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ACA could suffer death by a thousand cuts


For Kaiser Health News

The Affordable Care Act’s worst enemies are now in charge of the vast range of health coverage it created. They’re also discussing changes that could affect a wider net of employment-based policies and Medicare coverage for seniors.

Republicans failed last month in their first attempt to repeal and replace the ACA. But President Trump vows that the effort will continue. Even if Congress does nothing, Trump has suggested he might sit by and “let Obamacare explode.”

Health insurance for the 20 million who benefited from the ACA’s expanded coverage is especially at risk. But they’re not the only ones potentially affected. Here’s how what’s going on in Washington might touch you.

A three-year-old lawsuit threatens many plans.

A suit by the Republican-led House challenges some subsidies supporting private plans sold to individuals and families through the ACA’s online marketplaces, also called exchanges. It has already gained one court victory. By many accounts, it would wreck the market if successful, stranding up to 12 million without coverage.

“It’s the single-biggest problem facing the exchanges,” said Rachel Sachs, a health-law professor at Washington University in St. Louis. “That would make insurers not only exit tomorrow but also not want to offer plans in 2018.”

The litigation involves lesser-known ACA subsidies that reduce such out-of-pocket costs as copayments and deductibles for lower-income consumers. These are different from the law’s income-linked tax credits, which help pay for premiums.

Filed in 2014, when Barack Obama was president, the suit could backfire by politically harming the Republicans now in charge. House leaders have delayed the litigation and said they won’t drop the lawsuit but will continue the subsidies while it gets considered. The administration has not said how it plans to handle the lawsuit.

Policy confusion undermines coverage.

Even if Congress doesn’t repeal the ACA, the continuing battle makes insurance companies think twice about offering marketplace policies for next year. The less clarity carriers have about subsidies and whether the administration will promote 2018 enrollment, the likelier they are to bail or jack up premiums to cover themselves.

Preserving the subsidies, which limit out-of-pocket costs for lower-income consumers, “is essential,” said Kevin Lewis, CEO of Community Health Options, a nonprofit Maine insurer. “Markets don’t like uncertainty. The ‘sword of Damocles’ hanging over our collective heads is unsettling, to say the least.”

Democrats say Republicans are sabotaging Obamacare.

Shortly after taking power, Trump officials yanked advertising designed to maximize enrollment in marketplace plans just before a Jan. 31 deadline. It was partly restored after an outcry.

Then the administration said it would scrap an Obama-regime plan of rejecting tax returns from individuals who decline to say whether they had health insurance — weakening the requirement to be covered.

Trump aide Kellyanne Conway suggested in January  that the administration might entirely stop enforcing that requirement — the part of the law most hated by Republicans. If officials persist with that message, plans could attract even fewer of the young and healthy members whose premiums are needed to support the ill. That would cause more rising premiums and insurer exits.

“More mischief can be done,” said Dr. Peter Kongstvedt, a health industry consultant and senior faculty member at George Mason University. “It is absolutely possible that some markets will end up with no carriers unless a combination of state and federal government act to preserve the market” with taxpayer money.

Trump officials will move to roll back ACA coverage even if Congress doesn’t repeal.

Tom Price, M.D., secretary of the Department of Health and Human Services, has signaled his intent to reverse parts of the ACA through regulation even if Congress doesn’t repeal the law.

For example, Price couldn’t unilaterally eliminate coverage for birth control or maternity care, both of which many Republicans object to on moral grounds or because of cost. But birth control might no longer be free as a preventive benefit. Maybe the administration would let states limit the number of prenatal visits in maternity coverage. Perhaps more employers could gain religious exemption from providing birth control.

Medicaid coverage for low-income people could shrink.

Obamacare’s coverage expansion included government Medicaid coverage for folks with lower incomes. Thirty-one states and the District of Columbia expanded Medicaid to most adults with incomes below about $16,000 for singles and $28,000 for a family of three — although eligibility varies.

Republicans want to reduce the growth of Medicaid spending and give more control over the program to states. Discussions for a Medicaid overhaul focus on replacing ACA provisions with fixed, less-generous federal grants to states.

But even if the ACA survives, it’s likely the administration will give states more say in who gets Medicaid coverage and how much. Many Republicans favor work requirements for Medicaid recipients and raising out-of-pocket payments for patients.

Under the failed House replacement bill, the American Health Care Act, 9 million people in those states would have lost Medicaid coverage in 2020, estimated the nonpartisan Congressional Budget Office.

At the same time, however, Republican support for the ACA’s Medicaid expansion is growing, which might mean overall cutbacks would be less severe or Medicaid coverage could increase among the 19 states that didn’t expand the program under the ACA.

Some Republicans want to overhaul Medicare for seniors.

House Speaker Paul Ryan wants to restrain Medicare growth by giving members fixed, “premium support” payments to buy plans and possibly raise the age of eligibility. Both could lead to less coverage or greater out-of-pocket expense.

But the proposal wasn’t part of the Republicans’ replacement bill. Changing Medicare likely would trigger loud objections from AARP and other powerful lobbies. And Trump doesn’t seem inclined to back a change.

“I don’t think … Trump wants to meddle with Medicare or Social Security,” White House chief of staff Reince Priebus said in January.

Job-based coverage could become less generous.

Although ditching Obamacare would end the requirement for large employers to offer health insurance, most companies would keep their plans as a way to attract workers, analysts say.

But that coverage could become less generous. The ACA limits employer-plan members’ annual out-of-pocket cost and also prohibits caps on annual and lifetime benefits. At the same time, it prohibits waiting periods for covering a new worker’s preexisting illness.

Any replacement law signed by Trump might not include those protections.

Sharp’s pre-hospice program saves money


For Kaiser Health News

Gerald Chinchar isn’t quite at the end of life, but the end is not far away. The 77-year-old fell twice last year, shattering his hip and femur, and now gets around his San Diego home in a wheelchair. His medications fill a dresser drawer, and congestive heart failure puts him at high risk of emergency room visits and long hospital stays.

Chinchar, a Navy veteran who loves TV Westerns, said that’s the last thing he wants. He still likes to go watch his grandchildren’s sporting events and play blackjack at the casino. “If they told me I had six months to live or go to the hospital and last two years, I’d say leave me home,” Chinchar said. “That ain’t no trade for me.”

Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions.

Sharp HealthCare, the San Diego health system where Chinchar receives care, has devised a way to fulfill his wishes and reduce costs at the same time. It’s a pre-hospice program called Transitions, designed to give elderly patients the care they want at home and keep them out of the hospital.

Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans and teach them how to better manage their diseases. Physicians track their health and scrap unnecessary medications. Unlike hospice care, patients don’t need to have a prognosis of six months or less, and they can continue getting curative treatment for their illnesses, not just for symptoms.

Before the Transitions program started, the only option for many patients in a health crisis was to call 911 and be rushed to the emergency room. Now, they have round-the-clock access to nurses, one phone call away.

“Transitions is for just that point where people are starting to realize they can see the end of the road,” said San Diego physician Dan Hoefer, one of the creators of the program. “We are trying to help them through that process so it’s not filled with chaos.”

The importance of programs like Transitions is likely to grow in coming years as 10,000 Baby Boomers — many with multiple chronic diseases — turn 65 every day. Transitions was among the first of its kind, but several such programs, formally known as home-based palliative care, have since opened around the country. They are part of a broader push to improve people’s health and reduce spending through better coordination of care and more treatment outside hospital walls.

But a huge barrier stands in the way of pre-hospice programs: There is no clear way to pay for them. Health providers typically get paid for office visits and procedures, and hospitals still get reimbursed for patients in their beds. The services provided by home-based palliative care don’t fit that model.

In recent years, however, pressure has mounted to continue moving away from traditional payment systems. The Affordable Care Act has established new rules and pilot programs that reward the quality rather than the quantity of care. The health reform law, for example, set up “accountable care organizations” networks of doctors and hospitals that share responsibility for providing care to patients. They also share the savings when they rein in unnecessary spending by keeping people healthier. Those changes are helping to make home-based palliative care a more viable option.

In San Diego, Sharp’s palliative-care program has a strong incentive to reduce the cost of caring for its patients, who are all in Medicare managed care. The nonprofit health organization receives a fixed amount of money per member each month, so it can pocket what it doesn’t spend on hospital stays and other costly medical interventions.

Gerald Chinchar’s medicine is packed in a kitchen drawer for a Sharp HealthCare Transitions program nurse to check. (Heidi de Marco/KHN)

‘Something That Works’

Palliative care focuses on relieving patients’ stress, pain and other symptoms as their health declines, and it helps them maintain their quality of life. It’s for people with serious illnesses, such as cancer, dementia and heart failure. The idea is for patients to get palliative care and then move into hospice care, but they don’t always make that transition.

The 2014 report “Dying in America,” by the Institute of Medicine, recommended that all people with serious advanced illness have access to palliative care. Many hospitals now have palliative-care programs, delivered by teams of social workers, chaplains, doctors and nurses, for patients who aren’t yet ready for hospice. But until recently, few such efforts had opened beyond the confines of hospitals.

Kaiser Permanente set out to address this gap. Nearly 20 years ago, it created a home-based palliative care program, testing it in California and later in Hawaii and Colorado. Two studies by Kaiser and others found that participants were far more likely to be satisfied with their care and more likely to die at home than those not in the program. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

One of the studies, published in 2007, found that 36 percent of people receiving palliative care at home were hospitalized in their final months, compared with 59 percent of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t.

“We thought, ‘Wow. We have something that works,’” said Susan Enguidanos, an associate professor at the University of Southern California’s Leonard Davis School of Gerontology, who worked on both studies. “Immediately we wanted to go and change the world.”

But Enguidanos knew that Kaiser Permanente was unlike most health organizations. It was responsible for both insuring and treating its patients, so it had a clear financial motivation to improve care and control costs. Enguidanos said she talked to medical providers around the nation about this type of palliative care, but the concept didn’t take off at the time. Providers kept asking the same question: How do you pay for it without charging patients or insurers?

“I liken it to paddling out too soon for the wave,” she said. “We were out there too soon. … But we didn’t have the right environment, the right incentive.”

A Bold Idea

Dan Hoefer’s medical office is in the city of El Cajon, which sits in a valley in eastern San Diego County. Hoefer, a former hospice and home health medical director and nursing-home doctor, has spent years treating elderly patients. He learned an important lesson when seeing patients in his office: Despite the medical care they received, “they were far more likely to be admitted to the hospital than make it back to see me.”

When his patients were hospitalized, many would decline quickly. Even if their immediate symptoms were treated successfully, they would sometimes leave the hospital less able to take care of themselves. They would get infections or suffer from delirium. Some would fall.

His patients were like cars with 300,000 miles on them, he said. They had a lot of broken parts. “You can’t just fix one thing and think you have solved the problem,” he said.

And trying to do so can be very costly. About a quarter of all Medicare spending for beneficiaries 65 or older is to treat people in their last year of life, according to a report by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Hoefer’s colleague, Suzi Johnson, a nurse and administrator in Sharp’s hospice program, saw the opposite side of the equation. Patients admitted into hospice care would make surprising turnarounds once they started getting medical and social support at home and stopped going to the hospital. Some lived longer than doctors had expected.

In 2005, the pair hatched and honed a bold idea: What if they could design a home-based program for patients before they were eligible for hospice?

Thus, Transitions was born. They modeled their new program in part on the Kaiser experiment, then set out to persuade doctors, medical directors and financial officers to try it. But they met resistance from physicians and hospital administrators who were used to getting paid for seeing patients.

“We were doing something that was really revolutionary, that really went against the culture of health care at the time,” Johnson said. “We were inspired by the broken system and the opportunity we saw to fix something.”

Despite the concerns, Sharp’s foundation board gave the pair a $180,000 grant to test out Transitions. And in 2007, they started with heart failure patients and later expanded the program to those with advanced cancer, dementia, chronic obstructive pulmonary disease and other progressive illnesses. They started to win over some doctors who appreciated having additional eyes on their patients, but they still encountered “some skepticism about whether it was really going to do any good for our patients,” said Jeremy Hogan, a neurologist with Sharp. “It wasn’t really clear to the group … what the purpose of providing a service like this was.”

Nevertheless, Hogan referred some of his dementia patients to the program and quickly realized that the extra support for them and their families meant fewer panicked calls and emergency room trips.

Hoefer said doctors started realizing home-based care made sense for these patients — many of whom were too frail to get to a doctor’s office regularly. “At this point in the patient’s life, we should be bringing health care to the patient, not the other way around,” he said.

Across the country, more doctors, hospitals and insurers are starting to see the value of home-based palliative care and are figuring out how to pay for it, said Kathleen Kerr, a health care consultant who researches palliative care.

“It is picking up steam,” she said. “You know you are going to take better care of this population, and you are absolutely going to have lower health care costs.”

Providers are motivated in part by a growing body of research. A studypublished in January showed that in the last three months of life, medical care for patients in a home-based palliative care program cost $12,000 less than for patients who were getting more typical treatment. Patients in the program also were more likely to go into hospice and to die at home, according to the study.

Two studies of Transitions in 2013 and 2016 reaffirmed that such programs save money. The second study, led by outside evaluators, showed it saved more than $4,200 per month on cancer patients and nearly $3,500 on those with heart failure.

The biggest differences occurred in the final two months of life, said one of the researchers, Brian Cassel, who is palliative care research director at the Virginia Commonwealth University School of Medicine in Richmond.

One reason for the success of these programs is that the teams really get to know patients, their hopes and aspirations, said Christine Ritchie, a professor at UC San Francisco’s medical school. “There is nothing like being in someone’s home, on their turf, to really understand what their life is like,” she said.

Reddish parts of blue California depend heavily on Medicaid


FRESNO, Calif.

In 2012, when Jerry Goodwin showed up at a clinic with intense pain and swelling in his legs, doctors called for an ambulance even though the hospital was across the street. That generated a $900 bill — just the beginning of a nearly three-year ordeal for Goodwin, who was uninsured.

Diagnosed with cellulitis and an irregular heartbeat, Goodwin managed to get his emergency care costs covered through the hospital but then faced month after month of bills for follow-up care and medications.

Finally, in 2015, he was able to sign up for Medicaid coverage, which was expanded under the Affordable Care Act to cover many single adults without children. “That was a big relief,” said Goodwin, 64.

Now Goodwin and people like him are worried all over again.

Under Republican efforts to repeal, replace or reform the health law, many people on Medicaid — the nation’s single-largest insurer, with 72 million beneficiaries — could see their coverage slashed. The biggest chunk of them — 13.5 million — live in California. The state predicted Wednesday it could lose $24 billion in federal funding annually by 2027under the current GOP proposal.

Among the hardest hit regions would be the Central Valley, the state’s agricultural heartland, stretching hundreds of miles from Redding to Bakersfield. Toward the south, in Fresno County, about half the population of 985,000 relies on Medi-Cal, as California’s Medicaid program is known. In adjacent Tulare County, 55 percent of the more than 466,000 residents were enrolled in Medi-Cal as of January 2016.

Much has been said about the plight of conservative voters in the Midwest who rely on Medicaid, a program the Trump administration and congressional Republicans are determined to shrink. But despite its reputation as a deep-blue state, California also has several red — or reddish — counties in its interior with millions of low-income people who depend heavily on Medicaid. Many live in congressional districts represented by Republicans who want to scrap or change the Affordable Care Act, also known as Obamacare.

J. Luis Bautista, M.D., an internist at Bautista Medical Center in Fresno, Calif., examines farm worker Jose Gonzalez in February. 

The current Republican bill, the American Health Care Act, would cut Medicaid funding by 25 percent by 2026, covering 24 million fewer people than today, according to the nonpartisan Congressional Budget Office.

“These are remarkable estimates,” said John Capitman, the executive director at the Central Valley Health Policy Institute and a professor at California State University, Fresno, referring to the CBO projections. “The level of cuts are devastating, and for California and the Central Valley, this represents a huge loss.”

The bill faces opposition from the left and right and is undergoing last-minute changes in the run-up to a House floor vote Thursday. Despite several protests in the valley and around the state, at least half of Republican lawmakers in the state appear poised to support it; several others are noncommittal.

U.S. Rep. Devin Nunes, whose congressional district includes portions of Tulare and Fresno counties, likes the proposal, saying it will improve care for everyone, including current Medi-Cal participants.

“Medi-Cal is a broken healthcare system that’s been completely mismanaged by the State of California,” Nunes said in a recent statement.

Capitman said Medi-Cal is vital in the Central Valley because of its high poverty rate, uneven access to care and pockets with very poor health outcomes. Many of these communities also depend on the Prevention and Public Health Fund, which was established by the ACA to fight chronic diseases and also is in peril, he said.

The valley suffers high rates of diabetes, obesity and heart disease. The area has some of the country’s dirtiest air, triggering epidemic levels of asthma. Wage stagnation and high unemployment contribute to stress and poor mental health.

Some areas are far better off than others. Within 10 miles, Capitman said, you can find up to a 20-year difference in life expectancy. On average, life is much shorter for residents in Southwest Fresno, for instance, where heavy industry soils the air, homeless people camp on sidewalks, and fences cage in lots overgrown with grass and weeds.

Not far away, Petra Martinez, a former fieldworker, recently waited to see a doctor at a crowded downtown clinic. At 86, she receives coverage from both Medi-Cal and Medicare, the federal insurance program for the elderly. She needs medication for arthritis, epilepsy and diabetes, all of which is paid for her through her dual coverage.

Though the proposed House bill seemingly would not shrink spending on people with dual coverage, she is wary of what lies down the road.

“I’d like to think that we [seniors] will be OK, that maybe we won’t be affected by whatever changes are coming, but who knows?” Martinez said. “I don’t want to have to ask my children for money to go to the doctor.”

Dr. J. Luis Bautista, M.D., an internist at the clinic, estimates he’s seen a 20 percent increase in patient visits since the rollout of the ACA in 2014. The majority of his patients are on Medi-Cal.

“These are the people who usually wait until they’re very sick to come,” Bautista said. “We’ve seen people with high blood pressure who come in when they already have eye problems and heart problems. … They waited too long.”

But since the ACA rolled out, he said, preventive visits seem to have increased.

Dr. Bautista examines Kathy Macias, 53, while her mother, Connie Hernandez, 72, waits to be seen last month.

Fifteen miles outside the city of Fresno is Sanger, a largely Latino town of 25,000 where almost a quarter of residents live in poverty, according to the U.S. Census.

Here a neighborhood of newer houses with commuter residents isn’t far from another that lacks sidewalks and is strewn with aging or abandoned businesses and chain stores.

On a recent day, a hairstylist was tending to a client in a downtown salon nestled among boutiques, cafes and other small businesses. The stylist said she and her two teenagers are on Medi-Cal — and so are most of the people she knows. A single mother, she said she works six days a week but can’t afford to buy health coverage.

The salon’s owner interjected that she doesn’t oppose greater restrictions on who gets Medi-Cal — but plans on the state’s insurance exchange should be more affordable, so people will be drawn to buying coverage.

The women asked that they and the business not be identified.

Less than an hour southeast of Fresno, Iliana Troncoza lives in the city of Tulare, part of a heavily agricultural county of the same name. The county has one of the lowest incomes per capita in California.

Troncoza, a 47-year-old homemaker who takes care of her ailing husband, gets her health care at Altura Centers for Health, which runs seven clinics in the city. The thought of Medi-Cal cutbacks fills her with anxiety. Both she and her daughter, a college freshman, rely on the program for coverage.

Iliana Troncoza, 47, of Tulare, Calif., said she had gone without health coverage for six years before qualifying for Medi-Cal under the expansion.

Troncoza had gone without coverage for six years before qualifying under the ACA expansion. She traveled to Jalisco, Mexico, to remove a breast cyst because couldn’t afford the procedure in the U.S. Now, in her city, she can receive mammograms and ultrasounds, and has been able to obtain medication for her depression and anxiety, she said.

“It’s horrible to think that our Medi-Cal depends on people who don’t understand our situation,” Troncoza said.

Graciela Soto, CEO of Altura clinic system, said 75 percent of its patients are on Medi-Cal and 9 percent of patients are uninsured, mostly because of their immigration status. It’s quite a difference from 2012, before the ACA was implemented, when 50 percent of patients were on Medi-Cal and 35 percent uninsured, she said.

“The Medicaid expansion was wonderful for our patients,” Soto said.

Through the ACA, Soto said, many young women were able to access free or affordable birth control. That’s important, she said, because Tulare County has among the highest teen pregnancy rates in the state.

The region has a large population of migrant farm workers, many of whom don’t qualify for Medi-Cal. But a substantial portion of Latinos do qualify, as do non-Hispanic whites like Goodwin.

Among whites, the need for mental health and substance abuse services is growing, research suggests. Drug overdoses, alcohol abuse and suicide have significantly contributed to rising death rates, according to a study out of the Center on Society and Health at Virginia Commonwealth University.

In Fresno County, for example, the rate at which middle-aged white adults are dying from accidental drug poisoning has tripled since 1990, according to the report.

Some residents have turned to activism in their efforts to preserve ACA coverage. In January, Greg Gomez, a councilman for the city of Farmersville in Tulare County, led a small-scale protest outside Nunes’s office in Visalia.

It wasn’t just about politics — it was personal. Three of Gomez’s children are covered by Medi-Cal.

“The monthly premium to get my whole family covered by my employer would be about $2,000,” said Gomez, a computer systems engineer for Tulare County and former president for the local chapter of the Service Employees International Union. “That is totally out of reach. That’s why we need Medi-Cal. And that’s the story of a lot of Tulare residents.”


Congressman’s safely gerrymandered district lets him vehemently oppose ACA


The Blue Ridge Mountains in western North Carolina.


For Kaiser Health News


In this corner of Appalachia, poverty takes a back seat to art galleries, country clubs, golf course communities, five-star restaurants and multimillion-dollar houses.

From this perch, Rep. Mark Meadows, a real estate entrepreneur who capitalized on the area’s transformation into a prosperous retirement and vacation community, rose to political power quickly. Now the conservative Republican leads the House Freedom Caucus, controlling between 30 and 40 votes in Congress and showing few qualms about endangering his party’s best chance to repeal the Affordable Care Act.

“I am willing to invest the political capital to get it right,” Meadows, who has called the GOP replacement “Obamacare Lite,” said Thursday on MSNBC. “The next week is critical.”

And last Saturday, Meadows went to President Trump’s Mar-a-Lago Club in Florida to negotiate over the bill with Trump aides, along with with Sen. Ted Cruz (R-Texas) and Sen. Mike Lee (R-Utah).

Meadows’ confidence is warranted.

His gerrymandered district covers 17 counties, spanning 150 miles across western North Carolina. The populous liberal bastion of Asheville is mostly carved out of his district like a bite from a cookie. What’s left is a retiree-rich constituency of 750,000 people that is heavily Republican, mostly white and lives mainly in small, rural towns amid pockets of extreme wealth. Its survival could hinge on a Supreme Court ruling expected this year in a case alleging racial bias in the state Legislature’s 2011 redrawing of North Carolina’s congressional map.

Elected in 2012, Meadows, 57, has rebelled against the establishment Republican Party — helping shut down the government in 2013 and ousting Speaker John Boehner in 2015.

While Democrats and even moderate Republicans decry House Speaker Paul Ryan for cutting federal aid to help get people insured in the GOP bill, Meadows says the cuts don’t go deep enough. He vows to oppose any ACA replacement that does not bring down health costs for people and government. No such plan that actually controls costs is on the table, however.

Meadows wants to cut off all 10 million Americans who today get federal subsidies to buy health coverage, which he says the country can ill afford. With enough support, Meadows could either block the House leadership from passing its plan or force it to approve a more conservative replacement that would face little chance of getting through the more moderate Senate.

Meadows’ potential role as “Trumpcare” spoiler — is stirring concern in the White House and Congress. By Thursday, Meadows seemed to have gotten that message.

“The last thing I want is for the president to be mad at me,” Meadows told Politico. “He asked me to negotiate in good faith, so I have been working around the clock.”

Meadows was absent, though, from a Friday meeting in the Oval Office with members of the Republican Study Committee, another group of conservative representatives, where Trump said he had secured enough votes to pass the House bill.

Meadows’s hard line doesn’t bother most folks back in western North Carolina, where Obamacare is unpopular. Only about 5 percent of those in his district receive government-subsidized health plans made available by the law.

Meadows, who now lives in West Asheville, moved to North Carolina from Tampa to raise a family in the 1980s. The proprietor of a small sandwich shop here in Highlands before he shifted to real estate, Meadows is revered by his constituents.

Even the local hospital industry — which typically opposes any effort to scale back the health law — remains firmly in Meadow’s corner.

“We are big fans of Mark. He’s a man of integrity and he has the heart,” said Jimm Bunch, CEO of Park Ridge Health, a 103-bed hospital in Hendersonville, N.C. He heaps praise on Meadows even as the congressman fights to eviscerate the law that helped the hospital achieve one of its best financial years ever. As more patients got insurance, Park Ridge gained $600,000 a year in funding it used to provide free care to other patients.
Small-business owners, who provide most jobs in the district, are reluctant to take on Meadows., who is seeking to eliminate their government assistance to get health coverage.Because North Carolina did not expand Medicaid under Obamacare, many poor adults remained uninsured. The state’s uninsured rate fell from 20.4 percent in 2013 to 13.6 percent in 2016, 2.5 points higher than the national average, according to Gallup.

At Sanctuary Brewing, in Hendersonville, co-owner Joe Dinan said the Obamacare coverage he bought this year helped him get skin-cancer surgery on his head. “I don’t want to see the subsidy end,” Dinan said. He won’t say anything critical about Meadows though, demurring that Hendersonville is a small town.

Meadows insists no one will get left behind.

He wants to allow people to buy less-expensive policies with fewer benefits than now required under the ACA. His tax help would be in the form of deductions people take at the end of the year or a break on their payroll taxes — different than both the current law and the Trumpcare plan working its way through Congress now.

It worries Rachel Lewicki, 30, who works at the local tea and spice shop on Main Street in Highlands.

Lewicki recently had surgery for a uterine tumor, paid for by a subsidized health plan she bought under Obamacare that costs her less than $100 a month. Now she fears her good fortune will end. “It’s not fair,” she said. “The way things are going, I’m scared and so are a lot of people who need this help.”

Kent Loy, a volunteer at a thrift store in Hendersonville, speaks of Meadows in harsher, personal terms.

“It’s an attack on the poor and how someone who claims to be a Christian can take this behavior is beyond me,” said Loy, 71. “This should disqualify him from office.”

But it won’t, said Chris Cooper, professor of political science at Western Carolina University. Meadows has little to worry about in his heavily Republican district where he took 65 percent of the vote in November. “Taking out Asheville turned the district from being the most competitive district in the state to the most conservative,” Cooper said.

The political climate is challenging for cultivating grass-roots opposition, according to Susan Kimball, of Waynesville, N.C., who is part of Progressive Nation WNC, a group pushing to retain the ACA.

She said she has sought to meet Meadows in his district office several times to complain about his Obamacare stance, but to no avail.

Critics like her have recently pushed Meadows to hold a town hall meeting to hear their views, as many members of Congress did in the past month. His office said Meadows arranges such meetings only in August.

“I just feel like he doesn’t care,” Kimball said.

A cancer survivor, Kimball, 62, has benefited from Obamacare’s mandate that insurers provide coverage to people with preexisting health conditions. For $237 a month, Kimball has a subsidized Blue Cross plan that pays for visits to doctors and tests when she needs them.

She moved to Waynesville from South Florida four years ago, and the area’s conservatism has been an eye-opener.

“We were just moving to the mountains, and we didn’t know the region would become Tea Party central,” Kimball said.

Fact-checking news about GOP healthcare bill


For Kaiser Heath News

Republicans are in a hurry to get their “repeal and replace” healthcare bill to the House floor.

In just the week since it was introduced, two committees have approved the “American Health Care Act,” and a floor vote is planned before month’s end.

But in the rush to legislate, some facts surrounding the bill have gotten, if not lost, a little buried. Here are five things that are commonly confused about the h effort.

1. The GOP bill would replace the health law’s subsidies with tax credits.

Not really. The GOP bill would replace the Affordable Care Act’s tax credits with different tax credits.

Under the ACA, people with income above the poverty line (about $12,000 for an individual in 2017) and under four times the poverty line (about $47,000) who buy their own insurance are eligible for advanceable, refundable tax credits. “Advanceable” means they don’t have to wait to file their taxes, so the money is available each month to pay premiums; “refundable” means credits are available even to those with incomes too low to owe federal income tax. The ACA’s tax credits are based on income and the actual price of health insurance available to each individual.

The GOP bill also has advanceable, refundable tax credits. They are based on different criteria, though. The Republican tax credits would increase with age (from $2,000 for youngest adults to $4,000 for older adults not yet eligible for Medicare), and would gradually phase out with income (starting at $75,000 for individuals and $150,000 for families). They would not vary by geographic region or the cost of coverage. And while older adults would get credits twice as large as younger adults, another change in the bill would let insurers charge those older customers’ premiums that are five times as high. In the current law, the difference is 3-to-1.

There are actual subsidies in the ACA — they help people with incomes between 100 and 250 percent of poverty ($12,060 to $30,150 for an individual) pay their deductibles and coinsurance or copays. These subsidies are the subject of an ongoing lawsuit filed by the House against the Obama administration. Those subsidies would be repealed under the GOP bill.

2. Republicans have left popular provisions of the ACA in their bill because they are popular.

Not necessarily. True, the public supports the provisions of the law that allow adult children to stay on their parents’ health plans until they turn 26 and that prohibit insurers from rejecting or charging more to people with preexisting health conditions. Those things remain in the GOP bill.

But even if Republicans had wanted to get rid of those provisions, they likely could not. That’s because the budget rules Congress is using to avert a filibuster in the Senate forbid them from repealing much of the ACA that does not affect government spending.

3. This bill is one part of a three-part effort to remake the  law.

This is true; Republicans continually refer to their healthcare effort as having three “buckets.” One is the budget bill currently under consideration. A second is the power of Health and Human Services Secretary Tom Price, M.D., to make administrative changes that would undermine the ACA.

The third is follow-up legislation that would allow things like selling insurance across state lines and limiting damages in medical malpractice lawsuits. House Speaker Paul Ryan (R.-Wis.) referred to that in a Thursday press conference as “additional legislation that we feel is important and necessary to give us a truly competitive healthcare marketplace.”

What Republicans usually don’t say, though, is that the second and third parts are complicated. Changing federal regulations generally requires a cumbersome process of advertising the changes, soliciting comments and revising the rules. Controversial changes also can bring lawsuits and lengthy legal proceedings. In addition, any subsequent bills on the law would require 60 votes to pass the Senate because they would not be covered by the budget rules Republican are using for this first legislation. Republicans currently have a 52-48 vote majority in that chamber, and Democrats have so far been united in opposing the GOP’s health changes.

4. The bill’s Medicaid provisions just scale back the program’s expansion.

In truth, the Medicaid portions of the GOP bill would fundamentally restructure the Medicaid program.

The Affordable Care Act allowed states to expand Medicaid, whose cost is shared between the states and federal government, to everyone with incomes under 138 percent of poverty. Previously, eligibility was restricted to those in specific categories (primarily low-income pregnant women, children, seniors and those with disabilities). Because Medicaid was already a significant financial burden for states, the federal government offered to pay the entire cost for the expansion population for the first three years, eventually dropping back to 90 percent, which is still more than states get for traditionally eligible populations.

The GOP bill would end new enrollment in that expanded program in 2020. It would continue to cover people who had already qualified — but since many people in Medicaid churn in and out of the program, the number of enrollees is likely to gradually decline.

But that’s just the beginning of the Medicaid changes. The Republican bill would, for the first time ever, limit the amount the federal government provides to states for Medicaid spending. It would make payments based on the number of enrollees in each state and that “per-capita” cap is expected over time to shift more financial responsibility for the program to the states. The left-leaning Center on Budget and Policy Priorities estimates that states could be on the hook for an additional $370 billion over 10 years if the bill becomes law.

5. The GOP bill is a huge tax break for the wealthy.

This is technically true — the bill would provide nearly $600 billion in tax breaksover the next decade, almost all of it going to the wealthy, according to the nonpartisan Committee for a Responsible Federal Budget.

But that’s not because Republicans set out to lower taxes on wealthy people. It’s because they are repealing nearly all the taxes that helped pay for the health law’s benefits, and the Democrats had targeted many of those to higher-income people.

Social costs of repealing the ACA

Tara McKay, writing in Health Affairs, discusses the social costs associated with repealing the Affordable Care Act. Among her observations:

“In the United States, where health care is viewed as more of a commodity than a right, the promise of expanding access to health insurance, especially publicly subsidized insurance, is relational and redistributive. The most basic role of government is to protect its citizens, especially those who are most vulnerable. In order to achieve this, those of us with insurance have to understand the issue of expanding access to insurance as our issue. Instead, the social reality of the millions of uninsured Americans—those who were uninsured prior to the passage of the ACA, those who remained uninsured well after its implementation, and those who may lose coverage as a result of a repeal—is one of exclusion and marginalization not just from health care, but from our society as a whole.”

To read the piece, please hit this link.

GOP health plan to give more help to richer people


A Washington Post analysis of House Republicans’ newly unveiled plans  to rewrite the Affordable Care Act  would give more financial help to richer people and cut federal assistance to moderate- and low-income people.The new legislation would  let individuals earning up to $75,000 a year and married couples earning as much as $150,000  get a refundable tax credit; some Americans earning more than that also would get help,  albeit in lessening amounts.

The Post observed”

“These changes, aimed at curbing the federal spending on health care, reflect Republicans’ fundamentally different vision of government’s role. Rather than expand a social safety net for poorer Americans, at the risk of imposing financial burdens on future generations, they hope to set in motion free-market approaches that would change the way many Americans access health care.”


To read the analysis, please hit this link. 

How small Calif. insurer has done okay with ACA



Some large health insurance companies have suffered losses under the Affordable Care Act, leading to a few high-profile exits from the online marketplaces. Humana is just the latest, announcing in January that it will stop offering health insurance on the ACA health exchanges at year’s end.

But the administrators of a smaller, California-based insurer — Molina Healthcare — managed to turn a modest profit in the early years of the 2010 health law and break even in 2016. How did they do it?

“We understood the demographics of the people that we’re serving a little better,” said Dr. J. Mario Molina, CEO of Molina Healthcare, “because we’ve been doing it for so long.”

Despite a disappointing fourth quarter of 2016, Molina remains a fan of the Affordable Care Act overall and hopes Congress will consult with him and other insurers as it debates the health law’s fate.

“It doesn’t need to be scrapped and replaced,” he said. “It needs a tuneup.”

Molina’s business grew out of a network of Southern California medical clinics serving mostly low-income patients that was founded in 1980 by his father, David, also a doctor. Sometimes when his dad’s patients couldn’t pay, they would trade services, or give him items from their homes instead of cash, the younger Molina recalled: a glass decanter, a pipe organ, even a dog.

“My father was old-fashioned,” said the CEO. “He believed doctors had an obligation to take care of patients and that the primary issue was not how they were going to get paid.”

In 1994, David Molina started his health insurance company, focusing on getting care to patients on Medicaid — government health insurance for the poor and disabled.

That is what positioned Molina Healthcare to move into the Obamacare marketplaces so smoothly, Mario Molina said — most people who signed up for Obamacare plans represent low-income households.

“It’s a different population most insurance companies haven’t been interested in,” he said.

For example, transportation is an issue for his company’s customers. They often take the bus to medical appointments, he said, so they’d rather see a doctor close to home than at an academic hospital 30 miles away.

“We don’t contract with every hospital and every doctor,” he admitted. “It’s not everyone, but it’s enough so that you can find a doctor and the hospital and the services you need.” His company operates in 12 states and Puerto Rico.

Although some observers have criticized narrow insurance networks for not offering consumers enough choice, especially of medical specialists, having fewer doctors in the Molina Healthcare network has meant lower costs for the company and its customers. That means the health insurance company has been able to earn a modest profit — roughly 1 percent in the first couple years of Obamacare.

Some larger insurers are accustomed to creating health plans for big companies, who often want more doctors and more benefits included, in hopes of attracting and retaining top employees. But plans like that cost more.

“They’re looking at things sort of from the top down, and we’re looking at things from the bottom up,” Molina said.

He’s accustomed to running a low-cost, low-margin business, while big guys like Humana, Aetna and UnitedHealthcare aren’t. Industry analysts say that’s why some of the big players lost money with Obamacare.

“It’s easier to work up from a low-cost position than it is to work down from a higher-cost position,” said Josh Weisbrod, a health care consultant with Bain & Company. “For an insurer that is used to selling employer plans with rich benefit designs and broad networks, it is difficult for them to transition that to a narrow network of lower-cost providers.”


Molina Healthcare started with a system of medical clinics Dr. David Molina (left) founded in Long Beach, Calif., in 1980. (Courtesy of Molina Healthcare)

But Molina said there’s been a serious downside to his company’s success: a provision of the Affordable Care Act known as “risk transfer.” The provision was designed to help insurance companies cover lossesif they ended up with a lot of very sick, expensive patients. It works like this: Companies with fewer patients who have a chronic or serious illness pay some of their revenue to the companies that cover more patients who are sick.

It was a fine idea, Molina said, but the formula lawmakers came up with to calculate risk was all wrong.

“Let’s put it this way,” he said. “Currently Molina Healthcare is returning 25 percent of our premiums to the government, which are then distributed to our competitors. So we are really subsidizing our competitors and helping them, rather than forcing them to compete.”

And that is one of the things that hit Molina’s bottom line in 2016, resulting in much lower profits than originally projected for the year and a significant fourth quarter loss. Molina complained that the risk formula seems to punish efficiency rather than help those who had some bad luck.

“I think it was done by well-meaning people who had a theoretical knowledge but not a practical knowledge of insurance,” he said.

If lawmakers need guidance on how to fix Obamacare, he added, they should look at one state that definitely got it right: California.

California insurance regulators and health officials “forced everyone to really compete,” Molina said, “and that made everyone kind of sharpen their pencils and do a better job,” he said. “It’s kept everyone on their toes, and, as a result, I think there’s been more stability in the marketplace.”

There’s also more predictability. California may have more business regulations than other states, but Molina suggested that has created a level playing field.

“The state doesn’t make arbitrary decisions,” he said. “We can plan from year to year. We understand the rules. Imagine if you’re trying to play a game and the rules change in every quarter.”

Molina expressed hope that newly elected rule makers at the federal level will take his message to heart, too.

This story is part of a reporting partnership with KQED, NPR and Kaiser Health News.

Disease-prevention programs in the Trump administration

An article in Health Affairs looks at how the Trump administration could push disease-prevention efforts while it also kills much of the Affordable Care Act.

The authors note:

“Using the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015, legislation put forward by the new Secretary of Health and Human Services Dr. Tom Price, as a template, it is likely that the Prevention and Public Health Fund could be repealed given its budgetary impact. If full repeal of the ACA happens, the authority for some prevention-focused rules created through the ACA, such as rules on nutrition labeling of standard menu items at chain restaurants, would also disappear.

“Beyond the ACA, however, there is reason to believe that prevention can and may play a role in the Trump Administration and Republican Congress, given the core Republican philosophical objective of reducing federal entitlement spending. While Medicare premium support and Medicaid block grants may be strategies pursued by Republican leadership to reduce government spending on health care, overall health care expenditures continue to rise as evidenced by the latest national health spending data from the Centers for Medicare and Medicaid Services. Recent data on U.S. spending on personal healthcare and public health demonstrate that preventable chronic conditions such as diabetes, ischemic heart disease, and hypertension account for the highest amounts of health care spending. Without reducing the prevalence of chronic diseases, it will be difficult to achieve a sustained moderation of health care costs.

“To promote chronic disease prevention, any strategy will likely adhere to two fundamental Republican principles – 1) personal responsibility and 2) locally driven solutions. There are several possible ways the Trump administration could advance prevention consistent with these principles”

To read the article, please hit this link.

Fear of a “public-health crisis’ if ACA is quickly repealed


Downtown Princeton, Ill.


Kaiser Health News


Commuting past the barren winter fields in northern Illinois, Cathie Chapman worries about the future.

More than a year ago, she lost her job at a nearby rural hospital after it closed and, as Republicans work to dismantle the Affordable Care Act, wonders whether she’ll soon be out of work again.

“Many of my friends did not find jobs they love,” she said. “They’re working for less money or only part time. Some haven’t found any jobs yet, even after a year.”

Now she runs the pharmacy at Perry Memorial Hospital here, warily watching the Republicans’ repeal efforts.

“I think everybody who works in health care now feels a little uneasy,” said Chapman. “We don’t know what’s coming around the corner, and how it will affect us. But we know that change is happening so fast, it is exhausting and difficult to keep up with.”

Rural hospitals have long struggled to stay open. They have far fewer patients and thin profit margins. Dozens have closed across the country in recent years, mostly in states that didn’t expand Medicaid.

But in Illinois, which did extend Medicaid to nearly all poor adults, patients at Perry Memorial have gained coverage under the Affordable Care Act and many hospitals have found firmer footing.

If large numbers of people lose their insurance under the Republicans’ replacement, the hospital’s finances — and those of its patients — would be at risk, especially after the hospital invested so much money and time in complying with the health law, said chief executive Annette Schnabel.

“We have spent the last six years gearing up towards everything that we were responsible for doing in the ACA,” said Schnabel. If the hospital has to “totally go a different direction, how will we do that? It’s going to take a lot of work.”

And for some hospitals to survive or break even, it would require Congress to restore billions of dollars in funding that kept hospitals afloat before the 2010 law took effect.

Hospitals across the country made a high-stakes trade when they signed on to the Affordable Care Act. They agreed to massive cuts in federal aid that defrayed the cost of caring for the uninsured. In exchange, they would gain tens of millions of newly insured customers. Now that deal is in jeopardy, and many hospital executives anxiously await whatever comes next.

Those patients now have Medicaid coverage because of the Affordable Care Act, and the Cook County hospital system gained $200 million in new revenue to cover their services, breaking even for the first time. In Chicago, John H. Stroger Jr. Hospital of Cook County is among the nation’s busiest hospitals, handling most of the city’s gunshot victims. The vast majority of its patients used to be uninsured, and the county-run hospital struggled to take care of their medical and mental health needs.

“We have no interest in slipping back in what we’ve been able to do,” said Dr. John Jay Shannon, chief executive of the Cook County Health and Hospitals System. “We’re not able to do the kind of work that we do today with good will alone. Our staff are not a volunteer staff. We can’t get IV fluids and medical equipment on credit and a wink and a nod.”

Two hospital trade groups — the American Hospital Association and the Federation of American Hospitals — have warned of “an unprecedented public health crisis” if the law gets hastily scuttled.

They say if Congress repeals the law entirely and 20 million people are kicked off their insurance, hospitals will lose $166 billion in Medicaid payments alone in the next decade.

And hospitals face much steeper losses if certain Medicare cuts that were part of the law aren’t restored.

In Chicago, limo driver Jerold Exson is one patient who could lose coverage and have his hospital bills — once again — go unpaid. These days, the hospital helps enroll low-income adults such as Exson into Medicaid. In 2014, he was shot nearly a dozen times in a case of mistaken identity.

His medical care is now covered, and the hospital can provide follow-up surgeries, physical therapy and mental health treatment that were often off-limits to the uninsured.

Clinical psychologist Natalia Ruiz helps Exson manage the after-effects of gun violence. “I used to be real antsy,” said Exson who suffers from post-traumatic stress disorder. He recalled a recent moment when he was driving and a “rock hit the window, and it kind of sent me into a tailspin.”

The health law also shifted the business model for U.S. hospitals. It offered them financial incentives to move away from expensive ER visits to primary care and managing chronic conditions.

Earl Williams Sr. finally has brought his diabetes under control. He’s diligent about exercising, taking his medication and seeing his doctor.

“I had high sugar levels, I had high blood pressure, there was quite a few things that was going on with me that now I know how to control,” said Williams.

Before the Affordable Care Act, hospitals had little incentive to reduce emergency department visits, especially from Medicare patients who generate a lot of revenue.

At University of Chicago Medicine, an academic medical center, Dr. Kenneth Polonsky said if those incentives are rescinded and patients forgo preventive care, they’ll clog up already strained emergency rooms.

“We’ll go back to a very frustrating time, where people had limited options for health care, because of inability to get health insurance,” said Polonsky, dean of the Division of the Biological Sciences.

The uncertainty is also roiling county governments, which often fund medical care for the poor.

The burden on local taxpayers to fund the Cook County health system has dropped by $300 million since the health law went into effect, and repealing the law could force local governments to raise taxes.
In Waukegan, Ill., near the Wisconsin border, Vista Health System chief executive Barbara Martin said that with more patients covered and additional reimbursement from the ACA, she has invested in new equipment and hired hundreds of new employees across Vista’s two for-profit hospitals.“It’s a $300 million hole in our budget,” said Toni Preckwinkle, president of the Cook County Board of Commissioners. “There aren’t a lot of options other than raising more revenue. It’s a nightmare for us.”

She said if the 900,000 Illinois residents who gained insurance under the law lose coverage — and hospital revenue drops suddenly — hospital executives estimate 95,000 jobs could be lost.

“That certainly would impact jobs at Vista,” Martin said. “We’re going to go back to those days where hospitals were closing.”

But Edmund Haislmaier, a senior fellow at the Heritage Foundation, a conservative think tank, said the U.S. already pays too much for health care. A member of President Donald Trump’s transition team on health policy, Haislmaier said communities — and states and local governments — shouldn’t rely on hospitals to create jobs and fill budget holes.

“Hospitals, in particular, have become economic development projects,” he said. “If you’re paying tax dollars for Medicare or Medicaid, treating that as an economic development project is a problem, not a benefit.”
The most recent draft of the Republican’s proposal would eliminate the Medicaid expansion, which covers 14 million people, by 2020. To offset the increase in uninsured patients, the plan would reverse some of the payment cuts to hospital.More than a dozen top Republican lawmakers declined to be interviewed for this story. But a spokeswoman for Sen. Lamar Alexander, the Tennessee Republican who chairs the Senate Committee on Health, Education, Labor and Pensions, said in a statement that Alexander “is listening to hospitals, doctors, patients, state insurance commissioners, governors” as they draft the replacement plan.

Back in Chicago, patients like Earl Williams have been bringing their questions to their doctors, with the hope of some clarity.

At a recent checkup, Williams asked pointedly, “Am I going to have insurance in a month or two? That’s kind of scary for brothers that’s in the community.”

“You and I have been knowing each other for a long time, and I’m going to give it to you straight,” responded William’s physician, Dr. Pete Thomas. “And that is: It’s likely that it’s going to change. It’s not going to be the same.”

PBS NewsHour producer Jason Kane contributed to this story.

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