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Pre-existing conditions drive moderates’ concern over repeal bill
Moderate Republicans are largely withholding their support for the Obamacare repeal bill, arguing it would hurt people with pre-existing conditions
House Republican leaders hoped that the House Freedom Caucus’s endorsement of the latest Obamacare repeal bill would light a fire under enough moderates to get their whip count to the 216 votes needed to pass the measure. Instead, the holdouts are digging in, saying that the latest changes only moved the bill to the right and could put more Americans at risk of losing their health insurance.
“My concern has always been and what a lot of us talked about: people with pre-existing conditions, the elderly,” said Rep. Mario Díaz-Balart (R-Fla.). “How this makes the original bill better? Where is the part that is better for the folks I’m concerned about it? I’m not seeing it at this stage.”
Protections for people with pre-existing conditions have only been in effect for seven years, but proven to be one of the most popular and well-known features of the Affordable Care Act. Moderate Republicans are worried about stripping the safeguards without a reliable replacement. If the resistance from moderates holds, it would be enough to block Obamacare repeal in the House — or send the effort back to square one.
GOP leaders have been buttonholing moderates for two days, arguing that the latest changes — drafted by Rep. Tom MacArthur (R-N.J.) with consultation from the House Freedom Caucus — would ensure people with pre-existing conditions wouldn’t be priced out of a reconfigured market, pointing to high-risk pool requirements in state that choose to opt out of Obamacare provisions.
Backers of the repeal measure say the bill protects people with pre-existing conditions, arguing that people with coverage, for instance, can’t be priced out if they maintain it.
But buying into the plan would pose big political risks for centrists in swing districts. Voicing concerns about pre-existing conditions could prevent a tough vote on an issue that Democrats would surely spotlight in the 2018 election.
Several Republican sources say at least some moderates have climbed aboard, but they’re not inclined to say so publicly. House Appropriations Chairman Rodney Frelinghuysen (R-N.J.), who was widely panned by fellow Republicans for not supporting an earlier version of the repeal bill given his high-profile post, is expected to now support it, according to several sources.
Other than Frelinghuysen, there are no moderates who have publicly flipped to support the bill.
Republicans can absorb no more than 22 defections (depending on how many members are seated when the vote is held) from the 238-member Republican conference. The leaders still need fewer than 10 votes, according to several sources.
Rep. Ryan Costello (R-Pa.) said the latest changes to the bill didn’t bring him to a yes.
“Protections for those with pre-existing conditions without contingency and affordable access to coverage for every American remain my priorities for advancing healthcare reform, and this bill does not satisfy those benchmarks for me,” he said in a statement.
Rep. Barbara Comstock (R-Va.), one of the most vulnerable Republicans in 2018, said she is still a no. Rep. Carlos Curbelo of Florida is undecided— he’s still talking with leadership but claims no one is twisting his arm.
“They know better than to pressure me,” he said.
It’s not just traditional moderates who have qualms. Rep. Chris Smith (R-N.J.), who is very conservative on most social issues, is still a no.
Rep. Pete King (R-N.Y.) doesn’t want Obamacare’s Medicaid expansion repealed under the latest GOP plan, but told POLITICO he would vote to move the bill forward and assumes the Senate would restore Medicaid expansion. If the bill were to come back with Medicaid repealed, “it would be a problem,” he said.
The latest changes may have even eroded the support of moderates who backed the earlier repeal bill that was pulled in March. Rep. Adam Kinzinger of Illinois said he’s undecided. Rep. Steve King of Iowa, one of the House’s most conservative members, told reporters he’s undecided now, too.
Rep. Jim Renacci (R-Ohio), who supported the original repeal bill, is undecided but inclined to move the process forward.
“My biggest concern is that we’re changing things based on amendments written in backrooms and not everyone knows what is said and what’s part of the deal,” he said.
Some Republicans just don’t want to talk about it.
Rep. Darrell Issa of California paused to hear a reporter’s question on his vote, then kept walking.
How To Ease The Financial Pain Of High-Deductible Health Plans
How To Ease The Financial Pain Of High-Deductible Health Plans
No matter what happens to Obamacare, one health care trend is fairly certain to continue: A growing number of you will have high-deductible health plans, whether you’re insured through your employer or buy on the private market.
A high-deductible health plan is just what it sounds like: In exchange for a lower premium, you pay more of your own money for medical care until your insurance coverage kicks in.
The IRS defines a high-deductible plan as one with a deductible of at least $1,300 a year for an individual or $2,600 for a family.
Many deductibles are higher. For instance, Covered California, the state health insurance exchange, offers bronze-level plans this year with a $6,300 individual and $12,600 family deductible, plus a separate deductible for prescription medications.
How many of you have that kind of money lying around?
The most important thing you can do to lower your costs is to choose the right plan for yourself and your family during open enrollment (assuming you have a choice).
“A high-deductible plan will work better for younger, healthier people who don’t expect to have a lot of medical expenses,” says Walter Zelman, a health policy professor at California State University-Los Angeles. “If you know you’re going to use a reasonable amount of health care in a given year, the high-deductible plan is to be avoided.”
But since most of you are stuck with your plans until the next open enrollment period, here are some simple steps you can take now to control costs.
The Basics
Under the Affordable Care Act, most health plans must offer certain preventive services for free, including mammograms, colonoscopies and routine vaccinations.
Taking advantage of them can prevent more expensive coverage down the line, says Elizabeth Abbott, director of the state’s Office of the Patient Advocate.
“Get your flu shot,” she says. “If you keep up with all of your preventive services, you will save yourselves a fair amount of money because you’re less likely to get sick and won’t have to get invasive procedures.”
No matter what kind of appointment or procedure you’re scheduling, choose in-network providers whenever possible, says Betsy Imholz, special projects director for Consumers Union. “If you stay in network, your costs are going to be lower,” she says.
Cross-check with both your provider and your insurer to confirm network status.
And don’t forget — as I often do — that you may be able to avoid a doctor’s visit by calling your insurance company’s nurse advice line, Zelman says.
Prescription Drugs
Unless you take only specialty drugs to treat serious or rare conditions, these steps can probably save you money:
— Over-the-counter and generic drugs: If your doctor prescribes a brand-name drug, ask if there’s an over-the-counter or generic option you can try first. Generics cost a fraction of the brand-name version, says David Collum, assistant clinical professor for the Department of Pharmacy Practice at University of the Pacific in Stockton, Calif.
— Shop around: Many pharmacies (both chains and independents) offer discount programs for common generic drugs, charging $4 for a 30-day supply and $10 for a 90-day supply.
Don’t be afraid to switch pharmacies or buy drugs from different places, Abbott says. “If you’re taking five drugs, price those all out,” she says. “Don’t assume a particular pharmacy offers the best price for every drug.”
Consumers Union generally finds the best drug prices at Costco or by using GoodRx’s online search tool, Imholz says.
— Patient-assistance programs: Ask your pharmacist or doctor if they know of programs that can help you afford your prescription.
Groups such as the Patient Advocate Foundation and NeedyMeds also have compiled links to organizations — and even drug companies — that provide financial aid.
— Shorter initial prescription: If your doctor prescribes a pricey drug you haven’t taken before, ask her to write the prescription for a few days or a week and monitor the results, Collum suggests.
If the drug works for you, request a new prescription for a longer period. If it’s ineffective, at least you won’t be out for the cost of a full month of medication.
Comparison Shopping
Most of us wouldn’t buy a car or plane tickets without comparison shopping. So why not shop around for medical care, whose prices can vary wildly from provider to provider?
You could save hundreds or thousands of dollars.
First, ask your doctor for the specific medical code, called a CPT code, for the procedure or test that you need, says Jeanne Pinder, CEO of ClearHealthCosts, which aims to make medical prices more transparent.
Simply asking about the cost of a lower-back MRI won’t be sufficient. “You’ll want to call and say ‘How much does an MRI of the lower back, without contrast, CPT code 72148, cost?’” she says.
Armed with the code, reach out to different providers and your insurance company. Ask both how much the procedure would cost you, and whether the provider is in your plan’s network.
Along the way, consider bypassing your insurance for a particular treatment or prescription.
“You might be better off, as an insured person, paying cash,” Pinder says. “Many people don’t reach their deductible by the end of the year, anyway.”
If you go this route, don’t call your insurance plan. Just call providers (who don’t have to be in your network) and ask them “How much will this cost me?” and “What’s your cash price?” Pinder counsels.
If the provider asks whether you have insurance, repeat that you want to be a cash customer.
“Just keep saying, ‘I’m looking for the cash price. I’m a cash customer.’ If they ask if you have insurance, repeat that you’d like to pay cash,” Pinder says.
Take detailed notes, including the name of the person who gives you the quote, Pinder adds. Better yet, get it in writing.
Pinder took her own advice recently when a family member needed an MRI, which can cost thousands of dollars. She found one for $450 cash.
“We need to get used to having this conversation and asking those questions in that fashion,” she says. “By the time you start doing it, it doesn’t hurt anymore.”
Health care fixes miss the mark
http://www.detroitnews.com/story/opinion/2017/04/23/valenti-health-care/100822732/
The phrase “repeal and replace Obamacare” might be in the news, but any new legislation regarding it means little for Michiganians.
Obamacare and the Republicans’ fix, the American Health Care Act, are almost entirely focused on the individual insurance market, yet the majority of Americans receive employer-sponsored health insurance coverage. More importantly, more than one million Metro Detroiters are covered by employers who “self-fund” or self-insure their employee health care benefits.
What does self-insure mean? It means your employer pays, right out of its annual budget, 100 percent of employee medical claims. Your card might read Blue Cross Blue Shield or Aetna, but the insurance company is simply the administrator who collects the claims and sends them off to your employer for payment.
Regardless of who is paying, rising health care costs are the No. 1 threat to American prosperity. Health care costs forced General Motors, Chrysler and the city of Detroit into bankruptcy; health care costs are the main reason wages have not grown in 20 years; and, Michigan spends 40 percent (and growing) of its annual budget on health care — crowding out spending on everything else.
But fixing our health care cost problem today doesn’t require a single action from Congress. Instead of marching on Washington and yelling at elected officials, we should be talking to our CEOs and heads of human resources.
Self-insured employers have tremendous power to change health care. Most employers simply outsource health care benefit construction to consultants and brokers — the same people who are compensated to perpetuate our high-cost health care status quo.
When the lame, status quo attempts at cost-control fail, the usual employer response is to cut, cut, cut. They resort to using an axe to prune rose bushes; high deductible health plans are blunt force instruments that do not sustainably control health care costs and will eventually exacerbate our cost problem.
Indeed, a few, truly innovative employers are providing better employee benefits and reducing health care costs 20-50 percent. If everyone followed their lead, it could result in $2,500 to $5,000 annual raises for each of us and immediately pump $2 billion to 4 billion into the Metro Detroit economy every year.
The solution isn’t a secret. In fact, a non-profit/501(c)(3) called the Health Rosetta was formed to publicize the simple fixes. The organization was spurred by a concerned citizen and the former global head of Microsoft’s health care business named Dave Chase.
The Health Rosetta identifies a few, easy to implement, specific improvements, the most important of which focuses on the intake or front-end of the system: primary care. Hence, the Health Rosetta’s foundation is called Value-Based Primary Care or Direct Primary Care. Other improvements are then built on top, such as “Transparent Medical Markets,” where patients receive up-front pricing and even quality guarantees on a range of surgeries and procedures.
These are the kinds of solutions employers should be considering as everyone wrestles with skyrocketing health care costs.
Tom Valenti is the founding partner of Forthright Health.
California Employer Health Benefits: Prices Up, Coverage Down
Since 2000, the percentage of employers offering health benefits has declined in California and nationwide, although coverage rates among offering firms have remained stable. Only 55% of California firms reported providing health insurance to employees in 2016, down from 69% in 2000. Implementation of the Affordable Care Act (ACA) in 2014 does not appear to have impacted the overall trend in employer offer rates.
Nineteen percent of California firms reported that they increased cost sharing in the past year, and 27% of firms reported that they were very or somewhat likely to increase employees’ premium contribution in the next year. The prevalence of plans with large deductibles also continues to increase.
California Employer Health Benefits: Prices Up, Coverage Down presents data compiled from the 2016 California Employer Health Benefits Survey.
GOP Conservatives’ Goal To Relax Mandatory Health Benefits Unlikely To Tame Premiums
GOP Conservatives’ Goal To Relax Mandatory Health Benefits Unlikely To Tame Premiums
As House Republicans try to find common cause on a bill to repeal and replace the Affordable Care Act, they may be ready to let states make the ultimate decision about whether to keep a key consumer provision in the federal health law that conservatives say is raising insurance costs.
Those conservatives, known as the House Freedom Caucus, and members of a more moderate group of House Republicans, the Tuesday Group, are hammering out changes to the GOP bill that was pulled unceremoniously by party leaders last month when they couldn’t get enough votes to pass it. At the heart of those changes is the law’s requirement for most insurance plans to offer 10 specific categories of “essential health benefits.” Those include hospital care, doctor and outpatient visits and prescription drug coverage, along with things like maternity care, mental health and preventive care services.
The Freedom Caucus had been pushing for those benefits to be removed, arguing that coverage guarantees were driving up premium prices.
“We ultimately will be judged by only one factor: if insurance premiums come down,” Freedom Caucus Chairman Rep. Mark Meadows (R-N.C.) told The Heritage Foundation’s Daily Signal.
But moderates, bolstered by complaints from patients groups and consumer activists, fought back. And a brief synopsis of results from the intraparty negotiations suggests that the compromise could be letting states decide whether to seek a federal waiver to change the essential health benefits.
“The insurance mandates are a primary driver of [premium] spikes,” wrote Meadows and Sen. Ted Cruz (R-Texas) in an op-ed in March.
But do those benefits drive increases in premiums? And would eliminating the requirement really bring premiums down? Health analysts and economists say probably not — at least not in the way conservatives are hoping.
“I don’t know what they’re thinking they’re going to pull out of this pie,” said Rebekah Bayram, a principal consulting actuary at the benefits consulting firm Milliman. She is the lead author of a recent study on the cost of various health benefits.
Opponents of the required benefits point to coverage for maternity care and mental health and substance abuse treatment as driving up premiums for people who will never use such services.
But Bayram said eliminating those wouldn’t have much of an impact. Hospital care, doctor visits and prescription drugs “are the three big ones,” she said. “Unless they were talking about ditching those, the other ones only have a marginal impact.”
John Bertko, an actuary who worked in the Obama administration and served on the board of Massachusetts’ health exchange, agreed: “You would either have very crappy benefits without drugs or physicians or hospitalization, or you would have roughly the same costs.”
Maternity care and mental health and substance abuse, he said, “are probably less than 5 percent” of premium costs.
Of course, requiring specific coverage does push up premiums to some extent. James Bailey, who teaches at Creighton University in Omaha, Neb., has studied the issue at the state level. He estimates that the average state health insurance mandate “raises premiums by about one-half of 1 percent.”
Those who want to get rid of the required benefits point to the fact that premiums in the individual market jumped dramatically from 2013 to 2014, the first year the benefits were required.
“The ACA requires more benefits that every consumer is required to purchase regardless of whether they want them, need them or can afford them,” Ohio Insurance Commissioner Mary Taylor said in 2013, when the state’s rates were announced.
But Bayram noted most of that jump was not due to the broader benefits, but to the fact that, for the first time, sicker patients were allowed to buy coverage. “The premiums would go down a lot if only very healthy people were covered and people who were higher risk were pulled out of the risk pool,” she said. (Some conservatives want to change that requirement, too, and let insurers charge sick people higher premiums.)
Meanwhile, most of the research that has been done on required benefits has looked at plans offered to workers by their employers, not policies available to individuals who buy their own coverage because they don’t get it through work or the government. That individual market is the focus of the current debate.
Analysts warn that individual-market dynamics differ greatly from those of the employer insurance market.
Bailey said he “saw this debate coming and wanted to write a paper” about the ACA’s essential health benefits. But “I very quickly realized there are all these complicated details that are going to make it very hard to figure out,” he said, particularly the way the required benefits work in tandem with other requirements in the law.
For example, said Bertko, prescription drugs can represent 20 percent of costs in the individual market. That’s far more than in the employer market.
Bayram said another big complication is that the required benefits do double duty. They not only ensure that consumers have a comprehensive package of benefits but enable other parts of the health law to work by ensuring that everyone’s benefits are comparable.
For example, the law adjusts payments to insurers to help compensate plans that enroll sicker-than-average patients. But in order to do that “risk adjustment,” she said, “all of the plans have to agree on some kind of package. So if you think of essential health benefits as an agreed-upon benchmark, I don’t know how they can get rid of that and still have risk adjustment.”
Obamacare’s Insurers Struggle for Stability Amid Trump Threats
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Obamacare is stuck in limbo, and insurers and state regulators are struggling to set their plans for what’s increasingly shaping up as a chaotic year for the health-care program.
After the failure of Republicans’ first attempt to repeal and replace the Affordable Care Act and President Donald Trump’s subsequent threats to let the program “explode,” more health insurers are threatening to pull out next year, while others may sharply raise the premiums they charge. They’ll start to declare in the next few weeks whether they’re in or out.
Marguerite Salazar, Colorado’s insurance regulator, said that her state’s carriers, which include Anthem Inc. and Cigna Corp., haven’t said they’re leaving, though they don’t want to commit either.
“That’s my biggest fear, is that we would lose carriers in the individual market,” Salazar said. “We don’t want to set up an environment that would tell them, well, maybe we don’t need to be here.”
In Washington, Insurance Commissioner Mike Kreidler pushed back by a month the date when insurers have to say what they’ll offer. He’s urging them to stay and thinks most will, but “they’re not making commitments right now.”
“They’ve got those cards and they’re holding them close,” said Kreidler, a Democrat. “Right now, there’s so much uncertainty.” The fear is that they’ll follow the lead of Aetna Inc. and Wellmark Inc., which pulled out of Iowa’s Obamacare markets this month.
Trump’s Uncertainty
Much of the uncertainty is thanks to the Trump administration, which will play a key role in deciding whether the health law’s markets collapse or survive. Industry representatives — including company executives and insurance lobby CEO Marilyn Tavenner — are scheduled to meet Tuesday with Seema Verma, the head of the Centers for Medicare and Medicaid Services, the U.S. agency that oversees the law.
Trump’s latest threat has been to stop payments that subsidize co-pays and other upfront costs for lower-income people. Without them, insurers would likely boost their premiums or drop out entirely. The administration has refused to commit to keeping the payments going.
Health insurers see April 30 as a key deadline for a decision on the cost-sharing payments. They’ll start filing with some state regulators in May to say whether or not they’ll stay in the markets.
“Everybody is still in a wait-and-see mode,” said Kristine Grow, a spokeswoman for the industry group America’s Health Insurance Plans. AHIP and other industry groups are pushing the administration to commit to making the cost-sharing payments that Trump has threatened to halt. “Plans really need certainty,” she said.
High-Risk Pools for People with Preexisting Conditions: A Refresher Course
During the recent effort to repeal and replace the Affordable Care Act (ACA), some members of Congress and the Trump administration seemed to be experiencing a certain nostalgia for high-risk pools, which operated in 35 states before the ACA was enacted. At a CNN Town Hall Meeting in January, Speaker of the House Paul Ryan responded to a question about coverage for people with preexisting conditions by saying:
We believe that state high-risk pools are a smart way of guaranteeing coverage for people with preexisting conditions. We had a really good one in Wisconsin. Utah had a great one . . . . What I mean when I say this is, about 8 percent of all the people under 65 have that kind of preexisting condition . . . . So, by financing state high-risk pools to guarantee people get affordable coverage when they have a preexisting condition, what you’re doing is, you’re dramatically lowering the price of insurance for everybody else. So, if we say let’s just, as taxpayers—and I agree with this—finance the coverage for those 8 percent of Americans under 65 in a condition like yours, they don’t have to be covered or paid for by their small business or their insurer who is buying the rates for the rest of the people in their insured pool, and you’d dramatically lower the price for the other 92 percent of Americans.
As high-risk pools and other changes to the ACA continue to be debated, it is critical to deconstruct statements such as these and remind ourselves of how high-risk pools really worked and how unaffordable they were. It is important to remember that high rates of uninsurance and lack of affordability for all buyers in the individual market existed before the ACA, even in states with high-risk pools. In addition, policymakers seem to substantially underestimate the number of Americans with preexisting conditions who might be forced to purchase coverage through a high-risk pool if insurers are allowed to deny coverage in the marketplace.
Reality Check
The reality is that high-risk pool coverage was prohibitively expensive and there is little evidence to suggest that the existence of such pools made coverage less costly for others in the individual insurance market. Without substantially more federal funding than currently proposed, these facts are not likely to change. People with preexisting conditions may have “access” to coverage, but most will not be able to afford it and those who can will face limited benefits and extremely high deductibles and out-of-pocket payments.
High Drug Prices Remain a Conundrum, Analysts Say
The problem of high prescription drug costs has no easy solution, analysts said Tuesday at an event here sponsored by Johns Hopkins University.
“It’s a major problem … and there’s no light at end of tunnel,” said Joshua Sharfstein, MD, associate dean for practice and training at Johns Hopkins University’s Bloomberg School of Public Health in Baltimore.
Overall drug costs are growing 10%-12% a year, “far quicker than wages or medical cost growth,” he added. “And it inhibits our ability to address public health problems. When we have a challenge like hepatitis C, when people can’t get treatment because of the [high cost], we’re all at risk.”
Although many ideas for solving the problem are being discussed, none are moving forward, Sharfstein said. He noted that things could get worse if, for example, Congress were to pass something like the House Republicans’ American Health Care Act, which would have resulted in the loss of health insurance for an estimated 24 million people.
“If you take 24 million people off of insurance, that generates pressure to get as much out of every insured person for pharmaceuticals as possible,” meaning that drug prices could rise even higher, he said. “It’s entirely possible you’d see that shift continue, and it could really worsen all the different challenges we have.”
Blame Game Over High Drug Prices Escalates With New Ad
New punches were thrown in the blame game over U.S. drug prices Thursday.
Broadening its efforts to defuse outrage over skyrocketing prices, Pharmaceutical Research and Manufacturers of America, the industry’s lobbying association, started an advertising campaign urging insurers to share with customers more of the benefits of rebates they’ve negotiated. In response, the main health-insurance lobby pushed the blame back on drugmakers: “Enough with the distractions.”
Meanwhile, the head of one of the largest pharmacy benefit managers, who are often criticized by drugmakers for their lack of transparency, said his industry helps save money and manufacturers should stop faulting the middlemen.
Pharmacy benefit managers like Express Scripts Holding Co. — which manage drug benefits for employers and insurers, and privately negotiate prices on their behalf — receive discounts from manufacturers. The rebates lead to lower prices, but it’s up to insurers whether they are ultimately passed down to patients, Express Scripts Chief Executive Officer Tim Wentworth said in an interview on Bloomberg Television on Thursday.
“A hundred percent of the time, payers determine how they pass through,” he said.
Drug companies that raise prices “would blame the middleman,” the CEO said. Yet pharmacy benefit managers, or PBMs, are transparent with how they work within the health-care sector with payers. “For us it’s a real simple challenge: get the net cost as low as possible for our clients.”
Opaque System
The three main groups that are involved in the complex and opaque system of setting drug prices in the U.S. — drugmakers, insurance companies and PBMs — started to strongly fight off criticism months ago. The sector escalated its defense against Washington this year after drug prices became a frequent target for President Donald Trump. He’s threatened to use the government’s buying power to force prices down, which is the industry’s most dreaded option, but so far has not unveiled any specifics about how.
The new ad from PhRMA, which represents more than 50 companies and is one of the most powerful interest groups, is another step in its endeavor to demonstrate that other parts of the health-care industry are responsible for the costs faced by patients. In January, the group started a major initiative, including TV, radio and digital ads. Unlike most developed countries in the world, the U.S. doesn’t directly regulate medicine prices, and drugmakers have strongly resisted it.
The new campaign, “Share the Savings,” will include advertising across various mediums to educate the public about how the rebates for commercially insured patients with high deductibles and coinsurance aren’t passed along to consumers, PhRMA said in a statement. “Robust negotiations” have resulted in major discounts, the group said.
HENRY KOTULA 