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Subsidies worsen healthcare ‘system’ dysfunction

 

Megan McArdle writes in Bloomberg View that taxing hospitals is a bad way to fix the U.S. healthcare mess. Among her observations:

“Obamacare was supposed to increase utilization of the health-care system — which means utilization of hospitals, and therefore, their profitability. It was supposed to reduce the number of people who had medical bills they couldn’t pay. If you supported Obamacare, this is good news for your position: It shows the law working roughly as it was supposed to. So what’s the issue?

“Well, many hospitals have non-profit status, which means they don’t pay taxes on their revenue. To keep that nonprofit status, they are supposed to provide community benefits. One of the major benefits they provided was health care for people without insurance. Now that fewer people are without insurance, there is a question about just what constitutes a community benefit that would justify leaving these hospitals untaxed.  National Nurses United, a union that the article cites repeatedly, would like that community benefit to be defined as providing charity care. Hospitals would like it defined as ‘Anything we want to call community benefit.”’

“The labor union seems to be seeking to turn this provision of the tax code into a jobs program for nurses, by mandating that non-profit hospitals spend a certain amount of their revenue on charity care, an activity which will, of course, require the employment of many nurses. The hospitals, meanwhile, are trying to avoid paying a large tax bill, while avoiding any government interference in their operations. Both sides have wrapped themselves in the banner of the public good, as special interests are apt to do while they are sliding their hands into the taxpayer’s pocket.

“Neither side is necessarily wrong: Sometimes lobbyists promote good ideas that just happen to make their clients some money. And I find it all too easy to believe that hospitals are benefitting from a nice tax subsidy while not really doing much worth subsidizing.

“But if that’s the case, then the best solution is probably to stop subsidizing it, not to make the subsidy more complex. A lot of the current mess in the American health-care system can be traced back to the thicket of hidden subsidies and fiddling regulations we’ve enacted over the years, trying to fine-tune the system into some platonic ideal where nothing ever goes wrong and no one ever makes an unseemly amount of money. But fine tuning has not delivered us the platonic ideal of anything, except perhaps the word ‘dysfunction.’ It might be time to step back and rethink our approach.”

To read m0re, please hit this link.


McConnell seeks to hide GOP health bill’s pain until after the mid-terms

By MICHAEL McAULIFF

For Kaiser Health News

Senate Majority Leader Mitch McConnell is well aware of the political peril of taking health benefits away from millions of voters. He also knows the danger of reneging on the pledge that helped make him the majority leader: to repeal the Affordable Care Act usually pejoratively called “Obamacare”).

Caught between those competing realities, McConnell’s bill offers a solution: go ahead and repeal Obamacare, but hide the pain for as long as possible. Some of the messaging on the bill seems nonsensical (see: the contention that $772 billion squeezed out of Medicaid isn’t a cut). But McConnell’s timetable makes perfect sense — if you are looking at the electoral calendar.

Here are a few key dates in McConnell’s “Better Care Reconciliation Act” (BCRA) that seem aimed more at providing cover for lawmakers than coverage for Americans:

2019: First major changes and cuts to the Affordable Care Act exchanges happen after the 2018 midterm cycle, allowing congressional Republicans to campaign on a “fixed” health system, even though Obamacare is still largely in place next year.

2019: States share $2 billion in grants to apply for waivers under a much looser process through this fiscal year. These waivers could allow insurers to sell skimpy plans that have low price tags but don’t take adequate care of people with preexisting conditions. None of those waivers has to go into effect, however, until after 26 Republican governors face re-election in 2018.

2020: Stabilization cash that makes the markets more predictable and fair for insurers flows through the congressional midterm cycle and the 2020 presidential cycle. Then it disappears. Medicaid expansion funds hold steady through this crucial political window, too.

2024: States enjoy their last few sips of Medicaid expansion cash at the end of 2023 — just as, perhaps, a second Republican presidential term is ending.

2025: The bill changes the formula for the entire Medicaid budget (not just the Obamacare expansion), dramatically reducing federal funding over time. That starts eight years and two presidential election cycles from now.

McConnell insists everything about the bill has been aboveboard and transparent.

“Nobody’s hiding the ball here. You’re free to ask anybody anything,” McConnell said on June 13.

But he and his working group did literally hide the bill from Democrats and most Republicans, crafting it behind closed doors until there was just a week left before his goal to secure a vote on it. (That timing was thrown off Tuesday with the announcement the vote was delayed, but the dealmaking is just beginning.)

Meanwhile, at least two policy details in the bill may obscure the effects for several years and make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.

One is a stipulation that compels the federal government, for two years, to pay the cost-sharing reduction payments to insurance companies that President  Trump has threatened to end. The payments are part of the Affordable Care Act, and they flow to insurers on behalf of low-income marketplace customers to cover their out-of-pocket health expenses. Republicans had sued to stop the payments, adding considerable instability to ACA marketplaces next year. McConnell ends that uncertainty for two years.

On top of that cash infusion, the BCRA proposes a “Short-Term Stabilization Fund” that would also aim to help lower premium costs and could attract a few more insurers into counties that are sparsely covered now. It would dish out $50 billion to insurers — $15 billion per year in 2018 and 2019 and $10 billion per year in 2020 and 2021.

The money would make up for the billions that the Republican-led Congress has refused to appropriate for insurance companies under the ACA’s risk corridors program. Risk corridors aimed to offset losses for insurers whose costs were more than 103 percent of expected targets. Congress has so far paid only 12.6 cents on the dollar of those obligations and faces lawsuits from insurers that were stiffed.

In short, the two pots of money would go a long way toward addressing the instability in Obamacare created by the Republican-led Congress, but only through the next presidential cycle in 2020.

Beyond timing, the legislation’s features allow senators to make truthful arguments that disguise negative effects.

Perhaps the key claim is that the Senate bill would increase access to insurance. It might, in that insurance companies in states that waive standards would be free to offer much cheaper plans. But those plans would be cheaper because they wouldn’t cover essential health benefits or adequately cover preexisting conditions. Lower-income Americans might be able to buy a plan — possibly a $6,000 deductible for someone who makes less than $12,000 a year.

A spokesman for McConnell did not answer a request for comment. But Democrats are keenly aware of the electoral machinations in the bill.

“Everything about this legislation, from the process to the effective dates of many of the provisions, is driven by political expediency,” said Brian Fallon, a Democratic consultant and former lead spokesman for Hillary Clinton’s campaign. “Mitch McConnell only cares about getting the ‘win,’ not about the substance of the bill.”

Senate Democratic aides who spoke on background were not sure that the steps the bill takes to shore up markets for the next two elections would work when insurance companies can see what lies ahead. But they agreed the timing and short-term fixes might help McConnell twist the arms of reluctant Republican senators.

“I think it will be enormously helpful to McConnell in a room with a moderate Republican who wants to be told, ‘Hey, a lot of this stuff that’s going to happen in this bill that you’re hearing about, that’s worrisome is past your re-elect, it’s past 2018, it’s past 2020,’” one senior aide said. “‘Just vote for it, it’ll be fine, we’ll figure the rest out later.’”

Democrats said that McConnell’s hide-the-ball strategy will not work with voters, and they want Republican senators to know that before they vote.

“The polling already shows that, based on the fact that they control every aspect of government, Trump and the Republicans own everything that happens from now on in the healthcare system,” Fallon said.

Sen. Patty Murray (D.-Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee who has the task of leading the arguments against the GOP bill, thinks senators will imperil their political futures if they buy McConnell’s arguments.

“Senator McConnell is doing everything he can to persuade Senate Republicans that Trumpcare won’t be devastating for the people they serve, but the facts are that Trumpcare is going to cause families to pay more, gut Medicaid, and take coverage away from millions of people,” Murray said. “Any Senate Republican who votes for Trumpcare and believes patients and families won’t hold them accountable is being sold a bill of goods.”

Still, McConnell knows how to work a legislative calendar. Expect a July full of closed-door dealmaking with reluctant senators, leading up to maximum leverage before the August recess.


Providers denounce Senate GOP leaders’ healthcare bill

 

Leaders of the hospital sector and other major healthcare groups have denounced the Senate Republican leadership’s  Affordable Care Act repeal bill as  little or no improvement over the House bill, which  providers have criticized as imperiling the health of millions of patients.

Rick Pollack, president and CEO of the American Hospital Association, said of the”Better Care Reconciliation Act of 2017”:

“Unfortunately, the draft bill under discussion in the Senate moves in the opposite direction {from protecting coverage}, particularly for our most vulnerable patients. We urge the Senate to go back to the drawing board and develop legislation that continues to provide coverage to all Americans who currently have it.”

Bruce Siegel, M.D., president and CEO of America’s Essential Hospitals, said: “For the hospitals that protect millions of Americans and their communities—our essential hospitals—this bill might even accelerate decisions by some to reduce services or close their doors.”

“The Senate healthcare bill released today is just as bad as the version passed by the House of Representatives last month and is a threat to the health of America,” said George Benjamin, M.D., executive director of the American Public Health Association. He asserted that  Senate Republicans had committed “legislative malpractice.”

David O. Barbe, M.D., president of the American Medical Association, chimed in with:

“The AMA is reviewing the Senate health system reform legislation, guided by our key objectives that people who are currently insured should not lose their coverage and that Medicaid, CHIP and other safety-net programs should be adequately funded. The AMA strongly opposes Medicaid spending caps, and we have grave concern with a formula that will not cover needed care for vulnerable patients.”

And  Bernard J. Tyson, chairman and CEO of Kaiser Permanente, said:  “First, we need to cover more people, not fewer people.” He suggested   a three-part test to determine what healthcare progress ought to look like: Does it achieve wider  access, affordability and better outcomes?

Centers for Medicare & Medicaid Administrator Seema Verma, a Trump appointee, not surprisingly, praised the bill.

“I appreciate the work of the Senate as they continue to make progress fixing the crisis in healthcare that has resulted from Obamacare. Skyrocketing premiums, rising costs and fewer choices have caused too many Americans to drop their insurance coverage. Today, Obamacare is in a death spiral and millions of Americans are being negatively impacted as a result. They are trapped by mandates that force them to purchase insurance they don’t want and can’t afford.” {The term “Obamacare” is usually used by Republicans as a derogatory term for the Affordable Care Act, the law’s official name.}

“The Senate proposal is built on putting patients first and in charge of their healthcare decisions, bringing down the cost of coverage and expanding choices. Congress must act now to achieve the president’s goal to make sure all Americans have access to quality, affordable coverage.”

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GOP said to mull 4 ACA replacement provisions

dump

Politico reports that congressional Republicans Republicans and  Trump administration officials  “are scrambling to get Obamacare repeal efforts back on track by stuffing as much of a replacement policy as possible into a repeal bill.”

Four Affordable Care Act replacement measures are reportedly being considered.

The changes would include expanding Health Savings Accounts, enacting high-risk health-insurance pools, revising Medicaid and authorizing tax credits to help people buy insurance policies.

The idea is to  win over Republicans who have been insisting that repeal and replace be taken up simultaneously. Their ambivalence has been fueled in part by fear of voter anger if the GOP kills some popular parts of the ACA.

Politico reported that “replacement policies would be rolled into a measure repealing the 2010 healthcare law, which will be taken up and passed under an expedited process only requiring 51 votes for passage in the Senate. It’s still unclear whether the Senate parliamentarian will allow the replacement pieces to be inserted into the bill. But if she signs off, the policies could provide reassurance to GOP lawmakers eager to make good on longstanding vows to scrap the health law who want to vote on some replacement policy at the same time.”

To read more, please hit this link.

 


Hiltzik: Ryan determined to gut Medicare

 

gutting

National Economics and business columnist Mike Hiltzik writes in the Los Angeles Times that House Speaker Paul Ryan is determined to gut Medicare. Mr. Hiltzik writes:

“Bursting with the policymaking power that control of both houses of Congress and the White House gives Republicans, House Speaker Paul D. Ryan (R.-Wis.) has lost no time in teeing up a favorite goal: gutting Medicare.

“In an interview with Fox News Channel, Ryan said: ‘Obamacare rewrote Medicare … so if you’re going to repeal and replace Obamacare, you have to address those issues as well. … What people don’t realize is that Medicare is going broke, that Medicare is going to have price controls. … So you have to deal with those issues if you’re going to repeal and replace Obamacare. Medicare has got some serious problems because of Obamacare. Those things are part of our plan to replace Obamacare.’

“There’s no secret about what specifically Ryan has in mind. He intends to replace traditional Medicare, an efficient program offering guaranteed treatment and featuring rock-bottom administrative costs, with a privatized program. Seniors would get a federal voucher to help them pay premiums charged by commercial insurance plans. Ryan calls this system ‘premium support.’

“But since the value of the vouchers would rise at less than the rate of healthcare inflation, and the costs of private insurance typically rise faster than those of Medicare, an ever-larger share of healthcare costs would land on seniors’ shoulders. In 2011, when Ryan first proposed this change, the Kaiser Family Foundation calculated that by 2022, healthcare spending would consume roughly half of the typical 65-year-old’s Social Security check, compared to only 22% under the existing Medicare system.”

To read all of Mr. Hiltzik’s column, please hit this link.


Big insurers’ exits revive talk of Medicare for all

exit

As big insurers bail out of the insurance exchanges created by the Affordable Care Act, the idea of simplifying, and saving money on, the currently chaotic U.S. healthcare “system” by extending Medicare to all, or at least offering a “public option” on the exchanges, is gaining ground.

Polls suggest that a majority of the population would like Medicare for all but  the  insurance companies have a powerful lobbying and campaign-contribution operation in Washington to try to thwart that.

President Obama, pushing back against criticism of the Affordable Care Act in the wake of the insurance company exits from ACA’s insurance exchanges, has revived the idea of introducing a public, Medicare-like plan to compete with private insurers. He also has suggested that increased government subsidies could help draw more people into the ACA’s markets.

Bloomberg has noted also: “Another option is to simply give insurance companies more government money, but that would require action from a Republican Congress that would rather repeal Obamacare than fix it.”

‘There’s going to be absolutely zero interest among Republicans in bailing out Obamacare by giving it more money,”  Avik Roy, a healthcare expert who’s advised Republican presidential candidates Mitt Romney, Rick Perry and Marco Rubio on health policy, told Bloomberg.

With  such unknowns as who will control the White House and one or both houses of Congress after the November election, one would have to be very brave to make predictions.

To read the Bloomberg article on this developing story, please hit this link.


Study asserts insurance marketplaces are healthy

By PHIL GALEWITZ

For Kaiser Health News

Despite dire warnings from Republicans and some large insurers about the stability of the Affordable Care Act exchanges, an Obama administration report released Aug. 11 indicated that the individual health insurance market has steadily added healthier and lower-risk consumers.

Medical costs per enrollee in the exchanges in 2015 were unchanged compared with 2014, according to the Centers for Medicare & Medicaid Services. In contrast, per-member health costs rose between 3 percent and 6 percent in the broader U.S. insurance market, which includes 154 million people who get coverage through their employer and the 55 million people on Medicare, the report said.

Aviva Aron-Dine, senior counselor to U.S. Health and Human Services Secretary Sylvia Burwell, said the data was encouraging when many insurers have announced double-digit rate increases for 2017 and others have pulled back in some states to curtail financial losses.

“What we take from this is that the marketplace is on sound footing,” she said in a phone briefing with reporters. She also said the sharp 2017 rate increases could be intended to help insurers compensate for underpricing their premiums in 2014 and 2015 and not the first in a series of large annual rate hikes. Next year’s phase-out of the Affordable Care Act’s reinsurance programs — which helped insurers cover losses on higher-cost enrollees the past two years — is another reason why some insurers want higher rates for 2017.

Nearly 13 million Americans bought coverage for 2016 on the Obamacare marketplaces. More than 80 percent received federal subsidies that help them afford policies and insulate them from effects of premium increases.

Several insurers, including UnitedHealth Group and Humana, have said they will not sell 2017 individual plans on many state exchanges because they absorbed heavier-than-expected losses in part due to higher medical claims.

Aron-Dine said the administration always expected that rising enrollments would attract younger and healthier enrollees to balance the risk of insuring the older and sicker people who signed up initially. In 10 states with the highest enrollment growth from 2014 to 2015, the government reported, per-member per-month claims costs fell by an average of 5 percent.

Its study was based on claims data collected by CMS to administer the health law’s reinsurance and risk adjustment programs. Insurers submitted their 2015 data earlier this year.

What explains insurers’ losses from Obamacare if health costs have held steady?

Sabrina Corlette, research professor at the Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute, said some insurers priced their coverage too low in 2014 and 2015 — in part to grab market share — and are now trying to make up for it. She said insurers have based most of their 2017 rate increases on their 2015 results.

“This should reassure people that despite the narrative that these markets are going down the toilet, in fact the report shows the opposite … that these markets are generally performing pretty well,” Corlette said.

Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance, said the CMS report is good news for consumers. “This suggests the premium increases that we are seeing going into 2017 is likely to be a one-time adjustment … for pricing too low in the first few years,” she said. (Kaiser Health News is an editorially independent program of the foundation.)


Don’t blame ACA for healthcare-cost crisis

Eugene Steuerle writes in HealthAffairs that while much has been made of the financial cost of the Affordable Care Act, the cost of the act from expanding coverage for  those under 65 is a relatively small part of America’s huge healthcare-cost issue.

He writes:  “If we add in growth in tax subsidies for health insurance, then Obamacare programs for those younger than 65, including both Medicaid expansion and new health-insurance subsidies in the marketplace, entail only about 8 percent of the federal government’s cost for major health programs and 12 percent of the projected increase in annual cost within a decade. And even those additional Obamacare costs are offset partly by cuts established in the Affordable Care Act (ACA).

“By contrast, growth in Medicare makes up half or more of all federal major health program spending and of the projected increases; the tax break for employer-provided insurance and the Medicaid program for those eligible before Obamacare each also entail significantly higher costs than does Obamacare.”

America still has not faced what needs to be done to improve its mediocre medical outcomes while cutting costs in what is by far on a per-capita basis the world’s most expensive healthcare, including the planet’s highest paid physicians and healthcare administrators and the  most pricey medications.

It’s a system that still rewards waste and duplicati0n.

 


For different roads to bundled payments

roads

Healthcare economist Jeffrey C.  Bauer, Ph.D., in a Hospitals & Health Networks  piece, pushes bundled payments but also urges flexibility in how they are implemented. Among his remarks:

“Indeed, the need to move away from volume-based payment is a rare area of general agreement between Republicans and Democrats in an era of relatively low economic growth. Regardless of how much Obamacare is weakened as a result of upcoming elections and Supreme Court decisions, it’s almost impossible for me to imagine any change in Congress that would increase appropriations for medical expenditures in the foreseeable future. Bundled payment is not the only way Congress can constrain spending on health care, but it is the one most likely to survive battles over budgets and regulations.”

“Leaders of hospitals and health networks should not be discouraged by the lack of a consistent definition of bundled payment. I actually find the variability encouraging because I strongly oppose one-size-fits-all approaches to solving the problems of our medical marketplace. …”

“Remarkable differences in their organization, leadership and operations prove there are several ways to provide world-class healthcare in the United States. I am consequently energized by the opportunity for innovative health systems to customize bundled payment to the unique characteristics of their own circumstances.”

”These bundled-payment mechanisms will all incorporate fixed payments for managing chronic diseases and caring for episodes of acute illness or injury, but they will be implemented in different ways. Successful efforts will take several years to evolve, and they will require multi-stakeholder partnerships between purchasers, payers and patients.”

“Leading the shift from fee-for-service to bundled payment would be a significant step in the better direction {for U.S. healthcare}. ”


Trump’s seven-point healthcare program

 

The Trump for president campaign offers a seven-part healthcare-reform program:

  1. “Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.
  2. “Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.
  3. “Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.
  4. “Allow individuals to use Health Savings Accounts (HSAs).  {Editor’s note: These are already allowed — and used by millions.} Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate.
  5. “Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. (Editor’s note: Such transparency is already called for under the Affordable Care Act.} Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.
  6. “Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources.
  7. “Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers. (Editor’s note: Many  U.S. patients now get their  prescription drugs from Canada, which are generally much cheaper than American drugs.}

 

 

 

 

 


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