The Effect of Passing of the New Tax Bill, the Cost of Drugs and Obamacare signups on Health Care.

21740517_1305560666240256_2316702778312680128_nSo the New Tax Bill seems ready for passage if the House and the Senate can come together and resolve the differences. My concern is that the GOP is using this bill to attack the Affordable Care Act by removing the Individual Mandate to “force” all to purchase health care insurance. I do understand the rationale of removing the mandate but now the GOP hasn’t come up with the answer to the domino effect of eliminating this mandate, the probable increase in premiums by the insurance companies. Let’s review, early Saturday morning, the Senate voted to pass the Republican Party’s sweeping tax refom bill, and among other provisions, the bill would eliminate the penalty for not buying health insurance starting in 2019.

So next year, you still need to be covered — at least, as of now. The individual mandate clause of the Affordable Care Act (a.k.a. Obamacare) requires individuals to buy insurance or pay a penalty at tax time, unless they qualify for a limited number of exemptions. If the Senate’s proposal survives in the final version of the tax bill, then beginning in 2019 consumers will be able go without coverage and not face a fine. The penalty for going uncovered for 2018 will be $695 per adult or 2.5% of household income in excess of tax filing thresholds, whichever is higher.

Members of the House and the Senate will now work to reconcile their versions of the GOP tax bill. Lawmakers have said that they’d like to finalize a tax reform plan by Christmas, so they can send it to President Donald Trump for signing into law. The House tax bill didn’t waive the penalty for going uninsured.

Open enrollment ends Dec. 15 for Affordable Care Act plans. If you’re on the individual insurance market, you have until that date to sign up for a new plan or change your existing plan. While it’s possible that the final version of the GOP tax bill could have a different plan for the individual mandate, that may not become clear until after the sign-up deadline.

For now, the individual mandate penalty remains in place for 2018. Existing customers should shop around rather than allow the system to re-enroll them in their current plans, says Sabrina Corlette, research professor at the Center on Health Insurance Reforms at the Georgetown University Health Policy Institute. There are plenty of bargains out there: Kaiser Family Foundation estimates that more than half of subsidy-eligible, uninsured individuals could buy a bronze-level plan for no premium contribution—that is, a $0 premium.

And regardless of what the tax reform bill says, it’s simply a smart idea to have health insurance. “You should buy insurance because it helps you get access to care, and it’s critical financial protection in case something awful happens,” Corlette says.

You can expect the individual market to look very different if the penalty goes away, experts say. The non-partisan Congressional Budget Office estimates that repealing the individual mandate starting in 2019 would result in 4 million losing coverage in 2019 and 13 million losing coverage in 2027. Many healthy people would voluntarily opt to go without coverage, and insurers could raise their premiums to cover the remaining, sicker population. These higher premiums would in turn cause more consumers to become priced out of the market. Remember the insurance companies are going to always cover their loses and increase premiums to make sure they profit.

Technically, the GOP tax bill doesn’t repeal the individual mandate, Corlette says; it simply reduces the penalty for going uncovered to zero, But in practice, eliminating the penalty will have the same result as eliminating the individual mandate altogether.

How about the huge cost of drugs to patients, which contribute to the high cost of health care?

Report: Here’s What The Feds Can Do To Cut Drug Prices

Alison Kodjak researched an important facet of the high cost of health care, drug prices. What makes drug prices so high? Let us count the ways.

Drug prices are too high, and we had better do something about it. That is the nutshell conclusion of a 201-page report from the National Academies of Sciences, Engineering and Medicine.

“High and increasing costs of prescription drugs coupled with the broader trends in overall medical expenditures, which now equals 18 percent of the nation’s gross domestic product, are unsustainable to society as a whole,” says Norman Augustine, the former CEO of defense contractor Lockheed Martin and the chair of the committee that conducted the study released Thursday.

The same sentiments were expressed Wednesday by President Trump’s nominee to lead the Department of Health and Human Services. “Drug prices are too high,” said Alex Azar in a hearing before the Senate Health Education and Labor Committee.

But the National Academies didn’t stop there. The independent advisory group’s report lists dozens of suggestions for what U.S. officials could do to rein in those rising prices. Many have been tossed around Washington for years. And given the power of the pharmaceutical lobby — it has spent more than $200 million on lobbying so far this year, according to the Center for Responsive Politics — few of them are likely to be implemented soon.

Here’s a rundown of key recommendations:

Allow the federal government to negotiate drug prices and refuse to cover some expensive medications

This idea is not new, and Trump himself has advocated for allowing the government, through Medicare, to negotiate lower prices for the drugs it buys. But doing so would take an act of Congress.

Current U.S. law prohibits Medicare officials from interfering in the negotiations between drugmakers and the insurance companies that administer Medicare’s prescription drug program.

Medicare accounts for about 29 percent of all prescription spending, so bringing that purchasing power under one roof could give it the ability to force drugmakers to slash their list prices.

The National Academies report points out that the government negotiates or sets prices in almost every other industry where it is a buyer, including defense equipment, uniforms and even stationery.

“The effect of not allowing HHS to negotiate prices is to tilt the balance of bargaining power further in favor of drug manufacturers,” the report says.

It adds that Medicare and other government health plans also should have the authority to refuse to pay for medications that have cheaper equivalents or that aren’t adequately effective.

Speed the approval of generics and biosimilars and ensure patients have access

Scott Gottlieb, the administrator of the Food and Drug Administration, has been preaching this message since he took office in May.

“While FDA doesn’t have a direct role in drug pricing, we can take steps to help address this problem by facilitating increased competition in the market for prescription drugs through the approval of lower-cost generic medicines,” he said in a June blog post.

The National Academies point to so-called “pay for delay,” where a branded drugmaker pays a generic company to delay putting its competitor drug on the market.

The practice “tends to inflate prices and reduce the quantity of prescriptions for several years after the settlement,” the report says.

But eliminating pay-for-delay won’t be easy because courts have ruled that the agreements between the companies have to be evaluated individually.

Can we shed light on who pays what for prescription drugs?

This is something that lawmakers and regulators have called for many times. The prescription drug payments system is a tangled web of prices, incentives, discounts and rebates among drug companies, pharmacy benefit managers and insurance companies.

When pharmaceutical companies are criticized for raising their list prices, they routinely protest that nobody actually pays those prices. Yet the true money flows remain a mystery.

There are bills in both houses of Congress designed to increase drug price transparency, and several states — most recently California — have proposed or passed laws to require more information on what drug makers and pharmacy benefit managers actually charge for medications.

The National Academies panel recommends that HHS require pharmaceutical manufacturers to report each year the list price of medications, along with all the rebates and discounts in the system and, finally, the average price paid for those drugs.

Discourage those endless ads pushing prescription drugs and stop giving patients coupons to try medication

Pharmaceutical companies spend far more advertising their medication than they do on research into new products, the report notes. That marketing boosts drug costs both by directly increasing costs to drug makers that they then incorporate into the price of drug and by increasing consumer demand for medication they may not need.

“Direct-to-consumer advertising of prescription drugs can adversely influence consumer choices,” the report says.

The reports says lawmakers should prohibit drug companies from deducting the cost of advertising from their taxes and should also ban coupons that allow people to purchase expensive brand-name drugs for the same out-of-pocket cost as generics.

Cut the cost to consumers for their prescription drugs

This recommendation seems at odds with the earlier one calling for the elimination of coupons. But the National Academies report concludes that keeping costs low to consumers can ensure that patients take the medications they need, which could reduce overall health care spending.

Insurance companies often require patients to pay bigger copayments for expensive medications as a way to encourage them to use cheaper options.

“High cost sharing can also have downsides, since it can lead to reduced adherence or the discontinuation of medications because of high out-of-pocket costs to consumers,” the report says.

The report recommends that Congress limit how much people should have to spend on prescriptions in government-run health programs like Medicare and Medicaid.

Take away incentives for doctors to administer high-cost drugs

This recommendation goes to a failed effort by the Department of Health and Human Services to encourage doctors who treat cancer and arthritis to use lower-cost medications if they’re appropriate. Medicare pays doctors who administer drugs in their offices, including chemotherapy or arthritis drugs that are delivered intravenously, a percentage of the drug’s price.

That gives physicians a financial incentive to choose the most expensive medication available.

Last year, HHS proposed changes to that system, but doctors launched an intense lobbying effort against it.

Bruce Gould, the president of the Community Oncology Alliance, called it an “inappropriate, potentially dangerous and perverse experiment on the cancer care of seniors who are covered by Medicare.”

The program was killed. Given the outcry, the chances that HHS will try again are slim.

But there was dissent, too

The report also includes a dissenting opinion from two of the 16 members of the committee. The dissent defends the need for profits in the pharmaceutical industry to give companies the incentive to chase treatments and cures for difficult diseases like Alzheimer’s.

“Creating a drug is a problem completely subject to human biology with all its

intrinsic complexity, variability, and unpredictability,” the dissenting report reads. “If drug invention were simply an engineering problem, then by now we would have a vaccine for AIDS (35 years after the beginning of the outbreak) and a cure for Alzheimer’s disease.”

But even in the dissent, there was some agreements, specifically in the need for greater transparency in how drugs are priced, and how the money flows through the system. The dissenters suggest that pharmacy benefit managers have outsized power and take too much money from the system.

Trump has said he wants to make lowering drug prices a priority. This report offers up plenty of suggestions on how to do that.

Obamacare enrollment and the Exchanges

And Tami Lubby wrote that nearly 2.8 million people have signed up for 2018 Obamacare policies on the federal exchange during the first 25 days of enrollment season.

That’s quite a bit more than at this point in prior periods. Last year, 2.1 million people signed up in the first 26 days.

While those numbers may seem to bode well for the future of the health reform law, it depends on how you look at it.

True, an average of 111,300 have signed up each day this season, compared to 82,200 a year ago and 72,900 two years ago, according to data crunched by Get America Covered, which aims to promote Obamacare open enrollment.

“Enrollment continues to outpace previous years,” said Lori Lodes, a former Obama administration official who co-founded Get America Covered.

Another plus: The exchanges are attracting many new customers. Some 718,300 of those who signed up so far are new, compared to 519,500 last year. The rest are returning enrollees.

All but one of the 39 states in the federal exchange saw enrollment growth. Some 53% more residents in Maine have picked plans, while 52% more Texans and Wyoming residents have signed up. Only West Virginia saw a drop — of 1%.

Several states that run their own exchanges are also reporting increased interest. For instance, the Washington Health Benefit Exchange on Wednesday reported a 43% jump in new sign-ups and an 18% uptick in traffic through first four weeks of open enrollment. In New York, enrollment is outpacing last year by about 13%, with more than 140,000 consumers picking Obamacare plans and nearly 700,000 signing up for essential plans (for moderate-income residents) in the first four weeks.

All this is good news for Obamacare supporters, who say that the law is essential for and remains popular among millions of Americans despite President Trump and Congressional Republicans’ vows to repeal it.

But the picture is not as rosy if one considers that the open enrollment period is a little more than halfway over.

The Trump administration slashed the enrollment season so most people only have until Dec. 15 to pick plans, rather than the three months or more they had in previous years. (Some state-based exchanges have extended the period to as late as Jan. 30.)

That means the pace will have to pick up substantially to come close to the 9.2 million who signed up on the federal exchange by the end of open enrollment for 2017. (Another 3 million people picked plans through the state-based exchanges.)

Even Lodes acknowledged that in her assessment on Wednesday. “Another solid week for enrollment but we need it to pick up the pace to track enrollment from last year,” she said.

To be sure, many consumers wait until the last minute to enroll. So it’s tough to estimate how many people will sign up in the final 20-day stretch.

The pace, however, has been slowing since the enrollment period began on Nov. 1. In the first four days, an average of 150,400 people signed up daily. Those are likely sicker Americans who really need the coverage.

Obamacare supporters worry that many other potential enrollees — particularly the younger and healthier Americans that insurers crave and that keep premiums down — don’t realize that they have less time to sign up this year.

The administration cut the advertising budget for open enrollment by 90%, ending some of the most effective marketing tools, including television and radio spots.

Americans are noticing — or in this case, not noticing. Some 45% said they heard less about open enrollment than they had in previous years, according to a Kaiser Family Foundation poll conducted in mid-November. Another 38% said they heard about the same amount, while 16% said they heard more.

One thing that will boost the figures is that a hefty number of current enrollees will be automatically put into plans for 2018 on Dec. 16. Last year, about 2.2 million consumers were auto renewed in the federal marketplace.

Many experts expect sign ups will decline for 2018, after dipping by half a million this year. S&P Global projected that between 10.6 million and 11.4 million people will pick plans by the end of the enrollment period. Charles Gaba, a blogger who tracks enrollment at, estimates about 10 million people will sign up — 7.5 million on the federal exchange and another 2.5 million on the state exchanges.

Consumers aren’t considered enrolled until they make their first premium payment. Enrollment also varies during the year as people drop out because they find coverage elsewhere or they stop paying their premiums. Others join after losing their jobs or have other major life changes.

Matthew Herber, of the Forbes staff reviewed a survey that showed that Americans wanted healthcare reform, but were also cynical and afraid of change. Call it the central dilemma of healthcare reform: a new survey, released by CVS Health at the Forbes Healthcare Summit, illustrates a vexing problem for those who want to change the way Americans get medical care. Most people in the U.S. do inded think the country’s healthcare system is headed in the wrong direction and in need of reform. But the vast majority of those who do have insurance are happy enough with the plan they have– and likely afraid of change.

That leads to the quandaries that have beset both the Affordable Care Act and its potential replacement: how do you change what’s broken without breaking what works? The national survey of 2,201 adults was conducted online by Morning Consult on behalf of CVS Health, a sponsor of the summit, in October. Over half (56%) of Americans said that they feel the U.S. health care system does not work for them. Seventy-three percent said it is in need of reform. Forty-one percent say that the system has gotten worse, not better.

And if you have some time this holiday season you have to get to the movies and see “Wonder.” Wonder tells the story of Auggie Pullman, a fictional 10-year-old boy with a severe case of Treacher Collins syndrome — a rare genetic craniofacial disorder. Auggie must navigate new challenges in a new school, such as how to talk about his condition, make friends and handle bullying.

Due to the severity of his condition, Auggie has undergone nearly 30 surgeries before he enters middle school. When a classmate asks Auggie about plastic surgery, Auggie jokes, “This is after plastic surgery — it takes a lot of work to look this good.” There is truth to this light-hearted moment. Auggie’s birth defect, which ranges in severity, is characterized by underdeveloped facial bones that affect his eyes, ears, cheeks, palate and jaw structure.

Although Wonder is a fictional film, it represents reality for many of the children and young adults with craniofacial abnormalities. I have witnessed this firsthand in my fellowship in reconstructive surgery on the craniofacial rotation and later in my practice. It’s my hope that Wonder can serve as a catalyst for millions of people to better understand craniofacial disorders and the amazing children who persevere with these conditions.

A major highlight of the movie is watching some of Auggie’s classmates discover he is no different from their other friends. He’s a smart, nice kid with a great sense of humor. It’s the same message we’ve heard about judging others based on their color, race or creed. Don’t do it.

We are all much more than our physical differences. I hope Wonder reminds patients with facial differences that they possess the strength, wisdom and courage to defy the odds and overcome their adversity every day.




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