‘An Arm and a Leg’: Host Dan Weissmann Talks Price Transparency on ‘Axios Today’

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As we settle into the new year, we have two small doses of good news.

First, a new federal rule could help cut through one health care issue. Host Dan Weissmann talked about the rule — which requires hospitals to make public the prices they negotiate with insurers — in a short conversation with his former public-radio colleague, Niala Boodhoo, for the daily-news podcast “Axios Today.”

You’ll find more detail on that rule in this story from reporter Celia Llopis-Jepsen, whose reporting about a $50,000 “air ambulance” ride formed the core of a recent episode about how consumers get squeezed by insurers on one side and providers on the other.

Later in the episode, a listener describes how he used what he learned from “An Arm and a Leg” to head off an insurance nightmare.

Here’s a transcript for this episode.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Aunque controlen el Senado, demócratas necesitarán apoyo republicano en temas clave de salud

Ante la pandemia, los demócratas han abogado por ayudas más generosas, más presión sobre las farmacéuticas para que bajen los precios y más atención al racismo sistémico en la atención de salud.

El 20 de enero, con el control del Senado y la Cámara de Representantes, tendrán el poder de elegir qué propuestas de salud se votarán en el Congreso.

Las victorias del reverendo Raphael Warnock y Jon Ossoff en Georgia dieron a los demócratas dos escaños más en el Senado y la ventaja en un Senado dividido 50-50. Cuando la vicepresidenta electa, Kamala Harris, jure el cargo, su voto servirá como desempate, convirtiéndose así en el voto 51 de los demócratas.

Pero este estrecho margen de votos no eliminará el “filibusteo” (discursos obstruccionistas y dilatorios), lo que significa que los demócratas no tendrán suficientes votos para aprobar muchos de sus planes sin los republicanos.

Eso pondrá en peligro muchas propuestas demócratas de salud, como la de ofrecer a los estadounidenses una opción de seguro público patrocinada por el gobierno, y complicará los esfuerzos para aprobar más ayudas para la pandemia.

Queda por ver si los legisladores serán más proclives al compromiso después que una turba pro-Trump invadiera el Capitolio, el 6 de enero, atacando a la policía y dañando propiedad federal. Hubo cinco muertos.

Los estrechos márgenes de los demócratas en el Senado y en la Cámara de Representantes — donde pueden permitirse perder cuatro votos y aun así aprobar una legislación— también darán más influencia a algunos legisladores que, al no estar de acuerdo con los líderes de sus partidos, tendrán un incentivo para impulsar sus propias agendas a cambio de sus votos.

Habrá poco espacio para los desacuerdos intrapartidarios; y los demócratas dejaron claro, durante las primarias presidenciales, que no están todos de acuerdo sobre cómo lograr sus objetivos de salud pública.

En menos de dos semanas, los demócratas dirigirán los comités encargados de establecer la legislación sobre salud y de examinar a los nominados de Biden en esta área.

El control del Comité de Salud, Educación, Trabajo y Pensiones del Senado pasará a la senadora Patty Murray, demócrata de Washington, quien negoció el acuerdo de 2013 con el entonces presidente de la Cámara de Representantes, Paul Ryan, que puso fin a un largo cierre del gobierno, entre otros acuerdos bipartidistas.

En 2019, Murray y el presidente republicano del comité, el senador Lamar Alexander, de Tennessee, introdujeron un amplio paquete legislativo para reducir los costos de salud. Entre sus propuestas se encontraba una iniciativa para bajar los precios de los medicamentos recetados, mediante la eliminación de las lagunas legales que permiten a los fabricantes de medicamentos de marca bloquear a la competencia.

Durante una entrevista, antes de que los demócratas se aseguren el Senado, Murray dijo que el trabajo de su comité se centrará en los problemas que impiden a los estadounidenses recibir un tratamiento médico equitativo y asequible.

La prioridad, dijo, serán las disparidades raciales, evidenciadas por los desproporcionados índices de mortalidad entre las madres de raza negras, y entre las comunidades de color, que sufren los peores impactos de la pandemia de covid-19.

“No todos los que acuden al médico reciben la misma atención, sienten el mismo nivel de comodidad y muchas veces no se les cree”, dijo Murray.

Murray aseguró que presionará a los senadores para que consideren el impacto en las comunidades de color de cada pieza legislativa. “Esa será la cuestión en cada paso que demos”, añadió.

El miércoles 6, pidió a los republicanos que se incorporen a la lucha contra la pandemia “con políticas que ayuden directamente a los que más sufren y que nos ayuden a salir de esta crisis con más fortaleza y justicia”.

“Con una administración Biden-Harris y una mayoría demócrata en el Senado, los desafíos que enfrentamos no serán menores, pero finalmente tenemos la oportunidad de enfrentarlos y comenzar a tomar medidas”, declaró Murray. “Estoy deseando ponerme manos a la obra”.

El Comité de Finanzas del Senado, que supervisa Medicare, Medicaid y las políticas fiscales relacionadas con la salud, estará encabezado por el senador Ron Wyden, demócrata de Oregon.

Si bien el comité HELP también celebrará una audiencia de confirmación para Xavier Becerra, el candidato de Biden a la Secretaría del Departamento de Salud y Servicios Humanos; es el Comité de Finanzas el que votará para avanzar su confirmación.

En diciembre, los republicanos del Senado amenazaron con retrasar la nominación de Becerra antes de que Biden lo anunciara oficialmente. Los republicanos le reprochan a Becerra su falta de experiencia en el campo de la salud, cuestionan su apoyo a un sistema de salud de un solo pagador y se oponen a su defensa del derecho al aborto.

Como fiscal general de California, Becerra se enfrentó a las demandas presentadas por los funcionarios estatales republicanos contra la Ley de Cuidado de Salud A Bajo Precio (ACA).

Pero se espera que la escasa ventaja de los demócratas en el Senado sea suficiente para rechazar las objeciones de los republicanos a la nominación.

El mes pasado, Wyden alabó el compromiso de Becerra para responder a la pandemia, proteger la cobertura de los cuidados de salud y abordar las disparidades raciales; y dijo que esperaba con interés la audiencia de Becerra “para que pueda ponerse a trabajar y empezar a ayudar a la gente durante esta crisis sin precedentes”.

Además, después de meses de denunciar los fracasos de la administración Trump en el manejo de la pandemia, los demócratas controlarán qué proyectos de ley de ayuda se votarán.

El paquete del mes pasado no incluyó sus demandas de más fondos para los gobiernos estatales y locales, y los republicanos de la Cámara de Representantes bloquearon una iniciativa demócrata que pretendía aumentar los cheques de estímulo de $600 a $2,000.

Los demócratas se han unido en sus demandas de más ayuda, aunque a veces han estado en desacuerdo sobre cómo llevarla a cabo.

En el otoño, con las elecciones cerca y sin ningún acuerdo a la vista, los demócratas moderados, que buscaban ganar su propia elección, presionaron a la presidenta de la Cámara de Representantes, Nancy Pelosi, para que abandonara las negociaciones por un paquete de ayuda de $2,2 billones, que los republicanos calificaron como un fracaso, y aprobara una ayuda más modesta pero desesperadamente necesaria.

“Tanto el liderazgo demócrata, como el republicano, ha metido la pata. Todos son responsables”, declaró a Politico el representante Max Rose, demócrata de Nueva York. “Hagan algo ¡Hagan algo!” Rose perdió la reelección.

Voces más progresistas, como la de la representante Alexandria Ocasio-Cortez, demócrata de Nueva York, y el senador Bernie Sanders, independiente de Vermont, han presionado a favor de una ayuda más generosa, con mayores cheques de estímulo.

Más allá de la pandemia, el liderazgo demócrata ha mencionado el precio de los medicamentos como otra área de acción. Pero una de sus propuestas más populares, que autorizaría al gobierno federal a negociar los precios de los medicamentos para quienes están en Medicare, es poco probable que atraiga los votos republicanos que necesitaría.

Cuando los demócratas de la Cámara de Representantes aprobaron una de estas propuestas en 2019, los senadores republicanos aseguraron que ellos nunca la aprobarían.

Los miembros del ala más progresista de los demócratas, por su parte, argumentaron que la propuesta no era suficientemente agresiva.

Sin embargo, después de años de esfuerzos republicanos por socavar ACA, parece probable que la estabilización de la ley pueda cobrar fuerza en un Congreso controlado por los demócratas.

La Cámara de Representantes aprobó, el verano pasado, una legislación destinada a aumentar la cobertura y la asequibilidad, incluyendo la limitación de los costos de los seguros a no más del 8,5% de los ingresos y la ampliación de los subsidios.

Legisladores como Murray y Wyden se han apresurado a señalar que las consecuencias devastadoras de la pandemia, la pérdida de puestos de trabajo y la pérdida de cobertura del seguro, por nombrar sólo dos, han puesto de relieve la necesidad de fortalecer el sistema de salud.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Even With Senate Control, Democrats Will Need Buy-In From GOP on Key Health Priorities

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Democrats have argued for more generous pandemic relief, more pressure on drugmakers to lower prices and more attention to systemic racism in health care. On Jan. 20, with control of the Senate and the House of Representatives, they’ll have the power to choose which health care proposals get a vote in Congress.

The victories of the Rev. Raphael Warnock and Jon Ossoff in Georgia last week gave Democrats two more Senate seats and the upper hand in the Senate’s now 50-50 split. After Vice President-elect Kamala Harris takes the oath of office, she will serve as the tiebreaker as needed — in effect, Democrats’ 51st vote.

But that vote count is too small to eliminate the filibuster, meaning Democrats will not have enough votes to pass many of their plans without Republicans. That will likely doom many Democratic health care proposals, like offering Americans a government-sponsored public insurance option, and complicate efforts to pass further pandemic relief.

It remains to be seen how willing lawmakers are to compromise with one another in the aftermath of a pro-Trump mob’s breach of the Capitol on Wednesday. Thursday, Democrats demanded the president’s removal for inciting rioters who disrupted the certification of President-elect Joe Biden’s victory, assaulted Capitol Police officers and damaged federal property. One demonstrator and a police officer were killed, and three demonstrators died of medical emergencies.

Democrats’ slim margins in the Senate and the House — where they can afford to lose only four votes and still pass legislation — will also give individual lawmakers more leverage, handing those who disagree with party leaders an incentive to push their own priorities in exchange for their votes. There will be little room for intraparty disagreements, and Democrats made it clear during the presidential primaries that they disagree about how to achieve their health care goals.

In less than two weeks, Democrats will lead the committees charged with marking up health care legislation and vetting Biden’s health nominees.

The change will hand control of the Senate Health, Education, Labor and Pensions Committee to Sen. Patty Murray (D-Wash.), who brokered the 2013 agreement with then-House Speaker Paul Ryan that ended a long government shutdown, among other bipartisan deals.

In 2019, Murray and the committee’s Republican chairman, Sen. Lamar Alexander of Tennessee, introduced a wide-ranging package to lower health costs for consumers. Among its proposals was an initiative to lower prescription drug prices by eliminating loopholes that allow brand-name drugmakers to block competition.

In an interview before Democrats secured the Senate, Murray said her committee work will be focused on the problems that prevent all Americans from receiving equitable, affordable treatment in health care. Racial disparities, evidenced by disproportionate mortality rates among Black mothers and among communities of color suffering the worst impacts of the pandemic, will be a priority, she said.

“Not everybody goes into the doctor and gets the same advice, feels the same comfort level and is believed,” Murray said.

Murray said she will press for senators to consider how any piece of legislation will affect communities of color. “It will be the question I ask about every step we take,” she said.

On Wednesday, she called out Republicans for standing in the way of fighting the pandemic “with policies that would directly help those struggling the most and would help us build back from this crisis stronger and fairer.”

“With a Biden-Harris Administration and a Senate Democratic majority, the challenges we face won’t get any less tough — but we’ve finally got the opportunity to face them head on and start taking action,” Murray said in a statement. “I can’t wait to start getting things done.”

The Senate Finance Committee, which oversees Medicare, Medicaid and health-related tax policies, will be run by Sen. Ron Wyden (D-Ore.). While the HELP committee will also hold a confirmation hearing for Biden’s nominee for secretary of the Department of Health and Human Services, Xavier Becerra, it is the Finance Committee that will vote to advance his confirmation.

Senate Republicans signaled they would delay considering Becerra’s nomination before Biden officially announced his name last month. Calling him unqualified due to his lack of a health care background, they questioned his support for a single-payer health care system and opposed his efforts to preserve abortion rights. As California’s attorney general, Becerra led efforts to fight lawsuits brought by Republican state officials against the Affordable Care Act.

But Democrats’ slim edge in the Senate is expected to be enough to drown out Republicans’ objections to the nomination. Last month, praising Becerra’s commitment to responding to the pandemic, protecting health care coverage and addressing racial disparities, Wyden said he looked forward to Becerra’s hearing “so he can get on the job and start helping people during this unprecedented crisis.”

Also, after months of decrying the Trump administration’s failures managing the pandemic, Democrats will control which relief bills get a vote.

Last month’s package did not include their demands for more funding for state and local governments, and House Republicans blocked a Democratic effort to increase stimulus checks to $2,000, from $600.

Democrats have been united in their calls for more assistance, though they have disagreed at times about how to push for it.

In the fall, with the election approaching and no deal in sight, moderate Democrats in tough races pushed for House Speaker Nancy Pelosi to abandon negotiations for a $2.2 trillion relief package that Republicans called a nonstarter in favor of passing more modest but desperately needed relief.

“Every member of the leadership team, Democrats and Republicans, have messed up. Everyone is accountable,” Rep. Max Rose (D-N.Y.) told Politico. “Get something done. Get something done!” He lost his bid for reelection.

More progressive voices like Rep. Alexandria Ocasio-Cortez (D-N.Y.) and Sen. Bernie Sanders (I-Vt.) have been a force for more generous aid, particularly larger stimulus checks.

Beyond the pandemic, top Democrats have mentioned drug pricing as another area ripe for action. But one of their most popular proposals, which would authorize the federal government to negotiate drug prices for those on Medicare, is unlikely to attract the Republican votes it would need. When House Democrats passed one such proposal in 2019, Senate Republicans vowed it would never pass.

Members of Democrats’ more progressive wing, for their part, argued the proposal may not go far enough.

After years of Republican efforts to undermine the Affordable Care Act, though, it looks likely that efforts to stabilize the law could gain more traction under a Democratic-controlled Congress. The House passed legislation last summer aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income and expanding subsidies.

Lawmakers like Murray and Wyden have been quick to point out that the pandemic’s devastating consequences — lost jobs and lost insurance coverage, to name just a couple — have only underscored the need to strengthen the health care system.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Trump Administration Approves First Medicaid Block Grant, in Tennessee

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With just a dozen days left in power, the Trump administration on Friday approved a radically different Medicaid financing system in Tennessee that for the first time would give the state broad authority in running the health insurance program for the poor in exchange for capping its annual federal funding.

The approval is a 10-year “experiment.” Instead of the open-ended federal funding that rises with higher enrollment and health costs, Tennessee will instead get an annual block grant. The approach has been pushed for decades by conservatives who say states too often chafe under strict federal guidelines about enrollment and coverage and can find ways to provide care more efficiently.

The approval, however, faces an uncertain future because the incoming Biden administration is likely to oppose such a move. But to unravel it, officials would need to set up a review that includes a public hearing.

Meanwhile, the changes in Tennessee will take months to implement because they need final legislative approval, and state officials must negotiate quality of care targets with the administration.

TennCare, the state’s Medicaid program, said the block grant system would give it unprecedented flexibility to decide who is covered and what services it will pay for.

It said the new arrangement would allow the state to keep part of the money it saves from operating the program more efficiently. Trump administration officials said the approach adds incentive for the state to save money, unlike the current system, in which increased state spending is matched with more federal dollars. If Medicaid enrollment grows, the state can secure additional federal funding. If enrollment drops, it will get less money.

“This groundbreaking waiver puts guardrails in place to ensure appropriate oversight and protections for beneficiaries, while also creating incentives for states to manage costs while holding them accountable for improving access, quality and health outcomes,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “It’s no exaggeration to say that this carefully crafted demonstration could be a national model moving forward.”

Opponents, including most advocates for low-income Americans, say the approach will threaten care for the 1.4 million people in TennCare, which includes children, pregnant women and the disabled. Federal funding covers two-thirds of the cost of the program.

Michele Johnson, executive director of the Tennessee Justice Center, said the block grant approval is a step backward for the state’s Medicaid program.

“No other state has sought a block grant, and for good reason. It gives state officials a blank check and creates financial incentives to cut health care to vulnerable families,” she said.

Democrats have fought back block grant Medicaid proposals since the Reagan administration and most recently in 2018 as part of Republicans’ failed effort to repeal and replace major parts of the Affordable Care Act. Even some key Republicans opposed the idea because it would cut billions in funding to states that would make it harder to help the poor.

Implementing block grants via an executive branch action rather than getting Congress to amend Medicaid law is also likely to be met with court challenges.

The block grant approval comes as Medicaid enrollment is at its highest ever level.

More than 76 million Americans are covered by the state-federal health program, a million more than when the Trump administration took charge in 2017. Enrollment has jumped by more than 5 million in the past year as the economy slumped with the pandemic.

Medicaid, part of President Lyndon B. Johnson’s “Great Society” initiative of the 1960s, is an entitlement program in which the government pays each state a certain percentage of the cost of care for anyone eligible for the health coverage. As a result, the more money states spend on Medicaid, the more they get from Washington.

Under the approved demonstration, CMS will work with Tennessee to set spending targets that will increase at a fixed amount each year.

The plan includes a “safety valve” to increase federal funding due to unexpected increases in enrollment.

“The safety valve will maintain Tennessee’s commitment to enroll all eligible Tennesseans with no reduction in today’s benefits for beneficiaries,” CMS said in a statement.

Tennessee has committed to maintaining coverage for eligible beneficiaries and existing services.

In exchange for taking on this financing approach, the state will receive a range of operating flexibilities from the federal government, as well as up to 55% of the savings generated on an annual basis when spending falls below the aggregate spending cap and the state meets certain quality targets, yet to be determined.

The state can spend that money on various health programs for residents, including areas that Medicaid funding typically doesn’t cover, such as improving transportation and education and employment.

The 10-year waiver is unusual, but the Trump administration has approved such long-term experiments in recent years to give states more flexibility.

Tennessee is one of 12 states that have not approved expanding Medicaid under the Affordable Care Act that’s left tens of thousands of working adults without health insurance.

“The block grant is just another example of putting politics ahead of health care during this pandemic,” said Johnson of the Tennessee Justice Center. “Now is absolutely not the time to waste our energy and resources limiting who can access health care.”

State officials applauded the approval.

“It’s a legacy accomplishment,” said Tennessee Gov. Bill Lee, a Republican. “This new flexibility means we can work toward improving maternal health coverage and clearing the waiting list for developmentally disabled.”

“This means we will be able to make additional investments in TennCare without reduction in services and provider cuts.”

KHN chief Washington correspondent Julie Rovner contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Biden’s First Order of Business May Be to Undo Trump’s Policies, but It Won’t Be Easy

The party split in Congress is so slim that, even with Democrats technically in the majority, passing major health care legislation will be extremely difficult. So speculation about President-elect Joe Biden’s health agenda has focused on the things he can accomplish using executive authority. Although there is a long list of things he could do, even longer is the list of things he is being urged to undo — actions taken by President Donald Trump.

While Trump was not able to make good on his highest-profile health-related promises from his 2016 campaign — including repealing the Affordable Care Act and broadly lowering prescription drug prices — his administration did make substantial changes to the nation’s health care system using executive branch authority. And many of those changes are anathema to Democrats, particularly those aimed at hobbling the ACA.

For example, the Trump administration made it easier for those who buy their own insurance to purchase cheaper plans that don’t cover all the ACA benefits and may not cover preexisting conditions. It also eliminated protections from discrimination in health care to people who are transgender.

Trump’s use of tools like regulations, guidance and executive orders to modify health programs “was like an attack by a thousand paper cuts,” said Maura Calsyn, managing director of health policy at the Center for American Progress, a Democratic think tank. Approaching the November election, she said, “the administration was in the process of doing irreparable harm to the nation’s health care system.”

Reversing many of those changes will be a big part of Biden’s health agenda, in many cases coming even before trying to act on his own campaign pledges, such as creating a government-sponsored health plan for the ACA.

Chris Jennings, a health adviser to Presidents Barack Obama and Bill Clinton, said he refers to those Trump health policies as “bird droppings. As in you have to clean up the bird droppings before you have a clean slate.”

Republicans, when they take over from a Democratic administration, think of their predecessor’s policies the same way.

Though changing policies made by the executive branch seems easy, that’s not always the case.

“These are issue-by-issue determinations that must be made, and they require process evaluation, legal evaluation, resource consideration and timeliness,” said Jennings. In other words, some policies will take more time and personnel resources than others. And health policies will have to compete for White House attention with policies the new administration will want to change on anything from the environment to immigration to education.

Even within health care, issues as diverse as the operations of the ACA marketplaces, women’s reproductive health and stem cell research will vie to be high on the list.

A Guide to Executive Actions

Some types of actions are easier to reverse than others.

Executive orders issued by the president, for example, can be summarily overturned by a new executive order. Agency “guidance” can similarly be written over, although the Trump administration has worked to make that more onerous.

Since the 1980s, for example, every time the presidency has changed parties, one of the incoming president’s first actions has been to issue an executive order to either reimpose or eliminate the “Mexico City Policy” that governs funding for international family planning organizations that “perform or promote” abortion. Why do new administrations address abortion so quickly? Because the anniversary of the landmark Supreme Court abortion decision Roe v. Wade is two days after Inauguration Day, so the action is always politically timely.

Harder to change are formal regulations, such as one effectively banning Planned Parenthood from the federal family planning program, Title X. They are governed by a law, the Administrative Procedure Act, that lays out a very specific — and often time-consuming — process. “You have to cross your t’s and dot your legal i’s,” said Nicholas Bagley, who teaches administrative law at the University of Michigan Law School.

And if you don’t? Then regulations can be challenged in court — as those of the Trump administration were dozens of times. That’s something Biden officials will take pains to avoid, said Calsyn. “I would expect to see very deliberate notice and comment rule-making, considering the reshaped judiciary” with so many Trump-appointed judges, she said.

What Comes First?

Undoing a previous administration’s actions is an exercise in trying to push many things through a very narrow tube in a short time. Department regulations have to go not just through the leadership in each department, but also through the Office of Management and Budget “for a technical review, cost-benefit analysis and legal authority,” said Bagley. “That can take time.”

Complicating matters, many health regulations emanate not just from the Department of Health and Human Services, but jointly from HHS and other departments, including Labor and Treasury, which likely means more time to negotiate decisions among multiple departments.

Finally, said Bagley, “for really high-profile things, you’ve got to get the president’s attention, and he’s got limited time, too.” Anything pandemic-related is likely to come first, he said.

Some items get pushed to the front of the line because of calendar considerations, as with the abortion executive orders. Others need more immediate attention because they are part of active court cases.

“You have all these court schedules and briefing schedules that will dictate the timeline where they make all these decisions,” said Katie Keith, a health policy researcher and law professor at Georgetown University.

The Trump administration’s efforts to allow states to set work requirements for many low-income adults who gained Medicaid coverage under the Affordable Care Act’s expansion of the program is the highest-profile Trump action that falls into that latter category. The Supreme Court has agreed to hear a case challenging HHS approval of work requirements for Arkansas and New Hampshire in the next few months. Some Democrats are concerned about how the high court, with its new conservative majority, might rule, and the Biden administration will have to move fast if officials decide they want to head off that case.

But court actions also might help the Biden administration short-circuit the onerous regulatory process. If a regulation the new administration wants to rewrite or repeal has already been blocked by a court, Biden officials can simply choose not to appeal that ruling. That’s what Trump did in ending insurance company subsidies for enrollees with low incomes in 2017.

Allowing a lower-court ruling to stand, however, is not a foolproof strategy. “That raises the possibility of having someone [else] intervene,” said Keith. For example, Democratic attorneys general stepped in to defend the ACA in a case now pending at the Supreme Court when the Trump administration chose not to. “So, you have to be pretty strategic about not appealing,” she said.

Adding On?

One other big decision for the incoming administration is whether it wants to use the opportunity to tweak or add to Trump policies rather than eliminate them. “Is it undoing and full stop?” asked Keith. “Or undoing and adding on?”

She said there is “a full slate of ideologically neutral” policies Trump put out, including ones on price transparency and prescription drugs. If Biden officials don’t want to keep those as they are, they can rewrite them and advance other policies at the same time, saving a round of regulatory effort.

But none of it is easy — or fast.

One big problem is just having enough bodies available to do the work. “There was so much that undermined and hollowed out the federal workforce; there’s a lot of rebuilding that needs to done,” said Calsyn of the Center for American Progress. And Trump officials ran so roughshod over the regulatory process in many cases, she said, “even putting those processes back in place is going to be hard.”

Incoming officials will also have other time-sensitive work to do. Writing regulations for the newly passed ban on “surprise” medical bills will almost certainly be a giant political fight between insurers and health care providers, who will try to re-litigate the legislation as it is implemented. Rules for insurers who sell policies under the ACA will need to be written almost immediately after Biden takes office.

Anyone waiting for a particular Trump policy to be wiped from the books will likely have to pack their patience. But law professor Bagley said he’s optimistic it will all get done.

“One of the things we’ve grown unaccustomed to is a competent administration,” he said. “When people are competent, they can do a lot of things pretty quickly.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: Georgia Turns the Senate Blue

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Surprise Democratic victories in Georgia’s two runoff elections this week will give Democrats control of the Senate, which means they will be in charge of both houses of Congress and the White House for the first time since 2010. Although the narrow majorities in the House and Senate will likely not allow Democrats to pass major expansions to health programs, it will make it easier to do things such as pass fixes for the Affordable Care Act.

Meanwhile, the speedy development and approval of vaccines to protect against covid-19 is being squandered by the lack of a national strategy to get those vaccines into people’s arms. Straightening out and speeding up vaccinations will be a major priority for the incoming administration of President-elect Joe Biden.

This week’s panelists are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Georgia election results will make it easier for some of Biden’s Cabinet picks to be confirmed, including Xavier Becerra, his choice to head the Department of Health and Human Services.
  • Among the ACA fixes that congressional Democrats may seek is a restoration of a small penalty for people who do not have health coverage. That could negate the case before the Supreme Court now that was brought by Republican state officials.
  • One strategic error in the covid vaccine distribution efforts was that the release of the vaccine was not coupled with a major messaging campaign to explain what the vaccine does and dispel fears about it.
  • Late last month, a federal court blocked the Trump administration from implementing a plan to tie what Medicare pays for some drugs to the prices in other countries. It’s not clear if the Biden administration will continue the legal fight to keep the program, but the president-elect has suggested he is more interested in bringing down drug prices by negotiating with manufacturers.
  • The Trump administration has sued retail giant Walmart, alleging it unlawfully dispensed opioids from its pharmacies.

Also, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “One Hospital System Sued 2,500 Patients After Pandemic Hit,” by Brian M. Rosenthal

Alice Miranda Ollstein: Politico’s “Congress Using COVID Test That FDA Warns May Be Faulty,” by David Lim and Sarah Ferris

Mary Ellen McIntire: Bloomberg News’ “The World’s Most Loathed Industry Gave Us a Vaccine in Record Time,” by Drew Armstrong

Anna Edney: STAT News’ “How It Started: A Q&A With Helen Branswell, One Year After Covid-19 Became a Full-Time Job,” by Jason Ukman

To hear all our podcasts, click here.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Illinois, primer estado en ofrecer cobertura médica a adultos mayores indocumentados

Como jefa de enfermería en uno de los hospitales más concurridos de la red de seguridad de atención médica de Chicago, Raquel Prendkowski ha sido testigo del devastador número de víctimas que COVID-19 ha causado entre los residentes más vulnerables de la ciudad, incluyendo a personas que no tienen seguro médico por su estatus migratorio.

Algunos llegan tan enfermos que van directo a cuidados intensivos. Muchos no sobreviven.

“Vivimos una pesadilla constante”, dijo Prendkowski mientras trataba a pacientes con coronavirus en el Hospital Mount Sinai, fundado a principios del siglo XX para atender a los inmigrantes más pobres. “Ojalá salgamos pronto de esto”.

La enfermera cree que algunas muertes, y mucho sufrimiento, podrían haberse evitado si estas personas hubieran tenido un tratamiento regular para todo tipo de condiciones crónicas —asma, diabetes, enfermedades del corazón— que pueden empeorar COVID-19.

Y ahora se siente esperanzada.

En medio del brote del mortal virus que ha afectado de manera desproporcionada a las comunidades hispanas, Illinois se convirtió recientemente en el primer estado de la nación en extender el seguro médico público a todos los adultos mayores no ciudadanos de bajos ingresos, incluso si son indocumentados.

Defensores de los inmigrantes esperan que inspire a otros estados a hacer lo mismo. De hecho, legisladores demócratas de California están presionando para expandir su Medicaid a todos los inmigrantes indocumentados del estado.

“Hacer esto durante la pandemia muestra nuestro compromiso con la expansión y ampliación del acceso a la atención de salud. Es un gran primer paso”, señaló Graciela Guzmán, directora de campaña de Healthy Illinois, que promueve la cobertura universal en el estado.

Muchos inmigrantes indocumentados sin cobertura de salud no van al médico. Ese fue el caso de Victoria Hernández, una limpiadora de casas de 68 años que vive en West Chicago, Illinois. La mujer, nativa de la Ciudad de México dijo que, cuando no tenía seguro, simplemente no iba al médico.

Soportaba cualquier dolencia hasta que encontró un programa de caridad que la ayudó a  tratar su prediabetes. Dijo que tiene la intención de inscribirse en el nuevo plan estatal una vez que tenga más información.

“Estoy muy agradecida por el nuevo programa”, explicó a través de un traductor que trabaja para DuPage Health Coalition, una organización sin fines de lucro que coordina la atención de caridad para personas sin seguro médico como Hernández en el condado de DuPage, el segundo más poblado del estado. “Sé que ayudará a mucha gente como yo. Sé que tendrá buenos resultados, muy, muy buenos resultados”.

Primero, Healthy Illinois intentó ampliar los beneficios de Medicaid a todos los inmigrantes de bajos ingresos, pero los legisladores decidieron empezar con un programa más pequeño, que cubre a adultos mayores de 65 años o más que son indocumentados, o que han sido residentes permanentes, tienen tarjeta verde, por menos de cinco años (este grupo no califica para seguro de salud auspiciado por el gobierno).

Los participantes deben tener ingresos que estén en o por debajo del nivel de pobreza federal, que es de $12,670 para un individuo o $17,240 para una pareja. Cubre servicios como visitas al hospital y al médico, medicamentos recetados, y atención dental y oftalmológica (aunque no estancias en centros de enfermería), sin costo para el paciente.

La nueva norma continúa la tendencia de expandir la cobertura de salud del gobierno a los inmigrantes sin papeles.

Illinois fue el primer estado que cubrió la salud de niños indocumentados y también los transplantes de órganos. Otros estados y el Distrito de Columbia lo hicieron después.

El año pasado, California fue el primero en ofrecer cobertura pública a los adultos indocumentados, cuando amplió la elegibilidad para su programa Medi-Cal a todos los residentes de bajos ingresos menores de 26 años.

Según la ley federal, las personas indocumentadas generalmente no son elegibles para Medicare, Medicaid que no es de emergencia y el mercado de seguros de salud de la Ley de Cuidado de Salud a Bajo Precio (ACA). Los estados que ofrecen cobertura a esta población lo hacen usando sólo fondos estatales.

Se estima que en Illinois viven 3,986 adultos mayores indocumentados, según un estudio del Centro Médico de la Universidad de Rush y el grupo de demógrafos de Chicago Rob Paral & Associates; y se espera que el número aumente a 55,144 para 2030. El informe también encontró que el 16% de los inmigrantes de Illinois de 55 años o más viven en la situación de pobreza, en comparación con el 11% de la población nacida en el país.

Dado que la administración saliente de Trump ha promovido duras medidas migratorias, sectores del activismo pro inmigrante temen que haya miedo a inscribirse en el nuevo programa porque podría afectar la capacidad de obtener la residencia o la ciudadanía en el fututo, y trabajan para asegurarles que no lo hará.

“Illinois cuenta con un legado de ser un estado que acepta al recién llegado y de proteger la privacidad de los inmigrantes”, señaló Andrea Kovach, abogada que trabaja en equidad en la salud en el Shriver Center for Poverty Law en Chicago.

Se espera que la normativa cubra inicialmente de 4,200 a 4,600 inmigrantes mayores, a un costo aproximado de entre $46 millones a $50 millones al año, según John Hoffman, vocero del Departamento de Salud y Servicios Familiares de Illinois.

Algunos representantes estatales republicanos criticaron la expansión de la cobertura, diciendo que era imprudente hacerlo en un momento en que las finanzas de Illinois sufren por la pandemia. En una declaración condenando el presupuesto estatal de este año, el Partido Republicano de Illinois lo denominó “atención de la salud gratuito para los inmigrantes ilegales”.

Pero los defensores de la nueva política sostienen que muchos inmigrantes sin papeles pagan impuestos sin ser elegibles para programas como Medicare y Medicaid, y que gastar por adelantado en cuidados preventivos ahorra dinero, a largo plazo, al reducir el número de personas que esperan para buscar tratamiento hasta que es una emergencia.

Para Delia Ramírez, representante estatal de Illinois, ampliar la cobertura de salud a todos los adultos mayores de bajos ingresos es personal. A la demócrata de Chicago la inspira su tío, un inmigrante de 64 años que no tiene seguro.

Dijo que intentó que la legislación cubriera a las personas de 55 años o más, ya que la gran mayoría de los indocumentados no son personas mayores (señaló que muchos de los inmigrantes mayores —2,7 millones, según estimaciones del gobierno— obtuvieron el estatus legal con la ley de amnistía federal de 1986).

Un mayor número de inmigrantes más jóvenes también pueden estar sin seguro. En los Centros de Salud Esperanza, uno de los mayores proveedores de atención médica para inmigrantes de Chicago, el 31% de los pacientes de 65 años o más carece de cobertura, en comparación con el 47% de los de 60 a 64 años, según Jeffey McInnes, que supervisa el acceso de los pacientes a las clínicas.

Ramírez dijo que su tío la llamó después de ver las noticias sobre la nueva legislación en la televisión en español. Contó que su tío ha vivido en el país por cuatro décadas y ha trabajado para que sus cuatro hijos fueran a la universidad. También padece asma, diabetes e hipertensión, lo que lo hace de alto riesgo para COVID-19.

“Yo le dije: ‘Tío, todavía no. Pero cuando cumplas 65 años, finalmente tendrás atención médica, si es que aún no hemos conseguido legalizarte”, recordó Ramírez, emocionada, durante una reciente entrevista telefónica.

“Así que es un recordatorio para mí de que, en primer lugar, fue una gran victoria para nosotros y ha significado la vida o una segunda oportunidad de vida para muchas personas”, dijo. “Pero también significa que todavía tenemos un largo camino por recorrer para hacer de la atención de salud un verdadero derecho humano en el estado, y en la nación”.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Illinois Is First in the Nation to Extend Health Coverage to Undocumented Seniors

As a nurse manager for one of Chicago’s busiest safety-net hospitals, Raquel Prendkowski has witnessed covid-19’s devastating toll on many of the city’s most vulnerable residents — including people who lack health insurance because of their immigration status. Some come in so sick they go right to intensive care. Some don’t survive.

“We’re in a bad dream all the time,” she said during a recent day treating coronavirus patients at Mount Sinai Hospital, which was founded in the early 20th century to care for the city’s poorest immigrants. “I can’t wait to wake up from this.”

Prendkowski believes some of the death and suffering could have been avoided if more of these people had regular treatment for the types of chronic conditions — asthma, diabetes, heart disease — that can worsen covid. She now sees a new reason for hope.

Amid a deadly virus outbreak that has disproportionately stricken Latino communities, Illinois recently became the first state to provide public health insurance to all low-income noncitizen seniors, even if they’re in the country illegally. Advocates for immigrants expect it will inspire other states to do the same, building on efforts to cover undocumented children and young adults. Currently, Democratic legislators in California are pushing to expand coverage to all low-income undocumented immigrants there.

“The fact that we’re going to do this during the pandemic really shows our commitment to expansion and broadening health care access. It’s an amazing first step in the door,” said Graciela Guzmán, campaign director for Healthy Illinois, a group that advocates for universal coverage.

Undocumented immigrants without health insurance often skip care. That was the case for Victoria Hernandez, 68, a house cleaner who lives in West Chicago, a suburb. The Mexico City native said she had avoided going to the doctor because she didn’t have coverage. Eventually, she found a charity program to help her get treatment, including for her prediabetes. She said she intends to enroll in the new state plan.

“I’m very thankful for the new program,” she said through a translator who works for the DuPage Health Coalition, a nonprofit that coordinates charity care for the uninsured in DuPage County, the state’s second-most populous. “I know it will help a lot of people like me.”

Healthy Illinois pushed state lawmakers to offer health benefits to all low-income immigrants. But the legislature opted instead for a smaller program that covers people 65 and older who are undocumented or have been legal permanent residents, also known as green card holders, for less than five years. (These groups don’t typically qualify for government health insurance.) Participants must have an income at or below the federal poverty level, which is $12,670 for an individual or $17,240 for a couple. It covers services like hospital and doctor visits, prescription drugs, and dental and vision care (though not stays in nursing facilities), at no cost to the patient.

The new policy continues a trend of expanding government health coverage to undocumented immigrants.

Illinois was the first state to cover children’s care — a handful of states and the District of Columbia have since followed suit — and organ transplants for unauthorized immigrants. In 2019, California became the first to offer public coverage to adults in the country illegally when it opened eligibility for its Medi-Cal program to all low-income residents under age 26.

Under federal law, undocumented people are generally not eligible for Medicare, nonemergency Medicaid and the Affordable Care Act’s health insurance marketplace. The states that do cover this population get around that by using only state funds.

An estimated 3,986 undocumented seniors live in Illinois, according to a study by Rush University Medical Center and the Chicago demographer group Rob Paral & Associates — but that number is expected to grow to 55,144 by 2030. The report also found that 16% of Illinois immigrants 55 or older live in poverty, compared with 11% of the native-born population.

Given the outgoing Trump administration’s crackdown on immigration, some advocates worry that people will be afraid to enroll in the insurance because it could affect their ability to obtain residency or citizenship. Andrea Kovach, senior attorney for health care justice at the Shriver Center on Poverty Law in Chicago, said she and others are working to assure immigrants they don’t need to worry. Because the new program is state-funded, federal guidance suggests it is not subject to the “public charge” rule designed to keep out immigrants who might end up on public assistance.

“Illinois has a legacy of being a very welcoming state and protecting immigrants’ privacy,” Kovach said.

The Illinois policy is initially expected to cover 4,200 to 4,600 immigrant seniors, at an approximate cost of $46 million to $50 million a year, according to John Hoffman, a spokesperson for the Illinois Department of Healthcare and Family Services. Most of them would likely be undocumented.

Some Republicans criticized the coverage expansion, saying it was reckless at a time when Illinois’ finances are being shredded by the pandemic. The Illinois Republican Party deemed it “free healthcare for illegal immigrants.”

But proponents contend that many unauthorized immigrants pay taxes without being eligible for programs like Medicare and Medicaid, and that spending on preventive care saves money in the long run by cutting down on more expensive treatment for emergencies.

State Rep. Delia Ramirez, a Chicago Democrat who helped shepherd the legislation, advocated for a more expansive plan. She was inspired by her uncle, a 64-year-old immigrant who has asthma, diabetes and high blood pressure but no insurance. He has been working in the country for four decades.

She wanted the policy to apply to people 55 and older, since the vast majority of those who are undocumented are not seniors (she noted that a lot of older immigrants — 2.7 million, according to government estimates — obtained legal status under the 1986 federal amnesty law).

The real impact of this plan will likely be felt in years to come. At Esperanza Health Centers, one of Chicago’s largest providers of health care to immigrants, 31% of patients 65 and older lack coverage, compared with 47% of those 60 to 64, according to Jeffrey McInnes, who oversees patient access there.

Ramirez said her uncle called her after seeing news of the legislation on Spanish-language TV.

“And I said to him, ‘Tío, not yet. But when you turn 65, you’ll finally have health care, if we still can’t help you legalize,’” Ramirez recalled, choking up during a recent phone interview.

“So it is a reminder to me that, one, it was a major victory for us and it has meant life or a second chance at life for many people,” she said. “But it is also a reminder to me that we still have a long way to go in making health care truly a human right in the state and, furthermore, the nation.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: A Look Back at 2020 — What We Learned and Where We’re Headed

Can’t see the audio player? Click here to listen.

This episode turns the tables: Host Dan Weissmann gets interviewed about what he learned in 2020 and what’s ahead for the show — with T.K. Dutes, a radio host and podcast-maker who is also a former nurse, so she knows a thing or two about the health care system. She chronicled her career transition in an episode of NPR’s “Life Kit.”

During their conversation, Dutes shared stories about life before and after health insurance. She coins what could be a new tagline for “An Arm and a Leg”: “Where there’s money, there’ll be scams.”

Here’s a transcript of the episode.

For more of Dutes’ work, check out “Open World,” a podcast she published recently with Rose Eveleth. The first episode features a reading by and discussion with the writer N.K. Jemisin, who won a MacArthur “genius” award the day after the show came out. (Clearly, the MacArthur folks were listening.)

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Many Health Plans Now Must Cover Full Cost of Expensive HIV Prevention Drugs

Ted Howard started taking Truvada a few years ago because he wanted to protect himself against HIV, the virus that causes AIDS. But the daily pill was so pricey he was seriously thinking about giving it up.

Under his insurance plan, the former flight attendant and customer service instructor owed $500 in copayments every month for the drug and an additional $250 every three months for lab work and clinic visits.

Luckily for Howard, his doctor at Las Vegas’ Huntridge Family Clinic, which specializes in LGBTQ care, enrolled him in a clinical trial that covered his medication and other costs in full.

“If I hadn’t been able to get into the trial, I wouldn’t have kept taking PrEP,” said Howard, 68, using the shorthand term for “preexposure prophylaxis.” Taken daily, these drugs — like Truvada — are more than 90% effective at preventing infection with HIV.

Starting this month, most people with private insurance will no longer have to decide whether they can afford to protect themselves against HIV. Most health plans must begin to cover the drugs then without charging consumers anything out-of-pocket (some plans already began doing so last year).

Drugs in this category — Truvada, Descovy and, newly available, a generic version of Truvada — received an “A” recommendation by the U.S. Preventive Services Task Force. Under the Affordable Care Act, preventive services that receive an “A” or “B” rating by the task force, a group of medical experts in prevention and primary care, must be covered by most private health plans without making members share the cost, usually through copayments or deductibles. Only plans that are grandfathered under the health law are exempt.

The task force recommended PrEP for people at high risk of HIV infection, including men who have sex with men and injection drug users.

In the United States, more than 1 million people live with HIV, and nearly 40,000 new HIV cases are diagnosed every year. Yet fewer than 10% of people who could benefit from PrEP are taking it. One key reason is that out-of-pocket costs can exceed $1,000 annually, according to a study published in the American Journal of Public Health last year. Required periodic blood tests and doctor visits can add hundreds of dollars to the cost of the drug, and it’s not clear if insurers are required to pick up all those costs.

“Cost sharing has been a problem,” said Michael Crews, policy director at One Colorado, an advocacy group for the LGBTQ community. “It’s not just getting on PrEP and taking a pill. It’s the lab and clinical services. That’s a huge barrier for folks.”

Whether you’re shopping for a new plan during open enrollment or want to check out what your current plan covers, here are answers to questions you may have about the new preventive coverage requirement.

Q: How can people find out whether their health plan covers PrEP medications without charge?

The plan’s list of covered drugs, called a formulary, should spell out which drugs are covered, along with details about which drug tier they fall into. Drugs placed in higher tiers generally have higher cost sharing. That list should be online with the plan documents that give coverage details.

Sorting out coverage and cost sharing can be tricky. Both Truvada and Descovy can also be used to treat HIV, and if they are taken for that purpose, a plan may require members to pay some of the cost. But if the drugs are taken to prevent HIV infection, patients shouldn’t owe anything out-of-pocket, no matter which tier they are on.

In a recent analysis of online formularies for plans sold on the ACA marketplaces, Carl Schmid, executive director of the HIV + Hepatitis Policy Institute, found that many plans seemed out of compliance with the requirement to cover PrEP without cost sharing this year.

But representatives for Oscar and Kaiser Permanente, two insurers that were called out in the analysis for lack of compliance, said the drugs are covered without cost sharing in plans nationwide if they are taken to prevent HIV. Schmid later revised his analysis to reflect Oscar’s coverage.

Coverage and cost-sharing information needs to be transparent and easy to find, Schmid said.

“I acted like a shopper of insurance, just like any person would do,” he said. “Even when the information is correct, [it’s so] difficult to find [and there’s] no uniformity.”

It may be necessary to call the insurer directly to confirm coverage details if information on the website is unclear.

Q: Are all three drugs covered without cost sharing?

Health plans have to cover at least one of the drugs in this category — Descovy and the brand and generic versions of Truvada — without cost sharing. People may have to jump through some hoops to get approval for a specific drug, however. For example, Oscar plans sold in 18 states cover the three PrEP options without cost sharing. The generic version of Truvada doesn’t require prior authorization by the insurer. But if someone wants to take the name-brand drug, they have to go through an approval process. Descovy, a newer drug, is available without cost sharing only if people are unable to use Truvada or its generic version because of clinical intolerance or other issues.

Q: What about the lab work and clinical visits that are necessary while taking PrEP? Are those services also covered without cost sharing?

That is the thousand-dollar question. People who are taking drugs to prevent HIV infection need to meet with a clinician and have bloodwork every three months to test for HIV, hepatitis B and sexually transmitted infections, and to check their kidney function.

The task force recommendation doesn’t specify whether these services must also be covered without cost sharing, and advocates say federal guidance is necessary to ensure they are free.

“If you’ve got a high-deductible plan and you’ve got to meet it before those services are covered, that’s going to add up,” said Amy Killelea, senior director of health systems and policy at the National Alliance of State & Territorial AIDS Directors. “We’re trying to emphasize that it’s integral to the intervention itself.”

A handful of states have programs that help people cover their out-of-pocket costs for lab and clinical visits, generally based on income.

There is precedent for including free ancillary care as part of a recommended preventive service. After consumers and advocates complained, the Centers for Medicare & Medicaid Services (CMS) clarified that under the ACA removing a polyp during a screening colonoscopy is considered an integral part of the procedure and patients shouldn’t be charged for it.

CMS officials declined to clarify whether PrEP services such as lab work and clinical visits are to be covered without cost sharing as part of the preventive service and noted that states generally enforce such insurance requirements. “CMS intends to contact state regulators, as appropriate, to discuss issuer’s compliance with the federal requirements and whether issuers need further guidance on which services associated with PrEP must be covered without cost sharing,” the agency said in a statement.

Q: What if someone runs into roadblocks getting a plan to cover PrEP or related services without cost sharing?

If an insurer charges for the medication or a follow-up visit, people may have to go through an appeals process to fight it.

“They’d have to appeal to the insurance company and then to the state if they don’t succeed,” said Nadeen Israel, vice president of policy and advocacy at the AIDS Foundation of Chicago. “Most people don’t know to do that.”

Q: Are uninsured people also protected by this new cost-sharing change for PrEP?

Unfortunately, no. The ACA requirement to cover recommended preventive services without charging patients applies only to private insurance plans. People without insurance don’t benefit. Gilead, which makes both Truvada and Descovy, has a patient assistance program for the uninsured.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospital Prices Just Got a Lot More Transparent. What Does This Mean for You?

Hospitals face the new year with new requirements to post price information they have long sought to obscure: the actual prices negotiated with insurers and the discounts they offer their cash-paying customers.

The move is part of a larger push by the Trump administration to use price transparency to curtail prices and create better-informed consumers. Yet there is disagreement on whether it will do so.

As of Jan. 1, facilities must publicly post on their websites prices for every service, drug and supply they provide. Next year, under a separate rule, health insurers must take similar steps. A related effort to force drugmakers to list their prices in advertisements was struck down by the courts.

With the new hospital rule, consumers should be able to see the tremendous variation in prices for the exact same care among hospitals and get an estimate of what they will be charged for care — before they seek it.

The new data requirements go well beyond the previous rule of requiring hospitals to post their “chargemasters,” hospital-generated list prices that bear little relation to what it costs a hospital to provide care and that few consumers or insurers actually pay.

Instead, under the new rule put forward by the Trump administration, “these are the real prices in health care,” said Cynthia Fisher, founder and chairman of Patient Rights Advocate, a group that promotes price transparency.

Here’s what consumers should know:

What’s the Scope of the Intel?

Each hospital must post publicly online — and in a machine-readable format easy to process by computers — several prices for every item and service they provide: gross charges; the actual, and most likely far lower, prices they’ve negotiated with insurers, including de-identified minimum and maximum negotiated charges; and the cash price they offer patients who are uninsured or not using their insurance.

In addition, each hospital must make available, in a “consumer-friendly format,” the specific costs for 300 common and “shoppable” services, such as having a baby, getting a joint replacement, having a hernia repair or undergoing a diagnostic brain scan.

Those 300 bundles of procedures and services must total all costs involved — from the hardware used to the operating room time, to drugs given and the fees of hospital-employed physicians — so patients won’t have to attempt the nearly impossible job of figuring it out themselves.

Hospitals can mostly select which services fall into this category, although the federal government has dictated 70 that must be listed — including certain surgeries, diagnostic tests, imaging scans, new patient visits and psychotherapy sessions.

Will Prices Be Exact?

No. At best, these are ballpark figures.

Other factors influence consumers’ costs, like the type of insurance plan a patient has, the size and remaining amount of the annual deductible, and the complexity of the medical problem.

An estimate on a surgery, for example, might prove inexact. If all goes as expected, the price quoted likely will be close. But unexpected complications could arise, adding to the cost.

“You’ll get the average price, but you are not average,” said Gerard Anderson, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health who studies hospital pricing.

Tools to help consumers determine in advance the amount of deductible they’ll owe are already available from many insurers. And experts expect the additional information being made available this month will prompt entrepreneurs to create their own apps or services to help consumers analyze the price data.

For now, though, the hospital requirements are a worthy start, say experts.

“It’s very good news for consumers,” said George Nation, a professor of law and business at Lehigh University who studies hospital pricing. “Individuals will be able to get price information, although how much they are going to use it will remain to be seen.”

Will Consumers Use This Info? Who Else Might?

Zack Cooper, an associate professor of public health and economics at Yale, doubts that the data alone will make much of a difference for most consumers.

“It’s not likely that my neighbor — or me, for that matter — will go on and look at prices and, therefore, dramatically change decisions about where to get care,” he said.

Some cost information is already made available by insurers to their enrollees, particularly out-of-pocket costs for elective services, “but most people don’t consult it,” he added.

That could be because many consumers carry types of insurance in which they pay flat-dollar copayments for such things as doctor visits, drugs or hospital stays that have no correlation to the underlying charges.

Still, the information may be of great interest to the uninsured and to the increasing number of Americans with high-deductible plans, in which they are responsible for hundreds or even thousands of dollars in costs annually before the insurer begins picking up the bulk of the cost.

For them, the negotiated rate and cash discount information may prove more useful, said Nation at Lehigh.

“If I have a $10,000 deductible plan and it’s December and I’m not close to meeting that, I may go to a hospital and try to get the cash price,” said Nation.

Employers, however, may have a keen interest in the new data, said James Gelfand, senior vice president at the ERISA Industry Committee, which lobbies on behalf of large employers that offer health insurance to their workers. They’ll want to know how much they are paying each hospital compared with others in the area and how well their insurers stack up in negotiating rates, he said.

For some employers, he said, it could be eye-opening to see how hospitals cross-subsidize by charging exorbitant amounts for some things and minimal amounts for others.

“The rule puts that all into the light,” said Gelfand. “When an employer sees these ridiculous prices, for the first time they will have the ability to say no.” That could mean rejecting specific prices or the hospital entirely, cutting it out of the employer plan’s insurance network. But, typically, employers can’t or won’t limit workers’ choices by outright cutting a hospital from an insurance network.

More likely, they may use the information to create financial incentives to use the lowest-cost facilities, said Anderson at Johns Hopkins.

“If I’m an employer, I’ll look at three hospitals in my area and say, ‘I’ll pay the price for the lowest one. If you want to go to one of the other two, you can pay the difference,’” said Anderson.

Will Price Transparency Reduce Overall Health Spending?

Revealing actual negotiated prices, as this rule requires, may push the more expensive hospitals in an area to reduce prices in future bargaining talks with insurers or employers, potentially lowering health spending in those regions.

It could also go the other way, with lower-cost hospitals demanding a raise, driving up spending.

Bottom line: Price transparency can help, but the market power of the various players might matter more.

In some places, where there may be one dominant hospital, even employers “who know they are getting ripped off” may not feel they can cut out a big, brand-name facility from their networks, no matter the price, said Anderson.

Is the Rule Change a Done Deal?

The hospital industry went to court, arguing that parts of the rule go too far, violating their First Amendment rights and also unfairly forcing hospitals to disclose trade secrets. That information, the industry said, can then be used against them in negotiations with insurers and employers.

But the U.S. District Court for the District of Columbia disagreed with the hospitals and upheld the rule, prompting an appeal by the industry. On Dec. 29, the U.S. Court of Appeals for the District of Columbia affirmed that lower-court decision and did not block the rule.

In a written statement last week, the American Hospital Association’s general counsel cited “disappointment” with the ruling and said the organization is “reviewing the decision carefully to determine next steps.”

Apart from the litigation, the American Hospital Association plans to talk with the incoming Biden administration “to try to persuade them there are some elements to this rule and the insurer rule that are tricky,” said Tom Nickels, an executive vice president of the trade group. “We want to be of help to consumers, but is it really in people’s best interest to provide privately negotiated rates?”

Fisher thinks so: “Hospitals are fighting this because they want to keep their negotiated deals with insurers secret,” she said. “What these rules do is give the American consumer the power of being informed.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Democrats Are Running Hard on Health Care in Georgia’s Senate Runoffs. Republicans? Not So Much.


This story is from a reporting partnership that includes WABE, NPR and KHN. It can be republished for free.

Vice President Mike Pence was the clear celebrity draw at a Nov. 20 campaign event for Georgia’s two incumbent U.S. senators, Kelly Loeffler and David Perdue. Both Republicans are fighting to keep their seats against two Democratic challengers in the runoff election set for Jan. 5.

People were so eager to see Pence at the rally in Canton, Georgia, that parking spots were scarce and a long line of cars snaked through the parking lot of a community college. Some drivers jumped the curb and parked in the grass.

Hundreds of people, many unmasked, were given temperature checks before boarding large coach buses for a short ride to the rally site. The venue was a large, open space outside the conference center, but few attendees maintained physical distance

The runoff in Georgia was triggered when no candidate in either Senate race won more than 50% of the vote in the general election on Nov. 3.

In the midst of the coronavirus pandemic and with the fate of the Affordable Care Act in question, Republicans hope the two incumbents will win reelection, thus preserving their party’s 50-48 control of the Senate.

But if the two challengers, Raphael Warnock and Jon Ossoff, win their runoffs, Democrats will gain narrow control of the Senate, with Vice President-elect Kamala Harris serving as the designated tie-breaker.

Yana De Moraes came to the rally from another Atlanta suburb, Buford. She is uninsured and, after a recent hospital stay, said the high cost of medical care was weighing on her mind.

“We would like our health care costs lowered, so it could be more affordable,” she said, with a rueful laugh. “So you don’t get another heart attack while you’re getting a bill!”

De Moraes added she’d also like to see better price controls on prescription drugs to stop pharmaceutical companies from “robbing American people.”

Others on their way to the rally said they were looking for any kind of change, ideally one that minimizes government involvement in health care.

Barry Brown made the 40-mile drive from his home in Atlanta for the rally. He’s retired but too young to qualify for Medicare, so he has ACA insurance, which he affords with the help of a federal subsidy.

“It sort of works. It’s better than nothing,” Brown said. “I would like to see an improved health care situation. I don’t know what that will be, so maybe they’ll mention that today. I’m hoping so.”

But at the rally, Loeffler only briefly mentioned her health care plan, which focuses on reducing drug prices and giving people access to insurance options that cost less but offer fewer benefits.

When it was his turn to speak, Perdue didn’t talk much about health care either, though he did take a shot at Obamacare, which he’s voted multiple times to overturn.

“Remember a little thing called the Affordable Care Act? You think that was done bipartisan?” Perdue asked the crowd. “No! It was done with a supermajority! Can you imagine what they’re gonna do if they get control of the Senate?”

As the two Republicans have campaigned throughout the state, they have consistently stoked fears about what Democrats will do, and health care policy has not led their messaging.

Their Democratic challengers, however, have been all over health care in their own speeches.

Warnock opened his runoff campaign to unseat Loeffler with a modestly attended Nov. 12 event devoted to health care. That’s also been a focus for Ossoff in his bid to win Perdue’s seat.

“This is why these Senate runoffs are so vital,” Ossoff explained at a small, physically distanced event in the shadow of the Georgia Capitol building in Atlanta on Nov. 10.

Ossoff and Warnock support adding a public insurance option to the Affordable Care Act. They also have emphasized the role Democrats will play in resurrecting key parts of the law if the U.S. Supreme Court decides to overturn it. The justices are set to make a ruling next year.

“If the Supreme Court strikes down the Affordable Care Act, it will be up to Congress to decide how to legislate such that preexisting conditions remain covered,” Ossoff said.

Voters like Janel Green, a Democrat, connect with that message. She’s from the nearby suburb of Decatur and is fighting breast cancer — for the second time. Green wondered whether her private health insurance might try to deny her coverage if the protections in the ACA disappear.

“I have to worry about whether or not next year in open enrollment that I won’t be discriminated against, that I won’t have limits that would then potentially end my life,” she said.

More than one-quarter of Georgians have preexisting conditions that could make it hard to get coverage if the ACA is struck down, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

That possibility also drove Atlanta resident Herschel Jones to support the runoff. On a recent weekday morning, he dropped by an Ossoff campaign office to pick up a yard sign.

Jones, who has diabetes, is insured through the Veterans Health Administration. He said everyone deserves access to health care.

“It’s a main issue, because the Affordable Care Act benefits all those individuals who might have preexisting conditions,” Jones said.

One likely reason Ossoff and Warnock are running so much harder on health care than Perdue and Loeffler is because that strategy paid off for Democrats in the general election, said Ken Thorpe, a health policy professor at Emory University.

President-elect Joe Biden can thank independent voters for his win in Georgia, Thorpe said, and they were drawn to him because of his promise to uphold Obamacare.

“The threat of potentially losing health insurance in the midst of this pandemic turned out to be probably the major defining issue in the election,” Thorpe said.

Polling in the days leading up to the Nov. 3 election showed Democrats were motivated on the issues of health care and the coronavirus pandemic.

For Democrats to win Georgia’s Senate seats, Thorpe said, they’ll need to stay focused on those issues. That emphasis could help them attract additional moderate voters, as well as entice those in the party base to cast ballots a second time.

“The health care issue is the probably main motivating factor that’s gonna get Democrats and independents to the polls,” he said.

Still, no Democrat has ever won a statewide runoff race in Georgia. That means that even with a strong health care message, it’ll be tough for Ossoff and Warnock to break that trend and unseat the Republicans, Thorpe said.

This story is from a reporting partnership that includes WABENPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: All I Want for Christmas Is a COVID Relief Bill

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Congress appears to be inching ever closer to agreement on a long-delayed COVID-19 relief bill, which would extend unemployment insurance and other emergency programs set to expire in the next several days. That bill, however, apparently will not include the top-priority items for both political parties: business liability protections supported by Republicans and aid to states and localities sought by Democrats.

The bill is likely to be part of a giant spending bill to keep the federal government funded for the rest of the fiscal year. And it might include a last-minute surprise: legislation to put an end to “surprise” medical bills sent to patients who inadvertently obtain care outside their insurance network.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rebecca Adams of CQ Roll Call and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

  • Congress has essentially agreed on a federal spending bill for the rest of the fiscal year — which began in October. But it will likely wait as lawmakers continue squabbling over the COVID relief package, with negotiations now centering on small details.
  • Republicans for months have been hesitant to move forward on a bill that would provide more relief for consumers affected by the pandemic because party leaders did not like Democrats’ insistence that it include more state and local aid. But that provision has been jettisoned, so Republicans are less opposed to the measure. Plus, they see a political downside to holding up the bill: Their two Georgia candidates for Senate — facing Democratic opponents in a special runoff election — are being hammered on the issue.
  • The compromise on surprise medical bills came after supporters secured agreement among Democrats who had favored varying remedies and all the committees in the House and Senate on the bill, a consensus that was forged with major concessions by progressives.
  • But doctors’ groups and other industry critics are still attacking the surprise billing proposal — even though many observers see the bill as tilted in their favor over insurers — so its passage is not guaranteed. Supporters are banking on the looming end of the congressional session to move the measure over the finish line.
  • Vice President Mike Pence announced he will get vaccinated against COVID-19 in public this week in hopes of convincing anyone skeptical about the shots that they are safe. President-elect Joe Biden is planning to do the same soon. But this is a difficult stance for politicians. They don’t want to look as if they are pushing themselves ahead in line, but they also want to normalize the use of the vaccine.
  • About 200 state and local public health leaders have quit or been fired because of public opposition to measures to curb the coronavirus. Although President Donald Trump has reined in his criticism of some of these officials and their efforts, the opposition is still strong. Those critics may be buttressed by fears that new restrictions imposed to control the surging virus will hurt the economy.

Also this week, Rovner interviews Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health, about the future of employer-provided health insurance.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Texas Monthly’s “Texas Wedding Photographers Have Seen Some $#!+,” by Emily McCullar

Alice Miranda Ollstein: The New York Times’ “‘Like a Hand Grasping’: Trump Appointees Describe the Crushing of the C.D.C.,” by Noah Weiland

Mary Agnes Carey: NPR’s “How Do We Grieve 300,000 Lives Lost?” by Will Stone

Rebecca Adams: Bloomberg News’ “White House Official Recovers From Severe Covid-19, Friend Says,” by Jennifer Jacobs

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Readers and Tweeters Defend Front-Line Nurses and Blind Us With Science

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

The demand for skilled nurses during the pandemic is through the roof! Travel nurses command a hefty salary and they are worth every penny… #COVID19 #pandemic #RN https://t.co/gYQpkHqaoX

— Talmage Egan, MD (@UofU_Anes_Chair) November 26, 2020

— Dr. Talmage Egan, Salt Lake City

Nurses Deserve to Be Paid Handsomely

I read your article “Need a COVID-19 Nurse? That’ll Be $8,000 a Week” (Nov. 24) in the Springfield Journal-Register. It was an interesting article as I have a daughter who is a nurse. Nurses have been underpaid and unappreciated for years. It made me angry that the article characterized the wages some hospitals are willing to pay for nurses as exorbitant. Hogwash if you think someone should risk their life every hour of the day to care for COVID patients without proper compensation. How many doctors make over a million a year? You don’t cite that as unusual. I feel that nurses should go for the gold as they have been taken advantage of for years and, too bad, but good for them. Choose your words more carefully in the future. Nurses ROCK!!!!

— Mike Booher, Lincoln, Illinois

Hospitals go out of their way to avoid competing for nursing labor by raising wages. Now hospital executives and public health advocates act like it’s a travesty that COVID nurses are finally getting paid market rates to take on risky jobs. https://t.co/6z0idToVn6

— Devon M. Herrick (@DevonHerrick) November 24, 2020

— Devon M. Herrick, Dallas

Missing in the Mix of Vaccine Coverage

I must note two important omissions in the article “Time to Discuss Potentially Unpleasant Side Effects of COVID Shots? Scientists Say Yes” (Nov. 12). First, although these were interim trial results, the placebo arm should also have been reported out. What was the placebo infection rate? Reporting 90% effectiveness is irrelevant without reporting the placebo rate simultaneously. And one needs to align the infection rate in trial subjects with the incidence of disease in the U.S. population. They should be similar, but if not, any discrepancy must be explained (such as, no elderly people or children participating in the trial). Secondly, and perhaps more important: What other mitigating measures were volunteers in this trial required/advised to take? For example, physical distancing, masks, etc. I could find no mention of this, positively or negatively, when reading the protocol on clinicaltrials.gov. Any vaccine alone could not provide 94.5% efficacy. To determine the relative contributions of other measures, you’d need, say, a four-arm study — placebo with mask, placebo without mask, vaccine with mask, vaccine without mask. Statistically and clinically, one must account for other variables that may confound an apparent result.

This is a crucial point as the lay public is thinking that, by getting the vaccine, masks might no longer be necessary and they’ll have a 95% chance of not being infected. This is rubbish. The media and the public “experts” need to address this as they are setting themselves up for an immense PR failure and still greater skepticism. People may need to wear masks for many more months, maybe years, even with an effective vaccine.

— Stephen Zaruby, Truckee, California

I’m already confused 😕 https://t.co/UlJPh2EEvK

— hameen tariq (@hameentariq) November 23, 2020

— Hameen Tariq, Wilmington, Delaware

Exploring Cancer Drug’s Effects on COVID

Your story “Clots, Strokes and Rashes: Is COVID a Disease of the Blood Vessels?” (Nov. 13) was reprinted in my local newspaper. My brother, James L. Kinsella Ph.D., led the original work at the National Institutes of Health researching how the chemotherapy drug Taxol could reduce inflammation in coronary articles following the placement of coronary stents. This led to the very effective use of drug-eluting coronary stents. My unprofessional musing causes me to wonder if this anti-inflammatory response to Taxol might have some application as an early therapeutic intervention to reduce the inflammatory response of COVID-19 being studied by Dr. William Li. I can’t ask my brother; he passed away.

— Rick Kinsella, Oneida, New York

He wouldn’t be dead without covid. We’ve learned that things that aren’t life threatening are made life threatening by this disease. It attacks your blood vessels so it can exacerbate anything anywhere in your body that uses blood vessels. Stay safe indeed https://t.co/BFsqrKSFmH

— James McPicnic (@WhiteRatbit) December 3, 2020

— James “J.P.” McPicnic, Los Angeles

Women’s Health Should Not Be Up for Debate

Birth control medication is so much more than a pawn in politics (“Coming Abortion Fight Could Threaten Birth Control, Too,” Nov. 5). It changes the lives of so many women for the better. Birth control access has been proven to lead to higher rates of education for women, lower levels of child poverty, lower Medicaid costs for women’s health and higher productivity of society as a whole. It also treats a large number of medical conditions associated with women’s health. It effectively treats severe menstrual migraines, hormonal acne, endometriosis, severe menstrual pain, uterine abnormalities, anemia and heavy menstrual bleeding, among other health conditions. This medication is involved in treating so many women’s health concerns, improves infant and child health outcomes, and reduces child poverty, and yet almost 20 million women in the U.S. currently have no access to birth control medication. American politicians need to consider, if nothing else, the spillover costs to society when birth control access is reduced.

Women’s reproductive health should not be up for debate and yet it is at the center of so many political agendas. As a 24-year-old woman pursuing dual master’s degrees in public health and physician assistant studies, my focus should be on learning to become an exceptional health care provider, not whether my health will be up for debate in court. If politicians truly have the best interests of Americans at heart, they should be looking to expand birth control access, not restrict it.  Evidence needs to be incorporated into political agendas, and the evidence shows that when women succeed, society succeeds. Women’s education, health and reproductive rights should be at the forefront of every discussion on what constitutes a thriving population — the evidence has proven that women’s autonomy holds the answer and access to birth control is a vital piece of that.

— Gabby Henshue, Madison, Wisconsin

Scary times for women’s bodies.

“States could effectively ban contraception by arguing that some contraceptives act as abortifacients.” Threat is real. I’ve worked in states where this argument has been made.https://t.co/LmdWFRUNOZ

— Elizabeth M. Baskett (@EMBaskett) November 11, 2020

— Elizabeth M. Baskett, Denver

Injustice in High Gear

I was appalled at the charges on the medical bill from the Carson City emergency department for that child who fell off his bike (“Bill of the Month: After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion,” Nov. 25) — $18,000 for an exam and stitches? What would it take to sort out such problems in our health system? Lower prices from providers could only result in lower insurance premiums.

— Karen Johnson, San Rafael, California

Attempted subrogation, man, I tell yah https://t.co/spxcMlSiCk

— Annie M. Davidson (@attyannie) November 25, 2020

— Annie M. Davidson, St. Paul, Minnesota

KHN Morning Briefing: A Wealth of Information in One Spot!

I just wanted to say it is awesome to have portions of articles from many major news outlets because never does one tell the whole story. Case in point: I was trying to research what exactly President Donald Trump had done that “allowed doctors to discriminate against LGBT people,” and it was very helpful having a wide array of media sources on a single page to help get the bigger picture and try and weed through the bias of all of them (“Trump Administration’s Expanded Conscience Rule Will Allow Medical Professionals To Refuse To Provide Health Care Services,” May 3). Just sending my compliments. Keep up the great work.

— Nolan Steeley, Greensburg, Pennsylvania

💥Racism in #healthcare undermines #quality of care and patient safety. There’s hard work to be done to weed it out of all parts of society, especially clinical care. https://t.co/TbK0yIuraB

— Natalie S. Burke (@natalie4health) November 28, 2020

— Natalie S. Burke, Washington, D.C.

Education and Coverage Gaps Lead to Avoidable Amputations 

Coming to terms with systemic racism in health care is long overdue (“What Doctors Aren’t Always Taught: How to Spot Racism in Health Care,” Nov. 17). The way medicine is taught and the payment policies that shape the system have created persistent disparities in patient outcomes across racial and ethnic groups.

As a result, Black Americans are 80% more likely than whites to be diagnosed with diabetes and are twice as likely to die from the disease. Furthermore, Black American patients are up to four times more likely to experience an amputation than their white counterparts due to advanced peripheral artery disease (PAD), a common complication for people with diabetes and other chronic conditions. Similarly, Latinos are up to 75% more likely to experience an amputation than whites, while Native Americans are twice as likely to lose a limb.

As many as 85% of the nation’s 200,000 non-traumatic amputations could be prevented with access to screening and early detection. By screening for PAD through non-invasive arterial testing, the likelihood of an individual needing a PAD-related amputation can be reduced by up to 90%. Unfortunately, too few Americans — particularly racial and ethnic minorities — are even offered routine screening for PAD due to a widespread lack of understanding about the disease, as well as structural coverage barriers to simple, painless tests. As a result, many do not even know they have the disease until it is too late to save their limbs.

Communities of color deserve better. Members of the Congressional PAD Caucus — led by Rep. Donald Payne Jr. (D-N.J.) — recently introduced the Amputation Reduction and Compassion (ARC) Act to establish an education program about the disease — particularly for high-risk populations — and update reimbursement policy to disallow payment for non-emergent amputations unless arterial testing has been done in the three months before amputation. These simple solutions have the power to prevent thousands of avoidable amputations, and begin to correct health disparities in minority communities.

While we still have a long way to go as our country continues to grapple with systemic racism in health care, the ARC Act represents an important step toward ending disparities in PAD care.

— Dr. Foluso Fakorede, CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi

Racism in Health Care? Another example of injecting Politics. Inarguably, racism exists everywhere, but to make this a big issue is a disservice. Diff DX requires inclusion of Race/Ethnicity, to wit: Sickle Cell in Blacks,Alpha & Beta Thalassemia in Asians https://t.co/xyP54dPjH8

— Alexander R. Lim, MD (@AlexanderLim13) November 25, 2020

— Dr. Alexander R. Lim, Corpus Christi, Texas

‘Obamacare’ Unfairly Politicizes Health Law

I found this article interesting (“Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” Nov. 11) but was surprised that the Affordable Care Act was referred to as “Obamacare.” Please don’t politicize the ACA — we really need it to continue allowing people to access health care. Many people do not have health care through their workplace and are unable to afford private insurance premiums. I was once one of those people before I was hired at our local library. It was really tough. Thank you for your reporting.

— Pamela Elicker, Port Townsend, Washington

Putting People First on the Podcast

When you were talking about drug policy and the ballot in a recent podcast (“KHN’s ‘What the Health?’: Change Is in the Air,” Nov. 6), you used terms that are considered incorrect or stigmatizing. For example, saying “opioid epidemic” when it’s really a crisis and referring to substance use as “abuse.” The Associated Press and NPR, among others, have pledged to use people-first language, as also supported by the American Psychological Association.

— Deirdre Dingman, Philadelphia

The Backbone of the Insurance Industry

It’s disingenuous to assert that people “can’t always rely on insurance brokers to give them accurate information or steer them to comprehensive coverage” based on the unfortunate experience of one consumer with a short-term health plan, as Michelle Andrews did in the article “Think Your Health Care Is Covered? Beware of the ‘Junk’ Insurance Plan” (Dec. 4).

Agents and brokers are crucial to our nation’s efforts to get people covered. This year, they assisted almost half of all healthcare.gov enrollees — and brought 1.12 million new enrollees into the marketplace. It’s no wonder that a new report from the Centers for Medicare & Medicaid Services has called agents and brokers “instrumental in driving greater participation in the individual health insurance market.”

Further, agents and brokers have long maintained that short-term plans are not appropriate substitutes for comprehensive exchange coverage. We at the National Association of Health Underwriters stated as much in official comments filed with the Trump administration before it finalized a rule extending the duration of short-term plans to 12 months.

— Janet Trautwein, CEO of the National Association of Health Underwriters, Washington, D.C.

 


Not Tickling My Funny Bone

You ought to find some cartoonists who are not so flagrantly left-leaning — continuing to provide left-sided commentary is not right. It’s like all of the news stations pushing for socialism.

— Harry Gousha, Upland, California

Editor’s note: It is the tradition and mission among editorial cartoonists to satirize those in power. As with the nation’s leadership, the targets of political cartoons toggle from right to left. Balance is not these artists’ goal, but over time their commentary balances out. Stick with us, and we hope to amuse you in the future.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: Shopping for Health Insurance? Here’s How One Family Tried to Pick a Plan

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When host Dan Weissmann and his wife set out to pick a health insurance plan for next year, they realized that keeping the plan they have means paying $200 a month more. But would a “cheaper” plan cost them more in the long run?  It depends. And the COVID pandemic makes their choice a lot more complicated.

After trying to puzzle it out, Weissmann debriefs with Karen Pollitz, a health insurance expert at KFF, who knows about the angst of medical bills from personal experience.

Health insurance can be painful, but the alternative ― not having health insurance ― is so much worse. If you want to go deeper on health insurance, you might want to check out these episodes from the first season of the podcast:

  • In “Why You (and I) Will Likely Pick the Wrong Health Insurance,” we learn: Smart economists have proved it’s actually super hard — even they aren’t sure they’ll pick correctly.
  • In an episode inspired by KHN reporter Jenny Gold, we learn about insurance companies’ price-gouging. And often we end up paying the price.
  • In the first-ever episode of this show, Weissmann’s family confronts the big puzzle: Can we even get insurance that’ll work for us?
  • In “A ‘Deal’ on Health Insurance Comes With Troubling Strings,” we go on a journey with a kinda-famous “financial therapist” who says she gets rattled when it comes to picking health insurance. And she’s pretty uncomfortable — morally, personally — with some of the choices she’s made. (Also, Weissmann’s family makes another cameo.)

And here are some other helpful big-picture takes:

Want to go a lot deeper? Especially if you’re actually looking at buying health insurance, maybe on the Obamacare exchange?

Weissmann found healthcare.gov to be super usable this year, way better than the last time he checked.

“I punched in the answers to a few questions, and got to quickly tell it which doctors our family sees (and what meds we take) … and it provided a clear list that showed which plans cover our docs, how much they would cost us, etc.,” he said.

  • Subsidies are available for Affordable Care Act plans. KFF has this explanation of how they work. It’s a slog, but thorough. Print it out, grab a snack and settle in. This bit of research explains that a lot of people qualify for a plan with no premium. (KHN, which co-produces “An Arm and a Leg,” is an editorially independent program of KFF.)
  • KFF has a whole database of frequently asked questions about the ACA. Hundreds of Q’s and A’s, including 180-plus in Spanish.
  • Also great, also very thorough: The Georgetown University Center on Health Insurance Reforms has a whole site full of resources for navigating the ACA. (It’s actually for “navigators” — folks who help civilians understand the sign-up process.)

That’s a lot, right? Picking a plan can be overwhelming. But don’t let it get you down.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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With Becerra as HHS Pick, California Plots More Progressive Health Care Agenda

SACRAMENTO — President-elect Joe Biden didn’t back “Medicare for All” during his campaign.

Yet his choice of California Attorney General Xavier Becerra to serve in the nation’s top health care post is fueling California lawmakers’ most progressive health care dreams, including pursuing a government-run single-payer system at the state level.

“Now it’s much more real, and it energizes me in terms of pushing for single-payer now,” said state Assembly member Ash Kalra (D-San Jose), who is considering spearheading a new single-payer campaign next year — a move he argues is more plausible under the Biden-Harris administration, with Becerra at the helm of the U.S. Department of Health and Human Services.

“It’s not good enough to just say that we believe health care is a human right. We’re now obligated to act,” Kalra said.

Across California, Democrats are changing their political calculus for what could be possible if Becerra, 62, is confirmed to the powerful position. After nearly four years of battling President Donald Trump and federal policies they view as unfriendly, Gov. Gavin Newsom and other Democratic leaders welcome a strong ally who could help make California a laboratory for progressive ideas. He would set the agenda for key federal health care agencies, which have broad authority to steer more money to states and approve their ambitious health care proposals.

Becerra, whose mother emigrated from Mexico, would be the first Latino to serve in the position. He would lead a massive $1.3 trillion federal health care apparatus that oversees agencies responsible for Medicare, Medicaid, vaccines, prescription drug approval and the U.S. public health response to the coronavirus pandemic.

“It’s a game changer for us — the stale era of normalcy versus the fresh era of progress,” Newsom said Monday. “We’re going to take advantage of this moment and these relationships — not unfairly.”

A native Californian with 30 years of political experience, 24 of them in Congress, Becerra has long backed a progressive health care agenda, including single-payer, environmental justice and protecting immigrants’ access to safety-net care. He has fiercely defended the Affordable Care Act and fought to preserve reproductive rights. He has gone after deep-pocketed pharmaceutical companies, and successfully sued a large health system in California for anti-competitive practices.

Newsom said he’s already spoken to Becerra about California’s health care priorities and is “accelerating” a dramatic transformation of the state’s Medicaid program to better serve the chronically sick and those suffering from untreated mental illness.

Immigrant advocates, who are deploying a new strategy to expand the state’s Medicaid program to all income-eligible unauthorized immigrants, plan to lobby Becerra and the Biden administration for additional federal money that could help fast-track it. They also want Becerra to agree to allow young unauthorized immigrants known as “Dreamers” to purchase insurance through Covered California, the state exchange. And California Senate President Pro Tem Toni Atkins said she’s “excited” to seek renewed approval to use federal Medicaid dollars for nontraditional uses, such as combating homelessness and providing emergency housing assistance.

“We’ve had a lot less money to bank on under Trump, but Becerra at HHS bodes well for us,” said Cathy Senderling-McDonald, incoming executive director for the County Welfare Directors Association of California. “We can rethink and possibly open up more federal funding.”

Democrats are also seizing on Becerra’s past support for single-payer, which dates back to his early congressional career in the 1990s. He has described himself as a lifelong single-payer advocate, and when a reporter asked him last year whether the idea is too costly and “pie in the sky,” Becerra responded, “I love pie.”

A young XAVIER BECERRA, Biden’s pick to run HHS, lays out his health care principles as a congressman in 1994.

“We must have universal coverage. We must have portability. We must have choice of provider,” Becerra says, endorsing single-payer. pic.twitter.com/fkJVNV0DYQ

— Dan Diamond (@ddiamond) December 7, 2020

But it’s unclear whether Becerra as HHS secretary would embrace progressive — and expensive — health care ideas like single-payer. In his first public remarks on his nomination Tuesday, he touted his work helping to pass the Affordable Care Act and said on Twitter he would “build on our progress to ensure every American has access to quality, affordable health care.”

Some congressional Republicans are raising red flags about Becerra’s nomination, which must be confirmed by the U.S. Senate. They cite his anti-Trump stance and opposition to some federal policies, such as a Trump-era Obamacare rule that allows private employers with religious objections to deny workers contraceptive coverage. Becerra has sued the Trump administration 107 times, including 13 times on health care.

Although Becerra has no direct health care experience, “the court has become the arbiter of health policy, and he certainly got experience there,” said Trish Riley, executive director of the National Academy for State Health Policy.

In announcing Becerra as his Cabinet pick Tuesday, Biden described him as someone who is unafraid to take on special interests and has spent his career working to expand health care access and reduce racial health disparities. California, under Becerra’s leadership, led the defense of the federal health care law before the U.S. Supreme Court last month.

“No matter what happens in the Supreme Court, he’ll lead our efforts to build on the Affordable Care Act, to work to dramatically expand coverage and take bold steps to lower health care prescription drug costs,” Biden said at the news briefing.

In Congress, I helped pass the Affordable Care Act. As California’s Attorney General, I defended it. As Secretary of Health and Human Services, I will build on our progress and ensure every American has access to quality, affordable health care—through this pandemic and beyond.

— Xavier Becerra (@XavierBecerra) December 7, 2020

At the outset, however, Becerra would be consumed by managing the U.S. response to the coronavirus pandemic. In his new role, he would oversee the Centers for Disease Control and Prevention and the National Institutes of Health.

“The No. 1 task he’s going to be completely absorbed with is getting this pandemic under control. We need a consistent message,” said Bruce Pomer, a public health expert and chief lobbyist for the California Association of Public Health Laboratory Directors. “It’s going to be critical for the Biden administration to show people that it can be effective at keeping the American people safe.”

Becerra’s public comments Tuesday indicated the pandemic would be his top priority. “The COVID pandemic has never been as vital or as urgent as it is today,” Becerra said, adding that the economic fallout has “thrust families into crisis. Too many Americans are sick or have lost loved ones, too many have lost their jobs.”

But liberal California lawmakers and advocates say the pandemic has made their ambitious health care goals all the more urgent. And should Becerra back a progressive health agenda in California, similar proposals could follow from other states, said Mark Peterson, a professor of public policy, political science and law at UCLA.

“California has pushed the envelope on health care beyond where other states are,” he said. “And that gives more capacity for California sensibilities and ideas to get into the mix in Washington.”

This story was produced by KHN (Kaiser Health News), which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Xavier Becerra en sus propias palabras: “La atención de salud es un derecho”

El presidente electo Joe Biden nombró al fiscal general de California, Xavier Becerra, para dirigir el Departamento de Salud y Servicios Humanos (HHS) de los Estados Unidos. Becerra, quien sería el primer secretario latino del HHS, ha tomado algunas posiciones innovadoras en atención de salud, especialmente desde que se convirtió en fiscal general, en 2017.

Becerra ha demandado a la administración Trump docenas de veces por temas de atención médica, control de la natalidad, inmigración, cambio climático y más, con California liderando la defensa de la Ley de Cuidado de Salud a Bajo Precio (ACA) ante la Corte Suprema de Estados Unidos. Becerra también ganó un importante acuerdo legal contra Sutter Health, después de acusar al gigante de la atención de salud sin fines de lucro de usar su dominio del mercado en el norte de California para aumentar los precios de manera ilegal.

El año pasado, Becerra le dijo a KHN que sus puntos de vista han sido moldeados por su experiencia como hijo de inmigrantes mexicanos. Al describir el aborto espontáneo de su madre, dijo que todos deberían poder ir al médico: “Para mí, la atención médica es un derecho”, dijo. “He sido un defensor del pagador único toda mi vida”.

Aquí hay más de lo que le dijo a KHN sobre sus puntos de vista sobre la atención médica en los últimos años:

A principios del año pasado, Becerra le contó a Samantha Young, corresponsal política de California Healthline, sobre su experiencia como hijo de inmigrantes y cómo eso moldeó su carrera legal y política.

Hace dos años, Becerra participó del podcast “What a Health?”, que conduce Julie Rovner, corresponsal principal de KHN en Washington, en donde habló sobre su énfasis en la atención de salud como fiscal general.

El mes pasado, Becerra habló con Samantha Young sobre su defensa de la Ley de Cuidado de Salud a Bajo Precio (ACA) ante la Corte Suprema de los Estados Unidos.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Xavier Becerra in His Own Words: ‘Health Care Is a Right’

President-elect Joe Biden has tapped California Attorney General Xavier Becerra to lead the U.S. Department of Health and Human Services. Becerra, who would be the nation’s first Latino HHS secretary, has taken some ground-breaking positions on health care, especially since he became attorney general in 2017.

He has sued the Trump administration dozens of times on health care, birth control, immigration, climate change and more, with California leading the defense of the Affordable Care Act before the U.S. Supreme Court. Becerra has also won a major legal settlement from Sutter Health after accusing the nonprofit health care giant of using its market dominance in Northern California to illegally drive up prices.

Becerra told KHN last year that his views have been shaped by his experience as the son of Mexican immigrants. Describing his mother’s miscarriage, he said that everyone should be able to go to the doctor: “For me, health care is a right,” he said. “I’ve been a single-payer advocate all my life.”

Here’s more of what he told KHN about his views on health care in the past few years:

Early last year, Becerra told Samantha Young, California Healthline’s state politics correspondent, about his experience as the child of immigrants, and how that shaped his legal and political career.

Becerra joined KHN chief Washington correspondent Julie Rovner on her “What the Health?” podcast two years ago about his emphasis on health care as attorney general.

Last month, Becerra spoke with Samantha Young about his defense of the Affordable Care Act before the U.S. Supreme Court.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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California Lawmakers to Newsom: Give All Immigrants Health Coverage

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SACRAMENTO — California Democratic lawmakers so far have failed to convince Gov. Gavin Newsom that the state can afford to spend an estimated $2.6 billion a year to expand its Medicaid program to all unauthorized immigrants.

Now, they’re trying a new strategy.

Rather than working independently, a fiercely liberal state senator from Los Angeles and a moderate Assembly member from the Central Valley are joining forces to pressure Newsom to make California the first state in the nation to cover every income-eligible resident regardless of immigration status. Unauthorized immigrants up to age 26 can already qualify for Medi-Cal, the state’s Medicaid program for low-income residents.

Emboldened by the win of Democratic President-elect Joe Biden and spurred by the urgency of the coronavirus pandemic, state Sen. María Elena Durazo (D-Los Angeles) and Assembly member Joaquin Arambula (D-Fresno) plan to introduce a two-bill package on Monday that would cover unauthorized senior immigrants first, and eventually the remainder of California’s undocumented immigrant population.

“It’s a national issue. Look at how all the national Democratic candidates raised their hands in front of the world to support covering undocumented immigrants in health insurance,” Durazo told California Healthline. “We want a clear commitment to finally do this, not just lip service.”

Newsom has long touted his goal of achieving universal health coverage in California and made campaign promises to work toward a single-payer health care system. But after nearly two years in office, Newsom’s ambitious health care agenda has been sidetracked by deadly wildfires and a widening homelessness crisis — as well as the COVID-19 pandemic — and he has not managed to dramatically expand coverage.

California currently covers about 200,000 unauthorized immigrant children and young adults, according to the state Department of Health Care Services. The state budgeted about $375 million to cover young adults ages 19 through 25 this fiscal year, but does not track spending for undocumented immigrant children, according to the state Department of Finance.

Opening the low-income health program to all eligible undocumented immigrants would expand coverage to at least 915,000 low-income residents and cost an additional $2.6 billion annually, according to a projection this year by the nonpartisan state Legislative Analyst’s Office. There are an estimated 1.5 million undocumented immigrant Californians who are uninsured, estimates show, but not all of them would qualify.

Public support for expanding coverage to unauthorized immigrants has risen over the past few years, according to the Public Policy Institute of California. But expending scarce taxpayer resources on such an effort is politically risky, said Doug Herman, a Los Angeles-based national Democratic strategist.

“Gavin’s got bigger priorities right now and he has been wounded, so he has to be very cautious about what he does,” Herman said. “Look at the French Laundry and [Employment Development Department] scandals. The homelessness crisis is raging and the prison outbreak happened on his watch. This doesn’t rise to that level.”

Newsom communications director Jesse Melgar said no one from his office was available for comment.

Since Newsom took office, Durazo and Arambula have authored separate bills to expand Medi-Cal to more undocumented immigrants. Durazo has gotten close after negotiating with Newsom — only for the first-term Democratic governor to back out, citing costs.

Such proposals have received widespread legislative support among Democratic lawmakers, who hold supermajority power in both houses of the state legislature.

A worsening economic outlook and long-term budget pressures could once again derail their efforts. Because the federal government prohibits states from using federal Medicaid dollars to cover undocumented immigrants — except for emergency services — California would have to pick up most of the price tag, which could top $3 billion annually to cover everyone, including children and adults, according to the Legislative Analyst’s Office.

Newsom will be forced to weigh an onslaught of budget demands while managing, and paying for, the ongoing COVID-19 emergency.

“That gives Newsom the ability to delay or oppose anything that doesn’t fit his agenda,” Herman said.

But some lawmakers, immigration rights activists and health care advocates argue the COVID pandemic has made their campaign more urgent as Latino and Black residents get sick and die at disproportionate rates.

Politicians cannot ignore that the pandemic has exposed a broken health care system that has left millions of taxpaying Californians without health coverage because their immigration status renders them ineligible, said Sarah Dar, director of health and public benefits for the California Immigrant Policy Center, which is already lobbying the governor to support the Medi-Cal expansion.

“Now we have a full picture of what this crisis is, and the blatant disparities faced by our essential workers, so there’s no excuse,” she said. “Immigrant communities and farmworkers in the food and agricultural sector, like meatpacking plants, have literally been hotbeds for the spread of disease.”

Dar acknowledged financial pressures ahead for the state, and said advocates will be pushing for ways to generate money to pay for the expansion, possibly including tax increases.

There could be some hope for a one-time cash infusion. Fiscal estimates show California could reap a $26 billion surplus next year, largely from personal income tax receipts from high-income earners who have not suffered devastating economic losses during the pandemic, according to state fiscal analysts. Durazo and Arambula are eyeing that revenue for the Medi-Cal expansion.

“He has routinely stated his vision, but we’d like Gov. Newsom to deliver on health care for all during his governorship,” Arambula said. “I’m not going to sit and wait.”

Durazo said she would introduce a bill Monday to expand Medi-Cal to unauthorized immigrant Californians age 65 and older. She put a similar bill on hold in 2019, in exchange for a commitment from Newsom to include the proposal in this year’s state budget.

Newsom included the proposal in the first version of his state budget in January, but then withdrew it, citing soaring unemployment, business closures and an economy decimated by the pandemic.

Durazo and other backers decided to craft a new approach: Alongside Durazo’s bill to cover older adults, Arambula plans to introduce companion legislation to cover all undocumented immigrant adults.

The lawmakers are using the two bills as a negotiating tactic. Arambula and advocates said they hope to win coverage for undocumented immigrants 65 and older next year, while developing a plan with Newsom to expand coverage to the entire population at some point during his governorship.

Durazo said both bills are equally important and are intentionally being used to pressure the governor into action next year.

“This is our way to finally have a real conversation about what it’ll take to get everyone covered, given we’ll have federal partners with the Biden-Harris administration,” said Orville Thomas, director of government affairs for the California Immigrant Policy Center.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Trump Rule Gives Small Companies a New Tool to Help Workers Buy Health Coverage

Until October, Andrea LaRew was paying $950 a month for health insurance through her job at the Northwest Douglas County Chamber & Economic Development Corp. in the metro Denver area.

Her company didn’t contribute anything toward the premium. Plus, LaRew and her husband had a steep $13,000 deductible for the plan. But the coverage and the premium cost were in line with other plans available to the company since options for such a small work group — just LaRew and another employee wanted to enroll — weren’t plentiful.

Now they’re trying a new approach. Instead of a traditional plan, the chamber established an “individual coverage health reimbursement arrangement” (sometimes referred to as ICHRA) to which it allocates $100 a month per employee that they must put toward comprehensive coverage on the individual insurance market. These employer contributions may be used to pay for expenses such as premiums or cost sharing.

The reimbursements don’t count as taxable income to workers.

Proponents of the plans say they’re a good option for companies that may not feel they can afford to offer a traditional plan to workers but want to give them something to help with health care expenses. But consumer advocates are concerned they may shortchange some workers.

These small businesses can’t afford to offer health care coverage as the premium prices rise, said Garry Manchulenko, a principal at GMBA Advisors Group in the Denver metro area, who suggested the arrangement to the chamber. “They want to help their employees, but they can’t sustain these increases, particularly at the small-group level.”

Manchulenko said he’s suggesting the new setup for some of his clients, noting that in certain places premiums on the individual market are lower than those for group plans.

LaRew, 48, bought a plan similar to the group plan, but with a monthly price tag of $730 after she factors in the company’s contribution, a savings of more than $2,600 a year.

“It’s still super expensive for two healthy people,” said LaRew, who oversees many of the chamber’s administrative functions. But she appreciates that her premiums are deducted from her pretax income, just as when she was on the group plan.

She also liked having her pick of several plans. “I could choose my own individual plan that suits my family best, and not be tied to a group plan that works great for a co-worker but not for me.”

The new coverage option was established through a rule issued by the Trump administration last year. It could be helpful for workers like LaRew whose income is too high to qualify for the Affordable Care Act’s tax credits that help pay for policies sold on the individual market. It may also be attractive to part-time or seasonal workers who don’t qualify for their employer’s coverage, according to insurance brokers and policy experts familiar with the new option.

But consumer advocates warned that it could encourage employers who had offered a traditional insurance plan to switch to the new arrangement because of the cost savings. That might leave their workers with a more cumbersome enrollment process and less generous coverage.

“I do think there are pitfalls for employees,” said Jason Levitis, a nonresident fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “There’s confusion about the ICHRAs themselves.”

“And even if you know you need an ACA-compliant plan, how do you find one?” he asked, noting the prevalence of deceptive marketing of plans that don’t meet ACA standards.

In addition, because of a quirk in how the new rules work, lower-income workers who bought ACA marketplace plans because their employer didn’t offer coverage could lose the federal subsidies for their marketplace plans if their company puts an ICHRA in place.

Here’s how that could come into play. Only people earning 400% of the federal poverty level or less (about $51,000 for one person) are eligible for premium subsidies. In addition, in order to qualify the coverage offered by an employer must be considered unaffordable to the worker. If an employer offers an individual coverage health reimbursement arrangement, that means workers who would otherwise meet the poverty threshold would also have to contribute more than 9.78% of their income to buy the lowest-cost individual silver plan on the exchange. That amount would be based on the plan’s cost after factoring in the contribution from an employer.

If the worker’s contribution is lower than that standard, then the only assistance they are eligible for is through the ICHRA contribution. Federal rules don’t allow workers to accept both ICHRA contributions and premium tax credits.

“My concern is for people who are out there with a premium tax credit” who might lose that subsidy if they don’t meet the federal standard, said Peter Newell, director of the Health Insurance Project for the United Hospital Fund in New York, who authored an analysis of the new coverage option in October.

There are affordability caps in the ACA for regular employer-sponsored coverage, too, but those caps are generally lower than the caps for ICHRAs. As employers move to offer ICHRAs instead of traditional coverage, some workers will lose their premium tax credits because of the higher affordability threshold, Newell’s analysis found.

If this sounds complicated, it’s because it is, and brokers and advocates agree that many workers will need assistance figuring out what to do. In addition to running the numbers, people may need to work through where to buy a comprehensive plan that complies with the ACA. Such plans can be purchased on and off the exchange, but if workers want the company to deduct their premium costs from their salary, as LaRew did, they must purchase a plan outside of the exchange.

“There are so many paths to take and so many points of confusion, it’s super, super important that employees have some support going through this,” said Cat Perez, co-founder and chief product officer at Health Sherpa, whose technology platform helps people enroll in marketplace plans. It has incorporated information about ICHRAs.

Colorado is working with the broker community to drum up interest in the new product, said Kevin Patterson, chief executive officer of Connect for Health Colorado, the state’s insurance exchange.

“If we can get more people into the individual marketplace that makes it stronger,” Patterson said.

In theory that makes sense, but some analysts worry that the adoption of these new arrangements could drive up marketplace premiums by encouraging employers with sick workers to shift them into the individual market.

“This is a way to offer a lower premium option to some employers, but with the consequence of increasing premiums in the individual market and costs for the federal government via higher premium tax credits,” said Matthew Fiedler, a fellow in economic studies at USC-Brookings, who co-authored an analysis of the new offerings.

Still, larger employers aren’t currently very interested in embracing these new arrangements, said Jay Savan, a partner at human resources consultant Mercer.

The federal rules don’t allow employers to offer an employee both a traditional plan and an ICHRA simultaneously, and most large employers aren’t ready to replace their traditional plans.

“As long as it’s black-or-white, there are precious few employers of size that are willing to take that leap,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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During ACA Open Enrollment, Picking a Plan Invites New COVID Complications

People buying their own health insurance have even more to think about this year, particularly those post-COVID-19 patients with lingering health concerns, the “long haulers,” who join the club of Americans with preexisting conditions.

What type of plan is best for someone with an unpredictable, ongoing medical concern? That question is popping up on online chat sites dedicated to long haulers and among people reaching out for assistance in selecting insurance coverage.

“We are hearing from a lot of people who have had COVID and want to be able to deal with the long-term effects they are still suffering,” said Mark Van Arnam, director of the North Carolina Navigator Consortium, a group of organizations that offer free help to state residents enrolling in insurance.

The good news for those shopping for their own coverage is that the Affordable Care Act bars insurers from discriminating against people with medical conditions or charging them more than healthier policyholders. Former COVID patients could face a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression. Although some of these issues will dissipate with time, others may turn out to be long-standing problems.

So sign up, said Van Arnam and others to whom KHN reached out for tips on what people with post-COVID-19 should consider when selecting coverage. There’s no one-size-fits-all answer, but they all emphasized the need to consider a wide range of factors.

But don’t delay. Open enrollment in ACA plans is ongoing until Dec. 15 in most states — longer in some of the 14 states and the District of Columbia that run their own marketplaces.

Here are tips if you are shopping for health insurance, especially if you are a COVID long hauler or have other health issues:

Make sure to select an ACA-qualified plan.

It may be tempting to consider other, often far less expensive types of coverage offered by insurers, brokers, organizations and private websites. But those non-ACA plans offer less comprehensive coverage — and are not eligible for federal subsidies to help people who qualify cover the cost of the premiums. These are key factors for patients experiencing medical problems after battling the coronavirus.

Short-term, limited-duration plans, for example, are cheaper, but the insurers offering them don’t have to accept people with preexisting conditions — or, if they do enroll those people, the plans don’t cover the members’ medical conditions. Many short-term plans don’t cover benefits such as prescription drugs or mental health care.

Another type of plan that doesn’t meet ACA requirements are “sharing ministries,” in which members agree to pay one another’s medical bills. But such payments aren’t guaranteed — and many don’t cover anything considered preexisting.

Shop around to consider all the ACA plans available in your region.

This will help you meet your post-COVID medical needs while also getting the best buy.

Comparison-shopping also lets consumers adjust their income information, which may have changed from last year, especially after being sick, and could affect subsidy levels for those eligible for assistance in purchasing a plan.

Under the ACA, subsidies to offset premium costs are available on a sliding scale for people who earn between 100% and 400% of the federal poverty level. That range next year is $12,760 to $51,040 for an individual and $26,200 to $104,800 for a family of four.

Networks matter. Look for your doctor or hospital in the plan.

One of the first things to do once you’ve narrowed down your choices of plans is to dig deeper to see if the doctors, specialists and hospitals you use are included in those plans’ networks. Also, check plan formularies to see if the prescription medications you take are covered.

Many insurance plans don’t have out-of-network benefits, except for emergency care. That means if a doctor or hospital doesn’t participate in the network, consumers must switch medical providers or risk huge bills by receiving out-of-network care. This should be a concern for long haulers.

This subset of COVID patients who report lingering health concerns may need to see a range of specialists, including pulmonologists, cardiologists, neurologists, rheumatologists and mental health professionals.

“So, you are already talking about five or six,” said Erika Sward, assistant vice president for national advocacy at the American Lung Association.

To check the network status of medical providers, go to the healthcare.gov website, which will direct you to your state site if you are in one of the 14 states or the District of Columbia, which run their own. Enter a ZIP code and some other information to start looking for available plans.

Narrow the search using the “add your medical providers” button on healthcare.gov, or access each plan’s “provider directory” under plan documents to see which specific doctors and hospitals are included. To be safe, Sward said, call each office to make sure they are participating with that insurer next year.

Don’t just look at premium costs: Deductibles also matter.

Consumers must pay deductible amounts before the bulk of financial assistance kicks in. That can be a big hit, especially for those who need complex care all at once or very expensive prescription drugs. Long haulers, as well as others with chronic health conditions, often fall into this category.

Median deductibles — the mark at which half cost more and half cost less — vary across the different “tiers” of ACA plans, hitting $6,992 for bronze plans; $4,879 for silver plans and $1,533 for gold plans, according to an analysis by the Centers for Medicare & Medicaid Services.

Generally, plans with higher deductibles have lower monthly premiums. But getting past the deductible is a challenge for many.

What’s best for those with ongoing health conditions depends on individual circumstances.

“Balancing the deductibles and premiums is a really important consideration for consumers,” said Laurie Whitsel, vice president of policy research and translation at the American Heart Association.

Those with ongoing health conditions need to carefully weigh the expected annual out-of-pocket costs for various health plans, given that they may well be moderate to high users of health services. Healthcare.gov has a financial estimator tool that can help with the decision. Consumers can select whether they think they will have low, medium or high medical use next year to see the estimated total annual costs of each plan.

Frequent users of health services may discover that plans that initially seem least expensive, based solely on the premium or the deductible, may be costlier once all out-of-pocket factors are considered.

Finally, insurers in some markets are touting zero-deductible plans.

Instead of an annual deductible, such policies have higher copayment or coinsurance amounts each time a patient sees a doctor, gets a test or has surgery. Those can range from $50 to more than $1,000, depending on the visit, test or service provided. Still, for some costly services, those payments may amount to less than paying a deductible.

Broker John Dodd in Columbus, Ohio, said such plans appeal to some people who don’t want to have to shell out thousands of dollars in deductible payments before their insurance picks up the bulk of medical costs.

Still, he cautioned that many of the zero-deductible plans do have what can be a sizable deductible — hundreds or even thousands of dollars — for brand-name prescription drugs.

Long haulers should weigh those factors carefully, as such zero-deductible plans may be more suited to those who don’t expect to use a lot of medical care.

Read the fine print, because there are other costs.

While plans may tout similar premiums, their dissimilar structures could affect how much a consumer will shell out in flat-dollar copayments or percentage coinsurance to see a doctor, pick up a prescription, get a blood test or spend the night in the hospital. This is, again, something long haulers should focus on.

These details are spelled out in the plan’s “summary of benefits,” a required document under the ACA, which can be found on healthcare.gov or insurers’ websites.

Still, ACA plans limit how much a consumer must pay out-of-pocket for the year. Next year, the maximum is $8,550 for an individual or $17,100 for a family plan.

Ask for help.

While services such as Van Arman’s navigator program have seen stiff budget cuts during the past few years, consumers there and in many states still have access to online or phone help. Healthcare.gov has a “find local help” button that can refer people by ZIP code to navigators, assisters and brokers.

Finally, those affected by COVID who miss the open enrollment deadline can request an extension under rules that allow special enrollment for emergencies or disasters.

“It’s not a guarantee and you have to telephone the call center and ask for it,” said Karen Pollitz, a senior fellow at KFF.

Still, she said, it’s best to sign up before Dec. 15.

“Just get it done,” Pollitz said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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ACA could help millions of uninsured gain free coverage

Millions of Americans without healthcare insurance could be eligible to get coverage for free, or nearly free, through financial assistance offered under the Affordable Care Act. But many who recently lost their employer-based coverage may not be aware of the options available to them.

After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion

Adam Woodrum was out for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed.

“He cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum.


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Because they were on bikes, he called the fire department in Carson City, Nevada.

“They were great,” said Woodrum. “They took him on a stretcher to the ER.”

Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.

Then the denial letter came.

The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program

Total Bill: $18,933.44, billed by the hospital

Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health

Medical Service: Stitches and anesthesia during an emergency department visit

What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.

This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.

The legal name for the process of determining which type of insurance is primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?

Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.

Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.

About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.

The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.

The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”

Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.

The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.

“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”

When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.

The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”

Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”

Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.

“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”

Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.

Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.

That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.

Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.

“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.

After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.

His child just fell off his bicycle.

HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.

The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.

The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.

It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.

But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.

Don’t panic.

If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.

And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.

“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Were You Notified About Missing Tax Forms for Your ACA Subsidy? Blame COVID.

The notice from the federal health insurance marketplace grabbed Andrew Schenker’s attention: ACT NOW: YOU’RE AT RISK OF LOSING FINANCIAL ASSISTANCE STARTING JANUARY 1, 2021.

As he read the notice, though, the Blacksburg, Virginia, resident became exasperated. Schenker, his wife and their teenage son have a bronze-level marketplace plan. Based on their income of about $40,000 a year, they receive tax credits that cover the $2,036 monthly premium in full.

When they file their annual taxes they complete an IRS form that reconciles how much they received in advance tax credits against their actual income for the year. The letter from the marketplace said they hadn’t filed for 2019, but Schenker knew they had — just as they have every year.

“I was more annoyed than anything else,” Schenker, 55, said, remembering an earlier enrollment problem that took months to resolve. “I didn’t want to get stuck in some sort of appeals category.”

Schenker’s 25-year-old daughter, Kaily Schenker, who is part owner of the family’s organic farm, got the same letter about her plan. Schenker helps her with her taxes, and she also filed the Form 8962 paperwork, he said.

Officials at the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits. The letters, consumer advocates suggested, may be a result of the IRS extending the deadline for filing income taxes due to the coronavirus to July 15.

State-based marketplaces have similar requirements and likely send some version of this notice as well, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities who works on income tax issues related to the Affordable Care Act.

People who don’t file their taxes and the reconciliation form aren’t eligible for financial assistance with their marketplace coverage next year, including premium tax credits and any cost-sharing reductions they qualify for.

Because of the filing deadline extension, the tax form data may not have yet arrived when the federal marketplace initially asked the IRS for it in the fall, Straw said. Or other issues, including longer processing times for paper tax returns, could be responsible for a delay, Straw said.

“We don’t know how many people are in this boat,” Straw said. “We think it’s higher than in previous years because of anecdotal accounts from marketplace assisters around the country.”

Schenker said he and his daughter both filed paper returns — his family’s, in the spring, while his daughter took advantage of the pandemic extension.

Under ACA rules, people with incomes up to 400% of the poverty level ($86,880 for a family of three) can qualify for advance tax credits to help pay for coverage purchased through state or federal health insurance exchanges. When they sign up for insurance during open enrollment, their tax credits are based on estimates of their income for the coming year, and the exchanges pay insurers that amount directly. Then when people file their income taxes the following year, they use Form 8962 to reconcile their actual income against what they estimated and square off the amount in tax credits they received. If they received too much in subsidies, they must pay that back to the government.

According to the notice Schenker received, people who have already filed their 2019 tax return and Form 8962 don’t need to take any action.

Straw recommends a more hands-on approach.

“It’s really a dangerous thing to just wait and cross your fingers and hope that the data will resolve your issue,” she said.

Consumers who filed and reconciled taxes for 2019 can keep their tax credit in 2021, CMS officials said, by updating their 2021 HealthCare.gov application on or before Dec. 15 and checking the box that says, “Yes, I reconciled premium tax credits for past years.”

Straw encouraged marketplace customers to follow that advice. (State-based marketplaces generally follow the same process as the federal marketplace, perhaps with slight variations.)

Still, that might not be sufficient. Straw also recommends that people contact the IRS directly and ask for a tax transcript that shows their return was received, including Form 8962.

That way, if the marketplace does cut off premium tax credits and people have to appeal, they have documentation proving they filed the necessary forms. (If it comes to this, consumers can elect to continue receiving premium tax credits while they appeal.)

Unfortunately, people who run into this trouble might not get much expert help. Navigators are no longer required to help consumers with problems after they’ve enrolled, though they may still do so, Straw said.

Likewise, insurance brokers generally don’t help people with these problems, said Karen Pollitz, a senior fellow at KFF. (KHN is an editorially independent program of KFF.) Marketplace plan commissions are so low, “they’re much less likely to help people with complex problems,” she said.

After he got the letter, Schenker called marketplace representatives and was told to go ahead and apply for a plan for next year. He did so, making sure to check the box that said he’d filed his taxes, including the reconciliation form. And at the end of the application process, the system told him that, based on his income, his family is eligible for a tax credit of $2,000 a month. He picked a bronze plan.

He hopes that’s the end of it.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN on the Air This Week

KHN Midwest correspondent Lauren Weber discussed COVID-19 surges in Wisconsin with Wisconsin Public Radio’s “Central Time” on Nov. 13.

California Healthline correspondent Angela Hart and editor Emily Bazar discussed how the Supreme Court case about the Affordable Care Act could affect California with the CalMatters and Capital Public Radio’s “California State of Mind” podcast.

KHN chief Washington correspondent Julie Rovner discussed open enrollment for ACA marketplace plans with Maine Public Radio’s “Maine Calling” on Monday.

KHN Midwest correspondent Cara Anthony discussed protections against race-based hair discrimination with KTVU Fox 2 on Tuesday.

KHN senior correspondent Liz Szabo discussed COVID vaccine candidates with Newsy on Tuesday.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Surprise Federal Drug Rule Directs Insurers to Reveal What They Pay for Prescription Drugs

Health insurance companies will have to give their customers estimated out-of-pocket costs for prescription drugs and disclose to the public the negotiated prices they pay for drugs, under an unexpected new Trump administration rule.

The administration said those requirements, part of a broader rule issued Oct. 29 forcing health plans to disclose costs and payments for most health care services, will promote competition and empower consumers to make better medical decisions.

The new rule does not, however, apply to Medicare or Medicaid.

The drug price provisions, which would not begin until 2022, were a surprise because they were not included in the original proposed rule issued in 2019.

It’s the departing Trump administration’s most ambitious effort to illuminate the complex, secret and lucrative system of prescription drug pricing, in which health plans, drug manufacturers and pharmacy benefit management firms agree on prices. The administration and Congress have tried and failed to reform part of that system — the rebates paid by drugmakers to the pharmacy benefit managers to get their products onto insurance plan formularies. Those payments, which some call kickbacks, are widely blamed for driving up costs to patients.

Patient advocates and policy experts, while generally supportive of the administration’s transparency concept, are divided on the cost-saving value of the new rule. Many say Congress needs to take broader action to curb drug prices and cap patient costs. Groups representing drugmakers, pharmacy benefit managers and commercial health plans have denounced the initiative, saying it will damage market competition and raise drug prices.

Advocates say the new rule will help patients in private health plans, including employer-based plans, and their physicians choose less expensive medications. It may even enable health plans to buy drugs more cheaply for their members. Three in 10 Americans say they have opted not to use a prescribed drug as directed because of the high cost, according to a KFF survey last year. (KHN is an editorially independent program of KFF.)

Under the new federal rule, starting in 2024 an insurance plan member can request and receive estimates of out-of-pocket costs for prescription drugs, both online and on paper, taking into account the member’s deductible, coinsurance and copays. Insurers say most plans already offer such cost-estimator tools.

Helping patients find drugs that cost them less could boost their compliance in taking needed medicines, thus improving their health.

“You can call your insurer now and ask what your copay is,” said Wendy Netter Epstein, a health law and policy professor at DePaul University in Chicago. “Patients often don’t do that. Whether or not this has an impact depends on whether patients take the initiative to obtain this information.”

Starting in 2022 under the new rule, private plans also will have to publish the prices they negotiated with drug companies and benefit management companies online in a digital, machine-readable format. That may be particularly helpful to employers that provide health insurance to workers, enabling them to seek the lowest price the drug manufacturer is offering to other purchasers.

The rule will not require plans to disclose rebates and other discounts they negotiate with drugmakers and pharmacy benefit managers.

That’s a disappointment to employers that provide health insurance for their workers. “We’d like a much clearer idea of how much we’re paying for every drug every time it’s dispensed,” said James Gelfand, senior vice president for health policy at the ERISA Industry Committee, which represents large self-insured employers. “We want to know where every cent in rebates and discounts is going. We’ll at least begin peeling back the onion. You have to start somewhere.”

But other experts argue the rule will do little to make medications more affordable. Indeed, they warn that publishing what health plans pay drug manufacturers could crimp some plans’ ability to get price concessions, raising the premiums and drug prices that plan members pay. That’s because manufacturers won’t want to give those discounts knowing other health plans and pharmacy benefit managers will see the published rates and ask for the same deals.

“Insurers and pharmacy benefit managers currently use rebates that are hidden from view to drive prices lower,” said Dr. Aaron Kesselheim, a professor of medicine at Harvard University who studies prescription drug policy. “If you make that transparent, you kind of reduce the main strategy payers have to lower drug prices.”

Patient advocates also questioned how useful the published rates will be for patients, because plans don’t have to post list prices, on which patient cost-sharing amounts are based. There also are practical limits to patients’ ability to price-shop for drugs, considering there may be only one effective drug for a given medical condition, such as many types of cancers.

Still, if the public knows more about how much health plans pay for drugs — and can estimate the size of the rebates and discounts that aren’t being passed on to patients — that could heighten pressure on federal and state elected officials to tackle the thorny issues of high prices and gaps in insurers’ drug coverage, which powerful industry groups oppose.

“If the information is presented to consumers so they realize they are paying a higher price without the benefit of the rebates, you’ll get a lot of angry consumers,” said Niall Brennan, CEO of the Health Care Cost Institute, a nonprofit group that publishes cost data.

The Biden administration is expected to keep the new price disclosure rule for health plans. In July, the Biden campaign issued a joint policy statement with Sen. Bernie Sanders (I-Vt.) favoring increased price transparency in health care.

But Kesselheim and other experts say Congress needs to consider stronger measures than price transparency to address drug affordability. These include letting the federal government negotiate prices with drugmakers, limiting the initial price of new drugs, capping price increases and establishing an impartial review process for evaluating the clinical value of drugs relative to their cost. Those are policies Biden has said he supports.

“There’s a limit to what transparency can do,” said Shawn Gremminger, health policy director at the Pacific Business Group on Health, which represents large self-insured employers. “That’s why we’re increasingly comfortable with policies that get at the underlying prices of drugs.” As an example, he cited the Trump administration’s proposal to tie what Medicare pays for drugs to lower prices in other countries.

Commercial insurers, drug manufacturers and pharmacy benefit managers are strongly opposed to the drug transparency rule. “This rule will disrupt the marketplace dynamics and undermine the highly competitive negotiations that kept net prices for brand medicines at a growth rate of just 1.7% in 2019,” said Katie Koziara, a spokesperson for the Pharmaceutical Research and Manufacturers of America. She wouldn’t say whether her group would sue to block the rule.

The survival of the rule, which draws its legal authority from the Affordable Care Act, also depends on the U.S. Supreme Court upholding the constitutionality of that law in a case argued on Nov. 10.

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘An Arm and a Leg’: For Your Next Health Insurance Fight, an Exercise in Financial Self-Defense

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A listener asked: ‘How do I remain cool when calling insurance companies?” So we called veteran self-defense teacher Lauren Taylor for advice. She leads Defend Yourself, an organization that works to empower people against violence and abuse. 

As Taylor teaches it, self-defense involves a lot more than hitting and kicking. It’s about standing up for yourself in all kinds of difficult situations. Striking that posture includes using your words, and we asked Taylor to talk us through her top strategies. This year, she used them in her own health insurance fight.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: Transition Interrupted

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Five days after the election was called for President-elect Joe Biden, President Donald Trump has not conceded — and instead ordered his administration not to begin the transition of power. That could have serious ramifications for health care, particularly as nearly every state is experiencing a spike in COVID-19 cases.

One piece of good news is that early results for a coronavirus vaccine made by Pfizer look promising. But that vaccine, even if it is approved soon, won’t likely be ready for wide distribution for several months.

And for the third time in eight years, the Supreme Court heard a case that could invalidate the Affordable Care Act. Judging from the oral arguments, though, it appears the justices are likely to leave most or even all of the law intact.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Shefali Luthra of the 19th News.

Among the takeaways from this week’s podcast:

  • The transition teams advising Biden cannot officially contact current government officials. But many team members have long-standing relationships with people in the government and were talking to those officials before the election, so they have a good sense of what is happening in the administration.
  • The pandemic further complicates the handoff. The new administration will need to hit the ground running to distribute any coronavirus vaccine, so communication with Trump administration officials would be beneficial for the Biden team.
  • Two members of Biden’s COVID task force, Drs. Vivek Murthy, former surgeon general, and David Kessler, former commissioner of the Food and Drug Administration, have been briefing the former vice president since March on the threats of the coronavirus.
  • Since Democrats may not control the Senate — and if they do have control, it will be by the slimmest majority — Biden may be forced to make changes to health policy through executive actions and regulations. That will limit his ambitions.
  • Still, even these smaller moves can have major results, such as allowing Planned Parenthood to again participate in federal health programs to expand the number of providers from which low-income women can seek care.
  • The Pfizer vaccine requires extremely cold temperatures for storage, complicating the logistics for distribution. It is an obstacle but not an insurmountable one for most areas in this country.
  • Supreme Court justices signaled this week they might not strike the Affordable Care Act in its entirety. Several of the conservatives, including Justice Brett Kavanaugh, who was appointed by President Donald Trump, suggested that any ruling that the mandate to have insurance is unconstitutional does not have to doom the rest of the law.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: KHN and The Washington Post’s “In Medical Schools, Students Seek Robust and Mandatory Anti-Racist Training,” by Elizabeth Lawrence

Joanne Kenen: KHN’s “Trump’s Anti-Abortion Zeal Shook Fragile Health Systems Around the World,” by Sarah Varney

Stephanie Armour: KHN’s “Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” by Phil Galewitz

Shefali Luthra: Stat News’ “With a Meteoric Rise in Deaths, Talk of Waves Is Misguided, Say Covid-19 Modelers,” by Elizabeth Cooney

To hear all our podcasts, click here.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Workers Who Lost Jobs Due to COVID May Need Help Getting Coverage This Fall

Michelina Moen lost her job and health insurance in April. Only weeks earlier she had begun to feel ill and not her usual energetic self — in what she describes as a textbook case of “really bad timing.”

The Orlando, Florida, resident sought treatment in May. After a series of tests, doctors told Moen she had a rare kidney condition that would require months of treatment.

“Losing the coverage ended up being worse than losing the job,” said Moen, 36, a dancer who had worked for both Walt Disney World and Universal Studios. “It was very stressful.”

Moen rushed to find replacement coverage. With help from a social service agency, she enrolled in a plan through healthcare.gov, the federal Affordable Care Act insurance marketplace. Because she and her husband, Brett, were not working — he had been laid off by Disney, too — they qualified for federal subsidies, so the coverage cost her just $35 a month. Most of her medical expenses, which involve traveling frequently to Jacksonville for specialty treatment, are covered.

Moen’s husband recently found a job, however, and the increase in the couple’s income likely means her subsidy will fall and she’ll have to pay more for health insurance. Moen said she’ll evaluate her options and may switch plans during this year’s ACA open enrollment period, which began Nov. 1 and ends Dec. 15 for coverage starting Jan. 1.

“A priority is to continue seeing my medical team in Jacksonville,” Moen said.

Moen is one of millions of Americans who have been dropped from their jobs and their employer-provided health insurance since March, when the coronavirus first ravaged the economy. Although no official tally exists, studies indicate that at least 10 million workers lost their insurance but that about two-thirds of them found alternative coverage — through a new job, Medicaid, a spouse’s or parent’s plan, or the ACA marketplaces.

That leaves at least 3 million people without coverage, the most added in a single year since accurate record-keeping began in 1968. And experts are worried that, as the virus continues to play havoc with the economy, new rounds of business closings and layoffs could add to that number.

Navigators Want More Resources

The unprecedented situation has health insurance counselors (called navigators), ACA marketplace staff members and insurers scrambling to assist a possible surge of people looking for health insurance during open enrollment.

For the 36 states that rely on the federal ACA enrollment platform — healthcare.gov — the Trump administration awarded grants totaling $10 million for marketing and outreach this year, the same level as in 2019. In 2016, the last year of the Obama administration, navigator grants totaled $63 million.

Many navigator organizations say they don’t have the resources from the federal government to do the job as they would like.

“I’m trying not to panic,” said Jodi Ray, executive director of Florida Covering Kids & Families. “We’ve seen substantially more people needing coverage and help in recent months compared to last year, and more are new to being uninsured.”

Ray said her team is booked with appointments well into November. But she bemoans the fact that she has a third of the counselors she had a few years ago — 50, compared with 150 — and only a tiny ad budget.

Like Ray, Jeremy Smith, program director at First Choice Services in Charleston, West Virginia, said his team is expecting “tens of thousands more people” needing help compared with last year — but no bigger budget to serve them. First Choice provides telephone-based enrollment assistance in West Virginia, New Hampshire, Iowa and Montana with a federal grant of $100,000 per state.

“We are talking to a lot more people who have had job-based coverage for years,” Smith said. “This is the first time they are having to find insurance elsewhere. They don’t know what to do or who to trust.”

In Wisconsin, the governor shifted $1 million into health insurance outreach, in part to make up for a lack of federal funds, said Allison Espeseth, managing director at Covering Wisconsin, the state’s navigator agency. She said the money will go to radio and TV spots, billboards, bus ads and small grants to community organizations.

“A lot of people who lost jobs and insurance didn’t know they could enroll before open enrollment, so we are hoping to see them now,” Espeseth said.

Toula Barber, 60, is happy to be among those who got clear and useful help. “I’m not that savvy with computers and figuring all this stuff out,” said Barber, who lives in Manchester, New Hampshire. After she lost her job as a waitress in August, Barber’s health insurance lapsed at the end of September. A First Choice Services navigator helped her find a plan with coverage that started Oct. 1. She pays $200 a month after subsidies.

Because that plan has a $6,000 deductible, however, Barber said she would look for something better during open enrollment, in consultation with the same navigator.

An analysis published last summer found evidence of a shortage of enrollment assistance. It also pointed out that people who turned to insurance brokers rather than independent navigators for help sometimes were presented with the option of plans (such as short-term policies or cancer-only policies) that don’t meet ACA standards.

“The bottom line was that nearly 5 million people who sought help during the last open enrollment could not find it,” said Karen Pollitz, a senior fellow at KFF and one of the authors of the study. “I’m concerned that people will face barriers to finding help this year, too.”

Some States Are Pushing Harder

In contrast to the states that use the federal website, healthcare.gov, many of the 15 states that run their own ACA marketplaces are committing more resources to outreach and marketing this year to meet the higher demand.

“We market aggressively,” said Peter Lee, executive director of Covered California, that state’s marketplace. “We want everyone who needs coverage to get it.” Of Covered California’s $440 million budget this year, Lee said $140 million will go for marketing and outreach. In addition, California is inserting information about the marketplace and subsidized coverage in all unemployment checks.

Just short of 300,000 Californians have enrolled since the pandemic began, and about half did so because they lost employment-based coverage, said Lee.

At the same time, however, about 1 in 4 Covered California enrollees dropped out this year, higher than the normal turnover as some newly qualified for Medicaid and an unknown number could no longer afford the premiums. Still, enrollment was at an all-time high of 1.5 million as of June.

In New York, state officials and private groups have been helping people enroll in Medicaid, marketplace plans or other state-supported programs.

“We’ve been super busy since April,” said Elizabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, an independent advocacy group for low-income residents. “Our governor prioritized this, so it’s going well.”

One challenge Benjamin noted are the fears that a case currently before the Supreme Court might overturn the law. “Our clients keep asking whether the ACA will still be around next year,” she said. “We reassure them it will.”

Madeline McGrath, 27, sought insurance help from the service society in May after her coverage through the Peace Corps expired. The corps laid off all its overseas staff in March. Madeline was in Moldova. She returned home to Chazy, New York. She qualified for Medicaid, and just in the nick of time: A few weeks earlier, she had been diagnosed with Crohn’s disease, a chronic digestive disorder.

“I’ll stick with Medicaid since my co-payments are very low,” said McGrath, who is pursuing a graduate degree.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Fiscal general de California: los jueces deben ver que ACA es “indispensable”

Sacramento.- Cuando la Corte Suprema de los Estados Unidos esté escuchando el martes 10 un caso que podría decidir el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), California liderará la defensa de la ley federal que impacta en casi todos los aspectos del sistema de salud del país.

Por lo general, es tarea del gobierno federal defender una ley federal, pero la Administración Trump quiere que ACA, también conocida como Obamacare, se revoque.

Por eso, el fiscal general de California, Xavier Becerra, respaldado por más de 20 estados, defiende la ley contra el desafío presentado hace dos años por una coalición de funcionarios estatales republicanos.

Becerra ha sido uno de los adversarios más formidables de Trump: ha llevado a la administración a los tribunales decenas de veces por sus políticas, que van desde la inmigración y el control de la natalidad hasta el cambio climático. Se le considera uno de los principales contendientes para llenar la vacante del Senado que se abrirá ahora que la senadora por California Kamala Harris ha sido elegida vicepresidenta.

“Tan enérgicamente como un presidente y su administración están luchando para destruir la Ley de Cuidado de Salud a Bajo Precio, nosotros estamos luchando para salvarla para todos los estadounidenses”, dijo Becerra a los periodistas en una conferencia de prensa el lunes 9.

Si el tribunal anula toda la ley, el impacto se sentiría ampliamente. La ley proporciona seguro médico a más de 23 millones de estadounidenses. Permite a las personas que califican comprar seguros a través de los mercados estatales y el federal, y recibir subsidios.

También ha recomendado  a los estados expandir sus programas de Medicaid a más personas; previene que las compañías de seguros nieguen cobertura a personas con afecciones médicas preexistentes; prohíbe los límites de por vida en la cobertura; agrega beneficios a Medicare; y permite que los hijos permanezcan en los planes de sus padres hasta los 26 años.

El tema central en California vs. Texas es la multa fiscal federal por no tener seguro médico, como exige la ley. En 2017, el Congreso liderado por los republicanos redujo esta multa a cero, pero mantuvo intacta al resto de la ley, una medida que, según Becerra y otros expertos en leyes, muestra la intención del Congreso de apoyarla.

Sin embargo, funcionarios estatales republicanos dicen que la pérdida de la penalidad invalida el mandato de tener un seguro, así como toda la ley.

Becerra dijo que es posible que el tribunal determine que los impugnadores no tienen legitimidad para demandar al gobierno porque nadie ha sido perjudicado por una multa que cuesta cero.

Aunque la corte ha ratificado dos veces esta ley, la composición de la corte ha cambiado desde su último fallo sobre ACA en 2015. Desde entonces, Trump ha nombrado a tres jueces conservadores. Dos reemplazaron a otros conservadores, pero Amy Coney Barrett, quien fue confirmada a fines de octubre, ocupa el asiento de un ícono liberal, la jueza Ruth Bader Ginsburg.

Abbe Gluck, directora del Centro Salomón de Derecho y Políticas de Salud de la Escuela de Derecho de Yale, dijo que si el tribunal cree que el requisito del seguro médico es inconstitucional sin la penalidad, debería simplemente declarar inválida esa sección de la ley, pero no anularla por completo.

Pero “he aprendido que nunca se puede predecir lo que sucede en la corte cuando se trata de la Ley de Cuidado de Salud a Bajo Precio”, dijo Gluck. “Por eso hay más preocupación, porque el estatuto se ha vuelto tan fundamentalmente importante para una quinta parte de nuestra economía y para la atención médica de prácticamente todos los estadounidenses”.

Becerra habló con Samantha Young de California Healthline sobre su defensa del Obamacare y el enorme alcance de la influencia de la ley. La entrevista ha sido editada por extension, y para mayor claridad.

¿Cuáles son las posibilidades de que la Corte Suprema derogue la Ley de Cuidado de Salud a Bajo Precio?

Confiamos en que no solo verán la lógica legal detrás de esto, sino también la sabiduría y el éxito práctico de la Ley de Cuidado de Salud a Bajo Precio, lo cual pesa mucho a favor de que los jueces reconozcan no solo que es legal, sino indispensable. Cuando los jueces examinen los fundamentos de la Ley de Cuidado de Salud a Bajo Precio, encontrarán que es constitucional.

La composición de la Corte Suprema de los Estados Unidos ha cambiado desde la última vez que se pronunció sobre ACA. ¿Por qué cree que estos jueces decidirán de la misma manera?

Eso no debería cambiar el hecho de que los fundamentos de la ley siguen siendo los mismos. Los fundamentos de ACA son sólidos y funcionan. Espero que nueve jueces que revisan la misma ley observen ese precedente.

¿A qué debe prestar atención el público durante los argumentos orales?

Algo interesante de observar es cómo la corte interpreta las acciones tomadas por el Congreso en 2017, cuando aprobaron el proyecto de ley de exención de impuestos y redujeron a cero la tarifa o multa por el mandato individual. Ahora, estamos ante un presidente y al menos una cámara en el Congreso que está preparada para defender la Ley de Cuidado de Salud a Bajo Precio. ¿Cómo podría considerar el tribunal el hecho de que otro Congreso podría restablecer parte de ese mandato?

¿Cómo se relaciona esto con el argumento legal de que haber reducido a cero el mandato de alguna manera provocó la inconstitucionalidad de toda la ley? Creo que es una cuestión que el tribunal tendrá que examinar.

¿Qué pasará si la Corte Suprema de los Estados Unidos declara inconstitucional la Ley de Cuidado de Salud a Bajo Precio?

Volverán las preocupaciones. La atención preventiva de Medicare desaparecería. Los días en que los estadounidenses no tenían que preocuparse por la bancarrota por haber pisado un hospital prácticamente se esfumarían.

Tengo tres hijas. Hubo un tiempo que, como adultas, las tres estaban en nuestra cobertura de atención médica. Eso desaparecería porque la disposición que permite que los hijos adultos menores de 26 años permanezcan en la cobertura de los padres desaparecería. Y podría seguir y seguir.

¿Podrían los estados, incluido California, darse el lujo de intervenir por su cuenta?

No sé si hay algún estado que tenga la capacidad de reemplazar lo que hace la Ley de Cuidado de Salud a Bajo Precio. Es casi imposible. Parte de eso se debe a que no podemos replicar algunas de las cosas que puede hacer el gobierno federal. No tenemos esa jurisdicción federal, no tenemos esa amplitud y profundidad de alcance.

Si el tribunal anula ACA, ¿el Congreso no puede aprobar protecciones parciales que cuenten con el apoyo de los republicanos, como la cobertura de afecciones preexistentes?

Hemos escuchado a los republicanos decir “revocar y reemplazar” durante más de 10 años, y ha sido una retórica vacía desde el principio. Para los padres que tienen hijos con afecciones médicas preexistentes, no es reconfortante que alguien les prometa que reemplazarán un derecho que saben que ahora tienen para que sus hijo vayan al hospital. Y, ¿por qué desecharías eso por una promesa vacía que ya lleva 10 años?

La mayoría de los estadounidenses dirían: sigue construyendo sobre la base de la Ley de Cuidado de Salud a Bajo Precio. Mejorémosla, pero no descartemos lo que ha funcionado.

¿Cómo sabe que la Ley de Cuidado de Salud a Bajo Precio está funcionando?

Mi antiguo distrito congresional en Los Ángeles se encontraba entre los distritos congresionales con más cantidad de personas sin seguro de salud de la nación. En cuestión de años, una vez que entró en vigor la Ley de Cuidado de Salud a Bajo Precio, la tasa de personas sin seguro en ese distrito se redujo en un 50%. Fue simplemente astronómico.

La Ley de Cuidado de Salud a Bajo Precio hizo posible que las familias trabajadoras pudieran obtener cobertura y eso es enorme. Ese es el tipo de carga que se quita del alma.

¿Cree que tener a Joe Biden como presidente y a Kamala Harris como vicepresidenta en la Casa Blanca llevará a una mejora en la Ley de Cuidado de Salud a Bajo Precio?

Como candidato a presidente, Joe Biden dijo que se basaría en el éxito de la presidencia de Obama-Biden y se aseguraría que sigamos aumentando el número de estadounidenses con acceso a una atención médica asequible. Lo bueno es que finalmente tienes a alguien en la parte superior del tótem que dice que lo vamos a mejorar. Por eso esta elección fue tan importante.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Justices Bound to See ACA as ‘Indispensable,’ Says Californian Leading Defense

SACRAMENTO — When the U.S. Supreme Court hears a case Tuesday that could decide the fate of the Affordable Care Act, California will be leading the defense to uphold the federal law that touches nearly every aspect of the country’s health care system.

It’s usually the federal government’s job to defend a federal law, but President Donald Trump’s administration wants this law, also known as Obamacare, to be overturned.

So California Attorney General Xavier Becerra, backed by more than 20 other states, is defending the law against the challenge brought by a coalition of Republican state officials two years ago.

Becerra has been one of Trump’s most formidable adversaries, taking the administration to court scores of times over its policies, ranging from immigration and birth control to climate change. He is considered one of the leading contenders to fill the Senate vacancy that will open now that Sen. Kamala Harris of California has been elected vice president.

“Just as vigorously as a president and his administration are fighting to destroy the Affordable Care Act, we are fighting to save it for every American,” Becerra told reporters in a press conference Monday.

Should the court overturn the entire law, the impact would be felt widely. The law provides health insurance to more than 23 million Americans. It allows qualified people to buy subsidized insurance through federal or state insurance exchanges; permits states to expand their Medicaid programs to more people; prevents insurance companies from denying coverage to people with preexisting medical conditions; bans lifetime limits on coverage; adds benefits to Medicare; and allows children to stay on their parents’ plans up to age 26.

At issue in California v. Texas is the federal tax penalty for not having health insurance, as the law requires. The Republican-led Congress in 2017 zeroed out the penalty but kept the rest of the health law intact, a move Becerra and some other legal experts say shows congressional intent to support the law. The Republican state officials, however, say the loss of the tax invalidates the mandate to have insurance — as well as the entire law.

Becerra said it’s possible the court may determine that the challengers don’t have standing to sue the government because no one has been harmed by a zero-tax penalty.

Although the court has twice upheld the federal health care law, the composition of the court has changed since its last ACA ruling in 2015. Trump has appointed three conservative judges since then. Two replaced other conservatives, but Amy Coney Barrett, who was confirmed in late October, took the seat of a liberal icon, Justice Ruth Bader Ginsburg.

Abbe Gluck, faculty director of the Solomon Center for Health Law and Policy at Yale Law School, said that if the court believes the health insurance requirement is unconstitutional without the penalty, it should just hold that section of the law invalid but not overturn the entire law.

But “I have learned that you can never predict what happens in court when it comes to the Affordable Care Act,” Gluck said. “And that is why there is this heightened sense of concern, because the statute has become so fundamentally important to one-fifth of our economy and the health care of virtually all Americans.”

Becerra talked to California Healthline’s Samantha Young about his defense of Obamacare and the far-reaching influence of the law. The interview has been edited for length and clarity.

Q: What are the chances the Supreme Court could overturn the Affordable Care Act?

We’re confident they will see not just the legal logic behind it, but the wisdom and the practical success of the Affordable Care Act — all of which weigh heavily in favor of the justices recognizing that it’s not only legal but indispensable. When the justices look to the fundamentals of the Affordable Care Act, they’re going to find that it is constitutional.

Q: The makeup of the U.S. Supreme Court has changed since it last ruled on the ACA. Why do you think these justices will rule the same way?

That shouldn’t change the fact that the fundamentals of the law have remained the same. The fundamentals of the ACA are grounded, they’re solid, and they work. I would hope that nine justices reviewing the same law would look at that precedent.

Q: What should the public pay attention to during the oral arguments?

One thing interesting to watch is how the court interprets the actions taken by Congress in 2017 when they passed the tax break bill and zeroed out the individual mandate fee or penalty. Now, we’re looking at a president and at least one house in Congress that’s prepared to defend the Affordable Care Act. How might the court look at the fact that another Congress could reinstitute part of that mandate?

What does that do to the legal argument that having zeroed out the mandate somehow triggered the unconstitutionality of the entire law? I think that’s a question the court will have to examine.

Q: What happens if the U.S. Supreme Court declares the Affordable Care Act unconstitutional?

The worries return. Preventative care under Medicare would be gone. The days when Americans don’t have to worry about going personally bankrupt for having visited a hospital would pretty much be gone.

I’ve got three daughters. There was a time when all three of them as adults were on our health care coverage. That would be gone because the provision that allows adult children under the age of 26 to remain on a parent’s coverage would disappear. I could go on and on.

Q: Could states, including California, afford to step in on their own?

I don’t know if there’s any state who has the capacity to replace what the Affordable Care Act does. It’d be almost insurmountable. Part of that is because we can’t replicate some of the things that the federal government can do. We don’t have that federal jurisdiction, we don’t have that breadth and depth of reach.

Q: If the court overturns the ACA, can’t Congress pass piecemeal protections that have Republican support, such as coverage for preexisting conditions?

We have heard Republicans say “repeal and replace” for more than 10 years, and it’s been empty rhetoric from the beginning. I’ve gotta tell you that for parents who have children with preexisting medical conditions, it is no comfort to have someone promise you that they will replace a right that you know you now have for your child to visit a hospital. And, why would you throw that away for an empty promise that’s 10 years old?

Most Americans would say, Keep building on the Affordable Care Act. Let’s make it better, but don’t scrap what’s worked.

Q: How do you know the Affordable Care Act is working?

My former congressional district in Los Angeles ranked among the most uninsured congressional districts in the nation. In a matter of years, once the Affordable Care Act took place, the uninsured rate in that congressional district had gone down by 50%. It was just astronomical.

The Affordable Care Act made it possible for working families to secure coverage and that’s huge. That’s the kind of burden that’s lifted off your soul.

Q: Do you think having a President Joe Biden and a Vice President Kamala Harris in the White House will lead to an improved Affordable Care Act?

As a candidate for president, Joe Biden said that he would build on the success of the Obama-Biden presidency and make sure that we continue to increase the number of Americans who have access to affordable health care. The good thing is you finally have someone at the top of the totem pole who says we’re going to make it better. And that’s why this election was so important.



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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What to Know as ACA Heads to Supreme Court — Again

The Supreme Court on Tuesday will hear oral arguments in a case that, for the third time in eight years, could result in the justices striking down the Affordable Care Act.

The case, California v. Texas, is the result of a change to the health law made by Congress in 2017. As part of a major tax bill, Congress reduced to zero the penalty for not having health insurance. But it was that penalty — a tax — that the high court ruled made the law constitutional in a 2012 decision, argues a group of Republican state attorneys general. Without the tax, they say in their suit, the rest of the law must fall, too.

After originally contending that the entire law should not be struck down when the suit was filed in 2018, the Trump administration changed course in 2019 and joined the GOP officials who brought the case.

Here are some key questions and answers about the case:

What Are the Possibilities for How the Court Could Rule?

There is a long list of ways this could play out.

The justices could declare the entire law unconstitutional — which is what a federal district judge in Texas ruled in December 2018. But legal experts say that’s not the most likely outcome of this case.

First, the court may avoid deciding the case on its merits entirely, by ruling that the plaintiffs do not have “standing” to sue. The central issue in the case is whether the requirement in the law to have insurance — which remains even though Congress eliminated the penalty or tax — is constitutional. But states are not subject to the so-called individual mandate, so some analysts suggest the Republican officials have no standing. In addition, questions have been raised about the individual plaintiffs in the case, two consultants from Texas who argue that they felt compelled to buy insurance even without a possible penalty.

The court could also rule that by eliminating the penalty but not the rest of the mandate (which Congress could not do in that 2017 tax bill for procedural reasons), lawmakers “didn’t mean to coerce anyone to do anything, and so there’s no constitutional problem,” University of Michigan law professor Nicholas Bagley said in a recent webinar for the NIHCM Foundation, the Commonwealth Fund and the University of Southern California’s Center for Health Journalism.

Or, said Bagley, the court could rule that, without the tax, the requirement to have health insurance is unconstitutional, but the rest of the law is not. In that case, the justices might strike the mandate only, which would have basically no impact.

It gets more complicated if the court decides that, as the plaintiffs argue, the individual mandate language without the penalty is unconstitutional and so closely tied to other parts of the law that some of them must fall as well.

Even there the court has choices. One option would be, as the Trump administration originally argued, to strike down the mandate and just the pieces of the law most closely related to it — which happen to be the insurance protections for people with preexisting conditions, an extremely popular provision of the law. The two parts are connected because the original purpose of the mandate was to make sure enough healthy people sign up for insurance to offset the added costs to insurers of sicker people.

Another option, of course, would be for the court to follow the lead of the Texas judge and strike down the entire law.

While that’s not the most likely outcome, said Bagley, if it happens it could be “a hot mess” for the nation’s entire health care system. As just one example, he said, “every hospital is getting paid pursuant to changes made by the ACA. How do you even go about making payments if the thing that you are looking to guide what those payments ought to be is itself invalid?”

What Impact Will New Justice Amy Coney Barrett Have?

Perhaps a lot. Before the death of Justice Ruth Bader Ginsburg, most court observers thought the case was highly unlikely to result in the entire law being struck down. That’s because Chief Justice John Roberts voted to uphold the law in 2012, and again when it was challenged in a less sweeping way in 2015.

But with Barrett replacing Ginsburg, even if Roberts joined the court’s remaining three liberals they could still be outvoted by the other five conservatives. Barrett was coy about her views on the Affordable Care Act during her confirmation hearings in October. But she has written that she thinks Roberts was wrong to uphold the law in 2012.

Could a New President and Congress Make the Case Go Away?

Many have suggested that, if Joe Biden assumes the presidency, his Justice Department could simply drop the case. But the administration did not bring the case; the GOP state officials did. And while normally the Justice Department’s job is to defend existing laws in court, in this case the ACA is being defended by a group of Democratic state attorneys general. A new administration could change that position, but that’s not the same as dropping the case.

Congress, on the other hand, could easily make the case moot. It could add back even a nominal financial penalty for not having insurance. It could eliminate the mandate altogether, although that would require 60 votes in the Senate under current rules. Congress could also pass a “severability” provision, saying that, if any portion of the law is struck down, the rest should remain.

“The problem is not technical,” said Bagley. “It’s political.”

What Is the Timeline for a Decision? Could the Court Delay Implementation of Its Ruling?

The court usually hears oral arguments in a case months before it issues a decision. Unless the decision is unanimous or turns out to be very simple, Bagley said, he would expect to see an opinion “sometime in the spring.”

As to whether the court could find some or all of the law unconstitutional but delay when its decision takes effect, Bagley said that happened from time to time as recently as the 1970s. “That practice has been more or less abandoned,” he said, but in the case of a law so large, “you could imagine the Supreme Court using its discretion to say the decision wouldn’t take effect immediately.”

If the court does invalidate the entire ACA, Congress could act to fix things, but it’s unclear if it will be able to, especially if Republicans still control the Senate. If the justices strike the law, Bagley said, “I honestly think the likeliest outcome is that Congress runs around like a chicken with its head cut off, doesn’t come to a deal, and we’re back to where we were before 2010,” when the ACA passed.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Biden Wins, but His Health Agenda Dims With GOP Likely to Hold Senate

Former Vice President Joe Biden secured the 270 electoral votes needed to capture the White House on Saturday, major news organizations projected,  after election officials in a handful of swing states spent days in round-the-clock counting of millions of mail-in ballots and early votes.

The Democrat’s victory came after the latest tallies showed him taking an insurmountable lead in Pennsylvania, a state both Biden and President Donald Trump had long identified as vital to their election efforts.  Trump has signaled he will fight the election results in several states, filing a number of lawsuits and seeking recounts.

“America, I’m honored that you have chosen me to lead our great country,” Biden tweeted shortly after the news organizations called the race. “The work ahead of us will be hard, but I promise you this: I will be a President for all Americans — whether you voted for me or not.”

The Democratic celebration was tempered because it appeared the party would have a hard time taking back the Senate majority it lost in 2014. If that bears out, it will likely keep Biden and Democratic lawmakers from enacting many of the plans they campaigned on, including major changes in health care.

Party control of the Senate may not be determined until January — thanks to what preliminary returns suggest will be runoffs for both Senate seats in Georgia. No candidate for either seat reached the required 50% threshold.

Without a Democratic majority in the Senate, Biden will likely face strong Republican opposition to many of his top health agenda items — including lowering the eligibility age for Medicare to 60, expanding financial assistance for health insurance under the Affordable Care Act, and creating a “public option” government health plan.

However, his administration would be a bulwark to defend the ACA against Republican attacks, although the Supreme Court case challenging the health law — which will be heard next week — presents a major wild card for its future.

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Health care was a key element of Biden’s campaign, especially improving the federal response to the coronavirus pandemic. He championed the use of face masks and blasted the Trump administration for shifting to states much of the responsibility for fighting the virus and helping hospitals. He was regularly mocked by the president for wearing a mask, working and campaigning from home, and not having an in-person Democratic convention.

Even before the latest vote tallies were released late Saturday morning, Biden had begun moving toward setting up his administration. On Thursday his transition team unveiled a website, BuildBackBetter.com, although it was only one page. And the former vice president held a meeting Thursday with health and economic advisers on the pandemic.

In a brief television statement Friday night, Biden reiterated his commitment to fight the pandemic, which he said “is getting more worrisome across the country.”

“We want everyone to know on day one we are going to put our plan to control this virus into action. We can’t save any of the lives that have been lost, but we can save a lot of lives in the months ahead,” Biden said.

The electoral outcome is not the one Democrats were hoping for — or, to some extent, expecting, based on preelection polling. Andy Slavitt, who ran the Centers for Medicare & Medicaid Services during the Obama administration, noted that frustration in a tweet Wednesday. “A large disappointment is that many hoped for a significant repudiation of Trump & his indifference to human life, human suffering, his corruption, and goal of getting rid of the ACA. No matter the final total it will be hard to make that claim,” Slavitt said.

Still up in the air is how willing a Republican-led Senate will be to provide further relief to individuals, businesses and states hit hard by the pandemic, and whether they will participate in previously bipartisan efforts to curtail “surprise” out-of-network medical bills and get a handle on prescription drug prices.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN on the Air This Week

Columnist and California Healthline senior correspondent Bernard J. Wolfson discussed the start of open enrollment for health care plans in California with KPCC’s “Take Two” on Monday.

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Longtime Health Advocate Donna Shalala Loses House Reelection Race

Rep. Donna E. Shalala of Florida, the first-term Democratic member of Congress and former Health and Human Services secretary in the Clinton administration, lost her campaign for reelection Tuesday.

Shalala’s loss to Maria Elvira Salazar — a Republican and former television journalist who compared Democratic policy proposals to leftist oppression in countries like Cuba while campaigning in the Miami district — was a notable upset for House Democrats. While Democrats held onto control of the House, so far they have fallen short of expectations that they would secure an even stronger majority there.

Political forecasters like The Cook Political Report had projected it was “likely” Shalala would win. She lost 48.6% to 51.3%.

In the final weeks of the campaign, Shalala, 79, and Salazar, 58, traded attack ads that touched on the election’s significance for health care.

“Salazar supports Trump, who wants to eliminate the Affordable Care Act and remove coverage of preexisting health conditions,” a Shalala ad warned.

Salazar pointed to Shalala’s failure to disclose stock trades in violation of federal law. She also accused the representative, who was appointed to the federal commission overseeing the distribution of coronavirus relief to small businesses, of not doing enough for her constituents during the pandemic.

Shalala came to Congress in 2018, helping Democrats reclaim the House of Representatives on promises to defend the Affordable Care Act and popular consumer protections for those with preexisting conditions.

But 2020 is proving a much different election year. A political rematch after Shalala defeated Salazar two years ago, this election appeared to hinge on issues beyond health care coverage and affordability.

Early reports signal Shalala was not the only casualty of a strong showing by Republicans in the Miami-Dade area of South Florida. Another first-term Democratic member of Congress representing part of Miami-Dade County, Rep. Debbie Mucarsel-Powell, also lost. Former Vice President Joe Biden trailed Hillary Clinton’s showing there in 2016, when she won the district by almost 20 points.

Shalala first won the seat after it was vacated by Ileana Ros-Lehtinen, a retiring Republican who had held it for 30 years, including when her district went for Clinton in 2016.

At the time, it was seen as a vulnerability that Shalala did not speak Spanish while seeking to represent a heavily Latino district. Salazar, who worked for the Spanish-language news channel Univision, often campaigned in Spanish.

During her two years in Congress, Shalala served on the House Committee on Education and Labor and its subcommittee that addressed health issues, as well as the House Rules Committee — a sign of her favor with Democratic leaders.

After the Rules Committee held a hearing on a “Medicare for All” proposal in 2019, Shalala referred to it as “the first step in exchanging ideas on how we move toward universal health coverage.” But she also expressed concerns that Medicare is “not as good” as many private insurance plans and that some constituents would prefer to keep their plans.

“Why should we spend money when people have good private health insurance?” she told C-SPAN. “We need to cover those that don’t have coverage now.”

When President Bill Clinton appointed Shalala as the nation’s top health and human services official in 1993, she was seen as a controversial pick, too liberal for some. As chancellor of the University of Wisconsin in Madison, she had encouraged the school to adopt a speech code intended to restrict hate speech, a move later ruled unconstitutional in federal court.

Shalala served as health secretary until 2001, becoming president of the University of Miami until 2015 and then head of the Clinton Foundation until 2017.

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If They Sweep on Election Day, Dems Still Face a Challenge Meeting Health Promises

Democrats are favored to win both chambers of Congress after years of campaign-trail promises about health care. But with a pandemic, a more conservative Supreme Court and lingering disagreements between progressives and moderates, it could be difficult for Democrats to turn those promises into law.

In the final days of the campaign, COVID-19 and the threat posed to the Affordable Care Act and Roe v. Wade by the court’s bolstered conservative majority are consuming congressional Democrats — right down to keeping them in Washington well after they would usually go home to campaign.

Even if they capture the Senate in this election, Democrats are not expected to win a decisive enough majority to pass bills without some support from the GOP. The Senate’s filibuster rules could force Democrats to stick to legislation that can attract 60 votes — if they do not move to eliminate that requirement, as some are advocating.

Frederick Isasi, executive director of Families USA, a health consumer-focused organization that supported passage of the ACA more than a decade ago, said a slim margin could make it “exponentially more difficult” to pass major health care legislation.

Although progressives are pushing for more dramatic changes, Isasi said Democrats would have to consider, in particular, which measures their senators who won close races in more conservative states could support.

“There’s going to be a lot of focus on making sure that they can support this because the vote will be so tight,” he said.

Democrats argue that consumers’ concerns about health care, which led them to secure a House majority two years ago, will drive them to White House and Senate victories this fall. It has been 10 years since Democrats controlled both chambers of Congress and the White House. One week before the election, the political modeling website FiveThirtyEight gave former Vice President Joe Biden and Democrats an 87-in-100 chance of winning the presidency; a 73-in-100 chance of winning the Senate; and a 96-in-100 chance of holding the House.

A recent poll from KFF shows voters preferred Biden’s approach to health care over President Donald Trump’s on every key issue, including handling the pandemic. (KHN is an editorially independent program of KFF.)

Democrats set high expectations early in the presidential campaign, with progressive candidates during the primaries arguing over sweeping proposals for government-funded insurance before Biden won the nomination. He championed a more incremental approach of giving consumers an option to purchase a public insurance plan, which would also be free for some based on need. That plan is now part of the party platform.

But the pandemic, and the Trump administration’s decision to largely leave states to manage the health and economic repercussions, has changed the subject. On many popular issues like insuring more Americans and ending the practice of surprise medical billing, Democrats look no closer to agreement than they were months ago — even as the pandemic has made problems worse, with nearly 27 million people losing their employer-sponsored insurance in its first two months.

Sen. Patty Murray of Washington, expected to take over the Senate’s health committee if Democrats win, called health care affordability “a top priority for Democrats.”

“The bottom line for me is that everyone in this country should be able to get the health care they need without worrying about the cost — and I think this pandemic and economic crisis have underscored how important that is,” Murray said in a statement.

But the disagreements that pitted Biden against progressives like Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) during the primaries remain, with the party’s more liberal voices pushing for dramatic reforms to drive corporations out of the health care system. And in the halls of Congress, Democrats from traditionally “red” states may find fixing the ACA an easier sell than a government-funded public insurance option.

There is a lot of “ideological diversity” among Democrats, said Rodney Whitlock, a health care consultant who spent years working as a Republican Senate aide. Although Democrats like to refer to themselves as an inclusive, “big tent party,” he said in a recent podcast that such diversity can make it harder to agree and get much done, even if the party is in the majority.

Observers warn the party’s calculations could change if Democrats move to eliminate the Senate filibuster, removing one of the minority party’s most effective means of opposition.

If Democrats win control of Congress and the White House, there would be “incredible support among Democrats” to eliminate the filibuster to achieve their goals, especially on health care, said Robert Blendon, a professor of health policy and public opinion at Harvard University who has a new article on the election in the New England Journal of Medicine.

Democrats will effectively have a year to advance their agenda before the next election, he said, and liberal voters, who make up about 50% of Democratic voters, are angry about how Republicans have managed power and eager to embrace universal health coverage.

Their argument boils down to this: “This is our chance in history, and we’re not going to do it because we can’t get three votes” in the Senate, Blendon said.

“Policies that currently would have no chance in the Senate could come into play in 2021 if the legislative filibuster is removed,” Whitlock recently wrote. If that happens, he added, the health care industry would need to reevaluate proposals “that would have once seemed highly theoretical and unlikely.”

Without the power to set the agenda or the numbers to pass their proposals, congressional Democrats have spent the Trump presidency telling Americans — in heartbreaking public testimony, impassioned floor speeches and reams of stalled legislation — that they are the party to trust with health care.

These days, Democrats are quick to mention the need to shore up the Affordable Care Act, which Republican attorneys general and the Trump administration are seeking to overturn through a case the Supreme Court will hear Nov. 10.

Though even conservative scholars say Republican arguments in the case are weak, Democrats worry the death of Justice Ruth Bader Ginsburg and the confirmation of Justice Amy Coney Barrett could endanger the law.

If the ACA is overturned, other legislative priorities likely would fall by the wayside as lawmakers address the potential elimination of coverage and consumer protections affecting millions of Americans.

While in the minority, Democrats have proposed numerous ideas to strengthen the ACA, leaving some measures on the table for Democratic leaders to revisit when in power.

In June, the Democratic-controlled House passed legislation aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income. The bill would grant Medicare the authority to negotiate drug prices — drawing from a proposal crafted by House Speaker Nancy Pelosi and House Democratic leaders in 2019 and included in Biden’s platform.

That proposal initially ran afoul of progressives, though, who argued they had been cut out of writing the bill and that it was not aggressive enough.

Democrats also have failed to reach a consensus on banning surprise medical billing, which generally occurs when patients receive care unknowingly from a doctor or provider who is not in their insurance network. House Democrats disagreed earlier this year on proposals to solve the problem. A bipartisan proposal in the Senate also stalled, and efforts to ban surprise billing during COVID-19 proved ineffective.

In the meantime, as Democratic candidates talk up ideas like the public option to energize voters as voting draws to a close, Democratic leaders are making less specific promises.

“For the last four years, Donald Trump and Republicans have sabotaged the Affordable Care Act in the hopes of causing our health care system to collapse,” Sen. Chuck Schumer of New York, the Democratic minority leader, said in a statement. “If we Democrats win back the White House and the majority in the Senate, we will strengthen and improve our health care system to make it cheaper and easier for everyday Americans to get the care and coverage they need.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’: As Cases Spike, White House Declares Pandemic Over

Can’t see the audio player? Click here to listen on SoundCloud.

White House chief of staff Mark Meadows said this week that “we’re not going to control the pandemic,” effectively conceding that the administration has pivoted from prevention to treatment. But COVID-19 cases are rising rapidly in most of the nation, and the issue is playing large in the presidential campaign. President Donald Trump is complaining about the constant news reports about the virus, prompting former President Barack Obama to say Trump is “jealous of COVID’s media coverage.”

Meanwhile, as the case challenging the constitutionality of the Affordable Care Act heads to the Supreme Court on Nov. 10, open enrollment for individual health insurance under the law begins Sunday.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Anna Edney of Bloomberg News.

Among the takeaways from this week’s podcast:

  • Whichever candidate wins the presidency next week will have a heavy lift in mounting a strong public response to battle COVID-19. Polls suggest about a third of people do not believe some of the basic science about the virus or its prevention, such as that using masks can help stem transmission.
  • Dr. Scott Gottlieb, who once served as Food and Drug Administration commissioner under Trump, called for a temporary national mask mandate in his column in The Wall Street Journal. He suggested that masks should not be a political issue.
  • Gottlieb’s column has been supported by other commentators who suggest that masks need to become a social and cultural norm and compare the debate over their use to similar debates in the past about seat belts, smoking bans and harsh punishments for driving while intoxicated. Those measures all faced opposition from people who complained about civil liberties but gradually became accepted. The difference now is that public health advocates are looking for a quick acceptance of masks.
  • Part of the resistance to wearing face masks is that many people don’t understand their purpose and presume masks are for their own protection. But public health officials advocate masks as a way to protect others, especially vulnerable people, from any virus a mask wearer might shed, often without even realizing it.
  • Drugmakers and health experts are rolling back expectations about the timing of a COVID vaccine as the trials seek more data. One issue may be that not enough people in the placebo groups have contracted the coronavirus. That could be because people who volunteer for such an endeavor may be more aware of health issues and cautious about the disease.
  • Once a vaccine is approved, FDA and other federal health officials will face a number of complicating issues. Among them: How should trials of other vaccine candidates continue and how should the vaccine be distributed?
  • Enrollment for insurance plans on the Affordable Care Act’s marketplaces begins Sunday, but many consumers could be forgiven for not knowing that. There is precious little marketing or advertising for the plans, and some people think the Supreme Court is going to overturn the ACA, anyway, and its plans will go away. That’s not known yet and it may well be summer 2021 before there is an answer on that.

Also this week, Rovner interviews KHN’s Anna Almendrala, who reported the latest NPR-KHN “Bill of the Month” installment, about a patient who did everything right and got a big bill anyway. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New York Times’ “A Chance to Expand Medicaid Rallies Democrats in Crucial North Carolina,” by Abby Goodnough

Joanne Kenen: The New Yorker’s “A President Looks Back on His Toughest Fight,” by Barack Obama

Tami Luhby: KHN’s “Florida Fails to Attract Bidders for Canada Drug Importation Program,” by Phil Galewitz

Anna Edney: The Wall Street Journal’s “Health Agency Halts Coronavirus Ad Campaign, Leaving Santa Claus in the Cold,” by Julie Wernau, James V. Grimaldi and Stephanie Armour

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A $10,000 Obamacare Penalty? Doubtful.

“Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

In a Facebook post, Oct. 20, 2020

A viral Facebook post claims that former President Barack Obama’s health insurance law penalized a family a large amount of money for not buying health insurance and that President Donald Trump was responsible for stopping the practice.


This story was produced in partnership with PolitiFact. It can be republished for free.

The post features writing on the back of a car windshield that says, “Because our family couldn’t afford health insurance, Obama/Biden penalized us about $10,000, then took that $10,000 and used it to pay for others’ free Obamacare. Trump ended that theft.”

The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed. (Read more about  PolitiFact’s partnership with Facebook.) We found a similar post on Instagram.

The post appears to refer to the individual mandate penalty, a tax under the Affordable Care Act placed on those who chose not to get health insurance. At the end of 2017, Republican-backed tax legislation, also supported by Trump, zeroed out the fine. Beginning in 2019, people could no longer be penalized for not having health insurance. Thus, the mandate hasn’t been in effect for about two years.

But $10,000 — the hefty amount this family was supposedly penalized for not having health insurance — raised questions for us. And was that money really used to pay for other people’s health insurance? We decided to look into it.

The History of the Individual Mandate

The ACA was implemented in 2010 during the Obama administration. The aim of the health care law — often referred to as Obamacare — was to ensure everyone had health insurance.

To that end, the law used what health policy experts call a “carrot-and-stick” approach. For low-income and middle-income individuals who had difficulty affording health insurance, the government would provide tax subsidies to reduce the cost of insurance — that was the carrot. And to make sure everyone enrolled in a health insurance plan, those who didn’t sign up were fined, under what was known as the individual mandate provision. That was the stick.

The individual mandate, which didn’t kick in until 2014, was unpopular with the American public, according to polling at the time. A 2017 KFF poll showed that 55% of Americans supported the idea of eliminating the requirement that everyone must have health insurance or pay a fine. (KHN is an editorially independent program of KFF.)

Although one of Trump’s key campaign promises was to repeal and replace the ACA, efforts to do so failed in 2017 when the Republican-held Senate failed to get the votes it needed.

Instead, in their 2017 tax bill, Republicans set the penalty for the individual mandate to $0. Starting in 2019, Americans no longer had to pay a fine for not having health insurance. Trump signed the 2017 tax bill into law. So, it is true that Trump and congressional Republicans were responsible for neutralizing the penalty.

However, experts pointed out that the individual mandate is still in place, it’s just that the penalty is set to $0. In fact, the end of the penalty is behind the justification for a court case attempting to overturn the ACA, brought by Republican attorneys general and supported by the Trump administration. The plaintiffs argue that the health care law is no longer constitutional because the penalty no longer “produces at least some revenue” for the federal government. The Supreme Court will hear oral arguments on the case Nov. 10.

The Math

The viral social media posts claim that the family “couldn’t afford health insurance” and was penalized $10,000.

Health policy experts told us that while the social media post doesn’t give all the specifics needed to know if this was absolutely true, it seems unlikely a penalty would be this high.

One issue is the post doesn’t specify whether the $10,000 penalty was incurred in one year or over multiple years. It also doesn’t say how many individuals were part of the family.

Assuming the $10,000 penalty was incurred in one year, multiple experts told us that the family would have had an annual income above $400,000 and at least one person would have had to be uninsured for the entire year. That math is based on the penalty structure in place in 2018, the last year the mandate was enforced.

In 2018, the penalty was calculated one of two ways. The fine was the greater of the two results:

  • $695 for an adult and $347.50 for a child, up to a max of $2,085 per family annually, or
  • 2.5% of family income above a certain tax filing threshold (KFF estimated the tax filing threshold was $10,650 for a single individual or $21,300 for joint filers in 2018).

The first way to calculate the penalty obviously doesn’t apply since the max was $2,085 per year. So, the second would be the only way to get a $10,000-a-year penalty. To arrive at such a number, you would have to take 2.5% of the family’s income. In this case, 2.5% of a $400,000 income gets you close to $10,000.

And experts said it is highly unlikely that a family with a $400,000 income would have had difficulty affording health insurance.

“So I would highly doubt the veracity of what is written on that car windshield,”Karen Pollitz, a senior fellow in health reform and private insurance at KFF wrote in an email. “People with that much income almost always have job-based health benefits and, if not, generally are inclined to insure themselves very well in order to protect assets — otherwise, if hospitalized and uninsured, they could owe many multiples of the penalty amount in medical bills.”

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, also pointed out that a $10,000 penalty would have been rare.

“Very few American families would have paid anything close to that amount in penalty for not having insurance — the average penalty per person in 2017 was around $700,” Oberlander wrote in an email. “Moreover, only a small percentage of Americans ever paid the penalty for not having health insurance — in 2017, 4.6 million persons,” or about 1% of the population. (In 2017, 325 million people lived in the U.S., according to the Census Bureau.)

It’s also unclear whether it would have just been cheaper for the family to pay for health insurance rather than incur a $10,000 penalty, said Matthew Fiedler, a health policy scholar at the Brookings Institution.

“It depends on the ages of the members of the family, where they live, what year (or years) we are talking about, and the family’s income,” Fiedler wrote in an email. “There are conceivable scenarios where the family could have found a bronze plan for $10k or less. But there are also plenty of plausible scenarios where they could not have. Without knowing more about the family’s circumstances, it’s just hard to say with any confidence.”

Where Did the Penalty Money Go?

Experts also told us that the post’s assertion that the penalties paid for not having health insurance were directly applied to fund other people’s health insurance was off the mark.

The individual mandate penalties were assessed during each annual tax filing, and then payments were made the year after there was a lapse in insurance coverage.

Those penalties were collected just like any other tax payment.

“As a strict accounting, keep in mind, everything gets dumped into the Treasury regardless of the source, and then it is appropriated out of the Treasury by Congress,” said Edmund Haislmaier, a senior research fellow in health care policy at the Heritage Foundation. “It’s not like money goes into one account and then another.”

So, while it’s certainly possible that the penalty money could have been used to help pay for some of the ACA subsidies for other people, the money also could have gone to any other number of things the government pays for, like the military, disaster relief or education.

“You don’t know exactly where your taxes or penalties go,” said Evan Saltzman, an assistant professor in economics at Emory University. “Maybe a small share went to Obamacare, but that’s a stretch. You can’t track where every dollar you spent on your taxes is going.”

It’s also misleading to say that other individuals received “free Obamacare” from the penalty payment. The experts said that while Medicaid expansion, which was a part of the ACA, does provide health care coverage for low-income people who are eligible, those who bought insurance on the marketplace would still likely have paid for some part of their coverage after subsidies were applied.

Our Ruling

A viral social media post claims that a family was penalized $10,000 for not being able to afford health insurance. It also claimed the penalty money was taken to pay for others’ “free ObamaCare” and Trump stopped that practice.

It is true that Trump and Congress did zero out the individual mandate requirement, so people could no longer be penalized for not having health insurance. But after that, skepticism abounds.

For instance, it’s very unlikely that a family would face a $10,000 penalty in one year. Moreover, if such a family did face this penalty for not having health insurance, they would likely be in a high-income bracket for which health insurance tends to come from an employer or be affordable. And the charge that the penalty was used to provide “free coverage” for others doesn’t fit with federal accounting processes.

Experts said, though, that the lack of specifics about this family’s situation makes it difficult to be completely definitive.

We rate this claim Mostly False.

SOURCES

Census Bureau, QuickFacts United States,  accessed Oct. 27, 2020

The Commonwealth Fund, “The Effect of Eliminating the Individual Mandate Penalty and the Role of Behavioral Factors,” July 11, 2018

Email interview with Christine Eibner, the Paul O’Neill Alcoa chair in policy analysis at Rand Corp., Oct. 23, 2020

Email interview with Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill, Oct. 25, 2020

Email interview with Karen Pollitz, senior fellow in health reform and private insurance at KFF, Oct. 26-27, 2020

Email interview with Matthew Fiedler, fellow with the USC Brookings-Schaeffer Initiative for Health Policy at the Brookings Institution, Oct. 26, 2020

5th Circuit Court of Appeals’ technical revisions of opinion, accessed Oct. 27, 2020

H.R.1 — 115th Congress (2017-18), accessed Oct. 27, 2020

IRS.gov, “Individual Shared Responsibility Provision — Reporting and Calculating the Payment,” accessed Oct. 27, 2020

KFF, “Explaining California v. Texas: A Guide to the Case Challenging the ACA,” Sept. 1, 2020

KFF, Individual Mandate Penalty Calculator, Nov. 17, 2017

KFF, “Kaiser Health Tracking Poll — November 2017: The Role of Health Care in the Republican Tax Plan,” Nov. 15, 2017

LeadStories.com, “Fact Check: Trump, Congress DID End Tax Penalty for Non-Insured, but $10,000 Penalty NOT Likely,” Oct. 22, 2020

Phone interview with Edmund Haislmaier, Preston A. Wells Jr. senior research fellow at the Heritage Foundation, Oct. 23, 2020

Phone interview with Evan Saltzman, assistant professor in economics at Emory University, Oct. 23, 2020

PolitiFact, Repeal Obamacare Trump-O-Meter, July 15, 2020

Rand Corp., “How Does the ACA Individual Mandate Affect Enrollment and Premiums in the Individual Insurance Market?” published in 2015

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Sen. Graham Complains That 3 Blue States Get a Third of ACA Funding

Sen. Lindsey Graham has never been a fan of the Affordable Care Act — even though it’s helped dramatically lower the number of uninsured people in his home state of South Carolina.

The Republican, who heads the Senate Judiciary Committee, attacked the law at the confirmation hearings for Supreme Court nominee Amy Coney Barrett. Democrats have made the nomination a referendum on the health law, which will be the subject of a Supreme Court hearing on Nov. 10. They fear the court may overturn the entire law, which has led to huge expansions in coverage and blocked insurers from discriminating against people with preexisting conditions, among other consumer protections.

Graham suggested that South Carolina was getting the short end of funding because the health law is sending a disproportionate amount of its money to states represented by Democrats in Congress.

“Under the Affordable Care Act, three states get 35% of the money, folks. Can you name them? I’ll help you: California, New York and Massachusetts. They’re 22% of the population. Sen. [Dianne] Feinstein’s from California, [House Speaker] Nancy Pelosi’s from California, Chuck Schumer, the leader of the Democratic Senate, is from New York, and Massachusetts is [Sen.] Elizabeth Warren. Now, why do they get 35% of the money when they’re only 22% of the population? That’s the way they designed the law: The more you spend, the more you get.”

His statement got us wondering if those numbers are true.

Complicated Math

We asked Graham’s office for evidence to support his statement. His spokesperson responded with data he said was from the Centers for Medicare & Medicaid Services as well as the Medicaid and CHIP Payment and Access Commission, a congressional advisory board.

To look at total spending under the ACA, Graham’s office analyzed federal money that went to pay for the Medicaid expansion, tax credits given to consumers to subsidize premiums of insurance plans on the marketplace, cost sharing reduction subsidies (which were given to insurers to defray some of the costs they were required by the ACA to pick up for marketplace customers with very low incomes) and the Basic Health Program, which is an option in the ACA that lets states offer low-income residents different coverage than plans offered on the marketplaces.

Graham’s office did not share the actual reports used for the analysis, but staffers said they used 2016 data, even though more recent data was available. The numbers were based on calculations made in 2017 when Republican lawmakers sought to repeal and replace the ACA. Their analysis showed $118 billion in total 2016 federal spending on the ACA, with California, New York and Massachusetts receiving about $43 billion, or about 37% (slightly higher than what Graham cited at the hearing).

Nearly two-thirds of the funding was attributed to the expansion of Medicaid to all adults below the federal poverty level. The Supreme Court ruled that pursuing the expansion was an option left to states’ discretion — South Carolina opted against it. The federal government paid all those Medicaid costs from 2014 through 2016 for new enrollees and then gradually reduced its share to 90% today.

We decided to independently look at the spending using the latest available numbers. We reviewed federal data compiled by KFF as well as data provided directly from the U.S. Centers for Medicare & Medicaid Services and the states, when necessary. (KHN is an editorially independent program of KFF.)

It is important to note that the Trump administration ended the cost sharing reduction payments in October 2017. So, KHN’s analysis did not include spending for that program.

We analyzed the latest Medicaid expansion funding from 2018 and the latest Obamacare tax credit spending and also Basic Health Program spending from 2019. Only two states participate in that program, New York and Minnesota.

Adding up the latest data and the federal share of funding came to nearly $140 billion. Of that amount, New York, California and Massachusetts — which represent about 20% of the nation’s population — received a combined $40 billion, or about 29%.

The largest category of federal funding by far was the nearly $27.5 billion the three states together received from Medicaid expansion.

New York received about $5 billion in fiscal 2019 for the Basic Health Program.

Sifting through older datasets, one key discrepancy stands out in the figures used by Graham. He lists Massachusetts as receiving $6.1 billion in federal exchange subsidies — almost 20% of the national total — while federal data used by KFF in 2016 cites $360 million.

Graham insinuated that South Carolina wasn’t getting its fair share of money, calling the law “a disaster for the state.”

But the refusal by the state’s Republican leaders for the past seven years to expand Medicaid — which would have brought in billions of federal dollars — is the main reason for the funding disparity. South Carolina is one of 12 states that have not adopted Medicaid expansion.

That decision has left hundreds of thousands of the state’s residents uninsured because they have incomes too high for Medicaid but too low to qualify for federal subsidies to help them buy insurance plans sold on the ACA marketplaces. To qualify for a subsidy, consumers’ income must be at least at the federal poverty level, or $12,760 in 2020.

“A big driver of the flow of federal funds is related to that decision about whether to expand,” said Larry Levitt, KFF’s executive vice president for health policy. “It is not inherently in the design of the law.”

If South Carolina expanded Medicaid, about 330,000 more residents would be covered and the federal government would give an additional $1.6 billion in annual Medicaid funding to the state, according to an analysis by the Urban Institute. State Medicaid spending would rise by $250 million.

Even without expanding Medicaid, the uninsured rate in South Carolina has dropped from 20% in 2008 to about 13% in 2019, according to Census data.

More than 9 in 10 people in the state who get coverage through the ACA marketplace get tax credits to help them pay their monthly premiums.

In fact, South Carolina gets a larger share of those premium tax credits than most states. South Carolina, the nation’s 23rd-largest state by population size, ranks 11th in the number of residents getting those subsidies and ninth in receipt of the federal ACA premium subsidies, according to the federal data.

Disadvantage for ‘Fiscally Responsible States’

Kevin Bishop, a spokesperson for Graham, said the point of the senator’s remarks is that the ACA “is structured so that states that either expanded [Medicaid] or have favorable state eligibility will have a disproportionate share of funds. This gives an advantage to high-spending states.” States that are more “fiscally responsible” are at a disadvantage, he said.

Bishop acknowledged that ACA spending does change each year.

Levitt noted that Graham’s critique omitted an important perspective about other states. The senator did not mention that enrollees in two Republican-controlled states with large populations, Florida and Texas, receive more in ACA premium subsidies than people in New York or Massachusetts. However, neither of those Southern states has expanded its Medicaid program.

Still, experts noted that Graham’s comment that the more states spend the more they get from the ACA is partly true.

It accurately reflects the ACA’s Medicaid formula. As states expand Medicaid eligibility, they pick up more expenses and also receive more money in a federal match.

Joe Antos, a health economist with the conservative American Enterprise Institute, said Graham is correct that the Medicaid expansion was designed to help direct additional funding to wealthier states such as New York, California and Massachusetts. Those states, as well as some others, had broader Medicaid eligibility rules than poorer states before the law was enacted, so their Medicaid rolls were relatively larger already.

That’s why the Medicaid expansion was set at 138% of the federal poverty level, rather than 100%, he said. The higher amount meant those states could get a larger reimbursement for people already in their program.

But he said states that chose not to expand Medicaid under the law can’t blame the law for getting fewer federal dollars.

“If a state did not expand, it’s on them for having less federal funding,” Antos said.

Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation, said the expansion of Medicaid for those more progressive states significantly increased their funding. “New York made out like a bandit,” he said, noting the state had one of the nation’s largest Medicaid populations before 2010.

Our Ruling

Graham points to higher federal spending on ACA programs in three states that are represented by top congressional Democrats and complains that South Carolina is not faring as well. While his numbers are four years old, the latest numbers are just a few percentage points lower than what he cited — 29% compared with 35%.

He also left out some critical information — most important, that South Carolina didn’t pursue federal funding through Medicaid expansion.

His argument that the law was designed to help some states largely controlled by Democrats fails to note that many Republican-controlled states have received heavy federal funding, too, either because of ACA tax subsidies or Medicaid expansion, or both.

He also didn’t acknowledge that South Carolina does have a strong record of receiving federal subsidies for consumers buying insurance on the ACA marketplace.

We rate Graham’s statement as Half True.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Hospital Bills for Uninsured COVID Patients Are Covered, but No One Tells Them

When Darius Settles died from COVID-19 on the Fourth of July, his family and the city of Nashville, Tennessee, were shocked. Even the mayor noted the passing of a 30-year-old without any underlying conditions — one of the city’s youngest fatalities at that point.

Settles was also uninsured and had just been sent home from an emergency room for the second time, and he was worried about medical bills. An investigation into his death found that, like many uninsured COVID-19 patients, he had never been told that cost shouldn’t be a concern.

Back at the end of June, Settles and his wife, Angela, were both feeling ill with fevers and body aches. Then Darius took a turn — bad enough that he asked his wife to call an ambulance.

“My husband is having issues breathing and he’s weak, so we’re probably going to need a paramedic over here to rush him to the hospital,” she told the operator, according to the 911 recordings obtained by WPLN News.

Darius Settles was stabilized and tested for the coronavirus at the hospital, according to his medical records. The doctor sent him home with antibiotics and instructions to come back if things got worse.

Three days later, they did. And now he also knew he had COVID-19; his test results were in.

But Settles was between full-time jobs, playing the organ at a church as he launched a career as a suit designer. So he had no health insurance.

His wife, who works for Tennessee State University, said he was worried about costs as he went back to the hospital a second time; she tried to reassure him

“He said, ‘I bet this hospital bill is going to be high.’ And I said, ‘Babe, it’s going to be OK.’ And we left it alone, just like that,” she said.

When he returned to TriStar Southern Hills Medical Center, owned by the for-profit hospital chain HCA, physicians tested his blood oxygen levels, which are usually a first sign that a COVID-19 patient is in trouble. They had dropped to 88%. An X-ray of his lungs “appears worse,” the physician wrote in the record.

But the doctor also noted that after a few hours in the emergency room his oxygen saturations had improved and he was breathing on room air. The records show they discussed why he might not want to be admitted to the hospital since he was otherwise young and healthy and didn’t note any risk factors for complications.

And when Angela Settles called to check in, he seemed to be OK with leaving despite his persistent struggle to breathe.

He was a COVID-19 patient so, “I could not go up there to see him,” she said. “He was saying that I might as well go home.”

Angela Settles was surprised since her husband was the one who wanted to go to the hospital in the first place.

At first, she thought the hospital just didn’t want to admit a man without insurance who would have trouble paying a big bill. But TriStar Southern Hills admits hundreds of patients a year without insurance — more than 500 in 2019, according to a spokesperson.

And in this case, the federal government would have paid the bill. But no one said that when it might have made a difference to Darius Settles.

The Message Never Makes It to Patients

TriStar, like most major health systems, participates in a program through the Centers for Medicare & Medicaid Services in which uninsured patients with COVID-19 have their bills covered. It was set up through the pandemic relief legislation known as the CARES Act.

But TriStar doesn’t tell its patients that upfront. Neither do other hospitals or national health systems contacted by WPLN News. There’s no requirement to, which is one of the program’s shortcomings, said Jennifer Tolbert of KFF, who studies uninsured patients. (KHN is an editorially independent program of KFF.)

“This is obviously a great concern to most uninsured patients,” Tolbert said. Her research finds that people without insurance often avoid care because of the bill or the threat of the bill, even though they might qualify for any number of programs if they asked enough questions.

Tolbert said the problem with the COVID-19 uninsured program is that even doctors don’t always know how it works or that the program exists.

“At the point when the patient shows up at the hospital or at another provider site, it’s at that point when those questions need to be answered,” she said. “And it’s not always clear that that is happening.”

Among clinicians, there’s a reluctance to raise the issue of cost in any way and run afoul of federal laws. Emergency rooms must at least stabilize everyone, regardless of their ability to pay, under a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA. Asking questions about insurance coverage is often referred to as a “wallet biopsy,” and can result in fines for hospitals or even being temporarily banned from receiving Medicare payments.

Physicians also don’t want to make a guarantee, knowing a patient still could end up having to fight a bill.

“I don’t want to absolutely promise anything,” said Dr. Ryan Stanton, an ER physician in Lexington, Kentucky, and a board member of the American College of Emergency Physicians.

“There should not be a false sense that it will be an absolute smooth path when we’re dealing with government services and complexities of the health care system,” he said.

‘Could I Have Done More?’

Darius Settles knew he was in bad shape. But he didn’t attempt to make a third trip to the hospital. Instead of 911, he called his father, pastor David Settles, and asked his father to come pray for him.

When the elder Settles replied that he was always praying for his son, Darius said, “No, I really need you to pray for me. I need you to get the oil, lay hands on me and pray,” David Settles recalls, and so he went, despite concerns about getting COVID-19 himself.

He sat by his son’s side. Darius’ wife made some peppermint tea, and when they put it to his lips, Darius didn’t sip. They thought he had fallen asleep. But he was unconscious.

At that point, they called 911 again and the operator instructed them to get Darius to the floor and perform chest compressions until paramedics arrived.

For 11 minutes, Angela Settles pumped her husband’s chest, occasionally asking the dispatcher “what’s taking so long,” the 911 recordings show. Even after help showed up, Darius never revived.

Pastor Settles was back in the pulpit just a few weeks later, preaching on suffering and grief after the death of his son, “whom I watched as the breath left his body,” he told his congregation. “The Lord gives, and the Lord takes away.”

Darius Settles left behind his own son, who was 6. And his widow’s head is still spinning. She said she can’t shake a sense of personal guilt.

“Could I have done more?” Angela Settles asked. “That’s hard, and I know that he would not want me to feel like that.”

She wondered, too, if the hospital could have done more for him. And even after failing to disclose its policy for uninsured COVID-19 patients, it did send her a bill for part of her husband’s care. Asked why, a TriStar spokesperson said it was sent in error and does not have to be paid.

This story is from a reporting partnership that includes WPLNNPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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App-Based Companies Pushing Prop. 22 Say Drivers Will Get Health Benefits. Will They?

App-based driving services such as Uber, Lyft, DoorDash and Instacart are bankrolling California’s Proposition 22, which would keep their drivers classified as independent contractors, not employees.

Leading into the Nov. 3 election, the ballot measure — which has become the most expensive in state history — is mired in controversy and the subject of a lawsuit from Uber drivers alleging that the company inappropriately pressured them to vote for the initiative.

But what’s occasionally lost in the debate over Proposition 22 are the claims about what it will mean for app-based drivers.

Detractors, like unions and driver advocacy groups, say Proposition 22 would strip drivers of the protections of AB-5, a 2019 California law delayed by legal challenges. The law requires drivers to be classified as employees, which would afford them the associated benefits like paid sick leave, workers’ compensation and access to unemployment insurance.

Supporters, such as ride-sharing companies and the California Chamber of Commerce, say Proposition 22 would give drivers benefits, like a guarantee of minimum earnings and compensation when they are hurt on the job, while allowing them to maintain the flexible schedule of independent contractors.

In an online ad paid for by Lyft, the company says “Prop. 22 will give them … health care benefits.”

That sounds like drivers with Uber, Lyft and other app-based companies will automatically get health insurance if Proposition 22 passes. The truth is a little more complicated.

What Does ‘Health Care Benefits’ Mean?

We reached out to Lyft to back up its claim, and the company directed us to the “Yes on 22” campaign. This is how the campaign explained “health care benefits”:

Under Proposition 22, drivers who qualify — more on that in a minute — would get a stipend they could use to buy an insurance plan from Covered California, the state’s health insurance marketplace.

That stipend would be calculated like this: App-based companies would look at the statewide average monthly premium of bronze-level plans sold on the Covered California exchange.

The companies would then give qualified drivers a stipend of 82% of the average premium, said Geoff Vetter, a spokesperson for the Yes on 22 campaign. (On average, U.S. employers covered 82% of premiums costs for single coverage in 2019.)

So hypothetically, if bronze plans cost an average of $100 per month, Uber, Lyft or a similar company would provide qualifying drivers with $82 per month.

Drivers would be eligible for the full stipend — all $82 in the hypothetical case — if they average 25 hours per week of “engaged” time, which is time spent driving while there’s a passenger in the car. Time spent driving between passengers would not count.

“Most drivers work part time” and spend about one-third of their time waiting for rides and deliveries, according to the nonpartisan state Legislative Analyst’s Office. Using that equation, drivers would need to work an average of 37.5 hours per week for a single company in order to receive the full stipend.

A driver who averages at least 15 but less than 25 hours of engaged time each week would be eligible for 50% of the stipend — or $41 per month.

The stipend would be similar to employer-sponsored insurance because both employers and employees would contribute to the cost of insurance, Vetter said.

“For the people who do work closer to full time, it does give them that ability to receive health care coverage by getting a typical employer contribution for that coverage,” Vetter said.

Does a Stipend Equal Coverage?

But this stipend bears little resemblance to traditional employer-based insurance, which is what drivers would get if they were considered employees instead of gig workers, said Ken Jacobs, chair of the University of California-Berkeley Center for Labor Research and Education.

“It has very, very little relationship to what anyone would think of as job-based coverage,” Jacobs said. “It’s really wrong to think of this as health insurance.”

For instance, under Proposition 22, the stipends would be calculated and distributed quarterly, based on drivers’ hours. That could force drivers to periodically reassess what kind of coverage they would qualify for and could afford.

With traditional employer-sponsored insurance, a driver would enroll in a plan once per year and the premium wouldn’t change.

A vacation or illness could mean that drivers can’t maintain the hours required by the measure, costing them their stipend — and perhaps their insurance — for the quarter, and stripping them of the stability usually associated with job-based coverage, Jacobs said.

And getting money to buy an individual plan isn’t the same as participating in a large group plan offered by an employer, said Jen Flory, a policy advocate at the Western Center on Law & Poverty, a nonprofit organization that advocates for low-income Californians and opposes Proposition 22.

Covered California plans are typically less generous than the policies employees usually get through work, she said. And bronze-level plans, which have the lowest monthly premiums, also have the highest out-of-pocket costs for medical services.

Consider the deductible, which is how much a person needs to pay out-of-pocket before insurance starts paying for care.

In 2018, fewer than half of Californians who had work-based insurance had a deductible, and on average, that deductible was $1,402 for a single person, according to research from the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The deductible on a Covered California bronze plan for an individual in 2021 will be $6,300 for medical services plus $500 for prescription drugs. Proposition 22 ties the stipend “to the highest deductible, highest out-of-pocket plans on the market,” Flory said. “And it’s for workers who aren’t making a whole lot of money.”

Drivers could use the stipend to buy a more generous plan, but the monthly premium would be higher and the stipend would cover less of it.

Depending on their incomes and other factors, drivers may also be eligible for tax credits and state and federal subsidies to help them afford plans on the individual market. But Flory said this amounts to the government subsidizing health insurance that employers should be paying for themselves.

It’s also problematic to base the stipends on a statewide average of bronze premiums because that doesn’t take into account the huge regional differences in the cost of care, said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research.

“In the Bay Area, that contribution is going to buy a lot less than it would in Southern California,” Kominski said. “We’re a big state and have a lot of variation of health care costs.”

Our Ruling

The stipend offered under Proposition 22 is a “health care benefit,” but the wording is misleading and ignores critical information.

While neither Lyft nor the Yes on 22 campaign says the proposition will give drivers health insurance, saying that it will offer them “health care benefits” gives the impression that the stipend is similar to traditional job-based coverage. It’s not.

Drivers who value the ability to make their own schedules would have to figure out how to work an average of nearly 40 hours a week — essentially full time — to receive the full stipend. The stipend would cover a fraction of the premiums for health insurance that’s typically less generous than what they’d get as employees.

Moreover, because drivers’ stipends could change quarterly based on their driving time — which could be affected by vacation or illness — any coverage purchased with the stipend could carry a cloud of uncertainty.

We rate this claim as Half True.



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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The Trump Medicaid Record: Big Goals, Yet Few Successes

President Donald Trump entered office seeking a massive overhaul of the Medicaid program, which had just experienced the biggest growth spurt in its 50-year history.

His administration supported repealing the Affordable Care Act’s Medicaid expansion, which has added millions of adults to the federal-state health program for lower-income Americans. He also wanted states to require certain enrollees to work. He sought to discontinue the open-ended federal funding that keeps pace with rising Medicaid enrollment and costs.

He has achieved none of these ambitious goals.

Although Congress and the courts blocked a Medicaid overhaul, the Trump administration has left its mark on the nation’s largest government-run health program as it has sought to make states more responsible for assessing its impact and improving the health of enrollees.

One notable achievement: The Trump administration pushed some states to be more aggressive in weeding out ineligible recipients — an initiative that led to a drop in enrollment of children in several states, including Missouri and Tennessee. About half of those enrolled in Medicaid are children.

A recent report from the Georgetown University Center for Children and Families found that the number of uninsured children rose by more than 700,000 to 4.4 million from 2017 through 2019. The increase of uncovered children stands out since uninsured rates typically drop during periods of economic growth, such as the one occurring from 2017 to 2019.

Advocates for the poor say the administration’s efforts contributed to an increase in the number of uninsured children, after years of decline. “The administration has not succeeded on any of its goals in any meaningful way,” said Joan Alker, executive director of the Georgetown center. “But they still have inflicted some damaging changes to the program.”

“The administration has not prioritized the health of children,” said Bruce Lesley, president of the child advocacy group First Focus on Children.

Alker attributes the rise in uninsured children to federal officials’ decision to slash outreach funding for the Obamacare insurance exchanges — through which families eligible for Medicaid are often identified — and the administration’s focus on the “public charge” rule. That provision allows the federal government to more easily deny permanent residency status, popularly known as green cards, or entry visas to applicants who use — or are deemed likely to use — publicly funded programs such as food stamps, housing assistance and Medicaid.

Medicaid officials said the increase is partly due to loss of health coverage by middle-income families who are not eligible for Medicaid. They say those families don’t qualify for government subsidies for the ACA’s marketplace plans and were forced to drop their plans because of high premiums.

But Alker said federal data suggests that families who have incomes over the 400% federal poverty level eligibility limit for subsidies (about $87,000 for a family of three) saw a slower rate of increase in the number of uninsured children as opposed to lower-income kids.

A spokesperson for the federal government’s Centers for Medicare & Medicaid Services said the agency was “committed to ensuring that eligible children are enrolled and retained in coverage” and it spent $48 million in grants for outreach and enrollment effort last year.

The Trump administration opposes the ACA’s expansion of Medicaid, which provided billions in federal dollars to cover nondisabled, low-income adults. Yet seven states adopted the expansion during the past three years, including Republican-controlled Utah, Idaho, Oklahoma, Nebraska and Missouri.

Despite the aim to shrink the program, about 75 million people were enrolled in Medicaid in June 2020 — roughly the same number as in January 2017, when Trump took office.

One reason is that Medicaid enrollment soared this year following the COVID-19 outbreak as unemployment spiked to historic highs and federal stimulus money forbid states to drop anyone unless they moved out of state.

But that is far from the administration’s goal of “ushering in a new day” for Medicaid, as CMS Administrator Seema Verma said when she laid out her bold vision in a 2017 speech.

Verma acknowledged she was stepping into a hornet’s nest of entrenched stakeholders and interest groups.

“I would like to invite everybody here today who have fought the political healthcare battles over the last decade to take a deep breath, exhale and agree to reset as a group,” she said.

They didn’t. The administration’s major Medicaid changes were met with opposition from hospitals, doctors and patient advocacy groups, who feared the efforts would lead to cuts in funding or add obstacles for enrollees seeking care.

Officials spent two years seeking to allow states to require enrollees to work or volunteer as a condition for enrollment. They approved proposals from 10 states, but only Arkansas implemented the new requirement before a federal judge ruled it illegal. Arkansas’ brief experience resulted in more than 18,000 adults losing coverage.

After losing in federal district and appeals courts, the Trump administration has appealed to the Supreme Court, which will decide later this year whether to take the case.

The push for work requirements and other changes have altered the culture of Medicaid so that officials are more intent on keeping people out of the program instead of welcoming more in, said Lesley, of First Focus.

Before the pandemic, he said, the administration allowed states to add hurdles for families to get enrolled and stay enrolled, such as requiring them to more frequently recertify their income eligibility.

Aaron Yelowitz, a professor of economics at the University of Kentucky, said one of the Trump administration’s biggest impacts on Medicaid was prodding states to be more active in making sure they were covering only people who met the states’ eligibility rules. He noted the ACA gave states incentives to enroll newly eligible adults over traditional groups such as children and the disabled because the federal government paid a higher share of the cost.

Seeking Flexibility for States

The administration — as well as Republicans in Congress — favored a fundamental change in how Medicaid is funded. But Congress failed to move the program to a “block grant” approach, which would have given states a set annual amount — rather than the current system that provides funding determined by how many people qualify for the program and health costs. The GOP proposal also would have allowed states more flexibility in running the operations.

Critics predicted a block grant would have cut billions in state funding and led to cuts in services and eligibility.

Once the legislative proposal was dead, the administration sought to enact the strategy via its authority to test changes in payment methods. Only one state applied — Oklahoma — and it dropped its application this year after voters passed a Medicaid expansion ballot initiative.

Verma promised to give states more flexibility in running their programs in other ways, while also holding them more accountable for care to Medicaid enrollees. CMS has approved dozens of Medicaid waivers since 2017, including allowing states to be more innovative in helping enrollees with substance abuse or addiction problems and serious mental illness. It granted more than 30 states waivers to enhance treatment options.

With Medicaid paying for more than half of all births in the United States, Verma also sought to improve oversight of prenatal and early childhood services.

While CMS has started a scorecard to track Medicaid outcomes, the data is missing for several states or outdated on several measures. For example, the low-birthweight measure is missing data from more than 20 states and no data is listed on children born with an addiction.

CMS officials said they are working to provide more updated information on its report card.

Changes implemented by the administration, officials added, have elicited more timely data from states, allowing them to spot problems quicker. For example, in September, CMS determined that many children were delayed from March through May in seeing a doctor and getting important vaccines as the pandemic took hold. CMS pushed states and health providers to remedy the problem but did not offer specific help.

Asked during a recent phone briefing with reporters about Medicaid’s legacy under her stewardship, Verma didn’t mention the expansion, work requirements or efforts to turn Medicaid into a block grant program for states.

“We have aimed to try to ensure the program is sustainable for generations to come and ensure better outcomes for those it serves,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Savvy Patient Fought for the Price She Was Quoted − And Didn’t Give Up

When Tiffany Qiu heard how much her surgery was going to cost her, she was sure the hospital’s financial department had made a mistake. Qiu, who already knew from a breast cancer scare earlier that year that her plan required a 30% coinsurance payment on operations, pressed the person on the phone several times to make sure she had heard correctly: Her coinsurance payment would be only 20% if she had the procedure at Palomar Medical Center in Poway, California, about 38 miles south of where Qiu lives.

“I was kind of in doubt, so I called them a second time,” said Qiu. “They gave me the exact same amount.”

Qiu had been diagnosed with uterine polyps, a benign condition that was making her periods heavier and more unpredictable. Her OB-GYN proposed removing them but said it was safe to wait. Qiu said that she asked about the possibility of doing it in the doctor’s office under local anesthesia to make the procedure cheaper, but that her doctor rebuffed her suggestion because of her preference for general anesthesia.

Because Qiu thought she was getting a deal on her usual 30% share of the bill, she decided to go ahead with the polyp removal on Nov. 5, 2019. As she sat in the waiting room filling out forms, staffers let her know she needed to pay in full before the surgery.

Unease set in. The hospital asked for the 20% coinsurance — $1,656.10 — that she had been quoted over the phone, but Qiu hadn’t been told she needed to pay on the day of the procedure. As she handed over her credit card, she confirmed one more time that this would be her total patient responsibility, barring complications.

The surgery was over in less than 30 minutes, and she walked out of the hospital with her husband, feeling perfectly fine.

Then the bill came.

Patient: Tiffany Qiu is a 49-year-old real estate agent and mother of two who lives in Temecula, California. Her family of four is covered by a Blue Shield of California policy that she and her husband purchased on the marketplace. Last year, they paid a $1,455 monthly premium, with an individual annual $1,850 deductible and an individual out-of-pocket maximum of $7,550.

Total Bill: Palomar Health billed Blue Shield $22,219.64 for the polyp removal, which the insurer negotiated down to $8,576.79. Blue Shield paid $5,769.72 and stated in an explanation of benefits document that Qiu was responsible for a $334.32 deductible and $2,472.75 coinsurance.

Because Qiu had already paid $1,873.20 on the day of surgery, the hospital billed her an additional $933.87, which meant Qiu was on the hook for the remainder of her 30% coinsurance.

These figures don’t include the fees Qiu paid for anesthesia or her doctor’s services.

Service Provider: Palomar Medical Center in Poway is one of three hospitals in the Palomar Health system. Palomar Health is a San Diego County public health care district, which means the health care facilities are nonprofit and receive property taxes as a portion of their revenue stream. The system is governed by a board of directors elected from within the district’s boundaries.

What Gives: Hospitals and surgery centers sometimes offer discounts if patients are uninsured and able to pay with cash or a credit card. Physicians may even offer discounts on a patient’s share of the costs if they know the patient is unemployed or has fallen on hard times. But regularly offering discounts to attract patients is not common, and could even be fraudulent if the patients are insured through Medicare, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy.

In Qiu’s case, the hospital seemed to be offering a discount on the insurer’s normally required coinsurance.

“The hospital would be in breach of their contract with the insurance if they did not bill her for that amount,” said Martine Brousse, a California-based patient advocate and medical billing consultant for AdvimedPRO. “She owes what the insurance has calculated, and the facility has every right to demand payment.”

Copayments and coinsurance exist, in theory, so patients have “skin in the game.” They have to pay a clearly defined portion of the cost of their care, according to their policy, so they will shop around and use medical care judiciously (though many health experts say coinsurance amounts have gotten so high that many cannot afford them).

Resolution: If she hadn’t been quoted 20%, Qiu said, she would have shopped for a better deal. She flies to China often to visit her mother and was open to getting the surgery done there.

Qiu called the hospital to ask why she was being billed a second time, despite the lack of complications during the surgery. She remembers the back-and-forth over the remaining bill was exhausting, especially because it happened over the holidays.

“I got tired and said, ‘I don’t want to play this game anymore,’” Qiu recalled. “‘If you want to send it to collections, you can do it, but I’m not going to pay for it.’”

The bill landed at a collection agency called IC System. In a May 23 phone call, Qiu said, a representative offered to slash the remaining bill by 25% if she would just pay that day.

But Qiu refused, though she could easily afford to pay. She’s undaunted by the risk the unpaid bill poses to her credit score, preferring instead to fight the hospital on behalf of other patients who may not have the time or luxury to persist.

The experience left her feeling as if the hospital offered her a fake discount to reel in her business.

“I double-checked and tripled-checked with them,” Qiu said. “They have financial departments that should be verifying this with my insurance company.”

Another thing to note is how much the hospital billed Qiu for a simple outpatient procedure: $22,219.64. That amount is “totally laughable,” said Dr. Merrit Quarum, founder of WellRithms, a company that works with self-funded employers and other clients to make sense of complex medical claims.

Not only is the charge far out of line with what that procedure typically costs in that region (around $5,500), but Qiu is now stuck paying a larger amount as her share under the terms of her insurance. This is how those “sticker prices” that few people pay still drive up costs for individuals.

After a reporter’s call, Palomar Health looked back at phone records, confirmed Qiu’s version of events and said a hospital staffer had made a mistake by quoting her a 20% cost-sharing obligation. That percentage then got automatically put into her patient notes and was on the bill of estimated costs she signed and paid on the day of surgery, even though it was incorrect.

They apologized for giving the mistaken impression that Qiu was getting a discount. Staff members are not authorized to offer discounts when providing estimates, said Derryl Acosta, a spokesman for Palomar Health.

Acosta also pointed out other communication breakdowns, like dropping the complaint Qiu phoned in after she received the second bill in late November. Her issue did not get put into the standard customer complaint process, which would have elevated the problem and triggered an investigation into the phone records. That’s why Qiu’s bill was sent to the collection agency.

“We definitely admit that the call should have been handled differently,” Acosta said. “We now have a new call center that we believe will handle this type of call better.”

Because Palomar Health was able to see in their phone records that a staffer had confirmed the erroneous 20% coinsurance amount to Qiu, the health system will change her bill to reflect what she was promised. Qiu will get a statement in the mail saying she has a zero balance, Acosta said.

The Takeaway: Multiple medical billing advocates who reviewed Qiu’s case praised her for her tenacity in calling the hospital financial department twice before the procedure. But as she herself acknowledged, most people don’t have the time or spine to fight.

To avoid such situations, experts advised, patients should check in with their insurer about the discounts offered, as hospital staffers may be poorly trained or ill informed.

If a patient hears conflicting information about charges before a procedure, they need to approach their insurer to confirm the details of their own policy, said Brousse, the patient advocate.

The simple fact that a hospital staffer misinformed a patient isn’t a legal reason to force a hospital to lower a bill, Brousse said.

Also, get promises in writing — before the day of surgery. Make sure the offer is explicit about which services are included and what might count as a complication. Ask whether you’ll have to pay upfront.

Initial estimated bills can be full of asterisks and “weasel words,” said Akshay Gupta, co-founder of CoPatient, a medical bill review and patient advocacy company.

“Even though she tried to be diligent, obviously she still didn’t know that she would need to get something that was legally enforceable,” said Gupta.

Dan Weissmann, host of the podcast “An Arm and a Leg,” reported the radio interview of this story. Joe Neel of NPR produced the interview with KHN Editor-in-Chief Elisabeth Rosenthal on “Morning Edition.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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If Trump Wins, Don’t Hold Your Breath Waiting for That ACA Replacement Plan

If President Donald Trump wins reelection next week, it seems unlikely he will unveil the health plan he’s been promising since before his election in 2016. Still, other aspects of health care could be featured in his second-term agenda.

Not having a replacement plan for the Affordable Care Act may be just fine with many of his supporters and conservatives. Most Republicans don’t want the federal government to remake the nation’s health system, said Grace-Marie Turner, of the conservative Galen Institute. “It’s a different philosophy from Democrats, who think it needs to be a big program,” she said. “Conservatives, we think of it in a more targeted way.”

Trump, of course, repeatedly promises something big. “We will have Healthcare which is FAR BETTER than ObamaCare, at a FAR LOWER COST – BIG PREMIUM REDUCTION,” he tweeted Oct. 12 — hardly the first time he’s made a similar promise. “PEOPLE WITH PRE EXISTING CONDITIONS WILL BE PROTECTED AT AN EVEN HIGHER LEVEL THAN NOW. HIGHLY UNPOPULAR AND UNFAIR INDIVIDUAL MANDATE ALREADY TERMINATED. YOU’RE WELCOME!”

But Trump needs a contingency plan if the Supreme Court accepts his argument that the ACA should be overturned. The justices are scheduled to hear the case the week after Election Day. Administration health officials have pledged to have an alternative if the high court does as they ask. But they have refused to publicly share any details.

In September, Trump unveiled a package of health care proposals at a speech in North Carolina. The “America First Healthcare Plan” is less than an actual plan, though. It’s a vague set of claims about things that have not happened yet — like bringing down prescription drug prices — along with a laundry list of some of his administration’s lesser accomplishments on health issues, such as the initiative to help Americans with severe kidney disease and efforts to improve the availability of health care in rural areas.

As part of that overall health plan, Trump issued an executive order declaring “it has been and will continue to be the policy of the United States … to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.” But there is nothing in the order — or in the broader outline — to ensure that would be the case if the ACA were struck down. It would take congressional action to guarantee that.

The current court controversy over the ACA arose because Congress in its 2017 tax bill eliminated the financial penalty for not having health insurance. But Congress didn’t have the votes to get rid of the mandate itself under the rules for the tax bill. Republican state officials then sued, arguing that since the Supreme Court had once upheld the ACA’s mandate, calling it a tax, once the penalty was gone, the law should also be invalidated.

Trump frequently heralds his actions, erroneously saying he killed the mandate and arguing that he got rid of the most detested part of the law.

“He likes to use words, but I don’t think there’s been a substantive policy yet,” said Len Nichols, a health policy professor at George Mason University. “I have no clue what he would do” in a second term “other than trying to repeal the ACA.”

One thing Trump accomplished in his first term is a set of potentially far-reaching regulatory actions, many of which have been challenged in federal courts. Those include allowing states to implement work requirements for people who receive Medicaid health benefits and requiring hospitals and other health providers to make their negotiated prices available to the public.

Legal analysts have doubted the administration’s authority to implement many changes Trump has proposed. But considering Trump has appointed hundreds of federal judges, including Supreme Court justices, the legal landscape may be changing and more of those proposals could be allowed to proceed.

Still, Trump faces uphill battles on some of his preferred health initiatives, even if Republicans control Congress.

For example, said Dan Mendelson of the consulting group Avalere Health, “I would expect that if he’s reelected there would be a drug pricing agenda he continues to push.” Among his proposals is having Medicare pay for drugs based on what the medicines sell for in countries that negotiate prices. That would be complicated, Mendelson said, by the fact that “the broader Republican Party doesn’t want to move to a regulatory model in this country.”

But the Galen Institute’s Turner said not to discount the changes Trump has made, such as allowing broader sales of short-term health plans that are less expensive but offer fewer benefits than ACA plans. She said to expect actions in a similar vein in a second term. “He really has done a lot, using his executive authority, based on trying to make markets work better and give people more choice,” she said. “They are strategic, targeted approaches to specific problems.”

He’ll certainly have a specific problem if the ACA is struck down. Americans losing their insurance won’t want to wait to find out if he has a plan.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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How Bind Benefits’ CEO will use $105M to upend the health insurance market

Insurance startup Bind Benefits just raised $105 million in a Series B funding round to further expand into the fully insured market. CEO Tony Miller sees the company’s health plan product as a way for employers to stay agile while offering insurance in a rapidly changing world.

Did Trump Confuse the Public Option With ‘Medicare for All’?

During the final presidential debate, President Donald Trump claimed that 180 million people would lose their private health insurance to socialized medicine if the Democratic presidential nominee, former Vice President Joe Biden, is elected president.

“They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans,” said Trump.

Trump has repeated this claim throughout the week, and we thought the linkage of Biden’s proposed health care plan with socialism was something we needed to check out. Especially since Biden opposed “Medicare for All,” the proposal by Sen. Bernie Sanders (I-Vt.) that would have created a single-payer health system run completely by the federal government, and has long been attacked by Republicans as “socialist.”

The Trump campaign did not respond to our request asking where the evidence for this claim came from. Experts called it a distortion of Biden’s plan.

Where the Number Comes From

Experts agreed the number of people who have private health insurance either through an employer-sponsored plan or purchased on the Affordable Care Act’s health insurance marketplace is around 180 million people.

KFF, a nonpartisan health policy organization, estimated in 2018 that about 157 million Americans had health insurance through their employer, while almost 20 million had insurance they purchased for themselves. Together, that adds up to about 177 million with private health insurance. (KHN is an editorially independent program of KFF.)

What Does Biden Support?

Biden supports expanding the ACA through several measures, including a public option. Under his plan, this public option would be a health insurance plan run by the federal government that would be offered alongside other private health insurance plans on the insurance marketplace.

“The marketplace is made up of multiple insurers in areas,” said Linda Blumberg, a health policy fellow at the Urban Institute. “Sometimes there are five or more [plans]; sometimes there is only one. Biden is talking about adding a public option in the marketplace. You could pick between these private insurers or you could pick the public option.”

Getting rid of the so-called employer firewall is also part of Biden’s proposal.

This firewall was implemented during the rollout of the ACA. It was designed to maintain balance in the insurance risk pools by preventing too many healthy people who have work-based coverage from opting instead to move to a marketplace plan. And it all came down to who qualified for the subsidies that made these plans more affordable.

Currently, those who are offered a health insurance plan through their employer that meets certain minimum federal standards aren’t eligible to receive these subsidies, which come in the form of tax credits. But that leaves many low-income workers with health care plans that aren’t as affordable or comprehensive as marketplace plans.

Biden’s plan would eliminate that firewall, meaning anyone could choose to get health insurance either through their employer or through the marketplace. That’s where many Republicans argue that we could start to see leakage from private health insurance plans to the public option.

“The problem is healthy people leaving employer plans,” said Joseph Antos, a scholar in health care at the conservative-leaning American Enterprise Institute. That could mean the entire workplace plan’s premiums would go up. “You could easily imagine a plan where it spirals, the premiums go up, and then even more people start leaving the plans to go to the public option.”

Blumberg, though, said that because the marketplace would still include private health insurance plans alongside the public option, it doesn’t mean everyone who chooses to leave their employer plan would go straight to the public option.

She has done estimates based on a plan similar to the one Biden is proposing. She estimates that only about 10% to 12% of Americans would choose to leave their employer-sponsored plans, which translates to about 15 million to 18 million Americans.

KFF also did an estimate and found that 12.3 million people with employer coverage could save money by buying on the exchange under the Biden plan.

But “it’s not clear all of those people would choose to leave their employer coverage, though, as there are other reasons besides costs that people might want to have job-based insurance,” Cynthia Cox, vice president and director of the program on the ACA at KFF, wrote in an email.

Either way, none of the estimates are anywhere close to the 180 million that Trump claimed.

Is This Type of Public Option Socialism?

Overall, experts said no, what Biden supports isn’t socialized medicine.

“Socialized medicine means that the government runs hospitals and employs doctors, and that is not part of Biden’s plan,” Larry Levitt, executive vice president for health policy at KFF, wrote in an email. “Under Biden’s plans, doctors and hospitals would remain in the private sector just like they are today.”

However, Antos said that, in his view, the definition of socialism can really vary when it comes to health care.

“I would argue in one sense, we would already have socialized medicine. We have massive federal subsidies for everybody, so in that sense, we’re already there,” said Antos. “But, if socialized medicine means the government is going to dictate how doctors practice or how health care is delivered, we are obviously not in that situation. I don’t think the Biden plan would lead you that way.”

And in the end, Antos said, invoking socialism is a scare tactic that politicians have been using for years.

“It’s just a political slur,” said Antos. “It’s meant to inflame the emotions of those who will vote for Trump and meant to annoy the people who will vote for Biden.”

Our Ruling

Trump said 180 million people would lose their private health insurance plans to socialized medicine under Biden.

While about 180 million people do have private health insurance, there is no evidence that all of them would lose their private plans if Biden were elected president.

Biden supports implementing a public option on the health insurance marketplace. It would exist alongside private health insurance plans, and Americans would have the option to buy either the private plan or the public plan. While estimates show that a number of Americans would likely leave their employer-sponsored coverage for the public plan, they would be doing that by choice and the estimates are nowhere near Trump’s 180 million figure.

Experts also agree that the public option is not socialized medicine, and it’s ridiculous to conflate Biden’s plan with Medicare for All.

We rate this claim Pants on Fire.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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In Tamer Debate, Trump and Biden Clash (Again) on President’s Pandemic Response

In the second and final debate of the 2020 presidential race, President Donald Trump and former Vice President Joe Biden sparred over Trump’s handling of the pandemic and Biden’s plan to reform health care. In stark contrast to the first debate, there was more policy talk. There was also less interrupting.

Trump said a COVID-19 vaccine is “ready” and will be announced “within weeks,” shortly before conceding that it is “not a guarantee.”

Biden said Trump still has no comprehensive plan to deal with the pandemic, even as case counts continue to climb. “We’re about to go into a dark winter, and he has no clear plan,” Biden said.

Trump claimed Biden’s health care plan would lead to “socialized medicine,” conflating Biden’s proposal to introduce a government insurance option with more progressive proposals that would eliminate private insurance. “I support private insurance,” Biden said, promising, “Not a single person with private insurance would lose their insurance under my plan.”

You can read a full fact check for the evening, done in partnership with PolitiFact, here.

Meanwhile, we broke down the candidates’ closing coronavirus and other health-related claims so you can do your part: vote.

Here are the highlights:

Trump: “We are rounding the turn [on the pandemic]. We are rounding the corner.”False.“Rounding the corner” suggests that significant and sustained progress is being made in the fight against the coronavirus, and that’s not the case, according to the data.

The number of COVID cases is climbing once again, after falling consistently between late July and mid-September. Cases are now at their highest point since early August, with almost 60,000 new confirmed infections a day. That’s only about 10% lower than the peak in late July.

New daily hospitalizations today are lower than in previous spikes, but in the past few weeks there has been a modest increase. The positivity rate, which measures the percentage of tests that come up positive for the virus, has also been going up again in the past few weeks. Higher positivity rates are an indicator of community spread.

The one encouraging change is that, since a peak in August, deaths have fallen fairly consistently. That’s due to a combination of factors, including improved understanding of how to treat the disease. Yet COVID deaths have settled in at about 800 a day, keeping total deaths per week in the U.S. above normal levels.

Trump: His administration has done “everything” Biden suggested to address COVID-19. “He was way behind us.”We rated a similar claim Pants on Fire. While there are some similarities between Biden’s and Trump’s plans to combat COVID-19, experts told us any pandemic response plan should have certain core strategies. The Trump administration has released no comprehensive plan to battle the disease, except with regard to the development and distribution of vaccines. Trump’s main intervention was implementing travel restrictions, while efforts to roll out a widespread testing plan faced difficulties.

Biden released a public COVID plan; the first draft was published March 12. It included public health measures such as deploying free testing and personal protective equipment, as well as implementing economic measures such as emergency paid leave and a state and local emergency fund.

Trump: “As you know, 2.2 million people were expected to die. We closed the greatest economy in the world to fight this horrible disease that came from China.”His claim about the estimated deaths rates Mostly False. Trump frequently refers to this number to claim that his administration’s moves saved 2 million lives. However, the number is from a mathematical model that hypothesized what would happen if, during the pandemic in the U.S., neither people nor governments changed their behaviors, a scenario that experts considered unrealistic. The U.S. has the highest death toll from COVID-19 of any country, and one of the highest death rates. Also, credit for shutting down the economy doesn’t go primarily to Trump, but rather to states and local jurisdictions. In fact, Trump encouraged states to open back up beginning in May, even when there were high rates of COVID transmission in those areas.

Trump: “We cannot lock ourselves in a basement like Joe does.”We rated a similar claim False. It is one of Trump’s favored shots to say Biden isolated himself in his basement. In the first few months of the pandemic, Biden did run much of his campaign from his Delaware home. He built a TV studio in his basement to interact with voters virtually. But that changed.

In September alone, Biden gave remarks and held events in, among other places, Kenosha, Wisconsin; Lancaster, Pennsylvania; Warren, Michigan; Tampa, Florida; and Charlotte, North Carolina. We counted 14 locations.

Trump: Said of Dr. Anthony Fauci, “I think he’s a Democrat, but that’s OK.”This is wrong. Fauci, director of the National Institute of Allergy and Infectious Diseases, is not affiliated with a political party. He hasn’t endorsed any parties or candidates.

Biden: “We are in a circumstance where the president still has no plan, no comprehensive plan.”This is largely accurate. When Biden claimed during the first debate that Trump “still won’t offer a plan,” we noted the Trump administration’s “Operation Warp Speed” for vaccine development as well as its more detailed plan for vaccine distribution. But the administration has not released a comprehensive plan to address COVID-19.
Trump: “There was a spike in Florida. That is gone. There was a spike in Texas. That is gone. There was a spike in Arizona. It is gone.” 
This is inaccurate. Over the summer, Florida, Texas and Arizona experienced record surges in cases that later eased — but now they are all seeing new surges. Over the past week, The New York Times’ tracker notes, as of Friday, new infections are up 37% in Florida, 13% in Texas and 47% in Arizona, from the average two weeks earlier.
Trump: “When I closed [travel from China], he said I should not have closed. … He said this is a terrible thing, you are a xenophobe; I think he called me racist. Now he says I should have closed it earlier.”
Mostly False. Joe Biden did not directly say he thought Trump shouldn’t have restricted travel from China to stem the spread of the coronavirus.

Biden did accuse Trump of “xenophobia” in an Iowa campaign speech the same day the administration announced the travel restrictions — Jan. 31 — but his campaign said that his remarks were not related and that he made similar comments before the restrictions were imposed. Biden didn’t take a definitive stance on the subject until April 3, when his campaign said he supported Trump’s decision to impose travel restrictions on China.
Trump: “They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans.” 
Pants on Fire. About 180 million people have private health insurance. But there is absolutely no evidence that under Biden’s health care proposal all 180 million would be removed from their insurance plans. Biden supports creating a public option, which would be a government-run insurance program that would exist alongside and compete with other private plans on the health insurance marketplace.

Under Biden’s plan, even people with employer-sponsored coverage could choose a public plan if they wanted to. And estimates show that only a small percentage of Americans would likely leave their employer-sponsored coverage if a public option were available, and certainly not all 180 million. Experts said it is not socialized medicine.
Biden: “Not one single person with private insurance” lost their insurance “under Obamacare … unless they chose they wanted to go to something else.”
This is inaccurate. This is a variation of a claim that earned President Barack Obama our Lie of the Year in 2013. The Affordable Care Act tried to allow existing health plans to continue under a complicated process called “grandfathering,” but if the plans deviated even a little, they would lose their grandfathered status. And if that happened, insurers canceled plans that didn’t meet the new standards.

No one determined with any certainty how many people got cancellation notices, but analysts estimated that about 4 million or more had their plans canceled. Many found insurance elsewhere, and the percentage was small — out of a total insured population of about 262 million, fewer than 2% lost their plans. However, that still amounted to 4 million people who faced the difficulty of finding a new plan and the hassle of switching their coverage.

This story includes reporting by KHN reporters Victoria Knight and Emmarie Huetteman, and Jon Greenberg, Louis Jacobson, Amy Sherman, Miriam Valverde, Bill McCarthy, Samantha Putterman, Daniel Funke and Noah Y. Kim of PolitiFact.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Even With ACA’s Fate in Flux, Open Enrollment Starts Soon. Here’s What’s New.

Facing a pandemic, record unemployment and unknown future costs for COVID-19 treatments, health insurers selling Affordable Care Act plans to individuals reacted by lowering rates in some areas and, overall, issuing only modest premium increases for 2021.

“What’s been fascinating is that carriers in general are not projecting much impact from the pandemic for their 2021 premium rates,” said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.

Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.

That’s good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces. The federal market, which serves 36 states, opens for 2021 enrollment Nov. 1, with sign-up season ending Dec. 15. Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.

The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.

Here are a few things to know about 2021 coverage:

It might cost about the same this year — or even less.

Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.

“It’s the third year in a row with premiums staying pretty stable,” said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. “We’ve seen modest rate changes and influx of new insurers.”

That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.

Those increases priced out some enrollees, particularly people who don’t qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.

Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his ACASignups.net website, follows premium changes based on filings with state regulators. Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.

Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers’ requested rates, the percentage is lower, at 0.4%.

Another study, by KFF, of preliminary premiums filed this summer had similar findings: Premium changes in 2021 would be modest, only a few percentage points up or down. (KHN is an editorially independent program of KFF.)

It’s still worth it to shop around.

Actuaries and other experts say premiums vary by state or region — even by insurer — for a number of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.

Because subsidies are tied to each region’s benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)

Switching to the benchmark plan can help consumers maintain how much they spend in premiums.

Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses. “They might be eligible for a bigger” subsidy, said Myra Simon, executive director of commercial policies for America’s Health Insurance Plans, the industry lobbying group.

Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, consumers should check whether the doctors and hospitals they want to use are included in the plan’s network.

Premiums are just one part of the equation. Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.

“We encourage people to consider all their options,” said Simon.

What’s behind the variation.

Enrollees in some states next year will see premium decreases, according to Gaba’s website: Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland’s is down almost 12%. At the same time, Indiana’s average is up 10%. And Kentucky is up 5%.

Both Maine and Maryland attribute the decrease to state programs that provide reinsurance payments to health insurers to help offset high-cost medical claims.

In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.

Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to spend at least 80% of revenue on direct medical care. If insurers don’t meet that standard, they must issue rebates to policyholders. Many insurers were already on the hook to return money in 2020 for previous years.

Most insurers did not cite additional COVID treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.

Indeed, many insurers in the second quarter posted record profits.

“Some of them thought, ‘We’re going to make more than we thought this year in profits, so let’s not be aggressive with pricing next year,’” said Donna Novak, a member of the American Academy of Actuaries’ Individual and Small Group Markets Committee.

A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminated by the Trump administration effective for 2021.

Your choice of insurers may have widened.

More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.

“Insurers are seeing a profit or potential for it,” said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.

Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.

Insurers, he said, like the way the ACA is working.

“People on TV who say it’s not working, they don’t know what they’re talking about,” said Dodd. “It’s working well [for insurers] and every year it gets better.”

New stuff in some states, including a public option.

Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal healthcare.gov, which now covers 36 states.

Lawmakers in those states said running their own marketplaces gives them more control and may save them money over time.

In 19 Washington state counties, insurers are offering “public option plans,” which have all the standard benefits, including lower deductibles, and must meet additional quality standards.

As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an average of 160% of what Medicare would pay for the same services.

When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.

But three are more expensive.

The state’s marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during COVID-19 to a lack of incentives to get providers to participate.

It could also just be normal first-year jitters.

“It’s Year One. As with any market entry strategy, people are pretty conservative,” said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Nebraska gets approval to add work requirements to Medicaid expansion

Medicaid

After Nebraskans cast their vote for Medicaid expansion in 2018, the state is finally expanding coverage to more residents. As part of the state’s rollout, it split its expanded Medicaid plans into two tiers, with work and other requirements to access dental and vision coverage.

Job-Based Health Insurance Costs Are Up 4% This Year, 55% in Past Decade

Health insurance costs for Americans who get their coverage through work continued a relentless march upward with average family premiums rising 4% to $21,342 this year, according to a study published Thursday.

The annual survey by KFF found workers on average are paying nearly $5,600 this year toward family coverage, up from about $4,000 in 2010 and $1,600 in 2000. (KHN is an editorially independent program of KFF.)

While health insurance costs rose a modest amount in 2020, as has been the trend in recent years, they soared 55% in the past decade — more than twice the pace of inflation and wages.

About 157 million Americans rely on employer-sponsored coverage — far more than any other type of coverage, including Medicare, Medicaid and individually purchased insurance on the Affordable Care Act exchanges. More than half of employers provide insurance to at least some workers.

“Conducted partly before the pandemic, our survey shows the burden of health costs on workers remains high, though not getting dramatically worse,” Drew Altman, KFF’s CEO, said in a statement. “Things may look different moving forward as employers grapple with the economic and health upheaval sparked by the pandemic.”

The survey was conducted from January to July as the coronavirus pandemic took hold and upended the nation’s economy. Many of the details of the employers’ plans that the researchers examined were set before the virus hit.

Since 2012, the cost of family coverage has increased 3% to 5% annually. It’s been more than 15 years since these costs were rising at double-digit rates.

Employers help shield workers from much of the cost of their health insurance premiums, though employees often feel the impact via higher deductibles, copayments and lower wages.

On average, workers pay 17% of the premium for single coverage and 27% for family coverage, the survey found. Workers at smaller companies pay 35% of the premium for family coverage, compared with 24% for larger companies, the survey found.

The average annual deductible for single coverage is now $1,644, up 25% in the past five years and 79% in the past decade.

Workers with coverage are exposed to higher costs when using the hospital since 65% have coinsurance, which means they are responsible for a fixed share of the charge, and 13% contribute a copayment, or fixed fee per visit or service. The average coinsurance for hospital admission is 20% and average copayment is $311 per hospital admission.

Workers are protected for catastrophic costs through limits set on their out-of-pocket spending in provider networks, although those amounts vary by employer: 11% face a maximum of less than $2,000, while 18% are in a plan with a maximum of $6,000 or more.

The study also noted that large employers have made it easier for workers to access care by adopting coverage for telemedicine in recent years. Nearly 9 in 10 companies that have 200 or more workers and offer insurance covered these medical appointments done via telephone or computer this year, up from fewer than 3 in 10 in 2015, according to the research. During the pandemic, telemedicine usage has increased markedly as people sought care from the safety of their home.

The KFF study is based on a telephone survey of 1,765 randomly selected nonfederal public and private employers with three or more workers from January to July.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Does the Federal Health Information Privacy Law Protect President Trump?

Within one day, President Donald Trump announced his COVID diagnosis and was admitted to Walter Reed National Military Medical Center for treatment. The flurry of events was stunning, confusing and triggered many questions. What was his prognosis? When was he last tested for COVID-19? What is his viral load?

The answers were elusive.

Picture the scene on Oct. 5. White House physician Dr. Sean Conley, flanked by other members of Trump’s medical team, met with reporters outside the hospital. But Conley would not disclose the results of the president’s lung scans and other vital information, invoking a federal law he said allows him to selectively provide intel on the president’s health.

“There are HIPAA rules and regulations that restrict me in sharing certain things for his safety and his own health,” he told the reporters.

The law he’s referring to, HIPAA, is the Health Insurance Portability and Accountability Act of 1996, which includes privacy protections designed to shield personal health information from disclosure without a patient’s consent.

Because this is likely to remain an issue, we decided to take a look. In what cases does HIPAA restrict the sharing of information — and is the president covered by it?

Experts agreed that he is, but several noted there are exceptions to its protections — stirring debate over the airwaves and on Twitter regarding what information about the president’s health should be released.

Explaining the Protections

HIPAA and the rules for its implementation apply to medical providers — such as doctors, dentists, pharmacists, hospitals — and most health plans that either provide or pay for medical care.

In some cases, the law permits the sharing of medical information without specific consent, such as when needed for treatment purposes or billing. Examples include doctors or hospitals sharing information with other physicians or facilities involved in the patient’s care, or information shared about tests, drugs or other medical care so bills can be sent to patients.

Other than that, without specific patient consent, the law is clear.

“The default rule under HIPAA is that health care providers may not disclose a patient’s health information. Period,” said Joy Pritts, a consultant in Washington, D.C., and a former privacy official in the Obama administration.

The experts we consulted all agreed that Trump’s doctors are bound by HIPAA. Since he is their patient, they cannot share his medical information without his consent.

Patients can allow some information to be released while demanding that other bits be withheld.

That may be why the public has been given only select details about Trump’s COVID-19 status, such as when Conley discussed the president’s blood pressure reading but not the results of his lung scans.

Trump “can pick and choose what he wants to disclose,” Pritts said.

So it is up to Trump to give his doctors the green light to report to the public on his condition.

“HIPAA does not prevent the president of the United States from authorizing the disclosure of all publicly relevant information,” said Lawrence Gostin, a professor of global health law at Georgetown University. “He can share it if he wanted to and he can tell his doctors to share it.”

Elizabeth Gray, a teaching assistant professor of health policy and management at George Washington University, said that because Conley shared some medically private information with the American public, there must have been a conversation between the president and his doctors about what was OK to include in their press briefings.

“He would have had to have given his authorization,” said Gray. In other words, Trump OK’d the details his doctors mentioned, but when follow-up questions were asked, she said, HIPAA was “a shield” because “the president hadn’t authorized the release of anything else.”

Still, beyond HIPAA, other factors could lead to less-than-complete disclosure of the president’s health.

For starters, Trump is the commander in chief, and his personal physician is a member of the military.

“If your commander in chief says, ‘I’m giving you a command — forget about HIPAA,’” said Thomas Miller, a resident fellow with the American Enterprise Institute.

Pritts and others also said the president’s physician may not be covered by HIPAA if his care is provided by the White House medical unit, which does not bill for its services or involve health insurance.

But, “whether covered by HIPAA or not, a physician has an ethical obligation to maintain patient confidentiality,” Pritts said.

And Leaks?

It’s also important to note that HIPAA applies only to health care professionals and related entities working within that sphere.

So, when Sean Spicer, former White House press secretary, tweeted on Oct. 5 that a journalist had violated HIPAA (he misspelled it as “HIPPA”) by reporting that a member of the White House press shop had COVID-19, he was wrong, said the experts.

“Journalists are not bound by HIPAA,” said Gostin.

Gray likened HIPAA in that way to a door.

“Behind that door is health care information. Hypothetically, only doctors have access to that information, and HIPAA prevents health care providers from unlocking that door,” she said. “But, once the info gets out of that door, then HIPAA no longer applies.”

And the information is likely to come out — sooner or later, said Miller. “Leaking will take care of most reporting and disclosure” about the president’s health, he said.

The Exceptions

Within HIPAA are a couple of exceptions identifying when health information can be disclosed without the authorization of the patient.

For example, the law does allow for disclosure if it “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”

Might that apply here, given that Trump took a ride around Walter Reed in a government SUV with Secret Service agents, or returned to a White House filled with other employees?

Jonathan Turley, a professor of public interest law at George Washington University Law School, said he doesn’t think the public health exemption would apply in this case.

“If a patient is contagious and noncompliant, doctors can make disclosure in the interest of public health,” Turley wrote in an email. “However, the team of doctors stated that they felt that it was appropriate to send President Trump back to the White House to continue to recover.”

Moreover, Turley noted that nothing was withheld that would have qualified for this exception. “The world knows that the president is COVID-positive and still likely contagious,” he wrote. “It is unclear what further information would do in order to put the world on notice.”

Some experts, however, expressed a different view. They argued that the details of when the president last tested positive would provide insight into who may have been exposed and how long he should be considered infectious and asked to isolate. Even so, the law’s public health exemption is usually interpreted to mean such information would be shared only with state and local health officials.

There are two HIPAA exceptions that apply specifically to the president, said Gray.

“They could make that disclosure to people who need to know, to the Secret Service or the vice president, but it is essentially only to protect [the president],” said Gray. “There is also an armed forces exception, but disclosures are in regards to carrying out a military mission, which doesn’t apply here.”

What about national security?

Miller, at AEI, said concerns about national security could be among the reasons for more disclosure, such as questioning a president’s ability to carry out duties. But HIPAA wasn’t designed to address this point.

Some argue that because the president is not just an average citizen, he should waive his right to medical privacy.

“The president is not just an individual; the president is the chief executive,” said Charles Stevenson, an adjunct lecturer on American foreign policy at Johns Hopkins University. “The president loses a lot of privacy because our political system, our governmental system demands it. The president always has to be available to the military and that means the state of his health is a matter of national security.”

Historical precedent

Trump is one in a long line of presidents who have not been completely transparent in sharing their medical information.

“There’s a pretty strong tradition of these things being obscured,” said John Barry, an adjunct faculty member at the Tulane University School of Public Health and Tropical Medicine. And no federal law requires a president to provide this information.

One of the most notable examples is President Woodrow Wilson, said Barry.

Wilson likely caught the so-called Spanish influenza in 1919, which was kept secret. Later that year, he had a severe stroke that disabled him, the gravity of which was also hidden from the public.

President John F. Kennedy used painkillers and other medications while in office, which wasn’t made public until years after his death.

And when President Ronald Reagan was shot in 1981, he was much closer to death than his White House spokesperson described to the public. There were also questions about Reagan’s mental acuity while in his final years in office. He was diagnosed with Alzheimer’s disease five years after his final term.

Why would White Houses want to obscure health information of presidents?

“Every White House wants the public to think the president is healthy, strong and capable of leading the country,” said Barry. “That’s consistent across parties and presidencies.”

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Refuge in the Storm? ACA’s Role as Safety Net Is Tested by COVID Recession

The Affordable Care Act, facing its first test during a deep recession, is providing a refuge for some — but by no means all — people who have lost health coverage as the economy has been battered by the coronavirus pandemic.

New studies, from both federal and private research groups, generally indicate that when the country marked precipitous job losses from March to May — with more than 25 million people forced out of work — the loss of health insurance was less dramatic.

That’s partly because large numbers of mostly low-income workers who lost employment during the crisis were in jobs that already did not provide health insurance. It helped that many employers chose to leave furloughed and temporarily laid-off workers on the company insurance plan.

And others who lost health benefits along with their job immediately sought alternatives, such as coverage through a spouse’s or parent’s job, Medicaid or plans offered on the state-based ACA marketplaces.

From June to September, however, things weren’t as rosy. Even as the unemployment rate declined from 14.7% in April to 8.4% in August, many temporary job losses became permanent, some people who found a new job didn’t get one that came with health insurance, and others just couldn’t afford coverage.

The upshot, studies indicate, is that even with the new options and expanded safety net created by the ACA, by the end of summer a record number of people were poised to become newly uninsured.

What’s more, those losses could deepen in the months ahead, and into 2021, if the economy doesn’t improve and Congress offers no further assistance, health policy experts and insurers say.

“It’s a very fluid situation,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, a New York-based health research group. “The ACA provides an important cushion, but we don’t know how much of one yet, since this is first real test of the law as a safety net in a serious recession.”

Collins also noted that accurately tracking health insurance coverage and shifts is difficult in the best of times; amid an economic meltdown, it becomes even more precarious.

Coverage Was Already on the Decline

Some 20 million people gained coverage between 2010 and 2016 under the ACA’s expansion of Medicaid and its insurance marketplaces for people without employer-based coverage. A gradually booming economy after the 2008-2009 recession also helped. The percentage of the population without health insurance declined from about 15% in 2010 to 8.8% in 2016.

But then, even as the economy continued to grow after 2016, coverage began to decline when the Trump administration and some Republican-led states took steps that undermined the law’s main aim: to expand coverage.

In 2018, 1.9 million people joined the ranks of the uninsured, and the Census Bureau reported earlier this month that an additional 1 million Americans lost coverage in 2019.

The accelerating decline is helping fuel anxiety over the fate of the ACA in the wake of the death of Supreme Court Justice Ruth Bader Ginsburg. The high court is scheduled to hear a case in November brought by Republican state officials, and supported by the Trump administration, that seeks to nullify the entire law.

In July, researchers at the Urban Institute, a Washington, D.C., think tank, forecast that around 10 million workers and their dependents would lose employer coverage in 2020. But they estimated that two-thirds of them will have found new coverage by year’s end — leaving about 3.3 million uninsured.

A more recent Urban Institute report, released Sept. 18, and using 2020 data from the Census Bureau, calculated that of the roughly 3 million people under age 65 who had lost job-based insurance between May and July, 1.4 million found coverage elsewhere — most through Medicaid — and 1.9 million became newly uninsured. Notably, 2.2 million of those who lost their coverage were between 18 and 39 years old; 1.6 million were Hispanic.

Another recent study, using different methods, reported higher numbers for the same period. The analysis released by the Economic Policy Institute last month determined that between April and July 6.2 million people lost employer coverage. The authors didn’t calculate how many found alternative coverage via Medicaid or the ACA, however.

Other findings support the notion that the health insurance loss trend shifted by mid summer. KFF, for example, published an analysis Sept. 11 showing that most companies that offered coverage to begin with chose to continue insuring furloughed and temporarily laid-off workers between March and the end of June. But as the virus continued to batter the economy, employers moved to permanently shed those jobs. (KHN is an editorially independent program of KFF.)

“The issue now is that the temporary layoffs have greatly decreased and permanent job losses, including jobs that came with health coverage, are increasing,” said Cynthia Cox, a KFF vice president and director for the Program on the ACA.

Many low-income workers who lose their jobs and don’t have coverage through a spouse or parent turn to Medicaid, the federal-state health program for low-income people. The Centers for Medicare & Medicaid Services reported last week that enrollment in Medicaid and the Children’s Health Insurance Program grew by 4 million between February and June, a nearly 6% increase since the beginning of the coronavirus crisis.

The Impact of the Marketplaces

Gains and losses of coverage in the ACA marketplace are not yet clear, experts say. The Trump administration issued a report in June indicating that 487,000 people had, between January and June, enrolled in an ACA plan via the federal website, healthcare.gov. But that report failed to say how many people dropped an ACA plan in that period — for example, because they could no longer afford the premiums.

A study by Avalere, a health research and consulting firm in Washington, D.C., has estimated that enrollment in the ACA marketplaces since March could have swelled by around 1 million. That includes new enrollees in the 13 ACA marketplaces that states, plus the District of Columbia, operate. Many of those states held a “special enrollment period” when the pandemic hit. Healthcare.gov, run by the Trump administration, did not offer a special enrollment period.

About 11 million were enrolled in an ACA plan in February. Open enrollment for coverage that would start on Jan. 1, 2021, begins Nov. 1.

Jessica Banthin, a senior health policy researcher at the Urban Institute and until 2019 deputy director for health at the Congressional Budget Office, said it’s anyone’s guess how many people who lost their job-based coverage this year will choose this option. She said numerous factors will influence people’s health insurance decisions this fall, and into 2021.

Chief among them is gauging whether they might soon get a new job, or get back an old job, that offers insurance. That may hold some people back from enrolling in an ACA plan this fall, Banthin said. Plus, buying insurance may be too expensive, especially for families more concerned with paying for housing, food and child care while going without a paycheck.

“Health insurance may not be their immediate concern,” Banthin said. “Many people’s lives have been disrupted as never before. There’s a lot of trauma out there.”

Collins of the Commonwealth Fund said that, even before the pandemic, a growing proportion of families were vulnerable to loss of coverage and care.

In a survey of more than 4,000 adults early this year, Collins and colleagues found a “persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues.”

In large part, that’s because 1 in 5 respondents who had coverage were “underinsured.” Underinsurance reflects the extent to which coverage leaves people at risk of high out-of-pocket costs — a situation exacerbated by widespread job loss.

“Now is absolutely not be the time for the ACA to be further undermined, let alone killed outright,” said Stan Dorn, director of the National Center for Coverage Innovation at Families USA.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Fighting for Patient Protections While Attacking ACA — Hard to Have It Both Ways

Throughout the 2020 election cycle, candidates’ positions on health care have been particularly important for voters with underlying and often expensive medical needs — in short, those with preexisting conditions.

It’s no surprise, then, that protections for people who have chronic health problems like diabetes and cancer have become a focal point for candidates nationwide — among them, Matt Rosendale, the Republican contender for Montana’s only U.S. House seat.

On Sept. 22, Rosendale’s campaign hit airwaves and online streaming services with an ad featuring a Whitefish resident named Sandee, whose son was diagnosed with a life-threatening disease. Sandee told the story of how Rosendale came to her family’s aid, concluding that “Matt fights for everyone with a preexisting condition.”

As is often the case with health care policy, however, the truth is far from simple. Rosendale and many other Republican congressional candidates face the challenge of convincing voters they support these safeguards even as they oppose the Affordable Care Act, which codifies those safeguards.

Polls show broad public support for keeping the ACA’s preexisting condition protections.

We decided to investigate.

Rosendale is up against Democrat Kathleen Williams for the congressional seat now occupied by Republican Rep. Greg Gianforte, who has entered the state’s gubernatorial race. The open seat has been controlled by the GOP for the past 12 terms, but this year’s race is expected to be close. Williams, who also ran for the seat in 2018, has made health care her top campaign issue.

We contacted the Rosendale campaign to find out the basis for his ad’s claim. Campaign spokesperson Shelby DeMars listed a range of health policies backed by the candidate that would help people with preexisting conditions directly or indirectly by holding down health care costs. She specifically pointed to Rosendale’s work on the state’s reinsurance program as Montana’s state auditor and insurance commissioner, a post he was elected to in 2016.

“Matt Rosendale is a champion for those with pre-existing conditions and he has the record to prove it,” DeMars said via email. “It is because of the Reinsurance program he implemented that Montanans with pre-existing conditions can access the affordable healthcare coverage they need.”

Examining Reinsurance

In a nutshell, Montana’s reinsurance program is designed to help insurers cover costly medical claims with a mix of federal pass-through dollars and funding generated by a premium tax on all major medical policies in the state. Gov. Steve Bullock announced the formation of a bipartisan group tasked with developing reinsurance program legislation in fall 2018, and the state’s legislature approved the plan in 2019, allowing Rosendale to apply for and receive the necessary waiver under the Affordable Care Act.

Subsequent news accounts indicated the idea worked. In-state insurers credited the program with lowering premiums by 8% to 14% for 2020. As Montana Health Co-op CEO Richard Miltenberger told MTN News shortly after the 2019 legislative session, “It allows the insurance companies to have rate stabilization for those really big claims, the ones that are the earthquakes in health insurance.” He went on to say that this stability “brings the cost down for the consumer.” More to the point, the American Medical Association has also stated that reinsurance not only serves to subsidize high-cost patients but “protects patients with pre-existing conditions.”

But there’s a rub.

The reinsurance program that Rosendale touts wouldn’t exist without a state innovation waiver created by the ACA, which Rosendale says he’ll work to repeal. That effort will doubtless continue to fuel pitched battles in Congress, and how the U.S. Supreme Court may rule on a pending ACA challenge remains a point of speculation. One thing is clear, though: If the entire ACA is thrown out, the reinsurance program goes with it, along with Montana’s Medicaid expansion and the ban on insurers from excluding people with health problems from affordable coverage.

When asked about the resulting elimination of the reinsurance program, DeMars reiterated that Rosendale’s work as auditor has created a system that will ensure protections for preexisting conditions “regardless of what happens to the ACA.” She did not elaborate or explain what protections would remain if the ACA were repealed.

The Short-Term Plan Component

In defending his stance on preexisting conditions, Rosendale continues to be haunted by another health care policy specter from his political past. During his unsuccessful challenge against Democratic U.S. Sen. Jon Tester in 2018, Rosendale faced criticism for promoting short-term, limited-duration health insurance plans. Unlike plans offered on the individual marketplace, these short-term plans are exempt from the ACA’s ban on excluding people with preexisting conditions. And, under a 2018 regulatory change pushed by the Trump administration, the length of these short-term plans has been extended from three months to 12, with the potential to renew for up to three years.

As state auditor, Rosendale included those plans in his March 2020 roundup of year-round options for immediate coverage. They often exclude coverage for a variety of higher-cost benefits. In Montana, for example, a review by KFF found that of four short-term plans available in Billings in 2018, none offered coverage for maternity care, mental health, substance abuse or prescription drug services. (KHN is an editorially independent program of KFF.)

Historically, short-term plans were designed to help individuals fill gaps in health coverage. According to Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms, the role short-term plans play on today’s health insurance landscape is to attract younger, healthier individuals seeking low-cost options to cover catastrophic events. That splits insurers into two pools — those who are less likely to incur medical expenses, and those who are more likely to incur them. Costs on the individual market go up as a result, leaving people with preexisting conditions no other option than to pay higher premiums. Short-term plans are, Palanker said, “actively hurting people with preexisting conditions.”

“Promoting short-term plans and stumping on supporting protections for preexisting conditions are mutually exclusive,” she continued.

Asked whether the cost-lowering effect of a reinsurance program would be enough to offset the effects of short-term plans, Palanker said the only way such an offset would be enough is if the program encompassed short-term plans. She hasn’t seen that happen anywhere.

Our Ruling

A campaign ad says Rosendale “fights for everyone with a preexisting condition.” While it is true that health insurance premiums have dropped during Rosendale’s tenure as state auditor, the choice to establish Montana’s reinsurance program ultimately fell to decision-makers in the state’s legislature and the governor’s office. Since his ad’s claim simply states that he “fights” for people with preexisting conditions, his testimony in support of that program and role in securing the state waiver do seem to fit the bill.

In the long-term, however, Rosendale’s positions begin to run counter to the claim. His support for short-term, limited-duration plans poses a considerable threat to keeping health insurance affordable for all, and absent a solid plan from Congress to ensure that state reinsurance programs survive, his stated goal of repealing the ACA would actually serve to unravel the very protection he’s built his case on.

We rate this statement as Mostly False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN on the Air This Week

KHN senior correspondent Sarah Jane Tribble appeared on Newsy’s “Morning Rush” on Thursday to discuss rural hospital closures and KHN’s brand-new “Where It Hurts” podcast.

KHN chief Washington correspondent Julie Rovner appeared on Newsy’s “Newsy Tonight” program on Wednesday to fact-check the health claims made by President Donald Trump and former Vice President Joe Biden during Tuesday’s debate.

Rovner also appeared on WGN’s “Midday News” on Sept. 25 to discuss the impact of the death of Justice Ruth Bader Ginsburg on the Affordable Care Act.

KHN senior correspondent Phil Galewitz discussed Pinellas County’s important role in the presidential election in the swing state of Florida with WUSF’s “Florida Matters” on Tuesday.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Biden’s in the Ballpark on How Many People Have Preexisting Conditions

The first minutes of Tuesday’s presidential debate immediately turned to how President Donald Trump’s Supreme Court nominee to replace Justice Ruth Bader Ginsburg could undo the Affordable Care Act and its protections for people with preexisting conditions.

“There’s 100 million people that have preexisting conditions,” said former Vice President Joe Biden, the Democratic nominee, arguing that those patients could lose coverage protections if the federal health law were declared unconstitutional by the high court.

Protecting guarantees of coverage for people with medical issues is a key campaign issue. It’s among the ACA’s most popular provisions, and polling indicates that most Americans support keeping these protections in place.

Biden, who worked with then-President Barack Obama on the ACA’s enactment, is a strong supporter of the law. Trump, meanwhile, has called repeatedly for the law to be repealed and is backing a lawsuit by a group of Republican state attorneys generals trying to overturn it. The Supreme Court will hear oral arguments in the case Nov. 10.

The ACA guarantees that those with preexisting conditions cannot be denied coverage by health insurers. Despite promises that he will protect people with medical issues, Trump has not offered an alternative proposal to do so. He issued an executive order on health care Sept. 24 that included a commitment to preserving that safeguard, but legal experts said the executive order holds no enforcement power.

After Biden’s comment at the debate, Trump retorted, “There aren’t a hundred million people with preexisting conditions.”

We thought it was important to figure out if this number was right, especially as the ACA’s future hangs in the balance.

Estimates Vary

The Biden campaign provided us with several pieces of evidence to back up the candidate’s 100 million statistic, including a September article in The New York Times, a 2017 issue brief from the Department of Health and Human Services during the Obama administration and a 2018 estimate from Avalere, a health care consulting firm.

We consulted several health policy experts who also pointed us to the HHS brief and the Avalere estimate. They also cited a 2019 analysis from KFF, a nonpartisan health policy organization. (KHN is an editorially independent program of KFF.)

The HHS issue brief, published in January 2017, estimated that between 61 million and 133 million Americans have a preexisting condition.

The number varies based on how a preexisting condition was defined.

In the more conservative estimate of 61 million, a preexisting condition was defined as an illness or condition, such as cancer, cystic fibrosis or heart failure, that would qualify a person for a high-risk insurance pool. High-risk pools were in place before the ACA to help people with serious and expensive-to-treat illnesses gain health coverage. They were operated by some states, as well as by the federal government, but generally covered very few people and were a drain on government budgets.

But that 61 million number doesn’t include everyone who has a preexisting condition, said Linda Blumberg, an institute fellow in the Health Policy Center at the Urban Institute.

“That’s because it’s only capturing the conditions that people had which were in high-risk pools prior to the ACA,” said Blumberg. “We know from a lot of studies that we’ve done that insurance companies would write people up or deny them coverage for conditions that wouldn’t necessarily put you in a high-risk pool.”

Before the ACA, health insurance companies could deny you coverage for a condition as mild as seasonal hay fever.

“Insurance companies had tools they could use to protect themselves from risky people,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University in Washington, D.C. “They would dig through your medical history, and if they found something that might impose additional costs for them, they could do a variety of things.”

Corlette said those tools included the ability to deny coverage outright, charge individuals with preexisting health conditions higher premiums, or decide to offer them health insurance, but not cover the preexisting condition or the body part affected.

With that larger definition, the number HHS offered is 133 million people.

More recent estimates cite similar figures.

A 2018 analysis by Avalere, a health care consulting firm, estimated that 102 million Americans have preexisting conditions. A 2019 analysis by the left-leaning Center for American Progress suggested 135 million people.

And a 2019 analysis by KFF found that 54 million people have a preexisting condition that would likely make them completely uninsurable.

“The 54 million estimate is who wouldn’t have been able to be covered at all,” explained Cynthia Cox, director for the program on the ACA at KFF and one of the authors of the analysis.

“But, I think realistically, there are certainly over 100 million people who have a condition that would have caused them some trouble to get insurance on the individual market,” said Cox. “The 100 million includes both the 54 million who wouldn’t get coverage at all as well as the millions of others who might have had an exclusion or might have had to pay a higher premium.”

Based on the HHS estimate, Blumberg said, she would consider Biden’s 100 million figure conservative.

“If anything, he’s somewhat on the low side,” she said. “I think he was being cautious with range and that is appropriate.”

Why It Matters

While the number of individuals who have a preexisting condition varies based on the analysis, it’s clear that many Americans have a condition that could make it difficult to get comprehensive health insurance — or any insurance at all — if the ACA were overturned, said the experts.

And that’s the real point.

“It’s easy to forget what was common practice before the ACA for insurance companies to use various tactics to dictate coverage,” said Corlette. “So, the 100 million, 133 million, 54 million numbers are almost immaterial. The fact is, a heck of a lot of people will face these tactics from insurance companies if these protections disappear.”

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, agreed that the different numbers shouldn’t obscure the central idea: “The ACA provides strong consumer protections and access to health insurance for persons with preexisting conditions, and if the ACA goes away, so, too, will those protections, jeopardizing health coverage for millions of Americans.”

However, not all think that the ACA will be overturned if Trump is successful in getting his nominee, Amy Coney Barrett, confirmed as a new Supreme Court justice.

“The Supreme Court isn’t going to overturn the ACA,” said Joseph Antos, a health policy scholar at the right-leaning American Enterprise Institute. “The Supreme Court has an unbroken history since the 1700s of not expanding upon the specific case that is brought before them, so the idea that somehow preexisting condition protections will be tossed out by the Supreme Court is fairly absurd.”

Whoever is elected Nov. 3 will have to deal with the court’s decision. Although the arguments come next month, it’s unlikely a ruling will be issued until 2021.

Our Ruling

The experts all agreed that Biden was certainly in the ballpark with his estimate of 100 million people having preexisting conditions. His figure was even a little low based on a range provided in an HHS report, said one expert.

But a wide range of people — from 54 million to 135 million — could be affected, according to our reporting. Also, it is unclear how many people with preexisting conditions would be at risk of losing their insurance entirely, or facing higher costs or having their conditions excluded from coverage. Though Biden’s number is certainly within this range, he would need to provide more detail to support such a definitive number.

We rate Biden’s claim Mostly True.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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COVID + Influenza: éste es un buen año para vacunarse, aconsejan expertos

La temporada de influenza se verá diferente este año, ya que los Estados Unidos se enfrentan a una pandemia de coronavirus que ya ha matado a más de 176.000 personas.

Muchos estadounidenses son reacios a ir al médico y los funcionarios de salud pública temen que las personas eviten vacunarse.

Aunque a veces se considera incorrectamente como un resfriado, la gripe también mata a decenas de miles de personas en el país cada año. Los más vulnerables son los niños pequeños, los adultos mayores y las personas con enfermedades subyacentes. Cuando se combina con los efectos de COVID-19, los expertos en salud pública dicen que es más importante que nunca vacunarse contra la gripe.

Si una cantidad suficiente de la población se vacuna, más del 45% lo hizo la temporada de gripe pasada, podría ayudar a evitar un escenario de pesadilla este invierno, con hospitales llenos de pacientes con COVID-19 y los que sufren los efectos graves de la influenza.

Además de la posible carga para los hospitales, existe la posibilidad de que las personas contraigan ambos virus y “nadie sabe qué sucede si se contrae influenza y COVID simultáneamente porque nunca sucedió antes”, dijo la doctora Rachel Levine, secretaria de Salud de Pennsylvania, a reporteros.

En respuesta, este año los fabricantes están produciendo más suministros de vacunas, entre 194 y 198 millones de dosis, unas 20 millones más de las que se distribuyeron la temporada pasada, según los Centros para el Control y Prevención de Enfermedades (CDC).

Mientras se acerca la temporada de gripe, aquí hay algunas respuestas a preguntas frecuentes:

P: ¿Cuándo debo vacunarme contra la gripe?

La publicidad ya ha comenzado y algunas farmacias y clínicas ya tienen sus suministros. Pero, debido a que la efectividad de la vacuna puede disminuir con el tiempo, los CDC recomiendan no recibir la dosis en agosto.

Muchas farmacias y clínicas comenzarán las inmunizaciones a principios de septiembre. Generalmente, los virus de la influenza comienzan a circular a mediados o fines de octubre, pero se expanden masivamente más tarde, en el invierno. Se necesitan aproximadamente dos semanas después de recibir la inyección para que los anticuerpos, que circulan en la sangre y frustran las infecciones, se acumulen.

“Las personas jóvenes y sanas pueden comenzar a vacunarse contra la gripe en septiembre, y las personas mayores y otras poblaciones vulnerables pueden hacerlo en octubre”, dijo el doctor Steve Miller, director clínico de la aseguradora Cigna.

Los CDC recomiendan que las personas “se vacunen contra la influenza a fines de octubre”, pero señalaron que se puede recibir la vacuna más tarde porque “aún puede ser beneficiosas y la vacunación debe ofrecerse a lo largo de toda la temporada de influenza”.

Aun así, algunos expertos recomiendan no esperar demasiado este año, no solo por COVID-19, sino también en caso de que haya escasez debido a la abrumadora demanda.

P: ¿Cuáles son las razones por las que las que debería ofrecer mi brazo para vacunarme?

Hay que vacunarse porque brinda protección contra la gripe y, por lo tanto, contra la propagación a otras personas, lo que puede ayudar a disminuir la carga para los hospitales y el personal médico.

Y hay otro mensaje que puede resonar en estos tiempos extraños.

“Le da a la gente la sensación de que hay algunas cosas que pueden controlar”, dijo Eduardo Sánchez, director médico de prevención de la American Heart Association.

Si bien una vacuna contra la gripe no evitará COVID-19, recibirla podría ayudar al médico a diferenciar entre las dos enfermedades si se desarrolla algún síntoma (fiebre, tos, dolor de garganta) que ambas infecciones comparten, explicó Sánchez.

Y aunque las vacunas contra la gripe no evitarán todos los casos de gripe, vacunarse puede reducir la gravedad si la persona se enferma, dijo.

Todas las personas elegibles, especialmente los trabajadores esenciales, los que sufren de afecciones subyacentes y aquellos en mayor riesgo, incluidos los niños muy pequeños y las mujeres embarazadas, deben buscar protección, dijeron los CDC. La entidad recomienda la vacunación a partir de los 6 meses.

P: ¿Qué sabemos sobre la efectividad de la vacuna de este año?

Se deben producir nuevas vacunas contra la gripe cada año, porque el virus muta y la efectividad de la vacuna varía, dependiendo de qué tan bien coincida con el virus circulante.

Se calculó que la formulación del año pasado tuvo una eficacia de aproximadamente un 45% para prevenir la gripe en general, con una efectividad de aproximadamente un 55% en los niños. Las vacunas disponibles en el país este año tienen como objetivo prevenir al menos tres cepas diferentes del virus, y la mayoría cubre cuatro.

Todavía no se sabe qué tan bien coincidirá el suministro de este año con las cepas que circularán en los Estados Unidos. Las primeras indicaciones del hemisferio sur, que atraviesa su temporada de gripe durante nuestro verano, son alentadoras. Allí, las personas practicaron el distanciamiento social, usaron máscaras y se vacunaron en mayor número este año, y los niveles mundiales de gripe son más bajos de lo esperado. Sin embargo, expertos advierten que no se debe contar con una temporada igual de suave en los Estados Unidos, en parte porque los esfuerzos por usar mascara facial y de distanciamiento social varían ampliamente.

P: ¿Qué están haciendo diferente los seguros y sistemas de salud este año?

Las aseguradoras y los sistemas de salud contactados por KHN dicen que seguirán las pautas de los CDC, que exigen limitar y espaciar la cantidad de personas que esperan en las filas y las áreas de vacunación. Algunos están programando citas para vacunas contra la gripe para ayudar a controlar el flujo.

Health Fitness Concepts, una compañía que trabaja con UnitedHealth Group y otras empresas para establecer clínicas de vacunación contra la gripe en el noreste del país, dijo que está “fomentando eventos más pequeños y frecuentes para apoyar el distanciamiento social” y “exigiendo que se completen todos los formularios y arremangarse las camisas antes de entrar al área de vacunación contra la influenza”.

Se requerirá que todos usen máscaras.

Además, a nivel nacional, algunos grupos médicos contratados por UnitedHealth instalarán carpas, para que las inyecciones se puedan administrar al aire libre, dijo un vocero.

Kaiser Permanente planifica las vacunas directamente en autos en algunos de sus centros médicos y está probando los procedimientos de detección y registro sin contacto en algunos lugares.

Geisinger Health, un proveedor de salud regional en Pennsylvania y Nueva Jersey, dijo que también tendría programas de vacunación contra la influenza al aire libre en sus instalaciones.

Además, “Geisinger exige que todos los empleados reciban la vacuna contra la influenza este año”, dijo Mark Shelly, director de prevención y control de infecciones del sistema. “Al dar este paso, esperamos transmitir a nuestros vecinos la importancia de la vacuna contra la influenza para todos”.

P: Por lo general, me vacunan contra la gripe en el trabajo. ¿Seguirá siendo una opción este año?

Con el objetivo de evitar riesgosas reuniones en interiores, muchos empleadores se muestran reacios a patrocinar las clínicas de gripe en oficinas como han ofrecido en años anteriores. Y con tanta gente que sigue trabajando desde casa, hay menos necesidad de llevar las vacunas contra la gripe al lugar de trabajo. En cambio, muchos empleadores están alentando a los trabajadores a que reciban vacunas de sus médicos de atención primaria, en farmacias u otros entornos comunitarios. El seguro generalmente cubrirá el costo de la vacuna.

Algunos empleadores están considerando ofrecer cupones para vacunas contra la gripe a sus trabajadores sin seguro o a aquellos que no participan en el plan médico de la compañía, dijo Julie Stone, directora general de salud y beneficios de Willis Towers Watson, una firma consultora.

Estos cupones podrían, por ejemplo, permitir a los trabajadores obtener la vacuna en un laboratorio en particular sin costo.

Algunos empleadores están comenzando a pensar en cómo podrían usar sus estacionamientos para administrar vacunas contra la gripe enlos autos, dijo el doctor David Zieg, líder de servicios clínicos para el consultor de beneficios Mercer.

Aunque la ley federal permite a los empleadores exigir a los empleados que se vacunen contra la gripe, ese paso generalmente lo toman solo los centros de atención médica y algunas universidades donde las personas viven y trabajan en estrecha colaboración, dijo Zieg.

Pero sucede. El mes pasado, el sistema de la Universidad de California emitió una orden ejecutiva que requiere que todos los estudiantes, profesores y personal se vacunen contra la gripe antes del 1 de noviembre, con limitadas excepciones.

P: ¿Qué están haciendo las farmacias para alentar a las personas a vacunarse contra la gripe?

Algunas farmacias están haciendo un esfuerzo adicional para salir a la comunidad y ofrecer vacunas contra la gripe.

Walgreens, que tiene casi 9,100 farmacias en todo el país, continúa una asociación iniciada en 2015 con organizaciones comunitarias, iglesias y empleadores que ha ofrecido alrededor de 150,000 clínicas de gripe móviles hasta la fecha.

El programa pone especial énfasis en trabajar con poblaciones vulnerables y en áreas desatendidas, dijo el doctor Kevin Ban, director médico de la cadena de farmacias.

Walgreens comenzó a ofrecer vacunas contra la gripe a mediados de agosto y está animando a las personas a no demorar en vacunarse.

Tanto Walgreens como CVS están estimulando a las personas a programar citas y hacer trámites en línea este año para minimizar el tiempo que pasan en los locales.

En los CVS MinuteClinic, una vez que los pacientes se han registrado para recibir la vacuna contra la gripe, deben esperar afuera o en su automóvil, ya que las áreas de espera interiores ahora están cerradas.

“No tenemos un arsenal contra COVID”, dijo Ban, de Walgreens. “Pero quitar la presión del sistema de atención médica proporcionando vacunas por adelantado es algo que sí podemos hacer”.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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COVID + Influenza: This Is a Good Year to Get a Flu Shot, Experts Advise

Flu season will look different this year, as the country grapples with a coronavirus pandemic that has killed more than 172,000 people. Many Americans are reluctant to visit a doctor’s office and public health officials worry people will shy away from being immunized.

Although sometimes incorrectly regarded as just another bad cold, flu also kills tens of thousands of people in the U.S. each year, with the very young, the elderly and those with underlying conditions the most vulnerable. When coupled with the effects of COVID-19, public health experts say it’s more important than ever to get a flu shot.

If enough of the U.S. population gets vaccinated — more than the 45% who did last flu season — it could help head off a nightmare scenario in the coming winter of hospitals stuffed with both COVID-19 patients and those suffering from severe effects of influenza.

Aside from the potential burden on hospitals, there’s the possibility people could get both viruses — and “no one knows what happens if you get influenza and COVID [simultaneously] because it’s never happened before,” Dr. Rachel Levine, Pennsylvania’s secretary of health, told reporters this month.

In response, manufacturers are producing more vaccine supply this year, between 194 million and 198 million doses, or about 20 million more than they distributed last season, according to the Centers for Disease Control and Prevention.

As flu season approaches, here are some answers to a few common questions:

Q: When should I get my flu shot?

Advertising has already begun, and some pharmacies and clinics have their supplies now. But, because the effectiveness of the vaccine can wane over time, the CDC recommends against a shot in August.

Many pharmacies and clinics will start immunizations in early September. Generally, influenza viruses start circulating in mid- to late October but become more widespread later, in the winter. It takes about two weeks after getting a shot for antibodies — which circulate in the blood and thwart infections — to build up. “Young, healthy people can begin getting their flu shots in September, and elderly people and other vulnerable populations can begin in October,” said Dr. Steve Miller, chief clinical officer for insurer Cigna.

The CDC has recommended that people “get a flu vaccine by the end of October,” but noted it’s not too late to get one after that because shots “can still be beneficial and vaccination should be offered throughout the flu season.”

Even so, some experts say not to wait too long this year — not only because of COVID-19, but also in case a shortage develops because of overwhelming demand.

Q: What are the reasons I should roll up my sleeve for this?

Get a shot because it protects you from catching the flu and spreading it to others, which may help lessen the burden on hospitals and medical staffs.

And there’s another message that may resonate in this strange time.

“It gives people a sense that there are some things you can control,” said Eduardo Sanchez, chief medical officer for prevention at the American Heart Association.

While a flu shot won’t prevent COVID-19, he said, getting one could help your doctors differentiate between the diseases if you develop any symptoms — fever, cough, sore throat — they share.

And even though flu shots won’t prevent all cases of the flu, getting vaccinated can lessen the severity if you do fall ill, he said.

You cannot get influenza from having a flu vaccine.

All eligible people, especially essential workers, those with underlying conditions and those at higher risk — including very young children and pregnant women — should seek protection, the CDC said. It recommends that children over 6 months old get vaccinated.

Q: What do we know about the effectiveness of this year’s vaccine?

Flu vaccines — which must be developed anew each year because influenza viruses mutate — range in effectiveness annually, depending on how well they match the circulating virus. Last year’s formulation was estimated to be about 45% effective in preventing the flu overall, with about a 55% effectiveness in children. The vaccines available in the U.S. this year are aimed at preventing at least three strains of the virus, and most cover four.

It isn’t yet known how well this year’s supply will match the strains that will circulate in the U.S. Early indications from the Southern Hemisphere, which goes through its flu season during our summer, are encouraging. There, people practiced social distancing, wore masks and got vaccinated in greater numbers this year — and global flu levels are lower than expected. Experts caution, however, not to count on a similarly mild season in the U.S., in part because masking and social distancing efforts vary widely.

Q: What are insurance plans and health systems doing differently this year?

Insurers and health systems contacted by KHN say they will follow CDC guidelines, which call for limiting and spacing out the number of people waiting in lines and vaccination areas. Some are setting appointments for flu shots to help manage the flow.

Health Fitness Concepts, a company that works with UnitedHealth Group and other businesses to set up flu shot clinics in the Northeast, said it is “encouraging smaller, more frequent events to support social distancing” and “requiring all forms to be completed and shirtsleeves rolled up before entering the flu shot area.” Everyone will be required to wear masks.

Also, nationally, some physician groups contracted with UnitedHealth will set up tent areas so shots can be given outdoors, a spokesperson said.

Kaiser Permanente plans drive-thru vaccinations at some of its medical facilities and is testing touch-free screening and check-in procedures at some locations. (KHN is not affiliated with Kaiser Permanente.)

Geisinger Health, a regional health provider in Pennsylvania and New Jersey, said it, too, would have outdoor flu vaccination programs at its facilities.

Additionally, “Geisinger is making it mandatory for all employees to receive the flu vaccine this year,” said Mark Shelly, the system’s director of infection prevention and control. “By taking this step, we hope to convey to our neighbors the importance of the flu vaccine for everyone.”

Q: Usually I get a flu shot at work. Will that be an option this year?

Aiming to avoid risky indoor gatherings, many employers are reluctant to sponsor the on-site flu clinics they’ve offered in years past. And with so many people continuing to work from home, there’s less need to bring flu shots to employees on the job. Instead, many employers are encouraging workers to get shots from their primary care doctors, at pharmacies or in other community settings. Insurance will generally cover the cost of the vaccine.

Some employers are considering offering vouchers for flu shots to their uninsured workers or those who don’t participate in the company plan, said Julie Stone, managing director for health and benefits at Willis Towers Watson, a consulting firm. The vouchers could allow workers to get the shot at a particular lab at no cost, for example.

Some employers are starting to think about how they might use their parking lots for administering drive-thru flu shots, said Dr. David Zieg, clinical services leader for benefits consultant Mercer.

Although federal law allows employers to require employees to get flu shots, that step is typically taken only by health care facilities and some universities where people live and work closely together, Zieg said.

Q: What are pharmacies doing to encourage people to get flu shots?

Some pharmacies are making an extra push to get out into the community to offer flu shots.

Walgreens, which has nearly 9,100 pharmacies nationwide, is continuing a partnership begun in 2015 with community organizations, churches and employers that has offered about 150,000 off-site and mobile flu clinics to date.

The program places a special emphasis on working with vulnerable populations and in underserved areas, said Dr. Kevin Ban, chief medical officer for the drugstore chain.

Walgreens began offering flu shots in mid-August and is encouraging people not to delay getting vaccinated.

Both Walgreens and CVS are encouraging people to schedule appointments and do paperwork online this year to minimize time spent in the stores.

At CVS MinuteClinic locations, once patients have checked in for their flu shot, they must wait outside or in their car, since the indoor waiting areas are now closed.

“We don’t have tons of arrows in our quiver against COVID,” Walgreens’ Ban said. “Taking pressure off the health care system by providing vaccines in advance is one thing we can do.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Opposition to Obamacare Becomes Political Liability for GOP Incumbents

In the 2014 elections, Republicans rode a wave of anti-Affordable Care Act sentiment to pick up nine Senate seats, the largest gain for either party since 1980. Newly elected Republicans such as Cory Gardner in Colorado and Steve Daines in Montana had hammered their Democratic opponents over the health care law during the campaign and promised to repeal it.

Six years later, those senators are up for reelection. Not only is the law still around, but it’s gaining in popularity. What was once a winning strategy has become a political liability.

Public sentiment about the ACA, also known as Obamacare, has shifted considerably during the Trump administration after Republicans tried but failed to repeal it. Now, in the midst of the COVID-19 pandemic and the ensuing economic crisis, which has led to the loss of jobs and health insurance for millions of people, health care again looks poised to be a key issue for voters this election.

With competitive races in Colorado, Montana, Arizona, North Carolina and Iowa pitting Republican incumbents who voted to repeal the ACA against Democratic challengers promising to protect it, attitudes surrounding the health law could help determine control of the Senate. Republicans hold a slim three-vote majority in the Senate but are defending 23 seats in the Nov. 3 election. Only one Democratic Senate seat — in Alabama, where incumbent Doug Jones is up against former Auburn University football coach Tommy Tuberville — is considered in play for Republicans.

“The fall election will significantly revolve around people’s belief about what [candidates] will do for their health coverage,” said Dr. Daniel Derksen, a professor of public health at the University of Arizona.

The Affordable Care Act has been a wedge issue since it was signed into law in 2010. Because it then took four years to enact, its opponents talked for years about how bad the not-yet-created marketplace for insurance would be, said Joe Hanel, spokesperson for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis. And they continued to attack the law as it took full effect in 2014.

Gardner, for example, ran numerous campaign ads that year criticizing the ACA and, in particular, President Barack Obama’s assertion that “if you like your health care plan, you’ll be able to keep your health care plan.”

But now, Hanel said, the ACA’s policies have become much more popular in Colorado as the costs of health exchange plans have dropped. Thus, political messaging has changed, too.

“This time it’s the opposite,” Hanel said. “The people bringing up the Affordable Care Act are the Democrats.”

Despite Gardner’s multiple votes to repeal the ACA, he has largely avoided talking about the measure during the 2020 campaign. He even removed his pro-repeal position from his campaign website.

Democratic attack ads in July blasted Gardner for repeatedly dodging questions in an interview with Colorado Public Radio about his stance on a lawsuit challenging the ACA.

His opponent, Democrat John Hickenlooper, fully embraced the law when he was Colorado governor, using the measure to expand Medicaid eligibility to more low-income people and to create a state health insurance exchange. Now, he’s campaigning on that record, with promises to expand health care access even further.

Polling Data

Polling conducted by KFF for the past 10 years shows a shift in public opinion has occurred nationwide. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)

“Since Trump won the election in 2016, we now have consistently found that a larger share of the public holds favorable views” of the health law, said Ashley Kirzinger, associate director of public opinion and survey research for the foundation. “This really solidified in 2017 after the failed repeal in the Senate.”

The foundation’s polling found that, in July 2014, 55% of voters opposed the law, while 36% favored it. By July 2020, that had flipped, with 51% favoring the law and 38% opposing it. A shift was seen across all political groups, though 74% of Republicans still viewed it unfavorably in the latest poll.

Public support for individual provisions of the ACA — such as protections for people with preexisting conditions or allowing young adults to stay on their parents’ health plans until age 26 — have proved even more popular than the law as a whole. And the provision that consistently polled unfavorably — the mandate that those without insurance must pay a fine — was eliminated in 2017.

“We’re 10 years along and the sky hasn’t caved in,” said Sabrina Corlette, a health policy professor at Georgetown University.

Political Messaging

Following the passage of the ACA, Democrats didn’t reference the law in their campaigns, said Erika Franklin Fowler, a government professor at Wesleyan University and the director of the Wesleyan Media Project, which tracks political advertising.

“They ran on any other issue they could find,” Fowler said.

Republicans, she said, kept promising to “repeal and replace” but weren’t able to do so.

Then, in the 2018 election, Democrats seized on the shift in public opinion, touting the effects of the law and criticizing Republicans for their attempts to overturn it.

“In the decade I have been tracking political advertising, there wasn’t a single-issue topic that was as prominent as health care was in 2018,” she said.

As the global health crisis rages, health care concerns again dominate political ads in the 2020 races, Fowler said, although most ads haven’t explicitly focused on the ACA. Many highlight Republicans’ support for the lawsuit challenging preexisting condition protections or specific provisions of the ACA that their votes would have overturned. Republicans say they, too, will protect people with preexisting conditions but otherwise have largely avoided talking about the ACA.

“Cory Gardner has been running a lot on his environmental bills and conservation funding,” Fowler said. “It’s not difficult to figure out why he’s doing that. It’s easier for him to tout that in a state like Colorado than it is to talk about health care.”

Similar dynamics are playing out in other key Senate races. In Arizona, Republican Sen. Martha McSally was one of the more vocal advocates of repealing the ACA while she served in the House of Representatives. She publicly acknowledged those votes may have hurt her 2018 Senate bid.

“I did vote to repeal and replace Obamacare,” McSally said on conservative pundit Sean Hannity’s radio show during the 2018 campaign. “I’m getting my ass kicked for it right now.”

She indeed lost but was appointed to fill the seat of Sen. Jon Kyl after he resigned at the end of 2018. Now McSally is in a tight race with Democratic challenger Mark Kelly, an astronaut and the husband of former Rep. Gabby Giffords.

“Kelly doesn’t have a track record of voting one way or another, but certainly in his campaign this is one of his top speaking points: what he would do to expand coverage and reassure people that coverage won’t be taken away,” said Derksen, the University of Arizona professor.

The ACA has proved a stumbling block for Republican Sens. Thom Tillis of North Carolina and Joni Ernst of Iowa. In Maine, GOP Sen. Susan Collins cast a key vote that prevented the repeal of the law but cast other votes that weakened it. She now also appears vulnerable — but more for her vote to confirm Brett Kavanaugh’s nomination to the Supreme Court and for not doing more to oppose President Donald Trump.

In Montana, Daines, who voted to repeal the ACA, is trying to hold on to his seat against Democratic Gov. Steve Bullock, who used the law to expand the state’s Medicaid enrollment in 2015. At its peak, nearly 1 in 10 Montanans were covered through the expansion.

As more Montanans now face the high cost of paying for health care on their own amid pandemic-related job losses, Montana State University political science professor David Parker said he expects Democrats to talk about Daines’ votes to repeal cost-saving provisions of the ACA.

“People are losing jobs, and their jobs bring health care with them,” Parker said. “I don’t think it’s a good space for Daines to be right now.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What the Health?’ Replay: What’s at Stake When High Court Hears ACA Case

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The “What the Health?” panelists are taking a break for two weeks. But since the Supreme Court recently scheduled arguments in the case challenging the constitutionality of the Affordable Care Act, it seemed like a good opportunity to replay an episode from March, when the law turned 10.

As the “What the Health?” panelists point out in this episode, that’s a milestone that many considered unlikely. The past decade for the health law has been filled with controversy and several near-death experiences. But the law also brought health coverage to millions of Americans and laid the groundwork for a shift to a health system that pays for quality rather than quantity.

Yet the future of the law remains in doubt. Many progressive Democrats would like to scrap it in favor of a “Medicare for All” system that would be fully financed by the federal government. Republicans would still like to repeal or substantially alter it. And GOP officials have brought the case asking the Supreme Court to invalidate the entire law. Those arguments will be heard on Nov. 10.

This special episode, which first aired March 19, also includes a discussion between “What the Health?” host Julie Rovner and Kathleen Sebelius, who was secretary of Health and Human Services during the development, passage and implementation of the health law. KHN published a transcript of that interview.

Rovner, Joanne Kenen of Politico and Mary Agnes Carey of KHN, who have all covered the law from the start, discuss the ACA’s past, present and future.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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Republican Convention, Day 1: A Campaign-Style Trump Speech and More

Before the prime-time GOP showcase began, President Donald Trump took to the podium Monday afternoon and delivered an approximately one-hour campaign-style speech to delegates after he was officially renominated by the Republican Party as its candidate for president.

His comments were wide-ranging, and our partners at PolitiFact found many to be either wrong, misleading, premature or in need of clarification. Here is the complete rundown from that speech and a wrap-up story detailing the rest of the evening. (PolitiFact also fact-checked former Vice President Joe Biden’s acceptance speech during the Democratic National Convention.)

Monday’s evening broadcast was full of platitudes. Amy Ford, a West Virginia nurse, applauded Trump’s steps during the pandemic to expand telemedicine, saying these policies are “essential” and will “continue to aid many that are unable to find transportation or a way to the doctor for regular checkups. This is especially true in rural America.” Dr. G.E. Ghali, a Louisiana oral surgeon and chancellor of a medical research center, spoke as both a clinician and a patient about how the administration’s efforts to provide emergency-use authorization for emerging treatments saved lives.

Video vignettes heralded Trump’s leadership during the coronavirus, focusing on things like Operation Warp Speed, the administration’s initiative to speed vaccine development, rather than the statistics: nearly 6 million Americans who have contracted COVID-19 or the more than 177,000 who have died. Trump also spoke with a group of first responders — including nurses, postal workers and a police officer from Colorado who said she had contracted COVID-19 in late March and has since recovered. “That means we don’t have to be afraid of you at all, right?” Trump said to her. “Once you’re recovered, we have the whole thing with plasma happening. That means your blood is very valuable, you know that, right?”

What follows are some of Trump’s statements from his afternoon speech geared to health policy issues:

Trump has repeatedly claimed that President Barack Obama left him with an empty national stockpile of emergency supplies. But this is an exaggeration.

The stockpile had a shortage of N95 masks, which were depleted as a result of the H1N1 outbreak in 2009 and not substantially replenished during the Obama or Trump administrations.

ProPublica found that the budget battles during Obama’s tenure after the Republicans won the 2010 election also hurt the stockpile’s budget.

Budget figures going back to 2009 show overall funding for the stockpile dropped to its lowest level in 2013, to about $477 million. Allocations have grown steadily since then to a 2020 budget of $705 million.

“We eliminated Obamacare’s horrible and very unfair individual mandate, which basically knocked out Obamacare. We knocked out Obamacare.”

Saying Republicans “knocked out Obamacare” is a stretch. Trump did sign legislation to eliminate the requirement that Americans have health insurance or pay a tax penalty, but eliminating this requirement did not get rid of Obamacare, or the Affordable Care Act, as it is officially known.

The administration supports a lawsuit by a group of Republican state attorneys general that argues that the ACA should be ruled unconstitutional. The lawsuit’s argument focuses on the Supreme Court’s previous ruling that the ACA was constitutional because it was based on a tax, which Congress has the authority to levy. With the tax penalty now eliminated, the lawsuit argues, the law should be scrapped entirely. The Supreme Court has agreed to hear the case.

In the meantime, much of the health law’s key provisions remain in force. In 2020, at least 11.4 million Americans have purchased insurance through the online marketplaces created under the act. More than 10 million others have signed up for Medicaid under the expanded eligibility requirements passed as part of the law. And people who have private insurance have benefited from new rules enacted by the law, from the ability to keep young adults on a parent’s policy to an end to out-of-pocket payments for certain preventive measures.

“So we protected your preexisting conditions, very strongly protected.”

We rated a similar claim as Pants on Fire. Protections for preexisting conditions under Obamacare remain on the books, but it’s not for lack of trying by the Trump administration.

For starters, the administration backs the lawsuit that would eliminate protections for preexisting conditions by getting rid of Obamacare.

In addition, the administration has not put forth any plan that might keep those guarantees in place. Every replacement health bill the administration has endorsed has offered protections less generous than those offered by the ACA.

Finally, the administration has issued a rule loosening restrictions on the length of so-called short-term health plans. While such plans could be more affordable for individuals in the market for insurance, they are not required to provide preexisting condition protections.

PolitiFact’s Louis Jacobson, Amy Sherman, Samantha Putterman and Miriam Valverde contributed to this story.

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Veteran’s Appendectomy Launches Excruciating Months-Long Battle Over Bill

In late August 2019, Shannon Harness awoke to serious pain in the lower right side of his abdomen — a telltale sign of appendicitis.

He booked it to the emergency room of the only hospital in the county: Heart of the Rockies Regional Medical Center in Salida, Colorado. After a CT scan, doctors told Harness he had acute appendicitis and required immediate surgery.

A surgeon performed an appendectomy that night and released Harness the next day.

But a couple of days later, Harness felt sharp pains where his appendix had been. The pain grew until he was on the floor screaming.

“It was disturbing,” said Eliza Novick-Smith, his partner. “He has a pretty high pain tolerance,” given previous injuries from military service and mountain biking.

Harness went back to the hospital, where another CT scan revealed a blood clot the size of a brick floating in his pelvic area, a rare complication that most likely came from clipping and stapling the appendix tissue in the first surgery, said his surgeon. He would need another operation to check for the source of bleeding and to remove the clot.

After four more days in the hospital, he went home. It took him a couple of months to fully recover.

Then the bill came.

Patient: Shannon Harness, 39, an operations manager for a company that builds mountain bike trails across the country and a Marine Corps veteran. At the time of this incident, Harness had no insurance.

Total Owed: The original hospital bill was $80,232 for both surgeries — the first surgery cost $35,906 and the clot surgery cost $44,326. These amounts do not include payments to the surgeon, anesthesiologist, pathologist or radiologist.

Service Provider: Heart of the Rockies Regional Medical Center, a nonprofit critical access hospital in Colorado, where the surgeries were performed. Anesthesia, radiology and pathology were performed by other providers.

Medical Services: Laparoscopic appendectomy, followed by a second surgery a few days later, to resolve complications.

What Gives: Uninsured patients are extremely vulnerable to exorbitant hospital bills. It’s difficult to negotiate with a hospital without the leverage and bargaining power of an insurance company. Worse, uninsured patients are often billed three or four times what an insurer or government program would pay for the same service, said Anthony Wright, executive director of Health Access California, an organization advocating for affordable health care in California.

“As somebody who’s uninsured, you are getting an unnegotiated rate,” Wright said, derived from the hospital’s master price list. Insurers typically pay a rate that is a tiny fraction of that cost.

Harness was uninsured for seven years before this incident. His employer didn’t offer insurance, and the Affordable Care Act plan he qualified for cost $350 a month — an amount he didn’t have.

One option for uninsured patients is a hospital’s financial assistance program, a requirement in some states. In Colorado, every hospital is supposed to have a comprehensive charity care program for uninsured patients who earn less than 250% of the federal poverty level.

Heart of the Rockies hospital determines financial assistance on a sliding scale of family size and income. They also offer a self-pay discount of 15% to uninsured patients. Harness said the hospital’s financial services office initially told him he was ineligible for their assistance program as well as the Colorado Indigent Care Program. Harness had worked overtime the previous month and missed the qualification by around $200. The hospital would use only his past two pay stubs to verify his income, he said.

The hospital wouldn’t answer any questions about Harness’ care or bills, even though he gave it permission to do so.

Another quirk of the U.S. health care system that Harness encountered is that when surgeries don’t go as planned, and need revision with another operation, the patient (or his insurer) typically pays again. Medicare and some insurers have experimented with “bundled payments,” through which the hospital gets a set fee for the surgery and any follow-up care for 90 days thereafter.

Resolution: Harness filed a grievance with the hospital with the help of Novick-Smith, who is a lawyer, to push back on the bills for the two surgeries — $35,906 for the first and $44,326 more for the second —and express concerns with the quality of care.

Healthcare Bluebook, which estimates costs based on insurers’ claims data, says a fair price for an appendectomy in Salida is around $12,600. Dr. Gina Adrales, director of minimally invasive surgery at Johns Hopkins Medicine in Baltimore, said the complication Harness experienced is not common. The complication rate for an appendectomy is fairly low, she said.

In November, the hospital decided to give Harness a 30% discount for both surgeries, leaving him with a still hefty bill of $56,162.40.

The couple followed up repeatedly with the hospital for months, often finding representatives “hard to reach.” More than six months later, in March, the hospital told Harness he would have to pay for the second surgery because it was a risk he accepted by agreeing to the appendectomy.

Adam Fox, director of strategic engagement at Colorado Consumer Health Initiative, said it’s “especially important” to push back on bills resulting from surgical complications. “It usually indicates that something didn’t go right in the first surgery and at least that second surgery should be provided at a substantially reduced cost to the individual,” he said.

By May, the hospital gave in. Lesley Fagerberg, Heart of the Rockies’ vice president of financial services, wrote a response to Harness’ grievance, reducing the total bill by roughly the amount charged for the second surgery. But she didn’t explain how the hospital had come to that decision.

“Unfortunately, there was a complication in your appendectomy surgery,” Fagerberg wrote. “As explained in the consent to treat, a surgery/procedure has inherent risk. Your case has been reviewed and the total bill has been reduced by $31,218.60.”

Harness’ final bill from the hospital, Fagerberg wrote, stands at $22,304.17 after adjustments that included a self-pay discount.

Harness and Novick-Smith said that still seemed too high to them, and after some research, offered to pay the hospital $12,000 upfront. The hospital rejected this offer.

Now, Harness is working out a payment plan with the hospital. The hospital offers an interest-free payment plan if he can pay it off in two years, but for Harness, those monthly payments would be more than his rent.

“I would not be able to do it by myself, like, I wouldn’t have another choice other than taking out a loan,” Harness said. “Before the appendectomy, I was looking for property and homes to purchase, and that is pretty much completely off the table right now.”

Novick-Smith said she’s glad the hospital ultimately wrote off the bill for the second surgery. But she still feels angry with the hospital.

“What feels particularly hard is that the hospital markets itself in our community as this vital community resource and they provide a lot of jobs,” she said. “Their lack of transparency and lack of communication with us made this all a whole lot worse especially because there’s nowhere else to go.”

The Takeaway: The United States health care system is not forgiving to the uninsured, who, paradoxically, often face the highest bills of all patients. The benefit of having insurance is in part that your plan pays much of the bill, but also that you get the benefit of being charged the plan’s highly discounted rates. If your employer doesn’t provide health insurance, check whether you’re eligible for a public program, said Wright.

Harness now has VA Health Care. He initially avoided looking into VA Health Care because he felt “other vets needed it more.”

If you’re uninsured and stuck with a huge bill, Fox said, the first step is to ask for an itemized bill to ensure it reflects the actual service you received. The next step is to check the hospital’s charity care policy. Another resource uninsured patients can turn to are organizations like the Colorado Consumer Health Initiative.

“It’s by no means a perfect solution because there’s only so much that we can do to help consumers advocate for themselves in these cases, but we do our best,” Fox said.

If all else fails, Wright said, it’s best to put pressure on the hospital before they sell the bill to a collections agency. There’s less room for negotiation once a bill goes to collections, Wright said. And if all else really fails, you could try calling the press.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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Democratic Convention, Night 4: ‘Facts Over Fiction’ in Biden’s Speech

In a near-empty arena on the river in his hometown of Wilmington, Delaware, former Vice President Joe Biden accepted the Democratic nomination for president, promising hope over fear, fairness over privilege, love over hate.

And, he said, “Facts over fiction.”

Let’s see about that.

Our partners at PolitiFact examined a range of claims made by Biden, fact-checking or putting them in context. Here are excerpts related to health policy and the COVID-19 pandemic:

“Five million Americans infected with COVID-19.”

It’s a little higher than that. According to data from Johns Hopkins University, the number of positive tests as of Aug. 20 was 5,573,517.

“More than 170,000 Americans have died.”

This is accurate. Johns Hopkins data counted 174,248 U.S. deaths through Aug. 20.

“More than 50 million people have filed for unemployment this year.”

This, too, is accurate. Since March 21, 57.4 million Americans have filed initial unemployment claims.

“By far the worst performance of any nation on Earth.”

The United States leads the world in the number of COVID-19 cases and deaths. Using other metrics that account for population, the U.S. isn’t the absolute worst, but it still lags behind many other countries. For instance, the United States has the fifth-highest death rate per 100,000 people.

The virus is known to have infected a higher percentage of the population in the U.S. than in many other places. The U.S. has one of the highest rates globally of people who have tested positive — 16,430 per million residents, which is lower than Chile’s, but higher than that of any other large country.

“More than 10 million people are going to lose their health insurance this year.”

This number may be an underestimate. In a July report, the Urban Institute estimated that from April through December 2020, 10.1 million people will lose health insurance tied to a job that they lost during the pandemic. This analysis was done by looking at employment loss projections data from U.S. Labor Department reports.

But that number is lower than another estimate. KFF estimates that nearly 27 million people could lose their employer-sponsored health insurance and become uninsured due to the COVID-19 pandemic. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation). This 27 million figure includes both those who lost employer-sponsored insurance as well as dependents who may have been covered on the same plan. The estimate was based on assessing data from Labor Department unemployment claims and determining whether workers were eligible for ACA insurance.

“The assault on the Affordable Care Act will continue until it’s destroyed, taking insurance away from 20 million people, including more than 15 million people on Medicaid. And getting rid of the protections that President Obama worked so hard to get passed.”

Biden was referring to the coverage losses that would result if a Trump administration-backed lawsuit to overturn the Affordable Care Act is successful. And health policy experts and press reports cite numbers close to what Biden listed.

Close to 20 million people gained health insurance after the Affordable Care Act was enacted, either through the Medicaid expansion or as a result of its marketplace subsidies for individuals below 400% of poverty. So, it follows that if the ACA were overturned, their health coverage would be at risk.

Additionally, an Urban Institute estimate matches Biden’s 15 million figure regarding how many people would lose Medicaid coverage if the ACA were struck down. That would be a result of the federal government no longer helping states pay for Medicaid expansion.

There are other estimates that take into account the effects of the COVID-19 pandemic. The left-leaning Center for American Progress estimates that 3 million additional people (beyond the already estimated 20 million) could lose health insurance coverage because of COVID-19 and be eligible for other government programs, such as Medicaid.

And because the ACA ensures that those with preexisting conditions must be covered by health insurance, that “protection,” as Biden called it, would no longer be in place if the law were overturned, because President Donald Trump has not issued a health care plan that would offer a similar guarantee.

“And after all this time the president still does not have a plan” for the COVID-19 pandemic.

It’s unclear exactly what type of plan Biden is referring to in this general statement. It is true that, thus far, no national testing or contact tracing plan has been issued. Nor has the White House issued a national blueprint to address the COVID-19 pandemic, despite Trump saying he would do so in July.

“We are in the process of developing a strategy that’s going to be very, very powerful. We’ve developed as we go along,” Trump said July 21.

However, the White House has said that Trump does have a plan. Several plans, in fact, seem to have emerged.

Part of one Trump administration plan included restricting travel from areas that have been affected by the virus in March. This initially targeted only China, but then extended to Iran, Italy, South Korea and other European countries. The White House also said Trump worked to expand testing capacity by developing a public and private partnership that would bring more coronavirus testing to parking lots of big-name chain stores. (There were only a few in operation when we checked in April.)

Trump has also touted a plan to develop a COVID-19 vaccine as quickly as possible, called Operation Warp Speed. The goal of Operation Warp Speed is to deliver 300 million doses of a COVID-19 vaccine by January 2021. A federal plan for vaccine distribution is not yet ready.

Throughout the COVID-19 pandemic, Trump has emphasized he wanted state leaders to take control of virus response within their states. But critics say these efforts do not represent a coordinated strategy.

“We’ll have a national mandate to wear a mask, not as a burden, but to protect each other.”

A nationwide mask mandate is easier said than done, given current law.

The Congressional Research Service found that the Centers for Disease Control and Prevention could use the Public Health Service Act (Sec. 361) to issue regulations mandating the use of masks. But a mandate would likely run into legal problems with the Constitution and other laws, including the Religious Freedom Restoration Act of 1993, which requires courts to grant certain religious exemptions.

Meanwhile, the Supreme Court’s interpretation of the 10th Amendment prevents the federal government from controlling or requiring states to carry out federal directives. Congress could incentivize states to enact mask mandates, as long as the incentives aren’t considered significant enough to coerce or force states into enacting the mandate, the CRS report said.

A number of courts have affirmed state and local authority to impose social distancing measures and temporary business closures. Opponents of masks say that the requirement violates their First Amendment rights. At least one federal court has already rejected this claim and said the requirement regulates conduct, not speech.

Daniel Funke,  Louis Jacobson, Victoria Knight, Bill McCarthy, Samantha Putterman, Amy Sherman and Miriam Valverde contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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KHN’s ‘What The Health?’: Democrats in Array (For Now)

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Democrats have shown a remarkably united front, including on health care, in their socially distant, made-for-TV convention this week. That’s likely due, at least in part, to the physical separation of party members who disagree on issues — this year they cannot chatter on live television — and to the party truly being united in its desire to defeat President Donald Trump in November.

Meanwhile, the coronavirus pandemic continues to complicate efforts around the country to get students back to school, from preschool to college. And the Trump administration’s effort to eliminate anti-discrimination protections in health care for transgender people is put on hold by a federal judge.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Shefali Luthra of The 19th.

Among the takeaways from this week’s podcast:

  • Democrats’ online convention has helped make the party seem unified. But on health policy, divisions remain even though Vice President Joe Biden has agreed to broaden some of his plans, such as lowering the eligibility age for Medicare and agreeing to have federal regulators run a public option plan he is advocating. Progressives in the party still hope to move the debate next year back to establishing a “Medicare for All” system.
  • The heated Democratic primary campaign put a good deal of focus on health policy, including whether to support a Medicare for All system and efforts to make health care more affordable. But the convention rhetoric on health hasn’t focused much attention on that and instead has played up issues surrounding the Trump administration’s response to the coronavirus pandemic.
  • The emphasis on COVID-19 in recent months has also pushed out much of the debate on the issues of high drug prices and surprise bills.
  • As the question of a mail slowdown has enveloped the country, concerns are being raised about mail delivery of prescription drugs, especially for seniors and veterans. Despite anecdotal reports of missed deliveries, most drug industry experts say problems haven’t been widespread.
  • The controversies about reopening schools — both K through 12 and colleges — point to difficulties with the country’s COVID testing program. It is too hard and too expensive for schools to be able to test enough students to guarantee that the virus isn’t spreading.
  • Schools may want to reconsider which age groups they target for returning to the classroom. Since there is little evidence that younger kids spread the virus widely and since they may need the in-classroom experience more, it could make sense to bring them back to school sooner than older students. Plus, older students generally can better handle online classes.
  • Federal health officials have recently warned that the pandemic is having an impact on mental health for many people, raising levels of depression and anxiety. The physical isolation and the economic stresses are fueling much of that.
  • The Trump administration’s rule overturning an Obama administration rule on transgender protections in the Affordable Care Act has been put on hold by a federal judge. But the Obama-era rule had also been put on hold by another judge. So the question is in limbo until higher courts — perhaps the Supreme Court — take up the case.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Washington Post’s “Can Dogs Detect the Novel Coronavirus? The Nose Knows,” by Frances Stead Sellers

Margot Sanger-Katz: The Atlantic’s “The Plan That Could Give Us Our Lives Back,” by Robinson Meyer and Alexis C. Madrigal

Paige Winfield Cunningham: Stat News’ “Seven Months Later, What We Know About Covid-19 – And the Pressing Questions That Remain,” by Andrew Joseph, Helen Branswell and Elizabeth Cooney.

Shefali Luthra: KHN’s “Back to the Future: Trump’s History of Promising a Health Plan That Never Comes,” by Victoria Knight

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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GOP Senate Ad Misrepresents Mont. Governor’s Stance on Rural Hospitals, Public Option

An attack ad, which was released in mid-July, states that Montana Gov. Steve Bullock, a Democratic candidate for the Senate, supports a government-run health care program that would wreak havoc on the state’s health care infrastructure.

“Bullock’s health care plan will force rural hospitals to close. Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times,” says the narrator in the dark and grainy advertisement paid for by the National Republican Senatorial Committee (NRSC).

Bullock is running against first-term incumbent Republican Sen. Steve Daines in a race viewed as a toss-up. Given the COVID-19 pandemic, both candidates have been focusing on health issues.

Because this race is critical to determining whether Democrats or Republicans control the Senate, and considering that its themes are likely to be repeated in many congressional campaigns, we thought it was important to check the ad’s validity.

We first asked the NRSC for the evidence on which the ad was based. A spokesperson pointed to Bullock’s support for a “public option” health plan and provided us with a report predicting this proposal’s negative impact on rural hospitals, as well as quotes from both Republicans and Democrats about how the public option could lead to the eventual implementation of a “Medicare for All” program. (Medicare for All refers to the single-payer health system, advocated by Vermont Sen. Bernie Sanders, which would eliminate private insurance and replace it with a government-run health care system.)

We also reached out to the Bullock campaign for its response.

In a statement, Sean Manning, spokesperson for Montanans for Bullock said, “The claims in this ad are false. Montana hasn’t lost one rural hospital under Governor Bullock, and he will continue to support policies that protect rural hospitals while making affordable healthcare available to all Montanans in the Senate.” (According to the University of North Carolina Sheps Center for Health Services Research, no rural hospitals have closed in Montana since 2005.)

Hold Up ― Which Health Care Plan Is the NRSC Ad Talking About?

The ad vaguely refers to Bullock’s “health care plan” but doesn’t say outright what the candidate supports.

According to Bullock’s campaign website, he supports the creation of a public option.

A public option is generally defined as a health plan administered by the federal government that exists alongside and competes with private health insurance plans on the Affordable Care Act exchanges. Public option proposals differ by political candidate, and can take various forms, including Medicare or Medicaid buy-ins as well as a new government-run entity.

Opponents of such plans say that a public option, which would have the scale and regulatory power of the federal government to set lower reimbursement rates to providers, would have a competitive advantage and could put private insurance companies out of business. This would leave Americans with only one choice ― government-backed insurance. But that conclusion is debatable. Some health care scholars argue a public option would increase competition, leading to expanded access to health coverage, lower health care costs and lower premiums for consumers.

In the end, the outcomes from implementing this approach are difficult to predict unless a specific plan is released, said Benedic Ippolito, a health care research scholar at the American Enterprise Institute.

“Things can be radically different based on what the public option looks like,” said Ippolito. “The two big variables are, who is covered? And how does that insurer actually pay health care providers? You can imagine two public options looking totally different.”

The Payment Rate Is Key 

Now to tackle the first part of the ad, which says that “Bullock’s health care plan will force rural hospitals to close.”

This argument stems from the idea that a public option would lead to lower reimbursement rates, based on the model provided by Medicare, which pays less than private insurance. And, because many rural hospitals are already severely financially strapped, lowered payments would do them in, the argument goes.

When we asked the NRSC for the evidence to support this position, a spokesperson provided an August 2019 study conducted by Navigant, a consulting firm. The study was commissioned by the Partnership for America’s Healthcare Future, a health industry coalition including  drugmakers, insurance companies and private hospitals. The organization opposes Medicare for All and a public option.

The study modeled what would happen to rural hospitals if three separate public option approaches were implemented.

While it found that a public option could, depending on the scenario, cause a revenue reduction for rural hospitals of between 2.3% and 14%, the study reached these findings by assuming that the hospitals would be paid at Medicare rates.

Bullock’s campaign website, though, under his rural health care policy proposals, specifically states: “We need a public option that includes higher reimbursements for rural hospitals.”

We asked the Bullock campaign if it could provide us with details about what the “higher reimbursement” rate would be based on. It declined. A campaign staffer told us Bullock would support a public option that pays rural hospitals above Medicare rates. Since the reimbursement rates would be higher than Medicare’s, the assumptions in the Navigant study cannot be applied here.

“If the public option is a reasonably generous payer, that won’t be the end of rural health care,” said Ippolito. “But, you can easily imagine due to budgetary concerns, a public payer could have a lower reimbursement, which would have consequences.”

Some health policy experts argue that a public option would help rural hospitals by increasing the number of people in rural areas who have health insurance.

This would “benefit rural hospitals, since getting virtually nothing from uninsured patients is worse than getting a reasonably good rate from the public option,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins University in Baltimore.

That’s a Big Jump 

Next, we’re on to the NRSC ad’s second claim: “Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times.”

As several experts pointed out, this sentence doesn’t make a lot of sense. Medicare is already a government-run program.

Also, the design of most public option proposals thus far keeps Medicare and the public option as two separate government programs, said Linda Blumberg, a health policy analyst at the Urban Institute, a think tank.

The NRSC clarified its position and told us it was referring to the idea that a public option would stifle competition in the insurance market, eventually leading to only government-run insurance or Medicare for All. The evidence the NRSC provided to support this claim were quotes from a selection of Republicans, Democrats, professors, and experts from conservative think tanks saying that the public option is a stepping stone to this single-payer approach.

But others suggest that’s a big leap in logic.

“I think that analysis is almost surely wrong,” said Matthew Fiedler, a fellow with the Brookings Institution. “In a world where there is a public option, the negotiating dynamics between insurers and providers would change substantially.”

This would likely create an environment in which private insurers could negotiate lower rates and providers would have to respond to that change in revenue with more efficiencies, he added. However, depending on how a public option plan is structured — specifically if providers can opt out of participating — some in-demand providers may choose to stay in private-plan networks where they could negotiate higher payments. This would keep private plans competitive.

“I don’t think it’s reasonable to argue that a public option would drive all other plans out of the market,” Fiedler said.

Again, Ippolito said it all depends on how the public option program is designed, and he allowed that if providers and hospitals were paid at Medicare rates, the public option would have a huge competitive advantage over commercial insurers because it would be paying out less for services and then could charge lower premiums, and “there’s no question in the short run, that it would be disruptive.”

As we noted earlier, the prediction of any outcome is difficult without specifics. Without details of Bullock’s public option plan, it’s misleading to characterize the outcome of the public option as surely leading to Medicare for All.

Why It Matters 

The race between Bullock and Daines is indicative of a trend occurring in campaigns across the country. Republicans often paint Democrats as left of the general public and health care has often been one of the issues the GOP highlights in that effort.

In this case, the NRSC ad links  Bullock to Medicare for All, despite his expressed support for a public option. Sean Manning, Bullock’s campaign spokesperson, said the governor does not support Medicare for All.

Jeremy Johnson, an associate professor of political science at Carroll College in Helena, Montana, said that even before COVID-19 became a major campaign issue, Daines, echoing a Trump theme, had pushed the idea that he stood for freedom versus socialism.

“One of the things [Daines] gives as a symbol of socialism is Medicare for All,” said Johnson. “Because Bullock says he favors a public option, there is a conflation of that on the Republican side to mean Medicare for All.”

But the public option and Medicare for All are not the same program and it’s misleading to lump them together.

Our Rating 

The NRSC claimed in a television ad that Steve Bullock’s support for the public option would cause rural hospitals to close.

While the NRSC did provide us with one study that offered support for its rural hospital claim, the study was industry-funded and based on broad assumptions that don’t accurately reflect positions outlined on Bullock’s website. Thus, this claim doesn’t stand up.

The second part of the ad asserts that the public option would lead to the implementation of Medicare for All. While supporters and critics debate how a public option would affect the private health insurance market and some on both sides consider it a “glide path” to a single-payer health care system, it’s too big of a jump to say it would definitely trigger this outcome.

We rate this False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘Pennie’-Pinching States Take Over Obamacare Exchanges From Feds

Pennsylvania is rolling out its new “Pennie” this fall: a state-run insurance exchange that officials say will save residents collectively millions of dollars on next year’s health plan premiums.

Since the Affordable Care Act’s marketplaces opened for enrollment in fall 2013, Pennsylvania, like most states, has used the federal www.healthcare.gov website for people buying coverage on their own.

But in a move defying the usual political polarization, state lawmakers from both parties last year agreed the cost of using the federal marketplace had grown too high and the state could do it for much less. They set up the Pennsylvania insurance exchange (nicknamed “Pennie”), designed to pass on expected savings to policyholders. Although the final rates for 2021 are not yet set, insurers have requested about a 3% average drop in premiums.

Pennsylvania is one of six states shifting in the next several years from the federal insurance exchange to run their own online marketplaces, which determine eligibility, assist with enrollment and connect buyers with insurance companies. They will join 12 states and the District of Columbia with self-contained exchanges.

The transitions come amid mounting evidence that state marketplaces attract more consumers, especially young adults, and hold down prices better than the federal exchange. They’ve also been gaining appeal since the Trump administration has cut the enrollment period on healthcare.gov and slashed funds for advertising and helping consumers.

State policymakers say they can run their own exchanges more cheaply and efficiently, and can better respond to residents’ and insurers’ needs.

“It comes down to getting more bang for your buck,” said Rachel Schwab, a researcher at Georgetown University’s Center on Health Insurance Reforms in Washington, D.C.

The importance of state-run exchanges was highlighted this year as all but one of them held special enrollment periods to sign up hundreds of thousands of people hurt financially by COVID-caused economic turmoil. The federal exchange, run by the Trump administration, refused to do so, although anyone who has lost workplace insurance is able to buy coverage anytime on either the state or federal exchange.

Like Pennsylvania, New Jersey expects to have its state-run exchange operational for the start of open enrollment on Nov. 1.

In fall 2021, New Mexico plans to launch its own marketplace and Kentucky is scheduled to fully revive its state-run exchange, which was dismantled by its Republican governor in 2015. Maine has also announced it will move to set up its own exchange, possibly in fall 2021.

Virginia’s legislature passed an exchange bill this year and hopes to start it in 2022 or 2023.

Nationwide, about 11 million people get coverage through the state and federal exchanges, with more than 80% receiving federal subsidies to lower their insurance costs.

“Almost across the board, states with their own exchanges have achieved higher enrollment rates than their federal peers, along with lower premiums and better consumer education and protection,” according to a study published this month in the Journal of Health Politics, Policy and Law.

Controlling ‘Their Own Destiny’

Since 2014, states using the federal marketplaces have had a rise in premiums of 87% while state exchanges saw 47% growth, the study found.

In one key metric, from 2016 to 2019 the number of young enrollees in state exchanges rose 11.5%, while states using the federal marketplace recorded an 11.3% drop, a study by the National Academy for State Health Policy found.

Attracting younger enrollees, who tend to be healthy, is vital to helping the marketplaces spread the insurance risk to help keep premiums down, experts say.

When the Affordable Care Act was debated, Republicans and some Democrats in Congress were cautious about a one-size-fits-all approach to insurance and accusations about a federal takeover of health care. So the law’s advocates gave states more control over selling private health coverage. The law’s framers included a provision that allowed states to use millions in federal dollars to launch their own insurance exchanges.

Initially, 49 states took the money. But in 2011, conservative groups convinced Republican-controlled states that forgoing state-run exchanges would help undermine Obamacare.

As a result, most GOP-controlled states defaulted to the federal marketplace.

In the ensuing years, several states that had started their own marketplaces, such as Oregon, Nevada and Hawaii, reverted to the federal exchange because of technological problems. Nevada relaunched its exchange last fall.

“States want to control their own destiny, and the instability of healthcare.gov in the Trump administration has frustrated states,” said Joel Ario, managing director for the consulting firm Manatt Health Solutions and a former Obama administration official, who helped set up the exchanges. States running their own platform can use data to target enrollment efforts, he said.

An Effort to Hold Down Premium Increases

Marlene Caride, New Jersey commissioner of Banking and Insurance, said that “the beauty of [a state-based exchange] is we can tailor it to New Jersey residents and have the ability to help [them] when they are in dire need.”

About 210,000 New Jersey residents enrolled in marketplace health plans for this year.

New Jersey has been spending $50 million a year in user fees for the federal exchange. After startup costs, the state estimates, it will cost about $7.6 million a year to run its own exchange enrollment platform and $7 million a year for a customer service center.

Open enrollment on the New Jersey exchange — called Get Covered NJ — will run from Nov. 1 to Jan. 31.

New Jersey plans to provide additional government subsidies for lower-income enrollees. Those would supplement federal subsidies.

Kentucky officials said insurers there were paying $15 million a year in user fees for healthcare.gov, a cost passed on to policyholders. When the state switches to its own operation, it plans to collect $5 million in its first year to cover the startup costs to revive its Kynect exchange and another $1 million to $2 million in annual administrative costs. So insurers will pay lower fees and those savings will help cut premium costs, said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services.

States using the federal marketplace this year paid either a 2.5% or 3% surcharge to the federal government on premiums collected.

In Pennsylvania, where about 330,000 residents buy coverage through an exchange plan, those fees accounted for $90 million a year. State officials estimate they can run their own exchange for about $40 million and will use the savings for a reinsurance program that pays insurers to help cover the cost of extremely expensive health care needed by some customers. Removing those costs from the insurers’ responsibility allows them to drop premiums by 5% to 10%, the state projects.

“When we talk about bringing something back to state control, that is a real narrative that can appeal to both sides of the aisle,” said Jessica Altman, the state’s insurance commissioner. “There is nothing political about making health insurance more affordable.” (Altman is the daughter of Drew Altman, CEO of KFF. KHN is an editorially independent program of KFF.)

Without the savings from running its own exchange, Pennsylvania would not have been able to come up with the more than $40 million needed for the reinsurance program, state officials said.

In addition, Pennsylvania has extended its enrollment period to run an extra month, until Jan. 15 (federal marketplace enrollment ends Dec. 15). Pennie also plans to spend three to four times the $400,000 that the federal government allocated to the state for navigators to help with enrollment, said Zachary Sherman, who heads Pennie.

“We think increased outreach and marketing will bring in a healthier population and broaden enrollment,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Primary Care Doctors Look at Payment Overhaul After Pandemic Disruption

For Dr. Gabe Charbonneau, a primary care doctor in Stevensville, Montana, the coronavirus pandemic is an existential threat.

Charbonneau, 43, his two partners and 10 staff members are struggling to keep their rural practice alive. Patient volume is slowly returning to pre-COVID levels. But the large Seattle-area company that owns his practice is reassessing its operations as it adjusts to the new reality in health care.

Charbonneau has been given until September to demonstrate that his practice, Lifespan Family Medicine, is financially viable — or face possible sale or closure.

“We think we’re going to be OK,” said Charbonneau. “But it’s stressful and pushes us to cut costs and bring in more revenue. If the virus surges in the fall … well, that will significantly add to the challenge.”

Like other businesses around the country, many doctors were forced to close their offices — or at least see only emergency cases — when the pandemic struck. That led to sharp revenue losses, layoffs and pay cuts.

Dr. Kevin Anderson’s primary care practice in Cadillac, Michigan, is also scrambling. The practice — like others — shifted in March to seeing many patients via telemedicine but still saw a dramatic drop in patients and revenue. Anderson, 49, and his five partners are back to about 80% of the volume of patients they had before the pandemic. But to enhance their chances of survival, they plan to overhaul the way the practice gets paid by Medicare.

Jodi Faustlin, CEO of the for-profit Center for Primary Care in Evans, Georgia, manages 37 doctors at eight family medicine practices in the state. She’s confident all eight will emerge from the pandemic intact. But that is more likely, she said, if the company shifts from getting paid piecemeal for every service to a per-patient, per-month reimbursement.

One of those 37 doctors is Jacqueline Fincher, the president of the American College of Physicians. Fincher said the pandemic “has laid bare the flaws in primary care” and the “misguided allocation of money and resources” in the U.S. health care system.

“It’s nuts how we get paid,” said Fincher, whose practice is in Thomson, Georgia. “It doesn’t serve patients well, and it doesn’t work for doctors either — ever, let alone in a pandemic.”

Physicians and health policy experts say the pandemic is accelerating efforts to restructure primary care — which accounts for about half the nation’s doctor visits every year — and put it on a firmer financial footing.

The efforts also aim to address long-festering problems: a predicted widespread shortage of primary care doctors in the next decade, a rising level of physician burnout and a long-recognized underinvestment in primary care overall.

No data yet exist on how many of the nation’s primary care doctors have closed up shop permanently, hastened retirement or planned other moves following the COVID-19 outbreak. An analysis by the American Academy of Family Physicians in late April forecast furloughs, layoffs and reduced hours that translated to 58,000 fewer primary care doctors, and as many as 725,000 fewer nurses and other staff in their offices, by July if the pandemic’s impact continued. In 2018, the U.S. had about 223,000 primary care doctors.

“We think we’re going to be OK,” says Dr. Gabe Charbonneau, a primary care doctor in Stevensville, Montana. “But it’s stressful and pushes us to cut costs and bring in more revenue. If the virus surges in the fall … well, that will significantly add to the challenge.”(Tommy Martino for KHN)

“The majority [of primary care doctors] are hanging in there, so we haven’t yet seen the scope of closures we forecast,” said Jack Westfall, a researcher at the academy. “But the situation is still precarious, with many doctors struggling to make ends meet. We’re also hearing more anecdotal stories about older doctors retiring and others looking to sell their practices.”

Three-quarters of the more than 500 doctors contacted in an online survey by McKinsey & Co. said they expected their practices would not make a profit in 2020.

A study in the journal Health Affairs, published in June, put a hard number on that. It estimated that primary care practices would lose an average of $68,000, or 13%, in gross revenues per full-time physician in 2020. That works out to a loss of about $15 billion nationwide.

One main problem, said Westfall, is that payment for telehealth and virtual visits is still inadequate, and telehealth is not available to everyone.

Re-Engineering Primary Care Payments

The remedy being most widely promoted is to change the way doctors are reimbursed — away from the predominant system today, under which doctors are paid a fee for every service they provide (commonly called “fee-for-service”).

Health economists and patient advocates have long advocated such a transition — primarily to eliminate or at least greatly reduce the incentive to provide excessive and unneeded care and promote better management of people with chronic conditions. Stabilizing doctors’ incomes was previously a secondary goal.

Achieving this transition has been slow for many reasons, not the least of which is that some early experiments ended up paying doctors too little to sustain their businesses or improve patient care.

Instead, over the past decade doctors have sought safety in larger groups or ownership of their practices by large hospitals and health systems or other entities, including private equity firms.

A 2018 survey of 8,700 doctors by the Physicians Foundation, a nonprofit advocacy and research group, found, for example, that only 31% of doctors owned or co-owned their practice, down from 48.5% in 2012.

Fincher, the American College of Physicians president, predicts the pandemic will propel more primary care doctors to consolidate and be managed collectively. “More and more know they can’t make it on their own,” she said.

A 2018 survey by the American Medical Association found that, on average, 70% of doctor’s office revenue that year came from fee-for-service, with the rest from per-member, per-month payments and other methods.

The pandemic has renewed the push to get rid of fee-for-service — in large part because it has underscored that doctors don’t get paid at all when they can’t see patients and bill piecemeal for care.

“Primary care doctors now know how vulnerable they are, in ways they didn’t before,” said Rebecca Etz, a researcher at the Larry A. Green Center, a Richmond, Virginia, advocacy group for primary care doctors.

Charbonneau, in Montana, said he’s “absolutely ready” to leave fee-for-service behind.

However, he’s not sure the company that owns his practice, Providence Health System — which operates 1,100 clinics and doctors’ practices in the West — is committed to moving in that direction.

Anderson, in Michigan, is embracing a new payment model being launched next year under Medicare called Primary Care First. He’ll get a fixed monthly payment for each of his Medicare patients and be rewarded with extra revenue if he meets health goals for them and penalized if he doesn’t.

Medicare to Launch New Payment System

The Trump administration — following in the footsteps of the Obama administration — has been pushing for physician payment reform.

Medicare’s Primary Care First program is a main vehicle in that effort. It will launch in 26 areas in January. Doctors will get a fixed per-patient monthly fee along with flat fees for each patient visit. A performance-based adjustment will allow for bonuses up to 50% when doctors hit certain quality markers, such as blood pressure and blood sugar control and colorectal cancer screening, in a majority of patients.

But doctors also face penalties up to 10% if they don’t meet those and other standards.

Some private insurers are also leveraging the pandemic to enhance payment reform. Blue Cross and Blue Shield of North Carolina, for example, is offering financial incentives starting in September to primary care practices that commit to a shift away from fee-for-service. Independent Health, an insurer in New York state, is giving primary care practices per-patient fixed payments during the pandemic to bolster cash flow.

Meanwhile, two of the nation’s largest primary care practice companies continue to pull back from fee-for-service: Central Ohio Primary Care, with 75 practices serving 450,000 patients, and Oak Street Health, which owns 50 primary care practices in eight states.

“Primary care docs would have been better off during the pandemic if they had been getting fixed payments per month,” said Dr. T. Larry Blosser, the medical director for outpatient services for the Central Ohio firm.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Kaiser sees Q2 net income more than double to $4.5B

For the quarter ending on June 30, when many health systems face a rising number of Covid-19 cases, the Kaiser Foundation Health Plan more than doubled its net income to $4.5 billion. The nonprofit managed care plans attributed the increase to reduced operating expenses and “market fluctuations.”

‘An Arm and a Leg’: Financial Self-Defense School Is Now in Session

Can’t see the audio player? Click here to listen.

When you need medical care, it can be a lot like entering a casino — playing for your financial life with the deck stacked against you.

But in this episode, reporter Celia Llopis-Jepsen offers insight and tips no dealer will divulge. She got a health care executive to talk honestly — maybe more honestly than he realized — about how his company and others are playing the game when they send patients huge bills.

When she investigated one man’s $80,000 bill, here’s what Llopis-Jepsen found:

Providers who took some of the $175 billion in pandemic-related bailout funds that Congress authorized in March had to promise not to ding patients with surprise bills for COVID-related care. But don’t expect your provider to merely tell you if that rule applies in your case. (That $80,000 bill did not include a footnote that said, “Once insurance pays us, you can forget all about this.”)

If you get a bill for COVID treatment, you can look up the provider yourself. Llopis-Jepsen found a government database where you can see if your provider took bailout funds.

She also has a tip sheet for pushing back against your medical bills.

And this story — which shows you don’t always owe what you are charged — is packed with insight, too.

Podcast Scheduling Announcement

From here on out, look for financial self-defense lessons from “An Arm and a Leg” every two weeks, instead of occasional seasons. Because it is always a good time to learn how to stand up against unfair medical bills.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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This story can be republished for free (details).

KHN’s ‘What the Health?’: Still Waiting for That Trump Health Plan

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President Donald Trump keeps promising to unveil a comprehensive plan to replace the Affordable Care Act, but it keeps not appearing. However, this week he did order an expansion of telehealth for Medicare beneficiaries and a program to help struggling rural hospitals.

Meanwhile, the administration still lacks a comprehensive plan to fight the COVID-19 pandemic in the U.S., and Congress remains unable to agree on another round of COVID relief funding, despite broad agreement on the need.

Outside Washington, Missouri this week became the sixth state where voters approved an expansion of Medicaid under the Affordable Care Act over the objections of Republican governors and/or Republican-controlled legislatures.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Kimberly Leonard of Business Insider.

Among the takeaways from this week’s podcast:

  • If a compromise over a federal relief package is not reached, Trump said he will issue executive orders to provide enhanced unemployment benefits and protections for people facing eviction. Even if he can do that, other parts of the stimulus plan — including money for states and local governments facing major deficits, schools, and testing and tracing programs — will likely be out of luck.
  • Six states announced this week they are banding together to purchase quick-turnaround coronavirus tests as they try to increase the number of tests they can offer.
  • States that have been using National Guard troops during the coronavirus emergency to help provide services are facing the prospect of having to pick up part of the cost for those service members. The mobilization was set to expire soon, but this week the administration announced it would extend the use of the National Guard, if states helped pay for it.
  • No new health plan was offered by Trump despite his comments in an interview with Fox News anchor Chris Wallace two weeks ago that a plan would be unveiled by Aug. 2. Instead, the administration has rolled out a number of smaller initiatives, including proposals to lower prescription drug prices and extending telemedicine.
  • The loosening of Medicare’s rules for telehealth during the pandemic has proved popular and may be hard to roll back. It has helped overcome shortages of medical professionals in rural areas and in mental health services. Nonetheless, federal officials and some health policy analysts suggest that increased use of digital medical appointments could expand the nation’s overall health bill. For example, if a patient has a virtual visit with the doctor who then says the patient needs to be seen in person, the doctor can collect fees for two visits.
  • Among the big supporters of the Missouri measure to expand Medicaid was the health care industry, which spent heavily on the campaign.
  • It’s second-quarter earnings season, and most health care companies are reporting good profits, despite the upheaval caused by the coronavirus. Still, they warn that they could take a hit in the third quarter.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Vanity Fair’s “How Jared Kushner’s Secret Testing Plan ‘Went Poof Into Thin Air’,” by Katherine Eban

Alice Miranda Ollstein: The Atlantic’s “How the Pandemic Defeated America,” by Ed Yong

Kimberly Leonard: The New York Times’ “’The Biggest Monster’ Is Spreading. And It’s Not the Coronavirus,” by Apoorva Mandavilli

Tami Luhby: The Washington Post’s “Trump Keeps Promising an Overhaul of the Nation’s Health-Care System That Never Arrives,” by Anne Gearan, Amy Goldstein and Seung Min Kim

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Missouri Voters Approve Medicaid Expansion Despite GOP Resistance

Despite strong opposition from Republicans and rural voters, Missouri on Tuesday joined 37 states and the District of Columbia in expanding its Medicaid program. Voters in Missouri approved creating a state constitutional amendment that will open Medicaid eligibility to include healthy adults starting July 1, 2021.

Voters approved expansion by a margin of 6.5 percentage points.

Missouri joins five other mostly conservative states that have passed Medicaid expansion via ballot initiatives — most recently, Oklahoma, on June 30. Most of the remaining 12 states that have not expanded Medicaid are Republican-leaning states in the South.

Nika Cotton, owner of Soulcentricitea, a new tea shop in Kansas City, Missouri, woke to the news on Wednesday morning. Cotton, whose children are 8 and 10, said she will qualify for health care coverage under the expansion.

“It takes a lot of stress off of my shoulders with having to think about how I’m going to take care of myself, how I’m going to be able to go and see a doctor and get the health care I need while I’m starting my business,” Cotton said.

Medicaid expansion, which states have the option of adopting as part of the Affordable Care Act, extends eligibility in the program to individuals and families with incomes up to 138% of the federal poverty level. A family of three, like Cotton’s, could make up to $29,974 to qualify.

The federal government pays for 90% of expansion costs.

As of 2018, 9.3% of Missourians were uninsured. And in 2019, researchers from Washington University in St. Louis estimated that around 230,000 people in Missouri would enroll for Medicaid if it were expanded. The study also showed expansion would save the state an estimated $39 million a year, largely by eliminating the need for other state health spending.

Missouri’s adoption of expansion follows a trend of increasing support in largely Republican states, according to health policy expert Rachel Nuzum of the Commonwealth Fund.

“What we’ve seen in our surveys over the years is when you take the labels off of the policies, when you take the Affordable Care Act label off, when you take Medicaid expansion off, and just start asking people whether or not you think low-income families should have access to Medicaid coverage, the support is overwhelming,” Nuzum said.

Support for expansion came largely from voters in and around Missouri’s urban centers such as Kansas City, St. Louis, Springfield and Columbia. In Kansas City for example, 87.6% of voters backed the measure.

Amendment 2 was rejected overwhelmingly by conservative voters in the mostly rural parts of the state that have the highest uninsured and poverty rates. Voters in McDonald, Morgan and Scotland counties, which have the three highest uninsured rates in the state, rejected the measure by margins of nearly 2-to-1 or greater.

Expansion opponents warned that high enrollment in the program could lead to the state’s 10% share of the costs becoming a significant burden for Missouri, especially when state revenues are down.

“When state revenues fall, it begs the question, how are you going to pay for this?” said Ryan Johnson, in late July. He is a senior adviser for United for Missouri, a conservative policy advocacy organization.

“We’re concerned that they are going to have to raid public education,” he said, “and that’s a disservice to the kiddos who hope to go back to school this fall, the teachers, the administrators and everyone involved in the public education system.”

Responding to declining revenue related to the coronavirus, Missouri’s Republican governor, Mike Parson, recently reduced the 2021 budget by nearly $449 million, with education taking the hardest hit.

Health care experts have said that the economic effects of the pandemic, including high unemployment and lower state revenue, could strain the capacity of state Medicaid programs. However, health care advocates argue that expansion benefits individuals and families struggling as a result of the pandemic, and the influx of federal dollars and the jobs that result from expansion could help the economy.

“If we’re worried about the economy and we’re worried about people working, Medicaid expansion is actually a way to encourage people to work and not have that worry they’re going to lose health insurance for themselves or their families,” said Ryan Barker, vice president of strategic initiatives for Missouri Foundation for Health.

Republican state lawmakers have fiercely resisted Medicaid expansion. The expansion question was placed on the ballot after a petition.

Expansion advocates enlisted the Fairness Project, a Washington, D.C.-based campaigning organization, in developing and executing their campaign strategy. The Fairness Project has been involved in successful Medicaid expansion campaigns in other mostly conservative states, including Maine, Utah, Idaho, Nebraska and Oklahoma.

The “YES on 2” campaign was supported by a wide range of groups, including the Missouri Chamber of Commerce and Industry, the Missouri Hospital Association, the NAACP, the AFL-CIO and the AARP, among others. And, the coalition forged unlikely alliances, including Planned Parenthood supporters and Catholic Charities of St. Louis, which is operated by the Archdiocese of St. Louis.

YES on 2 campaign material made almost no mention of the Affordable Care Act, which has been unpopular in Missouri, and some of its flyers didn’t use the words “Medicaid expansion.”

Although support for the measure was much lower in conservative rural areas, Fairness Project executive director Jonathan Schleifer said Missouri’s expansion success relied on both activating progressive urban voters and engaging rural voters — though conservative resistance remained a significant obstacle to reforming health care policy.

“I think there’s still a lot of work to do to push back against the hundreds of millions of dollars, the public messages coming from as high as the White House, that there’s something wrong with the Affordable Care Act,” Schleifer said.

Opponents to expansion included Gov. Parson and other Republican lawmakers, Missouri Right to Life, Missouri Farm Bureau and Americans for Prosperity.

In the days leading up to the election, the “No on 2 in August” campaign sent a mailer suggesting that expansion would lead to an influx of undocumented immigrants seeking health care, but undocumented immigrants are not eligible for Medicaid and would not be under expansion, either.

The flyer, which featured a man in a medical mask emblazoned with the Mexican flag, read “Amendment 2 Means Illegal Immigrants Flooding Missouri Hospitals … While We Pay for It!”

The “No On 2 in August” campaign did not respond to requests for comment about the flyer.

Between serving customers on a busy morning on Wednesday, shop owner Cotton said her excitement about expansion was only slightly diminished by having to wait almost a year for it to take effect.

“It’s better late than never,” said Cotton. “The fact that it’s coming is better than nothing.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Covered California Announces Record-Low Rate Hike for 2021

Premiums for health plans sold through Covered California, the state’s Affordable Care Act insurance exchange, will rise an average of 0.6% next year — the smallest hike since the exchange started providing coverage in 2014, the agency announced Tuesday.

The modest increase follows an average statewide increase of 0.8% on coverage that started in January of this year, which was the previous record low.

The rate changes will vary across regions, ranging from an average increase of 5.6% in Santa Clara County to reductions of 2.1% in southwestern Los Angeles County and 2.6% in Mono, Inyo and Imperial counties.

Before the announcement, some industry observers had called for rate cuts, given the windfall health plans have reaped so far this year from lower spending on care. The COVID-19 pandemic shut down elective surgeries in the spring and has continued to sharply reduce patient visits to doctors, emergency rooms and outpatient clinics.

But Peter Lee, Covered California’s executive director, told California Healthline that lower spending by insurers due to the pandemic had “very, very little” impact on 2021 premiums.

Covered California’s insurance carriers “are seeing their health care costs rebound and are projecting that for the balance of the year they will catch up on the health expenses they thought they were going to spend for 2020,” Lee said. Health plans in the exchange projected increases in non-COVID medical costs of 4% to 8% next year and did not think they needed to budget extra for the pandemic, he said.

The rate increase was modest mainly because of a surge of new, “healthier” enrollees both during the regular enrollment period for 2020 coverage and the current “special” enrollment period — recently extended to Aug. 31 — for people whose coverage has been affected by the pandemic, Lee said. Covered California said an analysis of the medical risk and demographics of these newcomers showed “they are healthier on average than the equivalent cohorts from 2019.”

Other factors, it said, include the repeal of a federal tax on health plans, which reduced 2021 premiums by an average of 1.7%, and a cut next year in the “participation” fee health plans pay Covered California, from 3.5% of premiums to 3.25%.

Covered California provides coverage for about 1.5 million Californians who buy their own insurance. About 90% of them receive financial assistance from the federal or state government, or both, to help them pay for their premiums. The plans on the exchange are mirrored on the open market, where individuals buy insurance without financial assistance.

Some health system experts believe insurers will continue to spend less on patient medical care next year. Glenn Melnick, a professor of public finance at the University of Southern California’s Sol Price School of Public Policy, said last week that hospital volumes — especially emergency room and outpatient visits — still lag pre-COVID levels and could continue to do so until an effective vaccine is available.

Michael Johnson, a health insurance industry observer and critic who worked as an executive at Blue Shield of California from 2003 to 2015, said the modesty of 2021 premium rises seen in other states so far didn’t go far enough.

“Regulators should be forcing these plans to justify why they are not reducing rates, given the effect we’ve seen the pandemic is having so far,” Johnson said last week.
The average statewide increase among Covered California carriers is smaller than what’s been proposed in many other states.

A KFF analysis last month of proposed 2021 rates in the exchanges of 10 states and the District of Columbia showed a median increase of 2.4%, with changes ranging from a hike of 31.8% by a health plan in New Mexico to a cut of 12% by one in Maryland. (Kaiser Health News, which produces California Healthline, is an editorially independent program of KFF.)

This year’s rate announcements come as the Affordable Care Act remains under threat from a federal lawsuit by Republican officials in 18 states, joined by the Trump administration, who want to repeal it. If they prevail, more than 20 million people could lose their health coverage and popular consumer protections afforded by the ACA, including the ban on health plan discrimination against people with preexisting medical conditions, could be eliminated.

The Supreme Court plans to hear the case in the fall.

All 11 insurance companies operating in Covered California this year will remain in 2021, and no new ones will enter the marketplace. But Anthem Blue Cross and Oscar Health Insurance will expand their offerings geographically, the exchange said. Anthem will enter Inyo, Kern, Mono and Orange counties. Oscar will join the competition in San Mateo County. Many of the Covered California health plans are available only in certain regions of the state.

Kaiser Permanente is the largest carrier in the exchange, with about 526,000 enrollees this year, more than one-third of the total. Kaiser is followed by Blue Shield of California, with 392,000, and Health Net, with 232,000. Information on rate changes by individual carriers was not immediately available.

Rates differ not only from carrier to carrier and region to region, but also by the covered person’s age. Premiums also differ by benefit level, from the cheaper “bronze” coverage tier up to the highest, known as “platinum.” The lower the premium, the higher the deductibles and coinsurance payments for care.

The individual deductible for the bronze tier in 2021 is set at $6,300, unchanged from this year. For the silver tier, the second-cheapest level of coverage, the full individual deductible in 2021 will be $4,000, also unchanged from this year. But many silver enrollees are in plans that offer financial aid to reduce their share of medical costs, and that can push the 2021 silver deductible as low as $75.

Moreover, numerous medical services are not subject to the deductible in silver plans, including primary care and specialist visits, lab tests, X-rays and other imaging. In bronze plans, the first three primary care visits are not subject to the deductible.

Covered California said that, on average, exchange enrollees who plan to renew for 2021 can save 7.3% on premiums by switching to the least expensive plan in the same tier of coverage.

The 2021 rates are subject to final review by the state’s Department of Managed Health Care and Department of Insurance, but significant changes are unlikely.
The enrollment period for 2021 coverage starts Nov. 1 and runs through Jan. 31.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Don’t Count on Lower Premiums Despite Pandemic-Driven Boon for Insurers

When COVID-19 smacked the United States in March and April, health plans feared medical costs could skyrocket, jacking up premiums drastically in 2021, when millions of the newly unemployed might still be out of work.

But something else happened: Non-COVID care collapsed as hospitals emptied beds and shut down operating rooms to prepare for an expected onslaught of patients sickened by the coronavirus, while fear of contracting it kept people away from ERs, doctors’ offices and outpatient clinics. In many regions of the country, the onslaught did not come, and the billions of dollars lost by hospitals and physicians constituted huge savings for health plans, fattening their bottom lines.

But that doesn’t mean consumers will see lower premiums next year.

Numerous insurers across the country have announced plans to hike rates next year, though some have proposed cuts.

Peter Lee, executive director of Covered California, appeared skeptical about premium reductions in the state’s Affordable Care Act exchange, which is likely to announce 2021 health plan rates next week.

“Would we like zero increases? Absolutely. Would we like them negative? Yeah — but not if that means you’re going to increase premiums in a year by 20%,” Lee said in an interview with California Healthline this week. “We’ve been leaning on them to do what we always lean on them to do, and this is to have the lowest possible rates where you won’t be on a rate roller coaster. We want health plans to price right — not to price artificially low or artificially high.”

Covered California provides coverage for about 1.5 million residents who buy their own insurance.

If the insurance exchanges in other states offer any guidance for Covered California, it is in the direction of moderate premium increases for 2021, though there is wide variation.

A KFF analysis last week of proposed 2021 rates in the exchanges of 10 states and the District of Columbia showed a median increase of 2.4%, with changes ranging from a hike of 31.8% by a health plan in New Mexico to a cut of 12% in Maryland. (Kaiser Health News, which produces California Healthline, is an editorially independent program of KFF.)

Among the roughly one-third of filings that stated how much COVID-19 added to premiums, the median was 2%, with estimates ranging from minus 1.2% at a plan in Maine to 8.6% at one in Michigan.

The proposed premiums for ACA marketplace plans do not affect job-based coverage, but they may indicate how the pandemic is affecting premiums generally.

The consensus among industry experts is that COVID-19 has generated little pressure for rate rises, and health plans should err on the side of moderation. But some fear that many insurers will hold onto the reserves they’ve built up, citing the possibility of widespread vaccinations and concerns that the care forgone in 2020 could rebound with a vengeance next year.

“The tendency of health plans, when they are faced with any degree of uncertainty, is to be very conservative and price for the worst-case scenario,” said Michael Johnson, an industry observer and critic who worked as an executive at Blue Shield of California from 2003 to 2015. “Actuaries are less likely to get fired if the plan prices too high than if the plan prices too low. But I think regulators really need to push back hard on that.”

Lee said all 11 insurers participating in the exchange this year will remain in 2021, and no new ones will be added to the mix, though some of the current carriers will extend their coverage geographically. Ninety percent of consumers who buy their own health insurance get subsidies from the federal government or the state to help pay their premiums.

In January, California became the first state to offer subsidies to middle-income people who make too much money to qualify for federal subsidies. The lion’s share of the state subsidies is earmarked for those who earn between 400% and 600% of the federal poverty level, or $51,040 to $76,560 a year for an individual and $104,800 to $157,200 for a family of four.

The rate proposals expected to be unveiled next week will be subject to scrutiny by state regulators before they are finalized. Sign-ups for the plans start Nov. 1 and run through Jan. 31. This year, the average Covered California rate increase statewide was 0.8%, the lowest since the exchange started providing coverage in 2014.

The benefits reaped by health plans so far in the pandemic can be seen in strong second-quarter earnings and reduced spending on care. UnitedHealth Group, the nation’s largest health insurer, announced earlier this month that its net profit in the April-June quarter nearly doubled from the same period a year earlier. Its medical spending plummeted from 83.1% of premium revenue to 70.2% over that period.

Anthem, the parent company of Blue Cross of California, reported Wednesday that its net profit in the second quarter doubled from the same period in 2019, also on the back of plunging medical expenses.

Anthem said it offered one-month premium credits ranging from 10% to 50% to enrollees in individual, employer and group dental policies — including its Blue Cross plans in California.

UnitedHealth said it has provided $1.5 billion worth of financial support to consumers so far, including premium credits and cost-sharing waivers, and expects to pay out $1 billion in rebates.

But UnitedHealth, which does not participate in Covered California, is seeking a rate increase of 13.8% in the New York exchange. Anthem, which covers about 80,000 people in Covered California, is planning rate hikes of 16.6% in Kentucky and 9.9% in Connecticut.

On the other hand, Kaiser Permanente, which covers more than one-third of Covered California enrollees, plans rate cuts in other states, ranging from 1% in Hawaii to 11% in Maryland. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Lee downplayed the notion of a financial boon for California health plans, saying that, partly because of the use of telehealth, primary care has rebounded and the plans are paying for it. “So we don’t see this as being at this point a bonanza year for health plans,” he said. “Rather, it’s a year in which there are lessons learned for how we can deliver care in a pandemic.”

Still, the health plans are in a far stronger position than they had feared earlier this year.

In March, Covered California released a study showing that COVID-19’s impact on 2021 premiums for individuals and employers could range from an increase of 4% to more than 40%. But less than three months later, projections commissioned by the industry’s national advocacy group, America’s Health Insurance Plans, showed that even in the worst-case scenario of a 60% COVID infection rate — far above where it stands now — the pandemic would increase medical costs in 2020 and 2021 by 6% at most, and could even decrease them.

That moderate effect is largely attributable to what Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, called “a kind of yin and yang: If you have a lot of COVID, you don’t have a lot of other health care spending.”

Independent of the course the pandemic takes, emergency room and outpatient visits still lag behind pre-COVID levels and will probably continue to do so next year, to the continued benefit of insurers, predicted Glenn Melnick, a professor of health care finance at the University of Southern California’s Sol Price School of Public Policy. That could be good news for consumers, he said, potentially leading to lower premium increases or even reductions next year.

On the other hand, hospitals and doctors have lost money, and the ones whose contracts with health plans are up for renewal will be looking to make up those losses, Melnick said.

“Providers could be asking for 20-25% increases next year,” he said, “and if they’ve got market power, they can make it stick.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Missourians to Vote on Medicaid Expansion as Crisis Leaves Millions Without Insurance

ST. LOUIS — Haley Organ thought she had everything figured out. After graduating from a small private college just outside Boston, she earned her master’s degree, entered the workforce and eventually landed a corporate job here as a data analyst.

Life seemed to be going as planned until the national retailer that Organ worked for announced furloughs during the coronavirus pandemic. After nine weeks of mandatory leave, the 35-year-old was laid off. The company gave her a severance package and put an expiration date on her health insurance plan.

“I haven’t slept the whole night since about March,” Organ said earlier this summer. “I can’t turn my brain off, just worrying about everything.”

Organ filed for unemployment, adding her claim to more than 40 million others nationwide since the pandemic took hold in mid-March, according to the Department of Labor. That’s about 1 in 4 U.S. workers. As a result of the unemployment crisis, millions of people lost access to their private health insurance plans at a time when they might need it most.

Medicaid, the federal and state health insurance program for people with low incomes or disabilities, could have served as a safety net for Organ if she lived in one of the 38 states that have opted to expand under provisions of the Affordable Care Act. But in Missouri, Republicans who control both the governor’s office and the legislature have said the state cannot afford its share of the cost of expansion and have been adamant foes of the ACA, helping lead a lawsuit now before the U.S. Supreme Court that may nullify the law.

That opposition by state leaders has meant adults like Organ who don’t have dependent children or specific disabilities cannot qualify for Missouri’s Medicaid program — even if their incomes are well below the poverty line.

“This is literally the first time in my life I’ve had to worry about health care coverage,” Organ said. “It’s kind of been a rude awakening for me.”

Voters in Missouri will decide Tuesday whether to expand eligibility for MO HealthNet program (Missouri’s Medicaid program) to provide insurance to more than 230,000 additional people in the state, including many who find themselves newly struggling for health coverage amid a national health crisis. More than 700,000 initial unemployment claims were reported in Missouri from mid-March through the first week of July.

If Medicaid expansion passes in Missouri, coverage for those newly eligible people would begin in 2021. Advocates for the measure say Medicaid expansion would also create jobs, protect hospitals from budget cuts and bring billions of federal taxpayer dollars back to the state.

Missouri is the latest red state to try expanding Medicaid with a ballot measure to circumvent recalcitrant legislatures. Oklahoma approved a measure June 30.

But Missouri’s Republican Gov. Mike Parson, who has said he opposes expanding Medicaid, moved the ballot measure from the general election in November to the primary election on Tuesday. Democrats criticized the shift, noting that fewer voters traditionally turn out for the primary and suggesting it could be easier to defeat in August. The ongoing threat of COVID-19 could also keep some voters away from the polls.

In a statement, Parson said changing the election date will allow the state to prepare for the potential cost of expansion. But an analysis from Washington University in St. Louis suggests that expanding the program could save the state money by lowering the amount it must pay for uncompensated care and bolstering efforts to prevent certain diseases, thereby reducing treatment costs to the state. Under the terms of the Affordable Care Act, the federal government picks up 90% of the coverage costs for newly eligible enrollees, as compared with the 65% it pays for people who qualify under regular Medicaid rules.

Backers of expansion are cautiously optimistic that Missouri voters will approve the measure Tuesday, heartened by Oklahoma’s win last month and positive polling.

For people who qualify for the current Medicaid program, enrollment is open year-round, which means people can apply when needed.

“That’s why we call them safety-net programs,” said Jen Bersdale, executive director of Missouri Health Care for All, a group that has advocated for Medicaid expansion since 2012. “When you get dropped from a job, dropped from insurance, they are there to catch you until you’re back on your feet.”

Amid the pandemic, Medicaid already appears to be helping people newly out of work. In 22 states, Medicaid enrollment increased by an average 5% from February to May, according to Georgetown University Health Policy Institute data. Newer data for May in those same states suggests enrollment growth is accelerating.

Even without expanding the program, Missouri leads the group with an 8.8% increase since February in total Medicaid enrollment. While economic recessions often contribute to increasing Medicaid enrollment, the early spike in Missouri could signify reenrollment of a large number of people, mostly children, who had been dropped from the program two years in a row. A federal rule blocks disenrollment during the pandemic.

Even some Missourians already on Medicaid are worried about the ballot measure not passing. Without expansion of the program, Sally Terranova fears that her 16-year-old son, Colin, will be ineligible for Medicaid when he ages out of the kids’ coverage at age 19. He was diagnosed with Type 1 diabetes in 2016.

Terranova is concerned that her son wouldn’t be able to afford the insulin he needs without insurance. She worries even more when she hears stories about diabetics rationing their insulin.

“It’s bad enough he has this illness hanging over him,” Terranova said. “But he can live a good life and be healthy if he has access to health care.”

That’s one reason Terranova, 39, hopes to land a job with good benefits when she finishes graduate school in a year and half. She has studied social work for the past four years, so she understands the challenges low-income families face.

Terranova had moved from New York to Missouri to give her son a better life. They’ve called St. Louis home for 10 years, but the single mom is contemplating another big move for her son’s health. She’s thinking of going this time to a state that has already expanded the program.

Organ, whose health insurance expired in July, is now one of the lucky ones. She just got a new job and will get new health insurance when she starts next week. Still, she’s hoping the Medicaid measure will pass, as she now appreciates more than ever how much it could mean for others who have lost their jobs and lack coverage amid the COVID-19 pandemic. Instead of heading to a polling place Tuesday, though, Organ is planning to vote by mail.

“I’m trying to do everything I can to keep me and others safe,” Organ said. “But I want to make sure my voice is still heard.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Medi-Cal Agency’s New Head Wants to Tackle Disparities and Racism

When Will Lightbourne looked at the statistics behind California’s coronavirus cases, the disparities were “blindingly clear”: Blacks and Latinos are dying at higher rates than most other Californians.

As of Monday, Latinos account for 45.6% of coronavirus deaths in a state where they make up 38.9% of the population, according to data collected by the California Department of Public Health. Blacks account for 8.5% of the deaths but make up 6% of the population.

Lightbourne, who led California’s Department of Social Services under Gov. Jerry Brown, describes this pandemic as one that “rips the bandage off” a health care system long riddled with inequity.

So, when Gov. Gavin Newsom asked Lightbourne, 70, to come out of retirement in June to lead the Department of Health Care Services, he said, he couldn’t say no.

“He has committed his whole professional life to public service,” said Mike Herald, director of policy advocacy at the Western Center on Law & Poverty. “He’s not joking when he talks about the importance of these issues and the important role that government plays in addressing societal inequities.”

The Department of Health Care Services oversees the state’s Medicaid program for low-income people, called Medi-Cal, which provides health care to some 12.5 million Californians.

Lightbourne said he sees the job as a chance to refocus Medi-Cal on reducing disparities — improving people’s health not only by providing better access to doctors, but also by linking them with behavioral health programs and using health care dollars to get them into housing.

He said the department also plans to amend contracts with health providers and use routine performance reviews to make sure providers are addressing disparities.

Health care advocates say Lightbourne has a track record of getting things done.

At the Department of Social Services, he persuaded Brown, a known penny pincher, to increase cash assistance to low-income families, restoring cuts lawmakers had made in the Great Recession. And he was instrumental behind the scenes in the repeal of the contentious policy that had prohibited Californians from receiving increased welfare income if they had more children while receiving public assistance, Herald said.

“Will is very purpose-driven and has made substantive changes in every role he has ever had,” said Graham Knaus, executive director of the California State Association of Counties.

Before embarking on state service, Lightbourne served as director of the Santa Clara County Social Services Agency, the Human Services Agency of the City & County of San Francisco and the Santa Cruz County Human Services Agency.

Lightbourne’s local and state experience give him a valuable skill set as state and county officials grapple with providing health care to some of California’s most vulnerable residents during a pandemic, Knaus and other advocates said.

The task won’t be easy. The previous director of the Department of Health Care Services, Brad Gilbert, left the job after less than four months.

Lightbourne talked to California Healthline about why he returned to state government, how the department is responding to COVID-19 and how he hopes to improve access to health care for those who need it. The interview has been edited for length and clarity.

Q: Why did you come out of retirement to take a job that’s difficult under normal circumstances — and even tougher during a pandemic?

Events of the past six months have made it blindingly clear that we’ve got structural inequities that are not just immoral but are, at an existential level, unsurvivable. It’s a pandemic that landed on top of a pandemic of inequalities, opportunity and income that’s been raging since the 1980s. And that pandemic has been enabled by a pandemic of racism that has rotted in our society for generations.

I think we have to use the moment to insist that our publicly financed health care system really partners up with our public health network and with our social safety-net system to address community and population health with a laser focus on reducing disparities.

Q: How has the department responded to COVID-19 to address the most vulnerable Californians?

The growth in telehealth is something that would not have occurred without this experience. There’s work still underway to look at how we can come up with some approaches to reduce the number of people in skilled nursing facilities, where the rate of spread is so much more severe and with really mortal results.

I have the suspicion that we’re never really going to get to a point where we say the effect of COVID is over. The mere fact that so much health care utilization is down now, particularly down in the places where people who start at a disadvantage normally seek care, we’re going to find long-term health consequences into the future, even post-vaccine.

Q: In January, Gov. Newsom outlined a proposal to broaden a Medi-Cal program known as CalAIM that addresses physical and behavioral health needs in patients’ care, and even pays for their housing with health care money. Can your department still move forward with those goals even though there isn’t money in the budget for it?

We may be delayed to some extent. It was never intended initially as a big-bang system change. It was always going to be a degree of iterative development, and that remains true — whether some things have to go a little slower because of money reasons.

Q: You have talked about access to health care and how COVID-19 has really highlighted systemic disparities. In Medi-Cal, lack of access to care has long been a problem, especially in rural areas. So has inadequate care for children. Are those issues you intend to address?

One of the things we need is an adequate network of providers that really covers the medically underserved areas of the state. We need to work effectively with our rural health clinics, as well as our urban Federally Qualified Health Centers to expand access, particularly to the populations that historically haven’t had that access.

In terms of services for children, that’s a big part of that agenda both in physical and behavioral health and also the dental health system. There’s a big focus on how to improve access and preventive services for children.

Q: In the Great Recession, California lawmakers made many deep cuts to safety-net programs, some of which have been restored only recently. The governor proposed a number of health care-related cuts this year that were ultimately rejected by the legislature. How will you ensure that Medi-Cal enrollees won’t see their benefits scaled back in the future?

It’s going to be my job to make the case not to reduce services that poor people rely on. That said, we live in the real world and if we ever have to reduce things, my approach would be to try to say, “How can we reduce things we can readily rebuild rather than destroy things that are foundational?”

Goal No. 1 at this point is to work very closely with our congressional delegation to really encourage the federal government to support the core services and activities so that we can meet the needs of the people of the state.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

The COVID-19 Downturn Triggers Jump in Medicaid Enrollment

Reversing a three-year decline, the number of people covered by Medicaid nationwide rose markedly this spring as the impact of the recession caused by the outbreak of COVID-19 began to take hold.

Yet, the growth in participation in the state-federal health insurance program for low-income people was less than many analysts predicted. One possible factor tempering enrollment: People with concerns about catching the coronavirus avoided seeking care and figured they didn’t need the coverage.

Program sign-ups are widely expected to accelerate through the summer, reflecting the higher number of unemployed. As people lose their jobs, many often are left without workplace coverage or the money to buy insurance on their own.

Medicaid enrollment was 72.3 million in April, up from 71.5 million in March and 71 million in February, according to the latest enrollment figures released last week by the Centers for Medicare & Medicaid Services. The increase in March was the first enrollment uptick since March 2017.

About half of the people enrolled in Medicaid are children.

The increases varied widely around the country. Kentucky had the largest jump at nearly 7% from March to April. In addition, enrollment rose to 1.4 million in April from 1.2 million in February, according to the CMS data. That has continued, and today it’s up to 1.5 million, state officials said in an interview.

Kentucky has an aggressive outreach strategy using email or phone calls to contact thousands of residents who applied for state unemployment insurance, designed to make sure they know about Medicaid. “It’s been very effective, and in the past few weeks we’ve been enrolling 8,000 to 10,000 people a week,” said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services, which oversees Medicaid.

The Bluegrass State has also made enrollment easier by developing a one-page online form instead of having people fill out a 20-page application, he added.

“This is the right thing to do to help people get signed up for health care coverage and it supports the health industry in our state,” Friedlander said. “The health industry would collapse without Medicaid.”

Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C., said she expects Medicaid enrollment to keep rising this summer. “Given that there are no signs that the virus is coming under control anytime soon, job losses will become more permanent, and more folks will become eligible for Medicaid over time,” she said.

One reason Medicaid numbers have not grown faster, she suggested, is because people have more immediate needs than securing health coverage, especially if they are feeling well.

Many people are worried about getting unemployment insurance or getting evicted from their home, she noted. “That’s combined with the fact that many people are reluctant to go to their doctor because of safety concerns,” she said. “And, as a consequence, applying for Medicaid may not be at the top of their list.”

Chris Pope, a senior fellow at the Manhattan Institute for Policy Research, a conservative think tank, said the slower-than-expected growth in Medicaid could signal that people who were laid off had coverage through a spouse or a parent.

In addition, he said, “many jobs that went away did not offer health insurance,” citing millions of service-sector positions in industries such as hotels and restaurants that have been lost.

Beyond the surge in unemployment, Medicaid rolls have risen because states cannot discontinue coverage to people enrolled as of March 18, 2020, as a condition of receiving higher federal Medicaid funding included in a coronavirus relief package passed by Congress.

Medicaid is a countercyclical program, meaning enrollment typically rises during an economic downturn. But that forces states to face the fiscal challenge of paying for their share of the program even as tax revenue dries up.

An exception to this rule was the jump in enrollment starting in 2014 when the Affordable Care Act allowed states to expand Medicaid to cover everyone with incomes below 138% of the federal poverty level, or about $17,609 for an individual this year.

Enrollment soared by about 15 million people from 2014 to 2017, peaking at about 75 million as nearly three dozen states expanded the program. Since then, a strong economy and steadily declining unemployment levels led to a drop in Medicaid rolls until April.

Enrollment changes in April varied across the country.

California, which has the highest Medicaid enrollment in the country, saw its level hold relatively steady at 11.6 million people in April.

Nevada and Oklahoma posted nearly 4% enrollment growth rates between March and April’s data.

Florida’s Medicaid numbers jumped to 3.7 million in April from 3.6 million in March, nearly a 2.5% increase, the CMS data showed. Since then, Florida data shows enrollment has topped 4.1 million.

The Trump administration has been criticized by consumer advocates for not establishing a national campaign to promote Medicaid during the economic downturn and health crisis.

One indicator that Medicaid enrollment is still going up is the growing number of recipients in managed care plans in 16 states that reported data from March to May. Those plans have increased by a total of nearly 4%, according to a KFF report. (KHN is an editorially independent program of KFF.) Most states have shifted many of their Medicaid enrollees into these private health plans.

KFF estimated that nearly 13 million people who became uninsured after losing their jobs in March are eligible for Medicaid.

Robin Rudowitz, a KFF vice president, said there is typically a lag time of weeks or months before people who have lost their jobs and health coverage seek to enroll in Medicaid. The impact on Medicaid enrollment also lasts well after the immediate effect of a downturn, she said.

“There is a long tail,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Last Thing Patients Need During Pandemic: Being Last to Know a Doctor Left Network

NEW YORK — As the coronavirus spread silently through New York City early this year, Deborah Koeppel had an appointment with her cardiologist and two visits with her primary care doctor. Both physicians are members of Concorde Medical Group, a practice in Manhattan with an office conveniently located a few blocks from where Koeppel works.

She soon received notices telling her — after the fact — that those doctors were not in her health plan’s network of providers. According to the notices, she was on the hook for $849 in out-of-network cost sharing for three visits, which typically would cost her nothing from in-network providers.

Changes to health plan networks occur all the time as doctors retire, relocate or leave networks. And patients may be the last to find out about such changes because providers or insurers are not always required to inform them.

Koeppel also faced the loss of low-cost access to her in-network gynecologist and dermatologist.

“I felt sickened,” said Koeppel, 62, a senior social worker who kept working even as New York was hit by a brutal COVID-19 outbreak, with more than 1,000 deaths a day at its peak. “To me, it feels like physician abandonment. In the middle of something like this, you’re left without your doctors.”

Legislators, regulators and insurers have enacted special policies during the coronavirus pandemic, including paying for more virtual visits and eliminating copays for COVID-related testing and care. But long-standing issues, such as ever-shifting networks — often unbeknownst to patients — persist unchanged. And blindsiding patients with such changes is particularly hazardous at a time when many offices are partly closed, and patients are vulnerable and more likely than usual to need medical advice or attention.

That’s not how it should work, experts say. “Both parties should have responsibility for notifying their members,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms who co-authored a recent report examining state protections for patients who lose access to their doctors and other providers during contract disputes between providers and health plans.

The paper highlighted published examples of contract disputes that potentially affected hundreds of thousands of members, including 100,000 UnitedHealthcare members who lost access to eight Houston hospitals because of a contract dispute last year and the long-running feud in Pennsylvania between Highmark Health and the University of Pittsburgh Medical Center over in-network access to at least 11 hospitals.

Network changes that affect only a small number of patients or are the result of amicable negotiations between providers and insurers happen too, but they rarely make the news.

Health care experts agree that maintaining regular relationships with providers over time can help people manage chronic conditions and stay healthy. But patient protections from disruptions caused by network changes are scant. Most states have laws that permit health plan members to continue to see their doctors for a time after they leave the network, but only under certain limited circumstances, such as if they are pregnant or have a terminal illness. And some states require insurers to notify members in advance of network changes, Corlette said.

Deborah Koeppel learned her cardiologist and primary care doctor had been dropped from her insurance network ― shortly after her most recent appointments with both. “I felt sickened,” says Koeppel. “To me it feels like physician abandonment.” (Courtesy of David Koeppel)

But state laws don’t protect the majority of people who have coverage through health plans that are self-insured, meaning they pay members’ claims directly rather than buy insurance for that purpose. Those plans operate under federal guidelines and generally aren’t subject to state insurance regulation.

Koeppel is a member of 1199SEIU, the Service Employees International Union’s largest local, representing nearly 450,000 health care workers on the East Coast. She receives health care through the National Benefit Fund, a self-insured plan funded by contributions from the union members’ employers.

Koeppel has gone to doctors at Concorde for eight years. Until January, Concorde doctors participated in plans offered through the Independent Practice Association at NYU Langone Health, a large private health system. Eleven Concorde doctors treated members of the National Benefit Fund for 1199SEIU. In January, the physicians group joined Northwell Health, another large private health system in New York. Koeppel and 162 other 1199SEIU patients lost in-network access to their Concorde doctors as a result, said Terry Lynam, a Northwell spokesperson.

Northwell put out a press release in October announcing that Concorde Medical Group was joining the health system. In December, the Concorde Medical Group posted the upcoming change on its website.

But no one told the patients about the change.

The National Benefit Fund wasn’t notified of the change either, according to a statement from the fund. A staff member for the fund brought it to their attention.

Koeppel said she knows there are other doctors she can see — there are tens of thousands in network in the New York City area. But she was distraught to lose those with whom she’s developed a trusting relationship.

Her primary care physician “has been incredibly available by phone, just a really committed person who’s caring, warm and very reassuring,” she said.

After Koeppel complained to Northwell, administrators offered to write off any charges for her visits to Concorde physicians during the pandemic, she said.

And after a reporter contacted Northwell and the union’s National Benefit Fund about the network changes, the health system and the union agreed to a temporary contract extension from January 2020 through the end of August that allows 1199SEIU members to continue to see their Concorde doctors without cost sharing. The two parties are in negotiations for a new agreement that would give National Benefit Fund members in-network access to Concorde and other Northwell physicians after that date.

Northwell’s Lynam said that since there was no interruption in patient care, the timing of patients’ discovering the change is immaterial.

“Whether they found out in December that they had to find a new provider or they found out in June that they had to do so, the end result would be the same,” he said. “No patient was abandoned or harmed because they didn’t know earlier, and they would have been equally upset by the news whether they found out now or in December.”

Koeppel disagreed. If she had been informed of the upcoming change in October when Northwell put out its press release, Koeppel said, she would still have been upset. But she would have been better positioned to switch providers before January and would have had new physicians in place before the pandemic hit.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

With DACA Ruling, Did Supreme Court Grant Trump New Powers To Reshape Health Care?

President Donald Trump came into office vowing to repeal and replace Obamacare. While he successfully neutralized the health care law’s requirement that everyone carry insurance, the law remains in effect.

When Fox News host Chris Wallace noted that Trump has yet to put forward a replacement plan, Trump told him to stay tuned.

“We’re signing a health care plan within two weeks, a full and complete health care plan that the Supreme Court decision on DACA gave me the right to do,” Trump said July 19 on “Fox News Sunday.”

“The Supreme Court gave the president of the United States powers that nobody thought the president had.”

Trump said he would “do things on immigration, on health care, on other things that we’ve never done before.”

We wanted to know if the Supreme Court really did that. So we ran the president’s words by a number of people who study constitutional and administrative law. We heard several reasons why the Supreme Court might not have said what Trump thinks it said.

The Likely Source

We asked the White House press office for the basis of Trump’s assertion and never heard back. Several law professors pointed to a National Review article by University of California-Berkeley law professor John Yoo, best known as authoring a legal justification that led to waterboarding enemy combatants during the George W. Bush administration.

In the article, Yoo argues that when the Supreme Court ruled against the administration’s rollback of Deferred Action for Childhood Arrivals, or DACA, the court made it more difficult for new presidents to unwind the policies of their predecessors.

How might this give Trump new power?

In theory, Trump could enact a policy, even one judged illegal by the courts, and the person who follows him into office would need to jump through a number of hoops to undo it.

Yoo wasn’t sure if Trump could use the argument to make sweeping changes in health care, saying it “depends on what the administration policy actually says.”

But as Yoo sees it, should Trump establish a new program, the ruling “requires his successor to follow a burdensome process, which could take a year or more, to repeal it.”

Many legal experts disagree with Yoo’s interpretation. Before we go there, we need to recap the court’s DACA decision.

Court Sends DHS Back to the Drawing Table

President Barack Obama created DACA on the grounds that every administration has to allocate limited prosecution resources. Obama argued that it was more important to deport violent criminals, drug dealers and thieves than people who had come into the country illegally when they were little. So long as they had committed no serious offenses and met other criteria, they could apply to avoid deportation.

Under Trump, the Department of Homeland Security moved to end DACA. Supporters of the program sued, saying that under the Administrative Procedure Act, that action was arbitrary. In its June 18 ruling, a 5-4 majority on the Supreme Court agreed.

The ruling describes how Homeland Security Secretary Kirstjen Nielsen got in a procedural bind when she inherited the decision of her predecessor (Acting Secretary Elaine Duke) to end the program. She erred, Chief Justice John Roberts wrote, because instead of making the case for ending DACA as her own decision, she came up with new reasons to justify the earlier move.

“Because Nielsen chose not to take new action, she was limited to elaborating on the agency’s original reasons,” Roberts wrote. “But her reasoning bears little relationship to that of her predecessor and consists primarily of impermissible ‘post hoc rationalization.’”

The court didn’t say Homeland Security couldn’t change the policy. It said the Administrative Procedure Act requires an agency to consider the key options it faces and explain why it chose the one it picked. With DACA, it said the change needed to show a fuller vetting of its choices.

No New Power Created

So while Trump technically lost that case, he is using the ruling (and Yoo’s theory) to voice confidence that he can do things no one thought possible.

Legal scholars give several reasons that might be off the mark. Broadly, they say the court’s ruling changed nothing.

“It’s a straightforward application of long-standing administrative law doctrine that dates back at least to President Ronald Reagan,” said Cary Coglianese, director of the Penn Program on Regulation and a professor of law at the University of Pennsylvania. “Agencies have to explain why they are doing something. They have to look at the plausible alternatives and give a reason for the one they selected.”

Justice Brett Kavanaugh also did not see a new take on an old law. In his dissenting opinion, he called the ruling on the Administrative Procedure Act “narrow.”

In a similar vein, the court left intact the specific power behind DACA of selective enforcement of the law.

“That’s an ordinary part of executive branch practice, and nothing in the Supreme Court’s DACA decision should be read to authorize anything beyond that simple practice,” said Yale University law professor Cristina Rodríguez.

The path to undoing this sort of executive action may not be as long as Yoo described. The court spelled out how Nielsen could have ended DACA without much delay, said Eric Freedman, professor of constitutional law at Hofstra University Law School.

“If she had considered other possible solutions, what she did would have been fine,” Freedman said. “She would have complied with the Administrative Procedure Act and no one would have enjoined her.”

There is also something unusual about DACA itself that makes it less of a model for other steps Trump might take.

The program was in place for quite a while before Trump tried to end it. As a result, about 700,000 people ultimately counted on it. The court said that reliance on the program should have factored into the decision to end it.

A new policy from Trump wouldn’t have time to accumulate that critical mass.

“Anything Trump does now will be enjoined tomorrow,” said Josh Blackman at the South Texas College of Law. “So there will be no reliance, and the next administration could do what it wanted.”

Blackman said the court’s ruling did create some murkiness around challenging the legality of an unwanted policy. But he said an agency could justify a change strictly for reasons of policy, not law.

Lastly, the DACA decision was about a policy not to enforce the law in certain circumstances. Robert Chesney at the University of Texas Law School said that focus also limits the scope of the ruling.

“If Trump wants to create new rules, the example does not fit in the first place,” Chesney said.

A “full and complete health care plan” and major immigration changes would likely require new government actions. Without new laws from Congress, that would be out of reach.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Medicaid Mystery: Millions of Enrollees Haven’t Materialized in California

The predictions were dire: Coronavirus lockdowns would put millions of Americans out of work, stripping them of their health insurance and pushing them into Medicaid, the health insurance program for low-income people.

In California, Gov. Gavin Newsom’s administration projected that the pandemic would force about 2 million additional people to sign up for the state’s Medicaid program, called Medi-Cal, by July, raising enrollment to an all-time high of 14.5 million Californians — more than one-third of the state’s population.

But July is almost over, and Medi-Cal enrollment has hovered around 12.5 million since March, when the pandemic shut down much of the economy — though enrollment ticked up in May and June, according to the latest data from the state Department of Health Care Services, which administers the program.

Essentially, enrollment hasn’t budged even though nearly 3 million Californians are newly unemployed.

“It’s a mystery,” said Anthony Wright, executive director of Health Access California, an advocacy group for health consumers. “We have lots of plausible explanations, but they don’t seem to add up.”

Even the state is stumped. The enrollment data is preliminary, and Medi-Cal officials expect the numbers to grow as eligibility appeals and other “unusual cases” are resolved, but not by 2 million people, said Norman Williams, spokesperson for the Department of Health Care Services.

The department based its projections on the state’s experience with the Great Recession a decade ago, a comparison that it now acknowledges was misguided because the pandemic did not spur a purely economic crisis. The state failed to predict people would avoid care at clinics and hospitals during this public health crisis, and thus be less likely to need coverage immediately.

“The current situation is far more complex because it involves both economic and health decisions, creating a more complicated picture more closely related to that seen during the 1918 influenza pandemic,” Williams said in a prepared statement.

Even with the faulty comparison, it’s not clear why more Californians haven’t enrolled, he said.

“The state prepared an estimate based on the best data available, during an unprecedented and rapidly evolving situation,” he said.

The miscalculation meant the state likely allocated more money to Medi-Cal than the program now needs, even as lawmakers struggled to find ways to prevent deep health care cuts and close a massive $54 billion budget deficit as they negotiated the 2020-21 state budget in May and June.

And a more accurate estimate could have potentially funded new programs, such as expanding Medi-Cal to unauthorized immigrants age 65 and up, some state lawmakers and advocacy groups said.

Newsom backed that expansion of Medi-Cal, estimated to cost $80.5 million in the first year, in his January budget proposal but abandoned it in May, citing California’s financial crisis spurred by the pandemic.

“We are talking about life-or-death services, so to say I’m frustrated is putting it mildly,” said state Sen. Holly Mitchell (D-Los Angeles), who chairs the Senate budget committee and leads budget negotiations in the upper house. “It’s irritating to me that they can be so off.”

The new state budget puts Medi-Cal’s overall cost at $115 billion, of which $2.4 billion in state money has been earmarked for caseload growth. Yet it’s unclear how much of that could have been available to fund other programs or stave off cuts had the caseload projection been more accurate, department officials acknowledged.

Most states predicted their Medicaid enrollment would rise due to the pandemic, though many are seeing similar delays in Medicaid sign-ups, said Cindy Mann, a partner at the legal and consulting firm Manatt Health who served as federal Medicaid director for the Centers for Medicare & Medicaid Services during the Obama administration.

Washington state, like California, hasn’t seen its Medicaid caseload grow as expected, said MaryAnne Lindeblad, its Medicaid director. It projected up to 95,000 people would join the program by now, yet it has seen 80,000 new enrollees since March.

“It’s been a little bit surprising,” she said. “There’s so much going on in people’s lives right now and signing up for Medicaid doesn’t seem to be one of them.”

Yet a record number of Americans have lost health insurance as a result of the COVID-19 pandemic and corresponding economic crash, according to a new report from Families USA, a national health advocacy group. California experienced the largest increase in newly uninsured residents of any state so far when an estimated 689,000 people lost coverage between February and May this year, the study shows.

“It’s a different kind of downturn and that might explain some of the reason we’re seeing lags across the country,” Mann said. “But unless unemployment numbers turn around dramatically, which is not the prediction, I think we will see the number of uninsured people continuing to grow and turn to the program.”

There are several theories about why Californians who have lost their jobs during the pandemic have not yet enrolled in Medi-Cal.

For one, signing up for food and housing assistance appears “more urgent” than signing up for Medi-Cal, Williams said.

The pandemic has also created new sign-up hurdles. With libraries, schools, community centers and county health care offices largely closed during lockdowns, uninsured residents have had fewer places to enroll. Hospitals and clinics also frequently enroll uninsured people into the program, but many healthy people are avoiding treatment for fear of being infected with COVID-19.

And those who have lost jobs may still have work-based coverage because employers planned to rehire them and kept them on job-based insurance plans, or because they’ve signed up for COBRA insurance temporarily.

Enrollment could also be lagging because the service industry has been hit hard, and many low-income workers in restaurants, bars or salons were already enrolled in Medi-Cal.

“About a quarter who were at risk of losing jobs were already enrolled when the crisis started,” said Laurel Lucia, director of health care programs at the Center for Labor Research and Education at the University of California-Berkeley.

Vanessa Poveda lost her health insurance after losing her job as a server at a San Francisco gastropub. She thinks she probably qualifies for Medi-Cal but hasn’t signed up yet, in part because the task feels daunting. (Courtesy of Lindsay Thomas)

Vanessa Poveda, 28, wasn’t among the service workers already enrolled in Medi-Cal when the crisis hit. Instead, she had health insurance through her job as a server at Bartlett Hall, an upscale gastropub near San Francisco’s Union Square.

When Poveda was laid off during the first round of coronavirus closures in March, the restaurant extended her health coverage for 30 days before it expired, she said. Now unemployed and uninsured, she thinks she probably qualifies for Medi-Cal but hasn’t signed up.

“I haven’t really gotten around to it,” she said.

Because Poveda is relatively healthy, she said, enrolling in coverage isn’t as urgent as some of her other needs.

“Medical insurance is definitely a top priority for me,” she said, “but I also need a roof over my head.”

In California, another factor may be at play. The Trump administration’s “public charge” policy may be having an outsize impact on Medi-Cal enrollment because of the state’s large immigrant population, said Hamutal Bernstein, a researcher at the Urban Institute. The rule allows federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits such as Medicaid.

“A lot of immigrant families are being disproportionately impacted by economic and health hardship and are increasingly needing some of this assistance,” Bernstein said. But “a lot of people are afraid of getting any kind of help.”

Federal rules also prevent the state from kicking anyone off Medicaid during the pandemic, which means people who normally would have fallen off the program will stay enrolled, contributing to the state’s inflated projections, Williams said.

The department said it is working to get out the word that Medi-Cal is available, but Mitchell is urging the state to do more.

“I’m concerned not enough outreach is being done,” she said. “We expect people to magically know they may qualify for Medi-Cal and they should go online and apply.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Another Problem on the Health Horizon: Medicare Is Running Out of Money

Everyone involved even tangentially in health care today is completely consumed by the coronavirus pandemic, as they should be. But the pandemic is accelerating a problem that used to be front and center in health circles: the impending insolvency of Medicare.

With record numbers of Americans out of work, fewer payroll taxes are rolling in to fund Medicare spending, the numbers of beneficiaries are rising, and Congress dipped into Medicare’s reserves to help fund the COVID-19 relief efforts this spring.

“I think we have a real, impending health care crisis,” said Dr. David Shulkin, who was undersecretary for health at the Department of Veterans Affairs under President Barack Obama for two years and led the VA for a year under Donald Trump.

In April, Medicare’s trustees reported that the Part A Trust Fund, which pays for hospital and other inpatient care, would start to run out of money in 2026. That is the same as the projection in 2019. But the trustees cautioned at the time that their projections did not include the impact of COVID-19 on the trust fund.

“Given the uncertainty associated with these impacts, the Trustees believe that it is not possible to adjust the estimates accurately at this time,” said the report.

So Shulkin, now a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, did his own projections. Given even a conservative estimate of how many workers and businesses would not be contributing payroll taxes that finance Part A spending, he said, the trust fund could become insolvent as early as 2022 or 2023.

“I think this is something that needs more immediate attention,” he said.

Others who make projections agree the insolvency date is getting closer, maybe not as close as 2022.

The Committee for a Responsible Federal Budget, a nonpartisan group of budget experts focused on fiscal policy, estimates that the pandemic will cause the Part A Trust Fund to be unable to pay all of its bills starting in late 2023 or early 2024. “But we’re still very close,” said Marc Goldwein, the group’s senior vice president.

There are two ways the Trust Fund can get into trouble: Either the money flowing in is too little, or the payments going out for care are too much.

Most of those who watch Medicare finances agree that the larger problem right now is how much money is being collected for the Trust Fund. That money largely comes from the 1.45% payroll tax paid by employees and employers. With so many people out of work due to pandemic-related shutdowns, cash flowing in has dropped dramatically.

It’s far less clear what is happening on the spending side of Medicare Part A. (Medicare Part B, which pays physicians and other outpatient costs, is funded by beneficiary premiums and general tax funding, so it cannot technically become insolvent.)

While COVID-related hospital expenses for those on Medicare are expected to be substantial, Medicare hasn’t been reimbursing as much care of other sorts. In some cases, that’s because hospitals in COVID hot spots temporarily stopped doing elective procedures like joint replacements. In other cases, patients with non-COVID ailments have been afraid to go to hospitals for fear of catching the virus.

Also, said Goldwein, health care use tends to fall in recessions, even for Medicare, whose beneficiaries are largely retired.

In the end, he said, “we basically threw our hands up and said we don’t have the information” to estimate how health costs will affect the Trust Fund’s financing.

There is one other COVID-related policy that could hasten the depletion of the Trust Fund. At least $60 billion of the funding provided as part of the CARES Act to help hospitals weather the pandemic came not from the general treasury, but from the Trust Fund itself.

That money in “accelerated and advance payments” is supposed to be paid back, via a reduction in future payments. But there is a push in some quarters for that funding to be forgiven, which would make the Trust Fund’s hole even bigger.

It is not exactly clear what would happen if the Trust Fund were to become insolvent because it has never happened before. As the Congressional Research Service pointed out, “There are no provisions in the Social Security Act that govern what would happen if insolvency were to occur.”

It is important to remember that the fund becoming insolvent is not the same as being bankrupt. Insolvent means the Trust Fund would still have money flowing in, but not enough to pay for all the care Medicare patients will consume.

Most budget experts think that Medicare would reimburse hospitals and other Part A providers 100% of their claims until the fund truly runs out of money. Then it would pay claims only as more money flows in. Others think Medicare might reimburse only a percentage of those claims, but that might require congressional action.

Meanwhile, one would expect the hospital industry to be ringing the alarm bells as potential insolvency approaches. But that’s not happening.

“They’re more concerned with next month than with 2023 at this point,” said Goldwein.

Chip Kahn, president and CEO of the Federation of American Hospitals, agreed. “I’m not going to worry about this right this minute,” he said. “At this point, my focus is completely on COVID.”

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Administration Eases Rules to Give Laid-Off Workers More Time to Sign Up for COBRA

People who’ve been laid off or furloughed from their jobs now have significantly more time to decide whether to hang on to their employer-sponsored health insurance, according to a recent federal rule.

Under the federal law known as COBRA, people who lose their job-based coverage because of a layoff or a reduction in their hours generally have 60 days to decide whether to continue their health insurance. But under the new rule, that clock doesn’t start ticking until the end of the COVID-19 “outbreak period,” which started March 1 and continues for 60 days after the COVID-19 national emergency ends. That end date hasn’t been determined yet.

By extending the time frame to sign up for COBRA coverage, people have at least 120 days to decide whether they want to elect COBRA, and possibly longer depending on when they lost their jobs.

Take the example of someone who was laid off in April, and imagine that the national emergency ends Aug. 31. Sixty days after that date takes the person to the end of October. Then the regular 60-day COBRA election period would start after that. So, under this example, someone whose employer coverage ended at the beginning of May could have until the end of December to make a decision about whether to sign up for COBRA, with coverage retroactive to the beginning of May.

Some health policy experts question the usefulness of the change, given how expensive COBRA coverage can be for consumers, and how limited its reach: It isn’t an option for people who are uninsured or self-employed or who work for small companies.

“For ideological reasons, this administration can’t do anything to expand on the Affordable Care Act’s safety net,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “So they’re using these other vehicles. But it’s really a fig leaf. It doesn’t do much to actually help people.”

What does this rule change mean for workers? If you have lost your job, here are some things to consider.

Playing a Waiting Game

Under the new rule, workers can keep their COBRA options open far longer than before. It’s always been the case that people could take a wait-and-see approach to signing up for COBRA during the first 60 days after losing their coverage. If they needed care during that time, they could elect COBRA, pay the back premiums and continue their coverage. But if they didn’t need care during that time, they could save a chunk of money on premiums before opting for other coverage to kick in after the 60-day period.

Now, people have even more time to wait and see. Under the rule, once the administration declares the national emergency over, laid-off workers would get 120 days to decide whether to purchase their job-based insurance — 60 days under the new rule and the regular 60 days allowed as part of the COBRA law.

“It becomes a long-term unpaid insurance policy,” said Jason Levitis, a fellow at the Center for Health Policy at the Brookings Institution. “There’s no reason to enroll until something bad happens.”

This is not without risk, consumer advocates point out. Someone who has a serious medical emergency — a car accident or a stroke — might not be able to process their COBRA paperwork before they need medical care.

Waiting too long could also affect people’s ability to sign up for other coverage. When people lose job-based coverage, it triggers a special enrollment period that allows them to sign up for new coverage on their state health insurance marketplace for up to 60 days afterward.

“You could miss your opportunity to enroll in the [insurance] exchange” created under the Affordable Care Act, said Katy Johnson, senior counsel for health policy at the American Benefits Council, an employer advocacy group.

Don’t Count on the Boss to Clue You In

Employers are not mandated to tell people promptly about their eligibility for COBRA. The same federal rule that gives workers more time to sign up for COBRA also pushes back the notification requirements for employers.

“Once an employer lays you off, they don’t have to notify you that you’re eligible for COBRA until after the emergency period,” said Karen Pollitz, a senior fellow at KFF, the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

For many employers, especially large ones that outsource their benefits administration, notifications are routine and are continuing despite the federal change, said Alan Silver, a senior director at benefits consultant Willis Towers Watson. However, for smaller companies with fewer than 200 workers, getting the information out might be an issue, Silver said.

Costs Can Be Jaw-Dropping

Opting for COBRA is expensive because workers have to pay both their portion of the premium and their employer’s share, plus a 2% administrative fee. A 48-year-old paid $599 a month on average for individual COBRA coverage last year, according to a KFF analysis.

In addition, if people elect COBRA several months after losing their coverage, they could be on the hook for thousands of dollars in back premiums.

The upside for former employees is that sticking with their previous employer’s plan means they don’t have to start from scratch paying down a new deductible on a new plan. Nor do they have to find new doctors, as often happens when people switch health plans and provider networks change.

Ten percent of workers laid off or furloughed because of the coronavirus pandemic reported they had COBRA coverage, according to a survey conducted last spring by the Commonwealth Fund.

The COBRA extension is available only to people who worked at firms with 20 or more employees and had job-sponsored coverage before being laid off or furloughed. If the company goes out of business, there’s no health insurance to continue to buy.

Might Hospitals Step In to Pay Premiums?

Employers are typically not big fans of the program. Workers who elect COBRA are typically older and sicker than others with employer coverage, the KFF analysis found. They may have serious medical conditions that make them expensive to cover and raise employer costs.

Some policy experts are concerned that giving people more time to sign up for COBRA leaves the door open for hospitals or other providers to offer to pay sick patients’ back premiums in order to increase their own payment above what they’d receive if someone were on Medicaid or uninsured. Doing so could be a boon for some patients but raise health care costs for employers, said Christopher Condeluci, a health care lawyer who does legal and policy work around the Affordable Care Act and ERISA issues.

“Employers are worried,” said Pollitz. After getting laid off, “what if you’re uninsured and you wind up in the hospital six months in, and then the hospital social worker learns you’re eligible for COBRA and offers to pay your premium?”

For COVID Tests, the Question of Who Pays Comes Down to Interpretation

In advance of an upcoming road trip with her elderly parents, Wendy Epstein’s physician agreed it would be “prudent” for her and her kids to get tested for COVID-19.

Seeing the tests as a “medical need,” the doctor said insurance would likely pay for them, with no out-of-pocket cost to Epstein. But her children’s pediatrician said the test would count as a screening test — since the children were not showing symptoms — and she would probably have to foot the bill herself.

It made no sense. “That’s two different responses for the exact same scenario,” said Epstein, a health law professor at DePaul University in Chicago, who deferred the tests as she clarified the options.

Early on in the coronavirus pandemic — when scarce COVID testing was limited to those with serious symptoms or serious exposure — the government and insurers vowed that tests would be dispensed for free (with no copays, deductibles or other out-of-pocket expense) to ensure that those in need had ready access.

Now, those promises are being rolled back in ways that are creating turmoil for consumers, even as testing has become more plentiful and more people — like Epstein — are being advised to get them.

Late last month, the Trump administration issued guidance saying insurers had to waive patient costs only for “medically appropriate” tests “primarily intended for individualized diagnosis or treatment of COVID-19.” It made clear that insurers do not have to fully waive cost sharing for screening tests, even when required for employees returning to work or for assisting in public health surveillance efforts.

Left unclear are situations like that faced by Epstein — and others who seek a test to clear a child for summer camp or day care. Public health officials have been unanimous in the opinion that widespread, readily available testing is crucial for getting businesses and schools open again, and society back on its feet.

But who should bear the costs of that testing — or a share of them — is an unresolved question.

Who pays when all employees are required to have a negative COVID test in order to return to work? Or if a factory tests workers every two weeks? Or just because someone wants to know for their own peace of mind?

The questions may be compounded in some cities and states where tests are widely available at clinics or drive-thru centers. In New York, CityMD clinics bill insurers $300 for the service, according to an explanation-of-benefits document given to KHN by a patient. The related charge from the lab that processed the test, according to the same patient’s insurance statement, was $55. Most patients don’t have to pay a share of those amounts.

The clinic has a partnership with the city allowing anyone who wants a test for the virus to get one. Still, no test is truly free, as labs bill insurers or submit for reimbursement from government programs.

Until a recent spike in virus cases created long delays in many areas, some other regions also took a test-everyone-who-wants-a-test approach. While that is one way to get a picture of where the virus is spreading, it can also become a cash cow providing income to clinics and labs, as residents seek multiple “free” tests after each potential exposure.

In an email, a spokesperson for CityMD would not say how much the clinic is reimbursed for testing. The clinics do not bill for lab testing, she wrote, referring questions about those costs to the laboratories that process them.

Insurers will be making judgment calls — likely on a case-by-case basis — about how they will handle cost sharing for screening tests under the new Trump administration guidance.

What is clear: Insurers have argued against requirements that they waive all cost sharing for workplace COVID testing, noting they don’t do that for other screening efforts, such as drug-testing programs. For now, insurers will “continue to pay for tests recommended by a doctor,” Kristine Grow, spokesperson for AHIP, an industry group, wrote in an email to KHN.

But AHIP also sent a clear signal that it would not embrace cost sharing waivers for workplace or public health screening efforts. Earlier this month, the organization lobbied federal lawmakers to include funding in the next stimulus package for public health surveillance and workplace testing programs — a cost estimated between $6 billion and $25 billion annually in an earlier study commissioned by the group.

The Evolving Rules for Free Testing

The coronavirus relief legislation passed by Congress in March, and April guidance from the Trump administration implementing it, agreed that patients should not be burdened with payments for COVID testing and treatment that is “medically appropriate.”

But as the pandemic has evolved and grown, the definition of that term has both broadened and become fuzzier.

The Centers for Disease Control and Prevention says testing is appropriate for people who fall into five broad categories, including those with suspected exposure and those required to be tested for “purposes of public health surveillance,” which it defines as checking for disease hot spots or trends.

“There’s definitely a disconnect between what public health experts are recommending for testing and how it’s going to be paid for,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

And tension is mounting among insurers, employers and consumers over who should pay. While insurers say employers should cover the cost for back-to-work testing, many employers are struggling financially and may not be able to do so. At the same time, workers, especially those in lower-wage jobs, also cannot afford out-of-pocket costs for testing, particularly if it is required regularly.

Among those waiting to hear if their insurance will cover the test is Enna Allen of Glencoe, Illinois, who urged her au pair to get a test after the young woman traveled to New Orleans. She had been on a plane, after all, and New Orleans has its share of COVID cases.

“I wanted her to have a test before she returned to work with my kids,” said Allen.

As Allen called around to find a testing site, she explained the test was needed for employment — for someone with no symptoms. After some effort, she found a clinic that, for $275, offered a 15-minute rapid test and said it would accept her au pair’s insurance.

“I’m assuming they [the insurer] will cover it unless I get a bill weeks from now,” said Allen, who said she would pay the bill for her employee if that happens.

There is also a great gray area in deciding who should qualify for free testing after “suspected” exposure. What is suspected exposure? Sharing a small office with an infected co-worker? Participating in a protest? Or simply living in or visiting the Sun Belt, where community spread is accelerating?

“If the au pair went to a clinic and said she was just in New Orleans, and the doctor said that’s enough of a risk to order a test, even though she doesn’t have symptoms, my read of the guidance is the health plan has to cover it 100%,” said Corlette.

Yet a child who’s mainly been sheltering at home who needs a test before being admitted to summer camp probably would not meet the definition.

“That’s a different story because it’s harder to argue there’s been exposure or potential exposure,” said Corlette. “At the end of the day, there’s many ways to interpret the guidance.”

Congressional Democrats have accused the Trump administration in its new guidance of “giving insurance companies loopholes instead of getting people the free testing they need.”

Insurers, patients and politicians have locked horns before when screening tests were billed differently than those same tests for diagnostic purposes, since the boundary is often unclear. Under the Affordable Care Act, for example, colonoscopy screening for cancer is “free,” meaning no patient copayment. But if a polyp is found, doctors sometimes code the procedure as a diagnostic test, which can lead to hundreds or even thousands of dollars in copayments.

While vital, testing is costly — or can be. Medicare reimburses up to $100 for the COVID test. On top of that, there may also be costs associated with the office or clinic visit. And the price is widely variable in the private market, according to a report out last week by KFF, the Kaiser Family Foundation. Prices ranged from $20 to $850 for a single test. (KHN is an editorially independent program of the foundation.)

Media reports have shown tests average $100, but some labs bill insurers for thousands of dollars for each one.

Without a copay, many patients never learn how much their tests actually cost their insurers, which could lead to overuse.

Also, when patients are entirely shielded from the cost, test makers, labs and medical providers are more likely to seek price increases, said Heather Meade, a principal at Washington Council Ernst & Young.

In the end, consumers may still feel a resulting pinch in the form of higher premiums.

Wondering about the sharply different views of her doctors on whether her insurance would fully cover the cost, law professor Epstein called her insurer, which assured her the tests would be covered 100% at in-network providers with no copay or deductible, as long as they were coded correctly. The family will be tested soon, and it appears she’s dodged a financial bullet. But Epstein cautioned in an email: “It’s unclear to me how many insurers will maintain this policy.”

Must-Reads of the Week

While you, loyal reader, wait for a wonderful new permanent Friday Breeze writer to start breezing, welcome to this week’s rundown brought to you from St. Louis by me, Midwest correspondent Lauren Weber.

I’m sadly here to inform you the news is … still bad