Category Archives: Alex Azar

Health Insurance Inflation Hits Highest Point in Five Years and More on Medicare; and What is this about Abortion and SATs?

57358059_1998437466952569_3700281945192660992_nFirst of all, I must yell and scream at the idiots in the States, you know who you are, that have or are in the process of passing the most restrictive abortion bills. This is especially Alabama where Governor Kay Ivey signed the strictest anti-abortion law. Legislation to restrict abortion rights has been introduced in 16 states this year. The Alabama Senate approved a measure on last week that would outlaw almost all abortions in the state, setting up a direct challenge to Roe v. Wade, the case that recognized a woman’s constitutional right to end a pregnancy. The legislation bans abortions at every stage of pregnancy and criminalizes the procedure for doctors, who could be charged with felonies and face up to 99 years in prison. It includes an exception for cases when the mother’s life is at serious risk, but not for cases of rape or incest — a subject of fierce debate among lawmakers in recent days. The House approved the measure — the most far-reaching effort in the nation this year to curb abortion rights and was just signed by the Governor.

What the heck are you thinking, not even for rape or incest? You are forgetting the women who bare the brunt of your idiot decisions. Do you think that the Supreme Court will overturn Roe versus Wade, passed in 1973? Get real and attend to the real multiple crises out there!

And diversity scores on the SAT exams??? Again, what are you all thinking? I know to correct the “crises of rich parents who got their “unfortunate” children into the best of colleges. Next, the strategy to get our children into good colleges will be to take courses to improve their test-taking abilities, but now they will have to figure out how to improve their adversity scores. Mom and Dad, we need to move into the ghettos of Scarsdale, get on food stamps, get fired from your high paying jobs and become homeless. I know this all sounds crazy, but that is where we are.

Shelby Livingston wrote that the health insurance inflation rate hit a five-year peak in April, possibly because managed care is rising.

The Consumer Price Index for health insurance in April spiked 10.7% over the previous 12 months—the largest increase since at least April 2014, according to a Modern Healthcare analysis of the U.S. Bureau of Labor Statistics’ unadjusted monthly Consumer Price Index data.

In contrast, the other categories that make up the medical care services index—professional services and hospital and related services—rose 0.4% and 1.4% in April, respectively. The CPI for medical care services in April rose 2.3%, while overall inflation increased 2% year over year.

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Because of the way the BLS calculates the health insurance index, the change year over year does not reflect premiums paid by customers, but “retained earnings” after paying out claims. These earnings are used to cover administrative costs or are kept as profit.

The BLS redistributes the benefits paid out a portion of the health insurance index to other non-insurance medical care categories, such as physician services.

The likely reason health insurance inflation is rising is because of growth in managed care, including Medicare Advantage, Medicaid managed care and commercial insurance, according to Paul Hughes-Cromwick, an economist at Altarum. He noted that added administrative costs increase insurance price growth.

Hughes-Cromwick said the increase in the health insurance index could also be driven by the fact that insurers’ medical loss ratios may be decreasing as high premiums, particular in the individual health insurance exchanges, exceeded anticipated claims.

The medical loss ratio reflects the percentage of every premium dollar spent on medical claims and quality improvement. Insurers must pay at least 80% of premiums on those things and if they don’t, they must issue rebates to plan members, as part of the Affordable Care Act.

In response to rising inflation, a spokeswoman for America’s Health Insurance Plans, the industry’s biggest lobbying group, commented that “consumers deserve the lowest possible total costs for their coverage and care.” She pointed out the medical loss ratio requirements and said health insurers spend 98 cents of every premium dollar on medical care, operating costs that include care management, and preventing fraud, waste, and abuse.

Affordable Care Act exchange insurers hiked premiums higher than necessary in 2018 and now expect to pay out $800 million in rebates to individual market customers this year because they did not meet the medical loss ratio threshold, according to a Kaiser Family Foundation analysis published this month. Because medical loss ratios are declining, health insurers in the individual, small group and large group markets expect to issue $1.4 billion in rebates based on their 2018 performance, the analysis stated.

Still, health insurance profits have been on the rise. The eight largest publicly traded insurers posted net income of $9.3 billion in the first quarter of 2019, an increase of 29.9%. They made a combined $21.9 billion in profits over the course of 2018.

Medicaid waiver loophole sparks transparency concerns

Robert King noted that the CMS is doing a poor job in ensuring the public knows about major changes to Medicaid, including the installation of work requirements, a federal watchdog said Friday.

The Government Accountability Office’s report found that the CMS has limited transparency for amendments to existing Section 1115 waivers. That has allowed some states to score approval for their work requirements while skirting some rules, such as projecting how the changes will impact Medicaid enrollment.

The government watchdog noted that two of the four states it studied did not seek public comment on changes that could significantly impact Medicaid beneficiaries.

The transparency requirements for an amendment are more relaxed than a new waiver application, the GAO said. Arkansas and New Hampshire both added work requirements to their Medicaid programs through amendments to their existing Section 1115 waivers.

Currently, new waivers or extension requests must include whether the state thinks that enrollment will decrease and any spending changes. While amendments must address the impact on beneficiaries and explain the changes, there are fewer requirements for what information must be disseminated to the public.

The GAO also found that the CMS had inconsistent transparency requirements for amendments.

For example, the CMS determined Massachusetts’ amendment to waive non-emergency medical transportation was incomplete because the application didn’t include a revised design plan. However, the CMS-approved Arkansas’ work requirement amendment even though it did not include a revised design plan.

The GAO recommended that the CMS develop standard transparency requirements for new waivers, extension requests, and significant Section 1115 amendments.

In response, HHS said it has already implemented policies to improve transparency. GAO said those changes “do not apply to amendments.”

The CMS also lacks policies for ensuring that major changes to a pending application are transparent.

The report comes as the Trump administration is appealing a federal judge’s decision to strike down Medicaid work requirement programs in Kentucky and Arkansas.

Seven other states have received CMS approval for work requirements. Those states are Arizona, Indiana, Michigan, New Hampshire, Ohio, Utah, and Wisconsin. Another six states—Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia—have applications pending federal approval.

Industry enters new battle phase over surprise billing

Susannah Luthi reported that the knives are out over legislation to end surprise medical bills and specifics haven’t even been unveiled yet. But will this solve the problems of the healthcare crisis?

The industry is pushing back hard against a particular principle laid out by President Donald Trump last week.

The administration wants all out-of-network charges from a doctor at an in-network hospital to be wrapped into a single bill from the hospital.

How this provision will technically play out in policy is yet to be seen, as the Senate health committee plans to release its legislative package on surprise medical bills this summer.

But the administration’s position has roiled hospital groups and specialty physicians like emergency doctors, radiologists, and anesthesiologists, who don’t always share the same insurance network as hospitals and have higher than average charges.

“Untested proposals such as bundling payments would create significant disruption to provider networks and contract without benefiting patients,” American Hospital Association CEO Rick Pollack said in a statement shortly after Trump made his remarks. He reiterated the AHA’s position that all Congress needs to do is enact a ban on balance billing and leave the rest to the industry to figure out.

Specialty physicians argue that a single bill will complicate all the billing processes on the back-end with hospitals and insurers.

Dr. Sherif Zaafran, a Texas anesthesiologist, said he doesn’t see room within the White House framework for a policy he could support. He sees it as undercutting specialty physicians’ independence from hospitals. “As a patient, I think a single hospital bill on the surface sounds really good, but in the reality of how most of us practice it’s probably not very practical,” Zaafran said. “A single bill would imply you’re marrying the system for how a physician gets paid with other components that bill completely separately.”

He expects a resulting policy would end up cutting pay for both hospitals and ancillary physicians—hospitals taking a hit as they try to collect the fee and reimburse the physician, and physicians taking a hit if hospitals need to negotiate with insurers on their behalf.

“There are downstream effects that folks haven’t thought through,” Zaafran said.

But the administration’s stance shows how thinking around policy has morphed during months of scrutiny of the issue. And analysts have been documenting the trajectory of high ancillary physician charges in part to lay out the argument for payment bundles.

Discussions started last fall with an initial legislative push from a bipartisan group led by Sens. Bill Cassidy (R-La.) and Michael Bennet (D-Colo.). Cassidy and his co-sponsors introduced a draft proposal to cap out-of-network charges at a regional average. Not long after, Sen. Maggie Hassan (D-N.H.) pitched arbitration to settle disputes between insurers and providers.

As the months passed, the debate transitioned into a look at the underlying contracts between hospitals and insurers—even as policy analysts note that the problem of surprise medical bills is limited to a small number of hospitals.

Experts and economists from think tanks like the Brookings Institution, American Enterprise Institute, and the Urban Institute have weighed in, aided by data from states that have tried to curb the practice in the individual insurance markets that fall under their regulating power.

Several have warned that if lawmakers don’t handle the policy carefully, they could end up inflating overall costs, leading to higher premiums and expenses in an already costly system.

Joyce Frieden pointed out the solutions proposed by the President and hopefully most of the GOP.  President Trump announced an initiative Thursday aimed at ending the problem of surprise medical billing, in which patients undergoing procedures at in-network hospitals receive unexpectedly high bills because one or more of their clinicians was out of network.

Trump called surprise billing as I just outlined, “one of the biggest concerns Americans have about healthcare” and added, “The Republican Party is very much becoming the party of healthcare. We’re determined to end surprise medical billing for American patients and that’s happening right now.” He thanked the mostly Republican group of lawmakers who came to the White House to discuss the initiative, including Senators Lamar Alexander (R-Tenn.), Maggie Hassan (D-N.H.), Bill Cassidy, MD (R-La.), and John Barrasso (R-Wyo.) and representatives Kevin Brady (R-Texas), Devin Nunes (R-Calif.), and Greg Walden (R- Ore.).

Trump then announced guidelines that the White House wants Congress to use in developing surprise billing legislation. They include:

  • In emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. “So-called ‘balance billing’ should be prohibited for emergency care. Pretty simple,” he said
  •  When patients receive scheduled non-emergency care, they should be given a clear and honest bill up front. “This means they must be given prices for all services and out-of-pocket payments for which they will be responsible,” Trump said. “This will not just protect Americans from surprise charges, it will [also] empower them to choose the best option at the lowest possible price”
  •  Patients should not receive surprise bills from out-of-network providers that they did not choose themselves. “Very unfair,” he commented
  •  Legislation should protect patients without increasing federal healthcare expenditures. “Additionally, any legislation should lead to greater competition, more choice, and more healthcare freedom. We want patients to be in charge and in total control,” the president said
  •  All types of health insurance — large groups, small groups, and patients on the individual market should be included in the legislation. “No one in America should be bankrupted unexpectedly by healthcare costs that are absolutely out of control,” said Trump

He noted that “we’re going to be announcing something over the next 2 weeks that’s going to bring transparency to all of it. I think in a way it’s going to be as important as a healthcare bill; it’s going to be something really special.”

Also at the announcement was Martin Makary, MD, MPH, a surgical oncologist at Johns Hopkins University in Baltimore. “When someone buys a car, they don’t pay for the steering wheel separately from the spark plugs,” he said. “Yet, in healthcare, surprise bills and overpriced bills are commonplace and are crushing everyday folks … People are getting hammered right now.”

Trump also introduced two families who had experienced high medical bills. Drew Calver, of Austin, Texas, said that after a heart attack 2 years ago, “although I had insurance, I was still billed $110,000 … I feel like I was exploited at the most vulnerable time in my life just having suffered a heart attack, so I hope Congress hears this call to take action, close loopholes, end surprise billing, and work toward transparency.”

Paul Davis, MD, of Findlay, Ohio, said that his daughter was billed nearly $18,000 for a urine drug screening test. “She had successful back surgery in Houston and at a post-op visit, because she was given a prescription for narcotic pain relief — which she used as directed — the doctor said, ‘Oh, by the way, I’d like to get a urine specimen.’ Fine; she did it. A year later, a bill showed up for $17,850.”

He noted that her insurance company’s Explanation of Benefits said that the insurer would have paid $100.92 for the test had it been done by an in-network provider. “This type of billing is all too common … The problem of improper billing affects most [of] those who can afford it least. We must put aside any differences we have to work together to solve this problem.”

“Today I’m asking Democrats and Republicans to work together; Democrats and Republicans can do this and I really think it’s something [that is] going to be acted on quickly,” Trump said.

Healthcare groups responded positively to the announcement, with one caveat. “The AHA commends the Administration and Congress for their work to find solutions to this problem,” Rick Pollack, president, and CEO of the American Hospital Association (AHA), said in a statement. “The AHA has urged Congress to enact legislation that would protect patients from surprise bills. We can achieve this by simply banning balance billing. … Untested proposals such as bundling payments would create significant disruption to provider networks and contracting without benefiting patients.”

“ACEP appreciates the White House weighing in on this important issue and welcomes congressional action to address surprise medical bills,” said Vidor Friedman, MD, president of the American College of Emergency Physicians (ACEP), in a statement. “Emergency physicians strongly support taking patients out of the middle of billing disputes between insurers and out-of-network medical providers.”

“ACEP is concerned about the administration’s call for a single hospital bill,” he continued. “Such a ‘bundled payment’ approach may seem simple in theory for voluntary medical procedures. But if applied to the unpredictable nature of emergency care, this untested idea opens the door to massive and costly disruption of the health care system that would shift greater costs to patients while failing to address the actual root cause of surprise bills — inadequate networks provided by insurers.”

The president also mentioned another one of his administration’s healthcare initiatives. “We may allow states to buy drugs in other countries … because the drug companies have treated us very, very unfairly and the rules and restrictions within our country have been absolutely atrocious,” he said. “So we’ll allow [states], with certain permission, to go to other countries if they can buy them for 40%, 50%, or 60% less. It’s pretty pathetic, but that’s the way it works.”

And now back to Medicare. As you all probably remember the reason that physicians decided not to support the national plan was the confusion regarding reimbursement or payment to physicians. But the insurance companies as well as organized labor who opposed the compulsory system on the grounds that its passage would deprive the labor movement of an extremely effective issue with which to organize workers.

Also, with the entry of America into the First World War the interest in the passage of a compulsory health care bill waned. Because of the anti-German hysteria, the AALL bill opposition became more organized with the biased thoughts that mandatory health insurance was the product of a German conspiracy to impose Prussian values on America.

Renewed interest in mandatory health insurance didn’t emerge until during the New Deal as a consequence of the report of the Committee on Economic Security, the committee appointed by President Roosevelt in 1934. As the Depression worsened the President and his advisors were eager to offer an alternative social welfare package. Roosevelt and his advisors particularly those of the Committee on Economic Security advised the passage of a comprehensive social security system to include unemployment insurance, old-age security, and government-administered-health-care insurance.

The final report by the Committee on the Costa of Medical Care was issued in 1932, by the Committee under the chairmanship of Dr. Ray Lyman Wilbur who was the former Secretary of the Interior and former President of the AMA. The Committee actually concluded that the infrastructure in medicine as well as the medical services in the United States were inadequate and made recommendations for changes. And, despite the favorable climate especially among labor leaders, politicians and social scientists the President’s Committee on Economic Security recommender unemployment insurance and social security but not the passage of a mandatory health insurance bill.

But Roosevelt wanted to keep the subject of health insurance and therefore established an Interdepartmental Committee to Coordinate Health and Welfare Activities immediately following the passage of the Social Security Act and ordered his staff to keep the subject out there before the public. Over the next few years it was the subject of many books and extensive studies by the federal government, but no bill yet.

More to come!!

Poll: Support for ‘Medicare-for-all’ fluctuates with details and Medicaid. What is the Answer​?

50065252_1872612819535035_7021591760191094784_nSo, one of the options that the Democrats are pushing is “Medicare-for-All.” But do the voters like the idea? Ricardo Alonso-Zaldivar noted that Americans like the idea of “Medicare-for-all,” but support flips to disapproval if it would result in higher taxes or longer waits for care. Then how will the plan be financed?

That’s a key insight from a national poll released Wednesday by the nonpartisan Kaiser Family Foundation. It comes as Democratic presidential hopefuls embrace the idea of a government-run health care system, considered outside the mainstream of their party until Vermont independent Sen. Bernie Sanders made it the cornerstone of his 2016 campaign. President Donald Trump is opposed, saying “Medicare-for-all” would “eviscerate” the current program for seniors.

The poll found that Americans initially support “Medicare-for-all,” 56 percent to 42 percent.

However, those numbers shifted dramatically when people were asked about the potential impact, pro, and con.

Support increased when people were told “Medicare-for-all” would guarantee health insurance as a right (71 percent) and eliminates premiums and reduce out-of-pocket costs (67 percent).

But if they were told that a government-run system could lead to delays in getting care or higher taxes, support plunged to 26 percent and 37 percent, respectively. Support fell to 32 percent if it would threaten the current Medicare program.

“The issue that will really be fundamental would be the tax issue,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who reviewed the poll. He pointed out those state single-payer efforts in Vermont and Colorado failed because of concerns about the tax increases needed to put them in place.

There doesn’t seem to be much disagreement that a single-payer system would require tax increases since the government would take over premiums now paid by employers and individuals as it replaces the private health insurance industry. The question is how much.

Several independent studies have estimated that government spending on health care would increase dramatically, in the range of about $25 trillion to $35 trillion or more over a 10-year period. But a recent estimate from the Political Economy Research Institute at the University of Massachusetts in Amherst suggests that it could be much lower. With significant cost savings, the government would need to raise about $1.1 trillion from new revenue sources in the first year of the new program.

House Budget Committee Chairman John Yarmuth, D-Ky., has asked the Congressional Budget Office for a comprehensive report on single-payer. The CBO is a nonpartisan outfit that analyzes the potential cost and impact of legislation. Its estimate that millions would be made uninsured by Republican bills to repeal the Affordable Care Act was key to the survival of President Barack Obama’s health care law.

Mollyann Brodie, director of the Kaiser poll, said the big swings in approval and disapproval show that the debate over “Medicare-for-all” is in its infancy. “You immediately see that opinion is not set in stone on this issue,” she said.

Indeed, the poll found that many people are still unaware of some of the basic implications of a national health plan.

For example, most working-age people currently covered by an employer (55 percent) said they would be able to keep their current plan under a government-run system, while 37 percent correctly answered that they would not.

There’s one exception: Under a “Medicare-for-all” idea from the Center for American Progress employers and individuals would have the choice of joining the government plan, although it wouldn’t be required. Sanders’ bill would forbid employers from offering coverage that duplicates benefits under the new government plan.

“Medicare-for-all” is a key issue energizing the Democratic base ahead of the 2020 presidential election, but Republicans are solidly opposed.

“Any public debate about ‘Medicare-for-all’ will be a divisive issue for the country at large,” Brodie said.

The poll indicated widespread support for two other ideas advanced by Democrats as alternatives to a health care system fully run by the government.

Majorities across the political spectrum backed allowing people ages 50-64 to buy into Medicare, as well as allowing people who don’t have health insurance on the job to buy into their state’s Medicaid program.

Separately, another private survey out Wednesday finds the uninsured rate among U.S. adults rose to 13.7 percent in the last three months of 2018. The Gallup National Health and Well-Being Index found an increase of 2.8 percentage points since 2016, the year Trump was elected promising to repeal “Obamacare.” That would translate to about 7 million more uninsured adults.

Government surveys have found that the uninsured rate has remained essentially stable under Trump.

The Kaiser Health Tracking Poll was conducted Jan. 9-14 and involved random calls to the cellphones and landlines of 1,190 adults. The margin of sampling error for all respondents is plus or minus 3 percentage points.

Trump Seeks Action To Stop Surprise Medical Bills

A healthcare reporter, Emmarie Huettman reported that President Trump instructed administration officials Wednesday to investigate how to prevent surprise medical bills, broadening his focus on drug prices to include other issues of price transparency in health care.

Flanked by patients and other guests invited to the White House to share their stories of unexpected and outrageous bills, Trump directed his health secretary, Alex Azar, and labor secretary, Alex Acosta, to work on a solution, several attendees said.

“The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it,” Trump said during a roundtable discussion when reporters were briefly allowed into the otherwise closed-door meeting.

David Silverstein, the founder of a Colorado-based nonprofit called Broken Healthcare who attended, said Trump struck an aggressive tone, calling for a solution with “the biggest teeth you can find.”

“Reading the tea leaves, I think there’s a big change coming,” Silverstein said.

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or isn’t covered by their insurance, has received a flood of attention in the past year, particularly as Kaiser Health News, NPR, Vox and other news organizations have undertaken investigations into patients’ most outrageous medical bills.

Attendees said the 10 invited guests — patients as well as doctors — were given an opportunity to tell their story, though Trump didn’t stay to hear all of them during the roughly hourlong gathering.

The group included Paul Davis, a retired doctor from Findlay, Ohio, whose daughter’s experience with a $17,850 bill for a urine test after back surgery was detailed in February 2018 in KHN-NPR’s first Bill of the Month feature.

Davis’ daughter, Elizabeth Moreno, was a college student in Texas when she had spinal surgery to remedy debilitating back pain. After the surgery, she was asked to provide a urine sample and later received a bill from an out-of-network lab in Houston that tested it.

Such tests rarely cost more than $200, a fraction of what the lab charged Moreno and her insurance company. But fearing damage to his daughter’s credit, Davis paid the lab $5,000 and filed a complaint with the Texas attorney general’s office, alleging “price gouging of staggering proportions.”

Davis said White House officials made it clear that price transparency is a “high priority” for Trump, and while they didn’t see eye to eye on every subject, he said he was struck by the administration’s sincerity.

“These people seemed earnest in wanting to do something constructive to fix this,” Davis said.

Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins University who has written about transparency in health care and attended the meeting, said it was a good opportunity for the White House to hear firsthand about a serious and widespread issue.

“This is how most of America lives, and [Americans are] getting hammered,” he said.

Trump has often railed against high prescription drug prices but has said less about other problems with the nation’s health care system. In October, shortly before the midterm elections, he unveiled a proposal to tie the price Medicare pays for some drugs to the prices paid for the same drugs overseas, for example.

Trump, Azar, and Acosta said efforts to control costs in health care were yielding positive results, discussing, in particular, the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.

Discussing the partial government shutdown, Trump said Americans “want to see what we’re doing, like today we lowered prescription drug prices, the first time in 50 years,” according to a White House pool report.

Trump appeared to be referring to a recent claim by the White House Council of Economic Advisers that prescription drug prices fell last year.

However, as STAT pointed out in a recent fact check, the report from which that claim was gleaned said “growth in relative drug prices has slowed since January 2017,” not that there was an overall decrease in prices.

Annual increases in overall drug spending have leveled off as pharmaceutical companies have released fewer blockbuster drugs, patents have expired on brand-name drugs and the waning effect of a spike driven by the release of astronomically expensive drugs to treat hepatitis C.

Drugmakers were also wary of increasing their prices in the midst of growing political pressure, though the pace of increases has risen recently.

Since Democrats seized control of the House of Representatives this month, party leaders have rushed to announce investigations and schedule hearings dealing with health care, focusing in particular on drug costs and protections for those with preexisting conditions.

Last week, the House Oversight Committee announced a “sweeping” investigation into drug prices, pointing to an AARP report saying the vast majority of brand-name drugs had more than doubled in price between 2005 and 2017.

The Ground Game for Medicaid Expansion: ‘Socialism’ or a Benefit for All?

One of the other options is that of expanding Medicaid but is that socialism or a benefit for all. Michael Ollove noted that a yard sign in Omaha promotes Initiative 427, which would expand Medicaid in Nebraska. Voters in the red states of Idaho and Utah also will decide whether to join 33 states and Washington, D.C., in extending Medicaid benefits to more low-income Americans as envisioned by the Affordable Care Act. Montana voters will decide whether to make expansion permanent.

Nati Harnik noted that on a sun-drenched, late October afternoon, Kate Wolfe and April Block are canvassing for votes in a well-tended block of homes where ghosts and zombies compete for lawn space with Cornhusker regalia. Block leads the way with her clipboard, and Wolfe trails behind, toting signs promoting Initiative 427, a ballot measure that, if passed, would expand Medicaid in this bright red state.

Approaching the next tidy house on their list, they spot a middle-aged woman with a bobbed haircut pacing in front of the garage with a cellphone to her ear.

Wolfe and Block pause, wondering if they should wait for the woman to finish her call when she hails them. “Yes, I’m for Medicaid expansion,” she calls. “Put a sign up on my lawn if you want to.” Then she resumes her phone conversation.

Apart from one or two turndowns, this is the sort of warm welcome the canvassers experience this afternoon. Maybe that’s not so surprising even though this is a state President Donald Trump, an ardent opponent of “Obamacare,” or the Affordable Care Act, carried by 25 points two years ago.

Although there has been no public polling, even the speaker of the state’s unicameral legislature, Jim Scheer, one of 11 Republican state senators who signed an editorial last month opposing the initiative, said he is all but resigned to passage. “I believe it will pass fairly handily,” he told Stateline late last month.

Anne Garwood (left), a tech writer, and April Block, a middle school teacher, review voter lists in preparation for canvassing an Omaha neighborhood in favor of Initiative 427, which would expand Medicaid in Nebraska.

The Pew Charitable Trusts

Bills to expand eligibility for Medicaid, the health plan for the poor run jointly by the federal and state governments, have been introduced in the Nebraska legislature for six straight years. All failed. Senate opponents said the state couldn’t afford it. The federal government couldn’t be counted on to continue to fund its portion. Too many people were looking for a government handout.

Now, voters will decide for themselves.

Nebraska isn’t the only red state where residents have forced expansion onto Tuesday’s ballot. Idaho and Utah voters also will vote on citizen-initiated measures on Medicaid expansion. Montana, meanwhile, will decide whether to make its expansion permanent. The majority-Republican legislature expanded Medicaid in 2015, but only for a four-year period that ends next July.

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Polling in those three states indicates a majority supports expanding Medicaid. Like Nebraska, all are heavily Republican states easily captured by Trump in 2016.

Last year’s failed attempt by Trump and congressional Republicans to unravel Obamacare revealed the popularity of the ACA with voters. Health policy experts said it also helped educate the public about the benefits of Medicaid, prompting activists in the four states to circumvent their Republican-led legislatures and take the matter directly to the voters.

Activists also were encouraged by the example of Maine, where nearly 60 percent of voters last year approved Medicaid expansion after the state’s Republican governor vetoed expansion bills five times.

“Medicaid has always polled well,” said Joan Alker, executive director of the Center for Children and Families at Georgetown. “When you explain what it does, they think it’s a good idea. What has changed is the intensity and growing recognition that states without expansion are falling further behind, especially in rural areas where hospitals are closing at an alarming rate.

“And all of the states with these ballot initiatives this year have significant rural populations.”

For many in Nebraska, the argument — advanced in one anti-427 television ad — that Medicaid is a government handout to lazy, poor people simply doesn’t square with what they know.

“These aren’t lazy, no-good people who refuse to work,” said Block, a middle school teacher, in an exasperating tone you can imagine her using in an unruly classroom. “They’re grocery store baggers, home health workers, hairdressers. They are the hardest workers in the world, who shouldn’t have to choose between paying for rent or food and paying for medicine or to see a doctor.”

Extending Benefits to Childless Adults

The initiative campaign began after the Nebraska legislature refused to take up expansion again last year. Its early organizers were, among others, a couple of Democratic senators and a nonprofit called Nebraska Appleseed.

Calling itself “Insure the Good Life,” an expansion of the state slogan, the campaign needed nearly 85,000 signatures to get onto the ballot. In July, the group submitted 136,000 signatures gathered from all 93 Nebraska counties.

The initiative would expand Medicaid to childless adults whose income is 138 percent of the federal poverty line or less. For an individual in Nebraska, that would translate to an income of $16,753 or less. Right now, Nebraska is one of 17 states that don’t extend Medicaid benefits to childless adults, no matter how low their income.

Under Medicaid expansion, the federal government would pay 90 percent of the health care costs of newly eligible enrollees, and the state would be responsible for the rest. The federal match for those currently covered by Medicaid is just above 52 percent.

The Nebraska Legislative Fiscal Office, a nonprofit branch of the legislature, found in an analysis that expansion would bring an additional 87,000 Nebraskans into Medicaid at an added cost to the state of close to $40 million a year. The current Medicaid population in Nebraska is about 245,000.

The federal government would send an additional $570 million a year to cover the new enrollees. An analysis from the University of Nebraska commissioned by the Nebraska Hospital Association, a backer of the initiative, found the new monies also would produce 10,800 new jobs and help bolster the precarious financial situation of the state’s rural hospitals.

For economic reasons alone, not expanding makes little sense, said state Sen. John McCollister, one of two Republican senators openly supporting expansion and a sponsor of expansion bills in the legislature, over coffee in an Omaha cafe one day recently.

“Nebraska is sending money to Washington, and that money is being sent back to 33 other states and not to Nebraska,” he said. “It’s obviously good for 90,000 Nebraskans by giving them longevity and a higher quality of life, but it also leads to a better workforce and benefits rural hospitals that won’t have to spend so much on uncompensated care.”

He said the state could easily raise the necessary money by increasing taxes on medical providers, cigarettes and internet sales. If 427 passes, those will be decisions for the next legislature.

Among the measure’s opponents are Americans for Prosperity, a libertarian advocacy group funded by David and Charles Koch that has been running radio ads against the initiative. Jessica Shelburn, the group’s state director in Nebraska, said her primary concern is that expansion would divert precious state resources and prompt cutbacks in the current optional services Medicaid provides.

“While proponents have their hearts in the right place,” Shelburn said, “we could end up hurting the people Medicaid is intended to help.”

Georgetown’s Alker, however, said that no expansion state has curtailed Medicaid services.

When the Affordable Care Act passed in 2010, it mandated that all states expand Medicaid, but a 2012 U.S. Supreme Court ruling made expansion optional for the states. As of now, 33 states and Washington, D.C., have expanded, including states that tend to vote Republican, such as Alaska, Arkansas, and Indiana.

Expansion is not an election issue only in the states with ballot initiatives this year. Democratic gubernatorial candidates are making expansion a major part of their campaigns in Florida and Georgia.

Ashley Anderson, a 25-year-old from Omaha with epilepsy, is one of those anxiously hoping for passage in Nebraska. A rosy-faced woman, she wears a red polo shirt from OfficeMax, where she works part-time for $9.50 an hour in the print center. She aged out of Medicaid at 19, and her single mother can’t afford a family health plan through her employer.

Since then, because of Anderson’s semi-regular seizures, she says she can’t take a full-time job that provides health benefits, and private insurance is beyond her means.

Because Anderson also can’t afford to see a neurologist, she is still taking the medication she was prescribed as a child, even though it causes severe side effects.

Not long ago, Anderson had a grand mal seizure, which entailed convulsions and violent vomiting, and was taken by ambulance to the emergency room. That trip left her $2,000 in debt. For that reason, she said, “At this point, I won’t even call 911.”

Anderson might well qualify for Social Security disability benefits, which would entitle her to Medicaid, but she said the application process is laborious and requires documentation she does not have. As far as she is concerned, the initiative is her only hope for a change.

“You know what, I even miss having an MRI,” she said. “I’m supposed to have one every year.” She can’t remember the last time she had one.

For the uninsured, the alternatives are emergency rooms or federally qualified health centers, which do not turn away anyone because of poverty.

While the clinics provide primary care, dental care, and mental health treatment, they cannot provide specialty care or perform diagnostic tests such as MRIs or CAT scans, said Ken McMorris, CEO of Charles Drew Health Center, the oldest community health center in Nebraska, which served just under 12,000 patients last year.

Almost all its patients have incomes below 200 percent of poverty, McMorris said. Many have little access to healthy foods and little opportunity for exercise.

William Ostdiek, the clinic’s chief medical officer, said he constantly sees patients with chronic conditions such as diabetes and cardiovascular disease whose symptoms are getting worse because they cannot afford to see specialists.

“It’s becoming a vicious cycle,” he said. “They face financial barriers to the treatments they need, which would enable them to have full, productive lives. Instead, they just get sicker and sicker.”

Expansion, McMorris said, would make all the difference for many of those patients.

Some county officials also hope for passage. Mary Ann Borgeson, a Republican county commissioner in Douglas County, which includes Omaha, said her board has always urged the legislature to pass expansion. “Most people don’t understand — for counties, the Medicaid is a lifeline for many people who otherwise lack health care.”

Consequently, she said, the county pays about $2 million a year to reimburse providers for giving care to people who don’t qualify for Medicaid and can’t afford treatment, money that would otherwise be in the pockets of county residents.

‘That Is Socialism’

Insure the Good Life has raised $2.2 million in support of 427, according to campaign finance reports and Meg Mandy, who directs the campaign. Significant contributions have come from outside the state, particularly from Families USA, a Washington-based advocacy organization promoting health care for all, and the Fairness Project, a California organization that supports economic justice.

Both groups are active in the other states with expansion on the ballot. Well-financed, the proponents have a visible ground game and a robust television campaign.

The opposition, much less evident, is led by an anti-tax Nebraska organization called the Alliance for Taxpayers, which has filed no campaign finance documents with the state.

Marc Kaschke, former mayor of North Platte, said he is the organization’s president, but referred all questions about finances to an attorney, Gail Gitcho, who did not respond to messages left at her office.

Gitcho had previously told the Omaha World-Herald that the group hadn’t been required to file finance reports because its ads only provided information about 427; it doesn’t directly ask voters to cast ballots against the initiative.

Last week, the Alliance for Taxpayers began airing its first campaign ads. One of them complains that the expansion would give “free health care” to able-bodied adults. It features a young, healthy-looking, bearded man, slouched on a couch and eating potato chips, with crumbs spilled over his chest.

In a phone interview, Kaschke made familiar arguments against expansion. He said the state can’t afford the expansion, that it would drain money from other priorities, such as schools and roads. He said he fears the federal government would one day stop paying its share, leaving the states to pay for the whole program.

He also said, repeating Shelburn’s claim, that with limited funds, the state would be forced to cut back services to the existing population.

“We feel the states would be in a better position to solve this problem of health care,” Kaschke said. He didn’t offer suggestions on how.

Outside influence ruffles many Nebraska voters. Duane Lienemann, a retired public school agricultural teacher from Webster County near the Kansas line, said he resents outside groups coming to the state telling Nebraskans how to vote.

And he resents “liberals” from Omaha trying to shove their beliefs down the throats of those living in rural areas.

Their beliefs about expansion don’t fly with him.

“I think history will tell you when you take money away from taxpayers and give it to people as an entitlement, it is not sustainable,” Lienemann said. “You cannot grow an economy through transferring money by the government. That is socialism.”

It’s a view shared by Nebraska’s Republican governor, Pete Ricketts. He is on record opposing the expansion, repeating claims that it would force cutbacks in other government services and disputing claims, documented in expansion states, that expansion leads to job growth. But Ricketts has not made opposition to expansion a central part of his campaign.

Whether he would follow in the path of Maine’s Republican governor, Paul LePage, and seek to block implementation of the expansion if the initiative passed, is not clear. Ricketts’ office declined an interview request and did not clarify his position on blocking implementation.

For his part, Scheer, the speaker of the legislature, said he would have no part of that. “We’re elected to fulfill the wishes of the people,” he said. “If it passes, the people spoke.”

Rural Hospitals in Greater Jeopardy in the Non-Medicaid Expansion States

Michael Ollove reported that after marching 130 miles from rural Belhaven, North Carolina, to the state Capitol in Raleigh, protesters in 2015 rally against the closing of their hospital, Vidant Pungo. Medicaid expansion could be the difference between survival and extinction for many rural hospitals.

In crime novelist Agatha Christie’s biggest hit, “And Then There Were None,” guests at an island mansion die suspicious deaths one after another.

So you can forgive Jeff Lyle, a big fan of Christie’s, for comparing the 36-bed community hospital he runs in Marlin, Texas, to one of those unfortunate guests. In December, two nearby hospitals, one almost 40 miles away, the other 60 miles away, closed their doors for good.

The closings were the latest in a trend that has seen 21 rural hospitals across Texas shuttered in the past six years, leaving 160 still operating.

Lyle, who is CEO, can’t help wondering whether his Falls Community Hospital will be next.

“Most assuredly,” he replied when asked whether he could envision his central Texas hospital going under. “We’re not using our reserves yet, but I can see them from here.”

It’s not just Texas: Nearly a hundred rural hospitals in the United States have closed since 2010, according to the Center for Health Services Research at UNC-Chapel Hill. Another 600-plus rural hospitals are at risk of closing, according to an oft-cited 2016 report by iVantage Health Analytics.

Texas had the most hospitals in danger of closing (75), the health metrics firm said. And Mississippi had the largest share of hospitals at risk (79 percent).

Neither state has expanded Medicaid eligibility to more of its low-income residents under the Affordable Care Act, also known as Obamacare. In fact, the closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded.

Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure.

That is why Lyle and administrators of other rural hospitals in Texas and other non-expansion states are so adamant about their states joining the ranks of those that have expanded.

“It would mean a fair number of people we see who have no insurance would have insurance,” Lyle said. “And for us, a dollar is better than no dollar.”

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In Texas, the expansion would make 1.2 million more people eligible for Medicaid, according to a 2018 Kaiser Family Foundation analysis. An Urban Institute study in 2014 estimated that not expanding Medicaid would deprive Texas hospitals of $34.3 billion in federal reimbursements over 10 years.

Without that money, many rural hospitals in Texas and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.

By shedding those services, the hospitals diminish their reason for existing, said Maggie Elehwany, head of government affairs and policy for the National Rural Health Association.

The office of Republican Texas Gov. Greg Abbott and the most recent Republican chairmen of the health committees in the Texas legislature (the legislature has yet to make committee assignments for the current legislative session), Sen. Charles Schwertner and Rep. Four Price, did not return calls requesting comment for this story.

But not everyone believes Medicaid expansion is the answer to the problems facing rural hospitals. “Medicaid is as likely to prop up inefficient and wasteful hospitals as anything else,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute.

Another rural hospital in Texas, Goodall-Witcher in Clifton, which also operates two community health clinics and a nursing room, risked closing until residents of Bosque County voted in November to create a hospital taxing district.

“I’m not saying we would have closed the day after the election,” said Adam Willmann, the hospital’s CEO, “but I don’t know how much longer we could have gone.”

The additional taxes will bring the hospital an estimated $2.5 million a year and perhaps take it out of the red, but they won’t necessarily lift Goodall-Witcher out of financial peril, Willmann said.

“Medicaid expansion,” Willmann said. “That is one of the key things we could do to help us deal with the tough financial demands we face.”

The burden of Uncompensated Care

As envisioned by the ACA when it passed Congress in 2010, expansion states would extend benefits to all adults — including childless adults — whose income was at or below 138 percent of the federal poverty line. (In 2019, that would be an average individual income of $12,140, depending on the state.)

Initially, the federal government paid 100 percent of the health care costs of the expansion population. The federal share falls to 90 percent in 2020.

To date, 36 states plus Washington, D.C., have expanded Medicaid. By 2017, expansion under the ACA had covered 17 million new enrollees. Roughly another 4 million people would qualify in the remaining states, according to a 2018 Kaiser report.

Instead, many of those low-income residents remain uninsured or underinsured in plans with high deductibles and copayments.

But that doesn’t mean people don’t receive health care. Without health insurance, low-income people are less likely to get preventive care, which often results in worsening health conditions that frequently bring them to hospitals where they are guaranteed treatment. Under federal law, hospitals must stabilize and treat anyone showing up at the emergency room, regardless of their ability to pay.

Rural hospitals, like their urban counterparts, are forced to absorb those costs. But unlike bigger hospitals, their patient volumes, and operating margins are so low that “uncompensated care” burdens can be crippling.

For instance, Willmann said his hospital’s uncompensated tab last year was about $4.2 million, or 11 to 12 percent of his overall budget.

According to the Oklahoma Hospital Association, the state’s rural hospitals carried about $170 million in bad debt from charitable care and patients’ unpaid bills. Five rural hospitals have closed in the state since 2016.

A 2018 study in the journal Health Affairs found that the rate of closures of rural hospitals increased significantly in non-expansion states after 2014 when states began implementing the expansion. At the same time, closure rates decreased in expansion states.

Many administrators of rural hospitals are quick to say that Medicaid expansion alone will not solve their financial problems. Rural hospitals faced steep challenges long before the ACA.

Rural Americans tend to be older, in poorer health and less insured than those living elsewhere, the latter resulting in a greater share of uncompensated care for rural hospitals. Because of declining populations in rural areas, hospitals there often have empty beds, which means less revenue.

“It’s been a long, slow bleed,” said Fred Blavin, a health policy expert at the Urban Institute.

Automatic federal budget cuts beginning in 2013 (known as sequestration) reduced Medicare reimbursements, which are a particularly important source of revenue for hospitals. Congress has cut back on the amount hospitals can deduct for bad debt. Congress, in its budget tightening, reduced other forms of assistance to rural hospitals as well.

“You can put a Band-Aid on, but you still have 99 other wounds,” Willmann said.

Elehwany, of the National Rural Health Association, said that rural communities where hospitals are forced to close might be able to meet residents’ health needs by opening a new urgent care facility or maternal care center.

The loss of rural hospitals not only means patients having to travel longer distances to the next medical providers, but the closures also can often have a crippling effect on the local economy.

Goodall-Witcher Hospital is the largest employer in Bosque County. “Our payroll is bigger than the county’s entire budget,” Willmann said. “Can you imagine what it would do to this county to lose $9 million from the economy a year?”

A Health Services Research journal report found that when a rural area’s only hospital closes, income per capita falls by 4 percent and unemployment rises by 1.6 percent.

Willmann was relieved voters in his district supported the measure to create a hospital taxing district, but he acknowledged that it wasn’t a good deal for his county’s taxpayers. Their federal taxes help pay for the expansion in other states but not in Texas.

“Basically, you’re asking them to pay twice,” he said.

Rural hospital officials appear not to have the slightest hope that the deep red Texas legislature and the governor will get behind expansion.

“There is no likelihood of Medicaid expansion in Texas in the near term,” said John Henderson, CEO of the Texas Organization of Rural & Community Hospitals.

The government shutdown is over, but for how long? The New York Times finally got it correct when they wrote:

‘Our Country Is Being Run by Children’: Shutdown’s End Brings Relief and Frustration

 

Healthcare in 2019: Divided

 

49279916_1862477230548594_7693435305117876224_nAnd we continue with the shut down of 25% of the government. Maybe it isn’t such a bad deal for us with the waste and deficit. So, what can we anticipate for the New Year regarding healthcare? Miss Luthi reviewed that year one of a divided government in the Trump era begins with the Affordable Care Act again in legal peril. Political rhetoric around the law and healthcare generally will only intensify in the lead-up to the 2020 election cycle, but the industry is most closely watching how the administration will use executive authority to try to beat down soaring costs.

A Texas judge’s decision to overturn the ACA closed out a year where, despite congressional gridlock on healthcare, the Trump administration gained ground on systemic attempts to trim hospital payments and pharmaceutical prices, as well as reshape insurance markets. HHS Secretary Alex Azar maintains he will not bend to corporate pressure as he pushes policies like site-neutral payments and price transparency.

The policy outlook is less straightforward in Congress, where Democrats plan to use their newfound power in the House to blanket the Trump administration with oversight.

Meanwhile, Sens. Chuck Grassley (R-Iowa) and Lamar Alexander (R-Tenn.) will wrap up their legacies chairing the upper chamber’s two most influential healthcare committees—Finance and Health, Education, Labor, and Pensions, respectively. Grassley has a history of scrutinizing tax-exempt providers. And Alexander orchestrated a series of hearings in 2017 delving into the high cost of healthcare.

HHS and hospitals: It’s complicated

Hospitals want the Trump administration to more aggressively pushing executive authority to roll back red tape, particularly around the Stark law and accompanying regulations, which providers say stand in the way of some pay-for-value reforms, including building clinically integrated networks.

But hospitals have also been quick to sue over what they claim is an executive overreach, such as in the case of HHS’ sweeping cuts to the controversial 340B drug discount program. Pharmaceutical discounts through the program yield tens of millions of dollars annually for a growing number of hospitals, and it has become a territorial fight.

“This administration pushes the envelope on how far they can go with powers from Congress,” said Erik Rasmussen, a vice president at the American Hospital Association. “It’s a double-edged sword. When they go too far, we sue them.”

Hospitals sued over the government’s substantial clawback of money through a cut to 340B hospitals’ Medicare Part B drug reimbursements. Launched Jan. 1 of last year, the policy is winding its way through courts under ongoing litigation after a late-breaking 2018 win for hospitals in a federal district court. The cuts were extended to hospitals’ off-campus facilities at the beginning of this year.

Hospitals also poured lobbying dollars last year into a fight against Republican-sponsored legislation to cut back the 340B program. With a Democratic takeover of the House, hospitals are expecting a break on Capitol Hill and they plan to use the time to try to forestall political pressures over the program. Hospitals will have to disclose the community benefit funded by their 340B discount money from manufacturers, accurately estimate their discounts, and pledge to stick to the letter of the 340B law.

“We want to use the time while the field is fallow to make sure our fences are strong,” Rasmussen said. “Good fences make good neighbors.”

Hospitals and HHS anticipate a ruling on the so-called site-neutral payment policy, proposed in July and finalized in a watered-down version in November. The AHA, along with several other hospital groups, sued over the policy, again claiming executive overreach.

This administration pushes the envelope on how far they can go with powers from Congress. It’s a double-edged sword. When they go too far, we sue them.”

Under the new policy that starts this month, Medicare will pay off-site clinics the same rate it pays independent physicians for certain services.

Economist Douglas Holtz-Eakin, a former director of the Congressional Budget Office who heads the conservative American Action Forum, said it is unclear how hard the administration will ultimately come down on hospitals in light of the intense pressure.

“It has turned out to be harder than the administration expected,” Holtz-Eakin said of the payment policy. “They keep going back and forth on a policy to pay for the quality of the service, rather than paying the same rate for every site, and they’re just struggling.”

While the administration would like to keep balancing Medicare payments, he added, officials “don’t know where to go next” as they try to work out designs for these policy changes.

Hospital priorities for Congress: DSH payments

Congress has a hard deadline of Sept. 30 to decide how to manage the scheduled disproportionate-share hospital payment cuts, passed with the ACA, but never implemented.

Lawmakers last year authorized a one-year-only delay to billions of dollars in cuts to these payments, teeing up a potential legislative overhaul of the program in 2019. Republican Sen. Marco Rubio of Florida, one of the states least favored under the current formulas, has already introduced a proposal to start negotiations.

Hospital lobbyists, eager to protect overall DSH funding, have signaled lawmakers could modify the law, which has largely remained untouched since 1992.

“The devil’s in the details,” said Carlos Jackson of America’s Essential Hospitals—a trade group for hospitals that benefit significantly from the program. “We are happy to have conversations about changes, but the details matter.”

Jackson also questioned whether lawmakers in this supercharged political environment would be able to dive into real policy changes by September.

“Will they have the time?” he asked.

A small number of states—Alabama, Missouri, New Jersey, and New York—benefit more than others from DSH. Financially, the payments are a very big deal for hospitals with high numbers of Medicaid patients, such as major university medical centers.

Here, too, ongoing litigation is a complicating factor. Hospitals have challenged an Obama-era rule requiring them to deduct any Medicare or commercial insurance reimbursements from their total DSH allotment.

Hospitals also want the Democratic House to pick up where Republicans left off on a “Red Tape Relief” project targeting Medicare regulations that hospitals say cost them billions a year in extra work and unnecessary or redundant expenses.

Democrats haven’t decided what they will do, but lobbyists think House Republicans may be able to work with the Trump administration on policy work that could gain bipartisan support.

“It’s been a while since we’ve had a GOP minority in the House with a Republican president,” the AHA’s Rasmussen said. “Republicans in the House will still be important because they can work on the administration on this sort of thing.”

Tax-exempt hospitals are also bracing for the spotlight. Grassley—who for years has been investigating whether hospitals with not-for-profit status are producing enough justifying community benefit—is retiring in two years. Former and current aides said his scrutiny of hospitals with massive tax benefits will continue. Throughout this year, he has kept up communication with the IRS on how the agency monitors the activity of not-for-profit hospitals.

Pharmaceuticals: ‘It’ll be busy’

If hospitals are wary about mixed financial prospects in 2019, the pharmaceutical industry is preparing for full-on political war.

Manufacturers lost a key lobbying battle in 2018 when they tried to recoup billions of dollars from the money Congress appropriated through the Medicare Part D coverage gap known as the “donut hole.”

This year will bring much more: the specifics of a proposal to control U.S. drug prices by tying them to an international price index; step therapy in Medicare Part B; and the authority for Medicare Part D insurers to exclude some protected-class drugs that are currently off limits.

If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere.”

Said James Greenwood, President, and CEO of Biotechnology Innovation Organization.

“We face all of that, and then there’s the change in the majority of the House,” said James Greenwood, CEO of the Biotechnology Innovation Organization trade group. “Democrats have run very hard on the issue of drug pricing and investigation.”

There’s also Grassley, who has long been zealous on Big Pharma oversight.

“It’ll be busy,” Greenwood said.

He said he is focused on messaging and public perception of manufacturers who, he said “shoulder 95% of the rhetoric” for skyrocketing healthcare costs.

“If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere,” Greenwood said.

Manufacturers are also looking to the administration’s use of executive authority for some wins, specifically on 340B where they clash most intensely with hospitals.

“There’s a lot the administration can do,” Greenwood said. “The powers they are using with the other proposals, like (the CMS Innovation Center), they can apply to the 340B program.”

Insurers: Focus on the individual market

Obamacare’s individual market premiums have stabilized but at a high price. And as Democratic progressives push a single-payer approach in the lead-up to the 2020 presidential election, insurers want to make sure the individual market can attract people who have ditched or so far avoided the exchanges because of cost.

Justine Handelman of the Blue Cross and Blue Shield Association wants Congress to try again on reinsurance funding and to look at the expansion of the tax credit subsidy, particularly to draw younger people into the exchanges.

Given the breakdown of bipartisan talks to fund reinsurance and cost-sharing reduction payments in 2018, it’s unlikely the Democratic proposal to further subsidize the exchanges will go anywhere with the Trump administration and Republican Senate.

‘Medicare for all’? This we will discuss more in the next few weeks.

Key to watch as the year unfolds is what the fallout of the ACA litigation—panned by most legal analysts but also possibly headed to the Supreme Court—will herald for both parties for healthcare ahead of 2020 when progressive Democrats want their party to embrace “Medicare for all.”

Sen. Elizabeth Warren of Massachusetts, the first Democrat to jump into the presidential race, has already made the policy part of her platform.

Progressive Democratic Reps. Ro Khanna of California and Pramila Jayapal of Washington state, who are leading the way on a new “Medicare for all” draft, plan to push a floor vote on the legislation. They told Modern Healthcare they will introduce the new version once the 676 bill number is available—a nod to the original House legislation from former Rep. John Conyers (D-Mich.).

Dems hit GOP on health care with additional ObamaCare lawsuit vote

As Jessie Hellmann noted The House on Wednesday passed a resolution backing the chamber’s recent move to defend ObamaCare against a lawsuit filed by GOP states, giving Democrats another opportunity to hit Republicans on health care.

GOP Reps. Brian Fitzpatrick (Pa.), John Katko (N.Y.) and Tom Reed (N.Y.) joined with 232 Democrats to support the measure, part of Democrats’ strategy of keeping the focus on the health care law heading into 2020. The final vote tally was 235-192.

While the House voted on Friday to formally intervene in the lawsuit as part of a larger rules package, Democrats teed up Wednesday’s resolution as a standalone measure designed to put Republicans on record with their opposition to the 2010 law.

A federal judge in Texas last month ruled in favor of the GOP-led lawsuit, saying ObamaCare as a whole is invalid. The ruling, however, will not take effect while it is appealed.

Democrats framed Wednesday’s vote as proof that Republicans don’t want to safeguard protections for people with pre-existing conditions — one of the law’s most popular provisions.

“If you support coverage for pre-existing conditions, you will support this measure to try to protect it. It’s that simple,” said Rules Committee Chairman Jim McGovern (D-Mass.) before the vote.

Most Republicans opposed the resolution, arguing it was unnecessary since the House voted last week to file the motion to intervene.

“At best, this proposal is a political exercise intended to allow the majority to reiterate their position on the Affordable Care Act,” said Rep.Tom Cole (R-Okla.). “At worst, it’s an attempt to pressure the courts, but either way, there’s no real justification for doing what the majority wishes to do today.”

The Democratic-led states defending the law are going through the process of appealing a federal judge’s decision that ObamaCare is unconstitutional because it can’t stand without the individual mandate, which Congress repealed.

Democrats were laser-focused on health care and protections for people with pre-existing conditions during the midterm elections — issues they credit with helping them win back the House.

The Trump administration has declined to defend ObamaCare in the lawsuit filed by Republican-led states, which argue that the law’s protections for people with pre-existing conditions should be overturned. It’s unusual for the DOJ to not defend standing federal law.

The House Judiciary Committee, under the new leadership of Chairman Jerrold Nadler (D-N.Y.), plans to investigate why the Department of Justice decided not to defend ObamaCare in the lawsuit.

“The judiciary committee will be investigating how the administration made this blatantly political decision and hold those responsible accountable for their actions,” Nadler said.

Democrats are also putting together proposals to undo what they describe as the Trump administration’s efforts to “sabotage” the law and depress enrollment.

“We’re determined to get that case overruled, and also determined to make sure the Affordable Care Act is stabilized so that the sabotage the Trump administration is trying to inflict ends,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the Energy and Commerce Committee, which has jurisdiction over ObamaCare.

One of the committee’s first hearings this year will focus on the impacts of the lawsuit. The hearing is expected to take place this month.

The Ways and Means Committee, under the leadership of Chairman Richard Neal (D-Mass), will also hold hearings on the lawsuit and on protections for people with pre-existing conditions.

Those two committees, along with the Education and Labor Committee, are working on legislation that would shore up ObamaCare by increasing eligibility for subsidies, blocking non-ObamaCare plans expanded by the administration and increasing outreach for open enrollment.

GOP seeks health care reboot after 2018 losses

Alexander Bolton reviewed the future strategies of the GOP. He noted that the Republicans are looking for a new message and platform to replace their longtime call to repeal and replace ObamaCare after efforts failed in the last Congress and left them empty-handed in the 2018 midterm elections.

Republican strategists concede that Democrats dominated the health care debate heading into Election Day, helping them pick up 40 seats in the House.

President Trump hammered away on immigration in the fall campaign, which helped Senate Republican candidates win in conservative states but proved less effective in suburban swing areas, which will be crucial in the 2020 election.

While Trump is focused on raising the profile of illegal immigration during a standoff over the border wall, other Republicans are quietly looking for a better strategy on health care, which is usually a top polling issue.

“Health care is such a significant part of our economy and the challenges are growing so great with the retirement of the baby boomers and the disruption brought about by ObamaCare that you can’t just cede a critically important issue to the other side,” said Whit Ayres, a Republican pollster.

“Republicans need a positive vision about what should happen to lower costs, expand access and protect pre-existing conditions,” he added. “You’ve got to be able to answer the question, ‘So what do you think we should do about health care?’ ”

A recent Associated Press-NORC Center for Public Affairs Research poll showed that 49 percent of respondents nationwide said the government should tackle health care as a top priority, second only to economic concerns.

During his 2016 presidential campaign, Trump vowed to lower prescription drug costs, but the Republican-controlled Congress over the past couple of years focused on other matters. House Democrats who are now in the majority say they are willing to work with the White House on drug pricing, but it’s unclear if Republicans will take on the powerful pharmaceutical industry, long considered a GOP ally.

Republican candidates made the repeal of ObamaCare their main message in 2010, 2012, 2014 and 2016 elections. But after repeal legislation collapsed with the late Sen.John McCain’s (R-Ariz.) famous “no” vote, the party’s message became muddled and Democrats went on the offensive.

Some Republicans continued to work on alternative legislation, such as a Medicaid block grant bill sponsored by Sens. Lindsey Graham(S.C.) and Bill Cassidy(La.), but it failed to gain much traction and the GOP health care message was left in limbo.

“We should be the guys and gals that are putting up things that make health care more affordable and more accessible,” said Jim McLaughlin, another Republican pollster. “No question Democrats had an advantage over us on health care, which they never should have had because they’re the ones that gave us the unpopular ObamaCare.”

“We need to take it to the next level,” he added. “You can’t get [ObamaCare] repealed. Let’s do things that will make health care more affordable and more accessible.”

Senate Health Committee Chairman Lamar Alexander (R-Tenn.), a close ally of Senate Majority Leader Mitch McConnell(R-Ky.), says finding an answer to that question will be his top priority in the weeks ahead.

Alexander will be meeting soon with Sen. Patty Murray(Wash.), the top Democrat on the Health Committee, as well as Sens. Chuck Grassley(R-Iowa) and Ron Wyden(D-Ore.), the leaders of the Senate Finance Committee, to explore solutions for lowering health care costs.

“I’ll be meeting with senators on reducing health care costs,” Alexander told The Hill in a recent interview. “At a time when one-half of our health care spending is unnecessary, according to the experts, we ought to be able to agree in a bipartisan way to reduce that.”

He recently announced his retirement from the Senate at the end of 2020, freeing him to devote his time to the complex and politically challenging issue of health care reform without overhanging reelection concerns.

Alexander sent a letter to the center-right leaning American Enterprise Institute and the center-left leaning Brookings Institution last month requesting recommendations by March 1 for lowering health care costs.

In Dec. 11 floor speech, Alexander signaled that Republicans want to move away from the acrimonious question of how to help people who don’t have employer-provided health insurance, a question that dominated the ObamaCare debate of the past decade, and focus instead on how to make treatment more affordable.

He noted that experts who testified before the Senate in the second half of last year estimated that 30 to 50 percent of all health care spending is unnecessary.

“The truth is we will never have lower cost health insurance until we have lower cost health care,” Alexander said on the floor. “Instead of continuing to argue over a small part of the insurance market, what we should be discussing is the high cost of health care that affects every American.”

A Senate Republican aide said GOP lawmakers are prepared to abandon the battle over the best way to regulate health insurance and focus instead on costs, which they now see as a more fundamental issue.

“There’s no point in trying to talk about health insurance anymore. Fundamentally, insurance won’t be affordable until we make health care affordable, so we have to do stuff to reduce health care costs,” said the aide.

“There are lots of things that can be done to reduce health care costs that aren’t insurance, that aren’t necessarily partisan,” the source added.

“We’re looking at ideas that aren’t necessarily partisan and don’t advance the cause of single-payer health care and don’t advance the cause of ‘only the market’ but are about addressing these drivers of health care cost and try to change the trajectory.”

Another key player is Cassidy, a physician, and member of the Health and Finance committees, who has co-sponsored at least seven bills to improve access and lower costs.

One measure Cassidy backed is co-sponsored by Sen. Tina Smith(D-Minn.) and would develop innovative ways to reduce unnecessary administrative costs.

Another measure Cassidy co-sponsored with Sens. Maria Cantwell (D-Wash.) and Tom Carper (D-Del.) would allow individuals to pay for primary-care service from a health savings account and allow taxpayers enrolled in high-deductible health plans to take a tax deduction for payments to such savings accounts.

He is also working on a draft bill to prohibit the surprise medical billing of patients.

McConnell signaled after Democrats won control of the House in November that the GOP would abandon its partisan approach to health care reform and concentrate instead on bipartisan proposals to address mounting costs, which Democratic candidates capitalized on in the fall campaign.

Asked about whether the GOP would stick with its mission to repeal ObamaCare, McConnell said: “it’s pretty obvious the Democratic House is not going to be interested in that.”

Half the 600,000 residents aided by NYC Care are undocumented immigrants

As John Bacon of USA Today reported the comprehensive health care plan unveiled by New York City Mayor Bill de Blasio this week drew applause from the Democrat’s supporters but also skepticism from those in the city who question the value and cost of the effort.

De Blasio said NYC Care will provide primary and specialty care from pediatric to geriatric to 600,000 uninsured New Yorkers. De Blasio estimated the annual cost at $100 million.

“This is the city paying for direct comprehensive care (not just ERs) for people who can’t afford it, or can’t get comprehensive Medicaid – including 300,000 undocumented New Yorkers,” Eric Phillips, spokesman for de Blasio, boasted on Twitter.

State Assemblywoman Nicole Malliotakis, a Republican representing parts of Brooklyn and Staten Island, criticized the proposal as an example of de Blasio using city coffers “like his personal ATM.”

“How about instead of giving free health care to 300,000 citizens of other countries, you lower property taxes for our senior citizens who are being forced to sell the homes they’ve lived in for decades because they can’t afford to pay your 44 percent increase in property taxes?” she said.

Seth Barron, associate editor of City Journal and project director of the NYC Initiative at the Manhattan Institute think tank, noted that the city’s uninsured, including undocumented residents, can receive treatment on demand at city hospitals. The city pays more than $8 billion to treat 1.1 million people through its New York City Health + Hospitals program, he wrote.

Barron said the mayor is simply trying to shift patients away from the emergency room and into clinics. He said that dividing $100 million by 600,000 people comes to about $170 per person, the equivalent of one doctor visit.

“Clearly, the money that the mayor is assigning to this new initiative is intended for outreach, to convince people to go to the city’s already-burdened public clinics instead of waiting until they get sick enough to need an emergency room,” Barron wrote. “That’s fine, as far as it goes, but as a transformative, revolutionary program, it resembles telling people to call the Housing Authority if they need an apartment and then pretending that the housing crisis has been solved.”

The plan expands upon the city’s MetroPlus public option plan, as well as the state’s exchange through the federal Affordable Care Act. NYC Care patients will be issued cards allowing them access to medical services, de Blasio said.

The mayor’s plan has plenty of support. Mitchell Katz, president, and CEO of NYC Health + Hospitals said the plan will help his agency “give all New Yorkers the quality care they deserve.” State Sen. James Sanders Jr., who represents parts of Queens, said he looks forward “to seeing the Care NYC program grow and prosper as it helps to create a healthier New York.”

The drumbeat for improved access to health care is not limited to New York.

California Gov. Gavin Newsom on Monday asked Congress and the White House to empower states to develop “a single-payer health system to achieve universal coverage, contain costs and promote quality and affordability.”

Washington Gov. Jay Inslee on Tuesday proposed Cascade Care, a public option plan under his state’s health insurance exchange.

“We’re going to do all we can to protect health care for Washingtonians,” he said. “This public option will ensure consumers in every part of the state will have an option for high-quality, affordable coverage.”

Newsom pushes sweeping new California health-care plan to help illegal immigrants, prop up ObamaCare

Greg Re noted that shortly after he took office on Monday, California’s Democratic Gov. Gavin Newsom unearthed an unprecedented new health care agenda for his state, aimed at offering dramatically more benefits to illegal immigrants and protecting the embattled Affordable Care Act, which a federal judge recently struck down as unconstitutional.

The sweeping proposal appeared destined to push California — already one of the nation’s most liberal states — even further to the left, as progressive Democrats there won a veto-proof supermajority in the state legislature in November and control all statewide offices.

“People’s lives, freedom, security, the water we drink, the air we breathe — they all hang in the balance,” Newsom, 51, told supporters Monday in a tent outside the state Capitol building, as he discussed his plans to address issues from homelessness to criminal justice and the environment. “The country is watching us, the world is watching us. The future depends on us, and we will seize this moment.”

Newsom unveiled his new health-care plan hours after a protester interrupted his swearing-in ceremony to protest the murder of police Cpl. Ronil Singh shortly after Christmas Day. The suspect in Singh’s killing is an illegal immigrant with several prior arrests, and Republicans have charged that so-called “sanctuary state” policies, like the ones Newsom has championed, contributed to the murder by prohibiting state police from cooperating with federal immigration officials.

As one of his first orders of business, Newsom — who also on Monday requested that the Trump administration cooperates in the state’s efforts to convert to a single-payer system, even as he bashed the White House as corrupt and immoral — declared his intent to reinstate the ObamaCare individual mandate at the state level.

ANALYSIS: AS CALIFORNIA’S PROGRESSIVE POLICIES GET CRAZIER, WHAT’S THE SILVER LINING FOR THE GOP?

The mandate forces individuals to purchase health care coverage or pay a fee that the Supreme Court described in 2012 as a “tax,” rather than a “penalty” that would have run afoul of Congress’ authority under the Commerce Clause of the Constitution. Last month, though, a federal judge in Texas ruled the individual mandate no longer was a constitutional exercise of Congress’ taxing power because Republicans had passed legislation eliminating the tax entirely — a move, the judge said, that rendered the entire health-care law unworkable.

As that ruling works its way to what analysts say will be an inevitable Supreme Court showdown, Newsom said he would reimpose it in order to subsidize state health care.

Medi-Cal, the state’s health insurance program, now will let illegal immigrants remain on the rolls until they are 26, according to Newsom’s new agenda. The previous age cutoff was 19, as The Sacramento Bee reported.

Additionally, Newsom announced he would sign an executive order dramatically expanding the state’s Department of Health Care Services authority to negotiate drug prices, in the hopes of lowering prescription drug costs.

In his inaugural remarks, Newsom hinted that he intended to abandon the relative fiscal restraint that marked the most recent tenure of his predecessor, Jerry Brown, from 2011 to 2019. Brown sometimes rebuked progressive efforts to spend big on various social programs.

“For eight years, California has built a foundation of rock,” Newsom said. “Our job now is not to rest on that foundation. It is to build our house upon it.”

Newsom added that California will not have “one house for the rich and one for the poor, or one for the native-born and one for the rest.”

“The country is watching us, the world is watching us.”

In a statement, the California Immigrant Policy Center backed Newsom’s agenda.

“Making sure healthcare is affordable and accessible for every Californian, including undocumented community members whom the federal government has unjustly shut out of care, is essential to reaching that vision for our future,” the organization said. “Today’s announcement is a historic step on the road toward health justice for all.”

The Sacramento Bee reported on several of Newsom’s recent hires, which seemingly signaled he’s serious about his push to bring universal health care to California. Chief of Staff Ann O’Leary worked in former President Bill Clinton’s administration on the Children’s Health Insurance Program (CHIP), which offers affordable health care to children in families who exceed the financial threshold to qualify for Medicaid, but who are too poor to buy private insurance.

And, Cabinet Secretary Ana Matosantos, who worked in the administrations of Brown and former GOP Gov. Arnold Schwarzenegger, has worked extensively to implement ObamaCare in California and also worked with the legislature to expand health-care coverage for low-income Californians.

 This next year should be an exciting time if Congress and the President can figure out how to get along and how to work together to improve health care. I believe that if neither the President nor the Dems come together to solve this wall, fence, or monies for better illegal immigrant deterrents nothing will happen in healthcare and probably nothing will happen on any level. What a bunch of spoiled children!!

Onward!!!