The Health 202: Jayapal to roll out sweeping Medicare-for-All bill by month’s end

Image result for medicare at 50

Rep. Pramila Jayapal (D-Wash.) is seeking buy-in from more fellow Democrats for a sweeping Medicare-for-all bill she is poised to release near the end of the month.

It’s a proposal that has become a rallying cry for progressives and 2020 presidential candidates, but it is also exposing deep rifts in the Democratic Party over exactly how to achieve universal health coverage in the United States.

The Medicare for All Act of 2019, which Jayapal had planned to roll out this week but delayed because she was seeking more co-sponsors, would create a government-run single-payer health system even more generous than the current Medicare program. Her office hasn’t publicly released the details of the upcoming measure, but Democratic members told me it would cover long-term care and mental health services, two areas where Medicare coverage is sparse.

The bill also proposes to add dental, vision, prescription drugs, women’s reproductive health services, maternity and newborn care coverage to plans that would be available to people of all ages and would require no out-of-pocket costs for any services, according to a letter Jayapal sent to colleagues on Tuesday asking them to consider co-sponsoring the effort.

“Medicare for All is the solution our country needs,” the letter said. “Patients, nurses, doctors, working families, people with disabilities and others have been telling us this for years, and it’s time that Congress listens.”

The 150-page bill had 93 co-sponsors as of Tuesday, although Jayapal spokesman Vedant Patel said more Democrats have signed on since then. That’s still fewer than the 124 Democrats who co-sponsored a much less detailed Medicare-for-all proposal from then-Rep. John Conyers (D-Mich.) last year. A strategist who has been working with Democrats on health-care ideas told me there have been some frustrations that more members haven’t yet signed on to Jayapal’s bill, despite the fact that there are 40 more Democrats in the House this year.

But Jayapal said she’s confident she’ll have 100 co-sponsors by the time of the bill’s planned Feb. 26 release, explaining she’s not surprised members would take more time to consider it given its length.

“It’s a 150-page bill … it’s not an eight-page resolution,” Jayapal told me yesterday. “Now we’re actually putting detail into it, and so we feel confident we will continue to add cosponsors even after introduction.”

Patel also noted it’s still early in the year, saying he “disagrees” with the notion that it’s taking a long time to bring Democrats on board.

“It’s the second week of February and we are at more than 95 co-sponsors,” he said. “Coalition building is a process, but we are on track to introduce this historic legislation with resounding support at the end of the month.”

Yet differences are emerging among Capitol Hill Democrats over how to expand coverage, part of a larger debate roiling the party as 2020 candidates, many of them senators, and a new class of freshmen House Democrats move the party left not only on health care but also on the environment.

The cracks were especially apparent yesterday, as a separate group of lawmakers gathered to re-introduce their own proposal to allow people to buy in to Medicare starting at age 50. That measure, offered by Sen. Debbie Stabenow (D-Mich.) and Rep. Brian Higgins (D-N.Y.), would take a more incremental approach to expanding health coverage — one that could play better with voters who would stand to lose private coverage under a single-payer program.

Their bill, dubbed the “Medicare at 50 Act,” would allow people to buy Medicare plans instead of purchasing private coverage on the Obamacare marketplaces if they are uninsured or prefer it to coverage offered in their workplace.

And today, Sen. Brian Schatz (D-Hawaii) and Rep. Ben Ray Luján (D-N.M.) are reintroducing their State Public Option Act, which allows people to buy a Medicaid plan regardless of their income. That measure has broad backing from not just lawmakers (20 senators co-sponsored it last year) but also well-known health policy wonks including former Centers for Medicare and Medicaid Services Administrator Andy Slavitt.

Higgins is one of several Democrats on the House Budget Committee who have proposed a total of three separate and contrasting bills to expand Medicare to more people. The others are Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.), who have a bill to expand Medicare to all ages while still preserving employer-sponsored coverage, and Jayapal.

Once Jayapal rolls out her legislation, the Congressional Budget Office is expected to release an analysis of how much it would cost by the end of March or the beginning of April, Budget Committee Chairman John Yarmuth (D-Ky.) told me. At that point, the committee will hold a hearing with the CBO to go over the cost and its potential impact on the federal budget.

That’s where Jayapal could run into roadblocks.Given the extensive benefits she’s proposing, her bill would probably come at a steep cost to taxpayers — and paying for things is almost always Congress’s trickiest task. Of course, supporters of the legislation stress its benefits would fill in much-needed gaps in coverage under the current Medicare program.

“The biggest change I give her so much credit for is it has long-term care,” said Rep. Ro Khanna (D-Calif.), who is a co-sponsor of Jayapal’s Medicare-for-all bill. “This is huge.”

And then there’s also the question of how voters might react if told they would lose their current coverage. Sen. Kamala Harris (D-Calif.), who has gone the furthest of all the 2020 candidates in pushing for an overhaul of the U.S. health-care system, attracted widespread attention recently when she suggested she’d be fine with entirely eliminating private coverage in favor of government-run plans.

“We’re very aware that there is anxiety about — however imperfect — a system you know and doctors you know, and that is going to be all part of the hearing process, public input into: How do we build a system in this country that really cares about all Americans?” said Rep. Katherine Clark (D-Mass.), another co-sponsor of the Jayapal bill.




The healthiest and unhealthiest states in America: Where did your state rank for 2018?

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Hawaii reclaimed its title as the healthiest state in United Health Foundation’s 29th annual America’s Health Rankings report, which placed Louisiana as the least healthy state in the nation.

The report is the longest-running annual assessment of the nation’s health on a state-by-state basis from United Health Foundation, an arm of UnitedHealth Group.

Here are seven takeaways from the latest 188-page report, which calculates state health by analyzing five categories: health outcomes, health behaviors, community and environment, policy and clinical care. (Specific information on ranking methodology can be found here.)

1. The five healthiest states in the U.S. are Hawaii (No. 1), Massachusetts, Connecticut, Vermont and Utah, in ascending order. These same states ranked among the top five in 2017.

2. The five states with the most room for improvement are Arkansas (No. 46), Oklahoma, Alabama, Mississippi and Louisiana, in ascending order. Last year, Mississippi ranked as the least healthy state.

3. Maine experienced the greatest improvement in the past year, moving up seven spots from No. 23 to No. 16. Maine saw the most improvement in the categories of health behaviors and community and environment measures, with specific progress in smoking and the rate of children in poverty.

4. California and North Dakota each climbed five spots to the No. 12 and No. 13 ranks, respectively.

5. Oklahoma saw the greatest decline in rank, falling four places from No. 43 to No. 47. The downturn was largely driven by changes in health behaviors in the past year, including an 11 percent uptick in obesity rates and a 14 percent uptick in physical inactivity.

6. The report highlights some major setbacks for health of Americans. More are dying prematurely than in prior years, and suicide, drug deaths, occupational fatalities and cardiovascular deaths all increased. Obesity increased nationally and in all 50 states since 2017. The report also finds self-reported frequent mental distress and frequent physical distress increased in the past two years.

7. At the same time, several improvements are worth noting. The number of mental health providers per 100,000 population increased 8 percent since 2017, and the percentage of children in poverty decreased 6 percent in the same time frame. Stark differences by state still exist, however.

Here are the overall health rankings for each state in 2018. The full report contains breakdowns of the determinants for each state’s rank.

  1. Hawaii
  2. Massachusetts
  3. Connecticut
  4. Vermont
  5. Utah
  6. New Hampshire
  7. Minnesota
  8. Colorado
  9. Washington
  10. New York
  11. New Jersey
  12. California
  13. North Dakota
  14. Rhode Island
  15. Nebraska
  16. Idaho
  17. Maine
  18. Iowa
  19. Maryland
  20. Virginia
  21. Montana
  22. Oregon
  23. Wisconsin
  24. Wyoming
  25. South Dakota
  26. Illinois
  27. Kansas
  28. Pennsylvania
  29. Florida
  30. Arizona
  31. Delaware
  32. Alaska
  33. North Carolina
  34. Michigan
  35. New Mexico
  36. Nevada
  37. Texas
  38. Missouri
  39. Georgia
  40. Ohio
  41. Indiana
  42. Tennessee
  43. South Carolina
  44. West Virginia
  45. Kentucky
  46. Arkansas
  47. Oklahoma
  48. Alabama
  49. Mississippi
  50. Louisiana

Click to access ahrannual-2018.pdf


Doctors Start Movement in Response to NRA

Doctors Start Movement in Response to NRA

The feud between the National Rifle Association and the medical community still rages on, with the latest round coming from physicians who released an editorial saying they disagree with the NRA, published in the journal Annals of Internal Medicine on Monday.

In a tweet this month, the NRA told “anti-gun” doctors to “stay in their lane” after a series of research papers about firearm injuries and deaths was published in the Annals of Internal Medicine, including new recommendations to reduce gun violence.

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Ohio Gov. Kasich Stumps Again In Support Of Medicaid Expansion

Four years after going out on a limb to get Medicaid expansion enacted in Ohio, outgoing Republican Gov. John Kasich is worried about the future of the program. So he is now defending it — through a study and through the stories of people who have benefited from the coverage expansion.

One of those people is Brenda Jean Searcy, a 55-year-old law student who lives with her 93-year-old father in the Columbus suburb of Westerville. She says she had always been healthy but was felled by Lyme disease and then Graves’ disease; the diagnosis of the latter came after she had signed up for Medicaid through the expansion.

“I am very grateful to have Medicaid. It has made my life much better and made me much healthier,” Searcy says at a press conference.
Searcy is one of the 653,000 Ohioans who gained coverage through the Medicaid expansion, four years after Kasich defied his fellow Republican legislators in pushing Medicaid expansion through.

He claimed it would bring $13 billion in federal funding to help low-income people in Ohio get health care — especially those struggling with mental illness and addiction. Kasich is nearing the end of his second term and will leave office in January. He wants the Medicaid expansion to continue, and his Medicaid department commissioned an independent study on the effects of the expansion to support it.

Ohio Medicaid Director Barbara Sears says the analysis shows Medicaid expansion has cut in half the number of uninsured Ohioans. Ninety-six percent of people in the program with opioid addiction got treatment, and 37 percent of smokers were able to quit. One-third reported improved health, including better access to medical care for high blood pressure and diabetes. ER visits went down 17 percent, and there was a 10 percent increase in the number of people seeing primary care doctors. And most recipients said Medicaid expansion made it easier to find work, earn more money and care for their families.

The state’s budget office, part of the executive branch, estimates Medicaid expansion will cost nearly $5.2 billion in 2021, the first year Ohio will pay its full share of the costs as determined by the Affordable Care Act.

Ohio budget director Tim Keen says the state’s projected share would amount to $354.1 million. However, with drug rebates, assessments on managed care plans, a 1 percent tax on premiums and other offsets, the state’s share drops to $163.1 million. “Medicaid expansion is a significantly better deal for the states and for Ohio than the traditional program, and that’s important as one considers our ability to fund this program,” Keen says.

But Republican lawmakers have long had concerns about the program’s cost.

And so does the Republican candidate to replace Kasich, Attorney General Mike DeWine. After stating for months that he feels the Medicaid expansion is financially unsustainable, DeWine says he’ll keep it but makes changes, such as implementing work requirements and wellness programs. DeWine hasn’t made clear how much those changes would save the program – for instance, 96 percent of Medicaid expansion recipients in Ohio would be exempt from work requirements.

Kasich says he has talked to DeWine’s team about supporting the program. “I worry a little bit about somebody kind of nickeling and diming it away somehow — a little bit here, a little bit there — but I think they’ll be for it,”



Suicide rates rise sharply across the United States, new report shows


Suicide rates rose in all but one state between 1999 and 2016, with increases seen across age, gender, race and ethnicity, according to a report released Thursday by the Centers for Disease Control and Prevention. In more than half of all deaths in 27 states, the people had no known mental health condition when they ended their lives.

In North Dakota, the rate jumped more than 57 percent. In the most recent period studied (2014 to 2016), the rate was highest in Montana, at 29.2 per 100,000 residents, compared with the national average of 13.4 per 100,000.

Only Nevada recorded a decline — of 1 percent — for the overall period, although its rate remained higher than the national average.

Increasingly, suicide is being viewed not only as a mental health problem but a public health one. Nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it the 10th-leading cause of death. Among people ages 15 to 34, suicide is the second-leading cause of death.

The most common method used across all groups was firearms.

“The data are disturbing,” said Anne Schuchat, the CDC’s principal deputy director. “The widespread nature of the increase, in every state but one, really suggests that this is a national problem hitting most communities.”

It is hitting many places especially hard. In half of the states, suicide among people age 10 and older increased more than 30 percent.Percent change in annual suicide rate* by state, from 1999-2001 to 2014-2016 (Centers for Disease Control and Prevention)

“At what point is it a crisis?” asked Nadine Kaslow, a past president of the American Psychological Association. “Suicide is a public health crisis when you look at the numbers, and they keep going up. It’s up everywhere. And we know that the rates are actually higher than what’s reported. But homicides still get more attention.”

One factor in the rising rate, say mental health professionals as well as economists, sociologists and epidemiologists, is the Great Recession that hit 10 years ago. A 2017 study in the journal Social Science and Medicine showed evidence that a rise in the foreclosure rate during that concussive downturn was associated with an overall, though marginal, increase in suicide rates. The increase was higher for white males than any other race or gender group, however.

“Research for many years and across social and health science fields has demonstrated a strong relationship between economic downturns and an increase in deaths due to suicide,” Sarah Burgard an associate professor of sociology at the University of Michigan, explained in an email on Thursday.

The dramatic rise in opioid addiction also can’t be overlooked, experts say, though untangling accidental from intentional deaths by overdose can be difficult. The CDC has calculated that suicides from opioid overdoses nearly doubled between 1999 and 2014, and data from a 2014 national survey showed that individuals addicted to prescription opioids had a 40 percent to 60 percent higher risk of suicidal ideation. Habitual users of opioids were twice as likely to attempt suicide as people who did not use them.

High suicide numbers in the United States are not a new phenomenon. In 1999, then-Surgeon General David Satcher issued a report on the state of mental health in the country and called suicide “a significant public health problem.” The latest data at that time showed about 30,000 suicides a year.

Kaslow is particularly concerned about what has emerged with suicide among women. The report’s findings came just two days after 55-year-old fashion designer Kate Spade took her own life in New York — action her husband attributed to the severe depression she had been battling.

“Historically, men had higher death rates than women,” Kaslow noted. “That’s equalizing not because men are [committing suicide] less but women are doing it more. That is very, very troublesome.”

National Institute of Mental Health director Joshua A. Gordon explains some of the latest research surrounding suicide rates in the U.S. 

Among the stark numbers in the CDC report was the one signaling a high number of suicides among people with no diagnosed  mental health condition. In the 27 states that use the National Violent Death Reporting System, 54 percent of suicides fell into this category.

But Joshua Gordon, director of the National Institute of Mental Health, said that statistic must be viewed in context.

“When you do a psychological autopsy and go and look carefully at medical records and talk to family members of the victims,” he said, “90 percent will have evidence of a mental health condition.” That indicates a large portion weren’t diagnosed, “which suggests to me that they’re not getting the help they need,” he said.

Cultural attitudes may play a part. Those without a known mental health condition, according to the report, were more likely to be male and belong to a racial or ethnic minority.

“The data supports what we know about that notion,” Gordon said. “Men and Hispanics especially are less likely to seek help.”

The problems most frequently associated with suicide, according to the study, are strained relationships; life stressors, often involving work or finances; substance use problems; physical health conditions; and recent or impending crises. The most important takeaway, mental health professionals say, is that suicide is an issue not only for the mentally ill but for anyone struggling with serious lifestyle problems.

“I think this gets back to what do we need to be teaching people — how to manage breakups, job stresses,” said Christine Moutier, medical director of the American Foundation for Suicide Prevention. “What are we doing as a nation to help people to manage these things? Because anybody can experience those stresses. Anybody.”People without known mental health conditions were more likely to be male and to die by firearm. (CDC)

The rates of suicide for all states and the District of Columbia were calculated using data from the National Vital Statistics System. Information about contributing circumstances for those who died by suicide was obtained via the National Violent Death Reporting System, which is relatively new and in place in only 27 states.

“If you think of [suicide] as other leading causes of death, like AIDS and cancer, with the public health approach, mortality rates decline,” Moutier said. “We know that same approach can work with suicide.”



Medical Research, Drug Treatment And Mental Health Are Winners In New Budget Bill

Sen. Susan Collins, R-Maine (center), is joined on Wednesday by Sen. Lindsey Graham (from left), R-S.C., Sen. Lisa Murkowski, R-Alaska, and Rep. Greg Walden, R-Ore. Collins was pushing for provisions in the budget bill aimed at lowering premiums for people purchasing health insurance in the Affordable Care Act’s marketplaces. That didn’t happen.


The big budget deal reached this week in the House doesn’t include a long-sought-after provision to stabilize the Affordable Care Act marketplaces. But the $1.3 billion plan, set to fund the government through September, has lots of new money for medical research, addiction treatment and mental health care.

Here’s the rundown of what’s included in the 2,232-page spending bill, now in the hands of a Senate vote, based on summaries released by the House and Senate appropriations committees.

  • $78 billion in overall funding for the Department of Health and Human Services, a $10 billion increase
  • $3.6 billion to fight the opioid addiction crisis
    • This more than doubles the money allocated in fiscal 2017 and boosts funding for treatment and prevention, as well as helping to find alternatives for people suffering from pain.
  • $3.2 billion for mental health care
    • This is a 17 percent boost from last year and goes to treatment, prevention and research.
  • $37 billion for the National Institutes of Health
    • This is a $3 billion increase over fiscal 2017 and boosts spending on research into Alzheimer’s disease and a universal flu vaccine, among other things.

Lawmakers could not agree on language designed to stabilize the Affordable Care Act insurance markets and lower insurance premiums that Sens. Lamar Alexander, R-Tenn., and Susan Collins, R-Maine, have been fighting for since last fall. That bill would have reinstated the cost-sharing reduction payments, by which the government reimburses insurance companies that give the lowest-income customers a break on their copayments and deductibles.

Last year President Trump announced that the government would stop making the payments, a decision that drove the unsubsidized premiums on insurance policies higher.

Alexander says his proposal would restore those payments and cut premiums as much as 40 percent.

“Nothing is more important to Americans than health care, and nothing is more frightening than the prospect of not being able to afford health insurance, which is the case for a growing number of Americans,” he said at a news conference Wednesday.

But Democrats refused to support the provision because it also included language that would have barred any insurance policy sold on the ACA marketplaces from covering abortion.




Caring for veterans: A privilege and a duty


Veterans Day had its start as Armistice Day, marking the end of World War I hostilities. The holiday serves as an occasion to both honor those who have served in our armed forces and to ask whether we, as a nation, are doing right by them.

In recent years, that question has been directed most urgently at Veterans Affairs hospitals. Some critics are even calling for the dismantling of the whole huge system of hospitals and outpatient clinics.

President Obama signed a US$16 billion dollar bill to reduce wait times in 2014 to do things like hire more medical staff and open more facilities. And while progress has been made, much remains to be done. The system needs to improve access and timeliness of care, reduce often challenging bureaucratic hurdles and pay more attention to what front-line clinicians need to perform their duties well. There is no question that the VA health care system has to change, and it already has begun this process.

Over the past 25 years, I have been a medical student, chief resident, research fellow and practicing physician at four different VA hospitals. My research has led me to spend time in more than a dozen additional VA medical centers.

I know how VA hospitals work, and often have a hard time recognizing them as portrayed in today’s political and media environment. My experience is that the VA hospitals I know provide high-quality, compassionate care.

Treating nine million veterans a year

I don’t think most people have any sense of the size and scope of the VA system. Its 168 medical centers and more than one thousand outpatient clinics and other facilities serve almost nine million veterans a year, making it the largest integrated health care system in the country.

And many Americans may not know the role VA hospitals play in medical education. Two out of three medical doctors in practice in the U.S. today received some part of their training at a VA hospital.

The reason dates to the end of World War II. The VA faced a physician shortage, as almost 16 million Americans returned from war, many needing health care.

At the same time, many doctors returned from World War II and needed to complete their residency training. The VA and the nation’s medical schools thus became partners. In fact, the VA is the largest provider of health care training in the country, which increases the likelihood that trainees will consider working for the VA once they finish.

Specialized care for veterans

The VA network specializes in the treatment of such war-related problems as post-traumatic stress disorder and suicide prevention. It has, for example, pioneered the integration of primary care with mental health.

Many veterans live in rural parts of the U.S., are of advanced age and have chronic medical conditions that make travel challenging. So the VA is a national leader in telemedicine, with notable success in mental health care.

The VA’s research programs have made major breakthroughs in areas such as cardiac care, prosthetics and infection prevention.

I can vouch for the VA’s nationwide electronic medical records system, which for many years was at the cutting edge.

A case in point: Several years ago a veteran, in the middle of a cross-country trip, was driving through Michigan when he began feeling sick. Within minutes of his arrival at our VA hospital, we were able to access his records from a VA medical center over a thousand miles away, learn that he had a history of Addison disease, a rare condition, and provide prompt treatment.

I am therefore not surprised that the studies that have compared VA with non-VA care have found that the VA is, overall, as good as or better than the private sector. In fact, a recently published systematic review of 69 studies performed by RAND investigators concluded: “…the available data indicate overall comparable health care quality in VA facilities compared to non-VA facilities with regard to safety and effectiveness.”

The VA offers veterans more than health care

The most remarkable aspect of VA hospitals, though, is the patient population, the men and women who have sacrificed for their country. They have a common bond. A patient explained it this way:

“The VA is different because everyone has done something similar, whether you were in World War II or Korea or Nam, like me. You’re not thrown into a pot with other people, which would happen at another kind of hospital.”

The people who work at VA hospitals have a special attitude toward their patients. It takes the form of respect and gratitude, of empathy, of a level of caring that is nothing short of love. You can see it in the extra services provided for patients who are often alone in the world, or too far from home to be visited.

Take a familiar scene: a medical student taking a patient for a walk or wheelchair ride on the hospital grounds. It is common for nurses to say “our veteran” when discussing a patient’s care with me.

Volunteers and chaplains rotate through VA hospitals on a regular basis, to a degree unknown in most community hospitals. The social work department is also more active. The patients are not always so patient, but these visitors persevere. “They’re a good bunch of people,” one veteran said of the staff. “I know because I’m irritable most of the time and they all get along with me.”

Physicians everywhere are under heavy pressure these days, in part because of the increase in the number of complex patients they care for. Yet I have spent hours observing doctors in VA hospitals around the country as they sit with patients, inquiring about their families and their military service, treating the veterans with respect and without haste.

Earlier this year, I cared for a veteran in his 50’s, a house painter, whom we diagnosed with cancer that had metastasized widely. We offered him chemotherapy, which could have given him an extra few months, but he chose hospice. He told me he wanted to go home to be with his wife and play the guitar. One of the songs he wanted to sing was “Knocking on Heaven’s Door.”

I was deeply moved. I liked and admired the man, and I was disturbed that we had been unable to save him. My medical student had the same feelings. Before the patient left, the student told me, “He shook my hand, looked me in the eyes, and said, ‘Thanks for being a warrior for me.’”

That’s the special kind of patient who shows up at a VA hospital. Every single one of them should have the special kind of care they deserve. And we must ensure that the care is superb on this and every day.

Guns send thousands to the E.R. every year

Image result for Guns send thousands to the E.R. every year


Good morning … Our thoughts are with the victims of the horrific mass shooting in Las Vegas, and their families. If you haven’t yet, spend a minute with this graphic, from the Axios visuals team. Whatever your opinions about gun control, mental health interventions, or any other questions of public policy, it’s a stark look at the human toll of mass shootings.

Gun-related injuries send thousands of people to emergency rooms every year, even aside from mass shootings like the tragedy in Las Vegas. In 2015 alone, almost 35,000 people died from gun-related homicides and suicides, and the “clinical burden” from non-fatal gun injuries was three times higher, according to new research published in Health Affairs.

  • Men make up the vast majority of firearm-related E.R. admissions, and young men — ages 15-30 — are especially likely to end up in the hospital because of a gun.
  • A plurality of gun-related E.R. admissions resulted from an assault, followed by accidents, which accounted for about 35% of admissions.
  • Most patients admitted to emergency rooms with firearm-related injuries were discharged, either to home or other facilities. Roughly 37% were admitted for inpatient care, and about 5% died in the emergency room.

Go deeper: Health Affairs is providing free access to this study. You can read the whole thing here.

In Senate Health Care Bill, A Few Hidden Surprises

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A low-income person, eligible for Medicaid but not enrolled, is hit by a car or a bullet. Gravely injured, she arrives at the hospital unconscious. Thanks to expert, intensive care that lasts for days or weeks, she gradually recovers. Eventually, her health improves to the point where she can complete the paperwork needed to apply for Medicaid.

Such a hospital can be paid today, thanks to Medicaid’s “retroactive eligibility.” Even if the combination of medical problems and bureaucratic delays prevents an application from being filed and completed for several months, Medicaid will cover the care if the patient was eligible when services were provided.

The newest version of the Senate health bill—the Better Care and Reconciliation Act, or BCRA—would end this longstanding feature of the Medicaid program for beneficiaries who are neither elderly nor people with disabilities. If services are received in one calendar month and the application is completed the following month, the hospital would be denied all payment, even if the patient was eligible and the services were both essential and costly.

It does not matter if the state is led by a governor who understands the devastating impact of this change on hospital infrastructure, especially in rural areas where many hospitals are hanging on by a thread. Today, states have the flexibility to seek waivers that limit retroactive eligibility. Under the BCRA, that flexibility would disappear, as states are forced to end retroactive coverage, whether they like it or not.

Almost certainly, this provision would come as a surprise to most senators who are being asked to support the BCRA. It is only one of many unpleasant surprises lurking largely undiscovered throughout the bill. Following are other selected examples.

A Massive Expansion In Federal Power Over State Budgets

The BCRA grants the federal government startling new power over state Medicaid programs and state budgets. Federal dollars per person would be capped, based on state data about prior spending. But in setting the initial cap for each state, the secretary of Health and Human Services (HHS) could change the amount to rectify what the secretary views as problems in the “quality” of state data. In later years, many states could have their caps adjusted up or down by as much as 2 percent per year. That may sound like a small number, but when applied to billions of federal Medicaid dollars going to a state, it could make or break a state’s entire budget. Medicaid costs triggered by a public health emergency are exempt from the cap, but only if “the Secretary determines that such an exemption would be appropriate.” No statutory limits bound the Secretary’s use of this decision-making authority, which can have an extraordinary fiscal impact on states experiencing an epidemic or other public health crisis.

These provisions would give HHS remarkable new leverage over states, which current or future administrations could use to compel state policy changes in any desired direction. The aggressive use of available leverage has been an unfortunate feature of past administrations’ relationships to state Medicaid programs, but it could become substantially more pronounced with the increased federal authority granted by the Senate bill.

Adding To Uncertainties Surrounding State Expenditures

One recurring theme in Medicaid’s history involves state efforts to claim federal matching funds without spending the requisite state dollars. The Senate bill appears to increase this risk. Under Section 207 in the Senate bill, new opportunities emerge for states desperate to counteract the loss of billions of federal dollars. The bill authorizes unprecedented waivers involving federal funding for tax credits that help consumers buy private health insurance. So long as officials complete a form explaining how the waiver’s replacement of federal safeguards would provide an “alternative means” of increasing “access to comprehensive coverage, reducing average premiums, and increasing enrollment,” a state arguably could convert some or all of this federal money into so-called “pass-through” funds that can be used for purposes unrelated to health care. Unlike the Senate bill’s new public health emergency provisions, which require federal audits of state expenditures, states’ use of pass-through dollars has no statutory audit requirement. A state could convert subsidies meant for health insurance to other uses, or simply use the money to close a budget shortfall. As the Congressional Budget Office (CBO) explained about the virtually identical prior version of this section, the Senate health care bill would “substantially reduce the number of people insured” if states “reduced subsidies, received pass-through funds, and used those funds for purposes other than health insurance coverage.”

Medicaid Treatment For Mental Health And Substance Use Disorders

The bill repeals the current requirement that Medicaid programs must cover all “essential health benefits,” including treatment of mental health and substance use disorders. CBO found that, as the per capita limits in the Senate bill grow progressively tighter, federal Medicaid funding would eventually decline by more than a third, compared to current law. States facing such an enormous drop in federal support may see themselves as having no alternative but to cut services classified as optional, which the Senate bill redefines to include mental health and substance abuse treatment.

A Disordered Process

These problems could have been averted had the legislative process followed regular order, with hearings, legislative staff explaining the bill’s provisions, expert testimony, a public markup, and opportunities to address policy and drafting anomalies. Embedded in a measure with underlying policy goals that the authors of this blog post find fundamentally questionable, the picture that emerges is extraordinarily troubling—a legislative effort to divert more than a trillion dollars away from health care for people who are sicker, poorer, older, and indigent, while leaving states with such massive funding deficits and federal leverage that some states may attempt to stem their losses in ways that harm their vulnerable residents even more.

Even people sympathetic to the bill’s core aims, however, have good reason to oppose the Senate making such consequential decisions without taking the elementary legislative steps needed to detect and avoid terrible mistakes. Continuing to shun all the protections of regular order, the Senate appears poised to act on a bill that almost certainly includes additional unpleasant surprises going beyond those discussed here. With legislation that governs one-sixth of the US economy and that directly affects the health and economic security of millions of constituents, Senators are being asked to vote largely in the dark.