Friday, October 20, 2017

Health Care Reform Articles - October 20, 2017

A New Plan To Rescue The ACA: Medicare-At-55

by Thomas Bodenheimer - Health Affairs - October 16, 2017

On October 12, 2017, the Trump Administration announced that it would end subsidies that reduce out-of-pocket payments for low-income individuals. This action might drive insurers out of the exchanges and might encourage younger people to drop their individual insurance plans — thereby destabilizing the individual insurance market.
Extending Medicare to the 55-64 age group—who have relatively high health care costs—is a potential fix that could insure the near-elderly and provide stability to the marketplaces. It would remove expensive individuals and families from coverage by private insurance companies, who could in turn reduce premiums for individuals and families below the age of 55.
Under this proposal, Medicare-at-55 would be universal for people in the 55-64 age group and they would leave their current private insurance. It would require an increase in the Medicare payroll tax contribution which has not increased proportionately to increases in Medicare spending; other countries sustain their health insurance programs by gradually increasing their payroll tax contributions. To make this plan fiscally sustainable, the United States would need to do the same.

The Problem With Making Medicare-At-55 Optional

Medicare-at-55 is quite different from proposals suggested by Democrats in 2009 and 2017, which allowed people aged 55-64 to voluntarily buy into Medicare as an alternative to private insurance. The problem with the idea of Medicare buy-in is that relatively few of the near-elderly would choose it. Medicare premiums for this age group—about $8,200 per year for an individual—would be significantly higher than what they currently pay with employer-sponsored insurance and with individual insurance subsidized under the Affordable Care Act (ACA).
In addition, under an optional buy-in there would be confusion among potential enrollees on whether to use the buy-in and person-by-person enrollment would be administratively complex. Moreover, the buy-in would raise vexing legislative questions around premium levels, Medigap and Medicare Advantage policies, and whether people could buy-in to Parts A, B, and D separately.

Automatic Enrollment, Just Ten Years Earlier

 The better approach would be to implement a Medicare-at-55 concept in which everyone would be automatically enrolled in Medicare — just like the current system does for those 65 and above. Upon reaching the age of 55, eligible individuals (almost everyone in the 55-64 age group) would simply receive their red-white-and-blue Medicare card. Private insurers and employers would no longer be responsible for this age group, which would allow private insurers to reduce premiums on younger families because they would have a younger, and typically healthier, pool of people to cover. In 2015, per capita health care costs for people between 55 and 64 years of age were $9,707 compared with $6,637 for the 45-54 age group, $4,442 for the 26-44 cohort, and $2,915 for those between 19 and 25.
Once on Medicare at the age of 55, people could choose to get a Medicare supplement through their previous insurer or join a Medicare Advantage plan. While the 55-64 age group has higher health care costs than younger people, they have lower costs than current Medicare beneficiaries, which in 2015 incurred per capita spending of $11,904.
Keep in mind that this is not small group to be adding to Medicare’s risk pool. In 2015, there were 41.1 million people in the 55-64 age group. 24 million have access to employer-sponsored insurance, 3 million have subsidized individual insurance under the ACA, 2 million purchase unsubsidized individual insurance, and 3.4 million are uninsured. This leaves an estimated 8 to 9 million already on Medicare and/or Medicaid.

How Would We Pay For Medicare-At-55?

First, it is noteworthy that from 2010 to 2016, per capita Medicare spending growthwas 1.3% compared with 3.5% for private insurance. Second, it would be impossible for most people in the 55-64 age group to pay for their Medicare plan and—given the high per capita costs of this age group—it would be very expensive for the federal government to subsidize their plan. The costs of Medicare-at-55 would have to be borne by the younger population, who would benefit greatly as they reached 55.
The best revenue source for Medicare-at-55 is the current Medicare financing model: payroll tax for Medicare Part A, individual premiums and general federal revenues for Medicare Part B, and Part D through general federal revenues and out-of-pocket costs. The same model could be extended to the 55-64 age group, with an increase in the payroll tax, for example, from 2.9% (half from employers and half from employees) to 3.9% and an increase in the higher-income payroll tax from 2.35% to 3.35%. The precise increases would have to be calculated by federal actuaries and these increases could also be used to extend Medicare’s life from the current date of 2029.
To add to these Medicare revenues, which are distributed throughout the entire population, the new 55-64 beneficiaries would still pay their Part B premiums ($134 per month for incomes of $85,000 or less, more for higher incomes) and Part D (prescription drugs) premiums. Their out-of-pocket costs would depend on whether they have a Medicare supplement or Medicare Advantage plan. The 55-64 population would be subject to the same Medicare rules as the over 65 Medicare population.
To pay for the 55-64 age group to be folded into Medicare, not only the payroll tax, but the portion of Medicare financing provided by general federal revenues, needs to increase. Employers that insure their employees would be required to contribute through Medicare-earmarked payments. Otherwise these employers would receive a windfall since they would no longer be responsible for the health care costs of their 55-64 year-old employees.
Medicare-at-55 is a reasonable proposal to stabilize the ACA while providing reliable health insurance for the 55-64 age group. As the most expensive group insured through the ACA marketplaces moves to Medicare, insurers could reduce premiums for the remaining younger and healthier age groups. The transfer of the 55-64 cohort from employer-sponsored insurance to Medicare would allow insurers to also moderate their premiums in the employer market.
Many questions have yet to be answered in developing the concept of Medicare-at-55, but the idea deserves to be added to the mix of proposals designed to extend our nation’s insurance coverage and repair the ACA marketplaces.

2 Senators Strike Deal on Health Subsidies That Trump Cut Off

by Thomas Kaplan and Robert Pear - NYT - October 17, 2017

WASHINGTON — Two leading senators, hoping to stabilize teetering health insurance markets under the Affordable Care Act, reached a bipartisan deal on Tuesday to fund critical subsidies to insurers that President Trump moved just days ago to cut off.
At the White House, virtually as the deal was being announced, Mr. Trump voiced support for it while insisting that he would try again to repeal President Barack Obama’s signature health law.
The plan by the senators, Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, would fund the subsidies for two years, a step that would provide at least short-term certainty to insurers. The subsidies, known as cost-sharing reduction payments, reimburse insurance companies for lowering deductibles, co-payments and other out-of-pocket costs for low-income customers.
Without them, insurance companies said, premiums for many customers purchasing plans under the Affordable Care Act would shoot up, and with profits squeezed, some of the companies would probably leave the market.
“In my view, this agreement avoids chaos,” Mr. Alexander said, “and I don’t know a Democrat or a Republican who benefits from chaos.”
Mr. Trump appeared to back the deal, even as he berated insurance companies, declared the Affordable Care Act “virtually dead” and promised the demise of the health law in due time.
“It’ll get us over this intermediate hump,” the president said at a Rose Garden news conference, describing it as “a short-term solution so that we don’t have this very dangerous little period.”
Passage of the deal negotiated by Mr. Alexander and Ms. Murray is still far from assured. If approved, the agreement could provide a reprieve for the Affordable Care Act that would prevent 2018 premiums from increasing as much as they might otherwise have gone up. But consumers in many states will still face double-digit rate increases, and in many counties, health plans will be available from only one insurance company.
Moreover, Mr. Trump and other Republicans are still intent on repealing much of the Affordable Care Act, and an executive order issued last week by Mr. Trump could destabilize markets in 2019 and later years by encouraging sales of health plans that skirt the coverage requirements of the health care law.
“For a period of one year, two years, we will have a very good solution,” Mr. Trump said. “But we’re going to have a great solution, ultimately, for health care.”
Mr. Alexander, the chairman of the Senate health committee, said that in addition to funding the payments to insurers, the deal would also give states “more flexibility in the variety of choices they can give to consumers” — a change that should appeal to Republicans eager to give states more say over health care.
“This takes care of the next two years,” Mr. Alexander said. “After that, we can have a full-fledged debate on where we go long-term on health care.”
The agreement bears the hallmarks of bipartisanship. For Republicans, state governments would find it easier to obtain waivers from certain requirements of the Affordable Care Act. But there would be explicit protections for low-income people and people with serious illnesses.
Consumers of any age would be allowed to obtain catastrophic insurance plans that typically have low monthly premiums but high deductibles and other out-of-pocket costs. Catastrophic plans provide protection against serious illnesses and injuries, but consumers must pay most routine medical expenses themselves.
Under current law, catastrophic plans are available only to people who are under the age of 30 or have received an exemption from the federal coverage requirement because they cannot afford other insurance.
For Democrats, not only would the cost-sharing reductions be brought back, but millions of dollars would be restored for advertising and outreach activities that publicize insurance options available in the health law’s open enrollment period, which starts next month. The Trump administration had slashed that funding.
“We will spend about twice as much or more than President Trump wanted to expend,” Mr. Alexander promised.
Accusing Mr. Trump of taking steps to “sabotage health care in our country,” Ms. Murray said, “I’m really glad that Democrats and Republicans agree it’s unacceptable, and that the uncertainty and dysfunction cannot continue.”
Senator Chuck Schumer of New York, the Democratic leader, hailed the agreement as a model for how the two parties could work together on other issues, such as taxes.
“I don’t expect the Republicans to give up their goal of repealing A.C.A.,” Mr. Schumer said. “But in the meantime, stabilizing the system, preventing chaos and stopping the sabotage is in everybody’s interest.”
The fate of the cost-sharing subsidies has been in doubt since a federal district judge ruled in 2016 that the payments to insurers were unconstitutional, because Congress had never appropriated money for them. Mr. Trump, whose administration has been taking steps to undermine operation of the health law, declared last week that he would stop the payments.
If the cost-sharing payments were cut off and premiums increased, many low-income people would receive more financial assistance, in the form of larger tax credits, to help pay the higher premiums. But many middle-income people who do not receive such assistance would have to bear the additional cost on their own.
A coalition of state attorneys general filed suit on Friday, and Congress immediately came under pressure to take action to ensure that the payments would continue. Doctors, hospitals and insurers, as well as the National Governors Association and the U.S. Chamber of Commerce, urged lawmakers to provide the funding.
Mr. Alexander said that he spoke with Mr. Trump over the weekend, and that the president encouraged his efforts with Ms. Murray, the top Democrat on the Senate health committee. But it remains to be seen whether conservative-leaning Republicans will get on board with the agreement, and whether the House will accept it.
It is not clear how the agreement might move through Congress. Supporters of funding the subsidies could push to have the deal included in a measure to keep the government open past Dec. 8. Democratic votes will be needed to fund the government, and the health care deal could come to fruition when Democratic leverage is particularly strong.
Some Republicans have already said they do not wish to provide what they describe as a bailout to insurers.
“I think it would be a mistake for Congress to provide billions in bailouts to insurance companies without providing meaningful relief to the millions of Americans who have been hurt by Obamacare,” Senator Ted Cruz of Texas said Tuesday before the deal was announced.
Mr. Alexander said the agreement would include “the strongest possible language” to guarantee that money provided for cost-sharing payments goes to the benefit of consumers, not insurance companies. “I want that, Senator Murray wants that, the president wants that,” he said.
The Senate majority leader, Mitch McConnell of Kentucky, gave no indication on Tuesday about when — or whether — the chamber might move ahead with the plan drawn up by Mr. Alexander and Ms. Murray.
Senator John Thune of South Dakota, a member of the Senate Republican leadership, said there would be “a sense of urgency to move a bill,” since Mr. Trump intended to stop the payments right away.
The House is away for a weeklong recess, and a spokesman for Speaker Paul D. Ryan of Wisconsin declined to comment.
A leading conservative in the House, Representative Mark Walker of North Carolina, the chairman of the Republican Study Committee, immediately declared the deal to be “unacceptable.”
“Obamacare is in a ‘death spiral,’ ” Mr. Walker said. “Anything propping it up is only saving what Republicans promised to dismantle.”
Another leading conservative, Representative Mark Meadows of North Carolina, the chairman of the hard-line House Freedom Caucus, described the agreement as a “good start,” but said “much more work needs to be done.”
“Most importantly,” he added, “it bears repeating: Republicans cannot allow short-term solutions to become a distraction to repealing and replacing Obamacare — something we’ve promised to do for seven years.”

Will Mitch McConnell Help His Friend Get a Health Care Deal?

By Carl Hulse - NYT - October 19, 2017

WASHINGTON — Mitch McConnell and Lamar Alexander go way back.
The two Southern Republicans met in Washington in 1969 when Mr. Alexander was a promising young aide at the Nixon White House and Mr. McConnell an up-and-coming legislative assistant to Senator Marlow W. Cook of Kentucky.
The story goes that Senator Howard H. Baker Jr. suggested to Mr. Alexander, his fellow Tennessean, that he should look up Mr. McConnell, that he was a “smart young man and I think you’d like him.” A nearly 50-year friendship and political alliance was born.
In his book “The Long Game,” Mr. McConnell, now the Senate majority leader, says of Mr. Alexander: “Lamar would go on to become one of my closest confidantes and a very good friend.” Not many people are considered a close, let alone the closest, confidant of the notoriously reticent leader.
But deep friendship aside, Mr. McConnell will be extremely cautious in moving ahead with the health care compromise that Mr. Alexander struck with Senator Patty Murray, a Washington Democrat, in an effort to stabilize the insurance exchanges for those buying coverage under the Affordable Care Act. And considering that President Trump is giving mixed signals on the proposal and that many Republicans in both the Senate and House are already opposed to it, the outlook for the rare bipartisan deal is murky at best.
With Mr. McConnell’s blessing, Mr. Alexander engaged in a concerted effort to find a compromise with Ms. Murray, the senior Democrat on the health committee that Mr. Alexander leads. The goal was for Congress to officially appropriate the subsidies paid to make insurance more affordable for lower-income Americans while giving states more freedom in regulating insurance — an approach favored by Republicans.
The subsidies, estimated at $7 billion this year, were challenged in federal court by the House in 2014 and found unconstitutional because Congress had not approved them. Mr. Trump announced last week that he was cutting them off and Mr. Alexander said he feared millions of people could now find insurance out of their financial reach.
espite the serious negotiations, there was no firm commitment that a compromise would reach the Senate floor if one could be struck. In fact, Mr. Alexander deferred to Mr. McConnell last month when Mr. McConnell wanted to take one last shot at overturning the health care law. He broke off his talks with Ms. Murray, resuming them only when the repeal effort faltered once again.
All sides agree that Mr. Trump — in conversations with Mr. Alexander and Senator Chuck Schumer of New York, the Democratic leader — strongly encouraged the bipartisan talks and initially seemed to embrace the agreement to restore the subsidies as a way to buy time for another repeal push. So backers of the plan were blindsided when the president said on Twitter on Wednesday that he could not back what he considered an insurance industry bailout.
Mr. Schumer said the president was undercutting himself by wavering on deals he had helped set in motion, not just on health care but also on issues like immigration. Mr. Schumer suggested that Mr. Trump caved to conservative opposition to the health care compromise.
“This president cannot govern if whenever the hard right frightens him and says, ‘Jump,’ he says, ‘How high?’” Mr. Schumer said.
Backers of the compromise face a tough task in selling the idea to many Republicans who would now be voting not to repeal the health care law, but to temporarily prop it up to avoid a breakdown in the marketplace. In addition, many on Capitol Hill say the compromise could be an important first step toward stabilizing the overall program, making future attempts to repeal it even more difficult.
Mr. Trump’s view will be crucial. His endorsement could provide important political cover for those nervous about voting to bolster the health care law while his opposition could cause Republicans to flee, fearing they will come under attack from the president and his allies.
Mr. Alexander is not retreating. Trying to build momentum, he and Ms. Murray introduced the legislation on Thursday along with two dozen leading Republican and Democratic co-sponsors — an almost unheard-of event on a major bill in this highly polarized environment.
Among Republicans backing the measure were Senators Charles E. Grassley of Iowa, long active in health policy; Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, the authors of the most recent repeal plan; Bob Corker, Mr. Alexander’s Tennessee colleague who has been feuding with the president; and the group who thwarted Republican repeal efforts, John McCain of Arizona, Susan Collins of Maine and Lisa Murkowski of Alaska.
“I don’t believe Congress will want to fail to deal with a problem that will hurt millions of Americans if we allow it to continue,” Mr. Alexander said.
He and Ms. Murray said that they had built in protections to make sure the money went to consumers and that it was a mischaracterization to call it an industry bailout. They said both sides gave substantial ground in the talks. Ms. Murray told fellow Democrats this week that it was the toughest bargaining she had been involved in as a senator.
“It sends a powerful message that when members of Congress decide to get past our talking points and take a few steps out of our partisan corners, there is a lot we can agree on and a lot we can get done,” Ms. Murray said of the negotiation.
But to a large degree, the ultimate success of the talks depends on Mr. McConnell. He has been quiet so far about the bill and whether he would push it forward. The Senate would no doubt have to give it a strong vote for the plan to have any chance of moving through the House.
The support from a growing list of Republican co-sponsors is no guarantee that the Senate will consider the bill if Mr. McConnell views it as too politically risky. He refused to bring to the floor last year a bipartisan criminal justice overhaul that had broad support because of political considerations — despite the fact that Senator John Cornyn of Texas, the No. 2 Senate Republican, was a chief author.
Mr. Alexander has repeatedly predicted that some version of his new legislation will become law by the end of the year. For him to be proved right, he is going to need some help from his good friend Mitch McConnell.

Trump’s health subsidy shutdown could lead to free insurance

by Ricardo Alonzo Salvador - Associated Press - October 19, 2017

If President Donald Trump prevails in shutting down a major “Obamacare” health insurance subsidy, it would have the unintended consequence of making free basic coverage available to more people, and making upper-tier plans more affordable.
The unexpected assessment comes from consultants, policy experts, and state officials trying to discern the potential fallout from a Washington health care debate that’s becoming harder to follow.
What’s driving the predictions? It’s because another of the health law’s subsidies would go up for people with low-to-moderate incomes, offsetting Trump’s move.
“It’s a kind of counterintuitive result,” Kurt Giesa, a health insurance expert with the Oliver Wyman consulting firm, said.
According to one estimate, more consumers would sign up for coverage next year even though Trump says the Affordable Care Act is “virtually dead.”
On Wednesday, the fate of the health law’s subsidy for copays and deductibles remained unclear as a bipartisan congressional deal to continue payments ran into political roadblocks. Separately, state attorneys general asked a federal court to order the administration to keep the money flowing.
But if Trump succeeds, it may be like pushing down on one end of a see-saw only to see the other end go up.
His attempt to shut off the subsidy for copays and deductibles would cause a different subsidy to jump up, the one for premiums.
The Obama-era health care law actually has two major subsidies that benefit consumers with low-to-moderate incomes. The subsidy Trump targeted reimburses insurers for reducing copays and deductibles, and is under a legal cloud. The other subsidy is a tax credit that reduces the premiums people pay, and it is not in jeopardy.
If the subsidy for copays and deductibles gets erased, insurers would raise premiums to recoup the money, since by law they have to keep offering reduced copays and deductibles to consumers with modest incomes.
The subsidy for premiums is designed to increase with the rising price of insurance. So government spending to subsidize premiums would jump.
“This is where the counting gets sort of weird,” Matthew Buettgens, a senior research analyst with the Urban Institute, said.
The nonpartisan policy research group has estimated that richer premium subsidies could entice up to 600,000 more people to sign up for health law coverage, depending on how insurers and state regulators adjust.
The group also found that the federal government would end up spending more overall on health insurance through higher premium subsidies.
That hasn’t been lost on officials at the state level.
“It means many more Californians and people across the country will get a zero-premium bronze plan,” said Peter Lee, executive director of Covered California, the health insurance marketplace in the nation’s most populous state.
“Bronze” is the health law’s basic coverage level. “Silver” is the mid-range standard plan and the most popular. “Gold” is close to employer health insurance in value.
In addition to free bronze plans, many consumers would be able to buy a gold plan for about the same monthly premium as silver coverage, Wyman and the Urban Institute concluded.
Other states where consumers could see zero-premium bronze plans include Florida, Georgia, Illinois, Mississippi, Pennsylvania, Utah and Wyoming, according to an industry estimate.
It’s complicated, but here’s why:
— First, the subsidy for copays and deductibles is provided only if you have a silver plan.
— Next, the other subsidy, the one for premiums, is pegged to the cost of a lower priced silver plan.
In California, regulators instructed insurers to increase premiums for silver plans sold on the public marketplace to account for the loss of the subsidy for copays and deductibles.
Premiums for bronze plans and gold plans were shielded from that increase.
But because the federal subsidy for premiums is tied to the cost of a silver plan, that subsidy will be higher for everybody whose income qualifies them for financial assistance.
So consumers can use their richer premium subsidy to get a bronze plan for no monthly cost or very little or a gold plan for much less than they would pay now.
Lee, the California official, said he believes regulators in close to half the states have taken a similar approach.
Final premiums for 2018 have not been officially unveiled yet, and some states are still making adjustments. Sign-up season starts Nov. 1.

‘Drug Dealers in Lab Coats’

by Nicholas Kristof - NYT - October 19, 2017

For decades, America has waged an ineffective war on drug pushers and drug lords, from Bronx street corners to Medellin, Colombia, regarding them as among the most contemptible specimens of humanity.
One reason our efforts have failed is we ignored the biggest drug pushers of all: American pharmaceutical companies.
Our policy was: You get 15 people hooked on opioids, and you’re a thug who deserves to rot in hell; you get 150,000 people hooked, and you’re a marketing genius who deserves a huge bonus.
Big Pharma should be writhing in embarrassment this week after The Washington Post and “60 Minutes” reported that pharmaceutical lobbyists had manipulated Congress to hamstring the Drug Enforcement Administration. But the abuse goes far beyond that: The industry systematically manipulated the entire country for 25 years, and its executives are responsible for many of the 64,000 deaths of Americanslast year from drugs — more than the number of Americans who died in the Vietnam and Iraq wars combined.
The opioid crisis unfolded because greedy people — Latin drug lords and American pharma executives alike — lost their humanity when they saw the astounding profits that could be made.
It used to be in America that people became addicted to opioids through illegal drugs. In the 1960s, for example, 80 percent of Americans hooked on opioids began with heroin.
That has completely changed. Today, 75 percent of people with opioid addictions began with prescription painkillers. The slide starts not on a street corner, but in a doctor’s office.
That’s because pharmaceutical companies in the 1990s sought to promote opioid painkillers as new blockbuster drugs. Company executives accused doctors of often undertreating pain (there was something to this, but pharma executives contrived to turn it into a crisis that they could monetize). The companies backed front organizations like the American Pain Foundation, which purported to speak on behalf of suffering patients.
These front organizations, as well as professionals sometimes funded by the pharmaceutical industry, heralded pain as the “fifth vital sign,” along with pulse, temperature, respiratory rate and blood pressure. The opioid promoters hailed opioids as “safe and effective,” and they particularly encouraged opioids for returning veterans — one reason so many veterans have suffered addictions.
Pharma companies spent heavily advertising opioids — $14 million in medical journals in 2011 alone, almost triple what they had spent in 2001 and pitched them for a wide range of chronic pains, such as arthritis and back pain.
Companies even argued that signs of addiction were a reason to prescribe more opioids. Endo Pharmaceuticals distributed a book suggesting that when a patient showed strange behavior, “the clinician’s first response” should be to increase the dose of opioids.
Several of these examples come from a lawsuit by Ohio against major pharmaceutical companies, including Purdue, Teva, Cephalon, Johnson & Johnson and Janssen. A company affiliated with Purdue pleaded guilty of felony fraud in connection with its marketing of OxyContin, but none of its executives went to prison.
Drug companies employed roughly the same strategy as street-corner pushers: Get somebody hooked and business will take care of itself. So last year, Americans received 236 million opioid prescriptions — that’s about one bottle for every adult.
A Senate investigation found that one company, Insys Therapeutics, successfully redirected a powerful opioid called Subsys, meant for cancer pain, to patients without cancer. Sarah Fuller, a woman with neck and back pain, was prescribed Subsys by her doctor, who received payments from Insys.
Fuller died of an overdose of Subsys.
Meanwhile, Insys had the best-performing initial public offering in 2013, and revenue tripled in the next two years, the Senate report said. Likewise, the Sackler family, owner of the company that makes OxyContin, joined Forbes’s list of richest American families in 2015, with $14 billion.
It’s maddening that the public narrative is still often about an opioid crisis fueled by the personal weakness and irresponsibility of users. No, it’s fueled primarily by the greed and irresponsibility of drug lords — including the kind who inhabit executive suites. The Washington Post quoted a former D.E.A. official as referring to pharmaceutical company representatives as “drug dealers in lab coats.”
I was invited the other day to a gala honoring the C.E.O. of one of these pharma companies for his moral leadership. I wanted to throw up. Since 2000, more than 200,000 Americans have died from overdoses of prescription opioids — the consequence of a deliberate strategy to make money by ignoring public welfare.
Our pattern of opioid addiction points to a tragedy, driven by the greed of some of America’s leading companies and business executives, systematically manipulating doctors and patients and killing people on a scale that terrorists could never dream of.
There’s a lot of talk in the Trump administration about lifting regulations to free up the dynamism of corporations. Really? You want to see the consequences of unfettered pharma? Go visit a cemetery.

Warnings of 'Big Pharma Coup' as Trump Considers Drug Exec. for Health Secretary

"Trump has decided to cut out the middleman, and let a pharmaceutical executive literally run the health department."
by Jake Johnson - Common Dreams - October 18, 2017

"Just days after denouncing 'out-of-control' drug prices, President Donald Trump appears set to show he doesn't mean it by naming a former pharmaceutical company executive to run the U.S. Department of Health and Human Services," said Public Citizen president Robert Weissman. "In his public statements, Alex Azar has made clear that he is opposed to measures to restrain drug company profiteering and limit improper marketing and favors weaker drug safety approval standards."
Azar spent a decade as an executive with the pharma giant Eli Lilly, where he directed the company's sales operations. Before joining Eli Lilly, Azar served as deputy secretary of the HHS under George W. Bush.
As Politico reports, Azar also happens to be "one of the many drug industry executives" who contributed to Trump's presidential campaign—a fact that runs counter to the president's frequent criticism of elected officials who take cash from pharma executives.
If nominated, Azar would be filling the role left vacant by Tom Price, who resigned last month amid growing outrage over his use of private jets to travel across the U.S. on government business.
Weissman argued on Wednesday that while Price was a supporter of the pharmaceutical industry, Azar would take Big Pharma's influence on American healthcare to the next level.
"The swamp only gets worse," Weisman said. "Trump has decided to cut out the middleman, and let a pharmaceutical executive literally run the health department."
Weissman concluded that Azar's nomination would effectively foreclose the possibility of any substantive steps toward tackling high drug prices or pharma monopolies.
"Americans understand, passionately, that drug company price gouging leads to rationing of care. It is unethical and must end," Weissman said. "But it is highly unlikely that a pharmaceutical company executive who has made passionate arguments against price restraints is going to advance real reform."

The Outlook for Stabilizing Obamacare in 2018 and the President Who Can't Shoot Straight

by Robert Laszewski - Health Care Policy and Marketplace Review - October 19, 2017

The Alexander-Murray bipartisan effort to stabilize the Obamacare individual insurance markets will not pass the Congress on its own.  
The only chance it now has is to be added to a must-pass legislative deal, such as the one needed to fund the government by the December 8 deadline in order to avoid a government shutdown.
Also sitting in the queue, and certain to pass at some time, is the Children's Health Insurance Program (CHIP) reauthorization bill. The Congress is currently struggling over the pay-fors for this reauthorization but there is wide bipartisan agreement that it must be funded before the states start running out of money, which will begin in a few weeks. CHIP now covers nine million kids.
Conservative Republicans are adamant that they do not want to pass an “insurance company bailout” bill like Alexander-Murray. Particularly in the House, where Republicans were able to pass a "repeal and replace" bill, these members have already taken a controversial vote to cut Medicaid and insurance subsidy support and after that tough vote don't now want to have to explain why they have backtracked to "bail out" Obamacare with the Alexander-Murray short-term patch bill.

Tuesday, Trump pulled his initial support for the bill. That he would first support it and then abandon it just speaks to how little he understands the health issue and how essentially worthless his presidential leadership is toward getting a solution for Obamacare. This Trump flip-flopping just proves that there is only one place health care gets decided—in the Congress and a very divided Congress at that.
On health care, if leading conservative organizations told Trump to sign a ham sandwich he would do it and declare it, “A Marvelous victory, really a very marvelous victory.” 

If you want a description of a President who can't shoot straight, look at Trump’s citing the stock price gains among the big managed care companies as justification for his killing the cost sharing subsidies (CSRs) for low-income people in the insurance exchanges. 

Hasn’t anyone told Trump that almost all of those big publicly traded health insurers he's been railing against for their big stock price appreciation since Obamacare launched––Aetna, United, Humana, and Anthem–– have bailed, or are in the process of bailing, on all or most of their insurance exchange business and won’t be hurt by his action? It’s the not-for-profits that have largely stayed in the exchanges, not his intended targets!
There is no hope of the Republican caucus in either the House or the Senate advancing anything in the coming months—repeal and replace or a short-term patch––on their own. We saw them exhaust all of their policy ideas over the past four months. They claim they will again try to advance a Graham-Cassidy-like bill focusing on state block grants but until they can reconcile the cuts to Medicaid and the insurance subsidies the conservatives want with the cuts the moderates don’t want, they aren't going to pass anything.
That leaves us with the Democrats. The Dems don’t have a majority in either house. But there are must-pass bills on the table—such as funding the government by December 8 to avoid a shutdown and the reauthorization of CHIP before the states run out of money to continue health insurance for nine million kids. The most likely vehicle for them to exert their leverage will be on the shutdown bill. It will take 60 Senate votes to avert a government shutdown just before the Congressional holiday break (never underestimate an ideologues desire to get his holiday vacation). Look for the Dems to try to take the December 8th funding bill hostage toward getting something like Alexander-Murray. 
Of course, it they are successful, any short-term help for the insurance exchanges will be too late for 2018 since next year's open enrollment is scheduled to end on December 15th.

Congress, End the Health Care Chaos. You Have 9 Million Kids to Protect.

The Editorial Board - NYT - October 18, 2017

President Trump and Republicans in Congress have brought chaos to the American health care system by trying to destroy the Affordable Care Act and failing to reauthorize the Children’s Health Insurance Program, which, with bipartisan support for the past 20 years, has provided care for millions of children. Over the next few weeks they can choose to set things right or to destroy them.
Senators Lamar Alexander and Patty Murray on Tuesday announced a bipartisan deal that could help stabilize the A.C.A.’s insurance markets and undo some of the damage Mr. Trump has done through administrative actions. In an ideal world, Congress would quickly pass that bill, which includes several Republican priorities, and, at the same time, reauthorize CHIP, which now covers nearly nine million children. But with Mr. Trump in the White House and feckless Republicans leading Congress, it’s possible that none of this will get done, health care costs will be driven up and millions of children will be left without health insurance.
First up, the Alexander-Murray deal represents real progress. These two no-nonsense lawmakers — the leading Republican and Democrat on the Senate health committee — have done yeoman’s work trying to fix a mess created largely by Mr. Trump. Their bill would appropriate money for payments to insurance companies that the president said he was stopping last week. He said they amounted to an illegal corporate bailout — a blatant lie. These payments, authorized by the A.C.A., or Obamacare, compensate insurers for lowering the deductibles and co-payments for low-income families. Further, Mr. Alexander and Ms. Murray would require the administration to spend $106 million on advertising and on people to help people sign up for insurance when open enrollment begins on Nov. 1. Mr. Trump’s minions at the Department of Health and Human Services slashed spending on outreach efforts in recent months.
The deal also advances two Republican health care ideas: giving states more flexibility to make changes to the A.C.A. and letting more people sign up for high-deductible health care policies. Thankfully, Mr. Alexander and Ms. Murray have made sure that neither of these changes undermines Obamacare’s protections for people with pre-existing conditions and the requirement that insurers cover essential health services like maternity care and cancer treatment. These changes could make the law function better by allowing sparsely populated states to attract more insurers by, for example, making it easier for them to set up reinsurance programs that protect companies from losses from a few customers. And the proposed high-deductible plans could work well for a small subset of people who buy A.C.A. policies but do not receive subsidies because they earn too much money.
While these compromises provide some hope for the A.C.A., CHIP’s fate, and health care for nine million children, is being held hostage by Republican extremists in the House. The Republican and Democratic leaders of the Senate Finance Committee — Orrin Hatch and Ron Wyden — have worked together to extend the program, which expired on Sept. 30. But Republican House members such as Greg Walden of Oregon and Fred Upton of Michigan are demanding that spending on CHIP be offset by cuts to A.C.A. costs and unnecessary changes to Medicare and Medicaid. Of course, these same lawmakers who are so tightfisted with children’s medical care want to slash taxes on wealthy families with no effort to offset that loss of revenue.
State governments, which run CHIP, are continuing to cover children with money left over from earlier appropriations and with emergency infusions from the federal government. But 11 states are expected to run out of federal funds by the end of December and 20 states and the District of Columbia will get to that point in the first three months of next year, according to the Kaiser Family Foundation. CHIP, created in 1997 to cover lower-income families who could not get Medicaid, helped lower the uninsured rate for children to 5 percent, from 14 percent. Most children in CHIP are from families with incomes below twice the poverty level, or $49,200 for a family of four.
So far, neither Mr. Trump nor Republican leaders in Congress have taken these vital matters very seriously. Mr. Trump has made several contradictory statements about the Alexander-Murray proposal and he has not said much of anything about children’s health insurance.
That only makes it more crucial for members of Congress to heed Mr. Alexander, who said on Tuesday, “I don’t know a Democrat or a Republican who benefits from chaos.”

The Collapse of Trumpcare and the Rise of Single Payer

by Zachary Berger and Adam Gaffney - Common Dreams - October 18, 2017

Two major developments in September upended US healthcare politics. The month’s end saw the failure of a last-ditch blitz by Senate Republicans to dispatch the Affordable Care Act (ACA) via the Graham-Cassidy bill, a painful defeat for opponents of Obamacare, including President Trump. And on 13 September, Senator Bernie Sanders’ single-payer “Medicare-for-All” bill was released, galvanizing proponents of progressive healthcare reform.
Among the notable aspects of Sanders’ bill was its co-sponsorship by 16 Senators (as opposed to zero for Sanders’ last bill), among whom were most of the potential Democratic 2020 presidential contenders. Rising support for single-payer in the Senate follows a similar shift in the House of Representatives, where a majority of Democratic lawmakers now support Representative John Conyers’ single-payer bill.
The immediate impact of these single-payer bills—given that neither will pass in the current Congress—may seem modest. Yet in conjunction with the collapse of Republicans’ ACA repeal efforts, they could signal a new era in American healthcare politics.
Firstly, on the political level, Democrats’ growing embrace of single-payer is tantamount—as many have noted—to a historic shift in the so-called “Overton window,” or the boundaries of the politically possible. Indeed, it now seems likely that single-payer healthcare reform proposals will figure prominently not only in the 2020 Democratic presidential primaries, but in the general election as well.
Secondly, the bills—or something like them—could serve as a framework for legislation under a new government. Sanders’ bill (like Conyers’) would achieve the long-sought goal of universal coverage for US residents through a single public programme. It would eliminate most “cost-sharing”—e.g. copayments and deductibles— a radical departure from trends towards high patient exposure to healthcare costs. Indeed, the bill would cover comprehensive medical benefits without any fees at point of use; the only copayments are for prescription drugs (to incentivize the use of generics), and even these are capped and would not apply to “preventive” medications.
Such fundamental reform could do much good; given that lack of healthcare coverage (28 million remain uninsured at present, despite Obamacare) has been associated with premature deaths, it could be lifesaving. [1] The shift away from cost-sharing could also bring dramatic improvements in the financial and physical well-being of American patients. “Underinsurance” appears to be rising: one recent survey of insured patients seeking cancer treatment found that more than one in three had an unexpectedly high financial burden from care, and about one in six had “high or overwhelming financial distress.” For the latter group of cancer patients, out-of-pocket healthcare spending consumed nearly a third of income despite insurance coverage. [2,3]
Still, even supporters of single-payer reform recognize that Sanders’ bill is merely the first step. First, unlike the House counterpart, the Senate bill excludes long-term care from the new universal programme; it would continue to be provided through the current federal-state Medicaid programme and so would still be a means-tested, rather than a universal, benefit. Advocates also stress other areas for improvement in Sanders’ bill, including shifting hospitals to global budgets (to reduce hospital administrative spending); planned capital expenditures (to control long-term cost growth); and the exclusion of investor-owned health facilities (given concerns about the quality and inefficiency of corporate healthcare). [4]
No one claims, however, that this version of the bill will constitute final legislative text. It also lacks a funding mechanism. Most importantly, its passage will require a shift in the power balance in Washington, as well as greater familiarity and understanding among the electorate, given that new taxes will be needed to replace current spending private healthcare spending. Nonetheless, in addition to providing a potential model for future legislation, the bill serves a number of useful functions now: it has already spurred discussion of the inadequacies of the healthcare status quo (including unsustainable costs), and it provides a vision of the future that contrasts with the bleak plans of both the Republican Party and insurance company lobbyists.
Lawmakers from across the political spectrum are taking notice. “To my friends to the Left,” Senator Lindsey Graham (R-SC), sponsor of Republicans’ Graham-Cassidy bill, said, “I will do everything I can to stop and put a stake into the heart of single-payer healthcare.” [5]
Yet there is a reason why Graham’s bill crashed and burned, and why single-payer may one day succeed despite such threats of impalement. 52% of Americans disapproved of Graham’s bill; even among Republicans, only 46% were in favour, with 21% opposed and a third uncertain. [6] Single-payer, by contrast, is favoured by 53% of Americans, including 64% of Democrats, 55% of Independents, and even 28% of Republicans. [7]
Such poll numbers portend a grim prognosis for the conservative healthcare project. By contrast, as the notion of healthcare as a right—and not a commodity—increasingly becomes part of the national ethos, the prospects for single-payer reform continue to sweeten.

A different take on Medicaid expansion 
By David Jolly - Ellsworth American - October 19, 2017
In her Oct. 5 op-ed opposing Medicaid expansion in Maine, Sen. Kimberley Rosen includes a number of statistics about expansion in other states running over budget, with a fairly clear implication that the citizens of those states have ended up footing the bill (e.g. “West Virginia, a state very similar to Maine, ran 46 percent over budget in the first year alone, costing it an additional $198 million.”) I found these figures confusing and misleading given that the federal government paid 100 percent of a state’s Medicaid expansion costs from 2014 through 2016. Thus the cost of any budget overruns in those years was borne by the federal government, not by the state.
It is true that in 2017, states expanding Medicaid began bearing 5 percent of the costs, and from 2020 on, they will pay 10 percent. Still, this is considerably less than states’ share for those who qualify for Medicaid under the eligibility criteria in place prior to expansion. In Maine, this share is 37.2 percent. This means that if Maine expands Medicaid, it will pay 27 percent less of the cost of care for Medicaid recipients newly qualified under expanded Medicaid than it is and will be paying for traditional Medicaid enrollees.
Sen. Rosen also overlooks other important economic points about what Medicaid expansion would mean for Maine: There would be what economists call a multiplier effect associated with the 525 million federal dollars that came to Maine annually under expansion. Most of those dollars would support direct medical care. The largest part of the cost of that care is labor, and those health care workers paid with Medicaid expansion dollars will be spending much of that money in ways that support their local economy — in grocery stores, restaurants and movie theaters. The nonpartisan health policy journal Health Affairs estimates that the 90 cents that Maine would receive from the federal government for each dollar spent on Medicaid expansion would yield between $1.35 and $1.80 in state economic activity.
The state also would reap the benefit of the income taxes paid by those employed because of Medicaid expansion and the sales taxes on the economic activity expansion generates.
Right now, through their federal income taxes, the citizens of Maine are subsidizing the health care that 31 states with expanded Medicaid are providing their low-income citizens newly qualified for coverage under the expanded eligibility criteria. Shouldn’t taxpayers in other states be helping to pay for health coverage for low-income persons in Maine? This will only happen if and when Maine expands Medicaid.
Just days ago the Kaiser Family Foundation issued a report based on its review of 153 studies of the effects of expanding Medicaid ( the-effects-of-medicaid-expansion-underthe- aca-updated-findings-from-a-literature- review-september-2017/). Here are a few of its conclusions about the economic impacts of Medicaid expansion: Multiple studies found that states expanding Medicaid realized budget savings, revenue gains and overall economic growth.
New national research found that from 2010 to 2015, there were no significant increases in spending from state funds as a result of Medicaid expansion and no signifi cant reductions in state spending on education, transportation or other state programs as a result of expansion.
Medicaid expansions led to reductions in uninsured hospital visits and uncompensated care costs. (This is a particularly important result for financially strapped and struggling hospitals in rural Maine.) Economics aside, Sen. Rosen fails to note the primary reason for and benefit of Medicaid expansion — the health coverage it would provide to an additional 64,000 of Maine’s lowest-income citizens. How low? Those whose incomes are at or below 138 percent of the federal poverty level ($16,643 for a single person and $22,412 for a family of two). For these Mainers, health insurance is currently beyond their financial reach, but having it could be both life-enhancing and life-saving. In fact, a 2012 Harvard School of Public Health study found that expanding Medicaid to low-income adults improved health care outcomes and reduced mortality in three states. One of these states was Maine, which first expanded its Medicaid program back in 2003 under Dirigo Health.
Sen. Rosen concludes that “Medicaid expansion isn’t the answer we’re looking for.” Apparently the many Republican governors who expanded Medicaid in their states disagreed. These included governors in New Jersey, Michigan, Ohio, Indiana, Kentucky, Iowa, North Dakota, Nevada, Arizona and New Mexico. They recognized the economic benefit of accepting federal funds for Medicaid expansion, and they saw wisdom in extending health coverage to more low-income citizens under financial terms so favorable to their states. Perhaps some governors even saw this as an ethical obligation.
Sen. Rosen offers an incomplete and misleading economic analysis of Medicaid expansion, and she overlooks the very human and most important argument in its favor.
David Jolly is a resident of Penobscot and a retired associate professor of public health education at North Carolina Central University, where he taught public health policy with a focus on access to health care.

Tuesday, October 17, 2017

Health Care Reform Articles - October 17, 2017

Trump, Chieftain of Spite

by Charles M. Blow - NYT - October 15, 2017

It must be cold and miserable standing in the shadow of someone greater and smarter, more loved and more admired. It must be infuriating to have risen on the wings of your derision of that person’s every decision, and even his very existence, and yet not be able to measure up — in either stratagem or efficacy — when you sit where that person once sat.
This is the existence of Donald Trump in the wake of President Barack Obama. Trump can’t hold a candle to Obama, so he’s taking a tiki torch to Obama’s legacy. Trump can’t get his bad ideas through Congress, but he can use the power of the presidency to sabotage or even sink Obama’s signature deeds.
In fact, if there is a defining feature of Trump as “president,” it is that he is in all ways the anti-Obama — not only on policy but also on matters of propriety and polish. While Obama was erudite, Trump is ignorant. Obama was civil, Trump is churlish. Obama was tactful, Trump is tacky.
There is a thing present in Obama and absent from Trump that no amount of money or power can alter: a sense of elegant intellectualism and taste.
The example Obama set makes the big man with the big mouth look smaller by the day. But I believe that this nonadjustable imbalance is part of what has always fueled Trump’s rage against Obama. Trump, who sees character as just another malleable thing that can be marketed and made salable, chafes at the black man who operated above the coarseness of commercial interests and whose character appeared unassailable.
America — even many of the people who were staunch opponents of Obama’s policies — admired and even adored the sense of honor and decency he brought to the office. Trump, on the other hand, is historically unpopular, and not just in America. As The Pew Research Center pointed out in June: “Trump and many of his key policies are broadly unpopular around the globe, and ratings for the U.S. have declined steeply in many nations.” Trump is reviled around the globe and America’s reputation is going down with its captain.
All of this feeds Trump’s consuming obsession with undoing everything Obama did. It is his personal crusade, but he also carries the flag for the millions of Americans — mostly all Republicans — who were reflexively repulsed by Obama and the coalition that elected him.
Trump has done nearly everything in his power to roll back Obama’s policies, but none are as tempting a target as the one named after him: Obamacare.
Republicans — including Trump — campaigned for years on a lie. They knew it was a lie, but it was an enraging one that excited their base: Obama was destroying America’s health care system, but Republicans could undo the damage and replace it with their own, better bill.

First, Obama wasn’t destroying America’s health care system. To the contrary, he simply sought to make it cover more people. He moved to take American health care in a more humane, modern and civilized direction, to make it more universally accessible, even by the sick and poor who often took its absence as a given.
Second, the Republicans had no replacement plan that would cost less and cover as many or more people. That could not be done. So, their repeal-and-replace efforts failed. But that also meant that Trump’s promise was proven a lie. Trump has no problem lying, but in the end he wants his lies to look plausible.
Trump makes assertions for which there is no evidence — either knowingly lying, recklessly boasting or wishfully thinking — then seeks support for those statements, support that is often lacking because the statements are baseless.
He violates a basic protocol of human communication: Be sure of it before you say it. His way is to say something wrong, then bend reality to make it appear right. This is why the age of Trump is so maddening and stupefying: He is warping reality.
Last week he took more swipes at undermining the A.C.A.: Asking his administration to find ways to increase competition among insurers (a move many worry will move younger, healthier people out of the marketplace) and stopping the so-called “cost-sharing reduction” (CSR) payments — federal subsidies paid to insurance companies to help finance coverage for low-income Americans (a move many believe will send premiums soaring for those people).
Trump is doing this even though it will likely wreak havoc on countless lives. He is doing this even though a Kaiser Health Tracking Poll released Friday found that most Americans want Trump and Congress to stop trying to repeal the law, and instead work on legislation to stabilize the marketplaces and guarantee health care to Americans.
Furthermore, six in 10 Americans believe Congress should guarantee cost-sharing reduction payments, as opposed to only a third who view these payments as a “bailout of insurance companies,” as Trump has called them. There is no real reason to cut these payments, other than to save face and conceal the farce.
Trump isn’t governing with a vision, he’s governing out of spite. Obama’s effectiveness highlights Trump’s ineptitude, and this incenses Trump.

Not Dead Yet: Obamacare Insurers Are Hanging In There

by Reed Abelson and Margot Sanger-Katz - NYT - October 13, 2017

Despite President Trump’s best efforts, the Obamacare market hasn’t imploded yet.
While Thursday’s decisions to cut off government funding and invite competitionfrom flimsier, cheaper plans will jostle a vulnerable market, many of the major insurance companies say they will remain in the state marketplaces next year.
“It’s going to be business as usual,” said Michael F. Neidorff, chief executive of Centene, a major insurer that agreed to sell coverage in areas where competitors had bowed out. “We’ve stepped in and covered bare markets,” he said, adding that if any new bare spots emerged in coming weeks, the company would work with state regulators to try to fill them.
But for millions of consumers, and taxpayers, there will be a price to pay. Unless they shop around, consumers who don’t qualify for federal subsidies could face premiums that have been raised by 20 percent or more, just because of the loss of the federal funding.
And taxpayers will foot the bill for the higher subsidies required with higher prices. The Congressional Budget Office has estimated that eliminating the cost-sharing reductions could increase the federal deficit by $194 billion over a decade.
Mr. Trump has made his disdain for the Affordable Care Act clear in a variety of policies dating to his first week in office, and for months had threatened to stop paying insurers subsidies that help them provide lower deductibles and co-payments to low-income customers. Because of the uncertainty, most states had allowed insurers to set high enough prices for 2018 to account for the risk of cutoff subsidies. That means they are largely protected from the consequences of President Trump’s decision to eliminate the payments.
But not all. While many large carriers like Centene may be willing to stay, others are nervous, and their regulators were considering options Friday. New competition from plans exempt from the A.C.A. rules and much higher rates resulting from the loss of funding are making some insurers rethink their commitment to 2018. “They’re sharpening their pencils now to see if they are going to stay in or not,” said David M. Dillon, a fellow with the Society of Actuaries.
In addition to cutting off the subsidies, the president signed an executive order Thursday that may pave the way for competing plans that would be subject to fewer rules and could draw healthy customers out of the Obamacare markets. The administration has also cut back on its marketplace advertising budget by 90 percent, and slashed funding to groups that help customers understand their options and sign up for insurance.
“It’s a deliberate pattern,” said Chet Burrell, the chief executive of CareFirst, which is faced with a $50 million loss in Maryland if regulators do not allow it to increase its rates to make up for the loss of funding. “With active sabotage, this makes it more unstable.”
Mr. Burrell says CareFirst expects to continue offering coverage in the individual market regardless of what the Maryland regulator decides. But he said the administration’s actions “create profound instability and uncertainty for the future.”
Even as Mr. Trump created instability, his Department of Health and Human Services said Friday that it would take steps to help insurers stay in the market, despite the change. Caitlin Oakley, a spokeswoman, said the department would allow some plans to submit higher rates if their original prices had not taken account of the risk the subsidies would go away. The department “ is working on a case-by-case basis with those states where regulators explicitly required insurers to assume cost-sharing reduction payments would be made,” she said.
With or without the government payments to insurers, consumers who rely on subsidies for their premiums or their deductibles will be insulated from the changes, as long as carriers don’t flee. Insurers are still required to offer discounts to eligible customers, even if they don’t get reimbursed by the federal government. People who get their insurance through Medicaid will be unaffected.
But while the higher prices will keep most, if not all, insurers from exiting the markets, they will hurt customers who pay full price for their insurance. Around eight million Americans buy their own health plans and earn too much for government help. They will be footing the bill for double-digit increases linked to the increased policy uncertainty. Some may not be able to afford to keep their coverage.
The cumulative effect is very damaging, said Ceci Connolly, the chief executive of the Alliance of Community Health Plans. “How many cuts can this market and this law take before it’s just in smithereens?”
And even Mr. Neidorff says there is little doubt about Mr. Trump’s intent. “The world knows what his message has been from the beginning,” he said. “They want to unwind the Affordable Care Act.”
Insurers that raised their rates and whose customers are generally eligible for subsidies are the least affected by the loss of funding, and they are likely to stay. Health Care Service Corp. which offers Blue Cross plans in several states, said its participation would be unaffected, and other large Blue Cross plans like Florida Blue said they had priced in the uncertainty. Molina Healthcare, another large player in the market, said it plans to participate in the seven states where it had filed in 2018, although the company said it “will continue to evaluate our participation on a market-by-market basis.”
Anthem, which offers for-profit Blue Cross plans and had sharply reduced its participation in the marketplaces next year, in large part because of the turmoil in the market, declined to comment.
Alex Feldvebel, the deputy insurance commissioner in New Hampshire, said his department permitted insurers there to assume that government subsidies would go unpaid in 2018 when submitting their rates this summer. The carriers haven’t made their final decisions about whether to stay or go, but Mr. Feldvebel said he was reassured by preliminary conversations Friday. “We’re feeling pretty O.K. here that this will not throw everything into a cocked hat,” he said.
In Washington State, where the insurance department had not allowed carriers to price for the risk but had asked them to file two sets of rates, the state insurance commissioner reversed course, telling insurers Friday they could switch to the higher rates to make up for the lost government funds. The New Jersey insurance regulator also said insurers could refile higher rate requests, as did Oregon’s regulator.
The regulators, anxious to avoid any last-minute departures, are working closely with the insurers to make sure they stay.
“I am going to be doing my darnedest to reassure them,” said Mike Kreidler, the insurance regulator for Washington State. But he emphasizes that the administration’s actions have caused the companies to think hard about whether to stay. “It just continues that drumroll of uncertainty.”
He said he was worried about a mass exodus of insurers. “If one bolts, you could see them all bolt,” Mr. Kreidler said.

Trump Is Trying to Gut Obamacare. Here’s Why His Plan May Fail.

by Margot Sanger Katz - NYT - October 13, 2017

President Trump’s decision to stop paying subsidies to insurance companies that cover many low-income Americans is his most overt action so far to undermine the Obamacare markets, which reopen for sign-ups on Nov. 1.
But the timing of the announcement, late Thursday night, means the ending of subsidies may be less disruptive than it might have been months ago, when he began threatening such action. It still could cause insurers to leave some Obamacare markets and places where customers have no insurance choice, but it probably won’t cause the widespread meltdown it might have, if it had happened earlier this year.
The subsidies help insurance companies provide discounts on deductibles and other cost-sharing for consumers, which they are required to do by law. When Congress wrote the Affordable Care Act, it made clear that insurers were entitled to the payments, but it failed to provide a clear funding mechanism. The uncertainty in the legislative language opened the way for a lawsuit, and now the president’s decision.
In theory, precipitously ending the payments could lead to catastrophic market failures. Insurers set prices for their insurance this year, assuming the payments would continue to be made, and have no ability to raise them midyear to cover their losses. But, because the president has repeatedly signaled that the payments might cease and we are nearing the end of 2017, many plans set their prices for next year’s products assuming the subsidies would not be paid.
A few months ago, we called those increased prices an uncertainty tax. The uncertainty is gone now. But the conservative planning of the insurance industry means that many insurers can afford to keep offering insurance, even after the president cuts off the funding. Plans that priced for the threat will take a small haircut this year, but they can still make money, even without the payments, next year.
The Congressional Budget Office offered an estimate about what would happen if the president stopped making the payments, and it’s instructive. It estimated that, in the short term, the decision would cause instability: One million additional people would become uninsured in 2018, prices for insurance would rise by 20 to 25 percent, and insurers would drop out of some parts of the country.
But, in the long run, the budget office thought that health plans and state insurance regulators would hack their way around the problem, resulting in an uninsured rate that would be even lower than it is under current law. The catch: It would end up costing the government more money in subsidies that help lower-income people pay their premiums, about $6 billion this year and $26 billion by the end of a decade.
Some of that hacking has begun. In California, insurers have been instructed to impose a surcharge on just one type of plan to cover their lost subsidy payments. That arrangement means that some customers will pay a higher price, but no insurance company will lose its shirt.
In other states, things are more unsettled, because insurers and regulators didn’t price ahead. In those places, the consequences of the president’s decision will be felt unevenly, with some state markets proceeding as planned, and others making last-minute exits or other adjustments. Insurers have already signed final contracts with the government for next year, though they have an out if the subsidies go unpaid.
Congress can also act. The president is able to eliminate the subsidies because of the ambiguity in the language of the health law. If lawmakers vote that the subsidies should be paid, either for the coming year or indefinitely, the president will need to begin paying them again. Bipartisan negotiations in the Senate committee on Health, Education, Labor and Pensions this summer had focused on just such legislation, though they got derailed in a recent effort to pass a Republican bill to replace parts of Obamacare with block grants.
The bipartisan talks could resume, though passage of cost-sharing payments would require Republican support, and many G.O.P. lawmakers view them, as the president does, as a “bailout of insurance companies.” An unusually broad alliance of interests has urged Congress to appropriate the money, signaling just how disruptive their loss could be. A letter drafted in September was signed not just by health insurers, doctors, and hospitals, but also by the Chamber of Commerce.
Eliminating cost-sharing subsidies is not the only thing the president did Thursday, however. He also signed an executive order devised to help more customers exit Obamacare’s markets in search of less regulated insurance options. And Thursday’s actions follow a string of smaller policy choices that are likely to reduce Obamacare sign-ups. (My colleague Haeyoun Park has been keeping a helpful list of them here.) Taken together, the actions send a strong signal to insurance companies about the administration’s approach to the future of the Obamacare marketplaces. That message may prove as powerful as any strict loss calculation.

Medicaid expansion gives Maine a chance to address inequality in health care

by Jeffrey Graham - Bangor Daily News - October 13, 2017

In his remarks to the 1966 Medical Committee for Human Rights, Dr. Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.”
More than 40 years later, we have an opportunity to address this inequality by expanding access to Medicaid by voting yes on Question 2 this November. 
A “yes” vote on Question 2 will provide health care coverage to 70,000 Mainers, and it will help to make sure that no one has to choose between seeing a health care provider when they’re sick and going without food.
I am a doctor and consultant, and I work at C.A. Dean Hospital in Greenville, the smallest hospital in the state.
We see many patients who receive care through Medicaid, many of whom have serious illnesses. Without Medicaid, they wouldn’t be able to afford the primary care they need to avoid potential hospitalization and trips to the emergency room.
For example, one 64-year-old patient couldn’t afford health insurance, but because Maine has failed to expand Medicaid, he also didn’t qualify for coverage there. When he came to the hospital, he appeared to have incurable prostate cancer.
Without health insurance, he is having trouble even getting a biopsy.
There’s simply no excuse for this, particularly when we have the opportunity to expand Medicaid.
Hospitals are the cornerstones of their communities, along with local schools and churches. Not only do they provide critical services, they are often one of the top local employers.
Hospitals in Maine, and particularly rural hospitals, are hurting. They are having trouble making ends meet. Medicaid expansion could help.
Expanding Medicaid would bring $500 million new federal dollars per year into the state and create more than 3,000 health care jobs. This federal investment would help to strengthen and protect hospitals around the state, and ensure that they continue to serve their communities.
These are people like Adam Foley in Bangor, who falls into the coverage gap. He currently doesn’t qualify for Medicaid, but he doesn’t earn enough to qualify for a subsidy to help purchase insurance through the marketplace. I met Adam earlier this year at an event in Bangor.
And Kathleen Phelps from Winslow. She works as a hairdresser, but she still can’t afford health insurance and goes without care she needs. She’s too young for Medicare and doesn’t qualify for Medicaid.
These folks and thousands more like them would benefit from Medicaid expansion. That’s why the Maine Medical Association endorsed Question 2.
Adam and Kathy aren’t unique. Most of the people who will be covered under Medicaid expansion are working, but don’t get coverage from their employer, either because they work multiple part-time jobs and aren’t eligible for the insurance their employer offers or simply because the employer isn’t offering health insurance. 
It doesn’t have to be this way. 
With one vote, we can ensure thousands of Maine families will no longer be forced to roll the dice on their health. They will have access to preventive care and coverage for medical emergencies. Most importantly, they will have peace of mind.
Expanding Medicaid to individuals making about $16,000 per year protects our state’s most vulnerable residents — mothers and hard-working families often working two jobs to put food on the table. Medicaid expansion creates more secure and healthier families.
There is strong support for Medicaid expansion in the Legislature, where Republicans, Democrats and independents think it’s the right thing to do.
In fact, 31 other states and the District of Columbia — states lead by Republicans and Democrats — have expanded Medicaid in order to increase the number of people who have health care coverage. Not a single state has dropped expansion.
In states that have expanded Medicaid, insurance premiums on the private market have grown more slowly and there have been reductions in uninsured emergency room visits. Expansion helps to hold down costs for everyone who buys insurance.
One final point: Medicaid expansion could also help us address the opioid epidemic.
Right now, we are losing more than one person per day to drug overdoses. Medicaid expansion could help provide care and treatment to low-income Mainers struggling with opioid addiction and mental health issues. 
Come Election Day, with a yes vote on Question 2, Mainers have a chance to provide life-saving care to tens of thousands of people and to strengthen our state’s economy. Vote yes on Question 2 for a stronger, healthier Maine.
Dr. Jeffrey Graham lives in Glenburn.

The Benefits (and the Catch) of Health Savings Accounts

by Ann Carnns - NYT - October 13, 2017

It’s benefits open enrollment season at many employers, and workers are increasingly likely to hear about an option, known as an H.S.A., that can help them pay for medical expenses and save money on their taxes.
H.S.A.s, or health savings accounts, are not yet as familiar as their better-known cousin, the F.S.A., flexible spending account. But H.S.A.s are becoming more common, according to the latest data.
Devenir, an H.S.A. services firm, reports that the number of H.S.A. accounts increased by 16 percent year over year as of June 30, to more than 21 million. Assets held in the accounts grew 23 percent, to just under $43 billion. (Devenir’s data comes from a survey of 100 H.S.A. providers.)
H.S.A.s offer a triple tax benefit. Contributions can be deducted pretax from your paycheck, lowering your taxable income; any interest or investment gains on the money is tax free; and withdrawals from the account are tax free, as long you spend the money on eligible items.
And if you change jobs, the H.S.A. moves with you.
But there’s a catch: The savings accounts are available only with certain health insurance plans meeting specific criteria, like high deductibles — at least $1,300 for an individual and $2,600 for a family. (A deductible is the amount you pay for care before your health plan pays.)
The Employee Benefit Research Institute, which tracks a database of 5.5 million health savings accounts totaling $11.3 billion as of the end of 2016, found that H.S.A.-eligible health insurance plans covered nearly three in 10 employees last year.
High-deductible health plans typically have cheaper monthly premiums — but you’ll pay more out of pocket for care. The H.S.A. is meant to help cover those costs.
You can set aside as much as $3,400 for an individual, or $6,750 for a family, in an H.S.A. You can leave the money in a basic, interest-bearing savings account or, in some cases, invest the money — just as you would with a 401(k) retirement account — for the long term.
Ryan McCostlin, an expert in individual and family health care at the advisory firm Bernard Health, said the tax-free growth available with H.S.A.s made them powerful savings tools. “Consumers should put that money in the market and let it grow slowly over time,” Mr. McCostlin said in an email.
Fidelity, which offers H.S.A.s, said money invested in a health savings account could help provide cash to cover needed health and medical costs in retirement. It estimates that a 65-year-old couple retiring this year will need $275,000 to cover health and medical costs throughout retirement. (The cost estimate assumes enrollment in Medicare coverage but does not include extra costs like a nursing home or long-term care.)
Many H.S.A.s, however, require that you have a minimum amount saved — say, $1,000 — before you can invest. The idea is that you should have some money set aside before you take investment risks.
“If you will need the funds in the near future to pay medical bills, it may not make sense to invest,” said Roy Ramthun, an H.S.A. consultant.
But some account providers let you invest at any time. The health finance start-up Lively, for instance, allows H.S.A. participants to invest with no minimum balance. Lively offers a basic H.S.A. free, or charges users a flat $2.50 a month to invest in low-cost mutual funds and exchange-traded funds through the online brokerage firm TD Ameritrade.
(Basketball fans may be interested to know that one of Lively’s financial backers is the N.B.A. star Kevin Durant, who said in a prepared statement that he was “drawn to tech that helps people in real ways.”)
Here are some questions and answers about health savings accounts:
Do I have to spend the money in my H.S.A. by a certain date?
No. There’s no deadline for spending the money in an H.S.A.; the balance simply rolls over year to year. (The Employee Benefit Research Institute said more than 90 percent of H.S.A.s ended 2016 with funds to roll over for future expenses).
What can I buy using my H.S.A.?
H.S.A. funds can be used for a variety of health care and expenses, including co-payments, prescriptions, dental work and braces. HSA Bank, an account provider, offers a list of expenses that qualify under Internal Revenue Service guidelines. HSAStore, an online store, stocks eligible products.
Can I have an H.S.A. if I’m self-employed?
Yes. If you have an H.S.A.-compatible health insurance plan, you can set up a health savings account on your own. (Most H.S.A.-eligible plans are clearly labeled as such. If you’re not sure, ask your insurer.) The money you contribute is tax-deductible, even if you do not itemize deductions on your tax return. You can open an account through a bank or through a company that specializes in them. Devenir offers a search tool. Morningstar recently ranked accounts based on their fees and other criteria.

Donald Trump’s Terrible Executive Order on Health Care

by Amy Davidson Sorkin - The New Yoker - October 13, 2017

President Donald Trump is now trying to break the health-care system all by himself, although he has more help than he might acknowledge. On Thursday, Trump launched an assault on Obamacare from two angles. First, the White House staged a signing ceremony for an executive order designed to push people into what are known, accurately, as “junk” insurance plans—the kind, common before the passage of the Affordable Care Act, that never seem to cover people when they are actually sick and that extort and abandon those with preëxisting conditions. Trump, in his remarks at the ceremony, referred to this choice as “fleeing the failing Obamacare plans.” And then, a few hours later, he did more to make Obamacare fail, by saying that he would withhold the cost-sharing subsidies that the government currently pays insurance companies in order to reduce deductibles and co-pays for many low-income people. Companies will undoubtedly respond by leaving the Obamacare exchanges, where such plans are now sold. Both moves had one thing in common: they recklessly target vulnerable Americans. But in doing so, they will, as with so many of Trump’s moves, increase risks for everyone.
Although Trump used the executive-order signing to goad his fellow Republicans—“We’re going to also pressure Congress very strongly to finish the repeal and the replace”—they did much to make this day possible. Trump claimed that he had no choice but to defund the subsidies because paying them went against the will of Congress. This is the argument in a lawsuit, instigated by House Republicans, that is making its way through the federal courts. Basically, those Republicans argue that, although the plain language of the A.C.A. describes and authorizes the payment of subsidies, Congress should be allowed to vote on actually releasing the money every year. In effect, Congress promised the money when it passed the A.C.A., but now it wants the right to hold that money hostage on a regular basis. The case relies on a highly technical reading of the legislative fine print; nevertheless, the congressional challengers won a round in the lower courts, though that had been stayed pending an appeal—one that, on Thursday, the Trump Administration apparently decided to drop. (Attorney General Jeff Sessions had earlier said that he agreed with the House Republicans.) More than that, it is, at best, a technical ambiguity that any congressional majority interested in something other than utter chaos in the insurance markets could easily fix. Such a majority does not exist right now.
Indeed, the opposite is the case: the false stories that congressional Republicans drew of Obamacare—a system that, whatever its flaws, has increased the number of Americans with insurance by some twenty million, and made that coverage more reliable for many times that number— fed partisan demands for Trump to savage it. The Republican Party made a destructive promise that Trump, as its candidate, has been eager to keep. It may be the only thing that the Party can rely on him for, and, although some individual Republicans, such as Ileana Ros-Lehtinen, of Florida—who, not incidentally, is retiring at the end of this term—worried about the effect on their constituents, Party leaders were quick with their gratitude. Senate Majority Leader Mitch McConnell tweeted, “As #obamacare continues to fail Americans, I’m pleased @POTUS is promoting affordable policies to better meet the needs of families.” And the Speaker of the House, Paul Ryan, said that Trump’s decision to end cost-sharing subsidies was a “monumental affirmation of Congress’s authority.” That may seem like an odd way to describe a move that was also framed as a response to Congress’s failure to repeal the A.C.A., and which was a flanking attempt to undermine a major piece of legislation. But, as a shorthand for the affirmation of the congressional Republicans’ ideological authority, it was not far wrong.
These two moves are not the only sabotage attempts that the Trump Administration has been engaged in. It has rewritten rules to allow plans to stop covering many forms of birth control. It has made disabling cuts to programs that help people sign up for Obamacare, and made enrollment, across the board, harder—more of a labyrinth. Information about plans that people might be able to afford has been, effectively, hidden. Perhaps this is, finally, an example of Trump bringing his business expertise to Washington: the knowledge that bad marketing can cripple a good project.
But the most Trumpian aspect of the executive order is that it makes life easier for con men. It does so by allowing the sale of insurance plans that do not meet basic standards through “associations,” which might be made up of employers, interest groups, or just entrepreneurial opportunists—the exact rules still have to be written. Obamacare plans offer certain defined essential services, such as preventive and obstetric care and hospitalization, that an insurance plan has to cover, and cover substantially, to call itself an insurance plan. In other words, the A.C.A. made it harder for employers or insurers to claim that they were covering people if, when it counted, they really weren’t. (Such a bait and switch was common in the pre-Obamacare days; many people who went bankrupt after a medical emergency actually had insurance plans.) The executive order would create a sham market alongside the real one. One concern is that young, healthy people will be drawn to association plans because they don’t “need” comprehensive coverage, and are making what they believe is a rational calculation, albeit one that will drive up premiums in the Obamacare market, by making that pool of people, on average, sicker and older. (Paul Ryan, who has complained that it is unfair that healthy people help pay for sick people—the premise of insurance—is an association-plan enthusiast.)
But health-care needs have a way of changing quickly—we might each be separated from one category or the other by a single accident, diagnosis, or pregnancy. And some people and businesses won’t so much be making a choice as settling for what that they can afford in the short term: the plan, good or not, with the lowest sticker price. And, again depending on the specific rules that the Administration comes up with, people with preëxisting conditions will likely be more exposed to rate hikes—indeed, their co-workers might be, too, since an association would be able to set higher rates for a single business with a large number of people regarded as risks, whether because they are older or more likely to have children. (This means that, as a bonus, the executive order may encourage employment discrimination.) Another disorienting aspect is that an association would be able to sell its plans across state lines, in a way that would disregard the insurance regulations in the state in which the insured person lives. This would set up, effectively, a cross-country race to the bottom.
Another aspect of the executive order that is a setup for an insurance con is its expanded definition of “temporary” plans. Basically, these are policies, exempt from many regulations (someone can be dropped upon becoming sick, for example, or denied coverage for preëxisting conditions) that are designed for people who are between other plans—perhaps because of a job change—to buy in a pinch. But they also represent a loophole, which the Obama Administration tried to close, by defining “temporary” as no more than three months. Trump’s order extends it to a year. This is in keeping with an economy in which every little foothold that working families have seems temporary—it helps to make flimsiness a permanent state.
In presenting the plan at the executive-order signing, Trump did his best impression of a flim-flam man—that is to say, he was entirely in character. The guests included members of his Administration, some small-business representatives, and Senator Rand Paul, who believed that the Senate’s last attempt to break Obamacare was not radical enough. Trump didn’t have many details other than the promise that a “nightmare” was over, that millions of people would be “very happy,” and that the whole thing would produce better plans at no expense whatsoever to the government. “That’s not too bad, right?” he said.
As Trump started to walk out of the room, though, Vice-President Mike Pence suddenly looked anxious. He hurried after his departing boss with an outstretched arm. “Mr. President, you need to sign it!” Pence said. “Oh,” Trump said, to laughter, and then added, “I’m only signing it because it costs nothing.” Not for him, maybe, unless our political marketplace comes up with some way to measure the cost, to a President and his Party, of presiding over a disaster.

Why Trump’s Latest Health-Care Move Is a Spiteful Act of Vandalism

by John Cassidy - The New Yorker - October 13, 2017

The Trump Administration confirmed on Friday that it is stopping, with immediate effect, billions of dollars in payments to insurers that help keep the cost of health coverage affordable for about seven million low-to-middle-income families. In a statement, the White House said that the federal government couldn’t lawfully make the payments, which are an integral part of the subsidized private-insurance markets that emerged from the Affordable Care Act.
As my colleague Amy Davidson Sorkin pointed out earlier, the Administration’s legal argument is narrow and tendentious. In reality, this is a cynical political decision, made at Donald Trump’s behest, to sabotage the workings of the A.C.A. and to endanger the welfare of millions of hardworking American families who are unable to bear the full cost of a private-insurance policy.
Unlike the executive order on health care that Trump issued on Thursday, the impact of this decision isn’t ambiguous or dependent on the way various government agencies choose to interpret its language. The new policy will go into effect straight away. Under the instruction of the Justice Department, the Department of Health and Human Services, which administers Obamacare, is stopping payments to insurers, which are known as cost-sharing reduction payments.
Under the A.C.A., insurers are obliged to limit the out-of-pocket costs—for things like co-pays and, especially, deductibles—for households earning less than two and a half times the poverty line. (For a family of four, that’s about sixty-one thousand dollars.) The cost-sharing payments, which totalled about seven billion dollars in 2016, were designed to compensate insurers for the impact on their bottom line.
By stopping the payments immediately, the White House will throw the insurance market into turmoil. Insurers had already set their rates for 2018, and the open-enrollment season begins on November 1st. In calculating the premiums they would charge, some insurers assumed that they would continue to receive the cost-sharing reduction payments. Others assumed that the payments would stop. Now all the insurers know that they won’t get the money. But, under the terms of the A.C.A., they will still be obligated to limit the out-of-pocket costs for households under the income limit. That is an intentional recipe for confusion and chaos.
In the longer term, Trump’s decision will lead to substantially higher premiums, as insurers adjust their prices to reflect the lost revenue. The Congressional Budget Office, in a recent study, estimated that premiums would rise by twenty per cent, on average, if the cost-sharing reduction payments were eliminated. In some parts of the country, the private-insurance system could collapse completely, as insurers choose to exit the market.
Clearly, this is Trump’s intention. It has been widely reported that some of his advisers tried to talk him out of making this move on the grounds that it would be highly damaging. But Trump was so infuriated by Congress’s failure to pass a bill repealing Obamacare, or large parts of it, that he chose to go ahead anyway. Repeatedly frustrated in the legislative arena, he settled on this spiteful act of diktat.
As of Friday afternoon, Trump still hadn’t offered a public defense of his decision. But earlier, in one of his early-morning tweets, he openly gloated about the damage he was causing, writing, “The Democrats ObamaCare is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!” Other Administration officials have been equally heartless in their comments. “If the insurance companies want to try and raise their rates because they are no longer getting a bailout, that’s their problem,” Mick Mulvaney, the White House budget director, told reporters.
Paul Ryan and Mitch McConnell publicly supported the decision—no surprise there—but one or two elected Republican officials did cry foul. “Cutting health care subsidies will mean more uninsured in my district,” Ileana Ros-Lehtinen, a G.O.P. congresswoman from Florida, wrote on Twitter in advance of the official White House announcement. “@potus promised more access, affordable coverage. This does opposite.”
The White House’s decision to end the payments isn’t the end of the story. A group of state attorneys general have indicated that they will mount a legal challenge. And Congress could always render the legal battle moot by appropriating money for the cost-sharing reduction payments. But that would involve Republicans doing something to safeguard an important element of Obamacare, and that seems unlikely.
In any case, Trump is following the fallback strategy that he may have had in mind all along. During the campaign, he suggested that, rather than trying to repeal Obamacare, the Republicans should wait for it to collapse of its own accord and then step in. The problem with this strategy was obvious: the vast majority of the Obamacare exchanges, although they did have some problems, weren’t in any danger of collapsing. For Trump’s idea to work, somebody would have to subvert them.
That somebody turned out to be him. With his executive order encouraging the spread of cheap, unregulated insurance policies; with his Administration’s decision to slash spending on the advertising and promotion of Obamacare enrollment; and, now, with this latest premeditated act of vandalism, whose ultimate victims will include some of his own supporters, he has done all he can to bring the system crashing down around him. Even for a President with a record as dismal as his, this is a new low.

Timing of White House actions unrolling parts of ACA ‘couldn’t be worse,’ states say
by Amy Goldstein - The Washington Post - October 16, 2017

After threatening for months to end billions of dollars in payments promised to health insurers, President Trump finally dropped the ax with timing that could inflict maximal disruption on the Affordable Care Act enrollment season scheduled to begin in two weeks.
The most immediate upheaval is playing out in a set of states where regulators had ignored the risk that the president might carry out his threat and told insurers not to include any cushion in their 2018 rates for ACA health plans. Officials in at least three states are now debating whether to delay the Nov. 1 start of enrollment as they rush to consider higher premiums to make up for the abrupt loss of federal money.
But even in states that prepared for a possible cutoff of the “cost-sharing reduction” payments, Trump’s action so close to the fifth year’s sign-up period is sowing widespread confusion among consumers, according to leaders of insurance exchanges and ­enrollment-assistance organizations around the country. Along with other steps the White House has taken since late summer to undercut the ACA marketplaces, they predict this latest move is almost certain to suppress the number of Americans insured under the law next year.
“The timing couldn’t be worse,” said Allison O’Toole, chief executive officer of ­MNsure, the marketplace Minnesota created under the ACA. Hundreds more consumers than usual have phoned its call center in recent days, uncertain whether they can still get and afford health plans.
“Will the [president’s] drumbeat of ‘it’s a failing marketplace’ affect enrollment? Absolutely,” said Peter V. Lee, executive director of Covered California, which calculates that the payments’ end will cost its 11 marketplace insurers $188 million for the last three months of 2017 — more than the small profits many were anticipating for the year.
President Trump's health-care actions could have ripple effects throughout the Affordable Care Act's marketplaces. (Video: Jenny Starrs/Photo: Jabin Botsford/The Washington Post)
Insurers themselves could compound the damage, depending on how they respond. The Trump administration’s timing meant its announcement late Thursday came after the deadline for insurers in three dozen states relying on the ACA’s federal insurance marketplace to sign government contracts and lock in their rates for 2018 coverage. But a clause in the contracts lets insurers pull out within 90 days if the payments stop.
So far, no insurers have said they would defect. But concerns remain acute. As the number of companies selling ACA coverage has dwindled in the past two years, an increasing number of the nation’s counties have found themselves with just one participating insurer. Scores of counties recently appeared as if they would lack any insurers until state officials lured in replacements. If more leave this fall, states would have difficulty attracting others on such short notice.
“It seems entirely possible that some insurers will now exit the marketplace for 2018 and potentially leave bare counties,” said Larry Levitt, senior vice president of the Kaiser Family Foundation, a health policy organization.
The late changes in insurance rates, deterrence of would-be customers and potential unavailability of ACA coverage are the biggest ground-level effects of the president’s decision — a step so strident that health policy wonks for months had made a parlor game out of debating whether the president would have the nerve to do it.
The federal payments have been the more obscure of two types of subsidies created by the sprawling 2010 health-care law to help Americans afford coverage if they cannot get such benefits through a job. The better-known subsidies help lower the monthly premiums owed by nearly 85 percent of the roughly 10 million Americans with ACA coverage. 
The CSRs, as they are called, provide discounts for deductibles and other out-of-pocket insurance expenses to people with somewhat lower incomes — up to 250 percent of the poverty line, or about $30,000 for a single person and $61,000 for a family of four. Under the law, ACA health plans must continue those discounts. Trump’s move means that health plans will not be reimbursed for the last three months of the year or in the future. The payments had been expected to total $7 billion for 2017.
Dramatic as it is, the payments’ elimination does not go nearly as far as Trump and most congressional Republicans have sought this year as they attempted unsuccessfully to rewrite federal health-care law. Still intact is the ACA’s requirement that most Americans carry health coverage, though administration officials have hinted they may stop penalizing people who violate that mandate. Other consumer protections in the law still guarantee specific benefits in insurance sold to individuals or small businesses, forbid insurers to charge more or refuse to cover people who have had medical conditions, and ban yearly or lifetime limits on coverage.
Hours before the White House announced the end of the CSRs, the president took another significant step that could foster a proliferation of insurance capable of making end runs around such protections. Under an executive order that Trump signed on Thursday, federal agencies will develop new rules to widen access to “association” health plans and short-term insurance policies — both exempt from the ACA’s insurance regulations — and allow more policies to be sold from one state to another without meeting each state’s regulations.
As state officials prepared in the spring and summer for the upcoming enrollment period, most instructed insurers either to include a surcharge assuming the federal cost-sharing would end or to file two sets of rates as a Plan A and Plan B.
In Colorado, one of the states that asked for two sets, the insurance commission approved the higher rates on Friday. The state’s marketplace, Connect for Healthy Colorado, is now scrambling to load the necessary information into its computer system, according to Kevin Patterson, its chief executive. Colorado wants to start enrollment on time, Patterson said Saturday — but he is not yet sure whether it will be ready.
In Washington state, Insurance Commissioner Mike Kreidler also told insurers to file two rates. “In order to get the smoke to clear,” he said, the marketplace there “may consider holding back on when” enrollment begins.
Maryland is in worse shape, because the two insurers in its marketplace were told by regulators to file only rates that assumed the CSR payments would continue. Chet Burrell, chief executive of CareFirst BlueCross BlueShield, said officials asked state insurance regulators Friday to allow it to submit new rates — about 20 percent higher — to make up about $50 million it had been expecting in CSR money next year.
Maryland’s open enrollment, Burrell said, might need to be delayed.
At the Missouri Association of Area Agencies on Aging, executive director Catherine Edwards acknowledged the challenges. “It’s just another hurdle that we’re going to have to get over,” she said Saturday. “We’re just holding our breath to see what this does to the people coming to us.”
Carolyn Y. Johnson contributed to this report.

How to Fight the New Trumpcare

by David Leonhardt - NYT - October 15, 2017

Since Donald Trump’s election, a loose coalition of citizens, doctors, nurses, activists and others have rallied together to prevent their fellow Americans from losing health insurance. They won a big victory last month when Congress set aside its efforts to pass a destructive bill. But now the coalition has a new fight.
Trumpcare has begun, not through legislation but through executive action.
Last week, the administration took several steps to deprive people of health insurance. In doing so, it has both a short-term goal (have the federal government do less to help vulnerable citizens) and a long-term goal (sabotage Obamacare, so that Congress can more easily repeal the law).
Trump will probably accomplish at least part of the short-term goal and take insurance away from some people. But it is possible to minimize the damage, through an effective political response. Whether you’re a Democrat, Republican or independent — whether you have already been part of the citizen activism or not — I encourage you to get involved.
I know that activism can make people uncomfortable. To be honest, urging activism makes me a bit uncomfortable. (My original plan for today’s column involved the psychological lessons of the baseball playoffs.) But some principles — like access to decent medical care — are worth the discomfort.
How can people get involved? Start by understanding exactly what Trump is doing.
His main strategy is trying to prevent healthy people from entering the normal insurance market. The administration has all but stopped advertising the Obamacare insurance exchanges, which serve people who don’t already have coverage. Absent this outreach, people who desperately need insurance — the sick — will dominate sign-ups, and prices will soar. Imagine if the life insurance market were dominated by people who’d already turned 80.
Trump’s executive order last week went further in this direction. When it takes full effect, it will most likely allow a variety of cheap insurance plans that don’t cover many treatments. These plans will siphon healthy families from the normal markets, raising prices on the sick.
It will work nicely for healthy families, until it doesn’t. If they get sick and want insurance that pays for their treatments, they will be out of luck.
The executive order was one of two moves Trump made last week. He is also trying to cause chaos by canceling federal reimbursement payments to insurers. Without those payments, insurers may exit the market, leaving consumers without options.
Throughout, Trump has been pretty blunt about his intentions. He wants to make Obamacare “implode,” and, in the process, make repeal less politically toxic. His plan is dark, though not implausible. The Senate came within a single vote of repeal this summer.
But everyone who believes in decent medical care has ways to fight back.
First, it’s important to talk about what Trump is doing, with friends and family, on social media and in person. Already, 60 percent of Americans believe that Trump and Republican leaders are responsible for Obamacare going forward, according tothe Kaiser Family Foundation. That number deserves to keep rising.
If it does, Congress will feel pressure to undo some of Trump’s mischief, much as some members felt intense pressure to vote against repeal. Remember that many members of Congress, unlike Trump, are on the ballot next year. And Congress could easily restart the reimbursement payments he has stopped.
Second, activists can play a role in encouraging people to sign up for insurance — since Trump won’t. Several former Obama administration officials have started a group called “Get America Covered,” and it has published an online guide for volunteers. Now is a good time to get involved, because open enrollment starts next month. “We need your help spreading the word,” tweeted Lori Lodes, who runs the group.
Finally, there are the lawyers. Trump’s actions are legally vulnerable in several ways. Yuval Levin, who worked in the George W. Bush administration, has written that it considered taking some actions similar to Trump’s, but concluded they were illegal. State attorneys general have begun some legal challenges, and more may follow.
Just as Trump has both short-term and long-term goals, so should his opponents. For now, the priority is minimizing coverage losses, through outreach, lawsuits and lobbying. Doing so will also help the larger priority: preventing repeal, which would cause far more people to lose insurance than Trump can on his own.
“This stuff is really bad,” the health care expert Aviva Aron-Dine said, referring to last week’s announcements, “but it’s not nearly as bad as repeal. People should be able to hold both of those ideas in their head at the same time. Nobody should despair.”
So far, advocates for health care — both the professionals and the amateurs — have done a remarkably good job of choosing passion over despair. Don’t stop now.

Deep in Trump Country, a Big Stake in Health Care

by Patricia Cohen - NYT - October 16, 2017

MOUNTAIN HOME, Ark. — Marjorie Swanson was the first in the family to get a job at Baxter Regional Medical Center after moving to this rural Ozark town from Chicago’s South Side in 1995.
A year later, her husband was hired by the maintenance department. Six months ago, their daughter snagged a job as a pharmacy technician and shares the night shift with her fiancé, who works in housekeeping. Their son started in 2013 as a biomedical technician, repairing medical equipment. He was introduced to his wife by two nurses there: one who is now his mother-in-law and Beverly Green, an aunt through marriage.
“Without our hospital, I’d probably be working at McDonald’s,” said Ms. Green, who was born at the medical center 47 years ago and has worked there for the past 27, first as a nursing assistant, and now as a manager. “Almost everyone has someone related here.”
That’s not surprising in Baxter County, in a part of northern Arkansas known for two dragon-shaped fishing lakes filled with largemouth bass, walleye and bream. The hospital is the single largest employer, with 1,600 people paid to mop floors and code insurance forms, stitch wounds and perform open-heart surgery.
“We are the economic anchor of the community,” said Ron Peterson, Baxter Regional’s president and chief executive. “When we downsize, the whole community downsizes.”
So for residents of the nearly all-white county, who overwhelmingly voted for President Trump, the fight over the Affordable Care Act is about both lives and livelihoods, access to care and to jobs. And the cloud that remains over the law’s future is unsettling.
Even after the latest Senate effort to overturn the bill collapsed last month, Republicans insisted that the failure was not the final word on the matter for this Congress. “At some point there will be a repeal and replace,” Mr. Trump declared. In the meantime, he has moved to scrap subsidies to insurance companies that help cover low-income people and signed an executive order permitting policies exempt from some of the act’s coverage rules — actions that supporters of the law say will gut it.
Whatever happens, the economy of every state will be affected. Across the country, the health care industry has become a ceaseless job producer — for doctors, nurses, radiologists, paramedics, medical technicians, administrators and health care aides. Funding that began flowing in 2012 as a result of the Affordable Care Act created at least a half-million jobs, according to an analysis by Goldman Sachs.
In many rural areas, where economies are smaller and less diversified, the impact is magnified. Health care has long been an economic bedrock in Baxter County, with a population of 41,000. But its significance has grown since the Affordable Care Act passed. The hospital alone has added 221 employees, a 16 percent increase, since 2011. The health sector accounts for one in nine jobs nationwide, but one in four here — roughly equal to the share employed by the county’s manufacturers and retailers combined.
“I’m optimistic about the economy, but I’m not optimistic about this health care reform,” Marjorie Swanson said. Like many of her co-workers and neighbors, she dislikes parts of the law that President Barack Obama championed. But she also knows that undoing it now would reduce both the number of insured patients and the government payments that keep the hospital afloat.
One of 31 states (plus the District of Columbia) that chose to extend Medicaid coverage, Arkansas got extra money to cover more low-income residents. Its adult uninsured rate dropped 12.3 percentage points, more than nearly every other state.
Losing that Medicaid money now might not put Baxter Regional out of business, but it could compel the independent, nonprofit hospital to merge with a larger system and cut back its services and work force. And that could be as devastating as slashing jobs at a steel plant in a factory town.
Gathered in a conference room at the hospital between shifts, many in the extended Swanson clan, dressed in a rainbow of blue, red and maroon scrubs, said the law needed to be fixed, not scrapped. And they primarily blamed a corrupt Washington establishment — not Mr. Trump — for failing to do so.
“It’d be like getting a new job as a manager here and every single person is against you,” Ms. Green said of Mr. Trump. She grew up in a family that leaned Democratic, and she supported Bill Clinton, then the state’s governor, for president in 1992, but said she didn’t trust Hillary Clinton.
Still, she is anxious about how Republican-led changes in health care could affect her job. “Probably we’d have to move,” said Ms. Green, whose husband is a firefighter. “But where to go? My whole family’s here. There’s no one who comes for a holiday from somewhere else.”
Ms. Swanson, 52, nodded. “We’d have difficulty getting a job with insurance,” she said. “And where would we get our care?”
Hospitals in rural areas have long struggled financially, but over the past decade the rate of closings has grown steadily. As young people gravitate to urban centers for college and employment, populations have dwindled, and those left behind are often poorer, sicker and less apt to have health insurance.
Baxter Regional, serving a county seat that is a retirement destination, is in a stronger position than most of the nation’s 2,500 rural acute-care hospitals. It offers neurosurgery and an emergency cardiac catheterization lab, the state’s first 3-D mammograms and magnetic resonance imaging. Still, it exists on a financial knife edge even as it helps prop up the local economy. The average operating margin began dipping below the break-even point in 2006 and has hovered near there since.
The financial effect of the Affordable Care Act on the hospital has been mixed. The Medicaid expansion in Arkansas allowed residents earning 138 percent of the federal poverty level — $16,643 for an individual or $33,948 for a family of four — to buy private insurance paid for primarily by the federal government. That extended health care access to people in the hills and surrounding counties who had never been insured, and shrank charity-case costs.
But it also reduced Medicare reimbursements, which cover the elderly. This trade-off left many hospitals ahead, but not Baxter Regional, which has an unusually large share of Medicare patients — 67 percent compared with a national average of 40 percent.
The added $4 million in Medicaid payments did not make up for the $12 million lost through Medicare. As Mr. Peterson points out, however, the Republican proposals to remake the law would have decreased Medicaid money without restoring any Medicare cuts. Arkansas would be particularly hard hit because it is among a handful of states with provisions that automatically end expanded Medicaid benefits if federal funding is reduced. The results would include fewer insured patients and a lot more debt.
A repeal now, Mr. Peterson said, would be calamitous.
“I was not initially a proponent,” he said of the law. “But once Medicare was cut, then it was very important to make sure you got the whole benefit from the Medicaid expansion. Otherwise, you would have just seen the cuts. Why would I be for that?”
Arkansas State University-Mountain Home works closely with the hospital to produce job-ready students. Brittney Harkins, training to be a licensed practical nurse, practiced checking a heartbeat in a simulation lab.

Young people are still leaving. But health care offers a lure to draw them back.

It’s a five-minute drive from Baxter Regional to the office of Robin Myers, the chancellor of Arkansas State University-Mountain Home, a two-year college that works closely with the hospital to produce job-ready students.
“I can’t tell you how intricately we are tied together with the hospital,” Mr. Myers said. “We could not survive without them.”
“We’re really educating people in the health care professions to stay here,” he added, noting that the school’s typical student is a 28-year-old woman. Once housed in a funeral home and feed store, the college now occupies a stately campus completed in 2000 and styled on Thomas Jefferson’s neo-Classical design for the University of Virginia.
Mountain Home, like other rural towns, is seeing an outflow of young people. The kindergarten has 100 fewer children than it did five years ago. But Mr. Myers said that “if we have opportunities for them, they want to come back.”
Marjorie Swanson’s daughter, Alison, 23, returned after graduating from college in 2016 with a fine-arts degree. She found an internship with a Stanford University professor, but when it ended, she had no job and no way to afford San Francisco’s sky-high rents.
“I was broke,” she said. “I came back home and was just trying to save up money and working a minimum-wage job that was terrible.”
When a rare opening as a well-paid pharmacy technician arose, her mother urged her to apply. “I’m really, really fortunate, and I really like this job,” Ms. Swanson said. “I would have never thought I would have done this, but the opportunity was there.”
Dr. Lucas Bradley, a neurosurgeon who had just finished up his residency in Little Rock, grew up in Maine, not Mountain Home, but he and his wife, Karla, knew they wanted to raise their family in a small town. Without a growing full-service hospital, though, Dr. Bradley, 37, said he probably wouldn’t have moved here and bought a house. His children — six with a seventh on the way — wouldn’t attend nearby public schools. His wife wouldn’t shop at Harps or fill the car’s gas tank at Valero. His family wouldn’t attend one of the area’s churches.
An economic impact review by the hospital concluded that workers’ earnings combined with their spending on groceries, clothing and the like generated more than $216 million a year in economic activity and helped create 1,280 jobs beyond their own. The hospital spends an additional $19 million a year on goods and services in a dozen surrounding counties. Based on the loss of Medicaid expansion money, the review estimated that a repeal of the Affordable Care Act could mean up to 500 layoffs at the hospital.

Vacationers looking for ‘one square inch of heaven’ became retirees drawn to a community-centered hospital.

Even now, with a repaved Route 62 running through it, Mountain Home is still what residents call a place you’ve got to be coming to, to get to. Joe Miles, now 65 and president of Integrity First Bank, grew up about 90 miles downstream on the White River and used to hunt and fish here as a child. “You couldn’t get here except by ferry,” he recalled.
Spectacular Ozark scenery, lakes and a river crowded with trout, thanks to federal dam projects, started luring fishermen to the area in the 1950s. The next decade, a group of local businessmen pushed development at a time when the ambulance doubled as a hearse, and the traffic light at Seventh and Main Streets was removed because there were so few cars.
One was T. J. McCabe, a co-founder of Integrity First, who traveled to boat and recreational-vehicle shows in the Midwest, giving away deeds for “one square inch of heaven” and telling the recipients to come visit their property.
“And they would come,” Mr. Miles recalled. “What we’re reaping today are second and third generations from Chicago, Green Bay and Minneapolis.”
Vacationers — blue-collar workers with dependable pension plans — turned into retirees. They were drawn by the lower cost of living, natural beauty and, over time, a full-service, community-centered hospital that could treat hip fractures, diabetes and congestive heart failure without a three-hour drive.
Marjorie Swanson’s parents moved to Mountain Home after researching best-places-to-retire lists. It was during a vacation visit that she and her husband decided it would be a great place to raise their children.
Many of the retirees — who make up 30 percent of the county’s population — join a large network of volunteers at the hospital; a smaller circle of wealthier ones are big financial donors as well.
In a county where two-thirds of the public-school children qualify for free or reduced-price lunch, such contributions have funded scholarships that helped pay for Ms. Green’s advanced nursing training, and college for Alison Swanson and her brother, Matt. In addition, they have underwritten emergency-room furniture, wheelchairs, free wigs for cancer patients and more.
The stream of retirees slowed when the housing market crashed, and nest eggs turned into foreclosures. During the recession, those who came were like Sarah and Blair Brozynski, Chicago residents who had long vacationed here. They lost their jobs and moved to their summer house in Mountain Home, where they could live with their five children more cheaply.
Now director of education at the hospital, Ms. Brozynski, 47, remembers when the factories laid off workers, the hospital stopped hiring and a wave of closings hit resorts. Car lots were full because no one was buying.
“That was pretty sad, and we got a taste of it,” said Ms. Brozynski, whose husband is training to be a paramedic on a hospital scholarship. A son, also named Blair, is working in the hospital kitchen while he finishes college. She fears that if Republicans unwind the health care law, the tough times will return.

Many were skeptical about the Affordable Care Act, but its funding is cited as a lifeline in extending coverage.

Ms. Brozynski supported Mr. Obama’s health care legislation when it was first proposed, but many others in the county were skeptical. Some objected to the rise in premiums or a provision devised to keep the plan solvent — fining people who failed to sign up for coverage.
Now, whatever the criticisms, the dozens of employees interviewed at Baxter Regional and elsewhere all expressed thanks that more people had insurance. Michael Haynes, a 64-year-old real estate agent, credited the Affordable Care Act with saving his life. He didn’t have insurance before 2014. Without it, he would not have gone for a routine physical, which led to a diagnosis of prostate cancer and Hodgkin’s lymphoma. After chemotherapy treatments, he is in remission.
At the Christian Clinic — the health care provider of last resort — the number of nonpaying patients seen each week has dropped from 90 to about 50 because of the expanded coverage, said Dr. Paul Wilbur, the clinic’s chairman.
The law has brought insurance to more than 360,000 people in Arkansas, and it now covers 61 percent of children in the state’s small towns and rural areas. “That meant just a gigantic helicopter drop of federal funding,” said Mark Duggan, an economist at Stanford. If that is reversed, “the hospital sector is going to get really hard hit.”
Dr. Bradley, who voted for Mr. Trump and credits him with shaking up inside-the-Beltway cronyism, said the health care law had “benefited hospitals, patients and providers in the state of Arkansas.”
“There were lots of parts in that bill that were done right, parts that were necessary,” Dr. Bradley said. There were significant shortcomings, too, he said, but they are fixable. Sadly, he added, bitter partisanship has made the law a lasting target.
The endless fighting over the health care law has left some of the Swansons so frustrated that they wonder if starting from scratch is the only way to move forward.
“Let it implode and start from ground zero,” Marjorie Swanson suggested at one point. But that prospect, echoing a threat by Mr. Trump, scared other members of the family.
“What does that actually mean?” Ms. Green said. “If he’s going to let it fail and there’s no reimbursements and things are closing, how many casualties are in the wake?”

Maine Voices: Rural hospitals face downward spiral

by Andrew Coburn and Jay Mullen - Portland Press Herald - October 15, 2017

Data from the University of North Carolina-Chapel Hill indicate that the financial condition of many small, rural hospitals in Maine has deteriorated since 2011, with seven of the state’s 16 critical access hospitals having negative financial margins in 2015.
This August, we learned that health services in Jackman were threatened with the closure of the town’s nursing home and changes in the local emergency medical services. Also, this past summer, Calais Regional Hospital found itself unable to support its obstetrical services. This situation reflects a common pattern: Rural hospitals cannot provide a broad range of basic services because there are too few patients to cover the high fixed costs of those services. In response, hospitals eliminate services and reduce staff, but the financial problem only accelerates as patients begin to lose faith in their local hospital and choose to seek care elsewhere.
Faced with losing their local hospital, communities often mobilize to raise money or protest in an attempt to try to save their hospital. Rarely are the roots of the problem examined or discussed in a community forum where people can come together to understand the challenge. For example, the hospital’s financial problems are exacerbated when local residents choose not to use their local hospital.
Yet this behavior is rarely acknowledged or examined. Nor is the growing burden of chronic disease in rural communities closely reviewed, and the question asked: “What would turn this around?” And alternatives, such as building a regional service network with other hospitals with broader telehealth access to services, often become the focus of contentious negotiations among health care providers.
Hospitals and communities confront many challenges in the face of these potential closures. Ideally, communities and hospitals would have access to support and potentially financial assistance to develop a plan for transitioning to a new, rural health care future. To that end, we offer the following suggestions.
• First, Maine’s Office of Rural Health and Primary Care, in collaboration with hospitals and other health care stakeholders, should examine the current financial circumstances of Maine rural hospitals and health care providers to identify those facilities at highest risk.
 Second, communities and hospitals and their federal and state government partners need to consider alternative models for organizing hospital, emergency care and other services in the rural context. Freestanding emergency departments with the ability to deliver overnight observation and/or the development of regional delivery models, together with new payment models, are among the options being considered in several states.
 Third, rural communities, including health care providers, payers and employers, must acknowledge that both time and financial resources are needed to develop realistic plans for transitioning to a re-configured health system.
 Finally, Maine needs a point person and/or agency in state government tasked with the responsibility (and appropriately resourced) to work with the private sector and communities to mobilize the support and assistance needed to respond to short-term crises and implement longer-term plans.
The closure of OB services in Blue Hill in 2009, Lincoln in 2014 and Calais in 2017 are canaries in the coal mine. Let’s heed the warning immediately and start working with financially vulnerable rural hospitals, other providers, employers and communities to craft plans that ensure access to essential services in Maine’s rural communities.