Tag Archives: Health Policy

4 in 10 healthcare professionals work when they’re sick, risking patients

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Patients who are exposed to a sick healthcare worker are five times more likely to get a healthcare-associated infection.

A new study suggests that healthcare professionals should heed their own advice: Stay home when sick.

Some four in 10 healthcare professionals work while experiencing influenza-like illness, according to findings published in the November issue of the American Journal of Infection Control, the journal of the Association for Professionals in Infection Control and Epidemiology.

As in all workplaces, contagious employees risk infecting others when they turn up for work. But with higher concentrations of older patients and individuals with immunosuppression or severe chronic diseases in healthcare facilities, flu-like transmission by healthcare workers naturally presents a public health hazard.

The research pointed to an earlier study showing that patients who are exposed to a sick healthcare worker are five times more likely to get a healthcare-associated infection.

The annual study, conducted via a national online survey, collected data from from 1,914 professionals during the 2014-2015 flu season. Respondents self-reported influenza-like illness, defined as the combination of a fever and cough or sore throat, and listed factors that prompted them to turn up for work.

The survey assessed a variety of health occupations across multiple institutions: physicians; nurse practitioners and physician assistants; nurses; pharmacists; assistants/aides; other clinical pros; nonclinical pros; and students. Four types of work settings were assessed: hospitals, ambulatory care or physician offices, long-term care facilities and other clinical settings.

Of the 1,914 professionals surveyed, 414 reported flu-like illness. Of these, 183 — or 41.4 percent — reported working for a median duration of three days while experiencing flu-like symptoms.

Hospital-based healthcare professionals had the highest frequency of working with flu-like illnesses (49.3 percent), compared to those at long-term care facilities (28.5 percent). Clinical professional healthcare workers were the most likely to work with the flu (44.3 percent), with pharmacists (67.2 percent) and physicians (63.2 percent) among those with the highest frequency.

The survey found that assistants and aides (40.8 percent), nonclinical workers (40.4 percent), nurse practitioners/physician assistants (37.9 percent), and other clinical workers (32.1 percent) worked while sick.

The most common reasons for healthcare professionals to opt from taking sick leave included feeling that they could still perform their job duties; not feeling “bad enough” to stay home; feeling as if they were not contagious; sensing a professional obligation to be present for coworkers; and difficulty finding a coworker to cover for them. Among the workers who felt they could still perform their job duties, 39 percent sought medical attention for their symptoms, as did 54 percent of those who didn’t think they were contagious. Almost 50 percent of workers in long-term care settings who reported for work when sick reported doing so because they couldn’t afford to lose the pay.

Healthcare professionals with self-reported flu symptoms missed a median number of two work days. Of those, 57.3 percent visited a medical provider for symptom relief; 25.2 percent were told they had influenza. The Centers for Disease Control and Prevention recommends that anyone with such symptoms wait 24-hours after a fever breaks before returning to work.

Previously published results from the survey showed that only 77.3 percent of respondents reported getting a flu shot.

Hospital groups to sue CMS over $1.6 billion cut to 340B payments

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http://www.healthcarefinancenews.com/news/cms-finalizes-outpatient-payment-rule-reduces-hospitals-payment-rate-under-340b-drug-program?mkt_tok=eyJpIjoiWVdWa1lXTTBORFJpWTJSayIsInQiOiJndXNTdWM2czNvZzR6dDlRVXA4N3ZZWUhiV29FTzZ4VndOT3VGeUkzSGtGcms1QnlhSnNRTTlQbGRmcmY5UEpEY2VuWWg1UHIwTXVQUkg1ZklLZGN6SGYxMmpwc3lmZGJtK1pBcTNDNnZZZ0FmYzQ3Q2R2YWloNjVJSlorWStcL3QifQ%3D%3D

Credit: <a href="https://en.wikipedia.org/wiki/United_States_Department_of_Health_and_Human_Services#/media/File:DHHS2_by_Matthew_Bisanz.JPG">Matthew Bisanz</a>.

The final rule will also allow for higher payment when Medicare beneficiaries receive certain procedures in outpatient departments.

Several groups representing U.S. hospitals on Wednesday said they plan to sue the Centers for Medicare and Medicaid Services over a hospital outpatient prospective payment system final rule released Wednesday that reduces what hospitals are paid under the 340B drug program.

The rule lowers the cost of prescription drugs for seniors and other Medicare beneficiaries by reducing the payment rate to hospitals for certain Medicare Part B drugs purchased through the 340B program. The existing rule would have paid hospitals 6 percent above the sale price of drugs, but the final rule instead pays hospitals 22.5 percent less than sale prices, amounting to a $1.6 billion cut.

The American Hospital Association, Association of American Medical Collegesand America’s Essential Hospitals said they will seek litigation to prevent the cuts.

“CMS’s decision in today’s rule to cut Medicare payments to hospitals for drugs covered under the 340B program will dramatically threaten access to health care for many patients, including uninsured and other vulnerable populations,” AHA Executive Vice President Tom Nickels said in a statement. “We strongly urge CMS to abandon its misguided 340B rule, and instead take direct action to halt the unchecked, unsustainable increases in the cost of drugs.”

America’s Essential Hospitals CEO Bruce Siegel said the organization saw no reasonable rationale for diverting Medicare Part B reimbursement from hospitals in the 340B drug pricing program that are in the greatest need of support to providers not eligible for 340B discounts. CMS has no evidence that the policy will combat rising drug prices, he said.

“Congress clearly intended that the 340B program help hospitals that care for many vulnerable patients; this new policy subverts that goal,” Siegel said. “Essential hospitals operate with an average margin less than half that of other hospitals and depend on 340B program savings to stretch resources for patient care and community services. Given their fragile financial position, essential hospitals will not weather this policy’s 27 percent cut to Part B drug payments without scaling back services or jobs.”

340B Health said the rule is a backdoor effort to undermine an important drug discount program.

“Responding to a survey earlier this year, 340B hospitals were unanimous in saying implementation of the CMS rule would cause them to cut back services. For example, Genesis Healthcare System in Zanesville, Ohio, estimates a loss of $3 million in Medicare payments could force it to cancel critical services such as substance abuse treatment, cancer treatment, and behavioral health programs.The MetroHealth System Cancer Center in Cleveland, Ohio, estimates an $8 million loss would raise patients’ costs and reduce access to needed services including transportation and care navigation that are supported by 340B savings,” said 340B Health CEO Ted Slafsky.

However, the AIR340B Coalition said it would continue to advocate for regulatory action to better align the program with its original intent of helping vulnerable patients.

“We applaud the Administration for taking action to help address one aspect of the 340B program that has been leading to higher costs for Medicare and its beneficiaries,” the AIR340B Coalition said.

Areas of change it supports include clearly defining a 340B eligible patient, examination of hospital and satellite clinic eligibility criteria, and a more rational and legally supportable policy on contract pharmacy arrangements.

CMS said the savings will be reallocated equally to all hospitals paid under the hospital outpatient prospective payment system. Children’s hospitals, certain cancer hospitals, and rural sole community hospitals will be excluded from these drug payment reductions.

CMS will work with Congress for additional considerations on 340B for safety net hospitals, said CMS Administrator Seema Verma.

Consumers would save an estimated $320 million in copayments in 2018 under the new payment rule that gives Medicare beneficiaries the benefit of discounts hospitals receive under the 340B program, according to Verma.

“As part of the president’s priority to lower the cost of prescription drugs, Medicare is taking steps to lower the costs Medicare patients pay for certain drugs in the hospital outpatient setting,” Verma said.

The final rule will also allow outpatient payment to be made when Medicare beneficiaries receive certain procedures in a lower cost setting, the outpatient department. The new availability of the higher OPPS payment applies to six procedures, including total knee replacements, a common and costly Medicare surgical procedure, CMS said.

Starting in January 2018, Medicare beneficiaries undergoing any of the six procedures can opt to have them performed in a lower cost setting when a clinician believes such a setting is appropriate.

Additionally, the final rule provides relief to rural hospitals by placing a two-year moratorium on the direct physician supervision requirements for rural hospitals and critical access hospitals.

“CMS understands the importance of strengthening access to care, especially in rural areas,” Verma said. “This policy helps to ensure access to outpatient therapeutic services for seniors living in rural communities and provides regulatory relief to America’s rural hospitals.”

In a home health prospective payment system final rule, CMS is not finalizing the home health groupings model and will take additional time to further engage with stakeholders.

Trump and the Essential Health Benefits

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Trump and the Essential Health Benefits

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On Friday, HHS released a proposed rule that would make a number of adjustments to the rules governing insurance exchanges for 2019. The rule is long and detailed; there’s a lot to digest. Among the most noteworthy changes, however, are those relating to the essential health benefits. They’re significant, and I’m not convinced they’re legal.

By way of background, the ACA requires all health plans in the individual and small-group markets to cover a baseline roster of services, including services falling into ten broad categories (e.g., maternity care, prescription drugs, mental health services). Taken as a whole, the essential health benefits must be “equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary.”

The ACA’s drafters anticipated that HHS would establish a national, uniform slate of essential health benefits. Instead, the Obama administration opted to allow the states to select a “benchmark plan” from among existing plans in the small group market (or from plans for state employees). The benefits covered under the benchmark were then considered “essential” within the state.

At the time, Helen Levy and I concluded that HHS’s approach brushed up against the limits of what the law allowed. We noted, among other things, that the ACA tells HHS to establish the essential health benefits—not the states. And it’s black-letter administrative law that an agency can’t subdelegate its powers to outside entities, states included.

At the end of the day, however, Helen and I concluded that the Obama-era regulation passed muster. Our rationale bears repeating:

Although a federal agency cannot delegate its powers to the states, it “may turn to an outside entity for advice and policy recommendations, provided the agency makes the final decisions itself.” Here, the secretary gave the states a constrained set of options (e.g., choose a benchmark plan from among the three largest small-group plans in the state) and retained the authority to select a benchmark for any state that either does not pick a benchmark or chooses an inappropriate one. As such, the secretary remains firmly in control. Nothing in the ACA prevents her from deferring to states that select benchmark plans from among the few options she has provided. That choice to defer is itself an exercise of her delegated powers.

The Trump administration’s proposed rule would vastly enlarge this Obama-era subdelegation. For starters, the rule would allow a state to adopt another state’s benchmark, or part of a state’s benchmark, as its own. Michigan, for example, could borrow Alabama’s benchmark plan wholesale, or it could incorporate Alabama’s benchmark for mental health and substance use disorder treatment. More significantly, the rule would allow a state to “selec[t] a set of benefits that would become the State’s EHB-benchmark plan.”

You read that right: if the rule is adopted, each state can pick whatever essential health benefits it likes. No longer will it be choosing from a preselected menu; it’ll be picking the essential benefits out of a hat. In so doing, the proposed rule looks like it would unlawfully cede to the states the power to establish the essential benefits.

This extraordinary subdelegation of regulatory authority is subject only to the loosest of constraints: benefits can’t be “unduly weighted” toward any one benefit category or another, and the benchmark must “[p]rovide benefits for diverse segments of the population, including women, children, persons with disabilities, and other groups.” The selected benefits also can’t be more generous than the state’s 2017 benchmark (or any of the plans the state could have selected as its benchmark), but that’s a ceiling, not a floor, so states have lots of room to pare back.

The only meaningful constraint is that the benefits covered by the state’s benchmark must be “equal to the scope of benefits provided under a typical employer plan.” But another portion of the proposed rule would hollow out that requirement:

[W]e propose to define a typical employer plan as an employer plan within a product (as these terms are defined in §144.103 of this subchapter) with substantial enrollment in the product of at least 5,000 enrollees sold in the small group or large group market, in one or more States, or a self-insured group health plan with substantial enrollment of at least 5,000 enrollees in one or more States.

In other words, HHS is saying it will treat as “typical” any employer plan, in any state, that covers more than 5,000 people.

This looks like an innocuous change. It’s not. If the rule is adopted, it means that a single outlier plan can now count as typical, even if it’s way stingier than any other plan in the market. It also makes me wonder if HHS already has in mind some large employer with an unusually narrow health plan—maybe some hospital-based “administrative services only” plan, as Dave Anderson speculates. If so, voilá, the states can all ratchet down their essential benefits to that plan’s level.

I don’t think that’s legal. To know if a slate of health benefits is typical, you have to know something about how many health plans cover those benefits and how many don’t. The proposed rule eschews that comparative inquiry, and instead defines typicality with reference to the number of people who are covered by a single plan. Some random self-insured plan that excludes appendectomies could be treated as typical, even if it’s the only plan in the nation that does so.

In other words, HHS wants to define a “typical employer plan” to include atypical plans—which the agency emphatically cannot do. Yes, plans that enroll 5,000+ people are less likely to be outliers than smaller ones. But in a country as big and complicated as ours, there are bound to be some idiosyncratic quirks even in large plans. Those quirks would all be considered typical under HHS’s rule.

This definitional change, combined with the choose-your-own-adventure option to devise a benchmark, means that states will have wide authority to water down the essential health benefits requirement. Whether that’s good or bad is hard to say. Requiring plans to cover lots of services assures comprehensive coverage, but it also raises the cost of insurance. Because there’s no single “best” way to strike the balance, I think there’s a lot to be said for giving states the freedom to choose for themselves.

Wise or not, however, I’m skeptical that the Trump administration’s effort to hollow out the rule governing essential health benefits is legal. If HHS presses ahead with the rule, it could face tough sledding in the courts.

Why Advertising Is a Poor Choice to Tackle the Opioid Crisis

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Why Advertising Is a Poor Choice to Tackle the Opioid Crisis

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In declaring the opioid epidemic a public health emergency last week, President Trump promised that the federal government would start “a massive advertising campaign to get people, especially children, not to want to take drugs in the first place.” But past efforts to prevent substance abuse through advertising have often been ineffective or even harmful.

Perhaps the most famous American antidrug advertisement featured a sizzling egg in a frying pan to the sound of ominous music and a stern voice-over warning, “This is your brain on drugs.” A sequel to this ad featured Rachael Leigh Cook smashing an egg and the better part of a kitchen to dramatize the impact of heroin.

Many other ads denouncing drugs and emphasizing their destructive effects — as in the “Just Say No” campaign — appeared regularly on television and in print beginning in the 1980s. Most of them were funded by the White House Office of National Drug Control Policy, which received hundreds of millions of dollars a year from Congress for such campaigns.

Visually dramatic though the ads were, evaluations of them were deeply discouraging. The billions spent from the late 1980s through the mid-2000s at best had no effect on drug use, research shows. At worst, exposure to the campaign might have actually increased the likelihood of adolescent marijuana use. A study of over 20,000 youths 9 to 18 found that those who had been exposed to more antidrug ads expressed weaker intentions to avoid marijuana and more doubts that marijuana was harmful.

Why was the original campaign such a failure? In part it suffered from perverse incentives. Congress provided substantial money for the ads and was intensely interested in them at the height of the so-called war on drugs, creating internal pressure to make the ads appealing to members of Congress. But while ads that lectured or scared people about drugs might have seemed compelling to the modal member of Congress (a 60-year-old white male), they did not necessarily dissuade drug use by adolescents. In some cases, this kind of approach may make drugs more attractive as a sign of rebellion.

Other reasons that campaigns backfire is that they make adolescents aware of a drug that they might not have heard of, sparking curiosity in some to try it. Campaigns against drugs can also create a false sense that drug use is more common than it is, making those who don’t use drugs feel socially abnormal.

After the failure of the government’s initial antidrug media campaign, which was highlighted in the press and congressional hearings, it was significantly redesigned. The new approach, named Above the Influence, moved more toward the message that not using drugs exemplified and maximized youth freedom.

The retooled campaign had stronger results, with one study of over 4,000 adolescents showing that it reduced teenage marijuana use.

In switching tack, antidrug campaigns were taking a page from antismoking campaigns like the “truth.”This campaign, which research has estimated has deterred hundreds of thousands of adolescents from beginning to smoke, turns youthful rebellion to its advantage. Refraining from smoking was not about pleasing a parental authority figure; the “truth” pointed out to adolescents that people their parents’ age ran the tobacco companies and took them for saps (not cool). To be free thus meant to snub their seduction (cool).

Still, the positive results for Above the Influence and the “truth” are not the norm. A recent Cochrane review of rigorous studies collectively examining over 180,000 people reported that the average effect of mass media campaigns on drug use in randomized studies was essentially zero. Why is it so hard for media to change young people’s drug use?

By the time they reach adulthood, Americans are typically exposed to tens of thousands of advertisements promoting substance use, be it beer, cigarettes or more recently cannabis in some locations. Although opioids are not directly advertised to the public, seeking relief through pills certainly is (“Ask your doctor about …”).

Given this environment, it is not surprising that the comparatively small number of ads promoting the opposite message do not make much difference. In fact, it would probably be more consequential as a media strategy to stop the promotion of addictive products, but American courts are almost alone in the developed world in treating commercial speech comparably to the protection given free speech.

Media campaigns against drug use by young people thus can at most make a modest contribution to turning around the opioid epidemic, with some risk of making it worse if the lessons of past failed antidrug campaigns are not heeded. But the safest bet is that the results will be between those two end points: zero. To fight the opioid crisis, public money is probably best spent elsewhere.

Opioid Commission Unveils Blueprint To Fight Crisis, But Passes Funding Buck To Congress

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The group’s 56 recommendations include tightening prescription practices and expanding drug courts, prevention efforts, treatment access and law enforcement tactics.

President Trump’s bipartisan commission on the opioid crisis made dozens of final recommendations on Wednesday to combat a deadly addiction epidemic, ranging from creating more drug courts to vastly expanding access to medications that treat addiction, including in jails.

The commissioners did not specify how much money should be spent to carry out their suggestions, but they pressed Congress to “appropriate sufficient funds” in response to Mr. Trump’s declaration last week of a public health emergency.

The 56 recommendations — which covered opioid prescribing practices, prevention, treatment, law enforcement tactics and funding mechanisms — did not so much advocate a new approach as expanding strategies already being used.

Reaction from treatment advocates was mixed, with many expressing frustration that the commission had not called for a specific level of funding. Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health, which represents treatment providers, said that his group agreed with many of the recommendations, but that the report “starves the country for the real resources it needs to save American lives.”

Although the commission did not put a dollar amount on its recommendations, it had specific ideas for how federal money should be funneled to states. Its top recommendation was to streamline “fragmented” federal funds for addiction prevention and treatment into block grants that would require each state to file only a single application instead of seeking grants from dozens of programs scattered across various agencies.

The commission also appealed to the Trump administration to track more carefully the huge array of interdiction, prevention and treatment programs it is funding and to make sure they are working. “We are operating blindly today,” its report said.

Regina LaBelle, who was chief of staff in the White House Office of National Drug Control Policy under President Barack Obama, said the recommendations recognized “the importance of proper and appropriate treatments” for addiction, particularly medications that help people avoid cravings and symptoms of withdrawal. But, she added, “There needs to be more funding for this.”

The head of the commission, Gov. Chris Christie of New Jersey, a Republican, suggested in a television interview Sunday that Mr. Trump would soon ask Congress to allocate far more money for fighting the nation’s addiction problem. “I would say that you’re going to see this president initially ask for billions of dollars to deal with this,” he said on ABC’s “This Week.”

The White House issued a statement thanking the commission and saying it would review the recommendations.

It is hard to determine how much money is truly needed. When Senate Republicans added $45 billion in addiction treatment funds to an Obamacare repeal bill that ultimately failed, Gov. John Kasich of Ohio, a Republican, said that amount was akin to “spitting in the ocean.”

Richard Frank, a health economics professor at Harvard Medical School who worked in the Obama administration, estimated that it could cost roughly $10 billion a year to provide medication and counseling to everyone with opioid use disorder who is not already in treatment. Treating opioid-dependent newborns, meeting the needs of children in foster care because of their parents’ addiction and treating hepatitis C and other illnesses common among opioid addicts would cost “many billions more,” Mr. Frank said.

Mr. Frank also cautioned that block grants would not work if the administration decided to include federal Medicaid funding for addiction treatment in them. “When one starts to carve out certain services as grants, as opposed to insurance funding, one undermines the insurance,” he said. “It is a method of killing Medicaid with 1,000 nicks.”

Some of the commission’s other recommendations included making it easier for states to share data from prescription drug monitoring programs, which are electronic databases that track opioid prescriptions, and requiring more doctors to check the databases for signs of “doctor shopping” before giving a patient opioids.

The commission encouraged the federal Centers for Medicare and Medicaid Services to review policies that it claimed discouraged hospitals and doctors from prescribing alternatives to opioids, especially after surgery. According to the commission’s report, C.M.S. pays a flat, “bundled” payment to hospitals after patients undergo surgery, which includes treatment for pain. Because they get a flat fee, hospitals are encouraged to use cheap products – and most opioid medications are generic and inexpensive.

“Purchasing and administering a non-opioid medication in the operating room increases the hospital’s expenses without a corresponding increase in reimbursement payment,” the report said.

More broadly, the report said the federal government as well as private insurers should do a better job of covering a range of pain-management and treatment services, such as non-opioid medications, physical therapy and counseling. And it recommended that the Department of Health and Human Services and other federal agencies eliminate any reimbursement policies that limit access to addiction medications and other types of treatment, including prior authorization requirements and policies that require patients to try and fail with one kind treatment before getting access to another.

One prevention measure the commission did not embrace is expanding syringe exchange programs, which public health experts say save money and lives by reducing the spread of H.I.V. and hepatitis C with contaminated syringes.

“I was hoping to see that in this report,” Ms. LaBelle said.

The commission’s members – Mr. Christie, Gov. Charlie Baker of Massachusetts, a Republican; Gov. Roy Cooper of North Carolina, a Democrat; Pam Bondi, the Republican attorney general of Florida; Patrick Kennedy, a former Democratic congressman from Rhode Island and Bertha Madras, a Harvard professor – all voted for the final recommendations, which came about a month later than expected.

His voice quaking with emotion, Mr. Kennedy said during the commission’s meeting Wednesday that Congress needed to appropriate sufficient funds for the initiative, suggesting at least $10 billion.

”This town doesn’t react unless it hears from real people“ who will vote in the next election, he said, nodding to guests who had testified about their families’ searing experiences with addiction, stigma, lack of treatment options and the refusal of insurance companies to cover treatment.

Mr. Kennedy also noted that insurance coverage is crucial to fighting addiction; in another commission meeting earlier this year, he took Republicans to task for working to repeal the Affordable Care Act and cut Medicaid.

 

Trump suggests repealing ObamaCare mandate in tax bill

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Trump suggests repealing ObamaCare mandate in tax bill

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President Trump on Wednesday suggested using the GOP tax bill to repeal ObamaCare’s individual mandate.

“Wouldn’t it be great to Repeal the very unfair and unpopular Individual Mandate in ObamaCare and use those savings for further Tax Cuts,” Trump tweeted.

The idea is being pushed by Sen. Tom Cotton (R-Ark.) and also has the backing of House Freedom Caucus Chairman Mark Meadows (R-N.C.).

Meadows said Wednesday he supports repealing the mandate in tax reform and thinks “ultimately” it will be included because he is going to push for it. He said he has been talking to Cotton about it.

A Cotton spokeswoman told The Hill that Cotton and Trump spoke by phone about the idea over the weekend and “the President indicated his strong support.”

Senate Finance Committee Chairman Orrin Hatch (R-Utah) this week said that he wouldn’t rule out including repeal of the mandate in the tax legislation.

But other top Republicans have rejected the idea, including House Ways and Means Committee Chairman Kevin Brady (R-Texas), Senate Majority Whip John Cornyn (R-Texas) and Sen. John Thune (R-S.D.). They fear adding the ObamaCare change would jeopardize tax reform.

“Look, I want to see that individual mandate repealed,” Brady said during an interview with radio host Hugh Hewitt on Tuesday. “I just haven’t seen, no one has seen, 50 votes in the Senate to do it.”

Brady added that he would be open to adding a repeal of the mandate to the House bill if the Senate passed it first.

Asked Wednesday about the president’s tweet, Senate Majority Whip John Cornyn (R-Texas) threw cold water on the idea.

“I think tax reform is complicated enough without adding another layer of complexity,” Cornyn told The Hill.

Thune, meanwhile, said mandate repeal is “not currently a part of our deliberations.”

But Thune added that some members have expressed interest in the idea and said he was “somewhat” interested in it because of the revenue implications.

Sen. Mike Rounds (R-S.D.) on Tuesday also dismissed adding a repeal of the mandate to tax reform.

“If there was a way to do it, I’d be open to it, but I’m not going to pitch it because I want to focus on taxes in the tax reduction plan,” Rounds told reporters.

The Congressional Budget Office has estimated that repealing the mandate would save the government $416 billion over a decade.

The mandate requires people, with some exceptions, to pay a fine to the IRS if they do not have health insurance.

Experts have said repealing the mandate would result in massive premium spikes and a major increase in the number of uninsured people.

It could also send ObamaCare exchanges into a “death spiral” because it would discourage healthy younger individuals to sign up for insurance.

Asked about it on Wednesday after Trump’s tweet, Hatch again did not rule out the move, but cautioned that he wants to keep health care separate from tax reform, a point echoed by GOP aides.
“I think we ought to do tax reform. If they want to do something on health care they can do that separate,” Hatch said. It was not clear who “they” referred to.
“I’d have to really look at all sides of that. I’ve never been very excited about the individual mandate,” Hatch said.

Editorial: Trump’s response to opioid epidemic is more pep talk than plan

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http://www.stltoday.com/opinion/editorial/editorial-trump-s-response-to-opioid-epidemic-is-more-pep/article_d87072e3-4a28-5cae-a0aa-9c000eff82b7.html

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President Donald Trump promised to come out swinging with Thursday’s emergency declaration on opioid abuse. Swing, he did, but he failed to make contact.

By labeling the crisis a public health emergency, Trump skirted a legal definition that would have prompted emergency federal funding and placed the drug epidemic on a scale similar to major disaster response. He should have pledged a dollar amount equal to the challenge of combating an addiction epidemic that, by his own assessment, contributed to at least 64,000 U.S. overdose deaths last year.

Trump clearly grasps the magnitude of the problem, outlining it in the starkest terms: “Citizens across our country are currently dealing with the worst drug crisis in American history and even, if you really think about it, world history. … Drug overdoses are now the leading cause of unintentional death in the United States by far. More people are dying from drug overdoses today than from gun homicides and motor vehicles combined,” he said.

The driving force behind this epidemic is heroin and opioid abuse among an estimated 12 millions Americans. Trump labeled the United States as “by far the largest consumer of these drugs” in the world. “Opioid overdose deaths have quadrupled since 1999 and now account for the majority of fatal drug overdoses.”

Surely, a problem of this magnitude deserves a gargantuan plan of action. Trump’s speech Thursday contained no plan at all. He said the administration planned to announce a new policy to help relax restrictions that limit the number of beds in treatment facilities. He called for greater resolve.

He said he awaited a report from New Jersey Gov. Chris Christie, the head of a presidential commission on opioid abuse, to address the problem. Trump reiterated the previous administration’s program to alert doctors about the dangers of over-prescribing opioids. He promised lawsuits against “bad actors.”

As if invoking First Lady Nancy Reagan’s “just say no” campaign in the 1980s, Trump said, “One of the things our administration will be doing is a massive advertising campaign to get people, especially children, not to want to take drugs in the first place because they will see the devastation and the ruination it causes to people and people’s lives.”

Trump did outline expenditures for programs already in place to boost law enforcement, border security, addiction treatment and pain management. None of those programs, however, has stemmed the addiction tide.

“We’re going to do it. We’re going to do it,” Trump insisted.

This was Trump’s moment to go big and bold in confronting a crisis that kills more Americans in a single year than all the hurricanes, earthquakes, floods and fires the nation has suffered in the past decade. America needs a plan of action, not a pep talk.

CMS to allow states to define essential health benefits

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http://www.modernhealthcare.com/article/20171027/NEWS/171029872/cms-to-allow-states-to-define-essential-health-benefits

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The CMS proposed a rule late Friday aimed at giving states more flexibility in stabilizing the Affordable Care Act exchanges and in interpreting the law’s essential health benefits as a way to lower the cost of individual and small group health plans.

In the 365-page proposed rule issued late Friday, the agency said the purpose is to give states more flexibility and reduce burdens on stakeholders in order to stabilize the individual and small-group insurance markets and improve healthcare affordability.

The CMS said the rule would give states greater flexibility in defining the ACA’s minimum essential benefits to increase affordability of coverage. States would play a larger role in the certification of qualified health plans offered on the federal insurance exchange. And they would have more leeway in setting medical loss ratios for individual-market plans.

“Consumers who have specific health needs may be impacted by the proposed policy,” the agency said. “In the individual and small group markets, depending on the selection made by the state in which the consumer lives, consumers with less comprehensive plans may no longer have coverage for certain services. In other states, again depending on state choices, consumers may gain coverage for some services.”

However, the CMS acknowledged it’s unclear how much money the new state flexibility will save. States are not required to make any changes under the policy.

The CMS urged states to consider the so-called spillover effects if they choose to pick their own benefits. These include increased use of other services, such as increased used of emergency services or increased use of public services provided by the state or other government entities.

The agency in 2017 proposed standardized health plan options as a way to simplify shopping for consumers on the federally run marketplaces. The CMS said it would eliminate standardized options for 2019 to maximize innovation. “We believe that encouraging innovation is especially important now, given the stresses faced by the individual market,” the proposed rule states.

The CMS proposes to let states relax the ACA requirement that at least 80% of premium revenue received by individual-market plans be spent on members’ medical care. It said states would be allowed to lower the 80% medical loss ratio standard if they demonstrate that a lower MLR could help stabilize their individual insurance market.

The CMS also said it intended to consider proposals in future rulemaking that would help cut prescription drug costs and promote drug price transparency.

The Trump administration hopes to relax the ACA’s requirements and provide as much state flexibility as possible through administrative action, following the collapse of congressional Republican efforts this year to make those changes legislatively.

The proposed rule comes after months of calls from health insurers and provider groups for the federal administration to help stabilize the struggling individual insurance market. The fifth ACA open enrollment is slated to begin Nov. 1, and experts have predicted fewer sign-ups in the wake of a series of actions by the Trump administration to undercut the exchanges.

In the proposed rule, the CMS also proposes to exempt student health insurance from rate reviews for policies beginning on or after Jan. 1, 2019. The CMS said student health insurance coverage is written and sold more like group coverage, which is already exempt from rate review, and said the change would reduce regulatory burden on states and insurance companies.

The ACA requires that insurers planning to increase premiums by 10% or more submit their rates to regulators for review. The CMS proposed to increase the rate review threshold to 15% “in recognition of significant rate increases in the past number of years.”

The rule also tweaks a requirement that enrollees need to have prior coverage before attempting to get coverage via special enrollment after moving to a new area. Under the proposal, a person who lived in an area with no exchange qualified health plans will be able to obtain coverage.

Trump tells Senate to fix taxes — not Obamacare

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https://www.politico.com/story/2017/10/24/trump-obamacare-taxes-senate-republicans-244124

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The bipartisan effort to stabilize insurance markets gets pushed to the end of the year.

President Donald Trump on Tuesday steered Senate Republicans toward tax reform and away from health care, pushing off any deal to fund controversial Obamacare subsidies to the end of the year at best.

Trump joined Senate Republicans at their weekly policy lunch but gave no direction on what he wants to see in a health care bill. He praised Sen. Lamar Alexander’s (R-Tenn.) work on a bipartisan deal meant to stabilize the Obamacare markets, but his emphasis on taxes led senators in the room to believe Trump doesn’t want a stand-alone Obamacare vote anytime soon.

“There isn’t anything else other than taxes,” said Sen. John Cornyn (R-Texas).

A filibuster-proof majority backs the bipartisan deal Alexander brokered with Sen. Patty Murray (D-Wash.), but conservatives and the White House oppose it, meaning it won’t even come up for a vote in the Senate.

Without a clear directive from the president, Republicans are still debating whether to work with Democrats to fund Obamacare’s “cost-sharing” program, which helps low-income people pay their out-of-pocket medical bills. Trump abruptly cut off the subsidies — the subject of a court battle — earlier this month. Insurers still have to make the payments, and many boosted their premiums for 2018 to take those costs into account.

Alexander’s stabilization bid got even more muddled when a pair of top Republicans said they would release a different bill — rivaling the bipartisan proposal — to fund the subsidies. But their version would neuter the individual mandate for five years, a nonstarter for Democrats who would be needed to get a bill through the Senate.

The new version “proves that we should be focused on tax reform right now, because obviously we haven’t gotten our act together on health care,” said Sen. John Thune (R-S.D.).

Republicans are increasingly confident that the subsidies will get rolled into a large, year-end bill to fund the government and raise the nation’s debt limit. But there is no agreement on what exactly that will look like, and leadership-level negotiations on the year-end bill are weeks away.

The lack of clarity left Senate Republicans with enough wiggle room to interpret Trump’s Obamacare comments as they see politically fit.

Cornyn saw a “shoutout” by Trump to Alexander as encouragement for his bill. “He wasn’t specific, but that’s the way I interpreted it,” he said.

But Sen. Ted Cruz (R-Texas) — an Alexander-Murray skeptic — said Trump didn’t offer any clear support for the proposal over the GOP’s competing ideas.

“There was not significant discussion on Alexander-Murray,” Cruz said.

Sen. Orrin Hatch (R-Utah), another foe of Alexander-Murray, walked away with the same conclusion.

“He didn’t get into that in great depth — put it that way,” Hatch said. “All I can say is that he wasn’t too definitive.”

During the lunch meeting, Trump focused more on getting tax reform done so that the GOP can take another shot at repealing Obamacare in the future, instead of what should be done to stabilize the health care law in the interim.

“If we get taxes done, we’ll have momentum for health care,” said Sen. Lindsey Graham (R-S.C.), summing up Trump’s position. “He talked a lot about doing health care again.” Trump has repeatedly stated recently that the GOP now has the votes for repeal in the Senate — but senators say that’s not the case, that no one has flipped.

The meeting marked Trump’s first visit to the Senate GOP’s weekly policy lunch as president, and it came amid a rift with Sen. Bob Corker (R-Tenn.) and growing concern within the GOP that lawmakers will go into the 2018 midterm election without a legislative accomplishment. That’s amped up the pressure in the GOP to do tax reform.

But many Republican senators said after the lunch meeting that there was no discussion of petty politics and that Trump was focused on notching some GOP wins.

“It was the complete opposite of what I thought it would be — the atmosphere in the room and his complete focus,” said one senator.

The conservative Obamacare bill introduced Tuesday came from Hatch, the chairman of the Senate Finance Committee, and House Ways and Means Chairman Kevin Brady.

That bill, which would fund the cost-sharing program for two years, is designed to appeal to Republicans who want to fund the Obamacare program but feel that Alexander didn’t get enough conservative concessions in his negotiations with Murray.

It would eliminate Obamacare’s individual mandate penalties through 2021 and expand the use of health savings accounts. The Hatch-Brady bill would also exempt businesses from the employer mandate for 2015 through 2017 and apply certain “pro-life protections” to the cost-sharing funding.

“We must include meaningful structural reforms that provide Americans relief,” Hatch said. “This agreement addresses some of the most egregious aspects of Obamacare.”

Some of the provisions in the proposal — like the expansion of HSAs and employer mandate exemption — mirror the changes that the White House requested be made to the Alexander-Murray bill.

Alexander said he was encouraged by a growing consensus Congress should fund the payments to insurers for two more years.

“We’ve gone from a position where everybody was saying we can’t do cost sharing to responsible voices like Sen. Hatch and Chairman Brady saying we should,” he said.

But any cost-sharing bill will need 60 votes to get through the Senate, meaning Republicans will have to get at least eight Democrats to sign on. Undoing the mandates in the future would be a nonstarter for many Democrats.

“If it were just a matter of getting Republicans to agree with each other, we would have repealed and replaced Obamacare by now,” said a Senate GOP aide.

How Premiums Are Changing In 2018

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How Premiums Are Changing In 2018

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The premiums for 2018 Marketplace plans were recently released to give consumers a chance to look at their plan options before open enrollment begins on November 1. Premiums are rising significantly in many counties across the country, in part due to the decision of the Trump Administration to cease payments to insurers for cost-sharing reductions. Insurer participation also declined in many areas, leaving more counties with only one insurer, which likely contributed to the high rate of premium growth.

The map below illustrates how premiums changed for 2018 by looking at the change in the lowest-cost bronze, silver and gold plans by county in states participating in the federal Marketplace. Results are shown for a 40-year-old paying the full premium and for a 40-year old with an income of $25,000 (207% of poverty), $30,000 (249% of poverty), $35,000 (290% of poverty), and $40,000 (332% of poverty), who would be eligible for a premium tax credit.

Percent Change in Lowest-Cost Metal Plan Before and After Tax Credit, 2017-2018

Nationally, the unsubsidized premium for the lowest-cost bronze plan in the federal Marketplace is increasing an average of 17% between 2017 and 2018, the lowest-cost silver plan is increasing an average of 35%, and the lowest-cost gold plan is increasing an average of 19% (Table 1). These average increases are weighted by the number of plan selections by county in 2017 (see Methods). Premiums for silver plans are rising much more than those for bronze or gold plans because in many states insurers loaded the cost from the termination of the cost-sharing reduction payments entirely on the silver tier.

For consumers who receive premium tax credits, the amounts that they will have to pay will often be lower in 2018 (Table 2). The particularly large increase in premiums for silver plans means that tax-credit-eligible Marketplace enrollees will see much higher premium tax credits (which are calculated based on the second-lowest-cost silver plan in each area). These large credits make gold plans more easily attainable and make bronze plans much cheaper (or even available at no additional premium). In fact, after these increases, the lowest-cost gold premium is lower than the lowest-cost silver premium in 459 counties.

For example, a 40-year-old individual making $35,000 (249% of poverty) and eligible for a tax credit will on average pay 39% less in 2018 for their share of the premium for the lowest-cost bronze plan, 7% less for the lowest-cost silver plan, and 13% less for the lowest-cost gold plan. The savings are greater for subsidized enrollees with lower incomes and less for those with higher incomes (Table 2). The premiums for bronze plans may be particularly attractive to many people eligible for premium tax credits. For example, the tax credit for a 40-year-old individual making $25,000 covers the full cost of the premium for the lowest-cost bronze plan in 1,540 counties.

Counties Where the Lowest-Cost Bronze Plan Premium Costs Zero Dollars After the Tax Credit in 2018

The map below shows counties where the unsubsidized premium for the lowest-cost gold plan has a lower or comparable premium to the lowest-cost silver plan in 2018.

Counties Where the Lowest-Cost Gold Plan Costs Less than the Lowest-Cost Silver Plan

Discussion

The differences in premium changes across plan types and the peculiar effect these differences have on plan costs for both unsubsidized and subsidized enrollees makes it important that consumers shop around and carefully consider their options. Although CMS will no longer be paying insurers for reducing the cost sharing for lower-income enrollees, insurers remain obliged to provide the reduced cost sharing policies to eligible Marketplace enrollees. These policies generally have higher actuarial values than gold plans for enrollees with incomes below 200% of poverty so consumers will need to carefully consider whether it makes sense to switch even though gold-plan premiums may be comparable or less than silver plans. Consumers eligible for cost sharing reductions also will need to weigh the much lower premiums they would pay for a bronze plan with the much higher cost sharing they could encounter if they need care.