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.

This article first appeared October 26, 2018 on Kaiser Health News.

By Phil Galewitz

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."

Four more states will give voters in November's elections the opportunity to resolve the dispute over Medicaid expansion.

This article first appeared October 24, 2018 on Kaiser Health News.

By Shefali Luthra

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."

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.

This article first appeared October 22, 2018 on Kaiser Health News.

By Anna Gorman

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.

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.

This article first appeared October 16, 2018 on Kaiser Health News.

By Phil Galewitz

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."