GOP Has No Choice But To Keep Pushing Health Care Rock Up The Hill

GOP Has No Choice But To Keep Pushing Health Care Rock Up The Hill

KFF Health News, April 7, 2017

GOP House members, particularly those from conservative areas, "are going to go home and get hammered for not repealing Obamacare," said Thomas Scully, a health policy official in both Bush administrations.

This article first appeared April 6, 2017 on Kaiser Health News.

By Julie Rovner

This week's effort to resurrect the GOP bill to overhaul the Affordable Care Act has apparently met the same end as the first try in March — not even a vote on the floor of the House. Apparently the roadblock was the same, too. Efforts to gain votes from holdout conservatives repelled moderate Republicans in the House, while efforts to placate moderates kept conservatives from signing on.

So what was the purpose of the new effort, which was led mostly from the White House?

Republican health analysts said party officials had little choice but to keep trying to reach consensus — or at least enough consensus to pass a bill out of the House.

GOP House members, particularly those from conservative areas, "are going to go home and get hammered for not repealing Obamacare," said Thomas Scully, a health policy official in both Bush administrations.

The latest Kaiser Family Foundation monthly tracking poll suggests that might well be the case. Although three-quarters of the population wants President Donald Trump and his administration to make the health law work, 54 percent of Republicans said it was "a bad thing" that the House GOP bill failed to pass in March, and 58 percent of Republicans said the bill "did not go far enough to end Obamacare." (Kaiser Health News is an editorially independent project of the foundation.)

Chris Jacobs, a longtime GOP congressional staffer, said there are two imperatives still pushing for some kind of deal. "First, a seven-year commitment by the Republican Party" to repeal and replace the health law, "and second, the administration very clearly wants a win" on some sort of major policy initiative.

But apparently the ideas put forward by the White House to gain more conservative votes without losing moderate ones did not work as the administration hoped.

Conservatives were reportedly pleased early in the week when it appeared states would be allowed to opt out of most of the ACA's insurance regulations — including rules on what benefits must be covered and whether insurers can charge sicker people higher premiums or deny them coverage.

But moderates complained that would violate promises that the GOP would keep intact protections for people with preexisting health conditions. And the proposal was apparently scaled back.

What remained "was a substantial narrowing in an unproductive way for the proposal," Michael Needham of the conservative group Heritage Action told reporters on a conference call. Needham called the new version "a nonstarter" for conservatives.

On Thursday, Republicans announced agreement on an amendment to the health bill that would provide $15 billion to help compensate insurers for very high-cost patients.

But at a hastily called meeting of the House Rules Committee, even Chairman Pete Sessions (R-Texas) conceded that the amendment, at least for now, mostly provides a way for members to say they are making progress as they head home to face their constituents.

"What we're trying to do is lock in ideas so we [Republicans] have an opportunity to go home and amplify," he said.

Now Congress is poised to leave Washington for a two-week spring recess, from Monday through April 21, without their promised health bill. And what happens when they come back is unclear.

"They put themselves in this box canyon and have no way out of it," said political scientist Norman Ornstein of the American Enterprise Institute. "I just don't see a strategy here."

Scully said it's more a matter of time. Eventually Republicans will have to come together, because the alternative — leaving the ACA in place — is not acceptable to their voters. "They'll keep going back and forth until they find something that can pass," he said.

In addition to their internal differences, the calendar is working against the GOP. When Congress returns from break, it will have only a few days to pass a new temporary spending bill or the government will shut down.

Then there is a desire to turn to a tax overhaul. But in order to do that, Congress must pass a new budget resolution for the coming fiscal year. And as soon as they do, the provisions that would allow an overhaul of the health law to pass the Senate with a simple majority and no Democratic filibuster — which were part of an earlier budget resolution — would disappear.

Jacobs said a big part of the problem is that the GOP is still divided over what should happen with the health law. While the GOP mantra has been "repeal and replace" for several years, he said, "there are differences between the repealers and the replacers. They are two fundamentally distinct approaches separated by the word 'and.'"

Even if Republicans can't resolve their differences, they have to keep trying, said Doug Badger, a longtime Senate and White House staffer now at the conservative Galen Institute. "I really don't think they can get this done," he said. "But they can't say they can't get this done, even though it's over."

This story was updated to add details from Thursday's Rules Committee meeting.

Seema Verma, MPH

CMS Chief To Sit Out Watershed Decision On Medicaid Work Mandate In KY

KFF Health News, April 6, 2017

Seema Verma, the former health policy consultant now overseeing Medicare and Medicaid for the Trump administration, will not take part in one of her agency's most anticipated decisions because of a conflict of interest.

This article first appeared April 5, 2017 on Kaiser Health News.

By Phil Galewitz

Seema Verma, the former health policy consultant now overseeing Medicare and Medicaid for the Trump administration, will not take part in one of her agency's most anticipated decisions because of a conflict of interest.

The case concerns whether to allow Kentucky to become the first state in the nation to require some Medicaid recipients to work to qualify for health coverage. That change and others in Kentucky's proposal are generally favored by conservative Republicans — and have been encouraged by the Trump administration.

The work requirement is one of the most controversial features of Kentucky's proposed strategy to drastically remake its Medicaid expansion under the Affordable Care Act, which added about 440,000 low-income adults to the program since 2014. The state wants Verma's agency, the Centers for Medicare & Medicaid Services, to grant it a waiver from federal Medicaid rules to put its plan into effect.

Verma helped write Kentucky's Medicaid overhaul plan last year through her health consulting business, which worked closely with several states. The Obama administration did not rule on Kentucky's application after its submission in August, though it consistently denied efforts by Republican-controlled states to add a work requirement to Medicaid, the federal-state health insurance program for low-income Americans.

President Donald Trump has signaled that his administration will be open to allowing such a work requirement. Trump offered to allow states to add the mandate in his failed effort last month to persuade the House to pass a partial repeal of the Affordable Care Act, known as Obamacare.

"We are going to work with both expansion and non-expansion states on a solution that best uses taxpayer dollars to serve the truly vulnerable," Health and Human Services Secretary Tom Price and Verma said about their plans for Medicaid in a joint letter to governors in March.

With the exception of the work requirement, Kentucky's waiver request is largely modeled on the Indiana Medicaid expansion, which was chiefly designed by Verma as a top consultant to the state and then-Gov. Mike Pence, now the vice president.

The complex plan requires even the poorest enrollees to make small monthly contributions toward their coverage. Advocates say that gives them "skin in the game" to encourage them to make better health decisions. Critics worry the strategy will prevent poor people from enrolling in Medicaid and erode progress in reducing the uninsured population.

Kentucky Gov. Matt Bevin, who was elected in 2015, has argued his state can't afford Medicaid in its current form. Obamacare permitted states to use federal funds to broaden Medicaid eligibility to all adults with incomes at and below 138 percent of the federal poverty level, now $16,643 for individuals.

The Medicaid expansion under Obamacare in Kentucky has led to one of the sharpest drops in any state's uninsured rate, to under 8 percent in 2016 from 20 percent two years earlier.

Bevin threatened to roll back the expansion if the government would not allow him to make major changes, such as requiring Kentucky's beneficiaries to pay monthly premiums of $1 to $37.50 and mandating nondisabled recipients to work or do community service for free dental and vision care.

Budget pressures are rising this year in the 31 states and the District of Columbia where Medicaid was expanded as the federal government reduces its share of those costs. States are picking up 5 percent of the cost in 2017 and that portion will rise gradually to 10 percent by 2020. Under the health law, the federal government paid the full cost of the Medicaid expansion population for 2014-16.

Health experts said they were not surprised by Verma's recusal, though they expect it will not prevent CMS from ultimately approving the Kentucky waiver with some type of work requirement.

"It's certainly likely to be approved — the only question is some of the details, like who may be exempted," said Judy Solomon, a health policy expert with the left-leaning Center on Budget and Policy Priorities.

A CMS spokeswoman did not respond to queries about which CMS official would decide the Kentucky waiver request or what other decisions Verma might recuse herself from.

Verma also is expected to recuse herself from CMS' decision on the latest Indiana Medicaid expansion waiver, which was submitted Jan. 31.

In her Senate confirmation hearing, Verma said she would not participate in matters involving former clients or parties represented by former clients for at least one year. In addition to consulting projects with Indiana, Kentucky and other states, Verma worked with large Medicaid contractors including Hewlett Packard Enterprise and Milliman. She sold her consulting company, SVC, to another health care consultancy, Health Management Associates.

California doctors have long decried California's Medi-Cal rates, which are lower than those of Medicaid programs in 45 other states and the District of Columbia.

California Doctors Again Press For More Money To Treat Poor Patients

KFF Health News, March 30, 2017

California doctors have long decried California's Medi-Cal rates, which are lower than those of Medicaid programs in 45 other states and the District of Columbia.

This article first appeared March 30, 2017 on Kaiser Health News.

By Barbara Feder Ostrov

California's doctors and dentists have renewed their push for more money to treat Medicaid patients now that the state has been spared the drastic cuts proposed under the failed GOP health care bill.

But Democratic Gov. Jerry Brown — and some health advocates — say they have other priorities for improving the low-income health program, which serves some 14 million residents, or about a third of the state's population.

Doctors had pinned their hopes for better pay on a new tobacco tax passed by voters in November. Proposition 56 was estimated to add about $1.2 billion to the state's Medi-Cal fund for 2017-18. But Brown's proposed budget in January disappointed providers: He did not recommend raising doctors' Medi-Cal rates, instead earmarking the money to cover the program's overall costs.

California doctors have long decried California's Medi-Cal rates, which are lower than those of Medicaid programs in 45 other states and the District of Columbia. They argue that skimpy pay deters many doctors and dentists from treating poor patients.

Earlier this month, the California Medical Association and the California Dental Association, representing doctors and dentists, released their own budget proposal seeking to boost those payments. The proposal suggests giving doctors annual bonuses of up to $15,000 based on the proportion of their patients on Medi-Cal. The price tag on their plan could be as much as $607.5 million.

Now that it appears unlikely California will need to cope with the massive cuts in federal Medicaid funding anticipated under the GOP health bill, discussions about how to dole out state tobacco tax money will likely restart in earnest after being in a holding pattern during the debate in Congress, said Anthony Wright, executive director of the advocacy group Health Access.

"There's a lot of things that money could go for besides provider reimbursements," Wright said, noting that he and other advocates also favor restoring some Medi-Cal benefits, such as vision care, that were cut during the recession.

Francisco Silva, general counsel and senior vice president for the California Medical Association, said voters approved the tobacco tax ballot measure to improve patients' access to care and that the governor's January budget proposal "does not follow the will of the voters."

For patients on Medi-Cal, "if you don't address their ability to see a provider, you don't address access," Silva said. "Adding more patients to the back of the line and maintaining status quo" won't work.

Gov. Brown is scheduled to release a revised budget proposal in May that could change how the tobacco money would be spent. For now, it looks as though he won't budge on his budget priorities. "We continue to make our views very clear that these are proper and appropriate uses of the proceeds of Prop. 56," said the governor's budget spokesman, H.D. Palmer.

Palmer said it's now up to state lawmakers to define their own budget priorities, which could result in higher rates for health care providers.

Senators Demand Answers About Possible Probe Of HHS Secretary Price

Senators Demand Answers About Possible Probe Of HHS Secretary Price

KFF Health News, March 30, 2017

In a letter, seven senators called on Attorney General Jeff Sessions to assure them that any investigation of Tom Price would be "allowed to continue unimpeded."

This article first appeared March 29, 2017 on Kaiser Health News.

By Emily Kopp and Rachel Bluth

Nine senators are pushing U.S. Attorney General Jeff Sessions to reveal what he knows about a reported investigation into Health and Human Services Secretary Tom Price's stock trades that a top federal prosecutor might have begun before being fired by the Trump administration this month.

In a letter Wednesday, seven senators — six Democrats plus Vermont independent Bernie Sanders — called on Sessions to assure them that any investigation of Price — or others connected to the Trump administration — would be "allowed to continue unimpeded." Three Democratic senators sent a different letter a day earlier, asking Sessions to "provide greater clarity" about why Manhattan's former U.S. attorney, Preet Bharara, was fired and whether any investigation of Price was a factor in Bharara's removal.

ProPublica, a nonprofit news organization, reported March 17 that Price was being investigated by the U.S. attorney's office for his stock trades, though it did not specify which trades Bharara was investigating before his dismissal. The website attributed its report to an unnamed person familiar with the U.S. attorney's office, and neither the Justice Department nor other news media organizations have confirmed its existence.

If an investigation had begun, it would be hard to derail. But investigations of federal officials are always sensitive cases, said Donald Langevoort, a securities law professor at Georgetown University.

"The higher up the food chain you go, the more prominent the person is, the more confident you better be that you have the evidence you can present to a jury," he said. "But I think any attempt to quash an investigation would backfire considerably."

Price, a prominent Republican congressman until he joined President Donald Trump's Cabinet this year, was questioned extensively at his confirmation hearings about stock purchases he made in health care, pharmaceutical and medical device companies while serving on the House of Representatives' health subcommittee.

The activity raised conflict-of-interest concerns for some members of Congress because Price's trades overlapped with his sponsorship of bills, advocacy or votes on issues related to those companies or their industries.

The Democrats called attention to Price's investment in a small Australian biotech firm, Innate Immunotherapeutics, which Price testified he learned about from another congressman, Rep. Chris Collins (R-N.Y.), Innate's largest shareholder.

Price bought most of his shares at discounted prices in two private stock placements in 2016 offered to a small number of sophisticated investors — many with personal or professional ties to Collins.

Congressional Democrats slammed Price at his hearings for buying shares at advantageous prices not available to all investors. Some questioned whether Price had violated insider trading laws or the Stop Trading on Congressional Knowledge (STOCK) Act, which bans members of Congress from trading on stocks using information they received in carrying out their official duties.

"Despite the many unanswered questions that remained, Republicans rushed Price's nomination through the Senate without waiting for answers," seven senators said in Wednesday's letter.

When he was confirmed Feb. 10, Price agreed to divest his stock holdings within 90 days of taking his post. An HHS spokesperson said Price has completed those divestitures but declined to provide further information.

Sen. Elizabeth Warren (D-Mass.) was the only senator who signed both letters to Sessions.

Other names on Wednesday's letter were Patty Murray (D-Wash.), Ron Wyden (D-Ore.), Bernie Sanders (I-Vt.), Al Franken (D-Minn.), Tammy Baldwin (D-Wis.) and Maggie Hassan (D-N.H.).

Tuesday's letter was also signed by Richard Blumenthal (D-Conn.) and Jeff Merkley (D-Ore.).

Sessions' office confirmed it had received Tuesday's letter from the senators but declined to comment on either one. The U.S. Attorney's Office in Manhattan also had no comment.

Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth

Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth

KFF Health News, March 28, 2017

Two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money.

This article first appeared March 28, 2017 on Kaiser Health News.

By Fred Schulte

The Justice Department has joined a California whistleblower's lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.

Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben's case with that of another whistleblower.

Swoben has accused the insurer of "gaming" the Medicare Advantage payment system by "making patients look sicker than they are," said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the "larger frauds" ever against Medicare, with damages that he speculates could top $1 billion.

UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. "We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules," he wrote in an email.

Burns also said that "litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members and is wrong."

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.

Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.

"This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena," said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the "winners here are going to be American taxpayers."

Burns also contends that the cases against UnitedHealth could potentially exceed $1 billion in damages, which would place them among the top two or three whistleblower-prompted cases on record.

"This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope," Burns said.

On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.

But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.

"If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars," Hanagami said.

David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is "deeply concerned by ongoing improper payments" to Medicare Advantage health plans.

These overpayments "undermine the finances of the overall Medicare program," he said in an emailed statement. He said his group supports "more rigorous oversight" of payments made to the health plans.

The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.

The federal Centers for Medicare & Medicaid Services said in draft regulations issued in January 2014 that it would begin requiring that Medicare Advantage plans report any improper payment — either too much or too little.

These reviews "cannot be designed only to identify diagnoses that would trigger additional payments," the proposal stated.

But CMS backed off the regulation's reporting requirements in the face of opposition from the insurance industry. The agency didn't say why it did so.

The Justice Department said in an April 2016 amicus brief in the Swoben case that the CMS decision not to move ahead with the reporting regulation "does not relieve defendants of the broad obligation to exercise due diligence in ensuring the accuracy" of claims submitted for payment.

The Justice Department concluded in the brief that the insurers "chose not to connect the dots," even though they knew of both overpayments and underpayments. Instead, the insurers "acted in a deliberately ignorant or reckless manner in falsely certifying the accuracy, completeness and truthfulness of submitted data," the 2016 brief states.

The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them.

President Trump warned that the Obamacare insurance markets remain in serious danger "bad things are going to happen to Obamacare," he told reporters at the White House.

House Leaders 'Came Up Short' In Effort To Kill Obamacare

KFF Health News, March 27, 2017

President Trump warned that the Obamacare insurance markets remain in serious danger "bad things are going to happen to Obamacare," he told reporters at the White House.

This article first appeared March 24, 2017 on Kaiser Health News.

By Mary Agnes Carey

Despite days of intense negotiations and last-minute concessions to win over wavering GOP conservatives and moderates, House Republican leaders Friday failed to secure enough support to pass their plan to repeal and replace the Affordable Care Act.

House Speaker Paul Ryan pulled the bill from consideration after he rushed to the White House to tell President Donald Trump that there weren't the 216 votes necessary for passage.

"We came really close today, but we came up short," he told reporters at a hastily called news conference.

When pressed about what happens to the federal health law, he added, "Obamacare is the law of the land. … We're going to be living with Obamacare for the foreseeable future."

Trump laid the blame at the feet of Democrats, complaining that not one was willing to help Republicans on the measure, and he warned again that the Obamacare insurance markets are in serious danger. "Bad things are going to happen to Obamacare," he told reporters at the White House. "There's not much you can do to help it. I've been saying that for a year and a half. I said, look, eventually it's not sustainable. The insurance companies are leaving."

But he said the collapse of the bill might allow Republicans and Democrats to work on a replacement. "I honestly believe the Democrats will come to us and say, 'Look, let's get together and get a great health care bill or plan that's really great for the people of our country,'" he said.

Ryan originally had hoped to hold a floor vote on the measure Thursday — timed to coincide with the seventh anniversary of the ACA — but decided to delay that effort because GOP leaders didn't have enough "yes" votes. The House was in session Friday before his announcement while members debated the bill.

House Democratic leader Nancy Pelosi (Calif.) said the speaker's decision to pull the bill "is pretty exciting for us … a victory for the Affordable Care Act, more importantly for the American people."

The legislation was damaged by a variety of issues raised by competing factions of the party. Many members were nervous about reports by the Congressional Budget Office showing that the bill would lead eventually to 24 million people losing insurance, while some moderate Republicans worried that ending the ACA's Medicaid expansion would hurt low-income Americans.

At the same time, conservatives, especially the hard-right House Freedom Caucus that often has needled party leaders, complained that the bill kept too much of the ACA structure in place. They wanted a straight repeal of Obamacare, but party leaders said that couldn't pass the Senate, where Republicans don't have enough votes to stop a filibuster. They were hoping to use a complicated legislative strategy called budget reconciliation that would allow them to repeal only parts of the ACA that affect federal spending.

The decision came after a chaotic week of negotiations, as party leaders sought to woo more conservatives. Trump personally lobbied 120 members through personal meetings or phone calls, according to a count provided Friday by his spokesman, Sean Spicer. "The president and the team here have left everything on the field," Spicer said.

On Thursday evening, Trump dispatched Office of Management and Budget Director Mick Mulvaney to tell his former House GOP colleagues that the president wanted a vote on Friday. It was time to move on to other priorities, including tax reform, he told House Republicans.

"He said the president needs this, the president has said he wants a vote tomorrow, up or down. If for any reason it goes down, we're just going to move forward with additional parts of his agenda. This is our moment in time," Rep. Chris Collins (R-N.Y.), a loyal Trump ally, told reporters late Thursday. "If it doesn't pass, we're moving beyond health care. … We are done negotiating."

Trump's edict clearly irked some lawmakers, including the Freedom Caucus chairman, Rep. Mark Meadows (R-N.C), whose group of more than two dozen members represented the strongest bloc against the measure.

"Anytime you don't have 216 votes, negotiations are not totally over," he told reporters who had surrounded him in a Capitol basement hallway as he headed in to the party's caucus meeting.

Trump, Ryan and other GOP lawmakers tweaked their initial package in a variety of ways to win over both conservatives and moderates. But every time one change was made to win votes in one camp, it repelled support in another.

The White House on Thursday accepted conservatives' demands that the legislation strip federal guarantees of essential health benefits in insurance policies. But that was another problem for moderates, and Democrats suggested the provision would not survive in the Senate.

Republican moderates in the House — as well as the Senate — objected to the bill's provisions that would shift Medicaid from an open-ended entitlement to a set amount of funding for states that would also give governors and state lawmakers more flexibility over the program. Moderates also were concerned that the package's tax credits would not be generous enough to help older Americans — who could be charged five times more for coverage than their younger counterparts — afford coverage.

The House package also lost the support of key GOP allies, including the Club for Growth and Heritage Action. Physician, patient and hospital groups also opposed it.

But Ryan's comments made clear how difficult this decision was. "This is a disappointing day for us," he said. "Doing big things is hard. All of us. All of us — myself included — we will need time to reflect on how we got to this moment, what we could have done to do it better."

'Pre-Hospice' Saves Money By Keeping People At Home Near The End Of Life

KFF Health News, March 27, 2017

Sharp Healthcare has designed a program to give elderly patients the care they want at home and keep them out of the hospital.

This article first appeared March 27, 2017 on Kaiser Health News.

By Anna Gorman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Home Visit
Nurse Sheri Juan and social worker Mike Velasco, who both work for Sharp, walked up a wooden ramp to the Chinchars' front door one recent January morning. Juan rolled a small suitcase behind her containing a blood pressure cuff, a stethoscope, books, a laptop computer and a printer.

Mary Jo Chinchar was already familiar with Transitions because her mother had been in the program before entering hospice and dying in 2015 at the age of 101. Late last year, Gerald Chinchar's doctor recommended he enroll in it, explaining that his health was in a "tenuous position."

Chinchar, who has nine grandchildren and four great-grandchildren, likes to tell stories about his time in the Navy, about traveling the country for jobs and living in San Francisco as a young man.

He has had breathing problems much of his life, suffering from asthma and chronic obstructive pulmonary disease — ailments he partly attributes to the four decades he spent painting and sandblasting fuel tanks for work. Chinchar also has diabetes, a disease that led to his mother's death. He recently learned he had heart failure.

"I never knew I had any heart trouble," he said. "That was the only good thing I had going for me."

Now he's trying to figure out how to keep it from getting worse: How much should he drink? What is he supposed to eat?

That's where Juan comes in. Her job is to make sure the Chinchars understand Gerald's disease so he doesn't have a flare-up that could send him to the emergency room. She sat beside the couple in their living room, its bookshelves filled with titles on gardening and baseball. A basket of cough drops and a globe sat on a side table.

Any pain today? Juan asked. How is your breathing? Are you more fatigued than before? Is your weight the same? He replied that he had gained a few pounds recently but knew that was because he'd eaten too much bacon.

Posted on the couple's refrigerator was a notice advising them to call the nurse if Gerald had problems breathing, increased swelling or new chest pain.

Juan checked his blood pressure and examined his feet and legs for signs of more swelling. She looked through his medications and told him which ones the doctor wanted him to stop taking. "What we like to do as a palliative care program is streamline your medication list," she said. "They may be doing more harm than good."

Mary Jo Chinchar said she appreciates the visits, especially the advice about what Gerald should eat and drink. Her husband doesn't always listen to her, she said. "It's better to come from somebody else."

A Nearly Impossible Decision
On a rainy January day, doctors, nurses and social workers gathered in a small conference room for their bimonthly meeting to discuss patient cases. Information about the patients — their hospitalizations, medications, diagnoses — was projected on the wall. Their task: to decide if new patients were appropriate for Transitions and if current patients should remain there.

It's nearly impossible to predict how long someone will live. It's an inexact algorithm based on the severity of their disease, depression, appetite, social support and other factors. Nevertheless, the team tries to do just that, and they may recommend hospice for patients expected to live less than six months.

That was the case with an 87-year-old woman suffering from Alzheimer's disease. She had fallen many times, slept about 16 hours a day and no longer had much of an appetite. Those were all signs that the woman may be close to death, so she was referred to hospice.

Patients typically stay in Transitions about seven or eight months, but some last as long as two years before they stabilize and are discharged from the program. Others go directly to hospice, and still others die while they are still in Transitions.

The group turned its attention to an 89-year-old woman with dementia, who believed she was still a young Navy wife. She suffered from depression and kidney disease, and had been hospitalized twice last year.

"She's a perfect patient for Transitions," Hoefer told the team, adding that she could benefit from extra help. Another good candidate, Hoefer said later, was El Cajon resident Evelyn Matzen, who is 94 and has dementia. She had started to lose weight and was having more difficulty caring for herself. They took her in because "we were worried that it was going to start what I call the revolving door of hospitalization," Hoefer said.

About eight months after she joined the program, Matzen sat in Hoefer's office as he checked her labs and listened to her chest. Her body was starting to slow down, but she was still doing well, he told her. "Whatever you are doing is working."

Bill Matzen, who accompanied his mom to the appointment, said she had started to stabilize since going onto Transitions. "She is on less medication, she is in better condition, physically, mentally, the whole nine yards," he said.

Hoefer explained that frail elderly patients have fewer reserves to tolerate medical treatment and especially hospitalization. Bill Matzen said his mother leaned that the hard way after a recent fall. Though the Transitions nurse had come to see her, the Matzens decided to go to the hospital because they were still concerned about a bruise on her head. While she was in the hospital, Evelyn Matzen started hallucinating and grew agitated.

Being in the hospital "kicks her back a notch or two," her son said. "It takes her longer to recover than if she had been in a home environment."

A Changed Climate
Outpatient palliative care programs are cropping up in various forms. Some new ones are run by insurers, others by health systems or hospice organizations. Others are for-profit, including Aspire Health, which was started by former senator Bill Frist in 2013.

Sutter Health operates a project called Advanced Illness Management to help patients manage symptoms and medications and plan for the future. The University of Southern California and Blue Shield of California recently received a $5 million grant to provide and study outpatient care.

"The climate has changed for palliative care," said Enguidanos, the lead investigator on the USC-Blue Shield project.

Ritchie said she expects even more home-based programs in the years to come, especially if palliative care providers work alongside primary care doctors. "My expectation is that much of what is being done in the hospital won't need to be done in the hospital anymore and it can be done in people's homes," she said.

Challenges remain, however. In addition to questions about reimbursement, not enough trained providers are available. And some doctors are unfamiliar with the approach, and patients may be reluctant, especially those who haven't clearly been told they have a terminal diagnosis.

Now, some palliative care providers and researchers worry about the impact of President Donald Trump's plans to repeal the Affordable Care Act and revamp Medicare.

"It would be horrible," Kerr said. "Before, we had an inkling that this was helping a lot of folks. Now we know it is really helping."

Gerald Chinchar, who grew up in Connecticut, said he never expected to live into old age. His father, a heavy drinker, died of cirrhosis of the liver at 47. In his family, Chinchar said, "you're an old-timer if you make 60."

Chinchar said he gave up drinking and is trying to eat less of his favorite foods — steak sandwiches and fish and chips. He just turned 77, a milestone he credits partly to the pre-hospice program.

"If I make 80, I figured I did pretty good," he said. "And if I make 80, I'll shoot for 85."

KHN's coverage in California is funded in part by Blue Shield of California Foundation.

Axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed.

Late Move To Dump 'Essential' Benefits Could Strand Chronically Ill

KFF Health News, March 24, 2017

Axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed.

This article first appeared March 24, 2017 on Kaiser Health News.

By Jay Hancock

Updated, 7:09 AM

A last-minute attempt by conservative Republicans to dump standards for health benefits in plans sold to individuals would probably lower the average consumer's upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act.

But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care.

For example, a woman who had elected not to have maternity coverage could face financial ruin from an unintended pregnancy. A healthy young man who didn't buy drug coverage could be bankrupted if diagnosed with cancer requiring expensive prescription medicine. Someone needing emergency treatment at a non-network hospital might not be covered.

What might be desirable for business would leave patients vulnerable.

"What you don't want if you're an insurer is only sick people buying whatever product you have," said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner. "So the way to get healthy people is to offer cheaper products designed for the healthy people."

Such a change could give carriers wide room to do that by eliminating or shrinking "essential health benefits" including hospitalization, prescription drugs, mental health treatment and lab services from plan requirements — especially if state regulators don't step in to fill the void, analysts said.

As part of the push by House GOP leaders to gain more support for their plan, they amended the bill Thursday  to allow states to decide, starting next year, what if any benefits  insurers must provide on the individual market, rather than requiring health plans to include the law's essential health benefits, according to House Ways and Means Chairman Kevin Brady (R-Texas).

The Affordable Care Act requires companies selling coverage to individuals and families through online marketplaces to offer 10 essential benefits, which also include maternity, wellness and preventive services — plus emergency room treatment at all hospitals. Small-group plans offered by many small employers also must carry such benefits.

Conservative House Republicans want to exclude the rule from any replacement, arguing it drives up cost and stifles consumer choice.

On Thursday, President Donald Trump agreed after meeting with members of the conservative Freedom Caucus to leave it out of the measure under consideration, said White House Press Secretary Sean Spicer. "Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included," Spicer told reporters.

Pushed by Trump, House Republican leaders agreed late Thursday to a Friday vote on the bill but were still trying to line up support. "Tomorrow we will show the American people that we will repeal and replace this broken law because it's collapsing and it's failing families," said House Speaker Paul Ryan (R-Wis.). "And tomorrow we're proceeding." When asked if he had the votes, Ryan didn't answer and walked briskly away from the press corps.

But axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed, said Gary Claxton, a vice president and insurance expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

"They're not going to offer benefits that attract people with chronic illness if they can help it,"said Claxton, whose collection of old insurance policies shows what the market looked like before.

One Aetna plan didn't cover most mental health or addiction services — important to moderate Republicans as well as Democrats concerned about fighting the opioid crisis. Another Aetna plan didn't cover any mental health treatment. A HealthNet plan didn't cover outpatient rehabilitative services.

Before the ACA most individual plans didn't include maternity coverage, either.

The House replacement bill could make individual coverage for the chronically ill even more scarce than a few years ago because it retains an ACA rule that forces plans to accept members with preexisting illness, analysts said.

Before President Barack Obama's health overhaul, insurers could reject sick applicants or charge them higher premiums.

Lacking that ability under a Republican law but newly able to shrink benefits, insurers might be more tempted than ever to avoid covering expensive conditions. That way the sickest consumers wouldn't even bother to apply.

"You could see even worse holes in the insurance package" than before the ACA, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. "If we're going into a world where a carrier is going to have to accept all comers and they can't charge them based on their health status, the benefit design becomes a much bigger deal" in how insurers keep the sick out of their plans, she said.

Michael Cannon, an analyst at the libertarian Cato Institute and a longtime Obamacare opponent, also believes dumping essential benefits while forcing insurers to accept all applicants at one "community" price would weaken coverage for chronically ill people.

"Getting rid of the essential health benefits in a community-rated market would cause coverage for the sick to get even worse than it is under current law," he said. Republicans "are shooting themselves in the foot if they the offer this proposal."

Cannon favors full repeal of the ACA, allowing insurers to charge higher premiums for more expensive patients and helping consumers pay for plans with tax-favored health savings accounts.

In an absence of federal requirements for benefits, existing state standards would become more important. Some states might move to upgrade required benefits in line with the ACA rules but others probably won't, according to analysts.

"You're going to have a lot of insurers in states trying to understand what existing laws they have in place," Koller said. "It's going to be really critical to see how quickly the states react. There are going to be some states that will not."

Mary Agnes Carey and Phil Galewitz contributed to this story.

Trump's Promise To Rein In Drug Prices Could Open Floodgate To Importation Laws

KFF Health News, March 22, 2017

Four former commissioners of the Food and Drug Administration argue that consumer drug importation remains too risky to permit.

This article first appeared March 22, 2017 on Kaiser Health News.

By Rachel Bluth

With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.

Congress came close to allowing importation through the Medicare Modernization Act in 2003, but added one firm precondition that has prove a nonstarter. The secretary of Health and Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.

"That is a fairly absolute standard and a high bar to cross," said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard — guaranteeing that no imported prescriptions posed a threat — has kept any secretary of HHS from condoning it.

In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. "It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs," they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan and Andrew von Eschenbach, who headed the FDA at various times between 2002 through 2016.

The recent proposal, from Sen. Bernie Sanders (I-Vt.) and such Democrats as Cory Booker from New Jersey and Bob Casey from Pennsylvania, drops that requirement. Instead, it sets up a regulatory system where Canadian pharmacies who purchase their supply from manufacturers inspected by the Food and Drug Administration would be licensed to sell to customers across the border. The bill allows not only individuals but drug wholesalers and pharmacies to buy from Canada.

After two years, HHS could allow importation from other countries that meet standards comparable to those of the U.S.

(Another bill in Congress, proposed in January by John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.) focuses solely on allowing individuals to purchase from such pharmacies.)

Trump has promised that "pricing for the American people will come way down." Last week, he had a high-profile meeting at the White House with Elijah Cummings, Peter Welch (D-Vt.) and the head of Johns Hopkins Hospital, Redonda Miller, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cummings told reporters later that Trump said he supports Medicare price negotiation as well as the Sanders bill.

PhRMA, the drug industry's trade group, has denounced Sanders' proposal as it has others that enabled imports in the past.

"The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers," said PhRMA spokeswoman Nicole Longo.

Surveys indicate that up to 8 percent of Americans have bought medicines outside the U.S. even though the practice is technically illegal and imported pills are subject to confiscation.

Around 45 million Americans — 18 percent of the adult population — said last year they did not fill a prescription due to cost, according to an analysis of data from the Commonwealth Fund by Gabriel Levitt, president of PharmacyChecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company comparing prices offered in Canada to those in New York, shows drugs are frequently three times or more as costly in the U.S. as over the border.

For example, a simple Proventil asthma inhaler costs $73.19 in the U.S. vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in the U.S. but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.

Many previous bills to allow importation or to allow Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77 percent of Americans called drug prices "unreasonable" and well over half favored a variety of proposals to address them.

To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A General Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings and regulatory expenses.

Allowing people to legally import medications wouldn't totally solve the problem of high prescription drugs, advocates say, but would be a step in the right direction. Said Levitt: "The best way for Americans to afford their meds is to enact polices here to bring the prices down here."

KHN's coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Proposed changes could potentially saddle people on Medicaid with unaffordable medical bills, shortchange providers, and raise costs throughout the healthcare system.

GOP Bill's Unheralded Changes In Rules Could Undermine Health Of Neediest

KFF Health News, March 21, 2017

Proposed changes could potentially saddle people on Medicaid with unaffordable medical bills, shortchange providers, and raise costs throughout the healthcare system.

This article first appeared March 20, 2017 on Kaiser Health News.

By Emily Bazar

An under-the-radar provision in the Republican proposal to replace the Affordable Care Act would require the millions of Medicaid enrollees who signed up under the Obamacare expansion to renew their coverage every six months — twice as often as under current law.

That change would inevitably push many people out of coverage, at least temporarily, experts say, and help GOP leaders phase out Medicaid expansion — a key goal of the pending legislation.

"That's designed to move people off those rolls as soon as possible," said Ken Jacobs, chairman of the University of California, Berkeley, Center for Labor Research and Education.

The proposal to cut renewal time in half is among other changes that seem only procedural but could have a profound effect on Medicaid enrollees' health, pocketbooks and ability to get — and keep — coverage.

Another proposal would eliminate the ability of new Medicaid enrollees to request retroactive coverage for up to three months before the month they apply, which they can do under the current law — assuming they were eligible during that previous period.

Health care experts and advocates fear that could potentially saddle people on Medicaid with unaffordable medical bills, shortchange providers and raise costs throughout the health care system.

"These are changes to fundamental pieces of the Medicaid program," said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California in Sacramento, which represents human services directors from the state's 58 counties.

"They could result in people delaying their health care or having to pay out-of-pocket and not having any hope for reimbursement at all," she said.

But Michael Cannon, director of Health Policy Studies at the libertarian Cato Institute, said some of these changes would prevent fraud and keep ineligible people from obtaining benefits, thus saving taxpayer money.

"It's so hard to eliminate fraud in Medicaid, because someone always benefits from it," he said. "They don't want to give that up."

The expansion of Medicaid — the federal-state health care program for people with low incomes, known as Medi-Cal in California — would be phased out under the Republicans' plan starting in 2020.

The expansion, adopted by 31 states and the District of Columbia, added more than 11 million people to the rolls, including about 3.7 million in Medi-Cal. The federal government picks up a much higher proportion of the cost for this population than for traditional Medicaid enrollees.

In the GOP plan, people already covered under the expansion would continue to be funded by the federal government after Jan. 1, 2020, but if states opted to sign up new enrollees under the expansion criteria after that date, they wouldn't receive the more generous federal funding for them.

And those who remained in the program after 2020 but later lost eligibility would not draw the more generous federal funding for expansion enrollees if they became eligible again and re-enrolled at a later date.

In California, the potential loss of federal dollars caused by the rollback of the expansion would be massive. The state Legislative Analyst's Office estimated last month that the Golden State is slated to receive more than $17 billion from the federal government for the Medi-Cal expansion in 2017-18.

"We're talking about a big shift in costs to the state of California and potentially a major loss in coverage," said UC Berkeley's Jacobs.

The GOP legislation, which is scheduled for a vote on the House floor on Thursday, would impose the new renewal requirement on expansion enrollees starting Oct. 1.

"They're saying to states that do the expansion, 'We'll cover people who are continuously in the program, but we'll make it really hard for people to be continuously in the program,'" Jacobs said.

Wolf Faulkins, a resident of Mariposa, Calif., who enrolled in Medi-Cal in 2014 as a result of the expansion, said the proposed rule change regarding renewal would add one more layer to Medi-Cal's already considerable bureaucratic requirements, none of them logical or simple.

"If I were more of a senior citizen than I am now, I would be overwhelmed" by it, Faulkins, 61, said. "I would not be a happy camper." But he would complete the extra paperwork, he added, because his Medi-Cal coverage keeps him alive: Among other things, he has a heart condition and high blood pressure as well as knee and hand ailments.

Senderling-McDonald said the new paperwork will lead some enrollees to drop out for two reasons: Either they're no longer eligible, or they're eligible but the new bureaucratic hurdle stops them.

Faulkins agreed. Even though he would jump through the necessary hoops to keep his coverage, some others probably wouldn't, he guessed. "There are people who are just going to say, 'It's important, but it's too overwhelming. There's no one to advocate for me. There's no one to help me figure this out, " he said. "People are just going to get frustrated and say no."

The new renewal time frame has a precedent in California, which adopted a semiannual reporting requirement in 2003 for some enrollees that lasted about a decade. Though it was less cumbersome than the regular annual renewals, it nonetheless resulted in people dropping from the rolls, Senderling-McDonald said.

But the Cato Institute's Cannon believes six-month renewals are reasonable. "The savings from removing ineligible people would justify the paperwork involved," he said.

The paperwork imposed by these changes could be the least of the headaches for Medicaid beneficiaries.

Retroactive benefits, for example, are extremely valuable for new Medicaid enrollees who face medical bills during a gap in coverage, and losing them could cause financial pain.

"If they have had health expenses, like having to pay for a prescription out-of-pocket or a doctor's visit, or a woman goes into labor uninsured, they can say to the county, 'I had medical bills. Can you see if I was eligible during that time?'" said Senderling-McDonald.

Pregnant women are among the most frequent beneficiaries because they often don't know that they're pregnant right away, she added.

The GOP bill would end this, and would allow coverage to begin only the month in which enrollees apply. This provision would affect all Medicaid applicants and, like the change in renewal time, would begin Oct. 1.

Some experts believe the proposed change would increase medical debt for consumers hit with massive bills, and for providers who ultimately won't get paid for their services.

The three-month retroactive rule is "a big deal for hospitals as well as people, because it keeps them from being saddled with medical debt," said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington, D.C.

Senderling-McDonald warned that as more consumers racked up medical debt, the cost of it would shift to other people. "If someone has to declare bankruptcy when they are hit with bills they can't pay, everybody else takes the hit for it," she said. "They're going to raise insurance rates or costs of care for everybody. People who have coverage through employers or the private market could see their rates go up."

Cannon agreed that providers will get hit with more unpaid bills, but said that this provision would save the federal government money. "States have taxing authority and can fund these benefits themselves if they want to," he said. "If they don't, that should tell us something — that they don't value these benefits that much."

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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