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Friday, September 1, 2017

Health Care Reform Articles - September 1. 2017

Rewritten contracts cause unrest at MCMH

by Steve Fuller - The Ellsworth American - August 31, 2017

ELLSWORTH — Dissatisfaction among doctors has been a pre-existing condition at Maine Coast Memorial Hospital, according to two providers connected with the facility. That condition was exacerbated by recent changes made to practitioners’ contracts.
The two providers who spoke to The American said some physicians are leaving the hospital as a result of that feeling of dissatisfaction, though the president of Maine Coast Memorial said the contract changes have not resulted in the departure of any doctors so far.
“A few doctors have signaled their intent to leave the organization, but at this time all physicians are still employed and caring for patients at Maine Coast Memorial Hospital,” said MCMH President John Ronan, who is also the president of Blue Hill Memorial Hospital.
Ronan said Maine Coast Memorial recently made changes to contracts with its doctors in an effort to achieve consistency throughout the hospital’s parent organization, Eastern Maine Healthcare Systems (EMHS). Ronan said that a periodic review a few months ago found some of the contracts at MCMH were not consistent with other hospitals that are part of EMHS, which the Ellsworth hospital joined two years ago.
Though he declined to discuss specifics, Ronan said a “variety of things were looked at” by the EMHS legal team in the contract review process. He said “there were changes that were made” to the contracts, noting that EMHS has a standard template that covers issues including compensation and benefits.
“We have approximately 50 to 55 employed doctors that were part of that process,” Ronan said.
Dr. Craige Williamson, an orthopedic surgeon specializing in upper extremities, is not one of those doctors. He was formerly employed by Maine Coast Memorial but now has his own private practice, Maine Coast Hand and Shoulder. He works in both Bangor and Ellsworth. His office here is housed in the Maine Coast Memorial complex on Union Street.
Williamson came to work in Ellsworth 22 years ago because he saw MCMH as “a gem.” He said “bad blood” between providers and the hospital administration began to develop years ago but has “accelerated” since Maine Coast joined with EMHS. He cited a feeling of “a lack of respect for providers” as a root cause of that bad blood.
“I think the biggest problem is that they don’t understand the value of good people,” said Williamson. He left the employ of Maine Coast about a year and a half ago “out of disgust” and after being asked to make changes to the way his practice was run.
Williamson said that when Ronan attended a recent medical staff meeting, he “came into a room full of bees.”
Dr. Margaret Blom is an ophthalmologist who is affiliated with, but also not employed by, MCMH. Like Williamson, she spoke of dissatisfaction among members of the medical staff.
“I know a lot of unhappy people, people who are complaining that they’re losing their jobs because of the merger,” she said. “They’re heading for places where they can get better hours and more pay.”
Like Williamson, Blom said she believed Maine Coast’s joining with the larger, Brewer-based system made an existing problem worse.
“I don’t think the merger with EMHS made it any easier on the employees,” she said.
Williamson said the issue of staff leaving has manifested itself in two departments in particular, emergency and anesthesiology. Ronan said there were several departures from the latter department, one for personal reasons and a couple of others when people went to work at other EMHS member hospitals.
Ronan acknowledged those departures did create a “void” in the anesthesiology department but said the matter has now been addressed and resolved.
“As of yesterday we’ve got a plan in place to ensure we’ve got coverage for every shift,” he said, speaking Tuesday afternoon.
Williamson’s and Ronan’s accounts on the emergency department differ. Williamson said four doctors have either left or are soon leaving, naming them individually, and he said that would leave the department without doctors as of next month.
“Based on the knowledge we have, that is not the case,” said Ronan on Tuesday. “We have not had resignations from all of our providers.”
Both Williamson and Ronan said it can be difficult to recruit and retain doctors. Ronan said emergency department staffing is a particular challenge for all of the three dozen hospitals across Maine, and not just in Ellsworth.
“I know that every hospital president wonders how they’re going to keep their ER staffed over the next couple of years,” he said.
To that end, EMHS established two collaborative programs in the past couple of years (one for emergency medicine and the other for hospitalists) with the goal of creating a “pool” of “high-quality doctors” who can be called upon to serve any of its member hospitals. Ronan said that has actually been a helpful recruiting tool, in that the prospect of working in a system-wide collaborative is attractive to prospective doctors and allows them to build familiarity with multiple hospitals.
Ronan said the collaborative programs help “provide better coverage to the organization” as a whole. He said it also results in “increased access to clinical resources and better staffing coverage.”
Filling vacant positions or shifts sometimes requires the use of what are called locum tenens, or locums. The Latin phrase means “to hold a place.” Locums are physicians or specialists who fill-in on a short-term or long-term basis.
Williamson said the use of locums “does not allow the public to build relationships with their providers.” Ronan acknowledged that “generally a locum is more expensive” than having a doctor who is employed directly by the hospital, but said the long-term aim is to use the latter rather than the former.
“Our goal is to form the collaborative with all EMHS-employed physicians,” Ronan said, though “there may be times that locums are used to meet staffing needs during the building phase.”
Overall, Williamson said he thinks it is “unfortunate” Maine Coast chose to join forces with EMHS.
That is not an opinion shared by those running MCMH, including Board Chairwoman Debbie Ehrlenbach.
“Gaining access to expertise and processes that help Maine Coast’s operations and its compliance program were a big reason the board pursued an affiliation with EMHS that we completed in 2015,” she said in a written statement. “We are pleased with the plans that Maine Coast’s senior leadership has developed, working in partnership with EMHS, to ensure we will have sufficient physician coverage to continue to deliver high-quality care for residents of Ellsworth and other Down East communities.”


Calais residents unnerved by loss of obstetrics unit at local hospital

by Joe Lawlor - Portland Press Herald - August 31, 2017

CALAIS — The decision to end obstetrics services at Calais Regional Hospital is continuing to cause controversy in this Down East border town of 3,000 along the St. Croix River.
Hospital officials announced in May that they were being forced to close the obstetrics department this year to stave off deep financial problems that threaten the hospital’s survival. The final baby born in the obstetrics department was discharged from the hospital Tuesday.
“It has been painful for us to make these decisions,” Dee Dee Travis, the hospital’s vice president of community relations, said in an interview Wednesday. “It was sad, very hard, what we had to do.”
The Calais hospital is representative of the financial struggles of many rural hospitals, officials said. More than 80 of them have closed nationwide since 2010, according to the National Rural Health Association, leaving local residents farther away from hospital services.
Other hospitals, like the one in Calais, have ended money-losing services in efforts to have sufficient finances to keep operating.
Calais Regional Hospital is in Washington County, where births have been dwindling. They fell from more than 100 per year a decade ago to 64 in 2016 as the average age of the county population increased.
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Now the closest facility that delivers babies in non-emergencies is Down East Community Hospital in Machias, about a 50-minute drive away, and some expectant moms will choose to drive two hours to a hospital in Bangor. Women who still require prenatal doctor visits will be able to keep their appointments through the end of September.
The loss of services has upset some Calais residents. A community candlelight vigil was held in June, and in July the City Council approved a resolution of “no confidence” in the hospital board of directors.
Calais residents participate in a community meeting Wednesday organized by the Coalition for Healthy Washington County to address the closure of Calais Regional Hospital’s obstetrics unit. Members of the hospital’s board of directors had chairs reserved for them, left, but did not attend. Staff photo by Brianna Soukup
Councilor Mike Sherrard said the criticism of a hospital that has been operating “in secret” is justified.
“They dropped a bombshell on us,” Sherrard said. ‘We would have done whatever we could have to help to keep OB services, but we weren’t given that option. We can’t help if we’re kept in the dark. This didn’t happen overnight.”
HALF A MILLION IN SAVINGS ANNUALLY
Rod Boula, the hospital’s CEO, said recruiting doctors and nurses is difficult in rural areas. Making it public too far in advance that officials were contemplating closing obstetrics would have “caused a mass exodus” of employees, he said.
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Hospital officials said Wednesday that the facility has been operating in the red since 2010 and has zero reserves, and that without drastic measures the entire hospital could close.
“If we don’t make the necessary changes, we would last maybe a couple years at the most before we would close,” Boula said. “We’re still in a lot of danger.”
Rod Boula, CEO of Calais Regional Hospital, defends the board’s decision to make difficult but necessary changes, saying the facility “has to right itself. … We can’t be everything to everyone.” Staff photo by Brianna Soukup
Travis said the hospital is operating “payroll to payroll” and has no margin for error. Closing obstetrics will save about $500,000 per year.
The hospital has operated an average of $1.8 million per year in the red since 2010 and lost $1.2 million in 2016, according to documents provided by the hospital. It has lost a total of $12.8 million in seven years.
Through the first seven months of 2017, the hospital is operating $365,000 in the red, Boula said, but there are positions that need to be filled, so financial problems will persist next year even with the closing of obstetrics.
Research shows there has been an erosion in obstetrics services at rural hospitals over the past several years. In Maine, Penobscot Valley Hospital in Lincoln closed its obstetrics unit in 2014, and Blue Hill Memorial Hospital did the same in 2009.
Celia Geel, 30, of Calais, who is seven months pregnant with her second child, said she was upset to hear that she would not be able to deliver her baby in Calais in October. Instead, she and her husband will make the two-hour drive to Eastern Maine Medical Center in Bangor.
“I told him he better be watching some how-to YouTube videos,” she said.
Geel said she could try to stay in a Bangor hotel around her due date, but what if the baby doesn’t arrive for another week? She said she doesn’t have maternity leave and she can’t afford to take that much time off work. She’s trying to save up vacation time for after the baby is born.
“It’s causing a lot of unnecessary stress,” Geel said.
Some blame is being directed at Quorum Health Corp., a Tennessee-based for-profit company that operates the Calais hospital.
Todd Ricker, labor representative for the Maine chapter of National Nurses United, the nurses union, said the union will be delivering a letter to Quorum headquarters in Tennessee demanding that the company “leave our city now.”
“We do not need you in our community and we want you to go,” the letter says.
The union also hosted a public meeting Wednesday to discuss hospital services.
Boula said anger toward Quorom is misplaced because decisions are made locally by the hospital’s 15-person board of directors.
“This is a hospital that has to right itself,” Boula said. “We can’t be everything to everyone.”
A BIG LOSS FOR THE COMMUNITY
He said other service lines that he couldn’t publicly disclose may be closed or reduced in the coming years so the hospital can survive.
Caroline Coleman of Calais, who organized the June candlelight vigil and has three boys ages 7, 2 and 5 months, said access to health care for women in rural areas is already lacking, so to close obstetrics is a big loss to the community.
“As a mom, do I want to be five minutes away from the hospital, or 45 minutes away on a good day on a bad road,” Coleman said. She said some of the roads become especially dangerous and slow-going in the winter.
Travis said the Calais hospital is working with Down East Community Hospital and EMMC to have at least one obstetrician in Calais once per week so residents can attend pre-natal appointments locally.
Meanwhile, the Calais hospital is training emergency room nurses and doctors and the Emergency Department will deliver babies when the expectant mom can’t make it to the hospitals in Machias or Bangor.
But Alison Monaghan, an emergency room nurse, said it will be difficult for that department to become proficient at delivering babies when staffers will only be doing a few per year at most. And she said patients who need emergency cesarean sections will have to be transferred to EMMC because the Calais hospital will not be equipped to handle those deliveries.


The Sinister Side Effect of Amazing New Cancer Drug: One Dose Costs Nearly $500K

by Jessica Corbett - Common Dreams - August 31, 2017

On Wednesday, the U.S. Food and Drug Administration on Wednesday approved a new cancer therapy developed by the pharmaceutical company Novartis that experts hope may revolutionize the way doctors treat cancer—but the half-million dollar price tag has sparked a national conversation the costs of life-saving treatments.
In a clinical trial of this CAR-T cell therapy—which will hit the market as "Kymriah"—83 percent of children with acute lymphoblastic leukemia were cancer free after just three months and one dose.
"The therapy," STAT reports, "is made by harvesting patients' white blood cells and rewiring them to home in on tumors. Novartis's product is the first CAR-T therapy to come before the FDA, leading a pack of novel treatments that promise to change the standard of care for certain aggressive blood cancers."
"We're entering a new frontier in medical innovation with the ability to reprogram a patient's own cells to attack a deadly cancer," said FDA commissioner Scott Gottlieb. "New technologies such as gene and cell therapies hold out the potential to transform medicine."
But at what cost?
The price for one treatment set of Kymriah is at $475,000, which does not include any doctors' fees or additional bills for time spent at the hospital, meaning the end cost could be much higher. That is actually lower than anticipated—Wall Street analyst predicted as high as $750,000 per dose, and U.K. regulators said $700,000 "would be fair," STAT reports—but priced at nearly half a million dollars, the treatment has provoked a fierce debate about notoriously high costs for necessary, life-saving healthcare.
Despite Kymriah's success in the clinical trial, Walid Gellad, a doctor and professor at the University of Pittsburgh, suggested to Axios that treatments with undetermined effectiveness—even if they have the potential to save lives—shouldn't cost more than proven measures such as bone marrow or kidney transplants, adding: "This is an amazing therapy, but there has to be a limit at which point companies can no longer charge desperate patients, or taxpayers, enormous sums."
"While Novartis' decision to set a price at $475,000 per treatment may be seen by some as restraint, we believe it is excessive," said David Mitchell, founder and president of the advocacy group Patients For Affordable Drugs, and a cancer patient himself. "The drug pricing system in America is completely broken. Until policy in this country changes, the vicious cycle of patients struggling under high drug prices will continue."

Mitchell's group calculated that over $200 million in federal funding has been allocated to research related to the treatment, and Mitchell said, "Novartis has not acknowledged the significance of taxpayers’ investment," but Novartis chief executive Joseph Jimenez insisted to Forbes' Matthew Herper that his company's undisclosed investments "dwarf anything the government has invested through NIH grants."

The pharma exec also told Herper he hopes the discussion about Kymriah's cost could lead to a change in the way patients are charged for life-saving treatments. Writing for Forbes, Herper reports:
Jimenez sees Kymriah as his chance to put into practice new ideas about drug pricing he has advocated for years as a solution to the pharmaceutical industry's bad reputation and unsustainably rising prices: "indication-based" or "value-based" pricing. Drugs, he says, should be priced on the value they bring to the healthcare system, and insurers and governments should pay based on whether the medicines work. That's why Novartis has approached the Centers for Medicaid and Medicare Services and insurers about schemes where only patients who have responded to Kymriah in a month will incur a charge, despite the high cost of administering the treatment.
Journalists who cover the pharmaceutical industry noted that Jimenez's endorsement of response-based payments is a big deal in the debate about healthcare treatment pricing, but even if the government negotiates a deal for those who rely on Medicare and Medicaid, for cancer patients with private insurance or no insurance at all, this and other life-saving treatments could still remain out-of-reach.
High costs are already impacting cancer patients across the U.S. Recent analysis by Kaiser Health News found that because of continuously increasing costs for cancer treatments, "hundreds of thousands of cancer patients are delaying care, cutting their pills in half, or skipping drug treatment entirely."

And although there are more than 600 gene and cell therapies in clinical trials today, according to Bloomberg Technology, future treatments that resemble Kymriah, for different types of cancer and other diseases, are expected to come at similar or even higher costs.

Peter Bach, the director of Memorial Sloan Kettering's Center for Health Policy and Outcomes, who studies drug prices, told Bloomberg he see the industry's prices increasing with no end in sight. 

"We have gotten so comfortable with these numbers that are just beyond belief for these agents," Bach said. "And this is a highly profitable sector…. They just continue to move the goal posts" for how much companies can charge.
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Single Payer Doctors Out Sanders for Watered Down Bill

by Single Payer Action - August 31, 2017

Single payer activists say they will not support a proposed bill that Senator Bernie Sanders will introduce after Labor Day if the bill includes cost-sharing measures such as co-pays.
In a letter to Senator Sanders, Carol Paris, David Himmelstein and Steffie Woolhandler of Physicians for a National Health Program (PNHP) warn that PNHP “cannot endorse or wholeheartedly advocate for a reform that includes copayments for medically-necessary services.”
“While we would welcome the proposed reform as a useful step forward in advancing health justice, the persistence of copayments would unacceptably compromise the legislation’s ability to improve health and foster equality in care,” they write. “We urge you to reconsider the inclusion of copayments.”
The letter does not appear on the PNHP web site, but was sent to members, urging them to call Senator Sanders and tell him — “do not include copays in your single-payer bill, copays do not reduce administrative costs and — copays discourage patients from seeking medically-necessary care.”
“While your staff has not shared with us the details of the current draft, we understand from colleagues in other single-payer advocacy groups that it mandates copayments for medical services for most Americans and proposes a four-year delay before the implementation of the single-payer reform,” the doctors write. “We also understand that during the four year phase-in period, the bill would make available a public option, and provide some upgrades to and expansion of Medicare coverage.”
The doctors cited a number of studies showing that “copayments undermine the goal of eliminating financial barriers to care, a goal that is at the heart of our single-payer advocacy.”
“Copayments, even relatively modest ones, deter patients from seeking needed medical care,” they wrote.
“Retaining copayments would substantially diminish the administrative savings achievable through a single-payer reform. In order to implement copayments, the single payer insurer would need to track individuals’ changing incomes, family status — to calculate their income relative to the poverty level — and their copayments to date — to ascertain whether they’ve exceeded the out-of-pocket cap — and make that information available in real time to every hospital, clinic, lab and doctor’s office in the U.S. Providers would need to collect the copays, and bill patients unable to pay at the time of a visit.”
As for the four year delay in implementation of the Sanders plan, the doctors warned “against the proposed prolonged transition, although our objections to that aspect of the bill reflect practical concerns rather than medical ones.”
“Most of the administrative savings come only with the implementation of the full single-payer reform, while the proposed benefit improvements and incremental expansions of Medicare would incur substantial added costs,” they wrote. “Similarly, the proposed public option would likely turn into a de facto high-risk pool, raising costs. Hence medical costs during the transition years are likely to be even higher than would be the case without reform, and certainly higher than under the fully-implemented single-payer structure.”
“Claims that the Department of Health and Human Services would need many years to design and implement the rules and regulations for the single payer ignores the fact that Medicare was implemented less than one year after it was passed, a humane and politically wise step that foreclosed political attacks that might have reversed the program before it could be implemented.”
The Health Over Profit steering committee, which includes PNHP President Dr. Carol Paris, said the Sanders bill is not a single payer bill, but a multi-payer bill.
“Recent reports are that Sanders’ bill falls far short of HR 676 in fundamental ways. In fact, Sanders’ bill is a multi-payer system not a single payer system,” said Dr. Margaret Flowers of Health Over Profit. “His bill reportedly would allow private insurers to compete with the public system, allow the wealthy to buy their way out of the public system and allow investor-owned health facilities to continue to profit while providing more expensive and lower quality health care.”
“As a leader in the Democratic Party in the Senate, Sanders is trying to walk the line between listening to the concerns of his constituency, which overwhelmingly favors single payer health care, and protecting his fellow Democrats, whose campaigns are financed by the medical industrial complex. Sanders needs to side with the movement not those who profit from overly expensive US health care.”
“We understand that your legislation will allow employers to continue to provide employee health insurance that duplicates what the national health insurance covers to avoid conflict with the Employee Retirement and Income Security Act (ERISA),” the Health Over Profit activists wrote. “We urge you to include a carve out of ERISA for national health insurance so that the new system is a single payer system. Without doing so, your bill will be a multi-payer system. This is required to achieve administrative simplicity and significant cost savings. HR 676 allows private insurance that does not duplicate the benefits of the system. Employers and unions would be able to provide extra benefits beyond what the system covers.”
“We understand that your legislation will allow health providers to opt out of the national health insurance system. This would create a parallel health system for the wealthy and undermine the quality of the public system. Universal systems are of higher quality than tiered systems because they create a social solidarity in which everyone has an interest in making the system the best it can be. We urge you to reject a tiered healthcare system as healthcare is a human right and should not be based on wealth.”

Getting People to Enroll in Health Plans While Trump Attacks Them

by Abby Goonough - NYT - August 20, 2017

NASHVILLE — Sharon Barker isn’t used to recruiting new health insurance customers in deepest summer, long before the enrollment season for the Affordable Care Act. But this year, everything is different.
Despite surviving Republican efforts to repeal it, the law known as Obamacare remains vulnerable. President Trump has repeatedly threatened to end billions of dollars in payments to insurance companies, but his administration decided this week to continue them for another month.
An even more crucial question is whether administration officials who openly detest the law will lead a vigorous nationwide push to persuade the uninsured to buy policies sold under its banner, and existing customers to keep their coverage, when open enrollment for next year starts on Nov. 1.
The evidence so far suggests they won’t. The administration recently ended $23 million worth of contracts with two companies that helped people sign up for coverage. It also is cutting the enrollment period in half in most states, to 45 days. A number of advocacy groups that worked closely with the Obama administration to get the word out about open enrollment have heard nothing from the Trump administration about re-upping the partnerships this year.
All of this has Ms. Barker and other Obamacare enrollment counselors around the nation, many of whom rely on federal grants to carry out their work and to keep their jobs, revving up earlier than usual, and bracing for the strange new challenge of promoting coverage that the president is attacking at the same time. They are not even certain the law’s mandate that most Americans have health insurance or pay a tax penalty will be enforced.
A recent sticky Friday found Ms. Barker passing out fliers about open enrollment at a back-to-school fair in East Nashville. To every parent and grandparent who strolled past, she asked, “You have health insurance?” Nearby was her favorite prop: a wheel that passers-by could spin with a dial that landed on terms like “deductible” and “penalty,” which she cheerfully explained to those willing to listen.
For the law’s first four enrollment seasons, the Obama administration spent heavily on advertising, recruited celebrities like Katy Perry and companies like Uber to spread the word and scrutinized data to pinpoint potential customers. But this year, community-based enrollment groups, known as navigators, may be largely on their own.
“This is going to be the heaviest lift we have ever tried to undertake,” said Jessie Menkens, navigator program coordinator for the Alaska Primary Care Association. “We will be shouting out for people to recognize this really is not over — that regardless of what deliberations are happening in Washington, this is still truly the law of the land.“
The approximately 100 navigator groups around the country, which received $63 million in federal grants last year, are not sure the Trump administration will renew those grants, which are supposed to be awarded next month. Matt Slonaker, executive director of the Utah Health Policy Project, said he had had encouraging conversations with officials at the Centers for Medicare and Medicaid Services (known as C.M.S.), but “no one will know for sure until the grants are finalized.”
Mr. Slonaker also said that at a conference that C.M.S. held for navigators in June, employees of the agency said the federal government would not run any ads to promote open enrollment this year. A spokeswoman for the agency would not confirm whether that was true or answer other questions about the administration’s plans.
Other open questions include whether the Trump administration will automatically re-enroll people who did not actively cancel or change their plan, as Mr. Obama’s did, and whether it will increase staffing at call centers that help people sign up, given the compressed enrollment time frame.
Insurance companies had asked for the shorter enrollment period, saying it would allow them to collect a full year’s worth of premiums from Obamacare customers and reduce the number of people who wait until they are sick to sign up. The Obama administration had planned to cut the enrollment period to six weeks starting in 2018, but the Trump administration moved it up to this year.
Leaders of the state-based marketplaces say they feel largely in the dark.
“By this time in prior years, the states would have a really good sense of what the federal government was planning so we could plug the holes or leverage what they were doing,” said Mila Kofman, executive director of the D.C. Health Benefit Exchange Authority. “We just haven’t seen any details.”
It seems clear that Mr. Trump won’t be using his powerful Twitter account to encourage sign-ups. Nor are he and Tom Price, his health and human services secretary, likely to be visiting enrollment sites around the country like Mr. Obama and his health secretaries, Kathleen Sebelius and Sylvia Burwell, did.
Mr. Obama visited Nashville to promote the health law in 2015, going to the home of a breast cancer survivor who had benefited from the law, then taking her in his motorcade to an elementary school, where the two of them talked up the law to a cheering crowd.
Last year, Tennessee became a symbol of the law’s growing problems. Insurers sought some of the steepest premium increases in the country after posting major losses they blamed on their Obamacare customers’ high medical costs. Then BlueCross BlueShield of Tennessee decided to stop offering plans in Nashville, Memphis or Knoxville. Statewide enrollment dipped to 200,401 by February 2017, from 231,705 in March 2016.
The state became something of a poster child for the repeal-and-replace effort this year, when Humana announced it was pulling out of the Obamacare markets nationally. That left 16 Tennessee counties with no insurers for next year, a situation Mr. Trump seized on at a rally here in March. (BlueCross BlueShield has since agreed to offer coverage in those counties.)
The Health and Human Services department has produced a series of videos featuring Americans “burdened by Obamacare,” which Mr. Price has posted on Twitter. In response to a request from Senate Democrats, the Government Accountability Office is investigating the videos as part of a broader look at whether some of the anti-Obamacare actions by H.H.S. have violated restrictions on how federal funds can be spent.
Congressional Democrats said they would be sending a letter to Mr. Price on Friday, demanding detailed information about his plans for marketing and outreach during open enrollment. In the letter, the ranking Democrats on House and Senate committees with jurisdiction over health care said they were concerned the administration was “intent on depressing” sign-ups.
“It’s pretty powerful,” Ms. Barker said of the administration’s frequent attacks on the law, “and that’s what we’re up against.”
Ms. Barker’s salary is paid out of the $1.6 million grant that her nonprofit agency, Family and Children’s Services, receives under the law and shares with three other groups around the state. For now she remains upbeat, especially since Senator Lamar Alexander of Tennessee, the Republican who leads the Senate health committee, recently announced the committee would try to create bipartisan legislation next month to shore up the law.
“I’m thinking yes, that’s great!” Ms. Barker said. “I use that when I talk to people who are concerned — there’s a possibility that things will get better, that premiums will go down and this will all get worked out.”
At the back-to-school fair, she buttonholed an uninsured father who said he was moving to Memphis, telling him he might be eligible for a special enrollment period and pressing a phone number into his hand. He gave her a thumbs-up as he walked away.
As the event wound down, she made plans to stop on her way home at a TJ Maxx that was going out of business. Its employees, she reasoned, might need new insurance soon.

Trump Administration Sharply Cuts Spending on Health Law Enrollment

by Abby Goodnough and Robert Pear - NYT - August 312, 2017

WASHINGTON — The Trump administration is slashing spending on advertising and promotion for enrollment under the Affordable Care Act, a move some critics charged was a blatant attempt to sabotage the law.
Officials with the Department of Health and Human Services, who insisted on not being identified during a conference call with reporters, said on Thursday that the advertising budget for the open enrollment period that starts in November would be cut to $10 million, compared with $100 million spent by the Obama administration last year, a drop of 90 percent. Additionally, grants to about 100 nonprofit groups, known as navigators, that help people enroll in health plans offered by the insurance marketplaces will be cut to a total of $36 million, from about $63 million.
The officials said the administration believed that the cuts were necessary because of “diminishing returns” from advertising. They said the number of first-time enrollees in Affordable Care Act coverage fell by 42 percent this year, compared with 2016. In addition, they said that many navigator groups failed to meet their enrollment targets last year, despite sometimes receiving hundreds of thousands of dollars in federal funds.
The Senate Democratic leader, Chuck Schumer of New York, denounced the cutbacks. “The Trump administration is deliberately attempting to sabotage our health care system,” he said. “When the number of people with health insurance declines and costs skyrocket, the American people will know who’s to blame.”
Since Republicans in Congress failed to pass legislation to repeal and replace the law, a longstanding goal of the party, President Trump has stepped up attacks on the legislation and repeatedly insisted it was failing and insurance markets were imploding.
Over all, 12.2 million people selected or automatically re-enrolled in marketplace plans for 2017, although the Trump administration said in June that the number of customers who paid their premiums had dropped to 10.1 million. Similar drops have occurred in previous years after people lost coverage after they failed pay their premiums.
The administration officials who briefed reporters on Thursday said it made no sense to continue spending as much on promoting the law’s coverage options because most Americans know about them already. Instead of television ads, the administration will run radio and digital ads and send emails and texts to existing enrollees, they said. They added that any outreach would emphasize that the enrollment period will be much shorter this year — from Nov. 1 to Dec. 15. Last year’s open enrollment period ran from Nov. 1 through Jan. 31.
“People are aware the products are out there,” one official said, “and they are aware they can sign up.”
Although no navigator group will lose its funding completely, the amounts they get will be based on how close they came to meeting their enrollment goal for 2017. If a group reached only 30 percent of its enrollment goal, for example, it would receive 30 percent of the grant it got last year.
“We are moving forward by matching funding to performance,” one official said.
Another official added that last year, navigator groups enrolled about 80,000 people — less than half of what the groups aspired to, and only 0.7 percent of overall enrollees for 2017 — in marketplace plans. Some groups, they said, enrolled only a handful of people.
But the figures they cited appeared not to include people who met with navigators to sort through coverage options but enrolled later on their own — a not insignificant group, according to past surveys on enrollment.
Navigators defended their work. Alisha Keezer, a health care navigator at the Maine Lobstermen’s Association in Kennebunk, said the cutbacks were “shocking to all of us.”
“We had no forewarning,” Ms. Keezer said. “This is heartbreaking. Here in Maine, we have helped many fishermen enroll in coverage — self-employed people who have never had health insurance before.”
The navigator groups whose funding may be cut are only in the 38 states that rely on the federal Affordable Care Act marketplace, HealthCare.gov. Twelve other states run their own marketplaces and fund their own enrollment programs.
“It’s very disappointing that the administration is minimizing the importance of in-person assistance to millions of people who have relied on it to understand how to enroll and how to use their insurance,” said Shelli D. Quenga, the program director at the Palmetto Project in South Carolina, a nonprofit group that received about $1 million to help with outreach and enrollment in the last 12 months. “These are not easy discussions for people who may have been uninsured all their lives.”
Ms. Quenga said it was not true that most eligible people now know about the coverage available under the Affordable Care Act. “It’s ludicrous to believe that everyone now knows that the Affordable Care Act is alive and well and open for enrollment,” Ms. Quenga said. “Many people believe that the law is dead, or will be dead, based on the administration’s claims.”

In Hurricane Harvey’s Wake, We Need a Green ‘New Deal’

by Rebecca Elliot - NYT - August 31, 2017

For all of the uncertainties that await Houston and coastal Texas, we can be reasonably sure about one thing: Many of those flooded out by Hurricane Harvey will watch their investments and savings collapse into debt and bankruptcy. And the heaviest burdens, of course, will fall on the shoulders of low- and middle-income residents.
Preliminary estimates put losses from the storm at $30 billion to $40 billion. If past disasters are any indication, those numbers will only grow in the coming days and weeks. Whatever the ultimate figure, the losses will represent, in part, the aggregation of hundreds of thousands or more individual financial calamities. When the waters recede and Houstonians and others hit by this storm return home, with all their pluck and determination, to muck out and clear debris, many will learn too late that their homeowners’ insurance does not cover flood damage.
Even for the lucky 15 percent of homeowners in Houston and surrounding Harris County, who have a federal flood policy in place, collecting claims will most likely be a protracted and contentious process. (Hurricane Katrina and Sandy victims have stories to tell about fraudulent or erroneous claims adjustments, delayed payments and their homes being unlivable for years.) Many of the other 85 percent were not required to have a flood policy because they were not officially at “high risk” on the region’s flood maps — maps that President Trump no longer wants the government to pay for.
Those homeowners will be forced to fall back on some combination of disaster relief, loans and savings. Although homeowners with government-backed mortgages will be able to hold off on payments for at least 90 days, eventually they will have to honor mortgages on houses that are uninhabitable or even swept away. Renters may never return home.
In short, many Texans will be starting over economically.
As the legal scholar Michele Dauber has shown, President Franklin D. Roosevelt understood the relationship between “ruined landscapes and ruined lives.” Roosevelt likened the Great Depression to the devastation of the Dust Bowl, tornadoes in Georgia, and floods on the Mississippi and Ohio Rivers to build his case for the huge public investments and assistance programs that transformed the fates of Americans who were also starting over.
In the last several decades of American policy making, however, we have seen those protections and provisions eroded, along with divestments in the kinds of public goods like knowledge and infrastructure that help us to live safe and secure lives, in good times and bad. The outpouring of solidarity and support we have seen from ordinary people during Hurricane Harvey is not matched by programs that institutionalize a commitment to collective flourishing. This has been for many Americans its own kind of slow-motion disaster.
A recent report by American scientists concluded that the effects of climate change are already with us. In a world of more Harveys, rising sea levels, heat waves and droughts, what do we owe each other? The political trajectory we have been on suggests that the answer is, “Very little.”
Congress and state legislatures disburse emergency funds, which are then offset in budgets with cuts to social services and public spending. We are seemingly in a permanently reactive mode, with money often going to rebuild “back to normal” as though this is proof of bravery in the face of tremendous uncertainty. Recovery from previous disasters, like Hurricane Katrina, has had regressive effects, heightening the disparities between rich and poor and perpetuating systemic racism.
Certainly, the hurricane’s victims need all the help we can provide. But this historic storm, like the Great Depression, should also motivate a reconsideration of our broader social contract: a new New Deal.
Environmentalists and scholars have sometimes called this a “green New Deal” or “environmental Keynesianism.” We should invest in science and public education to train the next generation of engineers who will build safer homes and infrastructure. (President Trump promised us infrastructure but, just weeks before this storm, rescinded an Obama-era regulation that required structures built with federal money to take sea-level rise into account.) We should expand and enhance programs that make adaptation to climate change possible for ordinary Americans, helping them to retrofit their homes or relocate to safer ground.
We should plan recovery and rebuilding projects that address local poverty and exclusion, rather than line the pockets of developers. We should commit expenditures to the kinds of projects that mitigate climate change, like clean energy and public transportation. And we should strengthen our safety nets so that when the next storm’s victims are picking up the pieces, they are not also worried about job insecurity, rising health care costs and precarious retirements.
How we respond to Hurricane Harvey and the floods to come will demonstrate who and what we value. We care for one another — that much is clear from the rescue efforts. A new New Deal commits us to caring for one another after the disaster has passed.

Medicaid is insurance

by The Editorial Board - Bangor Daily News - September 1, 2017

Here’s how the federal government describes Medicaid: “Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.”
The Maine Department of Health and Human Services lists MaineCare, the state’s version of Medicaid, under the heading of Insurance in a list of DHHS programs. It goes on to define MaineCare as: free or low-cost health insurance for families with children and pregnant women. Under the listing of questions about the program is this query: Who is eligible for this insurance?
Insurance companies, hospitals and medical providers treat Medicaid as insurance. Schools, camps and sports programs recognize Medicaid, or MaineCare, as insurance on the forms parents are required to fill out.
Yet, last week, a group of Maine Republicans, including former party Chairman Rick Bennett, set out to convince the public, and Secretary of State Matt Dunlap, that Medicaid is not insurance. It is welfare, they argued.
Gov. Paul LePage joined in, threatening last week to sue Dunlap if the word “insurance” stays in the ballot question. The Medicaid expansion question, Question 2 on the Nov. 7 ballot, is currently proposed to read: “Do you want Maine to provide health insurance through Medicaid for qualified adults under age 65 with incomes at or below 138% of the federal poverty line (which is now about $16,000 for a single person and $22,000 for a family of two)?” The Secretary of State’s Office accepted public comments on the ballot question wording through Friday.
LePage and the GOP are not confused about what Medicaid is. They just need what they believe is a winning campaign strategy to defeat an expansion of Medicaid at the ballot box. Rather than convince voters that extending health insurance to more people is a bad idea, GOP leadership decided to fall back on the welfare argument, which has helped them win other elections. It is much easier to convince voters not to extend benefits to their friends and neighbors when they think they are getting welfare than it is to convince these same voters to deny health care to these same friends and neighbors. Health coverage will save lives and money. Welfare, the GOP thinking goes, gives people something they don’t deserve.
This is a cynical political move meant, first, to try to convince Dunlap to remove the word “insurance” from the ballot question, which he should not do. Failing that, we expect the GOP to mount an opposition campaign based on the idea that health insurance for the poor is welfare.
It is not.
Most fundamentally, people who are covered by Medicaid don’t receive any of the money. Instead, when they are treated at a doctor’s office or stay in a hospital, the medical provider bills Medicaid (or MaineCare) for the services. Payments are made directly to the provider, as is the case with any other insurance carrier.
Beyond all of this, extending health insurance to thousands of Maine residents who don’t currently have it is the right thing to do. The Maine Legislature has repeatedly approved expanding Medicaid to accomplish this. LePage has vetoed an expansion five times.
Stymied by LePage and Republicans lawmakers who have voted to uphold his vetoes, advocates for Medicaid expansion gathered signatures last year to put the question directly to Maine voters.
Thirty-one states have expanded Medicaid under a provision of the Affordable Care Act to offer health insurance coverage to poor residents who weren’t eligible for Medicaid. In states that have expanded Medicaid, the number of people without health insurance has dropped, resulting in better access to medical care for these newly eligible people. When people can see a doctor more regularly, their health often improves and their medical care is less expensive in the long term. The additional investments in health care have created new jobs and spurred economic growth in expansion states. Maine was expected to gain $1.2 billion in federal fundsover the next two years under legislation that died in the Legislature last year.
This is not welfare, this is a common sense way to ensure that more Mainers have access to health care, which benefits all of us.




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