Cooperating for better care.


Tag Archives

2 governors ready ACA reform proposals


With agreement in Congress hard to come by, Ohio Gov. John Kasich, a Republican,  and Colorado Gov. John Hickenlooper, a Democrat, say they’re very close to announcing  a bipartisan proposal to stabilize the insurance markets created by the Affordable Care Act that they say could be presented in as early as a week.

Part of the plan could include federal funding aimed at bringing down premiums by helping insurers cover the costs of the sickest enrollees.

They are expected to follow their insurance-market ideas with other proposals to revise the ACA.

To read more, please hit this link.

Under Trump, hospitals face the same penalties as under Obama


For Kaiser Health News

Amid all the turbulence over the future of the Affordable Care Act, one facet continues unchanged: President  Trump’s administration is penalizing more than half the nation’s hospitals for having too many patients return within a month.

Medicare is punishing 2,573 hospitals, just two dozen short of what it did last year under former President Obama, according to federal records released Aug. 2. Starting in October, the federal government will cut those hospitals’ payments by as much as 3 percent for a year.

Medicare docked all but 174 of those hospitals last year as well. The $564 million that  the government projects to save also is roughly the same as it was last year under Obama.

High rates of readmissions have been a safety concern for decades, with one in five Medicare patients historically ending up back in the hospital within 30 days. In 2011, 3.3 million adults returned to the hospital, running up medical costs estimated at $41 billion, according to the federal Agency for Healthcare Research and Quality.

The penalties, which begin their sixth year in October, have coincided with a nationwide decrease in hospital repeat patients. Between 2007 and 2015, the frequency of readmissions for conditions targeted by Medicare dropped from 21.5 percent to 17.8 percent, with the majority of the decrease occurring shortly after the health law passed in 2010, according to a study last year in the New England Journal of Medicine conducted by Obama administration health-policy experts.

Some hospitals began giving impoverished patients free medications that they prescribe for their recovery, while others sent nurses to check up on patients seen as most likely to relapse in their homes. Readmissions dropped more quickly at hospitals potentially subject to the penalty than at other hospitals, another study found.

“The sum of the evidence really suggests that this program is helping people,” said Dr. Susannah Bernheim, the director of quality measurement at the Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation, which measures readmission rates for Medicare.

But the pace of these reductions has been leveling off in the past few years, indicating that the penalties’ ability to induce improvements may be waning.

“Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term,” the New England Journal article said.

An analysis by Bernheim’s group found no decrease in the overall rate of readmissions between 2012 and 2015, although small drops in the medical conditions targeted by the penalties continued.

“We have indeed reached the limits of what changes in how we deliver care will allow us to do,” said Nancy Foster, vice president for quality at the American Hospital Association. “We can’t prevent every readmission. It could be that there is further room for improvement, but we just don’t know what the technique is to make that happen.”

The Hospital Readmissions Reduction Program was created through a section of the ACA designed to use the purchasing power of Medicare to reward hospitals for higher quality. Those penalties, along with other ones aimed at improving hospital care, have been spared the partisan rancor over the law, and they would have continued under the GOP repeal proposals that stalled in Congress. But they have also been largely ignored.

Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health, said the fight over abolishing the Affordable Care Act has drowned out talk about how to make the health care system more effective. “We’ve spent the last six months fighting about how we’re going to pay for health insurance, which is one part of the ACA,” he said. “There’s been almost no discussion of the underlying health care delivery system changes that the ACA ushered in, and that is more important in the long run to be discussing because that’s what’s going to determine the underlying costs and outcomes of the health system.”

The readmission penalties are intended to neutralize an unintended incentive in how Medicare pays hospitals that had profited from return patients. Medicare pays hospitals a lump sum for a patient’s stay based on the nature of the admission and other factors. Since hospitals generally are not paid extra if patients remain longer, they seek to discharge patients as soon as is medically feasible. If the patient ends up back in the hospital, it becomes a financial benefit as the hospital is paid for that second stay, filling a bed that would not have generated income if the patient had remained there continuously.

Because of how the readmission-penalty program was designed, it is not surprising that the new results are so similar to last year’s. As before, Medicare determined the penalties based on readmissions of the same six types of patients: those admitted for heart attacks, heart failure, pneumonia, chronic lung disease, hip or knee replacements or coronary artery bypass graft surgery. Hospitals were judged on patients discharged between July 2013 and June 2016. Because the government looks at a three-year period, two of those years were also examined in determining last year’s penalties.

This year, the average penalty will be 0.73 percent of each payment Medicare makes for a patient between Oct. 1 and Sept. 30, 2018, according to a Kaiser Health News analysis. That too was practically the same as last year. Forty-eight hospitals received the maximum punishment of a 3 percent reduction. Medicare did not release hospital-specific estimates for how much lost money these penalties would translate to.

More than 1,500 hospitals were exempted from penalties this year as required by law. Those include hospitals treating veterans, children and psychiatric patients. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, were excluded. So were Maryland hospitals because Congress has given that state extra leeway in how it distributes Medicare money.

Of the 3,241 hospitals whose readmissions were evaluated, Medicare penalized four out of five, KHN’s analysis found. That is because the program’s methods are not very forgiving: A hospital can be penalized even if it has higher than expected readmission rates for only one of the six conditions that are targeted. Every non-excluded hospital in Delaware and West Virginia will have their reimbursements reduced. Ninety percent or more will be punished in Arizona, Connecticut, Florida, Kentucky, Massachusetts, Minnesota, New Jersey, New York and Virginia. Sixty percent or fewer will be penalized in Colorado, Kansas, Idaho, Montana, Oregon, South Dakota and Utah.

Since the readmission program’s structure is set by law, the administration cannot make major changes unilaterally, even if it wanted to.

Congress last year instructed Medicare to make one future alteration in response to complaints from safety-net hospitals and major academic medical centers.

They have objected that their patients tended to be lower income than other hospitals and were more likely to return to the hospital, sometimes because they didn’t have a primary care doctor and other times because they could not afford the right medication or diet. Those hospitals argued that this was a disadvantage for them since Medicare bases its readmission targets on industry-wide trends and that it hurt them financially, depriving them of resources they could use to help those same patients.

Bernheim noted that despite those complaints, safety-net hospitals have shown some of the greatest drops in readmission rates. In October 2018, Medicare will begin basing the penalties on how hospitals compared to their peer groups with similar numbers of poor patients. Akin Demehin, director of policy at the hospital association, said, “We expect the adjustment will provide some relief for safety-net hospitals.”

Medicare is planning to release two other rounds of recurring quality incentives for hospitals later this year. One gives out bonuses and penalties based on a mix of measures, with Medicare redistributing $1.9 billion based on how hospitals perform and improve. The other, the Hospital-Acquired Condition Reduction Program, cuts payments to roughly 750 hospitals with the highest rates of infections and other patient injuries by 1 percent.

Centene reports strong insurance-marketplace business


FierceHealthcare reports:

“Driven by a strong performance in its health insurance marketplace business, Centene reported better-than-expected second-quarter earnings on Tuesday—the same day Senate Republicans were poised to vote to advance legislation to repeal the Affordable Care Act.

“The insurer, which primarily specializes in Medicaid managed care, said its its profits rose to $254 million ($1.44 earnings per share) in the quarter, up from $171 million in the second quarter of 2016. Its adjusted EPS of $1.59 beat analysts’ consensus estimate of $1.30 per share, and it raised its full-year guidance by 18 cents to a range of $4.70 to $5.06 per share.

“Centene said its “strong 2017 marketplace performance” exceeded its expectations in the second quarter by $0.12 diluted earnings per share, and added that its second-quarter earnings of 17 cents per share net benefit related to risk adjustment under the ACA.

“The insurer previously said it would expand its ACA exchange presence in 2018, even as policy uncertainty has driven other insurers to exit.”

To read more, please hit this link.

Why, after 7 years of heated rhetoric, the GOP has failed to kill the ACA


For Kaiser Health News

Seven years of Republican vows to “repeal and replace” the Affordable Care Act came to a crashing halt Tuesday, when it became clear that the Senate could not muster the necessary votes for any of three separate proposals that have been under consideration.

The failure, at least for now, breaks one of the key promises Republicans have made to their voters since 2010, when the ACA first became law.

“This has been a very challenging experience for all of us,” Senate Majority Leader Mitch McConnell (R.-Ky.) told reporters Tuesday afternoon. “It’s pretty clear that there are not 50 Republicans at the moment to vote for a replacement for Obamacare.”

Monday night’s declaration of opposition by conservative Senators Mike Lee (R-Utah) and Jerry Moran (R-Kan.) effectively scotched even the chance to start debate on the version of a bill unveiled last week.

McConnell added that the Senate would vote early next week on a plan, originally approved in 2015 and vetoed by President Obama, that would repeal parts of the health law. That approach would delay the effective date for two years to give lawmakers time to come up with a replacement.

However, the opposition of moderate Senators Susan Collins (R.-Maine), Shelley Moore Capito (R.-W.Va.) and Lisa Murkowski (R.-Alaska), ensures that vote will fail, too.

“To just say ‘repeal and trust us, we’re going to fix it in a couple of years,’ that’s not going to provide comfort to the anxiety a lot of Alaskan families are feeling right now,” Murkowski told reporters.

In retrospect, Republicans’ inability to overhaul the health law should not come as much of a surprise. Here are some of the reasons:

1. It’s hard to take things away from people.

Once launched, federal programs that provide people with benefits they find important and valuable are very difficult to rescind. In the case of healthcare, people’s lives can be at stake. In the current debate, patients who feared what would happen to their health coverage made their concerns known — loudly — to lawmakers.

2. Republicans have long been divided on health care.

Republicans’ dirty little secret the past seven years is that the only thing they fundamentally agreed on when it comes to healthcare was the slogan “repeal and replace.” There’s a reason they failed to have a plan ready when Donald Trump was elected president — all efforts to reach a consensus had thus far failed.

“I did not come to Washington to hurt people,” said Capito. “I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia’s decision to expand Medicaid.”

But the more conservative members, notably Sen. Rand Paul (R.-Ky.), have other priorities. “All of us promised we would repeal Obamacare,” Paul told reporters Tuesday. “If you’re not willing to vote the way you voted in 2015 then you need to go back home and you need to explain to Republicans why you’re no longer for repealing Obamacare.”

3. Presidential leadership on hard issues is important.

President Trump has been all over the place in what he said he wanted from a health bill. It was his original insistence that “repeal and replace” happen simultaneously that moved Congress away from its 2015 strategy of repealing first and replacing later. He hosted a celebration in the White House Rose Garden when the House passed its bill, then subsequently called the measure “mean” during a strategy meeting with senators.

When it became clear Monday night that the Senate effort was foundering, Trump tweeted: “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate.” But within hours he instead suggested, “As I have always said, let ObamaCare fail and then come together and do a great healthcare plan.”

The president “gave them an impossible assignment with his promises (more, better, cheaper for all) and neither policy nor bully pulpit help at crunch time,” said Len Nichols, a professor of health policy at George Mason University. “And now he’ll blame them for failing.”

Added Thomas Miller, of the conservative American Enterprise Institute: “We now have a randomized clinical trial that proves one cannot lead and govern via Twitter.”

4. Healthcare is complicated. Really.

Healthcare has not traditionally been a major voting issue for Republicans, and thus it has been a low priority — compared with issues like taxes and trade — for the officials they elect.

Adding to the complexity is that the Republicans’ bench is nowhere near as deep as the Democrats’ when it comes to health -policy expertise. Democrats have toiled on these issues for years. Even before the Affordable Care Act, many had served in Congress for decades and learned from the mistakes that were made on efforts like the failed health bill under President  Clinton.

5. Some parts of the ACA really are popular, even among Republicans.

The requirement for most people to have insurance or else pay a fine — the individual mandate — has consistently been unpopular among voters of all political stripes. But many other major provisions of the health law, such as guaranteeing coverage for people with preexisting conditions, remain broadly popular.

In fact, in recent months, the Affordable Care Act has been growing in popularity. Most polls show it more than twice as popular as GOP efforts to overhaul it.

“Republicans have to admit that some of the things in the ACA, we actually liked,” said Murkowski.

That left a huge gap between Republicans who wanted to maintain the popular benefits and those who wanted to repeal the law entirely. A gap that, so far, Republicans have been unable to bridge.

Rachel Bluth contributed to this story.

Six steps to address worst insurance problems


Timothy Jost, writing for the Commonwealth Fund, proposes six steps that he says that Congress should take immediately to address the most pressing health-insurance problems, before trying to make  broader, systemic changes in America’s fragmented healthcare “system”.

They are:

“First, it must focus on the individual market, where we face an immediate crisis.”

“Second, we need solutions that can be implemented immediately through existing programs.”

“{T}hird, we may need to accept short-term increases in federal spending to get us through the immediate difficulties, as we have when our country has faced other crises. … But in the short term, simply shifting the burdens to individuals who will lose insurance coverage or face much higher deductibles and premiums is not acceptable.”

“Fourth, Congress should reinstitute the ACA’s risk corridor program for 2018 and 2019 for any county with fewer than two insurers.”

“Fifth, Congress should leave the individual mandate in place until it can devise a credible replacement. ”

“Sixth, Congress should rework the premium tax credit formula for 2018 through 2020 to allow younger enrollees to claim more generous tax credits.”

To read Mr. Jost’s essay,  please hit this link.

Senate health bill would cut Medicaid and premium support and change coverage guarantees



For Kaiser Health News

Republicans in the U.S. Senate on Thursday unveiled a bill that would dramatically transform the nation’s Medicaid program, make significant changes to the federal health law’s tax credits that help lower-income people buy insurance and allow states to water down changes to some of the law’s coverage guarantees.

The bill also repeals the tax mechanism that funded the Affordable Care Act’s benefits, resulting in hundreds of billions of dollars in tax cuts for the wealthy and healthcare industry.

Most senators got their first look at the bill as it was released Thursday morning. It had been crafted in secret over the past several weeks. Senate Majority Leader Mitch McConnell (R.-Ky.) is seeking a vote on the bill before Congress leaves next week for its Fourth of July recess.

Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.

At lightning speed and with a little over a week for wider review, the Republicans’ bill could influence healthcare and health insurance of every American. Reversing course on some of the more popular provisions of the Affordable Care Act, it threatens to leave tens of millions of lower-income Americans without insurance and those with chronic or expensive medical conditions once again financially vulnerable.

Like the House measure, the Senate bill, which is being called a “discussion draft,” would not completely repeal the ACA but would roll back many of the law’s key provisions. Both bills would also — for the first time — cap federal funding for the Medicaid program, which covers more than 70 million low-income Americans. Since its inception in 1965, the federal government has matched state spending for Medicaid. The new bill would shift much of that burden back to states.

The bill would also reconfigure how Americans with slightly higher incomes who don’t qualify for Medicaid would get tax credits to help pay insurance premiums and eliminate penalties for those who fail to obtain insurance and employers who fail to provide it. It also would make it easier for states to waive consumer protections in the ACA that require insurance companies to charge the same premiums to sick and healthy people and to provide a specific set of benefits.

“We agreed on the need to free Americans from Obamacare’s mandates, and policies contained in the discussion draft will repeal the individual mandate so Americans are no longer forced to buy insurance they don’t need or can’t afford; will repeal the employer mandate so Americans no longer see their hours and take-home pay cut by employers because of it,” McConnell said on the floor of the Senate after releasing the bill. He also noted that the bill would help “stabilize the insurance markets that are collapsing under Obamacare as well.”

As expected, Senate Minority Leader Chuck Schumer (D.-N.Y.) assailed the bill, saying that it would “strip away health care benefits and protections from Americans who need it most” through changes in Medicaid and the ACA’s essential health benefits. “Even though much of the early reporting says the bill will keep certain protections for Americans with preexisting conditions,” he added, “the truth is it may well not guarantee them the coverage they need. By allowing states to waive essential health benefits, what the bill is saying to those Americans is: Insurance still has to cover you, but it doesn’t have to cover what you may actually need; it doesn’t have to cover all or even most of your costs.”

The White House had no immediate comment, but President  Trump has been pressuring Congress to pass a health bill quickly.

It is not clear that the bill will make it through the Senate, or that all of it will even make it to the Senate floor. The Senate (like the House) is operating under a special set of budget rules that allow it to pass this measure with only a simple majority vote and block Democrats from dragging out the debate by using a filibuster. But the “budget reconciliation” process comes with strict rules, including the requirement that every provision of the bill primarily impact the federal budget, either adding to or subtracting from federal spending.

For example, the legislation as released includes a one-year ban on Medicaid funding for Planned Parenthood. That is a key demand of anti-abortion groups and some congressional conservatives, because Planned Parenthood performs abortions with non-federal funding. But it is not yet clear that the Senate parliamentarian will allow that provision to be included in the bill.

Also still in question is a provision of the Senate bill that would allow states to waive insurance regulations in the Affordable Care Act. Many budget experts say that runs afoul of Senate budget rules because the federal funding impact is “merely incidental” to the policy.

Drafting the Senate bill has been a delicate dance for McConnell. With only 52 Republicans in the chamber and Democrats united in opposition to the unraveling of the health law, McConnell can afford to lose only two votes and still pass the bill with a tie-breaking vote from Vice President Mike Pence. McConnell has been leading a small working group of senators — all men — but even some of those have complained they were not able to take part in much of the shaping of the measure, which seems to have been largely written by McConnell’s own staff.

So far, McConnell has been fielding complaints from the more moderate and more conservative wings of his party. And the draft that has emerged appears to try to placate both.

For example, as sought by moderates, the bill would phase down the Medicaid expansion from 2020 to 2024, somewhat more slowly than the House bill does. But it would still end eventually. The Senate bill also departs from the House bill’s flat tax credits to help pay for insurance, which would have added thousands of dollars to the premiums of poorer and older people not yet eligible for Medicare.

A Congressional Budget Office report estimating the Senate bill’s impact on individuals and the federal budget is expected early next week. The House bill, according to the CBO, would result in 23 million fewer Americans having health insurance over 10 years.

For conservatives, however, the Senate bill would clamp down even harder on Medicaid in later years. The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s. That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs.

Defenders of the ACA were quick to react.

Sen. Ron Wyden (D.-Ore.) complained about changes to coverage guarantees in the ACA.

“I also want to make special note of the state waiver provision. Republicans have twisted and abused a part of the Affordable Care Act I wrote to promote state innovation, and they’re using it to give insurance companies the power to run roughshod over individuals,” he said in a statement issued shortly after the bill was released. “This amounts to hiding an attack on basic health care guarantees behind state waivers, and I will fight it at every turn.”

“The heartless Senate health care repeal bill makes healthcare worse for everyone — it raises costs, cuts coverage, weakens protections and cuts even more from Medicaid than the mean House bill,” said a statement from Protect Our Care, an umbrella advocacy group opposing GOP changes to the health law. “They wrote their plan in secret and are rushing forward with a vote next week because they know how much harm their bill does to millions of people.”

Deconstructing the latest House GOP health bill


For Kaiser Health News

The Republican overhaul of the federal health law passed by the U.S. House this month would result in slightly lower average premiums and slightly fewer uninsured Americans than an earlier proposal. But it would leave as many as one-sixth of Americans living in states where older and sicker people might have to pay much more for their health care or be unable to purchase insurance at all, the Congressional Budget Office said Wednesday.

In some states, said the report, “less healthy people would face extremely high premiums, despite the additional funding that would be available” in the bill to help offset those increases.

The report incorporates the changes to the bill made just before it narrowly passed the House on May 4. Those changes included an amendment offered by Rep. Tom MacArthur (R-N.J.) that would let states waive some key provisions of the health law, including requirements to cover “essential health benefits” and to offer insurance to people with preexisting conditions at no extra cost.

CBO said the current version would result in savings of $119 billion over 10 years and 23 million more uninsured people than would be expected under the current law.

According to the estimate, premiums would be slightly lower than under the Affordable Care Act, but mostly because “the insurance, on average, would pay for a smaller proportion of health care costs.”

Before the changes, the CBO estimated that the bill would result in savings of $150 billion over the next decade and grow the number of uninsured Americans by 24 million. That dollar figure was a considerable change from the original version of the bill that CBO said would have saved $337 billion, but lawmakers decided to spend back some of those savings on help for those likely to be cut off from insurance.

The two earliest versions of the bill could not muster enough support for the House leadership to bring them to a vote on the floor. Later, MacArthur and leaders of the conservative Freedom Caucus negotiated changes that they said should help bring down premium costs for consumers. That is the bill approved and now evaluated by CBO.

The CBO also estimated that in states deciding to take the option to waive requirements related to charging sicker people more, “the nongroup market would start to become unstable.” In particular, said the report, “people who are less healthy (including those with pre-existing or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”

And in states that chose to waive the requirements for essential benefits, even people with insurance “would experience substantial increases in what they would spend on health care,” because their policies might no longer cover expensive treatments like those for maternity care or mental health and substance abuse.

Despite repeated assertions by President Trump and congressional Republicans that the Affordable Care Act is collapsing, the CBO specifically said that the market would continue “to be stable in most areas” under current law. It predicted the same for the original version of the House bill.

In fact, the only place the CBO specifically said the individual insurance market might become unstable is in states that decide to waive the ACA’s coverage requirements. It did not guess which states might do that, but the report says that one-sixth of the population could be subject to that instability.

“What is clear is that these waivers make life much, much worse for people with preexisting conditions, for older people, for sicker people,” said Aviva Aron-Dine, a senior fellow at the Center on Budget and Policy Priorities and former Obama administration health staffer.

The savings in the bill are mostly the result of capping federal funding to states for the Medicaid program for those with low incomes and scaling back the tax credits that help some people with low and modest incomes pay for private insurance. An estimated 14 million of the 23 million people who would no longer have insurance would otherwise have obtained it through Medicaid.

The bill would also repeal nearly all the taxes imposed in the ACA to pay for the new benefits, including taxes on wealthy individuals and much of the health industry.

Reaction to the new estimate fell mostly along predictable party lines.

“CBO continues to find that through our patient-focused bill, premiums will go down and that our reforms will help stabilize the market,” said a statement from House Energy and Commerce Committee Chairman Greg Walden (R.-Ore.) and its health subcommittee chairman, Michael Burgess (R.-Texas).

By contrast, Rep. Steny Hoyer (D.-Md.) said the new estimate shows “TrumpCare will kick millions of Americans off their insurance coverage and force consumers to pay more for less.”

But the reaction was not completely partisan. Sen. Bill Cassidy (R-La.), a key swing vote in the Senate, said that “Congress’s focus must be to lower premiums with coverage which passes the Jimmy Kimmel test,” referring to the late-night host’s tearful monologue about the health problems of his newborn son. The House-passed bill, he said, “does not. I am working with Senate colleagues to do so.”

5 possible possible outcomes of GOP’s ACA-replacement drive


For Kaiser Health News

The House may pass its bill to repeal and replace parts of the Affordable Care Act. But Republicans’ pathway to fulfilling their seven-year effort to undo the federal health law is getting narrower by the day.

“As of now, they still don’t have the votes,” said Rep. Pete King (R.-N.Y.) as he was leaving a meeting of GOP members Tuesday. King has been a target for those pushing both for and against the bill.

The latest snag is over whether people with preexisting health conditions should have guaranteed access to affordable coverage, as the ACA mandates. An amendment that would let states waive some of those requirements has garnered the votes of reluctant conservatives but left more moderate Republicans concerned.

“I’ve supported the practice of not allowing preexisting conditions to be discriminated against from the very get-go,” Rep. Fred Upton (R.-Mich.), a former chairman of the House committee that handles most health issues, told a Michigan radio station Tuesday in explaining his decision not to support the bill. “This amendment torpedoes that.”).

House leaders stressed that they are still working to muster a majority to pass the bill, which was originally scheduled for a full floor vote in March.

Here are some possible ways the effort could play out.

1. The House passes its bill soon.

Approval in the House would send the measure to the Senate, where the fight will be very different. Congress is using a special budget procedure that allows the bill to pass with 51 votes. There are only 52 Republicans in the Senate, so they can’t afford to lose more than two GOP votes, assuming every Democrat opposes the measure. In that case, Vice President Mike Pence would be needed to break a tie.

While this special procedure makes the bill easier for Republicans to pass, the Senate’s budget “reconciliation” process must follow a series of specific rules that exclude provisions that don’t directly affect the federal budget.

Various parts of the House bill, including a recent change to let states waive some coverage rules that has ignited concerns about preexisting conditions, have been mentioned as possible violations of those Senate rules and would have to be taken out in order to qualify for the protections of reconciliation.

The Senate may also amend the bill and the House would have to approve those changes, which could again break the delicate coalition of House GOP support.

2. The House walks away from the debate.

In theory, the House could just leave health care for another day — or another year. That would be a huge setback for President  Trump, who campaigned on a pledge to “repeal and replace” the health law, as well as for congressional Republicans, who have been promising to do the same since the bill became law in 2010.

But if the law truly implodes for 2018, meaning insurers drop out of so many areas that millions of people have no insurance options, it could trigger an entirely different health debate.

3. The House decides to switch gears to tax reform.

Health care is not the Republicans’ only high priority. So is an overhaul of the federal tax code.

But Republicans want to use the same budget reconciliation procedure to pass their tax plan. That’s a problem.

In order to make sweeping tax changes under expedited budget rules, the House and Senate would have to move on to a fiscal 2018 budget resolution, which would override the 2017 budget blueprint. But as soon as it does, the protections for the health bill would expire.

There is another option. Each budget resolution can allow one spending bill and one tax bill to be protected by reconciliation rules. So Congress could simply start the process over in a 2018 budget resolution that would allow it to move on tax reform and changes to the health law simultaneously.

4. Congress tries to overhaul health law incrementally.

The House could abandon the budget process and simply pass bills without regard to whether they have an effect on the budget. The first step, though, would likely be for the House to repeal the ACA wholesale — giving Republicans political cover. Then they could take up smaller pieces of legislation, such as a bill that would allow health insurance to be purchased across state lines, a favorite idea of Trump’s. Those bills, however, would require 60 votes in the Senate, which seems unlikely given Democratic opposition.

If the GOP efforts to bring wholesale change to the ACA are exhausted, though, it may be possible for some moderate Republicans to craft legislation with Democrats to fix some of the issues that both parties see in the law.

5. The Senate gets rid of the legislative filibuster.

The Senate earlier this year abolished the need for 60 votes to fill a Supreme Court seat, which got Trump’s nominee, Neil Gorsuch, approved. Trump has been calling for Republicans to also get rid of the filibuster for legislation. “Either elect more Republican Senators in 2018 or change the rules now to 51%,” he tweeted on Tuesday.

But the legislative filibuster is the last protection for a Senate minority party, and Republicans know they will someday be that minority again. Senate Majority Leader Mitch McConnell (R.-Ky.) has said repeatedly he has no intention of taking this step, telling reporters Tuesday it “would fundamentally change the way the Senate has worked for a very long time.” And even if he changed his mind, he might have trouble persuading some of his Republican colleagues to go along.

Lobbying helps give ACA ‘surprising staying power’



K Street NW at 19th Street in Washington D.C., in Washington’s maze of high-powered “K Street lobbyist” and law firm office buildings.

Ricardo Alonso-Zaldivar, of the Associated Press, explains how lobbying by well-heeled provider groups is giving the Affordable Care Act “surprising staying power” and undermining Republican efforts to repeal it.

“For the providers, coverage gains and expanded benefits under the Affordable Care Act, or ACA, translate to better chances of keeping patients healthy, and fewer unpaid bills. They say such tangible results outweigh the shortcomings of the Obama-era law, which extended coverage to millions previously uninsured but remains politically divisive.”

“We need to be constantly pushing to get folks to do a bipartisan fix of the ACA,” Sister Carol Keehan, president and CEO of the Catholic Health Association, representing more than 600 hospitals, told Mr. Alonso Zaldivar. “We have to keep blocking and tackling until we get there.”

Recently the American Hospital Association, the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association have written congressional leaders warning of harm to patients if  any of the current GOP  versions of ACA replacement legislation become law.

And such patient-advocacy groups as the American Cancer Society Cancer Action Network, the American Heart Association, the American Diabetes Association, the American Lung Association, the March of Dimes and others raise similar concerns.

Particularly troubling to foes of the GOP legislation is that the latest drafts of the GOP legislation let  states get waivers of the ACA provision that requires insurers to charge people with medical problems the same premiums that the healthy pay. And consumers who have had a break in coverage could be charged more.

The great healthcare economic contradiction


For Kaiser Health News

In many ways, the healthcare industry has been a great friend to the U.S. economy. Its plentiful jobs helped lift the country out of the Great Recession and, partly due to the Affordable Care Act (ACA), it now employs 1 in 9 Americans—up from 1 in 12 in 2000.

As President  Trump seeks to fulfill his campaign pledge to create millions more jobs, the industry would seem a promising place to turn. But the business mogul also campaigned to repeal the ACA and lower healthcare costs—a potentially serious job killer. It’s a dilemma: One promise could run headlong into the other.

“The goal of increasing jobs in healthcare is incompatible with the goal of keeping healthcare affordable,” said Harvard University economist Katherine Baicker, who sees advantages in trimming the industry’s growth. “There’s a lot of evidence we can get more bang for our buck in healthcare. We should be aiming for a healthcare system that operates more efficiently and effectively. That might mean better outcomes for patients and fewer jobs.”

But the country has grown increasingly dependent on the health sector to power the economy—and it will be a tough habit to break. Thirty-five percent of the nation’s job growth has come from healthcare since the recession hit in late 2007, the single-biggest sector for job creation.

Hiring rose even more as coverage expanded in 2014 under the health law and new federal dollars flowed in. It gave hospitals, universities and companies even more reason to invest in new facilities and staff.  Training programs sprang up to fill the growing job pool. Cities welcomed the development—and the revenue. Simply put, rising health spending has been good for some economically distressed parts of the country, many of which voted for Trump last year.

In Morgantown, W.Va., the West Virginia University health system just opened a 10-story medical tower and hired 2,000 employees last year. In Danville, Pa., the Geisinger Health System has added more than 2,200 workers since July and is trying to fill 2,000 more jobs across its 12 hospital campuses and a health plan. Out West, the UCHealth system in Colorado expanded its Fort Collins hospital and is building three hospitals in the state.

In cities such as Pittsburgh, Cleveland and St. Louis, healthcare has replaced such  industries as coal and heavy manufacturing as a primary source of new jobs. “The industry accounts for a lot of good middle-class jobs and, in many communities, it’s the single-largest employer,” said Sam Glick, a partner at the Oliver Wyman consulting firm in San Francisco. “One of the hardest decisions for the new Trump administration is how far do they push on healthcare costs at the expense of jobs in healthcare.”

House Republicans, with backing from Trump, took the first swipe. Their American Health Care Act sought to roll back the current health law’s Medicaid expansion and cut federal subsidies for private health insurance. The GOP plan faltered in the House, but Republican lawmakers and the Trump administration are still trying to craft a replacement for the ACA.

Neither the ACA nor the latest Republican attempt at an overhaul tackle what some industry experts and economists see as a serious underlying reason for high healthcare costs: a system bloated by redundancy, inefficiency and a growing number of jobs far removed from patient care.

Labor accounts for more than half of the $3.4 trillion spent on U.S. healthcare, and medical professionals from health aides to nurse practitioners are in high demand. But the sheer complexity of the system also has spawned jobs for legions of data-entry clerks, revenue-cycle analysts and medical billing coders who must decipher arcane rules to mine money from human ills.

For every physician, there are 16 other workers in U.S. healthcare. And half of those 16 are in administrative and other nonclinical roles, said Bob Kocher, a former Obama administration official who worked on the ACA. He’s now a partner at the venture capital firm Venrock, in Palo Alto, Calif.

“I find super-expensive drugs annoying and hospital market power is a big problem,” Kocher said. “But what’s driving our health-insurance premiums is that we are paying the wages of a whole bunch of people who aren’t involved in the delivery of care. Hospitals keep raising their rates to pay for all of this labor.”

Take medical coders. Membership in the American Academy of Professional Coders has swelled to more than 165,000, up 10,000 in the past year alone. The average salary has risen to nearly $50,000, offering a path to the American Dream.

“The coding profession is a great opportunity for individuals seeking their first joband it’s attractive to a lot of medical professionals burned out on patient care,” said Raemarie Jimenez, a vice president at the medical coding group. “There is a lot of opportunity once you’ve got a foot in the door.”

Some of these back-office workers wage battle every day in clinics and hospitals against an army of claims administrators filling up cubicles inside insurance companies. Overseeing it all are hundreds of corporate vice presidents drawing six-figure salaries.

Administrative costs in U.S. healthcare are the highest in the developed world, according to a January report from the Organization for Economic Cooperation and Development. More than 8 percent of U.S. health spending is tied up in administration while the average globally is 3 percent. America spent $631 for every man, woman and child on health-insurance administration for 2012, compared with $54 in Japan.

America’s huge investment in healthcare and related jobs hasn’t always led to better results for patients, data show. But it has provided good-paying jobs, which is why the talk of deep cuts in federal health spending has many people concerned.

Linda Gonzalez, a 31-year-old mother of two, was among the thousands of enrollment counselors hired to help sign up Americans for health insurance as the ACA rolled out in 2014. The college graduate makes more than $40,000 a year working at an AltaMed enrollment center, tucked between a Verizon Wireless store and a nail salon on a busy street in Los Angeles.

In her cramped cubicle, families pull up chairs and sort through pay stubs and tax returns, often relying on her to sort out enrollment glitches with Medicaid. As the sole breadwinner for her two children, ages 9 and 10, she counts on this job but isn’t sure how long it will last.

“A lot of people depend on this,” she said one recent weekday. “It’s something I do worry about.”

Page 1 of 9123...Last

Contact Info

(617) 230-4965

Wellesley, Mass