Monday, November 13, 2017

Health Care Reform Articles - November 13, 2017

Election Results Invigorate Medicaid Expansion Hopes

by Abby Goodnough and Margot Sanger-Katz - NYT - November 8, 2017

WASHINGTON — The election results in Maine and Virginia have energized supporters of expanding Medicaid under the Affordable Care Act in several holdout states. After months of battling Republican efforts to repeal the law, they now see political consensus shifting in their direction.
Groups in Idaho and Utah are already working through the process of getting Medicaid expansion initiatives on next year’s ballots, hoping to follow Maine’s path after failing through the legislative route. And the outlook for legislative approval has brightened in Virginia after Democrats picked up at least 15 seats in the Republican-controlled House of Delegates and could potentially control the chamber once all the votes are counted.
Advocacy groups are also hoping the decisive victory in Maine, and exit pollssuggesting health care was the top issue in Virginia, will add momentum to efforts in Kansas and North Carolina.
“The results from Maine and Virginia send a very clear signal that the public is interested in moving past the type of obstruction we’ve seen from policymakers in some states,” said Katherine Howitt, associate director of policy at Community Catalyst, a consumer advocacy group.
The expansion debate in many states has been a political stew, with opposition a mix of fiscal concerns, philosophical resistance and stiff political opposition to Obamacare, which made Medicaid expansion possible. But many advocates hope growing public support for expansion and the fading of the Obama era will mean a softening of opposition among some governors and legislators who have long resisted the idea.
Expanding Medicaid was a key provision of the Affordable Care Act, meant to ensure that all Americans below or somewhat above the federal poverty line would qualify for government health insurance. But a Supreme Court decision in 2012 made the choice to expand coverage optional for states. Before Election Day, 31 states and the District of Columbia had chosen to accept federal funding to expand coverage.
In Virginia, the outgoing Democratic governor, Terry McAuliffe, tried repeatedly to expand Medicaid, but the majority Republican legislature kept blocking it. Advocates there hope that Democratic gains in the legislature, and perhaps some changes of heart among Republicans worried by the exit polls showing health care to be a top concern, could mean enough votes to approve expansion.
In Maine, legislators had voted to expand the program five times, but Gov. Paul LePage, a Republican, vetoed each bill. Though the outcome of the ballot initiative is not subject to a veto, Mr. LePage indicated in a statement Wednesday that his administration will not implement the change unless the legislature identifies funding sources for the state portion of the program’s costs.
Expansion supporters insisted the state had no choice but to expand Medicaid, but acknowledged Mr. LePage could make it difficult over the next year, his last in office.
“He could violate the law,” said Robyn Merrill, who helped run the pro-expansion campaign. “But if the people who are now eligible for coverage are denied it, they will have legal recourse.”
Not every state’s voters can count on ballot initiatives as a means of expanding Medicaid. Fewer than half the states in the country allow citizen-driven initiatives, including some of the largest that have declined to expand, like Texas and Georgia.
Neither does Kansas, where the Republican-controlled Legislature voted to expand Medicaid earlier this year but failed to override a veto by Gov. Sam Brownback. Mr. Brownback is awaiting confirmation to an ambassador at large position in the Trump administration, but Lt. Gov. Jeff Colyer, a fellow Republican who would replace him, has also indicated he would resist expansion.
Still, David Jordan, who leads the Alliance for a Healthy Kansas, an advocacy group, pointed out that if Mr. Colyer becomes governor, he will face re-election a year from now in a state where polls have found resounding support for expanding Medicaid.
“Yesterday’s results in Virginia and Maine should send a message to him,” Mr. Jordan said. “It could become really tough to go against this wave.”
But for many Republican politicians, the idea of expanding Medicaid remains hard to love. Providing government insurance coverage to poor adults who are not disabled is anathema to many. They view such help as discouraging work, though data suggests most new Medicaid recipients have jobs and states that expanded did not see reductions in employment among low-income people.
Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, which oversees the program, told state Medicaid directors on Tuesday that her department would begin approving state plans to condition Medicaid coverage for non-disabled adults on work or volunteer hours.
“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”
Several states have asked Ms. Verma’s office for permission to impose work requirements on Medicaid beneficiaries. Matt Salo, the executive director of the National Association of Medicaid Directors, said that he thought work requirements might make expansion more acceptable to some state legislatures, like Florida’s, that have been reluctant in the past. “You can rebrand that,” he said. “You can do that very effectively.”
The federal government paid the entire cost of expanding Medicaid for the first three years of Obamacare, but that changed this year. States now must pay 5 percent of the new beneficiaries’ medical bills, a proportion that will increase to 10 percent by 2020. So any state that expands now will need to find some funding to pay for its share.
States that expanded Medicaid expect to spend $8.5 billion from their own funds on expansion in the 2018 fiscal year, according to the National Association of State Budget Officers.
“Every political decision is about value, and the value is what’s the return for the money,” said Tony Keck, a former director of South Carolina’s Department of Health and Human Services, a state that has not expanded. Mr. Keck, now a hospital executive, said that legislators there thought it was more important to invest in existing populations of Medicaid beneficiaries than to expand the program to cover childless adults.
In Utah, a newly formed political committee called Utah Decides Healthcare just concluded seven required public hearings around the state and hopes to soon start gathering the 113,143 signatures needed to get an expansion question on next year’s ballot. The Republican-controlled legislature could interfere if the initiative were to pass, but RyLee Curtis, the campaign manager for the Utah effort, said she doubted it would because Gov. Gary Herbert and the State Senate had tried to expand Medicaid in the past.
Jonathan Schleifer, the executive director of the Fairness Project, a left-leaning group founded in California that donated nearly $700,000 to the pro-expansion campaign in Maine, said the group was eager to help the efforts in Utah and Idaho and scout out other states where ballot initiatives might work.
“Grassroots groups in other states were waiting to see what happened last night and now they know what’s possible,” said Mr. Schleifer, his voice hoarse from whooping at a victory party in Maine on Tuesday night. “In the next couple weeks we’ll be able to start talking about what other states have the ability to run these initiatives and the grassroots enthusiasm to do that.”

Maine becomes first state to approve Medicaid expansion by popular vote

by Edward D. Murphy and Joe Lawlor - Portland Press Herald - November 7, 2017

Maine voters passed a measure to expand Medicaid on Tuesday, giving about 70,000 Mainers health care coverage and making the state the first in the nation to approve Medicaid expansion at the ballot box.
With 75 percent of Maine precincts reporting, the measure was favored by 59 percent of the voters.
Support for the measure appeared to be strongest along the coast and in southern Maine, but it also was backed by voters in parts of more conservative northern Maine. A string of towns along the state’s northern border with Canada backed the measure – in Fort Kent, for instance, 55 percent of voters approved of Medicaid expansion.
About 200 Medicaid expansion supporters gathered at Bayside Bowl in Portland Tuesday night, where an exultant mood prevailed.
“We did it! We really did it,” Robyn Merrill, executive director of Maine Equal Justice Partners, said in a victory speech. “Tonight we are celebrating and you’ve earned it. People need more health care, not less.”
Merrill said the referendum enjoyed wide support throughout Maine, including rural areas, small towns and in Maine’s cities.
And, the message should spread beyond the state’s borders, she said.
“This should be sending a message to the 18 other states that haven’t yet expanded Medicaid,” Merrill said. “This will have national implications.”
Question 2 has attracted national attention in an off-year election, with no presidential vote, no congressional races and an ongoing effort by the Trump administration and Republicans in Congress to dismantle the Affordable Care Act.
Planned Parenthood in Portland was a staging area for a last-minute get-out-the-vote effort by Mainers for Health Care, the group supporting Medicaid expansion.
Volunteers were rolling in and out of the downtown Portland offices, mostly being dispatched to Westbrook to knock on doors of supporters and personally remind them to vote if they hadn’t already.
Katherine Fitzpatrick, 24, of Scarborough said she has a personal motivation to volunteer, as her father has been battling cancer since 2004, and their family’s out-of-pocket health care costs are tens of thousands of dollars every year.
“This is the least I can do,” said Fitzpatrick, who worked the phones and helped organize volunteers Tuesday. She’s been knocking on doors since July. “I’m feeling pretty good about it passing. People have gotten used to having health care and they’re not just going to let it go. People are now realizing health care is an individual right.”
Opponents sent out an Election Day email urging Mainers to reject expansion.
“It is clear that out-of-state interests are trying to force the Maine people into another failed Medicaid expansion. We expect Maine people will remember the nursing home cuts and hospital debt which resulted from the last expansion. The only way to stop that is to vote no on Question 2,” said Brent Littlefield, spokesman for the Welfare to Work PAC.
Medicaid expansion, while voluntary for states, is a key component in how the ACA provides coverage to low-income Americans. In Maine, about 70,000 adults who earn up to 138 percent of the federal poverty level, or $16,643 for a single person and $22,412 for a family of two, will be eligible for Medicaid.
The measure, proponents said, would help strengthen the finances of the state’s rural hospitals and create as many as 3,000 new jobs. But opponents have likened the program to welfare for able-bodied, working-age adults and said it will make it more difficult to steer state money to disabled Mainers who are on waiting lists for aid.
A legislative study said expansion would cost the state $93 million through 2019, while bringing in $1.2 billion in federal funding. Supporters gathered voter signatures to put the measure on Tuesday’s ballot, including 65,000 signatures on Election Day 2016 alone.
Maine is one of 19 states that refused to expand Medicaid under the ACA, and Gov. Paul LePage, a Republican, is a steadfast opponent who has vetoed five expansion bills that passed the Legislature.
The state expanded Medicaid during Democratic administrations in the 2000s, predating the ACA, and opponents blamed the previous expansion for causing state budget problems.
Voters who were against the referendum cited Maine’s previous experience expanding Medicaid as a reason to oppose.
“The only ones making out were the insurance companies,” said Kevin McCartan, an expansion opponent who voted “no” at the South Portland Community Center.
But Nicole Gallagher, also voting at the community center, said, “I looked at the income levels and thought that these people should have access to health care. I actually think everyone should have access to health care.”
Erin Elizabeth agreed, saying Medicaid expansion is “great.”
“We need this. The insurance companies are robbing us blind,” Elizabeth said.
Scott Clark, 67, voting at Cape Elizabeth High School, said he supported Medicaid expansion because he believes in “having more universal health care coverage.”

Maine’s governor wants to ignore the will of voters. He’s not alone.
by Josh Silver - The Washington Post - November 8, 2017

Less than a day after voters in Maine voted to expand Medicaid in their state, Gov. Paul LePage (R) moved quickly to subvert their democratic will, announcing Wednesday that he will not implement the expansion until it is “fully funded by the Legislature.”
This is not the first time that elected officials in the state have blatantly ignored voters in this way. Last year, Mainers approved an innovative reform known as “ranked-choice voting,” as an effort to ensure that their governor wins with a majority of the vote. But the state legislature did not agree with that decision, so it recently voted to delay and potentially repeal the initiative. In fact, it brazenly meddled with every single ballot measure passed by the state’s voters in 2016.

The news out of Maine is part of an ominous pattern: state legislators across the country resisting the will of the people by gutting or even repealing citizen initiatives. This is a shockingly undemocratic trend at a time when U.S. voters are already deeply unsatisfied with their elected leaders.
The citizen initiative — in which a group of voters brings a proposed law or constitutional amendment to the ballot for the public to approve or reject — exists in 26 states and the District. It has long been a critical tool for advancing key issues that are popular with the public but unlikely to make it through legislatures or city councils.
But more and more legislators have been willing to effectively deny their constituents’ political voices. Perhaps the most egregious repeal of a voter-approved initiative in modern history took place this year in South Dakota, where voters passed a suite of ethics and campaign finance reforms aimed at eradicating political corruption endemic to the state’s politics. The state’s legislature quietly declared an “emergency session” and swiftly repealed the citizen-approved measure intended to regulate their own corrupt behavior.
Unfortunately, South Dakotans and Mainers are not alone. In Massachusetts, the legislature amended and delayed implementation of a 2016 voter-approved ballot measure to legalize marijuana sales. The Missouri legislature has repealed measures covering a range of issues, from school funding to gun safety to animal cruelty. Missouri lawmakers are also exploring new rules to make it harder to get an initiative on the ballot. Lawmakers in Michigan have the same objectives, but they employ different tactics. They have specialized in undercutting or superseding a proposed initiative before it has a chance to even pass — a process known as preemption. 
And a year before the October massacre in Las Vegas, Nevada voters approved a ballot initiative to require background checks for gun purchases. A month later, the state’s attorney general said the measure could not be enforced.
This pattern of legislative tampering should alarm all Americans. When our elected officials repeal voter-approved laws designed to improve the very nature of our democracy, it hurts voters from across the political spectrum.
Thankfully, there are better paths: In 1996, Arizona voters approved a measure to legalize medical marijuana by a margin of 30 points, only to have it gutted by the legislature the next year. Enraged, Arizonans went back to the ballot in 1998 to pass Proposition 105, which blocks politicians from meddling with voter-approved laws if legislative changes do not “further the purpose” of the measure. We also find hope in places such as California, where the legislature is completely prohibited from changing the text of an initiative that has been enacted by voters. Nebraska requires a legislative supermajority to change or repeal a ballot initiative. 
Borrowing from these examples, we can support efforts to pass anti-tampering laws in the two dozen states that allow the initiative. We can advocate for supermajority requirements to amend or repeal any initiative, or better yet, we can forbid alltampering that fails to further the purpose of an initiative.
One such campaign, which my organization has led, has taken shape in South Dakota. Last week, grass-roots activists submitted more than 50,000 signatures to the secretary of state to place an amendment on the ballot. The proposal would finish what last year’s now-overturned initiative started by restricting lobbyist gifts to politicians, creating an independent citizen ethics commission, making political bribery a felony and — perhaps most important — preventing the state legislature from changing any initiative unless that change is first approved by the voters.
If voters across the political spectrum can stand up in the face of this legislative resistance, they’ll ensure that the true protectors of our democracy — the people themselves — have their voices heard in the fight against corruption.

Trump Administration Will Support Work Requirements for Medicaid
by Robert Pear - NYT - November 7, 2017

WASHINGTON — The Trump administration announced on Tuesday what it called “a new day for Medicaid,” telling state health officials that the federal government would be more receptive to work requirements and other conservative policy ideas to reshape the main government health program for low-income people.
Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said the administration would approve proposals from states to require work or community engagement for people who want to receive Medicaid. The Obama administration had turned down such proposals, saying they would not further the purposes of Medicaid, which are to promote health coverage and access to care.
But in a half-hour speech to the National Association of Medicaid Directors, which represents state officials, Ms. Verma said on Tuesday that Medicaid had a higher purpose: to help people “rise out of poverty and government dependence.”
Many people on Medicaid, including many who became eligible as a result of the Affordable Care Act, are able-bodied adults of working age, Ms. Verma said.
“These are individuals who are physically capable of being actively engaged in their communities, whether it be through working, volunteering, going to school or obtaining job training,” Ms. Verma said. “Let me be clear to everyone in this room: We will approve proposals that promote community engagement activities.”
She heaped criticism on the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.
“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”
Jason A. Helgerson, the Medicaid director in New York State, said on Twitter that Ms. Verma’s comments were “absolutely awful.” It was absurd for her to suggest that she was ushering in a new day for Medicaid by taking it away from millions of people, he said.
Ms. Verma worked for years as a consultant to state Medicaid officials. With her guidance, her home state of Indiana expanded Medicaid eligibility under the governor at the time, Mike Pence, while emphasizing “personal responsibility” by requiring beneficiaries to pay premiums and contribute to health savings accounts.
In her remarks on Tuesday, Ms. Verma did not renew Republican calls for repealing the Affordable Care Act. But she criticized the law’s expansion of Medicaid, an option that has been taken up by 31 states.
“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working age, able-bodied adults does not make sense,” Ms. Verma said.
Average monthly enrollment in Medicaid, according to the Congressional Budget Office, has climbed by nearly one-third, to 77 million people, since President Barack Obama signed the Affordable Care Act in 2010.
The Kaiser Family Foundation reports that at least six states — Arkansas, Indiana, Kentucky, Maine, Utah and Wisconsin — have pending waiver requests that would require work as a condition of eligibility for some Medicaid beneficiaries. New Hampshire submitted its own proposal last week.
“Community engagement” is a broad term that states define in various ways. It can include not only paid employment, but also volunteer activities, going to school, job training, searching for jobs, caring for elderly relatives and even treatment for drug or alcohol abuse.
Donna Checkett, a former Medicaid director in Missouri, said Ms. Verma’s position on requiring such activities was “180 degrees different from that of the previous administration.”
Cindy Mann, who was the top federal Medicaid official under Mr. Obama, said Ms. Verma’s objections to Medicaid coverage of working age, able-bodied adults were “upsetting and disturbing.”
The Affordable Care Act gave states the “flexibility and financing” to cover that population in diverse ways, without seeking a federal waiver, Ms. Mann said.
And she noted that the expansion of Medicaid had been defended by Republican governors including Chris Christie of New Jersey, John R. Kasich of Ohio, Rick Snyder of Michigan, Chris Sununu of New Hampshire and Brian Sandoval of Nevada.
Ms. Verma also announced changes to speed the review of state requests for waivers of the federal Medicaid law. She said the Trump administration could approve some waivers for 10 years. Waivers have typically been approved for five years, with the possibility of an extension for three years.
In addition, Ms. Verma said, “if we approve an idea in one state and another state wants to do the same thing, we will expedite those approvals.”
She said the Trump administration would issue a scorecard measuring and comparing states’ performance in improving the health of people on Medicaid. The federal government and the states together spend more than $550 billion a year on Medicaid, and people deserve to know if the money is “producing positive results,” she said.
Matt D. Salo, the executive director of the National Association of Medicaid Directors, said state officials agreed with Ms. Verma that they should focus on Medicaid beneficiaries and the outcomes of the care provided.
But, Mr. Salo said, “we have a lot of disagreement” with the contention that Medicaid should not be serving able-bodied adults of working age. State officials said that many Medicaid beneficiaries had low-wage jobs that did not provide health insurance for them or their family members.
Ms. Verma insisted that the Affordable Care Act had given states perverse financial incentives, paying a higher share of Medicaid costs for newly eligible beneficiaries.
“The A.C.A.,’’ she said, “moved millions of working-age, nondisabled adults into a program that was created to care for seniors in need, pregnant mothers, children and people with disabilities, stretching the safety net for some of our most fragile populations, many of whom are still on waiting lists for critical home-care services while states enroll millions of newly eligible able-bodied adults.’’

Medicaid Is Great, but Rural Maine Needs Hospitals, Too

by Zack Ringelstein - NYT - November 9, 2017

LEWISTON, Me. — This week Maine voted to become the 32nd state to expand Medicaid despite opposition by Gov. Paul LePage, who had vetoed five previous expansion bills passed by the state legislature and has now threatened to block the results of the ballot initiative. Unless Mr. LePage succeeds, about 80,000 more Mainers will be eligible for coverage, a victory in an unsettling year for health care in America.
With the Affordable Care Act under constant threat from the Trump administration and out-of-pocket costs rising faster than wages, health care topped the list of the most important issues facing Americans this year.
However, Maine and other rural states face a health care crisis that Medicaid expansion can’t fix on its own. It’s not about affordable coverage; it’s about access: For too many rural areas, doctors and hospitals are scarce.
In the postwar era, America made hospital construction and modernization a priority. On Aug. 13, 1946, Harry Truman signed the Hill-Burton Act, giving communities grants and loans for hospital construction. By 1975, almost one-third of American hospitals owed their creation to the law. Financing for Hill-Burton health care construction ended in 1997, but one rule from the original bill still applied: These hospitals had to give free or reduced care to people who couldn’t afford services. As rural areas aged and the population shrank because of manufacturing’s decline and the rise of a technology-driven economy centered on urban areas, hospitals struggled to stay in operation.
Under the Affordable Care Act, hospitals started shutting down at worrisome rates because of an increase in financial penalties for noncompliance with A.C.A. mandates, the cost of tighter reporting standards and smaller reimbursements for certain procedures. Since the A.C.A. became law in 2010, over 80 rural hospitals have closed nationwide. Maine alone has lost three hospitals in that time, about 10 percent of its rural total.
If closings continue at this rate, 25 percent of America’s rural hospitals will have disappeared in the decade after Obamacare’s passage. This does not take into account facility deterioration, doctor departures or department closures.
This is a big problem for Maine, which has the highest percentage of rural residents in the country, according to the most recent census data. Calais Regional Hospital in Down East Maine recently oversaw its last childbirth. The obstetrics department closed in late summer, forcing women in labor to drive 50 minutes to deliver their babies. Despite an opioid crisis that increases the chance of high-risk pregnancies, this same privately owned hospital shut down its pediatrics wing and intensive care unit in recent years, because of financial pressure from the management company halfway across the country in Tennessee.
This was hardly an isolated example in Maine. The town of Jackman closed its 24-hour emergency room in September, and Boothbay lost its only hospital in 2013. Rangeley, where my wife’s family lives, is an hour away from the nearest hospital and has no doctor in town.
Meanwhile, Maine Med in Portland, Maine’s largest city, is about to break ground for a $512 million addition just a few years after it finished a $40 million renovation. While rural Maine’s hospitals and departments are closing because of large losses, Maine Med had, for 2016, a $61 million surplus.
Medicaid expansion is a welcome source of new revenue to rural hospitals in Maine because more insured patients mean fewer uncompensated treatments. Still, it comes nowhere close to fixing the problem or, politically, putting any meaningful points on the Democratic scoreboard.
In 2016, Donald Trump won Maine’s rural congressional district by a 10-point margin and rural counties in America at large by a 26-point margin on a message of repealing and replacing Obamacare. As Maggie Elehwany of the National Rural Health Association said in an NPR interview this year, rural Americans voted for Mr. Trump in part because of health care. “They see their hospitals closing,” she noted. “And one hospital C.E.O. described it as a three-pronged stool. It’s the churches, the hospitals and the schools. If you lose one of those legs of that stool, the whole community collapses.”
Since President Trump hasn’t been able to deliver on any meaningful legislation to support rural voters, it is the Democrats’ time to deliver. One good step is a bill sponsored by the Democratic senators Tim Kaine of Virginia and Michael Bennet of Colorado called Medicare-X. It would give a public option to Americans in rural counties where limited competition has yielded higher-priced health insurance options.
It still doesn’t solve the heart of the rural problem. Democrats can’t just lower premiums and expand Medicaid. We must strengthen rural communities by making access to high-quality health care services a priority of any proposal. In any future legislation, we should demand grants for new hospitals, funds to modernize crumbling ones and financial incentives for top doctors to work in these areas. This will not only make rural communities healthier, but also more welcoming for growth and new business.
No person suffering from a heart attack should die because a hospital is too far. No pregnant mother should have to risk the health of her baby because she can’t make it to a delivery room in time. As Democrats, we believe that health care is a right. It would be a big mistake to expand health care insurance but offer no place to use it.

Mass. Senate approves sweeping health care bill

by Priyanka Dayal McCluskey - Boston Globe - November 10, 2017

Massachusetts senators approved a sweeping bill at midnight Thursday that seeks to control the rising costs of medical care and prescription drugs, including a controversial plan that would fine hospitals if spending rises too fast.
The legislation also would require pharmaceutical companies to submit to more scrutiny from state officials. The bill sailed through the overwhelmingly Democratic Senate by a 33-6 margin at the stroke of midnight, after two days of debate and much last-minute wrangling over technical language.
Senators approved several changes to their original bill, including to some sections that had drawn criticism from the health care industry, but they said it remained the same at its core. The bill’s drafters said it will help curb costs for consumers and the state budget, while improving patient care.
“Many of the issues we’re addressing here have gone unaddressed for a long time, and we just don’t have the ability to kick the can down the road anymore,” said Senator James T. Welch, a West Springfield Democrat and lead author of the bill.
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Opponents and skeptics say now is not the time for sweeping health care legislation, given the ongoing uncertainty around health care in Washington and the fact that Massachusetts passed a health care cost control bill in 2012.
Republican Bruce Tarr, the Senate minority leader, questioned the need for additional “bureaucracy” that could drive costs higher, and said lawmakers should focus instead on measures to increase the transparency around health costs.
Tarr, who voted against the bill, said the legislation’s “Achilles heel” is that it failed to seriously deal with the rising costs of the state Medicaid program, MassHealth.
The bill’s fate in the House remains unclear. House leaders have not said when they will take up health care legislation.
The 100-page bill attempts to help struggling community hospitals by setting a floor for the reimbursements they receive from insurers. Hospitals would have to be paid at least 90 percent of the average price of a service, according to the legislation.
Hospitals are already major contributors to health care spending, so to control costs, the bill also sets a benchmark for annual growth in hospital spending, estimated at 2.7 percent. If the hospital industry exceeds that benchmark, some hospitals would have to pay hefty penalties.
The idea of the penalties drew strong objections from the hospital industry, particularly the state’s largest health system, Partners HealthCare. Partners executives said their two biggest medical centers, Massachusetts General and Brigham and Women’s, would be fined unfairly under the measure.
The bill originally allowed for penalties against just three hospitals where spending is highest, but late Thursday, senators amended the language to provide for more flexibility. The amended bill would not limit the fines to just three hospitals.
“We heard what Partners said,” Welch said.
The Massachusetts Health & Hospital Association had also raised objections about the penalties. And the Massachusetts Association of Health Plans, which represents insurers, raised concerns that the bill could encourage many hospitals to spend more, not less, if only certain hospitals were subject to a penalty.
Senate President Stanley C. Rosenberg said the bill takes a “market-driven approach” to addressing price disparities among different hospitals. “We’re asking the market to correct itself,” he said.
Senators also approved a measure Thursday to study a single-payer health care system, a nod to the more liberal members of the chamber.
The Senate bill omits several proposals from Governor Charlie Baker to curb spending in the MassHealth program, which covers poor and low-income residents. Baker wanted to change eligibility rules and move some adults off of MassHealth and onto other subsidized plans, but lawmakers have so far rejected those ideas.
“My big concern with the Senate health care bill is it doesn’t save the state any money,” Baker told reporters Thursday. “If we don’t do some things to change the way our system operates, we put education spending at risk, we put transportation spending at risk, and we put general local aid to cities and towns, public safety, and fire protection at risk.”
Senator Karen E. Spilka, the Senate budget chief, said she was “dumbfounded” by the governor’s comment. Senate leaders predict that in 2020, their legislation would save an estimated $114 million in MassHealth, part of an overall savings in the health system of up to $525 million.
House leaders have not detailed their plans to deal with health care costs. “Right now, we’re just listening to stakeholders and hearing what people have to say,” said Representative Jeffrey Sanchez, the House budget chief. “Anything that we do, we want to make sure that it’s based off a very defined problem.”
The Senate bill would requires pharmaceutical companies for the first time to submit price and other data to the state Health Policy Commission, a watchdog agency. It would also require drug makers to testify at the commission’s annual hearing, where health care executives publicly discuss what they’re doing to control costs.
“We are concerned with the current form of the Senate bill but know it’s only the first step in the process,” Robert K. Coughlin, president of the Massachusetts Biotechnology Council, said in a statement Thursday. “We look forward to working with the House to develop approaches for the state to adequately measure the value that prescription drugs bring to patients and the healthcare system, in lives improved and costs avoided.”
The legislation would expand the role — or scope of practice — for several types of health care workers: nurse practitioners, nurse anesthetists, psychiatric clinical nurse specialists, optometrists, and podiatrists. It would also create a new type of dental care provider, called a dental therapist, who could do some of the work now left to dentists.
In addition, the legislation would require hospitals to get more aggressive in preventing patients from being re-admitted just days or weeks after being discharged.
The wide-ranging Senate bill includes many other provisions spanning MassHealth and the commercial health insurance market. It is the most comprehensive health care bill to be debated on Beacon Hill in five years. In 2012, lawmakers approved legislation that set a benchmark for controlling the overall growth in health spending to 3.6 percent a year, among other measures.

Trump Administration Guiding Health Shoppers to Agents Paid by Insurers

by Robert Pear - NYT - November 11, 2017

WASHINGTON — After cutting funds for nonprofit groups that help people obtain health insurance under the Affordable Care Act, the Trump administration is encouraging the use of insurance agents and brokers who are often paid by insurers when they help people sign up.
The administration said in a recent bulletin that it was “increasing partnerships” with insurance agents and viewed them as “important stakeholders” in the federal marketplace, where consumers are now shopping for insurance. But some health policy experts warned that a shift from nonprofit groups, which are supposed to provide impartial information, to brokers and agents, who may receive commissions for the plans they recommend, carries risks for consumers.
“Insurance agents can educate consumers about the marketplace, and that is a good thing,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But I worry that they work on a commission and therefore have a financial incentive to steer consumers to particular products, which may or may not be in the consumer’s best interest.”
In its bulletin, the administration said agents and brokers who are registered with the federal marketplace can “get sales leads” and new clients. And it offered them tips for “making the most of your marketplace participation during this open enrollment period,” which runs through Dec. 15.
Consumers can get contact information for agents and brokers, as well as nonprofit groups known as navigators, by clicking on “Find Local Help” on
From there, consumers can connect with a service the administration added this year specifically to connect them with licensed agents and brokers who can provide immediate assistance.
“Get help now!” says a federal website describing the new service, called Help on Demand. “A marketplace-registered agent or broker will contact you in 30 minutes or less to help you enroll. Agents’ and brokers’ services are generally free to you. They’re usually paid for by insurance companies.”
More than 43,000 agents and brokers have received training and been certified to sell health plans through the federal marketplace. Their advocates said they could provide a lifeline for consumers in a confusing and troubled marketplace.
Michael Lujan, a former president of the California Association of Health Underwriters, called agents “the unsung heroes of health care and the marketplace.”
“The Trump administration set out to sabotage the Affordable Care Act by defunding many of the nonprofit navigator groups,” Mr. Lujan said. “Agents can help fill the gap.”
Agents and brokers can recommend specific health insurance plans and typically receive commissions paid by the insurers whose plans they sell. By contrast, nonprofit navigators and other “assisters” cannot recommend specific plans. In fact, the Trump administration recently warned navigators that they could not accept payment from an insurer and could not be paid even by their own organizations on a per-application or per-enrollee basis.
The website for the Help on Demand service is operated by BigWave Systems, a privately held technology company in Colorado, “in partnership with,” the federal marketplace.
Personal and financial information provided by consumers is confidential. But an assessment prepared by the Department of Health and Human Services says, “BigWave Systems makes no warranties or representations regarding the security of the data submitted to the Help On Demand application, and use of the Help On Demand website is at the consumer’s own risk.”
Marcia Benshoof, a spokeswoman for BigWave Systems, said that personal information was encrypted and stored behind a firewall and that there had not been any unauthorized disclosures.
The administration has reduced funds for the navigator program by 41 percent, to $36.9 million, from $62.9 million last year. Among the states hit the hardest, according to data provided to Congress by the administration, are Georgia, down 61 percent; Michigan, down 72 percent; New Jersey, down 62 percent; and Ohio, down 71 percent.
A survey by the Kaiser Family Foundation found that insurance agents and nonprofit navigator groups differed in some ways. People using agents last year were less likely to be uninsured and less likely to have income low enough to qualify for Medicaid, it said.
California has had one of the most successful health insurance marketplaces in the country, and has studied the lessons to be learned from its experience.
“Agents are funded by health plan commissions and do not have an incentive or the resources to promote the overall marketplace,” said Peter V. Lee, the executive director of the state’s exchange. But he added, “Many of them are small-business owners who are trusted voices in their communities,” and they have enrolled hundreds of thousands of people in California.
Agents enrolled 47 percent of the people who had coverage this year through the state-run insurance marketplace known as Covered California. By contrast, nonprofit navigator groups generated about 3 percent of enrollment, according to the agency that runs the state marketplace. Many customers said they had bought insurance on their own without receiving assistance.
Patricia R. Martin of Chardon, Ohio, said she had always had health insurance through a large company for which her husband worked. When he died suddenly at 54, she said, she had to find other coverage, and a local agent provided invaluable assistance.
“Health insurance just boggles my mind,” Ms. Martin said. “It’s fine to go online, but I’d much rather deal with a person. I have complete faith in my agent.”
The open enrollment period for the federal marketplace lasts 45 days. But Nicholas A. Moriello, an insurance agent in Delaware, said agents “do marketing and outreach to customers” throughout the year and typically receive a commission or fee for each month that a consumer remains enrolled in a health plan.
“Agents and brokers are able to provide our recommendations to consumers, and that’s something they’ve really needed in trying to evaluate their choices,” Mr. Moriello said. “But in the same way that federal funding has been reduced for navigators, insurance companies all around the country have reduced the compensation that they pay to agents and brokers, and in some states they have eliminated it altogether. So I fear that in this year’s open enrollment, there may be a reduction in the number of agents and brokers for consumers to turn to.”
But with rising premiums, shrinking options and much confusion, consumers need more help.
Kelly L. Rector, an insurance broker in O’Fallon, Mo., near St. Louis, said many of her clients were “being required to give up their physicians” because Anthem Blue Cross and Blue Shield was pulling out of the local market and a company entering the market, Centene, had “a slimmer network with fewer doctors to choose from.”
Besides an increase in premiums for 2018, Ms. Rector said, “the biggest issue for some of my clients is that they will be unable to continue to see any of their current doctors.”

Why delivering babies is draining Maine’s small hospitals

by Meg Haskell - Bangor Daily News - November 12, 2017

Celia Geel of Calais would have much preferred to deliver her second baby in the familiar, hometown hospital where she gave birth to her daughter, Cora, 2½ years ago. Instead, after Calais Regional Hospital closed its labor and delivery department in August, Colton Scott Geel came into the world — a wailing, 8 pounds, 7 ounces of healthy baby boy — at Eastern Maine Medical Center in Bangor, nearly 100 miles from home.
In the months leading up to her due date on Oct. 28, Celia and her husband, Scott, were forced to choose: deliver at EMMC, at the other end of the lonely, winding highway known regionally as “the airline,” or Downeast Community Hospital, 40 bumpy miles away in Machias and the only hospital in Washington County still providing labor and delivery services.
In Machias, “if anything went wrong and we needed to be transferred to a bigger hospital, we’d be an hour further out of our way,” Geel, 30, who works with U.S. Customs and Border Protection at the Calais crossing, said. “So we decided to go to Bangor.”
Then, on Thursday, Oct. 26, Geel had a particularly restless night.
“There were no obvious signs of labor,” she said. “But the next morning my husband and I talked it over. He was terrified of going into labor and not making it [to EMMC].”
So, leaving 2-year-old Cora in the care of Celia’s mother, they made the long drive to Bangor, where her doctor confirmed she was not in labor but ready to be induced.
Saturday morning, Colton was born, without complications.
They got great care, Geel said, “but the trip added an extra layer of stress.” She missed the familiar surroundings and reassuring nearness of the Calais hospital and the opportunity for casual, drop-in visits from friends and family.
“We were very fortunate,” she said. “Not everyone will be that lucky.”
Celia Geel’s experience could become more the norm for women in Maine’s most rural areas, some experts say. The obstetrics closures are an early warning symptom that small hospitals can’t continue to provide a wide array of specialty services while maintaining a healthy bottom line. And while communities like Calais lament the cuts, those changes could ensure the survival of local hospitals as a vibrant center of community life.
In less than a decade, at least three small Maine community hospitals have closed their obstetric departments, citing financial pressures and insufficient demand. First, in 2011, it was Blue Hill Memorial Hospital in coastal Hancock County. In 2014, Penobscot Valley Hospital in Lincoln followed suit. And in May, Calais Regional Hospital announced it would phase out obstetric services, citing a steadily declining number of births — from more than 100 in 2007 to just 60 in 2016 — for the “heavy financial losses” that forced the department’s closure.
The last baby was delivered at the Calais hospital on Aug. 27 — Ashlynn DeMolet, weighing 7 pounds, 9.5 ounces — just before the town’s only obstetrician moved out of state.
As Maine’s far-flung rural communities grow older, smaller and poorer, experts say the decline of labor and delivery departments, along with other pricey, low-demand hospital services, is all but inevitable. But for some Mainers, the loss undermines the very notion of community.
“OB may not be a moneymaker,” Celia Geel said, “but it brings the community together. It’s the heartbeat of the hospital, really.”
But Andrew Coburn, a rural health care research specialist at the Muskie School of Public Service at the University of Southern Maine in Portland, said obstetrics has evolved into a high-cost, high-tech specialty that many small hospitals simply can’t afford.
Between substantial salaries for physicians and nurses, the latest equipment for anesthesia and surgical deliveries, and liability insurance, he said, “OB is one of those areas that is really expensive, so it’s the first to go.”
The trend is playing out across the country, he said, referencing a recent studyfrom the University of Minnesota showing that more than half of rural counties in the U.S. have no hospital where women can give birth.
But it won’t stop there, Coburn said.
“It’s really a canary in the coal mine, with respect to rural hospitals being able to support specialty services generally,” he said.
At the Maine Hospital Association, spokesman Jeffrey Austin said Maine’s nonprofit hospitals have a unique obligation to provide health services to the communities they serve.
“But, like any business, you respond to your community by seeing what the community actually demands,” he said.
In the past 10 years, Austin said, the birth rate in Maine’s small, rural hospitals has declined 15 percent, from 4,750 births to 4,000 births per year. The statewide rate has declined 12 percent.
In addition to the pressures of low volume, Austin said, 40 to 60 percent of births in Maine are covered by Medicaid, or MaineCare. That percentage is even higher in rural areas. Medicaid pays hospitals significantly less than commercial insurance — $3,500, on average, for an uncomplicated labor and delivery, compared to the commercial insurance average of about $7,500, according to hospital association data. Hospital costs, meanwhile, average around $5,000.
When revenues for a specific service fall below the cost of providing that service, Austin said, they “can’t stay open magically.” He emphasized that all hospitals have a legal obligation to provide emergency care, medical stabilization and, when appropriate, transportation services to patients in crisis — including emergency childbirth.
Settling in at home with her infant son and her toddler daughter, Celia Geel counted her blessings. Women in Calais and other rural Maine communities over the years have planned to deliver their babies in Bangor, she said, taking advantage of newer technologies or greater expertise in dealing with complicated births.
“But in the back of their minds, they always knew they could go to Calais Regional if they had to,” she said.

Trump Health Agency Challenges Consensus on Reducing Costs

by Abby Goodnough and Kate Zernike - NYT - November 12, 2017

WASHINGTON — For several decades, a consensus has grown that reining in the United States’ $3.2 trillion annual medical bill begins with changing the way doctors are paid: Instead of compensating them for every appointment, service and procedure, they should be paid based on the quality of their care.
The Obama administration used the authority of the Affordable Care Act to aggressively advance this idea, but many doctors chafed at the scope and speed of its experiments to change the way Medicare pays for everything from primary care to cancer treatment. Now, the Trump administration is siding with doctors — making a series of regulatory changes that slow or shrink some of these initiatives and let many doctors delay adopting the new system.
The efforts to chip away at mandatory payment programs have attracted far less attention than attempts by President Trump and congressional Republicans to dismantle the Affordable Care Act, but they have the potential to affect far more people, because private insurers tend to follow what Medicare does. That in turn affects the country’s ability to deal with soaring health care costs that have pushed up insurance premiums and deductibles.
The administration has proposed canceling or shrinking Medicare initiatives that required doctors to accept lump sums for cardiac care and joint replacements, two of Medicare’s biggest cost drivers. More than 1,100 hospitals were scheduled to take part in the cardiac initiative starting in January, and 800 have been participating in the joint replacement program.
And while Congress passed a bipartisan law in 2015 creating a new payment framework that is supposed to reward doctors for value over volume, Mr. Trump’s Department of Health and Human Services has exempted more doctors from a provision that created merit pay by giving them bonuses or penalties depending on the quality of their work.
In September, the department released an outline of a “new direction” for the Center for Medicare and Medicaid Innovation, set up by the Affordable Care Act to test models aimed at improving medical care and reducing costs. While the Obama administration had pushed large, mandatory experiments to test new models of pay, the Trump administration wants to encourage smaller, voluntary programs — and has asked the doctors to help design them.
“Clearly a great big foot has been put on the brake,” said Donald Crane, the chief executive of CAPG, a group of doctors and hospital administrators that, unlike many in the profession, has pushed to tie physician pay to quality measures rather than the old model of fee for service.
Mr. Crane was referring specifically to the scaling back of the cardiac and joint replacement programs by Tom Price, an orthopedic surgeon and Republican former congressman chosen by Mr. Trump as secretary of health and human services. Mr. Price, who resigned in September over his use of expensive private jets, had accused the Obama administration of trying to “commandeer clinical decision-making” by forcing doctors to participate in experiments that test new ways of paying for care. Mr. Trump is said to be close to appointing a successor — possibly Alex Azar, a former pharmaceutical company executive who worked in the Department of Health and Human Services under President George W. Bush — and doctors’ groups will be watching carefully to see if the agency continues in the same direction.
Already, other administration officials have signaled support for protecting doctors and giving them more say. The agency’s Centers for Medicare and Medicaid Services, led by Seema Verma, has suggested it will accept more recommendations than it did in the past from a committee of doctors formed by the American Medical Association on how much Medicare should pay for services and procedures — essentially letting doctors set their own pay.
Ms. Verma’s agency also issued the call for changing the direction of the innovation center. The formal “request for information” proposed, among other potential changes, allowing doctors and hospitals to contract directly with Medicare patients. This would allow doctors and other providers to propose their own prices, moving toward a long-held Republican goal of so-called premium pricing.
Research has shown that the traditional model of paying doctors, known as “fee for service,” often results in unnecessary or inappropriate care. The federal government has been slowly moving away from it since 1983, when Medicare changed some of its payments to hospitals.
But the changes now pushed by H.H.S. are a renunciation of the Obama administration in particular. It had sought to shift 30 percent of fee-for-service Medicare payments to alternative payments based on quality or value by 2016 — a goal it achieved — and 50 percent by 2018. To do so, it required doctors and hospitals in many regions of the country to adopt those new payment models.
Canceling mandatory bundled payments for cardiac and orthopedic procedures was a pet project for Mr. Price, who had fought against what he saw as unnecessary government intervention since his days as a surgeon in the suburbs north of Atlanta.
Mr. Price defended the old model in front of thousands of doctors and medical administrators gathered in June for the annual meeting of CAPG, the group pushing for new payment models, arguing that the health care system in the United States — “the finest,” he said, in the world — had developed around it.
“So we ought to recognize,” he told the group, that “fee for service may not be the end of the world.”
Many in the health care field criticized some of the rules issued by the Obama administration as overly prescriptive and welcomed the department’s effort to review them.
“Many experiments that the Obama administration launched were overly micromanaged,” said Grace-Marie Turner, an opponent of the health law and president of the Galen Institute, a research center that advocates free-market health policies. “Innovation has to percolate up from the bottom. The Obama administration tried to drive it from the top.”
Even with Mr. Price’s departure, the department still has numerous people who have advocated strongly for doctors and industry in the past. They include senior staff members who have worked representing medical device makers, pharmaceutical and hospital supply companies, the nursing home industry and physician specialty groups. The acting secretary of health and human services, Eric Hargan, is a former lawyer for the law and lobbying firm Greenberg Traurig who served as a deputy secretary at the agency during Mr. Bush’s tenure.
Miranda Franco, senior policy adviser at the law firm Holland & Knight, has closely tracked the changes. She said it appeared the administration was using the innovation center to further its priorities of “more provider-friendly approaches, more voluntary models.”
Ms. Verma, the administrator of the centers, seemed to confirm that when she wrote in a Wall Street Journal op-ed: “Providers need the freedom to design and offer new approaches to delivering care. Our goal is to increase flexibility by providing more waivers from current requirements.”
Last month, Ms. Verma also announced a plan to re-examine and streamline all the ways the federal government has been measuring the quality of the care doctors provide, saying in a speech, “We want to move to a system that pays for value and quality — but how we define value and quality today is a problem.” The goal, she said, was to relieve doctors of excessive regulatory burdens and make sure payment policies are “guided by those on the front lines serving patients.”
Gail Wilensky, the administrator of the Centers for Medicare and Medicaid in the first Bush administration, said she heard many complaints from doctors who felt that during the Obama presidency the agency was not listening to any of their ideas for how to move toward payment based on quality rather than quantity.
“It’s hard for me to believe that physicians will do any better than they would have done, having Tom Price there,” Ms. Wilensky said. “From their point of view, this was about as good as it was going to get.”
But Tim Gronniger, a deputy chief of staff at the centers during the Obama administration, argued that there was little demand from hospitals or physicians to cancel the bundled payments, or to delay the merit-based payments.
In fact, many doctors are still subject to the rules of the merit-based system, which passed with bipartisan support in Congress in 2015. And other value-based programs are continuing.
“They’ve confused people,” said Mr. Gronniger, now a senior vice president at Caravan Health, which helps health care providers shift to value-based payment models. “The risk that H.H.S. and Tom Price created is that some physicians incorrectly read the press release or hear from their colleagues that Medicare is canceling value-based purchasing and think all of that’s over.”
“Physicians and hospitals need to be engaged in this work,” he added, “and exempting them doesn’t do them any favors.”
Although little has changed since Mr. Price’s departure, there are signs that the agency is still trying to figure out the best way to proceed, said Michael Chernew, an economist at Harvard Medical School who supports moving away from fee for service.
Mr. Chernew said he was “cautiously hopeful” about H.H.S. continuing to promote alternative payment models, pointing out that Medicare rates under fee for service will remain flat over the next decade anyway under the payment law that Congress passed in 2015.
“My general sense, and I’ve met with them, is that they genuinely want to try to have a better set of payment models,” Mr. Chernew said of Ms. Verma and those working for her at the Centers for Medicare and Medicaid Services. “They don’t just want to try to blow everything up.”
He added, “If you take all the politics out of it, the right thing for them to do is move ahead.”

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