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

By Sarah Jane Tribble May 4, 2017

The state’s health secretary has reached out to the nation’s top health experts to explore tapping a patent law created in 1910 that gives federal regulators the power to appropriate inventions and develop a product in the interest of the public good.

The public outrage over high-priced hepatitis C drugs is taking a new twist as Louisiana’s top health official proposes using an obscure federal law to get the medicines at a much lower cost. If successful, other states could reap the benefits.

Right now, covering treatment for the 35,000 of Louisiana’s uninsured and Medicaid-dependent residents with hepatitis C would cost the state $764 million, a staggering sum that would have to be pulled from schools, public services and infrastructure programs. Louisiana’s budget runs $31.2 billion a year, but its discretionary line items, such as health care, account for just $3.6 billion.

“We don’t have the resources,” said Dr. Rebekah Gee, the state’s health secretary.

In an April 12 letter, Gee reached out to the nation’s top health experts to explore tapping a patent law created in 1910 that gives federal regulators the power to appropriate inventions and develop a product in the interest of the public good.

The law has been used before by government agencies, including the Department of Defense. In the 1960s and early ’70s, the government used it to buy several medicines at a lower cost, according to Hannah Brennan, a co-author of a 2016 paper on the law.

In response to Gee’s request, Dr. Joshua Sharfstein, an associate dean at Johns Hopkins Bloomberg School of Public Health, spent a recent afternoon with some of the country’s top academic and legal health officials considering the challenges of using the law, called U.S. Code Section 1498 under Title 28.

They concluded it should be tried.

“This is the path that would be the most viable to be able to get what you need for people in Louisiana,” Sharfstein told the group. Sharfstein, a former Maryland health secretary, was also the Food and Drug Administration’s deputy commissioner in the Obama administration.

Under the law, the Trump administration could sidestep patents and contract with a generic supplier to provide a lower-priced version of expensive antiviral drugs such as Sovaldi and Harvoni, which are made by industry leader Gilead Sciences.

The government would have to pay the drugmaker only reasonable compensation and prove that using the product benefits the U.S. government. And a favorable ruling for Louisiana would mean the strategy could be used across all 50 states.

Gee, who is working to raise bipartisan support to force a change in hepatitis C drug prices, said she believes the use of the patent law could be a “win-win” for the state and industry.

“Pharma needs to think about different approaches to profitability,” Gee said. “Sometimes quantity can be an important driver of profit, not just the price of each unit of this drug.”

Her proposal would ultimately need approval from Health and Human Services Secretary Tom Price, who oversees the federal agency that administers Medicaid. During his confirmation hearings, Price said he would be committed to making certain that drug prices “are able to be afforded by individuals.”

As a physician and longtime senator from Georgia, Price’s record indicates that he believes government influence should be reduced in health care and during his confirmation hearing praised a Medicare Part B program that allowed privately owned pharmacy benefit managers to negotiate drug prices.

Rachel Sachs, associate professor of law at Washington University in St. Louis who attended the Johns Hopkins meeting, said she believes “the case is strong” in invoking the law, even though drug companies may have multiple patents and exclusivity periods to protect their drugs.

“The federal government has a direct financial interest in controlling hepatitis C,” Sachs said, noting that many of those infected are covered by public programs like Medicaid or the prison system.

And, in 2015, the federal government’s Centers for Medicare & Medicaid Services said states should not unreasonably restrict coverage of the treatments for people with the disease. Last year, 324 Louisiana Medicaid enrollees were treated for an average price of $85,000 each.

The Pharmaceutical Research and Manufacturers of America, the trade association for drugmakers, declined to comment on the potential use of the law. Gilead did not return calls for comment.

The high prices of hepatitis C drugs have been an ongoing concern for public health officials. Last year, the National Association of Medicaid Directors asked Congress to take action, calling hepatitis C a “pervasive public health threat.” And last month, the National Academies of Sciences, Engineering and Medicine recommended its own plan to lower drug prices for vulnerable populations in order to solve the “serious public health problem.”

Hepatitis C infections, which spread through blood or other bodily fluids, are usually silent for many years until the virus damages the liver enough to cause symptoms such as jaundice and fatigue. People can spread the disease unwittingly and an estimated 2.7 million Americans now have chronic hepatitis C.

Dr. Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York, has created an online budget allocator tool to show how impossible it is for Louisiana to treat its Medicaid population without a lower price.

The tool, using estimates of drug costs from Gilead’s public filings, shows where millions of dollars would need to be shifted in the state’s discretionary budget to pay for hepatitis C treatments. For instance, cutting K-12 funding by $26 million — taking benefits away from about 3,500 students — would cover treatments for 3,176 hepatitis C patients.

Too often, Bach said, discussions about costs do not illustrate the trade-offs.

“These numbers are so large that it’s very difficult to think about them proportionately,” said Bach, who has also suggested that the U.S. government simply buy Gilead to lower the cost of treatments.

Brennan told the group that the Department of Defense’s Military Medical Supply Agency relied on Section 1498 to procure 50 drugs during a three-year period for a total savings of $21 million. In one example, the government procured the antibiotic nitrofurantoin for nearly four times less than the patent holder’s price.

“This was … a really important and routine use,” she said.

In the 1970s, use of the law for purchasing medicines petered out, Brennan said, likely because of pharmaceutical lobbying and the increasing importance placed on protecting patents.

But that has not stopped other government agencies from continuing to tap the law. Brennan’s paper notes that the government routinely relies on the patent law to act in the public’s interest for inventions ranging from electronic passports to genetically mutated mice. The U.S. Army Corps of Engineers used the law to clean up hazardous waste and, over the past decade, it was also used by the National Institutes of Health, National Gallery of Art, National Park Service and General Services Administration, according to the paper.

In 2001, Tommy Thompson, then-secretary of the Department of Health and Human Services, threatened use of the law to gain a lower price on the anthrax drug Cipro. And in 2015, Sen. Bernie Sanders (I-Vt.) asked the Department of Veterans Affairs to use the law to decrease the price of hepatitis C drugs.

Now, two years later, health experts are working with Gee to craft a proposal.

“This is exactly the moment and exactly the kind of scenario where we should” use such a law, Bach said.

This article first appeared May 02, 2017 on Kaiser Health News

By Michelle Andrews May 2, 2017

A small but growing number of hospitals and oncology practices are incorporating urgent care aimed specifically at cancer patients.

On an afternoon a few weeks ago, Faithe Craig noticed that her temperature spiked to just above 100 degrees. For most people, the change might not be cause for alarm, but Craig is being treated for stage 3 breast cancer, and any temperature change could signal a serious problem.

She called her nurse at the hospital clinic where she gets care at the University of Texas Southwestern Medical Center in Dallas, who told her to come in immediately for cancer urgent-care services at the hospital’s hematology oncology clinic.

“I thought I’d be waiting there all night,” said Craig, 33. But the hospital had already lined up a blood draw before she arrived and then sent her directly to get X-rays.

Clinicians had details of her cancer care at their fingertips. “They already knew my story and knew everything about me,” she said. The blood work showed she had severe anemia, requiring a blood transfusion, pronto.

It’s been more than a year since the medical center began providing same-day urgent care services to cancer patients. It’s an effort to help them avoid the emergency department and hospital admissions, said Dr. Thomas Froehlich, medical director of the all the center’s cancer clinics.

Cancer treatment “clearly carries a lot of side effects and toxicity, and there are also complications of dealing with the cancer,” Froehlich said. “Many of these things, if you can intervene early, you keep patients at home and out of the hospital.”

UT Southwestern isn’t alone. A small but growing number of hospitals and oncology practices are incorporating urgent care aimed specifically at cancer patients, in which specialists are available for same-day appointments, often with extended hours, sometimes 24/7.

Keeping cancer patients out of the emergency department makes sense not only because many of them have compromised immune systems that put them at risk in a waiting room full of sick people, but to provide the most efficient and appropriate care.

“What we hear from cancer physicians and administrators is that in the emergency department not all emergency physicians and nurses feel equally confident in their ability to treat cancer patients,” said Lindsay Conway, managing director of research at the Advisory Board, a health care research and consulting firm. “So they may admit them when it’s not necessary.”

Severe pain, nausea, fever and dehydration are not uncommon side effects of traditional chemotherapy. Newer immunotherapy treatments that activate the immune system to fight cancer can cause serious and sudden reactions if the body instead attacks healthy organs and tissues.

It can be difficult for non-cancer specialists to evaluate what these symptoms mean. “Targeted therapies are wonderful, but if you don’t know the drug, you’re going to have a hard time managing the person,” said Dr. Barbara McAneny, CEO of New Mexico Oncology Hematology Consultants in Albuquerque, which operates three cancer centers in New Mexico that together provide same-day urgent care services for more than a dozen cancer patients daily.

Offering same-day services fits in with a broader shift in oncology toward patient-centered care, said Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society.

“There’s a general sense within the practice of oncology that we need to do a better job of managing pain and side effects, and we need to provide a higher level of care,” Lichtenfeld said.

The federal Centers for Medicare & Medicaid Services is encouraging these efforts through new payment and delivery models designed to reward quality cancer care, Lichtenfeld said. In addition, starting in 2020 hospitals may be penalized financially if patients who are receiving outpatient chemotherapy visit the emergency department or are admitted to the hospital, according to a final rule issued in November.

Avoiding the emergency department makes financial sense for patients and insurers, too.

Johns Hopkins Hospital opened a six-bed urgent care center next to its infusion center a couple of years ago. Of the patients who land there, about 80 percent are discharged home, at an average total hospital charge of $1,600, said Sharon Krumm, director of nursing at Johns Hopkins Kimmel Cancer Center. (The patient and the insurer would divvy up that charge based on the patient’s insurance coverage.) Only 20 percent of cancer patients who visit the hospital’s emergency department are discharged home. Those who are have an average total hospital charge of $2,300. The others face the ER charges plus the hefty cost of a hospital admission.

Rebecca Cohen has been a frequent visitor to the Johns Hopkins urgent care center. Diagnosed more than two years ago with stage 4 lung cancer, Cohen, 68, is receiving immunotherapy. She’s been treated or checked for dehydration, electrolyte abnormalities, low hemoglobin, low sodium, blood clots and infection, among other things.

Before she started going to the cancer urgent care center, “you sat in the waiting room at the emergency room with people who had the most extraordinary diseases,” Cohen said. “Having stage 4 lung cancer, the thought of being exposed to pneumonia or bronchitis is more than scary.”

This article first appeared April 26, 2017 on Kaiser Health News.

By Judith Graham April 26, 2017

The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work

Acute shortages of home health aides and nursing assistants are cropping up across the country, threatening care for people with serious disabilities and vulnerable older adults.

In Minnesota and Wisconsin, nursing homes have denied admission to thousands of patients over the past year because they lack essential staff, according to local long-term care associations.

In New York, patients living in rural areas have been injured, soiled themselves and gone without meals because paid caregivers aren’t available, according to testimony provided to the state Assembly’s health committee in February.

In Illinois, the independence of people with severe developmental disabilities is being compromised, as agencies experience staff shortages of up to 30 percent, according to a court monitor overseeing a federal consent decree.

The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work: helping people get in and out of bed, go to the bathroom, shower, eat, participate in activities, and often dealing with challenging behaviors.

It portends even worse difficulties to come, as America’s senior citizen population swells to 88 million people in 2050, up from 48 million currently, and requires more assistance with chronic health conditions and disabilities, experts warn.

“If we don’t turn this around, things are only going to get worse” said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association, which represents nursing homes across the U.S.

“For me, as a parent, the instability of this system is terrifying,” said Cheryl Dougan of Bethlehem, Pa., whose profoundly disabled son, Renzo, suffered cardiac arrest nearly 19 years ago at age 14 and receives round-the-clock care from paid caregivers.

Rising Demand, Stagnant Wages

For years, experts have predicted that demand for services from a rapidly aging population would outstrip the capacity of the “direct care” workforce: personal care aides, home health aides and nursing assistants.

The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014. Yet, the population of potential workers who tend to fill these jobs, overwhelmingly women ages 25 to 64, will increase at a much slower rate.

After the recession of 2008-09, positions in Medicaid-funded home health agencies, nursing homes and community service agencies were relatively easy to fill for several years. But the improving economy has led workers to pursue other higher-paying alternatives, in retail services for example, and turnover rates have soared.

At the same time, wages for nursing assistants, home health aides and personal care aides have stagnated, making recruitment difficult. The average hourly rate nationally is $10.11 — a few cents lower than a decade ago, according to PHI, an organization that studies the direct-care workforce. There is a push on now in a handful of states to raise the minimum to $15 an hour.

Even for-profit franchises that offer services such as light housekeeping and companionship to seniors who pay out-of-pocket are having problems with staffing.

“All the experienced workers are already placed with families. They’re off the market,” said Carrie Bianco, owner of Always Best Care Senior Services, which is based in Torrance, Calif., with franchises in 30 states.

Finding new employees was so difficult that Bianco started her own 14-week training program for caregivers nine months ago. To attract recruits, she ran ads targeting women who had left the workforce or been close to their grandparents. In exchange for free tuition, graduates must agree to start working for her agency.

“There’s much more competition now — a lot of franchises have opened and people will approach our workers outside our building or in the lobby and ask if they want to come work for them,” said Karen Kulp, president of Home Care Associates of Philadelphia.

Hardest to cover in Kulp’s area are people with disabilities or older adults who live at some distance from the city center and need only one to two hours of help a day.  Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities and “these people are not necessarily getting service,” she said.

It isn’t possible to document exactly how common these problems are nationally. Neither states nor the federal government routinely collect information about staff vacancy rates in home care agencies or nursing homes, turnover rates or people going without services.

“If we really want to understand what’s needed to address workforce shortages, we need better data,” said Robert Espinoza, vice president of policy at PHI.

Hard Times In Wisconsin

Some of the best data available come from Wisconsin, where long-term care facilities and agencies serving seniors and people with disabilities have surveyed their members over the past year.

The findings are startling. One of seven caregiving positions in Wisconsin nursing homes and group homes remained unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.

“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”

Sauer and others blame inadequate payments from Medicaid — which funds about two-thirds of nursing homes’ business — for the bind. In rural areas, especially, operators are at the breaking point.

“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance, which offers skilled nursing, assisted living and independent living services in a rural area about 70 miles west of Green Bay.

Like other short-staffed operators, he’s had to ask employees to work overtime and use agency staff, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.

Wisconsin Gov. Scott Walker has proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years, but that won’t be enough to make a substantial difference, Loeser and other experts say.

The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.

Barbara Vedder, 67, of Madison, paralyzed from her chest down since a spinal cord injury in 1981, has witnessed the impact firsthand. Currently, she qualifies for 8.75 hours of help a day, while her husband tends to her in the evening.

“It’s getting much, much, much more difficult to find willing, capable people to help me,” she said. “It’s a revolving door: People come for a couple of months, maybe, then they find a better job or they get pregnant or they move out of state. It’s an endless state of not knowing what’s going to happen next — will somebody be around to help me tomorrow? Next month?”

When caregivers don’t show up or shifts are cut back or canceled, “I don’t get proper cleaning around my catheter or in my groin area,” Vedder continued. “I’ll skip a meal or wait later several hours to take a pill. I won’t get my range-of-motion exercises, or my wheelchair cushion might slip out of place and I’ll start getting sore. Basically, I start losing my health.”

Debra Ramacher and her husband have been unable to find paid caregivers since June 2015 for daughter Maya, 20, and son Michael, 19, both of whom have cerebral palsy, epilepsy and other significant disabilities. The family lives in New Richmond in western Wisconsin, about 45 minutes from the Minneapolis-St. Paul metropolitan area.

“At least three agencies told me they’ve stopped trying to hire personal care aides. They can’t find anybody and it costs them money to advertise,” said Ramacher, executive director of Wisconsin Family Ties, an organization for families with children with emotional, behavioral and mental disorders.

“It’s incredibly stressful on all of us, living with this kind of uncertainty,” she said.

Every few months, Ramacher tries to find caregivers on her own by putting ads up on Craigslist, in local newspapers and on job boards.

“We get a few bites,” she said. “Most recently, two people came and interviewed. One never got back to us; the other got a better job that paid more.”

In the meantime, she and her husband are being paid by Medicaid to look after Maya and Michael.

“We don’t want to be the caregivers; we want to have our own life,” Ramacher said. “But we don’t have any option.”

This article first appeared April 25, 2017 on Kaiser Health News.

By Steven Findlay April 25, 2017

In March, HHS Secretary Tom Price sent a letter to all 50 governors soliciting proposals for reinsurance and other options to help cover the costs of consumers with expensive medical conditions.

As congressional Republicans’ efforts to repeal and replace the Affordable Care Act remain in limbo, the Trump administration and some states are taking steps to help insurers cover the cost of their sickest patients, a move that industry analysts say is critical to keeping premiums affordable for plans sold on the law’s online marketplaces in 2018.

This fix is a well-known insurance industry practice called reinsurance. Claims above a certain amount would be paid by the government, reducing insurers’ financial exposure and allowing them to set lower premiums.

Two states — Alaska and Minnesota — that have seen double-digit increases in ACA plan premiums this year have already moved to implement reinsurance policies, and Oklahoma is making plans to seek federal approval to set up a program. The Idaho legislature also recently passed a health care reinsurance law, and Maine is considering taking similar action.

The Trump administration has told other states they should consider doing the same. On March 13, Health and Human Services Secretary Tom Price sent a letter to all 50 governors soliciting proposals for reinsurance and other options to help cover the costs of consumers with expensive medical conditions.

Long an advocate for more state control of health insurance, Price said the administration is “seeking to empower states with new opportunities that will strengthen their health insurance markets.”

“This is one practical way the administration and states can work together to reduce premiums,” said Matthew Fiedler, a health policy specialist at the Brookings Institution. “While it’s the insurers who get the [support] directly, reductions in insurers’ claims costs ultimately translate into lower premiums for consumers.”

The focus on reinsurance comes as insurers must tell state and federal regulators no later than June 21 whether they will participate in the ACA’s marketplaces in 2018, and what plans they will offer at what price. This issue is separate from other highly publicized efforts underway to preserve federal payments to insurers to cover the costs of deductibles and copayments for low-income enrollees.

The federal law offered the security of a reinsurance program to insurers during its first three years. It helped reduce premiums among insurers by 10 percent in 2014, the last year the impact was analyzed, according to the Congressional Budget Office.

But the ACA reinsurance program ended this year. That helped drive premiums up by an average 22 percent across the country, raising concerns about the stability of the state-based marketplaces — also called exchanges — that provide insurance for people who don’t get it through work or public programs such as Medicare or Medicaid.

Now officials from both political parties are eyeing another part of the health law to help reprise and finance reinsurance programs.

In his letter, Price encouraged states to consider a special provision — known as a Section 1332 waiver — that went into effect this year and opens an avenue for them to pursue exemptions from ACA rules as long as the state plan maintains equivalent or better coverage levels for residents and doesn’t raise federal spending.

The Trump administration is betting that some states can set up reinsurance programs with federal funding. Federal spending on the program would be kept in check because the move will reduce government spending on tax credits that the law gives some low-income exchange customers to help defray the cost of premiums.

Need To ‘Stabilize Things Fast’ 

Consider deep-red Oklahoma. State officials have always held the ACA at arm’s length, leaving the insurance marketplace’s management and details to federal officials. But after rate increases averaging 76 percent this year — second only to Arizona — state officials set up a task force to explore how to put a brake on insurance premiums. The group last month published a multifaceted, 60-page plan for a waiver request. State officials say they will submit the plan to HHS later this year. Among the proposed first steps: reinsurance.

“We are in critical condition,” said Buffy Heater, chief strategy officer at the Oklahoma Health Care Authority. “Reinsurance is a way to stabilize things fast and attract additional insurers and more enrollees.”

Enrollment in the Oklahoma marketplace plan grew just 1 percent in 2017, to 146,300, after fairly robust growth in 2014 and 2015. Still, only about 30 percent of eligible Oklahomans are enrolled, and the number of uninsured in the state grew by 20,000 people in 2017.

Blue Cross Blue Shield of Oklahoma, the only carrier now selling on the state’s insurance marketplace, concurs with Heater’s assessment. The company declined through a spokesman to address state officials’ concern that the insurer was poised to exit the market in 2018. But Kurt Kossen, senior vice president at the Illinois-based Health Care Service Corp., which owns the Oklahoma Blues plan, said in a statement: “We agree reinsurance and well-designed high-risk pools help lower premiums and encourage greater competition.”

The two main health insurance lobbying groups in Washington — America’s Health Insurance Plans and the Blue Cross Blue Shield Association — also support efforts to offer reinsurance.

“We are very much in favor of using reinsurance to help insurers pay for the most expensive claims and to stabilize the marketplaces,” said Kristine Grow, senior vice president for communications at America’s Health Insurance Plans.  

Alaska And Minnesota Spurred To Act

Building on its state-funded reinsurance program for 2017, Alaska has asked the federal government to set aside $51.6 million for a reinsurance pool there for 2018. Lori Wing-Heier, director of the state’s division of insurance, said the state’s $55 million fund this year enabled Premera Blue Cross Blue Shield, the sole insurer left on the exchange, to reduce an expected premium increase of 40 percent to just 7.3 percent.  But the state said it cannot keep up the effort alone and needs federal funding.

In Minnesota, where premiums for marketplace plans spiked by around 50 percent this year, the Legislature enacted a law this month that establishes a $271 million reinsurance pool for that state’s troubled ACA marketplace for 2018 and 2019. The funds are contingent on getting the same waiver from the federal government that Alaska seeks and that Oklahoma plans to pursue.

Consumer complaints about the price hikes for 2017 pushed Minnesota to set up a $326 million fund to bail out insurers and help consumers who didn’t qualify for federal premium subsidies. That state-based reinsurance fund reduced premiums by about 25 percent, said Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans. The state’s Department of Commerce has estimated that the 2018 reinsurance fund will reduce premiums by about 20 percent.

About 4 percent of Minnesotans — 235,000 people — get coverage in that state’s individual marketplace.

Back in Washington, D.C., some lawmakers have newfound fervor for insurance market stability and tools such as reinsurance. In their proposed bill to repeal and replace portions of the ACA, House Republicans included a 10-year, $100 billion fund to offset the burden of high-cost patients.

States would be allowed to establish reinsurance pools or set up separate high-risk insurance pools for patients with expensive medical conditions.

And even as the fate of the legislation to repeal the ACA remains uncertain, a group of Republicans in the House of Representatives this month sought to sweeten the pot with an additional $15 billion fund over nine years to help reimburse insurers for high-cost patients with certain preexisting conditions, such as cancer.

Democrats and health policy analysts immediately criticized this latest proposal.

“It’s not enough money to make a serious dent,” said Tim Jost, a professor of health law at Virginia’s Washington and Lee University and an expert on the health law. While the concept is sound, he said that the proposal is flawed because the House Republicans’ bill creates the need for it with “the other damaging changes it makes to the market.”

Jost, other policy analysts and consumer advocates also take issue with Republican proposals that appear to create equivalency between reinsurance and separate high-risk pools for people with preexisting conditions and high claims. In most states that have tried them, said Lynn Quincy, a health insurance specialist and senior policy analyst at Consumer Union, high-risk pools have failed to offer affordable coverage to people who need care the most.

“Reinsurance is the much preferred option,” Quincy said. “It doesn’t segregate sick people into a separate pool, and reinsurance has proved far more efficient and effective over the years.”