KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

California's ACA Rates To Rise 8.7% Next Year

KFF Health News, July 20, 2018

About 10% of individual policyholders in and outside the exchange are expected to drop their coverage next year because the ACA fines were eliminated.

This article first appeared July 19, 2018 on Kaiser Health News.

By Chad Terhune and Pauline Bartolone

Premiums in California's health insurance exchange will rise by an average of 8.7 percent next year, marking a return to more modest increases despite ongoing threats to the Affordable Care Act.

The state marketplace, Covered California, said the rate increase for 2019 would have been closer to 5 percent if the federal penalty for going without health coverage had not been repealed in last year's Republican tax bill.

The average increase in California is smaller than the double-digit hikes expected around the nation, due largely to a healthier mix of enrollees and more competition in its marketplace. Still, health insurance prices keep growing faster than wages and general inflation as a result of rising medical costs overall, squeezing many middle-class families who are struggling to pay their household bills.

The 8.7 percent increase in California ends two consecutive years of double-digit rate increases for the state marketplace.

"It's not great that health care costs are still increasing that much, but the individual market is not sticking out like a sore thumb like it has in other years," said Kathy Hempstead, senior adviser at the Robert Wood Johnson Foundation. "It's falling back to earth."

The future may be less bright. An estimated 262,000 Californians, or about 10 percent of individual policyholders in and outside the exchange, are expected to drop their coverage next year because the ACA fines were eliminated, according to the state. Peter Lee, executive director of Covered California, warned that the exodus of healthier consumers will drive up insurance costs beyond 2019 — not just for individual policyholders but for California employers and their workers.

"We are paying, in essence, a surcharge for federal policies that are making coverage more expensive than it should be," Lee said in an interview. "There will be more of the uninsured and more uncompensated costs passed along to all of us."

Critics of the Affordable Care Act say it has failed to contain medical costs and left consumers and taxpayers with heavy tabs . Nearly 90 percent of Covered California's 1.4 million enrollees qualify for federal subsidies to help them afford coverage.

Foiled in its attempt to repeal Obamacare outright, the Trump administration has taken to rolling back key parts of the law and has slashed federal marketing dollars intended to boost enrollment. Instead, the administration backs cheaper alternatives, such as short-term coverage or association health plans, which don't comply fully with ACA rules and tend to offer skimpier benefits with fewer consumer protections.

Taken together, those moves are likely to draw healthier, less expensive customers out of the ACA exchanges and leave sicker ones behind.

Nationally, 2019 premiums for silver plans — the second-cheapest and most popular plans offered — are expected to jump by 15 percent, on average, according to an analysis of 10 states and the District of Columbia by the Avalere consulting firm. Prices vary widely across the country, however. Decreases are expected in Minnesota while insurers in Maryland are seeking 30 percent increases.

In California, exchange officials emphasized, consumers who shop around could pay the same rate as this year, or even a little less.

Christy McConville of Arcadia already spends about $1,800 a month on a Blue Shield plan for her family of four, opting for "platinum" coverage, the most expensive type. Her family doesn't qualify for federal subsidies in Covered California.

She's worried about further increases and doesn't want to switch plans and risk losing access to the doctors she trusts. "We're getting right up to the limit," McConville said.

Amanda Malachesky, a nutrition coach in the Northern California town of Petrolia, said the elimination of the penalty for being uninsured makes dropping coverage more palatable. Her family of four pays almost $400 a month for a highly subsidized Anthem Blue Cross plan that has a $5,000 deductible.

"I've wanted to opt out of the insurance model forever just because they provide so little value for the exorbitant amount of money that we pay," said Malachesky, who recently paid several hundred dollars out-of-pocket for a mammogram. "I'm probably going to disenroll … and not give any more money to these big bad insurance companies."

Covered California is aiming to stem any enrollment losses by spending more than $100 million on advertising and outreach in the coming year. In contrast, the Trump administration spent only $10 million last year for advertising the federal exchange across the 34 states that use it.

Also, California lawmakers are looking at ways to fortify the state exchange. State legislators are considering bills that would limit the sale of short-term insurance and prevent people from joining association health plans that don't have robust consumer protections.

However, California hasn't pursued an insurance mandate and penalty at the state level, which both health plans and consumer advocates support. New Jersey and Vermont have enacted such measures.

Lee said it's up to lawmakers to decide whether a state mandate makes sense.

David Panush, a Sacramento health care consultant and a former Covered California official, said some lawmakers may be reluctant to push the idea, even in deep-blue California.

"The individual mandate has always been the least popular piece of the Affordable Care Act," he said.

Despite the constant uncertainty surrounding the health law, many insurers nationally are posting profits from their ACA business and some plans are looking to expand further on the exchanges.

In California, the same 11 insurers are returning, led by Kaiser Permanente and Blue Shield of California. Together, those two insurers control two-thirds of exchange enrollment. (Kaiser Health News, which publishes California Healthline, is not affiliated with Kaiser Permanente.)

The Covered California rate increases are fairly uniform across the state. Premiums are climbing 9 percent across most of Southern California as well as in San Francisco. Monterey, San Benito and Santa Cruz counties faced the highest increase at 16 percent, on average.

The rates are subject to state regulatory review but are unlikely to change significantly. Open enrollment on the exchange starts Oct. 15.

The ACA's expansion of coverage has dramatically cut the number of uninsured Californians. The proportion of Californians lacking health insurance fell to 6.8 percent at the end of last year, down from 17 percent in 2013, federal data show.

Health Insurers Are Vacuuming Up Consumer Data That Could Be Used to Raise Rates

KFF Health News, July 17, 2018

Without any public scrutiny, insurers and data brokers are predicting health costs based on data about things like race, marital status, how much TV consumers watch, whether they pay their bills on time or even buy plus-size clothing.

This article was first co-published by ProPublica and NPR on July 17, 2018.

By Marshall Allen

To an outsider, the fancy booths at last month's health insurance industry gathering in San Diego aren't very compelling. A handful of companies pitching "lifestyle" data and salespeople touting jargony phrases like "social determinants of health."

But dig deeper and the implications of what they're selling might give many patients pause: A future in which everything you do — the things you buy, the food you eat, the time you spend watching TV — may help determine how much you pay for health insurance.

With little public scrutiny, the health insurance industry has joined forces with data brokers to vacuum up personal details about hundreds of millions of Americans, including, odds are, many readers of this story. The companies are tracking your race, education level, TV habits, marital status, net worth. They're collecting what you post on social media, whether you're behind on your bills, what you order online. Then they feed this information into complicated computer algorithms that spit out predictions about how much your health care could cost them.

Are you a woman who recently changed your name? You could be newly married and have a pricey pregnancy pending. Or maybe you're stressed and anxious from a recent divorce. That, too, the computer models predict, may run up your medical bills.

Are you a woman who's purchased plus-size clothing? You're considered at risk of depression. Mental health care can be expensive.

Low-income and a minority? That means, the data brokers say, you are more likely to live in a dilapidated and dangerous neighborhood, increasing your health risks.Bottom of Form

"We sit on oceans of data," said Eric McCulley, director of strategic solutions for LexisNexis Risk Solutions, during a conversation at the data firm's booth. And he isn't apologetic about using it. "The fact is, our data is in the public domain," he said. "We didn't put it out there."

Insurers contend they use the information to spot health issues in their clients — and flag them so they get services they need. And companies like LexisNexis say the data shouldn't be used to set prices. But as a research scientist from one company told me: "I can't say it hasn't happened."

At a time when every week brings a new privacy scandal and worries abound about the misuse of personal information, patient advocates and privacy scholars say the insurance industry's data gathering runs counter to its touted, and federally required, allegiance to patients' medical privacy. The Health Insurance Portability and Accountability Act, or HIPAA, only protects medical information.

"We have a health privacy machine that's in crisis," said Frank Pasquale, a professor at the University of Maryland Carey School of Law who specializes in issues related to machine learning and algorithms. "We have a law that only covers one source of health information. They are rapidly developing another source."

Patient advocates warn that using unverified, error-prone "lifestyle" data to make medical assumptions could lead insurers to improperly price plans — for instance raising rates based on false information — or discriminate against anyone tagged as high cost. And, they say, the use of the data raises thorny questions that should be debated publicly, such as: Should a person's rates be raised because algorithms say they are more likely to run up medical bills? Such questions would be moot in Europe, where a strict law took effect in May that bans trading in personal data.

"We have a health privacy machine that's in crisis."
—Frank Pasquale

This year, ProPublica and NPR are investigating the various tactics the health insurance industry uses to maximize its profits. Understanding these strategies is important because patients — through taxes, cash payments and insurance premiums — are the ones funding the entire health care system. Yet the industry's bewildering web of strategies and inside deals often have little to do with patients' needs. As the series' first story showed, contrary to popular belief, lower bills aren't health insurers' top priority.

Inside the San Diego Convention Center last month, there were few qualms about the way insurance companies were mining Americans' lives for information — or what they planned to do with the data.

The sprawling convention center was a balmy draw for one of America's Health Insurance Plans' marquee gatherings. Insurance executives and managers wandered through the exhibit hall, sampling chocolate-covered strawberries, champagne and other delectables designed to encourage deal-making.

Up front, the prime real estate belonged to the big guns in health data: The booths of Optum, IBM Watson Health and LexisNexis stretched toward the ceiling, with flat screen monitors and some comfy seating. (NPR collaborates with IBM Watson Health on national polls about consumer health topics.)

To understand the scope of what they were offering, consider Optum. The company, owned by the massive UnitedHealth Group, has collected the medical diagnoses, tests, prescriptions, costs and socioeconomic data of 150 million Americans going back to 1993, according to its marketing materials. (UnitedHealth Group provides financial support to NPR.) The company says it uses the information to link patients' medical outcomes and costs to details like their level of education, net worth, family structure and race. An Optum spokesman said the socioeconomic data is de-identified and is not used for pricing health plans.

Optum's marketing materials also boast that it now has access to even more. In 2016, the company filed a patent application to gather what people share on platforms like Facebook and Twitter, and link this material to the person's clinical and payment information. A company spokesman said in an email that the patent application never went anywhere. But the company's current marketing materials say it combines claims and clinical information with social media interactions.

I had a lot of questions about this and first reached out to Optum in May, but the company didn't connect me with any of its experts as promised. At the conference, Optum salespeople said they weren't allowed to talk to me about how the company uses this information.

It isn't hard to understand the appeal of all this data to insurers. Merging information from data brokers with people's clinical and payment records is a no-brainer if you overlook potential patient concerns. Electronic medical records now make it easy for insurers to analyze massive amounts of information and combine it with the personal details scooped up by data brokers.

It also makes sense given the shifts in how providers are getting paid. Doctors and hospitals have typically been paid based on the quantity of care they provide. But the industry is moving toward paying them in lump sums for caring for a patient, or for an event, like a knee surgery. In those cases, the medical providers can profit more when patients stay healthy. More money at stake means more interest in the social factors that might affect a patient's health.

Some insurance companies are already using socioeconomic data to help patients get appropriate care, such as programs to help patients with chronic diseases stay healthy. Studies show social and economic aspects of people's lives play an important role in their health. Knowing these personal details can help them identify those who may need help paying for medication or help getting to the doctor.

But patient advocates are skeptical health insurers have altruistic designs on people's personal information.

The industry has a history of boosting profits by signing up healthy people and finding ways to avoid sick people — called "cherry-picking" and "lemon-dropping," experts say. Among the classic examples: A company was accused of putting its enrollment office on the third floor of a building without an elevator, so only healthy patients could make the trek to sign up. Another tried to appeal to spry seniors by holding square dances.

The Affordable Care Act prohibits insurers from denying people coverage based on pre-existing health conditions or charging sick people more for individual or small group plans. But experts said patients' personal information could still be used for marketing, and to assess risks and determine the prices of certain plans. And the Trump administration is promoting short-term health plans, which do allow insurers to deny coverage to sick patients.

Robert Greenwald, faculty director of Harvard Law School's Center for Health Law and Policy Innovation, said insurance companies still cherry-pick, but now they're subtler. The center analyzes health insurance plans to see if they discriminate. He said insurers will do things like failing to include enough information about which drugs a plan covers — which pushes sick people who need specific medications elsewhere. Or they may change the things a plan covers, or how much a patient has to pay for a type of care, after a patient has enrolled. Or, Greenwald added, they might exclude or limit certain types of providers from their networks — like those who have skill caring for patients with HIV or hepatitis C.

If there were concerns that personal data might be used to cherry-pick or lemon-drop, they weren't raised at the conference.

At the IBM Watson Health booth, Kevin Ruane, a senior consulting scientist, told me that the company surveys 80,000 Americans a year to assess lifestyle, attitudes and behaviors that could relate to health care. Participants are asked whether they trust their doctor, have financial problems, go online, or own a Fitbit and similar questions. The responses of hundreds of adjacent households are analyzed together to identify social and economic factors for an area.

Ruane said he has used IBM Watson Health's socioeconomic analysis to help insurance companies assess a potential market. The ACA increased the value of such assessments, experts say, because companies often don't know the medical history of people seeking coverage. A region with too many sick people, or with patients who don't take care of themselves, might not be worth the risk.

Ruane acknowledged that the information his company gathers may not be accurate for every person. "We talk to our clients and tell them to be careful about this," he said. "Use it as a data insight. But it's not necessarily a fact."

In a separate conversation, a salesman from a different company joked about the potential for error. "God forbid you live on the wrong street these days," he said. "You're going to get lumped in with a lot of bad things."

The LexisNexis booth was emblazoned with the slogan "Data. Insight. Action." The company said it uses 442 non-medical personal attributes to predict a person's medical costs. Its cache includes more than 78 billion records from more than 10,000 public and proprietary sources, including people's cellphone numbers, criminal records, bankruptcies, property records, neighborhood safety and more. The information is used to predict patients' health risks and costs in eight areas, including how often they are likely to visit emergency rooms, their total cost, their pharmacy costs, their motivation to stay healthy and their stress levels.

People who downsize their homes tend to have higher health care costs, the company says. As do those whose parents didn't finish high school. Patients who own more valuable homes are less likely to land back in the hospital within 30 days of their discharge. The company says it has validated its scores against insurance claims and clinical data. But it won't share its methods and hasn't published the work in peer-reviewed journals.

McCulley, LexisNexis' director of strategic solutions, said predictions made by the algorithms about patients are based on the combination of the personal attributes. He gave a hypothetical example: A high school dropout who had a recent income loss and doesn't have a relative nearby might have higher than expected health costs.

But couldn't that same type of person be healthy? I asked.

"Sure," McCulley said, with no apparent dismay at the possibility that the predictions could be wrong.

McCulley and others at LexisNexis insist the scores are only used to help patients get the care they need and not to determine how much someone would pay for their health insurance. The company cited three different federal laws that restricted them and their clients from using the scores in that way. But privacy experts said none of the laws cited by the company bar the practice. The company backed off the assertions when I pointed that the laws did not seem to apply.

LexisNexis officials also said the company's contracts expressly prohibit using the analysis to help price insurance plans. They would not provide a contract. But I knew that in at least one instance a company was already testing whether the scores could be used as a pricing tool.

Before the conference, I'd seen a press release announcing that the largest health actuarial firm in the world, Milliman, was now using the LexisNexis scores. I tracked down Marcos Dachary, who works in business development for Milliman. Actuaries calculate health care risks and help set the price of premiums for insurers. I asked Dachary if Milliman was using the LexisNexis scores to price health plans and he said: "There could be an opportunity."

The scores could allow an insurance company to assess the risks posed by individual patients and make adjustments to protect themselves from losses, he said. For example, he said, the company could raise premiums, or revise contracts with providers.

"No one gave anyone permission to do this."
—Erin Kaufman

It's too early to tell whether the LexisNexis scores will actually be useful for pricing, he said. But he was excited about the possibilities. "One thing about social determinants data — it piques your mind," he said.

Dachary acknowledged the scores could also be used to discriminate. Others, he said, have raised that concern. As much as there could be positive potential, he said, "there could also be negative potential."

It's that negative potential that still bothers data analyst Erin Kaufman, who left the health insurance industry in January. The 35-year-old from Atlanta had earned her doctorate in public health because she wanted to help people, but one day at Aetna, her boss told her to work with a new data set.

To her surprise, the company had obtained personal information from a data broker on millions of Americans. The data contained each person's habits and hobbies, like whether they owned a gun, and if so, what type, she said. It included whether they had magazine subscriptions, liked to ride bikes or run marathons. It had hundreds of personal details about each person.

The Aetna data team merged the data with the information it had on patients it insured. The goal was to see how people's personal interests and hobbies might relate to their health care costs. But Kaufman said it felt wrong: The information about the people who knitted or crocheted made her think of her grandmother. And the details about individuals who liked camping made her think of herself. What business did the insurance company have looking at this information? "It was a dataset that really dug into our clients' lives," she said. "No one gave anyone permission to do this."

In a statement, Aetna said it uses consumer marketing information to supplement its claims and clinical information. The combined data helps predict the risk of repeat emergency room visits or hospital admissions. The information is used to reach out to members and help them and plays no role in pricing plans or underwriting, the statement said.

Kaufman said she had concerns about the accuracy of drawing inferences about an individual's health from an analysis of a group of people with similar traits. Health scores generated from arrest records, home ownership and similar material may be wrong, she said.

Pam Dixon, executive director of the World Privacy Forum, a nonprofit that advocates for privacy in the digital age, shares Kaufman's concerns. She points to a study by the analytics company SAS, which worked in 2012 with an unnamed major health insurance company to predict a person's health care costs using 1,500 data elements, including the investments and types of cars people owned.

The SAS study said higher health care costs could be predicted by looking at things like ethnicity, watching TV and mail order purchases.

"I find that enormously offensive as a list," Dixon said. "This is not health data. This is inferred data."

Data scientist Cathy O'Neil said drawing conclusions about health risks on such data could lead to a bias against some poor people. It would be easy to infer they are prone to costly illnesses based on their backgrounds and living conditions, said O'Neil, author of the book "Weapons of Math Destruction," which looked at how algorithms can increase inequality. That could lead to poor people being charged more, making it harder for them to get the care they need, she said. Employers, she said, could even decide not to hire people with data points that could indicate high medical costs in the future.

O'Neil said the companies should also measure how the scores might discriminate against the poor, sick or minorities.

American policymakers could do more to protect people's information, experts said. In the United States, companies can harvest personal data unless a specific law bans it, although California just passed legislation that could create restrictions, said William McGeveran, a professor at the University of Minnesota Law School. Europe, in contrast, passed a strict law called the General Data Protection Regulation, which went into effect in May.

"In Europe, data protection is a constitutional right," McGeveran said.

Pasquale, the University of Maryland law professor, said health scores should be treated like credit scores. Federal law gives people the right to know their credit scores and how they're calculated. If people are going to be rated by whether they listen to sad songs on Spotify or look up information about AIDS online, they should know, Pasquale said. "The risk of improper use is extremely high. And data scores are not properly vetted and validated and available for scrutiny."

As I reported this story I wondered how the data vendors might be using my personal information to score my potential health costs. So, I filled out a request on the LexisNexis website for the company to send me some of the personal information it has on me. A week later a somewhat creepy, 182-page walk down memory lane arrived in the mail. Federal law only requires the company to provide a subset of the information it collected about me. So that's all I got.

LexisNexis had captured details about my life going back 25 years, many that I'd forgotten. It had my phone numbers going back decades and my home addresses going back to my childhood in Golden, Colorado. Each location had a field to show whether the address was "high risk." Mine were all blank. The company also collects records of any liens and criminal activity, which, thankfully, I didn't have.

My report was boring, which isn't a surprise. I've lived a middle-class life and grown up in good neighborhoods. But it made me wonder: What if I had lived in "high risk" neighborhoods? Could that ever be used by insurers to jack up my rates — or to avoid me altogether?

I wanted to see more. If LexisNexis had health risk scores on me, I wanted to see how they were calculated and, more importantly, whether they were accurate. But the company told me that if it had calculated my scores it would have done so on behalf of their client, my insurance company. So, I couldn't have them.

Senior research fellow Claire Perlman contributed to this story.

Editor's note: HealthLeaders Media secured permission from ProPublica to republish this article with a modified headline.

Staggering Prices Slow Insurers' Coverage Of CAR-T Cancer Therapy

KFF Health News, July 17, 2018

Most commercial insurers are covering CAR-T therapies now, but they do so on an individual basis, writing single-patient agreements each time.

This article first appeared July 17, 2018 on Kaiser Health News.

By Michelle Andrews

Patients whose blood cancers have failed to respond to repeated rounds of chemotherapy may be candidates for a new type of gene therapy that could send their cancers into remission for years.

But the two approved therapies, with price tags of hundreds of thousands of dollars, have roiled the insurance approval process, leading to delays and, in some cases, denials of coverage, clinicians and analysts say.

The therapy involves collecting patients' own T cells, a type of white blood cell, genetically modifying them, and then infusing them back into patients, where they hunt down and kill cancer cells. Known as CAR T-cell therapy, it has been called a "living drug."

Two drugs, Kymriah and Yescarta, were approved last year to treat patients whose blood cancers haven't responded to at least two other rounds of treatment. Kymriah is approved for people up to age 25 with a form of acute lymphoblastic leukemia, the most common cancer in children. Kymriah and Yescarta are both approved for adults with advanced lymphomas.

Researchers report that some critically ill patients who received the therapy have remained cancer-free for as long as five years.

"This is what patients need," said Dr. Yi Lin, a hematologist who oversees the CAR-T cell practice and research for the Mayo Clinic. "With the likelihood of getting patients into durable survival, we don't want to deny them the therapy." She said she receives no personal financial support from the drugs' makers.

But it comes at a cost. The drugs are hugely expensive. Kymriah and Yescarta cost $373,000 to treat adults with advanced lymphomas, while Kymriah costs $475,000 to treat acute lymphoblastic leukemia in children and young adults. In addition, many patients experience serious side effects that can land them in a hospital intensive care unit for weeks, pushing treatment costs more than $1 million.

All of this gives government and private insurers pause.

Most commercial insurers are covering CAR-T therapies now, but they do so on an individual basis, writing single-patient agreements each time, said cancer experts. Large insurers that are already familiar with complicated therapies like stem-cell transplants are getting speedier at handling CAR-T treatment requests, they said. But that's not always the case at smaller or regional plans, where delays can add weeks to the approval process.

"A request for CAR-T may end up with somebody on the payer authorization team who doesn't understand the technology or the urgency of the request, when somebody has only weeks or months to live," said Stephanie Farnia, director of health policy and strategic relations at the American Society for Blood and Marrow Transplantation.

Farnia is in contact with many of the more than 50 medical centers that are authorized to provide treatment. The process of getting to a treatment center and evaluated for therapy is involved, she said, "to then be substantially delayed due to paperwork is incredibly frustrating" for patients.

Medicare and Medicaid often pose greater coverage challenges than do private insurers, according to insurance experts.

Some Medicaid programs don't cover the treatment, said Dr. Michael Bishop, director of the cellular therapy program in the hematology-oncology section at the University of Chicago. Medicaid, the state-federal health program, covers children in low-income households and some adults.

"Medicaid has been very tough," he said. "Certain states just deny coverage, even states with balanced budgets."

Matt Salo, executive director of the National Association of Medicaid Directors, said states have to evaluate the cost as well as the drugs' effectiveness. "Medicaid is a finite pot of money, and it's stretched threadbare even on a good day," he said.

People who are on Medicare, the health insurance program for people age 65 and older and some people with disabilities, typically haven't faced coverage denials to date, clinicians say. But the government's reimbursement rates are raising concerns for providers.

Last spring, Medicare announced payment rates for providers who administer Yescarta and Kymriah on an outpatient basis. The payments would more than cover the costs of the drugs. Medicare beneficiaries' out-of-pocket costs would be capped at $1,340 plus their Part B deductible, if it hasn't been met, the agency said.

The problem with this plan: Facilities typically provide treatment on an inpatient basis, because of the potential for severe, systemic side effects.

"There's a lot of toxicity and questions about whether it can even be provided in an outpatient setting," said Gary Goldstein, the business manager at the blood and marrow transplant program at Stanford Health Care in Stanford, Calif.

For inpatient care, "CAR T-cell therapy … would be paid at a much lower amount compared to outpatient hospital use," according to officials at the Centers for Medicare & Medicaid Services.

The agency is considering how to handle payment for inpatient CAR-T care for the upcoming fiscal year that starts in October. For now, some medical centers are absorbing whatever Medicare doesn't pay.

"How can you tell a patient who's 66, ‘If only you'd gotten lymphoma when you were 64'? Goldstein asked.

But the current approach can't continue indefinitely, he said.

"Even if there aren't any centers that are making that decision today, if coverage doesn't change for Medicare, it absolutely is going to be a problem tomorrow," said Goldstein.

States Attacking ACA Would Hurt Most If Shield On Preexisting Conditions Were Axed

KFF Health News, July 17, 2018

Nine of the 11 states with the highest rates of preexisting conditions among adults under 65 have signed onto the lawsuit.

This article first appeared July 17, 2018 on Kaiser Health News.

By Harriet Rowan

If the Affordable Care Act’s protections for people with preexisting medical conditions are struck down in court, residents of the Republican-led states that are challenging the law have the most to lose.

"These states have been opposed to the ACA from the beginning," said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. "They’re hurting their most vulnerable citizens."

Twenty Republican state attorneys general and governors challenged the constitutionality of the ACA in federal court in February. Last month, U.S. Attorney General Jeff Sessions and the Department of Justice made the unusual decision not to defend key portions of the law against this legal challenge.

The states’ lawsuit argues that because Congress eliminated the Obamacare tax penalty for not having insurance coverage, effective next year, the entire law is unconstitutional. By extension, the suit calls on federal courts to find the health law’s protections for people with preexisting conditions unconstitutional — and Sessions agrees.

Nine of the 11 states with the highest rates of preexisting conditions among adults under 65 have signed onto the lawsuit to strike down the ACA, according to data from insurance companies and the U.S. Centers for Disease Control and Prevention. The 2015 data, the most recent available, were analyzed by the Kaiser Family Foundation in 2016. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Those who support the lawsuit contend that there are other means of protecting people with preexisting conditions.

"If a court strikes down the constitutionality of the ACA, there are ways to repeal and replace without Arizonans with preexisting conditions losing their coverage," said Katie Conner, a spokeswoman for Arizona Attorney General Mark Brnovich.

Conner said her boss, who is party to the lawsuit, believes preexisting conditions should "always be covered." In Arizona, more than 1 in 4 adult adults under 65 have a preexisting condition, according to the data.

The state with the highest rate of adults with preexisting conditions is West Virginia — 36 percent of those under age 65. That means that about 1 in 3 of them could have a hard time buying insurance through the individual marketplace without the ACA protections.

The office of West Virginia Attorney General Patrick Morrisey, who joined the legal challenge against the ACA, declined to comment. But a spokesman for Morrisey’s re-election campaign told PolitiFact last month that "help should be provided to those who need it most, including those with preexisting conditions."

Plaintiffs in the lawsuit "are paying lip service to these critical protections for people, but they are in fact engaged in a strategy that would get rid of those protections," said Justin Giovannelli, an associate research professor at Georgetown University's Center on Health Insurance Reforms. "Frankly, it's hard to square what they're saying on the one hand and what they're arguing in the courts on the other."

According to a poll released in June, also by the Kaiser Family Foundation, three-quarters of Americans say that maintaining protections for people with preexisting conditions is "very important." This includes majorities of Democratic, Republican and independent voters.

Before the health law was adopted, insurance companies routinely denied coverage to millions of people with preexisting conditions who purchased insurance through the individual marketplace. If they didn’t deny coverage outright, some health plans charged consumers exorbitant premiums, or offered policies that excluded coverage for pricey conditions. (Although many people got insurance through their employers or public plans that covered preexisting conditions, they could have been left vulnerable if their employment status or other circumstances changed.)

The ACA ended those practices.

Common conditions that led insurance companies to deny coverage included high blood pressure, cancer, obesity, diabetes and depression, among many others. Some people were denied for having acne, asthma or for being pregnant.

The KFF analysis estimated that at least 27 percent of adults under 65 — more than 50 million Americans — had at least one preexisting condition that would have jeopardized their coverage pre-ACA. The foundation said its estimates were an undercount because some diseases that insurers cited when declining coverage are not in the survey data. Also, each insurance company set its own rules and conditions for denials, making accurate counts of those who could be affected hard to nail down.

Less precise estimates by other researchers and the Department of Health and Human Services show that up to half of all adults under age 65 have at least one preexisting condition.

California Clinic Screens Asylum Seekers For Honesty

KFF Health News, July 16, 2018

As the Trump administration looks to reduce the number of asylum applicants, this clinic and others like it seek evidence that can help determine whether someone should gain asylum in the U.S.

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

By Anna Gorman

OAKLAND, Calif. — Dr. Nick Nelson walks through busy Highland Hospital to a sixth-floor exam room, where he sees patients from around the world who say they have fled torture and violence.

Nelson, who practices internal medicine, is the medical director of the Highland Human Rights Clinic, part of the Alameda Health System. A few times each week, he and his team conduct medical evaluations of people who are seeking asylum in the United States. The doctors listen to the patients' stories. They search for signs of trauma. They scrutinize injuries, including electrocution scars, bullet wounds and unset broken bones.

As the Trump administration looks to reduce the number of asylum applicants, citing loopholes and fraudulent claims, this clinic — and others like it in San Diego, Los Angeles, New York and Chicago — seeks evidence that can help determine whether someone should gain asylum in the U.S.

The Highland clinic opened in 2001 as a place for asylum seekers and refugees to get care. Five years later, the staff started offering forensic exams that aim to discern whether there is evidence of torture or abuse. Nelson, who took over as director in 2012, says his team does between 80 and 120 evaluations each year.

Nelson and his colleagues diagnose physical and psychological ailments and, in many cases, substantiate these patients’ claims about how they were hurt. Sometimes the asylum seekers have health coverage that pays for the exams, but the county covers the cost for those who don't.

"Our job is to make sure that the asylum office understands all the medical and psychological facts about a person's case so that they can make a decision," Nelson said.

Nelson bases his findings on an internationally recognized protocol for torture documentation.

For example, he may be called on to judge whether a scar or injury could have occurred as the patient describes. Sometimes, Nelson said, attorneys ask him to answer specific questions, such as, "Is this burn scar consistent with a cigarette burn?" or "Are these marks on his back consistent with being beaten with PVC pipe?"

Nelson has had some medical training on what to expect to see in cases of torture. He also applies his general expertise as a doctor in knowing how to interview and examine patients, and has learned something about the countries these asylum seekers are fleeing and the injuries they may have endured.

Juan Lopez Aguilar, who fled Guatemala three years ago, meets with Nelson at the Highland Hospital in Oakland, Calif., in June 2018. (Heidi de Marco/KHN)

For example, when someone is hit with a long, stiff object, it produces a pair of parallel bruises like railroad tracks, he said.

"That's a specific thing that I didn't learn in medical school or residency," he said, "but that I have learned through taking care of a lot of people who have been tortured."

In most cases, Nelson said, he finds evidence to support the stories his patients tell him. But there are also exams that don't yield definitive evidence.

Nelson also addresses the asylum seekers' health needs, sometimes diagnosing cases of tuberculosis or HIV that were previously undiagnosed. Nearly all of the patients he sees need mental health referrals, he said, because of years of torture or abuse in their native countries.

One of the patients Nelson recently treated is 60-year-old Juan Lopez Aguilar, an indigenous Maya who fled Guatemala three years ago. He said he was beaten and threatened off and on for nearly four decades because of his ethnicity and feared for his life back home. Lopez Aguilar's son also was murdered in 2005 and his daughter fled because of threats, his attorney said.

"I'm worried," Lopez Aguilar told the doctor through a translator, as he sat in the exam room. "There are a lot of gangs. They want to kill people in my community."

Nelson first examined and interviewed Lopez Aguilar earlier this spring and wrote a report corroborating the man's account for his asylum case, formally filed last year.

Lopez Aguilar, who grew up in a family of peasant farmers, told Nelson that his community was attacked by soldiers when he was in his 20s and that his father was killed during that attack. Lopez Aguilar moved to another part of Guatemala, where he continued to be the victim of "race-based harassment, extortion and threats," Nelson said.

The man's story echoes those of other clinic patients, Nelson said, and violence and discrimination against indigenous Mayan-speaking Guatemalans is common.

Lopez Aguilar, who has worked as a dishwasher, has now returned to the clinic for a regular medical visit. He tells the doctor in his native language that he has been having severe headaches and dizziness since soon after he arrived in the U.S.

His wife and some of his children are back in Guatemala, he explained, and he can't petition to bring his wife to the States unless and until he is granted asylum. That won't be before 2020, when his court date is scheduled.

Men like Lopez Aguilar have faced increasingly tough odds since early June, when U.S. Attorney General Jeff Sessions announced that gang violence and domestic abuse would no longer be considered grounds for granting asylum.

Nelson searches Tefamicael for signs of trauma and examines injuries and wounds. (Heidi de Marco/KHN)

To be eligible for asylum, applicants must prove they face physical violence, or fear it, based on factors such as race, ethnicity or religion.

Even before the Trump administration's recent crackdown, getting asylum was a difficult and time-consuming proposition. In 2017, only about 38 percent of asylum seekers in the U.S. were granted that status by the immigration court, according to data from the nonpartisan Transactional Records Access Clearinghouse at Syracuse University.

The harsher federal policies, including detentions at the border, have generated anxiety and uncertainty among those seeking asylum and their advocates and immigration lawyers.

"Every day is a roller coaster," said Oakland attorney Haregu Gaime, who frequently refers her clients to the Highland clinic.

Niloufar Khonsari, executive director of Pangea Legal Services, a Bay Area legal advocacy group, said the obstacles won't deter people from seeking a safe place to live or from seeking judicial help to stay in the U.S.

When applicants are examined at the Highland clinic, Khonsari said, it "definitely makes a difference for judges."

Gaime said the clinic's reports frequently help corroborate her clients' experiences in a way that their testimony alone cannot.

"Sometimes a traumatized person is not able to relay what happened to them in a way that tells the full story," she said.

Ira Mehlman, spokesman for the Federation for American Immigration Reform, which favors stricter controls on immigration, noted that there are limits to a doctor's ability to interpret these cases. Doctors may be able to determine if somebody suffered an injury, he said, but not necessarily the circumstances that led to it. "And they can't determine if it was because of political persecution," he said.

Mehlman said there is no question that there is violence in Central America and that gangs are rampant, but the U.S. can't accept everyone who is danger.

On the same morning that Nelson saw Lopez Aguilar at Highland clinic, he also examined Gebremeskl Tefamicael, an asylum seeker from Eritrea. Nelson took notes as he listened to Tefamicael's story of being conscripted into the military, then imprisoned and tortured.

Nelson asked Tefamicael exactly what his tormentors used to tie him up.

It was a rope made from tree bark, the patient responded, as Nelson wrote in his notebook a description of the scars on Tefamicael's wrists.

Afterward, Nelson's report for the court stated that Tefamicael's physical scars and psychological state are consistent with the man's description of what happened to him.

Nelson said he got involved with the clinic because he wanted to treat people who were underserved. People fleeing their countries and seeking asylum here are "definitely one of the more … underserved and generally marginalized" communities, he said.

Often, Nelson doesn't hear until months or years later whether his patients have been granted asylum. But when the request is approved, he said, he sees a tremendous change in them.

Getting asylum doesn't take away the trauma, but it relieves these people of the fear of returning to a country where they are not safe, Nelson said.

"When someone who has got a real basis for an asylum claim gets granted, and you were part of demonstrating why that should be the case," he said, "that feels really good."

Insurers Fall Short In Catching And Reporting Medicaid Fraud, Inspectors Find

KFF Health News, July 12, 2018

These companies tout their expertise at spotting suspicious billing patterns and chasing down criminals, but HHS OIG found their results don’t always match the rhetoric.

This article first appeared July 12, 2018 on Kaiser Health News.

By Chad Terhune

Despite receiving billions of dollars in taxpayer money, Medicaid insurers are lax in ferreting out fraud and neglect to tell states about unscrupulous medical providers, according to a federal report released Thursday.

The U.S. Health and Human Services' inspector general's office said a third of the health plans it examined had referred fewer than 10 cases each of suspected fraud or abuse to state Medicaid officials in 2015 for further investigation. Two insurers in the program, which serves low-income Americans, didn't identify a single case all year, the report found.

Some health plans terminated providers from their networks for fraud but didn't inform the state. The inspectors said that could allow those doctors or providers to defraud other Medicaid insurers or other government programs in the same state.

In addition, some insurance companies failed to recover millions of dollars in overpayments made to doctors, home health agencies or other providers. The inspector general said insurers stood to benefit financially from this because higher costs can justify increased Medicaid rates in the future. (The report didn't name specific insurers or states.)

Medicaid plans "are required by law to find fraud and abuse and to share information with states," said Meridith Seife, a deputy regional inspector general in New York and a co-author of the report. "We are concerned anytime we see evidence that managed-care organizations are not doing that in a rigorous way. There's a lot of taxpayer dollars at stake."

In general, Medicaid has struggled for years with poor oversight and billions lost to improper payments, drawing regular scrutiny from federal auditors but little improvement. Authorities have found clinics overprescribing opioids to Medicaid patients and doctors running pill mills. Hospitals and other providers have falsified Medicaid claims, paid illegal kickbacks for patient referrals and billed for unnecessary services.

Health insurers serve about 55 million Medicaid patients across 38 states, and play an increasingly vital role in running the giant public insurance program. States generally split the cost of Medicaid with the federal government.

One in 5 Americans is on Medicaid and enrollment is poised to rise even further as more states consider expansion under the Affordable Care Act. About 75 percent of Medicaid patients are part of a privatized system in which managed-care companies are paid fixed fees per patient to coordinate their care. Big, publicly traded companies such as UnitedHealth, Anthem and Centene dominate the business. In some states like California, evidence shows the funding often flows to the plans with little oversight, sometimes regardless of their performance.

These companies tout their expertise at spotting suspicious billing patterns and chasing down criminals using sophisticated data mining, but the inspector general found that their fraud-fighting results don't always match the rhetoric.

Andy Schneider, a former federal health official and now a research professor at Georgetown University's Center for Children and Families, said the lack of reporting to states is "a big problem."

"If states don't know a provider has ripped off the managed-care organization, how can they protect other state programs or insurers from that behavior?" he said.

Last year, new Obama-era rules went into effect that seek to strengthen fraud-detection efforts in Medicaid managed care. For now, the Trump administration has endorsed those changes.

Last month, the administration said they would monitor state compliance and conduct more audits.

"With historic growth in Medicaid comes an urgent federal responsibility to ensure sound fiscal stewardship and oversight of the program," Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement last month.

In a May 17 response to the inspector general, Verma cited the Obama administration's managed-care rules and she agreed with nearly all of the recommendations the inspector general made to help remedy the problems.

In the report, the inspector general's office examined data from the health plan with the largest Medicaid spending in each of the 38 states with managed care. Inspectors also conducted interviews with officials and insurance companies in five states. Among the findings:

The 38 plans received $62.2 billion in federal and state money in 2015. That represents about a quarter of the $236 billion Medicaid plans received that year. That figure has grown to nearly $300 billion last year, or about half of Medicaid spending overall.
The health insurers identified $57.8 million in overpayments related to fraud or abuse during 2015. Health plans only recovered $12.5 million, or 22 percent, of those overpayments. (Four of the health plans found no such overpayments all year.)
Insurers performed better on erroneous billing and other overpayments not related to fraud. Health plans collected 68 percent of the $831.4 million they identified in 2015.

Insurance industry officials say they couldn't comment specifically on the audit until they had more time to review the findings. They agreed that the number of cases identified and shared with states appeared relatively small in comparison to the Medicaid spending involved.

Jeff Myers, chief executive of Medicaid Health Plans of America, an industry trade group, said state contracts vary widely and may not require health plans to report every questionable provider or billing discrepancy.

"Those numbers do seem low," Myers said of the fraud instances cited in the report. "If the Trump administration and states decide they need to get more data and do more rigorous analysis, plans will provide it."

Myers pushed back on the inspectors' suggestion that insurers are purposely ignoring wasteful spending in order to boost their own revenue and profits from states.

"States look very seriously at ways to reduce Medicaid spending because every dollar spent on Medicaid is a dollar not spent somewhere else," Myers said.

Some health-policy experts said the federal report reflects the insurance industry's resistance to what it perceives as meddling in its private business even though plans are participating in a public program. "This kind of behavior, like not reporting bad actors, is totally consistent with their broader philosophy of ‘It's my money and let me run my business,'" said Schneider, the former federal official.

Christopher Koller, former Rhode Island health insurance commissioner, said states bear the responsibility to address these problems in their contracts with health plans.

"This is one more example of how state oversight can often be insufficient," said Koller, president of the Milbank Memorial Fund, a foundation focused on health policy. "States who think they can outsource all of the work to the private-sector ‘experts' are not serving their citizens well."

In 2015, the 38 health plans examined by inspectors collectively took 2,668 corrective actions, such as payment suspensions, against providers suspected of fraud or abuse, according to the report.

Eighteen health plans canceled contracts for a total of 179 providers "for cause" in 2015. Three of those insurers said they didn't typically notify the state of provider terminations.

Now the new Medicaid regulations require insurers to notify states about providers' terminations and other changes in their status, according to the report.

A Hospital's Human Touch: Why Taking Care In Discharging A Patient Matters

KFF Health News, July 12, 2018

Hospitals often fail to fulfill expectations, even though strategies to reduce preventable hospital readmissions have been widely adopted.

This article first appeared July 12, 2018 on Kaiser Health News.

By Judith Graham

The kidney doctor sat next to Judy Garrett's father, looking into his face, her hand on his arm. There are things I can do for you, she told the 87-year-old man, but if I do them I'm not sure you will like me very much.

The word "death" wasn't mentioned, but the doctor's meaning was clear: There was no hope of recovery from kidney failure. Garrett's father listened quietly. "I want to go home," he said.

It was a turning point for the man and his family. "This doctor showed us the reality of my father's condition," Garrett said, gratefully recalling the physician's compassion. A month later, her father passed away peacefully at home.

This kind of caring is what older adults want when they become seriously ill and move back and forth between the hospital and other settings, according to the largest study ever of patients' and caregivers' experiences with care transitions.

Two other priorities are also crucially important, according to recently published research: Patients and caregivers want to feel prepared to look after themselves or loved ones when they leave the hospital, and they want to know that their needs will be attended to until they stabilize or recover, however long that takes.

What's striking is how often hospitals fail to fulfill these expectations, even though it's been known for decades that care transitions are problematic and strategies to reduce preventable hospital readmissions have been widely adopted.

"Despite millions of dollars of investment and thousands of hours of effort, the health care system still feels very hazardous, unsafe and stressful from the perspective of patients and caregivers," said Dr. Suzanne Mitchell, assistant professor of family medicine at Boston University School of Medicine and lead author of the new report.

She's part of a team of experts spearheading Project ACHIEVE, a five-year, $15 million study investigating the effectiveness of interventions designed to improve care transitions. The focus is on what Medicare patients and caregivers need and want when a hospital stay ends and they return home.

One part of the project involves asking people who undergo these transitions — mostly older adults — about their experiences: what went well, what didn't. In addition to the new report, a survey of more than 9,000 patients and 3,000 caregivers is close to completion. Results will be published this fall.

Another part involves looking at what hospitals are doing to try to improve transitions, such as teaching patients and caregivers how to care for wounds or arranging follow-up phone calls with a nurse, among other strategies. A preliminary research report published last year found common problems with transition programs, including haphazard, uncoordinated approaches and a lack of teamwork and leadership.

Several areas deserve special attention, according to people who participated in focus groups and in-depth interviews for Project ACHIEVE:

Getting Actionable Information

Too often, doctors speak to patients and caregivers in "medicalese" and fail to address what patients really want to know — such as "What do I need to do to feel better?" — said Dr. Mark Williams, Project ACHIEVE's principal investigator and chief transformation and learning officer at the University of Kentucky HealthCare system.

"You really need someone to walk you through what you're going to need, step by step," Williams said.

Nothing of the sort occurred when Anita Brazill's parents, ages 86 and 87, were hospitalized seven times in Scranton, Pa., between Dec. 25, 2016, and Feb. 13, 2017.

First, her mother needed emergency gastrointestinal surgery, then her father became ill with pneumonia. Both went to an understaffed rehabilitation facility after leaving the hospital, and both bounced right back to the hospital — five times altogether — because of complications.

Each time her parents left the hospital, Brazill felt unprepared.

"You're out on the concrete of the discharge pavilion and they send you off by ambulance or car without a guidebook, without any sense of what to expect or who to call," she said.

Planning Collaboratively

Ideally, when preparing to release a patient, hospital staff should inquire about older patients' living circumstances, social support and the help they think they'll need, and discharge plans should be crafted collaboratively with caregivers.

In practice, this doesn't happen very often.

In May, Art Greenfield, 81, was admitted at 3 a.m. to a hospital near his home in Santa Clarita, Calif., with severe food poisoning and dehydration. Less than six hours later, after a sleepless night, a hospitalist he had never met walked into his room and told him she was sending him home because his situation had stabilized. (Hospitalists are physicians who specialize in caring for people in the hospital.)

"She had no idea if he could pee without the catheter they'd put in or get out of bed on his own," said Hedy Greenfield, 76, his wife. "I wasn't there, and no one asked him if there was somebody who could take care of him at home when he got there. Fortunately, he had the presence of mind to say I'm not ready, I need to stay another day."

Expressing Caring

Over and over again, patients and caregivers told Project ACHIEVE researchers how important it was to feel that health professionals care about their well-being.

Simple gestures can make a difference. "It's looking at you, rather than the computer," said Carol Levine, director of the families and health care project at United Hospital Fund in New York. "It's knowing your name and giving you a sense of ‘I'm here for you and on your side.'"

Without this sense of caring, patients and caregivers often feel abandoned and lose trust in health care professionals. With it, they feel better able to handle concerns and act on their doctors' recommendations.

Kathy Rust of Glendale, Calif., remembers walking into a room at an outpatient clinic and seeing a doctor stroking her mother's hair and calming her before reinserting a feeding tube that the 93-year-old woman had pulled out. "He was making sure she was comfortable," Rust said, recalling how moved she was by this doctor's sensitivity.

Anticipating Needs

Few people know what they'll need in the aftermath of a medical crisis: They want doctors, nurses, pharmacists, social workers or care managers to help them figure that out and devise a practical plan.

Under the CARE Act — now enacted in 36 states, the District of Columbia and Puerto Rico — hospital staff are required to ask patients if they want to identify a caregiver (some choose not to do so) and to educate that caregiver about medical responsibilities they'll face at home. But implementation has been inconsistent, Levine and other experts said.

Rust panicked the first time her mother's feeding tube came out, by accident. "I called the transition service at my hospital's outpatient clinic, and they sent someone over in 30 minutes," she said. "They were very reassuring that I had done the right thing in calling them, very calming. It was such a positive experience that I wasn't afraid to contact them with all kinds of questions that came up."

Too often, however, discharges are hurried and caregivers unaware of what they'll face at home. Levine tells of an older woman who was handed a pile of paperwork when her husband was being released from the hospital. "She couldn't read it because she had macular degeneration and no one had thought to ask ‘Do you understand this and do you have any questions?'"

Ensuring Continuity Of Care

"Patients and families tell us that once they leave the hospital, they don't know who's responsible for their care," said Karen Hirschman, an associate professor and NewCourtland Chair in Health Transitions Research at the University of Pennsylvania School of Nursing.

The name of a person to call with questions would be helpful as would round-the-clock access to emergency assistance — for months, if needed.

"It's not just ‘Now you're home and we called you a few times to follow up,'" Hirschman said. "It can take much longer for some patients to recover, and they want to know that someone is accountable for their well-being all the way through."

Judy Garrett found that having cellphone numbers for a home health care nurse and a doctor who made house calls was essential, until hospice took over shortly before her father's death.

"My advice to families is be physically present as much as possible, although I know that's not always easy," she said. "Appoint one person in the family to be the point person for medical professionals to reach out to. Request cellphone numbers, but use them only when you have to. And if you don't understand what professionals are telling you, ask until you do."

Outrageous Or Overblown? HHS Announces Another Round Of ACA Navigator Funding Cuts

KFF Health News, July 12, 2018

Some states that operate their own marketplaces are continuing to invest in these grass-roots aides.

This article first appeared July 12, 2018 on Kaiser Health News.

By Phil Galewitz

The Trump administration's decision Tuesday to slash funding to nonprofit groups that help Americans buy individual health insurance coverage sparked outrage from advocates of the Affordable Care Act. Using words like "immoral" and "cold-hearted," they saw it as the Republicans' latest act of sabotage against the sweeping health law.

But as the ACA's sixth open-enrollment period under the health law approaches in November, the lack of in-person assistance is unlikely to be a disaster for people seeking coverage, insurance and health experts say.

"I think alone it will have a very small impact on enrollment for 2019," said William Hoagland, a senior vice president with the Bipartisan Policy Center in Washington.

But combined with other recent actions by the Trump administration, the decision sets a negative tone, Hoagland said.

"It does send a signal of course that the administration is not promoting enrollment," he said.

The Centers for Medicare & Medicaid Services announced it is cutting money to the groups known as navigators from $36 million to $10 million for the upcoming 45-day enrollment period.

This reduction comes a year after the Trump administration decreased navigators' funding by 40 percent from $62.5 million — and cut advertising and other outreach activities.

CMS Administrator Seema Verma said the navigators that operate in the 34 states that use the federal marketplace — including many health and religious organizations — were ineffective and had outlived their usefulness.

She pointed out that they helped with fewer than 1 percent of enrollments in 2017 — though she counts navigators as "helping" only if consumers sign up in their presence.

CMS also notes that after last year's navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month's premiums) to 10.6 million people.

Florida Blue, an insurer that enrolls among the largest number of Obamacare consumers nationwide, said it won't miss the help from the federally funded grass-roots helpers.

"Given our large and unique distribution-channel strategy of utilizing our retail centers along with our telesales efforts, our dedicated field agents and our direct in-market enrollment efforts, we do not depend on navigators to enroll ACA members," said spokesman Paul Kluding.

Greg Fann, a fellow with the Society of Actuaries, said the role of navigators has been overstated.

"I am a numbers guy, and what really matters to people are the numbers and price of the coverage," he said. Nearly 9 in 10 people buying coverage on the ACA exchanges qualify for federal subsidies based on their incomes, and the amount those subsidies rose last year because of an increase in silver-plan premiums.

The navigators, Fann added, were needed more in 2013 and 2014 when the marketplaces were in their first years and millions of people who hadn't bought insurance before were considering the health law's new options.

Insurers and brokers, Fann said, should step in to make up for navigator funding.

Don't count on it, said Steve Israel, a Boynton Beach, Fla., insurance agent and past president of the Florida Association of Health Underwriters. He said most independent brokers want nothing to do with ACA plans because insurers have cut their commissions. "We've been sending people to navigators," Israel said.

Some states that operate their own marketplaces, however, are continuing to invest in these grass-roots aides.

Covered California, for example, is holding its navigator funding steady, dedicating $6.5 million to navigators in this year's budget.

That's more than half of what healthcare.gov is investing in navigators in 34 states.

California has 1.5 million people in Obamacare plans, second highest in the nation behind Florida, which has 1.6 million.

Death By 1,000 Cuts?

Trump spent his first year in office trying to repeal the health law and came within one vote in the U.S. Senate of achieving that goal. Immediately after Sen. John McCain (R-Ariz.) cast the deciding vote to block the dramatic repeal effort, Trump implored Republicans to let the law disintegrate.

"Let ObamaCare implode, then deal," Trump tweeted on July 28, 2017.

But his administration has not stood idly by.

The Republican-controlled Congress in December passed a law that next year will eliminate the requirement that most Americans have insurance, a move likely to drive healthier people out of insurance market and lead to higher prices for those who are left.

Just last week, CMS said because of a pending lawsuit it was suspending a program created by the law to even out the burden on health insurers whose customers are especially unhealthy or sick. That could take millions of dollars away from some insurers, causing them to hike prices or abandon markets.

The Trump administration also issued new rules to try to make it easier for individuals and small businesses to buy health plans that cost less than ACA coverage because they cover fewer medical services. These plans would bypass the law's protections that prevent companies from charging higher prices to women, older people and those with preexisting medical conditions.

Critics deride such plans as "junk insurance."

CMS now wants the navigators to promote these policies in addition to steering people toward ACA-compliant plans and Medicaid.

This adds to the concern about the lack of navigator funding.

The availability of such new types of coverage will increase consumer demand for specially trained navigators, said Elizabeth Hagan, a senior consultant with Transform Health, a consulting firm.

She said the problem with reducing consumer assistance is not so much that fewer people will buy coverage but that people will buy policies that don't fit their needs.

Jodi Ray, who leads the University of South Florida's navigator program — the largest one in the state — said her staffers do much more than help with enrollment. They also help consumers file appeals with insurers.

"This is how health care disparities are exacerbated — we will be put in the awful position of pitting populations that need assistance against each other in order to prioritize how we can use the resources," she said.

Democrats Rally Against Threats To The ACA To Block Trump's Supreme Court Nominee

KFF Health News, July 11, 2018

Unlike abortion, defending the health law is something on which all Senate Democrats agree.

This article first appeared July 10, 2018 on Kaiser Health News.

By Julie Rovner

Senate Democrats, who are divided on abortion policy, are instead turning to health care as a rallying cry for opposition to President Donald Trump’s Supreme Court nominee.

Specifically, they are sounding the alarm that confirming conservative District Court Judge Brett Kavanaugh could jeopardize one of the Affordable Care Act’s most popular provisions — its protections for people with preexisting health conditions.

“Democrats believe the No. 1 issue in America is health care, and the ability of people to get good health care at prices they can afford,” said Senate Minority Leader Chuck Schumer (D-N.Y.).

The Kavanaugh nomination, he added, “would put a dagger” through the heart of that belief.

Democratic senators spent Tuesday trying to connect the dots between potential threats to health care and Trump’s high court pick.

“President Trump as a candidate made it very clear that his priority was to put justices on the court who would correct for the fatal flaw of John Roberts,” said Sen. Chris Murphy (D-Conn.) on the Senate floor Tuesday. Chief Justice Roberts was the decisive fifth vote to uphold the ACA in a key case in 2012. “[Republicans’] new strategy is to use the court system to invalidate the protections in the law for people with preexisting conditions,” Murphy said.

Murphy — and many of his Democratic colleagues — are referring to a case filed in Texas in February by 20 Republican state attorneys general. The AGs charge that because the tax bill passed by Congress last year eliminated the tax penalty for not having health insurance, it rendered the entire health law void.

Their reasoning was that Roberts based his opinion upholding the ACA on Congress’ taxing power. Without the tax, the AGs argue, the law should be held unconstitutional.

The Trump administration, which would typically defend the ACA because defending federal law is part of what the Justice Department is tasked to do, opted to follow a different course of action.

In a response filed in June, political appointees in the department said eliminating the penalty should not invalidate the entire law. But it should nullify provisions that prevent insurers from refusing to sell insurance to people with preexisting conditions or charging them higher premiums.

If this argument were to be upheld by a newly reconstituted Supreme Court, the health law would be dealt a serious blow.

The lawsuit, however, is only in its earliest stages. And many legal scholars on both sides doubt it will get very far.

In an amicus brief filed with the court in June, five liberal and conservative legal experts who disagreed on previous ACA cases argued that both the Republican attorneys general and the Justice Department are wrong — that eliminating the mandate penalty should have no impact on the rest of the law.

Their position is rooted in something called “congressional intent.” When a court wants to invalidate a portion of a law, it usually also has to determine whether Congress would have considered other aspects of the law unworkable without it.

But that is not a problem in this case, the legal experts argued in their brief. “Here, Congress itself has essentially eliminated the provision in question and left the rest of a statute standing,” they wrote. “In such cases, congressional intent is clear.”

The merits of the lawsuit notwithstanding, the issue works well for Democrats.

For one thing, the health law’s preexisting condition protections are among its most popular parts, according to public opinion polls.

And unlike abortion, defending the health law is something on which all Senate Democrats agree. That includes some vulnerable senators in states that voted for Trump in 2016, including Sens. Joe Manchin (D-W.Va.), Heidi Heitkamp (D-N.D.) and Joe Donnelly (D-Ind.). None are strong supporters of abortion rights. But all have stood firm against GOP efforts to take apart the Affordable Care Act.

Manchin, for example, said in a statement about the nomination, “The Supreme Court will ultimately decide if nearly 800,000 West Virginians with preexisting conditions will lose their health care.”

Manchin’s opponent in November is Republican Attorney General Patrick Morrisey. He is one of the officials who filed the suit against the health law.

If High Court Reverses Roe v. Wade, 22 States Poised To Ban Abortion

KFF Health News, July 10, 2018

Reversing the landmark case would not automatically make abortion illegal across the country. Instead, it would return the decision about abortion legality to the states.

This article first appeared July 10, 2018 on Kaiser Health News.

By Julie Rovner

What would the U.S. look like without Roe v. Wade, the 1973 case that legalized abortion nationwide?

That’s the question now that President Donald Trump has chosen conservative Judge Brett Kavanaugh as his nominee to replace retiring Supreme Court Justice Anthony Kennedy.

Reversing the landmark case would not automatically make abortion illegal across the country. Instead, it would return the decision about abortion legality to the states, where a patchwork of laws are already in place that render abortion more or less available, largely depending on individual states’ political leanings.

“We think there are 22 states likely to ban abortion without Roe,” due to a combination of factors including existing laws and regulation on the books and the positions of the governor and state legislature, said Amy Myrick, staff attorney at the Center for Reproductive Rights, which represents abortion-rights advocates in court.

“The threat level is very high now,” Myrick said.

Kavanaugh never opined on Roe v. Wade directly during his tenure on the U.S. District Court in Washington, D.C. In his 2006 confirmation hearing for that position, though, he said he would follow Roe v. Wade as a “binding precedent” of the Supreme Court — which lower-court judges are required to do.

Abortion opponents are buoyed by the pick.

“Judge Kavanaugh is an experienced, principled jurist with a strong record of protecting life and constitutional rights,” said a statement from Susan B. Anthony List President Marjorie Dannenfelser. She spearheaded support for Trump in his presidential campaign after he promised to appoint to the Supreme Court only justices who would overturn Roe v. Wade.

Kennedy, by contrast, was a swing vote on abortion issues. He frequently sided with conservatives to uphold abortion restrictions. However, in key cases in 1992 and 2016, he sided with liberals to uphold Roe’s core finding that the right to abortion is part of a right to privacy that is embedded within the U.S. Constitution.

Even now, with Roe v. Wade’s protections in place, a woman’s ability to access abortion is heavily dependent on where she lives.

According to an analysis by the Guttmacher Institute, a reproductive-rights think tank, 19 states adopted 63 new restrictions on abortion rights and access.

At the same time, 21 states adopted 58 measures last year intended to expand access to women’s reproductive health.

Since 2011, states have enacted nearly 1,200 separate abortion restrictions, according to Guttmacher, making these types of laws far more common.

As of now, four states — Louisiana, Mississippi and North and South Dakota — have what are known as abortion “trigger laws.” Those laws — passed long after Roe was handed down — would make abortion illegal if and when the Supreme Court were to say Roe is no more.

“They are designed to make abortion illegal immediately,” said Myrick.

Another dozen or so states still have pre-Roe abortion bans on the books.

Some have been formally blocked by the courts, but not repealed. Those bans could, at least in theory, be reinstated, although “someone would have to go into court and ask to lift that injunction,” said Myrick.

States could simply begin enforcing other bans that were never formally blocked, like one in Alabama that makes abortion providers subject to fines and up to a year in jail.

At the same time, Myrick said, “there are 20 states where abortion would probably remain safe and legal.”

The Path To The High Court

Several major challenges to state abortion laws are already in the judicial pipeline. One of these will have to get to the Supreme Court to enable a majority to overturn Roe v. Wade.

“It’s not a question of if, it’s a question of what or when,” said Sarah Lipton-Lubet, vice president for reproductive health and rights at the National Partnership for Women and Families.

The cases fall into three major categories.

The first — and most likely type to result in the court taking a broad look at Roe v. Wade — are “gestational” bans that seek to restrict abortion at a certain point in pregnancy, said Lipton-Lubet.

Mississippi has a 15-week ban, currently being challenged in federal court. Louisiana enacted a similar ban, but it would take effect only if Mississippi’s law is upheld. Iowa earlier this spring passed a six-week ban, although that is being challenged in state court, not federal, under the Iowa Constitution.

The second category involves regulations on abortion providers.

One pending case, for instance, involves an Arkansas law that would effectively ban medication abortions. Finally, there are bans on specific procedures, including several in Texas, Arkansas and Alabama that would outlaw “dilation and evacuation” abortions, which are the most common type used in the second trimester of pregnancy.

Myrick and Lipton-Lubet agree that there is no way to predict which abortion case is likely to reach the high court first.

The case that’s actually closest to the Supreme Court, noted Myrick, is a challenge to an Indiana law that would outlaw abortion if the woman is seeking it for sex selection or because the fetus could be disabled. A federal appeals court found that law unconstitutional in April.

Many analysts also agree that even with the court’s likely philosophical shift, Roe v. Wade might not actually be overturned at all.

Instead, said Lipton-Lubet, a more conservative court could “just hollow it out” by allowing restrictive state laws to stand.

“The court cares about things like its own legitimacy,” said Myrick, “and how often a precedent has been upheld in the past.” Given that Roe’s central finding — that the decision to have an abortion falls under the constitutional right to privacy — has been upheld three times, even an anti-abortion court might be loath to overrule it in its entirety.

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About 10% of individual policyholders in and outside the exchange are expected to drop their coverage next year because the ACA fines were eliminated.

Without any public scrutiny, insurers and data brokers are predicting health costs based on data about things like race, marital status, how much TV consumers watch, whether they pay their bills on time or even buy plus-size clothing.

Most commercial insurers are covering CAR-T therapies now, but they do so on an individual basis, writing single-patient agreements each time.

Nine of the 11 states with the highest rates of preexisting conditions among adults under 65 have signed onto the lawsuit.

As the Trump administration looks to reduce the number of asylum applicants, this clinic and others like it seek evidence that can help determine whether someone should gain asylum in the U.S.

These companies tout their expertise at spotting suspicious billing patterns and chasing down criminals, but HHS OIG found their results don’t always match the rhetoric.

Hospitals often fail to fulfill expectations, even though strategies to reduce preventable hospital readmissions have been widely adopted.

Some states that operate their own marketplaces are continuing to invest in these grass-roots aides.

Unlike abortion, defending the health law is something on which all Senate Democrats agree.

Reversing the landmark case would not automatically make abortion illegal across the country. Instead, it would return the decision about abortion legality to the states.

The Path To The High Court

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