Trump Says He Knows About Health Care, But Some Of His Facts Seem Alternative

KFF Health News, May 15, 2017

“He seems to think it’s like a life insurance policy, which you can buy at a certain age and it keeps you at a fixed premium dollar forever,” says the health economist who ran Medicare under President George H.W. Bush.

This article first appeared May 15, 2017 on Kaiser Health News.

By Julie Rovner

Lost in all the coverage of the firing of FBI Director James Comey last week were a pair of in-depth interviews President Donald Trump gave that included lengthy comments on health care — one with Time magazine and the other with The Economist.

He acknowledged to Time interviewers that health care was not an area of expertise in his previous job. “It was just not high on my list,” he said. But he added that “in a short period of time I understood everything there was to know about health care.”

Not really.

Among the president’s more questionable claims was his description of the House-passed health bill as “You’re going to have absolute coverage.”

The last full estimate from the Congressional Budget Office predicted that a previous version of the bill would result in 24 million fewer people with insurance after 10 years.

Trump also told The Economist that “we’re getting rid of the state lines,” a reference to allowing health insurers to sell across state lines. Not only is that not in the GOP bill, many experts agree such a policy would not work to increase competition.

Possibly the most curious comment was this one, also in The Economist interview: “[T]his was not supposed to be the way insurance works. Insurance is, you’re 20 years old, you just graduated from college, and you start paying $15 a month for the rest of your life and by the time you’re 70, and you really need it, you’re still paying the same amount and that’s really insurance.”

“He seems to think it’s like a life insurance policy, which you can buy at a certain age and it keeps you at a fixed premium dollar forever,” said Gail Wilensky, a health economist who ran the Medicare and Medicaid programs under President George H.W. Bush. Except “you can’t buy health insurance that way,” Wilensky said. “Even if you stay continuously insured, that’s just not how it works.”

On the other hand, Wilensky said, it might not matter all that much how well a president understands the intricacies of health policy. “It matters whether he thinks it’s important,” she said. The president she worked for was much more comfortable on issues of foreign relations and defense. “It wasn’t that he didn’t care” about health, she said. “He just didn’t know that area the way he knew other areas.”

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, points out that a deep understanding of a subject by itself is not enough to produce policy change.

“Bill Clinton thought he knew health policy, and look at how that turned out,” he said, referring to the collapse of his health reform plan in Congress in 1994. Still, “ignorance surely doesn’t help,” he added.

David Blumenthal, president of the Commonwealth Fund and co-author of a book on presidents and health care, agreed with both Wilensky and Oberlander.

“A president has to know enough to sell the plan” to Congress and the public, he said. “But presidents can make mistakes by getting too deep in the details.” He pointed to not only Clinton but also President Jimmy Carter as chief executives who got mired in the small print of health policy.

At the same time, however, Blumenthal said that a president has “to lay out principles and parameters that the Congress knows if they meet he will sign the bill.” And while Trump has done that, “I don’t think he’s been entirely consistent with what he’s said, so it’s not clear how much the Congress is being guided by his principles,” he said.

One health issue Trump is clearly not ignorant about is his power to stop paying insurance companies who are providing help to some low-income policyholders in the health insurance exchanges. The “cost-sharing reductions” are the subject of a lawsuit that was appealed by the Obama administration, and Trump could, in fact, stop the payments by dropping the appeal.

Insurers say uncertainty about whether they will get that money is a key reason they are asking for higher rates or dropping out of markets.

Trump did not help allay that uncertainty. He told The Economist that “we don’t have to subsidize it. You know if I ever stop wanting to pay the subsidies, which I will.”

CMS Gives States Until 2022 To Meet Medicaid Standards Of Care

KFF Health News, May 11, 2017

Federal standards requiring states find ways of delivering care to Medicaid enrollees in home and community-based settings will take effect in 2022 instead of 2019, CMS announced this week.

This article first appeared May 11, 2017 on Kaiser Health News.

By Phil Galewitz

The Trump administration has given states three extra years to carry out plans for helping elderly and disabled people receive Medicaid services without being forced to go into nursing homes.

Federal standards requiring states find ways of delivering care to Medicaid enrollees in home and community-based settings will take effect in 2022 instead of 2019, the Centers for Medicare & Medicaid Services announced this week.

The standards were set by an Obama administration rule adopted in 2014 that governs where more than 3 million Medicaid enrollees get care.

Among other things, the rule requires states to provide opportunities for enrollees to engage in community life, control their own money and seek employment in competitive settings. It also ensures that enrollees in group homes and other residential settings get more privacy and housing choices that include places where non-disabled people live.

Matt Salo, executive director of the National Association of Medicaid Directors, applauded the delay.

“We have long been on record saying that the regulation was hopelessly unrealistic in its time frame,” he said. “Delaying it actually helps consumers because the underlying regulation was going to push too many changes too fast into a system that wasn’t ready.”

The Obama administration’s 2014 rule was an effort to create a federal standard to improve the quality of care that the disabled receive outside institutions.

Some states had tried ― and struggled ― to make changes on their own, partly due to a lack of funding and political difficulties of changing deeply-entrenched relationships with providers.

Some had, for instance, forced providers to change longstanding operations at group homes and so-called sheltered workshops such as Goodwill Industries where disabled people often work apart from other employees, performing menial tasks for less than minimum wage.

Helping disabled people find work in places where they are not segregated costs states more money, said Gary Blumenthal, CEO of the Association of Developmental Disabilities Providers.

The delay in implementing the federal rule is “a victory for the status quo and for states reluctant to embrace the [new standards],” he said.

States spent several years fighting the new rules during the Obama administration and that slowed their planning, said Elizabeth Priaulx, senior legal specialist with the National Disability Rights Network. She noted states were under pressure from nursing homes and for-profit group homes to resist the changes.

“It is unfortunate the delay had to occur,” but many states were not ready, she said.

The new rule also directs states and providers to reconfigure existing community settings such as group homes to ensure that people will have more privacy. “Without these dollars it’s difficult to change the system,” Blumenthal said.

Funds Already Shifting

In 2014, state Medicaid programs for the first time spent more on long-term care in home and community-based settings than on nursing homes. But there was great variation: Mississippi spent about 25 percent of its long-term care dollars on home and community care while Oregon and other states spent nearly 80 percent.

Camille Dobson, deputy executive director of the National Association of States United for Aging and Disability, said the delay was important for states worried about losing federal funding if they didn’t meet the new standards.

“It was very likely that most of the states would not have been in compliance by March 2019 and so CMS would [have been] faced with taking money away from programs that help people stay in their homes rather than go to nursing facilities,” Dobson said.

The administration’s announcement of the delay came less than a week after the House passed the American Health Care Act, which would take $880 billion over 10 years out of the Medicaid program. It was expected after Health and Human Services Secretary Tom Price in March invited states to apply for waivers from federal Medicaid rules that he said were too onerous to help improve the program.

So far, Tennessee is the only state that has received final approval from CMS for its implementation plan. States still face a 2019 deadline to gain approval for their implementation plans.

Kathy Carmody, CEO of The Institute on Public Policy for People with Disabilities in Illinois, said there is concern the Trump administration may not just delay the rule’s implementation, but eventually eliminate it altogether.

“We are disappointed,” she said, noting that Illinois ranks last or near last on several measures of care for people receiving home and community-based services. That includes having about half of its disabled Medicaid enrollees in residential care settings with seven or eight other disabled people and less than 6 percent of its disabled enrollees in competitive employment, she said.

“We were really hoping the rule would be a push from the federal government to help us evolve into the 21st century and get out of the mid-1980s where we are stuck,” Carmody said.

Grassley, Chaffetz Send Fiery Response To HHS Memo They Say Chills Whistleblowing

KFF Health News, May 10, 2017

The Congressmen are blasting a memo from HHS Secretary Tom Price’s chief of staff, which instructed employees not to have “any communications” with members of Congress or their staffs without first consulting the department.

This article first appeared May 08, 2017 on Kaiser Health News.

By Rachel Bluth

Two influential Republican congressmen are blasting a Department of Health and Human Services memo to division heads as a “potentially illegal and unconstitutional” infringement on whistleblowers’ rights to call attention to waste, fraud and abuse in the executive branch.

The May 3 memo from HHS Secretary Tom Price’s chief of staff, Lance Leggitt, instructed employees not to have “any communications” with members of Congress or their staffs without first consulting the department’s assistant secretary for legislation. Leggitt’s memo said he was only restating a long-standing policy on congressional relations and gave eight examples of contacts needing approval, including requests for calls, briefings, hearings and oversight.

The 10-sentence memo drew an incensed reply from Sen. Chuck Grassley (R-Iowa) and Rep. Jason Chaffetz (R-Utah), the chairmen, respectively, of the Senate Judiciary Committee and the House Committee on Oversight and Government Reform. They asked Price to clarify in writing Leggitt’s communication as soon as possible.

Their complaint was that the memo contained no exception for lawful, protected communications with Congress.

“In its current form, employees are likely to interpret it as a prohibition, and will not necessarily understand their rights,” they wrote in their letter to Price.

“Protecting whistleblowers who courageously speak out is not a partisan issue — it is critical to the functioning of our government,” added the lawmakers.

Grassley and Chaffetz warned that the memo could violate federal employees’ constitutional rights to petition the government, as well as violate other laws protecting government employees from reprisals for speaking with members of Congress.

Two experts on good government practices agreed with the congressmen’s viewpoint.

Liz Hempowicz, policy counsel at the Project on Government Oversight, said the memo’s failure to remind employees of their rights as potential whistleblowers made it illegal.

“If they don’t know they have that right, it’s essentially taking it away from them,” she said.

Thomas Scully, who served as administrator for the Centers for Medicare & Medicaid under President George W. Bush, said the Trump administration isn’t the first to try to coordinate congressional relations, but using a formal memo to do so surprised him.

Congress regularly seeks information from staffers in HHS — and other agencies — and certain employees often go to Capitol Hill to give technical briefings, testify or request more budget money, he said. “People should be able to go to the Hill whenever they need to, but if you’re up there pushing an agenda that’s different than the president’s, they’re going to get reined in one way or another,” he said. “You shouldn’t be up there as a free agent.”

Grassley and Chaffetz instructed Price to provide all documents and communications about Leggitt’s directive to their committees by May 18.

President Donald Trump has not yet named a nominee to head the HHS Office of Assistant Secretary for Legislation. Until then, employees complying with the memo will go through the acting assistant secretary, Barbara Clark.

Leggitt’s memo isn’t the first to stir controversy in HHS this month. Some media outlets reported last week that another directive ordered television monitors to be switched from CNN to Fox at the Food and Drug Administration’s main campus. Some details were disputed by an FDA spokesperson, and The Wall Street Journal reported the switch was temporary. The FDA is part of HHS.

Nearly 1 In 3 Recent FDA Drug Approvals Followed By Major Safety Actions

KFF Health News, May 10, 2017

Seventy-one of the 222 drugs approved in the first decade of the millennium were withdrawn, required a “black box” warning on side effects or warranted a safety announcement, researchers say.

This article first appeared May 10, 2017 on Kaiser Health News.

By Sydney Lupkin

The Food and Drug Administration is under pressure from the Trump administration to approve drugs faster, but researchers at the Yale School of Medicine found that nearly a third of those approved from 2001 through 2010 had major safety issues years after they were widely available to patients.

Seventy-one of the 222 drugs approved in the first decade of the millennium were withdrawn, required a “black box” warning on side effects or warranted a safety announcement about new risks to the public, Yale professor Dr. Joseph Ross and his colleagues reported in JAMA on Tuesday. The study included safety actions through Feb. 28.

“While the administration pushes for less regulation and faster approvals, those decisions have consequences,” Ross said. The Yale researchers’ previous studies concluded that the FDA approves drugs faster than its counterpart agency in Europe, and that the majority of pivotal trials in drug approvals involved fewer than 1,000 patients and lasted six months or less.

It took a median time period of 4.2 years after the drugs were approved for these safety concerns to come to light, and issues were more common among psychiatric drugs, biologic drugs, drugs that were granted “accelerated approval” and drugs that were approved near the regulatory deadline for approval.

Drugs ushered through the FDA’s accelerated approval process were among those that had higher rates of safety interventions. These approvals typically rely on surrogate endpoints, meaning that researchers measured something other than survival, such as tumor size, to determine whether the drugs worked.

“This [finding on surrogate endpoints] has the greatest relationship to policy today,” Ross said. “In the 21st Century Cures Act, there’s a push to have the FDA move to further support the use of surrogate markers … [but] they’re more likely to have concerns in the post-market setting.”

Former President Barack Obama signed the act into law on Dec. 13. Among other things, it offers ways to speed drug approval by pushing the FDA to consider different kinds of evidence beyond the three phases of traditional clinical trials. The new process has made some researchers worry that it will open the door for more unsafe approvals.

“I’m actually sympathetic to the idea that there are ways in which the FDA can be more streamlined and do a quicker job,” said Dr. Vinay Prasad, a hematologist-oncologist and professor at Oregon Health and Sciences University who did not work on the study. “The one place you don’t want to cut a corner is safety and efficacy prior to coming to market.”

Given criticism of the FDA’s mostly voluntary system for reporting new drug- and device-related health problems, it’s possible there are more unknown adverse side effects of which neither the FDA nor the general public is aware. The reports are not verified, and critics say this system is underutilized and filled with incomplete and late information. The FDA also monitors other available studies and reports to determine whether it needs to take action on a particular drug.

FDA spokeswoman Angela Hoague said the agency is reviewing Ross’ findings.

“In general, the FDA does not comment on specific studies, but evaluates them as part of the body of evidence to further our understanding about a particular issue and assist in our mission to protect public health,” she said.

Regardless, some observers may find the proportion of safety concerns alarming and others may be breathing a sigh of relief that it’s not higher, Ross said.

“That’s the million-dollar question: What’s the right amount? What’s the appropriate level of safety concerns to have identified only once the product is out of the gate?” said Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. He did not work on the study.

Surprisingly, drugs approved in under 200 days were less likely to have safety issues, which the authors speculate could be because “some approval packages provide clearer evidence of safety, allowing for more rapid regulatory approval.”

The study included market withdrawals of three drugs: the anti-inflammatory drug Bextra, a drug called Zelnorm that treats irritable bowel syndrome and the psoriasis drug Raptiva. Bextra and Zelnorm were withdrawn over cardiovascular risk, and Raptiva was withdrawn because of increased risk of a rare and fatal infection that damages material in the brain.

Still, it’s important to keep in mind that the post-approval safety issues cover the spectrum from relatively minor to serious, Alexander said. A good next step would be to dig into the extremely serious safety problems, determine whether the FDA could have flagged them sooner and how they might have been missed, he said.

Alexander commended the researchers, saying their study “underscores the importance of surveillance” after a drug has been launched. This helps researchers find new problems — and new benefits — associated with a drug.

“All too often, patients and clinicians mistakenly view FDA approval as [an] indication that a product is fully safe and effective,” he said. “Nothing could be further from the truth. We learn tremendous amounts about a product only once it’s on the market and only after use among a broad population.”

Why Blue States Might Ditch Beloved Obamacare Protections

KFF Health News, May 9, 2017

Opt-out provisions could accelerate the unraveling of Obamacare, even in places that fully embraced the landmark law.

This article first appeared May 09, 2017 on Kaiser Health News.

By Chad Terhune and Barbara Feder Ostrov  

Under the Republican health bill, it’s up to states whether to dismantle key parts of the Affordable Care Act.

Red, or GOP-leaning, states are sure to be interested in rolling back the law’s coverage requirements and freeing insurers to charge people more when they have preexisting conditions.

As strange as it sounds, deep-blue, heavily Democratic states supportive of Obamacare, including California and New York, may be forced to do the same, according to experts, regulators and consumer advocates.

The American Health Care Act, which narrowly passed the House on Thursday and now heads to the Senate, would significantly cut the federal subsidies on which many Americans rely to buy coverage. Unless the legislation fails or changes substantially, many consumers across the country could see the amount they pay every year for premiums increase by thousands of dollars, making coverage effectively unaffordable.

Few, if any, states would be able to fund subsidies on their own. To keep insurers in the market and bring costs down, state leaders might feel compelled to seek exemptions from rules that require health plans to provide 10 “essential health benefits” and prohibit them from charging higher rates for sicker consumers. The new GOP health care bill would allow such waivers.

“With the skimpier subsidies, states are going to be under enormous pressure to apply for these waivers,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

These opt-out provisions could accelerate the unraveling of Obamacare, even in places that fully embraced the landmark law.

“Certainly the Californias and New Yorks of the world will do what they can to hold onto the ACA protections. But when confronted with insurer exits and big price hikes, many states with the best of intentions may feel they have little choice but to get a waiver,” Corlette said.

The idea of opting out is unfathomable to many liberals who fought so hard to win the consumer protections in the Affordable Care Act. They’re hoping the Senate will dump the bill or, in its quest for more moderate votes, at least make the premium tax credits more generous or eliminate the waivers.

Republican leaders insist the current health law isn’t worth saving because it has left consumers with double-digit rate hikes, onerous deductibles and little or no competition in some states, as insurers exit the marketplaces.

Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means committee, said the GOP health bill grants states the flexibility they need to remove the “crushing mandates” that have led to “Obamacare plans you don’t want and can’t afford.”

House Speaker Paul Ryan (R-Wis.) struck a similar note in urging his colleagues to pass the bill. “Let’s make it easier for people to afford their insurance. … Let’s return power from Washington to the states,” he said on the House floor Thursday.

Consumer advocates in North Carolina, Colorado and other states are taking the threat of waivers seriously.

“No state is safe from such a waiver,” said Brendan Riley, a health policy analyst at the North Carolina Justice Center, an advocacy group focused on economic and social issues.

North Carolina would be one of the states hit hardest by the House bill, according to an analysis by the left-leaning Center on Budget and Policy Priorities. The state’s average premiums and out-of-pocket costs would rise by $7,549 annually.

Nationally, the average tax credit for enrollees in the online marketplaces would be 41 percent lower under the American Health Care Act by 2022, according to a study by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

The GOP bill also ends the penalty for not having coverage, which experts say might increase premiums as fewer healthy people sign up, leaving health plans with a higher proportion of sick patients.

All this could put the focus back on which benefits are deemed essential in health insurance — an all-too-familiar battle in statehouses before the ACA set a nationwide standard.

The health law now requires all plans sold on the individual and small-group markets to cover the 10 essential health benefits, including hospitalization, prescription drugs and mental health treatment. It has made coverage more comprehensive and prevented insurers from selling bare-bones plans that had cheaper premiums but often exposed consumers to huge medical bills after they sought care.

Before the ACA, coverage for maternity care, prescription drugs and substance abuse treatment often wasn’t available. State lawmakers were hesitant to approve new benefit mandates for fear of raising premiums.

Washington state Insurance Commissioner Mike Kreidler, a Democrat, said he sees a political fight over benefits on the horizon if the GOP bill advances.

“I certainly think there’s going to be political pressure applied to make adjustments [in essential health benefits],” he said. “I’d be vociferously and violently opposed to those changes.”

Adela Flores-Brennan, executive director of the Colorado Consumer Health Initiative, said she too has faith that her state’s Democratic governor and insurance commissioner would uphold essential benefits and protections for people with preexisting conditions.

But she and other patient advocates said that resolve may be tested by the lack of competition in some areas, which insurers could use as a bargaining chip for more leeway on regulations.

For instance, Flores-Brennan noted that industry giant Anthem is the sole company on the state’s insurance exchange in 14 Colorado counties. She said she worries the company could threaten to pull out if the state doesn’t opt for weaker standards.

California would be loath to cut benefits. If you’re selling a policy to a young adult without maternity care, that’s nuts.

John Baackes, CEO of L.A. Care
Health Plan

Even in California, a liberal bastion that enthusiastically implemented Obamacare, the law’s supporters are bracing for a fight over the waivers.

“As premiums go higher, it will create pressure on us to undercut the standards we have,” said Beth Capell, a lobbyist for the consumer advocacy group Health Access California.

In California, premiums and out-of-pocket costs would rise by $2,779, on average, under the House bill, according to the analysis by the Center on Budget and Policy Priorities.

“California policymakers will once again hear what we heard year after year before the ACA: ‘Some coverage is better than no coverage. More limited benefits are better than nothing,’” Capell said.

John Baackes, the chief executive of L.A. Care Health Plan, with about 26,000 enrollees in the California exchange, said state leaders would exhaust every other option before slashing coverage.

“California would be loath to cut benefits,” Baackes said. “If you’re selling a policy to a young adult without maternity care, that’s nuts.”

No matter the state, red or blue, experts anticipate vigorous debate over these waivers because consumer protections under Obamacare have become more popular.

Wisconsin Gov. Scott Walker, a Republican, experienced that firsthand last week when he suggested his state may opt out of the ACA’s preexisting condition rules — and then immediately backtracked amid strong opposition.

Michael Miller, director of strategic policy for Community Catalyst, a Boston-based national consumer group, said waiver requests won’t necessarily proceed “quietly even in the red states. … People have heart disease and cancer and asthma in those states, too.”

Medicare Failed To Investigate Suspicious Infection Cases From 96 Hospitals

KFF Health News, May 9, 2017

The lapse was discovered as by an OIG study designed to address concerns over whether hospitals are “gaming” a system in which it falls to the hospitals to report patient-infection rates.

This article first appeared May 09, 2017 on Kaiser Health News.

By Christina Jewett

Almost 100 hospitals reported suspicious data on dangerous infections to Medicare officials, but the agency did not follow up or examine any of the cases in depth, according to a report by the Health and Human Services inspector general’s office.

Most hospitals report how many infections strike patients during treatment, meaning the infections are likely contracted inside the facility. Each year, Medicare is supposed to review up to 200 cases in which hospitals report suspicious infection-tracking results.

The IG said Medicare should have done an in-depth review of 96 hospitals that submitted “aberrant data patterns” in 2013 and 2014. Such patterns could include a rapid change in results, improbably low infection rates or assertions that infections nearly always struck before patients arrived at the hospital.

The IG’s study, released Thursday, was designed to address concerns over whether hospitals are “gaming” a system in which it falls to the hospitals to report patient-infection rates and, in turn, the facilities can see a bonus or a penalty worth millions of dollars. The bonuses and penalties are part of Medicare’s Inpatient Quality Reporting program, which is meant to reward hospitals for low infection rates and give consumers access to the information at the agency’s Hospital Compare website.

The report zeroes in on a persistent concern about deadly infections that patients develop as a result of being in the hospital. A recent British Medical Journal report identified medical errors as the third-leading cause of death in the U.S. Hospital infections particularly threaten senior citizens with weakened immune systems.

Rigorous review of hospital-reported data is important to protect patients, said Lisa McGiffert, director of the Consumers Union’s Safe Patient Project.

“There’s a certain amount of blind faith that the hospitals are going to tell the truth,” McGiffert said. “It’s a bit much to expect that if they have a bad record they’re going to ’fess up to it.”

Yet there are no uniform standards for reviewing the data that hospitals report, said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine.

“There are greater requirements for what a company says about a washing machine’s performance than there is for a hospital on quality of care, and this needs to change,” Pronovost said. “We require auditing of financial data, but we don’t require auditing of [health care] quality data, and what that implies is that dollars are more important than deaths.”

In 2015, Medicare and the Centers for Disease Control and Prevention issued a joint statement cautioning against efforts to manipulate the infection data. The report said CDC officials heard “anecdotal” reports of hospitals declining to test apparently infected patients — so there would be no infection to report. They also warned against overtesting, which helps hospitals assert that patients came into the hospital with a preexisting infection, thus avoiding a penalty.

In double-checking hospital-reported data from 2013 and 2014, Medicare reviewed the results from 400 randomly selected hospitals, about 10 percent of the nation’s more than 4,000 hospitals. Officials also examined the data from 49 “targeted” hospitals that had previously underreported infections or had a low score on a prior year’s review.

All told, only six hospitals failed the review, which included a look at patients’ medical records and tissue sample analyses. Those hospitals were subject to a 0.6 percent reduction in their Medicare payments. Medicare did not specify which six hospitals failed the data review, but it did identify dozens of hospitals that received a pay reduction based on their reports on the quality of care.

The new IG report recommended that Medicare “make better use of analytics to ensure the integrity of hospital-reported quality data.” A response letter from Centers for Medicare & Medicaid Services Administrator Seema Verma says Medicare concurs with the finding and will “continue to evaluate the use of better analytics … as feasible, based on [Medicare’s] operational capabilities.”

Questions about truth in reporting hospital infections have percolated for years, as reports have trickled out from states that double-check data.

In Colorado, one-third of the central-line infections that state reviewers found in 2012 were not reported to the state by hospitals, as required. Central lines are inserted into a patient’s vein to deliver nutrients, fluids or medicine. Two years later, though, reviewers found that only 2 percent of central-line infections were not reported.

In Connecticut, a 2010 analysis of three months of cases found that hospitals reported about half — 23 out of 48 — of the central-line infections that made patients sick. Reviewers took a second look in 2012 and found improved reporting — about a quarter of the cases were unreported, according to the state public health department.

New York state officials have a rigorous data-checking system that they described in a report on 2015 infection rates. In 2014, they targeted hospitals that were reporting low rates of infections and urged self-audits that found underreporting rates of nearly 11 percent.

Not all states double-check the data, though, which Pronovost said underscores the problem with data tracking the quality of health care. He said common oversight standards, like the accounting standards that apply to publicly traded corporations, would make sense in health care, given that patients make life-or-death decisions based on quality ratings assigned to hospitals.

“You’d think, given the stakes, you’d have more confidence that the data is reliable,” he said.

Should Health Care Trainees Be Treated As Paid Employees?

KFF Health News, May 8, 2017

This article first appeared May 08, 2017 on Kaiser Health News.

By Anna Gorman May 8, 2017

Proposed legislation in California would require hospitals and clinics to pay minimum wage to students who are completing the training hours necessary to become allied health professionals.

Narciso Lara, 36, was trying to support his family in Salinas as a forklift driver but didn’t see any opportunity for advancement. So last year, he enrolled in a community college program to become a radiologic technologist.

Now, Lara takes classes at Foothill College in Los Altos Hills, Calif., and gets hands-on training at a health clinic nearby. By the end of the 22-month program, he will have completed 1,850 clinical hours — all unpaid.

That could change under the terms of proposed state legislation that would require hospitals and clinics to pay minimum wage to Lara and other students who are completing the training hours necessary to become allied health professionals. The current minimum wage in California is $10.50 an hour for organizations with more than 25 employees, and it is scheduled to rise to $15 over the next five years.

The bill, AB 387, would cover an estimated 50,000 people training for jobs such as respiratory therapists, vocational nurses, dietitians and pharmacy technicians. It would not cover marriage and family therapists or psychologists.

The legislation, authored by state Assemblyman Tony Thurmond (D-Richmond) and sponsored by the powerful SEIU-United Healthcare Workers West union, would broaden the definition of “employer” to include hospitals and clinics that are supervising trainees in the allied health professions.

At the heart of the issue is whether the trainees should be considered students or employees. Perhaps counterintuitively, getting a paycheck could have unexpected consequences for the trainees.

Lara said he would love to be paid while going to school, because his wife, a dental therapist, is supporting him and their children right now. But he worries that if hospitals and clinics had to pay students, they might be less willing to offer them training slots, and then there would be nowhere to get the requisite clinical hours.

“If this bill passes, I don’t know what’s going to happen. It’s scary actually,” Lara said.

Supporters say the bill would make it easier for more low-income students and working adults to become allied health professionals. To get certified or licensed, students have to complete anywhere from 160 to 1,850 unpaid clinical hours. That may be an insurmountable barrier for many, according to SEIU-UHW, which represents about 37,000 allied health workers in California.

“We are really talking about choking off a lot of people getting into these jobs,” said Michael Borges, political coordinator for SEIU-UHW.

Borges also said the students deserve compensation for their work, which the union estimates is worth at least $200 million in wages each year. “These are real trainees doing real work that provides a real benefit for these sites,” he said.

But accrediting bodies and community colleges have expressed concern about the bill. One agency, the Joint Review Committee on Education in Radiologic Technology, wrote a letter to Assemblyman Thurmond saying that pay for students is “inconsistent” with its accreditation policies.

Hospitals argue that paying wages would be a financial burden for them, especially since they already fund and provide the training and supervision required. The California Hospital Association estimates that paying allied health trainees would cost anywhere from $1.5 million annually for small hospitals to $36 million for larger health systems. Statewide, that would likely add up to a lot more than what the union estimates.

“The ramifications are huge,” said Cathy Martin, vice president of workforce policy for the California Hospital Association.

In addition, the association argues that the trainees aren’t employees, but rather students who — by law — must be supervised by licensed health care workers.

“These are unlicensed individuals who cannot provide care to patients without direct supervision,” Martin said. “They are learning what they need to know to become that licensed professional.”

Cedars-Sinai Medical Center in Los Angeles would probably have to reduce its number of slots for such trainees were the bill to pass, the hospital’s CEO Thomas Priselac told Thurmond in a letter. Cedars would be required to pay the more than 220 occupational and physical therapists, laboratory scientists and others it trains each year. It would also have to provide them with workers’ compensation, health insurance and other employee benefits, Priselac noted.

“The effects of this significant decrease in capacity within the current training system would exacerbate existing allied health care workforce shortages and put the development of a strong and diverse pipeline of future caregivers in jeopardy,” Priselac wrote.

Rachelle Campbell, director of the Foothill College radiologic technology program that Lara attends, said that helping students financially is a great idea but that the proposed legislation would have too many negative impacts.

“If our hospitals have to pay our students, they are going to walk away,” she said. “All of our contracts say students are not employees.”

The Foothill College radiology technologist training program places students at Stanford Medical Center, Santa Clara Valley Medical Center and other hospitals and clinics in the Bay Area. The students are under one-on-one, direct supervision for their first three quarters. After that, they have slightly more autonomy, but the supervisor must be within earshot, Campbell said.

These are real trainees doing real work that provides a real benefit for these sites.

Michael Borges, SEIU-United Healthcare Workers West political coordinator

Another one of her students, Rick Li, said he had to take out a loan to go back to school. But he is convinced he will make that money back when he graduates. The San Jose resident said he knew from the outset that the unpaid clinical hours were part of becoming a radiologic technologist.

“We are not really working for free,” said Li, 29. “We are working for our education.”

Li said that as a student he can make mistakes and learn from them. “If we were making money, we would be seen as techs rather than students. And if we don’t perform an exam correctly, they are going to judge us more harshly,” he said.

But Mayte Paniagua, an SEIU member who supports the bill, said going back to school about 15 years ago to become a pharmacy technician was a huge burden. The single mother had to leave her paid clerical job to work the unpaid training hours.

“I ended up finishing my internship program, but unfortunately I went into debt,” she said. “It’s not fair for other people out there to struggle just to get a better-paying job in health care.”

Paniagua, who now works as a pharmacy tech at Pacifica Hospital of the Valley in Sun Valley, said there really isn’t much difference between being a trainee and an employee.

“Technically the [trainees] are working,” she said. “They are hands-on. That’s why these people should get paid.”

Political Theater: How A Bill That Nearly All Opposed Managed To Pass The House

KFF Health News, May 5, 2017

This article first appeared May 05, 2017 on Kaiser Health News.

By Phil Galewitz 

Despite vocal opposition from nearly every major constituency affected by the bill, the vote produced the opposite result.

The AARP called the health bill that House Republicans narrowly approved Thursday “deeply flawed” because it would weaken Medicare and lead to higher insurance premiums for older Americans.

The American Medical Association said it would undo health insurance coverage gains and hurt public health efforts to fight disease. The American Hospital Association said the bill would destroy Medicaid, the state-federal health insurance program for the poor that expanded mightily under the Affordable Care Act and buoyed hospitals’ bottom lines.

Normally, that would spell failure.

But in today’s Washington, despite vocal opposition from nearly every major constituency affected by the bill, the vote produced the opposite result. The chorus of nays was not enough to stop the Republican-controlled House from approving the American Health Care Act, which repeals many critical parts of Affordable Care Act — the 2010 law known as Obamacare that has dropped uninsured rates in the United States to historic lows but, despite its lofty name, did little to rein in rising health costs. The AHCA will now move to the Senate, where GOP senators are expected to demand many changes.

Republicans have promised to repeal Obamacare since the day it was passed with only Democrats voting for it and have been campaigning on that promise ever since. While the House voted to repeal the act more than 60 times under the Obama administration, Thursday’s vote was the first one that really counted because the GOP controls Congress and the White House.

Peter Kongstvedt, a Virginia health industry consultant, said some House Republicans are likely betting the Senate blocks their legislation from going forward. “Nobody wins with this vote — that’s the damnedest part,” he said. “It’s a shallow political statement.”

The vote was about health care, but it was a display of political theater, too. Representatives sent a message not to hospitals, doctors and patients but to President Donald Trump and his devoted followers who propelled the GOP to power.

“The president needed a win and so does House Speaker Paul Ryan,” said Jason Fichtner, a health care expert at the conservative Mercatus Center at George Mason University in Fairfax, Va. “With this vote, they can go back to their constituents and say they did something about Obamacare.”

That is, the 217 GOP House members who voted for the bill. Twenty voted no, joining 193 Democrats.

Trump’s team scored him a touchdown, but their run to the goal line wasn’t politically pretty:

  • The bill passed without an updated analysis of costs and benefits from the nonpartisan Congressional Budget Office, whose review in March came before the GOP added sweeteners to win over its conservatives and moderates.
  • Democrats passed Obamacare after a year of debate. The GOP spent almost two months hammering out its replacement plan.
  • Business groups — such as the drug and hospital industries — played no part in shaping the AHCA. The Obama administration got both groups on board early on.

The GOP’s focus was not so much on what can lower prices and increase health coverage but how to persuade the right-wing Freedom Caucus to back the legislation.

In the end, passage mattered less about how the bill played in public polls — poorly — or among key interest groups — nearly all opposed. “Coming to agreement and avoiding the embarrassment of not coming to agreement was more important than what was in the final bill,” said Jim Morone, a political scientist at Brown University in Rhode Island. “Republicans have become a deeply ideological party … and they don’t care what interest groups think; they are going to press ahead.”

Part of the unlikely victory is that the bill makes the biggest change to Medicaid since the program was established in 1965 and there hasn’t been as much debate about that as one might expect. The AHCA could lead to huge cuts in federal funding of Medicaid, which now covers more than 75 million Americans.

Alan Levine, a hospital executive who was the top health official under former Republican governors Jeb Bush in Florida and Bobby Jindal in Louisiana, said Republicans who ran on repealing Obamacare felt they had no choice but to vote for the bill, despite its flaws. “I don’t think Republicans can face voters in 2018 and have a credible argument to keep them in control of Congress, if they did not do their No. 1 campaign priority to repeal Obamacare,” said Levine, CEO of Mountain States Health Alliance, a hospital system in Johnson City, Tenn.

Besides, he said, even if the GOP bill becomes law, it’s set up so that the changes won’t affect many people before the 2018 midterm elections. “People won’t feel this — good or bad — until well after the election.”

A Squeaker In The House Becomes Headache For The Senate: 5 Things To Watch

KFF Health News, May 5, 2017

This article first appeared May 05, 2017 on Kaiser Health News.

By Julie Rovner 

The bill moves across the Capitol to the Senate. With only a two-vote Republican majority and no likely Democratic support, it would take only three GOP “no” votes to sink the bill.

After weeks of will-they-or-won’t-they tensions, the House managed to pass its GOP replacement for the Affordable Care Act on Thursday by a razor-thin margin. The vote was 217-213.

Democrats who lost the battle are still convinced they may win the political war. As the Republicans reached a majority for the bill, Democrats on the House floor began chanting, “Na, na, na, na … Hey, hey, hey … Goodbye.” They claim Republicans could lose their seats for supporting a bill that could cause so much disruption in voters’ health care.

Now the bill — and the multitude of questions surrounding it — moves across the Capitol to the Senate. And the job doesn’t get any easier. With only a two-vote Republican majority and no likely Democratic support, it would take only three GOP “no” votes to sink the bill.

Democrats have made clear they will unanimously oppose the bill. “Trumpcare” is just a breathtakingly irresponsible piece of legislation that would endanger the health of tens of millions of Americans and break the bank for millions more,” said Senate Minority Leader Chuck Schumer (D-N.Y.).

And Republicans in the Senate have their own internal disagreements, too.

Here are five of the biggest flashpoints that could make trouble for the bill in the upper chamber.

Medicaid

House leaders correctly point out that their bill represents the biggest changes to the federal-state health program for the poor since its inception in 1965 — a point that appeared to be drowned out during the most recent House debate that focused on coverage for people with preexisting health conditions.

For the first time, federal funding for low-income people on Medicaid would be limited, resulting in what House Speaker Paul Ryan (R-Wis.) described at an event sponsored by the conservative National Review as “sending it back to the states, capping its growth rates.” It’s a longtime goal for many conservatives. Said Ryan, “We’ve been dreaming of this since I’ve been around.”

But it is not a consensus position in the party. Some moderates support the current program, especially for children and people with disabilities. In addition, many GOP governors took the federal government’s offer in the ACA of near-complete federal funding to expand Medicaid to non-disabled, working-age adults, and they are worried about the impact on their residents and their budgets if the expansion goes away and the program’s funding is restricted.

The House bill, wrote the Republican governors of Ohio, Michigan, Arkansas and Nevada in a letter to House and Senate leaders, “provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states.”

That pushback has also created doubts in the minds of some GOP senators. Sens. Rob Portman (R-Ohio), Bill Cassidy (R-La.) and Shelley Moore Capito (R-W.Va.) are among those who have expressed concerns about the House bill, as has Dean Heller (R-Nev.) It’s not clear if any of the House changes have satisfied those senators.

Increase In Number Of Uninsured People

The Congressional Budget Office’s initial estimate that the bill could lead to 24 million more Americans without health insurance within a decade spooked many lawmakers in the upper chamber. “You can’t sugarcoat it,” Cassidy told Fox News when explaining that “it’s an awful score.” The final House bill passed without the score being updated, although most outside analysts said the changes were likely to increase the number who would lose insurance.

And Democrats have been using those initial numbers to score rhetorical points, even if they lack the votes in either the House or Senate to stop the bill or change it. “The CBO’s estimate makes clear that Trumpcare will cause serious harm to millions of American families,” said Schumer. “Tens of millions will lose their coverage, and millions more, particularly seniors, will have to pay more for health care.”

Tax Credits

On one hand, even with the additional $85 billion added by House leaders to help older people pay for their insurance premiums, many moderates feel the age-based tax credits in the bill replacing those in the Affordable Care Act are too small, particularly for people in their 50s and early 60s. The CBO estimated that under the original version of the House bill, premiums for a 64 year-old with an income of $26,000 a year could rise from $1,700 currently to more than $14,000.

That brought a strong rebuke from the powerful AARP, which was an outspoken ACA supporter. “Although no one believes the current health care system is perfect, this harmful legislation would make health care less secure and less affordable,” said a statement from the group.

Sen. Susan Collins (R-Maine) has said she could not support the House bill in its original form because of concerns about the effects on older constituents.

On the other hand, some conservatives in the Senate are ideologically opposed to offering any tax credits. Sens. Ted Cruz (R-Texas), Mike Lee (R-Utah) and Rand Paul (R-Ky.) have all expressed concerns about the bill being too much like the ACA, with Paul referring to it as “Obamacare Lite.” They worry that the tax credits amount to a new entitlement.

“For me, it’s a big stumbling block still that there’s taxpayer money that’s being given to insurance companies,” Paul told reporters in late April. “And I’m just not in favor of taxpayer money going to insurance companies.”

Planned Parenthood

As Republicans have been vowing for years, the House-passed bill would defund Planned Parenthood, although only for a year. That’s likely because a permanent defunding would actually cost the federal government more money, according to the CBO, as some women who lose access to birth control would become pregnant, have babies and qualify for Medicaid. Birth control is vastly cheaper than health care for mothers and babies.

But while cutting funding for Planned Parenthood is overwhelmingly popular in the House, there are a handful of GOP senators, including Collins and Lisa Murkowski (R-Alaska), who have said they are likely to oppose a bill carrying this provision.

Procedural Problems

The budget process Republicans are using to avoid a Democratic filibuster in the Senate, called reconciliation, has very strict rules that require every piece of the bill to be directly related to the federal budget. It will be up to the Senate parliamentarian, a Republican appointee, to make those determinations.

That’s why the bill does not wipe away all the ACA’s private insurance regulations, including the requirement that insurers not discriminate against customers who have preexisting health conditions.

Some analysts have suggested that the House amendment sought by conservatives to allow states to waive some of the health law’s regulations might run afoul of Senate’s “Byrd Rule,” which limits what can be included in a budget reconciliation measure.

“It could be argued that any budgetary effects of the waiver are ‘merely incidental,’” said the Committee for a Responsible Federal Budget in a blog post.

Even Rep. Mark Meadows, R-N.C., who negotiated that amendment that won the backing of conservatives, conceded that it could prove problematic in the upper chamber. “There’s still a lot of work that needs to be done before we can celebrate and all go home,” he said in an interview outside the House chamber.

Democrats say it is one of several provisions in the House bill that might not pass parliamentary muster in the Senate.

For example, analysts have suggested that the GOP replacement for the much-disliked “individual mandate” requiring most people to have insurance or pay a fine might not pass Byrd Rule scrutiny either. That’s because the 30 percent premium penalty that people with a lapse in insurance would have to pay under the bill would go to the insurance company, not the federal government, so it would have no budget impact.

A third potentially problematic element of the original House bill would allow insurers to charge older adults five times more in premiums than younger adults — up from a ratio of 3-to-1 under the Affordable Care Act. That provision could be viewed as not directly affecting federal spending, some analysts predict.

Blue Shield CEO Says GOP’s ‘Flawed’ Health Bill Would Harm Sicker Consumers

KFF Health News, May 4, 2017

The CEO’s comments break with conventional wisdom, showing that at least one insurance industry leader has strong reservations about returning to the practice of scrutinizing people’s medical histories to determine rates.

This article first appeared May 04, 2017 on Kaiser Health News.

By Chad Terhune 

The chief executive of Blue Shield of California, the largest insurer on the state’s insurance marketplace, issued a blunt critique of the Republican health care bill, saying it would once more lock Americans with preexisting conditions out of affordable coverage.

In an interview with California Healthline on Wednesday, Paul Markovich said the GOP’s American Health Care Act is “flawed” and “could return us to a time when people who were born with a birth defect or who became sick could not purchase or afford insurance.” The bill is set to come up for a vote in the House of Representatives on Thursday. (California Healthline is produced by KHN.)

An amendment to the bill would allow states to roll back key consumer protections in the Affordable Care Act, including the popular provision that prohibits discrimination against patients with a history of illness. Some Republicans say that flexibility will help lower premiums overall and expand coverage choices for consumers.

Markovich, however, said “it’s a moral imperative” to guarantee coverage regardless of medical history. “The discrimination, whether on price or just on the ability to access insurance at all on preexisting conditions, is unconscionable. As a country, we are better than that,” he said.

The CEO’s comments carry weight because he leads a major Blue Cross Blue Shield plan. They also break with conventional wisdom, showing that some in the insurance industry have strong reservations about returning to the practice of scrutinizing people’s medical histories to determine rates.

Markovich said that his company has been in touch with policymakers behind the scenes, but that it decided to make a public statement now because a House vote appeared imminent.

Most major insurers have remained silent about the most controversial issues during the latest health care debate, although some have backed Republican funding proposals to help stabilize the exchanges or repeal an ACA tax on health insurance.

Markovich indicated that he is skeptical of Republican proposals to cover people with preexisting conditions through “high-risk pools.” He said a proposal unveiled Wednesday to add another $8 billion in the bill over five years to offset insurance costs for those patients falls far short of what would be needed.

More broadly, Markovich said the GOP bill would make health insurance unaffordable for millions of Americans by significantly reducing the premium tax credits consumers rely on. He also warned that the GOP’s proposal to deeply cut Medicaid would place an “impossible” fiscal burden on states such as California, “resulting in millions more people without access to care.”

About a third of Californians are covered by Medi-Cal, the state’s version of Medicaid.

Blue Shield, based in San Francisco, leads the Covered California exchange with 31 percent of enrollment, or nearly 390,000 customers. Industry giants Anthem and Kaiser Permanente are close behind. Overall, the exchange has 1.3 million enrollees. Blue Shield also participates in the state’s Medi-Cal managed care program. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

This year, Blue Shield raised its  premiums on the exchange by nearly 20 percent, on average. Like other insurers, the company filed its initial rates for 2018 this week with Covered California, though they are not yet public.

Markovich said the proposed rates remain in flux while insurers wait to see whether the Trump administration will pay them crucial subsidies that reduce the costs of deductibles and copayments for many lower-income consumers.

House Republicans have challenged the legality of those “cost-sharing” subsidies, and the White House has sent mixed signals on future funding. These payments to insurers are separate from the consumer tax credits used to offset premiums.

Covered California warned last week that premiums for 2018 could soar by 42 percent statewide, on average, if cost-sharing subsidies aren’t funded and the individual mandate to purchase coverage isn’t enforced.

Markovich said those estimates “are in the ballpark” of what his company forecasts as well. “This has the potential to have a really big impact on 2018 rates if the cost-sharing reduction subsidies are not being paid,” he said.

Molina Healthcare, another prominent insurer in California and on other exchanges, expressed similar frustration this week about the uncertainty surrounding the cost-sharing subsidies.

As critical as he was of the Republican bill, Markovich also indicated that Obamacare could use some improvement, too.

“We were and are big supporters of the ACA,” Markovich said. “It’s done a lot of good and we’ve taken a major step forward to cover people. But in some markets it’s not sustainable from a cost standpoint, and one of the flaws is it wasn’t bipartisan.”

The CEO called on Democrats and Republicans to work together on legislation that builds on the successes of the ACA and addresses the problems that remain.

The Republicans “have done some good work here, but we need to expand the conversation outside of one party,” he said.

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