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Monday, May 25, 2015

Health Care Reform Articles - May 25, 2015

Obama’s Game of Chicken with the Supreme Court

BY 


Sometime next month, the Supreme Court will decide King v. Burwell, and the conventional wisdom about the stakes in the case appears to have shifted. The case represents a challenge to the core of the Affordable Care Act. The plaintiffs charge that, based on a strict reading of single sentence (actually, four words), federal health-insurance subsidies should be available only in the sixteen states (and the District of Columbia) that set up their own health exchanges, or marketplaces. This means, they argue, that there should be no subsidies for people who now buy insurance on the federal exchange in the other thirty-four states. At the moment, about thirteen million people receive those subsidies.
The people with the most riding on the outcome, of course, are those thirteen million. Without subsidies, it’s likely that most of them will no longer be able to afford their insurance. Until recently, the perception has also been that the Democrats had the largest political stake in the case. After all, the A.C.A. is the signature achievement of the Democratic President. Suddenly, though, and paradoxically, it has come to seem that Obamacare’s Republican opponents are most at risk if the decision goes their way. They have the most to lose by winning. As Jonathan Chait wrote recently, “The chaos their lawsuit would unleash might blow back in a way few Republicans had considered until recently, and now, on the eve of a possible triumph, they find themselves scrambling to contain the damage.” In this view, the peril is especially great for Republicans, because, as Jonathan Cohn recently pointed out, the G.O.P. has failed to propose any kind of plan to address the loss of insurance for so many millions of people.
So that’s the theory: millions will suddenly be uninsured, and will blame Republicans. As Harry Reid, the Democratic leader in the Senate, put it recently, “I don’t think they will [win the case]. If they do, that’s a problem that the Republicans have.”
No, it’s not. If the Obama Administration loses in the Supreme Court, the political pain will fall almost exclusively on the President and his Party. To paraphrase Colin Powell and the Pottery Barn rule, President Obama will have broken health care, so he owns it. To the vast mass of Americans who follow politics casually or not at all, Obamacare and the American system of health care have become virtually synonymous. This may not be exactly right or fair, but it’s a reasonable perception on the part of most people. The scope of the Affordable Care Act is so vast, and its effects so pervasive, that there is scarcely a corner of health care, especially with regards to insurance, that is unaffected by it. So if millions lose insurance, they will hold it against Obamacare, and against Obama. Blaming the President in these circumstances may be unfair, but it’s the way American politics works.


By The BDN Editorial Board
Posted May 21, 2015, at 2:16 p.m.
Americans consistently spend more on prescription drugs than anyone else in the world. That spending reached new heights last year, jumping 13.1 percent to $373.9 billion. That works out to $995 per person, according to an April report by the IMS Institute for Healthcare Informatics, triple the amount Americans spent in 1995 when adjusted for inflation.
Maine residents, who spent more than $1.5 billion last year to fill prescriptions at pharmacies, lost their best short-term option earlier this winter for avoiding those stifling prescription drug costs. U.S. District Court Judge Nancy Torresen in February invalidated a 2013 state law that allowed licensed pharmacies in Canada, the U.K., Australia and New Zealand to dispense drugs to Maine residents.
Short of a federal solution to the U.S.’s prescription drug cost problem, this law was a logical and safe way to help Mainers save some money on needed treatments. But, Torresen determined, it flew in the face of federal law, which bars prescription drug imports from foreign pharmacies for personal use. (Attorney General Janet Mills declined to appeal Torresen’s ruling, citing the need for federal action.)
Rep. Chellie Pingree from Maine’s 1st District is proposing a partial solution, introducing legislation that would allow Americans to order drugs from licensed Canadian pharmacies. Sen. John McCain, R-Arizona, is sponsoring identical legislation in the Senate — Maine Sen. Susan Collins is a co-sponsor.
Specifically, the Pingree-McCain legislation would require the federal government to develop the rules necessary to make it happen within six months of the bill passing. That’s because the federal government has had the authority to allow prescription drug imports from Canada since 2003 and hasn’t acted on it without the force of a deadline in the law.
The prohibition on personal prescription drug imports is nonsensical. It’s about time Congress eliminated it. Drugs from licensed Canadian pharmacies are no less safe than drugs purchased from American pharmacies, and there’s no reason to deprive Americans of a simple way to lower their prescription drug costs.
But allowing imports from Canada is just the start of changing a system that keeps Americans paying unnecessarily higher prescription drug prices than everybody else. Americans pay nearly $1,000 per capita on prescription drugs, but Canadians — who pay the second most per capita — spend about 40 percent less. For name-brand drugs, the prices paid by Americans generally are at least double the prices one would find in the U.K. or Australia.
Part of the reason is that the U.S. imposes no price controls on prescription drugs, unlike every other nation in the Organization for Economic Cooperation and Development. Plus, Americans often have some of the earliest access to new, name-brand drugs — many of which simply are modifications of existing drugs that aren’t substantially better — soon after FDA approval, raising U.S. spending on prescription drugs when they are most expensive. Further, the U.S. doesn’t allow one of its largest prescription drug purchasers, Medicare, the ability to leverage its enormous buying power into lower prices. Private insurers can negotiate lower prices, as well as the Department of Veterans Affairs, but this leaves the negotiating to a fragmented market of many, relatively small payers.
Many have argued lower drug prices in the U.S. could translate into substantially less capital available for the research and development involved with bringing new drugs to market. But this argument ignores the fact that the vast majority of the research that leads to meaningfully different drugs — new molecular entities — is done in academic centers and sometimes in nonprofit and government research labs. A 2001 study in the journal Health Affairs found that just 15 percent of the research cited in drug patent applications to the FDA was done by industry. Further, a 2012 study in journal BMJ found pharmaceutical companies spent just 1.3 percent of their revenues on research into new molecular entities while spending at least a quarter on marketing.
If Americans’ exorbitantly higher prescription drug prices were needed to fund important medical breakthroughs, that would be one thing. But that’s not what the higher prices are paying for, meaning a key reason against allowing Medicare to negotiate better drug prices for its members, much less allowing Americans to purchase cheaper drugs from Canadian pharmacies, simply doesn’t stand up.


Awash in Paperwork, Maine Doctors Abandon Conventional Treatment Model 

By  • MAY 20, 2015
FALMOUTH, Maine - Many primary care doctors commit to the profession because of their passion for caring for patients. But the reality of the job often requires doctors to pack each day with patient appointments. As time with patients shrinks and administrative tasks swell, the quality of care can suffer.
Out of frustration, some Maine doctors have decided to abandon the conventional treatment model for something called direct primary care.
Last July, Catherine Krouse was just about done with her career choice. Fresh out of medical school and her residency in family medicine, she didn't feel eager for her future. She felt jaded.
"I knew for myself that signing a contract with a conventional model would be the end of me, that I wouldn't go back," she says. "I'd probably quit medicine."
Quit, because Krouse says the way health care has evolved, patients often come second to the other demands on doctors:  Filling out reimbursement forms. Calling insurance companies to battle for claims. Reviewing and signing off on stacks of patient paperwork.
"You just end up getting drained and drained and drained," Krouse says. "And then when your cup is completely empty, then you just get guarded and angry. And then you put up walls, and that really creates barriers."
So Krouse decided to set up a direct primary care practice. Earlier this month she opened Lotus Family Practice in Falmouth. She doesn't accept insurance. Instead, she charges patients a monthly membership fee. "So it's very direct. It's just patients and doctors. There's no one else in between."
Membership is $60 a month for adults, $20 for kids. It covers an unlimited number of visits, which last about 45 minutes. Patients can also call or text Krouse any time they want. She also provides generic drugs at wholesale cost. Those savings alone, she says, can cover the cost of membership. "Pennies. They cost pennies."
So, is direct primary care too good to be true?


Obesity epidemic is another reason for single payer

By James Binder, M.D.
The Charleston (W.Va.) Gazette, May 21, 2015
Our country would be better able to help its citizens prevent and manage chronic illnesses if we adopted a single-payer system. Our current primary care structure is designed to treat acute illnesses. Primary care providers do not have adequate time or the training to effectively treat the increasing burden of chronic conditions in our society, conditions such as obesity, diabetes mellitus, substance use disorders, depression.
Obesity will soon be our number one health problem. One-third of adults are obese.
Twenty percent of children 2 to 5 years of age are overweight or obese. Besides being associated with a number of serious medical conditions, such as heart disease and diabetes mellitus, obesity is associated with emotional/mental consequences (discouragement, depression) and social discrimination. Our national security is at risk with 30 percent of young Americans too heavy to meet the requirements for joining the Armed Services.
There are conscientious efforts to prevent and combat obesity being made right now in our communities and schools. However, these are often uncoordinated and unsustainable, not helping our children make lasting changes. A strong, multi-modal, evidence-based approach is needed.
Our current fragmented private insurance infrastructure has not and is not capable of supporting an effective response. Private insurance companies have one priority — to make a profit, not to improve the collective health of our nation.
The world-renowned Institute of Medicine published a blueprint to resolve the obesity epidemic (Progress in Childhood Obesity: How Do We Measure Up, 2006). An effective national response for preventing and treating childhood obesity would have three components:
  • Strong leadership and coordination.
  • Evaluation of approaches.
  • Monitoring progress of specific interventions and making adjustments when necessary.
A single-payer system would provide the infrastructure needed to implement each of these three components. Emphasis would shift from the micromanagement of each decision made by a clinician to the macromanagement of resources.
Micromanagement increases paperwork and expenses, discourages clinicians and patients alike, and is often ill-considered.
I treat a number of children with obesity as a pediatrician in a rural medical clinic. I recently referred a child with a BMI greater than 99 percent to a comprehensive Healthy Kids clinic in Charleston.
This child had failed stage I and II obesity treatments. Despite meeting the specific recommendations of the American Academy of Pediatrics for specialty referral, the family’s private insurance company refused to cover the treatment. The child had not yet developed an associated medical condition (e.g. diabetes mellitus).
This type of micromanagement would be unnecessary in a single-payer system because the emphasis would be on the collective health of the community, not the cost of one referral. It is so important that we return to a model based on caring professional judgment.
Even more importantly, we need to develop and implement programs that really work.
We know that it takes time to help families with such complex issues as weight control. The standard 15-minute clinic visits are not enough time to counsel families on complex issues, especially when there are other problems to discuss and five to seven minutes of that visit is spent on the computer, much of it devoted to meeting insurance company billing demands.
We know families must be involved in the solution since children learn good nutrition and healthy habits in the context of their immediate families. And, we know it takes coordination between communities, schools, industry, medical clinics, and the government to develop and sustain effective interventions.
A single-payer system would allow us to incorporate all these elements into treatment planning since its main goal is the collective health of the community.
Of course, the best strategy is to prevent the problem in the first place. Private insurers attach funding to individual patients. Broader societal goals are not funded. Less than 3 percent of health spending currently goes for prevention. We can do better than that.
A single -payer system would provide the framework to solve the problem and allow us to change our children’s environment. It would not solve the problem for us. We would still have to do that. However, we have the expertise and health professionals needed to accomplish that. We just need the framework. It is another reason many physicians support single payer.

Guiding Wealthy Retirees on Health Expenses

By 
Death and disease don’t discriminate, and that has many high-net-worth retirees worried. They realize fate could determine the quality of their retirement more than their lifetime of planning.
“They have command and control over other aspects of their life, but this is the unknown,” said Bill Hunter, director of retirement strategy for Bank of America Merrill Lynch. “It’s the who, what and when. Who will be afflicted? Will it be acute or chronic? Then the when: early in their retirement or in their later years?”
Enter big brokerage firms with services not typically associated with wealth management. Merrill Lynch, UBS, Morgan Stanley and Wells Fargo are either offering to connect wealthy clients with providers that offer specialized health care, or training advisers to deal with such worries about health and aging among clients.
They seem to be tapping a ripe market. According to research by Merrill Lynch and Age Wave, a consulting firm on aging, high-net-worth retirees reported more concern over retirement health care costs than the general population. This group was also much more likely to have estimated or tried to estimate costs for health care and long-term care in retirement.
While the research found that high-net-worth retirees are generally comfortable with the financial advice they have received, they are concerned about getting good advice on health issues, especially on finding the best doctors and understanding Medicare and supplemental insurance.


Multiple Sclerosis Patients Stressed Out By Soaring Drug Costs

by Richard Harris

American medicine is heading into new terrain, a place where a year's supply of drugs can come with a price tag that exceeds what an average family earns.
Pharmacy benefit manager Express Scripts says last year more than half a million Americans racked up prescription drug bills exceeding $50,000.
Barbara Haedtke of Portland, Ore., knows this all too well. When she was diagnosed with multiple sclerosis in 2001 at the age of 35, she was prescribed Avonex, at a cost of around $10,000 a year. Her health insurance paid most of that until she and her husband found themselves without jobs during an economic downturn. "We were in the hole, and so $10,000 was a lot of money," she says. "Under the best circumstances it's a lot of money, but then particularly it was really difficult."
The drug company gave her the medication at no charge until she once again had a job with insurance, and for that, she says, she's really grateful. But the story doesn't end there. Haedtke used Avonex for about a decade and watched with disbelief as the price more than tripled. She's now taking a new drug, Tecfidera, that's priced even higher — $66,000 a year, according to her pharmacy receipt.
The drug is supposed to help reduce the number of episodes that characterize multiple sclerosis, a disease in which nerve fibers gradually degenerate, causing muscle weakness, numbness, loss of balance and even paralysis. Haedtke describes these episodes as "terrifying," saying sometimes it feels like there's a cinder block on her leg when she tries to move. And she's had vision problems, too. It's hoped the new medication will also slow down the progression of permanent physical disability caused by the disease.
Still, Haedtke worries not just about the disease, but about the financial threat it poses. All the prescription medications for MS are extremely expensive.
A recent study from Oregon State University and the Oregon Health and Sciences University finds that the cost for MS drugs averages $60,000 a year, compared to $8,000 to $11,000 a year in the 1990s. The price for some climbed by an average of 30 percent per year for two decades, according to the report in the journal Neurology.



Obamacare: California exchange caps specialty drug costs for patients
by Chad Terhune - LA Times
ckling the high price of specialty drugs, California's Obamacare exchange capped what consumers will have to pay for expensive medications each month.
The new limits, set to go into effect in January, mark a first for state exchanges nationwide, according to Covered California. The exchange's four-member board approved the changes unanimously Thursday.
Most consumers will have their specialty drug costs capped at $250 per month, per prescription. But the exchange resisted pleas from patient advocates to extend that same limit to Bronze health plans, the cheapest coverage available on the state-run marketplace.
The monthly cap on Bronze plans will be $500 a month -- after a $500 pharmacy deductible is met.
Consumer groups generally applauded the state's move, but they said it didn't go far enough at protecting consumers from big medical bills.
“As it stands now the Bronze plan will not meet the needs of Californians with chronic conditions," said Liz Helms, chief executive of the California Chronic Care Coalition.
The exchange had lowered its proposed caps after hearing numerous complaints at last month's board meeting. California Insurance Commissioner Dave Jones had been one of the most vocal critics, and he had called for a $300 monthly limit on Bronze plans.
The exchange's decision "makes prescription drug coverage unaffordable to Californians who buy Bronze plans, one of the most popular health insurance levels of coverage," Jones said Thursday.

Panel Backs Bill Aimed at Boosting Maine Vaccination Rates

by Allanna Durkin, AP
AUGUSTA, Maine - A legislative committee has endorsed a bill that seeks to increase vaccination rates in Maine.
The Health and Human Services Committee voted 9-3 in support of Democratic Rep. Linda Sanborn's bill on Friday. It would require parents to consult with their doctor and get a form signed if they wish to opt out for philosophical reasons.
The bill received broad support from members of Maine's medical community. But it has been fiercely opposed by some parents, who say that lawmakers are trying to make it harder for them to make medical decision about their children.
The committee unanimously rejected a measure that sought to remove the philosophical exemption. Another legislative panel rejected a bill Friday that sought to prohibit discrimination against people who choose not to be vaccinated.

Health Beat: The Single-Payer System – Maybe it’s Time for Another Look

By Kathleen Kozak, M.D.
Honolulu Civil Beat, May 20, 2015

All across the nation, health insurance exchanges are facing some difficult financial realities. Right here at home, the Hawaii Health Connector has already announced a contingency plan for ceasing operations and deferring the management of the insurance exchange to the federal government as of Sept. 30.
The main reason is money. It’s very expensive to run the IT platform and also deal with all of the intricacies of the different insurance plans and their rules. The Health Connector is not sustainable the way it is run now. 
The billions of dollars that are spent on health insurance make the industry very profitable. But for whom?
The insurance industry has operating costs, and after paying their CEO millions of dollars, their chief executives, their presidents, vice presidents, secretaries, and even low-paid clerks, everyone gets a piece of the premiums. After all is said and done, there are millions of dollars spent on things other than actual care for the sick. That’s not even looking at what’s paid to hospitals, pharmacies and doctors like me.
What might streamline the health care costs now and into the near future? Well, when I first started in practice, I abhorred the idea, but perhaps a single payer system might be the best solution after all.
Under a single-payer system, all residents nationwide would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.
I’m all about free choice, and want people to have options, but from what I see right now, insurance companies make most of the decisions regarding care anyway.
Take medications. Each insurance plan contracts with different pharmaceutical companies to provide preferred drugs at a cheaper cost. Technically, the insurance plan didn’t say  someone can’t have his or her brand name drug to treat, say, high blood pressure, but that the cost would be so large each month that people are financially forced to choose the drug that is preferred on the insurance formulary.

Obamacare’s Big Gamble on Hospital Productivity

Can hospitals provide better care for less money? The assumption that they can is baked into the Affordable Care Act.
Historically, hospital productivity has grown much more slowly than the overall economy, if at all. That’s true of health care in general. Productivity — in this case the provision of care per dollar and the improvements in health to which it leads — has never grown as quickly as would be required for hospitals to keep pace with scheduled cuts to reimbursements from Medicare.
But to finance coverage expansion, the Affordable Care Act made a big bet that hospitals could provide better care for less money from Medicare. Hospitals that cannot become more productive quickly enough will be forced to cut back. If the past is any guide, they may do so in ways that harm patients.
The Obamacare gamble that hospitals can become much more productive conflicts with a famous theory of why health care costs rise. William Baumol, a New York University economist, called it the “cost disease.” (He wrote a book about it by that title; I blogged on it as I read it if you’d like to quickly get the gist.)
This theory asserts that productivity growth in health care is inherently low for the same reason it is in education: Productivity-enhancing technologies cannot easily replace human doctors or teachers. In contrast with, say, manufacturing — a sector in which machines have rapidly taken over functions that workers used to do, and have done them better and more cheaply — there are, at least for the time being, far fewer machines that can step in and outperform doctors, nurses or other health sector jobs.
But a new study casts doubt on that theory and suggests Obamacare’s bet may indeed pay off. The study, published in Health Affairs by John Romley, Dana Goldman and Neeraj Sood, found that hospitals’ productivity has grown more rapidly in recent years than in prior ones. Hospitals are providing better care at a faster rate than growth in the payments they receive from Medicare, according to the study.

Medi-Cal director talks shortages and modernization
Since California's health insurance program for the poor was expanded under the Affordable Care Act last year, enrollment has exploded, with more than 3.5 million people signing up for the first time. Almost 1 in 3 Californians — a total of 12.2 million people — now receive coverage through Medi-Cal.
But the sudden growth has raised questions about how state officials will serve millions of new beneficiaries and continue paying for the program, which currently costs the state $18 billion a year. There are also other big changes afoot as Medi-Cal switches patients into managed care — a system in which plans coordinate patients' care to keep costs down — and tries to move beyond its reputation as a health program of last resort.
In February, Jennifer Kent became the director of the state's Department of Health Care Services, which oversees Medi-Cal. Over the last decade, Kent, 41, has worked in a variety of roles within state government, including as associate director of the agency she now leads.
She oversees the country's biggest Medicaid program, and a department that manages the spending of more than $90 billion annually with 3,700 employees. The Times recently caught up with her to find out how she and her agency are coping. The interview was edited for length and clarity:
Does it feel overwhelming running such a big program?
Well, it's probably good that I've been inoculated from my previous work at the department. I think it can be overwhelming if you let it. You have to come to this job with a lot of flexibility.
For some people who want a very structured environment, this is maybe not the job for them. I tend to find it interesting.
I run, I go swim in the mornings before I come to work, so I get a lot of good thinking out in the hours before I actually show up in the office.
What have been the biggest challenges?
The Affordable Care Act really put a lot of focus on managed care. That is the organized delivery system of choice across both California and the country. Right now we're kind of putting all the different pieces in place for the long haul.


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Thursday, May 21, 2015

Health Care Reform Articles - May 21, 2015

How Medicare Advantage Investors Profited From Loose Government Lips 

By EDITOR • 22 HOURS AGO

On Wall Street, Feb. 3, 2011, was mostly a ho-hum day. But not for companies that sell Medicare Advantage plans. 
Several of those that offer the privately run Medicare coverage option hit the jackpot, tacking on billions of dollars in new value after federal officials signaled they might go easy on health plans suspected of overcharging the government. 
The stocks took off after the federal Centers for Medicare and Medicaid Services advised the plans in a memo that it was rethinking a move to ratchet up audits. Some of these plans are run by publicly traded insurance companies whose fortunes can rise and fall on a whiff of change in Medicare policy. 
At the time, health insurers were bracing for tougher audits, fearing they could wind up owing the government millions of dollars as a result. 
The memo was sent to Medicare Advantage plans, but wasn't available to the general public. 
A CMS spokesman said the two-paragraph memo was routine and that officials did nothing wrong in sending it out. But the advisory appears to contradict CMS regulations that urge officials to wait until after markets close to disclose information that could move stocks. The episode also raises fresh questions about the security and timing of so-called market-sensitive disclosures — and just who gains access to the information. 
"When the memo was released by people at the agency, they had to be brain dead if they thought it would not quickly make its way into the hands of those who influence stock prices," said Lynn E. Turner, a former Securities and Exchange Commission official and expert on financial reporting requirements. 
Big Jump
CMS said it began sending out the memo on an internal message system at 9:30 a.m. on Feb. 3 and it took "several hours" to reach all of the 6,500 health plan recipients. 
By mid-afternoon, a CMS official in Washington noted that shares in three major Medicare Advantage insurers had "shot up" as a result. 
"There's also an incredible volume — an atypical number of buyers and sellers," CMS official Misha Segal wrote in an email to several agency higher-ups at 2:37 p.m. (See the email traffic below.) 
UnitedHealth Group, the nation's biggest Medicare Advantage company, rose 4 percent, which "is nearly $2 billion in 'newly created equity' for the company," according to Segal. "This is a big jump." 
The huge stock rally — and the role CMS played in sparking it — is disclosed in agency emails and other records obtained by the Center for Public Integrity through a Freedom of Information Act lawsuit.
CMS officials, in a statement, said nothing was amiss.

Congress plots to pay for a trade deal by raiding Medicare

By Michael Hiltzik
Los Angeles Times, May 18, 2015
Medicare means many things to many people. To seniors, it's a program providing good, low-cost healthcare at a stage in life when it's most needed.
To Congress, it's beginning to look more like a piggy bank to be raided.
That's the only conclusion one can draw from a provision slipped into a measure to extend and increase the government's Trade Adjustment Assistance program, which provides assistance to workers who lose their jobs because of trade deals. The measure, introduced by Rep. David Reichert (R-Wash.), proposes covering some of the $2.7-billion cost of the extension by slicing $700 million out of doctor and hospital reimbursements for Medicare.
The plan on Capitol Hill is to move the Trade Assistance Program expansion in tandem with fast-track approval of the Trans-Pacific Partnership trade deal, possibly as early as this week. We explained earlier the dangers of the fast-track approval of this immense and largely secret trade deal. But the linkage with the assistance program adds a new layer of political connivance: Congressional Democrats demanded the expansion of the Trade Assistance Program, Congressional Republicans apparently found the money in Medicare, and the Obama White House, which should be howling in protest, has remained silent.
Medicare advocates have taken up the slack by raising the alarm. "To take this cut and apply it to something completely unrelated sets a terrible precedent," Max Richtman, head of theNational Committee to Preserve Social Security and Medicare, told me.
The Medicare raid was so stealthy that critics in Congress, including members of the Congressional Progressive Caucus, are just now gearing up to oppose it. "It was sort of buried" in the bill, Rep. Keith Ellison (D-Minn.), the caucus co-chair, told me Monday. The caucus expects to circulate a letter opposing the arrangement as soon as later this week. Ellison, an opponent of granting fast-track authority on the TPP, says the Medicare cut amounts to piling the costs of trade liberalization onto its victims.
"There will be fabulous wealth generated by the Trans-Pacific Partnership," he says. "The people who are hurt shouldn't have to pay for it with their jobs and then have inadequate Medicare when they get older."
Ellison labeled the extension of the assistance program a "consolation prize" for those injured by trade deals. But there are grounds to question how much good the Trade Adjustment Assistance actually does. 
Some of its benefits are direct. The program extends unemployment benefits for workers laid off because of competition from international trade and subsidizes their healthcare insurance. It funds job retraining programs and subsidizes job searches. Older workers can get limited "wage insurance" covering a portion of any wage reductions they suffer in moving to new jobs. Some of this assistance is skimpier in the new bill than they were in the last major reauthorization of the program in 2011, following trade deals with Colombia, South Korea and Panama. 
But in a 2008 study, Kara M. Reynolds of American University and her associate John S. Palatucci found that workers receiving trade assistance did scarcely better than other laid-off workers at finding new employment -- and that they earned on average 30% less at their new jobs, compared with the roughly 10% pay cut faced by unassisted workers. 
One reason, they posited, is that the workers in the trade program were in worse-hit industries and were trying to replace relatively high wages. But taking advantage of job training also kept them out of the workforce longer, which may have made them less desirable to employers.
What makes the Medicare cut especially stealthy is that it's slipped into the federal budget for 2024 -- it won't even show up on the books until the assistance program itself has expired. Moreover, it's pitched as an extension to the 2011 sequester, possibly to make it seem all the more painless.
The sequester, an economically damaging bit of fiscal hugger-mugger Congress devised as a route out of an impasse over the debt limit, left Medicare relatively but not entirely unscathed: much of the program was exempted from cuts, though provider reimbursements were pared by 2% each year through 2023. Last year, the Medicare sequester was extended into 2024 to cover a reversal of cost-of-living cuts to veterans' pension benefits -- another case of raiding Medicare for an unrelated program. The new proposal cuts Medicare provider benefits by another quarter of a percentage point from October 2024 through March 2025.
This is different from the $700-billion cost reduction in Medicare enacted via the Affordable Care Act. That includes efforts to make the program more efficient by improving the incentives governing how doctors and hospitals deliver care to their patients, along with reductions in payments to Medicare Advantage plans. Richtman points out that much of this amounts to a reallocation within Medicare -- "it's piled back into the program by paying for improvements in preventive care, closing the 'doughnut' hole in Medicare Part D (the prescription drug benefit)" and other measures. In the broadest sense, the cost reductions in Medicare are netted against other healthcare costs within the Affordable Care Act.
By contrast, the new proposal would take $700 million out of Medicare, period. Nothing in the TAA will help Medicare function better, augment its services to members, or cover healthcare costs. Slicing into physician and hospital reimbursements may have the opposite effect, by reducing members' access to care. "I'd characterize this as money stolen from Medicare," Richtman says.
The greater danger is that Congress gets addicted to looking to Medicare for spare cash. Richtman and other social insurance advocates have grown accustomed to keeping their eyes on efforts in Medicare legislation to tamper with the program's benefits and finances; now they have to watch out for raids from all directions. 


Learning A New Health Insurance System The Hard Way

By Jenny Gold 
The insurance program was called “Believe Me”  — but Kairis Chiaji had her doubts.
She and her husband Arthur were skeptical that the new health plan they purchased for 2015 would actually work out. That’s because their experience in 2014 had been a disaster, she said.
The Sacramento, Calif., couple had been thrilled to learn last year about the prospect of subsidized coverage under the nation’s health law, she recalled. Each of them had been uninsured for years when they signed up for coverage through the state exchange, Covered California.
“I just thought about how many people who are like me,” explained Kairis, 43, a self-employed natural hairstylist and doula. “If you have a lot of money, you’re covered. If you don’t have any money, you’re covered. When you’re in the middle, working hard every day, that’s when it’s really tough.”
When her children were little she worried about paying for their care if they were injured.
“I just simply told my children, listen, all I’ve got is a ruler and duct tape, so you’re not allowed to break any bones. Literally you can’t get hurt,” she said.
Arthur, an immigrant from Kenya who worked in food preparation, hadn’t had coverage since he left his home country,  which has a national health insurance program. “Everybody can afford insurance,” said Arthur, 39, who married Kairis in 2013. “And so that’s how I thought it was gonna be [in America]. That was not the case.”
At a health fair in February 2014, the Chiajis signed up for a plan with Anthem Blue Cross at a cost of $138 a month for the two of them. Her two oldest children, who are 18 and 22, were able to get insurance through Medicaid, the state and federal program for the poor, and her younger son has private insurance through his father, Kairis’ ex-husband.
Kairis and Arthur went home and waited to receive their insurance cards and first bill. Nothing arrived.
At the end of June, they finally received their cards and a bill for May, June and July, Kairis said.
They sent in one month’s payment, which they assumed would be for July since they hadn’t even known they were eligible for coverage in May and June. But Anthem told them  their payment only covered May, Kairis said.
When Kairis called Anthem to ask whether there had been a mistake, “they said you’re not covered [now] because you have to pay the months before now,” she said.
As she tried to resolve the problem, Anthem told her to hold off paying another bill until the insurer was able to process a change in their  income, which would lead to a slightly lower premium. So she waited, but didn’t get another bill.
Around that time, the couple brought two more children into their home, whom they are in the process of adopting from the foster system.  Arthur tried to go to the doctor for a physical exam to complete the adoption but was told by the medical office he wasn’t covered.
Kairis tried to clear things up on the phone with Anthem. “You wait on line for an hour, you get disconnected, they say no one can talk to you and hang up on you,” she said. “It was really frustrating.” When she called Covered California, she said, she got a message explaining operators were busy and she was disconnected.

The Problem of Underinsurance and How Rising Deductibles Will Make It Worse

Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014

Abstract
New estimates from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who were insured all year—or 31 million people—had such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured. These estimates are statistically unchanged from 2010 and 2012, but nearly double those found in 2003 when the measure was first introduced in the survey. The share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014. Half (51%) of underinsured adults reported problems with medical bills or debt and more than two of five (44%) reported not getting needed care because of cost. Among adults who were paying off medical bills, half of underinsured adults and 41 percent of privately insured adults with high deductibles had debt loads of $4,000 or more.

Ignoring the Penalty for Not Buying Health Insurance

Obamacare’s big stick doesn’t seem to be scaring many people into buying health insurance.
The health law includes many inducements for people to obtain health insurance — including free Medicaidcoverage for many low-income Americans and subsidies for those with moderate incomes. But it also includes the notorious “individual mandate,” a fine for those who can afford insurance but don’t buy it.
Because the law, and the fine, are new, many policy experts expected that some people would decline to sign up for insurance until they were hit with a penalty at tax time. Forecasters have estimated a big bump in marketplace enrollment next year, the first sign-up period after people have been fined. The Congressional Budget Office, for example, estimates 10 million more people will have Obamacare plans next year. The law’s structure relies on even healthy and otherwise disinclined consumers to enter insurance markets to help stabilize prices.
Certainly, some people who might otherwise go uninsured have been persuaded by the penalty. Polls have shown that it is a well-known provision of the law. And studies of the uninsured have shown that mentioning the penalty changes some people’s thinking about health insurance. At the end of the normal enrollment period in February, about 11.7 million peoplehad selected marketplace health plans or renewed their plans from 2014, according to the federal government.
http://www.nytimes.com/2015/05/21/upshot/penalty-for-not-buying-health-insurance-might-be-too-light.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&abt=0002&abg=0


Why Insurance Doesn’t Always Prevent Giant Medical Bills

Health insurance is supposed to help you pay for your health care, but it’s also supposed to protect you from financial ruin. A large new survey finds that, for nearly a quarter of insured adults, insurance has provided flimsy protection against huge medical bills.
The survey, from the health research group the Commonwealth Fund, looked at around 3,000 adults who had been insured all year, and found that in 2014, 23 percent of them were “underinsured,” according to a definition of financial exposure developed by the researchers. The group in the study included people with Medicaid, Medicare and their own health insurance, but also the large percentage of Americans with insurance through their jobs.
Many recent changes in the health care system — good and bad — tend to get pinned on the Affordable Care Act. But the Commonwealth study shows that the proportion of insured people with substantial medical costs has been essentially unchanged since 2010, the year the health law passed. In 2010, 22 percent of insured people met the definition of underinsured. In 2014, when many of the law’s major provisions went into effect, that proportion was 23 percent.
The big change in the country’s experience of health insurance appears to have happened between 2005 and 2010; five years before Obamacare passed, only 13 percent of insured Americans met the fund’s definition of underinsured. Since then, the study shows, the number of adults expected to pay a certain amount (a deductible) for their medical care before insurance kicks in has increased. So has the size of those deductibles.
Health plans that ask patients to reach a deductible before insurance foots the bill have become increasingly popular among employers that offer coverage to their workers. The plans are cheaper because they pay out a smaller share of bills. There is also evidence that having people pay for more of their health care out of pocket limits how much care they seek, and thus reins in insurance costs.

Sick man whose Obamacare story went viral could be thwarted by Supreme Court

by Greg Sargent - Washington Post

By now you may have learned of the plight of one Luis Lang, a South Carolina man whose story went viral after it was reported that he couldn’t afford to treat an illness that was threatening to make him blind — and blamed Obamacare for it. He has since come around to the view that Democrats may not be entirely to blame for his state of affairs — and says he is going to try to gain coverage through the law.
But there’s another potential twist to the tale: Just as he is now seeking to get on Obamacare, he could very well find himself unable to sign up for coverage, if the Supreme Court rules for the challengers in King v. Burwell next month.
Lang’s story has gone wild on the internet, turning him into a symbol of a number of intertwined narratives about the law: How Republican opposition to the Medicaid expansion has created a coverage gap claiming many low income people; how justifiable confusion about the complicated law is fueling anger at it; and so on.
It all started when the Charlotte Observer reported that Lang, 49, a self-employed Republican handyman who has never bought insurance, developed “bleeding in his eyes and a partly detached retina caused by diabetes.” The paper reported that subsequent medical bills quickly ate up his savings, whereupon he turned to the Obamacare exchange. He discovered his earnings fall below the window to qualify for a subsidy, yet he might not be able to get on Medicaid because South Carolina has not opted into the Medicaid expansion. He risks falling into the “Medicaid gap.”
The paper reported that his family blamed this on Obamacare, prompting criticism from bloggers and others, combined with a crowd-funding drive for his surgery. In a subsequent interview with Think Progress, Lang said he now thinks opposition to the Medicaid expansion is the culprit, is rethinking his GOP affiliation, and is going to try to get coverage from the law, though he still says he has issues with its implementation and blames both parties:
“Now that I’m looking at what each party represents, my wife and I are both saying — hey, we’re not Republicans!” Lang said….
“I put the blame on everyone — Republican and Democrat. But I do mainly blame Republicans for their pigheadedness,” Lang said. “They’re blocking policies that could help everyone. I’m in the situation I’m in because they chose not to expand Medicaid for political reasons. And I know I’m not the only one.”…
“I know we didn’t do it the right way,” Lang told ThinkProgress, explaining that he’s hoping to figure out the situation with his fluctuating income so he can be the first in line to sign up for a plan during the next open enrollment period.
Lang also told Think Progress that he now supports universal health care. As Steve Benen notes, he is only the latest example of people “who thought they hated ‘Obamacare,’ right up until they needed it.”


By Jackie Farwell - BDN Staff
If you’re a Medicare enrollee who has been hit by an unexpected medical bill, you might be familiar with the term “observation status.”
Hospitals increasingly are placing seniors under “observation” instead of admitting them as inpatients, and a Senate panel led by U.S. Sen. Susan Collins wants them to hit the brakes.
Many seniors are surprised to learn they were never admitted, even after staying overnight at a hospital and receiving treatment, testing and medications. Most learn about it when a bill arrives in the mail for out-of-pocket costs they never anticipated.
Why are hospitals doing this, why is it costing seniors money and how is Maine responding? Here’s a breakdown:
Observation status is for patients not healthy enough to go home but not sick enough to be admitted. Doctors use observation time to decide whether to admit a patient, such as by running tests or performing lab work. As Kaiser Health News explains, “this care requires a doctor’s order and is considered an outpatient service, even though patients may stay as long as several days.” Under Medicare guidelines, hospitals should decide whether to admit patients within 24 to 48 hours.
Patients “under observation” wind up in administrative limbo. Studies found hospitals began using observation stays as a substitute for inpatient status.
The number of Medicare beneficiaries under observation has jumped dramatically — 88 percent over the past six years, to 1.8 million in 2012, according to the Medicare Payment Advisory Commission.
Observation visits lasting longer than 24 hours more than doubled to 854,454 between 2006 and 2012, according to KHN.
Numbers on how many Maine people are affected by this issue are hard to come by, but about 275,000 residentsare covered by Medicare — that’s one in five Mainers.
Hospitals want to get paid for the care they provide. Medicare won’t reimburse hospitals for treating patients who were admitted but should only have been observed. That’s because the program wants to stamp out fraud and abuse. Inpatient care is more expensive than outpatient care and, therefore, is costlier for Medicare to cover.
So hospitals increased their shares of observation patients, wary of auditors who sniff around their books and decide some patients never should have been admitted, then deny reimbursement.
Seniors often need care that’s covered only after a hospital admission. If a senior spends time in the hospital under observation status, Medicare won’t pay for follow-up nursing home care that individual may need after discharge. “Skilled nursing care” includes treatments such as intravenous insulin injections for diabetics and physical therapy after an injury or surgery. Patients who never were formally admitted — whether they know it or not — don’t quality for skilled nursing care. They get two choices: forego it or pay for the care themselves.
“They just know that they are in the hospital,” Collins, chair of the Special Committee on Aging, said. “If they are admitted later to a skilled nursing facility for follow-up care, they may be shocked to learn that they will be liable for out-of-pocket costs totaling thousands of dollars.”
Seniors face other out-of-pocket costs. Outpatient care — which technically includes observation care — often comes with copayments for doctors’ fees, hospital services and medications patients must pay. Medicare won’t cover even routine drugs for patients in observation care. (Some seniors have a separate Medicare drug plan, but whether it covers such medication is up to the insurer, according to KHN.)
And, unlike with fees for inpatient care, Medicare sets no limit on the amount of outpatient expenses beneficiaries owe.
Many Medicare patients don’t know they’re being “observed.” Seniors often wrongly, but understandably, assume they’ve been admitted after spending a night or two in the hospital. Medicare does not require hospitals to inform patients they are in observation status or that they’ll be left holding the bag for the cost of any uncovered services — but hospitals must tell patients if they’re downgraded from inpatient to observation. While legislation has passed the U.S. House that would require such notification, Collins encouraged Medicare officials to make this change on their own even without a legislative fix.



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