Tag Archives: Medicare

Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

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https://www.commonwealthfund.org/publications/fund-reports/2018/jun/getting-ready-health-reform-2020-presidential?omnicid=EALERT%%jobid%%&mid=%%emailaddr%%

Getting Ready for Health Reform 2020

Abstract

  • Issue: The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue’s general significance as well as the ongoing debate over the Affordable Care Act.
  • Goal: To explain why campaign plans matter, review the health policy components of past presidential campaign platforms, and discuss the likely 2020 campaign health reform plans.
  • Methods: Review of relevant reports, data, party platforms, and policy documents.
  • Findings and Conclusions: Proposals related to health care have grown in scope in both parties’ presidential platforms over the past century and affect both agendas and assessments of a president’s success. Continued controversy over the Affordable Care Act, potential reversals in gains in coverage and affordability, and voters’ concern suggest a central role for health policy in the 2020 election. Republicans will most likely continue to advance devolution, deregulation, and capped federal financing, while Democrats will likely overlay their support of the Affordable Care Act with some type of Medicare-based public plan option. The plans’ contours and specifics will be developed in the months ahead.

This report is the first in a series on health reform in the 2020 election campaign. Future papers will delve into key reform design questions that candidates will face, focusing on such topics as: ways to maximize health care affordability and value; how to structure health plan choices for individuals in ways that improve system outcomes; and how the experience of other nations’ health systems can inform state block-grant and public-plan proposals.

Introduction

During the 2020 presidential campaign, which begins in earnest at the end of 2018, we are sure to hear competing visions for the U.S. health system. Since 1988, health care has been among the most important issues in presidential elections.1 This is due, in part, to the size of the health system. In 2018, federal health spending comprises a larger share of the economy (5.3%) than Social Security payments (4.9%) or the defense budget (3.1%).2 Moreover, for the past decade, partisan disagreement over the Affordable Care Act (ACA) has dominated the health policy debate. If health care plays a significant role in the 2018 midterm elections, as some early polls suggest it will,3 the topic is more likely to play a central role in the 2020 election.

This report on health reform plans focuses on policies related to health insurance coverage, private insurance regulation, Medicare and Medicaid, supply, and tax policy. It explains why campaign plans are relevant, their history since 1940, the landscape for the 2020 election, and probable Republican and Democratic reform plans. The Republican campaign platform is likely to feature policies like those in the Graham-Cassidy-Heller-Johnson amendment: a state block grant with few insurance rules, replacing the ACA’s coverage expansion. The Democratic platform will probably defend, improve, and supplement the ACA with some type of public (Medicare-like) health plan. The exact contours and details of these plans have yet to be set.

Importance of Campaign Plans

Campaign promises, contrary to conventional wisdom, matter.4 During elections, they tell voters each party’s direction on major topics (e.g., health coverage as a choice or a right in 1992). In some cases, candidates or party platforms include detailed policies (reinsurance in Republicans’ 1956 platform, prospective payment in Democrats’ 1976 platform). Campaign plans tend to be used to solidify party unity, especially in the wake of divisive primaries (2016, e.g.).5 Election outcomes are affected by such factors as the state of the economy, incumbency, and political competition rather than specific issues.6 That said, some exit polls suggest that candidates’ views on health policy can affect election outcomes.7

Campaign plans also help set the agenda for a president, especially in the year after an election. Lyndon B. Johnson told his health advisers, “Every day while I’m in office, I’m gonna lose votes. . . . We need . . . [Medicare] fast.”8 Legislation supported by his administration was introduced before his inauguration and signed into law 191 days after it (Exhibit 1). Bill Clinton, having learned from his failure to advance health reform in his first term, signed the bill that created the Children’s Health Insurance Program (CHIP) 197 days after his second inauguration. Barack Obama sought to sign health reform into law in the first year of his first term, but the effort spilled into his second year; he signed the ACA into law on his 427th day in office. These presidents, along with Harry Truman, initiated their attempts at health reform shortly after taking office.

In addition, campaign plans are used by supporters and the press to hold presidents accountable. For instance, candidate Obama’s promises were the yardstick against which his first 100 days,9 first year,10 reelection prospects,11 and presidency were measured.12 Though only 4 percent of likely voters believe that most politicians keep their promises, analyses suggest that roughly two-thirds of campaign promises were kept by presidents from 1968 through the Obama years.13

Health as a Campaign Issue (1912–2016)

The United States has had public health policies since the country’s founding, with its policy on health coverage, quality, and affordability emerging in the twentieth century. Teddy Roosevelt supported national health insurance as part of his 1912 Bull Moose Party presidential bid.14 Franklin Delano Roosevelt included “the right to adequate medical care and the opportunity to achieve and enjoy good health” in his 1944 State of the Union address, although it was not mentioned in the 1944 Democratic platform.15 Harry Truman is generally credited with being the first president to embrace comprehensive reform. He proposed national health insurance in 1945, seven months after F.D.R.’s death, and campaigned on it in 1948 as part of a program that would become known as the Fair Deal, even though it was not a plank in the Democratic platform. Legislation was blocked, however, primarily by the American Medical Association (AMA), which claimed that government sponsoring or supporting expanded health coverage would create “socialized medicine.”16 Health policy became a regular part of presidential candidates’ party platforms beginning about this time (Exhibit 2).

After Truman’s failure, the next set of presidential candidates supported expanding capacity (e.g., workforce training, construction of hospitals and clinics) and making targeted coverage improvements. In 1960, John F. Kennedy campaigned on a version of Medicare legislation: extending Social Security to include hospital coverage for seniors. It was opposed by the AMA as well, whose spokesman, the actor Ronald Reagan, claimed socialized medicine would eventually limit freedom and democracy.17 It took the death of Kennedy, the landslide Democratic victory in 1964, and persistence by Lyndon B. Johnson to enact Medicare and Medicaid, in 1965. This was about 20 years after Truman introduced his proposal; President Johnson issued the first Medicare card to former President Truman.

Shortly after implementation of Medicare and Medicaid, how best to address rising health care costs became a staple subject in presidential campaigns. Between 1960 and 1990, the share of the economy (gross domestic product) spent on health care rose by about 30 percent each decade, with the public share of spending growing as well (Exhibit 3). In his 1968 campaign, Richard Nixon raised concerns about medical inflation, and subsequently proposed his own health reform, which included, among other policies, a requirement for employers to offer coverage (i.e., an employer mandate).18 Nixon’s proposal was eclipsed by Watergate, as Jimmy Carter’s health reform promises were tabled by economic concerns. Presidents and candidates in the 1980s set their sights on incremental health reforms.19

In 1991, comprehensive health reform helped Harris Wofford unexpectedly win a Pennsylvania Senate race. In 1992, it ranked as the second most important issue to voters.20 Democratic candidates vied over health reform in the 1992 primaries, with Bill Clinton embracing an employer “pay or play” mandate. George H. W. Bush developed his own plan, which included premium tax credits and health insurance reforms. Five days after his inauguration, President Clinton tasked the first lady, Hillary Clinton, with helping to develop health care legislation in the first 100 days. Yet, mostly because he prioritized economic and trade policy, Clinton did not address a joint session of Congress until September and did not send his bill to Congress until November of 1993. Key stakeholders (including the AMA and the Health Insurance Association of America) initially supported but ultimately opposed the legislation. In September 1994, the Senate Democratic leadership declared it could not pass a bill.21 Less than two months later, Democrats lost their majorities in the House and the Senate, and did not regain them for over a decade. This created a view that comprehensive reform of the complex health system was politically impossible.22 Indeed, presidential candidates in 1996, 2000, and 2004 did not emphasize major health policies. That said, by 2004, health system problems had escalated and, at least on paper, the candidates’ plans addressing them had expanded.23

In 2008, health reform was a dominant issue in the Democratic primaries and platform. Hillary Clinton supported a requirement for people who could afford it to have coverage (i.e., the individual mandate). Barack Obama limited his support to a requirement that all children be insured. Both candidates supported an employer mandate.24 John McCain countered with a plan whose scope exceeded those of many Republican predecessors: it would cap the tax break for employer health benefits and use the savings to fund premium tax credits for the individual market.25 Attention to health reform waned during the general election, as the economy faltered. Even so, the stage was set for a legislative battle. President Obama opened the door to his rivals’ ideas at a White House summit in March 2009.26 After more than a year of effort, he signed the Affordable Care Act into law.27 Obama said that he did so “for all the leaders who took up this cause through the generations — from Teddy Roosevelt to Franklin Roosevelt, from Harry Truman, to Lyndon Johnson, from Bill and Hillary Clinton, to one of the deans who’s been fighting this so long, John Dingell, to Senator Ted Kennedy.”28

Nonetheless, the partisan fight over the ACA extended into the 2012 and 2016 presidential elections. Despite the ACA’s resemblance to his own 2006 reform plan for Massachusetts, Mitt Romney, as the 2012 Republican presidential candidate, vowed to repeal the ACA before its major provisions were implemented; Republicans would subsequently replace it with conservative ideas (mostly to be developed). Four years later, even though the health system landscape had dramatically changed following the ACA’s implementation, the Republicans’ position had not altered.29 Candidate Donald Trump joined his primary rivals in pledging to “repeal and replace Obamacare” (he also embraced unorthodox ideas such as Medicare negotiation for drug prices). Democratic candidate Hillary Clinton proposed a wide array of improvements to the ACA rather than a wholesale replacement of it with a “Medicare for All” single-payer proposal, as did her Democratic primary rival, Bernie Sanders.30 The intra-party differences among primary candidates in 2016 increased attention to the party platforms relative to previous elections.31 But despite continued voter interest (Exhibit 4), differences in health policy were not credited with determining the outcome of the 2016 election.

Setting the Stage for 2020

President Trump’s attempt to fulfill his campaign promise to repeal and replace the ACA dominated the 2017 congressional agenda. In January 2017, the Republican Congress authorized special voting rules toward this effort, while President Obama was still in office. On the day of his inauguration, Trump signed an executive order to reduce the burden of the law as his administration sought its prompt repeal.32 Yet among other factors,33 the lack of a hammered-out, vetted, and agreed-upon replacement plan crippled the Republicans’ progress.34 Speaker Paul Ryan had to take his bill off the House floor on March 24, 2017, because it lacked the necessary votes; the House passed a modified bill on May 4. Senator Mitch McConnell’s multiple attempts in June and July to secure a majority in favor of his version of a health care bill failed on July 26, when Senator John McCain cast the deciding vote against it. In September, Senators Lindsey Graham, Bill Cassidy, Dean Heller, and Ron Johnson failed to get 50 cosponsors for their amendment, the prerequisite for its being brought to the Senate floor.35 The Republicans subsequently turned to tax legislation and, in it, zeroed out the tax assessment associated with the ACA’s individual mandate. At the bill’s signing on December 22, Trump claimed that “Obamacare has been repealed,”36 despite evidence to the contrary.37

A different type of legislative effort began in mid-2017: bipartisan attempts to improve the short-run stability of the ACA’s individual market. This was in part necessitated by the Trump administration’s actions pursuant to the Inauguration Day executive order: reductions in education efforts, marketing funding, and premium tax credits, among others.38 On October 12, 2017, the president signed a second ACA executive order, directing agencies to authorize the sale of health plans subject to fewer regulatory requirements.39 On the same day, his administration halted federal funding for cost-sharing reductions, a form of subsidy, claiming the ACA lacked an appropriation to make such payments. Concerns that these actions would increase premiums, reduce insurer participation, and discourage enrollment prompted coalitions of bipartisan lawmakers to introduce bills. Most notable was a bill by Senators Lamar Alexander and Patty Murray; their proposal, released October 18, 2017, had 12 Republican cosponsors and implicit support from all Democrats, giving it the 60 votes needed in the Senate to overcome a filibuster.40 Yet the version that Senator McConnell ultimately brought to the floor for a vote, in March 2018, included changes that repelled Democrats, preventing its passage.41 Partisans on both sides have blamed this failure, in part, for emerging increases in health insurance premiums.

Indeed, benchmark premiums in the health insurance marketplaces rose by an average of over 30 percent in 2018 and are projected to increase by 15 percent in 2019, largely because of policy changes.42 Some data suggest that the growth in health care costs may be accelerating as well.43 This may have contributed to an increase in the number of uninsured Americans. One survey found that the number of uninsured adults, after falling to a record low in 2016, had risen by about 4 million by early 2018.44 These statistics could heighten candidates’ interest in health policy in 2020.

Public opinion, too, could help health reform gain traction. Tracking polls suggest that concerns about health care persist, with 55 percent of Americans worrying a great deal about the availability and affordability of health care, according to a poll from March 2018.45 Interestingly, while the partisan differences of opinion on the ACA continue, overall support for the ACA has risen, reaching a record high in February 2018 (Exhibit 5).

This concern about health care has entered the 2018 midterm election debate. It is currently a top midterm issue among registered voters, a close second to jobs and the economy.46 Some House Republicans who formerly highlighted their promise to repeal and replace the ACA no longer do so in light of the failed effort of 2017.47 Democrats, in contrast to previous elections, have embraced the ACA, unifying around its defense in the face of Republican “sabotage.”48 The debate also has been rekindled by Trump’s decision to abandon legal defense of key parts of the ACA.49 Regardless of what happens in the courts, this signifies his antipathy toward the law. Barring a midterm surprise, the next Congress is unlikely to succeed where the last one failed. As such, “repeal and replace” would be a repeat promise in Trump’s reelection campaign.

Likely 2020 Campaign Plans

Against this backdrop, presidential primary candidates and the political parties will forge their health care promises, plans, and platforms. Common threads from past elections are likely to be woven into the 2020 debate. The different parties’ views of the balance between markets and government have long defined their health reform proposals.50 Republicans will most likely still be against the ACA as well as uncapped Medicare and Medicaid spending, and for market- and consumer-driven solutions. Democrats will most likely blame Republicans’ deregulation for rising health care costs; defend the ACA, Medicare, and Medicaid; and advocate for a greater role for government in delivering health coverage and setting payment policy. Potential policies for inclusion in candidates’ plans have been introduced in Congress (Exhibit 6). But major questions remain, such as: how will these campaign plans structure choices for individuals and employers, promote efficient and high-quality care, and learn from the experience of local, state, national, and international systems?

Likely Republican Campaign Plan: Replace the ACA with Devolution and Deregulation

President Trump has indicated he will run for reelection in 2020.51 His fiscal year 2019 budget included a proposal “modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill.” It would repeal federal financing for the ACA’s Medicaid expansion and health insurance marketplaces, using most of the savings for a state block grant for health care services. It would also impose a federal per-enrollee spending cap on the traditional Medicaid program. States could waive the ACA’s insurance reforms.52 The congressional bill also would repeal the employer shared responsibility provision (i.e., the employer mandate) and significantly expand tax breaks for health savings accounts, among other policies.53 The framework for this proposal — repealing parts of the ACA, replacing them with state block grants, reducing regulation, and expanding tax breaks — is similar to the 2016 Republican platform.

Trump may continue to express interest in lowering prescription drug costs. In 2016 and early 2017, he supported letting Medicare negotiate drug prices54 — a policy excluded from the 2016 Republican platform and his proposals as president. His 2019 budget seeks legislation primarily targeting insurers and other intermediaries that often keep a share of negotiated discounts for themselves.55 On May 11, 2018, he released a “blueprint” to tackle drug costs, including additional executive actions and ideas for consideration. Polls suggest that prescription drug costs rank high among health care concerns.56

One policy initiative in the recent Republican platforms but not embraced by the president is Medicare reform. The idea of converting Medicare’s defined benefit into a defined contribution program and raising the eligibility age to 67 was supported by Vice President Mike Pence when he was a member of Congress and by Speaker of the House Paul Ryan.57 Major Medicare changes were excluded from the 2017 ACA repeal and replace proposals. In contrast, versions of Medicaid block grant proposals appeared in various bills, including the GCHJ amendment, as well as numerous Republican presidential platforms.

Historically, presidents running for reelection have limited competition in primaries. Those challengers, by definition, emphasize their differences with the incumbent, which may include policy. It may be that John Kasich will run on maintaining the ACA Medicaid expansion but otherwise reforming the program (his position as governor of Ohio throughout 2017). Or, Rand Paul could campaign on his plan to repeal even more of the ACA than the Republicans’ 2017 bills attempted to do. Incumbents tend to have slimmer campaign platforms than their opponents in general and primary elections, since their budget proposals, other legislative proposals, and executive actions fill the policy space (see Reagan, Clinton, George W. Bush, Obama). Exceptions include George H. W. Bush, who in 1992 developed a plan given voters’ concerns about health; and Nixon, who offered a proposal for health reform at the end of his first term.

Likely Democratic Campaign Plan: Improve the ACA and Add a Public Plan

It is possible and maybe probable that the ultimate Democratic Party platform in 2020 will resemble that of 2016: build on the ACA and include some sort of public plan option. Legislation has been introduced during this congressional session that builds on the law by extending premium tax credits to higher-income marketplace enrollees (e.g., Feinstein, S. 1307), lowering deductibles and copayments for middle-income marketplace enrollees (e.g., Shaheen, S. 1462), providing marketplace insurers with reinsurance (e.g., Carper, S. 1354), and strengthening regulation of private market insurance (e.g., Warren, S. 2582). Some proposals aim to increase enrollment following the effective repeal of the individual mandate, by, for example, raising federal funding for education and outreach, and testing automatic enrollment of potentially eligible uninsured people (e.g., Pallone, H.R. 5155). These proposals would have different effects on health insurance coverage, premiums, and federal budget costs.58

The Democrats will inevitably discuss a public plan in their platform, although the primary contenders will most likely disagree on its scale (e.g., eligibility) and design (e.g., payment rates, benefits).59 In September 2017, Senator Bernie Sanders introduced the Medicare for All Act (S. 1804). It would largely replace private insurance and Medicaid with a Medicare-like program with generous benefits and taxpayer financing. “Medicare for more” proposals have also been introduced: Medicare Part E (Merkley, S. 2708), an option for individuals and small and large businesses; Medicare X (Bennet, S. 1970), which is available starting in areas with little insurance competition or provider shortages; and a Medicare buy-in option, for people ages 50 to 65 (Higgins, H.R. 3748). A Medicaid option (Schatz, S. 2001), similar to Medicare Part E, offers a public plan choice to all privately insured people, aiming to capitalize on the recent popularity of that program. Publicly sponsored insurance plans have long been included in Democratic presidents’ platforms, although the government’s role has ranged from regulating the private plans (Carter, Clinton) to sponsoring them (Truman, Obama). It may be that the candidate who prevails in the primaries will determine whether the Democratic platform becomes “Medicare for all” or “Medicare for more.”

This may be the extent of Medicare policies in the 2020 Democratic platform. Relatively high satisfaction and low cost growth in Medicare have limited Democratic interest in Medicare policy changes in recent years. Similarly, Democrats have not introduced or embraced major reforms of Medicaid. However, the public concern about prescription drug costs has fueled Democratic as well as Republican proposals, some of which target the drug companies (e.g., addressing “predatory pricing,” allowing Medicare rather than prescription drug plans to negotiate the prices for the highest-cost drugs).60

Discussion

Predictions about presidential campaigns have inherent limits, as many experts learned in the 2016 election. Events concerning national security (e.g., conflict), domestic policy (e.g., a recession), or the health system (e.g., a disease outbreak) could alter the policy choices of presidential candidates. New ideas could emerge, or candidates could take unconventional approaches to improving the health system. And, while campaign plans have relevance, the long history of attempts at health reform underscores that by no means are promises preordained.

That said, perennial policies and recent political party differences will likely figure in 2020. Republican presidential candidates, with few exceptions, have adopted a small government approach to health reform: shifting control to states, cutting regulation, preferring tax breaks and block grants over mandatory federal funding, and trusting markets to improve access, affordability, and quality. Democratic presidential candidates have supported a greater government role in the health system, arguing that market solutions are insufficient, and have defended existing programs like Medicare, Medicaid, and, now, the ACA. Some will probably support the government’s taking a primary role in providing coverage given criticism of the efficacy and efficiency of private health insurers. The direction and details of the campaign plans for 2020 will be developed in the coming months and year. Given such plans’ potential to shape the next president’s agenda, now is the time to scrutinize, modify, and generate proposals for health reform.

 

 

More Medicare patients dying at home, JAMA study finds

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https://www.healthcaredive.com/news/more-medicare-patients-dying-at-home-jama-study-finds/526477/

Dive Brief:

  • More Medicare fee-for-service and Medicare Advantage beneficiaries are dying at home or in community settings than in acute care hospitals, according to new findings published in JAMA.
  • The study showed proportions of fee-for-service beneficiary deaths occurring in an acute care hospital decreased from 32.6% in 2000 to 19.8% in 2015. Proportions of deaths occurring in the home or in a community setting (foster care home, assisted living facilities) increased from 30.7% to 40.1% in the same time span.
  • Medicare Advantage beneficiaries were less likely to be hospitalized overall than those in traditional fee-for-service plans and, in the last 30 days of life, the difference in the hospitalization rates was 9.3% — a difference study author Joan Teno called “huge.”

Dive Insight:

Although most Americans over 65 say that they’d prefer to die at home, in 2009 only 24% of them actually did. Yet, in recent years, more and more Americans are choosing to live out their last days in their home or community instead of being admitted to a hospital.

The JAMA study reveals a potential patient response to the current inadequacy of end-of-life care as, for some older Americans, ending up in a hospital can mean high-cost and aggressive treatment in their final days.

Such treatment does not always equal better care. When it comes to their elderly patients, incumbent healthcare systems increasingly specialize in expensive, often unnecessary services as opposed to a value-based approach.

The findings come on the tide of the so-called “silver tsunami” as the American population skews ever older. The number of Americans aged 65 or older is projected to more than double by 2060, when they will eventually account for 24% of the total population.

New startups have emerged looking to address the institutional inadequacy of end-of-life care, viewing the aging population as a business opportunity. The growing companies zero in on technology-driven solutions in home health, chronic illness and end-of-life care as they look to scale to combat industry issues.

Such startups are a potential wake-up call for traditional healthcare organizations.

“Innovation comes from the private sector,” Teno, a professor of medicine at the University of Washington, told Healthcare Dive.

“I think the implication of this is that hospitals are going to have to change how they’re practicing. They’re going to have to come into new population-based business models that don’t have their entire survival based on their number of admissions,” she said.

On the hospital side, Teno called for multifaceted interventions that address the issue of care overuse and fragmentation in hospitals, such as care bundling and coordination, surveys measuring patient satisfaction and public reporting of readmission rates.

Despite the challenges, Teno was optimistic about ​study’s implications.

“We’re on the right path,” she said. “We need to wean ourselves off of this fee-for-service world of paying for a procedure and paying for volume, to paying for value.”

“The fee-for-service world provides perverse incentives,” Teno stressed, also noting that it tends to lead to hospital disorganization and miscommunication. 

Teno cited the growth of Medicare Advantage as a program (it accounts for a third of Medicare enrollees and spending), and the 9.3% difference in hospitalization rates between MA and fee-for-service as a good sign for the future of healthcare.

 

Squeeze On Affordable Health Insurance For 50- To 64-Year-Olds

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https://www.forbes.com/sites/howardgleckman/2018/06/21/the-trump-administrations-squeeze-on-affordable-health-insurance-for-50-64-year-olds/#4ea0538b1d94

Image result for high health premiums

In a series of recent decisions, the Trump Administration is taking steps that will sharply raise insurance premiums for people aged 50 to 64, just before they become eligible for Medicare. While these steps are likely to make coverage less expensive for young, healthy consumers, they will inevitably raise costs for middle-aged people with chronic conditions. For many, insurance will become unaffordable. And that lack of coverage will eventually result in higher costs for Medicare.

Trump is taking three major steps that will affect the availability of Affordable Care Act health insurance for middle-aged consumers.  

Repealing but not replacing

First, at the urging of the Trump Administration, Congress last year repealed the tax penalty that has to be paid by those without health insurance, effective for tax year 2019. The penalty is the ACA’s mechanism to push people to buy insurance. The logic: By broadening the pool of those with ACA insurance to include those less likely to incur significant medical costs, the individual mandate would keep premiums relatively low for everyone.

Then, early this month, the Trump Administration refused to defend the remaining provisions of the ACA in federal court. In the case Texas v. the federal Department of Health and Human Services, 20 red states argued that, absent the now-repealed individual mandate, the rest of the ACA will be unconstitutional. Thus, all its other provisions, including several important to those older consumers, also would be thrown out. They include premium limits for those 50-64, minimum benefit requirements,  and the ban on insurance companies rejecting potential purchasers due to pre-existing conditions.

Pre-existing conditions

Prior to the ACA, in a practice known as age-rating, 60-year-olds could pay premiums that were 11 times higher than younger buyers. The ACA capped that ratio at 3:1. AARP estimates that bumping it up to 5:1 would raise annual premiums for a 60-year-old by more than $3,000, or 22%.

Similarly, allowing carriers to underwrite for pre-existing conditions would make insurance widely unavailable for people aged 50 to 64. AARP estimates that 25 million people, or 40% of those 50 to 64, have a condition that could disqualify them from non-group insurance.

The Urban Institute’s Health Policy Center estimates that tossing out the remaining provisions of the ACA would result in 17 million people losing commercial insurance and another 15 million losing Medicaid and children’s health care under the CHIP program.

By Urban colleagues project that even those remaining  in the private individual insurance market “would likely have policies that cover fewer benefits and require more out-of-pocket spending for services.”

Rare agreement

The Texas lawsuit, and the Administration’s refusal to defend the law in court, has generated an outpouring of opposition. It created a rare moment when consumer groups, hospitals, and doctors agreed on a health policy issue.

But the story doesn’t end there. This week, the Trump Administration took one more step towards dismantling the ACA in a way that will likely harm pre-Medicare consumers: The Department of Labor adopted new rules opening the door to low cost, low-benefit health plans.  These will now be widely available to small businesses and, importantly, self-employed individuals.

The Congressional Budget Office estimates that 4 million people will buy these policies, sold by association health plans (AHPs). The consulting firm Avalere Health estimates that individual AHP premiums will be an average of $9,700 cheaper than ACA coverage, and that 1 million people will shift from marketplace plans to AHP policies. But it predicts premiums will rise by 3.5 percent for more comprehensive ACA insurance, largely because the remaining consumers will be older and sicker than AHP buyers.

President Trump promotes these plans as a less costly alternative to ACA coverage. This week he told the National Federation of Independent Business, “You’re going to save massive amounts of money and have much better health care. You’re going to save a fortune and you’re going to be able to give yourselves and your employees tremendous health care.”

Low cost, few benefits

But the plans do not include any minimum benefit requirements. Thus, they can exclude coverage for pregnancies, mental health issues, or drugs or hospital care. Carriers won’t be able to exclude buyers on the basis of pre-existing conditions but can adjust premiums based on age or sex. And, because they often exclude benefits important to those with chronic conditions, such as medications, they don’t need to underwrite: Those consumers simply won’t buy these policies.

Priced out of ACA coverage and uninterested in limited insurance that won’t cover their needs, it is easy to imagine many of those in their early 60s simply going without coverage (and care) until they become eligible for Medicare at age 65. That will not only put their health at risk, it will raise Medicare costs. Medicare spends about one-third more on medical care for those who join the program without having had insurance in the year before enrolling.

The result of all this: Trump is creating two separate individual health insurance markets, one for young and healthy people, and one for older and sick people.  Some young people may buy low-cost policies that will serve them well—until they get sick. Many older people won’t buy insurance at all, risking their health and, very likely, raising costs to government.

 

Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients

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https://www.npr.org/sections/health-shots/2018/06/13/619259541/medicare-takes-aim-at-boomerang-hospitalizations-of-nursing-home-patients

“Oh my God, we dropped her!” Sandra Snipes said she heard the nursing home aides yell as she fell to the floor.

She landed on her right side where her hip had recently been replaced. She cried out in pain.

A hospital clinician later discovered her hip was dislocated.

That was not the only injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice a day with a potent blood thinner despite written instructions to stop.

“She said, ‘I just feel so tired,’ ” her daughter, Laura Clark, said in an interview. “The nurses were saying she’s depressed and wasn’t doing her exercises. I said no, something is wrong.”

Her children also discovered Snipes’ surgical wound had become infected and infested with insects. Just 11 days after she arrived at the nursing home to heal from her hip surgery, she was back in the hospital.

The fall and these other alleged lapses in care led Clark and the family to file a lawsuit against the nursing home. Richmond Pines declined to discuss the case beyond saying it disputed the allegations at the time. The home agreed in 2017 to pay Snipes’ family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes’ case was extreme, return trips from nursing homes to hospitals are far from unusual.

With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerangs back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.

“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’ ” said David Grabowski, a professor of health care policy at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or assessing penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Payment Advisory Commission.

“We’re better, but not well,” Grabowski said. “There’s still a high rate of inappropriate readmissions.”

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a typical patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have their own incentives to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

“And they never quite get back to normal,” he said.

‘She Looked Like A Wet Washcloth’

Communication lapses between physicians and nursing homes is one recurring cause of rehospitalizations. Elaine Essa had been taking thyroid medication ever since that gland was removed when she was a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2013 when a bout of pneumonia sent her to the hospital.

When she returned to the nursing home — now named Wellsprings Post-Acute Care Center — her doctor omitted a crucial instruction from her admission order: to resume the thyroid medication, according to a lawsuit filed by her family. The nursing home telephoned Essa’s doctor to order the medication, but he never called them back, the suit said.

Without the medication, Essa’s appetite diminished, her weight increased and her energy vanished — all indications of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, did not grasp the cause of her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return from the hospital, “she looked like a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she demanded the home’s nurses check her mother’s blood pressure. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her deposition that the doctor told her, “I can’t believe that this woman is still alive.”

Essa died the next month. The nursing home and the medical practice settled the case for confidential amounts. Cynthia Schein, an attorney for the home, declined to discuss the case beyond saying it was “settled to everyone’s satisfaction.” The suit is still ongoing against one other doctor, who did not respond to requests for comment.

Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital.

Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.

“We’re always worried the bad nursing homes are going to get the message ‘Don’t send anyone to the hospital,’ ” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, where Sandra Snipes stayed, has a higher than average rehospitalization rate of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she was discharged to a different nursing home, according to the family’s lawsuit. But her hospital trips were not over: When she showed signs of recurrent infection, the second home sent her to yet another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and more than a liter of infected blood clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the blood thinner right off the bat, we don’t think any of this would have happened.”

Snipes returned home but was never able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t want to go back into the nursing home,” Clark said. “She was terrified.”

 

 

 

More than a quarter of major health systems plan Medicare Advantage launch, though many lack confidence

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http://www.healthcarefinancenews.com/news/more-quarter-major-health-systems-plan-medicare-advantage-launch-though-many-lack-confidence?mkt_tok=eyJpIjoiWkdSaE9UZzRPV0poTW1FeCIsInQiOiJTK1lnZEdEakdOVlZNYWRBSzF5M3o1d3BRWmpQXC8ydVBYN2lFY01mUEQwbnhTVjBIU2NScmdIMWtXcjN3NGpXb1NoSG53clwvXC90TzJ1QWFPRWpoeGFtXC9jSHl4TFwvbDgwMEZYaU1kVmxRa1NCNHloRk9lK0VUZFBkVEVuV1hHTytIIn0%3D

 

Executives say the top reason for launching a Medicare Advantage plan is the opportunity to capture more value.

A new survey from Lumeris found that 27 percent of major U.S. health system executives intend to launch a Medicare Advantage plan in the next four years. Despite that, confidence among these same execs is lacking, with only 29 percent reporting they felt confident in their organization’s ability to make the launch successfully.

“These survey findings are consistent with our conversations with healthcare executives across the country who are feeling a sense of urgency around Medicare Advantage strategies, but also realize that this type of work is vastly different than traditional health system operations,” said Jeff Carroll, executive director of health plans at Lumeris, by statement.

In April, The Centers for Medicare and Medicaid Services announced it was releasing Medicare Advantage encounter data for the first time by request from the CMS Research Data Assistance Center. The MA encounter data, starting from 2015, provides detailed information about services to beneficiaries enrolled in a Medicare Advantage managed plan. It will give researchers insight into the care delivered under MA plans and will help them improve the Medicare program, CMS said. Annual updates are planned.

According to the 90 executives Lumeris surveyed from major health systems, the top reason for launching a Medicare Advantage plan is the opportunity to capture more value by controlling a greater portion of the premium dollar as compared to fee-for-service Medicare.

Other key drivers cited include market and regulatory trends supporting Medicare Advantage. In particular, shrinking Medicare margins could threaten the viability of hospitals and health systems as the senior population continues to grow and becomes a larger proportion of providers’ patient panels.

The respondents also recognized that launching a Medicare Advantage plan will be challenging due to the complexities of operating an insurance plan, which are far different than the capabilities required to successfully operate a health system.

They also shared concerns about the significant financial investment required and an overall lack of expertise in the health plan space. The majority of respondents, 59 percent, indicated they were likely to use outside resources to launch their plans — and that those resources are very likely to include a vendor partner that can mitigate operational risk.

“Launching and managing a Medicare Advantage plan requires skills beyond the core competencies of most health systems, which is one reason many provider-sponsored plans fail in the first few years,” Carroll said. “Through those failures, it has become clear that providers who select the right partners increase the likelihood for greater success in a shorter period of time.”

 

KHN’s ‘What The Health?’ Health Care Politics, Midterm Edition

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https://khn.org/news/podcast-khns-what-the-health-health-care-politics-midterm-edition/

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The 2018 midterm elections were supposed to be a referendum on President Donald Trump, not about issues such as health care. Still, voters, Democrats and, to a lesser extent, Republicans seem to be keeping health care on the front burner.

The news from Medicare’s trustees that its hospital trust fund is on shakier financial footing than it was last year, hefty premium increases being proposed in several states and activity on Medicaid expansion all take on a political tinge as the critical elections draw closer.

Also this week, an interview with Matt Eyles, president and CEO of America’s Health Insurance Plans, the health insurance industry trade group.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Alice Ollstein of Talking Points Memo and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Outside Washington, concerns about health care accessibility and prices remain a big issue.
  • Democrats, looking toward the midterm elections in the fall, think that health care can be a potent issue for them. But many also believe that they can’t just run on complaints that the Republicans are sabotaging the Affordable Care Act. They are seeking to find a message that looks to the future.
  • Republicans see the plans by the White House to implement new regulations that allow expansion of association health plans and short-term health plans as a strong action that will thwart complaints that they haven’t fixed the ACA.
  • The states are beginning to release the initial requests from health insurers for premium increases. They vary substantially, but many appear to be partly attributed to the decision last year by Congress to repeal the penalty for people who don’t get insurance.
  • The report this week by the Medicare trustees that the hospital trust fund is closer to insolvency has ignited Democratic criticism of changes in health care law that were part of the GOP tax cut last year.
  • Arkansas has begun implementing its work requirements for healthy adults covered by the Medicaid expansion. It’s the first state to do that. But critics point out that those adults will have to register their work hours online only — and many do not have access to computers.

 

It Costs $685 Billion a Year to Subsidize U.S. Health Insurance

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https://www.bloomberg.com/news/articles/2018-05-23/it-costs-685-billion-a-year-to-subsidize-u-s-health-insurance

 

It will cost the U.S. government almost $700 billion in subsidies this year help provide Americans under age 65 with health insurance through their jobs or in government-sponsored health programs, according to a report from the nonpartisan Congressional Budget Office.

The subsidies come from four main categories. About $296 billion is federal spending on programs like Medicaid and the Children’s Health Insurance Program, which help insure low-income people. Almost as big are the tax write-offs that employers take for providing coverage to their workers. Medicare-eligible people, such as the disabled, account for $82 billion. Subsidies for Obamacare and for other individual coverage are the smallest segment, at $55 billion.

In total, the subsidies are equivalent to about 3.4 percent of the U.S. gross domestic product.

Financing Americans’ Insurance

In 2018, subsidizing health coverage will cost taxpayers almost $700 billion.

Also known as the Affordable Care Act, Obamacare reduced the number of uninsured, but 29 million people will likely go without health coverage in an average month this year, the CBO said. Thirty-five million Americans could lack coverage by 2028 as rising premiums and the elimination of the individual mandate drive more people to drop coverage.

The subsidies in the Affordable Care Act are designed to insulate people in the program from premium increases. The CBO projected that monthly premiums for a mid-range plan in the program will increase by 15 percent by 2019, and by about 7 percent annually through 2028.

One reason for the rising premiums is the actions of President Donald Trump. Last year, Trump topped funding for the cost-sharing reduction payments made to insurers under Obamacare to help Americans afford health costs.

The non-payment of those subsidies, less enforcement of a rule requiring people to have insurance and limited competition caused insurers to raise their premiums by about 34 percent in 2018, compared to 2017. That increased the cost of the subsidies to the federal government, according to the CBO.

Aetna whistle-blower put on leave after accusing CVS Caremark of $1B billing scheme

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https://www.beckershospitalreview.com/legal-regulatory-issues/aetna-whistle-blower-put-on-leave-after-accusing-cvs-caremark-of-1b-billing-scheme.html

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Aenta’s former chief Medicare actuary was placed on administrative leave after filing a whistle-blower lawsuit alleging pharmacy benefits manager CVS Caremark overbilled Medicaid and Medicare for prescription drugs, according to The Columbus Dispatch.

Here are four things to know about the lawsuit.

1. Sarah Behnke, Aetna’s former chief Medicare actuary, filed the pending whistle-blower suit after her internal investigation found CVS Caremark has been allegedly overbilling the federal government for prescriptions since 2007, according to the lawsuit. Ms. Behnke accused CVS Caremark of inappropriately billing the government $1 billion-plus in fraudulent charges.

2. Aetna placed Ms. Behnke on administrative leave after the whistle-blower suit was unsealed in federal court in early April. The unsealing comes as CVS Health, the parent company of CVS Caremark, is attempting to buy Aetna for $69 billion.

3. Ms. Behnke’s lawyer told The Columbus Dispatch Aetna’s decision to place its then-Medicare actuary on administrative leave was “retaliatory and inappropriate.”

4. CVS Caremark rejected the allegations and said it will hand documents over to the court by June 1. The company said it was unaware who filed the lawsuit until after its parent put out an offer to Aetna. CVS Health spokesperson Michael DeAngelis told the publication, “We believe this complaint is without merit, and we intend to vigorously defend ourselves against these allegations.” Aetna officials declined The Columbus Dispatch‘s request for comment.

 

Americans’ Confidence in Their Ability to Pay for Health Care Is Falling

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http://www.commonwealthfund.org/publications/blog/2018/may/americans-confidence-paying-health-care-falling?omnicid=CFC1404232&mid=henrykotula@yahoo.com

President Trump is expected to soon address the nation about the rising cost of prescription drugs. But Americans are worried about more than drug prices. New findings from the Commonwealth Fund Affordable Care Act Tracking Survey show that consumers’ confidence in their ability to afford all their needed health care continues to decline.

Last week, we reported that the survey indicated a small but significant increase in the uninsured rate among working-age adults since 2016. In this post, we look at people’s views of the affordability of their health care. The Affordable Care Act Tracking Survey is a nationally representative telephone survey conducted by SSRS that tracks coverage rates among 19-to-64-year-olds, and has focused in particular on the experiences of adults who have gained coverage through the marketplaces and Medicaid. The latest wave of the survey was conducted between February and March 2018.1

Findings

Confidence in Ability to Afford Health Care Continues to Decline

In each wave of the survey, we’ve asked respondents whether they have confidence in their ability to afford health care if they were to become seriously ill. In 2018, 62.4 percent of adults said they were very or somewhat confident they could afford their health care, down from a high of nearly 70 percent in 2015 (Table 1). Only about half of people with incomes less than 250 percent of poverty ($30,150 for an individual) were confident they could afford care if they were to become very sick, down from 60 percent in 2015 and about 20 percentage points lower than the rate for adults with higher incomes. There were also significant declines in confidence among young adults, those ages 50 to 64, women, and people with health problems. Declines were significant among both Democrats and Republicans.

People in Employer Plans Have the Greatest Confidence in Their Insurance

We asked people with health insurance how confident they were that their current insurance will help them afford the health care they need this year. Majorities of adults were somewhat or very confident in their coverage; those with employer coverage were the most confident. More than half (55%) of adults insured through an employer were very confident their coverage would help them afford their care compared to 31 percent of adults with individual market coverage and 41 percent of people with Medicaid (Table 2). The least confident were adults enrolled in Medicare. Working-age adults enrolled in Medicare were the sickest among insured adults and the second-poorest after those covered by Medicaid (data not shown).2

One-Quarter of Adults Said Health Care Became Harder to Afford

We asked people whether, over the past year, their health care, including prescription drugs, had become harder for them to afford, easier to afford, or if there had been no change. The majority (66%) said there had been no change, one-quarter (24%) said it had become harder to afford, and 8 percent said it had become easier (Table 3). People with individual market coverage were significantly more likely than those with employer coverage or Medicaid to say health care had become harder to afford. About one-third of adults with deductibles of $1,000 or more said health care had become harder to afford, twice the share of those who had no deductible. About one-third of those enrolled in Medicare and 41 percent who were uninsured also reported that their health care had become harder to afford.

Only About Half of Americans Would Have Money to Pay for an Unexpected Medical Bill

Accidents and other medical emergencies can leave both uninsured and insured people with unexpected medical bills, which usually require prompt payment. We asked people if they would have the money to pay a $1,000 medical bill within 30 days in the case of an unexpected medical event. Nearly half (46%) said they would not have the money to cover such a bill in that time frame (Table 4). Women, people of color, people who are uninsured, those covered by Medicaid or Medicare, and those with incomes under 250 percent of poverty were among the most likely to say they couldn’t pay the bill.

Health Care Is Among People’s Top Four Greatest Personal Financial Concerns

Fourteen percent of adults said that health care was their biggest personal financial concern, after mortgage or rent (23%), student loans (17%), and retirement (17%) (Table 5). Those most likely to cite health care as their greatest financial concern were people who could potentially face high out-of-pocket costs because they were uninsured or had high-deductible health plans.

Policy Implications

Uninsured adults are the least confident in their ability to pay medical bills. But the risk of high out-of-pocket health care costs doesn’t end when someone enrolls in a health plan. The proliferation and growth of high-deductible health plans in both the individual and employer insurance markets is leaving people with unaffordable health care costs. Many adults enrolled in Medicare for reasons of disability or serious illness also report unease about their health care costs. An estimated 41 million insured adults have such high out-of-pocket costs and deductibles relative to their incomes that they are effectively underinsured. As this survey indicates, the nation’s health care cost burden is felt disproportionately by people with low and moderate incomes, people of color, and women.

The ACA’s reforms to the individual insurance market have doubled the number of people who now get insurance on that market to an estimated 17 million, with approximately half receiving subsidies through the ACA marketplaces. The ACA also has made it possible for people who were regularly denied coverage by insurers — older Americans and those with health problems — to get insurance. They are now entitled by law to an offer should they want to buy a plan.

But as this survey suggests, the ACA’s reforms did not fully resolve the individual market’s relatively higher costs for all those enrolled, compared to employer coverage or Medicaid. Moreover, recent actions by Congress and the Trump administration, including the repeal of the individual mandate penalty and loosened restrictions on plans that don’t comply with the ACA, are expected to exacerbate those costs for many. In the survey, people with individual market coverage are more likely than those with employer coverage or Medicaid to say that their health care, including prescription drugs, has become harder to afford in the past year. They express less confidence than those with employer coverage that their insurance will help them afford their care this year. As explained in the first post, there are a number of policy options that Congress can pursue that would improve individual market insurance’s affordability and cost protection. In the absence of bipartisan Congressional agreement on legislation, several states are currently pursuing their own solutions. But if current trends continue, the federal government will likely confront growing pressure to provide a national solution to America’s incipient health care affordability crisis.

 

 

 

 

 

Medicare Beneficiaries Feel The Pinch When They Can’t Use Drug Coupons

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https://khn.org/news/medicare-beneficiaries-feel-the-pinch-when-they-cant-use-drug-coupons/

This week, I answered a grab bag of questions about drug copay coupons and primary care coverage on the health insurance marketplace.

Q: My doctor wants me to take Repatha for my high cholesterol, but my Medicare drug plan copayment for it is $618 a month. Why can’t I use a $5 drug copay coupon from the manufacturer? If I had commercial insurance, I could. I’m on a fixed income. How is this fair?

The explanation may offer you little comfort. Under the federal anti-kickback law, it’s illegal for drug manufacturers to offer people any type of payment that might persuade them to purchase something that federal health care programs like Medicare and Medicaid might pay for. The coupons can lead to unnecessary Medicare spending by inducing beneficiaries to choose drugs that are expensive.

“The law was intended to prevent fraud, but in this case it also has the effect of prohibiting Part D enrollees from using manufacturer copay coupons … because using the coupon would be steering Medicare’s business toward a particular entity,” said Juliette Cubanski, associate director of the Program on Medicare Policy at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

The coupons typically offer patients with commercial insurance a break on their copayment for brand-name drugs, often reducing their out-of-pocket costs to what they would pay for inexpensive generic drugs. The coupons help make expensive specialty drugs more affordable for patients. They can also increase demand for the drugmaker’s products. If patients choose to use the coupons to buy a higher-cost drug over a generic, the insurer’s cost is likely to be more than what it would otherwise pay.

In addition, consumers should note that the copay cards often have annual maximums that leave patients on the hook for the entire copayment after a certain number of months, said Dr. Joseph Ross, associate professor of medicine and public health at Yale University who has studied copay coupons.

The coupons may discourage patients from considering appropriate lower-cost alternatives, including generics, said Leslie Fried, a senior director at the National Council on Aging.

According to a 2013 analysis co-authored by Ross and published in the New England Journal of Medicine, 62 percent of 374 drug coupons were for brand-name drugs for which there were lower-cost alternatives available.

Q: Last year, my marketplace plan covered five primary care visits at no charge before I paid down my $2,200 deductible. This year, it doesn’t cover any appointments before the deductible, and I had to pay $80 out-of-pocket when I went to the doctor. Is that typical now? It makes me think twice about going.

Under the Affordable Care Act, marketplace plans are required to cover many preventive services, including an annual checkup, without charging consumers anything out-of-pocket. Beyond that, many marketplace plans cover services such as some primary care visits or generic drugs before you reach your deductible.

The likelihood of having a plan that offers some cost sharing for primary care before you reach your deductible (rather than requiring you to pay 100 percent of the cost until you hit that amount) varies significantly depending on whether you’re in a bronze, silver or gold plan, according to a recent analysis by the Robert Wood Johnson Foundation.

In 2018, 77 percent of silver-level plans offered some cost sharing for primary care visits before enrollees had paid off their typical deductible of $3,800, the analysis found. In most cases, that means people owe a copayment or coinsurance charge for each visit until they reach their deductible. A small number of plans offered a limited number of no-cost or low-cost visits first, and then people using more services either had to pay the full charge for each visit or owed cost sharing until the deductible was met.

Bronze plans were much stingier in what they offered for primary care before people reached their deductible, which was $6,400 or higher in half of plans. Only 38 percent of bronze plans offered any primary care coverage before the deductible, and generally patients still had to pay a copayment or coinsurace. A smaller percentage of bronze plans offered limited visits at no cost or low cost before the deductible.

The share of people who chose bronze plans grew from 23 percent in 2017 to 29 percent this year, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. While premiums are typically significantly lower in bronze plans than other “metal”-level plans, it can be worthwhile to check out how plans handle primary care services before the deductible, she said.