Conservatives Are Using the Courts to Attack Health Care for All Americans

A doctor in Milton, Massachusetts, wheels his patient into his office, February 2018.

Conservative state officials, in conjunction with the Trump administration, have launched an all-out attack on health care in the United States. They have brought a suit to overturn the entirety of the Affordable Care Act (ACA), which would have serious consequences for nearly every American who has health coverage, whether through their employer, the individual market, Medicare, or Medicaid. And they found a partisan judge who, last Friday, proved willing to ignore the rule of law and help them advance their political agenda through the courts.

For now, the ACA remains the law of the land. But if the partisan decision in Texas v. United States is upheld, the consequences could be devastating. The Urban Institute estimates that overturning the ACA would result in 17 million more Americans being uninsured in 2019—in addition to coverage reductions that would occur due to the elimination of the individual mandate penalty. Millions of American families could be left without access to health care—and without the financial safety and peace of mind that health insurance provides. Overturning the law would also have serious negative effects on public health and drug development and would shorten the life of the Medicare trust fund. Moreover, it would provide a major tax break to the wealthiest Americans, insurance companies, and drug manufacturers.

Supporters of the decision have talked about this as an effort to end “Obamacare,” which may cause some people to mistakenly believe it only affects those who obtain coverage through the individual marketplace. Nothing could be further from the truth: Virtually no American’s health care coverage would be safe from the effects of this decision. Here are just some of the impacts that this decision, if upheld, would have.

Risks for people who obtain coverage through their employer

  • Lifetime and annual limits on coverage: Polling shows that without the ACA’s ban on lifetime and annual caps on benefits, firms would choose to reinstate limits on coverage. Tens of millions of workers and dependents could face annual or lifetime limits.
  • Loss of coverage for young adult children: The ACA requires employer plans that cover dependents to include young adults up to age 26. More than 2 million young adults have gained coverage under the ACA’s dependent coverage provision.
  • Loss of free preventive services, including contraception: The ACA requires preventive services—such as immunizations; screenings for cancer, diabetes, and depression; and well-child visits—to be available at no cost to the patient. Womensave about $250 annually thanks to the lack of cost sharing for contraception.
  • Elimination of rebates to cover excessively high premiums: The ACA requires insurers to provide rebates if they overprice premiums relative to actual medical costs. Under the ACA’s medical loss ratio provision, insurance companies paid back $344 million in 2016 to people with employer coverage.

Risks for people who receive coverage through Medicare

  • Increases in premiums and out-of-pocket costs: Elimination of the ACA would increase some beneficiaries’ premiums, deductibles, and copayments in Medicare Part A and Part B; overturning the law would eliminate Medicare savings, and premiums are based on program spending.
  • Cost sharing for preventive services such as mammograms: Under the ACA, Medicare provides preventive services and covers a yearly wellness visit at no cost to the patient.
  • Possibility of falling back into the prescription drug coverage gap: The ACA narrowed the Part D coverage gap and was on track to completely fill it by 2020. Without the ACA, many seniors could face higher costs for prescription medications.

Risks for people who receive coverage through Medicaid

  • Loss of coverage under the Medicaid expansion: About 12 million people are covered under the Medicaid expansion, which was funded mostly by the federal government under the ACA.
  • Higher costs for preventive services such as children’s vaccines: The ACA provided a financial incentive for states to provide preventive services to Medicaid beneficiaries free of charge, which a number of states currently utilize.
  • Fewer options to receive care in homes and communities: The ACA provided new options to states to allow elderly enrollees and enrollees with disabilities to receive care in their homes. If the law is overturned, more enrollees will be forced into institutional care.

Risks for people who buy insurance on their own

  • Loss of tax credits that make coverage affordable: Nearly 9 in 10 enrollees in the ACA marketplaces receive premium tax credits. Without the ACA, enrollees would lose financial assistance toward monthly premiums, as well as funding that helps lower deductibles and copayments.
  • Increased costs or denial of coverage due to pre-existing conditions: Without the ACA, individual market insurers would be allowed to charge more, exclude coverage benefits, or turn away people based on medical history. More than 133 millionAmericans with pre-existing conditions could be subject to discrimination if they ever needed individual market coverage.
  • Increased costs for older enrollees: The ACA limits how much more insurance companies can charge older people for coverage relative to younger ones. Without the ACA’s protections, the elderly and near-elderly would see their premiums rise

The legal reasoning behind the lower court’s decision to overturn the ACA is so poor that it has been decried by even some of the most strident conservative legal critics of the law—including those who have backed the previous efforts to overturn it through the courts. Congress has tried and failed to repeal the ACA, and voters in the midterm elections made it clear that they care about keeping protections for pre-existing conditions. Yet the court’s ruling has been approvingly cited by conservative political officials, including President Donald Trump. As such, the decision is best understood not as a legal opinion but instead as a policy preference pursued through the U.S. judiciary. That preference could not be clearer: to give the country’s wealthy and special interests massive taxes cuts—and pay for them with everyone else’s health care.




Amazon’s vision for the future of health care is becoming clear

Image result for Amazon’s vision for the future of health care is becoming clear

  • Amazon made some bold first steps into health care this year.
  • We asked health-care experts to help us figure out where the company is going next.
  • Amazon could innovate in a lot of areas from pharmacy to subsidizing healthy food.

Amazon might take its time getting into new industries. But whether it’s online retail, cloud computing or groceries, its vision is typically ambitious.

Now, it’s health care’s turn.

This year, the company made a few early strides in the $3.5 trillion sector. Here are some of the highlights:

With all that in mind, we talked to some experts in the space to put the pieces together and figure out where Amazon might be going next.

Becoming Dr. Amazon

So imagine you have a sore throat. You let Alexa know, and it responds by asking if you want to book an appointment at the doctor’s office or get a virtual consult. You pick the virtual option, and the doctor through Alexa asks you about your symptoms. It decides to send a courier to your home with a tiny portable device to do some basic tests for things like strep throat. The strep test is positive, so the virtual doc sends over a prescription for an antibiotic. (We’re assuming that all the Amazon services are fully compliant with privacy and other laws.)

All this happens within a few hours, and you never need to leave your house to sit in a medical office or stand in line at the pharmacy.

That vision of the future might seem like science fiction, but it’s plausible to some health industry insiders.

“I wouldn’t be surprised if Amazon starts out in health by providing things like over-the-counter medicines, and then moves into making the experience easier for managing your health,” said Tom Robinson, a San Francisco-based partner at Oliver Wyman, who consults with health and life sciences companies.

Robinson said it’s possible for Amazon’s Alexa to become a “front door” of sorts for health care. If it can provide virtual care, including diagnostic testing and pharmacy, it could become a “closed loop” system. It wouldn’t be able to deal with all problems, Robinson points out, as some can only be managed in person. But it could do a lot for basic ailments, preventative care and potentially even to help people with chronic medical conditions.

Food as medicine?

Now that Amazon owns Whole Foods, it could also help people eat healthier.

As Jason Langheier, CEO of a food-tech start-up called Zipongo, told CNBC, Amazon could create a web-based service for people to access meal plans, kits, recipes and even subsidies on fresh foods for those who are already suffering or at risk for disease.

It might inch closer to that, he suggests, by nudging people to eat healthier food options online, which could include some advertising and product placements. “With its underbelly of e-commerce, Amazon can touch the one thing (food) that has the greatest public health impact.”

We haven’t seen many signs of progress around in this area yet, although its employer group is likely looking at poor diet as a leading contributor of preventative (and expensive) illness.




The GOP’s health problem: They like big chunks of the Affordable Care Act

A protester in New York holds a sign saying, "ACA saves lives"

Now that a Texas judge has ruled that the entire Affordable Care Act is unconstitutional — all because of its individual mandate — Republicans may find themselves wishing for a different outcome.

The big picture: There is little hope of a deal with Democrats on health reform in a divided Congress if the decision is upheld. Democrats will now use the 2020 campaign to paint Republicans as threatening a host of popular provisions in the ACA. And here’s the kicker: protections for pre-existing conditions, the provision that played such a big role in the midterms, is not even the most popular one.

Here are just some of the more popular provisions that would be eliminated — in order of their popularity, according to the Kaiser Family Foundation’s November tracking poll:

  • Young adults can remain on their parents’ health insurance policies until age 26: 82% of the public supports this, including 66% of Republicans.
  • Subsidies for lower and moderate income people: 81% support this, including 63% of Republicans.
  • Closing the “donut hole” so there’s no gap in Medicare prescription drug coverage: 81% like this, as do 80% of Republicans.
  • Eliminating costs for many preventive services: 79% support this, as do 68% of Republicans.
  • Medicaid expansion: 77% like it, as do 55% of Republicans.

The list goes on, but notably, further down but still very popular: 65% of the public supports protecting people with pre-existing conditions, as do 70% of Democrats, 66% of independents and 58% of Republicans. The fact the pre-existing conditions does not top the list shows how popular all of the other provisions are.

The Republican attorneys general brought their lawsuit in a different political environment, when Republicans held the House, Senate and the White House. If that had continued, they could have had reason to hope that a ruling in their favor, if upheld by higher courts, could have helped them achieve their goal of repeal and replace legislation.

The bottom line: Their world has changed politically, with Democrats preparing to take control of the House next year, and Republicans may have been better off settling for the repeal of the mandate penalty that Congress already passed. The mandate was by far the least popular part of the law and gave them something to crow about. Now, they may have bought more than they bargained for.





Trump administration rolls back ACA contraception mandate

Image result for separation of church and state

The Trump administration will immediately soften the Affordable Care Act’s contraception mandate, broadening exemptions for employers who have a religious or moral objection to helping provide birth control to their employees.

What’s happening: Churches and some religious organizations have always been exempt from the contraception mandate, but the Trump administration is broadening the exemptions to all nonprofit organizations as well as for-profit companies, including publicly traded corporations.

Key points: These are broad exemptions.

  • Allowing exemptions based on a “moral” objection is a big step. Previous exemptions and carve-outs were limited to employers’ religious beliefs.
  • When the Supreme Court ruled that Hobby Lobby should be able to get an exemption from the mandate, it limited its decision to companies that are closely controlled by a few people. Hobby Lobby, for example, already closed on Sundays and otherwise reflected the faith of its owners. These new rules will allow any company to seek an exemption.

The background: The ACA requires employers to include certain preventive services — including contraception — in their employees’ health care plans, without copays or other forms of cost-sharing. Churches have always been exempt. The Supreme Court also allowed an exemption for closely held corporations whose owners have a religious objection to contraception.

The Obama administration had tried to work out a middle ground for other “religious-affiliated” employers, but they said that process was still an encroachment on their religious liberty.

How To Ease The Financial Pain Of High-Deductible Health Plans

How To Ease The Financial Pain Of High-Deductible Health Plans

No matter what happens to Obamacare, one health care trend is fairly certain to continue: A growing number of you will have high-deductible health plans, whether you’re insured through your employer or buy on the private market.

A high-deductible health plan is just what it sounds like: In exchange for a lower premium, you pay more of your own money for medical care until your insurance coverage kicks in.

The IRS defines a high-deductible plan as one with a deductible of at least $1,300 a year for an individual or $2,600 for a family.

Many deductibles are higher. For instance, Covered California, the state health insurance exchange, offers bronze-level plans this year with a $6,300 individual and $12,600 family deductible, plus a separate deductible for prescription medications.

How many of you have that kind of money lying around?

The most important thing you can do to lower your costs is to choose the right plan for yourself and your family during open enrollment (assuming you have a choice).

“A high-deductible plan will work better for younger, healthier people who don’t expect to have a lot of medical expenses,” says Walter Zelman, a health policy professor at California State University-Los Angeles. “If you know you’re going to use a reasonable amount of health care in a given year, the high-deductible plan is to be avoided.”

But since most of you are stuck with your plans until the next open enrollment period, here are some simple steps you can take now to control costs.

The Basics

Under the Affordable Care Act, most health plans must offer certain preventive services for free, including mammograms, colonoscopies and routine vaccinations.

Taking advantage of them can prevent more expensive coverage down the line, says Elizabeth Abbott, director of the state’s Office of the Patient Advocate.

“Get your flu shot,” she says. “If you keep up with all of your preventive services, you will save yourselves a fair amount of money because you’re less likely to get sick and won’t have to get invasive procedures.”

No matter what kind of appointment or procedure you’re scheduling, choose in-network providers whenever possible, says Betsy Imholz, special projects director for Consumers Union. “If you stay in network, your costs are going to be lower,” she says.

Cross-check with both your provider and your insurer to confirm network status.

And don’t forget — as I often do — that you may be able to avoid a doctor’s visit by calling your insurance company’s nurse advice line, Zelman says.

Prescription Drugs

Unless you take only specialty drugs to treat serious or rare conditions, these steps can probably save you money:

— Over-the-counter and generic drugs: If your doctor prescribes a brand-name drug, ask if there’s an over-the-counter or generic option you can try first. Generics cost a fraction of the brand-name version, says David Collum, assistant clinical professor for the Department of Pharmacy Practice at University of the Pacific in Stockton, Calif.

— Shop around: Many pharmacies (both chains and independents) offer discount programs for common generic drugs, charging $4 for a 30-day supply and $10 for a 90-day supply.

Don’t be afraid to switch pharmacies or buy drugs from different places, Abbott says. “If you’re taking five drugs, price those all out,” she says. “Don’t assume a particular pharmacy offers the best price for every drug.”

Consumers Union generally finds the best drug prices at Costco or by using GoodRx’s online search tool, Imholz says.

— Patient-assistance programs: Ask your pharmacist or doctor if they know of programs that can help you afford your prescription.

Groups such as the Patient Advocate Foundation and NeedyMeds also have compiled links to organizations — and even drug companies — that provide financial aid.

— Shorter initial prescription: If your doctor prescribes a pricey drug you haven’t taken before, ask her to write the prescription for a few days or a week and monitor the results, Collum suggests.

If the drug works for you, request a new prescription for a longer period. If it’s ineffective, at least you won’t be out for the cost of a full month of medication.

Comparison Shopping

Most of us wouldn’t buy a car or plane tickets without comparison shopping. So why not shop around for medical care, whose prices can vary wildly from provider to provider?

You could save hundreds or thousands of dollars.

First, ask your doctor for the specific medical code, called a CPT code, for the procedure or test that you need, says Jeanne Pinder, CEO of ClearHealthCosts, which aims to make medical prices more transparent.

Simply asking about the cost of a lower-back MRI won’t be sufficient. “You’ll want to call and say ‘How much does an MRI of the lower back, without contrast, CPT code 72148, cost?’” she says.

Armed with the code, reach out to different providers and your insurance company. Ask both how much the procedure would cost you, and whether the provider is in your plan’s network.

Along the way, consider bypassing your insurance for a particular treatment or prescription.

“You might be better off, as an insured person, paying cash,” Pinder says. “Many people don’t reach their deductible by the end of the year, anyway.”

If you go this route, don’t call your insurance plan. Just call providers (who don’t have to be in your network) and ask them “How much will this cost me?” and “What’s your cash price?” Pinder counsels.

If the provider asks whether you have insurance, repeat that you want to be a cash customer.

“Just keep saying, ‘I’m looking for the cash price. I’m a cash customer.’ If they ask if you have insurance, repeat that you’d like to pay cash,” Pinder says.

Take detailed notes, including the name of the person who gives you the quote, Pinder adds. Better yet, get it in writing.

Pinder took her own advice recently when a family member needed an MRI, which can cost thousands of dollars. She found one for $450 cash.

“We need to get used to having this conversation and asking those questions in that fashion,” she says. “By the time you start doing it, it doesn’t hurt anymore.”

Editor’s Corner: Lack of preventive care in the US may hurt hospitals

Editor's corner

Bold statements are fairly rare from the heads of large hospital systems, but Robert Ostrowsky, the head of RWJBarnabas Health, made a pretty strong assertion in a recent interview with the Asbury Park Press: Hospitals should keep their communities healthy. But they don’t.

“It’s not easy because no one is willing to pay for that right now, meaning I don’t get reimbursed by insurance companies to keep somebody healthy and the government doesn’t seem to want to pay us to keep someone healthy,” Ostrowsky told the publication. “They all prefer to pay us when someone gets sick and they want us to spend less when that person is sick. That’s where the concentration has been. But an ounce of prevention. If they would take X number of dollars and say, ‘Here, use it to keep people healthy,’ actuarially, that will show you eventually spend less on sickness care.”

That needs to change for a variety of reasons that have begun to cascade into something profound. Princeton economist Alan Krueger has recently published a study (.pdf) showing a strong correlation between poor health and lack of workforce participation.

Retail Clinics Increase Medical Spending, Research Shows

Retail Health Clinic at Walgreens

By creating a new demand for previously unmet medical services, retail clinics are driving up medical spending, a study from RAND Corporation and Harvard University concludes. But one of the nation’s largest retail clinic chains, MinuteClinic, refutes the findings.