White House pitch to bolster Obamacare includes tough trade-offs for Democrats


The White House is pictured. | Getty

The White House is seeking a package of conservative policy concessions — some of which are certain to antagonize Democrats — in return for backing a legislative package bolstering Obamacare markets, according to a document obtained by POLITICO.

The document indicates the administration will support congressional efforts to prop up the wobbly marketplaces, in exchange for significantly expanding short-term health plans and loosening other insurance regulations.

The document also makes severalreferences to abortion language that will be problematic for Democrats. A potential stumbling block in passing any stabilization package is whether conservatives will insist on including language prohibiting the use of government dollars to pay for abortions.

“Although congressional efforts to provide taxpayer money to prop up the exchanges is understandable, any such efforts must also provide relief to middle-class families harmed by the law and protect life,” the document states.

The source of the document provided to POLITICO isn’t identified and it isn’t dated. The White House declined to comment on the document but didn’t question its authenticity. A spokesperson for HHS said the department does not comment on leaked documents.

Two health policy experts who have been in contact with White House officials indicated that the document is consistent with ideas the administration has discussed for creating more stability and flexibility in the insurance markets.

“It’s legit,” said one former White House policy official.

Republican and Democratic lawmakers have been in delicate negotiations over a stabilization package that could clear the House and Senate. Democrats want to bolster the federal health care law after Republicans failed in their efforts to repeal it last year.

The list of White House policy requests includes allowing insurers to charge older enrollees up to five times as much as their younger counterparts, as opposed to the current three-to-one cap. That policy would require amending the Affordable Care Act.

The White House is also seeking to allow short-term plans — which offer skimpier benefits with lower premiums — to be renewed. Short-term plans, exempt from Obamacare rules, can deny people coverage or charge them more based on a health condition, in a process known as underwriting. The Trump administration recently proposed expanding the maximum length of these plans from three months to one year. However, the White House document envisions allowing people to renew this coverage “without those individuals going through health underwriting.”

The document doesn’t include support for reinsurance, which insurers have been pushing to shield them from the costs of particularly expensive customers.

The document also reiterates that the administration supports funding for cost-sharing reduction payments, which Trump cut off in October. The president’s budget proposal including funding for the payments, which help insurers reduce out-of-pocket costs for low-income Obamacare customers.

There is at least one item on the White House list that could garner bipartisan support: Expanding the use of health savings accounts. Last week, a bipartisan group of House members introduced a package of potential changes, and business groups have been pushing for HSA proposals to be part of the appropriations package Congress must pass by March 23.

Republicans fear another year of eye-popping premium increases will hit voters just before Election Day — and that they’ll get the blame this time since they’re now in charge.

But the White House asks could further unsettle those talks. In particular, the emphasis on abortion language tripped up earlier negotiations.

Democrats have been seeking a very different list of policies to boost the markets. They want to increase the subsidies provided to Obamacare customers, reinstate funding for outreach and marketing, and prevent the executive branch from expanding the availability of what they deride as “junk” insurance plans.

“People nationwide are looking at higher premiums and out-of-pocket costs as a direct result of the damage President Trump has done on health care,” said Sen. Patty Murray (D-Wash.), who has been in the middle of negotiations over a stabilization package, in a statement to POLITICO. “I certainly hope the president and Republican leaders won’t once again sabotage an opportunity to undo some of the damage they’ve done by choosing to play politics with women’s health and making last-minute, harmful demands that would raise families’ costs even more and place an age tax on seniors.”


Kaiser Health News report questions safety of ASCs: 5 things to know


Image result for ambulatory surgery center

Ambulatory surgery centers are often considered low-cost alternatives to expensive in-hospital care, but a new report from Kaiser Health News and USA Today raises questions about the safety of ASCs and the regulations that govern their practices.

Here are five things to know about the report.

1. The report claims the proliferation of increasingly complex surgeries at ASCs has shone a light on facilities’ poor preparation for emergency scenarios. ASCs are required to have patient transfer agreements to local hospitals in the event of an emergency, complying with state and federal regulations. The report cited examples of patients who were transferred from ASCs in rural areas where hospitals were up to 30 miles away and were unable to access the emergency care needed.

2. ASCs are a surgical site option for elective procedures for patients who are good candidates for the outpatient setting, typically otherwise healthy patients without comorbidities. Not every patient is a good candidate for outpatient surgery; those with pre-existing conditions are better suited for the hospital.

Preexisting conditions can complicate even the most routine surgeries, and the report claims over 260 patients have died since 2013 after procedures at ASCs. Though federal regulations require ASCs keep resuscitation equipment on hand in case of emergencies, a number of the patient deaths detailed in the article took place in facilities that skirted these regulations. However, the Ambulatory Surgery Center Association issued a statement March 2 in response to the article, reporting more than 200 million successful procedures have been performed in ASCs across the country over the same five year period.

3. The report cites examples of patients who felt hurried out of ASCs and dying on the way home.

“The stories these reporters tell are indeed tragic and will no doubt be deeply concerning to readers. Unfortunately, the article fails to provide a comparison to other sites of care and make clear that medical errors occur across all sites of care, including hospitals, and typically at much higher rates than in ASCs,” said Rebecca Craig, RN, MBA, the CEO of Fort Collins, Colo.-based Harmony Surgery Center and Peak Surgical Management.

4. In the third quarter of 2017, the most recent data available, the rate of all cause emergency department visits within one day of ASC discharge was 0.69 percent, according to statistics from ASC Quality.

5. Physicians are allowed to have ownership in ASCs, collecting a percentage of the facility fee for each case. The article’s authors suggest this ownership may influence their decision to direct cases to the center , but the laws governing ASC referrals vary by state, with some states barring surgeon referrals to any ASC in which they or a family member maintain a financial interest.

Americans’ Views on Health Insurance at the End of a Turbulent Year



The Affordable Care Act’s 2018 open enrollment period came at the end of a turbulent year in health care. The Trump administration took several steps to weaken the ACA’s insurance marketplaces. Meanwhile, congressional Republicans engaged in a nine-month effort to repeal and replace the law’s coverage expansions and roll back Medicaid.

Nevertheless, 11.8 million people had selected plans through the marketplaces by the end of January, about 3.7 percent fewer than the prior year.1 There was an overall increase in enrollment this year in states that run their own marketplaces and a decrease in those states that rely on the federal marketplace.

To gauge the perspectives of Americans on the marketplaces, Medicaid, and other health insurance issues, the Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017, including 541 people who have marketplace or Medicaid coverage. The findings are compared to prior ACA tracking surveys, the most recent of which was fielded between March and June 2017. The survey research firm SSRS conducted the survey, which has an overall margin of error is +/– 2.7 percentage points at the 95 percent confidence level. See How We Conducted This Study to learn more about the survey methods.


Adults were asked about:

  • INSURANCE COVERAGE 14 percent of working age adults were uninsured at the end of 2017, unchanged from March–June 2017.
  • AWARENESS OF THE MARKETPLACES 35 percent of uninsured adults were not aware of the marketplaces.
  • REASONS FOR NOT GETTING COVERED Among uninsured adults who were aware of the marketplaces but did not plan to visit them, 71 percent said they didn’t think they could afford health insurance, while 23 percent thought the ACA was going to be repealed.
  • CONFIDENCE ABOUT STAYING COVERED About three in 10 people with marketplace coverage or Medicaid said they were not confident they would be able to keep their coverage in the future. Of those, 47 percent said they felt this way because either the Trump administration would not carry out the law (32%) or Congress would repeal it (15%).
  • SHOULD AFFORDABLE HEALTH CARE BE A RIGHT? 92 percent of working-age adults think that all Americans should have the right to affordable health care, including 99 percent of Democrats, 82 percent of Republicans, and 92 percent of independents.

California confronts the complexities of creating a single-payer healthcare system


California confronts the complexities of creating a single-payer healthcare system

California Assembly Speaker Anthony Rendon may have expected to torpedo the idea of a statewide single-payer healthcare system for the long term last June, when he blocked a Senate bill on the issue from even receiving a hearing in his house.

He was wrong, of course. His shelving of the Senate bill created a political uproar (including the threat of a recall effort), forcing him to create a special committee to examine the possibility of achieving universal health coverage in the state. On Monday and Wednesday, the Select Committee on Health Care Delivery Systems and Universal Coverage held its final hearings.

The panel ended up where it started, with the recognition that the project is hellishly complex and politically daunting but still worthwhile — yet can’t happen overnight. “I’m anxious to see what it is that we can actually be working on this year,” committee Co-Chair Jim Wood (D-Healdsburg) said toward the end of Wednesday’s seven-hour session. “Some of the logistics and the challenges we have to deal with are multiyear challenges.”

The No. 1 experience missing from the American healthcare system is peace of mind.

Little has changed since last year, when a measure sponsored by the California Nurses Assn., SB 562, passed the Senate in June and was killed by Rendon (D-Paramount) in the Assembly. The same bill, aimed at universal coverage for all residents of the state, including undocumented immigrants, is the subject of the select committee’s hearings and the template for statewide reform.

Backers of the Healthy California program envisioned by the bill feel as if they’re in a race with federal officials intent on dismantling healthcare reforms attained with the Affordable Care Act, and even those dating from the 1960s with enactment of Medicare and Medicaid.

In just the last few weeks, the U.S. Department of Health and Human Services has approved adding a work requirement to Medicaid in Kentucky and begun considering a plan to place lifetime limits on Medicaid benefits — profound changes in a program traditionally aimed at bringing healthcare to needy families.

The Republican-controlled Congress effectively repealed the individual mandate in the Affordable Care Act. That is likely to drive up premiums for unsubsidized middle-income insurance buyers and has prompted California and other states to consider implementing such a mandate on their own. (Idaho is moving distinctly in the opposite direction from California, proposing to allow “state-based health plans” that allow insurers to discriminate against applicants with pre-existing conditions.

Healthy California would be the most far-reaching single-state project for universal health coverage in the nation. That’s to be expected, since the state’s nation-leading population (39 million) and gross domestic product ($2.6 trillion) provide the impetus to solve big social and economic issues on its own.

The program would take over responsibility for almost all medical spending in the state, including federal programs such as Medicare and Medicaid, employer-sponsored health plans, and Affordable Care Act plans. It would relieve employers, their workers and buyers in the individual market of premiums, deductibles and co-pays, paying the costs out of a state fund.

All California residents would be eligible to obtain treatment from any licensed doctor in the state. Dental and vision care and prescription drugs would be included. Insurance companies would be barred from replicating any services offered by the program.

Doctors and hospitals would be paid rates roughly analogous to Medicare reimbursements, and the program would be expected to negotiate prices with providers and pharmaceutical companies, presumably by offering them access to more than 39 million potential patients.

Wood stressed that the goal of reform is to lower healthcare prices, or at least to slow the rate of growth. Yet that may mean focusing on the wrong challenge.

The mechanics of cost reduction aren’t much of a mystery. As several witnesses at the latest hearings observed, the key is reducing unit prices — lower prices per dose of drug, lower reimbursements for physicians and hospitals, all of which are higher in the U.S. than the average among industrialized countries. It will also help to remove insurance industry profit and overhead (an estimated 15% of healthcare spending), not to mention the expenses they impose on billing departments at medical offices and hospitals, from the system.

The real challenge, however, lies in the politics of transitioning to a new healthcare system. Advocates of reform often overlook an important aspect of how Americans view the existing system. Although it’s roundly cursed in the abstract, most people are reasonably satisfied with their coverage.


That’s because most people seldom or never experience difficult or costly interactions with the healthcare system. Horror stories of treatments denied and astronomical bills charged are legion. But the truth is that annual healthcare spending is very heavily concentrated among a small number of people.

The top 5% of spenders account for half of all spending, the top 20% of spenders for about 80%. According to the National Institute for Health Care Management, the bottom 50% of spenders account for only about 3% of all spending.

These are annual figures, so over a lifetime any person may have more contacts with the system. But that may explain why it’s hard to persuade Americans to abandon a system many consider to be just good enough for something entirely new, replete with possibilities that it could turn out to be worse.

The nurses association is pegging its reform campaign to the uncertainties built into the existing system. “The experience of most Americans is that they’re satisfied with what they’re getting, but there’s a great deal of anxiety,” says Michael Lighty, the group’s director of public policy. “The No. 1 experience missing from the American healthcare system is peace of mind. People are not afraid that what they have will be taken away, but that what they have will not be adequate for what they need.”

In terms of funding, the idea is for the state to take over the $370 billion to $400 billion a year already spent on healthcare in California. (The higher estimate is from the state Legislative Analyst’s Office, the lower from the nurses association.) That includes $200 billion in federal funds, chiefly Medicare, Medicaid, and Obamacare subsidies; and an additional $150 billion to $200 billion in premiums for employer insurance and private plans and out-of-pocket spending by families.

University of Massachusetts economist Robert Pollin, the nurses’ program consultant, estimates that the program will be about 18% cheaper than existing health plans, thanks to administrative savings, lower fees for drugs, physicians, and hospitals, and a step up in preventive services and a step down in unnecessary treatments.

That would leave about $106 billion a year, as of 2017, needed to replace the employer and private spending that would be eliminated. Pollin suggests doing so through an increase of 2.3% in the sales tax and the addition of a 2.3% gross receipts tax on businesses (or a 3.3% payroll tax, shared by employers and workers), instead of the gross receipts tax. Each levy would include exemptions for small businesses and low-income families.

Anyone with experience in California tax politics knows this is a potential brick wall. Taxes of this magnitude will generate intense opposition, despite the nurses’ argument that relief from premiums and other charges means that families and business will come out ahead.

But that’s not the only obstacle. A workaround would have to be found for California Constitution requirements that a portion of tax revenues be devoted to education. A California universal coverage plan would require “a high degree of collaboration between the federal government and the state,” Juliette Cubanski of the Kaiser Family Foundation told the committee Monday. Waivers from Medicare and Medicaid rules would have to be secured from the Department of Health and Human Services; redirecting Medicare funds to the state might require congressional approval.

A federal law that preempts state regulations of employee health benefits might limit how much California could do to force employer plans into a state system.

Obtaining the legal waivers needed from the federal government to give the state access to federal funds would take two to three years “with a friendly administration,” Wood said. “We don’t have a friendly administration now.”

Advocates of change are understandably impatient in the face of rising healthcare costs and the federal government’s hostility to reform. Shocked gasps went up from the hearing audience Wednesday when Wood casually remarked, “It is absolutely imperative that we slow this down.” Startled by the reaction, he quickly specified that he meant “slow the costs down.”

The desire to pursue the goal of universal coverage, whether through a single-payer model or a hybrid, plainly remains strong in Sacramento, in the face of the vacuum created by the Republican Congress and Trump White House.

As Betsy Estudillo, a senior policy manager for the California Immigrant Policy Center put it at Wednesday’s hearing, “The nation needs California’s leadership, now more than ever.”


Trump budget seeks savings through ObamaCare repeal


Trump budget seeks savings through ObamaCare repeal

The White House budget for fiscal 2019 seeks major savings by repealing ObamaCare and endorsed a Senate GOP bill as the best way to do so.

“The Budget supports a two-part approach to repealing and replacing Obamacare, starting with enactment of legislation modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill as soon as possible,” the White House said in its budget request.

The legislation from Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Ron Johnson (R-Wis.) and Dean Heller (R-Nev.) would replace ObamaCare with a series of block grants to states.

The budget proposes over $90 billion in savings over 10 years if the policies in the Graham-Cassidy bill were enacted. Combined with other provisions like Medicaid changes, the White House projects there would be nearly $675 billion in savings over a decade tied to repealing ObamaCare.

Advocacy groups were quick to denounce the proposal, which is unlikely to gain traction in Congress.

“By asking Congress to revive the deeply unpopular Graham-Cassidy repeal bill that ended protections for Americans with pre-existing conditions, gutted Medicaid, ripped away coverage from millions, and raised costs for millions more, while also proposing drastic cuts to Medicare, Trump has chosen to ignore the American public’s overwhelming preference for a bipartisan path forward on health care,” said Protect Our Care campaign director Brad Woodhouse.

Republican leaders have signaled that they are not interested in diving back into the contentious ObamaCare repeal fight this year. The Senate last year failed to pass a repeal bill, and there is no indication that the votes have shifted since then.

A number of Republicans have even discussed taking bipartisan actions to stabilize ObamaCare markets and try to bring down premiums through actions such as funding known as reinsurance.

Graham has said he will continue fighting for his bill and is not completely alone. Sen. Ted Cruz (R-Texas) is also calling for Congress to not give up on repeal this year.


Association health plan proposal: Experts wary of weak consumer protections, oversight issues


stethoscope, coins and calculator

The new proposal to expand association health plans promises to provide more affordable insurance options for small-business owners and employees. But some experts aren’t convinced that this is the right solution.

For one, the proposal’s promises of consumer protections aren’t as strong as they seem, said Timothy Jost, a Washington and Lee University professor emeritus who closely follows the ACA.

Association health plans can’t charge higher premiums or deny coverage based on health status, according to the Department of Labor (DOL). But because AHPs would be subject to large-employer market rules, they wouldn’t have to cover the list of essential health benefits that the Affordable Care Act mandates.

The upshot, Jost told FierceHealthcare, is that insurers could legally weed out those with costly conditions while still complying with regulations that bar them from denying those individuals coverage or hiking their premiums.

“If you can’t exclude someone because they have cancer, it’s easy to just not cover chemotherapy,” he said. “Or if you can’t exclude people who have mental illness, it’s easy to just not cover mental health care.”

And Larry Levitt, senior vice president of the Kaiser Family Foundation, pointed out in a Twitter post that insurers could still hike premiums based on factors other than health status:

 The association health plan regulation prohibits variation in premiums based on health. It does not prohibit premium variation based on any other factor, such as gender, age, industry or occupation, or business size.
 Cherry-picking enrollees

Association health plans are also likely to be marketed toward the healthiest, youngest individuals, Jost noted.

“I doubt anybody is going to be out there writing association coverage for occupations that are predominantly people who are older or have chronic health problems,” he said.

The problem, then, is that AHPs would siphon more low-risk consumers out of the individual marketplaces—thus skewing that risk pool and likely causing insurers to raise premiums.

“I think everybody understands that this is going to undermine the market for ACA-compliant plans,” Jost said.

Andy Slavitt, the former Centers for Medicare & Medicaid Services acting administrator, laid out his own criticisms in a Twitter thread—including pointing out that breaking up risk pools goes against the proposal’s stated purpose of giving small businesses more clout:

 The regulation aims to push the idea of what can be considered an association.

Someone I talked to today referred to it as being able to create an “air breathers association.” Essentially, making it as rude-less as possible.

 Many of the premises of AHPs have been shown not to work in the past.

For example, the rule says AHPs will create “increased buying power”. Breaking up pools does exactly the opposite.

Instead, a “Runners’ Association” just sends a clear signal that these are healthy people.

Limited impact

Merrill Matthews, Ph.D., a resident scholar at the right-leaning Institute for Policy Innovation, praised the new proposed rule, noting that it allows small businesses to do what large employers have long been able to: self-insure.

“Self-insured employers have been able to avoid many of the state and federal mandates imposed on the small group and individual markets, which helped employers keep down the cost of coverage,” he said.

But even Matthews acknowledged that the impact of the proposed policy changes is likely to be limited, as it will only apply to small employers and possibly some self-employed individuals. Since the proposed changes are “unlikely to provide much relief” for those affected by high premiums in the individual market, he said, “Congress still needs to repeal the Affordable Care Act.”

Questions about oversight

Perhaps the biggest issue that Jost saw with the new proposal was the fact that AHPs have had past issues with insolvency, bankruptcy and even fraud.

“There’s just a long history of association health plans being formed that are thinly capitalized, that pay large salaries and expenses for their owners, and disappear when the going gets rough,” he said.

For its part, the DOL said it will “closely monitor these plans to protect consumers.” But Jost pointed out that the agency has experienced staff and budget cuts that might undermine that goal.

Even the DOL itself said in the proposed rule that “the flexibility afforded AHPs under this proposal could introduce more opportunities for mismanagement or abuse, increasing potential oversight demands on the department and state regulators.”

Ultimately, what plays out will largely be decided by how states respond to the new regulations once they are implemented, Jost added.

“In states that try to take an aggressive approach to regulating them, there won’t be that much activity,” he said. “And in states that take a hands-off approach and let anything go, there will be probably quite a bit of activity until [AHPs] start going belly up.”