Sarah Kliff at Vox had a great article on the GOP’s new proposal to automatically enroll people without insurance into high-deductible health plans. Sens. Bill Cassidy (R-LA) and Susan Collins (R-ME) included the idea in their Obamacare replacement plan. The Senate Finance Committee also has a health care plan called the Patient CARE Act that envisions an auto enrollment feature to scoop up the people who don’t buy coverage themselves.

Republicans disagree with a mandate but can agree on automatically enrolling people into a health plan that they did not choose?

A short summary of how the plan would work:

Lawmakers could require insurers to offer products whose premiums match the value of the federal tax credits. If the basic, age-adjusted federal tax credit for a 40-year-old man in a given state is, say, $3,000, then every insurer in the state would have to make a policy available for such customers with a $3,000 premium.

Insurers would adjust the upfront deductibles in these plans as necessary to ensure that the premium equals the credit. Most consumers in the individual market would thus have the option to get an insurance plan with no cost to themselves. This no-premium coverage would necessarily have higher deductibles than costlier options, but it would provide financial protection against expensive medical claims, which is the primary purpose of insurance.

There are major problems with this proposal including that no system exists to track who is uninsured, and it would be tough to build it, and the health care plan would not cover anything.

 

 

Secretary Tom Price had a strange and somewhat incoherent interview with CNN’s Dr. Sanjay Gupta.

Here are the most insane moments of their interview:

#1 – Price refused to admit that it “defies common sense” to strip away $1 trillion from healthcare funding when Trump promised to get all Americans insured with the government’s help.

#2 – Price declared that Medicaid patients are only concerned about losing their Medicaid because they are afraid of something “new.”

#3 – Price struggled to defend efforts to gut the requirement for essential health benefits, which provide coverage for things like hospitalizations, maternity care and prescription drugs, offering such sweeping generalities that the only reply Dr. Gupta could offer was, “I don’t know what that means.”

#4 – Price could not refute Gupta’s assertion that TrumpCare would legalize healthcare “plans that are cheap but useless.”

#5 – Even though the TrumpCare plan he tried to push through Congress would put insurance out of reach for 24 million people and repeal the individual mandate, Price proved himself utterly divorced from realty by agreeing that “absolutely,” everyone should have insurance.

The Department of Health and Human Services told the New York Times it intended to continue making “cost-sharing reduction” payments, which compensate insurance companies that cover low-income customers in the exchanges established by Obamacare. Eliminating the payments would make premiums spike by about one-fifth, or cause insurers to get out altogether.  Already, the uncertainty is prompting some insurers to drop out for 2018. Some 7 million people, or 58%, of those who signed up for Obamacare coverage for 2017 qualify for these cost-sharing subsidies.

But President Donald Trump is threatening not to reimburse health insurers for covering low income people as a way of forcing the passage of Trumpcare.  In an interview with the Wall Street Journal, Trump said health care remained a top priority for him, but that he was still undecided about whether his administration would fund what are known as cost-sharing reduction payments, which reduce deductibles and co-payments for lower-income people.

The payments were the subject of a House lawsuit under House Speaker John Boehner, which argued the Obama administration did not have the authority to make the payments without congressional approval. The lawsuit is still ongoing.
Senate Minority Leader Chuck Schumer slammed Trump’s comments, saying, “This cynical strategy will fail. President Trump is threatening to hold hostage health care for millions of Americans, many of whom voted for him, to achieve a political goal of repeal that would take health care away from millions more,” the New York Democrat said in a statement.
South Carolina Republican Rep. Mark Sanford told the Post and Courier last month that White House budget chief and South Carolina native Mick Mulvaney, a former House Freedom Caucus member, delivered a message to him from Trump that Trump hoped Sanford voted against the health care bill so the President could support a primary challenger against him.
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CNN reported that Paul Ryan does not want to work with Democrats to repair the Affordable Care Act despite Trump’s attempt to blame Democrats for failing to work with the Republicans. White House press secretary Sean Spicer said President Donald Trump is “absolutely” willing to work with Democrats on a way forward on health care.

“If this Republican Congress allows the perfect to become the enemy of the good, I worry we’ll push the President to working with Democrats. He’s been suggesting that much.”
“What I worry about, Norah (O’Donnell), is if we don’t do this, then he’ll just go work with Democrats to try to change Obamacare — and that’s hardly a conservative thing,” he said.
House Speaker Paul Ryan says he has no interest in working with Democrats on getting health care legislation passed, disputing a suggestion by the White House to reach across the aisle and bypass conservative House Republicans.

 

The The Urban Institute estimates millions of Americans will lose Medicaid coverage if Republicans Block Grant Medicaid. Block Granting Medicaid is one of the ways Republicans want to pay for tax cuts for their wealthy donors.

What will happen to the millions of future older Americans who are in danger of losing Nursing Home care through Medicaid.  Kaiser Family Foundation shows:8617-02-figure-1.png

“… According to 2012 estimates, among people age 65 and over, an estimated 70 percent will use LTSS, and people age 85 and over – the fastest growing segment of the U.S. population – are four times more likely to need LTSS compared to people age 65 to 84.6,7 Approximately seven in ten people age 90 and above have a disability, and among people between the ages of 40 and 50, almost one in ten, on average, will have a disability that may require LTSS. …”II

The other sets of facts show Medicaid represents the majority of Long Term Care”.

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Vox had two great articles on the opiod crisis.  Drug overdoses now kill more Americans than HIV/AIDS did at its peak. In 2015, more than 52,000 people died of drug overdoses, nearly two-thirds of which were linked to opioids like Percocet, OxyContin, heroin, and fentanyl. That’s more drug overdose deaths than any other period in US history — even more than past heroin epidemics, the crack epidemic, or the recent meth epidemic. And the preliminary data we have from 2016 suggests that the epidemic may have gotten worse since 2015.  Vox has maps and charts that tell the story:

  1.  Drug overdoses now kill more people than gun homicides and car crashes combined.
  2. Drug, painkiller, heroin, and other opioid overdose deaths are still on the rise.
  3. Opioid overdoses are one reason US life expectancy declined for the first time in decades.
  4. The epidemic is much worse in some states than others.
  5. By and large, the drug overdose epidemic has hit white Americans the hardest.
  6. Americans consume more opioids than any other country.
  7. In some states such as South Carolina, doctors have filled out more painkiller prescriptions than there are people.
  8. Drug companies have made a lot of money from opioids.
  9. At the same time, Americans report greater levels of pain.

A Senate investigation into the pharmaceutical companies’ role and responsibility for the nation’s worst drug overdose crisis in history:  Sen. Claire McCaskill (D-MO), the top Democrat on the Senate Homeland Security and Governmental Affairs Committee, announced that she is requesting marketing, sales, and addiction study material from the companies behind America’s top five opioid products. The investigation, she said, will draw out the role that opioid manufacturers played in causing the epidemic and letting it continue.

As USA Today noted, McCaskill will need Republican support on the committee to be able to subpoena opioid makers’ documents should the companies not comply with her requests.

Drug manufacturers played a major role in the epidemic. By marketing their opioid painkillers as safe and effective, they convinced doctors to prescribe painkillers in droves to patients. That allowed the drugs to proliferate, leading not just to widespread painkiller misuse but also to the misuse of more dangerous opioids like heroin and illegally manufactured fentanyl. With this, the risk of overdose increased — spawning the opioid crisis we have today. As opioid painkiller sales increased, more people got addicted — and died.Annual Review of Public Health

Much of this was the result of misleading marketing by major drug companies. In fact, Purdue Pharma, a producer of “hillbilly herion” OxyContin, in 2007 was forced to pay hundreds of millions of dollars in fines due to its false claims about opioids.

In wide-ranging investigations, the Los Angeles Times has uncovered more evidence of how Purdue’s misleading advertisement played out at the ground level. It found that Purdue exaggerated the effectiveness and safety of OxyContin, while covering up any criticisms and complaints about the drug. As a particularly egregious example of why Purdue and its marketers did this, one sales memo uncovered by the Times was literally titled “$$$$$$$$$$$$$ It’s Bonus Time in the Neighborhood!”

Other opioid makers have faced similar allegations. Insys, a drugmaker, allegedly pushed its fentanyl spray for uses far beyond late-stage cancer pain treatment, according to McCaskill’s office. A sales representative claimed that the company’s informal motto was, “Start them high and hope they don’t die.”

A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

Most Americans (50%) get health insurance through their work, and another 34 percent rely on the government through Medicare or Medicaid. Because of the ACA, only 9 percent are uninsured. The rest — those who are too young to qualify for Medicare and too rich to qualify for Medicaid but want to buy insurance — deal with insurers that sell plans to individuals.

The Obamacare exchanges created to help some 13 million Americans buy quality and affordable insurance outside of the employer-based market. And the overwhelming majority of these people happen to live in rural parts of the country — the very same places that voted for Donald Trump.

Map of counties with 1 ACA insurer and how they voted in the 2016 election

Will Trump undermine these marketplaces or try to make them work by messing with or weakening provisions like the individual mandate or the subsidies?

If Trump wants to reduce the whole structure of the ACA into unworkable rubble so that Democrats will have to agree to replace it, the administration will have to sabotage it. Unfortunately, there’s a pretty easy path for them to do it.

First, the administration could eliminate enforcement of the individual mandate, which requires Americans to buy health insurance or pay a tax penalty.

Second, the administration could cut outreach about open enrollment.

Third, if Trump wants to throw Obamacare’s exchanges into chaos, he could choose to stop defending a lawsuit filed by the House of Representatives that attempted to halt the government from making what are known as “cost-sharing reduction” payments to insurers. Under the Affordable Care Act, carriers are required to limit how much low-income customers pay out of pocket for things like deductibles and co-pays. In return, the companies are supposed to get direct subsidy payments from Washington to cover the expense. Those checks are worth billions to the industry, since more than half of marketplace enrollees benefit from cost-sharing reductions, and are absolutely essential to making the marketplaces work.

Republicans in the House of Representatives sued the Obama administration a few years ago to stop the payments, arguing that because Congress had never technically allocated the money to fund them, the government was disbursing the cash illegally. If Trump drops the appeal, it could have profoundly damaging consequences for the insurance market. Insurers would still be required to keep offering low-income customers their discounts but wouldn’t be compensated for it. The result would be financially disastrous.  Ending the cost-sharing reduction payments would require an active decision on the Trump administration’s part.

The Atlantic had a good article explaining the six signs that show how Trump will sabotage the Affordable Care Act.

  1.  Withdraw the appeal of the lawsuit that allows cost sharing reduction subsidies to insurers. The ACA subsidies at the center of the suit—otherwise known as cost-sharing reductions, which are different than the ACA tax credits for premiums—limit out-of-pocket costs for the 6 million people who both bought insurance through the ACA exchanges and who earn up to 250 percent of the federal poverty level. If insurers do not receive these funds, they may leave the exchanges altogether—ending coverage for customers.
  2. Refuse to enforce the individual mandate which is a Conservative idea to insure personal responsibility and accountability is designed to ensure healthier and therefore more stable insurance pools. The second major test to determine whether the President is choosing sabotage over governing will be if he directs his administration not to enforce the current individual-mandate provisions within the ACA.
  3. Refusing to advertise enrollment and shortening the time to enroll.  If the Trump administration reduces, it will be a clear indication that it is choosing sabotage over governing.
  4. Limiting risk corridors—a piece of the ACA designed to help health plans adjusting to new, unpredictable marketplaces. Additional funding is critical to ensuring stability in these relatively new marketplaces.  The program also lowers premiums for even non-subsidized enrollees who have been exposed to the highest premium hikes. Whether the Trump administration supports or opposes efforts to stabilize insurance markets, then, offers another crucial test.
  5. Whether Trump uses tweets, cell-phone calls, or White House meetings, investing time and political capital in to spur major health-care players to constructively participate in the ACA or conversely, to fear that if they do they will be on Trump’s black list, will be his fifth test.
  6. Will he issue regulations that weaken insurance? The hardest thing may be to detect an administration that avoids the most blatant acts of sabotage, but looks to kill the ACA with a thousand cuts. If the overwhelming number of health experts and consumer groups like the National Association of Insurance Commissioners, Kaiser Family Foundation, the American Cancer Society, AARP, and the Georgetown University Center on Health Insurance Reforms conclude it is an attack on the stability of the ACA—it should raise red flag that it is indeed a concerted effort to weaken the ACA.

Health-care experts agree with the Congressional Budget Office and S&P that the ACA is mostly stable—and as The New York Time’s Margot Sanger-Katz recently put it, “Obamacare is not on the verge of explosion.

Will he follow the law as his Constitutional oath requires or allows his supporters to lose health care?

The New York Times reported that the Congressional Budget Office said that around 24 million fewer Americans would have health insurance in 2026 under the Republican repeal plan than if the current law stayed in place.

The Republican bill would actually result in more people being uninsured than if Obamacare were simply repealed. Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to another recent C.B.O. report. In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates.

The people who would end up without health insurance are slightly different in the two cases. The current bill would cause more people to lose employer insurance, while a straight repeal bill would most likely cause more people who buy their own coverage to become uninsured. A simple repeal would be worse for Americans with pre-existing conditions, but the current bill would be worse for older Americans who are relatively healthy. Both approaches would lead to major reductions in the number of Americans covered by Medicaid.

The C.B.O. estimated what would happen after a simple repeal when it considered a bill that Congress passed last year. But the similarity of the two estimates highlights some of the difficulties of the current proposal, both for Democrats, who are strongly criticizing potential coverage losses, and for the repeal-or-die crowd, who hate the structure of this new bill.

The kind of full repeal that some Republicans are calling for would, of course, be hard to pass. Even if every member of their caucus supported the approach, most experts believe that repealing Obamacare’s major insurance provisions would require a type of legislation that would be vulnerable to a Senate filibuster, and would thus require at least eight Democratic votes.

All of the Republican approaches would result in meaningful reductions in the number of Americans with health coverage.

Healthcare Finance News reported that The Medicare Payment Advisory Commission (MedPAC) is recommending 5 percent payment cuts to home health agencies and inpatient rehabilitation facilities and no increases next year for long-term care hospitals, hospices, ambulatory surgical centers and skilled nursing facilities.

The bipartisan, 17-member commission recommends freezing skilled nursing facility payment rates for two years while the payment system is revised.

MedPAC said in its report to Congress that payment changes would ideally bring all types of post-acute care into a unified payment system.

“For years, the commission has noted that PAC (post-acute care) payment systems do not encourage efficient care and are not equitable across different patient stays,” the report said.

 

They also recommended requiring ambulatory surgical centers to submit cost data, eliminating therapy visits as a factor in payment, and expanding the inpatient rehabilitation facility outlier pool for high-cost enrollees.

In 2015, fee-for-service program spending on post-acute care services totaled $60 billion, according to the report.

Implementing its recommendations would reduce fee-for-service program spending by over $30 billion over the next 10 years, the report said.

If Congress had implemented the commission’s 2008 recommendations for skilled nursing facilities and home health agencies, spending would have been reduced by about $11 billion between 2009 and 2016, it said.

 

In 2016, MA enrollment increased by 5 percent to 17.5 million beneficiaries or 31 percent of all Medicare enrollees. The average beneficiary was able to choose from 18 Medicare Advantage plans in 2017.