he fight over President Trump’s pick of Appeals Court Judge Brett Kavanaugh to the Supreme Court is on, with Democrats launching what The Washington Post called “an all-out blitz” to defeat the nomination.
So get ready to hear a lot about health care in the coming days.
The Washington Post’s Dana Milbank notes that former Republican senator Jon Kyl, now a lobbyist for the pharmaceuticals industry, has been tapped to guide Kavanaugh’s path through the Senate. Why? Because by picking Kavanaugh, “Trump has guaranteed that health care will be at the center of the confirmation fight,” Milbank says.
Democrats welcome that fight, even if they have little chance of actually blocking the nomination. “The liberal base is fired up about abortion rights, but Senate Democratic Leader Charles Schumer (N.Y.) will seek to emphasize access to affordable health care as much as Roe v. Wade in the battle over the Supreme Court,” The Hill’s Alexander Bolton reports.
Focusing on health care might make sense for Democrats in a number of ways:
If confirmed, Kavanaugh may get to weigh in on any of a number of cases with the potential to reshape health policy well beyond abortion rights. Despite his long legal record, “many of his health-related decisions are open to parsing from either side of the aisle and don’t actually provide a clear insight into where he’d stand on the Supreme Court,” The Washington Post’s Colby Itkowitz says.
Here are some key issues and cases that could be decided by the Supreme Court and Kavanaugh:
Obamacare’s protections for people with pre-existing medical conditions: Americans overwhelmingly support keeping these protections in place, according to a Kaiser Family Foundation poll from last month, but Trump’s Justice Department has asked a federal court to rule that those provisions of Obamacare are invalid. The case will soon be heard in a district court in Texas and could make its way to the Supreme Court before long. Sen. Joe Manchin of West Virginia, one of the few Democrats who might back Kavanaugh, said in a statement that he wants to hear where the judge stands on the ACA protections for those with pre-existing conditions before deciding whether to confirm him.
Medicaid: A federal court late last month blocked Kentucky’s plan to introduce work requirements for Medicaid recipients. The Trump administration is likely to appeal the ruling. Other states are also implementing work requirements. “As more states experiment with these programs and the cases wind their way through the courts, the Supreme Court may weigh in and shape how low-income Americans access Medicaid across the country,” Arielle Kane, director of health care at the Progressive Policy Institute, writes at the New York Daily News. The high court could also be asked to consider whether private health care providers can sue over Medicaid reimbursement rates, a question that could open the door to state funding cuts.
Risk adjustment payments to insurers: The Trump administration just froze billions of dollars of payments to insurers who enroll costlier-than-expected patients. The payments come from money collected from other insurers in the individual market. Legal challenges involving these payments are making their way through the courts. In the meantime, “the insurers in the individual market must manage uncertainty and constant change — resulting in higher prices for health care consumers,” Kane writes.
Industry consolidation: “Last year, four of the largest insurers tried, and failed, to merge into two. This year, CVS has proposed merging with Aetna, Amazon has acquired PillPack, and Walmart is seeking to combine with Humana,” Kane writes. “This so called ‘vertical integration’ raises questions about monopolies, competition and health-care pricing. It is likely that at some point courts will weigh in.”
A reckoning is coming, outgoing BlueCross executive says.
A reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.
Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:
1. The effects of the recently passed tax bill. “If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.
Burrell noted that 74 million people are currently covered by Medicaid, 60 million by Medicare, and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”
2. The increasing obesity problem. “Thirty percent of the U.S. population is obese; 70% of the total population are either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”
3. The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”
To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”
Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue on quality but there is a profound issue on costs.”
4. The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.
5. The lackluster performance of new payment models. “Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.
“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect accessibility of care.”
“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”
A nightmarish accident on a Boston subway platform on Friday — described in gory detail by a local reporter, Maria Cramer, as it unfolded and quickly retweeted by thousands — is one you might expect to see in an impoverished country.
In the face of a grave injury, a series of calculations follow: The clear and urgent need for medical attention is weighed against the uncertain and potentially monumental expense of even basic services, like a bandage or a ride to the hospital, and that cost, in turn, weighed against all the known expenses of living that run through any given head on any given day.
This discord, between agony and arithmetic, has become America’s story, too.
The United States spends vastly more on health care than other industrialized countries, nearly 17 percent of the nation’s gross domestic product in 2014, according to a report by the Commonwealth Fund, compared with just 10 percent of G.D.P. in Canada and Britain. But that disparity is not because Americans use more medical services — it’s because health care is far more expensive here than in other countries. One 2010 study by the Organization for Economic Cooperation and Development found that hospital costs were 60 percent higher in the United States than in 12 other nations.
And that cost is often passed on to patients, either in the form of deductibles and other out-of-pocket expenses or through ever-soaring insurance premiums.
The Affordable Care Act has improved access to health care, especially for lower-income families that now qualify for Medicaid or subsidies to buy private health insurance. Wider access, however, has not come cheaply for most people. As a result, many Americans, including those who are insured, have determined that they must avoid going to the hospital, visiting doctors or filling prescriptions that they need. A 2017 Kaiser Family Foundation survey found that 43 percent of people with insurance said that they struggled affording their deductibles, and 27 percent said that they put off getting care because of cost. Turning to GoFundMe and other crowdsourcing websites has become the norm in medical crises.
Whether the woman on the train platform received the medical attention she needed is unknown. Ms. Cramer said on Monday that she had not been able to get an update on the woman’s condition yet. Ms. Cramer went on to tweet that after several minutes had passed, an ambulance still had not arrived. Instead, fellow passengers tried to help. “One man stood behind her so she could lean against him,” she wrote. “Another pressed cold water bottles to her leg.”
Health care is a complicated problem, one exacerbated by the gridlock in Washington. But the trade-offs that everyday people are being asked to make, the calculations they are being forced to undertake in the scariest of situations, suggest that far too many of America’s politicians have placed too little value on the well-being of its citizens. Nothing will change until their fellow citizens step into the ballot box and insist on something better.
President Trump has declared that Obamacare is finished, dead, gone, essentially repealed. And yet, despite the administration’s efforts to undermine the law’s marketplaces, the number of Americans who enrolled in and started paying for Affordable Care Act plans grew slightly this year, according to reports released Monday by the Centers for Medicare and Medicaid Services (CMS).
At the same time, rising premiums are taking a toll, forcing many middle-income Americans — individuals making more than about $48,000 a year, or families of four making more than about $100,000 — to drop coverage. “Taken together, these reports show that state markets are increasingly failing to cover people who do not qualify for federal subsidies even as the Exchanges remain relatively stable,” CMS said.
Here’s a look at what the new reports show:
* While the total number of people who picked a plan for 2018 fell, the number of people who paid for coverage rose from 10.3 million in February 2017 to 10.6 million this past February, an increase of about 3 percent. “The increase is striking because it happened even though federal health officials last year slashed ACA funding to grass-roots groups that help consumers sign up for coverage, cut advertising and other outreach activities by 90 percent, and shortened the enrollment period by half,” writes Amy Goldstein at The Washington Post.
* CMS argued that, based on historical trends, a “significant number” of people will wind up dropping coverage during the year even after making their initial payments. Of the 10.3 million who paid for their plans as of March 15, 2017, only 8.9 million were still in those plans by the end of the year. “This is likely caused by consumers struggling to pay premiums as costs continue to increase,” the CMS report said.
* A larger share of enrollees has been getting federal subsidies. In 2014, the first year Affordable Care Act plans became available, 55 percent of those enrolled in individual market plans on or off the new Obamacare exchanges got financial help, according to Bloomberg. Last year, 62 percent did. In all, more than 8 million people got subsidies last year, while 5 million bought individual plans without financial help. “When premiums rise a lot, a lot more people become eligible for subsidies,” Matthew Fiedler, a fellow at the U.S.C.-Brookings Schaeffer Initiative for Health Policy, told The New York Times.
* As insurance prices rose by an average of 21 percent last year, signups among people who did not qualify for subsidies fell by 1.3 million — a drop of 20 percent compared with 2016. Subsidized enrollees fell by just 3 percent. “These reports show that the high-price plans on the individual market are unaffordable and forcing unsubsidized middle-class consumers to drop coverage,” CMS Administrator Seema Verma said in a statement. Trump administration policies may have played a part in the decline, too, and some people may have stopped buying their own insurance because they found jobs with employer coverage. “But it’s reasonable to think that most of the attrition can be attributed to the spike in prices, as the Trump administration concludes,” writes Margot Sanger-Katz of The New York Times.
What it all means: “The individual health insurance market under the ACA is financially sustainable as subsidies rise to match premium increases,” Larry Levitt of the Kaiser Family Foundation tweeted. “However, the lack of affordable insurance for middle-class people ineligible for subsidies does not seem politically sustainable.”
Bloomberg looks at an important trend in health care coverage: the rise of employer-based high-deductible plans that mean many patients and families simply can’t afford to get sick.
Some companies are now rethinking those policies, Bloomberg’s John Tozzi and Zachary Tracer report, after realizing that their goal of reducing costs by getting patients to have more “skin in the game” instead led workers to delay or forgo care, including medications. Patients didn’t become “better” health-care consumers. They simply cut back on what they thought they couldn’t afford — potentially driving up costs in the long run.
“High-deductible plans do reduce health-care costs, but they don’t seem to be doing it in smart ways,” said Neeraj Sood, director of research at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.
The trend: Nearly 40 percent of large employers offer only high-deductible plans, up from 7 percent in 2009, according to a survey by the National Business Group on Health cited by Bloomberg. And half of all covered workers now have a deductible of at least $1,000 for an individual, up from 34 percent in 2012 and 22 percent in 2009, according to the Kaiser Family Foundation. Nearly one in four covered workers has a deductible of $2,000 or more.
The key quote: “Why did we design a health plan that has the ability to deliver a $1,000 surprise to employees?” Shawn Leavitt, a senior human resources executive at Comcast, said at a recent conference, according to Bloomberg. “That’s kind of stupid.”
Why it matters: As employers move away from simply shifting more and more costs to their workers, Axios’ Sam Baker notes, they’re also paying more attention to bringing down underlying health care prices .