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Sunday, March 31, 2019

Health Care Reform Article - March 31, 2019

What Happens if Obamacare Is Struck Down?

By Reed Abelson, Abby Goodnough and Robert Pear - NYT - March 26, 2019


The Affordable Care Act was already in peril after a federal judge in Texas invalidated the entire law late last year. But the stakes ramped up again this week, when President Trump’s Justice Department announced it had changed its position and agreed with the judge that the entire law, not just three pieces of it, should be scrapped.
A coalition of states is appealing the ruling. If it is upheld, tens of millions more people would be affected than those who already rely on the nine-year-old law for health insurance. Also known as Obamacare, the law touches the lives of most Americans, from nursing mothers to people eating at chain restaurants.
Here are some potential consequences, based on estimates by various groups.
Of the 23 million people who either buy health insurance through the marketplaces set up by the law (11.4 million) or receive coverage through the expansion of Medicaid (12 million), about 21 million are most at risk if Obamacare is struck down. That includes 9.2 million who receive federal subsidies.
On average, the subsidies covered $525 of a $612 monthly premium for customers in the 39 states that use the federal marketplace, HealthCare.gov, according to a new report from the Department of Health and Human Services. If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.
States could not possibly replace the full amount of federal subsidies with state funds.
Medicaid, the government insurance program for the poor that is jointly funded by the federal government and the states, has been the workhorse of Obamacare. If the health law were struck down, more than 12 million low-income adults who have gained Medicaid coverage through the law’s expansion of the program could lose it.
In all, according to the Urban Institute, enrollment in the program would drop by more than 15 million, including roughly three million children who got Medicaid or the Children’s Health Insurance Program when their parents signed up for coverage.
The law ensures that states will never have to pay more than 10 percent of costs for their expanded Medicaid population; few if any states would be able to pick up the remaining 90 percent to keep their programs going. Over all, the federal government’s tab was $62 billion last year, according to the Congressional Budget Office.
Losing free health insurance would, of course, also mean worse access to care and, quite possibly, worse health for the millions who would be affected. Among other things, studies have found that Medicaid expansion has led to better access to preventive screenings, medications and mental health services.
The health law took effect just as the opioid epidemic was spreading to all corners of the country, and health officials in many states say that one of its biggest benefits has been providing access to addiction treatment. It requires insurance companies to cover substance abuse treatment, and they could stop if the law were struck down.
The biggest group able to access addiction treatment under the law is adults who have gained Medicaid coverage. The Kaiser Family Foundation estimated that 40 percent of people from 18 to 65 with opioid addiction — roughly 800,000 — are on Medicaid, many or most of whom became eligible for it through the health law. Kaiser also found that in 2016, Americans with Medicaid coverage were twice as likely as those with no insurance to receive any treatment for addiction.
States with expanded Medicaid are spending much more on medications that treat opioid addiction than they used to. From 2013 through 2017, Medicaid spending on prescriptions for two medications that treat opioid addiction more than doubled: It reached $874 million, up from nearly $358 million in 2013, according to the Urban Institute.
The growing insured population in many states has also drawn more treatment providers, including methadone clinics, inpatient programs and primary care doctors who prescribe two other anti-craving medications, buprenorphine and naltrexone. These significant expansions of addiction care could shrink if the law were struck down, leaving a handful of federal grant programs as the main sources of funds.
As many as 133 million Americans — roughly half the population under the age of 65 — have pre-existing medical conditions that could disqualify them from buying a health insurance policy or cause them to pay significantly higher premiums if the health law were overturned, according to a government analysis done in 2017. An existing medical condition includes such common ailments as high blood pressure or asthma, any of which could require someone buying insurance on their own to pay much more for a policy, if they could get one at all.
Under the A.C.A., no one can be denied coverage under any circumstance, and insurance companies cannot retroactively cancel a policy unless they find evidence of fraud. The Kaiser Family Foundation estimated that 52 million people have conditions serious enough that insurers would outright deny them coverage if the A.C.A. were not in effect, according to an analysis it did two years ago. Its estimates are based on the guidelines insurers had in place about whom to cover before the federal law was enacted.
Most Americans would still be able to get coverage under a plan provided by an employer or under a federal program, as they did before the law was passed, but protections for pre-existing conditions are particularly important to those who want to start their own businesses or retire early. Employers would sometimes refuse to cover certain conditions, and companies would have to decide if they would drop any of the conditions they are now required to cover.
The need to protect people with existing medical conditions from discrimination by insurers was a central theme in the midterm elections, and Democrats attributed much of their success in reclaiming control of the House of Representatives to voters’ desire to safeguard those protections. Many Republicans also promised to keep this provision of the law, although exactly how was unclear. Before the law, some individuals were sent to high-risk pools operated by states, but even that coverage was often inadequate.
The 156 million Americans who get coverage through an employer, as well as the roughly 15 million enrolled in Obamacare and other plans in the individual insurance market, are protected from caps that insurers and employers used to limit how much they had to pay out in coverage each year or over a lifetime. Before the A.C.A., people with conditions like cancer or hemophilia that were very expensive to treat often faced enormous out-of-pocket costs once their medical bills reached these caps.
While not all health coverage was capped, most companies had some sort of limit in place in 2009. A 2017 Brookings analysis estimated that 109 million people would face lifetime limits on their coverage without the health law, with some companies saying they would cover no more than $1 million in medical bills per employee. The vast majority of people never hit those limits, but some who did were forced into bankruptcy or went without treatment.
About 60 million people are covered under Medicare, the federal insurance program that covers people over 65 years old and people with disabilities. Even though the main aim of the A.C.A. was to overhaul the health insurance markets, the law “touches virtually every part of Medicare,” said Tricia Neuman, a senior vice president for the Kaiser Family Foundation, which did an analysis of the law’s repeal. Overturning the law would be “very disruptive,” she said.
Medicare beneficiaries would have to pay more for preventive care, like a wellness visit or diabetes check, which are now free. They would also have to pay more toward their prescription drugs. About five million people faced the so-called Medicare doughnut hole, or coverage gap, in 2016, which the A.C.A. sought to eliminate. If the law were overturned, that coverage gap would widen again.
The law also made other changes, like cutting the amount the federal government paid hospitals and other providers as well as private Medicare Advantage plans. Undoing the cuts could increase the program’s overall costs by hundreds of millions of dollars, according to Ms. Neuman. Premiums for as many as 55 million people under the program could go up as a result.
The A.C.A. was also responsible for promoting experiments into new ways of paying hospitals and doctors, creating vehicles like accountable care organizations to help hospitals, doctors and others to better coordinate patients’ care.
If the groups save Medicare money on the care they provide, they get to keep some of those savings. About 12 million people are now enrolled in these Medicare groups, and it is unclear what would happen to these experiments if the law were deemed unconstitutional. Some of Mr. Trump’s initiatives, like the efforts to lower drug prices, would also be hindered without the federal authority established under the A.C.A.
The A.C.A. required employers to cover their employees’ children under the age of 26, and it is one of the law’s most popular provisions. Roughly two million young adults are covered under a parent’s insurance plan, according to a 2016 government estimate. If the law were struck down, employers would have to decide if they would continue to offer the coverage. Dorian Smith, a partner at Mercer, a benefits consulting firm, predicted that many companies would most likely continue.
Doctors and hospitals could lose a crucial source of revenue, as some people lose insurance. The Urban Institute estimated that nationwide, without the A.C.A., the cost of care for people who cannot pay for it could increase as much as $50.2 billion.
Hospitals and other medical providers would incur losses, as many now have higher revenues and reduced costs for uncompensated care in states that expanded Medicaid. A study in 2017 by the Commonwealth Fund found that for every dollar of uncompensated care costs those states had in 2013, the health law had erased 40 cents by 2015, or a total of $6.2 billion.
The health insurance industry would be upended by the elimination of A.C.A. requirements. Insurers in many markets could again deny coverage or charge higher premiums to people with pre-existing medical conditions, and they could charge higher rates to women. States could still regulate insurance, but consumers would see more variation from state to state. Insurers would also probably see lower revenues and fewer members in the plans they operate in the individual market and for state Medicaid programs.
The A.C.A. requires nutrition labeling and calorie counts on menu items at chain restaurants.
It requires many employers to provide “reasonable break time” and a private space for nursing mothers to pump breast milk.
It created a pathway for federal approval of biosimilars, which are near-copies of biologic drugs, made from living cells.
https://www.nytimes.com/2019/03/26/health/obamacare-trump-health.html?


The Case for Medicare for All

You’d be able to keep your doctor with no premiums or copays, and overall spending would decline.

by Robert Pollin - Common Dreams -  March 28, 2019

"Other countries currently provide good health care to residents at a fraction of the U.S. cost," writes Pollin. "As of 2017, the U.S. spent $3.3 trillion on health care—17% of gross domestic product. Germany, France, Japan, Canada, the U.K., Australia, Spain and Italy spent between 9% and 11% of GDP on health care. Yet some measures—like those based on the amenable mortality rate, which tracks medically preventable deaths—rank the U.S. well below those countries." (Photo: National Nurses United/Flickr/cc)
A single-payer health-insurance system can finance good-quality coverage for all U.S. residents while still reducing overall health-care spending by roughly 10%, according to a study I co-authored last November. All Americans would be able to get care from their chosen providers without having to pay premiums, deductibles or copayments.
Other countries currently provide good health care to residents at a fraction of the U.S. cost. As of 2017, the U.S. spent $3.3 trillion on health care—17% of gross domestic product. Germany, France, Japan, Canada, the U.K., Australia, Spain and Italy spent between 9% and 11% of GDP on health care. Yet some measures—like those based on the amenable mortality rate, which tracks medically preventable deaths—rank the U.S. well below those countries.
"Under Medicare for All [prescription-drug] prices could fall, conservatively, by about 40%."
The U.S. ranks so poorly in large part because so many Americans lack access to health care. Roughly 30 million people, 9% of the U.S. population, are uninsured. Another 26%, 86 million people, are underinsured—they have insurance but are unable to access medical care because their deductibles or copays are prohibitively high. If all these people were covered under a single-payer system, our study estimates that the overall cost of treatments would rise by about 12%, from $3.3 trillion to $3.6 trillion. Our 12% figure draws from our literature review and the 2016 estimates of Kenneth Thorpe of Emory University. It is modestly higher than the 11.3% estimate the Mercatus Center reported last July.
But Medicare for All could also eliminate 19% of total health-care spending. The largest saving, about 9% of total system costs, would come from dramatically reduced administrative costs in contracting, claims processing, credentialing providers and payment validation—all of which would be unified under one federal agency. Private insurers spend about 12% of their collective budget on administration, while Medicare operates much more efficiently, with administrative costs at around 2%.
Dramatic administrative cuts would mean far less paperwork for doctors and nurses. But administrative simplification would also entail large-scale job loses for the roughly two million people employed both by private health insurers and on the management side of hospitals and doctors’ offices. Our study proposes generous transitional support for these displaced workers, including income, retraining and relocation funds and pension guarantees. We estimate the full cost of this support would amount to about $120 billion, equal to a roughly 2% increase a year in total system costs if spread over a two-year transition phase.
The second major saving our study identified would come from the government negotiating down prescription-drug prices, which would eliminate about 6% of total system costs. Prescription-drug prices in the U.S. are about twice as high as in other advanced economies. Under Medicare for All these prices could fall, conservatively, by about 40%. Further savings would result through operating Medicare for All under a global budgeting system like the one in Canada. Such systems allow regulators to oversee billing and expenses industrywide, allowing them to control fees for physicians and hospitals, reduce unnecessary treatments and fraud, and encourage preventive care.
"Taking the cost reductions and expanded coverage into account, we estimated that Medicare for All could operate with an overall budget of $2.93 trillion—nearly 10% less than current spending."
Taking the cost reductions and expanded coverage into account, we estimated that Medicare for All could operate with an overall budget of $2.93 trillion—nearly 10% less than current spending. To finance this, the government begins with $1.9 trillion already in hand—nearly 60% of the total needed—that pays for Medicare, Medicaid and smaller public programs. The government would therefore need to take about $1 trillion out of what businesses and families now pay to private insurers.
Our study has a few ideas to generate those funds. We propose that all businesses that currently purchase health insurance for their employees be mandated to pay 92% of what they now spend into Medicare for All—saving 8% of their health-care expenditures. Larger firms that haven’t provided coverage for every worker would pay $500 for each uninsured worker, while small businesses would be exempt from these premiums. This measure would raise more than $600 billion. After two or three years, this system could make a transition to a 1.78% tax on gross receipts or an 8.2% payroll tax, either of which would generate the needed $600 billion.
The remaining $400 billion would come from two measures: a national sales tax of 3.75% on nonnecessities, which would generate about $200 billion, and a wealth tax of 0.38%, after exempting the first $1 million of all families’ net worth, for another $200 billion. We also propose taxing long-term capital gains as ordinary income. The sum of these revenue streams will allow Medicare for All to operate with a 1% budget surplus.
Families would pay these taxes instead of premiums, deductibles and copays to private insurers. Except for those in the highest income brackets, this will produce significant savings for families as well as for businesses. Net health-care spending for middle-income families that now purchase insurance for themselves would fall by fully 14% of their income.
Add it all up and Medicare for All is actually the cheaper option for good-quality care in the U.S.
https://www.commondreams.org/views/2019/03/29/healthcare-everyone-and-it-will-cost-less-economic-case-medicare-all

The doctor’s strike that nearly killed Canada’s Medicare-for-all plan, explained

Building a single-payer system is hard, but not impossible. Just ask Saskatchewan. 

by Sarah Kliff - VOX - March 29, 2019

A few weeks ago, New York Times columnist David Brooks anointed Medicare-for-all as the “impossible dream.”
“There is no plausible route from here to there,” he declared.
The argument that Brooks outlines makes sense. There are many interests lined up against a single-payer system in the United States. Hospitals don’t want it. Doctors don’t want it. And insurers definitely don’t want it, given that it would be a death knell for their industry.
Transitioning to a Medicare-for-all system would no doubt be really, really hard. It would require unwinding a multi-billion dollar health insurance industry that employs about a half-million Americans. Private health insurers exist at the core of the American economy; as the New York Times pointed out this weekend, insurers’ stocks are a staple of the mutual funds that often make up our retirement accounts.
Both the Medicare-for-all plans I’ve read and the interviews I’ve done with their authors in Congress suggest that more prep work is needed for the massive upheaval that would come with eliminating private insurance.
Building a Medicare-for-all system would be hard, but there is nothing about America that makes single-payer an impossibility. The experience of other health care systems suggests that, with enough political will, single-payer advocates can overcome the exact type of opposition Brooks discusses.
There is no better place to learn this lesson than from our neighbors to the North in Canada. Brooks cites Canada as a country where people “love their single-payer health care system.” Brooks brings up Canada as an example of a country that is different from ours, one where there is widespread acceptance of more government involvement in health care.
But it wasn’t always like that. Canada experienced massive upheaval and protest when its single-payer system launched in 1962. Back then, Canadian single-payer opponents were making the exact same arguments against the program as American single-payer opponents do today: that it was too much government in medicine, that physicians would no longer be able to practice medicine in the way they saw fit. The doctors even went on strike (for more than three weeks) when the system launched.
“It was a very close call,” says Greg Marchildon, a professor at the University of Toronto who studies the history of Canadian health care. “The doctors were totally against it, half the population was totally against it and the other half were totally for it. It could have gone either way.”
The history of Canadian health care, it turns out, can actually offer a glimpse of what America’s future could look like if a committed government tried to enact Medicare-for-all.

When Canada launched single-payer, thousands of doctors went on strike

In 1960, the Canadian province of Saskatchewan elected a socialist premier named Tommy Douglas who had campaigned on a promise to bring universal insurance to his province. (Incidentally — just because I couldn’t leave this fact out — Tommy Douglas turns out to be Kiefer Sutherland’s grandfather. Who knew!)
Douglas followed through on that promise: In late 1961, his government passed the Saskatchewan Medical Care Insurance Act. The province already had government-sponsored hospital insurance, but this new bill would layer on a plan to cover doctor visits.
There was no comparable insurance scheme for doctor visits, which meant that patients could still end up with a significant bill from the doctor who saw them in the hospital.
“Doctors continued to bill independently,” Marchildon, the historian, says. “If they worked in the hospital, the patient would end up getting a bill for that.”
Some doctors did participate in smaller, publicly-run health plans that cities offered, but many found it more lucrative to accept private payments from wealthier clients. 
Canadian doctors were not pleased with the new plan, which would move all Saskatchewan residents into a public health program. The Canadian Medical Association denounced the law, as did the provincial medical association. They produced pamphlets (like this one here) that said things like “Political medicine is the type of medicine this Province can expect if government—any government, controls you and your doctor. It would mean red tape, high costs and inferior medical care.”
The arguments doctors made back then sound an awful lot like the ones we hear against single-payer today. “It places the control of medicine in the hands of the government and its appointees,” one doctor warned at a public forum. “This we could never accept.”
But Douglas refused to back down. On July 1, 1962, Saskatchewan launched North America’s first universal, government-run health insurance scheme for hospital and doctor visits.
That same day, Saskatchewan’s doctors went on strike.
Groups sprung up around Saskatchewan to support the striking doctors known as KODs, which stood for “Keep our doctors.” They organized a rally at the provincial capital, and thousands attended. Some of the participants carried small effigies of Premier Douglas, hanging from a noose (you can see them in the archival clip from the Canadian Broadcasting Corporation below). 
“We would like to defend the freedom of the individual and the doctors,” one woman who spoke at that rally urged. “The majority of the people of the province desire an immediate dispension of this act.”
Day by day though, the strike seemed to lose momentum. Turnout for that rally wasn’t nearly as high as the organizers had hoped. Patients wanted their doctors back. Meanwhile, the government refused to back down on the idea of government-run health insurance for all.
Saskatchewan flew in a British doctor to act as negotiator, helping the government and the doctors broker a deal. That deal became known as the Saskatoon Agreement. The doctors acquiesced to the single-payer system. The government, for its part, agreed that the doctors would remain independent contractors (rather than government employees, similar to how the National Health Service in Britain employs their doctors).
The doctors went back to work and single-payer began to spread to other provinces. British Columbia created a medical insurance program in 1965, largely modeled on Saskatchewan’s system. In 1966, the federal government passed a law where it would kick in money to finance these provincial health systems. The promise of federal funding quickly encouraged more provinces to create their own Medicare programs (including the most populous province, Ontario, in 1969).
Within 10 years of the Saskatchewan doctor strike, all of Canada was covered with government-sponsored health insurance.

What Saskatchewan can teach the United States about health care: it’s hard, but it’s possible

Brooks is right: Canadians are really proud of their health care system. In 2004, the Canadian Broadcasting Corporation ran a primetime special where they had millions of viewers vote on who was the greatest Canadian.
The winner wasn’t a hockey player — it was none other than Tommy Douglas, the father of Canada’s health care system. There are foundations and even a four-hour biopic film all devoted to Douglas, who is a pivotal figure in Canadian history.
Canadians are so proud of their health care system that it makes it hard to remember that there was a time when it was really controversial. The moment that it launched was a moment when it seemed like the whole thing might collapse.
If a future president tries to pass a Medicare-for-all system, it will undeniably be a brutal fight. There was a bruising political battle over the Affordable Care Act when it was passed, and that plan was significantly less disruptive than single-payer would be.
As more Democrats endorse the idea, health care industries are already creating new coalitions to fight back. Who knows, maybe the doctors here would go on strike too!
A Medicare-for-all fight would be hard because that type of system requires massive change. That was true in Saskatchewan in 1962, and it’s true in the United States. But hard and impossible are two quite different things, and there isn’t much that convinces me that we fall into a different category.
I asked Marchildon how he felt about this comparison: Is it fair to compare pre-single-payer America to the pre-single-payer Canada of the 1960s?
“I think it’s quite similar,” he said. “I don’t think the interests are, quantitatively, so much more powerful in the US than they were in Canada. What’s missing in the US is the federal government being willing to pull the levers in a way that allows states to innovate with their own solutions.”

Judge Blocks Medicaid Work Requirements in Arkansas and Kentucky

by Abby Goodnough - NYT - March 27, 2019



WASHINGTON — A federal judge on Wednesday threw out Medicaid work requirements in two states, a blow to Republican efforts to profoundly reshape a program that has provided free health insurance to the poorest Americans for more than 50 years.
In twin rulings, Judge James E. Boasberg of the Federal District Court for the District of Columbia rejected for a second time Kentucky’s attempt to require recipients to work or volunteer as a condition of coverage and blocked a similar rule in Arkansas, which has resulted in more than 18,000 people there losing coverage since last summer.
So far, the Trump administration has allowed eight states to begin requiring many of their Medicaid recipients to work, volunteer or train for a job to be eligible for benefits. Seven other states are seeking permission from the Department of Health and Human Services to impose similar rules.
Seema Verma, the Trump appointee in charge of the Medicaid program, has described the goal as helping people “rise out of poverty and government dependence.”
Judge Boasberg, an Obama appointee, had already ordered the department to re-evaluate the impact of Kentucky’s work requirement in a ruling last June, saying it had not adequately considered whether it “would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.”
In the first of his new decisions, he found the approval of Arkansas’s work rule by Alex M. Azar II, the health and human services secretary, was “arbitrary and capricious” for a similar reason. Mr. Azar had failed, the judge wrote, to “consider adequately” the impact of Arkansas’s plan on Medicaid coverage.
“The court finds its guiding principle in Yogi Berra’s aphorism, ‘It’s déjà vu all over again,’” Judge Boasberg wrote.
Arkansas officials had asked the judge to leave the work requirements in place in the event that he ordered Mr. Azar to further weigh their potential impact, saying that freezing them would cause too much disruption.
The judge disagreed, writing that “the road to cure the deficiency in this case is, at best, a rocky one” and that any disruption “must be balanced against the harms that plaintiffs and persons like them will experience if the program remains in effect.”
In the Kentucky case, Judge Boasberg said the state’s plan, with only minor changes since his last ruling, “has essentially the same features as it did before.” He said that Mr. Azar’s review and approval of the Kentucky program were fatally flawed because federal officials did not adequately consider “the coverage-loss consequences” of the work requirements.
The rulings presented a serious setback not only for President Trump and Mr. Azar, but for Ms. Verma, who has led the call for conditioning government health coverage on work.
She has insisted that Medicaid must not be “used as a vehicle to serve working age, able-bodied adults.” And she affirmed her goals Wednesday evening after the latest rulings came out.
“We will continue to defend our efforts to give states greater flexibility to help low income Americans rise out of poverty,” Ms. Verma said. “We believe, as have numerous past administrations, that states are the laboratories of democracy and we will vigorously support their innovative, state-driven efforts to develop and test reforms that will advance the objectives of the Medicaid program.”
Both states’ plans are aimed at hundreds of thousands of working-age adults who became newly eligible for Medicaid when the Affordable Care Act allowed states to expand it starting in 2014. Arkansas’s version requires most Medicaid recipients between the ages of 19 and 49 to spend 80 hours a month at a job or in “community engagement” activities, like volunteering or training for a job. Kentucky’s, which has not yet been rolled out because of the court case, does the same for people between 19 and 64.
Both the Kentucky and Arkansas rules allowed exemptions for people deemed too sick to work, pregnant women, full-time students or primary caregivers of dependent children or disabled family members.
The Trump administration had asserted that some people in Kentucky who lost Medicaid would gain commercial insurance coverage. But Judge Boasberg appeared skeptical, writing that federal officials “cited no research or evidence that this would happen.”
Kentucky officials, meanwhile, had made the case that the work requirements could save money for the state and thus make its expansion of Medicaid “fiscally sustainable.” Gov. Matt Bevin, a Republican whose Democratic predecessor expanded the program, has warned repeatedly that he will end the expansion for financial reasons if the work rules don’t survive in court.
But Judge Boasberg rejected the financial argument. Federal officials, he said, “made no finding” that the waiver would save any amount of money or make the program more sustainable.
In seeking federal permission to introduce work requirements, Kentucky had estimated that 95,000 fewer residents would have been enrolled in Medicaid within five years, although its lawyers said many of those people would have found jobs that offered insurance. Lawyers for the plaintiffs predicted the number would be much greater, and the early results in Arkansas — thousands losing coverage for either failing to meet the 80-hours-per-month requirement or failing to correctly report their compliance — bolstered their case.
Adam Meier, the secretary of Kentucky’s Cabinet for Health and Family Services, said in a statement, “Although a setback to our implementation schedule, we believe that we have an excellent record for appeal and are currently considering next steps.”
He added, “The judge illogically concluded that Medicaid is all about paying for health care for as many people as possible without regard to whether this coverage actually makes people healthier. We emphatically disagree because a health care program like Medicaid, by its very nature, must take into account whether it improves people’s health.”
Gov. Asa Hutchinson of Arkansas, a Republican, said that he was “disappointed” in the ruling and would discuss it further in a news conference on Thursday.
The other states that have won federal approval for Medicaid work requirements are Arizona, Indiana, Michigan, New Hampshire, Ohio and Wisconsin. New Hampshire’s requirement, the next to take effect, is the subject of a third lawsuit, filed last week.
https://www.nytimes.com/2019/03/27/health/medicaid-work-requirement.html?smid=nytcore-ios-share


Why Trump’s New Push to Kill Obamacare Is So Alarming 

by Nichols Bagley - NYT - March 27, 2019



Attorney General William Barr was supposed to be a voice of reason in the Trump administration. An old Washington hand, he had the stature and the backbone to protect the Justice Department from a White House that often seems to disdain the rule of law.
Turns out it isn’t so.
In a stunning two-sentence letter to a federal appeals court, the Justice Department announced on Monday that it would now seek the invalidation of the entire Affordable Care Act — every last one of its thousands of provisions.
The irresponsibility of this new legal position is hard to overstate. It’s a shocking dereliction of the Justice Department’s duty, embraced by Republican and Democratic administrations alike, to defend acts of Congress if any plausible argument can be made in their defense.
Nor is the Affordable Care Act some minor statute that can be shoved aside without disruption. It is now part of the basic plumbing of the American health care system. It guarantees protections for people with pre-existing medical conditions. It expanded Medicaid to cover 12.6 million more people, and it offers crucial protections to the 156 million Americans who get insurance through employers.
Beyond that, the law forces insurers to cover preventive care and contraception without charge; changed how hospitals and physicians bill for their services; requires fast-food restaurants to post calorie counts; cut hundreds of billions of dollars of Medicare spending; imposed hundreds of billions of dollars in taxes; and much, much more.
Unceremoniously ripping up the law would inflict untold harm on the health care system — and on all Americans who depend on it. Yet the Trump administration has now committed itself to doing just that.
The letter was submitted in a pending case, brought by a group of red states, in which a federal judge in Texas ruled that no part of the Affordable Care Act could stand. The judge reasoned that Congress created a constitutional problem when, in its big tax reform bill in 2017, it eliminated the financial penalty for going without insurance.
Because of that purported constitutional defect, the court held, the entire law had to fall. The ruling was indefensible: Legal scholars across the board criticized it as outrageous and predicted it would almost surely fall upon appeal.
Indeed, even the Trump administration couldn’t bring itself to argue that the entire law should be scrapped. It agreed there was a constitutional problem, but said that the right remedy was to keep most of the law in place. Only those parts requiring private insurers to sell coverage at the same price to healthy and sick people alike — the protections for people with pre-existing conditions — would have to be struck.
That, too, was an outrageous position. It flouted the Justice Department’s duty to defend, a solemn duty, and one that goes to the heart of the rule of law. Without it, the sitting administration could pick which laws it wanted to defend in the courts and which it wanted to abandon. Laws could rise or fall based on nothing more than partisan disagreement. That’s inconsistent with a constitutional system that assigns to Congress — not the president — the power to legislate.
And so, at the confirmation hearing on his nomination to become attorney general, Mr. Barr said that he would review the Justice Department’s position in the Texas lawsuit. Apparently he did just that — but instead of mounting a vigorous defense, he doubled down on killing Obamacare. It’s as if Mr. Barr said to his predecessor, Jeff Sessions: “You thought your position was crazy? Hold my beer.”
Does the administration really think that the very position it advanced just months ago is so untenable that it must now adopt one that is even more extreme?
The shift in legal position won’t make much of a difference in the lawsuit itself. Because a group of blue states has intervened, the appeals court will hear a full-throated defense of the law. Most observers expect the court to uphold the Affordable Care Act; if so, the Supreme Court may choose not to hear the case.
But the Trump administration has signaled loud and clear that its campaign against Obamacare is not over; that it will stop at nothing to achieve in court what it could not achieve in Congress; and that it doesn’t care how many people are hurt if the Affordable Care Act is undone.
It has also put health care back at the center of the political conversation. Republicans already took a beating on the issue in the fall midterm elections, and Democrats, who released a bill in the House to strengthen the Affordable Care Act, want to keep running on it. They’ll be sure to remind voters of the Trump administration’s zealous commitment to taking away their health care.
Along the way, the Justice Department has trashed the duty to defend. That’s not to be taken lightly. The duty is a close cousin to the president’s constitutional duty to enforce the law. If the Justice Department really thinks that Obamacare is so blatantly unconstitutional that it can’t be defended, that implies that the president is violating the Constitution whenever he applies it.
It’s not hard to see that as an incipient justification for refusing to enforce any law that the president believes to be unconstitutional, however ridiculous or partisan that belief might be. Hopefully it doesn’t come to that. But the failure to defend the Affordable Care Act is an ominous sign to anyone who cares about the rule of law.
https://www.nytimes.com/2019/03/27/opinion/trump-obamacare-affordable-care-act.html?


 
Building on the ACA to Achieve Universal Coverage

Matthew Fiedler, Ph.D., Henry J. Aaron, Ph.D., Loren Adler, B.A., Paul B. Ginsburg, Ph.D., and Christen L. Young, J.D. -
NEJM - March 28, 2019
For decades leading up to enactment of the Affordable Care Act (ACA), the United States failed to reduce the percentage of Americans
who lacked health insurance coverage. Since the 
ACA’s passage, the percentage of U.S. residents without coverage has fallen by almost half, from 16% to approximately 9%. Yet more needs to be done if we are to achieve universal coverage.

The bar graph, which draws on estimates by researchers at the Urban Institute, shows which groups remained uninsured in 2017.1 In our view, these estimates make clear that achieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase coverage through the health insurance marketplace to make coverage more attractive, ensuring that people actually enroll in the affordable coverage for which they are eligible, and addressing coverage for undocumented immigrants.


The first step — ensuring that all states expand Medicaid cover- age to people with incomes be- low 138% of the federal poverty level, the standard set in the ACA — can be achieved with a combi- nation of carrots and sticks.4 The stick is a reduction in the base federal matching rate for Medic- aid spending in states that con- tinue to refuse to implement the Medicaid expansion. The carrot is an increase in the matching rate for states that expand Med- icaid coverage. These changes need not be particularly large to be effective; for example, increas-

ACA’s passage, the percentage of U.S. residents without coverage has fallen by almost half, from 16% to approximately 9%. Yet more needs to be done if we are to achieve universal coverage. 

The bar graph, which draws on estimates by researchers at the Urban Institute, shows which groups remained uninsured in 2017.1 In our view, these estimates make clear that achieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase coverage through the healthinsurance marketplace to make coverage more attractive, ensuring that people actually enroll in the affordable coverage for which they are eligible, and addressing coverage for undocumented immigrants. 
 
Policymakers can tackle each of these steps and thereby finish the job of ensuring universal coverage by building on the ACA. The framework presented here has many elements in common with proposals put forward by others, including teams at the Urban Institute and the Center for American Progress.2,3 The similarities among these pro- posals reflect the fact that each seeks to fill the same gaps in the U.S. health insurance system. 

For people who are concerned about the fiscal cost, political feasibility, or disruption associated with a single-payer approaching expansion states’ base federal matching rate by about 2 per- centage points (or reducing non- expansion states’ base federal matching rate by the same amount) would make expansion effectively free for a typical state. The small size of these adjust- ments would insulate this ap- proach from being judged uncon- stitutionally coercive. The Supreme Court struck down the approach taken in the ACA, which condi- tioned the entirety of each state’s Medicaid funding on its willing- ness to expand coverage. Here, the vast majority of Medicaid fund- ing would be unaffected. The small size of the adjustments would also limit unintended con- sequences for Medicaid benefi- ciaries if, contrary to our expec- tations, some states continued to resist expansion. States would also need to be barred from im- plementing Medicaid-eligibility re- strictions such as work require- ments, substantial premiums, and limits on retroactive coverage of services delivered before formal Medicaid enrollment. 
 
The second step involves increasing and expanding eligibility for the subsidies available through the ACA’s health insurance marketplaces to encourage more people to take up coverage. This step includes increased tax credits to offset insurance premiums, high- er cost-sharing subsidies to offset out-of-pocket costs, and extension of subsidies to people with in- comes exceeding 400% of the federal poverty level, the current income limit on eligibility for marketplace assistance. Extensions along these lines are essential for achieving universal coverage, given that people who were eligible for subsidies but did not buy coverage accounted for fully one quarter of the non elderly uninsured population in 2017, and some people with incomes above the current income eligibility threshold also face burdensome premiums.
Marketplace subsidies would also need to be extended to workers who are currently ineligible because they are offered coverage at work that is considered “affordable” under the ACA’s standards but still imposes onerous premiums. This group accounted for roughly one tenth of the uninsured population in 2017. In addition to increasing coverage, this change would reduce premium and out-of-pocket costs for many currently insured low- and moderate income workers who face burdensome costs.
 
Even after these two steps are undertaken, some people would remain uninsured. Some would be eligible for Medicaid or the Children’s Health Insurance Pro- gram (CHIP) but would not en- roll in these programs. Though technically uninsured, they are financially protected against the costs of a serious illness because such coverage is generally retro- active. Even so, policymakers can streamline enrollment procedures to encourage more people to en- roll before the onset of illness. 

For higher-income people, however, a different approach is need- ed. Thus, the third step covers anyone who is not eligible for Medicaid or CHIP and who does not have other coverage. They would be automatically enrolled in a “backstop” insurance plan, which could be either public or private. Health care providers would submit claims to the backstop plan whenever people in this group used health care services. On each year’s income tax return, people who lacked coverage other than the backstop plan for at least 1 month during the year would pay a premium for the backstop plan for each month they lacked other coverage, whether or not they actually used the backstop coverage. The premium would be reduced by the amount of any tax credit for which they were eligible. The expansion of market- place subsidies described above would help make automatic enrollment in the backstop plan palatable by reducing these net premiums. 
 
In combination, these steps would expand coverage to all legal U.S. residents. However, they would not reach the one sixth of the population who were undocumented immigrants and there- fore ineligible for both Medicaid and marketplace subsidies. The final step to universal coverage would be to ensure this group access to insurance programs. This goal can be achieved by creating a path to citizenship or in other ways. Expanding insurance coverage is far from the only ra- tionale for reforming immigration policy, but without some such reform, genuinely universal cover- age is impossible.
How much this approach would cost the federal government de- pends on parameters we have not fully specified — notably, the size of the marketplace-subsidy expansions. However, we anticipate that legislation in line with this framework would have federal costs broadly similar to those of the ACA’s coverage expansions,as such legislation would drive the uninsured rate from about half its pre-ACA level to zero. These costs could be covered by measures similar to those that paid for the ACA, which included reforms to Medicare payments and revenue increases.
Policies aimed at reducing the unit prices of health care services, such as introducing a public plan that would pay the lower prices currently paid by public programs and that would com- pete with private plans, could also help to finance this agenda. Policies that successfully reduced health care prices would reduce the cost of providing marketplace subsidies and, if applied to the employer-sponsored insurance market, would also reduce the revenue lost to the tax exclusion for employer-sponsored coverage. 

In addition to expanding coverage, the proposals discussed above — notably those to expand marketplace subsidies and reduce the unit prices of health care services — would reduce premiums and out-of-pocket costs for many people who already have coverage. These reforms could be combined with other reforms to improve coverage for people who are already insured. The additional reforms could include implementation of rules to eliminate surprise out-of-network bills, lowered caps on annual out-of- pocket spending, and expansion of the list of services that insurers must cover without cost sharing to cost-effective services that pose little risk of overuse, such as generic drugs that treat chronic conditions.5
Nearly 9 years after the ACA became law,proposals to expand insurance coverage are again a major topic of public debate. The approach described here provides a blueprint for achieving the widely shared goal of universal coverage at a manageable fiscal cost and with minimal disruption for the hundreds of millions of Americans who are already insured.

                                                                   
The New England Journal of Medicine - March, 2019




Editor's Note;

What follows is a short inteview I did for Ruthanne Shpiner of KPFA Radio in Berkeley, California.  The statement that expanding Medicare to All would destroy the program is becoming an increasingly used Republican talking point. I also heard it during the Maine second district election race last year. Since the Democrat narrowly won using rank-choice voting, I guess it didn't work very well for the incumbent, Bruce Poliquin.

-SPC

Seema Verma was appointed to head up the Center for Medicare and Medicaid services by President Trump. Verma spoke at the Commonwealth Club in San Francisco on July 25th, 2018.
Ruthanne Shpiner has more.


Ruthanne: Verma has a great deal of power as head of CMS, overseeing a $1 trillion budget. The agency sets policy for Medicare, Medicaid, and the federal insurance exchanges under the Affordable Care Act. In the body of Verma's presentation, she addressed Medicare for all. Verma stated that expanding Medicare to include everyone would sabotage the program for those it was intended for, seniors and people with disabilities. Verma said quote, "We don't want to divert the purpose and focus away from you seniors." Close quote. She continued, "In essence, Medicare for all would become Medicare for none", close quote. Philip Caper is a physician in Maine and a founding board member of Maine All Care, a nonprofit   group committed to making health care in Maine, universal, accessible and affordable for all. Doctor Caper, Verma said quote, "I think a lot of the analysis has shown it, a single payer system is unaffordable." Continuing, quote, "it doesn't make sense for us to waste time on something that's not going to work." Close quote. What is your response to Ms. Verma's claims that Medicare for all is impractical and unaffordable?

Dr. Caper - Well, I disagree with Ms. Verma's assessment. There's not a scintilla of evidence that expanding Medicare would hurt the program. In fact, the evidence shows just the opposite. The more people who are on Medicare, the stronger it becomes and the less vulnerable to political attack it becomes. I find it deplorable that a public servant would use their bully pulpit to try to scare seniors into opposing expansion of one of the most popular and effective federal programs ever created. The greatest contribution she could make to the public welfare will be to return to the private sector where I'm sure she'd be more comfortable, as soon as possible.


Ruthanne: In addition to what you have written and spoken about, what is your response to Seema Verma's objections to expanding Medicare to include everyone. Wasn't the eventual expansion of Medicare part of the plan for Medicare back when it was created in 1965?
Yes, it was. The original architects of Medicare saw it being expanded to everybody eventually, people such as Dr. Philip Lee, who was one of the original architects of Medicare, but that's correct.


Ruthanne Shpiner, PACIFICA radio KPFA, Berkeley.


Surprise medical bills: The doctor is not in your insurance plan

by Liz Kowalczyk  - Boston Glove - March 29, 2019


The expectant mother was in labor at South Shore Hospital when she requested a common pain medicine, which was administered by an anesthesiologist. Home with a newborn days later, she was surprised when a bill arrived from the doctor’s group for $2,143.44.
Another patient who went to Emerson Hospital’s emergency department for what turned out to be a broken rib also received a surprise bill: $300.91, for the services of the doctor who read the X-ray.
Neither of the patients initially knew the reason behind the hefty additional charges, according to complaints they filed with state regulators. They sought care at hospitals that were fully covered by their insurance plans. What they didn’t know was that the two doctors were not — and had billed the patients directly for their services.
Getting an out-of-the-blue medical bill — such as when a hospital uses doctors that are outside a patient’s insurance network — has become a nationwide phenomenon. It’s one that has forced exasperated patients to fight with medical providers and insurers at a time when they are already paying for a greater share of their health care.
Patients should not have to “contact their health plan and complain,’’ said David Seltz, executive director of the Massachusetts Health Policy Commission, which monitors health care spending in the state. “Through no fault of their own they are being put in this situation.’’
An analysis by the policy commission found that 10,000 Massachusetts patients in just one year may have received surprise bills for so-called out-of-network care, and policy experts believe that figure underestimates the extent of the problem.
States are increasingly passing laws to protect patients from these charges, such as limiting the dollar amount of out-of-network fees. Massachusetts legislators last year considered doing just that, but failed to pass a sweeping health care bill by the end of the session. A key legislator said approving stricter rules around out-of-networking billing is a priority this year. A bipartisan group of US senators is also taking up the issue.
Over the past two years, about 115 patients have filed formal complaints about surprise medical bills with Massachusetts Attorney General Maura Healey’s office, including the two patients at South Shore and Emerson hospitals, according to a Globe review of the documents obtained through a public records request.
Some patients received surprise bills for so-called facility fees, assessed when a patient is treated in an ordinary physician’s office or urgent-care center, but then receives an expensive outpatient bill from the hospital that owns the facility. An investigation by Healey’s office into facility fees charged by Partners HealthCare and its hospitals, including Massachusetts General and Brigham and Women’s, led to a settlement in September requiring Partners to better notify patients of the fees.
More than 35 percent of complaints filed with Healey were over out-of-network charges, which can be up to 200 percent higher than what insurers pay in-network doctors. Among the physicians that were outside the patients’ insurance networks were anesthesiologists assisting in colonoscopies and emergency medicine doctors repairing broken bones and treating heart attacks, something that frustrated patients told Healey’s office they had no way of knowing in advance. Radiologists and pathologists also directly billed patients out-of-network charges.
It’s not unusual for a hospital to have practitioners working in their facilities who are not covered by all their agreements with insurers, a technicality that is often not apparent to patients.
In the South Shore and Emerson cases, the hospitals said out-of-network bills are unusual; most doctors accept the same insurance plans as the hospitals. The physicians’ groups that employ the anesthesiologists and emergency medicine doctors, South Shore Anesthesia Associates and Emerson Emergency Physicians, each said it works with patients and insurers to resolve uncovered charges.
But the Emerson and South Shore patients told Healey’s office that the physicians sent their bills to collection agencies after they refused to pay them. The hospitals and doctors said they could not respond fully to the Globe’s questions about the complaints because the patients’ names were removed by the attorney general’s staff to protect their privacy.
In another complaint, a man who arrived at the Newton-Wellesley Hospital emergency department with a fractured eye socket unknowingly saw an out-of-network doctor who billed him $796.
“Newton-Wellesley Emergency Medicine Specialists works with those patients to decrease the bill to an amount that is comparable to in-network regional payor rates,’’ hospital spokesman John Looney said in a statement.
Another patient with sepsis, a life-threatening infection, went to an undisclosed emergency department, where doctors advised admitting the person. The hospital did not have an open bed, so staff called Northeast Regional Ambulance to take the patient to another hospital. The ambulance company turned out to be outside the patient’s insurance network, resulting in a $2,079.08 bill.
“This was an emergent situation and there was no other ambulance service available within a 50-mile radius,’’ the patient wrote.
Most patients received surprise bills for hundreds of dollars, but a dozen were on the hook for thousands. The highest out-of-network bill reported was $4,600 for lab tests at a Cambridge Health Alliance facility.
Compounding their exasperation, patients often said that despite repeated calls, hospital and insurance company staff could not — or would not — explain the bills. One person wrote of making 20 phone calls, and many patients said they never received return calls.
Some of these complaints may have been resolved after the patient contacted Healey’s office, which tries to mediate disputes.
The policy commission analysis found that about 10,000 patients in 2014 may have ended up with hefty bills for out-of-network care. But that review covered only two insurers, Blue Cross Blue Shield of Massachusetts and Tufts Health Plan, both of which have broad networks of doctors.
“We have no evidence that this has gotten any better,’’ Seltz said.
The problem is more pronounced for consumers insured by large national companies such as Aetna, Cigna, and UnitedHealthcare, which contract with most hospitals but not all local physicians’ groups, experts said. Most of the complaints reviewed by the Globe were filed by patients with national insurers.
Massachusetts has a consumer protection law that provides some recourse for patients, but health care experts and state legislators believe it should be strengthened. And, it does not apply to self-insured companies, which account for 60 percent of patients with commercial insurance in Massachusetts, and are regulated under federal, not state law.
Michael Caljouw, vice president of government and regulatory affairs for Blue Cross, said the insurer will pay the out-of-network bill when the “member did not have a reasonable choice.’’ But he would not say if that includes, for example, a woman who ends up with an out-of-network anesthesiologist during childbirth.
Seltz called these measures “a woefully inadequate solution to the problem.’’ Even if an insurer pays the bill, it is still paying a higher fee to that out-of-network physician, which raises overall health care costs.
That begs the question of why doctors groups do not join all provider networks in the first place.
Several emergency medicine doctors and anesthesiologists blamed insurance companies for the problem, particularly the national companies, which they said want to keep their networks small as a way to shift costs to consumers.
Emerson in Concord contracts with groups of anesthesiologists, emergency medicine doctors, pathologists, and radiologists to provide those services. Dr. Joseph Bergen, Emerson’s chairman of emergency medicine, said that “some of these bigger companies, they will not pay rates that allow us to take care of their patients. We are happy to be in network,we just need to be paid a fair price,’’ he said.
But Aetna and UnitedHealthcare pointed to doctors’ groups, some of which chose not to join insurance networks simply so they can charge exorbitant fees, the companies said.
“We also believe that hospitals have the responsibility to be clear on the network status of all of the health care professionals that serve their patients,’’ said Aetna spokesman Ethan Slavin in a statement.
National doctors’ organizations, insurers, and policy experts agree that consumers should receive advance notice for non-emergency procedures when doctors are not covered by their insurance plan. And, that generally insurers, not patients, should have to pay a fair out-of-network rate. New York and Connecticut are among the states that have passed laws to this effect.
In Massachusetts, the disagreement has come over exactly how that rate is determined. State Senator James Welch, a West Springfield Democrat, said reaching consensus on the issue is a “major priority.’’
“People having health care procedures are in a very vulnerable state,” Welch added. “The last thing they need to worry about is any surprise payment.’’
https://www.bostonglobe.com/metro/2019/03/29/surprise-medical-bills-the-doctor-not-your-insurance-plan/pPjYw5ZzcnKljuzNdHiEJN/story.html?

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