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Direct primary care seen as partial safety net

 

By CHARLOTTE HUFF

For Kaiser Health News

JARRELL, Texas

Darrell Kenyon had been punting for years on various medical issues — fatigue, headaches, mood swings. The 43-year-old uninsured carpenter was particularly worried about his blood pressure, which ran high when he checked it at the grocery store. Then he heard about a different type of physician practice, one that provided regular primary care for a monthly fee.

“Insurance for the self-employed is through the roof,” Kenyon told Dr. Loy Graham, as she examined him one morning in August. Two years ago, Graham had hung out her shingle in this central Texas town of nearly 1,400, about 40 miles north of Austin.

Under the practice model, called direct primary care, patients are charged monthly — typically $20 to $75, depending on age, in Graham’s practice — for basic, office-based medical care and frequently cell phone and other after-hours physician access. Proponents of the model, which is also supported as a practice option by the American Academy of Family Physicians, say it can provide a safety net for those with limited treatment options, including the uninsured and people in the country illegally. The alternative is particularly helpful in states such as Texas that haven’t expanded Medicaid access, the advocates add.

But there’s a sizable catch: Direct primary care is not insurance.

Carolyn Engelhard worries that strapped individuals will decide the easier access to primary care is “good enough” and won’t investigate insurance options. “It can be a false security,” said Engelhard, who directs the health-policy program at the University of Virginia School of Medicine, in Charlottesville. “There’s sort of the illusion that it’s kind of like insurance.”

Lower-income Texans would be better off with coverage on the Affordable Care Act’s insurance exchange, where they could get a subsidy to reduce the cost of their premiums, Engelhard said. The policy would have a deductible, “which they might feel that they can’t afford,” she said. “But they would be protected if they got cancer or if they had an automobile accident.”

Graham estimates that at least three-quarters of her roughly 450 patients lack insurance, even though she advises them to carry some kind of catastrophic coverage for major health expenses. But the cost for such policies can be daunting. Like Kenyon, some of Graham’s patients are self-employed with fluctuating incomes or work for businesses that don’t offer coverage. Even if their employer offers affordable coverage for the employee, premiums for dependents might make coverage financially out of reach. Roughly 1 in 5 of her patients speak primarily Spanish. Some are undocumented, working in construction and other labor-intensive jobs in the region.

Despite her concerns, Engelhard said, such flat-fee practices might offer “one of the few viable options” for those living here under the radar, given they’re not eligible for ACA-related coverage. “So they are completely dependent on paying out-of-pocket for medical care,” she said.

‘Better Than Nothing’?

Nationally, direct primary care is relatively new and very much a niche option. Nearly 3 percent of family physicians practice it, according to a 2017 survey by the American Academy of Family Physicians. Some critics have questioned whether the model’s growth is already stalling, after one of its earliest providers, Seattle-based Qliance, closed its clinics this year.

Graham, who practiced traditional medicine in central Texas for decades, said she was drawn to the option after growing weary of packing too many patients into each day. She was considering leaving medicine and had started developing a lavender farm as an alternative source of income when she heard about direct primary care.

In 2015, she opened her practice in a small strip mall in Jarrell, figuring that nearby residents — with limited access to primary care — might take a chance on the different style of medicine.

John Bender, M.D., an academy board member who is part of a larger practice that’s transitioning to direct primary care, said that the low monthly fees are attracting patients who view insurance as out of reach. “I think something [in terms of medical care] is better than nothing,” said the Fort Collins, Colo., family physician, who estimates that roughly half of the practice’s 800-plus direct primary care patients are uninsured.

“I can spare them quite a few urgent care and emergency room bills,”  Dr. Bender said, noting that his office handles anything from strep throat to stitches for minor gashes. Moreover, the cost is within reach of people on tight budgets, he said. “In fact, a carton of cigarettes runs $49, which just happens to be the price of my monthly subscription fee [for adults].”

In Texas, 16.6 percent of the state’s residents were uninsured as of 2016, the highest rate nationally, according to the most recent Census Bureau data. The Lone Star State didn’t expand Medicaid access and has one of the nation’s lowest income-eligibility cutoffs. A single mother with two children can’t earn more than $3,781 annually to qualify for coverage herself, according to a 2017 Medicaid report by the Center for Public Policy Priorities, an Austin-based nonprofit research and advocacy organization.

Dr. Felicia Macik, who launched her direct care practice in 2014 in Waco, estimates that 10 to 15 percent of her patients are uninsured, including some who drop coverage because they can’t afford the premiums. “I’m frightened for them,” she said. “It could decimate a family if something happened and they didn’t have any coverage.”

But Macik pointed out that getting regular primary care, rather than avoiding the doctor entirely due to lack of insurance, might avert costlier complications like an asthma attack or a diabetic crisis.

Uninsured individuals who sign up for these practices are rolling the dice, said Dr. Mohan Nadkarni, an internist who co-founded the Charlottesville (Va.) Free Clinic, which treats lower-income individuals. “For routine regular care, it may work out,” he said. “But it’s gambling that you’re not going to get sicker and need further care.”

Two years ago, Dr. Loy Graham opened a flat-fee primary-care practice in Jarrell, Texas. She estimates that at least 75 percent of her patients lack health insurance.  (Photo by Charlotte Huff.)_

For instance, a patient can develop severe heartburn and require further tests and referrals to specialists to look for the underlying cause — potentially anything from an ulcer to esophageal cancer — that could quickly run up a hefty bill, Nadkarni said. Another patient with chest pain might need a similarly costly work-up to rule out heart problems, including a potentially life-threatening blockage, he said.

Graham said that her monthly fees cover anything that she can handle in the office. During Kenyon’s visit, she froze a small growth off one ear. Shortly afterward, she gave a steroid injection to an older woman with a painful, swollen wrist.

She has negotiated low fees with a local laboratory; the battery of blood tests and urinalysis she ordered for Kenyon cost him just under $40. “This is concierge medicine for normal people,” said the 61-year-old family physician.

Physician enthusiasts maintain that jettisoning the paperwork and other overhead costs associated with insurance enables them to take on fewer patients — roughly 600 to 800 for direct care practices compared with 2,000 to 2,500 typically, according to the family physicians academy — and thus spend more time with each one.

As A Safety Net, It’s A Stretch

Erika Miller first came to see Graham two years ago for severe headaches. The 30-year-old mother of three, who is working on her college degree and has a full-time job, doesn’t have insurance.

Graham diagnosed high blood pressure. Getting that under control helped alleviate her headaches, Miller said. She also has shed 50 pounds under Graham’s guidance.

But Graham can’t handle everything for her patients. Last year, Miller went to the emergency room at Scott & White Medical Center, in nearby Temple, with severe abdominal pain. It was her appendix, which had to be removed. The safety-net hospital started Miller on a payment plan based on her income, totaling roughly $500.

“If the question is: `Is [direct primary care] better than nothing?’ Then I would say, ‘Yes,’” Engelhard said. But along with leaving uninsured patients financially vulnerable to a medical curveball, she said, these smaller practices — by seeing fewer patients per doctor — risk aggravating the nation’s primary care shortage if they become more common.

Graham countered that she nearly left medicine, but these days — as she continues to build her practice — she’s reaching some patients who had previously fallen through the health system’s cracks. On that summer morning, Kenyon left Graham’s office with a prescription for a blood pressure medication and an appointment to return in several weeks to discuss his lab results.

Kenyon and his wife, Denise, later described how they had signed up last year for a family policy through the Affordable Care Act. But the monthly premium was $750 and the deductibles were $3,500 per person, Denise Kenyon said.

She called around and couldn’t find a family doctor who would take the coverage. After several months, they stopped paying the premiums, figuring that the money they saved would pay for a lot of medical care.

Both are now patients of Graham’s; their combined monthly bill totals $125, which they can budget for, Darrell Kenyon said. “I do have good months and bad months, as far as pay is concerned,” he said. “If I have a bad month, it’s still affordable.”


Community health centers anxiously await congressional rescue

 

By RACHEL BUTH

For Kaiser Health News

One community health center in New York has frozen hiring. Another in Missouri can’t get a bank loan to expand.

The nation’s 1,400 community health centers are carefully watching expenses in case the financial rescue they hope Congress delivers very soon doesn’t arrive. With four days left in the government’s fiscal year, Congress has not voted on reauthorizing billions of dollars now going to community health centers and other health programs for the 2018 budget year that starts Sunday.

“The anxiety level is increasing on almost a daily basis,” said Dan Hawkins, senior vice president of the National Association of Community Health Centers (NACHC) in Washington, D.C. “There is broad support and agreement in Congress that it should get done, but we are working against a ticking clock and a crowded legislative calendar.”

For the past two weeks, the GOP’s scramble to repeal the Affordable Care Act before the month ends pushed other healthcare matters off the congressional agenda. That effort ended Tuesday when Senate Republicans said they would not seek a vote this week because they lacked enough support to pass the bill.

It’s not clear if lawmakers’ lighter agenda will now leave room for funding health centers or deciding other issues, such as renewing the Children’s Health Insurance Program (CHIP), which also expires Sept. 30. At a hearing Sept. 25,  Senate Finance Committee Chairman Orrin Hatch (R.-Utah) urged his colleagues to work with the Senate’s health committee to settle the matter. NACHC officials privately express optimism that a deal might come later in October if not by Sunday.

Community health centers operate in more than 9,500 locations, serving 27 million people, according to the NACHC. They are the main source of healthcare for many low-income Americans — and the only source of primary care in many underserved areas.

Health centers provide preventive care, counseling, dentistry and primary care to everyone, whether or not they can pay. A sliding fee scale based on income and family size is available to patients without insurance.

In 2015, nearly 1 in 6 Medicaid beneficiaries received health-center services, the Kaiser Family Foundation reported this year. (Kaiser Health News is an editorially independent program of the foundation.)

“The end result is these are people who will be locked out of health care” without new funding, Hawkins said.

Community health centers gained billions of dollars in federal revenue under the ACA, which created a special trust fund to support them from 2011 through 2015. The Community Health Center Fund was extended in 2015 for two years with an additional $3.6 billion annually.

That money represents 70 percent of all federal grants to health centers and about a fifth of their annual revenue. Medicaid reimbursements account for the largest share, about 40 percent.

One beneficiary is Pamela Richardson, a 60-year-old patient of Valley Community Healthcare,in North Hollywood, Calif., who suffers from an iron- absorption disorder called hereditary hemochromatosis. She was unable to get health insurance before Obamacare prohibited insurers from excluding people with preexisting medical conditions. The clinic helped her sign up for coverage through the Medi-Cal expansion.

Once Richardson was covered, she received long-delayed primary care, which revealed she had “scary high” blood pressure and a lump in one breast (which proved benign). “When you don’t have insurance you don’t get breast exams. You don’t have Pap smears,” she told a KHN reporter earlier this year. “I wish people had a little more patience with Obamacare. Once you get what’s wrong with you under control, the cost would come down.”

California has by far the most federally funded health centers and they serve 6.2 million Californians, according to CaliforniaHealth+ Advocates, which represents state clinics. They have received over $1.6 billion from 2011 through 2016 from the Community Health Center Fund, more than any other state, the Congressional Research Service reported in January.

If health centers receive no new funds for 2018, the ensuing financial crunch would cost 51,000 jobs, force the centers to close 2,800 locations and cause 9 million people to lose healthcare services, according to a budget document that the Health and Human Services Department gave Congress in July.

Uncertainty about what Congress will do now is already causing problems. Hawkins said his members call him and his staff every day, fretting about employment contracts, lease agreements and equipment rentals that run past Oct. 1.

Neighborhood Health in Nashville, Tenn., has federal grant money that will carry it through Jan. 31, but CEO Mary Bufwack said some of her 180 staff members live paycheck to paycheck and are getting nervous about Neighborhood’s stability.

Bufwack is worried the health center won’t receive money it needs to replace a clinic, a project now being planned.

She fears that a new doctor she recruited to join Neighborhood next June will take another job before she can get his signature on an employment contract. And she doesn’t want to do that until she’s sure about her budget.

Mostly, she worries that whatever Congress gives her will be only for one year.

“We’re already worried about next Sept. 30,” Bufwack said.


GOP targets Medicaid, which covers many millions, for massive cuts

By PHIL GALEWITZ

Kaiser Health News

When high levels of lead were discovered in the public water system in Flint, Mich., in 2015, Medicaid stepped in to help thousands of children get tested for poisoning and receive care.

When disabled children need to get to doctors’ appointments — either across town or hundreds of miles away — Medicaid pays for their transportation.

When middle-class older Americans deplete their savings to pay for costly nursing home care, Medicaid offers coverage.

The United States has become a Medicaid nation.

Although it started as a plan to cover only the poor, Medicaid now touches tens of millions of Americans who live above the poverty line. The program serves as a backstop for America’s scattershot health care system, and as Republicans learned this year in their relentless battle to replace the Affordable Care Act, efforts to drastically change that can spur a backlash.

The latest Republican proposal — by Senators Lindsey Graham (S.C.) and Bill Cassidy (La.) — is being pummeled by doctors, insurers, hospitals and patient advocates because it would scrap the health law’s Medicaid expansion and reduce federal funding for Medicaid. Senate leaders are trying to get a vote before Sept. 30, when special budget rules would allow the package to pass with only 50 votes.

Today, Medicaid is the nation’s largest health insurance program, covering 74 million, or more than 1 in 5 Americans. Over the next weeks, Kaiser Health News will explore the vast reach of the program. Twenty-five percent of Americans will be on Medicaid at some point in their lives — many are just a pink slip away from being eligible.

Medicaid funding protects families from having to sell a home or declare bankruptcy to pay for the care of a disabled child or elderly parent. It responds to cover disaster relief, public health emergencies and programs in schools that lack other sources of funding.

Millions of women who don’t qualify for full Medicaid benefits each year obtain family planning services paid for by Medicaid. These women have incomes as high as triple the federal poverty rate, or over $36,000 for an individual. And thousands of women, who otherwise don’t qualify for the program, get treated each year for breast and cervical cancers through Medicaid.

“Instead of cutting Medicaid, [lawmakers] increased public awareness of its value and made it even harder to cut in the future,” said Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill and a supporter of the federal health law. The Medicaid cuts passed the House, but the ACA overhaul legislation fell short in the Senate in July.

Medicaid is the workhorse of the health system, covering:

  • 39 percent of all children.
  • Nearly half of all births in the country.
  • 60 percent of nursing home and other long-term care expenses.
  • More than one-quarter of all spending on mental health services and over a fifth of all spending on substance abuse treatment.

Unlike Medicare beneficiaries, who keep that insurance for life, most Medicaid enrollees churn in and out of the program every few years, depending on their circumstances.

Such numbers underline the importance of Medicaid, but also provoke alarm among conservatives and some economists who say the U.S. cannot afford the costs over the long run.

Bill Hammond, director of health policy of the fiscally conservative Empire Center for Public Policy in Albany, N.Y., said Medicaid has been a big help for those it was designed to cover — children and the disabled. But it has grown so big that the cost hurts state efforts to pay for other necessary public services, such as education and roads. “I can’t think of any other anti-poverty program that reaches so many people. … It’s too expensive a benefit.”

“We need to transition people to get coverage in the private sector,” he said, noting how millions on the program have incomes above the federal poverty level.

It May Be The Person Down The Block

Joana Weaver, 49, of Salisbury, Md., who has cerebral palsy, has been on and off Medicaid since birth. For the past few years, it’s paid for home nursing services for six hours a day to help her get dressed, bathed and fed. That’s kept her out of a nursing home and enabled her to teach English part time at a local community college.

“For me, Medicaid has meant having my independence,” Weaver said.

Like Weaver, many people getting Medicaid today are not easily typecast. They include grandmothers — one-quarter of Medicaid enrollees are elderly people or disabled adults.

Or the kid next door. About half of Medicaid enrollees are children, many with physical or mental disabilities.

Many of the rest — about 24 million enrollees — are adults under 65 without disabilities who earn too little to afford health insurance otherwise. About 60 percent of non-disabled adult enrollees have a job. Many of those who don’t work are caregivers.

“It’s the mechanic down the street, the woman waiting tables where you go for breakfast and people working at the grocery store,” said Sara Rosenbaum, a health policy expert at George Washington University in Washington, D.C.

While all states rely on Medicaid, it’s used more in some places than others because of varying state eligibility rules and poverty rates. As of August, about 44 percent of New Mexico residents are insured by Medicaid. In West Virginia and California, the rate is nearly 1 in 3.

Jane and Fred Fergus, in Lawrence, Kan., said Medicaid has been a cornerstone in their lives since their son, Franklin, was born eight years ago with a severe genetic disability that left him unable to speak or walk. He is blind and deaf on one side of his body.

Although the family has insurance through Fred’s job as a high school history teacher, Franklin was eligible for Medicaid through an optional program that states use to help families let their children be cared for at home, rather than moving to a hospital or nursing home. Medicaid pays all his medical bills, including monthly transportation costs to Cincinnati Children’s Hospital, where for the past 18 months he has been receiving an experimental chemotherapy drug to help shrink tumors blocking his airway, Jane Fergus said. It also covers his wheelchair, walker and daily nursing care at home.

“We have such great health care for him because of Medicaid,” his mother said.

Jane Fergus was never politically active until this year, when she feared that the GOP plans to cut Medicaid funding would reduce services for her son.

“If there is a silver lining in all this debate, it’s that we have been given a voice, and people in power are being educated on the role of Medicaid,” she said.

Moving Beyond Its Roots

Medicaid was born in a 1965 political deal to help bring more support for President Lyndon Johnson’s dream of Medicare, the national health insurance program for the elderly.

Over the past 40 years and in particular since the 1980s, Medicaid expanded beyond its roots as a welfare program. In 1987, Congress added coverage for pregnant women and children living in families with incomes nearly twice the federal poverty level (about $49,200 today for a family of four).

In 1997, Congress added the Children’s Health Insurance Program to help cover kids from families with incomes too high for Medicaid.

And since September 2013, Obamacare allowed states to expand the program to anyone earning under 138 percent of poverty (or $16,394 for an individual in 2016), adding 17 million people.

In addition, more than 11 million Medicare beneficiaries also receive Medicaid coverage, which helps them get long-term care and pay for Medicare premiums.

“Medicaid is plugging the holes in our health system,” said Joan Alker, executive director of the Georgetown University Center for Children and Families, “and our health system has a lot of holes.”

But that comes at a steep price. 

A Blessing And A Curse

With increasing enrollments and health costs steadily rising, the cost of Medicaid has soared. Federal and state governments spent about $575 billion combined last year, nearly triple the level of 2000.

Those dollars have become both a blessing and a curse for states.

The federal government matches state Medicaid spending, with Washington paying from half to 74 percent of a state’s costs in 2016. Poorer states get the higher shares.

The funding is provided on an open-ended basis, so the more states spend the more they receive from Washington. That guarantee protects states when they have sudden enrollment spikes because of downturns in the economy, health emergencies such as the opioid crisis or natural disasters such as Hurricane Katrina.

The program is the largest source of federal funding to states. And Medicaid is often the biggest program in state budgets, after public education.

“Medicaid is the elephant in the room for health care,” said Jameson Taylor, vice president for policy for the Mississippi Center for Public Policy, a free-market think tank. He said states have become dependent on the federal funding to help fill their state budget coffers. While the poorest states, such as Mississippi, get a higher percentage of federal Medicaid dollars, that still often isn’t enough to keep up with health care costs, he said.

Extensive Benefits

Medicaid provides significant financing for hospitals, community health centers, physicians, nursing homes and jobs in the health care sector.

But the revenue stream flows further. Billions in annual Medicaid spending goes to U.S. schools to pay for nurses; physical, occupational and speech therapists; and school-based screenings and treatment for children from low-income families, as well as wheelchairs and buses to transport kids with special needs.

Medicaid also often covers services that private health insurers and Medicare do not — such as non-emergency transportation to medical appointments, vision care and dental care. To help people with disabilities stay out of expensive nursing homes, Medicaid pays for renovations to their homes, such as wheelchair ramps, and personal care aides.

Rena Schrager, 42, of Jupiter, Fla., who has severe vision problems, has relied on Medicaid  for more than 20 years. Although she often has difficulty finding doctors who will accept Medicaid’s reimbursements — which are often lower than private insurance and Medicare — she is grateful for the coverage. “When you do not have anything else, you are glad to have anything,” Schraeger said.

As it’s grown, Medicaid has become more popular, another reason why politicians are cautious to curtail benefits or spending.

A recent survey by the Kaiser Family Foundation showed three-fourths of the public, including majorities of Democrats (84 percent) and Republicans (61 percent), hold a favorable view of Medicaid. That’s nearly as high as Americans’ views on Medicare. (Kaiser Health News is an editorially independent program of the foundation.)

But it may still have a bull’s-eye on its back.

“The fact that the House passed a bill to cut $800 billion from Medicaid and it came one vote short to passing the Senate shows Medicaid is stronger than maybe many Republican leaders anticipated,” said Oberlander. “But politically it is still in a precarious position.”

 


An analysis of the new GOP bid to kill the ACA

By JULIE ROVNER

F0r Kaiser Health News 

Republican efforts in Congress to “repeal and replace” the federal Affordable Care Act are back from the dead. Again.

While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Senators Lindsey Graham (R.-S.C.) and Bill Cassidy (R.-La.), along with Senators Dean Heller (R.-Nev.) and Ron Johnson (R.-Wis.)

They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.

An earlier attempt to replace the ACA this summer fell just one vote short when Senators Susan Collins (R.-Maine), Lisa Murkowski (R.-Alaska) and John McCain (R.-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.

After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes ­— which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.

Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.

“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.

Here are five things to know about the latest GOP bill: 

1. It would repeal most of the structure of the ACA.

The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.

It would eliminate the tax on medical devices. 

2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.

Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.

3. It would fundamentally restructure the Medicaid program.

Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.

The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill. 

4. It’s getting mixed reviews from the states.

Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R.-Wis.) and Doug Ducey (R.-Ariz.), are being offset by opponents including Chris Sununu (R.-N.H.), John Kasich (R.-Ohio) and Bill Walker (I-Alaska).

On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letter to Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.

Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”

5. The measure would come to the Senate floor with the most truncated process imaginable.

The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R.-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.

Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.

Meanwhile, the Congressional Budget Office said this week that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”

That has outraged Democrats, who are united in opposition to the measure.

“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D.-N.Y.) on the Senate floor Tuesday.


How much freedom should states get to change healthcare systems?

Mattie Quinn, in governing.com, reports on the debate over how much freedom the Trump administration should give the states to change their healthcare systems. More flexibility, she notes, would make it easier to adopt healthcare industry-backed changes — and let conservatives enact policies rejected by the Obama administration.

Among her observations:

“Advocates of greater flexibility are likely to find an ally in Seema Verma, the new administrator of the federal Centers for Medicare and Medicaid Services (CMS). Verma was an architect of Indiana’s system. In a 2013 congressional hearing, she described the Medicaid bureaucracy as a set of ‘rigid, complex rules’ that have ‘created an intractable program that does not foster efficiency, quality or personal responsibility.”’

“But as veterans of efforts to streamline government bureaucracy and improve program efficiency know all too well, there are always going to be up-front costs. Health policy experts worry that the kind of large, across-the-board cuts to Medicaid funding being proposed in Congress would work against the kind of flexibility initiatives that appeal to the program’s state administrators.”

To read more, please hit this link.

 

 


AHA sends Congress suggestions for regulatory relief

The American Hospital Association has forwarded some options to Congress to consider for regulatory relief for healthcare organizations.

Tom Nickels, the AHA’s executive vice president for government relations and public policy, told Congress that although the government has eased some  rules, a huge burden on hospitals remains.

He wrote: “Indeed, the regulatory burden faced by hospitals is substantial and unsustainable. In addition to the sheer volume, the scope of changes required by the new regulations is beginning to outstrip the field’s ability to absorb them.

 Here are a few highlights as summarized by FierceHealthcare:

  • “Offer an Anti-Kickback safe harbor and Stark exemption for clinical integration agreements and patient assistance, as these laws can hinder care coordination.
  • “Issue an enforcement moratorium on the ‘96-hour’ rule, which requires critical access hospitals to certify that a patient could reasonably be transferred or discharged within 96 hours.
  • “Allow providers access to patient substance abuse treatment records without an individual patient’s consent.
  • “Suspend the “deeply flawed” star ratings on Hospital Compare, which Nickels said experts have disputed as accurate indicators of clinical quality.
  • “Reduce the number of clinical quality measures to the ones that ‘matter,’ as the Centers for Medicare & Medicaid Services currently uses upwards of 90 measures.
  • “Protect Medicare payments to disproportionate share hospitals.
  • “Adjust readmission rate evaluations to account for social risk factors.
  • “Make bundled-payment programs voluntary.”

To read the AHA letter, please hit this link.

To read the FierceHealthcare commentary, please hit this link.


Capitalizing on Medicaid APMs

 

Deloitte has studied Medicaid alternative-payment models (APMs) to see how payers and others can best capitalize on them. The consulting firm looked at:

  • Patient-centered medical home initiatives.
  • Medicaid Health Homes.
  • Episode of care payments.
  • Accountable Care Organizations.

The firm concluded that:

  • “Many states are taking advantage of Medicaid program flexibility and federal financing to implement APMs in a variety of ways.
  • “Although many state initiatives are underway, relatively few have been evaluated for their impact on total cost of care of health outcomes.
  • “The potential impact of Medicaid alternative payment models on care delivery can depend considerably on how much of a provider’s revenue comes from Medicaid.
  • “Medicaid models may need to evolve to incorporate more financial risk and increase participants’ meaningful use of electronic health records (EHRs) to qualify as advanced APMs under MACRA.’’

“Despite limited evidence, APMs continue to spread, and federal and state policies are increasing pressure on providers and insurers to participate. Aligning Medicaid AMPs’ design, reporting requirements, and financial incentives with other payers could potentially increase their impact and likelihood of success. This could be particularly true for specialists or other providers who treat a low volume of Medicaid patients.’’

To read the report, please hit this link.

 

 

 


How to ensure Medicaid patients have enough access to specialists?

 

Michael H.  Katz, M.D.,   writes in JAMA:

“Timely access to specialists has been a longstanding concern for patients with Medicaid compared with patients who have private insurance. Thus, instituting requirements that Medicaid managed care plans adhere to timeliness and proximity standards seems like an excellent solution to a longstanding problem. However, as with so many things in health care, the issue is more complicated.”

To read his essay, please hit this link.

 


Most Americans in poll say ACA should be improved, not killed

 

By PHIL GALEWITZ

For Kaiser Health News

Move on.

That’s what most people say Congress and the Trump administration should do after the Senate failed to approve legislation in July to  revamp the Affordable Care Act, according to a survey this month.

Nearly 8 in 10 Americans say President  Trump should be trying to make the health law work, according to poll conducted by the Kaiser Family Foundation. This includes large majorities of Democrats (95 percent) as well as half of Republicans (52 percent) and President Trump’s supporters (51 percent). (Kaiser Health News is an editorially independent program of the foundation.)

Almost 6 in 10 people think the Republicans should work with Democrats to improve the health law.

Only 17 percent of the public — and 40 percent of Republicans — think the Trump administration should take steps to make the health law fail, the survey said.

Trump has threatened to end funding to insurers to cover cost-sharing subsidies that cover the out-of-pocket health expenses for millions of low-income people buying coverage on the Obamacare exchanges. Insurers say such a move would force them to leave the health law marketplaces or raise premiums. Nearly two-thirds of the public oppose the president’s negotiating tactics, the survey said.

Just 21 percent of respondents — but 49 percent of Republicans — want the GOP to continue working on a plan to repeal and replace Obamacare, the survey said.

The GOP-controlled Senate failed to pass a health bill before it left for a summer break last week. The House in May passed a bill to partially repeal the law and drastically cut Medicaid.

About 60 percent of people says that Trump and congressional Republicans are responsible for any problems with the health law. Trump has said the public will blame Democrats for any problems.

The health law is more popular than ever, with 52 percent of respondents saying they hold a favorable view of it.  There has been a 9-percentage-point increase in people who hold a favorable view since November.

Still, confusion about the law remains.

Even though only about 10 million people receive coverage through the marketplaces, about 60 percent of Americans believe that their family will be negatively affected by rising premiums in the marketplaces.

The same number of people say that insurers’ decisions not to sell insurance plans in certain marketplaces will affect everyone with insurance. Marketplace coverage affects only those buying individual insurance — not  those who get job-based plans or Medicare or Medicaid.

The poll of 1,211 adults was conducted Aug. 1- 6.The margin of sampling error is plus or minus 3 percentage points.


Court rules that Medi-Cal cut to hospitals was illegal

 

A federal appeals court has ruled that the federal government erred in approving  California’s request to temporarily cut Medi-Cal (the state’s Medicaid program) reimbursement for hospital outpatient care by 10 percent during the  Great Recession.

The ruling by a three-judge panel of the U.S. 9th Circuit Court of Appeals said the Feds can approve such cuts only if evidence shows that the aid  recipients  will  continue to have access to the same services as the general population.

California imposed the cutback  from July 2008 through February 2009.

Robert Leventhal, a lawyer who represented more than 50 hospitals in the case, told the Los Angeles Times that if the ruling stands, the state and  federal governments will have to pay back California hospitals hundreds of millions of dollars.

To read more, please hit this link.


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