Tag Archives: Medicaid

Paul Ryan says GOP aiming to cut Medicare, Medicaid spending

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In further proof that Republicans are not giving up their push to enact major changes to healthcare policy, House Speaker Paul Ryan has signaled that the party will focus on cutting Medicare and Medicaid spending next year.

“We’re going to get back, next year, at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an interview with conservative talk show host Ross Kaminsky.

In addition to welfare, it’s the “healthcare entitlements”—Medicare and Medicaid—that are the major targets, Ryan said, reasoning that they are some of the biggest drivers of national debt, alongside military spending.

As evidenced by a 2015 tweet, President Donald Trump pledged as a candidate not to cut Social Security, Medicare or Medicaid, but the GOP’s legislative attempts to repeal the Affordable Care Act would have slashed Medicaid funding drastically.

Both the president and GOP lawmakers have pledged to revisit that legislation in 2018, and Ryan noted he’s making headway with convincing Trump to back Medicare cuts.

“I think the president’s understanding [that] choice and competition works everywhere in healthcare, especially in Medicare,” he said.

But while Ryan contended that entitlement reform was the logical next step after passing a tax bill that reduces revenue, Democrats don’t see it that way. They argue that Republicans only want to cut key government programs to make up for the fact that their tax bill is estimated to increase the deficit by at least $1 trillion over a decade.

Republicans’ tax bill will also have healthcare policy implications. The Senate’s version of the bill repeals the Affordable Care Act’s individual mandate, and House conservatives have said they want that provision to make it into the final draft of the legislation.

Study: ‘Big five’ insurers depend heavily on Medicare, Medicaid business

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Even as they’ve retreated from the Affordable Care Act exchanges, the country’s biggest for-profit health insurers have become increasingly dependent on Medicare and Medicaid for both profits and growth.

In fact, Medicare and Medicaid accounted for 59% of the revenues of the “big five” U.S. commercial health insurers—UnitedHealthcare, Anthem, Aetna, Cigna and Humana—in 2016, according to a new Health Affairs study.

From 2010 to 2016, the combined Medicare and Medicaid revenue from those insurers ballooned from $92.5 billion to $213.1 billion. The companies’ Medicare and Medicaid business also grew faster than other segments, doubling from 12.8 million to 25.5 million members during that time.

All these positive trends, the study noted, helped offset the financial losses that drove the firms to reduce their presence in the individual marketplaces. Indeed, the big five insurers’ pretax profits either increased or held steady during the first three years of the ACA’s individual market reforms (2013-2016). Their profit margins did decline during those three years, but stabilized between 2014 and 2016.

Not only do these findings demonstrate the “growing mutual dependence between public programs and private insurers,” the study authors said, but they also suggest a useful policy lever. The authors argued that in order to help stabilize the ACA exchanges, federal and state laws could require any insurer participating in Medicare or state Medicaid programs to also offer individual market plans in those areas.

Nevada has already done something similar: It offered an advantage in Medicaid managed care contract billing for insurers that promised to participate in the state’s ACA exchange. The state credited that policy with its ability to coax Centene to step in and cover counties that otherwise would have lacked an exchange carrier in 2018.

It’s far less certain, though, whether such a concept will ever be embraced at the federal level during the Trump administration, since its focus has been on unwinding the ACA rather than propping it up.

Either way, recent events underscore the study’s findings about how lucrative government business has become for major insurers. One of the main goals of CVS’ proposed acquisition of Aetna is to improve care for Medicare patients, which would help the combined company “be more competitive in this fast-growing segment of the market,” CVS CEO Larry Merlo said on a call this week.

Aetna CEO Mark Bertolini added that the transaction has “incredible potential” for Medicare and Medicaid members, as the goal is to provide the type of high-touch interaction and care coordination they need to navigate the healthcare system.

 

Outlook Darkens for Not-for-Profit Hospitals

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The revised outlook from Moody’s comes amid a larger-than-expected drop in cash flow this year and the ongoing uncertainty regarding federal healthcare policy for public and not-for-profit hospitals.

Moody’s Investors Service has downgraded from stable to negative its 2018 outlook for the not-for-profit hospital sector based on an expected drop in operating cash flow.

“Operating cash flow declined at a more rapid pace than expected in 2017, and we expect continued contraction of 2%-4% through 2018,” said Eva Bogaty, a Moody’s vice president.

“The cash flow spike from insurance expansion under the Affordable Care Act in 2014 and 2015 has largely worn off, but cash flow has not stabilized as expected because of a low revenue and high expense growth environment,” Bogaty said.

In a briefing released Monday, Moody’s said hospital revenue growth is slowing and is expected to remain slightly above medical inflation, which declined to a low of 1.6% in September. Hospitals can’t translate volume growth into stronger revenue growth because of the lower reimbursement rate increases across all insurance providers and higher expense growth.

In addition, rising exposure to governmental payers will dampen revenue growth for the foreseeable future due to a rapidly aging population and low reimbursement rates. Medicare and Medicaid, represent 60% of gross patient revenue in 2017, Moody’s said.

Key drivers of expense growth include rising labor costs, driven by an acute nursing shortage and ongoing physician and medical specialist hiring. Technology costs are also rising as systems are upgraded and IT staff is needed for training and maintenance. While the ACA’s arrival heralded a drop in bad debt from 2014-16, bad debt rebounded in 2017 and will continue to grow at a rate of 6%-7% in 2018, Bogaty said.

“Rising copays and use of high deductible plans will increase bad debt for both expansion and non-expansion states,” she said.

In the near-term, uncertainty regarding federal healthcare policy will have a marginal fiscal impact on NFP hospitals. Bogaty said ambiguity surrounding the ACA does affect the planning and modelling of long-term strategies, while recent federal tax proposals will add to rising costs for hospitals.

The outlook could be revised to stable if operating cash flow resumes growth of 0%-4%. A change to positive could result from expectations of accelerated operating cash flow growth of more than 4% after inflation, Moody’s said.

Five health-care fights facing Congress in December

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Five health-care fights facing Congress in December

Five health-care fights facing Congress in December

Health-care issues are at the top of Congress’s hefty December to-do list.

Republicans spent much of the year on a failed bid to repeal and replace ObamaCare. That’s left several programs and taxes hanging in the balance as the year draws to a close, in addition to the latest health-care drama thrust into the GOP tax-reform debate.

Here are five of the biggest health-care issues Congress will face next month.

Will Republicans repeal the individual mandate?

Weeks ago, Sen. Tom Cotton (R-Ark.) began to push for a repeal of the individual mandate to be added into the GOP tax overhaul. It worked, at least in the upper chamber.

To Democrats’ dismay, the Senate Finance Committee passed a tax-reform bill before breaking for Thanksgiving that included repeal of the ObamaCare mandate that Americans without health insurance pay a fee.

The House already passed a bill out of its chamber on a party-line vote — legislation that didn’t include repealing the individual mandate. But leaders have said they’re open to it if the Senate is able to muster enough votes to pass tax reform with the repeal.

It appears that the upper chamber might be able to pull it off.

Sen. Susan Collins (R-Maine) has said the repeal shouldn’t be in the bill, but hasn’t said she would vote against the tax-reform bill if it was included. Sen. John McCain (R-Ariz.) hasn’t rung any alarms that he would vote against the bill, saying he wants to see the whole package before deciding, and applauding the Finance Committee for holding hearings on the measure.

In a boost to the effort, Sen. Lisa Murkowski (R-Alaska) wrote in the Fairbanks Daily News-Miner Tuesday that she backs repealing the individual mandate. All three senators voted against a scaled-down version of an ObamaCare repeal bill in late July, effectively sinking the measure.

GOP leaders have signaled that a bipartisan stabilization bill from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) could pass if the individual mandate is repealed. On Sunday, Collins said she would like the Alexander-Murray bill, along with a bipartisan bill to provide funding for high-cost enrollees she introduced, to pass before tax reform does.

Sen. John Cornyn (Texas), the Senate’s No. 2 Republican, said that the deal is “likely” to be included in an end-of-the-year package.

But that effort could face resistance from Democrats, who have balked at repealing the individual mandate, and say that runs counter to the bipartisan spirit that Alexander-Murray was crafted under.

Will Congress reauthorize critical health programs it let lapse?

It’s been nearly two months since funding for the Children’s Health Insurance Program (CHIP) and community health centers expired. Advocates are holding out hope that lawmakers will reauthorize both before the new year, but are frustrated that Congress failed to reauthorize the dollars by a Sept. 30 deadline.

Roughly 9 million low- and middle-income children rely on CHIP for health coverage. Some states have asked the Centers for Medicare and Medicaid Services for funding to hold them over in the interim, and the agency has awarded about $607 million in redistributed funds to states and U.S. territories.

Community health centers have been crafting contingency plans as they wait for Congress to reauthorize a fund that amounts to 70 percent of their federal funding. These centers are a large source of comprehensive primary care for over 26 million of the nation’s most vulnerable people.

Some have already instituted hiring freezes. Others are examining which services they could cut or scale back. If the funding lapses, staff could be laid off, facility renovations or expansions could be canceled or delayed and hours of operation could be reduced.

Though the uncertainty has caused angst for health centers, they haven’t yet seen a monetary impact. But that impact could come on Jan. 1 for 25 percent of centers and on Feb. 1 for another 17 percent, because that’s when their new grant periods begin.

The Health Resources and Services Administration plans to help out on a prorated, monthly basis, according to a spokesperson.

But advocates hope it won’t come to that. The House passed a bill to fund CHIP for five years and community health centers for two. It passed on a party-line vote, as Democrats criticized how Republicans planned to pay for the bill.

The Senate Finance Committee passed a bipartisan, five-year CHIP extension, but hasn’t yet released offsets. Sens. Debbie Stabenow (D-Mich.) and Roy Blunt (R-Mo.) have introduced a bipartisan bill to extend community health center funding for five years.

Will Congress fund the opioid response?

In late October, President Trump declared the opioid epidemic a national public health emergency.

But the move didn’t come with millions of new dollars to combat the crisis, nor did it include a funding ask to Congress. This has frustrated Democrats and many advocates, who say a significant infusion of federal funds is needed to make an emergency declaration effective.

It’s not clear if money will come.

Senate Democrats introduced a bill to provide $45 billion over 10 years to address the crisis — a nod to a similar amount of funding Republicans included in an ObamaCare repeal bill, in part to attempt to offset changes to Medicaid.

But Republicans haven’t named a dollar figure. With a jam-packed December, advocates worry the new year could begin without more money to help curb the crisis of prescription painkillers and heroin that’s ravaged the country.

As for the administration, Hogan Gidley, White House deputy press secretary, said in a statement that “we will continue discussions with Congress on the appropriate level of funding needed to address this crisis” but didn’t say how much that would be.

What does Congress do on ObamaCare taxes?

Behind the scenes, industry lobbyists are working hard to ensure several ObamaCare taxes won’t kick in come January.

The medical device industry wants a full repeal of a 2.3 percent tax on the sale of certain medical devices, such as pacemakers and MRI machines.

“We feel we’re very much in play and that is for full repeal,” said Greg Crist, a spokesman for the medical device trade association AdvaMed. “We’re talking with staff and leadership for the right vehicle.”

The insurance industry is pushing for at least a one year delay of the health insurance tax. Both taxes were delayed in a 2015 spending bill, though for different durations; the medical device tax was paused for two years, and the health insurance tax for just 2017.

Ways and Means Chairman Kevin Brady (R-Texas) addressed the ObamaCare taxes during a marathon hearing on House Republican’s tax-reform bill, saying the legislation wasn’t the right vehicle to repeal or delay them. But, he added, he is working to do so by the end of the year.

“As the ranking member and members on both sides of the aisle know — we have been working with them over the past month to find a path forward,” Brady said. “We are working on common-sense temporary and targeted relief from many of these taxes to be acted on in the House before the end of the year.”

Employer groups are also pushing for a delay of the so-called Cadillac tax, a 40 percent fee levied on pricey employer-sponsored plans slated to begin in 2020. Critics of the tax argue a delay is needed now because employers will begin planning for 2020 next year.

Will Congress help Puerto Rico fund its Medicaid program?

The storm-ravaged island territory could be out of federal dollars for its Medicaid program in a matter of months.

Federal disaster funds haven’t been earmarked to go to the joint state-federal health insurance program for low-income and disabled Americans. On Nov. 17, the White House asked Congress for $44 billion for disaster relief. The notice mentioned Puerto Rico’s Medicaid program, but didn’t put a dollar amount on it.

“Though the Administration expects to work with Puerto Rico and the Congress on medium-term liquidity issues through a future request, the Administration is aware of legislation being considered to address Medicaid sooner,” the letter stated.

Puerto Rico Gov. Ricardo Roselló has asked for $1.6 billion annually for five years. Democratic lawmakers and advocates have been pushing to fulfill that request.

 

Senate GOP Tax Cut Bill Heads To Full Senate With Individual Mandate Repeal

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https://www.healthaffairs.org/do/10.1377/hblog20171117.748105/full/

November 19 Update: Distributional Effects Of Individual Mandate Repeal

Late in the day of November 17, 2017, the Congressional Budget Office released a letter it had sent to Senator Ron Wyden, ranking member of the Senate Finance Committee, on the Distributional Effects of Changes in Spending Under the Tax Cuts and Jobs Act as of November 15, 2017 as they are affected by repeal of the Affordable Care Act’s Individual Responsibility Provision. The letter updated the analysis the JCT had released on November 15 of the distributional effects of the Tax Act that had focused solely on the effects of the legislation on revenues and refundable tax credits. The update also addressed changes the repeal of the mandate would cause in other federal expenditures, including cuts in Medicaid, cost-sharing reductions (which CBO sees as mandatory spending and thus includes in its analysis), and Basic Health Program spending, as well as increases in Medicare disproportionate share hospital payments.

The analysis concludes that under the Tax Bill, federal spending allocated to people with incomes below $50,000 a year would be lower than it would otherwise have been over the next decade. For example, CBO projects federal spending for people with incomes under $10,000 will be $9.7 billion less in 2027 than it otherwise would have been, spending on people with incomes from $10,000 to $20,000 will be $9.8 billion less; spending on people with incomes from $20,000 to $30,000 will be $8.7 billion less, spending on people with incomes from $30,000 to $40,000 will $3 billion less; and spending on people with incomes from $40,000 to $50,000 will be $1.2 billion less. The CBO calculated these figures by calculating the number of people who are projected to drop Medicaid enrollment in each income category and their average Medicaid cost considering age, income, disability status, and whether they gained coverage under the ACA.

More controversially, the CBO determined that individuals with incomes above $50,000 would benefit from the repeal. People with incomes between $100,000 and $200,000 would receive $1.7 billion more and people with incomes over $1 million would receive $440 million more. These increases are due to the increased expenditures on Medicare that will result from the bill, half of which the CBO distributed evenly across the population and half of which it allocated in proportion to each tax filing unit’s share of total income. As the increased Medicare disproportionate share payments are in fact paid directly to providers to cover their costs for serving the uninsured, who will predominantly be low-income, this seems to be an odd way to allocate these expenditures, although it is apparently standard CBO cost allocation practice, and ensuring that hospitals are not overwhelmed by bad debt does benefit people from all income categories.

The CBO specifies that it only considered the cost of the spending or spending reduction to the government, not the value placed on that spending by the recipients of the coverage it would purchase. A person who fails to enroll in Medicaid because the mandate is dropped is unlikely to value it at its full cost. Moreover, and importantly, the CBO did not take into account the cost of the mandate repeal to those who will feel it most acutely—individuals who are purchasing coverage in the individual market without subsidies who will face much higher premiums if the mandate is repealed.

The CBO also failed to consider the medical costs that will be incurred by individuals who drop health insurance coverage or the costs to society generally of a dramatic increase in the number of the uninsured.

Original Post

On November 16, 2017, the Senate Finance Committee approved by a party-line 14-to-12 vote a tax cut bill that will now be sent to the full Senate. The bill includes a repeal of the penalty attached to the Affordable Care Act (ACA)’s individual responsibility provision. This provision requires individuals who do not qualify for an exemption to obtain minimum essential coverage or pay the penalty.

A “Twofer” For Republicans: Additional Continuing Revenue And Elimination Of The ACA’s Least Popular Provision

The repeal of the individual mandate was included in the tax bill for two reasons. First, the Joint Committee on Taxation (JCT­) scored the repeal as reducing the deficit by $318 billion over ten years. This repeal would provide enough savings, including continuing savings in years beyond 2027, to allow Republicans to permanently reduce the corporate tax rate without increasing the deficit by more than $1.5 trillion or otherwise violating budget reconciliation requirements. Second, it would allow Republicans to get rid of the least popular provision of the ACA, making up in part for their failing to repeal the ACA despite a summer of efforts.

The savings that will supposedly result from the repeal of the individual mandate come entirely from individuals losing health coverage which the federal government would otherwise help finance.  A cost estimate released by the Congressional Budget Office (CBO) on November 8, 2017 projected that repeal of the mandate would cause 13 million individuals to lose coverage by 2017, including five million individual market enrollees, five million Medicaid recipients, and two to 3 million individuals with employer coverage.

The CBO estimated that this loss of coverage would result in reductions over ten years of $185 billion in premium tax credits and $179 billion in Medicaid expenditures and a change in other revenues and outlays of about $62 billion, primarily attributable to increased taxes imposed on people who would lose employer coverage. (The increases would be offset by $43 billion in lost individual mandate penalty payments and a $44 billion increase in Medicare disproportionate share hospital payments to hospitals that bore the burden of caring for more uninsured patients.)

The total reduction in the federal deficit, in the opinion of the CBO, would be $338 billion over ten years. (The difference between the $318 billion in savings in the JCT tax bill score and the $338 billion in the earlier CBO/JCT individual mandate repeal cost estimate is presumably due to the fact that the Finance bill would only repeal the mandate penalty, not the mandate itself, and some individuals would presumably continue to comply with the mandate even without the penalty because it is legally required.) The JCT also projects that the repeal of the mandate will effectively result in a tax increase for individuals with incomes below $30,000 a year because of the loss of tax credits that will accompany the loss of coverage, further tipping the benefits of the tax cut bill toward the wealthy.

Behind The Coverage Loss Estimate

At first glance, the estimate that 13 million would lose coverage from the repeal of the mandate, including five million who would give up essentially free Medicaid, seems improbable.  Moreover, supporters of the tax bill contend that no one would be forced to give up coverage—coverage losses would all be voluntary. And, the argument continues, most of the people who are now paying the mandate penalty earn less than $50,000 a year, so repeal of the mandate will in fact be beneficial to lower-income individuals.

In fact, the CBO’s estimates of coverage losses (and budget savings) may be too high. The November 8 CBO estimates were lower than earlier estimates, and the CBO admits that it is continuing to evaluate is methodology for estimating the effect of the individual mandate. There is substantial confusion regarding the mandate requirement. A fifth of the uninsured, according to a recent poll, believe that the individual market is no longer in effect while another fifth do not know whether it is or not. Compliance with the mandate may already be slipping—the Treasury Inspector General reported in April that filings including penalty payments were as of March 31 down by a third from 2015. Part of the potential effect of repeal is already being felt.

Although the mandate repeal would not go into effect until 2019, media coverage will surely cause even further confusion and even more people to drop coverage, likely dampening enrollment for 2018 in the open enrollment period currently underway.

S&P Global released a report on November 16 estimating that only three to five million individuals would lose coverage from the mandate repeal. Coverage losses of this magnitude, however, would only result in savings of $50 to $80 billion over the ten-year budget window, meaning the tax bill would add another $240 to $270 billion to the deficit and put it in violation of the budget reconciliation rules.

Whatever the level of loss of coverage under a mandate repeal, it is reasonable to believe that it would be extensive. The CBO estimated that repeal of the mandate would drive up premiums in the individual market by 10 percent. Without the mandate, healthy individuals would drop out, pushing up premiums for those remaining in the market. Unlike the increases caused by the termination of cost-sharing reduction payments, this increase would likely be loaded onto premiums for plans of all metal levels and onto premiums for enrollees across the individual market, including off-exchange enrollees. Moreover, repeal of the mandate would likely cause another round of insurer withdrawals from the individual market as insurers concluded that the market was just too risky. Insurers left as the lone participant in particular markets without competition to drive down premiums would likely raise their premiums well above 10 percent.

Who Would Have The Most To Lose From A Mandate Repeal?

The biggest losers from a mandate repeal would be individuals who earn more than 400 percent of the federal poverty level and thus bear the full cost of coverage themselves.  These are the farmers, ranchers, and self-employed small business people who have traditionally bought coverage in the individual market. They are also include gig-economy workers and entrepreneurs who have been liberated by the ACA from dead-end jobs with health benefits to pursue their dreams. Their increased premiums might well offset any tax cut they receive under the bill.

If members of these groups are healthy, they might be able to find cheap coverage through short-term policies which the Trump Administration has promised to allow to last longer than the current three month limit and to be renewable. But those policies will not cover individuals with preexisting conditions.  And if healthy individuals are allowed to purchase full-year “short-term” coverage without having to pay an individual mandate penalty, even more healthy people will leave the individual market, driving premiums up even higher as the individual market becomes a high risk pool for individuals not eligible for premium tax credits. As premiums increased, so would premium tax credits, driving up the cost for the federal government.

The CBO estimate that five million will lose Medicaid coverage seems questionable, as Medicaid coverage is essentially free for most beneficiaries. But, particularly in Medicaid expansion states, there is a thin line between individual market and Medicaid eligibility, and many people who apply for individual market coverage find out that they are in fact eligible for Medicaid. Without the mandate, fewer are likely to apply at all. Moreover, Medicaid does not have open enrolment periods—people can literally apply for Medicaid in the emergency room, and many do. Without the mandate many will likely forgo the hassle of applying (or more likely reapplying) for Medicaid and only get covered when they need expensive hospital care. But they will thereby forgo preventive and primary care that could have obviated an emergency room visit or hospitalization.

Finally, in many families, parents are insured in the individual market but children are on Medicaid or CHIP. Without the mandate, the parents may forgo coverage, causing the children to lose coverage as well—and with it access to preventive and primary care.

The Involuntary Impact From ‘Voluntary’ Coverage Losses

Even if these coverage losses are “voluntary,” they will affect many who continue to want coverage. As already noted, as healthy people leave insurance markets, costs will go up for those who remain behind. Some of these will be people who really want, indeed need, coverage but will no longer find it affordable, and who will thus involuntarily lose coverage. Indeed, this effect may extend beyond the individual market. As healthy individuals drop employer coverage, costs may go up for those employees left behind.

Moreover, the voluntarily uninsured will inevitably have auto accidents or heart attacks or find out that they have cancer. Many will end up receiving uncompensated care, undermining the financial stability of health care providers saddled with ever higher bad debt, and driving up the cost of care for the rest of us.

Republican repeal bills offered earlier this year included other approaches to encouraging continuous enrollment—imposing health status underwriting or late enrollment penalties on those who failed to maintain continuous coverage, for example. The tax bill includes no such alternatives, nor could it.  It may be possible that states could step into the gap. Massachusetts, for example, had an individual mandate penalty even before the ACA; it was the model for the ACA. The District of Columbia Exchange Board has recommended that D.C. impose its own individual mandate tax if the federal mandate ceases to be enforced. Perhaps other states will step into the gap. But I am not counting on many doing so.

The individual mandate is there for a reason. It is intended to drive healthy as well as unhealthy individuals into the individual market and thus make coverage of people with preexisting conditions possible. It has been a significant contributor to the record reductions in the number of the uninsured brought about by the ACA. Without the individual mandate, the number of the uninsured would once again rise. Maybe not by 13 million, but nonetheless significantly.

 

Beyond Showmanship And Spite: Toward A Health Care “Grand Bargain”

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https://www.healthaffairs.org/do/10.1377/hblog20171116.24714/full/

Is a deal on health care possible? Conventional wisdom says no. “Repeal and Replace” is dead, and Republicans have moved on. So have many Democrats, toward pursuit of a single-payer plan that’s going nowhere on Capitol Hill but energizes the party’s core. Last month, President Donald Trump said he’ll “dismantle” the Affordable Care Act (ACA) on his own—and backed this up with executive orders that risk the stability of the insurance exchanges.

Democrats are angry that Trump and congressional Republicans want to repeal the ACA and roll back its expansion of health insurance coverage. Republicans are angry that Democrats pushed “Obamacare” through Congress on a party-line basis, and they see the ACA as big government running amok. Both parties are positioning themselves for primaries, and neither shows much interest in the risky work of compromise.

We’re alarmed. One of us is a Cato Institute-friendly “free-market”eer who wrote a book arguing (tongue in cheek) that Medicare is the work of the Devil. The other helped to develop President Barack Obama’s 2008 campaign health plan and believes that failure to ensure everyone’s access to health care is an assault on human decency. But we’ve come together because we believe that failure to resolve the present impasse will have hugely destructive consequences for millions of Americans’ access to health care—and for our national confidence in our political system’s capacity to function.

Designing A Deal

President Trump has cut off cost-sharing reduction subsidies to insurers and issued a directive to allow coverage options less comprehensive than the ACA requires—measures that threaten to unravel the individual and small-group markets by incentivizing younger and healthier people to exit. Meanwhile, the uncertainty that besets federal funding under the ACA for Medicaid expansion poses huge fiscal risks for states, as does Congress’s failure, so far, to renew funding for the Children’s Health Insurance Program (CHIP). And over the longer term, soaring private and public spending on medical services that deliver doubtful value erodes US productivity and well-being.

We think a bipartisan “grand bargain” to stabilize the US health care system is feasible—if key decision makers can move beyond showmanship and spite. To this end, we outline a deal that: honors but balances the competing values at stake, steadies both market and public mechanisms of medical care financing, and puts the nation on a path toward sustainability in health spending.

Our grand bargain builds on federalism. Vastly different values, priorities, and interests stand in the way of nationwide health policy uniformity. Allowing states to sort out controversial matters within broader limits than the ACA now imposes would permit creative policy alternatives to unfold and encourage local buy-in. We needn’t and shouldn’t mandate definitive answers to bitterly contested questions that can be reasonably negotiated at the state or local level. Instead, we should open political and market pathways for the emergence of answers to these questions over time.

Moving to this long game will require all sides to pass on their pursuit of a quick political win. Doing so is the key to moving from cycles of backlash and volatility to a system that builds confidence and delivers high-quality, compassionate health care to all.

The Long Game: Seven Steps Toward a Compromise that Can Work And Endure

With these basic principles in mind, we propose the following seven steps:

Moving Beyond Maximalism—Medicaid Rollback And “Medicare for All”

Republicans should end their campaign to roll back the ACA’s Medicaid expansion, and Democrats should stand down on their quest for single payer. Both pursuits inspire true believers but will go nowhere on Capitol Hill for the imaginable future.

State Flexibility

Give states more flexibility to design their Medicaid programs and to govern their insurance exchanges. One approach would be to simply allow states complete flexibility to design their own coverage rules. Alternatively, we could give states more flexibility but ensure, via federal law, that Medicaid and plans sold on the exchanges provide affordable access to effective preventive, diagnostic, and therapeutic services. States could also be allowed but not required to offer a public option through their exchanges. Instead of an all-or-none answer to the public plan question, the nation would have a framework for market-driven, state-by-state resolution. Similarly, states should be allowed to decide whether to prohibit, permit, or require enrollment of Medicaid beneficiaries in private plans. Finally, when it comes to care that serves culturally contested purposes—including, but not limited to, gender reassignment or confirmation and late termination of pregnancies for nontherapeutic reasons—states should be given autonomy to go their own ways. More federalism will achieve greater stability than would temporary nationwide imposition of one or another approach by whichever party happens to hold the electoral upper hand.

Health Savings Accounts That Appeal To Everyone

An expanded role for tax-protected health savings should have bipartisan appeal. We propose that every lawful US resident be auto-enrolled in a health savings account (HSA), funded through a refundable tax credit, scaled to income and family size. People could opt out but would lose this credit if they did. Few would do so, enabling HSAs to become a means for pursuing both market discipline and social equity.

Repeal The Individual Mandate

Sacrilege, you’re surely thinking, if you’re a Democrat who’s spent seven-plus years defending the mandate, the ACA’s most disliked element. But the mandate isn’t needed to keep healthy people in community-rated risk pools—it’s the intensity of the incentives, whether framed as penalties or subsidies, that matters. Even the mandate’s most outspoken economist-defender, Jonathan Gruber, concedes that high-enough subsidies for the purchase of insurance can substitute for it.

Such subsidies could be supplied in conservative-friendly fashion by allowing all who buy coverage on the exchanges to put HSA funds (including the tax credit we urge) toward their premiums. Sign-up for coverage could also be made more user-friendly through auto-enrollment, subject to opt-out, in “silver” plans (for tax filers who aren’t otherwise covered and aren’t Medicaid eligible). A more robust approach might condition the refundable HSA tax credit on tax filers’ purchasing insurance (or not opting out of auto-enrollment).

Congressional Authorization Of Funding For Both The ACA’s Cost-Sharing Reductions And CHIP

There is bipartisan support for restoring the ACA’s cost-sharing reduction subsidies and extending CHIP. Although annual appropriations are the norm, Congress should guarantee funding for the cost-sharing reductions for a two-year period, with automatic renewal for an additional two years if per capita subsidies rise by no more than the Consumer Price Index (CPI) during the prior two years. By so doing, Congress can reaffirm its authority over appropriations while helping to stabilize markets for individual coverage. Likewise, Congress should renew CHIP’s funding for several years—we urge three as a compromise—to both stabilize state budgets and secure health care for the millions of children who depend on this program.

The “Long Game”—Reining In Medical Spending

A long-term effort to contain spending growth is essential for US fiscal stability and consumer well-being. The ACA created a framework for doing this. The Independent Payment Advisory Board (IPAB) can limit Medicare spending, subject to congressional veto, if growth exceeds target rates. And the 40 percent “Cadillac tax” on high-cost private health plans will cover a rising share of the private market as medical costs increase. Together, these policies have the potential to contain clinical spending by capping demand. But there’s bipartisan opposition to both. The IPAB, which hasn’t yet been established, and the Cadillac tax, now delayed until 2020, are fiercely opposed by stakeholders with lots to lose, and they’re at high risk of repeal.

A grand bargain should follow through on both of these strategies, plus add similar restraints on Medicaid spending and on the amounts spent to subsidize coverage through the exchanges. Most other nations employ global budgeting to control health spending. For reasons of federalism, public philosophy, and market structure, global budgeting isn’t an option for the US. But a coordinated scheme of restraint, based on the best available behavioral and economic modeling, could apply similar braking power to our entire health economy. There’s plenty of room for argument about design details (that is, should per capita growth targets be based on the CPI? The CPI plus 1 percent?) and methods of restraint (that is, the IPAB approach? Spending caps for public programs? The Cadillac tax versus caps on tax deductibility of insurance premiums?). Continued bipartisan evasion will only make the problem worse.

Pursuing Therapeutic Value

Much more must be done to use health care resources wisely as constraints tighten. Tying financial rewards closely to clinical value via paymentpractices, market exclusivity policies, and other incentives will be critical—and will require the clearing of legal and regulatory obstacles. Voluntary action must also play a role: The grand bargain we’ve sketched here creates myriad opportunities for providers, patients, and insurers to gain by insisting on value from a sector of the economy that too often fails to deliver it.

To be sure, politics could foil all efforts to forge compromise. But there is a way forward. Our proposals achieve much that is important to both the ACA’s fiercest critics and staunchest defenders. They work in concert to address the political and market crises that immediately threaten our health care system, while laying the foundation for a long-term approach to control medical spending’s unsustainable growth.

Medicaid Expansion Has Improved the Financial Outlook for Safety-Net Hospitals

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http://www.commonwealthfund.org/publications/issue-briefs/2017/nov/financial-impact-state-medicaid-expansion-safety-net-hospitals

Abstract

  • Issue: Safety-net hospitals play a vital role in delivering health care to Medicaid enrollees, the uninsured, and other vulnerable patients. By reducing the number of uninsured Americans, the Affordable Care Act (ACA) was also expected to lower these hospitals’ significant uncompensated care costs and shore up their financial stability.
  • Goal: To examine how the ACA’s Medicaid expansion affected the financial status of safety-net hospitals in states that expanded Medicaid and in states that did not.
  • Methods: Using Medicare hospital cost reports for federal fiscal years 2012 and 2015, the authors compared changes in Medicaid inpatient days as a percentage of total inpatient days, Medicaid revenues as a percentage of total net patient revenues, uncompensated care costs as a percentage of total operating costs, and hospital operating margins.
  • Findings and Conclusions: Medicaid expansion had a significant, favorable financial impact on safety-net hospitals. From 2012 to 2015, safety-net hospitals in expansion states, compared to those in nonexpansion states, experienced larger increases in Medicaid inpatient days and Medicaid revenues as well as reduced uncompensated care costs. These changes improved operating margins for safety-net hospitals in expansion states. Margins for safety-net hospitals in nonexpansion states, meanwhile, declined.

Background

Through their missions or legal mandate, safety-net hospitals provide care to all patients, regardless of their ability to pay.1 They include public hospitals, which are often providers of last resort in their communities; academic medical centers, which combine their teaching function with a mission to serve vulnerable populations; and certain private hospitals.

Safety-net hospitals deliver a significant level of care to low-income patients, including Medicaid enrollees and the uninsured, typically providing services that other hospitals in the community do not offer — trauma, burn care, neonatal intensive care, and inpatient behavioral health, as well as education for future physicians and other health care professionals. They are also an important source of care to uninsured individuals who are ineligible for Medicaid or subsidized marketplace coverage because of their citizenship status.2

Several studies have suggested major reductions in uncompensated care and improved financial status at safety-net institutions in states that expanded Medicaid compared to those in states that did not expand.3,4 However, these results were based on interviews with a limited number of safety-net health system executives and staff. Our analysis expands on this research by examining changes in key financial metrics — that is, uncompensated care, Medicaid costs and revenues, and total hospital margins–across safety-net hospitals nationally using standardized data.

When compared to other short-term acute care hospitals, hospitals that met our safety-net hospital criteria had substantially higher Medicaid revenue and uncompensated care levels than non-safety-net hospitals. Safety-net hospitals, however, had lower operating margins (Exhibit 1).

Below we discuss findings on the impact of the Affordable Care Act’s (ACA) Medicaid expansion on safety-net hospitals’ financial status. The ACA allowed states to expand Medicaid eligibility to nonelderly adults with incomes up to 138 percent of the federal poverty level. The reduction in the number of uninsured under the ACA coverage expansions was expected to reduce the uncompensated care that hospitals provide, thus improving their financial status. As of 2015, 31 states and the District of Columbia had expanded Medicaid, while 19 states had not.5

We measure changes in the financial status of safety-net hospitals in states that expanded Medicaid prior to 2015 (326 hospitals) versus safety-net hospitals in states that did not expand or expanded in 2015 or after (268 hospitals). (See “How We Conducted This Study” for complete methods.)

Key Findings

Our analysis of Medicare cost report data for federal fiscal years 2012 and 2015 shows a sizable contrast in financial performance between safety-net hospitals in states that expanded Medicaid under the ACA and those in states that did not. Performance metrics included the following:

    • Hospital operating margins.6 Operating margins improved for safety-net hospitals located in Medicaid expansion states compared with declines for those in states that did not expand. From 2012 to 2015, operating margins for safety-net hospitals in Medicaid expansion states increased from –3.2 percent to –2.1 percent in 2015 (Exhibit 2, Appendix A). In contrast during the same period, operating margins for safety-net hospitals in nonexpansion states declined from 2.3 percent to 2.0 percent. Largely accounting for this difference were increased Medicaid revenues and reduced uncompensated care costs. Even after expansion, safety-net hospitals’ operating margins in Medicaid expansion states were lower than those in nonexpansion states.
    • Medicaid inpatient days. From 2012 to 2015, safety-net hospitals in Medicaid expansion states experienced larger growth in Medicaid utilization than those in nonexpansion states (Exhibit 3). During the study period, Medicaid inpatient days in expansion states rose 13.5 percent. In comparison, Medicaid inpatient days in nonexpansion states fell slightly, by 0.9 percent.
    • Medicaid revenues and costs.7 The rise in use of safety-net hospitals in Medicaid expansion states resulted in these hospitals’ increased Medicaid revenue and costs compared to a slight decline in nonexpansion states (Exhibit 4). From 2012 to 2015, safety-net hospitals’ Medicaid revenues as a share of net patient revenues rose 12.7 percent in Medicaid expansion states. In contrast, during the same period, safety-net hospitals’ Medicaid revenues as a share of net patient revenues declined 1.8 percent in nonexpansion states. However, safety-net hospitals’ profit margins on Medicaid patients fell from 6.8 percent to 0.7 percent in expansion states, suggesting that the revenues received for newly eligible patients did not keep pace with the higher cost of treating these patients.
    • Uncompensated care costs.8 In 2012, safety-net hospitals’ uncompensated care costs as a percent of total hospital operating costs equaled 6.7 percent in expansion states compared to 5.7 percent in nonexpansion states (Exhibit 5). By 2015, however, the safety-net hospitals’ share of uncompensated care declined to 3.5 percent in expansion states, or a reduction of 47.4 percent. By comparison, in nonexpansion states that year, uncompensated care costs as a share of total hospital operating costs fell to 5.3 percent, a 7.8 percent reduction.

Discussion

These data suggest that the Medicaid expansion created by the ACA had a significant positive financial impact on safety-net hospitals in states that expanded Medicaid eligibility relative to those in states that did not expand. Safety-net hospitals in expansion states saw larger increases in Medicaid patient volume and revenue, reduced uncompensated care, and improved financial margins compared to safety-net hospitals in nonexpansion states. Although our study’s results are specific to safety-net hospitals, other studies have found similar trends across all hospitals in expansion and nonexpansion states.9

The improved financial stability of safety-net hospitals could allow these hospitals to continue expanding outpatient capacity, invest in strategies to improve care coordination, hire new staff, and develop better infrastructure to monitor costs.10 Such investments can also help prepare hospitals for new payment arrangements that may require them to assume more financial risk for patient care and outcomes. Improvements not only benefit the institutions and Medicaid patients but the communities these hospitals serve.

Current attempts to repeal the ACA aim to eliminate the Medicaid expansions over time and curtail Medicaid spending by more than $800 billion over 10 years. The Congressional Budget Office estimates that about 14 million people could lose their Medicaid coverage by 2026, which would have an adverse effect on safety-net hospitals in those states. Specifically, safety-net hospitals’ gains in reduced uncompensated care and improved overall financial margins could be lost in the future.

 

Ambulance trips can leave you with surprising — and very expensive — bills

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https://www.washingtonpost.com/national/health-science/ambulance-trips-can-leave-you-with-surprising–and-very-expensive–bills/2017/11/17/6be9280e-c313-11e7-84bc-5e285c7f4512_story.html?tid=ss_tw-bottom&utm_term=.78d3dfa36d97

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One patient got a $3,660 bill for a four-mile ride. Another was charged $8,460 for a trip from a hospital that could not handle his case to another that could. Still another found herself marooned at an out-of-network hospital, where she’d been taken by ambulance without her consent.

These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting 21 states to pass laws over the years protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills and with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.

Patients usually choose to go to the doctor, but they are vulnerable when they call 911 or get into an ambulance. The dispatcher picks the ambulance crew, which may be the local fire department or a private company hired by the municipality. The crew, in turn, often picks the hospital. Moreover, many ambulances are not summoned by patients, but by police or a bystander.

Betsy Imholz, special projects director at the Consumers Union, which has collected more than 700 patient stories about surprise medical bills, said at least a quarter concern ambulances.

“It’s a huge problem,” she said.

Forty years ago, most ambulances were free for patients, provided by volunteers or town fire departments using taxpayer money, said Jay Fitch, president of Fitch & Associates, an emergency services consulting firm. Today, ambulances are increasingly run by private companies and venture capital firms. Ambulance operators now often charge by the mile and sometimes for each “service,” such as providing oxygen. If the ambulance is staffed by paramedics rather than emergency medical technicians, that will result in a higher charge — even if the patient didn’t need paramedic-level services. Charges range from zero to thousands of dollars.

The core of the problem is that ambulance companies and private insurers often can’t agree on a fair price, so the ambulance service doesn’t join the insurer’s network. That leaves patients stuck with out-of-network charges that are not negotiated, Imholz said.

This happens to patients frequently, according to a recent study of more than half a million ambulance trips taken by patients with private insurance in 2014. The study, by two staffers at the Federal Trade Commission, found that 26 percent of these trips were billed on an out-of-network basis.

That figure is “quite jarring,” said Loren Adler, co-author of a recent report on surprise billing.

The KHN review of complaints revealed two common scenarios leaving patients in debt: First, patients get into an ambulance after a 911 call. Second, an ambulance transfers them between hospitals. In both scenarios, patients later learn the fee is much higher because the ambulance was out-of-network, and after the insurer pays what it deems fair, they get a surprise bill for the balance, also known as a “balance bill.”

The Better Business Bureau has received nearly 1,200 consumer complaints about ambulances in the past three years; half were related to billing, and 46 mentioned out-of-network charges, spokeswoman Katherine Hutt said.

While the federal government sets reimbursement rates for patients on Medicare, it does not regulate ambulance fees for patients with private insurance. Those patients are left with a highly fragmented system in which the cost of a similar ambulance trip can vary widely from town to town. There are about 14,000 ambulance services across the country, run by governments, volunteers, hospitals and private companies, according to the American Ambulance Association. (The Washington area reflects that mix.)

For a glimpse into the unpredictable system, consider the case of Roman Barshay. The 46-year-old software engineer, who lives in Brooklyn, was visiting friends in the Boston suburb of Chestnut Hill last November when he took a nasty fall.

Barshay felt a sharp pain in his chest and back, and he had trouble walking. An ambulance crew responded to a 911 call at his friends’ house and drove him four miles to Brigham and Women’s Hospital, taking his blood pressure as he lay down in the back. Doctors there determined he had sprained tendons and ligaments and a bruised foot, and released him after about four hours, he said.

After Barshay returned to Brooklyn, he got a bill for $3,660, or $915 for each mile of the ambulance ride. His insurance had covered nearly half, leaving him to pay the remaining $1,890.50.

“I thought it was a mistake,” Barshay said.

But Fallon Ambulance Service, the private company that brought him to the hospital, was out-of-network for his UnitedHealthcare insurance plan.

“The cost is outrageous,” said Barshay, who reluctantly paid the bill after Fallon sent it to a collection agency. If he had known what the ride would cost, he said, he would at least have been able to refuse the ride and “crawl to the hospital myself.”

In a statement, UnitedHealthcare said: “Out-of-network ambulance companies should not be using emergencies as an opportunity to bill patients excessive amounts when they are at their most vulnerable.”

“You feel horribly to send a patient a bill like that,” said Peter Racicot, senior vice president of Fallon, a family-owned company based outside Boston.

But ambulance firms are “severely underfunded” by Medicare and Medicaid, Racicot said, so Fallon must balance the books by charging higher rates for patients with private insurance.

Racicot said his company has not contracted with Barshay’s insurer because they couldn’t agree on a fair rate. When insurers and ambulance companies can’t agree, he said, “unfortunately, the subscribers wind up in the middle.”

It’s also unrealistic to expect EMTs and paramedics at the scene of an emergency to determine whether their company takes a patient’s insurance, Racicot added.

Ambulance services must charge enough to subsidize the cost of keeping their crews ready around the clock, said Fitch, the ambulance consultant. In a third of the cases where an ambulance crew answers a call, he added, they end up not transporting anyone and the company typically isn’t reimbursed for the trip.

In part, Barshay had bad luck. If his injury had happened just a mile away — inside Boston’s city limits — he could have ridden a city ambulance, which would have charged $1,490, according to Boston EMS, a sum that his insurer probably would have covered in full.

Very few states have laws limiting ambulance charges, and most state laws that protect patients from surprise billing do not apply to ground ambulance rides, according to Brian Werfel, a consultant to the American Ambulance Association. And none of the surprise-billing protections apply to people with self-funded employer-sponsored health insurance plans, which are regulated only by federal law. That’s a huge exception: 61 percent of privately insured employees are covered by self-funded employer-sponsored plans.

Some towns that hire private companies to respond to 911 calls may regulate fees or prohibit balance billing, Werfel said, but each locality is different.

Insurers try to protect patients from balance billing by negotiating rates with ambulance companies, said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans. But “some ambulance companies have been resistant to join plan networks” that offer Medicare-based rates, she said.

Medicare rates vary widely by geographic area. On average, ambulance services make a small profit on Medicare payments, according to a report by the Government Accountability Office. If a patient uses a basic life support ambulance in an emergency in an urban area, for instance, Medicare payments range from $324 to $453, plus $7.29 per mile. Medicaid rates tend to be significantly lower.

There’s evidence of waste and fraud in the ambulance industry, Donaldson added, citing a study from the Office of Inspector General at the Department of Health and Human Services. The report concluded that in 2012 Medicare paid more than $50 million in improper ambulance bills, including for supposedly emergency-level transport that ended at a nursing home, not a hospital. One in 5 ambulance services had “questionable billing” practices, said the report, which noted that Medicare spent $5.8 billion on ambulance transport that year.

Most complaints reviewed by Kaiser Health News did not appear to involve fraudulent charges. Instead, patients got caught in a system in which ambulance services can legally charge thousands of dollars for a single trip — even when the trip starts at an in-network hospital.

That’s what happened to Devin Hall, a 67-year-old retired postal inspector in Northern California. While he faces Stage 3 prostate cancer, Hall is also fighting a $7,109.70 bill from American Medical Response, the nation’s largest ambulance provider.

On Dec. 27, 2016, Hall went to a local hospital with rectal bleeding. Because the hospital didn’t have the right specialist to treat his symptoms, it arranged for an ambulance ride to another hospital about 20 miles away. Even though the hospital was in his network, the ambulance was not.

Hall was stunned to see that AMR billed $8,460 for the trip. His federal health plan, the Special Agents Mutual Benefit Association, paid $1,350.30 and held Hall responsible for $727.08, records show. (According to his plan’s explanation of benefits, it paid that amount because AMR’s charges exceeded the plan’s Medicare-based fee schedule, which is based on Medicare rates.) But AMR turned his case over to a debt collector, Credence Resource Management, which sent an Aug. 25 notice seeking the full balance of $7,109.70.

“These charges are exorbitant — I just don’t think what AMR is doing is right,” said Hall, noting that he had intentionally sought treatment at an in-network hospital.

He has spent months on the phone calling the hospital, his insurer and AMR trying to resolve the matter. Given his prognosis, he worries about leaving his wife with a legal fight and a lien on their Brentwood, Calif., house for a debt they shouldn’t owe.

After being contacted by Kaiser Health News, AMR said it pulled Hall’s case from collections while it reviews the billing. After further review, company spokesman Jason Sorrick said the charges were warranted because it was a “critical care transport, which requires a specialized nurse and equipment on board.”

Sorrick faulted Hall’s health plan for underpaying, and said Hall could receive a discount if he qualifies for AMR’s “compassionate care program” based on his financial and medical situation.

“In this case, it appears the patient’s insurance company simply made up a price they wanted to pay,” Sorrick said.

In July, a California law went into effect that protects consumers from surprise medical bills from out-of-network providers, including some ambulance transport between hospitals. But Hall’s case occurred before that, and the state law doesn’t apply to him because of his federal insurance plan.

The consumer complaints reviewed by Kaiser Health News reveal a wide variety of ways that patients are left fighting big bills:

• An older patient in California said debt collectors called incessantly, including on Sunday mornings and at night, demanding an extra $500 on top of the $1,000 that his insurance had paid for an ambulance trip.

• Two ambulance services responded to a New Jersey man’s 911 call when he felt burning in his chest. One of them charged him $2,100 for treating him on the scene for less than 30 minutes — even though he never rode in that company’s ambulance.

• A woman who rolled over in her Jeep in Texas was charged a $26,400 “trauma activation fee” — a fee triggered when the ambulance service called ahead to the emergency department to assemble a trauma team. The woman, who did not require trauma care, fought the hospital to get the fee waived.

In other cases, patients face financial hardship when ambulances take them to out-of-network hospitals. Patients don’t always have a choice in where to seek care; that’s up to the ambulance crew and depends on the protocols written by the medical director of each ambulance service, said Werfel, the ambulance association consultant.

Sarah Wilson, a 36-year-old microbiologist, had a seizure at her grandmother’s house in rural Ohio on March 18, 2016, the day after having hip surgery at Akron City Hospital. When her husband called 911, the private ambulance crew that responded refused to take her back to Akron City Hospital, instead driving her to an out-of-network hospital that was 22 miles closer. Wilson refused care because the hospital was out-of-network, she said.

Wilson wanted to leave. But “I was literally trapped in my stretcher,” without the crutches she needed to walk, she said. Her husband, who had followed by car, wasn’t allowed to see her right away. She ended up leaving against medical advice at 4 a.m. She landed in collections for a $202 hospital bill for a medical examination, a debt that damaged her credit score, she said.

Ken Joseph, chief paramedic of Emergency Medical Transport, the private ambulance company that transported Wilson, said company protocol is to take patients to the “closest appropriate facility.” Serving a large area with just two ambulances, the company has to get each ambulance back to its station quickly so it can be ready for the next call, he said.

Patients such as Wilson are often left to battle these bills alone, because there are no federal protections for patients with private insurance.

Rep. Lloyd Doggett (D-Texas), who has been pushing for federal legislation protecting patients from surprise hospital bills, said in a statement that he supports doing the same for ambulance bills.

Meanwhile, patients do have the right to refuse an ambulance ride, as long as they are older than 18 and mentally capable.

“You could just take an Uber,” said Adler, co-author of the surprise-billing report. But if you need an ambulance, there’s little recourse to avoid unexpected bills, he said, “other than yelling at the insurance company after the fact, or yelling at the ambulance company.”

Puerto Rico’s Dire Health-Care Crisis

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https://www.theatlantic.com/politics/archive/2017/10/puerto-ricos-health-care-crisis-is-just-beginning/544210/

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It’s been two months since Hurricane Maria hit Puerto Rico, but nearly 10 percent of the island’s 3.4 million residents still don’t have access to clean, safe water. Half of the electric grid is still out of service, which has made it difficult to safely store food or medicines that need to be refrigerated. The outages have also left many residents vulnerable to heat exposure; temperatures remain in the high 80s on the island.

There’s also growing concern that Puerto Rico’s Medicaid program — which covers nearly half of Puerto Ricans — will soon run out of money to pay doctors and hospitals. The territory’s governor has asked the Trump administration to waive Puerto Rico’s share of Medicaid costs, and some Democratic senators have made similar appeals.

 

 

How the elections could put the brakes on anti-ACA plans

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https://www.axios.com/how-the-elections-could-put-the-brakes-on-anti-aca-plans-2508099820.html

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The most important issue in an election is sometimes, but seldom, the factor that actually determines the outcome of the election. That’s what we saw happen in Virginia this week. Health was the top issue in the Virginia race, according to exit polls, but it was only one of many factors that drove the election.

The bottom line: The election may have been more of a referendum on President Trump than health care — but the results in Virginia and in the Maine referendum on Medicaid expansion will still have a practical impact on what happens next, including the appetite for Affordable Care Act repeal and for cutting Medicaid to pay for tax cuts.

The details: Voters in Virginia named health care as far and away their top issue in the election in the network exit poll. It’s not surprising that the issue was at the top of their minds; they have been hearing all about the ACA in the news for months and about Medicaid expansion in their state.

Yes, but: Notably, the exit poll did not include the economy on the list of issues voters could choose. Fox News did ask about the economy and, as the chart shows, it and health were statistically tied in their poll.

Between the lines: When voters rank health care as a top issue in an election, it does not necessarily mean health care drove their vote. Voters’ views of the candidates themselves are generally a bigger factor. The candidates were also proxies for voters’ feelings about President Trump, and many more voters in Virginia said they were voting to express opposition to Trump than their support for him (34% vs. 17%).

Most voters who chose health care as their top issue in Virginia voted for Northam, possibly signaling that Democrats may be able to campaign on health care and the ACA in upcoming elections.

What to watch: The Maine vote on Medicaid expansion was a different story. Maine voters cast their ballots on a specific referendum to expand the Medicaid program, and it won resoundingly. The result speaks to a lesson learned in the repeal and replace debate: Medicaid and Medicaid expansion are far more popular than Republicans seem to think they are, largely because Medicaid now covers 74 million Americans and matters to a broad cross section of the American people.

The impact: The immediate political implication is that it will be much tougher to cut Medicaid to help pay for tax cuts. Another lesson is that expanding Medicaid could be a winner in other states, especially with the federal government picking up 90 percent of the costs and the Trump administration ready to let red states put a conservative stamp on their programs. Medicaid is not Social Security or Medicare yet, but politically it is a lot closer than Republicans may realize.

A lot can and probably will happen between now and 2018. But for now, the prominence of health care in the Virginia election could throw a scare into moderate Republicans about continuing to pursue ACA repeal. And the Maine referendum on Medicaid expansion could make them more cautious about cutting Medicaid.