may have boosted enrollment.

“Enrollment defied expectations and the Trump administration’s efforts to undermine it,” said Lori Lodes, a former Obama administration health official who joined with other Obama alumni to try to promote enrollment in the absence of federal outreach efforts. “The demand for affordable coverage speaks volumes — proving, yet again, the staying power of the marketplaces.”

“The ACA is not repealed and not going away,” tweeted Andy Slavitt, who oversaw the ACA under President Barack Obama.

The tax bill passed by Congress this week repeals the fines for those who fail to obtain health coverage, but those fines do not go away until 2019. Still, that has added to the confusion for 2018 coverage.

And it remains unclear whether Congress will make another attempt to repeal the law in 2018.

“I think we’ll probably move on to other issues,” Senate Majority Leader Mitch McConnell (R-Ky.) said in an interview Friday with NPR.

 

Children’s Health Insurance Program Still in Limbo After Yet Another Patch

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https://www.bloomberg.com/news/articles/2017-12-21/children-s-health-insurance-gets-yet-another-patch-in-house-bill

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  • States running out of money after failure to reauthorize CHIP
  • Bill provides $2.85 billion meant to last through March

A critical government program that provides health-care coverage to 9 million low-income kids received yet another patch to help stretch it out a few more months — with still no long-term fix in sight.

Congress passed short-term legislation Thursday night that includes $2.85 billion to help fund the program, known as CHIP, through the end of March. The measure will help cover the estimated 1.9 million children across 24 states and Washington, D.C., that stood to lose coverage for care such as doctors visits and hospitalizations in January as states have dipped into reserve funds. But the temporary relief still leaves CHIP and families that rely on it in a state of uncertainty.

“You can’t run an insurance program this way,” said Sara Rosenbaum, a professor at the Milken Institute School of Public Health at George Washington University. Lawmakers are forcing health officials who run the program “to go month-to-month.”

Funding for the Children’s Health Insurance Program lapsed at the end of September when lawmakers couldn’t reach agreement on a five-year reauthorization of the program. They’ve since failed to come up with a solution and instead passed short-term fixes — even though CHIP is one of the few programs that enjoys bipartisan support. Both Republicans and Democrats have disagreed on how to pay for a full reauthorization.

“We share a commitment to extend full funding for CHIP as soon as possible,” Senate Finance Committee Chairman Orrin Hatch, a Republican, and Senator Ron Wyden, the top Democrat on the committee, said in a joint statement.

The spending legislation passed Thursday is part of a last-ditch proposal that keeps the government open through Jan. 19 while a longer-term budget solution is worked out. Both the House and Senate approved the spending measure before government-wide funding expired Friday.

Hard on Families

CHIP, created in 1997, is a shared federal-state program for children of parents who can’t afford private insurance but make too much to qualify for the Medicaid government program for the poor. States have broad discretion in setting eligibility, and have the option to cover pregnant women as well.

Funding for CHIP — which also covers dental care and prescriptions, among other services — amounts to almost $16 billion, with more than 90 percent coming from the federal government.

Even with passage of another patch, the limbo is hard on families.

“It’s a pretty bad Christmas or holiday present for a lot of families,” said Diane Rowland, executive vice president of the Kaiser Family Foundation, a bipartisan nonprofit focused on national health issues. “You can predict that there will be relief that the funding has been extended, but it will be combined with a lot of anxiety.”

As for states that can’t plan ahead, “this is creating an administrative nightmare,” Rowland said.

States have to start preparing for a possible shutdown of the program well before the day comes when they run out of money.

‘Stress and Turmoil’

“This whole situation is causing chaos,” said Cathy Caldwell, director of the bureau of Children’s Health Insurance with the Alabama department of public health. “We are causing confusion to families, stress and turmoil.”

Alabama health officials were forced to warn on Dec. 15 they would stop taking new enrollees on New Year’s Day and that the 84,000 children currently in the program could lose coverage Feb. 1.

Democrats have opposed a House GOP proposal to reauthorize CHIP for five years because it would be paid for by taking money from a fund set up under Obamacare to invest in prevention efforts. Bipartisan talks with the Senate and the White House on other funding offsets are “well down the road,” said House Minority Leader Nancy Pelosi, a California Democrat.

 

Keep Harmful Cuts in Federal Medicaid Disproportionate Share Hospital Payments at Bay

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http://www.commonwealthfund.org/publications/blog/2017/dec/harmful-cuts-in-federal-medicaid-dsh?omnicid=EALERT1329977&mid=henrykotula@yahoo.com

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  • While the ACA has had a major impact on reducing hospitals’ uncompensated care burdens, compensated care remains a challenge for many hospitals in poor communities
  • The White House and Congress have a final shot at once again ensuring that the poorest communities are not left without vital health care resources

Congress may delay a funding reduction for state Medicaid disproportionate share hospital (DSH) payments — direct, supplemental payments to hospitals serving high numbers of low-income patients — as part of end-of-year legislation. Although protecting the poorest communities from the loss of DSH funds has emerged on a short list of must-dos, final passage is far from certain. It may hinge on finding a funding strategy other than the one originally chosen by the House of Representatives — a more than $6 billion cut in critical public health funding from the Prevention and Public Health Trust Fund.

For nearly four decades, DSH payments have been a crucial part of Medicaid policy. But in light of the major gains in coverage anticipated for the poor under the Affordable Care Act’s adult Medicaid expansion, Congress scheduled a substantial reduction in federal Medicaid DSH payments beginning in 2014. Lawmakers assumed, not unreasonably, that the coverage expansions would translate into additional hospital revenue, thereby alleviating the need for as much direct DSH payment supplementation.

The relatively rosy scenario for DSH hospitals — especially those serving the poorest communities — changed dramatically in 2012 when the United States Supreme Court made Medicaid expansion optional; as of the end of 2017, nearly 3 million poor adults in 19 states continue to go without the Medicaid coverage they should be receiving.

To be sure, the ACA has had a major impact on reducing hospitals’ uncompensated care burdens. The Medicaid and CHIP Payment and Access Commission (MACPAC), which advises Congress on federal Medicaid policy, reports that between 2013 and 2014, hospital uncompensated care spending dropped by $4.6 billion, a 9 percent decrease, with the greatest declines occurring in Medicaid expansion states. But uncompensated care remains a crucial issue for many hospitals, especially those located in the poorest communities, and, in particular, hospitals serving poor communities in Medicaid nonexpansion states.

Additionally, even in Medicaid expansion states, a considerable number of low- and moderate-income adults who qualify for subsidized marketplace coverage remain uninsured. Even among those with subsidized marketplace plans whose incomes also are low enough to qualify for cost-sharing assistance (250 percent of poverty, or an annual income of about $30,000, and below), unpaid medical bills continue to add to hospitals’ uncompensated care burdens.

Should final congressional action before the holiday include a DSH cut delay, it would be the latest in a line of postponed Medicaid DSH cuts enacted by Congress over several years. Without another postponement, hospitals will lose $2 billion of the almost $12 billion federal allotment for fiscal year 2018. If this last-minute effort to stop the cuts once again as part of the spending bill does not succeed, then over 10 years, the cuts would reduce DSH payments by some $43 billion according to MACPAC.

For many reasons — the number of states that have failed to expand Medicaid; the number of Americans who continue to report that insurance coverage is unaffordable; high deductibles and other patient cost-sharing even among those with private health insurance — continuing to push back the day of reckoning on federal DSH funding reductions is a matter of high importance, not only for individual hospitals but for the communities whose health care systems these hospitals help anchor. The situation facing hospitals in nonexpansion states is especially grim; according to one estimate, failure of 19 states to implement the ACA Medicaid expansion can be expected to translate into an additional loss of $81.5 billion by 2026.

The White House and Congress have a final shot at once again ensuring that the poorest communities are not left without vital health care resources — and doing so in a way that does not pit health care against public health.