Tag Archives: Health Policy

Medicaid Is Great, but Rural Maine Needs Hospitals, Too

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This week Maine voted to become the 32nd state to expand Medicaid despite opposition by Gov. Paul LePage, who had vetoed five previous expansion bills passed by the state legislature and has now threatened to block the results of the ballot initiative. Unless Mr. LePage succeeds, about 80,000 more Mainers will be eligible for coverage, a victory in an unsettling year for health care in America.

With the Affordable Care Act under constant threat from the Trump administration and out-of-pocket costs rising faster than wages, health care topped the list of the most important issues facing Americans this year.

However, Maine and other rural states face a health care crisis that Medicaid expansion can’t fix on its own. It’s not about affordable coverage; it’s about access: For too many rural areas, doctors and hospitals are scarce.

In the postwar era, America made hospital construction and modernization a priority. On Aug. 13, 1946, Harry Truman signed the Hill-Burton Act,giving communities grants and loans for hospital construction. By 1975, almost one-third of American hospitals owed their creation to the law. Financing for Hill-Burton health care construction ended in 1997, but one rule from the original bill still applied: These hospitals had to give free or reduced care to people who couldn’t afford services. As rural areas aged and the population shrank because of manufacturing’s decline and the rise of a technology-driven economy centered on urban areas, hospitals struggled to stay in operation.

Under the Affordable Care Act, hospitals started shutting down at worrisome rates because of an increase in financial penalties for noncompliance with A.C.A. mandates, the cost of tighter reporting standards and smaller reimbursements for certain procedures. Since the A.C.A. became law in 2010, over 80 rural hospitals have closed nationwide. Maine alone has lost three hospitals in that time, about 10 percent of its rural total.

If closings continue at this rate, 25 percent of America’s rural hospitals will have disappeared in the decade after Obamacare’s passage. This does not take into account facility deterioration, doctor departures or department closures.

This is a big problem for Maine, which has the highest percentage of rural residents in the country, according to the most recent census data. Calais Regional Hospital in Down East Maine recently oversaw its last childbirth. The obstetrics department closed in late summer, forcing women in labor to drive 50 minutes to deliver their babies. Despite an opioid crisis that increases the chance of high-risk pregnancies, this same privately owned hospital shut down its pediatrics wing and intensive care unit in recent years, because of financial pressure from the management company halfway across the country in Tennessee.

This was hardly an isolated example in Maine. The town of Jackman closed its 24-hour emergency room in September, and Boothbay lost its only hospital in 2013. Rangeley, where my wife’s family lives, is an hour away from the nearest hospital and has no doctor in town.

Meanwhile, Maine Med in Portland, Maine’s largest city, is about to break ground for a $512 million addition just a few years after it finished a $40 million renovation. While rural Maine’s hospitals and departments are closing because of large losses, Maine Med had, for 2016, a $61 million surplus.

Medicaid expansion is a welcome source of new revenue to rural hospitals in Maine because more insured patients mean fewer uncompensated treatments. Still, it comes nowhere close to fixing the problem or, politically, putting any meaningful points on the Democratic scoreboard.

In 2016, Donald Trump won Maine’s rural congressional district by a 10-point margin and rural counties in America at large by a 26-point marginon a message of repealing and replacing Obamacare. As Maggie Elehwany of the National Rural Health Association said in an NPR interview this year, rural Americans voted for Mr. Trump in part because of health care. “They see their hospitals closing,” she noted. “And one hospital C.E.O. described it as a three-pronged stool. It’s the churches, the hospitals and the schools. If you lose one of those legs of that stool, the whole community collapses.”

Since President Trump hasn’t been able to deliver on any meaningful legislation to support rural voters, it is the Democrats’ time to deliver. One good step is a bill sponsored by the Democratic senators Tim Kaine of Virginia and Michael Bennet of Colorado called Medicare-X. It would give a public option to Americans in rural counties where limited competition has yielded higher-priced health insurance options.

It still doesn’t solve the heart of the rural problem. Democrats can’t just lower premiums and expand Medicaid. We must strengthen rural communities by making access to high-quality health care services a priority of any proposal. In any future legislation, we should demand grants for new hospitals, funds to modernize crumbling ones and financial incentives for top doctors to work in these areas. This will not only make rural communities healthier, but also more welcoming for growth and new business.

No person suffering from a heart attack should die because a hospital is too far. No pregnant mother should have to risk the health of her baby because she can’t make it to a delivery room in time. As Democrats, we believe that health care is a right. It would be a big mistake to expand health care insurance but offer no place to use it.

No Limit: Medicare Part D Enrollees Exposed to High Out-of-Pocket Drug Costs Without a Hard Cap on Spending

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No Limit: Medicare Part D Enrollees Exposed to High Out-of-Pocket Drug Costs Without a Hard Cap on Spending – Issue Brief

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Introduction

Prescription drugs play an important role in medical care for 59 million seniors and people with disabilities.  Medicare beneficiaries have access to outpatient prescription drug coverage through the Part D prescription drug benefit, which is administered by private stand-alone prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PDs). Since the start of the Medicare Part D program in 2006, the drug benefit has helped to lower out-of-pocket drug spending for all enrollees. Beneficiaries in Part D plans with low incomes and modest assets are eligible for additional assistance with plan premiums and cost sharing through the Low-Income Subsidy (LIS) program, reducing out-of-pocket costs even further for this population.

The Centers for Medicare & Medicaid Services (CMS) establishes guidelines that all Part D plans must follow for the design of the drug benefit and the value of coverage that must be offered. Plans are allowed to vary, however, along dimensions that affect beneficiaries’ access to and costs for medications, including which drugs are covered and cost-sharing requirements. The standard Part D benefit in 2017 includes a deductible ($400), followed by 25 percent coinsurance for prescriptions up to an initial coverage limit ($3,700 in total costs), and then a coverage gap where enrollees without low-income subsidies pay a larger share of their drug costs until their out-of-pocket drug spending exceeds a catastrophic coverage threshold ($4,950). The Affordable Care Act (ACA) included a provision to phase out the Part D coverage gap by requiring plans to cover a growing share of total drug costs and providing a manufacturer price discount of 50 percent for brand-name drugs filled in the gap, with the amount of the manufacturer discount counting towards the out-of-pocket threshold that triggers catastrophic coverage. Once enrollees’ drug spending reaches the catastrophic threshold, those without the LIS pay up to 5 percent of their total drug costs; those who qualify for the full low-income subsidy pay nothing for their drugs in this phase of the benefit. Plans typically place drugs that cost over $670 per month on a specialty drug tier, with coinsurance that ranges from 25 percent to 33 percent.

Concern has been rising in recent years about the growing cost burden on Medicare and beneficiaries posed by new, unique, and expensive specialty drugs used to treat a range of diseases. The Medicare Boards of Trusteesand the Medicare Payment Advisory Commission have documented this rising cost burden on the Medicare program, which is reflected in higher Part D program spending overall, as well as higher spending for reinsurance of high-cost Part D enrollees who reach the catastrophic coverage phase of the benefit, where Medicare pays for 80 percent of drug costs. Although Part D provides coverage of catastrophic drug expenses, enrollees who do not receive the LIS are still responsible for up to 5 percent of their drug costs in this phase of the benefit. For very high-priced medications, this relatively small coinsurance rate can translate to a significant amount of out-of-pocket costs for beneficiaries who do not receive low-income subsidies.

This analysis examines the out-of-pocket prescription drug cost burden for Medicare beneficiaries in Part D plans who do not receive low-income subsidies, focusing on those enrollees who have drug costs that exceed the catastrophic coverage threshold. We refer to this group as Part D enrollees with high out-of-pocket drug costs. Although these enrollees do not comprise the entire group of enrollees who have high total drug spending that exceeds the catastrophic coverage threshold, they are exposed to a potentially large cost burden because they do not receive the financial protection of the low-income subsidies. We analyze Medicare prescription drug event claims data for 2015, the most recent year of publicly available Medicare claims data, and trends since 2007, the first full year of the Part D drug benefit. For detail on the data and methods, see the Methodology.

Discussion

In recent years, the high and rising cost of prescription drugs has emerged as a pressing issue for consumers, public programs, and private insurers. As our analysis shows, Medicare beneficiaries who do not receive the additional financial protection provided by low-income subsidies are not insulated from this cost burden and can incur substantial out-of-pocket costs for their medications. We find that one million Medicare beneficiaries in Part D plans who were not receiving low-income subsidies had high out-of-pocket costs in 2015—that is, drug spending above the catastrophic coverage threshold—and their annual out-of-pocket spending averaged over $3,000 in 2015.

Our analysis indicates that out-of-pocket costs above the catastrophic threshold represent a growing concern for people with Medicare, and both MedPAC and Medicare’s actuaries have shown that rising spending for catastrophic coverage has placed greater fiscal pressure on Medicare. Our analysis also shows that the number of Part D enrollees who did not receive low-income subsidies and had out-of-pocket spending above the catastrophic threshold has increased over time. Looking to the future, we would expect to see continued increases in the number of enrollees reaching the catastrophic coverage threshold in 2016 and later years, due in part to the ACA changes to the coverage gap as well as the greater availability and use of high-priced drugs. These trends have cost implications both for beneficiaries and, as the Medicare actuaries have projected, for Medicare.

Part D enrollees with high out-of-pocket costs in 2015 spent an average of $1,215 out of pocket on their prescriptions filled above the catastrophic threshold, or $1.2 billion in the aggregate. In other words, Part D enrollees would have collectively saved $1.2 billion if Part D had a hard cap on out-of-pocket spending, rather than requiring enrollees to pay up to 5 percent coinsurance in the catastrophic coverage phase. Placing a hard cap on out-of-pocket spending under Part D would save money for enrollees, but would increase costs to Medicare and would not address underlying concerns related to high-priced drugs.

While Part D has helped make drugs more affordable for people with Medicare, and the ACA has provided additional relief to enrollees with high drug costs by gradually closing the coverage gap, the absence of an annual out-of-pocket spending limit under Part D exposes enrollees to significant costs—unless their incomes and assets are low enough to qualify for low-income subsidies. Various proposals to reduce drug costs—including allowing the federal government to negotiate prices for Medicare beneficiaries, and allowing Americans to import drugs from Canada and other countries—enjoy broad, bipartisan public support. With a growing number of people on Medicare facing high out-of-pocket drug costs, alleviating this burden remains an issue for federal policymakers to address.

Why Tax Reform Could Be a Serious Threat to Health Care

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http://www.commonwealthfund.org/publications/blog/2017/nov/why-tax-reform-could-be-a-serious-threat-to-health-care

After nine months of unsuccessful efforts to repeal and replace the Affordable Care Act (ACA), Congress has moved on to the challenge of reforming the U.S. tax code. At first glance, it may appear that Congress has shifted priorities: The House tax proposal released last week doesn’t propose to repeal the Affordable Care Act’s individual mandate requiring health insurance, nor does it fund tax reform with cuts to Medicaid.

However, this shift in congressional focus does not mean that Republicans in Washington are done with the ACA. The executive branch continues to undermine the individual health insurance marketplaces. As Sara Collins points out in a recent post on To the Point, two presidential actions last month — the first bypassing ACA consumer protections to allow multistate association health plans, and the second ending payments to insurers for cost-sharing subsidies — are likely to increase premiums on the marketplaces by 2019. Executive branch decisions to cut funding for marketplace outreach are already making it difficult for young, healthy people to explore their insurance options, which could depress enrollment for 2018 and further destabilize the marketplaces.

Moreover, this shift in focus does not mean that the attempts to deeply cut federal health care programs are over, either. Even if congressional leaders lose their appetite for full-scale ACA repeal bills, the futures of tax reform and health care will be intertwined for at least three reasons.

First, some conservatives in the House and Senate remain committed to including ACA repeal provisions in the tax bill. And, while they initially lost in their efforts to attach a repeal of the individual mandate to the current House Bill, conservatives may withhold support unless such a provision is included in the final bill.

Second, the House tax proposal is expensive: the proposed tax cuts total $5 trillion. The budget resolution Congress passed last month allows up to $1.5 trillion of the total cost of the tax cut to be paid for with an increase in the federal deficit. That means the U.S. Treasury will have to borrow money to cover 30 percent of the cost of the House bill — a notable departure from Reagan-era tax cuts that were fully offset. This shortfall will go up over time, because several of the bill’s tax code changes expire in a few years.

While the current House proposal includes $3.5 trillion in revenue-generating provisions to help pay for the remaining 70 percent of the tax cuts, several provisions are unpopular with rank-and-file Republicans. These include a 50 percent cut to the maximum home mortgage deduction and elimination of the current deduction for state and local income taxes. If some Republicans force these provisions out of the bill or modify them to affect fewer taxpayers — changes likely to be sought by Republicans representing districts in large Blue states with high housing costs and high state taxes — then the bill will not raise the revenue required by the budget resolution. Congressional leadership would be forced to pay for tax cuts with other sources of revenue or with cuts in federal spending. Key targets would be cuts to Medicaid and Medicare.

Third, tax reform may ultimately affect access to health care in the not-so-distant future, even if specific health provisions are not included in the bill. Should it pass, the ballooning federal deficit that will follow its implementation will invariably lead to calls to reduce federal spending. Medicaid, Medicare, and ACA coverage will again be in the crosshairs given the portion of federal spending — 28 percent in 2017, growing to 40 percent in 2037 according to the Congressional Budget Office — these health programs represent.

Don’t Nudge Me: The Limits of Behavioral Economics in Medicine

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Don’t Nudge Me: The Limits of Behavioral Economics in Medicine

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Whenever I talk to physicians about outcomes that are worse than you’d expect, they are quick to point out that noncompliance — when a patient does not follow a course of treatment — is a major problem.

Sometimes prescriptions aren’t filled. Other times they are, but patients don’t take the drugs as prescribed. All of this can lead to more than 100,000 deaths a year.

A thorough review published in The New England Journal of Medicine about a decade ago estimated that up to two-thirds of medication-related hospital admissions in the United States were because of noncompliance, at a cost of about $100 billion a year. These included treatments for H.I.V., high blood pressure, mental health and childhood illnesses (it can be difficult to get children to take their medicine, too).

To address the issue, researchers have been trying various strategies, including those rooted in behavioral economics. So far, there hasn’t been much progress. A systematic review published five years ago in Annals of Internal Medicine looked at all kinds of trials that tried to improve patient compliance. It found some limited successes in improving patient compliance in different disorders, but most of the trials were small and not easily generalized outside the research setting.

A more recent Cochrane review concluded that “current methods of improving medication adherence for chronic health problems are mostly complex and not very effective.”

At first glance, behavioral economics — the basis of Richard Thaler’s recent Nobel Prize in Economics — seems like a rich field of potential solutions. People tend to do things, like donate organs, when it’s the default option as opposed to something they need to request. They tend to be less likely to miss appointments if you tell them how many other patients show up for theirs. They tend to be more likely to engage in preventive behaviors like using sunscreen if you focus on the benefits, not the harms. Many are turning to ideas like these to improve medication adherence.

But those excited about the potential of behavioral economics should keep in mind the results of a recent study. It pulled out all the stops in trying to get patients who had a heart attack to be more compliant in taking their medication. (Patients’ adherence at such a time is surprisingly low, even though it makes a big difference in outcomes, so this is a major problem.)

Researchers randomly assigned more than 1,500 people to one of two groups. All had recently had heart attacks. One group received the usual care. The other received special electronic pill bottles that monitored patients’ use of medication. Those patients who took their drugs were entered into a lottery in which they had a 20 percent chance to receive $5 and a 1 percent chance to win $50 every day for a year.

That’s not all. The lottery group members could also sign up to have a friend or family member automatically be notified if they didn’t take their pills so that they could receive social support. They were given access to special social work resources. There was even a staff engagement adviser whose specific duty was providing close monitoring and feedback, and who would remind patients about the importance of adherence.

This was a kitchen-sink approach. It involved direct financial incentives, social support nudges, health care system resources and significant clinical management. It failed.

The time to first hospitalization for a cardiovascular problem or death was the same between the two groups. The time to any hospitalization and the total number of hospitalizations were the same. So were the medical costs. Even medication adherence — the process measure that might influence these outcomes — was no different between the two groups.

The researchers in this trial deserve praise for their frank assessment of their results, as well as for trying to brainstorm ways in which they might achieve success in the future. Getting patients to change their behavior is very hard. In the past, we’ve tried making drugs free to patients to get them to adhere to their medications and improve outcomes. That failed. We’ve tried lotteries (as in the study above) to nudge people to achieve better compliance. That failed.

Maybe financial incentives, and behavioral economics in general, work better in public health than in more direct health care. There have been successes, after all, with respect to weight loss — although these seemed to disappear over time. We’ve also seen promise with respect to smoking cessation, although these come with caveats as well.

Experts caution that the interventions that achieve success are often very intensive. They demand a great deal of attention, and can be quite expensive. Moreover, they are very focused, usually on a single issue or condition.

The problem is that health has so many moving parts. The health care system has even more. Trying to improve any one aspect can make others worse. Behavioral economics may offer us some fascinating theories to test in controlled trials, but we have a long way to go before we can assume it’s a cure for what ails Americans.

The problem with American health care is the care

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The problem with American health care is the care

A bipartisan health care deal recently brokered by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would give states greater power over health policy. But even if this nascent legislation falters, states will likely see their influence grow through actions of the Trump administration.

If state governors are going to be in the driver’s seat, they should understand something that Congress, with its narrow focus on insurance coverage, seems to have missed: the main problem with American health care is the care. Although it is important to have stable insurance markets, changes to coverage or benefit design will ultimately do little to reduce costs or make Americans healthier.

Our health care system is stuck in the 1950s, when the prevailing epidemics were polio and influenza. Today’s public health challenges are chronic diseases like diabetes, obesity, and opioid addiction. Half of all adults — 117 million Americans — have a chronic condition; the projected cost is $794 billion in lost productivity alone between 2016 and 2030.

For the most part, chronic diseases aren’t caused by microbes but by problems for which there are no pills or vaccines: deeply rooted personal, social, financial, and behavioral issues, messy, real-life problems like job layoffs, eviction notices, or loneliness. These issues have a profound effect on health, particularly in working-class communities where health care costs are high.

Our health care system hasn’t caught up with the evolving face of disease in America. It is still mostly a workforce of doctors and nurses who dutifully treat patients in hospitals with expensive drugs and high-tech medical devices. If we could reconfigure health care to detect and address the root causes of costly illness, health reform would be a true success.

Several initiatives have laid a path forward. This year, the Center for Medicare and Medicaid Innovation will begin Accountable Health Communities, a five-year grant that enables hospitals and doctor’s offices to check their patients for real-life issues that affect health. Once these have been identified, community health workers — trained laypeople from local communities — would help support patients and connect them to resources like housing or child care. This type of support can have a profound effect on health and lower costs.

In a recent study, my colleagues and I found that a community health worker program called IMPaCT lowered hospitalizations by 30 percent and reduced cigarette smoking, obesity, the severity of diabetes, and mental illness. This model yields a 2-to-1 return on investment, which has prompted large health systems and payers to invest millions in scaling it up.

The current debate around state waivers is focused on limiting health insurance coverage or scaling back essential benefits. Maine has joined Wisconsin, Kentucky, Arkansas, and Utah in submitting waiver applications that impose premiums for Medicaid beneficiaries and coverage lockouts that bar them from re-enrolling in health insurance coverage if they lose it because of unpaid premiums. Maine anticipates that its proposed waiver would lose its members a collective 55,000 months of coverage.

Instead of this approach, governors could apply for waivers to shift Medicaid funds into programs that screen for and address root causes of health through hospitals and doctor’s offices. These programs could yield significant cost savings while improving health, instead of cutting coverage.

Reshuffling insurance coverage schemes as a way to reduce costs is basically a shell game — a dangerous one — that does little to address the core ills of the system. It would be a wasted opportunity if health care reform did not also transform the way we deliver health care so Americans can have better health at lower cost.

 

Blue Cross Blue Shield insurers are still doing well

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https://www.axios.com/the-blue-cross-blue-shield-insurers-are-still-doing-well-2507217868.html

 

 Blue Cross Blue Shield health insurance companies have more than quintupled their net profits in the first half of this year compared with the same six months of 2016, according to an analysis of financial records by Fitch Ratings.

The bottom line: We reported over the summer that the Blues, which have the most exposure to the Affordable Care Act marketplaces, are making a lot of money despite the Trump administration’s threats and actions against the ACA. Why are profits still growing for the Blues? They raised premiums a lot, people are not going to the doctor or hospital as much, and the federal government modified some enrollment policies to the benefit of insurers.

The details: Fitch analyzed the first-half financial documents of 34 Blue Cross Blue Shield companies, including the publicly traded Anthem as well as other large Blues brands such as Health Care Service Corp. and Blue Shield of California. Almost every company improved its finances year over year, leading to the following aggregate financial data for the first six months of 2017:

  • $135 billion of revenue (up 7%)
  • $7.7 billion underwriting profit, or the amount of money made after subtracting medical costs from premiums paid (up 194%)
  • $6.5 billion net profit (up 441%)
  • 85.9% medical loss ratio, which reflects how much of the premium dollar is spent on medical care (down 0.8 percentage points)

What was true previously is still true now: Most health insurers are not currently losing their shirts on the ACA’s individual marketplaces, although next year could be different depending on what happens to the law’s cost-sharing subsidies. While the higher premium rates have not harmed people who get federal subsidies, they have caused more financial pain for middle-class people who have to pay the full cost of their health insurance.

Looking ahead: Congress delayed the ACA’s health insurer tax throughout 2017 — another reason why companies have done so much better this year. Insurers have conducted a lobbying blitz to get Congress to repeal or delay that fee again, and legislation that would delay the tax for another two years could be folded into a year-end package.

Are Payers the Leading Cause of Death in the United States?

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https://www.medpagetoday.com/blogs/revolutionandrevelation/68935?utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202017-11-07&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days

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Milton Packer wonders if people suffer and die because it is cost effective.

As everyone knows, we are in the midst of a horrific opioid addiction epidemic. Physicians are prescribing opiates for pain relief, and patients are becoming addicted to them. One-fifth of patients who receive an initial 10-day prescription for opioids will still be using opiates a year later. That is simply extraordinary.

Physicians are prescribing opiate formulations that are highly addictive. But they do not need to do that.

There are several newer formulations that relieve pain and are far less addictive than older agents. But they are prescribed uncommonly. Why is that?

It is not because physicians are uninformed.

It is because payers will not pay for the alternatives. The less-addictive opiates are more expensive, so payers have declined to support them. Patients get addicted because paying for highly addictive opiates saves the payers money.

The New York Times also noted that the treatment of opiate addiction is expensive. It is far cheaper for payers if physicians continue to prescribe opiates than if physicians enrolled a person into a drug addiction program.

What does that look like? Patients get more prescriptions for opiates instead of getting the help they need.

The Payers Are in Charge

If you are looking for someone to blame for the opioid epidemic, you can certainly blame physicians. You can blame pharmaceutical companies. But while you are at it, don’t forget to include payers.

This conclusion should not be surprising. We live in a world where payers — not physicians — determine what drugs and treatments patients receive.

If patients have a life-threatening condition, it is not unusual for a payer to demand that a physician first prescribe a cheaper and less effective alternative. Physicians know that the drugs they are allowed to use may not work very well, but frequently, payers demand that they be tried first anyway.

What happens if the patient doesn’t respond to the cheap drug?

Often, the physician continues to prescribe it, because — to gain access to the more effective drug — physicians need to go through a painful process of preauthorization. For many practitioners, it isn’t worth it.

Don’t patients eventually get the drugs that they need?

No. All too often, physicians stop trying. Or patients get frustrated and give up. Often, payers says “No!” no matter how many times they are asked. And if the drug is for a life-threatening illness and enough time passes by, then the patient may no longer be alive to demand that they get the right drug.

So we spend more for healthcare than any other country in the world, but Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician’s knowledge or judgment. They are being driven by what payers are willing to pay for.

How many people are affected by all of this?

Everyone.

That includes me and my family. That includes everyone that I know.

Medicine has made incredible progress in the last 20-30 years. But you are not likely to benefit from it.

Do you want to blame the high cost of drugs? You can do that, but if you do, you will be missing the point. We should expect better drugs to be more expensive than less effective ones. But we do not expect to have a company decide that we will get the inferior drug simply because they want to make a profit.

Are payers the leading cause of death in the United States? If you think this is a crazy question, please think again.

GOP unlikely to repeal ObamaCare mandate in tax measure

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GOP unlikely to repeal ObamaCare mandate in tax measure

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The House is unlikely to repeal the mandate to buy insurance under ObamaCare as part of its tax-reform bill, GOP sources say, though the issue could return down the road.

President Trump and conservative lawmakers are pushing for the individual mandate to be repealed in the bill, but House Ways and Means Committee Chairman Kevin Brady (R-Texas) has expressed worry that the controversial measure would jeopardize the broader tax-reform bill, given the Senate’s failure on health care earlier this year.

“It hasn’t ever been in the [House] bill,” said one Republican on the Ways and Means Committee who has been taking part in the negotiations. “I expect that it will be added somewhere down the sausage-making venture.”

“I agree there is a chance, but I think if it gets included, it would be on the Senate side,” added a second Ways and Means Republican.

Senate GOP leaders said they plan to roll out their own tax bill on Thursday. Sen. Tom Cotton (Ark.) has been the leading GOP senator pushing to include repeal of the mandate in the tax bill.

House leaders emerging from a meeting Monday evening said no final decision has been made on the individual mandate issue, and Brady and Speaker Paul Ryan (R-Wis.) both said in interviews in recent days that they have not ruled out the idea.

“We have an active conversation with our members on a whole host of ideas on things to add to this bill and that’s one of the things being discussed,” Ryan said during an appearance on “Fox News Sunday.”

But Brady expressed concerns about including the mandate’s repeal at an event last week.

“There are pros and cons to this,” Brady said at an event Friday hosted by Politico. “Importing health care into a tax-reform debate has consequences.”

If Congress doesn’t act, Trump has vowed that he will. The president is reportedly considering taking executive action on the insurance mandate if Congress leaves it out of the tax-reform bill.

A lobbyist told The Hill the administration is working on guidance, which might not be in the form of an executive order, that would expand what are known as “hardship exemptions” that allow people to be exempted from the mandate’s requirement to have health insurance or pay a fine.

Brady said Monday that repeal of certain ObamaCare taxes would not be included in tax reform. Instead, he said he is working with Democrats on temporary relief from measures like the medical device tax and health insurance tax.

“We are working on common-sense temporary and targeted relief from many of these taxes to be acted on in the House before the end of the year,” Brady said.

Repealing the mandate could destabilize health insurance markets, experts warn, by removing an incentive for healthy people to enroll. The Congressional Budget Office has previously estimated that repealing the mandate would increase premiums by 20 percent.

Trump has been pushing to repeal the mandate in the tax-reform bill. Brady said last week that Trump had asked for it twice on the phone and once in person. Trump also told a meeting of Republican lawmakers at the White House last week that he wanted to repeal the mandate in tax reform and floated adding it in the Senate, attendees said.

Two conservative leaders, House Freedom Caucus Chairman Mark Meadows (R-N.C.) and Republican Study Committee Chairman Mark Walker (R-N.C.), have been pushing leadership to repeal the mandate in the tax bill. Walker has been slightly more aggressive, calling it a “good move.”

“When given the opportunity to actually address even part of an ObamaCare repeal with a simple majority, our leadership consistently finds excuses to justify their failure,” said a conservative House lawmaker who favors adding repeal to the bill.

“The individual mandate will be repealed by the president while Congress makes excuses.”

A number of lawmakers — both on and off the Ways and Means panel — are predicting the tax legislation Brady unveiled last week would attract the 218 GOP votes needed for passage.

While a handful of vocal New York and New Jersey Republicans are objecting to a provision of the bill that scraps or limits state and local tax deductions, most moderate Republicans have signaled they will go along with the legislation rather than derail one of the GOP’s top campaign promises of the 2016 elections.

So there is a reluctance among GOP vote-counters to add the insurance provision and upset that fragile balance.

“I believe it’s going to be a very strong vote based on my interactions with members and their passion to reform the tax code,” Rep. Jason Smith (R-Mo.), who serves on both the Ways and Means Committee and Ryan’s leadership team, said of the current version of the bill.

200 health, business groups endorse bipartisan ObamaCare bill

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200 health, business groups endorse bipartisan ObamaCare bill

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More than 200 health and business groups have endorsed a bipartisan bill to shore up ObamaCare’s insurance markets.

Senate Health Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.) announced the support Wednesday as part of their latest push to get the bill passed.

Those in support include influential groups such as the American Medical Association and the American Hospital Association.

But the bill still faces an uphill battle to becoming law. While it appears to have the support needed to pass the Senate, Majority Leader Mitch McConnell (R-Ky.) has said he won’t call it for a vote without approval from President Trump.

The bill would fund ObamaCare’s insurer subsidy payments for two years and give states additional flexibility to change their ObamaCare requirements.

Trump has called the bill a bailout for insurance companies and is pushing for more conservative changes.

But Murray said Tuesday she hasn’t had any discussions with the White House about making changes to the legislation, calling for it to be brought up as is.

The bill thus appears to be at a standstill. Many observers think its only real chance is to be included in a larger deal on spending in December.

Maine Medicaid expansion vote seen as ‘Obamacare’ referendum

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https://www.apnews.com/59f70b01af374560baccce244cca0b3d/Maine-Medicaid-expansion-vote-seen-as-‘Obamacare’-referendum

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The roiling national debate over the government’s proper role in health care is coming to a head in a state more commonly known for moose, lobster and L.L. Bean.

On Nov. 7, voters in Maine will decide whether to join 31 other states and expand Medicaid under former President Barack Obama’s Affordable Care Act. It is the first time since the law took effect nearly four years ago that the expansion question has been put to voters.

The ballot measure comes after Maine’s Republican governor vetoed five attempts by the politically divided Legislature to expand the program and take advantage of the federal government picking up most of the cost.

It also acts as a bookend to a year in which President Donald Trump and congressional Republicans tried and failed repeatedly to repeal Obama’s law.

Activists on both sides of the issue are looking at the initiative, Maine Question 2, as a sort of national referendum on one of the key pillars of the law, commonly known as Obamacare. Roughly 11 million people nationwide have gained coverage through the expansion of Medicaid, the state-federal health insurance program for lower-income Americans.

Republican consultant Lance Dutson called Maine’s initiative a national bellwether in which the needs of the people could trump political ideology.

A pillar of former President Barack Obama’s health care law faces a test in Maine, where voters will decide whether to expand Medicaid. If voters pass the initiative, Maine would become the 32nd state to accept the expansion. (Oct. 31)

“People believe there are good parts to Obamacare and bad parts to Obamacare. And without taking Medicaid expansion, we are leaving one of the good parts on the table while still suffering from the bad parts of it,” said Dutson, who supports Question 2.

Maine may not be the last state to put the Medicaid question before voters. Expansion proponents in Idaho and Utah have launched similar efforts in those states aimed at the 2018 ballot.

If the initiative passes, an estimated 70,000 people in Maine would gain health coverage. The issue is personal to many in an aging, economically struggling state with a population that is smaller than the city of San Diego.

Nature painter Laura Tasheiko got dropped from Medicaid three years ago after successfully battling breast cancer. Since then, she has relied on the charitable services of a hospital near her home in Northport, a seaside village of less than 2,000 people about 100 miles northeast of Portland.

She worries about having another serious health problem before she is eligible for Medicare when she turns 65 next year.

“Some of the after-effects of the chemo can be severe, like heart failure,” she said. “Having no insurance is really scary.”

Maine’s hospitals support the Medicaid expansion and say charity care costs them over $100 million annually. The initiative’s supporters have reported spending about $2 million on their campaign, with hundreds of thousands of dollars coming from out-of-state groups. By comparison, the lead political action committee established to oppose the measure has spent a bit less than $300,000.

Among those who say Maine will benefit from the expansion is Bethany Miller. She said her adult son, Kyle, needed Medicaid because he couldn’t afford subsidized monthly insurance premiums even though he was working.

She remembers watching as her son’s eyes went hollow and his body turned skeletal in the weeks before he died, at age 25, from a diabetic coma a year ago.

“He had a job, but he didn’t make enough money to pay for his basic needs and his insulin, and he couldn’t live without his insulin,” said Miller, who lives in Jay, a small paper mill town about 70 miles north of Portland.

LePage, a Trump supporter, is lobbying furiously against the initiative. He and other critics warn that the expansion will be too costly for Maine, even with the federal government picking up most of the tab. After 2020, the state’s share of paying for the expansion population would be 10 percent.

LePage warns that he would have to divert $54 million from other programs — for the elderly, disabled and children — to pay for Medicaid expansion.

“It’s going to kill this state,” he said.

LePage said he considers Medicaid another form of welfare and wants to require recipients to work and pay premiums.

Maine currently serves about 268,000 Medicaid recipients, down from 354,000 in 2011. LePage credits the drop to his administration’s tightened eligibility restrictions.

If Question 2 passes, the Medicaid expansion would cover adults under age 65 with incomes at or below 138 percent of the federal poverty level. That’s $16,643 for a single person or $22,412 for a family of two.

State Rep. Deborah Sanderson, a Republican, said Maine is already struggling to serve its rapidly aging population as nursing homes shutter and rural hospitals struggle.

“I get accused on occasion of trying to pit one population of folks against another,” she said. “It’s a case of only having a certain amount of resources to take care of a large number of needs.”

Finances are a concern in a state marked by factory closures and sluggish wage growth.

But with more people living on the margins, advocates of the expansion say that is all the more reason to extend the benefits of Medicaid. About 8 percent of Maine residents do not have insurance, a little less than the national percentage.

Democratic Sen. Geoffrey Gratwick, a retired rheumatologist, said he has seen many patients throughout his career who did not have health insurance and came to him with a disease already in its late stages. He voted for all five Medicaid expansion attempts.

“They are just as good people as you or I, but their lives will be shorter and they will be sicker,” he said. “Compassion, common sense and our economic interest demand that we get them the health care they need.”

Nathalie Arruda and her husband, Michael, are in that group that is sometimes without insurance. They live in the farming community of Orland, halfway between New Hampshire and the state’s eastern border with New Brunswick, Canada.

The couple run a computer business and rely on herbal teas and locally grown greens to stay healthy as they fall in and out of Medicaid eligibility. LePage restricted Medicaid eligibility for adults with dependents, like the Arrudas.

“There have absolutely been times when my husband or I have put off getting something looked at that we probably should have because we didn’t have coverage,” Arruda said.

In Miller’s view, her son would still be alive if LePage had signed one of the Medicaid expansion bills sent to him by the Legislature.

When Kyle turned 21, he was one of thousands who lost MaineCare coverage under the governor’s reforms. She said he juggled construction jobs but couldn’t afford his $80 subsidized monthly premium for private insurance.

He struggled to pay medical bills from emergency room visits, Miller said.

Before Kyle died last November, he had landed a steady job at a plastics factory that promised health insurance. He didn’t live long enough to get the coverage, falling into a diabetic coma.

“He started rationing his insulin so he could buy food,” his mother said. “And it cost him his life.”