Health Care Reform Articles - November 8, 2017

Maine Voters Approve Medicaid Expansion, a Rebuke of Gov. LePage

by Abby Goodnough - NYT - November 7, 2017

Voters in Maine approved a ballot measure on Tuesday to allow many more low-income residents to qualify for Medicaid coverage under the Affordable Care Act, The Associated Press said. The vote was a rebuke of Gov. Paul LePage, a Republican who has repeatedly vetoed legislation to expand Medicaid.

At least 80,000 additional Maine residents will become eligible for Medicaid as a result of the referendum. Maine will be the 32nd state to expand the program under the health law, but the first where voters, not governors or legislators, decided the issue. Other states whose leaders have resisted expanding the program were closely watching the campaign, particularly Utah and Idaho, where newly formed committees are working to get Medicaid expansion on next year’s ballots.

Supporters, including advocacy groups that collected enough signatures to get the question on the ballot, said the measure would help financially fragile rural hospitals, create jobs and provide care for vulnerable people who have long gone without.

Mr. LePage and other opponents, including several Republicans in the state Legislature, said Medicaid expansion would burden the taxpayers and the state budget, and described it as a form of welfare.

“The truth is that Medicaid expansion will just give able-bodied adults free health care,” Mr. LePage said in a recent radio address. “We don’t mind helping people get health care, but it should not be free. ‘Free’ is very expensive to somebody.”

The pro-expansion side may have benefited from energized public support for government health programs in a year when President Trump and Republicans in Congress tried repeatedly to repeal the Affordable Care Act and cut spending on Medicaid, which covers one in five Americans. Senator Susan Collins of Maine, one of the few Republicans who firmly opposed the repeal efforts, has been an outspoken defender of Medicaid, although she did not take a position on the ballot question.

The health law gives states the option of allowing any citizen with income up to 138 percent of the poverty level — $16,642 for an individual, $24,600 for a family of four — to qualify for Medicaid, which states and the federal government both pitch in to pay for.

Under the Affordable Care Act, the federal government picked up the cost of new enrollees under Medicaid expansion for the first three years and will continue to pay at least 90 percent. States cover a significantly larger portion of the expenses for the rest of their Medicaid population.

Maine’s Legislature, which is controlled by Democrats in the House and Republicans, by one vote, in the Senate, could try to block the referendum, but since it voted for Medicaid expansion five times already, supporters and opponents alike believe it is unlikely to meddle. And the governor has no authority to veto the outcome, although he could may try to delay putting it in place during his remaining year in office. And if Congress eventually succeeds in repealing the Affordable Care Act, states with expanded Medicaid will likely have to scale back their programs.

https://www.nytimes.com/2017/11/07/us/maine-medicaid-healthcare.html?_r=0

Maine voters approve measure to expand Medicaid

by Patrick Whittle - AP/ PBS - November 8, 2017

PORTLAND, Maine — Maine voters on Tuesday approved a measure allowing them to join 31 other states in expanding Medicaid under the Affordable Care Act, the signature health bill of former President Barack Obama.

The referendum represented the first time since the law took effect that the question of expansion had been put in front of U.S. voters.

Some 11 million people in the country have gotten coverage through the expansion of Medicaid, a health insurance program for low income people.

The vote in Maine was a rebuke of Republican Gov. Paul LePage, who vetoed five different attempts by the state Legislature to expand the program. It follows repeated failures by President Donald Trump and his fellow Republicans in Congress to repeal Obama’s law.

“This is an exciting night in Maine, but also an exciting night for the country,” said David Farmer, spokesman for pro-expansion Mainers For Health Care. “Voters have made it clear they want more health care, not less.”

For supporters and opponents of “Obamacare,” Maine’s question took on the form of a referendum on one of the most important pieces of the Affordable Care Act. And it was taking place in a politically charged atmosphere with GOP efforts to undermine, or repeal, the health overhaul.

Here in the nation’s Northeast corner, the issue was personal to many in a rural state that has the nation’s oldest population and the region’s lowest wages.

Passage of the proposal would mean an estimated 70,000 people in Maine would gain health coverage. About 268,000 people currently receive Medicaid in the state.

Maine’s governor blamed an earlier Medicaid expansion for increasing state hospital debt, and he opposes giving able-bodied people more access to Medicaid.

LePage often summarizes his argument by saying: “Free is expensive to somebody.” He also warned that he would have to divert $54 million from other programs — for the elderly, disabled and children — to pay for the state’s share of the expansion once it’s fully implemented.

LePage’s office didn’t immediately respond to a request for comment.

Mainers For Health Care touted the proposal as a “common sense move” to ensure health care coverage for more people. Maine’s hospitals also supported the Medicaid expansion and say charity care costs them over $100 million annually.

The initiative’s supporters have reported spending about $2 million on their campaign, with hundreds of thousands of dollars coming from out-of-state groups. By comparison, the lead political action committee established to oppose the measure has spent a bit less than $300,000.

This may not be the last state vote.

Backers of Medicaid expansion in Idaho and Utah have started similar efforts to get the question on the 2018 ballots in their own states. If it passes in Maine, some 70,000 people would gain health coverage.

https://www.pbs.org/newshour/politics/maine-voters-approve-measure-to-expand-medicaid

Maine just resoundingly became the first state to expand Medicaid by ballot initiative

by Amber Phillips - The Washington Post - November 8, 2017

Less than two months after Republicans' latest effort to repeal the Affordable Care Act imploded, a purple state just made a decidedly blue-state move to essentially expand Obamacare.

On Tuesday, Maine became the first state to expand Medicaid with a ballot initiative. And it passed overwhelmingly: Maine voters agreed to grant health care to an estimated 70,000 low-income residents by a nearly 20-percentage point margin by the time the measure was called by election watchers. In other words, a sizable number of voters in Maine just voted to do the exact opposite of what the state's Republican governor and Republicans in Washington have been trying to do.

Maine Gov. Paul LePage vetoed a bipartisan legislative deal to expand Medicaid under the Affordable Care Act at least five times. Since Republicans took control of Washington in January, they've spent more than half the year trying to repeal Obamacare with proposals that would have drastically cut Medicaid. But Maine's Sen. Susan Collins (R) was one of the defining “no” votes that ultimately ended the GOP efforts, saying the plans would pull the rug out from too many in her state.

What happened in Maine could provide momentum for progressives to get voters in other states to expand Medicaid, such as Alaska and Idaho, where groups have already started similar Medicaid expansion ballot initiatives next year.

“This will send a clear signal to where the rest of the country is on health care,” said Jonathan Schleifer, executive director of the Fairness Project, which helped put together the ballot initiative. As Republicans have tried to roll back Obamacare, public support for an active government role in health care has spiked.

Schleifer said his group has spent the past year in Maine — and some $2 million — laying the groundwork for this. After Trump won the election and Republicans held on to Congress, they went to their tried-and-true method of ballot initiatives to try to fight back.

“Looking at what progressives were able to accomplish by ballot initiatives in 2016, we asked ourselves what do we do for biggest challenge out there, which is the threat to Affordable Care Act,” Schleifer said. “We asked ourselves: What can we do to not just hold the line but to advance things?”

Schleifer is right. The left has had spectacular success over the past four years going around Republican legislatures to change state policy on everything from guns and minimum wage with ballot initiatives. In fact, when put to the voters over the past 20 years, minimum wage increases have rarely lost.

Last November was no different. Voters in four out of four states resoundingly approved minimum wage hikes in 2016. (The last time Congress approved a minimum wage hike, George W. Bush was president.) In Arizona, the vote for a high minimum wage outperformed Trump by 10 percentage points. Voters in eight of nine states also voted to ease restrictions on marijuana, and three of four states voted to put in place gun restrictions.

Ballot initiatives are an important tool for progressives in the Trump era, just like how conservatives used them in the '90s when Democrats dominated government. Other national groups descended on Maine to help this pass. Planned Parenthood's Maine political group said they knocked on over 8,600 doors in Portland over the last week of the election.

Not all progressive ballot advocates are as bullish on Maine's ballot initiative to change the health-care landscape.

Kellie Dupree with the Ballot Initiative Strategy Center, which helps progressive groups strategize ballot initiatives, said expanding Medicaid can be a tough sell as it requires taxpayer money.

“We'll wait to see how these policies shape up,” she said.

Most of Democrats' reasons to celebrate this past year has been the absence of legislation. So at the very least, expanding Medicaid in a state like Maine is a notable change of pace for a party largely locked out of power.

https://www.washingtonpost.com/news/the-fix/wp/2017/11/07/maine-could-become-the-first-state-to-expand-medicaid-by-ballot-initiative/?

Hospitals at center stage of Medicaid expansion debate by Joe Lawlor - Portland Press Herald - November 5, 2017 Hospitals would gain about $260 million in annual revenue if voters approved Medicaid expansion, with hospital officials making the case that it would be a much-needed boost to the bottom line, especially for rural hospitals struggling to stay afloat. The extra revenue would more than erase hospitals’ total operating losses. Excluding Maine Medical Center, Maine’s hospitals lost a total of $50 million in fiscal year 2016, according to the Maine Hospital Association. Nineteen of the state’s 36 hospitals are losing money, the association says. The 23 rural hospitals are under the greatest threat of closure or cutting vital services because of financial pressures caused by a number of factors. A key factor in the losses is the increase in unreimbursed care stemming from people who don’t have health insurance. If voters say “yes” to Medicaid expansion on Nov. 7, Maine would become the 32nd state to do so, and about 70,000 Mainers would become eligible for free insurance. Advocates say people would be better cared for and rural hospitals could keep their doors open and maintain services if voters approved Medicaid expansion. Advertisement “It will provide critical support for rural hospitals,” said Robyn Merrill, executive director of Maine Equal Justice Partners, the nonprofit that got Medicaid expansion on the ballot. “A number of hospitals are operating in the red and are truly struggling and at risk of closing their doors. It has implications for all of us, and especially for communities that rely on rural hospitals.” LEPAGE: ‘DON’T BE MISLED BY HOSPITALS’ Opponents of Medicaid expansion are pointing to hospitals as a reason to reject the referendum, saying that hospital CEOs make high salaries and that hospitals already enjoy tax-exempt status as nonprofits. Gov. Paul LePage has frequently attacked hospitals during public statements in the weeks before the election. “Don’t be misled by hospitals. They only want to expand Medicaid to put more money in their pocket and the wallets of their CEOs. It has nothing to do with improving healthcare,” LePage said in his weekly radio address Wednesday. The governor is a steadfast Medicaid expansion opponent who has vetoed five attempts by the Legislature to broaden the program, which operates in Maine as MaineCare. Advertisement The debate over Question 2 on Tuesday’s ballot has put hospitals at center stage in the run-up to the voting. If Maine expanded Medicaid, the state would pay $54 million per year while receiving $525 million annually in federal money, according to the non-partisan Office of Fiscal and Program Review. The federal government pays for 90 percent or more of the cost of expansion. Medicaid expansion is a major component of how the Affordable Care Act provides health insurance to low-income Americans. But a 2012 U.S. Supreme Court decision made Medicaid expansion voluntary, which is why some states, like Maine, have not expanded Medicaid. ‘A DIRECT HIT TO OUR BOTTOM LINE’ Rural hospitals have more patients with Medicaid, Medicare or who are uninsured when compared to urban hospitals like Maine Med, which have more private insurance patients. Medicaid and Medicare reimburses at lower levels than private insurance, but more than the uninsured, who usually can pay little or none of their hospital bills. When the LePage administration cut Medicaid after the governor assumed office in 2011, rural hospitals ended up with more uninsured patients instead of patients with private insurance, according to hospital officials. Maine’s Medicaid population has plummeted from 356,000 in 2011 to 268,000 in 2017, according to the Maine Department of Health and Human Services. About 36,000 people lost coverage as LePage cut eligibility, including childless adults and parents with minor children who earned between 100 percent and 200 percent of the poverty level. Advertisement “It’s been a direct hit to our bottom line,” said Tom Moakler, CEO of Houlton Regional Hospital. Moakler said in 2011, the hospital was in the black by $20,000. For the 2016-17 fiscal year, the hospital lost $690,000, and is only able to make payroll by taking out a line of credit. During that same time period, Moakler said “bad debt” or charity care for patients who are uninsured, ballooned from $1.4 million to $3.4 million. In an attempt to stay solvent, Houlton closed its skilled nursing center, cut back on administration costs and eliminated positions through attrition, in areas such as case management and radiology. “We did all that, and we’re still in the red,” Moakler said. Moakler said if Medicaid expansion were approved, Houlton would be in much better financial shape and be able to invest in capital improvements, such as replacing outdated technology. Advertisement Calais Regional Hospital closed its obstetrics unit in August in a move that hospital officials said was necessary because the hospital is in danger of closing. The hospital’s annual revenues are about $30 million and it has lost an average of $1.8 million per year over the past seven years. Closing maternity services saves about $500,000 per year. Penobscot Valley Hospital eliminated maternity services in 2015 as a cost-cutting measure. Andrew Coburn, a public health professor at the University of Southern Maine and an expert on rural health care, said Medicaid expansion will help alleviate financial problems at rural hospitals, but it’s not the solution. “Rural hospitals are facing many financial threats,” Coburn said. “Medicaid expansion will help, but they will still be under a lot of financial pressure.” He said low volume and changing demographics are also hurting some hospitals. For instance, when people retire, they convert from private insurance – which pays hospitals more – to Medicare, which has a lower reimbursement rate. CONTINUED LARGE LOSSES ‘UNSUSTAINABLE’ At Franklin Community Health Network, which includes Franklin Memorial Hospital in Farmington, the hospital operated with a $4.9 million loss in 2016. Advertisement Tim Churchill, CEO at Franklin Community, said cutbacks to Medicaid, job loss in Franklin County and other issues facing rural Maine added up to a “perfect storm” of financial problems for the hospital. Recruiting physicians is difficult, and in order to maintain services, they have to hire traveling doctors, which are much more expensive than a full-time staff physician. “We would be greatly helped by Medicaid expansion,” Churchill said. Franklin is part of MaineHealth, which is overall in the black by $47 million out of $2.2 billion in operating revenue. MaineHealth owns 10 hospitals in Maine and is the parent company of Maine Medical Center. Maine Med is in the black by $61 million. Al Swallow, executive vice president and treasurer of MaineHealth, said continued large losses such as what Franklin is going through, is “unsustainable” even though as a whole MaineHealth is in the black. “Long term, our ability to maintain access to care is dependent on each entity being fiscally sound going forward,” Swallow said. Swallow said Medicaid expansion would be “extremely helpful” for hospital finances. Advertisement “Yes, Medicaid does not pay as much as private insurance does. But it’s still better than nobody being paid,” Swallow said. Reductions in uncompensated care by having more people with Medicaid would nearly double MaineHealth’s operating surplus, from $47 million to $89 million, according to financial statements released by MaineHealth. Coburn said it’s unrealistic to expect networks to take on more struggling independent rural hospitals in Maine. “Hospitals are not looking to add more debt and financial weight to their bottom line,” Coburn said. EXPANSION FOES POINT TO TAX-FREE STATUS Meanwhile, opponents refer to Maine’s 2002 Medicaid expansion as a reason to vote “no.” The previous expansion pre-dated the ACA, and federal money to help pay for more services was less generous. Budget problems in Medicaid, exacerbated by the recession, caused the Legislature to delay reimbursement payments to hospitals. LePage successfully advocated paying off $105 million in hospital debt in 2013. Advertisement Brent Littlefield, a political consultant and spokesman for the Welfare to Work PAC, which opposes Medicaid expansion, said hospitals in Maine enjoy tax-free status for a reason. Hospitals are saving a bundle on property taxes alone, he said. Littlefield also pointed out that hospitals can afford to pay administrators handsomely, with the average hospital CEO earning more than $300,000, according to a 2013 Press Herald article. And not all rural hospitals are losing money. The Welfare to Work PAC criticized Medicaid advocates Maine Equal Justice Partners, the nonprofit that supports expansion, for highlighting financial issues at Down East Community Hospital in Machias. Down East released a statement on its Facebook page, saying that “(although) there are many hospitals that are struggling and there are legitimate reasons to expand Medicaid, Down East Community Hospital is doing well at this time. Our operating margins are positive and have been so for several years now.” Littlefield said for hospitals to ask for additional government help by expanding Medicaid is “sort of like having your cake and eating it too.” “They are supposed to take money that they would have spent on taxes and spend that money instead on providing care for those in need,” Littlefield said. “If the hospitals want taxpayers to pick up this cost, are they then open to say they’re willing to be taxed?” http://www.pressherald.com/2017/11/05/hospitals-at-center-stage-of-medicaid-expansion-debate/ What Did Bernie Sanders Learn in His Weekend in Canada?

by Margot Sanger-Katz - NYT - November 2, 2017

TORONTO — As he tells it, Senator Bernie Sanders of Vermont fell in love with the Canadian health system 20 years ago when he brought a busload of his constituents across the border to buy cheaper prescription drugs. Now he wants to make Americans fall in love with his proposal to make the United States system a lot more like Canada’s.

That’s one reason he took the equivalent of a busload of staffers, American health care providers and journalists to Toronto last weekend, in a two-day trip that was part immersion, part publicity tour. Canadian government officials and hospital executives showed him high-tech care, compassionate providers and satisfied patients, all as videographers recorded.

He ended the trip with a speech at the University of Toronto titled, “What the U.S. Can Learn From Canadian Health Care.”

But our question is this: What did Bernie Sanders learn from his weekend in Canada?

Lesson 1: He’s a ‘rock star’

Mr. Sanders — after wedging himself into Row 21 and taking extensive notes on a legal pad during the flight — had barely gotten off the plane in Toronto when an airport security guard chased him down the hallway, telling him, “You’re like a hero to me.”

A team of cardiac nurses at Toronto General Hospital asked to take pictures after he toured their unit. At a full 1,600-seat university auditorium on Sunday, he received repeated and sustained standing ovations. College students waited for hours to get into the auditorium and see him speak.

Mr. Sanders, who drew huge crowds as a presidential candidate in the United States last year, learned firsthand that he is also a household name in Toronto. His policy vision, decidedly from the left in the United States, matches mainstream Canadian views.

“You received the welcome here that is normally reserved for celebrity rock stars,” said Greg Marchildon, the director of the North American Observatory on Health Systems and Policies at the University of Toronto.

Ed Broadbent, the chairman of the progressive Broadbent Institute, called Mr. Sanders the most important social democrat in North America — even though Mr. Sanders is not a Canadian social democrat, and is not even a particularly powerful member of the Senate.

Lesson 2: Doctors like the system as much as patients do

Many developed countries have achieved universal health coverage, but Canada is relatively distinct in its insistence that individuals should not have to pay any money at the point of care. When Canadians go to the doctor or hospital, they just show their Canadian “Medicare” card.

At Women’s College Hospital, executives showed Mr. Sanders an empty billing window. The hospital, they told him, has one employee who manages bills. “For the entire hospital?” Mr. Sanders said, in mock disbelief.

Several patients told him about the comfort that comes from not having to pay for their care directly. And doctors, too, said they felt more comfortable recommending their patients get an operation or see a specialist than they might if those treatments weren’t free.

“I didn’t have to fill out any forms; I didn’t have to worry about how I was going to pay for the simple job of staying alive,” said Lilac Chow, a kidney transplant patient at Toronto General Hospital, who had been brought in to share her experience with the senator.

Whenever Mr. Sanders was asked what he learned about the Canadian system, the value of free care came up.

“What I think stuck out to me was from both the patients and the physicians, the importance of not having to worry about money in terms of the doctor-patient relationship,” he said in an interview after his trip on Tuesday.

His Medicare-for-All bill includes free care as a central feature. If the legislation became law, no American would pay directly for a doctor, dentist or hospital visit, and co-payments for prescription drugs would be limited. (Taxpayers would, of course, finance the system.)

Lesson 3: Sometimes, you have to wait

At a round-table discussion at Women’s College Hospital, the chief of surgery noted that Canadian patients can’t always get all the care they want right away. “Wait times, you could argue are a problem for certain procedures,” said Dr. David Urbach, before discussing the ways the province and hospital were working to shorten the lines. Mr. Sanders quickly turned to the glass-half-full interpretation. “What you are arguing — correct me if I’m wrong — is that waiting times are not a problem, and it’s an issue you are dealing with,” he said.

In Canada, where government finances health insurance and the private sector delivers a lot of the care, patients with life-threatening emergencies are treated right away. But patients with cataracts or arthritis often have to wait for operations the Canadian system considers elective. A governmental review of the Ontario system recently found that wait times were getting worse in some cases, like knee replacements.

The Canadian system puts hospitals on a budget and limits the number of specialists it trains, both factors that can lead to lines for complex care that’s not life-threatening. The system also limits access to services, like M.R.I. scans, that are much more abundant south of the border.

On his weekend tour, Mr. Sanders didn’t see the places where patients might wait. Hospital executives instead showed him a refugee primary care clinic, a neonatal intensive care unit and a cardiac surgery unit.

But he points out that many Americans who are uninsured — or who have limited savings and insurance with high deductibles — may wait even longer than Canadians for elective, or even urgent, care.

“If you’re very, very rich, you’ll get the highest-quality care immediately in the United States,” Mr. Sanders said, in the interview. “If you’re working class, if you’re middle class, it is a very, very different story.”

The Commonwealth Fund, a health research group, ranked the United States health system at the bottom of its most recent 11-country rankings, published in July. But Canada did only a little better, at No. 9. Of all the measures in the study, Canada ranked the worst on the “timeliness” of care. (A team of Upshot experts eliminated Canada in the first round in an eight-country virtual bracket tournament of international health system performance.)

Any single-payer system will need to grapple with how much it should spend over all, and where it will save money. Mr. Sanders’s Medicare-for-All bill currently includes few details about how the government would set budgets and allocate resources once all Americans were brought into the government system.

Lesson 4: Even Canada’s system has holes

Mr. Sanders wants to bring big, sweeping change to the American health care system. Unlike the Affordable Care Act, which filled in holes in an existing system, his Medicare-for-All plan would take away the health coverage that most Americans hold now, replacing it with a single, very generous government system. It would do away with the premiums, deductibles and co-payments that individuals and businesses pay for health care, and instead impose large tax increases.

That is not the kind of change that would be politically trivial. In his speech, he noted that the creation of a single-payer system in Canada and Britain followed grass-roots movements, and political landslides by the parties that favored the change. “Real change always happens from the bottom up,” he said, to big applause. “You’ve got to struggle for it. You’ve got to fight for it. You’ve got to take it. And that is the history of all real change in this world.”

Yet even in Canada, he learned, changes to the health care system have been difficult. The Canadian system, with insurance run at the province level, covers doctors and hospitals. But decades after the 1984 Canada Health Act, many Canadians pay for supplemental private insurance through their jobs for prescription drugs, dentistry and optometry — despite a growing recognition that medications are essential to care.

“Any one of us around the table is just a job loss away from having access to prescription medications, and that’s a problem,” said Danielle Martin, a vice president at Women’s College Hospital and policy researcher, who helped organize the trip, at a round-table discussion.

“I’m on my own going to the dentist,” said Naomi Duguid, a patient, sitting across the table. “It’s the only time I get to experience what it must be like to be an uninsured American.”

Ontario has recently started a program that will provide coverage for medications to residents under 25. And there is a patchwork of drug coverage programs for older people, the poor and those who get insurance from work. But even in Canada, it’s tough to find the resources to expand coverage.

“We have to find the money to fund the program up front,” said Kathleen Wynne, the premier of Ontario, who helped establish the youth drug coverage program.

Lesson 5: Canadians seem to value fairness more than Americans do

Equity. Fairness. Throughout the weekend, Mr. Sanders kept asking Canadians what they thought about the higher taxes they’d paid to finance their system. Every one among the patients and doctors selected to meet him said the trade-off was worth it because it made the system fair.

“I think it’s a really fair way to do it,” said Frederick Brownridge, 67, of Etobicoke, Ontario, as he sat by the window in his Toronto General Hospital room, with IV lines in his arms. Mr. Brownridge had had two heart valves repaired and a double bypass three days earlier. “It also means if you’re in a lower economic status or higher economic status, you’ll get the treatment you need.”

On Tuesday, Mr. Sanders said the uniformity of this message really stuck out to him: “There really is, I think, a deep-seated belief in Canada that health care is a right, and whether you’re rich or whether you’re poor or whether you’re middle class, you are entitled to health care.”

In the United States, though, Republicans control the presidency and the Congress, and many candidates last year ran on a promise to roll back government support for health care coverage.

Several recent public opinion surveys show majority support for a government guarantee of health coverage, but support declines substantially when pollsters mention that government coverage would mean higher taxes.

Mr. Sanders said he knows his bill isn’t going to become law anytime soon, but he thinks discussing the idea will help make its underlying values more broadly acceptable.

“When you talk about health care, you’re not just talking about health care,” he said in his Toronto speech. “You’re talking about values, because how a society deals with health care is more than medicine. It’s more than technology. It is about the values that those societies hold dear.”

https://www.nytimes.com/2017/11/02/upshot/bernie-sanders-went-to-canada-and-learned-a-few-things.html

Bernie Sanders, and Health Care
by Ian Austen - NYT - November 4, 2017

When Bernie Sanders made his way to Toronto last weekend, Margot Sanger-Katz, a health policy reporter in The Times’s Washington bureau, tagged along. Her resulting article in The Upshot is both a nicely drawn portrait of Mr. Sanders’ excursion and a thorough comparison of Canada’s health care system with that of the United States. Ms. Sanger had some additional thoughts about the trip for Canada Letter readers:

It was probably about the 10th time that a patient or doctor in Canada used the word “fair” that I started to realize how important the value was to Canadians.

Mr. Sanders was making what his staff called a “cross-border learning tour,” though it was clear from the start that he already knew quite a lot about the Canadian system, and had found much to like about it.

He is pushing hard for the Democratic Party in the United States to embrace the notion of a single-payer health care system like Canada’s. His legislative proposal shares many Canadian particulars — government-financed insurance, no direct payment at the point of care, private doctors and hospitals, global budgets.

But Mr. Sanders also clearly admires and envies the values that lie beneath the Canadian system — a commitment to equity and a right to health care that is less commonly heard when Americans talk about what they want from their system. In many ways, he was in Canada to learn about how to achieve that change of heart.

At a public event, he was asked how to make this change by Dr. Danielle Martin, a physician, hospital executive and advocate. “The journey is not easy,” Mr. Sanders said. “The journey never has been easy for human rights and human dignity.”

Afterward, I asked Dr. Martin whether she thought the sentiment or the policy had come first in Canada. Did Canadians embrace a government health care system because they believed in equity? Or did they come to value equity because they’d been exposed to a health care system that promoted it? Some of both, she said, but “the system itself creates a language.”

“We’re not genetically different people here on the other side of the border,” she said. “There is no reason why we would have different values, except there was a movement here.”

And I have two related questions for you: Is public health care a defining feature of Canada? If so, how is that reflected in the nation? Please email your thoughts to nytcanada@nytimes.com so that I can share some of them with other newsletter readers It was probably about the 10th time that a patient or doctor in Canada used the word “fair” that I started to realize how important the value was to Canadians. Mr. Sanders was making what his staff called a “cross-border learning tour,” though it was clear from the start that he already knew quite a lot about the Canadian system, and had found much to like about it. He is pushing hard for the Democratic Party in the United States to embrace the notion of a single-payer health care system like Canada’s. His legislative proposal shares many Canadian particulars — government-financed insurance, no direct payment at the point of care, private doctors and hospitals, global budgets. But Mr. Sanders also clearly admires and envies the values that lie beneath the Canadian system — a commitment to equity and a right to health care that is less commonly heard when Americans talk about what they want from their system. In many ways, he was in Canada to learn about how to achieve that change of heart. At a public event, he was asked how to make this change by Dr. Danielle Martin, a physician, hospital executive and advocate. “The journey is not easy,” Mr. Sanders said. “The journey never has been easy for human rights and human dignity.” Afterward, I asked Dr. Martin whether she thought the sentiment or the policy had come first in Canada. Did Canadians embrace a government health care system because they believed in equity? Or did they come to value equity because they’d been exposed to a health care system that promoted it? Some of both, she said, but “the system itself creates a language.” “We’re not genetically different people here on the other side of the border,” she said. “There is no reason why we would have different values, except there was a movement here.” And I have two related questions for you: Is public health care a defining feature of Canada? If so, how is that reflected in the nation? Please email your thoughts to nytcanada@nytimes.com so that I can share some of them with other newsletter readers It was probably about the 10th time that a patient or doctor in Canada used the word “fair” that I started to realize how important the value was to Canadians. Mr. Sanders was making what his staff called a “cross-border learning tour,” though it was clear from the start that he already knew quite a lot about the Canadian system, and had found much to like about it. He is pushing hard for the Democratic Party in the United States to embrace the notion of a single-payer health care system like Canada’s. His legislative proposal shares many Canadian particulars — government-financed insurance, no direct payment at the point of care, private doctors and hospitals, global budgets. But Mr. Sanders also clearly admires and envies the values that lie beneath the Canadian system — a commitment to equity and a right to health care that is less commonly heard when Americans talk about what they want from their system. In many ways, he was in Canada to learn about how to achieve that change of heart. At a public event, he was asked how to make this change by Dr. Danielle Martin, a physician, hospital executive and advocate. “The journey is not easy,” Mr. Sanders said. “The journey never has been easy for human rights and human dignity.” Afterward, I asked Dr. Martin whether she thought the sentiment or the policy had come first in Canada. Did Canadians embrace a government health care system because they believed in equity? Or did they come to value equity because they’d been exposed to a health care system that promoted it? Some of both, she said, but “the system itself creates a language.” “We’re not genetically different people here on the other side of the border,” she said. “There is no reason why we would have different values, except there was a movement here.” And I have two related questions for you: Is public health care a defining feature of Canada? If so, how is that reflected in the nation? Please email your thoughts to nytcanada@nytimes.com so that I can share some of them with other newsletter readers https://www.nytimes.com/2017/11/03/world/canada/canada-letter-bernie-sanders-health-care.html

Health Care Reform Articles - November 2, 2017

Federal government failed in Puerto Rico following Hurricane Maria

by Larry Kaplan - Portland Press Herald - October 28, 2017

We owe the U.S. citizens there the same commitment and vigor that we offered to Houston and Miami.

CAPE ELIZABETH — As a 35-year veteran of multiple international humanitarian medical relief missions (in Cambodia in 1979, in Honduras in 1998 and in Haiti in 2010), I am accustomed to landing on the ground a few days after a catastrophe and daily treating 90 to 100 acute care patients. I’ve seen endless cases of physical trauma, pneumonia, diarrhea, skin infections, conjunctivitis and a host of tropical infections. So when I signed up with Project Hope to join its medical team in Puerto Rico a week after the devastation of Hurricane Maria, I expected a similar experience.

What I soon learned was that U.S. government agencies and American nongovernmental organizations completely misunderstood or failed to evaluate the medical conditions in Puerto Rico immediately after the hurricane.

Before the hurricane, Puerto Rico, a U.S. commonwealth of 3.4 million people, received relatively good medical services through private insurance and U.S. government-sponsored health care programs. Unfortunately, Puerto Ricans appear to be plagued, perhaps because of their diet, with chronic diseases such as diabetes, hypertension and heart disease, but they were being treated for such disorders.

So when my Project Hope team ventured out of San Juan into towns that suffered massive infrastructure destruction and personal property losses, the team of experienced medical personnel with decades of international experience treating acute diseases ended up distributing a limited number of medications for treatment of chronic diseases, medications not available because pharmacies and hospitals were closed. No wonder that the USNS Comfort, a naval vessel with roughly 800 medical and support personnel and 250 beds that docked in San Juan on Oct. 3 and sailed around the island, treated on average 12 patients a day. Or why 200 medical personnel, employees of the U.S. Public Health Service, spent the majority of their 10-day tour idle in the San Juan Convention Center, waiting for assignments.

Had Federal Emergency Management Agency experts better understood medical conditions in Puerto Rico, these resources could and should have been diverted to backing up the island’s 70 hospitals with generators, medicines and potable water and clearing roads so residents would have access to hospitals and clinics in the immediate aftermath. What Puerto Rico experienced after Hurricane Maria was not an acute medical crisis, but a public health catastrophe and the gross failure of U.S. government agencies to deliver to the victims of the hurricane life-saving essentials of food, clean water and shelter.

Twelve days after the hurricane, my Project Hope team traveled by car on passable roads to Toa Baja, a coastal town 45 minutes west of San Juan. Toa Baja, where entire neighborhoods were submerged by overflowing rivers and now littered with decaying garbage, human waste, animal carcasses and discarded household furniture covered with mildew, had not received any material aid from the central Puerto Rican government or FEMA in the first 10 days after the hurricane.

It wasn’t until the municipal government and Toa Baja residents organized their resources to provide food, clothing and shelter – and local medical personnel set up a temporary emergency room with medications later transported by Project Hope – that services started to reach the community.

How ironic that the acute diseases that I had expected to encounter when I first entered Puerto Rico are now appearing with serious health consequences: bacterial infections from tainted water, bronchitis and asthma from air pollution, polluted groundwater, numerous animal-borne diseases and skin diseases from lack of ability to bathe or wash clothes with uncontaminated water.

And Puerto Ricans continue to die from chronic diseases such as diabetes, kidney failure and hypertension because they still cannot readily access medications and medical care.

The U.S. government did not conduct itself admirably in Puerto Rico in the first month after Hurricane Maria. For a country that rebuilt Europe after World War II and is magnanimous in victory to our enemies in defeat, we now owe it to the U.S. citizens of Puerto Rico to rebuild their island with the same vigor and commitment that we offered to the citizens of Houston and Miami.

http://www.pressherald.com/2017/10/28/maine-voices-the-u-s-government-failed-in-puerto-rico-after-hurricane-maria/

Opposing Medicaid expansion is not a conservative position

by Lance Dutson - Bangor Daily News - October 30, 2017

Gov. Paul LePage’s opposition to Medicaid expansion is one of the most destructive acts of his tenure in office — denying healthcare to 70,000 low-income Mainers purely out of spite. And it’s predicated on a series of logical fallacies that should make his allegedly conservative followers cringe with embarrassment.

Here’s the most obvious one: If you spend $54 million in order to get $500 million, it’s not “costing” you anything. It’s a $446 million net gain. Those are roughly the terms of Medicaid expansion: The federal government will give Maine more than $500 million a year in funding for healthcare for low-income Mainers if we contribute $54 million to the same cause. 

This nearly 10-to-one return is the deal our alleged businessman governor is opposing.

It is not fiscally conservative to deny hundreds of millions of dollars in federal funding because we will need a 10 percent match. It’s fiscally ludicrous. 

Anyone able to do basic elementary school math should be able to understand this. It’s why Republican governors in other states — including Vice President Mike Pence when he was governor of Indiana — have already accepted expansion. In total, 31 other states and the District of Columbia have expanded Medicaid.

Maine accepts federal matches on all kinds of things — roads, bridges, first responder funding, to name a few — much of it with far less favorable terms than what the Affordable Care Act (ACA) provides for Medicaid expansion. Additionally, many of our biggest employers rely almost entirely on federal funding — companies like Bath Iron Works, for example. 

Can you imagine BIW turning down a shipbuilding contract for the US Navy that would profit them a billion dollars because they’d have to spend $140 million in infrastructure upgrades to be able to build it? 

Speaking of BIW, there’s another massive logical flaw coming from LePage’s camp. They claim $500 million a year in federal health care funding won’t have a positive impact on Maine’s economy. (Seriously, they are saying this.) 

If you are one of the people who thinks $500 million a year in new economic activity won’t have a positive impact on our state, consider this: BIW’s entire annual payroll is $400 million.  

In fact, expanding Medicaid would be a lot like opening another BIW in Maine — a federally funded job machine supporting 6,000 skilled workers and swirling hundreds of millions of new dollars into Maine’s economy.

Still not convinced? Consider this: Maine’s entire lobster industry revenue is $533 million.

But LePage and company say $500 million won’t help our economy.

Another major logical flaw in Medicaid expansion opposition hits at the heart of the GOP’s anti-ACA sentiment. Republicans dislike Obamacare for one simple reason: it makes insurance more expensive. So how then can you oppose a program that makes it less expensive for people to get insurance? 

The proposed expansion of Medicaid would give health insurance to people making up to 138 percent of the poverty level. This means a couple things. First, it means the recipients are working — otherwise they’d have no income. It also means these people are the ones at ground zero of America’s healthcare crisis. They’re working, they aren’t making much, and they can’t afford health insurance. 

Aren’t these the exact people Republicans claim to care about when they decry the impacts of Obamacare?

If lowering the cost of health insurance is not the primary goal of the anti-Obamacare crowd, what is?

The bottom line is Team LePage doesn’t care about the fiscal impact of Medicaid expansion. They simply care that it’s a Democratic program, and it helps poor people. LePage Republicans have such a blind tribal rage that it doesn’t matter if it’s a good deal for Maine’s economy or not, or that it helps mitigate the core problem with Obamacare — prohibitively expensive health insurance.

They simply want to wreck another social service program because that’s what they do.

LePage has put Maine in the absurd position of shouldering all the negative market impacts of Obamacare without receiving any of the positive benefits meant to offset them. It’s clear by now that he is not a fiscal conservative, and that his sycophant followers aren’t either. They are angry populists whose causes border at times on anarchy. They will oppose things simply for the destructive impact of their opposition.

And standing in the way of federal money meant to provide health insurance for tens of thousands of working low-income Mainers simply out of spite is pretty darn destructive.

Fortunately, LePage and his lackeys don’t get to make the decision this time. 

On Nov. 7, voters can finally right this ridiculous wrong by voting yes on Question 2.

Lance Dutson, a principal of Red Hill Strategies, is a Republican communications consultant. He has served on the campaign teams of U.S. Sens. Susan Collins and Kelly Ayotte, as well as the Maine Republican Party.

https://lancedutson.bangordailynews.com/2017/10/30/column/opposing-medicaid-expansion-is-not-a-conservative-position/

Maine Voices: Medicaid expansion in Maine would come at steep cost, loss of medical-care price control

by Martin Jones - Portland Press Herald - November 1, 2017

FREEPORT — When Medicare and Medicaid were passed as amendments to the Social Security Act in 1965, Medicare for the elderly was the main event. Medicaid was an add-on designed to provide aid to poor parents and to the blind and disabled. In 1966, there were 4 million Medicaid beneficiaries.

Today, Medicaid has 73 million enrollees, about 23 percent of the population. Around 12 million of these individuals have been added as a result of the program’s expansion under Obamacare. Most of them are working-age adults, with and without children, with incomes up to 138 percent of the poverty level. Most have access to employer insurance or to generous Obamacare subsidies. Even before the Obamacare expansion, the history of Medicaid had become the best example we have of how a welfare program can grow far beyond the intended scope and cost estimates of its designers.

Public policy based on good intentions usually has a cost, and in the case of Medicaid, the cost has been very high. Expansion advocates paint a very rosy picture of the economic benefits that would result from an inflow of federal dollars. But the picture completely ignores the cost of the federal funding and simply treats it as free money.

Medicaid is already the third- largest domestic item in the federal budget. The Congressional Budget Office estimated in June that program outlays will rise at an annual rate of 5.4 percent over the next 10 years, considerably faster than growth in the economy or federal revenues, and will be $655 billion in 2027. It is feckless to pretend that providing federal funds to the states for Medicaid has no cost and only provides benefits.

Although the states pay only about 40 percent of Medicaid’s cost on average, it is now the second-largest item in their budgets, and many of them have been struggling with their portion of the program’s expense for years. Yet 31 of them couldn’t resist the temptation to expand their programs when the federal government offered to pay 100 percent of the cost initially, declining to 90 percent in 2020 and beyond. The expansion states began paying their part of the expansion cost this year, and over the next several years many of them will find that even 10 percent of increased program expenses will put additional stress on their budgets.

In Maine, the Office of Fiscal and Program Review estimates that expansion would cost the state $31 million in 2019 and nearly $55 million by 2021 – and the cost would continue to rise after that. Even if some of the cost is offset by increased economic activity, the additional burden on the state’s budget would be substantial. Maine, like other expansion states, would have to pay the additional cost by raising taxes, making cuts elsewhere in the budget, reducing eligibility for other beneficiaries, reducing provider reimbursements or some combination of these. The necessary adjustments would be difficult and painful.

There is an even larger and more important issue relating to Medicaid. The greatest flaw of Obamacare is that it widened and deepened the role of the third-party payment system, which is the primary driver of higher health care and insurance costs.

When someone else pays the bills, consumers don’t care about expense. It will be impossible to control the rising cost of care and escalating insurance premiums unless consumers have more control over their health care dollars, have an incentive to seek value and providers have an incentive to create it. Medicaid removes any incentive to restrain demand or to seek value. This is a cold reality that Medicaid and universal care advocates don’t want to hear.

There will always be individuals and families with special and expensive needs that are not accommodated easily in the existing private-public policy framework. Advocates think that Medicaid is the simple solution to these needs because the care is free and there are no limits on claims. But a general policy covering a large segment of the population to meet the needs of a relatively small number of individuals is likely to be extremely expensive, as Medicaid has proven to be. It would be far more efficient and cost effective to provide targeted, means-tested assistance to those with special needs than to expand free care to a large number of mostly healthy individuals who have other options for insurance.

http://www.pressherald.com/2017/11/01/maine-voices-medicaid-expansion-in-maine-would-come-at-a-steep-cost-and-make-controlling-the-price-of-medical-care-even-harder/

When Silver Costs More Than Gold: How Trump’s Actions Have Scrambled Insurance Prices

by Margot Sanger-Katz and Kevin Quealy - NYT - October 27, 2017

The rates for next year’s Obamacare plans are out, and they show how President Trump’s actions have scrambled the insurance marketplace.

Usually, plans known as gold have higher monthly premiums but lower out-of-pocket costs than “silver” plans, which have tended to cost less each month and have been the most popular plans.

But this month, Mr. Trump carried out a longstanding threat and ended certain subsidies for insurers. To compensate for the lost funding, insurers increased the prices of their plans — heavily in the silver category and less so in others.

Now the silver plans will be more expensive in many markets than gold plans that have much lower deductibles. For people who qualify for government subsidies, that’s good news: Their subsidies will rise with the rising cost of silver plans, and they’ll be able to afford a plan that requires much less out-of-pocket spending for their health care. For those who don’t, it highlights just how expensive many silver plans have gotten as a result of the president’s action, and how hard people may need to work to find an affordable option.

The least expensive gold option for next year is cheaper than the least expensive silver option in about a sixth of counties using Healthcare.Gov to market plans, as you can see on our map. Gold is a better option in much of New Mexico, Wyoming, Kansas, and parts of Wisconsin, Pennsylvania and Georgia. There are also a substantial number of counties in Texas, Florida, Oklahoma, South Carolina and Michigan where the price difference between a gold plan and a silver plan with a much higher deductible is smaller than $25 a month.

That is confusing, and consumers are likely to be surprised when the enrollment period opens on Wednesday.

The Trump administration created this pricing chaos by eliminating cost-sharing subsidies, a payment to insurance companies that was tied up in a legal dispute. But it has also taken steps to limit the damage. It permitted states and insurers to change their prices at the last minute to compensate for the change. It made price information for next year publicly available a week early, so customers could have more time to window-shop and explore their options.

It also organized plans on its site in order of their premium price, so that customers who live in a place where a gold plan costs less than the cheapest silver plan would have an easier time figuring that out.

If you live in one of the places where the gold plan is cheaper than the silver plan, and you earn more than about $24,000, you should not buy the more expensive silver option. The gold plan will cost less, and have a lower deductible. There are also high-deductible bronze plans that will have substantially lower premiums that you may also want to consider. If you qualify for a government subsidy, those will be your best options.

If you earn too much to qualify for federal help buying insurance, you should also steer clear of the more expensive silver plans on HealthCare.gov. But there may be cheaper options in the silver category if you buy directly from an insurance company. A broker may be able to help you examine all of those options.

If you earn less than $24,000, a silver plan will still be your best choice. That’s because you qualify for additional discounts that will lower your deductible and co-payment, making a silver plan even more generous than a gold plan. Premium subsidies, which are unaffected by the president’s actions, will protect you from premium price increases.

The loading of cost increases onto silver plans also makes it hard to easily describe how much more expensive insurance will be next year, compared with this year. The consulting group Avalere Health published a report Wednesday saying that the average silver plan on HealthCare.gov would increase in price by 34 percent — by far the largest annual price increase since the Obamacare markets began.

Normally, that silver price increase is a good barometer for what’s happening with the entire health insurance market. But the Avalere report highlighted that the prices of other plan types aren’t rising as fast. Gold plans are going up, on average, by 16 percent. Bronze plans are rising, on average, by 18 percent.

Some of those increases are probably because of Trump administration actions as well. The government has cut back on advertising and outreach to help enroll healthy customers, and has signaled that it may not enforce the government mandate to obtain insurance as vigorously as the Obama administration did. In their filings with regulators, insurance companies said they were increasing premiums to address that broader policy uncertainty.

Our map draws on prices that were published online Wednesday for 2018 plans on HealthCare.gov. The website serves 39 states, and the precise prices we examined were for single customers who don’t smoke, age 40, though the trends should be the same for customers with different family sizes and ages. Information from the remaining states, which run their own marketplaces, will become available next week.

https://www.nytimes.com/2017/10/27/upshot/when-silver-costs-more-than-gold-how-trumps-actions-have-scrambled-insurance-prices.html

How a Republican Idea for Reducing Medicare Costs Could Affect You

by Austin Frakt - NYT - October 30, 2017

Last month, as Republican leaders were preoccupied with another unsuccessful attempt to replace Obamacare, a senior Trump administration official issued a warning about a different major medical program, Medicare.

The official, Seema Verma, administrator of the Centers for Medicare and Medicaid Services, wrote in The Wall Street Journal that Medicare was facing a fiscal crisis. She announced that she was asking the agency’s innovation center for ideas to address it, and that part of the answer was to give consumers “incentives to be cost-conscious.” This has some Democrats worried that she’s trying to move Medicare toward something called premium support, which would be a huge change for consumers.

Before we get into the pros and cons, what’s the fiscal crisis? According to projections from this year’s Medicare Trustees’ report, the fund that pays for Medicare-financed hospital care will be depleted in 12 years, and care for other services will consume an ever-larger share of the economy and federal revenue. Citing trends like those, Republicans included the outlines of a Medicare premium support plan in the House of Representatives’ fiscal year 2018 budget resolution, as they did in several prior ones.

In broad terms, “premium support” means the government pays a contribution toward premiums, and beneficiaries pay the rest. In a sense, today’s Medicare program already has such a structure. For either the traditional program or a private Medicare Advantage plan, the government pays a preset premium stipend (alternatively called a subsidy, credit or voucher) that varies across these two parts of the program. In all cases, stipends grow at the rate of health care costs.

If Medicare already has a form of a premium support model, what’s all the fuss about?

The important difference is in how stipend levels are set. Today’s stipends are not driven by the market, but are set according to legislatively established formulas. But the type of premium support Medicare reformers usually advocate — what people generally mean when they use this term — would use market signals to set stipend levels.

“Premium support could result in increased efficiency in the Medicare program,” said Bryan Dowd, a health economist at the University of Minnesota, and co-author of a book that analyzed various premium support options. That efficiency could push the hospital trust fund depletion date further into the future and reduce “the financial burden on future generations.”

Premium support models take many forms, but there are two crucial variables. One is how stipend levels are set, which determines how much of beneficiaries’ own money they need to contribute. The other key feature of premium support is how much the stipend grows over time. Both aspects are hotly debated.

In some versions of premium support, the stipend level would grow more slowly than health care costs, forcing people to pay more out of pocket over time to purchase coverage. In other versions, the stipend level would grow at the same rate as health care costs, so beneficiaries would continue to pay about the same share of their own money for health insurance.

Most premium support approaches would retain traditional Medicare, though its fate would be uncertain, a source of controversy. “A lot rides on how the government’s support level differentially impacts the cost to beneficiaries of private plans versus traditional Medicare,” said Timothy McBride, a health economist with Washington University in St. Louis. Geography also plays a role. “If traditional Medicare is disadvantaged, that would hit rural beneficiaries harder, because a larger share of rural America relies on the traditional program than do urban Americans.”

As a report this month from the Congressional Budget Office reveals, how much premium support could save the government varies considerably depending on how stipend levels are established. Across the variations the C.B.O. examined, Medicare spending could fall by as much as 9 percent or as little as about 0.5 percent. But premiums could rise, including the premium for traditional Medicare. Under one projection, the C.B.O. estimates, traditional Medicare’s premium could double.

In all the scenarios the C.B.O. analyzed, stipend levels would be based on bids from Medicare Advantage plans and traditional Medicare that reflect the cost to cover a person for standard Medicare services. Stipend levels would keep pace with overall health care costs, but they could still be lower than what many Medicare beneficiaries receive today.

For example, tying the stipend to the second-lowest bid and requiring all Medicare beneficiaries to be subject to that new, lower level would save $419 billion over 2022-2026, the C.B.O. estimated.

Tying it to the average bid or requiring only new beneficiaries to be subject to the new stipend would save less. In either case, people would have access to plans that don’t cost more than today’s. But those who opted for more expensive plans because they offer more benefits, or the traditional program because it covers any doctor willing to accept Medicare patients, would pay more out of pocket. Consequently, more people would opt for cheaper, private plans — and fewer would choose traditional Medicare.

This worries some health policy experts. “Traditional Medicare has been the leader in reforming the health care payment and delivery system to improve efficiency,” said Paul Van de Water, senior fellow with the Center on Budget and Policy Priorities. “It has outperformed private insurance in holding down the growth of health costs, but its ability to continue to do that would shrink significantly if premium support caused its enrollment to dwindle.”

Exactly how much more people would pay depends not only on the plans they select, but also on where they live. In some markets, many plans, including the traditional program, might charge premiums close to the second-lowest bid. In others, plans that many beneficiaries may want might cost a lot more.

In the premium support debate, there’s a fundamental lesson: It’s conceptually simple to reduce federal spending on health care, but it’s very hard to do so in a way that doesn’t increase costs for at least some consumers. To actually reduce total (not just federal) health care spending for everyone, one has to overhaul how care is delivered, not just how it is paid for. That’s much harder.

https://www.nytimes.com/2017/10/30/upshot/how-a-republican-idea-for-reducing-medicare-costs-could-affect-you.html

How to Be a Smart Obamacare Shopper

by Margaret Sanger-Katz and Haeyoun Park - NYT - November 1, 2017

The Trump administration’s actions to scale back Obamacare have made it harder and more complicated to find the best health plan. But the pricing chaos has also created great deals for some consumers, who can sign up during open enrollment beginning today. Here’s our advice on how to shop — the best strategy depends on how much you earn.

If you qualify for big discounts on deductibles and co-payments, it’s probably best to stick to the cheapest silver plan.

If you earn below 200 percent of the federal poverty level, or about $24,000 for a single person, you can get lower out-of-pocket medical costs because the government pays insurers to give you discounts.

The Trump administration ended these subsidies, but the law requires that insurers still give the discounts to consumers. That means a silver plan is still going to be the best deal, since you will be able to get a rich set of benefits for a fraction of your income.

While premiums have risen over all, there are still many places where the cost of the least expensive silver plan will cost less for people like you, according to data from the Kaiser Family Foundation.

Change in price of lowest-cost silver plan after subsidies for a 40-year-old earning $20,000, 2017 to 2018

Less expensive

than 2017

Source: Kaiser Family Foundation | Note: Map looks at states that sell health plans through the federal HealthCare.gov website. Information about the remaining states will be made public in November.

It’s worth looking at the different silver options to see which ones cover the doctors and hospitals you care about.

If you get premium subsidies but not big discounts, you may be better off with a gold or bronze plan.

If you earn between 200 percent and 400 percent of the poverty level, about $24,000 to $48,000 for a single person, you qualify for help paying your premiums from the federal government.

Because most states are increasing prices on silver plans, which are used to calculate your subsidy, you are likely to have more buying power this year if you want to buy a gold plan, with a lower deductible. In the past, the cheapest gold plans have always cost more than the cheapest silvers.

Where gold is cheaper than silver for a 40-year-old earning $30,000, after premium subsidies

Source: Kaiser Family Foundation | Note: Map looks at states that sell health plans through the federal HealthCare.gov website. Information about the remaining states will be made public in November.

You may also be able to use your enhanced subsidy to buy a free high-deductible bronze plan. (If you do, you may want to sock away some of your savings, so you can pay that deductible if you have a big medical emergency.)

Where a bronze plan is free for a 40-year-old earning $30,000, after premium subsidies

Source: Kaiser Family Foundation | Note: Map looks at states that sell health plans through the federal HealthCare.gov website. Information about the remaining states will be made public in November.

If you are older than 40 or earn less than $30,000, there may be even more places where you can find a free bronze plan.

Even if you are not in a place where you can benefit from a cheaper gold or free bronze plan, the law’s subsidy structure still protects you from price increases. Indeed, many people who buy the least expensive silver plans for 2018 will pay less out of pocket than they did this year.

If you don’t get any government subsidies, you are probably better off looking outside the Obamacare marketplace.

If you make over 400 percent of the federal poverty level, or about $48,000 for a single person, you can’t collect a subsidy, and you’re on the hook for the whole price of your coverage.

But in many states, though not all, there will be silver plans you can buy directly from an insurer that will cost less than the plans that are sold on the Obamacare marketplace. A human or online broker can help you explore all those options.

Look at the example below, to get a sense of the better deals you may be able to find outside the state exchange.

Average monthly premium for a 40-year-old in Scranton, Pa., without subsidies

On and off exchange

Source: Pennsylvania Insurance Department

If you have Obamacare coverage this year, don’t just renew your coverage without exploring all your options.

This is such an odd year for price increases that switching may get you better coverage for less money. Even if you like your plan, you should make sure it remains the best choice for you.

The last day to enroll for coverage is Dec. 15 in most states.

https://www.nytimes.com/interactive/2017/11/01/us/choose-best-obamacare-plan-open-enrollment.html?_r=0

Choosing a Health Insurance Plan Is Not ‘Shopping’

by Helaine Olden - NYT - November 2, 2017

It’s time to select a health insurance plan for 2018! Whether we get covered through an employer or the Affordable Care Act exchanges, we’ll be told to carefully review our options to find a plan that will give us the best coverage for the least amount of money.

We will be told we need to shop.

“I encourage you to shop around,” Senator Jeanne Shaheen, Democrat of New Hampshire, told her Facebook followers who are choosing plans from the A.C.A. marketplaces. The human resources giant Mercer wrote last year, “This open enrollment, think of employees as shoppers.” The American Diabetes Association, the American Institute of Architects, the Robert Wood Johnson Foundation and Aetna all use the terms in their literature or on their websites.

Make it stop!

This is not shopping. Shopping is a fun activity, like choosing a pie from the bakery or picking out cereal at the supermarket. The farthest thing from “shopping” is the arduous annual ritual of reviewing the complex and all but impossible to decipher health insurance options.

That’s partly because insurers do their best to make the experience as miserable as possible. Many of them offer up less-than-accurate lists of providers and participating institutions. They reserve the right to deny you coverage of a service, and you won’t know if they have until the day you need it — and maybe after the fact. Prospectuses are complex, and few of us fully understand them. Only 9 percent of Americans can properly define all four of these rather vital phrases: health plan premium, health plan deductible, out-of-pocket maximum and coinsurance, according a survey recently released by United Healthcare.

No surprise, reviewing our health insurance options doesn’t score high on the fun-o-meter. A 2016 Harris Poll discovered almost half of the employees they questioned always found choosing an insurance plan stressful. A similar number told Aflac they would rather talk to an ex or walk across hot coals than enroll in a health insurance plan. And yet another United Healthcare survey found more than a quarter of respondents would rather lose their credit card, smartphone or luggage, not to mention suffer a flat tire, than review their health insurance options during open-enrollment periods.

Plus, we have choices when we do the real kind of shopping. If we don’t like the luggage in one store, we can always head to another. But if we don’t like the health insurance options our employer selects, or the options on the local exchange — well, short of changing jobs or moving, we’re stuck. That’s hardly the definition of consumer empowerment.

Yet the term “shopping” puts the onus on the patient, not the overpriced American system of medical care. This is no exaggeration. At an election town hall last year, a woman confronted Hillary Clinton, explaining that her health insurance costs doubled to over $1,000 a month after the Affordable Care Act went into effect. Mrs. Clinton responded that she would work to keep costs down but told the woman to “keep shopping, because what you’re telling me is much higher than what I hear from other families.”

Isn’t it absurd to describe us as shoppers? When I go shopping at the mall, I get perfume samples and free chocolates. When I consider health insurance plans, I am offered no such things.

Moreover, 326 million Americans cannot combat our high-cost medical system with one savvy purchase. The term prioritizes the values of the marketplace and financial world. It also signals that instead of contemplating how to make the medical-industrial complex work for us, our energy is channeled into getting the best deal we can from a system that’s designed not for our benefit, but to extract the greatest amount of profit from every patient.

Health care is much more than a mere consumer item, even if we do spend money to get it. It’s fundamental to our lives. So hear me out. Whether you are a reporter on deadline, an insurance official discussing plans or someone reviewing your options, just say people should “choose” or “pick” a plan. But whatever you do, don’t conflate the pleasurable experience of real shopping with the dreary task of finding a health insurance plan.

https://www.nytimes.com/2017/11/02/opinion/health-insurance-shopping-obamacare.html

As Open Enrollment for Obamacare Begins, Confusion Reigns

by Abby Goodnough and Robert Pear - NYT - October 31, 2017

MACON, Ga. — David Branch knew that his job, helping people sign up for Obamacare, would be harder this year. But Mr. Branch didn’t fully realize the scope of his challenge until a group that he approached with his fliers insisted that the Affordable Care Act had been repealed.

“They said: ‘Why are you guys here? Obamacare is done,’ ” Mr. Branch recalled Friday as he finished a training session here.

In fact, the Affordable Care Act has survived blow after blow since President Trump took office in January, including repeated attempts by Congress to repeal it. But as the fifth open enrollment period starts Wednesday, the law is reeling from continued attacks by Mr. Trump that have sown confusion and anxiety among the roughly 10 million Americans with coverage through its insurance marketplaces and millions more who remain uninsured.

Most recently, Mr. Trump announced plans to cut off subsidies that reimburse insurance companies for assistance they are required to provide to low-income customers who struggle with co-payments and deductibles. The cuts resulted in a crazy quilt of premiums for 2018 that differs radically from the pattern of the last four years, which will upend expectations of consumers in many states.

And the administration’s sharp cuts to advertising for the law’s open enrollment period and to groups that employ enrollment “navigators” like Mr. Branch have almost certainly limited public awareness that now is the time to enroll. Those who have heard Mr. Trump’s message that insurance premiums are way up may not realize that the subsidies that help low- and middle-income Americans pay those premiums will rise as well.

The enrollment period for the federal marketplace has been cut in half, to 45 days, with hardly any publicity by federal officials. No one is sure how well government call centers and computer systems will handle the expected surge of applications leading up to the Dec. 15 deadline for people to enroll through HealthCare.gov.

In Washington and across the nation, supporters of the law are doing what they can to combat misperceptions.

“Consumers are unclear whether the marketplaces still exist, whether they still have an obligation to get coverage, whether the mandate exists, whether they can get financial assistance,” said Kelley Turek, a policy analyst at America’s Health Insurance Plans, a trade group. “Our message is: Come back. The marketplaces are still here.”

Here in Georgia, what had been the largest navigator group, Insure Georgia, lost 86 percent of its $2.3 million federal grant and had to lay off half its staff, leaving Mr. Branch and 10 other counselors to provide enrollment assistance for all 159 counties in the state. Humana is leaving the insurance marketplace here, and while three other insurers will remain, all but 10 counties will have a single company selling coverage for next year. Rates for popular silver-level “benchmark” plans are rising by 47 percent on average here, according to the Department of Health and Human Services, although most customers will qualify for subsidies that will grow by a similar amount. The department found that premiums for benchmark plans are increasing by 37 percent nationwide, compared with 24 percent last year.

Other types of plans may be less expensive, because to compensate for the funds they will lose now that Mr. Trump has ended the cost-sharing payments, insurers have generally raised the price of silver plans more than those in the bronze, gold and platinum categories. As a result, some gold plans will now be less expensive than some silver plans, even though gold plans cover more of the costs of a typical consumer.

Sorting through these complications will be difficult for many consumers.

At a Halloween “safety expo” at Coliseum Medical Centers here on Saturday, several hundred parents and children filed past an Insure Georgia table by the front door, where Amber Higgins, another navigator, asked over and over, “Do y’all have health insurance? You know anyone who’s doing without it?”

“My niece who just moved here from Ohio,” said one woman, taking a flier.

“My sister in Texas,” said another.

“Me,” said yet another woman, scanning the income requirements for receiving subsidies, which Ms. Higgins had placed in a frame.

The response was not surprising. Georgia has the nation’s fourth-highest number of uninsured residents, after Texas, California and Florida. In some of the state’s rural counties, enrollment under the Affordable Care Act dropped by as much as 36 percent this year, according to a new report, which pointed to the diminishing choice of insurers in rural areas as a likely reason.

Briana Zoellick, 26, told Ms. Higgins she had checked the HealthCare.gov website when it started allowing people to preview their options last week and was astonished to learn that her family’s subsidy would be a lot bigger next year even though their income has risen. Ms. Zoellick, a medical assistant and mother of two, said she and her husband, a graphic designer, canceled their coverage earlier this year because they could not afford their portion of the premium, about $140 a month.

Next year, she has learned, their subsidy will rise to more than $800, from $650 — “incredible,” she said — and their share will be less than before.

Yet Ms. Zoellick said her husband remained wary of signing up because of everything he had heard about Mr. Trump ending the payments to insurers. Many customers are mistakenly assuming that what he is blocking is premium subsidies, which are separate and not affected by Mr. Trump’s action.

“He was like, ‘I don’t know if that’s going to actually happen because of what Trump’s doing,’ ” Ms. Zoellick said, referring to their higher subsidy.

The California marketplace, run by an independent state agency, is spending $111 million on advertising, more than 10 times as much as the federal government intends to spend for the entire country. The New York marketplace, run by the state Health Department, is spending $15 million.

“Despite attempts at the federal level to take health care from New Yorkers, our marketplace is ready to open Nov. 1 as strong as ever,” said Donna Frescatore, the executive director of the New York insurance marketplace. “For many consumers, prices in 2018 will be the same as this year, or lower for the same level plan.”

In some states that run their own insurance exchanges, consumers will have more time to sign up. The deadline is Jan. 14 in Minnesota, Jan. 15 in Washington State and Jan. 31 in California and New York.

While many consumers will have fewer choices and will face higher premiums next year, the situation varies greatly from state to state.

In Tulsa, Okla., seven health plans will be available, all from one company. For the most popular plans, the average premium for a 35-year-old will be about $560 a month, according to HealthCare.gov. In Phoenix, consumers will have a choice of five plans, all from one company. For the two popular silver plans, premiums for a 35-year-old average $470 a month.

Mike Kreidler, the insurance commissioner in Washington State, approved rate increases averaging 36 percent last week, and he attributed 10 percentage points of the increase to Mr. Trump’s decision to cut off the subsidies known as cost-sharing reduction payments.

“I fear that many will go uninsured,” Mr. Kreidler said, while noting that some plans would not be affected by the president’s action.

In Macon next year, 13 plans will be available, all from Blue Cross Blue Shield of Georgia. A 50-year-old woman with income of $30,000 will be eligible for a subsidy of $597 a month. That subsidy would lower her premium to an average of $236 a month for silver plans and $77 a month for bronze plans, according to HealthCare.gov.

But for a 50-year-old woman in Macon with annual income of $50,000, costs would be much higher. She would not be eligible for financial assistance and would have to pay $768 a month — more than 18 percent of her income — for the cheapest silver plan. Prices in rural southwest Georgia and a few other parts of the state will be even higher, although in Atlanta they will be lower.

For Pat and John Curry of Augusta, who are both 57 and own a small coffee-roasting business, options will range next year from a bronze plan for $1,526 a month with a $13,500 family deductible to a gold plan for $3,142 a month and a $3,900 family deductible. Blue Cross is the only insurer selling in their county. The couple, who each have chronic conditions and take multiple daily medications, said they would research whether buying a plan directly from Blue Cross would be cheaper.

Ms. Curry will also consider buying coverage only for her husband, who is getting follow-up care for cancer.

“I don’t know what we’ll be doing for insurance,” Ms. Curry said, looking at rates under the Affordable Care Act, “but it won’t be this.”

https://www.nytimes.com/2017/10/31/us/politics/obamacare-open-enrollment-trump-attacks.html