With Divided Congress, Health Care Action Hightails It to the States

https://www.rollcall.com/news/policy/divided-congress-health-care-action-states

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Medicaid expansion was the biggest winner in last week’s elections.

Newly-elected leaders in the states will be in a stronger position than those in Washington to steer significant shifts in health care policy over the next couple of years as a divided Congress struggles with gridlock.

State Medicaid work requirements, prescription drug prices, insurance exchanges and short-term health plans are among the areas with the potential for substantial change. Some states with new Democratic leaders may also withdraw from a multistate lawsuit aimed at killing the 2010 health care law or look for ways to curb Trump administration policies.

But last week’s biggest health care winner is undeniably Medicaid expansion, with upwards of half a million low-income Americans poised to gain insurance coverage following successful expansion ballot initiatives and Democratic victories in key governors’ races.

“In state health policy, it was a big election,” said Trish Riley, executive director of the nonpartisan National Academy for State Health Policy. “It was a year when many candidates had pretty thoughtful and comprehensive proposals.”

Boost for Medicaid expansion

Voters in three deep-red states — Nebraska, Idaho and Utah — bucked their Republican lawmakers by approving ballot initiatives to extend Medicaid coverage to more than 300,000 people.

Meanwhile, Democratic gubernatorial wins in Kansas and Wisconsin boosted the chances of expansion in those states. And Maine’s new governor-elect is expected to act quickly to grow the government insurance program when she takes office in January.

The election outcomes could bring the biggest increase in enrollment since an initial burst of more than two dozen states expanded Medicaid under the 2010 health care law in the early years of the landmark law’s rollout.

“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong,” said Jonathan Schleifer, head of The Fairness Project, an advocacy group that supported the initiatives, referring to the 2010 health care law. “Americans want to live in a country where everyone can go to the doctor without going bankrupt.”

The successful ballot initiatives require state leaders to move quickly toward expansion. In Idaho, the state must submit an expansion plan to federal officials within 90 days of the new law’s approval, while Nebraska must submit its plan by April 1, according to the nonpartisan Kaiser Family Foundation. Utah’s new law also calls for the state to expand beginning April 1.

In Kansas, where Medicaid supporter Laura Kelly prevailed, state lawmakers passed expansion legislation last year only to have it vetoed by the governor. Meanwhile, Wisconsin’s new Democratic governor Tony Evers, who eked out a win over Republican incumbent Scott Walker, has said he will “take immediate action” to expand, though he faces opposition from a Republican-controlled legislature.

Expansions in the five states would bring the number of states that adopted expansion under the health law to 38, plus the District of Columbia.

Still, Democrats fell short of taking one of the biggest Medicaid expansion prizes — Florida — after Andrew Gillum’s defeat. The outcome of Georgia’s tight governor’s race was still unclear as of Monday, with Republican Brian Kemp holding a narrow lead over Democrat Stacey Abrams. Both Abrams and Gillum made health care, and Medicaid expansion in particular, central to their campaigns.

Florida might be a 2020 target for an expansion ballot initiative, along with other states such as Missouri and Oklahoma, according to The Fairness Project.

Expansion supporters also suffered defeat last week in Montana, where voters did not approve a ballot initiative that would have extended the state’s existing Medicaid expansion, which covers nearly 100,000 people but is slated to expire next year. However, state lawmakers have until June 30 to reauthorize the program, according to Kaiser.

In Maine, Democratic gubernatorial winner Janet Mills is expected to expedite expansion implementation. GOP Gov. Paul LePage stymied implementation over the past year, despite nearly 60 percent of voters approving an expansion ballot initiative in 2017.

Medicaid’s future

The midterm results carry other ramifications for Medicaid, including whether states embrace or move away from controversial work requirements backed by the Trump administration.

Gretchen Whitmer, a Democrat who won Michigan’s governor race, opposed the idea and could shift away from an existing plan to institute them that’s awaiting federal approval.

“This so-called work requirement is not for one second about getting people back to work. If it was, it would have been focused on leveling barriers to employment like opening up training for skills or giving people child care options or transportation options,” Whitmer said in a September interview with Michigan Radio. “It was about taking health care away from people.”

Kansas, Wisconsin and Maine also have work requirement proposals that new Democratic governors could reverse.

But experts also say it’s possible some states, including those with Democratic governors, could end up pursuing Medicaid work requirements if that’s what it takes to get conservative legislators to accept expansion like Virginia did earlier this year.

Nebraska Republican state senator John McCollister, who supports expansion, predicted recently that the legislature would fund the voter-approved expansion initiative. But he indicated lawmakers might pursue Medicaid work requirements too.

Marie Fishpaw, director of domestic policy studies at the conservative Heritage Foundation, warned that states expanding Medicaid would face challenges. She called expansion “a poor instrument for achieving the goal that they’re trying to achieve.”

A number of new governors, including Whitmer, could pursue the so-called “Medicaid buy-in” concept.

More than a dozen state legislatures, such as in Minnesota and Iowa, explored the idea in recent years, according to State Health and Value Strategies, part of the nonprofit Robert Wood Johnson Foundation. Nevada lawmakers passed a “Medicaid buy-in” plan last year that was vetoed by the governor.

There are a variety of ways to implement such a program, but the goal is to expand health care access by leveraging the government insurance program, such as by creating a state-sponsored public health plan option on the insurance exchanges that consumers could buy that relies on Medicaid provider networks. Illinois, New Mexico, Maine and Connecticut are among the states that could pursue buy-in programs, Riley said. States are considering the concept as a way to increase affordability and lower cost growth by getting more mileage out of the lower provider rates Medicaid pays, said Katherine Hempstead, a senior policy adviser with Robert Wood Johnson Foundation.

“So many [people] struggle with the affordability of health care,” Hempstead said. “That is an environment in which Medicaid buy-in opportunities could flourish.”

Health care law

This month’s election also carries implications for the future of states’ administration of the 2010 health care law.

States that flipped to Democratic governors could switch to creating their own insurance exchanges rather than relying on the federal marketplace, said Joel Ario, a health care consultant with Manatt Phelps & Phillips and the former head of the federal health insurance exchange office under the Obama administration. The costs of running an exchange have come down in recent years, so it’s potentially cheaper for a state to run its own, Ario said.

Trump administration actions, such as cuts in federal funding for insurance navigators that help consumers enroll and the expansion of health plans that don’t comply with the law, may make states such as Michigan or Wisconsin rethink use of the federal exchange, he said.

“If [the administration] continues to promote policies that really leave a bad taste in the mouth for Democratic governors, I think they’ll be asking questions,” Ario said.

States where governors and attorneys general offices went from red to blue are likely to pull out of a lawsuit by 20 state officials that aims to take down the health care law, he added.

Wisconsin’s Evers vowed that his first act in office will be to withdraw from the lawsuit.

“I know that the approximately 2.4 million Wisconsinites with a pre-existing condition share my deep concern that this litigation jeopardizes their access to quality and affordable health care,” Evers wrote in a letter he said he plans to send to the state attorney general.

Hempstead said that states with both Republican and Democratic leaders will likely continue to pursue reinsurance programs, which cover high-cost patients, to bolster their marketplaces.

Republican governors could also pursue waivers under a recent Trump administration guidance that allows states to circumvent some requirements of the health law under exemptions known as 1332 waivers. But experts say it’s too soon to know exactly what approaches states might take.

“It will be interesting to see what the 1332 guidance means and whether it opens doors for some things and not for others,” Hempstead said. States that shifted to Democratic governors could also look to ban some Trump-supported policies, such as expansions of short-term and association health plans that avoid the health care law’s rules.

States are also likely to take steps to address high prescription drug costs in the coming years, with a number of new governors wanting to improve transparency, explore drug importation from other countries and target price gouging, Riley said.

“There’s a long history of the states testing, fixing, tweaking and informing the national debate,” said Riley.

 

HEALTHCARE WINNERS AND LOSERS FROM ELECTION NIGHT 2018

https://www.healthleadersmedia.com/strategy/healthcare-winners-and-losers-election-night-2018

The most significant developments of the night focused around Medicaid expansion, how healthcare leaders who ran for public office fared in the elections, and several down-ballot healthcare initiatives.


KEY TAKEAWAYS

Healthcare leaders who were elected: Gov. Rick Scott, Lauren Underwood, RN, and former HHS Secretary Donna Shalala.

Races where healthcare was a major factor: mixed bag for vulnerable House Republicans who voted to repeal-and-replace the ACA, as well as Medicare for All proponents.

Healthcare ballot initiatives: Three states approve Medicaid expansion, one does not; Massachusetts votes down Question 1.

The 2018 midterm elections are over but made a significant impact on healthcare policies at the federal and state level across the country, while also determining who will be in office to enact them.

The future of healthcare policymaking will be influenced by the decisions made by millions of voters on Tuesday night, as Democrats took back the House while Republicans held onto control in the Senate.

Healthcare was a top priority for voters as they made their way to the polls to vote on issues such as Medicaid expansion and the healthcare leaders seeking to represent them on Capitol Hill.

Below are some of the most significant healthcare-related developments from the 2018 midterms:

MEDICAID EXPANSION APPROVED IN 3 RED STATES, DEFEATED IN MONTANA

Three traditionally conservative states joined Maine in approving Medicaid expansion via ballot initiative, while voters in Montana sank the measure which was attached to a proposed tobacco tax hike proposal.

More than 300,000 residents across Nebraska, Idaho, and Utah are likely to receive extended Medicaid coverage as a result of expansion. The number of places with Medicaid expansion now totals 37 states as well as the District of Columbia.

Support for the measure exceeded 60% in Idaho, while Utah and Nebraska approved Medicaid expansion with 54% and 53% of the vote, respectively.

Montana, voting on the most expensive ballot measure in state history, voted down the expansion proposal, which will sunset at the end of the year.

NURSE STAFFING RATIO PROPOSAL SHOT DOWN IN MASS.

Last night, Massachusetts voters had their say on ballot Question 1, which sought to implement nurse- to-patient ratios in hospitals and other healthcare settings.

It was met with a resounding ‘no’ from the electorate, with about 70% voting against the measure and almost 30% voting for it.

For months, the law has been hotly debated. Those in favor said it would improve patient safety and care. Those opposed said it didn’t account for patient acuity and would create a financial burden on hospitals and healthcare systems.

Had the law passed, Massachusetts would have joined California as the only other state to require that level of mandatory ratios.

PROPONENTS OF MEDICAID WORK REQUIREMENTS

As expected, two of the three governors who received federal approval for Medicaid work requirements and were on the ballot for the midterms, Gov. Chris Sununu, R-N.H. and Gov. Asa Hutchinson, R-Ark., cruised to election night victories.

Sununu defeated Democratic challenger Molly Kelly by a 52% to 46% margin while Hutchinson dispatched Democratic opponent Jared Henderson with 65% of the vote.

The most vulnerable of the three Republican incumbents, Wisconsin Gov. Scott Walker, was unseated by Democratic opponent Tony Evers by just over a single percentage point.

Wisconsin had just received CMS approval for its Medicaid work requirements last week, which was the latest development in a race dominated by healthcare issues that ultimately pushed Walker out of office. 

ADDITIONAL HEALTHCARE BALLOT INITIATIVES YIELD MIXED RESULTS

Oklahoma voters rejected the Walmart-backed Question 793, which would have amended the Oklahoma Constitution to give optometrists and opticians the right to practice in retail stores. Walmart gave nearly $1 million in the third quarter alone to proponents of the initiative, which was narrowly defeated by less than 6,000 votes.

Nevada voters approve exemption of durable medical goods from state sales tax. Local media in Nevada are reporting that more than 67% of voters in state voted for Question 4, which amends the Nevada Constitution to require the state legislature to exempt some durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax.

California voters roundly rejected an initiative to cap the profits of kidney dialysis providers at 15% above direct patient cost. However, Golden State voters approved a ballot initiative that authorizes $1.5 billion in bonds to fund capital improvements at the state’s 13 children’s hospitals.

BITTERSWEET NIGHT FOR VULNERABLE HOUSE REPUBLICANS AND MEDICARE FOR ALL PROPONENTS

The race in Kentucky’s 6th Congressional District set the tone for the night among House races, as Rep. Andy Barr, who was targeted by Democrats for his support of House GOP plans to repeal-and-replace the ACA, faced Democratic challenger Amy McGrath, who voiced support in Medicare-for-All legislation.

A neck-and-neck race throughout the early part of the evening, Barr ultimately defeated McGrath, but other vulnerable House Republicans did not fare as well.

In New York, Rep. John Faso lost to Democratic challenger Antonio Delgado in the 19th Congressional District, a race highlighted by disagreements over healthcare policy, and Rep. Claudia Tenney, a vocal critic of the ACA, was unseated by Democratic opponent Anthony Brindisi in the 22nd Congressional District.

Sen. Bernie Sanders, I-VT, and Rep. Pramila Jayapal, D-Wash., two of the most notable proponents of Medicare for All were reelected, while newcomer Alexandria Ocasio-Cortz, a self-described Democratic Socialist, became the youngest woman ever elected to Congress in New York’s 14th Congressional District.

However, other Medicare for All proponents did not perform as expected across the country, with Tallahassee Mayor Andrew Gillum losing a tight gubernatorial race in Florida to Republican Rep. Ron DeSantis, and Rep. Beto O’Rourke falling to Republican incumbent Sen. Ted Cruz in the Texas Senate race.

HEALTHCARE LEADERS ON THE BALLOT

After a lengthy primary season and contentious general election cycle, numerous healthcare leaders won their respective elections Tuesday night.

Healthcare was one of the most prominent issues concerning voters in the midterm election cycle, punctuated by more than 60 declared candidates with healthcare backgrounds running for public office in 2018.

Around 35 candidates made it to the general election ballot and more than two dozen received a stamp of approval from the voters.

Most notably were Gov. Rick Scott, former head of Columbia/HCA, who won a neck-and-neck race against Sen. Bill Nelson, D-Fla.,Lauren Underwood, RN, a former HHS adviser under former President Barack Obama, who defeated Rep. Randy Hultgren, R-Illi., and former HHS Secretary Donna Shalala, who won a hotly contested campaign in Miami.

 

 

THE RACES AND ISSUES HEALTHCARE LEADERS NEED TO WATCH ON ELECTION NIGHT

https://www.healthleadersmedia.com/strategy/races-and-issues-healthcare-leaders-need-watch-election-night

The 2018 midterm elections will decide the fate of numerous healthcare-related ballot measures as well as which leaders will shape health policy in the coming years.


KEY TAKEAWAYS

Issues to watch: Medicaid expansion in 4 states, a healthcare bond initiative in California, and the debate over preexisting condition protections.

Candidates to watch: Wisconsin Gov. Scott Walker, former Gov. Phil Bredesen, former HHS Secretary Donna Shalala, and others.

Healthcare has been an overarching issue for voters in the 2018 midterm election cycle, with many focusing on the future of the Affordable Care Act when it comes to national health policy but also taking stock of state and local ballot initiatives as well.

Several traditionally Republican states will decide whether to expand Medicaid under the ACA; staffing requirements for nurses are a hot-button topic in Massachusetts; and a major children’s hospital bond is on the table in California. 

Beyond the issues are the candidates, including many Republican leaders on Capitol Hill in tight races to defend their seats after voting to repeal and replace the ACA. At the state level, Republican governors and their attorneys general are having their healthcare records put to the test as Democrats make protecting preexisting conditions and rejecting Medicaid work requirements key parts of the campaign.

Here are the key issues and candidates healthcare leaders will be watching as results begin rolling in Tuesday evening, with voters determining the direction of healthcare policymaking for years to come.

MEDICAID EXPANSION IN 4 RED STATES

One year after voters approved Medicaid expansion in Maine, the first state to do so through a ballot initiative, four other states have the opportunity to join the Pine Tree State.

Montana: The push to extend Medicaid expansion in Montana before the legislative sunset at the end of the year is tied to another issue: a tobacco tax hike. The ballot measure, already the most expensive in Montana’s history, would levy an additional $2-per-pack tax on cigarettes to fund the Medicaid expansion which covers 100,000 persons.

Nebraska: Initiative 427 in traditionally conservative Nebraska, could extend Medicaid coverage to another 90,000 people. The legislation has been oft-discussed around the Cornhusker State, earning the endorsement of the Omaha World-Herald editorial board.

Idaho: Medicaid expansion has been one of the most talked about political items in Idaho throughout 2018. Nearly 62,000 Idahoans would be added to the program by Medicaid expansion, some rural hospitals have heralded the move as a financial lifeline, and outgoing Gov. Bruce Otter, a Republican, blessed the proposal last week.

Utah: Similar to Montana’s proposal, Utah’s opportunity to expand Medicaid in 2018 would be funded by a 0.15% increase to the state’s sales tax, excluding groceries. The measure could add about 150,000 people to Medicaid if approved by voters, who back the measure by nearly 60%, according to a recent Salt Lake Tribune/Hinckley Institute poll.

4 MORE BALLOT INITIATIVES

In addition to the four states considering whether to expand Medicaid, there are four others considering ballot initiatives that could significantly affect the business of healthcare.

Massachusetts mulls nurse staffing ratios. Question 1 would implement nurse-to-patient staffing ratios in hospitals and other healthcare settings, as Jennifer Thew, RN, wrote for HealthLeaders. The initiative has backing from the Massachusetts Nurses Association.

Nurses have been divided, however, on the question, and public polling prior to Election Day suggested a majority of voters would reject the measure, which hospital executives have actively opposed. The hospital industry reportedly had help from a major Democratic consulting firm.

California could float bonds for children’s hospitals. Proposition 4 would authorize $1.5 billion in bonds to fund capital improvement projects at California’s 13 children’s hospitals, as Ana B. Ibarra reported for Kaiser Health News. With interest, the measure would cost taxpayers $80 million per year for 35 years, a total of $2.9 billion, according to the state’s Legislative Analyst’s Office.

Proponents say children’s hospitals would be unable to afford needed upgrades without public assistance; opponents say the measure represents a fiscally unsound pattern. (California voters approved a $750 million bond in 2004 and a $980 million bond in 2008.)

Nevada nixing sales tax for medical equipment? Question 4 would amend the Nevada Constitution to require the state legislature to exempt certain durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax. The proposal, which passed a first time in 2016, would become law if it passes again.

Bennett Medical Services President Doug Bennett has been a key proponent of the measure, arguing that it would bring Nevada in line with other states, but opponents contend the measure is vaguely worded, as the Reno Gazette Journal reported.

Oklahoma weighs Walmart-backed optometry pitch. Question 793 would add a section to the Oklahoma Constitution giving optometrists and opticians the right to practice in retail mercantile establishments.

Walmart gave nearly $1 million in the third quarter alone to back a committee pushing for the measure. Those opposing the measure consist primarily of individual optometrists, as NewsOK.com reported.

INCUMBENTS, PLAINTIFFS, PREEXISTING CONDITIONS

It’s been more than two months since Republican attorneys general for 20 states asked a federal judge to impose a preliminary injunction blocking further enforcement of the Affordable Care Act, including its coverage protections for people with preexisting conditions. Some see the judge as likely to rule in favor of these plaintiffs, though an appeal of that decision is certain.

Amid the waiting game for the judge’s ruling, healthcare policymaking—especially as it pertains to preexisting conditions—rose to the top of voter consciousness in the midterms. That explains why some plaintiffs in the ACA challenge have claimed to support preexisting condition protections, despite pushing to overturn them.

The lawsuit and its implications mean healthcare leaders should be watching races in the 20 plaintiff states in the Texas v. Azar lawsuit: Alabama, Arizona, Arkansas, Florida, Georgia, Indiana, Kansas, Louisiana, Maine Gov. Paul LePage, Mississippi Gov. Phil Bryant, Missouri, Nebraska, North Dakota, South Dakota, South Carolina, Tennessee, Texas, Utah, West Virginia, and Wisconsin. Thirteen of those plaintiff states have active elections involving their state attorneys general, and several have races for governor in which the ACA challenge has been an issue, including these noteworthy states:

  • Texas: Attorney General Ken Paxton, a Republican representing the lead plaintiff in the lawsuit, is facing a challenge from Justin Nelson, a Democrat, and the race seemed to be competitive, as The Texas Tribune reported. Gov. Greg Abbott was expected to win against Democratic challenger Lupe Valdez.
  • Florida: Attorney General Pam Bondi, a Republican, is term-limited, so she’s not running for reelection. Ashley Moody, a Republican, and Sean Shaw, a Democrat, are facing off for Bondi’s position. Moody expressed support for Florida’s participation in the ACA challenge, while Shaw said he would pull the state out, calling the case a “partisan stunt,” as the Tampa Bay Times reported. Bondi has campaigned, meanwhile, for Republican gubernatorial candidate Ron DeSantis, who’s facing off with Democrat Andrew Gillum. Gillum said he would back a state law to protect people with preexisting conditions, while DeSantis said he would step in if federal action removed the ACA’s preexisting condition protections, as the Miami Herald reported. Gillum and DeSantis are vying to succeed term-limited Gov. Rick Scott, a Republican who’s running for U.S. Senate.
  • Wisconson: Attorney General Brad Schimel, a Republican, is facing a challenge from Josh Kaul, a Democrat who has slammed Schimel’s participation in the ACA challenge, as The Capital Times reported. Gov. Scott Walker, a Republican, said he supports preexisting condition protections, despite authorizing his state’s participation in the lawsuit. Democratic challenger Tony Evers accused Walker of “talking out of both sides of his mouth,” as the Milwaukee Journal Sentinel reported.

PROPONENTS OF MEDICAID WORK REQUIREMENTS

Five states have received approvals from the Centers for Medicare and Medicaid Services to institute Medicaid work requirements: Kentucky, Indiana, Wisconsin, New Hampshire, and Arkansas. (Only four have active approvals, however, since a federal judge blocked Kentucky’s last summer.)

Three incumbent governors who pushed for work requirements are running for reelection:

New Hampshire: After receiving approval for New Hampshire’s Medicaid work requirements, Republican Gov. Chris Sununu said the government is committed to helping Granite Staters enter the workforce, adding that it is critical to the “economy as a whole.” Despite spearheading a controversial topic in a politically centrist state, Sununu has not trailed against his Democratic opponent Molly Kelly in any poll throughout the midterm elections.

Arkansas: Similarly, Arkansas Gov. Asa Hutchinson, is running in a race where he has held a sizable lead over his Democratic challenger Jared Henderson. Since enacting the work requirements over the summer, the state has conducted two waves where it dropped more than 8,000 enrollees.

Wisconsin: The most vulnerable Republican governor of a state with approved Medicaid work requirements is Wisconsin Gov. Scott Walker, who has been neck and neck with Democratic nominee Tony Evers. While the Badger state only received approval for its Medicaid work requirements last week, healthcare has been a central issue of the campaign as Walker, a longtime opponent of the ACA, works to address premium costs in the state and defend his record on preexisting conditions.

Indiana and Kentucky: Indiana Gov. Eric Holcomb and Kentucky Gov. Matt Bevin are not on the ballot this year.

When HealthLeaders issued its first list in April of the healthcare leaders running for public office during the primaries, there were more than 60 candidates with relevant healthcare backgrounds out on the campaign trail.

Now, for the general election, that list has nearly been halved, with 35 candidates still remaining. 

This collection of healthcare leaders includes registered nurses, former insurance company executives, physicians, and former government health policy leaders.

U.S. Senate: Running for the Senate are Florida Gov. Rick Scott, former Tennessee Gov. Phil Bredesen, former Celgene CEO Bob Hugin, and State Sen. Leah Vukmir.

U.S. House: Among those aiming to join the House are Lauren Underwood, RN, former HHS Secretary Donna Shalala, and Dr. Kim Schrier.

 

 

How Will the Midterm Elections Impact Healthcare?

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With the midterms less than a week away,  a new poll published October 18th by the non-partisan Kaiser Family Foundation got a lot of attention. Over seventy percent of voters say health care is a very important issue in deciding who to vote for. 

But exactly what happens to key healthcare initiatives, especially the Affordable Care Act including expansion of Medicaid in many states—which tends to be more popular among Democratic lawmakers than Republicans–depends on whether it’s the Democrats or Republicans who get control of the House, says Eric Feigl-Ding, MPH, Ph.D., a health economist and visiting scientist at the Harvard Chan School of Public Health in Cambridge, Mass.

Based on multiple polls, the New York Times reported on October 23 that a likely outcome is that Democrats will gain the majority in the House of Representatives and the Republicans will keep the majority in the Senate. But the Times and many other news outlets continually point out that many factors including the news of each day make it difficult to predict the outcome.

Feigl-Ding says having opposing parties in the House, Senate and White House could make it harder to pass national legislation. Changes can still happen to the ACA, however, because the President can continue to make certain executive level decision such as ending the penalty for not having health insurance which he did last year. That change takes effect in 2019.

In terms of new legislation, Feigl-Ding says a split Congress and White House means that passing legislation will be difficult because what comes from the House side, if most members are Democrats in the next sessions, could be more liberal and the corresponding bills from the Senate, likely to remain Republican, could be more conservative. So, says Feigl-Ding, either a bill won’t pass at all, or there will have to be much more of a compromise. “And assuming they would get to compromise is a big assumption, that then requires the president to agree to sign that legislation,” adds Feigl-Ding.

A report this week by strategy and policy group Manatt Health, based in Washington, DC lists the health care issues the firm thinks will dominate in states and the federal government after the elections:

  • The role of Medicaid as either a welfare program or health insurance for low-income Americans: While Democrats generally support continued expansion of Medicaid with no cost or work requirements for low-income adults, Republican governors in a number of states—with the approval of the Trump administration– have introduced premiums, work requirements, increased paperwork and penalties for falling off on requirements those that can keep many adults from applying for or remaining on Medicaid.
  • Differences in states about expanding and stabilizing the Affordable Care Act (ACA) Marketplace or promoting non-ACA coverage: The ACA allows states to open their own health insurance marketplaces or simply offer access to the federal marketplace. According to 2017 data from the National Academy for State Health Policy, more consumers sign up for health care coverage in states that run their own marketplaces
  • Drug prices: According to the Organization for Economic Development, an international forum with 36-member countries, consumers in the U.S. spend just over $1,100 on prescription drugs each year, more than consumers in any other country. President Trump has promised to help lower drug prices and on October 25 he released a plan that would tie some drug prices for patients on Medicare to an index based on international prices. Those prices are often far lower than Americans pay. PhRMA, the largest drug trade association announced its opposition to the plan the same day it was announced.

According to the report what states do will depend on the election outcomes for governors in more than a dozen states and many of those races are as impossible to predict as the Congressional races.

Other important health care issues for 2019-20120 include:

Pre-Existing Conditions 

Listening to ads for some Republicans candidates for Congress makes it appears protecting pre-existing conditions will be a top priority for some Republicans, even among some who voted against them previously. But Feigl-Ding says keeping coverage for preexisting conditions in health insurance plans also requires figuring out how to pay for it. Under the original ACA legislation, the hope was that a financial penalty for not having health coverage would keep more healthy people in the plans—along with the prohibition against letting insurers “cherry pick” only healthy consumers. But that penalty is now gone. “Take that away and you probably can’t sustain the preexisting conditions, says Feigl-Ding.

Medicaid Work Requirements and Other Conditions of Eligibility.

Legal challenges in several states could impact the implementation of work requirements. Some governors have said they’ll cut the number of state Medicaid beneficiaries to save money if work requirements are overturned.

ACA Repeal. Twenty states are challenging the constitutionality of the ACA in Texas v. The U.S., a case that could make it to the Supreme Court.

Association Health Plans and Short-Term Plans. Several Democratic state attorneys general have filed a lawsuit against the administration’s rule promoting association health plans that allow individuals and small businesses to join to purchase health care coverage and short-term plans. The suit argues that the new rules for both avoid protection for people with pre-existing conditions, according to Manatt.

No one has a crystal ball for what will happen, but everyone has hindsight. According to the Manatt report, in 2010 Republicans replaced Democratic governors in eleven states, and all but one of those states ended plans to establish a state-based health insurance marketplace (SBM). In five states where Democrats replaced Republicans, all those states set up those marketplaces.

And whatever the outcome of the 2018 elections, their impact on healthcare may only be short lived. At a foundation briefing on the midterm elections earlier this week Mollyann Brody, Executive Director, Public Opinion and Survey Research at the Kaiser Family Foundation reminded the crowd that “the day the 2018 elections are over the 2020 campaign starts.”

Still the end of the week also brought a glimmer of hope. In response to President Trumps remarks on October 25thabout his administration’s plan to test new drug pricing models in Medicare Part B help to lower drug prices Frederick Isasi, executive director of FamiliesUSA, a liberal leaning health insurance advocacy group, released a statement that said, in part, “I hope this is a serious policy that will be formally proposed and finalized by the Trump administration. If so, it is an important step forward for our nation’s seniors and taxpayers.”

 

 

Medicaid rolls set to be slashed under Trump-approved work rules

http://thehill.com/policy/healthcare/406624-medicaid-rolls-set-to-be-slashed-under-trump-approved-work-rules

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The thousands of people who lost Medicaid coverage this month in Arkansas for not following newly implemented work requirements may be a sign of what’s to come in other GOP-led states.

Indiana and New Hampshire are slated to implement their Medicaid work requirements next year, and a slew of other states are awaiting approval from the Trump administration.

Arkansas has served as a test case of sorts since it was the first state to implement work requirements, and this month it became the first state to kick off beneficiaries for not following them.

The state removed more than 4,000 people from the Medicaid rolls, with some estimates saying that number could climb to 50,000 when the requirements are fully implemented in 2019.

“I think other states should be thinking seriously about the warnings that Arkansas’ experience has for their states,” said Erin Brantley, a senior research associate at George Washington University’s Milken Institute of Public Health.

While many people in Arkansas’ program are exempt from reporting their activities to the state because they’re already working, others are not, meaning they need to file monthly reports through an online portal to show they are meeting the requirements.

Of those who lost coverage this month, about 95 percent didn’t file the necessary documents with the state. That led to their removal from Medicaid, though some may have been working working the required 80 hours a month.

It’s unclear why those participants didn’t file reports, especially if they were working, though some say it could be due to confusion, an inability to access a computer or general unawareness about the new requirements.

The state said it conducted “extensive” outreach that included sending more than 136,000 letters and emails and making more than 150,000 phone calls from April through August.

“It seems that [the state] is doing some outreach, but a lot of individuals still don’t know about the new requirements and are not setting up their accounts,” said Robin Rudowitz, associate director of the Kaiser Family Foundation’s program for Medicaid and the uninsured.

“There are many lessons to be learned about online reporting, and communication, and having individuals understand what the requirements are,” Rudowitz said. “The changes to these programs are difficult to communicate.”

In a report published in the journal Health Affairs this month, the author conducted interviews with 18 Medicaid recipients in northeast Arkansas and found that a dozen had not heard about the state’s new requirements.

Seema Verma, head of the U.S. Center for Medicare and Medicaid Services, which is responsible for reviewing state requests for work requirements, characterized Arkansas’ recent removal of Medicaid recipients as a positive step.

“I’m excited by the partnerships that Arkansas has fostered to connect Medicaid beneficiaries to work and educational opportunities, and I look forward to our continued collaboration as we thoroughly evaluate the results of their innovative reforms,” Verma said in a tweet the same day that 4,000 recipients lost coverage.

The work requirements have prompted lawsuits in Kentucky and Arkansas by advocates who say they are harmful to those in need. The judge that blocked a similar program in Kentucky earlier this year will also preside over the Arkansas case.

The Trump administration says “able-bodied” adults on Medicaid should work if they’re able to. In all three states, the work requirements apply only to those who gained coverage through ObamaCare’s Medicaid expansion, which allowed for covering more low-income adults.

It’s unclear how the work requirements will impact beneficiaries in Indiana and New Hampshire when they are rolled out next year, but both states are planning to rescind coverage for those who don’t meet the new work rules.

Beneficiaries in Indiana will have to work at least eight months each year, and an 80-hour-a-month requirement will be gradually phased in over an 18-month period. Compliance with the requirements will be checked annually instead of monthly, like in Arkansas.

New Hampshire beneficiaries subject to the new requirements must work 100 hours a month beginning in January. Enrollees who don’t meet the threshold for one month will have their coverage suspended.

Some argue that the true purpose of Medicaid work requirements is to cut spending for the federal program, a priority of conservatives for years.

“This policy is clearly not designed to help people find work. It’s designed to take them off Medicaid,” said Joan Alker, executive director of the Center for Children and Families at the Georgetown University School of Public Policy, referring to the Arkansas policy.

“It’s nothing to do with promoting work, supporting work — it’s about creating red tape for folks who are not able to jump over these bureaucratic hurdles for one reason or another — no internet access, they may not know, may be homeless, may not get the letter,” she said. “Those are the ones that will lose coverage.”

 

 

The Health 202: ‘Medicare for all’ is the dream. ‘Medicaid for more’ could be the reality.

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/08/02/the-health-202-medicare-for-all-is-the-dream-medicaid-for-more-could-be-the-reality/5b61d4ed1b326b0207955ea2/?utm_term=.f54d337c2d74

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“Medicare for all” is the hottest position on the left these days, but there’s a quieter push afoot to create a public option using Medicaid. 

Chanting “Medicaid for more” may not sound as bold for progressives seeking to prove their bona fides before the midterm elections. Yet all the most-hyped 2020 Democratic presidential candidates are on board with the idea, including the Medicare expansion’s biggest champion, Sen. Bernie Sanders (I-Vt.).

The idea in concept is simple: Allow states to open up their Medicaid programs to anyone regardless of income. Those people could buy in to the social safety net and have access to Medicaid’s provider network and benefits. The groundwork for expanding the program for low-income Americans has already been laid to some extent as 34 states have expanded Medicaid under the Affordable Care Act.

Sen. Brian Schatz (D-Hawaii) has introduced the “State Public Option Act” to promote states to expand Medicaid — co-sponsored by some familiar Democratic faces: Sanders, Elizabeth Warren (Mass.), Cory Booker (N.J.), Kamala Harris (Calif.) and Kirsten Gillibrand (N.Y.). But the real efforts are happening at the state level where legislatures all over the country are seriously considering the idea.

Heather Howard, a lecturer at Princeton University who also helps states with their health-care systems, said many plans are in their infancy, but that 14 states across the country have made moves to, at minimum, weigh the benefits and challenges of shifting Medicaid to a publicly available health insurance option.

“There are a lot of policy considerations to think about, but while the federal policy debate is stalled, you have states thinking about what tools do we have. [Medicaid] is the immediate tool you have,” she told me.

That’s because Medicare is operated at the federal level so any major changes to it have to be decided in Washington. Medicaid, on the other hand, is run by the states, so they have more discretion over how the program is set up. 

There are real critiques of Medicaid as it now exists, such as low reimbursement rates for doctors and uniform access to care. To offer it to everyone would require responding to those criticisms as well as new questions such as the cost to states, whether states have to apply for federal waivers to alter the program and whether a public option lives on or off the ACA exchanges.

This week stakeholders across New Mexico met with President Obama’s former Centers for Medicare and Medicaid Services Administrator Andy Slavitt to begin some of those conversations. Earlier this year, New Mexico’s state legislature passed a bill to create a committee to study a Medicaid buy-in program. Medicaid is popular there; one-third of New Mexicans are enrolled. Yet 230,000 people remain uninsured in the state, according to Kaiser Family Foundation data, and proposed premium rates for 2019 for those who don’t qualify for ACA subsidies are increasing anywhere from 9.2 percent to 18.5 percent.

Slavitt is the board chair of a new group, United States of Care, which has an impressive roster of bold-faced names leading it from investor Mark Cuban to former Obama speechwriter Jon Favreau to former congresswoman Gabrielle Giffords (D-Ariz.) and her astronaut husband Mark Kelly. In the absence of Washington leadership, the group is working with states on ways to improve health care.

Allison O’Toole, the group’s director of state affairs, was also on the ground in New Mexico this week and told me there’s a “real hunger” and “momentum” around the idea of allowing states to expand Medicaid.

“Washington is in gridlock and not addressing people’s real concerns around the cost and affordability of health care,” O’Toole said. “This has created a greater sense of urgency and necessity by states to pick up that ball and run with it.”

With the Republicans’ failure to repeal the ACA and the public outcry when they tried, Democrats are feeling emboldened this year to talk ambitiously about their health-care goals. 

Health care is a leading issue heading into November, and polls show at least half of Americans are in favor of a “Medicare for all” program. But even if Democrats win the House majority and make gains in the Senate, President Trump has said Obamacare is unsustainable and his administration has worked persistently to chip away at it.

That’s why Michael Sparer, a public- health professor at Columbia University, believes “Medicaid for more” is not only good policy, but also good politics. It’s the type of proposal, he reasons, that could peel off moderate Republicans in a way that a national Medicare program never could. 

It’s true that Medicaid is a favorite GOP punching bag. The Trump administration is urging states to add work requirements to their programs and the GOP playbook has long included capping how much the federal government pays each state to administer Medicaid.

Yet 34 states, including many with Republican governors, expanded the ACA under Medicaid to include more low-income residents, and several more red states are on the precipice of following them. It’s a program that has endured and grown for 53 years.

“The Medicaid buy-in is more of a compromise program, it’s not viewed as a big national program. People who believe in states’ rights can view it as states having more flexibility,” Sparer said.

Sparer has written extensively on the topic and told me his support for expanding Medicaid is heavily influenced by the political viability of focusing on the program for low-income Americans versus the one covering seniors — meaning states don’t have to wait for a new president to do something meaningful. But that doesn’t mean he thinks national political figures like Sanders should stop talking about “Medicare for all.”

“The advantage is [Medicaid buy-in] is incremental, it adds populations here and there. But incremental isn’t a great political slogan. You put ‘let’s change the system’ on a bumper sticker and I get that,” he said. “But the more there’s momentum for ‘Medicare for all,’ then ‘Medicaid for more’ could be the back up plan.”

“Given the ever-present debate,” he added, “a more incremental path is a better path.”

 

 

Reinsurance in Wisconsin expected to stabilize individual market

https://www.healthcarefinancenews.com/news/reinsurance-wisconsin-expected-stabilize-individual-market?mkt_tok=eyJpIjoiTVdJMVlUVmtNMlppTUdZNSIsInQiOiJublwvXC83VVdcL2dcL1U3a3FHNGNMRHppSldoOThiRGtNQXk4UFJyZE5FUkRQeWZWZEQ1NDMxT3FZeGRhZjdGOUlnQUtaQTUyeEMrcnBSaDNKQjZLWEIzRkVCaFlNelNXSmI1R1ZrZFdOcXlzTWVUcGk3OXl5WnNRZDlaTjhjN09WM3MifQ%3D%3D

Under the Wisconsin Health Care Stability Plan, the state pays for 50 percent of the cost of claims between $50,000 and $250,000.

Wisconsin has received a federal waiver to leverage $200 million to implement a state-based reinsurance program to cover high-cost claims in the individual health insurance market.

Reinsurance covers a portion of the most expensive claims. The move helps to stabilize the individual market by reducing insurer claim costs and decreasing premiums.

Insurers don’t have the uncertainty that a small number of high-risk individuals could dramatically increase their expenses because there aren’t enough healthy consumers to balance out the risk pool.

Under the Wisconsin Health Care Stability Plan, the state pays for 50 percent of the cost of claims between $50,000 and $250,000.

The Department of Health and Human Services and the Department of the Treasury on Sunday approved the 1332 state innovation waiver under the Affordable Care Act. The five-year program starts Jan. 1, 2019 and ends Dec. 21, 2023.

The approved waiver allows the state to have access to $200 million in reinsurance funding. The federal government will pay an estimated $166 million and the state, $34 million.

The program is budget neutral to the federal government. The money comes from savings from premium tax credits. The federal waiver allows the premium tax credits to be passed through to the state, rather than going directly to the consumer.

Consumers will see the savings in an expected 3.5 percent drop in their premiums in the individual market, starting in 2019, according to a released statement from the Centers for Medicare and Medicaid Services and Wisconsin Governor Scott Walker. This compares to a 44 percent rate hike on premiums in 2018.

Walker submitted the waiver request for the state’s Health Care Stability Plan in April.

In an unrelated waiver request, Wisconsin has asked to impose work requirements as a condition of Medicaid beneficiaries receiving coverage.

While CMS Administrator Seema Verma and HHS Secretary Alex Azar have reportedly said that a judge’s decision in Kentucky barring work requirements will not stop the Trump administration from considering similar waivers, Wisconsin’s request awaits federal approval.

Last month, a federal judge blocked Kentucky’s plan to implement a work requirement waiver. In light of the action, CMS decided to reopen Kentucky’s 30-day federal public comment through August 18.