The administration says it's looking to assist those left behind by the ACA. The efforts are dramatically reshaping the individual insurance market to one that looks more as it did before the 2010 law.
In the span of less than 12 hours last week, the Trump administration took two seemingly contradictory actions that could have profound effects on the insurance marketplaces set up by the Affordable Care Act.
First, officials issued guidance Monday morning that could weaken the exchanges set up for people who buy their own insurance. The new approach makes it easier for states to get around some ACA requirements, including allowing the use of federal subsidies for skimpier plans that can reject people with preexisting conditions.
Yet, the other move — a proposed rule unveiled Monday evening — could bolster ACA marketplaces by sending millions of people with job-based coverage there, armed with tax-free money from their employers to buy individual plans.
Both efforts play into the parallel narratives dominating the bitter political debate over the ACA.
The administration, frustrated that Congress did not repeal the law, say some critics and policy experts, is working to undermine it by weakening the marketplaces and the law's consumer protections. Those efforts make it easier for insurers to offer skimpier policies that bypass the law's rules, such as its ban on annual or lifetime limits or its protections for people with preexisting conditions. Congress also zeroed out the tax penalty for not having coverage, effective next year. Combined, the moves could reduce enrollment in ACA plans, potentially driving up premiums for those who remain.
The administration and Republicans in Congress say they are looking to assist those left behind by the ACA — people who don't get subsidies to help them buy coverage and are desperate for less expensive options — even if that means purchasing less robust coverage.
"These are people who were buying insurance before [the law] and then the rules changed and they could not buy it because they could not afford it," said Joe Antos, a resident scholar at the conservative American Enterprise Institute. "They have been slowly dropping out of insurance coverage altogether."
The efforts are dramatically reshaping the ACA and the individual insurance market to one that looks more as it did before the 2010 law, when regulation, coverage and consumer protections varied widely across the country.
"Some states will do everything they can to keep individual markets strong and stable. Others won't," said Sabrina Corlette, research professor at the Center on Health Insurance Reforms at Georgetown University.
So what expectations should consumers have? Here are three key takeaways:
Protections for preexisting health problems are uncertain.
Polls show that keeping the ACA's guarantees on coverage for people with medical problems is a top concern for Americans, and Democrats have made their defense of the health law a key part of their midterm election campaigns.
Republicans have gotten that message and even those who voted to repeal the ACA or joined a lawsuit by 20 red states to overturn it now say they want to protect people with preexisting conditions. Still, GOP lawmakers have not introduced any plan that would be as protective as the current law.
In August, the administration released a rule allowing expanded use of short-term plans, which are less expensive than ACA policies. To get those lower prices, most of these plans do not cover prescription drugs, maternity care, mental health or substance abuse treatments.
The move is unlikely to benefit people with health problems, as short-term plans can reject people with preexisting conditions or decline to cover care for those medical problems.
Under the rule, insurers can sell them starting in 2019 for up to a year's duration, with an option to renew for up to three years, reversing an Obama-era directive that limited them to 90 days.
Administration officials estimate such plans could draw 600,000 new enrollees next year, and others have estimated the numbers could be far higher. The concern is if many healthy people in 2019 switch out of the ACA market and choose short-term plans, premiums will rise for those who remain, including those with preexisting conditions or make the ACA market less attractive for insurers.
Where you live matters more.
One of the biggest changes ushered in with the ACA was a standard set of rules across all states.
Before the law took effect, consumers buying their own coverage saw tremendous variation in what was offered and what protections they had, depending on the state where they lived.
Most states, for example, allowed insurers to reject people with medical conditions. A few states required insurers to charge similar premiums across the board, but most allowed wide variations based on age, gender or health. Some skimpy plans didn't cover prescription drugs, chemotherapy or other medical services.
By standardizing the rules and benefits, the ACA barred insurers from rejecting applicants with medical conditions or charging them more. Women and men get the same premium rates and insurers could charge older people no more than three times what they charged younger ones.
Under the new guidance issued this week giving states more flexibility on what is offered, consumers could again see a wide variation on coverage, premium rules and even subsidy eligibility.
"It shifts pressure to state politicians," said Caroline Pearson, a senior fellow at NORC, a nonpartisan research institution at the University of Chicago. That could play into the calculus of whether a state will seek to make broad changes to help people who cannot afford ACA plans, even if the trade-off affects people with medical conditions.
"You risk making some worse off by threatening those markets," said Pearson. "That is always going to be hard."
Millions more will join the "buy-your-own" ranks.
The proposed rule released Tuesday allows employers to fund tax-free accounts — called health reimbursement arrangements (HRAs) — that workers can use to buy their own coverage on the ACA marketplaces.
The administration estimates about 10 million people would do so by 2028 — a substantial boost for those exchanges, which policymakers say never hit the enrollment numbers needed to attract enough insurers and hold prices down.
John Barkett, senior director of policy affairs at Willis Towers Watson, a benefits consulting firm, said he expects employers to "seriously consider" the new market. The infusion of workers will improve options by attracting more insurers, he added.
"These people coming in will be employer-sponsored, they'll have steady jobs," Barkett noted, and will likely stick with coverage longer than those typically in the individual market.
Currently more than 14 million people buy their own insurance, with about 10 million of those using federal or state ACA marketplaces. The others buy private plans through brokers.
The proposed rule won't be finalized for months, but it could result in new options by 2020.
If these workers seeking coverage are generally healthy, the infusion could slow premium increases in the overall ACA marketplace because it would improve the risk pool for insurers.
But, if employers with mainly higher-cost or older workers opt to move to the marketplaces, it could help drive up premiums.
In an odd twist, the administration notes in the proposed rule that the ACA has provisions that could protect the marketplace from that type of adverse selection, which can drive up prices. But most of the protective factors cited by the rule have been weakened, removed or expired, such as the tax penalty for being uninsured and the federal subsidies for insurers to cover lower deductibles for certain low-income consumers.
Benefits consultants and policy experts are skeptical about how many companies will move to the HRA plan, given the tight labor market. Continued uncertainty about the fate of the ACA marketplace may keep them reluctant to send workers out on their own, they say.
Health benefits are a big factor in attracting and retaining workers, said Chris Condeluci, a Washington attorney who previously worked for Sen. Chuck Grassley (R-Iowa) and served as counsel to the Senate Finance Committee during the drafting of the ACA.
"Most employers believe their group health plan will provide better health coverage than an individual market plan," he said.
Proposition 8 would wipe out DaVita's earnings in California, according to recent investment firm reports. Passing the initiative 'would be so devastating,' to the tune of $450 million a year, that DaVita 'would likely walk away from the state altogether.'
It's been a year of playing defense for DaVita Inc., one of the country's largest dialysis providers.
A federal jury in Colorado this summer awarded $383.5 million to the families of three of its dialysis patients in wrongful death lawsuits. Then this month, the Denver-based company announced it would pay $270 million to settle a whistleblower's allegation that one of its subsidiaries cheated the government on Medicare payments.
But its biggest financial threat is a ballot initiative in California that one Wall Street firm says could cost DaVita $450 million a year in business if the measure succeeds.
Despite these recent hits, the company continues to rake in profits and receive favorable ratings from stock analysts. Its shares are trading at about $65 a share, only about 19 percent below a 52-week high set in January. That's largely because DaVita controls about one-third of a growing market, health experts say.
"They don't really have many rivals, and they perform a necessary, lifesaving service," said Leemore Dafny, a professor of business administration at Harvard Business School. "If you're producing something people want to buy and you're the only one making it, people are going to buy it."
Patients with chronic kidney failure often need dialysis to filter the impurities from their blood when their kidneys can no longer do that job.
And as Americans live longer and get heavier, more people become diagnosed with kidney disease and possibly need dialysis. In 2015, 124,114 new patients received dialysis, up from 94,702 in 2000, a 31 percent increase, according to the U.S. Renal Data System.
DaVita is one of the largest dialysis providers in the country, operating more than 2,500 clinics nationwide. In California, the company operates 292 clinics, half of all chronic dialysis clinics in the state.
Its parent company, DaVita Inc., reported $10.9 billion in revenue last year and $1.8 billion in profits, almost all of which came from its dialysis business.
This year, company officials project the dialysis group will bring in $1.5 billion to $1.6 billion in profits. It's a big turnaround for a corporation that could barely make payroll in 1999, when it was under review by the Securities and Exchange Commission for questionable accounting practices. Its success has largely been credited to CEO Kent Thiry, a colorful personality who has dressed up as a Musketeer and ridden a horse into corporate meetings to rally workers.
Now those big profits — generated from treating sick patients — has put a target on the company's back, as well as that of its biggest competitor, Fresenius Kidney Care.
The Service Employees International Union succeeded this year in placing Proposition 8 on California's Nov. 6 ballot, which would limit dialysis center commercial revenues to 115 percent of patient care costs. The ballot fight pits a well-funded industry against labor and the California Democratic Party.
DaVita declined to make anyone available for this article, but in a statement said Proposition 8 "will limit patients' access to life-saving dialysis treatments, jeopardizing their care."
Last year, roughly two-thirds of DaVita's dialysis revenue came from government-based programs, such as Medicare and Medicaid. But that isn't enough to cover its costs, according to the company's 2017 annual report, which states that DaVita loses money on each Medicare treatment it provides. (Medicare covers dialysis for people 65 and older, and for younger patients after private insurance has provided coverage for 30 months.)
Instead, DaVita generates profits from commercial health plans, which it acknowledges pay "significantly higher" rates than government programs. The ballot measure targets those higher rates, which Dafny describes as "their bread and butter."
The prospect of the measure passing led DaVita to delay or cancel plans to open new clinics in California despite growing patient demand, Javier Rodriguez, chief executive officer of DaVita Kidney Care, told investors on a call in May, according to the online equity research website Seeking Alpha.
A few months later, Rodriguez declined to provide a dollar amount when asked how the initiative would impact the company. Rather, he warned investors that it would become "unsustainable" for the industry to treat the estimated 66,000 dialysis patients in California, should the measure succeed.
Wall Street analysts agree that Proposition 8 would wipe out DaVita's earnings in California, according to recent reports issued by investment firms J.P. Morgan and Baird. Passing the initiative "would be so devastating," to the tune of $450 million a year, that DaVita "would likely walk away from the state altogether," according to a March Baird report.
DaVita has poured $66.6 million into the opposition campaign as of Oct. 25, and rival Fresenius has contributed $33.6 million. That dwarfs $17.3 million in union contributions in support of the measure, according to campaign records filed with California's secretary of state office.
Both Wall Street firms conclude that Proposition 8 is likely to fail, citing the industry's massive spending and the union's record of failure at the polls on other issues.
The company's legal troubles don't worry stock analysts, either; Baird's October report on DaVita's financial performance dedicates just two sentences to them. It notes that DaVita "is subject to numerous ongoing government investigations and inquiries, similar to most large-scale, high-profile Medicare providers."
There are no specific references to the Colorado jury award this summer, which the company is appealing, over the death of three patients who died of cardiac arrest after treatment at DaVita clinics. Nor was there concern about this month's $270 million settlement over Medicare billing.
That's because those incidents are seen by investors as the cost of doing business — one-time hits that don't affect a company's earnings power in the future, said Matthew Gillmor, a senior research analyst at Baird.
"Almost all companies I follow, at some point, have had to pay a fine to the government," Gillmor said.
Thiry, DaVita's CEO, acknowledged that settlements, which aren't good public relations, are a reality for large corporations, when The Denver Post asked him last year about the company's previous legal battles.
"If, in a trial, you are found to be wrong on even a small part of the case, it could mean that you are excluded from Medicare, which typically would mean bankruptcy for your company," Thiry said. "So, you are essentially forced to settle."
Stanford Health Care operates the largest hospital system in both cities where the price cap proposal is on the ballot. Stanford officials say the measures could undermine quality.
At a time of mounting national anger about rising health care prices, the country's largest union of health workers has sponsored ballot measures in two San Francisco Bay Area cities that would limit how much hospitals and doctors can charge for patient care.
The twin measures in Palo Alto and Livermore, sponsored by the Service Employees International Union-United Healthcare Workers West, take aim primarily at Stanford Health Care, which operates Stanford Hospital and Clinics, the facility with the third-highest profits in the country from patient care services, according to a 2016 study.
The union also is sponsoring Proposition 8, a statewide measure that would impose a cap on profits for dialysis clinics. Together, the state and local measures seek to draw on public outrage over sky-high medical prices. And, for municipalities, they amount to a novel and untested effort to rein in those prices through the ballot box.
"I've been in this field almost 50 years, and I've never seen a local government regulating hospital prices," said Paul Ginsburg, director of public policy at the Schaeffer Center for Health Policy & Economics at the University of Southern California. A number of states set hospital rates in the 1970s, and two states, Maryland and West Virginia, do so today, he said.
Opponents question the legal authority of cities to regulate health care pricing, and they predict a flood of litigation against the measures if they pass. The city councils of both cities oppose the proposals, arguing that local officials with no expertise in health care costs would be required to create a new bureaucracy to regulate them.
Stanford Health Care officials say the measures could undermine quality. "It would threaten [the system's] ability to provide top-quality health care to patients from Palo Alto and across the region," according to a September statement from the system.
Ginsburg expressed skepticism. "Of course, you could cut rates too much and harm hospitals financially," he said. “But if done with intelligence, you could accomplish some price reduction without harming quality."
For the union, the ballot measures could help it gain leverage in future bargaining or organizing efforts with Stanford and other hospitals. Stanford Health Care operates the largest hospital system in both cities where the price cap proposal is on the ballot. Stanford has opened, has acquired or is building health care centers with clinics and specialty services in Emeryville, Pleasanton and Redwood City — Bay Area cities where the SEIU-UHW tried but failed to place similar price-control measures on local ballots.
But union officials say their motive is simply to rein in prices. "Stanford Health is nonprofit. They don't pay property taxes or incomes taxes," said Sean Wherley, an SEIU-UHW spokesman. "Taxpayers are subsidizing their operations and getting wrung out by over-the-top prices."
Stanford and other health systems have been on a buying spree in recent years acquiring hospitals and physician practices, and this concentration of ownership has stifled market competition and further boosted prices for insurers and patients.
The Palo Alto and Livermore initiatives, which also affect other medical systems in the cities, would cap prices charged by hospitals and other health care providers at 115 percent of "the reasonable cost of direct patient care."
And there, some experts say, lies the rub.
"What is a seemingly simple idea — limiting prices to 115 percent of 'costs' — is neither simple in execution, nor concept," said Benedic Ippolito, a research fellow at the American Enterprise Institute who studies health care financing. "What costs are acceptable? How will we stop providers from increasing costs as much as possible" to compensate for the cap?
Under the initiatives, hospitals and other medical providers would be obliged to pay back any charges above the cap each year to private commercial — but not government — insurers, and to patients who pay for their own care. They would also owe the cities a fine equal to 5 percent of the excess charges. Fines collected by the cities could be used to pay for enforcing the laws.
Stanford estimates that Proposition F, the Palo Alto measure, would reduce the health system's budget by 25 percent, forcing it to make cutbacks and possibly end essential services, said David Entwistle, the health system's president and chief executive officer.
Livermore would need to spend $1.9 million a year on the staff required to implement Measure U — its version of the proposal — and would likely incur another $750,000 to $1 million in legal and startup costs, according to an analysis conducted for the city by Henry Zaretsky, a health economist who has worked for the state and the California Hospital Association.
Patients in the wealthy region expect high-quality services but also can be savvy consumers and passionate voters. It is an open question whether the measures would pass.
Industry consolidation is far more pronounced in Northern California than in Southern California, according to a recent study from the University of California-Berkeley. As a result, inpatient hospital prices in the north were 70 percent higher and outpatient costs as much as 55 percent higher than in the south. The price disparities, even within the Northern California region, can be dramatic.
For instance, independent doctors in the Bay Area are reimbursed, on average, a median $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits, according to a 2017 Kaiser Health News analysis of claims data from Amino, a health cost transparency company. That compares with $5,238.13 for the same bundle of services for Stanford physicians (and $8,049.84 for doctors employed by the University of California-San Francisco).
The higher cost of medical care also pushes up insurance premiums for patients. Health plans purchased on the state insurance exchange were 35 percent higher in Northern California than in Southern California, the 2018 UC Berkeley study showed.
Earlier this year, California Attorney General Xavier Becerra took aim at medical industry consolidation and the high prices associated with it. He sued Sutter Health, one of the nation's largest health systems, saying it was systematically overcharging patients and illegally driving out competition in Northern California.
To C. Duane Dauner, a former president and CEO of the California Hospital Association, the ballot proposals are "a power play by SEIU-UHW to put pressure on Stanford Health Care." The union wants Stanford "to be neutral when they try to organize employees in Redwood City, Emeryville, Pleasanton and Livermore," said Dauner, who heads the campaign committee opposing both measures.
Larry Tramutola, a veteran campaign consultant who is not involved on either side, agrees.
"I don't think it has anything to do with controlling health care prices," said Tramutola, who recently managed successful local initiatives to tax sodas and ban menthol cigarettes. "It's about bargaining. Win or lose on this, other hospitals in other places will take notice and realize that SEIU is a formidable foe."
Protect Our Local Hospitals and Health Care, the campaign committee opposing the measures, has raised $4.2 million so far this year. The union's political action committee has spent $1.5 million in support of the initiatives.
If the push is successful, about 62,000 Idaho adults would be added to the program that covers 73 million low-income Americans. It would be a major advance for the ACA into one of the most conservative parts of the country.
BOISE, Idaho — Standing outside the gun shop she co-owns, next to her SUV sporting "NRA" on the license plate, Christy Perry pledges full support for President Donald Trump.
"He's doing a good job," said Perry, a four-term Republican member of the Idaho legislature who has voted for a litany of conservative causes, including weakening labor unions, restricting abortion and boosting charter schools.
With those credentials, Perry hopes for another big win on Election Day — one that puts her at odds with Trump and GOP orthodoxy.
She's helping lead the drive to persuade state voters to expand Medicaid — a central tenet of the Affordable Care Act, the 2010 law embraced by Democrats and derided by many Republicans.
Perry has been pushing for Medicaid expansion the past several years in the state legislature, but those efforts were thwarted by top House leaders. Now a ballot initiative, Proposition 2, puts the matter before Idaho voters.
Perry said Medicaid coverage is desperately needed by people struggling in low-wage jobs and the economics make sense for the state given the federal government will pay a 90 percent share. An expansion will reduce or eliminate the need for other Idaho-funded programs to help the uninsured, she said.
She said the state can't wait any longer.
"The longer you wait, the more people die" because they miss out on care, she said.
If the push is successful on Nov. 6, about 62,000 Idaho adults would be added to the state-federal health insurance program that covers 73 million low-income Americans. It would be a major advance for Obamacare into one of the most conservative parts of the country.
Idaho is one of the remaining 17 GOP-controlled states where lawmakers have steadfastly resisted expanding Medicaid.
But voters in Idaho, Nebraska and Utah will decide next month whether to buck their political leaders and go forward with the expansion. The issue is also on the ballot in Montana, which expanded Medicaid in 2016. There, residents will decide whether to continue it past 2019.
Of those states, Idaho is arguably the least politically hospitable for Medicaid expansion. Trump carried Idaho by the largest margin — nearly 32 percentage points.
Last year, Maine became the first state to approve expanding Medicaid via a ballot referendum, although the GOP governor has stalled implementation.
Unlike Maine, where political power has been split between Democrats and Republicans in recent years, Idaho, Utah and Nebraska are solidly GOP territory.
Trump and Republican congressional leaders have vowed to repeal the health law, which made expansion possible by providing the bulk of the funding for those who qualify for new coverage.
Perry, 50, doesn't see a problem getting Trump voters to back the expansion. She said that the Republican failure to repeal the law last year opened the door for conservative states to go forward.
"I think people here listen to that and it now falls to states to go ahead" with expansion, she said.
Supporters of the referendum were successful at garnering 70,000 signatures to put the vote on the ballot, but they face a steep challenge educating the electorate about the complexities of Medicaid financing.
Tim Dunnagan, dean of the College of Health Sciences at Boise State University, said few Idaho voters know that most states — including neighboring Oregon and Washington — have already expanded Medicaid. Because the issue can be confusing, he said, voters may gravitate to their long-held concerns about paying more taxes and government overreach.
"There is a strong sentiment that if the federal government is involved, it is not a good thing," he said. "There's a fierce individualism out in the West."
Perry and the broad coalition endorsing the referendum — including teachers, employers, county sheriffs and the health industry — seek to remind voters that they are already paying for the health law's provisions through their federal taxes and the expansion would bring $400 million in federal funds into the state.
The expansion would cover residents with incomes below 138 percent of the federal poverty level, or nearly $17,000 a year for an individual. Currently, Idaho adults who do not have children and are not disabled are not eligible for Medicaid. Those with children can only qualify with incomes up to 26 percent of the poverty level, or $3,156 a year.
The expansion also would eliminate a gap for residents whose income is too low to qualify for government subsidies to buy private coverage but who earn too much to qualify for Medicaid.
Supporters have canvassed neighborhoods across the state in recent weeks. Hundreds of volunteers use lists of registered voters and a special app on their phone to detail their results.
On a recent evening, about 20 people gathered about 10 miles east of downtown Boise, where a field organizer gave them voter lists and instructions on how to approach homeowners.
Tracy Olson, 54, a nurse turned real estate agent, and Jill Galanter, 55, a physical therapist, went to an upper-income planned community. About two-thirds of the people they met said they support expansion, and most of the rest had not heard about it. Only a couple of people said they oppose the ballot question.
In their one-minute pitch, Olson and Galanter explained the coverage gap for low-income residents and the millions in federal dollars the state can gain by expanding. They didn't mention the ACA. That's not an oversight, organizers said.
"Obamacare has a negative connotation here," Perry said.
Mike Brown, 50, an engineer, told Olson he didn't know the issue but added that his health costs have soared in recent years. He nodded as Olson explained whom the expansion would help.
"I can sympathize," he said. They recorded him as a "leaning yes."
Richard Rapp, 75, a retired head of the career center at Boise State University, said he will support the expansion for humanitarian reasons. "Too many people don't have adequate coverage, and that ends up costing us all," he said.
Later that week, another volunteer, Lauren Necochea, also found support in the Nampa area, west of Boise.
Norm Holm, 67, listened to her pitch. "It makes sense to me," said Holm, a registered Republican. "Everyone deserves a decent shot at health care."
Asked if he knew that the Medicaid expansion is part of the ACA, Holm shook his head. "If they can't do away with it, maybe this is a way to make it better," he said, adding that he believes the health law has good and bad parts.
In contrast, opponents of the referendum stress how Medicaid expansion is part of what they call the "failed Obamacare."
The Idaho Republican Party and the conservative Idaho Freedom Foundation are fighting the ballot initiative. Foundation officials say it would divert dollars that could be spent on roads and education.
"Medicaid expansion is a cornerstone of Obamacare, which has failed to cover everyone and has led to increasing health costs," said Fred Birnbaum, vice president of the foundation.
His group plans to run radio commercials, use social media and put out flyers.
Lawmakers opposed to expanding Medicaid have argued that the state could not afford its share of the cost without having to raise taxes. Under the law, the federal government pays about 90 percent of the costs for expansion and states cover the rest.
But a state-funded report this year found it would cost Idaho relatively little — $105 million over 10 years, which includes savings from state and county funds that would no longer be needed to help the uninsured. Idaho's budget tops $3 billion a year.
Brad Little, the GOP nominee for governor who is widely expected to win in November, said he would abide by the will of the voters.
Perry is not the only Republican state lawmaker who has come out in support of expansion, but she is one of the most prominent. Perry tried — and failed — to get lawmakers to expand Medicaid. She is not running for re-election.
"Christy is well-known among GOP women and well-liked," said Toni Lawson, vice president of government relations at the Idaho Hospital Association, which supports the initiative. She said persuading GOP women to vote for expansion will be key to a victory.
Perry said her gun store ownership and mainstream conservative values will help gain voters' trust on Medicaid.
"Idaho is a conservative, Christian and right-to-life state, and Medicaid expansion fits right in with our morals and values we have," she said. "It's about doing the right thing."
Medicaid enrollment fell by 0.6 percent in 2018 — its first drop since 2007 — due to the strong economy and increased efforts in some states to verify eligibility, a new report finds.
But costs continue to go up. Total Medicaid spending rose 4.2 percent in 2018, same as a year ago, as a result of rising costs for drugs, long-term care and mental health services, according to the study released Thursday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
States expect total Medicaid spending growth to accelerate modestly to 5.3 percent in 2019 as enrollment increases by about 1 percent, according to the annual survey of state Medicaid directors.
About 73 million people were enrolled in Medicaid in August, according to a federal report released Wednesday.
Medicaid, the state-federal health insurance program for low-income Americans, has seen its rolls soar in the past decade — initially as a result of massive job losses during the Great Recession and in recent years when dozens of states expanded eligibility using federal financing provided by the Affordable Care Act. Thirty-three states expanded their programs to cover people with incomes under 138 percent of the federal poverty level, or an income of about $16,750 for an individual in 2018.
Medicaid spending and enrollment typically rise during economic downturns as more people lose jobs and health benefits. When the economy is humming, Medicaid enrollment flattens as more people get back to work and can get coverage at work or can afford to buy it on their own. The national unemployment rate was 3.7 percent in September, the lowest since 1969.
The falling unemployment rate is the main reason for the drop in Medicaid enrollment, but some states have reduced their rolls by requiring adults and families to verify their eligibility. Arkansas, for example, has cut thousands of people after instituting new steps to confirm eligibility.
The brightening economic outlook for states has led many to increase benefits to enrollees and payment rates for health providers.
"A total of 19 states expanded or enhanced covered benefits in fiscal 2018 and 24 states plan to add or enhance benefits for the current fiscal year, which for most states started in July," the Kaiser report said. "The most common benefit enhancements reported were for mental health and substance abuse services. A handful of states reported expansions related to dental services, telehealth, physical or occupational therapies and home visiting services for pregnant women."
A dozen states increased pay to dentists and 18 states added to primary care doctors' reimbursements for fiscal year 2019.
Medicaid covers about 20 percent of U.S. residents and accounts for nearly one-sixth of health care expenditures. Nearly half of enrollees are children.
Overall, the federal government pays about 62 percent of Medicaid costs with state's picking up the rest. Poorer states get a higher federal match rate.
Seventeen Republican-controlled states have not expanded Medicaid. For individuals accepted into the program as part of the ACA expansion, the federal government paid the full cost of coverage from 2014 through 2016. It will pay no less than 90 percent thereafter.
In 2018, the states' share of spending rose 4.9 percent. This was the first full year that states were responsible for part of the cost of the expansion. States expect their spending will grow about 3.5 percent in 2019.
Robin Rudowitz, one of the authors of the study and associate director of the Kaiser Commission on Medicaid and the Uninsured, said the survey found many states were using Medicaid to address the opioid crisis by expanding benefits for substance disorders and also by implementing tougher restrictions on prescriptions.
"Almost every governor wants to do something, and Medicaid is generally a large part of it," she said.
While the Trump administration's approval of work requirements for some adults on Medicaid has generated controversy over the past year, the report shows that states are making many other changes to the program, such as increasing benefits and changing how it pays providers to get better value.
Last year, nearly 60 percent of Maine residents voted to expand the state's Medicaid program — an option provided by the Affordable Care Act that would extend health insurance to tens of thousands of the state's low-income people.
But the state's Republican governor, Paul LePage, a longtime opponent of Medicaid expansion, has refused to implement the policy because he doesn't want to raise taxes to pay the state's share of the cost.
The impasse highlights how the intense political push and pull over Medicaid expansion persists even when voters bypass legislators and decide the issue directly at the ballot box. Nevertheless, four more states — Idaho, Montana, Nebraska and Utah — will give voters in November's elections the opportunity to resolve the dispute.
"It's always treacherous" for politicians to raise taxes, said Matt Salo, who heads the National Association of Medicaid Directors. "But there are ways around it. You can figure out ways that are politically palatable."
When the ACA's Medicaid expansion took effect in 2014, proponents say, it set up an enticing deal. It allowed states to cover people with incomes up to 138 percent of the federal poverty level, including childless single adults.
The federal government paid the entire cost of the new enrollees. In 2017, states were to take on 5 percent of those costs. By 2020, that amount will increase to 10 percent.
States that didn't pursue the expansion pay as much as half the cost of coverage. And, in 2018, median eligibility for a family of four was 43 percent of the poverty level, or about $10,800. No childless adults were eligible.
So far, 33 states plus the District of Columbia have opted to expand, extending coverage to almost 12 million Americans, according to federal estimates last year. In those states, the expense ranges from tens of millions of dollars to hundreds of millions.
Rather than being a cash drain, many health policy researchers and economists note, expansion has generally boosted state economies, with higher employment, reduced state spending on health care services for the uninsured and consumer spending elsewhere that would have gone to health care.
"The state savings are so significant, they make it much more manageable," said Adam Searing, an associate professor of practice at Georgetown University's Center for Children and Families. "The issue of how it gets paid for — it's still an important issue, but it's not as front and center."
Different approaches work for different states, Salo said, and all invite political complications.
In Montana, voters are considering Initiative 185, a ballot question that would continue the state's Medicaid expansion and fund it by increasing what is known as a "sin tax" on tobacco products, including electronic cigarettes.
It's a counterintuitive double whammy in such a conservative state: persuading voters first to favor an Obamacare policy, and second to finance it with a tax hike.
By taking on cigarettes, the campaign has incurred the wrath of Big Tobacco, which has put forth more than $12 million in contributions and expenditures to fight the measure.
"Anytime you go up against the tobacco industry, you are mainly going to have them as your opponent," said Amanda Cahill, who directs government relations for Montana's American Heart Association chapter and is part of the "Yes on I-185" campaign.
Voters can be skittish about a tax increase, she said, but many are receptive to the campaign's argument that it pays off in the long term.
New Hampshire took a parallel "sin tax"-type approach. It uses money from an alcohol tax to help fund expansion, a deal negotiated this year.
In Utah, voters will consider newly expanding Medicaid and funding it with a 0.15 percent increase to the state's sales tax, though the hike would exempt groceries. Current polling suggests strong voter support. Nebraska and Idaho also have Medicaid expansion on the ballot, though they would punt the funding question to state legislatures.
Other states have tried a different strategy: shielding consumers from direct taxes and instead financing expansion through taxes on industry players that benefit from Medicaid expansion. The most notable example: hospitals. For these facilities, reducing the number of uninsured, low-income people reduces the burden of uncompensated care and improves their bottom line. Research from states that have already expanded Medicaid supports this idea.
Virginia, Oregon and Colorado already have such taxes or fees in place. (Oregon voters in January approved a tax on both health insurance and hospitals to fund expansion.)
But it hasn't been easy. Virginia's legislature voted this summer to expand Medicaid eligibility after failing five times. During Statehouse debates, funding was a "very significant concern," said Michael Cassidy, president of the Commonwealth Institute for Fiscal Analysis, a Richmond-based think tank that has long supported the policy.
Proponents of expansion showed economic projections that Virginia would benefit financially, since fewer uninsured people would need state-funded health services, and the injection of federal cash would boost the state economy.
The legislature eventually approved a tax on hospitals, by garnering support from their trade group, the Virginia Hospital and Healthcare Association. But the path to approval was "quite contentious," Cassidy said. Critics argued the cost was too great and could drive up health care expenses.
Medicaid advocates haven't begun planning ballot initiatives for 2020 yet, but there are six states that haven't expanded eligibility where voters could take on the question directly: Florida, Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.
As political analysts have long argued, the issue isn't entirely about funding. States can surmount that obstacle if there is political will.
"If you're talking about why did certain states not do the expansion, the fear of the cost — while a real issue — has never been within the top three of the actual reasons why they actually didn't do it," Salo said. "It all has been political and ideological."
Medicare-for-all means bringing all Americans under the government's insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone's medical bills. But few politicians are speaking precisely.
After decades in the political wilderness, "Medicare-for-all" and single-payer health care are suddenly popular. The words appear in political advertisements and are cheered at campaign rallies — even in deep-red states. They are promoted by a growing number of high-profile Democratic candidates, like Alexandria Ocasio-Cortez in New York and Rep. Beto O'Rourke in Texas.
Republicans are concerned enough that this month President Donald Trump wrote a scathing op-ed essay that portrayed Medicare for all as a threat to older people and to American freedom.
It is not that. But what exactly these proposals mean to many of the people who say they support them remains unclear.
As a renegade candidate for the 2016 Democratic nomination for president, Sen. Bernie Sanders (I-Vt.) opened the door to such drastic reform. Now, with Republicans showing little aptitude for fixing an expensive, dysfunctional health system, more voters, doctors and politicians are walking through it.
More than 120 members of Congress have signed on as co-sponsors of a bill called the Expanded and Improved Medicare for All Act, up from 62 in 2016. And at least 70 have joined Capitol Hill's new Medicare for All Caucus.
But some worry the terms "Medicare-for-all" and "single-payer" are at risk of becoming empty campaign slogans. In precise terms, Medicare-for-all means bringing all Americans under the government's insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone's medical bills. But few politicians are speaking precisely.
Celinda Lake, a Democratic pollster, said, "People read into 'Medicare-for-all' what they want to read into it."
For every candidate with a clear proposal in mind, another uses the phrases as a proxy for voter frustration. The risk, some critics say, is that "Medicare-for-all" could become a Democratic version of the Republican "repeal and replace" slogan — a vote-getter that does not translate to political action because there is neither agreement about what it means nor a viable plan.
"If you're on the left, you have to have something on health care to say at town halls," said David Blumenthal, president of the Commonwealth Fund. "So you say this and move on. That's part of the motivation."
Dr. Carol Paris, the president of Physicians for a National Health Program, an advocacy group, said she has fielded a number of calls from candidates asking for tutorials on Medicare-for-all.
"I'm heartened, but not persuaded" that all the high-profile talk will result in any action, she said. She worries about what she called "faux 'Medicare-for-all' plans" that don't live up to the mantra.
Polling highlights health care as a top voter concern, and pressure is building for politicians to take meaningful action that could redress the pain caused by personal health care costs that continue to rise faster than inflation.
Maybe that action would be negotiating lower drug prices or fixing flaws in the insurance system that allow for surprise medical bills and high out-of-pocket costs. Republican candidates mostly continue to bad-mouth "Obamacare" as the root of all problems in American health care (of course, it's not), and some still push to repeal it. They tend to offer only vague assurances that, for example, they will guarantee that people with preexisting conditions can find affordable insurance — proposals that do not withstand expert scrutiny.
But more and more voters seem to think the country needs more radical change.
Yet experts suggest voter support may not withstand warnings of tax increases or changes to employer-sponsored insurance. A 2017 poll from the Kaiser Family Foundation found that support for Medicare-for-all dropped when respondents were told that their taxes might increase or that the government might get "too much control over health care" — a common Republican talking point. (Kaiser Health News is an editorially independent program of the foundation.)
The broader goal — affordable, universal health care — could be achieved by a range of strategies. For models, we can look to nations that have generally achieved better health outcomes, for less money, than the United States.
Canada and Britain come particularly close to true single-payer. Their governments pay medical bills with money raised through taxes and have monopolistic negotiating power over prices. But after that, the systems differ.
In Canada, which is Sanders' inspiration, the government provides health insurance for most medical needs, with no out-of-pocket costs. People can, and often do, buy a second, private plan for any unmet health needs, such as prescription drugs.
Britain goes a step further. Its government owns hospitals and employs many specialists via the National Health Service. A small private system exists, catering mainly to wealthier people seeking faster access to elective procedures.
Other countries achieve universal health care (or nearly so), but without single-payer. France and Germany have kept an insurance system intact but heavily regulate health care, including by setting the prices for medical procedures and drugs, and requiring all citizens to purchase coverage.
These more incremental options have not captured the American imagination to the same extent as Medicare-for-all. But adopting such a system would require the biggest shift, with significant implications for taxes, patient choice, doctors' salaries and hospital revenue.
Enthusiastic politicians sometimes gloss over those consequences. For example, Liz Watson, a Democrat running in Indiana's 9th Congressional District, suggested the impact on doctors' income was not much of a concern, because they would see a "huge recovery" on expenses since they would no longer need to navigate the bureaucracy of insurance paperwork. But analysts across the board agree single-payer would cut revenue for doctors — many say by about 12 percent on average.
And many voters seem confused by the fundamentals. In polling by the Kaiser Family Foundation, about half of Americans said they believed they would be able to keep their current insurance under a single-payer plan, which is not the case.
Optimism without specifics carries risk, as President Barack Obama learned after promising that people wouldn't lose their doctors under the Affordable Care Act. That promise haunted the Obama administration — it was singled out as PolitiFact's "Lie of the Year" in 2013 and is still mocked by members of the Trump White House.
There's also the thorny issue of how Medicare-for-all would affect the thousands of jobs at private insurers. "We have an insurance industry in Omaha, and people say, 'I worry about those jobs,'" said Kara Eastman, a Democrat running on Medicare-for-all in Nebraska's 2nd Congressional District. She suggested people could be retrained, saying there would have to be "repurposing of positions."
Critics of Medicare-for-all, on the other hand, tend to exaggerate the costs of single-payer: "Denmark's top tax bracket is nearly 60 percent!" (True, although that's largely not because of health care.) "Doctors' incomes will drop 40 percent!" (True, specialists in private practice would probably see pay cuts, but primary care doctors could well see an increase.)
Canadians generally pay higher taxes than Americans do — specifically a goods and services tax, and higher taxes on the wealthy. In Germany, working people pay 7.5 percent of income as a contribution toward comprehensive insurance.
But many Americans pay far more than that when you count premiums, deductibles, copayments and out-of-network charges. Estimates of the tax increases required to support a Medicare-for-all or single-payer system are all over the map, depending on how the plan is structured, the prices paid to providers and drugmakers, and the generosity of benefits.
As a politician famously noted, "Nobody knew health care could be so complicated."
Some candidates do have clear proposals in mind. Ocasio-Cortez, for example, running for the House from New York's 14th District, is firm: a single, government-run health plan that covers everyone with no copayments or deductibles and perhaps allows Americans to buy supplemental private coverage. It's the Canadian approach, textbook single-payer.
But many who back Medicare-for-all are vague or open toincremental approaches, like a "public option" that maintains the current insurance structure while allowing people to buy into Medicare.
O'Rourke casts Medicare-for-all as a starting point for discussion. But he said that what matters most is "high-quality, guaranteed universal health care." Getting there, he added, "will inevitably require some compromise" — like a public option. Notably, he has not signed on as a co-sponsor of the Medicare-for-all bill because that plan does not allow for-profit providers to participate.
Jared Golden, a Democratic House candidate from Maine's 2nd District, says in his campaign materials that he favors "something like Medicare for all," but he clarified that at least initially, he would argue to lower the Medicare eligibility age, a change that wonks often call "Medicare for more."
And the Wisconsin Democrat Randy Bryce, who is running to replace Speaker Paul Ryan in the House, said he would support a public option or lowering the eligibility age for Medicare. "I don't want to say that there's only one way to go about it," Bryce said.
But many other candidates — both for Congress and for governorships — who are talking "Medicare-for-all" on the campaign trail either did not acknowledge or declined multiple requests to be interviewed on the subject. They include Andrew Gillum, who is running for governor in Florida; Gina Ortiz Jones of Texas’ 23rd District; the California candidate for governor Gavin Newsom; Massachusetts 7th District candidate Ayanna Pressley; and Pennsylvania 1st District candidate Scott Wallace.
Lake, the pollster, suggested that policy details simply aren't as relevant in a midterm year and that for now we shouldn't expect a candidate's support for Medicare-for-all to be anything more than a way to signal his or her values. But she suggested that will change in the run-up to 2020, adding, "When we head into the presidential election, people will probably be pickier and want more details."
That gives politicians and voters a few years to decide what they mean and what they want when they say they support Medicare-for-all or single-payer health care. For now, it's hard to read too much into promises.
Paris, who lives in Nashville, said she was surprised and excited to hear that her representative, Jim Cooper, a Blue Dog Democrat, had signed up as a co-sponsor of the Medicare for all bill.
As rates of sexually transmitted infections steadily rise nationwide, public health officials and experts say primary care doctors need to step up screening and treatment.
Julie Lopez, 21, has been tested regularly for sexually transmitted diseases since she was a teenager. But when Lopez first asked her primary care doctor about screening, he reacted with surprise, she said.
"He said people don't usually ask. But I did," said Lopez, a college student in Pasadena, Calif. "It's really important."
Lopez usually goes to Planned Parenthood instead for the tests because "they ask the questions that need to be asked," she said.
As rates of sexually transmitted infections steadily rise nationwide, public health officials and experts say primary care doctors need to step up screening and treatment.
"We know that doctors are not doing enough screening for STDs," said David Harvey, executive director at the National Coalition of STD Directors. The failure to screen routinely "is leading to an explosion in STD rates," he said, adding that cutbacks in funding and a lack of patient awareness about the risks make it worse.
The federal government's Centers for Disease Control and Prevention has set guidelines for annual screening for sexually active individuals. Among them: women under 25 should be tested for gonorrhea and chlamydia, and men who have sex with men should get tested for syphilis, chlamydia and gonorrhea.
However, testing does not always happen as recommended. For example, only about half of sexually active women ages 16 to 24 with private health plans or Medicaid were screened for chlamydia in 2015. The rate was slightly better in California.
Nationally, reported cases of chlamydia, gonorrhea and syphilis are at an all-time high, CDC data show. In one year, from 2016 to 2017, nationwide rates of chlamydia rose by 7 percent, gonorrhea by 19 percent and syphilis by 11 percent.
Rates of congenital syphilis, which passes from mother to baby during pregnancy or delivery, increased by 44 percent during that time. Nearly one-third of the congenital syphilis cases are from California. The state also saw a record number of STDs last year: more than 300,000 cases of gonorrhea, chlamydia and early syphilis among adults.
Because sexually transmitted infections are often asymptomatic, screening is essential. Untreated STDs can lead to serious health problems, such as chronic pain, infertility or even death.
"Providers and primary care providers play a crucial role in combating these rising STD rates," said Dr. Laura Bachmann, chief medical officer for the CDC division of STD prevention. "If providers don't ask the questions and don't apply the screening recommendations, the majority of STDs will be missed."
State governments don't have enough money to combat the rising number of cases, in part because federal STD funding for them has remained stagnant, Harvey said. Last year, he said, $152.3 million in federal funding was appropriated for prevention, the same as eight years earlier.
Experts cite several reasons primary care physicians don't routinely diagnose and treat STDs. They may worry that they won’t be compensated for providing STD services, or they may not be familiar with the most up-to-date recommendations about testing and treatment. For example, the CDC in 2015 updated the medications it recommends to treat gonorrhea.
Perhaps most commonly, many family physicians are reluctant to discuss sexual health with their patients. One study showed that one-third of adolescents had annual visits that didn't include any discussion about sexuality.
"We're in this situation with health care providers and patients — each waiting for the other to start [the conversation]," said Dr. Edward Hook, professor at the University of Alabama-Birmingham School of Medicine. "Doctors worry if they ask patients about their sexual history that it will somehow be offensive to them."
Dr. Michael Munger, president of the American Academy of Family Physicians, said he remembers that his conversations around sexual health were uncomfortable at first. "There are a lot of challenging conversations you can have with patients," he said. "But this is important. If we don't do it, who will?"
Rob Nolan, a writer from Los Angeles, said he gets tested every six months, but he prefers to do so at the Los Angeles LGBT Center rather than during visits with his regular doctor, who rarely asks about sexual health.
Nolan, who said he has had experience with STDs, considers the clinic's staff to be more knowledgeable about sexual health than those at a regular doctor's office. "They just seem specialized in it," he said. "And there is zero shame when you are in the clinic."
Physicians also may have other, more immediate health issues to address during the short time they have with patients. Taking a sexual history and talking about sexual health falls to the bottom of many doctors' priorities, said Dr. Leo Moore, acting medical director of the division of HIV and STD programs for the Los Angeles County Department of Public Health.
Julia Brewer, a nurse practitioner at Northeast Community Clinic in Hawthorne, Calif., said she screens for STDs as a regular part of women's health exams. But she said her colleagues frequently refer cases to her rather than having the conversations themselves. "The family providers are overwhelmed with diabetes and high blood pressure," she said. Sexual health, she said, can end up being an "afterthought."
The L.A. County public health department, which identified STDs as a key priority for the next five years, recently sent representatives to doctors' offices to teach providers how to address sexually transmitted infections. They distributed information detailing screening recommendations, sample sexual history questions and treatment guidelines.
The Los Angeles County Medical Association also plans to get the word out to doctors through social media and other efforts. "It's an epidemic and we have to treat it that way," said CEO Gustavo Friederichsen. "Doctors have to feel a sense of urgency."
Dr. Heidi Bauer, who heads the California Department of Public Health's STD control branch, said the state also is trying to educate doctors so they will screen more routinely. The department provides both in-person and online training for doctors to learn about STDs, and publishes downloadable information with current guidelines.
At the same time, Bauer urged the federal government to make its screening recommendations more comprehensive. Outside of pregnancy, for example, there are no recommendations for routine syphilis screening for women. "We are seeing this huge re-emergence of syphilis," she said. "We haven't been testing and syphilis is very challenging to diagnose."
The CDC plans to review the recommendations in the next year, Bachmann said.
This pattern of requests for taxpayers to help pay for major projects 'could leave children's hospitals with little incentive to control their costs,' a Johns Hopkins University Carey Business School professor said.
Back in 2004, California's children's hospitals asked voters to approve a $750 million bond measure to help fund construction and new medical equipment. In 2008, they asked for $980 million more. Now they're hoping voters will agree on Nov. 6 to cough up an additional $1.5 billion.
The state's 13 children's hospitals treat California's sickest kids — including those with leukemia, sickle cell disease, rare cancers and cystic fibrosis — so approving their fund-raising requests is an easy "yes" for many voters.
Despite the feel-good nature of the requests, some health care experts and election analysts question the hospitals' multiple appeals for taxpayer money — and are warning voters to review this year's proposal with a critical eye.
"I think it's a misuse of the initiative process for private groups to sponsor ballot measures that are intended to benefit them exclusively," said Elizabeth Ralston, a former president of the League of Women Voters of Los Angeles who analyzes state finance measures for the group. The league recommends a "no" vote on the measure.
Repeatedly asking taxpayers to pay for the construction of state-of-the-art facilities is not standard practice, according to critics who believe it raises questions about financial accountability — and whether the hospitals truly need some of the projects on their wish lists.
This pattern "could leave children's hospitals with little incentive to control their costs," said Ge Bai, a professor at the Johns Hopkins University Carey Business School, who added that each hospital should take care of itself.
The initiative, Proposition 4, needs a majority vote to pass. The 2004 and 2008 children's hospital bond measures passed with 58.3 percent and 55.3 percent of the vote, respectively.
The California Children's Hospital Association said its members can't afford to pay for their building and technology needs without help from the state's taxpayers, who would be on the hook to pay off $1.5 billion plus interest. The state Legislative Analyst's Office estimates that would come to $2.9 billion — or about $80 million a year over the next 35 years.
Private donations often aren't the answer because donors frequently specify how their money should be used, said Ann-Louise Kuhns, the association's CEO. The posh playrooms and gardens at some of these hospitals, for example, are completely funded by private donations, she said.
"We do fund-raise, we ask donors to make contributions and we issue our own debt," Kuhns said. "But it's hard to completely close that gap for what's needed … without a little bit of assistance."
The association, which sponsored the initiative, said the bond measure would help pay for construction, remodeling, equipment and seismic retrofitting at the state's eight private, nonprofit children's hospitals and the five that are part of the University of California medical system.
The California Health Facilities Financing Authority would have to approve the hospitals' use of the bond money. The agency weighs whether projects would expand access and improve patient care but does not determine whether a project is necessary or prudent.
That's up to the hospitals.
California Children's Hospitals
The state's 13 children's hospitals — eight private nonprofits and five that are part of the University of California medical system — are asking voters to approve a $1.5 billion bond measure on the Nov. 6 ballot to help them pay for construction and equipment. If the measure passes, the private hospitals will receive about three-quarters of the proceeds, or about $135 million each, regardless of their profits or losses.
The campaign in support of the bond measure — funded by the nonprofit hospitals themselves — has raised nearly $11 million this year, according to the California secretary of state’s office.
In their last financial reports audited by the state, six of the eight private, nonprofit hospitals reported annual profits ranging from $18 million to nearly $176 million. The bond issuance would provide each with $135 million, regardless of its profits or losses.
Almost three-quarters of the bond proceeds would go to the nonprofits because they have the most beds, but nonprofit hospitals already receive certain perks, Bai explained. For instance, they're exempt from paying property taxes, as well as state and federal income taxes.
Eighteen percent would be allotted to the UC system hospitals. And the proposal would offer 10 percent in competitive grants for approximately 150 hospitals that aren't classified as pediatric hospitals, but treat children nonetheless.
The hospitals argue they need to expand because they are facing greater demand for services, as general and community hospitals increasingly transfer their patients to them for specialized pediatric care.
Children's hospitals also rely heavily on Medi-Cal, the state's insurance program for low-income people, Kuhns said. Medi-Cal pays hospitals less than private insurance.
Nancy Kane, a professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health, pointed out that nationwide "many children's hospitals have the same payer mix, but manage to do this anyway without the government paying for their capital."
Kuhns said that California hospitals also face deadlines to meet seismic safety mandates. By 2020, they must be ready to withstand a major earthquake, and by 2030, they must be deemed safe enough to continue operating after a quake.
About 28 percent of the beds in the eight nonprofit children's hospitals do not meet the 2030 seismic standards, so significant investments must be made, she said.
Tim Curley of Valley Children's Healthcare in Madera said the previous bond measures helped pay for a 60,000-square-foot expansion of operating rooms. If this year's bond measure is approved, the hospital would consider renovating its laboratories and pharmacy, he said.
At the end of last year, it had just under $28 million in funds remaining from the 2008 bond, a report by the financing authority said.
Loma Linda University Children's Hospital is still using its share of the 2008 bond to help with the construction of a nine-story tower that will house most departments and labs.
The new tower, expected to be completed by 2021, will help the children's hospital operate independently of the rest of the medical center — which serves adults — and meet the growing demand for space, said Scott Perryman, a senior administrator.
But Ralston, with the League of Women Voters, said Californians should consider whether the money could be better used elsewhere.
"You're committing state money," she said, "and that means that's money not spent on something else" like affordable housing or aging roads.
Should voters nonetheless approve this third bond measure, Bai wonders if and when the requests for taxpayer money will stop. "There are always new things to buy," she said.
Medicare often pays higher-than-necessary rates to doctors and hospitals and can't take steps used by private insurers to control costs, the CMS administrator said.
The Trump administration's top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.
Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.
"We only have to look at some of Medicare's major problems to know it's a bad idea," Verma told health insurance executives at a meeting in Washington.
CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can't take steps used by private insurers to control costs.
"We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population," she added.
Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn't add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.
Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.
Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. "That is ridiculously low," she said.
Verma also lamented the traditional Medicare program's limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.
Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that "Medicare is not always nimble, particularly in adjusting benefits," and officials have long complained that Congress micromanages the program. Still, he added, "with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes."
Verma for months has spoken out against the "Medicare-for-all" proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America's Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.
Proponents of "Medicare-for-all" are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program's existing challenges of controlling costs and improving care.
"But their solution is literally to do more of what's not working," she added. "It's like the man who has a pounding headache, who then takes a hammer to his head to make it go away."
Verma's comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.
"In payment reform, Medicare has a record of being a leader and innovator," he said. "For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare's price regulation has produced substantial savings."
Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.
More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan's network of providers.
"Medicare Advantage represents value for our beneficiaries and taxpayers," Verma said.
She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.
It is "one of the most significant changes made to the Medicare program" and "will have a major impact" on improving health for plan members, she said.
But the private plans have taken a cautious approach to adding those benefits.
About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.
At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.
"We are operating in a vacuum of good evidence," said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.
Verma did not mention a report last month by the Department of Health and Human Services' inspector general that found many Advantage plans were improperly denying claims from patients and doctors.
Administration critics were quick to note that omission.
"Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly" — is "striking," said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is "her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored."