Dramatic and, to some, offensive, tactics are nothing new for this California union of about 100,000 registered nurses, which has made a name for itself in the state and nationally as a progressive and aggressive political powerhouse.
To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, extreme.
Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.
To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.
Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.
Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly.
Dramatic and, to some, offensive, tactics are nothing new for this California union of about 100,000 registered nurses, which has made a name for itself in the state and nationally as a progressive and aggressive political powerhouse. Its reach has only broadened with the advent of social media. Leader DeMoro counts more than 29,000 Twitter followers, and CNA’s operation has a knack for mobilizing protesters and drawing crowds.
“The politicians are afraid of these angry intense grass-roots activists” mobilized by the union, said Mike Madrid, a Republican and principal at the public affairs firm Grassroots Lab, who believes the tactics could backfire. “Using fear and intimidation as a tactic in the legislature usually doesn’t get you too far.”
Others are impressed with the union’s drive and creativity, recalling how in 2005 CNA members taunted California’s then-governor, Arnold Schwarzenegger, trailing him wherever he went to protest his attempts to roll back hard-won nurse-to-patient requirements in hospitals. Activists dressed up as the Republican leader and staged theatrical protests at baseball games, rock concerts and even the San Francisco Ritz-Carlton.
In the single-payer fight, the union has shown it will go just as fervently after Democratic leaders in a heavily Democratic legislature. While the union isn’t responsible for everything freelance activists do in a campaign, the Assembly Democratic caucus has condemned the “bullying tactics” and violent rhetoric in the CNA-led effort.
Though not always admired for its approach, the CNA often gets results — or works up a sweat trying. It counts among its legislative successes the 1999 passage of the strict nurse-to-patient ratios, the nation’s first such mandate to bolster staffing in hospitals. It has fended off attempts to overturn that law, worked to protect employee pensions and pushed for campaign financing reform. And it lent its considerable political muscle to Bernie Sanders’ presidential campaign.
Historically, the nurses have had the upper hand in labor negotiations, says Joanne Spetz, director of the Health Workforce Research Center at UC-San Francisco. That’s partly because in some areas of California it represents most or all of the registered nurses, including many thousands who work for the managed-care giant Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
Members of the California Nurses Association Board of Directors, Martha Kuhl (left) and Nancy Casazza, show their support for a 1994 state proposition to implement single-payer health care in California. (Courtesy of the California Nurses Association)
The union, founded in 1903, has always “punched above its weight,” said Thad Kousser, chair of the political science department at University of California-San Diego.
Sherry Bebitch Jeffe, a professor of public policy communication at the University of Southern California, agreed.
“I’m not sure we would be discussing single-payer if not by the push of the nurses’ association,” Jeffe said.
The union, which is affiliated with National Nurses United, makes no apologies for its approach, saying it is determined to hold lawmakers accountable. And it has no intention of backing off its campaign for a single-payer system in the state, an effort that would put the California government in charge of funding health care.
“We’re going to demand that the legislature legislate and move this bill,” said Michael Lighty, director of public policy at California Nurses Association/National Nurses United. The group planned to stage a “people’s assembly health committee” mock hearing Tuesday in Sacramento.
Lighty said that the rallies reflect Californians’ desperation and fear about losing health coverage under Republican proposals to repeal Obamacare more than anything else.
Although Lighty said the union’s elected nurse leaders collectively decide on its actions, supporters and critics alike see DeMoro as setting the tone and agenda.
People focus on DeMoro because she “pushes the parameters of the politically possible” and that rubs “defenders of the status quo” the wrong way, Lighty said. DeMoro, on vacation, was unavailable for comment.
Former state senator Sheila Kuehl, who attempted several times to pass a single-payer bill, said the California Nurses Association has always been “very aggressive for the things they believed in.”
Former state senator Sheila Kuehl, who authored single-payer legislation in the 2000s, participates in a 2008 rally in San Francisco. (Courtesy of the California Nurses Association)
A smaller health consumer advocacy group persuaded Kuehl to carry the bill for the first time in 2003-04, Kuehl recalled, but the California Nurses Association brought more visibility and credibility when they joined her effort. Eventually, it became a co-sponsor.
“CNA, as fierce and progressive as they are, gave the idea a real boost,” said Kuehl, now a Los Angeles County supervisor.
Two of her bills passed through the legislature, but both were vetoed by Schwarzenegger.
Kuehl doesn’t buy the argument that the union’s in-your-face strategies may hurt their chances of passing single-payer later. Union members made nasty comments about Schwarzenegger at their rallies and that didn’t hurt the CNA’s reputation, she said.
Madrid, the Republican political consultant in Sacramento, says the CNA’s aggressive advocacy for a single-payer health system reflects the intense political polarization seen around the country right now — as well as conflicts among members of left-leaning causes.
More mainstream Democrats, including Assembly Speaker Anthony Rendon — the recipient of online death threats — say the legislature’s priority is to defend California against a GOP-proposed repeal of the Affordable Care Act and massive cuts to Medicaid, the state and federal health plan for the poor.
Rendon also said the single-payer bill, though approved by the state Senate, was “woefully incomplete” and needed to be recast. Among other problems, it carried a $400 billion annual price tag, according to an analysis by the state Senate Appropriations Committee.
But the CNA sees an opportunity for broader change and believes single-payer can move forward even as the state fights the Republican proposals in Washington.
If the single-payer bill stays idle in the legislature this year, the group vows to try again next year, making it a campaign issue in the 2018 elections.
“The best way to fight the GOP is to have an alternative,” Lighty said.
California Healthline correspondent Ana B. Ibarra contributed to this report.
The Senate bill would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year.
A little-discussed provision in the Senate health care bill is designed to boost the number of hospital beds for psychiatric care, providing a long-sought victory for mental health advocates.
The provision would amend an obscure Medicaid funding rule that has sharply limited the number of beds for those with schizophrenia, bipolar disorder or other mental illnesses.
Yet leading mental health groups say they see no reason to celebrate.
That’s because the Senate bill would also wring out $772 billion from Medicaid — the joint state-federal insurance program that is the single-largest provider of care for people with serious mental illness. The nonpartisan Congressional Budget Office has said that the Senate bill, drafted by Republicans as a replacement for the Affordable Care Act, would reduce overall Medicaid spending by 26 percent by 2026 and by 35 percent the following decade.
The loss of those funds would devastate health care services for people with mental illness, who are some of the most vulnerable and disadvantaged people in the country, said Bethany Lilly, deputy director of policy and legal advocacy at the Bazelon Center for Mental Health Law, an advocacy group.
“Medicaid is the safety net for people with serious mental illness,” said Ronald Honberg, senior policy adviser at the National Alliance on Mental Illness.
Without decent mental health care and support services, people with psychotic disorders can quickly deteriorate, ending up in overcrowded emergency rooms, jail and prison cells or dangerous city streets, Honberg said. “This bill is a prescription for making all these problems worse.”
Republicans who crafted the Senate draft bill have noted that Medicaid spending will still increase under their plan but at a rate lower than currently projected. The Senate bill would make Medicaid spending more sustainable, said Julia Lawless, a spokeswoman for the Senate Finance Committee, one of the Senate committees that oversees health legislation.
“Even before Obamacare’s unprecedented Medicaid expansion, the program was plagued by quality issues, states were barred from using innovative solutions to improve patient care, and both federal and state Medicaid spending was growing at unprecedented, unsustainable levels,” Lawless said. “The Senate bill will reverse this course and slow the growth of Medicaid without cutting actual benefits.”
The Medicaid program has traditionally refused to pay for inpatient stays in large freestanding psychiatric hospitals, making exceptions for patients under age 21 and facilities with 16 beds or fewer. The rule, which has changed little since Medicaid was created five decades ago, was aimed to prevent the federal government from paying for long-term care in psychiatric institutions.
But the Medicaid rule also has contributed to a severe shortage of psychiatric beds for people in crisis, said John Snook, executive director of the Treatment Advocacy Center, a nonprofit that focuses on people with serious mental illness.
Last year, the Centers for Medicare & Medicaid Services eased the policy, paying for up to 15 days of inpatient hospital care for patients in Medicaid managed-care plans. But in a letter to the Medicaid program last year, the National Association of Medicaid Directors noted that some patients with mental illness or substance abuse disorders might need closer to a month of inpatient care.
The Senate bill, dubbed the Better Care Reconciliation Act, would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year.
The Medicaid change was included in the Republican bill because several senators were concerned that patients didn’t have enough access to hospital care for mental illness and addiction, according to a GOP Senate aide who was authorized to speak only on condition of anonymity. The senators involved included Orrin Hatch (R-Utah) and Rob Portman (R-Ohio).
While Honberg welcomes that change, he said that reducing overall Medicaid spending could devastate rural hospitals and ones that serve as “safety nets” — providing free care to people who are uninsured or poor — and force closures.
If these hospitals go out of business, the total number of hospital beds available to people with mental illness could shrink, not expand, Honberg said.
Medicaid pays for a wide variety of supportive services for people with schizophrenia and other serious mental illnesses, beyond doctor’s visits and medications, Honberg said. States can use Medicaid funds to pay for case managers; transportation to and from doctor’s appointments; supportive housing, which helps people with serious mental illness live independently; supported employment, which provides job training and other services; and teams of professionals who assist people who need intensive, comprehensive help navigating the health system and social services.
While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to a Kaiser Health News analysis of federal health inspection data.
Cheryl Powers fixes the hair of her mother, Elaine Fisher, at the Rehabilitation Center of Bakersfield in Bakersfield, Calif., where Fisher moved after problems at a previous home. She fractured a hip after slipping from a wheelchair. (Jenna Schoenefeld for The New York Times)
In 2012, Parkview Healthcare Center’s history of safety violations led California regulators to issue an ultimatum reserved for the most dangerous nursing homes.
The state’s public health department designated Parkview, a Bakersfield, Calif., nursing home, a “special focus facility,” requiring it to either fix lapses in care while under increased inspections or be stripped of federal funding by Medicare and Medicaid — a financial deprivation few homes can survive. After 15 months of scrutiny, the regulators deemed Parkview improved and released it from extra oversight.
But a few months later, Elaine Fisher, a 74-year-old who had lost the use of her legs after a stroke, slid out of her wheelchair at Parkview. Afterward, the nursing home promised to place a nonskid pad on her chair but did not, inspectors later found. Twice more, Fisher slipped from her wheelchair, fracturing her hip the final time.
The violation drew a $10,000 penalty for Parkview, one of 10 fines totaling $126,300 incurred by the nursing home since the special focus status was lifted in 2014.
While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to a Kaiser Health News analysis of federal health inspection data. Of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.
These nursing homes are in 46 states. Some gave patients the wrong medications, failed to protect them from violent or bullying residents and staff members, or neglected to tell families or physicians about injuries, inspection records show. Years after regulators conferred clean bills of health, levels of registered nurses tend to remain lower than at other facilities.
Yet, despite recurrences of patient harm, nursing homes are rarely denied Medicare and Medicaid reimbursement. Consequences can be dire for patients like Fisher.
The Parkview Healthcare Center in Bakersfield, Calif., has a history of safety violations, including one involving Fisher. (Brian P. Hall for The New York Times)
“She used to go to bingo every day and she was very involved in the nursing home,” said her son-in-law, Eric Powers. He said that although Fisher moved to a different nursing home for better care, “after this whole thing, she has to be on painkillers. She’s mainly in her room all the time. It’s the saddest thing in the world.”
Parkview’s owner at the time of the violations, LifeHouse Health Services, did not respond to requests for comment. Dr. David Silver, who purchased Parkview last fall, said he had replaced top management and staff members who resisted a new approach.
“We were not happy with the level of patient care,” he said.
Regulators rarely return homes to the watch list, instead issuing fines for subsequent lapses. Some homes continue operating despite multiple penalties.
“When you’re looking at these large corporations, that’s just the cost of doing business,” said Neil Gehlawat, who is representing Fisher in her pending lawsuit against Parkview. “It doesn’t have the effect of changing behavior.”
‘Worst Of The Worst’
The Centers for Medicare & Medicaid Services, or CMS, sets the federal standards for nursing homes and determines whether they are in compliance, based on inspections performed primarily by state health departments. States license facilities and have the authority to revoke the licenses.
Special focus facility status is reserved for the poorest-performing facilities out of more than 15,000 skilled nursing homes. The federal government assigns each state a set number of slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.
More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts negotiated by President Barack Obama and Congress. This year, the $2.6 million budget allows only 88 nursing homes to receive the designation, though regulators identified 435 as warranting scrutiny. California and Texas each has six slots, the most of any state. Twenty-nine states have just one.
Especially troubling is that more than a third of operating nursing facilities that graduated from the watch list before 2014 still hold the lowest possible Medicare rating for health and safety: one star of five, KHN’s analysis found.
“You have this recidivism of nursing homes that are special focus facilities,” said Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan. “These are the worst of the worst and they’re back?”
CMS defended the program, saying that nursing homes on the watch list showed more improvement than did comparably struggling facilities not selected for enhanced supervision. “CMS continues to work to improve oversight to prevent any facility from regressing in performance,” the statement said.
Andrew Edwards is among the patients who were harmed by nursing homes that had earlier been given a clean bill of health by Medicare and health regulators. (Doug Kapustin for KHN)
Short-Term Oversight
Special scrutiny was lifted for about one-fourth of the nursing homes in less than a year. Facilities need to pass only two consecutive inspections without major violations or substantiated complaints.
“The period of time is just not long enough for them to show that they can sustain improvement,” said Robyn Grant, director for public policy at the National Consumer Voice for Quality Long-Term Care in Washington. “There needs to be some significant changes in the program.”
In 2010, NMS Healthcare of Hagerstown, Md., left the watch list after 10 months.
Last year, Maryland’s attorney general sued the facility and its owner, Neiswanger Management Services, alleging that they evicted frail, infirm and mentally disabled residents “with brutal indifference” when their health coverage ran out or the facility had the opportunity to get someone with better insurance.
Among those was Andrew Edwards, who was told by NMS that he was being discharged to an assisted-living center, according to the lawsuit. Instead, in January 2016, the staff sent him to a crowded, unlicensed Baltimore City row house where the owner confiscated his bank card and withdrew $966 over his objections, the lawsuit said. Although NMS said it had arranged for his outpatient kidney dialysis, “that was false,” Edwards said in an interview. He ended up in an emergency room after he missed his treatment.
NMS maintains it stopped referring patients to that owner when told of the conditions. This month, CMS expelled the Hagerstown nursing home from Medicare and Medicaid after citing it for more violations. The company is closing the facility. NMS, which still runs other homes in Maryland, has sued state regulators, claiming they are vindictively trying to drive the chain out of business.
Few Terminations
Some nursing homes on the watch list do maintain improvements. After Evergreen Nursing Home in southern Alabama was designated a special focus facility in 2005, the owners brought in new managers and added nursing supervisors, said Kimberly Bush, the facility’s administrator.
Medicare now rates Evergreen a five-star facility. “I’d like to say there’s some kind of magic recipe to this, but it’s just doing the job and holding people accountable,” Bush said.
But even prolonged supervision does not guarantee progress. Poplar Point Health and Rehabilitation in Memphis stayed on the watch list for 2½ years until 2009. A federal lawsuit brought last year claims that Poplar and its owner, Vanguard Healthcare, regularly provided “nonexistent, grossly substandard, worthless care” as far back as 2010. Vanguard, now in bankruptcy court, declined to comment.
The ultimate enforcement threats are termination from Medicare and Medicaid or closure by state or federal authorities. But only 17 percent of former special focus facilities are no longer operating, and that can include ones that went out of business for unrelated reasons, KHN found.
State regulators are reluctant to close nursing homes because of the upheaval it causes patients and families. In some areas, there are no alternative facilities nearby, making termination even less appealing.
“At the end of the day, there are those centers that cannot be corrected, can’t fix themselves, and the best thing for the patients and the residents might be for them to move to another location,” said Lyn Bentley, an executive at the American Health Care Association, a nursing facility trade group. But, she said, “it’s always difficult to close someone’s home.”
Lack Of Nurses
Too few nurses, particularly registered nurses, provide care at some of the most troubled homes, KHN’s analysis shows. Registered nurse staffing was still 12 percent lower than at other facilities, even three years after the homes were released from the watch list.
In 2009, Pennsylvania health regulators released Golden LivingCenter-West Shore in Camp Hill after 17 months of supervision. The company said in a recent statement that when a home was put on that list, “we mobilize the resources necessary to help get that LivingCenter back into compliance.”
But data from Medicare’s Nursing Home Compare website show the facility has among the worst nurse-to-patient staffing ratios in the nation, with registered nurses devoting an average of 12 minutes for each patient daily. The state average is 58 minutes daily per patient.
Golden LivingCenter-West Shore was fined $59,150 in 2015 after being cited for, among other violations, allowing a resident’s feeding tube to become infested with maggots, records show. Also, Golden Living agreed to pay $750,000 to settle three cases involving patient injuries from falls that occurred after extra oversight ended, court records show.
Last year, Golden Living sold its Pennsylvania homes to Priority Healthcare Group.
Priority is following a common strategy for shedding an unwanted reputation: changing the facility’s name. In California, Parkview — where Fisher slipped out of her wheelchair — is being rebranded too, as Kingston Healthcare Center.
If confirmed, practicing anesthesiologist Jerome Adams, MD, would be the second health official from VP Mike Pence’s home state to join the administration. Seema Verma, who helped shape Indiana’s Medicaid expansion, now heads the Centers for Medicare & Medicaid Services.
Several weeks before President Donald Trump nominated Indiana's state health commissioner Jerome Adams to be the next U.S. surgeon general, Adams toured the Salvation Army Harbor Light detox center in Indianapolis, the only treatment facility in the state for people without insurance.
Adams' supporters say the visit is an example of how he has prioritized the opioid epidemic during his tenure as Indiana's top health official. Addiction specialists and advocates say he has led important progress in implementing lifesaving policies. They believe that if confirmed, Adams would use his on-the-ground experience to guide national policy.
"I believe that Dr. Adams understands the value of community grass-roots efforts, that they should be included at the table with decision-makers," said Justin Phillips, founder of the prevention-focused group Overdose Lifeline, who toured the detox center with Adams. "They need to understand what's realistic in the field."
If confirmed by the Senate, Adams would be the second health official from Vice President Mike Pence's home state to join the Trump administration. Seema Verma, who helped shape Indiana's Medicaid expansion, now heads the Centers for Medicare & Medicaid Services.
A practicing anesthesiologist, Adams was appointed Indiana Health Commissioner by then-governor Mike Pence in October 2014. Four months into the job, he announced an HIV outbreak in rural Scott County, Ind., after health workers documented 26 cases of HIV there. By May 2015, the number of confirmed infections had risen to 158, spread almost entirely through injection drug use. Eighty-eight percent of them also tested positive for hepatitis C. Today, the number of confirmed HIV cases has reached 219.
Health workers credit Adams with persuading Pence to allow Indiana counties to create syringe exchanges to contain the spread of the disease. "We wouldn't have syringe exchange if it wasn't for him," said Carrie Lawrence, a public health researcher at Indiana University who helps implement syringe exchange programs throughout the state.
Pence had expressed moral reservations about syringe exchanges — a sentiment that Adams told The New York Times he originally shared. But in March 2015, the governor acted on advice from Adams and the Centers for Disease Control and Prevention and authorized a 30-day emergency syringe exchange, citing a public health emergency. Later that spring, Pence signed a law legalizing syringe exchanges in Indiana.
Beth Meyerson, co-director of Indiana University's Rural Center for AIDS/STD Prevention, worked closely with Adams throughout that period. She said that early on, when it became clear to legislators that a clean-syringe exchange program was needed to reduce the spread of HIV and hepatitis C, Adams was able to bring public health evidence to the table.
"Dr. Adams navigated the very ideological political environment that was created by then-governor Pence," she said. "There's just no doubt the governor wouldn't have listened to me or listened to the leaders in the Legislature, but he would listen to Jerome Adams."
She said she thinks Adams will have sway working with Pence on a national scale, too. "He will navigate [Washington], I suspect, the same way that he did in Indiana, which is to listen to communities, work with several partners across the arena, and bring public health evidence to the table again as an advocate for community health," Meyerson said.
Adams has since supported other state laws aimed at curbing the opioid epidemic, including a bill that increased access to the overdose antidote naloxone, and another that restricts the amount of opioid medication a prescriber may give to adult patients who have not previously taken opioids and to children.
Still, Meyerson said expectations about what Adams might do in Washington have to be tempered by political reality. Even in Indiana, the laws he helped pass haven't been as comprehensive as she and other public health workers would have liked. The original syringe exchange law "was an administrative nightmare," she said. It has since been updated by Indiana Gov. Eric Holcomb, making it easier for counties to start exchanges.
Funding also remains an issue. Indiana ranks 49th in the country in public health spending. "So all of these counties who have tried to move forward for syringe access are doing so with both hands tied behind their backs, because they do not have the resources to make this happen," Meyerson said.
A CDC report shows the wide disparities in opioid use across counties in the U.S.: Six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties.
Ryan Hampton was prescribed opioids after he broke his ankle, but his doctors provided no plan to wean him off the powerful painkillers. (Courtesy of Chris Hazell)
Ryan Hampton was sitting at his computer at work when he began sweating, feeling sick and unable to concentrate. He went to the bathroom, splashed water on his face and called his friend for help.
That was the day he realized he was addicted to opioids.
Hampton, now 36 and living in Los Angeles, said the prescription for his pain medication had run out and he didn’t realize he would face withdrawal problems.
“I hadn’t made this connection yet because I really didn’t know what was going on with my body,” he recalled of that day in 2004. His doctors, he said, never discussed possible side effects of the drugs they prescribed for him after he broke his ankle the year before, nor did they offer a plan to wean him off the drugs. He described his doctors’ prescribing behavior as “increase, increase, increase.”
Frightened and unable to kick his habit, he turned to heroin before finally getting treatment and dealing with his addiction.
Hampton’s experience is all too familiar for many people prescribed opioids for pain. But federal researchers reported Thursday they are seeing an important change in the trend lines for these potent drugs.
The amount of opioids prescribed in the United States peaked in 2010 and has been declining gradually since then as public health and law enforcement officials raised alarms about growing numbers of overdoses and offered new guidance to doctors about dispensing the drugs, according to a study from the Centers for Disease Control and Prevention.
Still, the amount in 2015 is three times higher than at the turn of the century, they said.
The study analyzed morphine milligram equivalents (MME) per capita and found that the metric — which accounts for differences in opioid drug type and strength — reached 782 MME in 2010 and fell to 640 MME in 2015.
The report, which analyzes prescription data from 2006 to 2015, also shows the wide disparities in opioid use across counties in the U.S.: Six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties. The researchers found that the hardest-hit areas were non-urban counties with larger percentages of white residents, high numbers of diabetes and arthritis patients and high unemployment and Medicaid rates.
For instance, a CDC map showing prescription rates per person revealed that rates in California’s more rural and less populated northern counties dwarfed those in almost all other parts of the state.
“The amount of opioids prescribed in the U.S. is still too high, with too many opioid prescriptions for too many days at too high a dosage,” said the CDC’s acting director, Dr. Anne Schuchat.
Researchers said they did not yet have data for 2016 or 2017.
Among the significant findings, researchers said, was that the number of days an opioid prescription was supposed to last increased 33 percent in recent years. In 2006, the average supply was about 13 days, while in 2015 it was nearly 18.
According to the report, the decrease in opioid use may be related to publication of national guidelines in 2008 and 2010 that drew attention to increased dangers of high-dosage opioids. Prescription rates began to drop after that, which “might reflect growing awareness among clinicians and patients of the risks associated with opioids.”
Still, the variations in prescription practices across the country suggest better guidance is needed, the researchers wrote.
While the research shows progress, opioids are still being massively over-prescribed, said Dr. Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University.
“Opioid prescribing has not come down that much,” Kolodny said. “We are just now beginning to see intervention.”
The study pointed out that efforts by Ohio, Kentucky and Florida to more closely regulate opioid prescriptions have helped drive down use.
Nationally, however, overdose death rates continue to climb, the study noted.
“Health care providers have an important role in offering safer and more effective pain management while reducing risks of opioid addiction and overdose.” Schuchat said.
Greg Williams, co-founder of Facing Addiction, agreed. Williams supports making education for providers mandatory, to ensure appropriate prescribing. And he said it is necessary for physicians to talk about addiction as a possible side effect with their patients.
This was something never done in Hampton’s case.
“The report is showing us that we have made very little progress,” Kolodny said. “We still have a very long way to go.”
Critics argue the plans can prove risky for seniors who need to see specialists, because they often face hurdles getting access. A recent GAO report adds new weight to the criticism.
When Sol Shipotow enrolled in a new Medicare Advantage health plan earlier this year, he expected to keep the doctor who treats his serious eye condition.
"That turned out not to be so," said Shipotow, 83, who lives in Bensalem, Pa.
Shipotow said he had to scramble to get back on a health plan he could afford and that his longtime eye specialist would accept. "You have to really understand your policy," he said. "I thought it was the same coverage."
Boosters say that privately run Medicare Advantage plans, which enroll about one-third of all people eligible for Medicare, offer good value. They strive to keep patients healthy by coordinating their medical care through cost-conscious networks of doctors and hospitals.
But some critics argue the plans can prove risky for seniors in poor or declining health, or those like Shipotow who need to see specialists, because they often face hurdles getting access.
A recent report by the Government Accountability Office, the auditing arm of Congress, adds new weight to criticisms that some health plans may leave sicker patients worse off.
The GAO report, released this spring, reviewed 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to “preferred doctors and hospitals” or other medical care, as the leading reasons for leaving.
“People who are sicker are much more likely to leave (Medicare Advantage plans) than people who are healthier,” James Cosgrove, director of the GAO's health care analysis, said in explaining the research.
David Lipschutz, an attorney at the Center for Medicare Advocacy, says the GAO findings were alarming and should prompt tighter government oversight.
"A Medicare Advantage plan sponsor does not have an evergreen right to participate in and profit from the Medicare program, particularly if it is providing poor care," Lipschutz says.
The GAO did not name the 35 health plans, though it urged federal health officials to consider a large exodus from a plan as a possible sign of substandard care. Most of the 35 health plans were relatively small, with 15,000 members or fewer, and had received poor scores on other government quality measures, the report said. Two dozen plans saw 1 in 5 patients leave in 2014, much higher turnover than normal, the GAO found.
Medicare Advantage plans now treat more than 19 million patients, and are expected to grow as record numbers of baby boomers reach retirement age.
Kristine Grow, a spokeswoman for America's Health Insurance Plans, an industry trade group, says Medicare Advantage keeps expanding because most people who sign up are satisfied with the care they receive.
She says that patients in the GAO study mostly switched from one health plan to another because they got a better deal, either through cheaper or more inclusive coverage.
Grow says many Medicare Advantage plans offer members extra benefits not covered by standard Medicare, such as fitness club memberships or vision or dental care, and do a better job of coordinating medical care to keep people active and out of hospitals.
"We have to remember these are plans working hard to deliver the best care they can," Grow says. Insurers compete vigorously for business and "want to keep members for the long term," she adds.
Some seniors, wary of problems ahead, are choosing to go with traditional Medicare coverage. Pittsburgh resident Marcy Grupp says she mulled over proposals from Medicare Advantage plans but worried she might need orthopedic or other specialized health care and wanted the freedom to go to any doctor or hospital. She's decided on standard Medicare coverage and paid for a "Medigap" policy to pick up any uncovered charges.
"Everything is already in place," says Grupp, a former administrative assistant who turns 65 this month.
The GAO report on Medicare Advantage comes as federal officials are ramping up fines and other penalties against errant health plans.
In the first two months of this year, for instance, the federal Centers for Medicare & Medicaid Services fined 10 Medicare Advantage health plans a total of more than $4.1 million for alleged misconduct that "delayed or denied access" to covered benefits, mostly prescription drugs.
In some of these cases, health plans charged patients too much for drugs or failed to advise them of their right to appeal denials of medical services, according to government records. Industry watchers predict more penalties are to come.
Last month, CMS officials ended a 16-month ban on enrollment in Cigna Corp.'s Medicare Advantage plans. CMS took the action after citing Cigna for "widespread and systematic failures" to provide necessary medical care and prescription drugs, policies officials called a "serious threat to enrollee health and safety."
A flurry of whistleblower lawsuits have surfaced, too. In late May, Freedom Health, a Florida Medicare Advantage insurer, agreed to pay nearly $32 million to settle allegations that it exaggerated how sick some patients were to boost profits, while getting rid of others who cost a lot to treat.
Freedom Health allegedly kept a list of some "unprofitable" patients that it discouraged from staying in the health plan, while encouraging healthier, "more profitable" members to remain, according to the whistleblower suit. Federal regulations prohibit health plans from discriminating based on a person's health.
Asked by Kaiser Health News for comment, Freedom Health corporate counsel Bijal Patel emailed a statement that read, in part: "We agreed to resolve the case so that we can continue focusing on providing excellent care."
Casey Schwarz, a lawyer with the Medicare Rights Center, a consumer service organization, notes that health plans are required to have a formal process for patients to appeal denials of medical services. She says patients should know their rights and insist on them.
"We want people to vote with their feet and leave plans not serving them," Schwarz says.
WASHINGTON — The path to 50 votes for an Obamacare replacement bill seemed to narrow dramatically Thursday as efforts to craft a quick compromise foundered — but Senate Majority Leader Mitch McConnell has $200 billion to build a bridge to victory. His dealmaking may be just beginning.
While many policy experts, lobbyists and senators Kaiser Health News spoke to this week seemed skeptical that the Better Care Reconciliation Act could be saved, they said they could envision a way for McConnell (R-Ky.) to succeed in crafting a bill that would partially replace the Affordable Care Act.
McConnell has significant wiggle room in his repeal bill. Under the budget rules he is using to move the legislation, he needs to reach $133 billion in deficit reduction over 10 years. The Congressional Budget Office estimated that the BCRA would save $321 billion.
That leaves about $200 billion in deficit savings that McConnell can afford to give back and use to make deals with as many as a dozen senators who oppose his draft bill.
“There’s clearly a path to do this,” said Matt Salo, the executive director of the National Association of Medicaid Directors. “McConnell has enough candy to do it, and enough time. It’s still a very real possibility.”
Figuring out exactly how to spread the confectionery around, though, is no simple matter.
The key problem for the bill is very similar to the one that nearly brought down the House version of similar legislation: Conservatives want to repeal more of Obamacare and do it quickly while more centrist Republicans are worried about the damage that would be done by extracting $772 billion from Medicaid and eliminating popular consumer protections for health insurance.
To start with, moderate senators such as Rob Portman (R-Ohio), Shelley Moore Capito (R-W.Va.), Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) all want the expansion of Medicaid under Obamacare preserved or at least rolled back much more gently than the Senate and House bills propose. And they want to preserve treatment dollars for the opioid crises raging through their states. Two Republican senators up for re-election in tight races next year — Dean Heller in Nevada and Jeff Flake in Arizona — have similar concerns.
“Obviously, anybody who had expanded the Medicaid population wants some kind of softer landing than is outlined. That’s a biggie,” said Flake.
But even a senator from deeply conservative Kansas, Sen. Jerry Moran, opposed the bill’s draconian cuts, which likely would punish the rural hospitals in his state.
All of them need money added back to Medicaid, especially after a new CBO analysis released Thursday said the program’s cuts jump from 25 percent after the first 10 years to a staggering 35 percent in the second decade.
They also have concerns about provisions that would allow states to waive minimum standards in the ACA, including its essential health benefits and protections for people with preexisting conditions.
On the conservative side, the pressure has been on to cut taxes established by the health law, and to roll back insurance regulations, so that states could craft whatever rules they want. The House repeal bill would let states get waivers for the 10 essential benefits in Obamacare. Sen. Ted Cruz (R-Texas) sponsored an amendment that goes further and would let insurers directly offer plans that don’t comply with the ACA standards as long as they also offered one plan that did in the affected state.
These competing interests would seem to be diametrically opposed. But McConnell’s ability to tap that $200 billion could go a long way to ease the friction, and Sen. Mike Rounds (R-S.D.) stepped forward Wednesday and Thursday to suggest which tax cut to forgo — a politically toxic one that primarily benefits the rich. That’s the 3.8 percent net investment tax on families that earn more than $250,000.
Not only would this provide McConnell with an additional $172 billion for his dealmaking, it would mute Democrats’ criticism of the bill as a mechanism to reward rich Republican donors while depriving poorer Americans of health care.
How McConnell doles out that largesse is another part of the puzzle. Capito and Portman had asked for $45 billion to fight the opioid crisis that is so critical to Ohio, West Virginia and other states, and aides speaking on background say they are likely to get it.
Senators like Flake, Moran and Heller could certainly be tempted by easing the blow to Medicaid and, in spite of long styling themselves fiscal conservatives, could keep a tax hike in place.
“That’s not the issue Nevada’s worried about,” said Heller, referring to the taxes. “It’s insurance for poor people.”
Even Sen. Ron Johnson (R-Wis.), who initially aligned himself against the Senate bill with Cruz and Sens. Rand Paul (R-Ky.) and Mike Lee (R-Utah), sounded open to Rounds’ idea.
“We’re $20 trillion in debt, so I think we should seriously consider retaining some of the tax revenue that funds the subsidies,” Johnson told reporters as he fast-walked to a closed-door meeting of the GOP caucus with Vice President Mike Pence on Thursday.
On the conservative side, even Lee suggested he was sensitive to the charge that Republicans were cutting taxes for the rich to stiff the poor. But Cruz hasn’t said he would be willing to keep the taxes in place. Pressed by reporters Thursday on whether the tax was a deal killer for him, he strolled onto an elevator and stayed deliberately silent as he waited for the doors to close.
There are some other levers McConnell has, but they are issues unrelated to the health bill. McConnell and senators would have to act as if it is not quid pro quo. For instance, Murkowski might be swayed by an offer of an unrelated bill to open the Arctic National Wildlife Refuge to oil drilling. (She laughed when a reporter made that suggestion earlier this year but didn’t say she’d turn it down.) Heller is locked in a battle with the administration to ensure that the Yucca Mountain nuclear waste storage facility never opens in his state. McConnell’s support keeping it closed would appeal to him, although it would be hard for him to brag about it later in connection to the health bill.
One Republican health care lobbyist and former Capitol Hill aide said the behavior of the conservatives showed that if the bill is to pass, they will have to cave.
“The conservatives are going to have to capitulate a long way, but when they do that, are they getting anything in return?” the lobbyist said.
What they could get in return is some version of Cruz’s amendment, but the lobbyist and others noted it could not be as extreme, since essential health benefits and protections for people with preexisting conditions were among the top concerns for Senate moderates when the House passed its bill.
Several GOP insiders and a couple of Democrats said it would still be a stretch to get to the 50-vote mark, but none would rule it out.
Speaking privately so they could be candid, aides from both parties saw similar political downsides for Republicans. One senior Democratic aide summed it up succinctly.
“We suffered for a few cycles over health care, but at least we had people who could talk about it who were helped,” the aide said. “They won’t have that.”
Still, the GOP remains committed to trying to fulfill the pledge they’ve made for seven years, and even vulnerable senators like Flake were not giving up.
“We’ve still got a long way to go, I think,” Flake said. “In some ways, we’re going around in circles, but I think we’re getting closer on some elements.”
Flake said the lawmakers were sending various amendments that contain those elements to the CBO and expected to have numbers back next week while the Senate is on recess. Those numbers will be crucial.
“We’re just trying to get to 50 votes,” Rounds said. “We’ve got a lot of work to do yet. We just want to make it the best we can.”
The medical loss ratio has fans among policy experts, who say it pushes insurers to be more efficient and creates a better value. But insurers consider the MLR onerous, and some had to change the way they do business because of it.
If Senate GOP leaders have their way, the check may not be in the mail.
Many consumers collected unexpected rebates after the Affordable Care Act became law, possibly with a note explaining why: Their insurer spent more of their revenue from premiums on administration and profits than the law allowed, so it was payback time.
More than $2.4 billion has been returned to customers since the provision went into effect in 2011, averaging about $138 per family in 2015.
Those rebates could end under the Senate proposal — now on hold until after the July Fourth holiday — to repeal the ACA.
Insurers consider the requirement — known as the medical loss ratio (MLR) — onerous, and some had to change the way they do business because of it. To be sure, the rule didn’t resonate much with consumers, even if they received a rebate, because the amounts were relatively small, possibly enough to cover a family dinner out.
The MLR has fans among policy experts, who say it pushes insurers to be more efficient and creates a better value.
“When they struggle to pay premiums, when they’re making those sacrifices, [consumers] want most of the value of those premiums to go to actual medical care,” said Mila Kofman, a former insurance commissioner in Maine, who now runs the D.C. Health Benefit Exchange Authority.
Like much else related to the ACA, the provision was controversial from the start. It states that insurers can spend no more than 15 percent of their customer revenue on administration and profits when selling large group plans to employers, or 20 percent for individual coverage. If plans exceed this mark, they have to pay back the excess, either to employers or to people who bought coverage from them on the individual market. Employers who got rebates for their work-based plans could decide how to redistribute the money as long as it was used to benefit employees.
The Senate GOP health proposal, the Better Care Reconciliation Act, would end that requirement in 2019 and let states decide whether to continue such limits and rebates.
In some ways, this change would be a gift to insurers.
The provision, as is, “limits their profitability” and, along with other factors, may have contributed to an exodus of plans from some markets, explained Christopher Condeluci, of CC Law & Policy in Washington.
“By allowing states to craft more flexible” rules, the Senate measure may make it “easier for insurers to operate,” said Condeluci, who served as tax and benefits counsel to the U.S. Senate Finance Committee when the ACA was being drafted.
From the start, insurers argued the one-size-fits-all rule was too strict and sought the broadest possible definition of medical expenses. Supporters maintained it could help slow premium increases or at least make them more in line with the underlying growth of medical costs. This point is “really important,” said Tim Jost, an emeritus law professor who studies the health care law and serves as a consumer advocate before the National Association of Insurance Commissioners.
When the ACA took effect, health care inflation had slowed, but “insurers were still regularly raising premiums far above the actual growth in claims,” he said. “They were making a huge profit.”
The first year the provision was in effect, insurers paid more than $591 million in rebates for policies covering more than 8.8 million customers, averaging $98 per family. Not all insurers exceeded the limit, and the amount of rebates varied by insurer and state.
Over time, the number of customers in plans that exceeded the limit fell but was still nearly 5 million at last count.
The reason: Insurers both trimmed administrative costs and, in some cases — especially in the individual market — saw their spending on sicker-than-expected customers rise, making it less likely they would exceed limits. Indeed, some insurers were spending more than 90 percent of revenue on medical costs by 2014, according to a report by the Urban Institute and the Robert Wood Johnson Foundation. Some insurers have also reported losses on their individual market coverage.
Before the ACA, many states set rules on how much of their premium revenue insurers must spend on medical care — although those rules often did not apply to job-based insurance. The amounts varied, and they were often lower than what the ACA requires. North Dakota, for example, required 55 percent of revenue be spent on medical care, while New Jersey set the percentage at 80, according to a 2010 issue brief in the journal Health Affairs.
Like many other aspects of the Senate bill, the impact on consumers would vary by state.
The Congressional Budget Office, in its review of the bill, predicted that about half of people live in states that would maintain the current requirement. Others would loosen it and allow a greater share of premium costs to go toward administrative costs and profits. “In those states, in areas with little competition among insurers, the provision would cause insurers to raise premiums and would increase federal costs for subsidies through the marketplaces,” noted the CBO. The analysis also said the provision would have “little effect” on the number of people who have insurance.
The future of care delivered in post-acute facilities sits on unsteady ground with proposed cuts to Medicaid threatening to limit services and coverage.
ORANGE, Va. — Alice Jacobs, 90, once owned a factory and horses. She raised four children and buried two husbands.
But years in an assisted living facility drained her savings, and now she relies on Medicaid to pay for her care at Dogwood Village, a nonprofit, county-owned nursing home here.
“You think you’ve got enough money to last all your life, and here I am,” Jacobs said.
Medicaid pays for about two-thirds of the 1.4 million elderly people in nursing homes, like Jacobs. It covers 20 percent of all Americans, and 40 percent of poor adults.
On Thursday, Senate Republicans joined their House colleagues in proposing steep cuts to Medicaid, part of the effort to repeal the Affordable Care Act. Conservatives hope to roll back what they see as an expanding and costly health care entitlement. But little has been said about what would happen to older Americans in nursing homes if these cuts took effect.
Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage.
“The states are going to make it harder to qualify medically for needing nursing home care,” predicted Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. “They’d have to be more disabled before they qualify for Medicaid assistance.”
States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.
The 150 residents of Dogwood Village include former teachers, farmers, doctors, lawyers, homemakers and health aides — a cross section of this rural county a half-hour northeast of Charlottesville. Many entered old age solidly middle-class but turned to Medicaid, once thought of as a government program exclusively for the poor, after exhausting their insurance and assets.
A combination of longer life spans and spiraling health care costs has left an estimated 64 percent of the Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation. (KHN is an editorially independent project of the foundation.)
“People are simply outliving their relatives and their resources, and fortunately, Medicaid has been there,” said Mark Parkinson, president of the American Health Care Association, a national nursing home industry group.
With more than 70 million people enrolled in Medicaid at an annual cost of more than $500 billion, the program certainly faces long-term financial challenges. Federal Medicaid spending is projected to grow by 6 percent a year on average, rising to $650 billion in 2027 from $389 billion this year, according to the Congressional Budget Office.
Even if Congress does not repeal the Affordable Care Act, Medicaid will remain a target for cuts, experts say.
“The Medicaid pieces of the House bill could be incorporated into other pieces of legislation that are moving this year,” said Edwin Park, a vice president at the Center on Budget and Policy Priorities, a Washington nonprofit that focuses on how government budgets affect low-income people. “Certainly, nursing homes would be part of those cuts, not only in reimbursement rates but in reductions in eligibility for nursing home care.”
While most Medicaid enrollees are children, pregnant women and non-elderly adults, long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them.
“Moms and kids aren’t where the money is,” said Damon Terzaghi, a senior director at the National Association of States United for Aging and Disabilities, a group that represents state agencies that manage programs for these populations or advocate for them. “If you’re going to cut that much money out, it’s going to be coming from older people and people with disabilities.”
The House health care bill targets nursing home coverage directly by requiring every state to count home equity above $560,000 in determining Medicaid eligibility. That would make eligibility rules tougher in 10 states — mostly ones with expensive real estate markets, including California, Massachusetts and New York — as well as in the District of Columbia, according to an analysis by the Center for Budget and Policy Priorities.
Dogwood Village receives about half of its $13 million annual operating costs from Medicaid, with rates from $168 to $170 a day. Some residents who come to the facility after a hospital stay are initially covered by Medicare, but if they stay longer than 100 days, that benefit ends, and those without savings move to Medicaid.
“You have patients who have spent their life savings, and they come here,” said Kristen Smith, the admissions coordinator. Smith said patients now were older and sicker than they used to be, frequently arriving directly from a hospital.
“It used to be hips and knee” surgeries, she said. “And now a lot of those patients are going home. What we’re seeing is more complex, sicker patients.”
With cinder-block walls brightened by pictures of horses that evoke this equestrian county, the nursing home offers crafts, bingo and other activities.
Mary Ann Mohrmann is 85, the average age of Dogwood Village residents. An elementary school teacher for 25 years, she has Charcot-Marie-Tooth disease, a neurological disorder that has weakened her legs, feet and thumbs and compromised her fine motor skills.
Two of her children have it, too, she said. None of them can take care of her at home. “I’ve been here years,” she said. “I don’t know how many.”
Medicaid helps pay for care for people with disabilities, like Nancy Huffstickler, 64, who has been here four years and regards herself as “a medical disaster.”
She listed her ailments: spinal cancer in remission, restless legs syndrome, high blood pressure and multiple ulcers. She has had spinal reconstructive surgery and a hip replacement. She is undergoing physical therapy with the hope that, one day, she will be able to leave her wheelchair and use a walker.
Huffstickler is fearful of Republicans’ health care changes. “It may save the federal government money, but what about us?” she asked.
Major Medicaid cuts would compel the facility to cut staff, supplies and amenities — changes that would affect the quality of care for all residents, not just those on Medicaid.
If that does not save enough money, the facility might have to reduce the number of Medicaid residents, said Vernon Baker, who resigned as administrator in April. “It’s not like our toilet paper or paper towels are like the Ritz-Carlton’s,” he said.
Some residents do not even know they are on government insurance; administrators often complete the paperwork to start Medicaid once other insurance expires. Others are embarrassed that they are dependent on a program that still carries stigma.
They should not be, said Jennifer Harper, the assistant director of nursing. Relying on Medicaid for nursing home care has become the new normal.
“These folks have worked their whole lives, some with pretty strenuous jobs, and paid into the system,” she said. But with changes looming, she said, “it may be a system that fails them.”
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.
California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday.
The reductions in the nation’s largest Medicaid program would start at $3 billion in 2020 and would escalate to $30.3 billion annually by 2027, according to an analysis released by the state departments of finance and health care services.
“It is not Medicaid reform,” Jennifer Kent, director of the state Department of Health Care Services, said in an interview. “It is not entitlement reform. It is simply a huge funding reduction in the Medicaid program. We are deeply concerned what that means for the long-term viability of the program as it stands today.”
Medicaid covers a staggering 13.5 million low-income Californians — children, people with disabilities, nursing home residents and others. About 3.8 million of them, many of whom are chronically ill, became eligible for coverage under the Affordable Care Act, informally known as Obamacare.
California would face the biggest losses of any state, according to a report issued Wednesday by the consulting firm Avalere Health. Federal funding would drop by 26 percent over 10 years, the report said. Many states, including Alabama, Georgia, Texas and Florida, would face a drop of less than 10 percent.
The Senate bill to repeal and replace the ACA would be a “massive and significant fiscal shift” of responsibility from the federal government to states, according to the analysis. It would force difficult decisions about who and what to cover and how much to pay doctors, hospitals and clinics, the report said.
In addition to expanding its Medicaid population early and vigorously under Obamacare, the state began covering undocumented immigrant children last year. California’s program, known as Medi-Cal, also provides dental care and other services that are optional under federal Medicaid rules.
The state’s Medicaid director, Mari Cantwell, said Republican proposals present a fundamental problem that can’t be solved by making cuts around the edges.
“Nothing is safe — no population, no services,” Cantwell said. “It is really disheartening and honestly horrifying to think about the world under this Senate bill and what it would mean.”
The losses are more than what was predicted under the House bill. The analysis said that’s because the cost shift increases over time under the Senate proposal.
Ken Bascom, 62, was diagnosed with kidney cancer after becoming eligible for Medi-Cal in 2014. Bascom is now cancer-free but said that without insurance, “more likely than not, I would’ve been dead.” (Anna Gorman/KHN)
GOP leaders in Congress have been trying to repeal the ACA for seven years, deeming it disastrous public policy that costs too much and leaves consumers with rising premiums and too few choices for care.
The Senate bill would overhaul Obamacare in several ways. Besides revamping the Medicaid program, it would dramatically change the system of tax credits used to help low-income Americans get health coverage. The Congressional Budget Office concluded that the bill would cut the federal deficit by $321 billion over the next decade while leaving 22 million more Americans without health insurance.
Unable to lock down the support he needs in the Senate, Majority Leader Mitch McConnell on Tuesday postponed a vote on the bill until after the July Fourth holiday. Its fate remains uncertain as senators head back to their districts for a weeklong recess.
Under the legislation, the federal government would pay a fixed amount to states for Medicaid expenditures, a per capita rate, instead of paying for a share of all expenses incurred.
State health leaders predict that the state’s costs would outpace the federal government’s allocation, meaning California would have to come up with an additional $37.3 billion between 2020 and 2027.
“Whether it’s drugs or cost of living going up or new technologies in health care, there are costs we can’t control,” Cantwell said. “And if you have a trend factor that doesn’t really reflect the reality of what health care looks like, the state is always going to be in a place of not being able to bring the costs within that target.”
The proposed financial caps would have a “devastating and chilling effect” on spending in the Medicaid program and would pinch providers further, the analysis said. California already ranks near the bottom for how much it pays Medicaid providers.
The Senate’s overhaul of Obamacare would also force hospitals and clinics serving the poor and uninsured to live within the new financial limits, leading to “uncompensated care in the hundreds of millions, if not billions annually,” according to the analysis.
In addition, the Senate bill would phase out funding for the expansion of Medicaid, which enabled 3.8 million single, childless adults and others in the state to qualify. Under the Affordable Care Act, the federal government pledged to pay for 90 percent of their costs. But the Senate bill would reduce that to 50 percent beginning in 2024.
Without the promised federal funds, California would have to spend five times more than previously estimated to continue covering those newly eligible. By 2027, the cumulative cost to California would be $74.1 billion, according to the analysis.
California leaders vowed Tuesday to fight the bill, known as the Better Care Reconciliation Act. “Simply stated, this is a terrible bill and we must defeat it,” said Democratic Sen. Dianne Feinstein in a call with reporters.
Sen. Kamala Harris, also a Democrat, added that the most vulnerable populations are the ones who have most to lose: children, people with disabilities, seniors. “This bill is nothing short of a disaster, and it’s no wonder they did it in secret because they have nothing to be proud of,” said Harris, who aims to kill the bill before it hits the Senate floor.
The fallout would be particularly bad in Los Angeles County, home to 1 of every 20 Medicaid recipients in the nation, county officials said Tuesday.
“L.A. County will be ground zero for the plan’s deadly consequences,” said county Supervisor Sheila Kuehl during a press conference. “This is not just about money. … This is about the people who count on us for health care.”
During the conference, several Los Angeles County residents and union members held up signs that read “Healthcare is a Human Right” and, in Spanish, “SALUD para todos,” or “Health for everyone.”
Ken Bascom, 62, who lives in Venice, Calif., and attended the gathering, said he lost his job and his employer-based insurance during the recession. Soon after Bascom became eligible for Medi-Cal in 2014, he was diagnosed with kidney cancer. Now cancer-free, Bascom said he often thinks about what would have happened if he hadn’t been able to get health care.
“More likely than not, I would’ve been dead,” said Bascom, who gets care at Venice Family Clinic. “It’s very scary.”
Also in attendance was Steven Martin, 27, who said he depends on insurance he got through Obamacare to pay for his leukemia treatment. Martin, who has private insurance through Covered California, the state’s exchange, said his medication costs tens of thousands of dollars each year.
“Without insurance, I’m not going to have access to my medication,” he said.
Los Angeles County Health Agency Director Mitch Katz said the ACA made a “huge difference” in the county — dramatically cutting the uninsured rate, reducing wait times at emergency rooms and helping connect patients to primary care doctors.
“The emergency rooms themselves often had two- and three-day waits,” he said. “Because of the ACA, that is no longer the case. … The emergency room now is back to what is should be — for emergencies.”
Katz said he feared all of that would change if the Republicans succeed in overhauling the health law.