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Monday, January 23, 2017

Health Care Reform Articles - January 23, 2017

What’s happening to America's Dysfunctional medical system?


Letter to the Editor - Ellsworth American - January 12, 2017

Dear Editor:
A small saga of the elusive eye drops. I went to the drugstore to renew my prescription of my eye drops, which I use for glaucoma. The pharmacy informed me that they weren’t able to be renewed yet. I asked why and they told me that the insurance company refused to fill it until next week. The folks there at Hannaford were as helpful as they could be and called the insurance people to explain that I was out of the drops. I went home and called these people myself and asked who was in charge of these decisions. I was informed that it was one of their pharmacists. I then asked them why he was practicing medicine without a license. Actually, I was really mad as hell and let them know it. A very nice young woman on the other end spent two hours trying to get them to override it and fill the prescription.
After about two hours, she said I had 24 hours to pick it up. By this time it was dark and beginning to snow. At 89 years old, I hesitated to make the trip back into town, 15 miles away. The next day I did get back to the folks at the pharmacy, but they knew nothing of this so-called override. Once more, another nice young technician tried to deal with these crooks. Finally, after many hours they got an override, but by this time I was back home after getting a few samples from my doctor.
What is happening to our medical system? The insurance companies have us all in a stranglehold, as well as the criminal pharmaceutical companies. Family doctors are becoming as scarce as hen’s teeth as they are being told how to practice medicine by these huge profit-making machines, so are opting out of the profession. Who can blame them? They have to pay huge amounts of money to protect themselves from being sued. Oh, yes, we live in a litigious society. Some people make a good living suing organizations and medicine is a mother lode. Years ago, an attorney neighbor back in New Jersey, when told that the state had put in a no-fault program for automobile insurance, said, “Well, I guess I’ll have to go for the medical field to make a living.” So, OK, then we have the lawyers with their claws in the whole mess. Meanwhile, I finally did get my eye drops thanks to some very nice, persistent people, but how many other folks out there have similar stories to tell? And now just today I heard that the insurance companies are starting to plan to insure automobile mechanics. Look, they have got health insurance, veterinary, dental and god knows what else and now the Republican Congress wants to do away with Medicare and Medicaid. What’s to become of the poor, the sick and the elderly? How free is our country anyway? I wonder.
Mary Welsh
Sullivan

The Republican Health Care Con

The Editorial Board - NYT
Republicans say the Affordable Care Act provides health insurance that manages to be both lousy and expensive. Whatever the flaws of these policies, the new Trump administration is trying to pull off a con by offering Americans coverage that is likely to be so much worse that it would barely deserve the name insurance. It would also leave many millions without the medical care they need.
This reality became increasingly clear when President Trump’s choice to run the Department of Health and Human Services, Tom Price, testified before a Senate committee last week. He looked pained as he described the terrible predicament of people who earned around $30,000 to $50,000 a year and had to deny “themselves the kind of care that they need” because they had Obamacare policies with deductibles of $6,000 to $12,000. Yet, earlier in the same hearing, Mr. Price extolled the virtues of policies that would be woefully inadequate — policies that cover medical treatment only in catastrophic cases. Such policies often have deductibles of around $14,000 for family coverage. This is simple hypocrisy. Condemn the policy you don’t like, propose something far worse as a replacement and claim that it is much better.
Mr. Price and Mr. Trump have recently said that their goal is to offer health care to many more people than are covered by the current health care law, which has driven the uninsured rate to historic lows. Mr. Trump went so far as to say he would provide “insurance for everybody” — something his press secretary, Sean Spicer, later walked back. But Mr. Price’s testimony and the legislation he introduced in the House, where until recently he was the Budget Committee chairman, show that the new administration will make decent health care less affordable and less accessible for most people. And Mr. Trump was already trying to undo parts of the A.C.A. through an executive order on Friday, just hours after being sworn in.
At last week’s confirmation hearing, Mr. Price suggested that Congress and the new administration could improve health care by expanding health savings accounts, in which people can put aside money, tax-free, to pay for out-of-pocket health costs in the future. But those accounts would not help families earning the median household income of $56,000 a year because these families would never be able to sock away enough money to, say, pay for cancer treatment or major surgery. These accounts would primarily benefit the wealthy, who want to shield more of their income from taxation and can easily afford to pay high out-of-pocket costs.
The best description of what Mr. Price stands for can be found in a bill he introduced in 2015, the Empowering Patients First Act. It would “empower” Americans by eliminating the health care law’s expansion of Medicaid that has helped more than 10.7 million newly eligible people enroll in that government-run insurance program. It would also drastically cut subsidies that have helped 11.5 million people purchase private insurance on federal and state health exchanges. Under his bill, people buying insurance for themselves would get between $1,200 and $3,000 a year in subsidies, down from an average of $4,600 that people get now on HealthCare.gov. The bill would even get rid of the requirement that allows young people to stay on their parents’ insurance policy until age 26, a provision that is widely popular. And it would hurt people who get insurance through their employers by setting a cap on how much of that expense businesses can claim as a deduction on their taxes. Experts say that over time this would encourage companies to stop offering health benefits to workers.
When it comes to health care, Mr. Price and other Republicans say their goal is to give people more choices. It is hard to argue against choice. But in the ideological world inhabited by Mr. Price, House Speaker Paul Ryan and many other Republicans, choice is often a euphemism for scrapping sensible regulations that protect people.
Some Americans might well be tempted by this far-right approach. They would have to pay less up front for these skeletal policies than they do now for comprehensive coverage. But over time, when people need health care to recover from accidents, treat diabetes, have a baby or battle addiction, they will be hit by overwhelming bills. The Trump administration seems perfectly willing to sell those people down the river with false promises.

Trump Issues Executive Order Scaling Back Parts of Obamacare

by Julie Hirschfeld and Robert Pear

WASHINGTON — In his first executive order, President Trump on Friday directed government agencies to scale back as many aspects of the Affordable Care Act as possible, moving within hours of being sworn in to fulfill his pledge to eviscerate Barack Obama’s signature health care law.
The one-page order, which Mr. Trump signed in a hastily arranged Oval Office ceremony shortly before departing for the inaugural balls, gave no specifics about which aspects of the law it was targeting. But its broad language gave federal agencies wide latitude to change, delay or waive provisions of the law that they deemed overly costly for insurers, drug makers, doctors, patients or states, suggesting that it could have wide-ranging impact, and essentially allowing the dismantling of the law to begin even before Congress moves to repeal it.
The order states what Mr. Trump made clear during his campaign: that it is his administration’s policy to seek the “prompt repeal” of the law, which has come to be known as Obamacare. But he and Republicans on Capitol Hill have not yet devised a replacement, making such action unlikely in the immediate term.
“In the meantime,” the order said, “pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act, and prepare to afford the states more flexibility and control to create a more free and open health care market.”
The order has symbolic as well as substantive significance, allowing Mr. Trump to claim he acted immediately to do away with a health care law he has repeatedly called disastrous, even while it remains in place and he navigates the politically perilous process of repealing and replacing it.
Using the phrase “to the maximum extent permitted by law,” the order directs federal agencies to move decisively to implement changes, including granting flexibility that insurers and states had long implored the Obama administration to provide.
It also instructs them to work to create a system that allows the sale of health insurance across state lines, which Republicans have long proposed as the centerpiece of an alternative to the law.
“This action demonstrates that President Trump is committed to fixing the damage caused by Obamacare as soon as possible,” said Senator John Barrasso, Republican of Wyoming.
The order does not direct the Department of Health and Human Services to ease any particular aspect of the 2010 law, but it could result in a substantial weakening of one of its central features: the so-called “individual mandate” that requires most Americans to have health insurance or pay a tax penalty.
While the Obama administration allowed “hardship exemptions” to the mandate, the Trump administration could conceivably interpret the requirement in a more lenient way, so that more people would not be penalized.
Likewise, federal officials could be more receptive to state requests for waivers under Medicaid, the federal-state program that covers more than 70 million low-income people. A number of Republican governors and state legislators would like to charge higher premiums or co-payments than are now allowed. Some states want to provide a less generous, less expensive package of benefits, or require some able-bodied adults to engage in work activities as a condition of receiving Medicaid.



Still, while Mr. Trump’s directive allows officials to take steps that increase costs for consumers, that result is not inevitable. Indeed, the order says officials should try to reduce costs and burdens on consumers.

Over the last six years, insurance company executives have bitterly complained that federal insurance regulations were extremely prescriptive and onerous. By relaxing some of those rules, the Trump administration could make the individual insurance market more attractive to insurers. And insurers might then be more willing to stay in or return to the public marketplaces established under the Affordable Care Act.
In the last year, a number of insurers have dropped out of those markets, leaving consumers with fewer health plans to choose from.
House Republican leaders recently asked governors for recommendations on health policy, and governors from both parties said the federal government should scale back its regulation of health insurance.
Gov. Bill Haslam of Tennessee, a Republican, said this month that federal officials should “reconsider the premise that health insurance public policy should be directed from Washington.” He said that federal rules for setting insurance rates and defining “essential health benefits” should be more flexible.

What Does Trump’s Executive Order Against Obamacare Actually Do?

by Margot Sanger-Katz

Donald J. Trump ran on a campaign promise to dismantle the Affordable Care Act. So it should not come as a surprise that he has signed an executive order urging his administration to fight it as much as possible.
But that order, alone, won’t allow President Trump to unwind the sprawling health law known as Obamacare.
Mr. Trump and Republican leaders in Congress are engaged in negotiations about legislation that might substantially undo or replace the health law. Even before the inauguration, Congress took a first step toward gutting major provisions.
But as that process underscores, major changes to health policy will require new legislation. The Trump executive order should be seen more as a mission statement, and less as a monarchical edict that can instantly change the law.
Mr. Trump has sent a strong signal that he intends to fight the health law, but he sent signals that were strong on the campaign trail, too, just in less legalistic language. And the order, crucially, notes that agencies can act only “to the maximum extent permitted by law.” (How the Trump administration interprets those permissions, of course, is yet untested.)
The order spells out the various ways that a Trump administration might fight the parts of the health law until new legislation comes: by writing new regulations and exercising discretion where allowed. Regulations can be changed, but, as the order notes, only through a legal process of “notice and comment” that can take months or years.
On matters of discretion, the administration can move faster, but there are limited places where current law gives the administration much power to quickly change course.
How much of the order is bluster and how much it signals a set of significant policy changes in the pipeline is unclear. The order was not specific and did not direct any particular actions.
“Right off the bat, what do they do — something incredibly cryptic that nobody understands,” said Rodney Whitlock, a vice president of M.L. Strategies, a Washington consulting firm. Mr. Whitlock was a longtime health policy aide to Senator Chuck Grassley, a Republican from Iowa.
The easiest way for the Trump administration to undermine the health law would be to stop defending a lawsuit brought by the House of Representatives. That suit said that the Obama administration lacked the authority to pay certain Obamacare subsidies. A lower court ruled for the House, meaning that by simply withdrawing from the appeal, the Trump administration could start a process to eliminate those subsidies and cause a collapse of the insurance market. Mr. Trump’s order said nothing about that policy choice.
Another important area of discretion has to do with exemptions to the law’s unpopular individual mandate to obtain insurance. Under the law, all Americans who can afford it are expected to obtain health insurance, unless they have experienced some hardship that would make it impossible. People who feel there has been such a hardship can apply for an exemption, and employees in the Department of Health and Human Services and the Internal Revenue Service can decide on their case. Under a Trump administration, it might become easier to claim hardship and get out of the requirement to buy insurance.
But people seeking those exemptions will still have to apply for them, in writing, and can do so only at particular times of the year. Current law requires them to provide documentation supporting their claim that they have recently filed for bankruptcy, for example, or been evicted, and they must legally attest to their honesty. The Trump administration could create new categories of hardship, but that would take time. And rules that effectively eliminate the requirement would almost certainly result in litigation.
“It’s not a hardship to have to comply with the law, almost by definition,” said Timothy Jost, a professor of law at Washington and Lee University. Mr. Jost, who supports the health law, has examined the underlying regulations in detail.
Defanging the individual mandate could have significant consequences for the individual insurance markets. If fewer healthy people buy insurance, the costs of insuring everyone else will rise, leading insurance companies to raise prices or flee the market.
Last week, the Congressional Budget Office published its estimate of what would happen under a law that eliminated the mandate and some other provisions: 18 million people would lose their insurance next year alone. It’s possible that insurers will look at the language of the order and get skittish, setting off a market collapse next year. But the order itself doesn’t yet change any rules. The health and human services department and the I.R.S. will have to take further action.
“Is this mostly a symbolic gesture or a signal that they intend to take apart the law piece by piece to the extent they can?” said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health research group. “At a minimum, this creates a lot of uncertainty for insurers at a pretty critical time.”
The order directs the administration to give states more autonomy in directing health policy. And there’s a clear mechanism for that: Medicaid law provides a process in which states can waive many of the program’s usual rules to attempt “demonstration projects.”
Administrations have latitude under the law to decide what sort of new programs qualify. Mr. Trump’s selection for the administrator of the Centers for Medicare and Medicaid Services, Seema Verma, has been an innovator in pushing this process in more conservative directions. Her selection, even more than the order, was a signthat the Trump administration would become more open to new Medicaid rules, including possible work requirements to obtain coverage, or premiums even for very poor Americans.
But, as with the exemptions, there is still a process for such policy changes. States must submit detailed applications for waivers for the rules, and there is a legal review process that typically takes months.
Mr. Trump recently promised that his team was developing a health care plan far better than the Affordable Care Act, that would insure more people and lower their costs. For people who heard that and thought Mr. Trump had gone soft on Obamacare, his executive order may come as a shock. But nothing in the order changes the law on its own. Whether Mr. Trump’s intention is a smooth transition or a rapid disruption in current policy will be determined by what comes next.

With executive order, Trump tosses a ‘bomb’ into fragile health insurance markets
by Juliet Allperrin and Sean Sullivan - Washington Post
President Trump’s executive order instructing federal agencies to grant relief to constituencies affected by the Affordable Care Act has begun to reverberate throughout the nation’s health-care system, injecting further uncertainty into an already unsettled insurance landscape.
The political signal of the order, which Trump signed just hours after being sworn into office, was clear: Even before the Republican-led Congress acts to repeal the 2010 law, the new administration will move swiftly to unwind as many elements as it can on its own — elements that have changed how 20 million Americans get health coverage and what benefits insurers must offer some of their customers.
But the practical implications of Trump’s action on Friday are harder to decipher. Its language instructs all federal agencies to “waive, defer, grant ­exemptions from or delay” any part of the law that imposes a financial or regulatory burden on those affected by it. That would cover consumers, doctors, hospitals and other providers, as well as insurers and drug companies.
The prospect of what could flow from pulling back or eliminating administrative rules — including no longer enforcing the individual mandate, which requires Americans to get coverage or pay an annual penalty, and ending health plans’ “essential benefits” — could affect how many people sign up on the Affordable Care Act marketplaces before open enrollment ends Jan. 31 for 2017 coverage, as well as how many companies decide to participate next year.
Robert Laszewski, president of the consulting firm Health Policy and Strategy Associates, called the executive order a “bomb” lobbed into the law’s “already shaky” insurance market. Given the time it will take Republicans to fashion a replacement, he expects that federal and state insurance exchanges will continue to operate at least through 2018.
As Republicans in Congress gear up to repeal the Affordable Care Act, two Pennsylvanians reflect on their different experiences under Obamacare. (Alice Li/The Washington Post)
“Instead of sending a signal that there’s going to be an orderly transition, they’ve sent a signal that it’s going to be a disorderly transition,” said Laszewski, a longtime critic of the law, which is also known as Obamacare. “How does the Trump administration think this is not going to make the situation worse?”
Teresa Miller, Pennsylvania’s insurance commissioner, said Saturday that several insurers on her state’s exchange “seriously considered leaving the market last year” and that Trump’s action could propel them to indeed abandon it in 2018. In fact, she added, some have raised the possibility of withdrawing from the ACA’s exchanges during 2017, which would mean consumers could keep their plans but no longer receive federal subsidies to help them afford the coverage.
“That would create a nightmare scenario,” Miller said.
As of this year, nearly a third of all counties nationwide have just one insurer in the federal marketplace, and almost two-thirds have two or fewer insurers.
The White House did not return requests for comment over the weekend.
On Capitol Hill, Republican leaders offered cautious praise for the president’s executive order. Yet more broadly, the GOP remains in a state of uncertainty on health care, with unresolved questions about the path forward.
Sen. Lamar Alexander (R-Tenn.), the chairman of the Health, Education, Labor and Pensions Committee, was briefed on the details of Trump’s order only Thursday, according to a GOP aide who spoke on the condition of anonymity to describe private talks.
Alexander said in a statement late Friday that Trump was “right to make the urgent work of rescuing Americans trapped in a collapsing Obamacare system a top priority on his first day in office.”
Senate Majority Leader Mitch McConnell (R-Ky.), speaking on “Fox News Sunday with Chris Wallace,” focused primarily on what Trump could do through executive action.
“President Obama implemented a lot of Obamacare himself, so President Trump will be able to undo a lot of it himself,” McConnell said. Asked whether he knew what the new president’s replacement plan is, he said Senate Republicans are working with the administration “to have an orderly process.”
The GOP-led House and Senate have passed a budget measure that was designed to serve as a vehicle for repealing key parts of the law. But they have yet to rally around a consensus idea for when and what to do to replace it. They were placed under further pressure to act quickly after Trump vowed “insurance for everybody” in a recent interview with The Washington Post.
A key Trump ally said Sunday that the president’s decision to sign the order on his first day in office, coupled with his recent comments about moving swiftly on repealing and replacing the law, has applied pressure on GOP lawmakers to act faster than they might have initially planned.
“I think Trump has consistently moved that needle with the mindset of our conference,” Rep. Chris Collins (R-N.Y.) said.
Democratic leaders, however, are casting the executive order as evidence that Republicans are in a state of disarray on health care.
“They don’t know what to do. They can repeal, but they don’t have a plan for replace,” Senate Minority Leader Charles E. Schumer (N.Y.) said in an interview that aired Sunday morning on CNN’s “State of the Union.” “The president’s executive order just mirrored that.”
At least publicly, the insurance industry’s reaction has been muted. America’s Health Insurance Plans spokeswoman Kristine Grow, whose group represents nearly 1,300 insurers, said in an email Saturday that it is “too soon to tell” what the executive order will mean for the industry.
“There is no question the individual health-care market has been challenged from the start,” Grow said. “The president said he would take swift action to move our country to improve it, and he has.”
A key question following Trump’s order is what actions Republican-led states might take to withdraw from key provisions of the law. Florida Gov. Rick Scott’s (R) office said Saturday that he was reviewing his options.
Jackie Schutz, a Scott spokeswoman, said the governor “appreciates” that the new administration is “swiftly taking action.” But as to how and when Scott would seek to take advantage of it, “we’re still looking into it to see what it specifically means to Florida,” Schutz said.
Ohio Gov. John Kasich (R), who met with Senate Finance Committee Orrin G. Hatch (R-Utah) and nearly a dozen other GOP governors on Thursday to discuss the future of Medicaid, said afterward that there are “some fundamental things that we can do that can settle people down so they are not worried they are going to lose their coverage but that at the same time bring significant changes to the Obamacare package.”
Kasich, who expanded Medicaid in his state under the Affordable Care Act, said that one option he favors is paring Medicaid coverage to people with incomes up to 100 percent of the poverty level, rather than the current 138 percent, and then letting those above 100 percent go on the marketplace to get coverage.
Asked whether he could guarantee that none of his constituents would lose health-care coverage, Kasich responded, “I can’t guarantee anything.”
And more radical changes could be coming to Medicaid, the program that provides care for 70 million low-income Americans. In keeping with much-contemplated GOP proposals, senior Trump adviser Kellyanne Conway said on Sunday TV talk shows that the president intends to turn the entitlement program into block grants to states. 
Even if the new administration is eager to grant waivers to states, it does not have the political appointees in place at the Health and Human Services and Treasury departments to do so.
But timing is important. While the exact deadline varies depending on the state, insurers generally must decide by the spring whether to participate in Affordable Care Act marketplaces for the next year and, if so, propose the rates they would like to charge. Their decisions could be complicated if the president’s order results in rule changes that affect the benefits those health plans must include – or alters rules in other ways that, in turn, prompt fewer healthy customers to seek coverage through the marketplaces.
Chris Jennings, who served as a senior White House adviser on health care in the Clinton and Obama administrations, said that in the health-care arena, “more than any other domestic policy, details matter. Plans, they live off a comma, or an incentive, or a disincentive, or a penalty, or an enforcement mechanism.”
Ceci Connolly, president and CEO of the Alliance of Community Health Plans, said her members are in a particularly difficult position because they are unlike large national companies that can “pick and choose” which markets they operate in under the federal exchange.
“Local nonprofit plans are in their communities, so they can’t look around for certain markets and pull out of ones that they don’t like,” said Connolly, who added that her group’s “biggest concern” is that some consumers might stop paying their premiums if they believe they will not be penalized for lacking coverage. That could lead to hospital and doctor visits that would not be reimbursed, which then would impose costs on providers and insurers more broadly.
With fewer than 10 days to go in the current enrollment period, Mila Kofman, executive director of the D.C. Health Benefit Exchange Authority, said that “all of this discussion of whether or not people will have access to affordable quality health insurance is very unsettling.”
Some residents have asked Kofman whether she can assure them they will get the same health benefits if Congress and the administration overhaul the system in the coming months. “I tell them, ‘Sign up. We will certainly do everything we can to ensure that you’ll have access to quality health insurance.’ ”
Yet Mona Mangat, a solo practitioner in allergy and immunology in St. Petersburg, Fla., is not sure what to say when patients ask her whether they will be able to afford the kind of prescriptions and services they have taken advantage of under the Affordable Care Act.
“Unfortunately, I don’t have an answer for them,” Mangat said. “I say, ‘Oh my God, I don’t know what’s going to happen.’”


Can President Trump’s executive order unravel the Affordable Care Act?
By Jonathan H. Adler

President Trump signs his first executive order in the Oval Office, which will direct agencies to ease the regulatory burdens associated with the Affordable Care Act, as Vice President Pence swears in retired Gen. James Mattis and retired Gen. John F. Kelly. (Reuters)
As promised, newly inaugurated President Donald Trump issued an executive order directing members of his administration to take steps that will facilitate the repeal and replacement of the Affordable Care Act, a.k.a. Obamacare. Is this a big deal? It depends.
As a formal matter, there is only so much that an executive order can do. EOs are not the only form of executive action, and they are not a particularly important one. They are simply one means for the president to exercise the authority that has already been delegated to the executive branch.
As Nicholas Bagley notes, EOs are, in many respects, a communications strategy. They are a formal, public means of declaring administration policy and providing clear, across-the-board directives to federal agencies. Instead of telling executive branch officials individually to take specific actions, an EO enables the president to tell the entire executive branch to begin taking certain sorts of actions, such as to develop policies and proposed regulations or administer federal contracts in a particular way (and provided that the instructions do not conflict with federal law).
This specific EO reiterates that it is administration policy to seek the repeal and replacement of the ACA and directs relevant agencies — Health and Human Services, Treasury, etc. — to utilize their authorities under the act “to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.” The heart of the order, Section 2, directs federal agencies as follows:
To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.
Under normal circumstances, this would not mean much, as it would simply direct agency officials to use whatever discretion they have to loosen the ACA’s constraints and burdens on states, individuals and insurance companies, and the ACA offers only so much flexibility. Therein lies the rub.
The Obama administration was particularly aggressive in asserting the authority to grant waivers, defer burdens and delay implementation of various ACA provisions, even where the law did not authorize such acts. Put in the most charitable terms, the Obama administration took a particularly elastic view of what the executive branch could do under the law. But don’t just take my word for it. Bagley has documented these transgressions at length. (I’ve also discussed these actions in various papersand testimony.)
As Bagley notes with regard to this EO, many of the Obama administration’s actions implementing the ACA will make it easier for the Trump administration to take equivalent actions of questionable legality. The lawfulness of executive action is often evaluated by reference to prior executive practice, so the Obama administration’s success in taking such steps (and the relative silence of the legal commentariat, Bagley excepted) will strengthen the Trump administration’s hand when it begins granting questionable waivers, suspends requirements under the guise of exercising enforcement discretion and opts to place a hold on unpopular provisions. And as the initial steps toward repeal-and-replace further destabilize insurance markets, this will only justify additional waivers and suspensions, all made in the name of minimizing disruption and enhancing administrability.
Bagley warned that this could happen. Writing in the New England Journal of Medicine, Bagley explained how the Obama administration’s unilateral delays of the employer mandate penalty and other measures could be turned against the act by an unsympathetic president.
The delays nonetheless set a troubling precedent. . . .  a future administration that is less sympathetic to the ACA could invoke the delays as precedent for declining to enforce other provisions that it dislikes, including provisions that are essential to the proper functioning of the law. The delays could therefore undermine the very statute they were meant to protect — and perhaps imperil the ACA’s effort to extend coverage to tens of millions of people.
More generally, the Obama administration’s claim of enforcement discretion, if accepted, would limit Congress’s ability to specify when and under what circumstances its laws should take effect. That circumscription of legislative authority would mark a major shift of constitutional power away from Congress, which makes the laws, and toward the President, who is supposed to enforce them.
With its initial EO, the Trump administration is seeking to make Bagley’s warning prophetic.
As I read the EO, it also ensures that state waivers will be granted on very generous terms and that HHS will quickly settle any remaining lawsuits concerning the so-called contraception mandate. After all, since some religious employers are effectively exempted from the mandate, there is no argument that HHS lacks the authority to accommodate those employers, such as Little Sisters of the Poor, who believe that the mandate burdens their exercise of religion.


Affordable Care Act Repeal Would be a Disaster for Maine

Maine Center for Economic Policy
The Affordable Care Act (ACA) provides tens of thousands of Mainers with affordable health care for the first time. Repeal of the ACA would plunge young adults, older Mainers, and those living in rural areas into poverty, as well as financially burden the state’s hospitals and physicians, and make Maine businesses less competitive.
Health care is essential for families to overcome addiction, move into stable employment, and provide a better future for their children. Retaining the ability to access hundreds of millions of dollars in Medicaid funding and federal insurance subsidies is crucial to the future economic health of our state.
Maine’s congressional delegation should work with their colleagues and the incoming administration to build on the success of the ACA. Repealing the law without a replacement would roll back lifesaving progress made in the past few years.
The ACA Improved Access to Affordable Health Insurance
The share of Maine’s non-elderly adult population without health insurance fell from 14.6 percent to 11.7 percent since the passage of the ACA.1 Maine’s progress would be even greater were it not for restrictions on Medicaid eligibility enacted by Governor LePage’s administration, which removed approximately 35,000 Mainers from that health care program.2
Young adults (aged 18-24), older adults (aged 55-64), and rural Mainers who are more likely to work part-time, seasonally, or be self-employed—groups that previously had the hardest time obtaining affordable insurance—have realized the largest gains from the ACA.
The ACA Made Health Care More Affordable
More than 75,000 Mainers are enrolled in an individual health insurance plan through the Healthcare.gov marketplace lowering their out-of-pocket costs and bringing some $390 million in federal subsidies annually to the state.3 One in three marketplace enrollees are over the age of 55 and half earn less than 200 percent of the federal poverty level ($32,000 for a household of two).

The ACA has successfully curtailed the rising costs of insurance premiums in the U.S. and particularly in Maine where annual increases have slowed from an average of eight percent annually pre-ACA to two percent annually, a greater reduction than elsewhere. Average health insurance premiums for Maine employer-sponsored policies have gone from being 13 percent above the national average in 2002 to parity in 2015,4 making health insurance more affordable for Maine businesses that want to provide insurance for their employees and improving their competitiveness relative to the rest of the nation.
The ACA Provides Vital Resources to Battle the Opioid Epidemic
The lack of insurance among those suffering from addiction affects hospitals by increasing charitable care for uninsured patients. It also affects employers by removing tens of thousands of workers from the labor force. A quarter of a million Mainers are thought to have a mental illness (including substance abuse).5 An estimated 19,000 of these Mainers obtain their health insurance through the federal marketplace,6 while an unknown number remain uninsured. Three-quarters of those treated for substance abuse in 2014 were either unemployed or not in the labor force, nearly double the proportion of the general population.7
ACA Repeal Would Cause Hospital Debt to Balloon
Repeal of the ACA would be a financial disaster for Maine’s hospitals and health care providers. It would mean a reduction in health care spending in Maine of $560 million in 2019, and $4.4 billion over the following decade.8 Without the ACA, uncompensated care costs for Maine health providers would triple, resulting in additional costs of $475 million in 2019.
Repeal of the ACA Means Losing the Opportunity for Medicaid Expansion
Repealing the ACA’s Medicaid Expansion provision would deny Maine the opportunity afforded 31 other states and the District of Columbia to expand Medicaid. Expansion would bring to Maine $346 million annually to insure 75,000 low- income Mainers9 and save the state $40 million annually from the use of federal funds for state services.10 The federal funding would also generate additional economic activity, and support or retain 4,500 jobs in health care and related fields.11
The Maine Center for Economic Policy is a non-partisan, non-profit policy research organization committed to advancing economic justice and prosperity for all Maine people. Visit MECEP’s web site for a copy of our full report, Affordable Care Act Repeal Would be a Disaster for Maine.
http://www.mecep.org/wp-content/uploads/2017/01/MECEP-ACA-Repeal-Executive-Summary-01-19-17-FINAL.pdf?utm_source=ACA+Repeal++1-20-2017&utm_campaign=1%2F20%2F2017+ACA+repeal&utm_medium=email

Maine’s rural hospitals fear crisis if Obamacare is repealed without comparable replacement

By insuring tens of thousands of their patients, the Affordable Care Act has helped hospitals and clinics to stay open.
by Colin Woodard - Portland Press-Herald
Love it or hate it, the Affordable Care Act has helped Maine’s hospitals stay solvent, and experts fear its repeal could make it hard for some of them to avoid cutbacks and even closure.
President Trump and the Republican-controlled Congress have vowed to repeal the law, also known as Obamacare, but it’s unclear whether they will replace it with a viable and comparable alternative. On Monday, Maine’s senior U.S. senator, Susan Collins, will reintroduce an alternative plan she co-sponsored in 2015 that would allow states to opt for other solutions, but its prospects are unclear.
Absent a comparable alternative, an ACA repeal would leave 80,000 Mainers who receive health insurance through its exchange without coverage. Some would presumably find alternate coverage, but tens of thousands would not be able to afford it, meaning big losses for Maine’s hospitals and clinics, which are obligated by state law to provide “medically necessary” care to those unable to pay.
“We’re all worried,” says Jeffrey Austin, vice president of government affairs at the Maine Hospital Association, who estimates that the state’s hospitals receive $200 million a year from ACA-subsidized insurance policies. “The average operating margins in Maine hospitals are about 1 percent. There just isn’t room for dramatic negative impacts.”
The Washington Post reported late Friday that Trump had signed an executive order giving federal agencies broad powers to unwind regulations created under the Affordable Care Act, including enforcement of the penalty for people who fail to carry the health insurance that the law requires of most Americans.
FEW PATIENTS HAVE COMMERCIAL INSURANCE
Maine’s rural hospitals are particularly vulnerable to the negative effects of repeal because, apart from the ACA, few of their patients have commercial insurance. Many have Medicare, the federal program for the elderly, and some have MaineCare, the state’s version of Medicaid, which covers the very poor, but hospitals say the payments they receive from those programs don’t cover their costs. The rest have no insurance at all, but under state law must be given medically necessary treatment if their incomes are less than 150 percent of the federal poverty level and under federal law must provide emergency treatment to everyone.
“The extent to which we’re challenged by bad debt and charity care presents significant problems,” says Katie Fullam Harris, senior vice president for public relations at MaineHealth, the state’s largest health care network, with hospitals and acute care centers in seven counties. A full ACA repeal, she says, would dramatically increase the number of uninsured and underinsured, and cost MaineHealth nearly $1 billion over the next decade, with serious consequences.
A study released Friday by the Maine Center for Economic Policy estimates that if the ACA is repealed, uncompensated care costs to Maine hospitals would triple to $475 million in 2019. Revenues would also decline by $560 million, the study estimated, as the underinsured avoided or were priced out of treatments, creating a total hit of nearly $1 billion statewide.
That’s a significant number in a state whose three tertiary care hospitals – Maine Medical Center in Portland, Eastern Maine Medical Center in Bangor, and Central Maine Medical Center in Lewiston – had total combined revenues of $2.8 billion in 2014.
“There would have to be substantial changes to the infrastructure and the way that health care services are delivered in the state of Maine,” Harris says. Although she and other hospital industry officials avoided specifics, some agreed that they would include staff layoffs, the closure of hospital departments and termination of services, and even the possible failure of some hospitals.
LOSSES CONCENTRATED IN RURAL TOWNS
In fiscal year 2016, five of MaineHealth’s seven local health care systems ran in the red, including the networks serving much of York, Knox, Waldo, Franklin and western Oxford counties. Only Maine Medical Center in Portland, Lincoln Health in the Damariscotta area and Western Maine Health, based around Stephens Memorial Hospital in Norway, made money – despite the fact that the network primarily serves the more affluent third of the state.
Officials at two hospitals in more remote parts of the state – Down East Community Hospital in Machias and Cary Medical Center in Caribou – declined and did not respond to interview requests, respectively.
Statistics on ACA marketplace enrollments in Maine show those who could potentially lose their insurance are disproportionately concentrated in rural townsthat also have a high proportion of self-employed individuals. The program is most heavily used in logging or fishing communities like Greenville Junction, Pemaquid, North Haven, Vinalhaven and Round Pond (where more than a fifth of all residents are insured via Obamacare) or Beals, Stratton, Brooklin, Sedgwick, Chebeague Island and Stonington (where 1 in 6 is insured through the ACA).
Most larger towns and cities had an Obamacare-insured rate of only 3 percent to 5 percent, including Bangor, Lewiston, Auburn, Augusta, Waterville, Westbrook and Biddeford. Portland’s rate is 9.3 percent.
PAYMENT MIX WOULD CHALLENGE HOSPITALS
Maine hospitals and clinics are already under stress for a variety of reasons. Maine is the most elderly state in the nation, and older people typically require more frequent and expensive care. Gov. Paul LePage declined to expand Medicaid eligibility under the ACA, which would have greatly reduced the number of uninsured patients they treat.
The poor state of the economy – especially in the so-called “rim counties” of western, northern and far eastern Maine – means there are fewer workers with employer-sponsored health insurance. This is happening at the same time many surgical services are being concentrated at larger hospitals, reducing inpatient use and revenues.
“As mills close and large employers leave, one of the things they take with them is commercial insurance coverage for the local population,” says Austin of the Maine Hospital Association. “What’s left is Medicare, Medicaid and the uninsured, and it’s very difficult to survive with that payer mix.”
Gordon Smith, executive vice president of the Maine Medical Association, which represents the state’s physicians, says for these reasons a repeal of the ACA without a comparable replacement would be “as devastating to Maine as any other single state.” And he’s not optimistic about the outcome in Washington, D.C., under Trump’s nominee for Health and Human Services secretary, Tom Price, a longstanding critic of Obamacare.
“Nobody thinks Secretary Price and others are going to have a system that’s highly dependent on public sources (of funding). They’re talking high-risk pools and health savings accounts,” he says. “People will have ‘universal access’ to health insurance, but they’ve always had that, if they could pay for it.”
MORE OUT-OF-POCKET COSTS AND BAD DEBT
Andrew Coburn, a nationally recognized expert on rural health at the University of Southern Maine, agrees the road ahead will likely be difficult for Maine hospitals. “If you take what has been proposed before on the Republican side, you have to assume that replacement plans offered will be less generous, with fewer subsidies, higher deductibles and more co-insurance,” he says. “The impact on hospitals will be more and more, these out-of-pocket costs will have to be borne by the hospitals as bad debt or charity care.”
The Maine Hospital Association, the Maine Medical Association and MaineHealth all say they have been closely engaging Maine’s four-person congressional delegation, imploring them to ensure that if the ACA is repealed it is replaced with something that provides comparable insurance to the 80,000 Mainers currently covered.
Maine’s U.S. senators split on a vote Jan. 12 that cleared the way for the ACA to be repealed with a simple majority rather than a filibuster-proof one, which would have potentially allowed the Senate’s minority Democrats to block the effort. Sen. Collins voted for the measure, independent Sen. Angus King against.
The text of Collins’ replacement bill – to be introduced Monday by her Republican colleague Bill Cassidy of Louisiana – hasn’t been released but it is modeled on the 2015 Patient Freedom Act, which allowed states to either keep using the ACA or to instead divert their federal subsidies to fund their own state exchange programs or to residents’ health savings accounts. Her office did not respond to an interview request.

Choice for Health Secretary Is Vague on Replacing Affordable Care Act

by robert Pear and Thomas Kaplan - NYT

WASHINGTON — Representative Tom Price, the man President-elect Donald J. Trump has chosen to lead the Department of Health and Human Services, promised on Wednesday to make sure people do not “fall through the cracks” if the Affordable Care Act is repealed, and set a goal to increase the number of people with health insurance.
But at a hearing before the Senate Health, Education, Labor and Pensions Committee, Mr. Price provided only vague reassurance to members of both parties who pressed him for specific policies.
Republicans concluded he was well qualified; Democrats were not satisfied.
“Just days ago, President-elect Trump promised, quote, ‘insurance for everybody,’” said Senator Patty Murray of Washington, the senior Democrat on the committee. “But Congressman Price, your own proposals would cause millions of people to lose coverage, force many people to pay more for their care, and leave people with pre-existing conditions vulnerable to insurance companies’ rejecting them or charging them more.”
In four hours of testimony, Mr. Price, an orthopedic surgeon from the affluent northern suburbs of Atlanta, set lofty goals for a plan to replace the Affordable Care Act, President Obama’s signature domestic achievement, but did not say how he would achieve them.
Mr. Price, 62, also denied impropriety in his trading of stocks in health care and pharmaceutical companies, saying he had left many details to his broker. The Wall Street Journal reported last month that he had traded more than $300,000 worth of shares while promoting legislation that could have affected the companies he owned stock in.
Senator Al Franken, Democrat of Minnesota, said one investment looked like a “sweetheart” deal. But Mr. Price said, “I had no access to nonpublic information.”
Like several other candidates for top jobs in the Trump administration, Mr. Price put a little distance between himself and the president-elect on several issues.
Mr. Trump said last week that drug companies were “getting away with murder” and that Medicare should negotiate with drugmakers to secure lower prices, a position long championed by Democrats and fiercely opposed by Republicans.
Asked if he would press Congress to authorize such negotiations, Mr. Price did not give a definitive answer. “I think we need to find solutions to the challenges of folks’ gaining access to needed medication,” he said.
He added that, if confirmed, he would try to give states more freedom and flexibility under Medicaid, the federal-state program that provides coverage for more than 70 million low-income people. In response to questions, he said states should be allowed to require certain able-bodied adults without children to work, seek work or participate in job training as a condition of receiving Medicaid. Some Republican governors want to impose such requirements, but the Obama administration has turned down their proposals.
Mr. Price praised Indiana’s program to expand Medicaid eligibility under the Affordable Care Act with conservative policies that state officials say promote “personal responsibility.”
“States know best” how to care for their Medicaid beneficiaries, he said, adding, “What Indiana has done is really a best practice, I think, for many other states to follow.”
Mr. Trump has not said much about the future of Medicaid in the 31 states that have expanded eligibility, with large amounts of federal money.
Democratic senators were often frustrated in their efforts to get Mr. Price to say whether he supported the coverage requirements and insurance mandates in the Affordable Care Act.
In a typical response, he said that patients should have “access to the kind of coverage that they want,” rather than having it dictated to them by the government.
Senator Christopher S. Murphy, Democrat of Connecticut, said that Mr. Price appeared to support the coverage and protections provided by the Affordable Care Act, but that “we don’t get any specifics as to how that’s going to occur” if the law is repealed.
Without mandating coverage of specific benefits, Mr. Price said, the Trump administration could “make certain that individuals had the care and the kind of coverage that they needed for whatever diagnosis would befall them.”
He said the administration could put in place “a different construct” that “would allow for every single person to gain access to the coverage that they want and have nobody fall through the cracks.”
He did not say how the Trump team would guarantee such protection.
Mr. Trump has expressed support for a provision of the 2010 health law under which insurers must allow children to stay on their parents’ policies until the age of 26. This is “baked into the insurance programs that are out there right now,” Mr. Price said.
“I think that the insurance industry has included individuals up to age 26 on their parents’ policies virtually across the board,” he said, “and I don’t see any reason that that would change.”
Democrats were skeptical. Senator Maggie Hassan of New Hampshire said there was no guarantee that such protections would continue in the absence of federal requirements. Insurance companies did not routinely cover drug abuse treatment in the past and might not do so in the future without a requirement, she said.
The Congressional Budget Office said Tuesday that the number of uninsured Americans could increase by 18 million in one year if Congress repealed major parts of the health care law while leaving others. Mr. Price tried on Wednesday to allay fears of disruption.
“I think there’s been a lot of talk about individuals losing health coverage,” Mr. Price said. “That is not our goal, nor is it our desire, nor is it our plan.”
“One of the important things that we need to convey to the American people is that nobody’s interested in pulling the rug out from under anybody,” he said. “We believe that it’s absolutely imperative that individuals that have health coverage be able to keep health coverage and move, hopefully, to greater choices and opportunities for them to gain the kind of coverage that they want for themselves and for their families.”
Mr. Price said he would “absolutely” consider administrative action to stabilize the market for insurers, which are supposed to submit proposals for 2018 coverage in April. Insurers say it will be nearly impossible to calculate premiums if they have no idea what will replace the health care law.
Mr. Price championed “medical innovation” as an essential ingredient of high-quality care but criticized the Center for Medicare and Medicaid Innovation, which was created by the health law to test new ways of paying doctors, hospitals and other providers.
He said that the agency had great promise, but that too often, its experiments were compulsory for doctors and nearly nationwide in scope. He said he “adamantly opposed the mandatory nature” of some payment models, like one for joint replacement surgery and one for expensive drugs administered in doctors’ offices.
Mr. Price said he would not object if Medicare tested payment methods with small pilot projects that could expand if successful.
The health committee will not vote on Mr. Price’s nomination. Another hearing has been scheduled for Tuesday by the Senate Finance Committee, which will vote on whether to recommend confirmation. The committees share authority over issues for which the Health and Human Services Department is responsible.



Blame Technology, Not

Longer Life Spans, for
Health Spending Increases

by Austin Frakt - NYT

American life spans are rising, and as they are, health care spending is, too. But longevity is not contributing to the spending increase as much as you might think.
The median age in the United States will rise to about 40 by 2040, up from 37.7 today. That’s partly because the average American lives three years longer today — reaching nearly 79 years old — than in 1995. The Congressional Budget Office credits population aging for a substantial portion of its projected increase in health care spending — from 5.5 percent of the economy today to almost 9 percent by 2046.
But research suggests that living longer, by itself, isn’t a big driver of rising health care spending. Because the baby boom generation is so large — members of which are now in their 50s to late 60s — the average age of Americans would rise even if life expectancy didn’t. For every 100 working-age American today, there are about 25 Americans over 65. By 2040 there will be 37.
Older people need more health care, and they spend more. Compared with the working-age population (people 19 to 64 years old), those 65 to 74 spend two times as much; those 75 to 84 spend four times as much; and those 85 and older spend six times as much. And the growth in health care spending is faster for retirees than for younger Americans.
The real culprit of increased spending? Technology.
Every year you age, health care technology changes — usually for the better, but always at higher cost. Technology change is responsible for at least one-third and as much as two-thirds of per capita health care spending growth. After accounting for changes in income and health care coverage, aging alone can explain only, at most, a few percentage points of spending growth — a conclusion reached by several studies.
Some health care technology helps us live longer. The vast majority of the seven years of life expectancy gains in the latter half of the 20th century were because of better — and more costly — treatments for premature infants and cardiovascular disease, according to analysis by the Harvard health economist David Cutler and his colleagues. But recent work led by the Stanford economist Raj Chetty reminds us that factors outside the health system — like smoking rates and education levels — also influence longevity.
Just how much longer life spans boost spending depends on how many of those extra years are spent in good health versus poor health. Several studies warn that Americans will spend more of those years in poor health and with disability, which would push health spending higher.
But other analysis suggests that the leading causes of death, including cancer, heart disease and stroke, are being pushed off until later in life, giving us more years of good health. A recent study by Mr. Cutler and researchers from Harvard and the National Bureau of Economic Research found that between the early 1990s and the late 2000s, the elderly population gained more disability-free years than years with disability.
Perhaps some of the additional money we pour into the health system each year is doing some good. “Certainly we must address the problems associated with financing health care spending and health disparities,” said Michael Chernew, a Harvard health economist and a co-author on the study. “But we can take some solace in evidence that more people are living longer and better.”
These findings are consistent with other work showing that higher health care spending by older patients has more to do with their proximity to death than with their age. One study found that hospital expenses grow 1,000 percent in the last five years of life, but increase only 30 percent from 65 years old to 80. Another study found that a majority of Americans over age 85 have no limitations to their daily activities because of health, which suggests that age is a poor marker of health and its associated costs.
A decade ago, in a study published in Health Policy, two German health economists calculated how much incorporating the effect of shifting the spending near death could reduce health care spending projections. They took an extreme approach by assuming all of the increase in health care spending as one ages is in the proximity to death (none to greater age). So imagine that instead of incurring high costs and dying at, say, 75, one lives five more years in relative health, shifting those higher costs to just before age 80. The effect, according to their study, is to reduce estimates of health care spending because of aging by 40 percent.
In other words, living longer doesn’t increase health care spending so much as it delays the large amount spent near death. Some health care spending is associated with those intervening, relatively healthy years, just not much compared with that spent in one’s final years.
Living longer offers many benefits. That it isn’t, by itself, a major contributor to health care spending is a nice bonus.

Trump’s Vow to Repeal Health Law Revives Talk of High-Risk Pools

by Reed Abelson - NYT
Joanne Fitzgerald was getting divorced and was stressed out. When stomach painkicked in, she saw a doctor to have it checked out.
That was her mistake.
The doctor diagnosed a mild form of gastritis, an inflammation of the stomach lining, and recommended some over-the-counter medicine. But when the divorce became final, in 2008, she lost health coverage from her husband’s employer, and insurer after insurer refused to cover her because of the condition. She was finally offered a policy that excluded coverage for anything related to her gastrointestinal tract.
“I thought I was being smart in going to the doctor and getting checked out,” Ms. Fitzgerald, 55, who currently lives in Washington, D.C., said recently. “Then I tried to go get insurance and everyone denied me.”
Her fortunes changed under the Affordable Care Act, the major health law signed by President Barack Obama that required insurers to cover pre-existing medical conditions. She was one of the millions of people who jumped at the opportunity and bought a policy available under the new law.
Now, after President Trump and the Republican-controlled Congress have vowed to repeal and replace the health law, one of the most vexing questions is whether people like Ms. Fitzgerald will be covered.
About 27 percent of people under 65 are thought to have some sort of pre-existing condition that will most likely leave them without individual insurance if the law is repealed, according to a recent study. The guarantee of coverage has already become a rallying cry for people who want to keep the law.
The issue “is the third rail” for the Republicans, said Michael Turpin, a longtime health industry executive.
Before the law, a fairly typical life event — like a divorce or the loss of a job — and a relatively minor medical condition could upend a person’s health coverage options. Stories of sick people unable to get coverage when they needed it most were legion.
Mr. Trump insists he wants to keep the pre-existing requirement for insurers, and other top Republicans say people who want coverage should not be turned away. Details about how they will cover people with existing medical conditions have not yet emerged, but many lawmakers have started pushing an idea — known as high-risk pools — that left many people uncovered or with strict limits to their coverage in the past.
The challenge for lawmakers is this: How do you get insurers to cover people who will definitely need costly medical care — and do so without making insurance too expensive for everyone?
The Affordable Care Act addresses that question by requiring everyone to get coverage or face a tax penalty. That mandate is meant to increase the number of healthy people who have insurance, distributing the costs of caring for those who are sick across a wider population. The thinking is that if enough healthy people sign up, the costs of sick people will be offset for insurers.
Top Republicans, though, say the system is not working and point to double-digit price increases for premiums.
“There is a better way to fix that problem without giving everybody else all these massive premium increases,” the House speaker, Paul D. Ryan, said at a recent televised forum.
Finding a fix is far from simple. Before the law was passed, insurance companies evaluated the health of each person applying for coverage before offering a policy, and priced the plan to reflect the possible cost of care. The companies wanted to minimize the risk of losing money by paying for costly medical care for too many of their customers.
Often, insurers offered no options to people with pre-existing conditions, because they considered the potential costs to be too high. As a result, 35 states had high-risk pools, the program again on the lips of top lawmakers, including Mr. Ryan.
The high-risk programs offered a separate insurance pool for people with potentially expensive medical conditions. The idea is that by separating sick people from the majority of people who are healthy, insurers could offer cheaper rates to the healthy people. Insurers could charge higher prices to those with existing medical conditions, but they would also rely on other sources of funding, including from the government, to cover their costs.
The system worked for Dan Nassimbene and his wife, who had breast cancer but is in remission. They enrolled in Colorado’s high-risk pool for three years. She paid about $375 a month for a plan that covered most of her treatments.
In 2014, though, the high-risk pool was closed, and Mr. Nassimbene bought a plan that met the requirements of the Affordable Care Act. The cheapest plan he could buy for himself and his wife cost around $900 a month and came with a family deductible of around $12,000, much higher than it was before. His income was too high for him to receive any government subsidies, which help about 80 percent of people buying such plans.
“I had coverage but no access,” said Mr. Nassimbene, 55. He has since switched to a Christian health care sharing ministry, in which members cover one another’s medical bills. It does not qualify as coverage under the law.
In many cases, the high-risk pools were overburdened financially, leaving many people without insurance or with tight restrictions on coverage. Insurers refused to cover the individuals who were likely to have the highest expenses, like those who had H.I.V. or serious kidney disease, and the pools lost money.
Many states had to turn applicants away — in some states, only a small percentage of those who applied received coverage — and the insurance was sharply limited to control spending.
In Washington, over 80 percent of the people referred to the state’s high-risk pool never got health insurance, said Mike Kreidler, the state’s insurance commissioner. In California, which relied on lawmakers to allocate money as part of the state budget, there was a waiting list, recalled Richard Figueroa, who was a senior administrator for the program.
The pool operated on a first-come-first-served basis, Mr. Figueroa said, without regard to people’s income or the severity of their medical condition.
“There were people literally dying on the waiting list,” he said.
In addition, most of the states offering coverage had caps on payments for medical care. Washington’s annual maximum was $2 million, while California’s limit was $75,000 a year. Under the Affordable Care Act, insurance plans cannot have such a limit.
In California, the program dwindled away until it served only 6,300 at the end of 2011.
Dennis Carr, for example, worked as an independent real estate agent when the financial markets crashed in 2008. He had savings, but he eventually had to drop his Blue Cross plan because his income had tailed off and he could not afford it. Mr. Carr, who is now 51, said his goal was to resume coverage as soon as he was financially secure.
When he reapplied to the same insurer a few months later, he was rejected — and then rejected again by another insurer because of his asthma and a sinus condition.
“It was just a real, real slap,” Mr. Carr said.
He was directed to California’s high-risk pool but found the premiums too high. He moved to Mexico as a way to afford his medications. He now lives in Phoenix, where he has coverage through an employer.
“For all the thousands of people who self-selected out because they couldn’t afford it, it broke our hearts on a daily basis,” Mr. Figueroa, the California official, said.
For others, the coverage offered by the high-risk pools was too limited for them to receive the care they needed.
Beth Martinez, 40, who has multiple sclerosis, was forced to join Texas’ high-risk pool when she and her husband moved to Austin. Only six visits to the doctor were covered, and she found she could not afford the annual M.R.I. recommended to monitor her disease because of her high deductible. At one point, she said, she went four years without an M.R.I.
She and her husband now live in California and are covered through private plans offered through that state’s marketplace, which meet all the health law’s requirements for pre-existing conditions. Because she can work only part time, she is eligible for federal subsidies, which bring the couple’s costs to $70 a month. Ms. Martinez had paid $275 a month in the Texas pool to cover herself, and her husband was uninsured.
She now gets the M.R.I.s she needs under her plan, and her policy even pays for physical therapy, which allows her to put in longer hours at her job as a hairstylist and makeup artist.
That sort of quality coverage, Ms. Martinez said, is a big departure from what she had through the high-risk pool, adding that “it was definitely some of the worst insurance I had in my life.”


Trump’s Health Plan Would Convert Medicaid to Block Grants, Aide Says

by Robert Pear - NYT

WASHINGTON — President Trump’s plan to replace the Affordable Care Act will propose giving each state a fixed amount of federal money in the form of a block grant to provide health care to low-income people on Medicaid, a top adviser to Mr. Trump said in an interview broadcast on Sunday.
The adviser, Kellyanne Conway, who is Mr. Trump’s White House counselor, said that converting Medicaid to a block grant would ensure that “those who are closest to the people in need will be administering” the program.
A block grant would be a radical change. Since its creation in 1965, Medicaid has been an open-ended entitlement. If more people become eligible because of a recession, or if costs go up because of the use of expensive new medicines, states receive more federal money.
If Congress decides to create block grants for Medicaid, lawmakers will face thorny questions with huge political and financial implications: How much money will each state receive? How will the initial allotments be adjusted — for population changes, for general inflation, for increases in medical prices, for the discovery of new drugs and treatments? Will the federal government require states to cover certain populations and services? Will states receive extra money if they have not expanded Medicaid eligibility under the Affordable Care Act, but decide to do so in the future?
Ms. Conway, speaking on the NBC program “Sunday Today,” said that with a block grant, “you really cut out the fraud, waste and abuse, and you get the help directly” to intended beneficiaries.
Medicaid covers more than 70 million people at a combined cost of more than $500 billion a year to the federal government and the states. More than 20 million people have gained coverage under the Affordable Care Act, more than half of them through Medicaid.
The new Congress has approved a budget that clears the way for speedy action to repeal the health care law, President Barack Obama’s signature domestic achievement. And Mr. Trump has said Congress should take action to repeal and replace the law at the same time, putting pressure on lawmakers to agree on an alternative.
As a candidate, Mr. Trump said he wanted to “maximize flexibility for states” so they could “design innovative Medicaid programs that will better serve their low-income citizens.” On Friday, in his first executive order, he directed federal officials to use all their authority to “provide greater flexibility to states” on the health law.
As part of their “Better Way” agenda, House Republicans said in June that they would roll back the Affordable Care Act’s expansion of Medicaid and give each state a set amount of money for each beneficiary or a lump sum of federal money for all of a state’s Medicaid program — “a choice of either a per capita allotment or a block grant.”
Governors like the idea of having more control over Medicaid, but fear that block grants may be used as a vehicle for federal budget cuts.
“We are very concerned that a shift to block grants or per capita caps for Medicaid would remove flexibility from states as the result of reduced federal funding,” Gov. Charlie Baker of Massachusetts, a Republican, said this month in a letter to congressional leaders. “States would most likely make decisions based mainly on fiscal reasons rather than the health care needs of vulnerable populations.”
Gov. Robert Bentley of Alabama, a Republican, said that if a block grant reduced federal funds for the program, “states should be given the ability to reduce Medicaid benefits or enrollment, to impose premiums” or other cost-sharing requirements on beneficiaries, and to reduce Medicaid spending in other ways.
In Louisiana, Gov. John Bel Edwards, a Democrat, said he was troubled by the prospect of a block grant with deep cuts in federal funds. “Under such a scenario,” he said, “flexibility would really mean flexibility to cut critical services for our most vulnerable populations, including poor children, people with disabilities and seniors in need of nursing home and home-based care.”
Gov. John W. Hickenlooper of Colorado, a Democrat, said that block grant proposals could shift costs to states and “force us to make impossible choices in our Medicaid program.”
“We should not be forced to choose between providing hard-working older Coloradans with blood pressure medication or children with their insulin,” Mr. Hickenlooper said.
https://www.nytimes.com/2017/01/22/us/politics/donald-trump-health-plan-medicaid.html?hpw&rref=health&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well

Replace Obamacare with single-payer national health insurance

By Claudia Fegan, M.D.
STAT, January 20, 2017
During the bruising 2016 presidential campaign, Donald Trump vowed to repeal Obamacare “on day one of the Trump administration.” Today is that day. If soon-to-be President Trump makes good on that promise, I urge him to replace it with single-payer national health insurance.
If it, or some other equitable form of insurance, isn’t quickly put in place, I worry about the patients who will die when they lose access to timely health care.
The Affordable Care Act expanded coverage to 20 million people and improved their access to care. Every day I see its beneficial impact on the patients I serve as the chief medical officer at Chicago’s largest public hospital. Tens of thousands of our patients were covered for the first time, many under the law’s Medicaid expansion, and we were able to provide them care that was previously out of their reach.
While the ACA represents an important step forward in other respects, such as eliminating penalties for preexisting conditions and covering children until age 26 on their parents’ plan, our health care system is still the worst of any wealthy nation.
Millions remain uninsured, and most Americans’ coverage comes with gaping holes, like a hospital gown that looks pretty good in front but leaves a lot hanging out in back. Patients often find they can’t afford care, given the high deductibles and copays, and their choice of doctors and hospitals is often restricted. Costs continue to soar, and greedy corporations have gained an even tighter stranglehold on health care.
Defending that status quo, as many Democratic politicians have been trying to do, is a losing battle. The ACA continues to allow insurance companies to limit access to health care, and the pharmaceutical industry to limit access to lifesaving treatment with predatory pricing.
Soon-to-be President Trump and the Republicans want the law repealed. Most people in favor of that happening want something better, not a return to the past. Replacement has to move forward to universal and upgraded coverage and move away from shifting costs to the patients least able to bear the financial burden of illness rather than going backward to the bad old pre-ACA days.
Here’s one inspiring vision of health care reform that would lift the vast majority of Americans: single-payer national health insurance. Enactment of a single-payer plan would demonstrate that we are a caring nation. People shouldn’t die in the richest country in the world due to lack of access to care.
According to a Gallup poll last year (and a similar Kaiser survey), more than half of Americans wanted to repeal the ACA, and most Americans still have a dim view of the law. They know it is not working. They know the deductibles are too high and they can’t afford the copayments. (Curiously, on the eve of its repeal, a growing number of Americans say they support the law.)
But the Gallup poll also showed that 58 percent of Americans — including 41 percent of Republicans and 53 percent of those who favored repeal — wanted the ACA replaced with “a federally funded health care program providing insurance for all Americans,” in other words, single-payer reform. They want a plan that covers the care they need and lets them see the providers they choose with no out-of-pocket costs.
Now is the time for a single-payer health system — improved Medicare for all. It would take the hundreds of billions now wasted on insurance bureaucracy and billing paperwork and use that money to expand and upgrade coverage. It would cover all of the uninsured. And it would abolish copayments and deductibles for the 91 percent of Americans who are currently covered by health insurance.
After Trump’s election, my newly insured patients began to ask if they were going to lose their health insurance. Trump has said he has a plan to cover everyone, cut costs, and cut painful deductibles and copayments that limit access to care. But so far there is no firm plan, he is notoriously unpredictable, and his cabinet nomineesindicate that his administration will take a different course.
Single-payer health systems have a proven track record on cost control. When Canada passed its single-payer medical insurance plan in the 1960s, its health spending was commensurate with ours and growing at the same rate. Today, Canada spends about half of what the US does. Much of the savings have come from slashing insurance overhead and paperwork. Where insurance giant Aetna keeps about 20 cents of every premium dollar for itself, the comparable figure for overhead in Canada’s system is 2 cents, and for Medicare it’s 3 cents. And Canada has saved vast amounts by simplifying hospitals’ and doctors’ billing paperwork.
Republican plans for the ACA threaten the health of my patients and millions of other Americans, and the status quo is unacceptable. That’s why I, and the 20,000 colleagues who have joined me in Physicians for a National Health Program, are fighting for single payer — a health reform that would cure America’s health care ills, not just provide some pain relief.
Now is the time to take that step.

Medicare coverage for all

By Thomas Clairmont, M.D.
Seacoastonline.com (Portsmouth, N.H.), Letters, Jan. 13, 2017
Your editorial on Jan. 9 stated "There is no health-care reform that will lower premiums, cut deductibles and increase choice all at the same time."
That is totally untrue and it is embarrassing that such tripe should be presented to the public who are overpaying and underutilizing health care services.
Expansion of Medicare to cover every citizen comprehensively, equitably, affordably, with a lifetime portable policy, does indeed lower premiums, eliminates deductibles, and offers full choice of your doctor and hospital. In fact, no other plan can work. Every major country provides full lifetime coverage to all of their citizens at less than half of what we are paying in the United States. None permit the price gouging occurring today. None have bankruptcy related to medical care.
There are several plans readily available for review. Senator Sanders, who won 22 states and might have won if not for the chicanery of the DNC, presented his plan night after night to rousing audiences. You can read his ideas on his website or in his new book "Our Revolution." University of Massachusetts Economics Professor Friedman argues that "Medicare for All saves billions." Physicians for a National Health Program have their ideas encapsulated in HR 676. Every plan includes you fully for life and includes dental health and mental health and prescriptions.
Why hasn't the media presented these ideas for your consideration?
Why do Democrats and Republicans oppose full coverage for all of their constituents?
Why wouldn't you want to have a plan that costs less than 10 percent of your income for total coverage that is permanent?
Health care and its costs are on the minds of every citizen almost every day. Expanding Medicare to cover all of you makes sense to me. Apparently not doing it makes cent$ for those who don't. What other reason is their opposition?


Maine GOP Sen. Collins Unveils Proposal to Replace Obamacare

By Patty Wight - MPBN

PORTLAND, Maine - Maine U.S. Sen. Susan Collins joined with fellow Republican Sen. Dr. Bill Cassidy of Louisiana today at a press conference in Washington to unveil their plan to replace the Affordable Care Act.
The "Patient Freedom Act of 2017" would give states the choice of whether to keep the ACA or choose a default option to cover its uninsured population, "by providing a standard plan that had a high deductible, a basic pharmaceutical coverage, some preventive care, and it would be financed through Health Savings Accounts," Collins said.
Collins said states that choose the default option would receive the amount of money they would receive under the Affordable Care Act, including money they would be eligible for under Medicaid expansion.  The Patient Freedom Act would also allow states to choose no federal help.


Sen. Collins proposes ACA replacement that would give uninsured $5,000 for health care

Collins is touting the plan as an acceptable replacement for the Affordable Care Act that could garner Democratic support.
by Joe Lawlor - Portland Press Herald

Sen. Susan Collins (R-Maine) and a Louisiana senator are rolling out their replacement for the Affordable Care Act today and touting it as a bipartisan compromise.
“I really believe this approach can bring both sides together,” Collins said during a phone interview with the Press Herald Monday morning. The ACA is currently under threat of repeal by a Republican-led Congress and President Donald Trump, who has vowed to repeal and replace the ACA. Trump has not yet unveiled the administration’s replacement plan.
Collins said the replacement plan she’s introducing with Louisiana Republican Sen. Bill Cassidy would likely result in more people being insured than is currently under the ACA.
“Our goal is to expand the number of people insured,” Collins said.
The plan gives wide latitude to the states to devise health policy. States could choose to keep the ACA intact, including Medicaid expansion and the health insurance marketplace.
“We believe in some states the ACA is working well. We don’t mandate a one-size-fits-all approach,” Collins said. “If the ACA is working in your state, you can keep it.”
But Collins said in many states the ACA is underperforming, and the Patient Freedom Act of 2017 gives states the option to still receive the same funding that they would under the ACA, but use it to develop plans for insurance for low- to moderate-income residents. 
Under one of the options states could choose, everyone who does not otherwise have access to insurance – such as through an employer or Medicare – would be automatically enrolled in a standard high-deductible insurance plan, and $5,000 would be deposited into a health savings account for an individual. The amount would be $10,000 for a married uninsured couple.
The money in the health savings account would be used to pay for deductibles and co-pays. 
Collins said there would be some variance based on geography because the cost-of-living and the cost of insurance varies by region.
But Collins was also quick to point out that the standard plan would not be a catastrophic plan. The plan would have health services that would be covered by insurance.
“This is real insurance,” Collins said.
Collins said under the bill, individuals would receive the $5,000 if they earned up to $90,000 or $150,000 for a married couple. After the income thresholds are reached, the $5,000 would be gradually reduced.
Collins said the Patient Freedom Act eliminates the “cliff” problem inherent in the ACA individual marketplace, where someone who earns more than 400 percent of the federal poverty limit – about $97,000 for a family of four – is cut off from all subsidies.
This story will be updated.

Congressional Republicans try to find health care compromise

The alternative plan to be proposed by Maine's Sen. Susan Collins is just one of several on the table.
by McClatchy Washington Bureau

WASHINGTON — President Trump wants Congress to move quickly this week to dismantle the Affordable Care Act, but congressional Republicans are far from a consensus on a repeal-and-replace effort that won’t leave millions of their constituents without insurance.
Monday, two senators who have cautioned colleagues to delay repeal until they’ve settled on a replacement will announce an alternative plan to give states the choice to keep the health care law or be granted flexibility to expand Medicaid and other coverage options.
That alternative, from Sens. Susan Collins, R-Maine, and Bill Cassidy, R-La, runs counter to the plans on the table, including one from Trump’s health secretary nominee Tom Price, known as the “Empowering Patients First Act.” That would offer tax credits, encourage the use of health savings accounts and urge states to develop high-risk pools.
“I’m not saying that it’s perfect, but it’s important that we put specific proposals on the table,” Collins said on the Senate floor about the plan she will advance this week. Repeal without replacement or repeal with a delay, as some lawmakers have suggested, would send insurance markets into a tailspin, she said.
In addition to Price’s plan, Republicans have considered House Speaker Paul Ryan’s “A Better Way.” Ryan’s plan would also offer tax credits to help people pay for insurance, and he wants to overhaul Medicare, which Trump has promised not to cut.
Complicating the situation, Trump’s pledge for “insurance for everybody” conflicts with what many fiscal-minded Republicans intend to do – and the yawning gap between congressional conservatives and their president on the issue is something Democrats are eager to exploit.
“I guess we have to wait for President Trump’s Twitter to figure out what the Republican plan is going to be,” said Rep. Ben Ray Lujan, D-N.M. He is a member of Democratic leadership, which has sought to highlight Republican contortions over finding a solution. “They’re all on different pages and when they try to clean it up they contradict each other all over again,” Lujan said.
Although the new Trump White House website does not list health care as one of the administration’s “top issues,” and it didn’t come up in his inaugural address, Trump addressed repeal in one of his first acts as president. He signed an executive order Friday that reiterates his administration’s intent to seek “the prompt repeal” of the 2010 law that has extended health care to 20 million Americans. But the executive order itself notes that regulations can be changed only through the traditional process of “notice and comment,” which can take months or even years.
And it will require his political appointees to be in office, which has yet to happen, particularly as Senate Democrats look to slow the nomination of Rep. Tom Price, R-Ga., Trump’s choice for health and human services secretary. Price goes before the Senate Finance Committee Tuesday for a confirmation hearing.
Trump has said his administration has a health care plan “very much formulated down to the final strokes.” But his promise a week ago of “insurance for everybody” has Republicans with an eye on fiscal restraint worried that he’s promising more than they can deliver. Vice President Mike Pence sought last week to clarify Trump’s words, telling CNN that Trump is talking about “making insurance affordable for everyone.”
Price also distanced himself from Trump’s pledge. He said at a Senate hearing that he was committed to seeing that Americans have “access” to health care coverage, which Democrats point out is not the same thing as guaranteeing coverage.
Trump’s most recent pledge would suggest “a much more expansive plan than he even talked about on the campaign trail or than any of the proposals coming from Congress,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. “We’re in a period of very little clarity.”



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