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Health care’s ‘upstream’ conundrum

By DAVID H. FREEDMAN - The Agenda - January 10, 2018

01/10/2018

At the heart of America's vaunted health care system is a frustrating puzzle. The United States pays three times as much per citizen as the average of other wealthy nations—far more than even the second-highest spender, Switzerland, adding up to $3 trillion a year. Yet for all that enormous expenditure, we come in dead last among those nations in lifespan. And as the bills climb, our life expectancy is actually shrinking.

What’s going so wrong? If our national health care were a corporation, that return on investment would get its CEO immediately fired. Plenty of experts are ready to point fingers at various causes: our lack of universal health care, industrialized food system, suburban lifestyles, and profit-driven tangle of insurers and drug companies and hospitals. Surely those play a role. And yet other countries face each of these, and other challenges as well, and still manage to spend less and enjoy better health overall.

Looming over the American conversation about public health is a growing suspicion that there's a bigger reason for our uniquely poor showing, one that has been staring us in the face for years. It's an explanation rooted in one simple statistic: While we pay more for health care than any other country in the world, when it comes to spending on social services—education, subsidized housing, food assistance and more—we rank in the bottom 10 among developed countries.

It's easy to think of “health” as just another category of social-service spending. But a great deal of modern research suggests that it might be more accurate to think of it as the payoff of all the other services put together. Elizabeth Bradley, president of Vassar College and a former Yale researcher widely seen as the world's foremost expert in the relationship between social services and health, has documented how the ratio of a country's social-service spending to health care spending is highly correlated with health outcomes around the world. "The right question for our political agenda is, 'What's going to give us the most bang for the buck in health outcomes?'" says Bradley. "What our work has shown is that the answer is spending on social services."

For a cost-conscious government ever wary of spending taxpayer money on public programs, this kind of expansive view of “health” sounds politically forbidding. But if you really care about health—and as a society, we clearly do, to the tune of $672 billion a year in Medicare, $565 billion in Medicaid, $329 billion raked in by the pharma industry and a $1 trillion by hospitals—there is good reason to believe that money pumped into social services would do more for our national health than money invested directly in health care.

In fact, it's possible to see America's astronomical health costs as a bill coming due from our reluctance to pay for everything else. "We spend so much on health care because we're mopping up for our lack of investment in education, housing and other areas," says Corey Rhyan, an analyst at the Center for Sustainable Health Spending at health care think tank Altarum.

In public health, there's a buzzword for all these other factors: the "social determinants of health," the complex set of home-and-community factors that shapes every American life. A simple way to think of it might be as looking "upstream" from health, toward the influences we encounter long before we need medical care to fix the problems they’ve caused. What if, instead of plowing more money into medicine, we could shift those?

Of course, that's not how our policy conversation has gone. When we debate housing services, or education spending, we rarely focus on their potentially huge downstream benefits on public health. And when we debate health care spending, we don't discuss the lack of “upstream” social services that has made much of that care necessary.

Why don't policymakers start looking further upstream? One problem is that it has been difficult to put hard numbers on the health care payback from social-service spending—and especially hard to get numbers relevant in the what-have-you-done-for-me-lately world of elected officials. But in recent years, economists and public-health experts have started to focus more on answering that question, trying to build an economic case for tackling health through upstream changes, instead of playing an expensive game of catch-up downstream. And the numbers are starting to come in, thanks to a growing range of innovative social-good programs that measure hard health care benefits, as well as a renewed effort on the part of academic researchers to give policymakers the data they need.

Five years ago those sorts of programs and tools were scarce. But more recently, they've quietly been arriving on the scene, driven in part by imaginative new approaches to what we should be measuring, and how. If these approaches work, they could start changing not only our policy conversation, but the politics around it, offering hard-headed evidence of savings that Republicans could get behind as easily as Democrats. The stakes couldn’t be higher: Last year health care passed retail as America’s largest industry, and our aging population makes it overwhelmingly likely that we’ll be shifting yet more of our GDP into medical spending for decades to come. If we wanted to start bending that curve right now, what levers should we really push?

IN THE BIG PICTURE, it's become hard to refute the evidence that upstream investment matters to health—and matters a lot. In one analysis, Bradley and her colleagues crunched 74 different studies that had examined the issue, and found a fairly consistent set of health benefits from social spending. In a separate study of U.S states, Bradley calculated that if such a shift in spending in a state were enough to increase the ratio of social spending to health care spending by 20 percent, it would on average equate to reducing the ranks of the obese in that state by 85,000, along with other health improvements. As strange as it sounds, that means the best way to improve health might often be to shift money away from health care.

That’s not an easy political case to make, in part because putting hard dollar values on decisions like that is so tricky. In fact, for a long time researchers didn't even try. A study published in the British Medical Journal, for instance, found that nearly half the studies that looked at both the costs and health care-savings benefits of social programs simply presented the data without bothering to do a full cost-benefit analysis.

Even when the benefits are clearly visible, policymakers immediately run into the so-called "long pocket" problem: The costs of social spending start piling up immediately, while most of the health benefits pay off years and even decades in the future. That's politically unappealing to elected officials on two- and four-year cycles, to say nothing of appointees who need to show results while they're still in office. And politics aside, investing for distant returns is both psychologically and economically hard to justify. "To the extent that investment is diverted somewhere, you give up a stream of benefits that could have been had if you invested somewhere else," says David Weimer, a policy economist at the University of Wisconsin-Madison. Even in the unlikely chance that researchers managed to run a study for 40 years to fully capture the long-term benefits of a program, Weimer points out, there's a pretty good chance that the original program would feel irrelevant in a much-changed world.

For those reasons, program sponsors and researchers are now focusing on the shorter term, trying to prove that social spending can pay off quickly in reduced health care costs. One sweet spot is in subsidized housing, where benefits often accrue right away, especially for the most challenging patients.

In Portland, Oregon, in 2011, the city's housing bureau, in collaboration with county agencies, began placing more than 7,000 residents without homes in a large, new facility. Because most of the residents were covered by Medicaid and received healthcare from local public facilities, it was possible to track the costs of their care from the start. Within a few years, those costs had on average fallen by 55 percent—adding up to an annual drop in health care costs of about $1,100 per person. A similar program in Chicago, led by the city's housing and health agency and University of Illinois Hospital, reduced health care costs by 42 percent.

A few private-sector organizations are jumping in, too, particularly on the food side. Humana Health, which provides both health insurance and health care, is running programs in Louisville, Kentucky and four other Southern cities, offering healthier food to vulnerable parts of the community, and has already documented an average $15-per-month-per-patient reduction in health care costs. UnitedHealthcare, another insurance and care provider, has announced a comparable program in Mississippi in collaboration with Alcorn State University. [UnitedHealthcare is financial underwriter for POLITICO’s Agenda 2020 series, but was not involved in conceiving or editing this story.]

The savings these programs report may seem relatively small, but they're at least proof of concept, and are expected to grow over time as the health benefits help slow or even head off expensive long-term conditions like diabetes and heart disease. What's more, any reduction in health costs stands in sharp and welcome contrast to what has long been a steep, steady upward march. "We're getting pretty clean evidence now that communities that invest in these programs see lower medical spending," says Glen Mays, a public health researcher at the University of Kentucky.

One of the most closely watched programs has been that run by Minneapolis-based Hennepin Health, an accountable care organization for patients on Medicaid run by the surrounding county. Minnesota sharply expanded Medicaid eligibility in the state in 2011 and again in 2014, bringing in about 10,000 new enrollees under Hennepin's care, representing well over $300 million in new health care costs. These enrollees, all of whom were poor and many of whom didn't have permanent housing, were being admitted to the hospital at three times the rate of other nonelderly adults, and were visiting the emergency department an astonishing 13 times as often, according to Ross Owen, the health strategy director for Hennepin County. Each such admission or visit can easily rack up thousands of dollars in costs, making reducing them good targets for a program. "Those are the low-hanging fruits of these kinds of interventions," says Owen.

Though Hennepin is a health care organization, it started paying for a range of housing and other social services for its patients—services far outside of medicine—in hopes that they’d pay off by reducing the need for medical care. So far, five years into the program, it has found that emergency department visits have dropped 35 percent, while outpatient doctor visits—a much more cost-effective way to provide care—have risen 21 percent. Overall, health care costs for enrollees have been dropping 11 percent per year. The fast results have kept the county eager to maintain the program and even to expand it, says Owen. "Requiring decades to show savings from an investment doesn't match the way health care financing works," he explains.

ONE BIG OBSTACLE to using these insights is that the broader American health system really isn’t set up to benefit from long-term preventive investments. Right now, the incentive to spend on upstream services is largely limited to agencies and organizations that, like Hennepin Health, are in "closed systems"—that is, where the payer also provides the care, so the organization spending money will be the same one reaping the benefits. Other such closed systems include Kaiser Permanente and Veterans Affairs, which notably have also have been providing housing benefits to their neediest enrollees. But most of American healthcare doesn't work this way: Payers and providers operate in separate and competing realms. Insurers have an incentive to keep costs down, but most don't hang onto individual customers long enough for distant payoffs to matter. Hospitals and doctors, meanwhile, make more money by providing more care, so they have no obvious financial incentive to invest in social services that will leave patients needing less of it.

Of course, government and other agencies can fund those services, but if those savings do materialize, they may never come back to the taxpayers who funded them. Even local governments can get cut out, because the federal government would be the biggest beneficiaries of any savings in Medicaid or Medicare treatment. It's called the "wrong pocket" problem: The money comes out of one party's pocket, but the benefits go into someone else's.

And justifying the investments with the biggest benefits may be an even steeper challenge. Many researchers have come to believe that the most important long-term health payoffs are likely to come from investments in education, environmental cleanup and urban design—areas even further removed from health care, and where the payoffs that are even more diffuse and distant. But now researchers may be closing in on ways to convincingly document those more elusive gains, as well.

The first problem they’re encountering is just how little information is available to work with. A study published in the BMJ surveyed the research on the question and found the longest follow-up period of health outcomes ended less than four years after the social-service intervention. For many kinds of investments, like better education, and for many types of health payoffs, like diabetes or Alzheimer's, that would barely even be the starting point for observing returns. "Expectations that health impacts will be observed in this short timescale may be naive," the authors drily noted.

And "health" itself is a frustratingly hard thing to put a clear economic value on. In health care economics writ large, benefits and their values can be very subjective, and can veer into difficult moral issues. One crude but effective way to measure at least the relative value of upstream interventions is simply to determine which ones leave people less likely to die sooner. For example, one study calculated that every $1,000 invested in the education of a low-income child can add more than a month to the child's life--which adds up to a much higher return on investment than, say, colorectal cancer screening, and exceeds by a factor of three the widely accepted threshold for the level of risk reduction required to justify a public-health intervention.

Researchers at the University of Michigan found that the sorts of conditions addressed by social-service spending figure heavily in mortality and health. They concluded that about one out of five deaths can be attributed to conditions in the immediate environment; that low-income individuals are 29 percent more likely to die in any given time period than those of middle income; and that social circumstances account for 40 percent of what influences health. A United Kingdom study found that a jump in the mortality rate coincided with a drop in social-service spending there in 2010, leading to 120,000 more deaths from 2010 to 2017 than there would have been if the pre-2010 rate had held steady. It's no different in the U.S., says Alex Sutherland, research leader at Rand Europe. "The impact of tiny investments can be dramatic," he says. "A 1 percentage point increase in social spending would add up to 16 million additional years of life across the whole U.S. population."

While these sorts of findings bring home the impact of social services on health, they don't really give policymakers the hard-dollar numbers that would help politicians make a more clear-eyed case to the public. One way to do that, says Weimer, is to come up with so-called "shadow prices" for things like an extra year of life, or a percentage drop in the risk of a disease. "Economists come up with rules of thumb that allowing valuing savings in commuter time as, for example, half the wage rate," he says. "We need to develop the same sort of thing for health improvements." These shadow prices could then be discounted in a straightforward way if they kick in over time, and then added up like any other return on investment.

BUT THERE MAY be an even better way to make the accounting case for the long-term health benefits of social spending—one that borrows a tactic from pharmaceutical studies. Those studies frequently use surrogate endpoints like lower cholesterol as a way to forecast longer-term heart benefits. Several researchers are now working on approaches that look for short-term health markers that strongly correlate with long-term outcomes. One of them is Andrew Fenelon, a public-health scientist at the University of Maryland's Population Research Center, who's planning to integrate federal data on 40,000 households with biomarkers like blood pressure to come up with projections of how spending on housing is likely to affect long-term health and to do it within a few years rather than a few decades. "We usually rely on self-reported health," he says. "But biomarkers give us a way of validating the data with objective clinical measures."

In a similar vein, researchers are looking at cholesterol levels in a Pittsburgh low-income neighborhood that recently got a supermarket after years as a food desert. So far, new cases of high cholesterol have dropped 10 percent in a year. And Mays is involved in a study with Eskenazi Health in Indianapolis that's integrating electronic medical records with community social-service resources. That's an approach that could pay off on both the cause and effect sides: first, by making it easier for health care providers to flag patients who would most benefit from a social intervention and funnel them directly into services; and then by ensuring that downstream health results are tabulated directly alongside records of past interventions for clear cost/benefit calculations.

Some researchers think that the best biomarkers for linking social service investment to long-term health will involve those that indicate inflammation, strongly correlated with stress, and now seen by many in medicine as important factors in everything from heart disease to cancer to Alzheimer's. Inflammation markers can shift quickly with changes in the environment, notes Apostolos Davillas, senior research officer at the Institute for Social and Economic Research at the University of Essex in the U.K. "When you see elevated inflammation biomarkers it's a clear indicator that something's happening in the body's stress pathway," he says. "It can show us how socioeconomic status can literally get under someone's skin." Davillis is already working with blood samples that provide inflammation data that can be pulled together with other health care markers, like BMI, along with detailed social and economic data. "It's the only good way to evaluate the effects of social policies on the health of the population," he says. Future efforts could add in measurements of diet, exercise levels, alcohol and tobacco consumption, and other lifestyle indicators that are all correlated with long-term health outcomes.

One of the most ambitious new efforts is being funded by the Gates Foundation. The project brings together researchers from Harvard and Stanford to sift through and analyze a wealth of data from 1999 to 2014 covering neighborhood conditions, socioeconomic status, biomarkers and health outcomes all across the U.S. population. The goal is to nail down how long-term health outcomes vary with income and neighborhood factors, and to use those findings to identify the social policies that are likely to provide the biggest returns in long-term health. The scope of the project, as well as of the caliber and weight of its sponsor and participants, are good indicators of both the scale of the challenge and the enthusiasm about its potential.

IT'S ONE THING if this and many other projects together succeed in building a clear-cut, hard-dollars case for the big health payback of social-service spending. Having those results matter is another thing. There's no guarantee that, even in the face of strong proof to the contrary, politicians won't keep on with business as usual, continuing to throw the bigger bucks at health care—which has big, well-funded lobbies and enjoys broad public support—rather than the social conditions that make the care necessary. After all, they've done a pretty good job of shrugging off the evidence so far. "It's been making less and less sense to look at medical diagnoses when you want make health-related spending decisions, and more and more sense to look at demographics," says Hennepin's Owen. "The way we distribute resources in this country ignores that reality."

But the more scientifically and economically hard-nosed these measurements get, the broader a constituency they could attract. Bradley, who advocated for more social-service spending in her 2013 book "The American Health Care Paradox," suggests that a more powerful, long-term economic case for health-related savings wouldn't just change the policy conversation—it could change the politics around the issue.

When conservative cost-cutters take aim at America's unsustainable medical spending, they tend to sharpen their knives for safety-net programs like Medicare and Medicaid. What if the smartest economic move to rein in those costs were actually to spend money, but direct it judiciously elsewhere? That could make this kind of public-health reform more than a progressive fantasy. "Bobby Jindal and other Republican governors said they liked the idea as a way to spend less on Medicaid and to make the best investments possible," Bradley says. Some in Congress want to get private investment involved in providing support for social-service programs that pay off in clear, measurable savings in healthcare, among other benefits. That approach, called "social impact bonds," has been winning some bipartisan support, including from no less a Republican stalwart than Orrin Hatch.

The quest to demonstrate powerful, broad, long-term health benefits to a range of social-service investment offers the chance to reshape the politics around American social spending. That means looking at improvements that tend to play out over one or more decades. Such long-pocket payoffs may not normally play well in politics, but if the case were strong enough and the returns big enough, legislators might not be able to say no.

David H. Freedman is co-founder and Executive Editor of Global HealthCare Insights Magazine, and a contributing editor at The Atlantic. His most recent book is "Wrong: Why Experts Keep Failing Us."

https://www.politico.com/agenda/story/2018/01/10/long-term-health-nation-problems-000613

The Trump Plan to Hurt the Poor by Pretending to Help Them

The Editorial Board - NYT - January 11, 2018

When Ohio and Michigan expanded their Medicaid programs to broaden coverage, residents who became eligible found it easier to look for work, according to studies by the Ohio Department of Medicaid and the University of Michigan. That’s because having Medicaid gave them access to primary care doctors and prescription medicine that helped them live normal lives and get jobs.

That’s how you help people in the real world. The Trump administration said Thursday that it would get poor people to work by letting state governments deny them Medicaid if they don’t have a job.

The Centers for Medicare and Medicaid Services argues that this draconian step will encourage more Medicaid beneficiaries to get a job and thus “promote better mental, physical and emotional health.” There’s no evidence that this is true, and the data from Michigan and Ohio shows that it contradicts the truth. There is good reason to worry that fewer people will have a job in states that adopt this cruel policy.

Arkansas, Indiana, Kentucky and seven other states are seeking waivers from federal law to initiate the policy, and the agency says it is ready to grant them the waivers in the coming days if the states meet certain minimal conditions, like exempting people who are pregnant, disabled or caring for family members.

The new policy would be attempting to solve a problem that doesn’t exist. About two-thirds of Medicaid beneficiaries are either seniors, disabled people or children. Of the remaining one-third, nearly 80 percent are in families with at least one working person and 60 percent have full- or part-time jobs, according to the Kaiser Family Foundation. This policy change is merely a bureaucratic obstacle to keep poor people from obtaining Medicaid. Eligibility for the program varies from state to state, but the national median income limit for a single person to qualify for Medicaid is $16,642 a year.

Republican lawmakers who have demonized the program as welfare for “able-bodied adults” have long sought to require Medicaid beneficiaries to work. Those lawmakers have been particularly angry about the expansion of Medicaid under the Affordable Care Act, which they have been trying to repeal since it was passed in 2010.

Taking Medicaid away from people who are out of work would damage some of the most vulnerable people in the country. Among them are residents of rural areas who are struggling with opioid addictions and, as a result, cannot hold down permanent jobs. It will also hurt people who, through no fault of their own, lose their jobs and are not able to quickly find another one because they live in a depressed area or because economic changes have made their skills less valuable. Then there are people with chronic conditions like diabetes who do not qualify for disability, but are often unable to work.

“Even though sometimes I can get a job, you’ve got to understand — sometimes I can’t even walk,” Jimmy Brunson, a diabetic in Arkansas, told The Times last year.

It is not clear that the Trump administration can legally allow states to impose a work requirement. Experts say federal law allows the government to grant waivers only if they help to advance the aims of Medicaid, which is to provide medical care to low-income people. It strains credulity for the administration to argue that denying health insurance to people on the basis of their employment status meets that test. Public interest groups acting on behalf of Medicaid recipients are likely to challenge such waivers in court.

Maybe Americans shouldn’t be surprised that this administration wants to take health care away from the poor, given that it has spent so much time trying to wreck the A.C.A. But they should be angry.

https://www.nytimes.com/2018/01/11/opinion/domestic-violence-trump-poor.html

Dollars, Cents and Republican Sadism

by Paul Krugman - NYT - January 11, 2018

Democrats want to strengthen the social safety net; Republicans want to weaken it. But why?

G.O.P. opposition to programs helping the less fortunate, from food stamps to Medicaid, is usually framed in monetary terms. For example, Senator Orrin Hatch, challenged about Congress’s failure to take action on the Children’s Health Insurance Program, a part of Medicaid that covers nearly nine million children — and whose federal funding expired back in September — declared that “the reason CHIP’s having trouble is that we don’t have money anymore.”

But is it really about the money? No, it’s about the cruelty. Over the past few years it has become increasingly clear that the suffering imposed by Republican opposition to safety-net programs isn’t a bug, it’s a feature. Inflicting pain is the point.

To see what I mean, consider three stories about health care policies.

First, there’s the saga of Medicaid expansion under the Affordable Care Act. The Supreme Court allowed states to opt out of this expansion. But accepting expansion should have been a no-brainer for every state: The federal government would initially pay the full cost, and even in the long run it would pay 90 percent, meanwhile bringing money and jobs into state economies.

Yet 18 states — all of them with Republican-controlled legislatures, governors or both — still haven’t expanded Medicaid. Why?

For a while you could argue that it was about cynical political strategy: Medicaid expansion was a policy of Barack Obama, and Republicans didn’t want to give a Democratic president any policy successes. But that story can’t explain states’ continuing resistance to the idea of providing health coverage to thousands of their own citizens at minimal cost.

No, at this point it’s clear that G.O.P. politicians simply don’t want lower-income families to have access to health care and are actually willing to hurt their own states’ economies to deny them that access.

Second, there’s the issue of work requirements for Medicaid. Some states have been petitioning for years for the right to force Medicaid recipients to take jobs, and this week the Trump administration declared that it would allow them to do so. But what was driving this demand?

The reality is that a vast majority of adult Medicaid recipients are in families where at least one adult is working. And a vast majority of those who aren’t working have very good reasons for not being in the labor force: They’re disabled, they’re caregivers to other family members or they’re students. The population of Medicaid recipients who “ought” to be working but aren’t is very small, and the money that states could save by denying them coverage is trivial.

Oh, and of the 10 states reportedly seeking to impose work requirements, six have accepted the A.C.A. Medicaid expansion, which means that most of the money they could save by kicking people off would be federal, not state, dollars. So what’s this about?

The answer, surely, is that it isn’t about saving money, it’s about stigmatizing those who receive government aid, forcing them to jump through hoops to prove their neediness. Again, the pain is the point.

Finally, there’s the case of children’s health insurance. Again, federal funding expired back in September, and millions of children will lose coverage soon if that funding isn’t restored. So what will it cost the Treasury if Congress does what it should have done months ago, and restores funding? The answer, according to the Congressional Budget Office, is — nothing. Or actually less than nothing. In fact, a 10-year extension of CHIP funding would save the government $6 billion.

How is this possible, given the roughly $14 billion a year CHIP currently spends on health? The key point, laid out in a budget office analysis a few months ago, is that many (but not all) families whose children are currently covered by CHIP could alternatively be covered by subsidized private insurance through the Obamacare exchanges.

Private insurance is, however, considerably more expensive than Medicaid, which uses its bargaining power to hold down costs. (The cost of private insurance has gone up even further now that Republicans have repealed the individual mandate, worsening the risk pool.) As a result, subsidies for private insurance would end up costing more than the direct coverage children currently get through CHIP.

And don’t imagine that, because many children thrown off CHIP would find alternative sources of coverage, the kids would be alright. For one thing, a significant number wouldn’t get covered: The number of uninsured kids would rise substantially. Furthermore, private insurance, which often involves large out-of-pocket expenses, is much worse than CHIP for lower-income families.

So Republican foot-dragging on CHIP, like opposition to Medicaid expansion and the demand for work requirements, isn’t about the money, it’s about the cruelty. Making lower-income Americans worse off has become a goal in itself for the modern G.O.P., a goal the party is actually willing to spend money and increase deficits to achieve.

https://www.nytimes.com/2018/01/11/opinion/dollars-cents-republican-sadism.html

Trump’s Medicaid Work Requirement Will Backfire

by Jered Bernstein and Hannah Katch - NYT - January 11, 2018

Just because President Trump and the Republican Congress were unable to pass health care legislation that would have unwound the coverage benefits of the Affordable Care Act doesn’t mean such attacks are behind us. To the contrary, Republicans are now making an end run around Congress to accomplish one of their harshest goals: kicking economically vulnerable people off Medicaid.

The administration’s new approach — one that no administration before it has taken — is to provide waivers to states that allow them to impose work requirements for Medicaid benefits. Thus far, the Centers for Medicare and Medicaid Services has received requests for such waivers from 10 states. C.M.S. released guidance on Thursday describing how states can institute these work requirements.

Even before Thursday, C.M.S. had unilaterally changed the standards a waiver must meet to accord with Medicaid’s core mission — specifically, that whatever they do, states must increase and strengthen health coverage for people of limited means. Now the administration will be considering waivers that are likely to deprive thousands of low-income people of health care.

Some of these people will lose coverage because they can’t find jobs to fulfill the work requirements. Others will lose it because they fail to complete paperwork proving they’re working or that they qualify for exemptions. For example, people with mental illness, addiction or chronic disease often struggle to meet bureaucratic demands; in programs that already demand that beneficiaries work, such individuals have often been punished for falling short on work requirements even though they’re supposed to qualify for exemptions.

Instead of requiring states to increase and strengthen coverage, C.M.S. will now allow them to use waivers to promote “upward mobility” or “responsible decision-making.” If those sound good to you, understand that they are known euphemisms for work requirements. The key point, as the Medicaid analyst Jessica Schubel points out, is that neither of those goals align with Medicaid’s mission of providing comprehensive health insurance to low-income people. They would instead, she said, “let states kick people off coverage if they don’t comply with new requirements that have nothing to do with health insurance.”

People losing coverage could suffer severe harm. A study of Medicaid expansion in Kentucky and Arkansas found that it led to significant gains in access to care, financial security and health, with increases in the share of low-income adults going for checkups, getting regular care for chronic conditions and reporting that they are in excellent health. It also found large decreases in the share of people struggling to pay medical bills and relying on hospital emergency rooms for care. Under the new waivers, these gains will be reversed.

It’s also essential to recognize that Medicaid work requirements won’t work. There’s no evidence that Medicaid discourages work, which comports with common sense: You can’t pay rent or buy groceries with health coverage. About 80 percent of able-bodied adult Medicaid recipients are part of working families (that is, either they or their spouses work), and about 60 percent work themselves. Among adults on Medicaid who don’t work and could be subject to the work requirement, more than a third have a chronic health problem or disability, about half take care of their family or go to school, and just under 10 percent can’t find work.

It’s far more likely that Medicaid work requirements will backfire, at least in terms of improving beneficiaries’ living standards. By providing coverage for workers in jobs that are unlikely to provide such benefits, and by helping to stabilize the finances of people with illnesses, Medicaid has been found to help people stay employed or find work.

Of course, not all of the Republicans’ efforts to shrink Medicaid are occurring through executive, as opposed to congressional, action. The new tax law’s repeal of the Affordable Care Act’s individual mandate could, according to the nonpartisan Congressional Budget Office, cut five million from the Medicaid rolls by 2027. That’s because, absent the mandate, fewer low-income people will find out that they’re eligible for Medicaid, especially in expansion states.

By letting states impose work requirements in Medicaid, the administration will hurt many of the very people Mr. Trump said that he wanted to help when he ran for president. And announcing this policy in the wake of the tax overhaul makes the administration’s priorities especially stark: Reductions in coverage will be phased in alongside hundreds of billions in tax cuts for wealthy households and corporations.

Since congressional Democrats cannot stop the administration from issuing waivers, this battle now moves to the states. State legislatures and advocates for low-income families must insist that their representatives and elected officials not go down the path of requesting waivers. Medicaid is working, as are most able-bodied adults who are eligible for it. The administration’s bid to cut the program under the guise of mobility-enhancing work requirements must be seen for what it is.

https://www.nytimes.com/2018/01/11/opinion/trumps-medicaid-backfire.html

Individual Mandate Now Gone, G.O.P. Targets the One for Employers

by Robert Pear - NYT - January 14, 2018

WASHINGTON — Having wiped out the requirement for people to have health insurance, Republicans in Congress are taking aim at a new target: the mandate in the Affordable Care Act that employers offer coverage to employees.

And many employers are cheering the effort.

While large companies have long offered health benefits, many have chafed at the detailed requirements under the health law, including its reporting rules, which they see as onerous and expensive. Now that relief has been extended to individuals, some companies believe they should be next in line.

The individual mandate and the employer mandate are “inextricably entwined,” said James A. Klein, the president of the American Benefits Council, an influential lobby for large companies like Dow Chemical, Microsoft and BP, the oil and gas producer.

“It is inequitable to leave the employer mandate in place when its purpose — to support the individual mandate — no longer exists,” Mr. Klein said. “We are urging Congress to repeal the employer mandate.”

Opposition to the employer mandate could increase as more employers are fined for not offering coverage or for not meeting federal standards for adequate, affordable coverage. Since October, the Internal Revenue Service has notified thousands of businesses that they owe money because they failed to offer coverage in 2015, when the mandate took effect.

Representatives Devin Nunes of California and Mike Kelly of Pennsylvania, both Republicans, recently introduced a bill, supported by party leaders, to suspend the mandate, canceling any penalties that would be imposed for any year from 2015 to 2018.

“The employer mandate is a job-killer, a wage-killer and a business-killer,” Mr. Kelly said.

But Tom Leibfried, a health care lobbyist at the A.F.L.-C.I.O., called the proposals to repeal or weaken the employer mandate “a very bad idea.”

“The Affordable Care Act was built on a framework of shared responsibility,” Mr. Leibfried said. “If you get rid of the employer mandate, you will see people lose coverage from their employers.”

Such a move could also increase costs for the federal government. Even though Congress has eliminated the penalties for people who go without insurance, millions of consumers are still eligible for financial aid in the form of tax credits to help them pay insurance premiums. These subsidies increase with the rapidly rising cost of insurance. If fewer people receive coverage from employers, more will qualify for subsidized coverage in the public marketplaces created by the Affordable Care Act.

“The employer mandate holds down the cost of premium tax credits for the federal government,” said Catherine E. Livingston, a tax lawyer at the law firm Jones Day who was the health care counsel at the I.R.S. from 2010 to 2013. “Any employee who receives an offer of affordable coverage from an employer is not eligible for the tax credit. And the employer mandate provides a strong incentive for employers to offer affordable coverage.”

But it has also limited companies’ options in providing health benefits, they say.

“Most large employers like Hallmark provide employer coverage today,” said Tresia Franklin, the company’s director of employee relations. “Employers want flexibility to offer the health benefits that make the most sense for their employees.”

Employers with 50 or more full-time employees must provide information to the I.R.S. on what insurance, if any, they offer to each of their employees. They may also be required to report the value of coverage.

The I.R.S. has used such information to help enforce other provisions of the Affordable Care Act, including the individual mandate.

In addition, larger employers may be subject to tax penalties if they do not offer “minimum essential coverage” to employees who work at least 30 hours a week, on average. The penalty is $2,260 a year multiplied by the number of full-time employees in excess of 30.

The Congressional Budget Office has estimated that employers will pay $12 billion in penalties this year and a total of more than $200 billion in the coming decade.

Alden J. Bianchi, an employee benefits lawyer in Boston, said he had two or three dozen letters on his desk from the I.R.S. demanding payment of penalties by employers who had supposedly failed to offer coverage to employees.

In some cases, he said, the government is seeking “substantial penalties in the millions of dollars.”

The House passed legislation last year to dismantle much of the Affordable Care Act, including the penalty used to enforce the employer mandate.

The mandate “interferes with market-driven compensation arrangements, encourages employers to cut hours and employees, and stifles new job creation,” said a report on the bill by Republican members of the House Ways and Means Committee.

Democrats who support the Affordable Care Act say it has not harmed employment, hours of work or wages. And they note that millions of jobs have been created since the law was signed by President Barack Obama in 2010.

Members of both parties are trying to get rid of another part of the Affordable Care Act, which imposes a tax on high-cost employer-sponsored health coverage — the “Cadillac tax,” opposed by labor unions and employers.

Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee, said it was possible that lawmakers could delay the tax as part of a bipartisan deal on government spending that they are trying to negotiate.

“Even Democrats who put that awful tax in place believe it needs to be delayed,” Mr. Brady said.

https://www.nytimes.com/2018/01/14/us/politics/employer-mandate.html?

Viral Video of Hospital Dumping Woman Into Freezing Cold Stirs Demand for 'Medicare for All'

by Jake Johnson - Common Dreams - January 12, 2018

Described as a horrifying depiction of "the reality of U.S. for-profit healthcare," a Baltimore-based psychotherapist this week caught on video University of Maryland Medical Center staff "dumping" a clearly incapacitated young woman into the freezing Maryland weather wearing only a thin hospital gown and socks.

"Is this what healthcare in Baltimore City has come to?" asked Imamu Baraka, who captured the "disturbing" scene on his cell phone. The video has since garnered more than two million views.

Baraka's video soon sparked national headlines and widespread outrage, with many noting that "patient dumping" is a pervasive and under-discussed product of a system that does not guarantee healthcare as a right to all.

RoseAnn DeMoro, executive director of National Nurses United, concluded that the only solution is to "implement single-payer, Medicare for All or Americans continue to suffer/die."

Others echoed DeMoro's call, arguing that the medical center's behavior is essentially "attempted murder."

The hospital issued an apology following the flood of outrage, taking "full responsibility for this failure" to provide "basic humanity and compassion."

"We are taking this matter very seriously, conducting a thorough review, and are evaluating the appropriate response, including the possibility of personnel action," hospital spokeswoman Lisa Clough said in a statement.

https://www.commondreams.org/news/2018/01/12/viral-video-hospital-dumping-woman-freezing-cold-stirs-demand-medicare-all?

Maine Obamacare insurer sues US government for $5.7 million

by Lori Valigra - Bangor Daily News - January 11, 2018

A Lewiston-based health insurance cooperative is suing the U.S. government to recoup subsidies it claims it is owed under the Affordable Care Act, also known as Obamacare.

The nonprofit Community Health Options is seeking $5.7 million in cost-sharing reduction payments. Those are discounts the insurer gives to its members that the federal government had been reimbursing monthly since 2014 under an ACA provision.

A Department of Justice ruling last year said there were no funds directed for the payments and discontinued them from October through December 2017.

However, Community Health Options claims that under Section 1402 of the ACA, the federal government did not fulfill its obligations to pay.

“Section 1402 requires health plans to provide cost-sharing reductions to members, and then the health plans to be reimbursed by the U.S. government under the ACA,” said Stephen McBrady, attorney at Crowell and Moring LLP in Washington, D.C., the counsel for Community Health Options.

“The government made monthly payments to the health exchanges since the ACA started in 2014, and it did so in 2015, 2016 and through September of 2017,” he added. “Community Health Options could not change its health plan part way through the year [to make up for the halt in reimbursements], so it was financially harmed. The $5.7 million matters to a nonprofit.”

If Community Health Options wins the case, the money will come from the U.S. Department of the Treasury’s judgment fund.

Community Health Options is the largest provider of individual health insurance plans in Maine and focuses on previously uninsured and underinsured clients, according to the lawsuit.

Last year, about 79,500 Mainers were covered by an ACA plan, according to the Henry J. Kaiser Family Foundation, and most of those qualified for a subsidy.

The lawsuit has yet to receive a hearing date in the U.S. Court of Federal Claims.

McBrady said a separate class action lawsuit filed against the United States by Common Ground Healthcare Cooperative of Wisconsin last June has added a count that includes the lack of cost-sharing reduction payments.

McBrady said Community Health Options decided to file individually instead of joining the class action lawsuit to resolve its lawsuit expediently.

Separately, Community Health Options is appealing a 2016 lawsuit it lost against the government requesting $23 million in back payments under a temporary program designed to help stabilize costs in the ACA health insurance market.

http://bangordailynews.com/2018/01/11/business/maine-obamacare-insurer-sues-us-government-for-5-7-million/

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Health Care Reform Articles - January 15, 2018