Pages

Thursday, June 22, 2017

Health Care Reform Articles - June 22, 2017

Senate Leaders Unveil Bill to Repeal the Affordable Care Act

by Robert Pear and Thomas Kaplan - June 22, 2017

WASHINGTON — Senate Republicans, who have promised a repeal of the Affordable Care Act for seven years, took a major step on Thursday to achieve that goal as they unveiled a bill to end the health law’s mandate that nearly everyone have health care, remake and cut the Medicaid program and create a new system of federal tax credits to help people buy health insurance.
The Senate bill — once promised as a top-to-bottom revamp of the health bill passed by the House last month — instead maintains its structure, with modest adjustments. The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.
But the Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House measure, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.
It would also repeal virtually all the tax increases imposed by the Affordable Care Act to pay for itself, in effect handing a broad tax cut to the affluent, paid for by billions of dollars sliced from Medicaid, a health care program that serves one in five Americans, not only the poor but two-thirds of those in nursing homes. The bill, drafted in secret, is likely to come to the Senate floor next week, and could come to a vote after 20 hours of debate.
If it passes, President Trump and the Republican Congress would be on the edge of a major overhaul of the American health care system — one-sixth of the nation’s economy.
The premise of the bill, repeated almost daily in some form or other by its chief author, the Senate majority leader, Mitch McConnell of Kentucky, is that “Obamacare is collapsing around us, and the American people are desperately searching for relief.”
Mr. Trump shares that view, and the Senate bill, if adopted, would move the president a great distance closer to being able to boast about final passage of a marquee piece of legislation, a feat he has so far been unable to accomplish.
In the Senate, Democrats are determined to defend a law that has provided coverage to 20 million people and is a pillar of former President Barack Obama’s legacy. The debate over the repeal bill is shaping up as a titanic political clash, which could have major implications for both parties, affecting their electoral prospects for years to come.
Mr. McConnell faces a great challenge in amassing the votes to win Senate approval of the bill, which Republicans are trying to pass using special budget rules that will allow them to avoid a Democratic filibuster. But with only 52 seats, Mr. McConnell can afford to lose only two Republicans, with Vice President Mike Pence breaking the tie. He may have already lost one — Senator Rand Paul, Republican of Kentucky, has indicated repeatedly that the bill is too liberal for him.
Democrats are unified in opposing the repeal efforts, and they have already assailed Republicans for the work they have done so far, criticizing them for putting the bill together without a single public hearing or bill-drafting session.
In the short term, the possible electoral consequences are more muted in the Senate than in the House, as only two of the Senate Republicans who face re-election next year, Dean Heller of Nevada and Jeff Flake of Arizona, are seen as vulnerable.
But Republican leaders still must contend with internal divisions that will be difficult to overcome. Numerous Republican senators from states that expanded Medicaid are concerned about how a rollback of the program could affect their constituents, and they face pressure from governors back home.
Some senators have concerns based on other issues specific to their states, including the opioid epidemic that has battered states like West Virginia and Ohio. And some of the Senate’s most conservative members could resist a bill that they view as not going far enough in dismantling the Affordable Care Act.
Senators will not have long to sort out their differences. Mr. McConnell wants to hold a vote before lawmakers return home for the Fourth of July recess. If the repeal bill is still looming over the Senate, Republicans are certain to face intense pressure from constituents who wish to see the Affordable Care Act remain in place.
The assessment being made by senators will be shaped in part by an analysis of the bill to be released by the Congressional Budget Office, the official scorekeeper on Capitol Hill.
The budget office found that the bill passed by the House last month would leave 23 million more people without insurance in a decade. Mr. Trump recently told senators that the House bill was “mean,” though weeks earlier he had celebrated its passage.

How Senate Republicans Plan to Dismantle Obamacare

by Hoeyoun Park and Margot Sanger-Katz - NYT - June 22, 2017

Senate Republicans on Thursday unveiled a draft of their plan to repeal and replace the Affordable Care Act, which they expect to vote on next week.
The bill is similar to the one passed by the House in May, but it makes several significant alterations, including deeper cuts and structural changes to Medicaid, a program that insures one in five Americans, including two-thirds of nursing home residents.

How the Senate bill alters major parts of Obamacare


Repeal
Change
Keep
Taxes created under Obamacare
Medicaid expansion
Pre-existing conditions policy
Subsidies for out-of-pocket costs
Tax credits for premiums
Dependent coverage until 26
Individual mandate
Essential health benefits
Employer mandate
Prohibitions on annual and lifetime limits
Restrictions on charging more for older Americans
Health savings account

Medicaid expansion


Change
OBAMACARE Raised the eligibility cutoff to 138 percent of the poverty level in any state that chose to expand the program, around $16,000 for a single person. The federal government pays at least 90 percent of the costs for newly eligible beneficiaries.
SENATE BILL Allows the 31 states that expanded Medicaid to continue getting federal funding through 2023, with reduced funding starting in 2021. The bill sharply curtails federal support for Medicaid expansion in 2024, likely causing many states to end the expansion.
Separate from the expansion, the bill caps future federal funding per enrollee, based on how much each state has spent historically. States also have the option to receive a lump-sum block grant for some beneficiaries.
The Congressional Budget Office estimated that similar policies in the bill passed by the House would cut more than $800 billion from the program over a decade. The Senate formula puts the program on a budget and substantially reduces future Medicaid spending.

Taxes created under the Affordable Care Act


Repeal
OBAMACARE Imposed new taxes to help pay for coverage expansion. They include taxes on investment income, wages above $200,000, medical devices, prescription drugs and indoor tanning.
SENATE BILL Permanently eliminates most of the taxes. A tax on high cost employer health plans, established under Obamacare, but yet to kick in, would be imposed beginning in 2026.

Subsidies for out-of-pocket costs


Repeal
OBAMACARE Provides subsidies to help people with lower incomes pay for out-of-pocket costs like deductibles and co-payments.
SENATE BILL Preserves the subsidies through 2019, then eliminates them altogether. This means many low-income people would face high deductibles.

Tax credits for premiums


Change
OBAMACARE Gives tax credits to middle-income Americans to offset the cost of premiums, based on their income and the cost of insurance in their area.
SENATE BILL Changes the formula for subsidies to make them less generous, and lowers the threshold for people who can receive financial assistance from 400 percent to 350 percent of the federal poverty level, or about $42,000 for a single person. The shift in subsidy structure would hurt older people. The bill also expands the subsidies to Americans living below the poverty line, who were ineligible under Obamacare.

Essential health benefits


Change
OBAMACARE Requires all insurers to offer 10 categories of essential health benefits, like maternity treatment and hospital care.
SENATE BILL Preserves this rule, but states could apply to waive the standards. This means that some types of care, like maternity benefits, prescription drugs or addiction treatment, might not be covered in states that waive the rule.

Prohibitions on annual
and lifetime limits


Change
OBAMACARE Bars insurers from setting a limit on how much they have to pay to cover someone.
SENATE BILL Preserves this rule, but gives states the option to eliminate it as part of a waiver of insurance market rules.

Pre-existing conditions policy


Keep
OBAMACARE Requires insurers to cover people regardless of pre-existing medical conditions and bars them from setting prices based on a person’s health history.
SENATE BILL Preserves this rule, but patients with serious illnesses may find that their coverage is less valuable if they live in a state that eliminates benefit requirements or allows limits on coverage.

Restrictions on charging more for older Americans


Change
OBAMACARE Bans insurers selling policies to directly to individuals from charging their oldest customers more than three times what they charge their youngest ones.
SENATE BILL Allows insurers to charge older customers five times as much as younger ones.

Individual mandate


Repeal
OBAMACARE Requires all Americans to buy health insurance or pay a tax penalty, with exceptions for people who have experienced hardships.
SENATE BILL Eliminates the penalties.

Employer mandate


Repeal
OBAMACARE Requires larger companies to provide affordable insurance to their employees, or face financial penalties.
SENATE BILL Eliminates the penalties.

Health savings account


Change
OBAMACARE In 2017, allows an individual to put $3,400 and a family to put $6,750 into a tax-free health savings account.
SENATE BILL Allows people to put more money into their health savings accounts, up to the maximum allowed for out-of-pocket costs, and lets spouses make additional contributions.

Dependent coverage until 26


Keep
OBAMACARE Allows children to stay on their parents’ insurance policies until age 26.

Where Senators Stand on the Health Care Bill

by Alicia Parlapiano and Mercy Benzaquan - NYT - June 22, 2017

Senate Republican leaders on Thursday unveiled their bill to repeal the Affordable Care Act. It needs at least 50 votes to pass (Vice President Mike Pence could cast a tie-breaking vote). Read what the bill would do.
Every Democrat is expected to oppose the bill, which means three Republican “no” votes would block it. Here is where every senator stands so far:
48 No
6 Concerned
35 Unclear
11 Supportive
The full list of lawmakers’ positions:
Republican 
Democrat 
Independent

No

Dianne Feinstein
Calif.
"Robin Hood in reverse"
Kamala Harris
Calif.
"makes draconian cuts"
Christopher S. Murphy
Conn.
"evil, intellectually bankrupt bill"
Brian Schatz
Hawaii
"worse than the House bill."
Richard J. Durbin
Ill.
"would be a disaster"
Tammy Duckworth
Ill.
"guts Medicaid funding"
Joe Donnelly
Ind.
Chris Van Hollen
Md.
"Disgraceful."
Angus King
Maine
Amy Klobuchar
Minn.
Claire McCaskill
Mo.
Maggie Hassan
N.H.
"even more heartless"
Jeanne Shaheen
N.H.
"a wolf in sheep's clothing"
Robert Menendez
N.J.
"downright nasty"
Martin Heinrich
N.M.
"It puts families last"
Tom Udall
N.M.
"a disgrace and a disaster"
Chuck Schumer
N.Y.
Bob Casey
Pa.
"That's obscene."
Patrick J. Leahy
Vt.
"shameful"
Bernie Sanders
Vt.
"the most harmful piece of legislation I have seen in my lifetime"
Maria Cantwell
Wash.
"still mean."

Unclear

Lisa Murkowski
Alaska
"going to review the legislation"
Dan Sullivan
Alaska
Richard C. Shelby
Ala.
Luther Strange
Ala.
John Boozman
Ark.
Tom Cotton
Ark.
Jeff Flake
Ariz.
John McCain
Ariz.
"look forward to thoroughly examining this legislation"
Cory Gardner
Colo.
Marco Rubio
Fla.
"will decide how to vote"
Johnny Isakson
Ga.
"if we do nothing, Obamacare will fail, and Americans will suffer."
David Perdue
Ga.
Joni Ernst
Iowa
Charles E. Grassley
Iowa
"I’m studying it."
Michael D. Crapo
Idaho
Jim Risch
Idaho
Todd Young
Ind.
"reviewing the discussion draft"
Jerry Moran
Kans.
Bill Cassidy
La.
Roy Blunt
Mo.
Thad Cochran
Miss.
Roger Wicker
Miss.
John Hoeven
N.D.
Deb Fischer
Nebr.
Ben Sasse
Nebr.
Rob Portman
Ohio
James M. Inhofe
Okla.
"continuing to review the details"
James Lankford
Okla.
"will make a decision after the CBO score"
Lindsey Graham
S.C.
"will carefully review this legislation"
Michael Rounds
S.D.
Shelley Moore Capito
W.Va.
"I will review the draft legislation"

Supportive

Mitch McConnell
Ky.
"It's time for #BetterCare."
John Thune
S.D.
"will help stabilize markets that are already collapsing"
Lamar Alexander
Tenn.
"benefits for Tennesseans"
John Barrasso
Wyo.
"a vast improvement over Obamacare"
Michael B. Enzi
Wyo.

 

The Health Care of Millions Depends on a Few Senators

The Editorial Board - NYT - June 21, 2017

We do not know a lot about what is in the health care bill that Republicans are trying to rush through the Senate, but what we do know suggests it will be as bad or worse than the dreadful legislation that the House passed in May.
The Senate majority leader, Mitch McConnell, is doing everything he can to keep the public in the dark about his plan to undo major provisions of the Affordable Care Act, or Obamacare. But Washington being Washington, a few details have become public. All are alarming and depressing. And as they emerge, and the public unveiling of the bill grows closer — it could come on Thursday — the need for a few wise Republicans to stand with Senate Democrats to say “no” becomes ever more urgent.
One provision under consideration in the Senate, according to news reports, would reduce federal spending on Medicaid more than the Dickensian House version does. That would put even more pressure on states to reduce care for the nearly 75 million people who benefit from that program.
Another change would make it much easier for states to let insurance companies sell policies that do not cover treatments like chemotherapy or drugs like insulin, leaving people with pre-existing health problems and those who become sick worse off.
Whatever their differences, the Senate and House versions have this in common: a callous disregard for the health care of millions of people plus a kind of frantic wish to pass something, no matter how destructive and poorly thought out, that lets President Trump and other Republicans claim that they have repealed Obamacare.
The House bill, the American Health Care Act, would rob 23 million people of health insurance and make it harder for millions of others to get the care they need, according to the Congressional Budget Office. It would cut federal spending by about $1.1 trillion over 10 years while giving the wealthy big tax cuts. Those numbers might be somewhat different for the Senate bill but, according to experts, not by much.
Polls show that most Americans do not support the changes the Republicans want to make. A CBS News poll published on Tuesday found that 59 percent of people disapproved of the House bill. That explains why Mr. McConnell wants to have a vote on his legislation before Congress leaves town for the Fourth of July without any hearings or much public debate. He is trying to thread the needle between the ultraconservative and the more moderate members of his caucus. He knows that he can pass the bill with just 50 Republicans and a tiebreaking vote from Vice President Mike Pence.
Democratic senators are trying to slow the train by putting up procedural roadblocks to unrelated bills. They are also demanding public hearings on the bill, which Mr. McConnell has so far failed to provide. These tactics are unlikely to stop Mr. McConnell, but at the very least they have shone a spotlight on his reprehensible tactics.
But the country needs more than a spotlight. What it needs is at least three Republican senators to come out against the bill. Susan Collins of Maine, the most moderate senator in the G.O.P., is expected to be one of them. Lisa Murkowski of Alaska could well be another because the bill would take a huge toll on people in her state, which has very high health care costs. Under the House bill, the insurance premiums for a 40-year-old in Fairbanks who earns $30,000 a year would jump by about $8,500, to $10,430, according to the Kaiser Family Foundation. Those numbers should also be of concern to the other senator from Alaska, Dan Sullivan, who has so far not shown his hand.
Other Republican senators who ought to be particularly alarmed include Shelley Moore Capito of West Virginia, Rob Portman of Ohio and Dean Heller of Nevada. Their states expanded Medicaid under the A.C.A. and stand to lose billions of dollars in federal funds under the House and Senate bills. That will make it harder for their states and others to place older adults in nursing homes, provide care to the disabled and offer addiction treatment to people ensnared in the opioid epidemic.
The health care of millions of Americans rests in the hands of a few Republican senators. Who among them will be willing to defy their party and fight for their constituents?

Middle Class, Not Poor, Could Suffer if Trump Ends Health Payments

by Abby Goodnough - NYT - June 20, 2017

ASHEVILLE, N.C. — Jane and Abe Goren retired here five years ago to escape the higher cost of living they had abided for decades in the suburbs of New York City. They did not anticipate having to write monthly checks for health insurance that would exceed their mortgage and property taxes combined.
Ms. Goren, 62, is paying nearly $1,200 a month for coverage through the individual insurance market (her husband, 69, is on Medicare) and accumulating enough debt that her sons recently held a fund-raiser to help. For next year, her insurer, Blue Cross and Blue Shield of North Carolina, has proposed raising premiums by an average of 22.9 percent, a spike it is blaming squarely on President Trump.
For months, the Trump administration has threatened to stop billions of dollars in payments that lower out-of-pocket medical costs for nearly six million low-income patients. Mr. Trump’s hedging has created deep uncertainty in the Affordable Care Act markets, the impact of which may become clearer on Wednesday, the deadline for insurers to say whether they plan to sell next year on the federal marketplace created under the health law and to file rate requests.
North Carolina has more than 300,000 people benefiting from these “cost-sharing” subsidies, which reimburse insurers for absorbing the deductibles and co-payments of low-income customers. The Affordable Care Act requires that these customers’ out-of-pocket costs be lowered one way or another. If the federal government stops reimbursing insurers, many insurers have said they will make up for it by raising premiums.
Paradoxically, that will primarily hurt not poor customers but millions of middle-class people like the Gorens, who earn too much to qualify for premium assistance under the law and will bear the full brunt of any rate increase.
Across the nation, individual market customers like them are seeing signs of big premium increases, which insurers are largely attributing to the possibility of losing the federal cost-sharing subsidies and of Mr. Trump’s not enforcing the health law’s mandate that most people have coverage or pay a penalty. Mr. Trump has repeatedly pointed to such increases as signs that the markets are in “a death spiral” and to bolster support as the Republican Senate leadership rushes to vote on a bill to repeal and replace the Affordable Care Act next week.
Maryland’s largest insurer, CareFirst, has asked to raise rates by an average of 52 percent, for example, while Virginia’s largest insurer, Anthem, has proposed an average rate increase of 34 percent.
Pennsylvania’s insurance commissioner said rates would rise by 8.8 percent next year if the cost payments continue; if Mr. Trump ends them, rates will soar by 36.3 percent. While some insurers and state regulators have discussed limiting the sharpest increases to plans for people who receive premium subsidies — allowing unsubsidized customers to get lower rates outside the marketplaces — it remains to be seen how widespread such actions would be.
Some insurers are pulling out of the marketplaces completely: Several dozen counties in Ohio, Missouri and Washington State have no insurers signed up for next year.
In North Carolina, Blue Cross and Blue Shield said it would have sought an 8.8 percent average increase, instead of 22.9 percent, if not for the uncertainty.
In Ms. Goren’s case, her coverage has been a lifesaver. Infected with hepatitis C through a blood transfusion 30 years ago, she was found to have liver cancer in 2014 and received a new liver last September. Though transplants are among the most expensive surgeries, costing hundreds of thousands of dollars, under the health law her out-of-pocket costs are capped at about $7,000 a year.
But combined with her monthly premiums — which have nearly tripled since 2014, the first year people could buy Affordable Care Act plans — the financial burden is enough that Ms. Goren started taking her Social Security retirement benefits early, which lowers the amount.
“We will use every available resource we have financially until we’ve ground it down to nothing,” Ms. Goren said during an interview in her home in a rural subdivision outside Asheville. “But I’m scared of what’s coming.”
With the distinct possibility that the Affordable Care Act could soon be repealed altogether, she is afraid to touch the $15,000 that her two sons raised this spring through a 5K race to help with her medical expenses.
“We’re sitting on it like Horton with the egg,” Ms. Goren said, referring to the Dr. Seuss book.
When President Barack Obama was still in office, the Republican-controlled House sued to stop the cost-sharing subsidies on grounds that Congress had not appropriated the money. A judge sided with the House last year, but the Obama administration appealed. Mr. Trump, who has talked about using the payments as a bargaining chip to help pass a Republican health bill, has twice asked the court to delay a ruling.
Although the 5.9 million low-income Americans who do benefit from cost-sharing payments will continue to have deductibles and co-payments waived as long as the Affordable Care Act survives, they, too, are facing uncertainty about the future of their health care. If Republicans in Congress succeed at repealing and replacing the law — still a big “if,” but the House has already passed a bill that would do so and the Senate is hurrying to finish its own version — insurance costs for low-income Americans could leap. The House bill provides flat premium subsidies based on age, not income — a formula that penalizes older and poorer people.
Lonnie Carpenter, 55, a self-employed roofer in Winston-Salem, N.C., is in that category. His back was badly injured in a car accident in 2013, and he has not been able to work full time since. Last year, his spinal surgery was paid for by his Affordable Care Act plan from UnitedHealthcare. He owed only about $2,000 thanks to cost-sharing reductions, compared with $11,000 for an operation in 2014, before he got subsidized insurance under the law.
“I’m in a position where I’m maxed out with bills because I’ve missed so much work in the last four years,” Mr. Carpenter said. “But it would have been a whole lot tougher to survive without that insurance. If I hadn’t had that, I’m being honest, I don’t know where I’d be right now.”
Cost-sharing reductions apply to people with annual incomes up to 250 percent of the poverty level; that comes to $29,700 for a single person and $60,750 for a family of four. Deductibles for those with incomes below 150 percent of the poverty level were reduced to $243 on average this year, from $3,703, according to Avalere Health, a consulting firm.
Even as Mr. Trump has remained coy about whether to continue the cost-sharing reductions next year — or even, for that matter, after this month — some powerful Republicans in Congress have begun lobbying for him to do so. They include Representative Kevin Brady of Texas, the chairman of the House Ways and Means Committee, and Senator Lamar Alexander of Tennessee, chairman of the Senate Health Committee, who urged in a hearing last week that the payments be extended through 2019.
“The payments will help to avoid the real possibility that millions of Americans will literally have zero options for insurance in the individual market in 2018,” Mr. Alexander said, adding that Republicans should “do some things temporarily that we don’t want to do in the long term.”
In North Carolina, Blue Cross and Blue Shield increased rates even more this year and last than it is proposing for 2018, blaming unexpectedly high claims costs among its marketplace customers. But the insurer said last month that it now had “a better handle on expected medical costs,” and thus would seek a far more modest rate increase if the cost-sharing payments were guaranteed.
“You don’t mean to wish your life away, but my prayers are that I wake up and my wife is 65,” said Mr. Goren, a former radio advertising salesman, referring to the age at which people become eligible for Medicare. “We saved, but that money, it goes fast.”

G.O.P. Rift Over Medicaid and Opioids Imperils Senate Health Bill

by Robert Pear and Jennifer Steinhauer - NYT - June 20. 2017

WASHINGTON — A growing rift among Senate Republicans over federal spending on Medicaid and the opioid epidemic is imperiling legislation to repeal the Affordable Care Act that Senate leaders are trying to put to a vote by the end of next week.
President Trump had urged Republican senators to write a more generous bill than a House version that he first heralded and then called “mean,” but Republican leaders on Tuesday appeared to be drafting legislation that would do even more to slow the growth of Medicaid toward the end of the coming decade.
And conservative senators, led by Patrick J. Toomey of Pennsylvania, are determined to hold the line on federal spending, pitting two Senate factions against each other.
Senator John Cornyn of Texas emerged from a contentious closed-door lunch with Republican senators on Tuesday saying that he hoped the Senate would be able to meet the deadline of a vote before July 4. “But,” he added, “failing that, I’ve always said we need to get it done by” the end of July.
The emerging Senate bill, like the one approved narrowly by the House in early May, would end Medicaid as an open-ended entitlement program and replace it with capped payments to states, Republicans said. But starting in 2025, payments to the states would grow more slowly than those envisioned in the House bill.
Republican senators from states that have been hit hard by the opioid drug crisis have tried to cushion the Medicaid blow with a separate funding stream of $45 billion over 10 years for substance abuse treatment and prevention costs, now covered by the expansion of Medicaid under the Affordable Care Act.
But that, too, is running into opposition from conservatives. They have been tussling over the issue with moderate Republican senators like Rob Portman of Ohio, Shelley Moore Capito of West Virginia and Susan Collins of Maine.
Without some opioid funding, Mr. Portman cannot vote for the bill, he said, adding, “Any replacement is going to have to do something to address this opioid crisis that is gripping our country.”
Republicans hold 52 seats in the Senate and can afford to lose only two of their members if they hope to pass the bill, which is opposed by all Democrats and the two independents.
Two Democratic senators from states plagued by opioid addiction, Bob Casey of Pennsylvania and Joe Manchin III of West Virginia, said the Republican proposal for federal grants would not come close to mitigating the harm caused by the bill’s Medicaid cuts, pushed just as overdose deaths are soaring. From 2005 to 2014, according to the latest data available, opioid-related hospital visits increased nearly 65 percent, to 1.27 million emergency room visits or inpatient stays a year.
While the proposed money for drug abuse treatment is relatively modest compared with spending for other items like Medicaid and premium tax credits, without it, hundreds of thousands of addicts would go without treatment, advocates say. The issue holds outsize political importance for senators like Mr. Portman, who has made advocacy for treatment legislation a calling card with voters at home.
“The opioid issue has been a particular concern of mine and has been for years,” said Mr. Portman, who has been leading the efforts with Senator Capito. “The reality is we have the worst drug crisis that our country’s ever faced, and it’s being driven by opioids.”
Senator John Barrasso, Republican of Wyoming, who serves on a group shaping the final bill, said: “We need to address the opioid crisis in America. I want us to find a bipartisan solution with adequate funding.”
But Republican leaders would not commit to Mr. Portman’s proposal.
The Medicaid and opioid issues are far from the only ones dividing Republican senators, who have been kept largely in the dark about a bill they are supposed to finally see on Thursday. Republican leaders are determined to keep their seven-year promise to unravel President Barack Obama’s signature health care law, but the near unanimity they need on a replacement is proving elusive.
The House bill would allow per-capita Medicaid payments to states to grow along with the prices of medical goods and services, starting in 2020, with an extra allowance for older Americans and people with disabilities. Senator Toomey and several other conservatives have been pushing for a slower growth rate, to reflect increases in the overall Consumer Price Index, starting in 2025. Medical prices have historically grown faster than the overall index.
“I think that’s a problem,” Senator Capito of West Virginia told the website Axios, reflecting the misgivings of a state that relies heavily on the program. “I think that sort of defeats the purpose of keeping people on, and at a level at which the program can be sustained.”
Several Republican senators, including Orrin G. Hatch of Utah, the chairman of the Finance Committee, have indicated they would like to exempt disabled children from the caps.
Senator Collins’s concerns cover almost the entire landscape of Republican problems: the loss of care for Medicaid recipients, the worries of states with especially high health care costs, and money for opioid treatment (8 percent of all births in her state, Maine, were to addicted mothers last year, she said). Then there are her complaints about the process.
“First, we haven’t seen the bill,” Ms. Collins said. “Second, it has yet to receive a score from the Congressional Budget Office. And third is the process we are using.”
That process — an arcane budget procedure that Republicans denounced when Democrats used it to pass just a small part of the Affordable Care Act — could make some provisions vulnerable to Democratic challenges to the bill. Not knowing which provisions will stay and which could be removed on the Senate floor makes evaluating the substance of the bill that much harder.
Republican aides speculated that the restrictions on the growth of Medicaid, among other issues, could be altered later by Senate Republican leaders, in a bid to pick up support from the moderates.
A bill this large with so much in flux days before it is to receive a vote on the floor is largely without precedent in the Senate.
Senior Republican senators said six weeks ago that they would start afresh in writing a bill to undo Mr. Obama’s health care law, but the legislation they are developing is similar in many respects to the bill passed by the House.
The Senate bill would eliminate penalties for people who do not have insurance and larger employers who do not offer it to employees — eviscerating the individual and employer mandates that were hallmarks of the Affordable Care Act. The Senate bill, like the House measure, would provide billions of dollars to states to help stabilize insurance markets, which Republicans say are tottering in many states.
The Senate bill would also allow states to opt out of many federal insurance standards. Republican leaders said they wanted to protect people with pre-existing conditions, but it was not immediately clear how they would do so.
Democrats stepped up their protests over the secrecy of the bill-writing process on Tuesday, and some Republicans chimed in. Senator Mike Lee, Republican of Utah, was a member of a health care working group formed by Senator Mitch McConnell of Kentucky, the majority leader, but even he was vexed by the process.
“It has become increasingly apparent in the last few days that even though we thought we were going to be in charge of writing a bill within this working group, it’s not being written by us,” Mr. Lee said in a video on Facebook. “It’s apparently being written by a small handful of staffers for members of the Republican leadership in the Senate. So if you’re frustrated by the lack of transparency in this process, I share your frustration.”

Draft Order on Drug Prices Proposes Easing Regulations

By SHEILA KAPLAN and KATIE THOMAS
In the early days of his administration, President Trump did not hesitate to bash the drug industry. But a draft of an executive order on drug prices appears to give the pharmaceutical industry much of what it has asked for — and no guarantee that costs to consumers will drop.
The draft, which The New York Times obtained on Tuesday, is light on specifics but clear on philosophy: Easing regulatory hurdles for the drug industry is the best way to get prices down.
The proposals identify some issues that have stoked public outrage — such as the high out-of-pocket costs for medicines — but it largely leaves the drug industry unscathed. In fact, the four-page document contains several proposals that have long been championed by the industry, including strengthening drugmakers’ monopoly power overseas and scaling back a federal program that requires pharmaceutical companies to give discounts to hospitals and clinics that serve low-income patients.
Mr. Trump has often excoriated the drug industry for high prices, seizing on an issue that stirs the anger of Republicans and Democrats alike. He has accused the industry of “getting away with murder,” and said that he wanted to allow the federal government to negotiate directly with drug companies over the price of drugs covered by Medicare.
But the proposed order does little to specifically call out the drug industry and instead focuses on rolling back regulations, a favorite target of the administrationacross many federal agencies.
“I do believe that the president wants to do something to lower drug prices for people, but this is a far cry from what he said on the campaign trail,” said David Mitchell, the founder of Patients for Affordable Drugs, a nonprofit that does not take money from the industry. “I don’t see anything there that addresses the drug companies getting away with murder, and it appears that is because Pharma has captured the process.”
With a new administration in place, the pharmaceutical and health products industry spent $78 million in lobbying in the first quarter, a 14 percent increase over last year, according to the Center for Responsive Politics.
The draft executive order, obtained from an official with knowledge of the proposals, was prepared before last week’s meeting of cabinet members and other high-level administration officials. John Czwartacki, a spokesman for the Office of Management and Budget, said the session was the “first of many meetings which will be held throughout the summer,” adding that “they will be working to identify both root causes and innovative solutions, leaving no stone unturned.”
Many of the people Mr. Trump has hired to work on drug policy have ties to the industry. Joe Grogan, the associate director of health programs in the budget office, worked as the head of federal affairs for Gilead, whose expensive hepatitis C drugs have helped fuel the debate over rising drug costs. Tom Price, the secretary of health and human services, was a Republican congressman whose policies were seen as industry-friendly and who opposed measures like allowing Medicare to negotiate drug prices. And the new commissioner of the Food and Drug Administration, Scott Gottlieb, was a longtime consultant to the drug industry.
Several of the proposals appear to reflect that industry influence. For example, the document directs the United States trade representative to conduct a study of price differences between the United States and other countries, and to review trade agreements that may need to be revised “to promote greater intellectual property protection and competition in the global market.”
The pharmaceutical industry has said that Americans pay the highest prices to compensate for low prices in other countries. However, “other countries pay lower prices for drugs in part because their governments control prices,” said Allan Coukell, senior director of health programs at the Pew Charitable Trusts. “It’s unclear what ability the U.S. would have to change that.”
The draft order targets a program, 340B, that requires the drug industry to give discounts to hospitals and clinics that serve large numbers of low-income patients. The industry has complained that the program is being abused, while hospitals say they would have to cut services without it.
“That’s one that sticks out as a bit of a head scratcher,” said Dr. Joshua M. Sharfstein, a professor at Johns Hopkins Bloomberg School of Public Health who was a top F.D.A. official under President Barack Obama. “This is the executive order to lower drug prices — why would you put in a provision that would raise drug prices?”
In recent weeks, the industry has shown signs it believes it is getting a fairer shake.
In May, Joseph Jimenez, the chief executive of Novartis, told investors that he believed the administration would offer a solution that “will preserve the business model of how we innovate and discover and develop and launch in the U.S., as opposed to some of the bigger and more draconian elements that were discussed earlier,” according to Bloomberg.
Dr. Sharfstein and others said they were intrigued by one proposal, known as value-based pricing, that appeals to the industry and policy wonks alike. The idea refers to paying drug companies for the value that a drug brings — refunding money if a drug fails to prevent a costly health condition, for example.
Some proposals appear to address alleviating the rising out-of-pocket costs that patients are being asked to pay. One calls on reducing burdens caused by “regulatory or administrative actions” that cause Medicare beneficiaries to pay the list price for drugs when the companies that run the drug plans — known as pharmacy benefit managers — get a lower price from drugmakers. Another would target regulations “that inappropriately or unfairly contribute to higher prices or cost-sharing for medical products for American patients.”
Dan Mendelson, president of Avalere Health, a health advisory company whose clients include drug companies and insurers, said, “All of our research shows that when a patient faces high cost-sharing for a drug, they’re more likely not to take it.”
Still, it was unclear how much issues could be addressed through administrative or regulatory changes. Indeed, many of Mr. Trump’s most aggressive statements on the issue — including allowing Medicare to directly negotiate the price of drugs — would require legislative action.
Congress has been consumed by negotiation over the replacement of the Affordable Care Act, and while several drug-pricing bills have been introduced, few have gained much traction so far.
For its part, the F.D.A. is taking action that even Mr. Trump’s critics say may well help drive down prices. Mr. Gottlieb is expected this week to announce a new plan to make sure the generic drug approval process isn’t being gamed in ways that hamper competition.

American healthcare is at a crossroads. Where is the Democrats' bold vision?

Ross Barkan
How close the Senate Republicans are to repealing the Affordable Care Act is anyone’s guess. The same holds what for a replacement bill will truly look like. Negotiations, to the horror of anyone with a half-functioning conscience, are occurring in secret, and no Republican will reveal what sort of punishment is in store for the most vulnerable Americans.
Democrats in the Senate, unlike the House, hold some leverage. Republicans can afford to only lose two votes and still pass a bill, and there are enough moderates from swing states to balk at any radical restructuring of American healthcare. The Senate majority leader, Mitch McConnell, would like to hold a vote before the 4 July recess, doing Donald Trump’s dirty work before vacation time. 
To slow the bill’s progress, Chuck Schumer, the leader of the Senate Democrats, will listen to the demands of various progressive groups and slow down the business of the body as much as he can. On Monday night, Democrats held the Senate floor, taking turns bashing Republican repeal efforts. 
They are preparing to block lengthy committee hearings, since any senator can stop a hearing from extending past the first two hours of the Senate’s day. They will object to all unanimous consent requests in the Senate, employing various parliamentary maneuvers to call attention to Republican secrecy.
Given the years of Republican obstruction under Barack Obama – unprecedented obstinacy pioneered by McConnell – this is all well-deserved. Democrats should do whatever they can to foil a disastrous, retrogressive austerity agenda. If they don’t, they should quit and find other lines of work. They will be without purpose.
What’s still missing, however, is the alternative vision. It’s the fatal flaw of today’s Democratic party and one that has gone unaddressed since Hillary Clinton’s catastrophic loss. There is no argument for a new healthcare system coming from either side. 
Republicans, drunk on fulfilling an idiotic campaign pledge made in the heat of Obama’s presidency, are only promising to make healthcare worse for the people who need it most. Democrats are left with a mealy-mouthed defense of the status quo. 
This is a problem, one that Democratic leaders in Congress and the Democratic National Committee aren’t trying to solve. It’s one thing to say you will do whatever it takes to protect a flawed but functional healthcare system that was never overwhelmingly popular to begin with, that still left plenty of people who weren’t desperately poor or sick with expensive healthcare plans. It’s quite another to start telling Americans how you plan to start fixing the system when you return to power.
Democrats are assuming history will take care of them, and in the short term, it probably will. Trump is hated enough to cost his party dearly in the midterms next year and his re-election bid will be a challenge. In just a few years, it’s not out of the realm of possibility that Democrats will have full control of government again, as they did at the dawn of 2009.
But that majority proved fleeting. Building a party around bogeyman Trump and Russia hysteria will mean a party without a core, because these things won’t last. 
Bernie Sanders was a folk hero to millennials during the 2016 campaign, yet no other powerful Democrat has seen fit to start aping his message wholesale. No one has said the Democrats will run on single-payer healthcare in 2018, promise to make college tuition free in 2018, or form a coherent anti-war platform in 2018. 
To truly slay Trump’s majority and remain in power for years to come, Democrats must not only stand for something but justify their existence in concrete ways to people of all races and classes who will benefit from a rational federal government. 
Strangely, Democrats aren’t doing this. Out of power, their argument is still simply: we aren’t Trump, we’re not crazy. The DNC still hasn’t performed an autopsy report on the 2016 election. Beyond Sanders and Elizabeth Warren, no Democrat seems especially concerned with articulating a rationale for the party, a reason millions of Americans should continually vote Democratic. 
There’s a certain comfort to being a minority party, an impotent oppositional faction scoring points on Twitter for holding the floor of the Senate. It’s easy. It’s even fun. Trump is a clown, Trump is a maniac, Trump is a Putin stooge – Democrats always win the late night shows, the internet, the memes. MSNBC is a ratings king. Everyone is buying resistance merchandise.

The Democratic party is the younger party, the hipper party, the one that will tell you, again and again, in ever more creative ways, just how destructive Trump is. It just won’t tell you much else.

G.O.P. Health Plan Is Really a Rollback of Medicaid

by Margot Sanger-Katz - NYT - June 21, 2017

Tucked inside the Republican bill to replace Obamacare is a plan to impose a radical diet on a 52-year-old program that insures nearly one in five Americans.
The bill, of course, would modify changes to the health system brought by the Affordable Care Act. But it would also permanently restructure Medicaid, which covers tens of millions of poor or disabled Americans, including millions who are living in nursing homes with conditions like Alzheimer’s or the aftereffects of a stroke. 
“This is the most consequential change in 50 years for low-income people’s health care,” said Joan Alker, the executive director of the Center for Children and Families at Georgetown University. “This is a massive change that has hardly been discussed.”
Since its founding, Medicaid has operated as a partnership between the federal government and the states. Each pays a share of patients’ medical bills, with no overall limit on spending. The American Health Care Act would try to slim down  the federal share of that spending, by limiting how much the federal government would pay for each person enrolled in the program. The Senate version of the legislation, expected this week, is likely to make the payments still leaner in later years.
The results, according to independent analyses, would be major reductions in federal spending on Medicaid over time. States would be left deciding whether to raise more money to make up the difference, or to cut back on medical coverage for people using the program. The Congressional Budget Office estimates that the changes would lead to a reduction in spending on Medicaid of more than $800 billion over a decade. (That figure also includes additional cuts to the Obamacare Medicaid expansion.)
Medicaid is the country’s largest government health care program, covering more Americans than its better-known sibling, Medicare. 
Its reach is broad: About half of all births in the country are covered by Medicaid, and nearly 40 percent of children are covered through the program. Medicaid covers the long-term care costs of two-thirds of Americans living in nursing homes, many of them middle-class Americans who spent all of their savings on care before becoming eligible.
It covers children and adults with disabilities who require services that most commercial health insurance doesn’t include. It covers poor women who are pregnant or raising young children. Those populations were all included in the program before Obamacare became law.
It also provides insurance for poor adult Americans, and recent evidence shows that its expansion under Obamacare has given more poor people access to health care services and reduced their exposure to financial shocks.
The Republican approach would set a formula for determining a maximum payment for each person in the program. Then that cap would grow by a set  rate each year. Lawmakers are negotiating about the rate to use, but all of the options are intended to grow more slowly than expected under the current system. The gap would be left for states to fill — or cut.
“While details remain elusive, this is shaping up to be the largest intergovernmental transfer of financial risk in our country’s history,” said Matt Salo, the executive director of the National Association of  Medicaid Directors, in an email. Mr. Salo said that some of his directors would welcome caps if they came with more program flexibility, but said the current approach amounted to a funding cut. 
The growth in medical spending tends to be uneven year over year, which means states might hit the caps in one year and fall under them in another, even without any program changes. Researchers at the Brookings Institution recently looked back at historical Medicaid spending to see what would have happened under a cap. They found that random variation was substantial.
Medicaid advocates worry particularly that a fixed growth rate doesn’t account for this varying pattern of health expenditures, which might shoot up in a year where there’s an epidemic or an important new treatment. Many Medicaid budgets increased in recent years after the introduction of  expensive but effectivemedications for hepatitis C, for example. States had to pay more for the drug, but federal spending also increased to match it.
“Could you imagine tomorrow if finally we had a Zika virus vaccine, and that vaccine costs $50K a dose?” said Sara Rosenbaum, a professor of health law and policy at George Washington University. “Would you not want every woman of childbearing age to be immunized?”
Advocates for the structural change point to inefficiencies and waste in the current program. There is some evidence that Medicaid programs enroll some people who are not eligible and sometimes cover some services that are not medically necessary. James Capretta, a fellow at the conservative American Enterprise Institute, said that the current system, where the federal government matches all state spending, discourages efficiency.
But he and co-authors have also suggested a different, more generous approach than the one in the Republican legislation.
Most researchers who study the program closely say that it is already quite lean. Major savings, they say, will be hard to achieve without reducing medical benefits or cutting higher-cost patients from the program.
Trump administration officials and Republican members of Congress have argued that the Medicaid changes won’t cause anyone to lose insurance coverage directly. That statement is true in only the narrowest sense. 
Because the funding cuts would fall to states, it is state officials who would  decide whether to save money by raising taxes, reducing payments to nursing homes oreliminating benefits like home-based care for disabled beneficiaries, a few available options under the law. 
The Congressional Budget Office estimates that enrollment in Medicaid would decline substantially over a decade, as states pursued a variety of strategies to save money, some of which would push people out of the program.
Still, the Medicaid caps have not drawn the same public outcry as other provisions of the law that would cut back on coverage more directly. Several Republican senators have expressed concerns about changes to Obamacare’s Medicaid expansion, which broadened the program to include more low-income adults in 31 states. 
Others worry about changes to private insurance subsidies that would make insurance less affordable to older, middle-class Americans. Fewer have spoken out about the cuts to Medicaid’s legacy beneficiaries. That means that, as the Senate works out final details, the forced diet for Medicaid is likely to stay in the bill.


Abortion Adds Obstacle as Republicans Plan to Unveil Health Bill

by Robert Pear and Thomas Kaplan - NYT - June 21. 2017

WASHINGTON — Abortion flared up Wednesday as the latest hot-button issue to complicate passage of a bill to repeal and replace the Affordable Care Act, which Senate Republican leaders hope to unveil on Thursday and pass next week.
The repeal bill approved last month by the House would bar the use of federal tax credits to help purchase insurance plans that include coverage of abortion. But senators said that provision might have to be jettisoned from their version because of complicated Senate rules that Republicans are using to expedite passage of the bill and avoid a filibuster.
If that provision is dropped, a bill that has already elicited deep misgivings among moderate Republicans — and stiff resistance from Democrats, health care providers and patient advocacy groups — could also generate concern among abortion opponents, as well as conservative lawmakers.
Further complicating the measure’s prospects, insurance companies, which took a leading role in the health care fights of 1993-94 and 2009-10 but have been conspicuously quiet this year, released a blistering letter objecting to Republican plans to remake Medicaid and cut its funding.
The changes being considered in Congress could “amount to a 25 percent shortfall in covering the actual cost of providing care to our nation’s neediest citizens,” the top executives of 10 insurance companies wrote this week. “These amounts spell deep cuts, not state flexibilities, in Medicaid.”
As senators struggle to develop a health care bill, their handiwork appears to be too moderate for some Senate conservatives and too conservative for some Senate moderates. The latest version, without the abortion-coverage prohibition and with steep Medicaid cuts, may prove unacceptable to some in both camps. To pass it, Senate leaders can afford to lose only two Republican votes of the 52 in the chamber.
Republican senators got a glimpse Wednesday of the highlights of the bill, which was drafted in secret by the majority leader, Senator Mitch McConnell of Kentucky, and top aides. White House officials were granted a formal briefing, which risked irking many senators who had yet to see the actual bill.
The House abortion provision has sweeping implications because many health plans subsidized under the Affordable Care Act include coverage for abortion services. The provision has encountered outspoken opposition from officials in states like Oregon, where most health plans on the public insurance exchange cover abortion.
But senators said the provision might have to be dropped for a more prosaic reason: It may not comply with the Senate rules that Republicans are using to speed the health care bill through the Senate.
The bill is scheduled to go to the Senate floor next week under these procedures, which limit debate and preclude a Democratic filibuster.
“It’s one of the problems we have to work with,” Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee, said of the abortion issue. “We’re not quite sure how that’s going to be resolved.”
Mr. McConnell is determined to get a vote on the bill by the end of next week, before a break for the Fourth of July holiday, but he still does not have enough committed votes to ensure passage.
Senator Rand Paul, Republican of Kentucky, made clear on Wednesday that he was not on board with the Republican bill.
“I’m still hoping we reach impasse, and we actually go back to the idea we originally started with, which is repealing Obamacare,” Mr. Paul said, adding, “I’m not for replacing Obamacare with Obamacare lite.”
The House bill and the Senate version, like the Affordable Care Act, would provide tens of billions of dollars in tax credits to help people pay insurance premiums.
The federal government is expected to spend more than $30 billion this year on tax credits to help lower- and middle-income people pay premiums. The Senate bill would provide more assistance to lower-income people than the House bill, which bases tax credits on a person’s age.
The Senate bill would also repeal most of the taxes imposed by the Affordable Care Act. It would delay the effective date of a tax on high-cost employer-sponsored health coverage, but Republicans plan to offer an amendment next week to eliminate this “Cadillac tax,” which is opposed by labor unions and employers.
Senators Thom Tillis of North Carolina and Susan Collins of Maine, both Republicans, said they understood that the House restrictions on the use of tax credits for insurance covering abortion had encountered parliamentary problems.
“What I heard earlier from the parliamentarian is they didn’t think it would pass” muster under Senate rules, Mr. Tillis said.
Mr. Tillis and Ms. Collins said they understood that Senate Republican leaders were hoping to devise some kind of workaround to address concerns of anti-abortion lawmakers. But it was not clear whether those anti-abortion lawmakers would be satisfied with such a plan, which could involve separate legislation.
Republicans have been promising to repeal the health law ever since it was signed by President Barack Obama in 2010. On Wednesday, in the final hours before the Senate repeal bill was to be unveiled, members of Congress, consumer groups and health care executives engaged in frenetic advocacy in hopes of shaping the bill.
Women’s groups and at least two moderate Republicans, Ms. Collins and Senator Lisa Murkowski of Alaska, continued to object to a provision of Mr. McConnell’s bill that would cut off funds for Planned Parenthood.
In a letter to Mr. McConnell on Wednesday, more than two dozen House members in the conservative Republican Study Committee listed several parts of the House bill they view as crucial, including cutting funds to Planned Parenthood and restricting the use of the tax credits. The bill, they wrote, fulfills “an important conservative commitment to promote life and protect the unborn.”
Leaders of the 10 insurance companies told Mr. McConnell that proposed caps on federal Medicaid spending would cause “an enormous cost shift to the states,” which could force them to raise taxes, reduce benefits, cut payments to health care providers or eliminate coverage for some beneficiaries. Among those signing the letter were top executives of AmeriHealth Caritas, Molina Healthcare, Blue Shield of California and Healthfirst, in New York.
But Senator John Kennedy, Republican of Louisiana, said the Medicaid provisions were one of the bill’s chief attractions for him.
“In my state,” Mr. Kennedy said, “we are now spending 47 percent of our budget on Medicaid. That’s up from 23 percent in 2008. It’s crowding out money for universities and roads and public safety and coastal restoration, and it just keeps climbing.”
Even senators who might support the legislation said they did not want to be rushed.
Asked how he felt about the prospect of having a vote on the bill a week after its release, Senator John McCain, Republican of Arizona, said, “I feel terrible about it.”
Senator Ron Johnson, Republican of Wisconsin, said, “I need the information, I need to hear from constituents, and that’s going to take some time.”
Debate on the Senate bill will be shaped by an analysis from the Congressional Budget Office, which will estimate the impact on federal spending and the number of people without health insurance. Under the House bill, the office said, the number of uninsured would be 23 million higher than under the Affordable Care Act in 2026. And for some older Americans and sick people, it said, premiums and out-of-pocket costs could be significantly higher.


With Health Law in Flux, Insurers Scramble to Meet Filing Deadline

by Reed Abelson - NYT - June 21, 2017

As health insurers scrambled to decide whether to stay or go by Wednesday’s deadline to file plans for the federal marketplace, Anthem, one of the Obamacare market’s major players, announced that it would pull out of two more states, Wisconsin and Indiana, in 2018.
The company, which offers for-profit Blue Cross plans in 14 states, had already said this month that it would stop selling coverage in the marketplace next year in Ohio. 
In making the announcement, Anthem said offering plans had “become increasingly difficult due to a shrinking and deteriorating individual market, as well as continual changes and uncertainty in federal operations, rules and guidance.”
Even as Senate Republicans hurry to finish their plan to overhaul the law, insurers are racing to meet not just federal but also state deadlines to submit rate requests.
While the Wednesday deadline does not represent a final commitment by any insurer, “it will be a good indicator of the health of these markets,” said Sabrina Corlette, a research professor at Georgetown University.
House Speaker Paul D. Ryan, whose home state of Wisconsin was among those Anthem plans to exit, pointed to the decision as reason the Republicans needed to pass their overhaul of the health care legislation.
“This law has failed our state,” he said. “Obamacare is clearly collapsing, and we have to step in before more families get hurt.”
Anthem’s exit underscores the rapidly changing dynamics of the market. Other insurers have indicated they will stay — and a few are even expanding into more states.
Oscar Health, the New York insurance start-up, said on Wednesday that it expected to offer policies in three additional states for 2018: Ohio, New Jersey and Tennessee. The company, which covers about 105,000 people, also plans to expand in California and Texas while remaining in New York. Oscar had previously sold policies in New Jersey but did not offer them there this year.
Backed by venture capitalists, including Josh Kushner, one of the company’s founders and the brother of Jared Kushner, President Trump’s son-in-law, Oscar has focused almost exclusively on selling insurance in the market created by the Affordable Care Act.
“We’re confident that when the dust settles, the market for health insurance will stabilize in time for 2018,” Mario Schlosser, the company’s chief executive, wrote in a blog post. “For all of the political noise, there are simply too many lives at stake for representatives in Washington, D.C., not to do what’s right for the people.”
Other insurers also appear to be gambling on the current market, in spite of the political turbulence. Molina Healthcare, another major player in the market that has expressed concerns about its stability, said it had filed initial proposals in all nine states where it has business, according to a company spokeswoman.
Medica, a small nonprofit insurer, said on Monday that it would offer plans statewide in Iowa, although it is seeking rate increases that average 43 percent. Its decision would cover the yawning gap left by Aetna and the state Blue Cross plan, which left the market for next year, raising the possibility that no carrier would offer coverage to the bulk of the state’s residents.
Centene, another large insurer, announced its plans last week to offer coverage for the first time in Nevada, Missouri and Kansas.
But other insurers have emphasized they remain ambivalent about staying. Health Care Service Corporation, which operates nonprofit Blue Cross plans, said it would file proposals in all five states where it offers coverage, but could still decide to leave. The insurer covers more than one million people in the individual market.
The overall market appears to be worsening as more insurers leave, said Dan Mendelson, the president of Avalere, a consultant, who said “there is a lot of variation by local market.”
“There are some markets that are doing fine,” he said, while others, particularly rural ones, could still be left without an insurer willing to offer coverage.
Anthem’s departure from Wisconsin and Indiana, where the company is headquartered, does not seem to add to the dozens of so-called bare counties across the country where no insurer has yet said it will offer insurance in the state marketplace for that area.
Anthem covers about a million people through the state marketplaces or exchanges, and has filed proposals to sell policies in other states, like Connecticut.
In the three states that it is leaving, the insurer will offer at least one plan outside of the marketplace that reserves the option of returning to that state to offer coverage.
“Anthem’s view of the future of the marketplaces has clearly turned negative, driven by some underlying market instability and uncertainty drummed up by the Trump administration,” said Larry Levitt, an executive with the Kaiser Family Foundation.
If an insurer misses the Wednesday deadline, regulators could still choose to accept a last-minute application, as they did last year in Arizona, to make sure residents have access to a policy through the state marketplace. “State officials and governors are going to be very pragmatic to make sure people have coverage,” Ms. Corlette said.
To stay, insurers are asking for much higher prices, according to Avalere, which analyzed filings in eight states. Insurers are seeking an 18 percent increase, on average, for the most popular so-called silver plans.
Many insurers are blaming the current political uncertainty when requesting much higher rates. The Trump administration and Congress have yet to commit to critical funding for subsidies worth billions of dollars to low-income individuals. Insurers are also concerned that the administration will stop enforcing the penalties people face when they choose to go without coverage, which they say would also drive up prices.
In Washington State, Molina is seeking rate increases that average 38.5 percent, citing the lack of enforcement and the return of a special tax on insurers. In developing its rates, the company said it assumed that major provisions of the law, including the existing subsidies and tax credits, would continue.
In Connecticut, Anthem wants an average rate increase of 33.8 percent, much of which it attributed to higher medical costs and increased demand for services.
“We are forecasting that the individual market will continue to shrink and that those individuals with greater health care needs will be the most likely to purchase and retain their coverage,” the insurer told state regulators.
Companies are likely to seek very high rates, said Ms. Corlette. They “are going to build all of this uncertainty into their rates to the maximum extent to protect themselves,” she said, and insurance regulators will have to decide whether to push back.
Even those insurers that plan to stay say the market has been challenging. While its losses have, Oscar lost about than $200 million last year and said that other changes were needed to stabilize the market. “We are not immune to the pressures in the individual market,” Mr. Schlosser said.
But he said the insurer’s partnerships with health systems like the Cleveland Clinic to offer new plans in northeastern Ohio should allow it to be successful. “If you have the right products and the right partner, you can make it work,” Mr. Schlosser said.

Will overconfidence prompt the GOP to blunder on health care?
by Jennifer Rubin - The Washington Post - June 22, 2017

The downside for Republicans in an over-hyped win in Georgia’s 6th Congressional District race? Arrogance and over-confidence, a deadly combination, that can prompt politicians to disregard voters and common sense. We will see if that condition afflicts Republicans if they attempt to ram home a health-care bill that remains known only to Senate Majority Leader Mitch McConnell (R-Ky.) and his staff. (Even Republicans on the super-secret committee do not yet know exactly what it looks like.)
The Democrats argue that their process to pass Obamacare was more open. But like the Republican health-care bill, their final text was written behind closed doors.(Meg Kelly/The Washington Post)
We start with the voters, who consistently have told pollsters they really do not like American Health Care Act (AHCA) the House passed. The latest Reuters poll tells a familiar picture: “The June 9-13 poll shows that a majority of the country thinks the American Health Care Act would be harmful for low-income Americans, people with pre-existing health conditions and Medicaid recipients. Overall, 41 percent of American adults oppose the House plan, while 30 percent support it. Another 29 percent said they ‘don’t know,’ according to the poll.” Some polls show support for the plan at less than 20 percent.
Just how unpopular is the GOP health-care plan? “Based on an aggregate of polling from the Roper Center public opinion data, [Chris] Warsaw said the AHCA is less popular than Obamacare, the Troubled Asset Relief Program (the bank bailout), the Dodd-Frank regulations, President George W. Bush’s tax cuts, and even the failed healthcare plan from President Bill Clinton.” Oh.
Well, the Senate bill will be different, GOP leaders might tell their troops. How different? And will it be even less popular? As details leak out it seems that the overarching structure of the bill mirrors the House approach: Substantial cuts in Medicaid, big tax cuts for the rich and roll-back of the guarantee on minimum benefits and/or protection against preexisting conditions. Ultimately, it may wind up looking a whole lot more like the House bill than one would have guessed listening to GOP senators’ critiques of the AHCA.
Republicans will have no way of knowing, absent some hearings and an extended period of debate, whether this will be better received by the public and other stakeholders (e.g., hospitals, doctors). Republicans seem to operate in some smug political bubble in which they imagine whatever they pass will be popular, at least with their base. The House experience should have disabused them of the notion they can sell a dog’s breakfast to the American people. When it comes to health care, the details matter a whole lot.
Perhaps Republicans, flush with confidence after a four-point victory in a Republican 9.5+ district, believe the president can sell the American people on anything. After all, he sold the country on him. Well, President Trump hasn’t made the AHCA popular. To the contrary, his own popularity, perhaps as a result of the ACHA, has fallen precipitously from an already low mark. (Pollster.com’s average has his disapproval at approximately 55 percent, his approval at 40 percent.)
Republicans seem to have forgotten all the lessons of the Affordable Care Act, the very lessons they rode to majority control of both houses:
  • People don’t learn to like something as complex as a whole new health-care system (until someone threatens to take it away).
  • People don’t like fussing with their health care.
  • Logistical and human problems become the responsibility of the party who devised the plan.
  • The victims of a poorly devised health-care system are the most vulnerable and hence the most sympathetic.
  • Health-care costs will continue to rise and, rather than notice the slow-down in the rate of increase, people will blame the new system for raising costs.
And all of those issues arose with regard to a plan that was giving people coverage — not taking it away or making it more costly.
Rather than jump off the cliff with no net, Republicans might consider consulting with their own states’ governors. The National Governors Association released a document on Tuesday authored by six Republicans and seven Democrats. In it they set out a list of priorities including engagement with the states on Medicaid changes; “Advanceable and refundable premium tax credits [that] reflect income, age and regional variation in costs”; support for behavior health and information technology efforts; and maintaining funding for “public health and maternal and child health programs such as the Prevention and Public Health Fund, Children’s Health Insurance Program and the Title V Maternal and Child Health Services Block Grant” and opioid abuse prevention and treatment.
You see, if Congress had hearings, lawmakers could actually hear from governors and include popular programs with a track record of success. Nah, they’d rather vote blind for something the public will hate as much or more than the House version.



Posted by at

1 comment:

  1. JeroldDecember 5, 2017 at 9:00 AM

    Hello, this is an very important message I need to pass to someone out there passing through marital problems that all hope is not lost whatever the problem maybe, here is what you need to know to save your marital problem, I was once facing challenges in my relationship till I came across an article talking about the man I want to introduce to you reading this article right now. Dr Ekpen of Ekpen Temple is the man I want to recommend to you having marital problem which he can help you with his powerful spell to solve whatever the problem is, that you are facing in your marital life. Contact him today at: ekpentemple@gmail.com or whatsapp him on +2347050270218 you will be glad you did.

    ReplyDelete

Subscribe to: Post Comments (Atom)