Obamacare’s Kindest Critic
by The New York Times Editorial Board - July History will almost surely rank health care reform as one of President Obama’s greatest accomplishments. About 20 million Americans have insurance that might otherwise have been unaffordable, and the law has cost much less than anticipated. But one senior administration official thinks the Affordable Care Act has fallen short. His name: Barack Obama.
Presidents usually wait until their memoirs to review their work. Not, in this case, Mr. Obama, who recently marked the act’s sixth anniversary with an unusual article in The Journal of the American Medical Association. Health care costs are still much too high, he wrote, and 29 million people still lack coverage. He then sketched some ideas for the presumptive presidential nominees. Hillary Clinton is likely to listen, having proposed improvements of her own. Donald Trump, not so much. He has so far adopted the “repeal and replace” position of his party.
Six years ago, 16 percent of Americans did not have health insurance; that number is now down to 9.1 percent. People forced to pay out of their own pocket were often bankrupted. Some went without care, and others resorted to charity care at emergency rooms. The law has helped many of these people by expanding Medicaid, which insures the poor. For millions of others, it created health care exchanges where people could buy coverage with the help of government subsidies.
The act also required individuals to either buy insurance or pay a penalty (to help spread the costs), while mandating that businesses with more than 50 full-time workers provide insurance to their employees.
Also impressive is what the law has not done. Republicans who derisively labeled the program Obamacare said it would cost jobs and wreck the federal budget. Yet the economy has added more than 14 million jobs since Mr. Obama signed the measure, and, according to the Congressional Budget Office, the law has cost $157 billion, or one-quarter less than was forecast in 2010.
Still, too many people have been left out. For one thing, 19 states, including Florida, North Carolina and Texas, still have not expanded Medicaid, even though the federal government offered to pay the full cost for the first three years and 90 percent starting in 2020. If these states had opted in, four million more people would be eligible. But the Republicans who control the governments in these states are ideologically opposed to the health reform law.
And despite the subsidies, many people still can’t afford health care. For some middle-class families who buy coverage on the exchanges, the cost of insurance and out-of-pocket expenses like co-pays and deductibles can add up to nearly a quarter of household income, according to the Urban Institute. It is no wonder then that nearly 80 percent of those who still do not have insurance say they cannot afford it.
Mr. Obama proposes several fixes. He recommends that the government offer its own health insurance, a so-called public option, on the exchanges in some parts of the country. That could help make health care more affordable in rural areas and smaller cities where only two or three insurers sell coverage. Republicans and some moderate Democrats fear that this could be the first step to a single-payer health care system. But there might be more support for a policy that is intended strictly for people in places with few choices.
Mrs. Clinton supports the public option and has even suggested that people between the ages of 55 and 64 be allowed to buy into Medicare, though she has not yet provided details of how that would work. Mr. Trump has said he wants universal health coverage, and has proposed tax deductions and allowing insurers to sell policies across state borders. Tax deductions would help some people but wouldn’t be enough, experts say. And insurers can already expand into other states as long as they follow the laws and regulations of the states in which they want to do business.
In addition to the public option, lawmakers ought to consider bigger subsidies for insurance offered through the exchanges, an idea Mrs. Clinton supports. This can be done at a modest cost paid for by slightly higher taxes, according to several experts. In addition, both federal and state governments ought to do more to educate people about the subsidies available to help them buy insurance.
The system could also be made more efficient. The Affordable Care Act has pushed insurers, doctors and hospitals to focus on preventive care, as Mr. Obama notes in his article, and lawmakers can build on that progress. Congress, he added, should allow Medicare to negotiate drug prices with pharmaceutical companies, an idea that could help lower costs but faces stiff opposition from Republicans and even some Democrats.
Yet another way to reduce spending on drugs, experts say, is to set up a system under which government pays more for effective medicines than for comparable drugs with less impressive results. The Obama administration recently proposedexperimentally testing these and other changes within Medicare. The pharmaceutical industry is resisting and has pressured legislators to do so, too.
What Mr. Obama has done here is unusual — asking someone else to burnish a legacy of which he is personally proud. If the candidates (and Congress) pay attention, his request may also do a world of good for millions of Americans for whom decent health care remains out of reach.
US Justice Department Steps In to Halt Health Insurance Mega-Mergers
Many credited the reporting of International Business Times journalist David Sirota for drawing attention to potentially deleterious deals
by Diedre Fulton
The U.S. Department of Justice is suing to block two mega healthcare mergers, saying the acquisitions would "fundamentally reshape the health insurance industry" to the detriment of consumers.
The antitrust lawsuits were announced Thursday by Attorney General Loretta Lynch in response to Anthem's $54 billion proposal to acquire Cigna and Aetna's $37 billion bid to takeover Humana.
"If allowed to proceed," Lynch said in prepared remarks, "these mergers would fundamentally reshape the health insurance industry. They would leave much of the multi-trillion dollar health insurance industry in the hands of three mammoth insurance companies, drastically constricting competition in a number of key markets that tens of millions of Americans rely on to receive healthcare."
"If the 'Big Five' were to become the 'Big Three,'" Lynch said, referring to the major health insurance providers, "not only the bank accounts of the American people would suffer—but also the American people themselves."
Eleven states and the District of Columbia joined the attempt to block the Anthem deal, which would combine the nation's second and fourth largest insurers. Eight states and D.C. joined the suit to block the Aetna deal, which combined the third and fifth largest.
In particular, USA Today noted, "[t]he Aetna-Humana deal would combine two of the four largest providers of Medicare Advantage plans, threatening to drive up costs for certain seniors, and would undermine competition in public exchanges in Florida, Georgia and Missouri, the government said."
UnitedHealthcare is currently the largest health insurer in the nation.
Many credited the reporting of International Business Times journalist David Sirota for drawing attention to potentially deleterious Anthem-Cigna merger.
Indeed, Sirota reported Thursday, the "deal hit turbulence" earlier this year:
There were reports of internal management squabbles between the two companies, and then an International Business Times investigative series about the merger set off a firestorm in Connecticut, which has been leading the national multistate review of the transaction. The series—which prompted a state ethics probe—documented personal and familial ties between Cigna and Gov. Dannel Malloy’s lead regulator on the deal. It also documented how Cigna and Anthem had pumped significant campaign contributions into Malloy-linked political groups as his administration led the merger review.
On Twitter Thursday, Sirota called the exposé "one of the biggest investigative stories of my career."
CNN reports that "[b]oth Anthem and Aetna said they intend to fight the suits."
This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License
http://www.commondreams.org/news/2016/07/21/us-justice-department-steps-halt-health-insurance-mega-mergers
Maine Joins Suit to Block Anthem's Acquisition of Cigna Corp.
By MAL LEARY
AUGUSTA, Maine - Maine Attorney General Janet Mills has joined a federal lawsuit to block Anthem's plan to acquire Cigna Corporation for $48 billion. Mills says both are significant insurance providers in Maine.
"Probably more than half the people of Maine who are employed by the largest employers and in the small market, more than half are covered either by Cigna or Anthem, mostly Anthem," Mills says.
Mills warns that the merger would reduce competition and could result in insurance rate increases for Mainers.
Anthem says the law suit is based on a flawed analysis and a misunderstanding of the highly-regulated health insurance business.
U.S. Says Florida Network Defrauded Medicare and Medicaid of Over $1 Billion
by Eric Lichtblau - NYT
WASHINGTON — In the biggest health care fraud case the Justice Department has ever brought, prosecutors charged on Friday that the owner of a network of Florida nursing facilities orchestrated an elaborate scheme to defraud Medicare and Medicaid of more than $1 billion over the last 14 years.
The case, featuring allegations of bribes to Miami doctors, hush money to witnesses, and laundering of huge profits through shell companies, shone a light on a lucrative Medicare black market that has surfaced in the last decade.
“Medicare fraud has infected every facet of our health care system,” Wifredo A. Ferrer, the United States attorney in Miami, said Friday in announcing the indictments of the owner of the medical facilities, Philip Esformes, and two others.
Mr. Esformes’s lawyer said on Friday that the businessman, who runs about 30 health care facilities in Florida and other states, “strongly asserts his innocence.”
Prosecutors, however, described him as the “mastermind” of a conspiracy that cycled some 14,000 elderly people in and out of nursing homes and assisted-living facilities, whether they needed medical care or not.
With the help of doctors, pharmacists, health care consultants and other medical personnel who got kickbacks for their roles, the facilities billed Medicare and Medicaid for high-priced drugs, medical procedures and health equipment that the patients either did not need or never received, prosecutors said.
In some cases, they charged, Mr. Esformes’s operation “preyed upon” the elderly patients by giving them narcotics so that they would have to remain longer in the care facilities to treat their addictions and “the cycle of fraud could continue.”
The Justice Department charged that Mr. Esformes, 47, who owns homes in both Miami Beach and the Chicago area, profited handsomely from the ill-gotten proceeds.
He reported assets of $78 million two years ago, and he withdrew more than $4 million in cash over the years from his many banking accounts, using proceeds from the scheme to pay for a $600,000 watch, the leasing of private jets and chauffeured limousines, and periodic trips with escorts to a Ritz-Carlton Hotel in Orlando, prosecutors charged in Federal District Court in Miami.
The scheme produced “staggering losses in excess of $1 billion,” said George L. Piro, the special agent in charge of the F.B.I. office in Miami. Leslie R. Caldwell, who leads the Justice Department’s criminal division, said that the $1 billion in fraudulent billings made the prosecution the biggest that the department had ever brought against individuals in a health care case.
“This was a whole network of people scratching each other’s backs, paying kickbacks and giving each other referrals,” she said. “It shows what people can do when they’re determined to put their hand in the Medicare pot.”
The indictments refer to other unnamed participants accused of taking part in the billing scheme, including doctors and pharmacists, and Ms. Caldwell said the Justice Department was continuing its investigation to determine whether additional charges should be brought.
With evidence of Medicare fraud growing, federal officials have created “strike forces” in Miami and eight other locations in recent years to better identify and prosecute suspects. They have also turned more frequently to data analytics tools to look for red flags. The effort has led to charges against 2,900 people in the last decade, with the fraudulent billings totaling $10 billion.
Ms. Caldwell said that in prosecutions like the one in Miami, “we’re getting better at focusing on the worst of the worst.”
Mr. Esformes has faced legal scrutiny before in Florida and Illinois over the operations of his nursing and assisted-living facilities. In 2006, he and his partners agreed to pay $15.4 million to settle a civil lawsuit brought by federal officials over accusations of Medicare fraud in the Miami area.
But prosecutors charged in the indictment announced on Friday that he continued the fraudulent billings even after that settlement, using intermediaries, shell companies and money laundering operations to disguise the scheme.
He is also accused of trying to pay an associate, Guillermo Delgado, who was prosecuted earlier in the same investigation, to flee to Europe rather than stand trial.
Mr. Esformes is charged with health care fraud, paying and receiving kickbacks, obstruction of justice and other crimes, and prosecutors said he could face a life sentence if convicted. The Justice Department asked on Friday that he be held without bail because his wealth and history made him a risk to flee.
Michael Pasano, a Florida lawyer representing him, said in an email after the charges were announced that “Mr. Esformes is no flight risk and is anxious to get back to his family and to be working on defending against these charges.”
He said that Mr. Esformes asserts his innocence and “insists all billings related to his facilities are legitimate and appropriate.”
As for the details of his client’s lifestyle, he said that “we will not comment on unfair and spurious allegations,” and he added that the Justice Department’s “only purpose” in including them was “to taint and defame Mr. Esformes.”
Lives Upended by Disputed Cuts in Home-Health Care for Disabled Patients
by Nina Bernstein - NYT
Widowed and disabled after a lifetime of New York factory work, including decades making baby dolls with glue that proved to be toxic, Alejandra Negron depends on a little help for nearly every step she takes. For years, she has had just enough help to stay safely in her own tidy one-bedroom apartment in Manhattan, despite pulmonary disease, asthma, diabetes, arthritis and a heart condition.
Medicaid, the state and federal health care program for the poor, covers the cost of a home-care aide during the day, and Ms. Negron’s two daughters and a granddaughter take turns staying over at night and on weekends, despite their own jobs and family obligations.
But last winter, that carefully stitched web of caregiving was abruptly torn apart by a call from Senior Health Partners of Healthfirst, a managed care insurance company that has been one of the beneficiaries of Medicaid’s overhaul of long-term care for disabled and aged people in New York. The company informed Ms. Negron that her home care was immediately being cut to 25 hours a week from 50, and her aide, the mother of a 7-year-old, was rescheduled to work from Thursday through the weekend, not Monday to Friday.
“I panicked,” Ms. Negron’s daughter Carmen Hernandez said, recalling the scene she found at her mother’s apartment that day. The aide was in tears, and Ms. Negron, 72, was petrified that she would have to go to a nursing home. “My mother said, ‘If you put me in a home, I’m going to commit suicide.’”
“I started to cry,” Ms. Hernandez added. “I didn’t know what to do.”
Now a detailed report by a coalition of more than 100 nonprofit groups shows that the crisis in Ms. Negron’s family has been repeated in hundreds of households covered by Senior Health Partners. Since January 2015, that company and at least two others have been systematically cutting the hours of home care for their disabled clients, typically without proper notice or legal justification, the study found. By law, only a change in a client’s medical condition or circumstance is supposed to allow a reduction.
The study was co-sponsored by Medicaid Matters, which is an advocate for Medicaid beneficiaries, and by the New York chapter of the National Academy of Elder Law Attorneys. It independently confirms similar allegations made earlier this year in a federal class-action lawsuitfiled against Senior Health Partners and the New York State Health Department on behalf of disabled and aged clients threatened with cuts in home care. And it echoes the patterns explored in articles in The New York Times about the pitfalls of managed long-term care, which beginning in 2012 replaced a fee-for-service system with a flat rate for each patient enrolled, regardless of how much care was provided to them.
The flat rate “creates a perverse incentive” for Senior Health Partners, the lawsuit says. “The less care they provide to each individual, the more they earn.”
Between June 2015 and December 2015, the study found a sixfold increase in hearings that challenged home-care reductions. In more than 90 percent of those 1,042 hearings, the companies lost or simply withdrew proposed cuts when challenged. Though Senior Health Partners is only one of more than 20 such plans in New York, serving about 12 percent of managed long-term care clients, it accounted for 56 percent of those hearings.
Not counting settlements, managed care companies prevailed only 1.2 percent of the time. But the report said that many of the most vulnerable clients had no way to fight cuts, unaware that they could appeal. And even those who prevailed at hearings have often faced new cutbacks, said Elizabeth Jois, a lawyer at the New York Legal Assistance Group.
That was what happened to Ms. Negron, who is one of the named plaintiffs in the lawsuit. Her daughter turned to Ms. Jois, who appealed. When Ms. Hernandez, 54, showed up at the hearing to testify for her mother, taking time off from her job as the newborn screening coordinator at Mount Sinai Beth Israel, the company withdrew its proposed reduction.
But in May, despite its own finding that her mother’s condition had worsened, the company cut her mother’s hours of care to 40 from 50. At a hearing last week, Ms. Hernandez was astonished when the company’s lawyer argued that her mother could urinate or defecate in a “pull-up” diaper and wait in a chair for two or three hours until a family member could leave work and come to change her.he decision is pending.
Senior Health Partners, which calls itself “a not-for-profit managed care organization sponsored by some of the most prestigious and nationally recognized hospitals and medical centers in New York,” said it could not discuss pending litigation.
“Senior Health Partners’ primary concern at all times is the health and well-being of all our members, who are among the most vulnerable citizens of New York,” it added in an emailed statement.
The State Health Department initially declined to respond to the report’s findings, citing the litigation, but then issued a general defense of managed long-term care. It pointed to a survey in which 87 percent of all members said their plan was good or excellent, and it said that members could change plans.
But advocates said most plans shun anyone with many needs and are reluctant to increase hours for patients who need more. The Legal Aid Society is preparing its own litigation against Senior Health Partners on behalf of a woman who is in a wheelchair and whose request for more hours of help was repeatedly denied, even after she was seriously injured in a fall, said Patricia Bath, a spokeswoman for Legal Aid.
That client’s experience reflects Senior Health Partners’ pattern of denying requests for more home care hours, Ms. Bath added, citing a Legal Aid review of more than 135 state decisions issued in the past year for people appealing such denials. Senior Health Partners’ denials have been overturned 80 percent of the time, she said.
At Ms. Negron’s apartment, Ms. Hernandez fought back tears.
“It’s like mental torture,” she said, as her mother dozed after a breathing treatment. “I don’t want her to be by herself if her last breath comes.”
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