Wednesday, April 4, 2018

Health Care Reform Articles - April 4, 2018

Building The Political Voice That Our Health Deserves

by Jake Williams - Health Affairs - March 28, 2018

There is only one advocacy organization in America that directly deploys the full range of political tools—from lobbying to directly influencing candidate elections—exclusively for the advancement of the population’s overall health. We are that group, and we don’t view our exclusivity over here at Healthier Colorado as a bragging right, but rather an indication of needed change. Americans lack the political voice we need to lift up our health, and we want company in our lonely “club” dedicated to providing that voice.
For two straight years, American life expectancy has declined. By virtually every measure, the health status of Americans is inferior to that of our peers. We live shorter lives of lesser quality, despite spending way more per capita on health care than any other country on the planet. Science and technology alone cannot make us all healthier. These forces on their own cannot bestow equal access to their benefits. Nor can they address the societal biases that lead to the unnecessary health disparities that afflict Americans. The top 1 percent of American income-earners, for example, get to live an astounding fifteen years longer than the bottom 1 percent of income-earners do.
We have all the technology. We spend all the money. We have an enormous and benevolent philanthropic sector, much of which is dedicated to improving health through direct service, but it has become abundantly clear that improving the health of 326 million Americans cannot be accomplished without using the scale of impact that can only be achieved through public policy change.
That brings me to what we don’t have. We have never had a credible political movement of Americans focused on the overall improvement of American health. Instead, advocacy has been narrow, temporary, and/or outsourced to entities that have a variety of other priorities. This has not worked and will not work in our country’s pay-to-play political system.

The Political Deficit Impacting Our Health

Organizations advocating for pro-health public policy for regular Americans often end up bringing a pamphlet to a bazooka fight. Their advocacy is largely restricted to the dissemination of facts, which often cannot be delivered directly to decision makers on the specific topic being legislated, in order to avoid activity that would be classified by the Internal Revenue Service as "lobbying." Moreover, pro-health organizations advocating for or against candidates in elections is extremely rare. On the other hand, oppositional corporate stakeholders wield well-funded political operations that engage elected officials directly, and deliver meaningful political rewards and punishments that influence policy on all of the determinants of health, from what we eat to the services we receive. In fact, the health care sector alone puts more money into federal lobbying (more than half a billion dollars in 2017) than any other economic sector does. It also put nearly $281 million into federal candidate elections in 2016.
Meanwhile, health lobbying and electoral expenditures from a consumer or grassroots perspective (gun control advocates excepted) do not even register as a category in political expenditure databases. Other grassroots movements, such as the environmental movement, have managed to do much better. The environmentalists spent nearly $96.5 million on federal elections in 2016 and more than $17.3 millionon federal lobbying in 2017.
In the past two years, Healthier Colorado has spent $1.2 million on state and local elections in Colorado. We give money to pro-health Republican and Democratic candidates. We led the campaign to pass the nation’s second-ever voter-approved sugary drinks tax. We and our 40,000 members helped pass ground-breaking legislation on topics ranging from mental health to social determinants of health to health care. We won five local ballot measures in 2017 alone as part of our Partnerships in Local Advocacy (PiLA) program, in which we provide campaign funding and strategic consultation to partners who want to pursue local health policy change. We are proud of what we have achieved so far, but we also realize that we cannot ultimately win in Colorado unless we win beyond Colorado. We need to change the country and federal policy, so this political movement must extend beyond the borders of our state.

How We're Building A Political Movement

We have been taking a number of steps to build this political movement nationwide, beginning by sharing the story of our birth. Healthier Colorado is a creation of the Colorado Health Foundation and was officially launched in September 2014. In Creating a Healthier Colorado: The Colorado Health Foundation’s Bold Investment in a Voice Our Health Deserves, the foundation describes the thinking that went into spinning off an independent 501(c)(4) organization that became Healthier Colorado, which later created a sister 501(c)(3) organization called The Fund for a Healthier Colorado. Though our creation occurred in somewhat unique circumstances, the story told by the foundation contains lessons applicable to any funder interested in creating an organization or funding an existing organization to engage in political advocacy.
In 2017 I published The Voice Our Health Deserves, a white paper that explains why we need to create a national movement and political apparatus to advance health, and how we start doing it. After receiving a positive reception, I decided to write a book that expands on the topic. With a working title of the same name as the white paper, the book will be out later in 2018 with the hope of further catalyzing this movement.
Meanwhile, Healthier Colorado has been collaborating with health funders across the country to spread the gospel of investing in advocacy. I participated in two such presentations at the annual Grantmakers in Health conference in 2017, one with the Colorado Health Foundation, and another with the Northwest Health Foundation (NWHF). (I want to give a shout-out to the NWHF, which, as a funder with 501(c)(4) legal status, engages in a range of political activity similar to what Healthier Colorado does.) Earlier this year, I worked with the Public Health Institute and Healthy Food America to convene a California meeting of funders from several states to discuss how the field of health funders can enhance advocacy. We are currently working on convening an East Coast meeting on the same topic.
A social movement is a group of people with a shared purpose and collective identity that impacts society by engendering political and cultural change. We’re still at the stage of gathering our group of people, but we have momentum. Consider this your invitation to join us!

by NORC - University of Chicago - March 27, 2018
While more than $3.3 trillion, nearly a fifth of the gross domestic product, is spent on healthcare in the United States,1 a new national poll finds that three-quarters of Americans think they’re not getting their money’s worth. Americans report that costs are a factor in a number of decisions they make about their care. For example, 40 percent say they skipped a recommended medical test or treatment in the last 12 months due to cost, and 32 percent were unable to fill a prescription or took less of a medication because of its cost.
The West Health Institute and NORC at the University of Chicago poll offers new insights into how Americans feel about the costs of healthcare and how they report those costs affect their medical decisions and personal finances. It also reveals what Americans think about how lawmakers are handling the issue.
The nationwide survey was conducted February 15-19, 2018, using the AmeriSpeak® Panel, the probability-based panel of NORC at the University of Chicago. Online and telephone interviews using landlines and cell phones were conducted with 1,302 adults. The overall margin of sampling error is plus or minus 3.8 percentage points.
The high cost of healthcare strikes fear in many Americans. In fact, 4 in 10 surveyed say they fear the costs associated with a serious illness, which is more than the number who say they fear the illness itself. That fear is often based on personal experience. For example, those who reportskipping a recommended test or treatment because of the cost are about twice as likely as those who have not reported this experience to say they fear the cost of getting seriously ill.
For the majority of Americans, healthcare costs have a significant and enduring impact on financial health. Fifty-three percent of respondents say they have had a least one of the following situations occur because of healthcare costs in the last year: 36 percent report depleting their savings, 32 percent say they racked up credit card debt, 30 percent believe they had to decide between paying medical bills and basic necessities, and 41 percent report they couldn’t save any money because of their spending on healthcare. Additionally, more than a quarter say they had a medical bill turned over to a collection agency.
These experiences and dissatisfaction are evident in people’s assessments of how the government is handling healthcare costs and the policies they want implemented. About half of Americans disapprove of the way their representative in Congress is handling the cost of healthcare. When it comes to healthcare, Social Security, policies that affect young people, and policies that affect seniors, more than a quarter of all Americans lack trust in both political parties.
The vast majority of Americans think healthcare access for seniors should be a priority for Congress, and a majority support maintaining or increasing funding for Medicare and Social Security. The survey finds most Americans would be willing to take an increase in payroll taxes to pay for it. Though those age 18-29 are decades from retirement, more than one-third say it’s important their congressional representatives advance policies to help seniors. These numbers rise with age—78 percent of those age 60 and older, 69 percent of those age 45-59, 50 percent of those age 30-44, and 36 percent of those age 18-29 say it’s important.

  • Key findings include:
  • Americans say they often go without needed care or choose less expensive options due to costs. For example, 40 percent say they skipped a recommended medical test or treatment in the last 12 months due to cost, and 32 percent were unable to fill a prescription or took less of a medication because of the cost.
  • Sixty percent of those who report skipping a recommended test or treatment due to cost say they fear the cost of a serious illness compared to 27 percent of those who have not reported skipping a test or treatment because of the cost. When it comes to fear of getting a serious illness itself, 47 percent of people who have skipped a test or treatment due to cost are afraid of becoming ill compared to 24 percent of those who have not done this.
  • Over half of Americans say they have received a medical bill for a cost they thought was covered by their health insurance in the past 12 months, and a similar proportion report receiving a medical bill saying the amount they owed was higher than expected. More than a quarter say they had a medical bill turned over to a collection agency.
  • Thirty percent report they have had difficulty paying for basic necessities, like food, heat, and housing, 36 percent say they have had to use up all or most of their savings, 32 percent report borrowing money or increasing credit card debt, and 41 percent believe they decreased contributions to a savings plan because of healthcare expenses.
  • Six in 10 Americans say it is important for their congressional representative to spend time advancing policies to help seniors gain access to high-quality, affordable healthcare and supportive services.
  • Over half of Americans want their representative in Congress to increase funding for Medicare (56 percent) and Social Security (53 percent). Forty-two percent want an increase in spending for Medicaid, and 37 percent for the Affordable Care Act, also known as Obamacare.
  • There is majority support for expanding Medicare to include eye exams for prescription glasses (75 percent), dental care (73 percent), hearing aids (71 percent), and long-term care (69 percent), even if it means an increase in the Medicare payroll tax.
  • About half of Americans disapprove of the way their representative in Congress is handling the cost of healthcare, whereas just 15 percent approve, and a third neither approve nor disapprove.

Five Things You Should Know
from the West Health Institute/NORC Survey on Healthcare Costs, Coverage, and Policy...
  • 2)  Forty percent say they skipped a recommended medical test or treatment in the last 12 months due to cost, and 32 percent were unable to fill a prescription or took less of it because of its cost.
  • 3)  Four in 10 say they fear the costs associated with a serious illness, which is more than the number who say they fear the illness itself.
  • 4)  OverhalfofAmericanssaythey received a medical bill they thought was covered by insurance or where the amount they owed was higher than expected, and more than a quarter say they had a medical bill turned over to a collection agency in the past 12 months.
  • 5)  About half of Americans disapprove of the way their representative in Congress is handling the cost of healthcare. 

Eradicating poverty would dramatically reduce TB cases, study finds

by Hannah Summers - The Guardian - March 24, 2018

Programmes to tackle poverty could be just as effective in the fight against tuberculosis as medicines and vaccines, research has found.
Eradicating extreme poverty would lead to an 84% reduction in TB cases by 2035, according to a report published to coincide with World Tuberculosis Day on Saturday.
Nine scientists and policymakers carried out research examining incidences of TB across 192 countries for a study that appears in Lancet Global Health.
The conclusions were reached by looking at the links between people living on less than $1.90 a day and the coverage of various social programmes in each country. Researchers then related this to the current levels of TB, projecting the associations forward 20 years.
More than 95% of deaths from TB occur in low- and middle-income countries, so the association between poverty and TB are well established. However, researchers say the latest findings are significant in providing new evidence of the links.
“This study is important to show that preventative measures have great impact,” explained Daniel Carter, research fellow at the London School of Hygiene and Tropical Medicine.
“We tend to only engage with TB patients when they are already ill, but this is not enough to eliminate TB. Poverty reduction could be just as effective in tackling the disease as drugs and vaccines.”
Carter, who co-authored the study, added: “Science is sexy but poverty elimination is not. If a biomedical tool were to show the same efficacy on TB it would be immediately implemented, but expanding social programmes requires more political will and ambition from health and development leaders.”
Tuberculosis is among the top 10 causes of death worldwide. In 2016, 10.4 million people fell ill with TB and a further 1.7 million died from the disease.
The bacterial infection mainly affects the lungs and can be spread through inhaling tiny droplets from the coughs or sneezes of an infected person. There is a vaccine for TB, but it has limited effectiveness.
The countries worse affected by the disease include India, China, Philippines, Pakistan, Nigeria and South Africa. 
In its 2015 End TB Strategy, the World Health Organisation, for the first time, called for social support and poverty alleviation strategies for people with TB.
Now scientists say there is a growing body of evidence that social programmes are alleviating the burden in some regions. 
A study in Brazil found a state-led cash transfer programme, conditional on eligible families sending children to school and giving them basic vaccinations, can improve treatment outcomes for TB by 10%.
“Social protection programmes, such as Brazil’s Bolsa Familia scheme, could potentially lift vulnerable individuals far enough out of poverty that they never contract TB in the first place,” said Carter.
The programme covers around 14 million families – amounting to 25% of the Brazilian population – who have a family per capita income of less than £30 a month. Cash assistance of £35 a month to each household has halved extreme poverty in the region. 
Carter said the 10% improvement figure is significant because the programme is not specifically targeted at TB patients. If such a programme was extended to all those suffering from TB it would be incredibly cost-effective.
Carter acknowledges drugs and vaccines for TB play an important role, but added: “Eradicating TB will never be about DNA sequencing or shorter drug regimens. Biomedical innovation takes money and time – two things TB patients do not have. 
“Anti-poverty policies are available now and the evidence suggests they work. The battle to end TB is not just against a pathogen, but an ideology.”
Tom Wingfield, clinical lecturer in infectious diseases at Liverpool University, agrees. 
“Recent global TB control strategy has been disproportionately focused on medicines and tests rather than addressing the social causes of the TB epidemic.”
Wingfield has been gathering evidence of the links between poverty reduction and TB in shanty towns near Lima, Peru along with the research group, Innovation for Health and Development.
The team examined the hidden costs in TB-affected households including travel to clinics, food and lost income. When the costs exceeded a fifth of a household’s annual income the patient was more likely to abandon treatment or die. 
“Our findings had identified a crucial factor explaining why medicines alone were not controlling TB. In response we provided social and financial support for affected households – bank transfers of up to $40 a month and visits by our research nurses,” he said.
“The intervention was a success. Supported TB patients were significantly more likely to complete their treatment or be cured, and their children were more likely to take medicine to prevent TB.”

Soaring premiums send thousands in Maine over a health care cliff

Insurance costs have grown by as much as 110 percent for those who earn too much to receive Affordable Care Act subsidies.

by Joe Lawlor - Portland Sunday Telegram - April 1, 2018

Escalating premiums and deductibles have driven about 10,000 Mainers over a health care “cliff,” where they can barely afford coverage thanks to a vulnerability in the Affordable Care Act exploited by the actions of the Trump administration.
Depending on the plan chosen, premiums have increased by about 70 percent or more since 2014 for people who earn too much to qualify for subsidies for the federal health care program. By contrast, ACA enrollees with subsidies have been mostly shielded from rate increases. The lack of a cap on premium increases, or other cost controls, for ACA enrollees who earn more than 400 percent of the federal poverty limit leaves them unprotected, making the “affordable” part of the program for some impossible.
Those cost hikes have accelerated since President Trump took office, and ratepayers are expected to be pummeled with giant rate increases again in 2019. Rates haven’t yet been filed with the Maine Bureau of Insurance, but will be by May.
“The cliff is real,” said Erik Wengle, a research analyst with the Urban Institute, a Washington-based think tank. “These plans have gotten quite expensive, and as they’ve gotten more expensive, we’re seeing people getting priced out.”
People earning more than 400 percent of the federal poverty limit – about $81,000 for a family of three, $65,000 for a two-person family or $48,000 for a single person – are not eligible for subsidies in the ACA marketplace.
“These are people firmly in the middle class,” Wengle said.
This subset – consistently about 10 to15 percent of the 75,000 Mainers who have ACA marketplace insurance – have seen their premiums soar. A 40-year-old single nonsmoker in Cumberland County who earns $50,000 per year has seen premiums for a silver plan increase from $284 per month in 2014 – the first year the ACA marketplace was in effect – to $489 in 2018, a 72 percent increase. If that same person lived in Aroostook County, he or she would have seen premiums increase from $376 per month to $790 per month, a 110 percent hike, according to an Urban Institute analysis.
Meanwhile, those who qualify for the subsidies are mostly protected from premium increases, because the subsidies go up roughly the same amount that premiums increase. For example, some silver plans in 2018 cost about $300 to $350 for those just under 400 percent of the poverty level, while bronze plans can be purchased for about $75 to $150, depending on where in Maine you live.
For those who don’t qualify for subsidies, they shoulder the entire burden of the increases.
Eric Cioppa, Maine Bureau of Insurance superintendent, said the state intends to start a reinsurance program for 2019 that will help keep insurance premiums in check, but affording insurance will still be difficult, especially for those who make more than 400 percent of poverty level.
“It’s literally becoming unaffordable if you’re over 400 percent,” Cioppa said.
The ACA categorizes its plans as bronze, silver or gold, with bronze having the lowest premiums but high deductibles; gold offering generous benefits, higher premiums and lower deductibles; and silver plans falling in the middle.
For the Rices of Durham and the Williamses in Stonington, both empty-nester families that earn more than 400 percent of the poverty limit, going over the affordability cliff means sky-high deductibles and premiums.
“I have to bite my tongue when people complain about a $20 premium increase. I feel like saying, ‘Are you kidding me? Let me show you what I pay,’ ” said Jane Rice, a financial adviser who owns a Christmas tree farm with her husband, David, 60.
Rice, 57, said her husband has previously had prostate cancer and currently is being treated for esophageal cancer, and they expect to hit the out-of-pocket maximum, which this year is about $25,000, including premiums and deductibles.
Their total premiums are $1,500 per month with an $11,000 deductible.
Both are self-employed small-business owners who don’t have access to employer-based insurance – one of the key categories of people the ACA was designed to help. And for business owners who make less than 400 percent of the poverty level, it has kept insurance relatively affordable. But those who earn more have increasingly had to pay more.
Rice said she’s been told a few times that they “need to make less money.” The cliff effect creates a reverse incentive, because health care costs increase dramatically once enrollees earn slightly more than 400 percent of the poverty level.
“I reject that. I want to be successful and for our businesses to be successful,” Rice said.
She declined to list their family income, but she said the only way they’ve been able to afford insurance is by being frugal.
“We live within our means and we are hard-working people,” Rice said. “Sometimes it feels like we are paying the equivalent of insurance for six people, not two. It has just been ridiculous. It is just not right.”
Judy and John Williams of Stonington said they earn about $100,000 but they’ve also seen the cost of health insurance jump to nearly unaffordable levels. But as a couple nearing retirement age, they value insurance and know they need it, even though they’ve been generally healthy. As lobstermen, the couple don’t have access to employer-based insurance.
John is 63 and Judy is 62, and they pay a combined premium of $1,997. Their deductible was $750 four years ago, but now it’s $5,400.
“We have to spend nearly $12,000 before the insurance kicks in,” John Williams said. “We’re very fortunate that we can pay the premiums, but it’s a lot of money.”
He said that they are looking forward to age 65 when Medicare kicks in and coverage is free, although many often purchase “gap insurance” to pay for things that insurance doesn’t cover. But he said he doesn’t mind knowing that people who earn less can get insurance for far less.
People earning up to about $27,000 in Maine can qualify for zero-premium bronze plans through the ACA, while typical premiums for people who earn about $40,000 to $45,000 are about $200 to $300 per month, depending on age and where you live. Insurers can charge up to three times more based on age, and can charge more based on address.
Williams said the disparity is unfortunate, but doesn’t change his opinion that insurance should be affordable. He said it doesn’t bother him that some at lower incomes have access to zero-premium insurance while he and Judy have expensive insurance.
“People that need insurance should be allowed to have it. Everyone should be able to afford insurance,” Williams said.
The Trump administration in 2017 ended cost-sharing reduction payments to insurance companies – payments that were designed to help lower-income people afford out-of-pocket costs such as co-pays and deductibles. Ending the cost-sharing reduction payments had no effect on lower-income people, but increased premiums for people earning more than 400 percent and skewed the market. To prevent further weakening of the ACA marketplace, state insurance commissioners, including in Maine, responded with complicated work-arounds that resulted in zero-premium bronze plans and lower-cost gold plans that were much better deals than in previous years.
The ACA, as former President Barack Obama’s signature domestic policy achievement, has been caught up in partisan politics almost since it was signed into law in March 2010. Trump campaigned against it, and has vowed to get rid of it.
Most Republicans in Congress agreed with Trump, while Democrats have stood behind it and worked with a few moderate Republicans, including Maine Sen. Susan Collins, to save the law.
In 2017, Congress attempted to repeal the ACA, but those efforts failed by one vote in the Senate, with Collins one of three senators to buck the party and vote to preserve Obamacare. But in a year-end party-line vote, Collins sided with Republicans on a tax cut package that included repealing the Affordable Care Act’s individual mandate. Collins supported the tax bill in exchange for Republican leadership promises to pass ACA stabilization measures, but those efforts collapsed last month.
Repealing the individual mandate – which requires people to purchase insurance or pay a penalty – makes it more likely that young, healthy people will not purchase insurance, driving up costs, according to health care experts.
Ann Woloson, executive director of Consumers for Affordable Health Care, an Augusta-based health advocacy group, said the cost of insurance for those making more than 400 percent of the poverty limit prices people out if they have any kind of significant debt – such as car payments, mortgages and other loans.
“It is unaffordable and unsustainable for people,” Woloson said. “We are creating a sicker, more expensive health insurance marketplace.”
One of the fixes touted by Collins – a federal plan to direct $30 billion over three years for reinsurance – would have helped keep premiums in check for people above the subsidy threshold. But it was paired with another reform – restoring the cost-sharing reduction payments – that received a mixed review in a Congressional Budget Office report released last week.
The work-arounds created by states lowered premiums for many, so unwinding those work-arounds when restoring the insurance company payments would cause many earning less than 400 percent to experience premium increases. The mixed CBO report and a fight over Obamacare abortion restrictions supported by Republicans deep-sixed the deal.
Democrats have since launched a counterplan that would, among other things, cap costs for those making more than 400 percent of poverty level to 8.5 percent of their income. With Republicans in control of Congress, it’s not likely to go anywhere, at least this year.
Woloson said the ACA is still standing and helping about 20 million Americans, through Medicaid expansion and ACA coverage. Maine voters approved Medicaid expansion in November but Republican Gov. Paul LePage is fighting Democrats in the State House over implementation costs.
Complicating the health care picture is a state-run reinsurance program that was put on hold when the ACA started. A LePage-era reform, it is likely to be relaunched and take effect in 2019.
The state’s reinsurance plan – called the Maine Guaranteed Access Reinsurance Association – redistributes insurance money by charging a fee of $4 per person per month on individual, small and large group plans, and funneling the revenue only to individual plans. The plan would also tap into federal money to help pay for what is estimated to be a $90 million program in 2019, according to Milliman, an insurance consultancy firm. That will help keep premiums 10 percent lower than they otherwise would be, but since rates haven’t been filed yet, Cioppa, the Maine Bureau of Insurance superintendent, said it’s unknown what the rate hikes will be for 2019.
The Trump administration is also promoting the expansion of short-term and association plans that would further undermine the ACA markets, Woloson said. Those short-term and association plans would be exempt from “essential health benefits” that all ACA plans are required to cover, such as maternity care, mental health, prescription drugs and substance use treatment. While they would carry lower premiums, Woloson said, patients would often find that many services aren’t covered, which was often the case with individual plans purchased prior to passage of the ACA. Often these plans were called “junk insurance” and if allowed to flourish would further weaken the ACA and could cause premium spikes, Woloson said.
The Trump administration has indicated that the association and short-term plans are on the way, but they are still going through federal rule-making.
Kevin Lewis, chief executive officer of Community Health Options, a nonprofit that provides ACA insurance, said what will happen with short-term and association plans is a “big looming question” of “paramount importance.”
Cioppa said Maine law currently allows for “rigorous” regulation of short-term and association plans. As long as the federal government doesn’t try to usurp state authority to regulate those plans, Cioppa said that Maine will be able to prevent them from weakening the ACA marketplace.
In addition to the 10,000 who have ACA marketplace plans and earn more than 400 percent of the federal poverty limit, an additional 9,000 people have off-marketplace plans, and many of them also would not qualify for subsidies.
Meanwhile, John Williams, the Stonington lobsterman, said the system needs an overhaul.
“All I know is, there’s got to be a better way of doing this than what we’re doing now,” Williams said.

Report Details How Skyrocketing Prescription Drug Costs Are Harming Nation's Seniors

Sen. Claire McCaskill says publication shows "that the pricing decisions made by these drug companies are outrageous."
by Andrea Germanos - Common Dreams - March 26, 2018

A new report by Sen. Claire McCaskill (D-Mo.) shows how older Americans are getting hit by soaring drug prices while the pharmaceutical industry rakes in billions.
"Can you imagine if you went to an auto dealership and last year's exact model was being sold at a 20 percent mark-up, and then you went back the next year and it had happened again?" McCaskill said in a statement. "That's exactly what's happening in the prescription drug industry, where the cost of identical drugs skyrockets year after year."
For Manufactured Crisis: How Devastating Drug Price Increases Are Harming America's Seniors, the Committee on Homeland Security and Governmental Affairs (on which McCaskill is the top-ranking Democrat) looked at the 20 most-prescribed brand-name drugs for Medicare Part D beneficiaries. They include Crestor, Lyrica, Restasis, Symbicort, Tamiflu, and Xarelto.
Over the past five years, the prices for each of the 20 increased, on average going up 12 percent per year. That annual change, the report notes, is roughly 10 times higher than the average annual rate of inflation.
For 12 of the drugs, the prices increased over 50 percent between 2012 and 2017.
For six of the 20, the prices shot up more than 100 percent over the five-year period.
And for one drug—Nitrostat—the price soared 477 percent over the time span.
Paying for the medication can add up quickly, even for those with Medicare. The report notes, for example, that in 2013, "$1 out of every $5 that Medicare beneficiaries spent in out-of-pocket healthcare costs (excluding premiums) went towards prescription drugs."
The report also notes, "Even smaller percentage increases can result in significantly higher prices for expensive and commonly prescribed prescription drugs." Take, for example, Crestor, which went up 12 percent each year. In 2012, the weighted average wholesale acquisition cost was $349.31. In 2017, that cost was $615.65.
While seniors are feeling the sting of these increases, drug manufacturers are not.
"Price increases for the top 20 most commonly prescribed brand-name drugs for seniors have driven an astonishing increase in sales revenue for their manufacturers," the report states. "Despite the fact that total prescriptions written for these drugs decreased by more than 48 million between 2012 and 2017, total sales revenue resulting from these prescriptions increased by almost $8.5 billion."
According to McCaskill, the report shows "that the pricing decisions made by these drug companies are outrageous."
McCaskill's report comes the same month she led a bipartisan group of senators in introducing legislation (S.2554 and S.2553) addressing prescription drug costs. The group is hoping to bar so called "pharmacy gag clauses," which prevent pharmacists from letting consumers know if the medication they are seeking would cost less if paid out of pocket rather than through insurance.
Lowering the costs of prescription drugs could mean the difference between life or death, or at least a healthier life or death, for some. A CDC report from 2015 foundthat almost 7.8 percent of U.S. adults—roughly 25 million people—did not take their medication as prescribed, either skipping doses or not refilling prescriptions, in order to save money. Among those aged 65 and over, the percentage was 4.4 percent—over 14 million Americans.

Under pressure, California Assembly pitches alternatives to single-payer health care

by Angela Hart and Taryn Luna - The Sacramento Bee - March 26, 2018

California Assembly Speaker Anthony Rendon is refusing to advance this year a controversial single-payer health care bill that would dramatically reshape the state's health care financing and delivery system. Instead, he's orchestrating an alternative, narrower approach that seeks to achieve universal coverage and make Obamacare more affordable.
Rendon this year gave lawmakers in his house "autonomy to come up with a package" of health care bills, he said in a recent interview. Now, without engaging the other side in the Senate, the Assembly has unveiled a major legislative push on health care that would expand coverage and lower consumer costs while laying the groundwork for a future system financed by taxpayers. 
Five Assembly lawmakers late Friday released 14 bills they're expected to promote as a package this year. Together, they would offer financial assistance to people struggling to pay for soaring insurance premiums and out-of-pocket costs, require health insurers to spend more on patient care instead of profits, create a public insurance option and offer health coverage to undocumented immigrants.
But they will likely run into similar political and financial problems faced last year by Senate Democrats, who passed the Senate Bill 562 single-payer health care bill in June without a way to pay for its $400 billion price tag. The move kept the bill alive and allowed Senate Democrats seeking election to higher office to say they voted for single-payer, an issue that has become a litmus test in the minds of progressive activists in the Democratic Party.
No detailed costs exist for the Assembly's new health care bills, but economic estimates from the state Legislative Analyst's Office indicate the measures could range from the low billions to as high as $10 billion. Gov. Jerry Brown could be a tough sell. He has voiced concerns over a major budget ask and has not made health care a core priority during his last year in office.
Brown's office declined to answer questions about what he'd be willing to do this year, instead pointing to California's past efforts to implement Obamacare. Brown said when he released his proposed budget in January that "we have to move with caution ... the path forward will not be as easy as what we've done up to date."
For California to create a single-payer system, it could need $200 billion from taxpayers. Here's a look at the kind of taxes increases that would be needed.  Sharon Okada
Even if he does engage, pushing anything costly through in an election year will be tough for Democrats, who are already facing steep criticism for raising gas taxes last year.
"As is often the case with aspirational bills like these, it's not clear yet where the money would come from to pay for them," said Larry Levitt, a health economist at the Kaiser Family Foundation. "Figuring out how to finance the increased coverage and subsidies could prove controversial."
The Assembly's actions are also drawing ire from the California Nurses Association, the lead sponsor of the single-payer bill, which has condemned anything short of single-payer as a gift to drug companies and the insurance industry. 
"How many bills does it take to change a light bulb? What an insane approach ... There's only one way to have a uniform, rational, comprehensive system that protects patients and covers everyone," said Chuck Idelson, a spokesman for the nurses union. "None of these bills will do anything to stop price-gouging by the insurance industry ... This is using state money to pad insurance industry profits without doing anything to prevent them from continuing to raise (insurance) rates."
The nurses union hasn't given up this year. It is still pushing the single-payer bill and denouncing Rendon, saying he's cozy with corporate interests that oppose it. They contend the Assembly's legislative efforts on health care amount to political cover for holding up the bill.
Rendon said the nurses' desire to have single-payer is not realistic this year. In discussing that position, he has faced intense scrutiny and pressure to come up with an alternative approach. He painted the Senate's move in passing the bill last year as political theater. 
"It seemed like a stunt to me," Rendon said. "It seemed to be an entirely symbolic piece of legislation and I didn't think it had any place in a serious discussion about health care."
Sen. Ricardo Lara and Senate President Pro Tem Toni Atkins, then without the high-ranking leadership post, carried the bill and pledged to continue to figure out a way to pay for it. Then-Senate Leader Kevin de León had suggested hearings with both houses.
Lara, campaigning to be the state insurance commissioner, and de León, in an uphill battle to unseat U.S. Sen. Dianne Feinstein, both later won endorsements from the nurses union. 
Rendon said he alone made the decision to deny it a committee hearing after it cleared the Senate floor.
"It seemed to have nothing to do with real people, real services, real mechanisms," he said in the interview. "It was completely lacking in substance."
Atkins didn't push against Rendon's disparaging comments about the bill.
"Well, look at what we handed him," she said. "I'm just not going to hold that against him. You know, we've all had to deal with it. He has felt the heat more than most. So, I'm going to suggest that he has a right to have his perspective because he's paid the price."
Atkins, who has publicly pledged to leave rivalries between the two houses in the past, acknowledged the leaders will eventually have to engage to convince a "frugal" Jerry Brown to provide funding on any substantial legislation.

Greg Kesich: Now we know – Maine’s Medicaid savings came at a terrible price

The money could have made drug treatment available for thousands, but instead we have a deadly, damaging crisis on our hands.
by Greg Kesich - Portland Press Herald - March 27, 2018

Maine was sliding into a public health crisis in 2010, although most people didn’t know it.
We were focused on the Great Recession and a gubernatorial campaign in which the state’s budget shortfall was the most important issue. The candidate that talked the loudest about cutting the most ended up winning the race.
So when Paul LePage took the oath of office in 2011, more attention was paid to his proposed Medicaid cuts than the 155 drug overdose deaths that year. Those cuts went into effect in 2013, by which time the annual overdose tally had climbed to 208. It jumped to 272 the next year, 376 in 2016 and last year reached 418.
Twelve-hundred-and-seventy-four deaths later, the administration’s policy of dumping people off Medicaid (known here as MaineCare) and refusing federal funds to expand eligibility for others has made drug treatment unaffordable to thousands of Mainers who desperately need it.
In hindsight, it looks like a terrible error in judgment. But if you want remorse, don’t look to Mary Mayhew, LePage’s commissioner of health and human services and current Republican candidate for governor.
She’s not trying to hide her role – she’s campaigning on it. In a Facebook post last week, Mayhew wrote: “I fought to make millions of dollars in savings under the LePage administration and I intend to continue finding ways to streamline our health care system.” Attached was a 2013 Press Herald story that outlined Medicaid cuts for 27,000 Mainers.
Streamlining sounds good, as long as you are not one of the 25,000 Maine people who have unsuccessfully tried to get drug treatment, according to the Substance Abuse and Mental Health Services Administration. We tend not to judge health care on cost alone.
Mayhew designed the cuts to Medicaid and she opposed Medicaid expansion, which was passed five times by the Legislature but could not overcome LePage’s veto. She is still against expansion, which was approved by voters last year in a referendum, drawing nearly 60 percent of the vote. And she travels the country to convince other states not to expand their programs.
When a columnist in Utah asked why, she responded flatly, “It’s a government program.”
The same could be said about Social Security and Medicare, but don’t expect Mayhew to get any flak from the other Republicans competing with her anti-government campaign for governor. The primary has turned into a contest of who can out-LePage LePage.
In her defense, Mayhew is right that Medicaid is no magic wand for the opioid crisis. The nine states that have higher overdose death rates than Maine all have expanded eligibility (and they all had high opioid problems before they expanded).
If this were a problem that money alone could solve, she said from the campaign trail Tuesday, “you wouldn’t see overdoses in Hollywood.”
Mayhew said she had no regrets about policies she advanced, and that she does not believe they shortchanged anyone who needed help. “Because I believe that Medicaid has significant priorities that need to be fulfilled on behalf of our elderly and disabled,” she said. “And when it comes to substance abuse, there are other resources available.”
But there is a different health care system for people who don’t have insurance. An uninsured heart attack patient can be treated in an emergency room, but he probably won’t be able to see a doctor for regular follow-up visits to monitor his weight and medications.
The same is true for someone without insurance who overdoses. She can be revived at a hospital, maybe even get a bed for a week in detox, but that’s it. Without insurance, it’s unlikely that she will be able to get medication-assisted treatment, the acknowledged “gold standard” for care.
And overdose deaths are just part of the problem. Suicides by drug users are not typically counted, but they also result from the epidemic. Drug-affected babies are being cared for in neonatal intensive care units at great cost to the public. Maine is one of seven states in which the rate of hepatitis C, a disease spread by intravenous drug use, is twice the national average.
Doctors here say that endocarditis, infections of the heart lining, are also appearing more frequently in Maine hospitals, often because people inject drugs in unsanitary conditions.
When you add $55,000 a year to keep a drug user in jail, trying to care for children who were abandoned by addicted parents, and lost years of productive work by tens of thousands of people, the Medicaid savings don’t look quite as good.
Maybe we should have known better eight years ago, but we didn’t. Now we know, and the candidates for governor ought to know too.

Supporters of voter-approved Medicaid expansion press LePage, lawmakers as deadline nears

The administration, however, shows no sign of changing its stance that it will take no action until the expansion 'has been appropriately funded.'
by Kevin Miller - Portland Press Herald - March 27. 2018

“Medicaid expansion is the law,” Robyn Merrill, co-chair of Mainers for Health Care, said Tuesday. “Maine people have spoken and the obligation under the law is clear. Voters sent a strong message … they want more than 70,000 Mainers to receive health care coverage under Medicaid expansion.” Staff photo by Joe Phelan
AUGUSTA — Supporters of Medicaid expansion in Maine called on Gov. Paul LePage and lawmakers to work together to begin implementing the voter-approved law as the July 2 implementation date approaches.
But the LePage administration and lawmakers remain locked in a dispute over funding, potentially setting the stage for legal wrangling over an issue that has been debated in Maine for years.
When Mainers voted in November to expand Medicaid coverage to an estimated 70,000 additional adults, the law they approved laid out a series of compliance deadlines for the state. The first deadline – next Tuesday, April 3 – is when the Maine Department Health and Human Services is required to file a plan with federal officials for expanding Medicaid services. The second deadline, July 2, falls 180 days after the law’s effective date and is when the state is supposed to begin offering Medicaid coverage to adults under age 65 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.
On Tuesday – one week before the DHHS filing deadline and 98 days before coverage is supposed to begin – supporters of the Medicaid expansion law converged on the State House to demand action. As a way to fund the law, supporters say, Maine can dip into the projected $140 million state surplus expected to accrue by the end of the current two-year budget in June 2019.
“Medicaid expansion is the law,” said Robyn Merrill, co-chair of the Mainers for Health Care coalition that led last year’s ballot initiative campaign. “Maine people have spoken and the obligation under the law is clear. Voters sent a strong message on Medicaid expansion with 59 percent of the vote, so they want more than 70,000 Mainers to receive health care coverage under Medicaid expansion.”
Yet the LePage administration shows no sign of backing down from the governor’s insistence that the Legislature fund the state’s share of expansion – estimated at about $60 million a year – before it takes steps to implement it. The administration reiterated that position – first outlined by LePage in a Dec. 11 letter to lawmakers – in a recent, terse response to lawmakers’ questions on implementing the expansion.
“Per the directives outlined in that (Dec. 11) letter, the Department of Health and Human Services will not be taking any action to implement Medicaid expansion until it has been appropriately funded,” DHHS Commissioner Ricker Hamilton wrote to the leaders of the Legislature’s Appropriations and Financial Affairs Committee and the Health and Human Services Committee on March 20. “Once Medicaid expansion is appropriately funded, the department will submit to the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services a state plan amendment.”
The budget-writing Appropriations and Financial Affairs Committee has been discussing options for funding expansion. But the committee’s Democratic co-chair said the Legislature doesn’t need to allocate money for DHHS to file an amendment plan with federal officials. And if the governor needs money to hire additional DHHS staff, as he claims, then the LePage administration should submit a bill to the Appropriations Committee requesting that funding, said Rep. Drew Gattine, D-Westbrook.
“We sit here every day and he is putting forward tons and tons of bills to let us know about his priorities,” Gattine, a vocal supporter of expansion, said of the governor’s habit of introducing bills in the final days of a legislative session. “If he doesn’t meet that (implementation) deadline, there will be 70,000-plus people in the state of Maine who are aggrieved and won’t be receiving services they are entitled to” under the expansion law.
This is merely the latest in a years-long battle over Medicaid expansion in Maine.
The Affordable Care Act – also known as Obamacare – allowed states to expand Medicaid to provide health coverage to adults earning up to 138 percent of the federal poverty level. To date, 32 states plus the District of Columbia have chosen to expand Medicaid. The federal government agreed to cover 100 percent of the expansion costs during the initial years, followed by gradual annual decreases until the federal government pays 90 percent in 2020.
LePage has rebuffed every effort to expand Medicaid in Maine – including by vetoing bipartisan bills sent to his desk – because he argues that expansion will prove too costly for the state, even with the federal match. After voters intervened last November, LePage sent lawmakers a lengthy letter insisting that the Legislature fund the expansion – without increasing taxes, tapping into the state’s Rainy Day Fund or employing other “one-time funding mechanisms or budget gimmicks” – and eliminate the wait lists for DHHS programs for the elderly and disabled.
“Show me the money,” LePage told lawmakers in his Feb. 13 State of the State address. “It would be fiscally irresponsible for the Legislature to demand we implement Medicaid expansion without adequate funding. It is simply not too much to ask the Legislature to prioritize our truly needy over those looking for a taxpayer-funded handout.”
After Tuesday’s rally, expansion supporters held posters showing a clock face underneath the message “Counting on care” as they sought to pressure LePage and lawmakers to end the deadlock.
Merrill, who is executive director of the progressive legal aid and advocacy organization Maine Equal Justice Partners, said afterward that it was time for both sides to begin working together. There is enough money in Maine’s Medicaid account to cover the costs of expansion through at least next May or June, Merrill said, plus the state can tap into the estimated $140 million surplus to cover any additional administrative costs to hire DHHS staff.
“He certainly could start taking steps today to get this done,” Merrill said. “And also the fact of the matter is he could come to the table and talk and meet with legislators about how to get it done.”
Merrill said she was unsure how her organization and others would respond if the LePage administration ignores the April 3 deadline to file a state amendment plan with federal health officials. But she added they’ll be watching closely.
“If he chooses not to comply with the law, well then he’ll be in violation of the law and we’ll have to decide what action to take,” Merrill said. “There is a legal team that we are working with that is ready to pursue litigation when and if appropriate, but we really don’t want to fight this out in the courts. We are hopeful that the governor, the administration and lawmakers will come together to get this done. And so this next month is going to be really important because this is really their opportunity to do that.”

Bill Nemitz: On Affordable Care Act fixes, Sen. Collins’ perceived clout came up short

The senator said there would be repercussions if her party's promises to her weren't kept, yet none have materialized.

by Bill Nemitz - Portland Press Herald - March 29, 2018

Is Senate Majority Leader Mitch McConnell, on whose assurances Collins hung her credibility, about to suffer the wrath of Maine’s senior senator?
Well … um … no. Apparently, we had that part all wrong.
Collins insisted Wednesday that the deal she struck with McConnell back in December, as articulated in a statement they jointly introduced on the Senate floor, called for him to “support” her efforts to bring forth the ACA fixes.
Which he eventually did, she said, by getting behind the ACA legislation when it finally made its way to the full Senate last week as an amendment to the spending bill.
“I feel that Mitch kept his end of the bargain,” Collins said.
Problem was, the ACA measure never made it to a vote. Nor did it make its way onto the spending bill passed by the House, where a standoff developed between Democrats and conservative Republicans over, of all things, abortion.
In a nutshell, the dispute centered on Republican efforts to insert language into the ACA package that would have explicitly invoked the longstanding prohibition on the use of federal funds for elective abortion – commonly referred to as the Hyde amendment.
Meaning, when it was all said and done, women who choose to exercise their right to obtain an abortion could have been denied coverage under their federally subsidized, ACA insurance policies.
Even worse, insurers might have steered clear of abortion coverage altogether for fear of jeopardizing their access to federal ACA subsidies.
Democrats, not surprisingly, objected strenuously to the last-minute insertion of the Hyde language.
Noting that the ACA was originally constructed to allow abortion coverage under federally subsidized health insurance policies, they argued, any efforts to shore up the ACA going forward should do likewise.
Bottom line, for all her assurances way back when that her ACA rescue package “has to pass” or there will be hell to pay, Collins now is reduced to granting McConnell absolution simply for not standing in her way, and blaming this colossal failure on – what else – the inability of the two major parties to get along.
What a far cry that seems from December, when McConnell was but one of the party heavyweights whose promises had Collins convinced, without a sliver of doubt, that her ACA fixes were a slam dunk.
“Seriously,” she said at the time, “the speaker said that I’m going to get them, the president said that I’m going to get them and has said it publicly, the vice president has said it, Mitch McConnell has said it. I have now covered both chambers and the administration and I believe that it will (pass).”
As Benjamin Franklin once said, “To follow by faith alone is to follow blindly.”
Now, all Collins can do is blame anyone and everyone – from Senate Democrats to House Republicans, from House Speaker Paul Ryan to House Minority Leader Nancy Pelosi – for the collapse of a deal built in large part with her own political capital.
“I just think this was such a lost opportunity,” Collins said. “And I cannot believe that we have reached the point in Washington where partisan politics, and everyone looking at who’s going to lose or gain in the November election, poisoned a chance and prevented us from really helping people. That’s the lesson that I took from this.”
Here’s another: Shaky promises are like boomerangs – no matter how well you launch one, it’s going to come back on you.

Letter to the editor: Sen. Collins gets snookered, and public will pay a heavy price

Sen. Susan Collins betrayed Maine and the American people when she supported the Republican tax plan last December. She claimed to have voted as she did in order to save medical insurance options for those who need government-supported health insurance. She told us at the time that she had “ironclad” assurances from Senate Majority Leader Mitch McConnell that her legislation to strengthen the Affordable Care Act would be voted upon. It didn’t happen.
More recently, as the $1.3 trillion spending bill was being constructed in darkness to fund the government through September, Sen. Collins said she had the support of President Trump to include her plan to shore up health care program. That didn’t happen, either.
Sen. Collins could have resisted both the tax plan and the spending plan, but she didn’t. She claimed she’d been assured that she could make the health insurance system stronger. To the surprise of nobody, she was misled by Trump and McConnell. Having been snookered, she could have registered her dismay at being publicly humiliated by voting against the spending legislation. But she didn’t.
Why did she vote for the spending plan? She said that the Democrats made her do it because they would not compromise. Does she expect us to believe that? What will it take before Sen. Collins sees that she is being played for a patsy? And at our expense.
Now the Affordable Care Act has begun its death spiral. Social Security and Medicare are in danger because of the huge deficits enabled by her votes on tax relief for the wealthy and on spending beyond our means.
Len Freeman

David J. Shulkin:
Privatizing the V.A. Will Hurt Veterans


by David Shulkin - NYT - March 28, 2018

It has been my greatest professional honor to serve our country’s more than 20 million veterans. Almost three years ago, I left my private sector job running hospitals and came to Washington to repay my gratitude to the men and women who put their lives on the line for our country.
I believe strongly in the mission of the Department of Veterans Affairs, and nothing about my political experience in Washington could ever change that. I also believe that maintaining a strong V.A. is an essential piece of the puzzle that is the United States’ national security system: We can only expect our sons and daughters to risk their lives and fight for our freedom if we can keep our promise to care for them when they return home broken, injured or traumatized. There is no excuse for not holding up our end of the bargain. The mission set forth by President Abraham Lincoln to care for those who have “borne the battle” is a sacred duty that I will remain committed to always.
During my tenure at the department, we have accomplished a tremendous amount. We passed critical legislation that improved the appeals process for veterans seeking disability benefits, enacted a new G.I. Bill and helped ensure that we hire the right people to work at the department. We have expanded access to health care by reducing wait times, increasing productivity and working more closely with the private sector. We have put in place more and better mental health services for those suffering from the invisible wounds of war. We are now processing more disability claims and appeals than ever before and, for the first time, allowing veterans to see the status of their appeals by simply logging on to their accounts. Unemploymentamong veterans is near its lowest level in years, at 3.5 percent, and the percent of veterans who have regained trust in V.A. services has risen to 70 percent, from 46 percent four years ago.
It seems that these successes within the department have intensified the ambitions of people who want to put V.A. health care in the hands of the private sector. I believe differences in philosophy deserve robust debate, and solutions should be determined based on the merits of the arguments. The advocates within the administration for privatizing V.A. health services, however, reject this approach. They saw me as an obstacle to privatization who had to be removed. That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.
Until the past few months, veteran issues were dealt with in a largely bipartisan way. (My 100-0 Senate confirmation was perhaps the best evidence that the V.A. has been the exception to Washington’s political polarization). Unfortunately, the department has become entangled in a brutal power struggle, with some political appointees choosing to promote their agendas instead of what’s best for veterans. These individuals, who seek to privatize veteran health care as an alternative to government-run V.A. care, unfortunately fail to engage in realistic plans regarding who will care for the more than 9 million veterans who rely on the department for life-sustaining care.
The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war. Working with community providers to adequately ensure that veterans’ needs are met is a good practice. But privatization leading to the dismantling of the department’s extensive health care system is a terrible idea. The department’s understanding of service-related health problems, its groundbreaking research and its special ability to work with military veterans cannot be easily replicated in the private sector.
I have fought to stand up for this great department and all that it embodies. In recent months, though, the environment in Washington has turned so toxic, chaotic, disrespectful and subversive that it became impossible for me to accomplish the important work that our veterans need and deserve. I can assure you that I will continue to speak out against those who seek to harm the V.A. by putting their personal agendas in front of the well-being of our veterans.
As many of you know, I am a physician, not a politician. I came to government with an understanding that Washington can be ugly, but I assumed that I could avoid all of the ugliness by staying true to my values. I have been falsely accused of things by people who wanted me out of the way. But despite these politically-based attacks on me and my family’s character, I am proud of my record and know that I acted with the utmost integrity. Unfortunately, none of that mattered.
As I prepare to leave government, I am struck by a recurring thought: It should not be this hard to serve your country.

Iowa tries another end run around the Affordable Care Act
by Amy Goldstein - The Washington Post - April 2, 2018

As a growing number of Republican-led states look for end runs around the Affordable Care Act, Iowa is embracing a strategy that contends not all health plans are actually health insurance. 
Gov. Kim Reynolds (R) is scheduled Monday to sign into law a bill allowing the century-old Iowa Farm Bureau to collaborate with the state’s dominant insurer to sell “health benefit plans,” which are expected to cost health customers less than ACA coverage because they will not have to comply with federal requirements.
The legislation says that such plans “sponsored by a nonprofit agricultural organization . . . shall be deemed not to be insurance.” That means they will be allowed to avoid both federal and state insurance regulations.
Within Iowa, this new curve around the ACA has sparked debate over whether the strategy is a creative path to offer some residents an alternative to spiking prices in the insurance marketplace the state created under the federal law — or a path to substandard coverage that will divide the healthy from the sick.
More broadly, the strategy is among the ripple effects across the country from Congress and the Trump administration having decreed that Americans who flout the law’s individual insurance mandate will no longer be charged penalties. When enforcement of the mandate ends next year, consumers will not risk a fine for being uninsured or having health coverage that lacks some of the ACA’s required benefits and consumer protections.
Despite congressional Republicans’ failure last year to repeal much of the sprawling 2010 health-care law, the recent moves by both the federal government and GOP states are nevertheless chipping away at a central goal of the Democrats who created it: fostering comprehensive coverage nationwide for people without access to affordable health benefits through a job, while prohibiting insurance industry practices that often had put health plans out of reach for individuals with prior or current medical problems.
“If the ACA’s insurance rules can’t be repealed, then an alternative is to get people the option of escaping them,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. “Without the penalty, the door is wide open for plans like this.”
Iowa lawmakers approved the Farm Bureau plan last month as federal agencies are taking steps to carry out a directive by President Trump to make it easier for Americans to buy coverage that skirts those requirements.
In January, the Labor Department proposed new rules that would widen access to association health plans — originally intended for small businesses that band together — by enabling individual consumers to buy them and reclassifying them so that such plans do not have to include such benefits as maternity care and mental health services. The Iowa measure also allows the sale of association health plans that follow the new federal rules.
Then in February, the Department of Health and Human Services proposed to broaden Americans’ ability to rely on short-term health plans that similarly circumvent the ACA’s required benefits and protections. Such plans could be sold for up to a year, rather than the current three months, and federal officials have said they would like them to be renewable from year to year.
Meanwhile, Idaho is attempting a different route around the ACA rules. Gov. C.L. “Butch” Otter in January issued an executive order to allow insurers to sell health plans missing some of the federal requirements as long as the companies also sell at least one plan inside Idaho’s ACA marketplace. The federal Centers for Medicare and Medicaid Services recently told Idaho officials that the approach appears likely to be illegal, but it has been holding meetings and conference calls to try to work out a solution.
For Iowa, the Farm Bureau plan is the state’s second attempt to bypass parts of the ACA. Last year, the state’s insurance commissioner asked federal health officials to allow Iowa to take about $350 million in ACA money for 2018 and use it in different ways to help people pay for plans outside the marketplace. State officials said at first that the Trump administration seemed receptive. But when the government had not given approval as last fall’s ACA enrollment season neared, Iowa withdrew the proposal.
The Hawkeye State’s latest strategy has a back-to-the-future quality. Starting in 1969, the nonprofit Iowa Farm Bureau sold Wellmark Blue Cross Blue Shield policies to its members. The arrangement ended when the ACA came along, because those health plans did not meet the federal law’s rules and would have exposed consumers to penalties.
Wellmark, the state’s largest health insurer, had sold ACA plans but announced last spring that it would pull out of that marketplace in 2018. Aetna also withdrew from Iowa, and the only marketplace insurer remaining, Medica, raised its prices by an average of 57 percent.
Iowa Insurance Commissioner Doug Ommen said that he was officially undecided about the new Farm Bureau legislation but that he sympathizes with the need for more-affordable coverage. As consumers have been “hammered” by the ACA rates, he said, enrollment in Iowa’s marketplace has tumbled from nearly 75,000 in 2016 to about 61,000 last fall to 46,000 last month. 
The dropouts are primarily people with incomes too high to qualify for ACA subsidies. That is the group Iowa officials expect to be attracted to the new coverage, which is why Ommen predicts it will not undercut the marketplace.
Kaiser’s Levitt said defining some Wellmark health plans as not insurance “is weird.” The unregulated plans, he said, could prompt questions about their financial solvency or whether dissatisfied customers have appeal rights.
According to Ommen, the Farm Bureau modeled its idea after a similar arrangement sponsored by the Tennessee Farm Bureau, which began decades ago and has continued in the ACA era. The Obama administration never challenged it.
Iowa Farm Bureau spokeswoman Laurie Johns said that about 15,000 of its members contacted their state legislators to support the bill. The new plans could be on sale through bureau agents in every county as early as the fall for current members or anyone who pays a $55 annual fee to join, she said.
Reynolds’s office said in a statement Thursday that the state’s individual insurance market “has collapsed because of Obamacare.” The statement said that she had “called on the legislature to do everything it could to make health insurance affordable for Iowa families, farmers and small business owners. This bill does that, and Gov. Reynolds is eager to sign it.”
The bureau and Wellmark still must decide on the benefits and rates, as well as questions such as how to handle people with medical conditions. “The details have yet to be worked out,” Johns said.

Groups press LePage to file Medicaid expansion plan as time runs out

Advocates for expansion keep pressure on the administration to act as Attorney General Janet Mills announces a $35 million windfall that she says could fund the program through the current two-year budget.
by Kevin Miller - Portland Press Herald - April 3, 2018
AUGUSTA — Advocates for expanding Medicaid in Maine sought Tuesday to keep pressure on the LePage administration, even as Attorney General Janet Mills announced a $35 million legal windfall she said could pay for expansion.
Tuesday was the deadline for the Maine Department of Health and Human Services to file a plan with federal regulators for how the state planned to expand Medicaid coverage to an estimated 70,000 additional adults as part of a ballot initiative approved by Maine voters last November. But Gov. Paul LePage has said repeatedly that his administration would not move forward with implementation until the Legislature fully funds expansion, raising the specter of potential legal challenges.
On Tuesday, expansion advocates held a news conference calling on LePage to submit the state’s implementation plan to the federal Centers for Medicare and Medicaid Services.
House Speaker Sara Gideon, D-Freeport, said she was hopeful the LePage administration would do its job and submit the application for the waiver the state would need to move forward with expansion.
“Our bipartisan Appropriations Committee will continue to work towards implementing Medicare expansion fully so that 70,000 of our neighbors can finally afford access to health care,” Gideon said. “We will appropriate the funds that are necessary when we need them. That is the job of the Legislature as a separate but equal branch of the government and we will determine when that day is.”
Last November, 59 percent of voters supported the ballot measure directing Maine to join the more than 30 other states that have expanded Medicaid as part of the Affordable Care Act.
There are conflicting assessments for how much expansion would cost the state even with the federal government footing 90 percent of the bill. While a recent study funded by the Maine Health Access Foundation estimated it will cost roughly $30 million in the current two-year budget, the LePage administration has pegged the costs at $60 million during the first year and as much as $100 million annually in future years.
Mills, meanwhile, announced Tuesday that her office and attorneys general in eight other states had reached an agreement with tobacco companies that will result in an additional $35 million for Maine as part of a 1998 legal settlement with the industry. Mills, one of seven Democratic primary candidates for governor, said that state law requires money from the historic settlement with tobacco companies to be used for “health care for children and adults, maximizing to the extent possible federal matching funds.”
“In other words, these funds are available to pay for Medicaid expansion as enacted by the people last November in the current biennium,” Mills said in a news conference held immediately after the event organized by Medicaid expansion advocates. “There is overwhelming evidence that states which have taken advantage of Medicaid expansion experience lower health care costs, healthier families and stronger economic growth.”
Mills said the agreement was finalized in the past several weeks, but that the timing of her announcement and Tuesday’s Medicaid expansion events was coincidental.
The Legislature would need to approve spending the additional settlement money – which is deposited into the Fund for a Healthy Maine – on Medicaid expansion. Given the politics surrounding Medicaid expansion, it was unclear Tuesday whether such a vote is feasible before the legislative session ends later this month.
Asked whether her proposal had legislative approval, Mills responded: “I can’t imagine why they would oppose it. It’s a gift.”
LePage fired back later Tuesday with a statement accusing Mills of consistently opposing past administration efforts to use tobacco settlement money for Medicaid programs.
“This political stunt would be nothing more than a down payment on giving free health care to 80,000 people, which will require ongoing and sustainable long-term funding,” LePage said. “If the Attorney General thinks a one-time settlement is enough to fund Medicaid expansion, she won’t make a very good governor.”
Organizations such as Mainers for Health Care, which led the Medicaid expansion ballot initiative, have threatened to pursue legal action against the LePage administration if it does not begin to implement the law. Mills declined to comment on whether her office would represent the LePage administration in any hypothetical lawsuit, but indicated that she believes the administration should be moving forward with implementation.
“The law is the law. Medicaid expansion has been enacted into law by the people,” Mills said. “There is really, in my view, no legal way to get around that. And the funds are available to get us through the biennium.”

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