House Seeks To Cap Malpractice Awards As Part Of Health Care Update

KFF Health News, June 27, 2017

Under the House bill, states that have caps on non-economic damage awards could keep those in place. In states without such caps, even if the state constitution prohibits them or state courts have struck them down, the federal $250,000 cap would apply.

This article first appeared June 27, 2017 on Kaiser Health News.

By Michelle Andrews

Last week, a jury awarded a Pennsylvania man $620,000 for pain and suffering in a medical malpractice lawsuit he filed against a surgeon who mistakenly removed his healthy testicle, leaving the painful, atrophied one intact.

However, if a bill before the House of Representatives passes, the maximum he would be able to receive for such “non-economic” damages would be $250,000.

Non-economic damages cover losses that are hard to put a dollar amount on such as suffering, loss of a limb, pain, and loss of companionship. In addition, medical malpractice awards may include monetary damages to cover medical costs and loss of future wages. Sometimes punitive damages may be awarded as well as punishment for reckless or other harmful behavior.

The bill is part of a package of proposed reforms that supplement the American Health Care Act, the House measure to replace the Affordable Care Act that was narrowly approved in May. The Trump administration pledged to support the tort reform legislation.

Passage is far from certain. Groups across the political spectrum oppose the measure. Patients advocates say it would be unfair to seriously injured people whose lives are changed forever because of medical negligence. Many conservatives don’t embrace it either because it would impose federal standards on tort law, an area where states have traditionally determined the rules.

The Congressional Budget Office estimated that the bill would lower health care costs by reducing medical liability insurance premiums and the use of health care services by providers worried about being sued. This would lead to lower spending on federal health care programs and lower medical insurance liability premiums. The effect would be to reduce deficits by nearly $50 billion over 10 years.

Supporters say caps on medical malpractice awards discourage frivolous lawsuits and reduce the cost of health care because providers no longer need to practice defensive medicine.

Yet research shows that costs from medical liability make up just 2 to 2.5 percent of total health care spending.

About half of states have a cap of some sort on non-economic damages in medical malpractice cases, according to Joanne Doroshow, executive director of the Center for Justice and Democracy, a consumer advocacy organization for civil justice issues.

Under the House bill, states that have caps on non-economic damage awards could keep those in place. In states without such caps, even if the state constitution prohibits them or state courts have struck them down, the federal $250,000 cap would apply.

The case of the Pennsylvania man’s surgery is a “never event,” one that experts on patient safety say should never occur. Since that state doesn’t have a cap on non-economic damages, if the House bill had been in effect, it would limit the amount that the jury could award the patient to $250,000. The patient, Steven Hanes, 54, also was awarded $250,000 in punitive damages.

Hanes declined to be interviewed, but his attorney, Braden Lepisto, said his client was shocked to learn of the proposed cap. “He felt that the $250,000 cap was ridiculous because that amount would not compensate him for what he has gone through and will go through moving forward,” Lepisto said in an email. He added, “The reality is that there are many individuals who are injured from medical negligence who do not have ‘economic loss’ as defined by the law. Nonetheless, their lives are altered from the pain and suffering, loss of life’s pleasures, and the emotional effects of the injuries.”

The House bill would also come into play in Florida, where earlier this month the state Supreme Court struck down caps on non-economic damages in medical negligence cases because the court ruled they violate the equal protection clause of the state constitution. The House bill would supersede the state court decision and impose the cap in Florida cases.

Although the damages cap is noteworthy, other elements of the House bill also trouble consumer advocates. For example, it would establish a three-year statute of limitations following an injury for consumers to bring a lawsuit, or a one-year limit from the date that the consumer discovers or should have discovered an injury.

“Because it’s [worded as] whichever comes first, for all intents and purposes it’s one year,” said Doroshow. “That is a drastic change. Almost no state has a statute of limitations that severe.”

The bill would also set limits on the amounts that lawyers can recover in contingency fees from consumer judgments. This seemingly consumer-friendly provision could actually harm patients, said Doroshow.

Medical malpractice cases are complex and expensive to bring, she noted. “If you have a law that caps the ability of the attorney to recover from the judgment, they’ll think twice before taking a case,” Doroshow said. “It hurts the patient’s ability to have a competent attorney or any attorney at all.”

Meanwhile, some supporters of tort reform say the House bill goes about it the wrong way.

“The federal government doesn’t really have a legitimate role to play here,” said Dr. Jeffrey Singer, a general surgeon in Phoenix who is an adjunct scholar at the libertarian Cato Institute, located in Washington, D.C.

Conservatives might be relying too much on the idea of tort reform to bring down health care costs, he said.

“It’s become almost a part of the canon of people who align themselves with the market-oriented conservative reforms school,” he said. “But it should be done at the state level and we’re fooling ourselves if we think that it’ll be the magic bullet.”

Texas Hospitals Fear Losing $6.2B Medicaid Deal

KFF Health News, June 26, 2017

State officials are hoping to win a 21-month extension of an agreement that began in 2011 and will expire in December. The Trump administration signed off on a similar pact with Florida in April.

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

By Phil Galewitz

Texas rejected billions in federal aid to expand Medicaid under the Affordable Care Act, calling the program “broken.” But now it’s asking the Trump administration to renew a deal that’s brought the state an additional $6.2 billion a year under Medicaid to help care for the poor.

Half the money is used to help hospitals finance care for the uninsured, and the rest goes to hospitals and other providers to test regional programs to improve care and access, such as opening school-based health clinics to steer people away from expensive emergency room visits.

State officials are hoping to win a 21-month extension of an agreement that began in 2011 and will expire in December.

The Trump administration signed off on a similar pact with Florida in April, increasing extra Medicaid funds to that state from $600 million a year to $1.5 billion annually. In December, the Obama administration extended a pact with Tennessee to 2021. It is worth at least $500 million a year to the state.

Several states receive such funds but Texas’ allocation is the highest. To put Texas’ request in perspective, $6.2 billion represents more than a third of what the federal government now contributes to the state’s Medicaid program annually. Texas kicks in the balance to pay for its $29 billion Medicaid program, which covers nearly 4.8 million people.

Hospitals are counting on the cash to absorb the costs of uncompensated care, which they say has escalated even as the state’s uninsured rate fell from 20 percent in 2013 to 16 percent in 2015, according to the Kaiser Family Foundation’s estimates. (Kaiser Health News is an editorially independent program of the foundation.)

Without the money, programs and services to the poor will have to be cut, including many new health clinics opened to expand access, hospitals say.

“Absent the dollars from the waiver, we would have to start to close the clinics and cut back on the manpower,” said George Masi, CEO of Harris Health System, a large public health system based in Houston.

The uninsured rate has fallen in Houston, but surrounding Harris County still has more than 1 million people without health insurance.

George Masi, CEO of Harris Health System in Houston, meets with staff at one of the system's health centers. (Courtesy of Harris Health System)

Between population growth and demand from undocumented immigrants, “there is growing need for more uncompensated care,” Masi said. Undocumented individuals are ineligible for Medicaid but cannot be refused emergency care.

When the Obama administration first approved Texas’ Medicaid waiver — and billions in extra Medicaid dollars to go with it — federal officials viewed the action as a glide path toward a formal Medicaid expansion starting in 2014, which the Affordable Care Act encouraged states to undertake. The law required the federal government to fully pay the extra costs of bringing more people onto Medicaid rolls for the first three years in every state that took the offer. Thirty-one states, plus the District of Columbia, did so.

Obamacare Medicaid funding would have added 1 million Texans to the program.

But after the U.S. Supreme Court made the Medicaid expansion optional for states, Texas lawmakers bristled at having anything to do with Obamacare or expanding government health coverage. That left the state’s hospitals in a tough financial spot since they lost some federal funding under the law without gaining patients covered by a Medicaid expansion. Texas hospitals are eager to keep the federal waiver in place as the turmoil in Congress over repealing and replacing Obamacare only increases their jitters.

Last year, the Obama administration was reluctant to promise to maintain extra funding levels to states that did not expand Medicaid and left their hospitals on the hook for treating uninsured people who would have been covered under the law. The Centers for Medicare & Medicaid Services told Texas to expect its Medicaid waiver funding to be cut by billions starting in 2018.

Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Texas, a left-leaning think tank, said Texans would be better served by expanding Medicaid but, since that isn’t politically possible, the waiver money is vital to help hospitals care for the uninsured. “The hospitals still have tons of uncompensated care and it will be painful for them without this money,” she said.

Texas set up 21 regional health programs to oversee hundreds of pilot programs paid for by the waiver money intended to improve care to the poor. The demonstration projects paid for by the waiver money probably could not continue without the federal funds, according to an evaluation report released last month by Texas Department of Health and Human Services. The report concluded some projects did help improve patient outcomes, but it’s too soon to determine if they can help lower hospitals’ costs of uncompensated care.

At Baylor Scott & White Health, based in Dallas with facilities in north and central Texas, the waiver money has provided more than $200 million in funding over the past five years for uncompensated care and another $132 million for health projects. “This money allows us to care for uninsured folks that otherwise might not get care,” said Bill Galinsky, vice president for government finance at the health system.

Baylor Scott & White has participated in 37 health projects funded by the waiver to develop ways to treat more than 100,000 low-income people. Other efforts included placing 10 social workers in primary care clinics to provide one-stop care for patients with mental health and physical health needs. The system has also worked with community agencies to increase providing healthy meals to families. “We are cautiously optimistic” that the waiver money will continue, Galinsky said.

Harris Health used part of its $350 million a year in Medicaid waiver dollars to open six primary care clinics with integrated mental health services. “Before the waiver, the primary care doctors could treat the backache or strep throat but would struggle to deal with the depression or bipolar,” Masi said.

Adding psychiatrists and psychologists to work alongside primary care doctors has helped reduce demand for inpatient mental health care, he said.

Without continued federal funding, most of the new positions would disappear, according to Masi.

Memorial Hermann, one of the state’s largest hospital systems, which is also in Houston, also allocated a portion of its waiver money — $150 million a year — to do more than care for the uninsured, said Dr. Benjamin Chu, the former CEO, who was interviewed before his resignation was announced June 19.

The hospital system opened crisis prevention units and school-based health clinics. Other funds paid for a team that manages mental health patients after discharge from hospitals, connecting them with follow-up services to reduce repeated visits to an emergency room.

“This money is very important,” Chu said.

Senate Health Bill Would Revamp Medicaid, Alter ACA Guarantees, Cut Premium Support

KFF Health News, June 23, 2017

Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.

This article first appeared June 22, 2017 on Kaiser Health News.

By Julie Rovner

Republicans in the U.S. Senate on Thursday unveiled a bill that would dramatically transform the nation’s Medicaid program, make significant changes to the federal health law’s tax credits that help lower-income people buy insurance and allow states to water down changes to some of the law’s coverage guarantees.

The bill also repeals the tax mechanism that funded the Affordable Care Act’s benefits, resulting in hundreds of billions of dollars in tax cuts for the wealthy and health care industry.

Most senators got their first look at the bill as it was released Thursday morning, and some immediately voiced concerns. It had been crafted in secret over the past several weeks. Senate Majority Leader Mitch McConnell (R-Ky.) is seeking a vote on the bill before Congress leaves next week for its Fourth of July recess.

Four conservative Republicans - a number large enough to stop the bill from passage - announced in the afternoon that they were withholding support. “Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor," said the statement from Sens. Rand Paul (R-Ky.), Ted Cruz (R-Texas), Ron Johnson (R-Wis.), and Mike Lee (R-Utah). "There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”

Senators had promised that their ACA replacement would be very different than the version that passed the House in May, but the bill instead follows the House’s lead in many ways.

At lightning speed and with a little over a week for wider review, the Republicans' bill could influence health care and health insurance of every American. Reversing course on some of the more popular provisions of the Affordable Care Act, it threatens to leave tens of millions of lower-income Americans without insurance and those with chronic or expensive medical conditions once again financially vulnerable.

Like the House measure, the Senate bill, which is being called a “discussion draft,” would not completely repeal the ACA but would roll back many of the law’s key provisions. Both bills would also - for the first time - cap federal funding for the Medicaid program, which covers more than 70 million low-income Americans. Since its inception in 1965, the federal government has matched state spending for Medicaid. The new bill would shift much of that burden back to states.

The bill would also reconfigure how Americans with slightly higher incomes who don't qualify for Medicaid would get tax credits to help pay insurance premiums and eliminate penalties for those who fail to obtain insurance and employers who fail to provide it. It also would make it easier for states to waive consumer protections in the ACA that require insurance companies to charge the same premiums to sick and healthy people and to provide a specific set of benefits.

"We agreed on the need to free Americans from Obamacare's mandates, and policies contained in the discussion draft will repeal the individual mandate so Americans are no longer forced to buy insurance they don't need or can't afford; will repeal the employer mandate so Americans no longer see their hours and take-home pay cut by employers because of it," McConnell said on the floor of the Senate after releasing the bill. He also noted that the bill would help "stabilize the insurance markets that are collapsing under Obamacare as well."

As expected, Senate Minority Leader Chuck Schumer (D-N.Y.) assailed the bill, saying it would "strip away health care benefits and protections from Americans who need it most" through changes in Medicaid and the ACA's essential health benefits. "Even though much of the early reporting says the bill will keep certain protections for Americans with preexisting conditions," he added, "the truth is it may well not guarantee them the coverage they need. By allowing states to waive essential health benefits, what the bill is saying to those Americans is: Insurance still has to cover you, but it doesn't have to cover what you may actually need; it doesn't have to cover all or even most of your costs."

The White House had no immediate comment, but President Donald Trump has been pressuring Congress to pass a health bill quickly.

It is not clear that the bill will make it through the Senate, or that all of it will even make it to the Senate floor. The Senate (like the House) is operating under a special set of budget rules that allow it to pass this measure with only a simple majority vote and block Democrats from dragging out the debate by using a filibuster. But the “budget reconciliation” process comes with strict rules, including the requirement that every provision of the bill primarily impact the federal budget, either adding to or subtracting from federal spending.

For example, the legislation as released includes a one-year ban on Medicaid funding for Planned Parenthood. That is a key demand of anti-abortion groups and some congressional conservatives, because Planned Parenthood performs abortions with non-federal funding. But it is not yet clear that the Senate parliamentarian will allow that provision to be included in the bill.

Also still in question is a provision of the Senate bill that would allow states to waive insurance regulations in the Affordable Care Act. Many budget experts say that runs afoul of Senate budget rules because the federal funding impact is “merely incidental” to the policy.

Drafting the Senate bill has been a delicate dance for McConnell. With only 52 Republicans in the chamber and Democrats united in opposition to the unraveling of the health law, McConnell can afford to lose only two votes and still pass the bill with a tie-breaking vote from Vice President Mike Pence.

Sen. Tim Scott (R-S.C.) told reporters that he is "open to moving forward on the bill" but expects negotiations will result in more changes. "We have a lot of time now, seven days, to figure out what we like, what parts we plan to keep. This is only draft legislation."

McConnell has been leading a small working group of senators - all men - but even some of those have complained they were not able to take part in much of the shaping of the measure, which seems to have been largely written by McConnell’s own staff.

So far, McConnell has been fielding complaints from the more moderate and more conservative wings of his party. And the draft that has emerged appears to try to placate both.

For example, as sought by moderates, the bill would phase down the Medicaid expansion from 2020 to 2024, somewhat more slowly than the House bill does. But it would still end eventually. The Senate bill also departs from the House bill’s flat tax credits to help pay for insurance, which would have added thousands of dollars to the premiums of poorer and older people not yet eligible for Medicare.

A Congressional Budget Office report estimating the Senate bill’s impact on individuals and the federal budget is expected early next week. The House bill, according to the CBO, would result in 23 million fewer Americans having health insurance over 10 years.

For conservatives, however, the Senate bill would clamp down even harder on Medicaid in later years. The cap imposed by the House would grow more slowly than Medicaid spending has, but the Senate’s cap would grow even more slowly than the House’s. That would leave states with few options, other than raising taxes, cutting eligibility, or cutting benefits in order to maintain their programs.

Defenders of the health law were quick to react.

Sen. Ron Wyden (D-Ore.) complained about changes to coverage guarantees in the ACA.

“I also want to make special note of the state waiver provision. Republicans have twisted and abused a part of the Affordable Care Act I wrote to promote state innovation, and they’re using it to give insurance companies the power to run roughshod over individuals,” he said in a statement issued shortly after the bill was released. “This amounts to hiding an attack on basic health care guarantees behind state waivers, and I will fight it at every turn.”

Tony Brooks, 42, of Philadelphia, was one of the about 60 people with disabilities who crowded the hallway around Senate Majority Leader Mitch McConnell’s office on Capitol Hill Thursday. Brooks said he wasn’t there to protest, he was there to ask for his rights and ask senators to keep Medicaid funding. (Rachel Bluth/KHN)

“The heartless Senate health care repeal bill makes health care worse for everyone - it raises costs, cuts coverage, weakens protections and cuts even more from Medicaid than the mean House bill,” said a statement from Protect Our Care, an umbrella advocacy group opposing GOP changes to the health law. “They wrote their plan in secret and are rushing forward with a vote next week because they know how much harm their bill does to millions of people.”

Tony Brooks, 42, from Philadelphia, was one was of the 60 or so people with disabilities who crowded the hallway around McConnell’s office to lobby the senators to not cut Medicaid funding. Without Medicaid, Brooks, who uses a wheelchair, said he wouldn’t be able to afford his medication, his rent and his medical care. Brooks got choked up when he talked about a friend who had to stay in a nursing home until his death because insurance wouldn’t cover the care he needed to go home. Without Medicaid, Brooks said he was afraid he would end up in a nursing home or shelter too.

“We are people with disabilities, we are human beings. Don’t look at us as garbage,” Brooks said.

Staff writers Rachel Bluth and Carmen Heredia Rodriguez contributed to this article.

Deep Cuts To Medicaid Put Rural Hospitals In The Crosshairs

KFF Health News, June 23, 2017

“A lot of hospitals like [ours] could get hurt,” says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.

This article first appeared June 23, 2017 on Kaiser Health News.

By Bram Sable-Smith, Side Effects Public Media

For the hundreds of rural U.S. hospitals struggling to stay in business, health policy decisions made in Washington, D.C., this summer could make survival a lot tougher.

Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding.

"A lot of hospitals like [ours] could get hurt," says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.

The GOP's repeal of the Affordable Care Act calls for deep cuts to Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities. The House version of the repeal law cuts Medicaid by $834 billion over 10 years, and the Senate revision of that bill cuts the program even more on a different timetable. The Congressional Budget Office has not yet scored the Senate version of the bill, but it said the House version would result in 23 million more people being uninsured in the next 10 years.

Loss of coverage is a problem for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for most health indicators, including premature deaths, quality of life and adult smoking rates. Closing the county's hospital could make those much worse.

And a rural hospital closure goes beyond people losing health care. Jobs, property values and even schools can suffer. Pemiscot County already has the state's highest unemployment rate. Losing the hospital would mean losing the county's largest employer.

"It would be devastating economically," Noble said. "Our annual payrolls are around $20 million a year."

All of that weighs on Noble's mind when he ponders the hospital's future. Pemiscot's story is a lesson in how decisions made by state and federal lawmakers have put these small hospitals on the edge of collapse.

Back in 2005, things were very different. The hospital was doing well, and Noble commissioned a $16 million plan to completely overhaul the facility, which was built in 1951.

"We were going to pay for the first phase of that in cash. We didn't even need to borrow any money for it," Noble said, while thumbing through the old blueprints in his office at the hospital.

But those renovations never happened. In 2005, the Missouri legislature passed sweeping cuts to Medicaid. More than 100,000 Missourians lost their health coverage, and this had an immediate impact on Pemiscot Memorial's bottom line. About 40 percent of their patients were enrolled in Medicaid at the time, and nearly half of them lost their insurance in the cuts.

Pemiscot Memorial had plans for expansion and improvements that the county hospital was ready to make — and pay for — in 2005, before the state legislature slashed Medicaid rolls. (Bram Sable-Smith/Side Effects Public Media)

Those now-uninsured patients still needed care, though, and as a public hospital, Pemiscot Memorial had to take them in.

"So we're still providing care, but we're no longer being compensated," Noble said.

And as the cost of treating the uninsured went up, the hospital's already slim margins shrunk, and it went into survival mode.

The Affordable Care Act was supposed to help with the problem of uncompensated care. It offered rural hospitals a potential lifeline by giving states the option to expand Medicaid to a larger segment of their populations. In Missouri, that would have covered about 300,000 people.

"It was the fundamental building block [of the ACA] that was supposed to cover low-income Americans," said Sidney Watson, a St. Louis University health law professor.

In Missouri, Kerry Noble and Pemiscot Memorial became the poster children for Medicaid expansion. In 2013, Noble went to the state Capitol to make the case for expansion on behalf of the hospital.

"Our facility will no longer be in existence if this expansion does not occur," Noble told a crowd at a press conference.

"Medicaid cuts are always hard to rural hospitals," Watson said. "People have less employer-sponsored coverage in rural areas and people are relying more on Medicaid and on Medicare."

But the Missouri legislature voted against expansion.

For now, the doors of Pemiscot Memorial are still open. The hospital has cut some costly programs — like obstetrics — outsourced its ambulance service and has skipped upgrades.

"People might look at us and say, ‘See, you didn't need Medicaid expansion. You're still there,'" Noble said. "But how long are we going to be here if we don't get some relief?"

This story is part of a partnership that includes KBIA, NPR and Kaiser Health News.

The Association of Health Care Journalists and The Commonwealth Fund are supporting a yearlong series of stories on rural health care by Side Effects Public Media and KBIA.

Promises Made To Protect Preexisting Conditions Prove Hollow

KFF Health News, June 23, 2017

Built into the Senate ACA replacement bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.

This article first appeared June 22, 2017 on Kaiser Health News.

By Jay Hancock and Rachel Bluth

Senate Republicans praised the Affordable Care Act replacement bill they presented Thursday as preserving coverage for people with cancer, mental illness and other chronic illness.

But the legislation may do no such thing, according to health law experts who have read it closely.

Built into the bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.

Depending on what states do, plans sold to individuals might exclude coverage for prescription drugs, mental health, addiction and other expensive benefits, lawyers said. Maternity coverage might also be dropped.

Somebody with cancer might be able to buy insurance but find it doesn’t cover expensive chemotherapy. A plan might pay for opioids to control pain but not recovery if a patient became addicted. People planning families might find it hard to get childbirth coverage.

“The protection your insurance provides could depend a lot on where you live,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. In some states, “over time, [patients with chronic illness] might find it increasingly difficult to find insurance companies that will offer plans that cover their needs.”

The Senate provisions aren’t expected to affect job-based health plans or Medicare for seniors. It would mainly affect the kind of insurance sold to individuals through the Affordable Care Act’s online exchanges, which cover about 10 million people.

Obamacare overhauls in both the House and Senate would also limit spending on Medicaid for low-income people, which analysts say would cause coverage losses for millions.

The Senate legislation, expected to be voted on next week, follows a widely criticized House bill that would also overhaul the Affordable Care Act, in its case giving states the option of denying coverage or raising premiums for those with preexisting illness.

On Thursday Republican Senators touted their bill as avoiding those features.

“I feel comfortable that no one is going to be denied coverage because they’ve been sick before,” said Sen. Lindsey Graham (R-S.C.) The bill “doesn’t change [protections for] preexisting illnesses, which is good,” he said.

Not explicitly. But it still gives insurers a potential way to shrink coverage for the chronically ill, albeit less obviously, said health law scholars.

“There’s nothing in the Senate bill that specifically would allow withdrawal of coverage for a person with a preexisting condition,” said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform. “What it does do is allow states to get waivers” allowing exceptions to rules requiring comprehensive coverage, he said.

The Affordable Care Act required carriers to offer “essential health benefits” covering a wide range of services including hospitalization, maternity, prescription drugs and mental health.

Both the Republican House bill and the Senate bill would let states change that rule. Under those measures, states could set their own standards that might not be as generous, allowing insurers to exclude benefits for those with preexisting illness.

The New War On Sepsis

KFF Health News, June 21, 2017

Nurses are at the core of an anti-sepsis initiative at St. Joseph Hoag Health in California. From 2015 to 2016, the death rate for all of its hospitals dropped from 15 percent to 12 percent for severe sepsis/shock, and from 12 percent to 9 percent for all sepsis cases.

This article first appeared June 21, 2017 on Kaiser Health News.

By Anna Gorman with photos by Heidi de Marco

Dawn Nagel, a nurse at St. Joseph Hospital in Orange, Calif., knew she was going to have a busy day, with more than a dozen patients showing signs of sepsis. They included a 61-year-old mechanic with diabetes. An elderly man recovering from pneumonia. A new mom whose white blood cell count had shot up after she gave birth.

Nagel is among a new breed of nurses devoted to caring for patients with sepsis, a life-threatening condition that occurs when the body’s attempt to fight an infection causes widespread inflammation. She has a clear mission: identify and treat those patients quickly to minimize their chance of death. Nagel administers antibiotics, draws blood for testing, gives fluids and closely monitors her charges — all on a very tight timetable.

“We are the last line of defense,” Nagel said. “We’re here to save lives. If we are not closely monitoring them, they might get sicker and go into organ failure before you know it.”

Sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, a nationwide advocacy group based in San Diego. More than 1 million people get severe sepsis each year in the U.S, and up to 50 percent of them die from it. It is also one of the most expensive conditions for hospitals to treat, costing $24 billion annually.

Most hospitals in the U.S. have programs aimed at reducing sepsis, but few have designated sepsis nurses and coordinators like St. Joseph’s. That needs to change, said Tom Ahrens, who sits on the advisory board of Sepsis Alliance.

“From a clinical point of view, from a cost point of view, they make a huge impact,” said Ahrens, a research scientist at Barnes-Jewish Hospital in St. Louis.

A patient finds out she has sepsis at St. Joseph Hoag Health. Sepsis is a life-threatening condition caused by the body’s response to infection. (Heidi de Marco/KHN)

Recent federal rules could help foster such a change: The Centers for Medicare & Medicaid Services began requiring hospitals in 2015 to measure and report on their sepsis treatment efforts. They must make sure certain steps are completed within the first three hours after sepsis is identified, including getting blood cultures, giving intravenous fluids and starting patients on a broad-spectrum antibiotic.

Sepsis is difficult to diagnose, but if it’s caught early enough it can be treated effectively. If not, patients are at risk of septic shock, which can lead to organ failure and death.

St. Joseph Hoag Health, an integrated medical system in Orange County, Calif., that operates St. Joseph and six other hospitals, began employing dedicated sepsis nurses throughout the system in 2015. Hoag Hospital in Newport Beach and its namesake sister facility in Irvine were the first to try out the nurses about seven years ago, and four other hospitals have since followed.

The hospitals in the St. Joseph Hoag Health system treat about 8,000 cases of sepsis each year, at a cost of $130 million, according to Andre Vovan, a critical care physician who oversees St. Joseph Hoag’s anti-sepsis programs.

The health system also created sepsis care checklists and a mobile app to help coordinate care for patients at risk. But the nurses are at the core of the initiative. They know how to treat sepsis like “the back of their hands,” Vovan said. “Their familiarity allows them to do it faster.”

Speed is critical in sepsis: evidence shows that patients who get treatment quickly are more likely to survive.

Nagel has worked as a nurse at St. Joseph Hospital for 18 years and as part of the hospital’s sepsis unit since 2015. She tracks patients and starts antibiotics, takes labs, gives fluids and checks on patients, all on a strict timetable to reduce patients’ chances of going into septic shock. (Heidi de Marco/KHN)

“It’s so much easier to give someone salt water and antibiotics. It’s a lot harder when they are in the ICU and you are trying to get them off a ventilator,” said Cecille Lamorena, who is in charge of the sepsis nurses at St. Joseph Hospital.

Sepsis nurses give families an idea of what to expect — both during the patients’ hospital stay and after their discharge, Vovan said.

“We want the families to understand that just because you survive sepsis, it doesn’t mean you can get home and run a marathon,” Vovan said. “It can take weeks to months to recover.”

Sepsis nurses and coordinators also serve as on-site experts to ensure that required standards are followed by others, said Dr. David Carlbom, medical director at Harborview Medical Center in Seattle. The sepsis nurse coordinator there, Rosemary Mitchell Grant, educates staff and tracks data collected through the medical records. She also carries out projects to improve outcomes and helps organize an annual sepsis conference.

Nagel tracks patients’ progress, orders antibiotics and gives fluids to reduce patients’ chances of going into septic shock. (Heidi de Marco/KHN)

“Hospitals that don’t have a systematic approach could have a delay in recognition of sepsis,” Carlbom said, noting that busy acute care nurses might miss its subtle signs.

The St. Joseph Hoag Health effort seems to be working. From 2015 to 2016, the death rate for all of its hospitals dropped from 15 percent to 12 percent for severe sepsis/shock, and from 12 percent to 9 percent for all sepsis cases, Vovan said. The length of time patients stay in the health system’s hospitals is also dropping, he said. At St. Joseph Hospital in Orange, the number of patients who went into septic shock dropped 50 percent in the same two-year period, Lamorena said.

The sepsis program has support from doctors, including Dr. Matthew Mullarky, an emergency room physician at St. Joseph. He said he relies on the hospital’s sepsis nurses to help find and follow patients who are at risk. “With the knowledge they have, they ensure we are moving in the right direction quickly,” Mullarky said. “These patients are so overwhelmingly sick.”

At the hospitals in the St. Joseph Hoag network, there is always a dedicated sepsis nurse on duty. Dawn Nagel said that at St. Joseph Hospital, where she works, “sometimes I feel there should be three of us.”

Nagel weighs several factors as she tries to identify patients at risk. She scouts for signs they are worsening — a drop in blood pressure, confusion, increased heart rate, a high white-blood-cell count. And since sepsis is a response to infection, she wants to know if there is one. Pneumonia and urinary tract infections are the most common.

Nagel, who has worked as a nurse at St. Joseph for 18 years, seems to know everyone she passes in the halls. She spends the day bouncing between the emergency room, the maternity ward and the medical-surgical floor. She pitches in wherever needed, grabbing a pillow for one patient, starting an IV for another.

She carries a binder with tracking sheets for each patient. All potential sepsis patients are followed for at least 24 hours, during which they get visits from the sepsis nurse. Nagel’s phone rings constantly — nurses and doctors asking if she can check on patients. She also receives alerts on the in-house sepsis app embedded in her phone. When she meets with patients, she hands them a brochure on sepsis and explains more about it.

Nagel checks up on Scott Steffens. (Heidi de Marco/KHN)

One afternoon in May, Nagel checked up on Donald Hammock, 82. He already was being treated for sepsis with fluids and antibiotics, and Nagel wanted to ensure they were working. “I’m just another set of eyes to make sure you’re getting better, not worse,” she told him. “I’m like your infection babysitter.”

Hammock said he was glad for the extra attention. He had been treated for severe sepsis in 2011 after spiking a fever, and his blood pressure had dropped precipitously. At the time, Hammock said, he didn’t know anything about the illness. “I could have died right there.”

“I’m glad you got in here,” Nagel replied. “As you know, you can get really sick with sepsis.”

After a quick exam, Nagel told Hammock his vitals looked stable, he seemed alert, and his lungs sounded clear. “You are looking good to me,” she said.

She crossed him off her list and headed to the next room.

Despite A Growing Appetite, Buffet-Style Flat-Fee Clinics Shutter In Seattle

KFF Health News, June 20, 2017

After Qliance, a pioneering practice shut five clinics this month, some question whether direct primary care can succeed.

This article first appeared June 20, 2017 on Kaiser Health News.

By Michelle Andrews

In recent years, a small but growing number of practices embraced a buffet approach to primary care, offering patients unlimited services for a modest flat fee instead of billing them a la carte for every office visit and test. But after a pioneering practice shut its doors earlier this month, some question whether “direct primary care,” as it’s called, can succeed.

Many doctors and patients say they like the arrangement. Direct primary care practices typically don’t accept insurance, which frees physicians from treatment preapprovals and claims paperwork. They say that allows them more time and energy for their patients. Patients can consult with their doctor or a nurse practitioner as often they need to, typically for around $100 a month. (Some employers buy the service for their workers.) Patients need to carry a regular insurance plan for hospitalization, specialists and other services. In the long run, the result should be better patient health and lower health care costs overall.

But some health care experts are concerned that the set-up encourages the “worried well” to get more care than they need. They describe unlimited primary care as a blunt instrument that doesn’t necessarily improve the odds that patients will get evidence-based services that improve their health. Others argue it’s important to find a way to provide cost-effective primary care within the health insurance context, not outside it.

Although only a sliver of practices do direct primary care, the number is on the rise, said Shawn Martin, a senior vice president at the American Academy of Family Physicians. He puts the figure at about 3 percent.

Seattle-based Qliance, founded in 2007, was an early leader in this type of care. With startup funding from high-profile investors Jeff Bezos and Michael Dell, by 2015 the company was serving 35,000 patients at several clinics in the Seattle area, including individuals, workers at companies like Expedia and Comcast and Medicaid patients through a contract with the state’s Medicaid insurer. The company said medical claims for Qliance patients were 20 percent lower than those of other patients because Qliance members went to the emergency room less often, were hospitalized less frequently and saw fewer specialists, among other things.

By early 2017, though, Qliance was faltering. The company had lost some large employer clients, and its patient base had shrunk to 13,000. On June 15, it closed five of its clinics. Dr. Erika Bliss, the company’s CEO, said that in general the market is reluctant to pay what it takes for primary care to flourish, and in some cases payers were resistant to rewarding the company, even when Qliance exceeded targets on quality and savings. She will continue to operate one site that provides occupational health for Seattle firefighters.

“The bottom line is it’s not for free,” she said. “You can’t do this for $25 [per person] per month. If we start doing it for $50 to $100 per month then we can start doing serious primary care.”

The closure took January Gens by surprise. A Qliance patient for a couple of years, Gens, 45, had worked with her primary care doctor there to manage crippling pain from endometriosis. The $79 monthly fee was worth every penny, she thought. She had been able to reduce the dosage of some of her medications and was awaiting a referral to start physical therapy when she learned that Qliance was shutting down. Now she’s not sure what she’ll do.

“I had felt very lucky to have found Qliance, to know I had a doctor and could always be seen when needed without causing more damage to the family budget,” Gens said. “Now it’s just gone.”

(Photo courtesy of January Gens)

Patients who have chronic conditions that need ongoing management may benefit from direct primary care, said Dr. A. Mark Fendrick, an internist who directs the University of Michigan’s Center for Value-Based Insurance Design.

But for people who are generally healthy and without symptoms that need to be diagnosed, “unlimited primary care is no guarantee that the services that are provided will improve the health of those people,” he said.

As an example, Fendrick noted that the annual checkup, one of the most popular primary care services, isn’t clinically helpful for most people, according to the Choosing Wisely initiative, a program of the ABIM Foundation that identifies overused and unnecessary medical services.

An examination of research related to direct primary care practices found that they charged patients an average $77.38 per month. “Concierge” medical practices are similar to direct primary care, but their monthly fees are typically higher — averaging $182.76 — and they generally bill insurers for their services, the study found. However, the study, published in the November-December 2015 issue of the Journal of the American Board of Family Medicine, concluded that there was a paucity of data related to the quality of care provided by these practices.

Some analysts say that while they’re sympathetic to doctors’ frustration with large numbers of patients, insurance companies’ intrusion into patient care and billing hassles, the answer isn’t to turn their backs on insurance.

“I think absolutely this type of care could be done inside insurance, but it means we have to learn how to pay within the system for the things that doctors should be doing and are doing in direct primary care,” said Robert Berenson, a fellow at the Urban Institute.

As things stand now, the direct-care model can create difficulties for some patients. Take the situation where someone goes to his direct primary care provider for an earache, but antibiotics don’t work and he needs to be referred to an ear, nose and throat specialist. That patient, who likely has a high-deductible plan to provide non-primary care services, will probably be on the hook financially for the entire cost of care provided by the specialist rather than insurance paying a share.

Qliance’s Bliss scoffs at the idea that patients may get stuck paying more out-of-pocket if they have direct primary care. Most people these days have high-deductible health plans, she said. “The reality is that unless you have Medicaid, you are on the hook no matter what.”

Offering unlimited primary care inside the insurance system is no guarantee of success in any case. One such experiment, a subsidiary of UnitedHealthcare called Harken Health with clinics in the Chicago and Atlanta areas, announced it will shut down at the end of the year.

The company confirmed that it would phase out membership at the end of the year but didn’t respond to a request for further comment.

5 Things Being Weighed In Secret Health Bill Also Weigh It Down

KFF Health News, June 20, 2017

While Senate Majority Leader Mitch McConnell continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill. Spoiler: No one knows what the final Senate bill will look like — not even those writing it.

This article first appeared June 16, 2017 on Kaiser Health News.

By Julie Rovner

Anyone following the debate over the “repeal and replace” of the Affordable Care Act knows the 13 Republican senators writing the bill are meeting behind closed doors.

While Senate Majority Leader Mitch McConnell (R-Ky.) continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill.

Spoiler: No one knows what the final Senate bill will look like — not even those writing it.

“It’s an iterative process,” Senate Majority Whip John Cornyn (R-Texas) told Politico, adding that senators in the room are sending options to the Congressional Budget Office to try to figure out in general how much they would cost. Those conversations between senators and the CBO — common for lawmakers working on major, complex pieces of legislation — sometimes prompt members to press through and other times to change course.

Although specifics, to the extent there are any, have largely stayed secret, some of the policies under consideration have slipped out, and pressure points of the debate are fairly clear. Anything can happen, but here’s what we know so far:

1. Medicaid expansion

The Republicans are determined to roll back the expansion of Medicaid under the Affordable Care Act. The question is, how to do it. The ACA called for an expansion of the Medicaid program for those with low incomes to everyone who earns less than 133 percent of poverty (around $16,000 a year for an individual), with the federal government footing much of the bill. The Supreme Court ruled in 2012 that the expansion was optional for states, but 31 have done so, providing new coverage to an estimated 14 million people.

The Republican bill passed by the House on May 4 would phase out the federal funding for those made eligible by the ACA over two years, beginning in 2020. But Republican moderates in the Senate want a much slower end to the additional federal aid. Several have suggested that they could accept a seven-year phaseout.

Keeping the federal expansion money flowing that long, however, would cut into the bill’s budget savings. That matters: In order to protect the Senate’s ability to pass the bill under budget rules that require only a simple majority rather than 60 votes, the bill’s savings must at least match those of the House version. Any extra money spent on Medicaid expansion would have to be cut elsewhere.

2. Medicaid caps

A related issue is whether and at what level to cap federal Medicaid spending. Medicaid covers more than 70 million low-income people. Medicaid covers half of all births and half of the nation’s bill for long-term care, including nursing home stays. Right now, the federal government matches whatever states spend at least 50-50, and provides more matching funds for less wealthy states.

The House bill would, for the first time, cap the amount the federal government provides to states for their Medicaid programs. The CBO estimated that the caps would put more of the financial burden for the program on states, who would respond by a combination of cutting payments to health care providers like doctors and hospitals, eliminating benefits for patients and restricting eligibility.

The Medicaid cap may or may not be included in the Senate bill, depending on whom you ask. However, sources with direct knowledge of the negotiations say the real sticking point is not whether or not to impose a cap — they want to do that. The hurdles: how to be fair to states that get less federal money and how fast the caps should rise.

Again, if the Senate proposal is more generous than the House’s version, it will be harder to meet the bill’s required budget targets.

3. Restrictions on abortion coverage

The senators are actively considering a measure that would limit funding for abortions, though it is not clear if it would be allowed to remain in the bill under the Senate’s rules. The Senate parliamentarian, who must review the bill after the senators complete it but before it comes to the floor, will decide.

The House-passed bill would ban the use of federal tax credits to purchase private coverage that includes abortion as a benefit. This is a key demand for a large portion of the Republican base. But the Senate version of the bill must abide by strict rules that limit its content to provisions that directly impact the federal budget. In the past, abortion language in budget bills has been ruled out of order.

4. Reading between the lines

A related issue is whether House language to temporarily bar Planned Parenthood from participating in the Medicaid program will be allowed in the Senate.

While the parliamentarian allowed identical language defunding Planned Parenthood to remain in a similar budget bill in 2015, it was not clear at the time that Planned Parenthood would have been the only provider affected by the language. Planned Parenthood backers say they will argue to the parliamentarian that the budget impact of the language is “merely incidental” to the policy aim and therefore should not be allowed in the Senate bill.

5. Insurance market reforms

Senators are also struggling with provisions of the House-passed bill that would allow states to waive certain insurance requirements in the Affordable Care Act, including those laying out “essential” benefits that policies must cover, and those banning insurers from charging sicker people higher premiums. That language, as well as an amendment seeking to ensure more funding to help people with preexisting conditions, was instrumental in gaining enough votes for the bill to pass the House.

Eliminating insurance regulations imposed by the ACA are a top priority for conservatives. “Conservatives would like to clear the books of Obamacare’s most costly regulations and free the states to regulate their markets how they wish,” wrote Sen. Mike Lee (R-Utah), who is one of the 13 senators negotiating the details of the bill, in an op-ed in May.

However, budget experts suggest that none of the insurance market provisions is likely to clear the parliamentarian hurdle as being primarily budget-related.

Update: This story was updated on June 19 to clarify the description of the third category in the article.

White House Task Force Echoes Pharma Proposals

KFF Health News, June 19, 2017

Senior administrative officials met Friday to discuss an executive order on the cost of pharmaceuticals, a roundtable informed by Trump’s "Drug Pricing and Innovation Working Group."

This article first appeared June 16, 2017 on Kaiser Health News.

By Emily Kopp

President Donald Trump repeatedly talks tough about reining in the pharmaceutical industry, but his administration’s efforts to lower drug prices are shrouded in secrecy.

Senior administrative officials met Friday to discuss an executive order on the cost of pharmaceuticals, a roundtable informed by Trump’s “Drug Pricing and Innovation Working Group.” Kaiser Health News examined documents that shed light on the workings of this working group.

The documents reveal behind-the-scenes discussions influenced by the pharmaceutical industry. Joe Grogan, associate director of health programs for the Office of Management and Budget (OMB), has led the group. Until March, Grogan served as a lobbyist for Gilead Sciences, the pharmaceutical company that priced its hepatitis C drugs at $1,000 per pill.

To solve the crisis of high drug prices, the group discussed strengthening the monopoly rights of pharmaceuticals overseas, ending discounts for low-income hospitals and accelerating drug approvals by the Food and Drug Administration. The White House declined to comment on the working group.

The group initially met May 4 in the Eisenhower Executive Office Building and has since met every two weeks. In addition to OMB, the working group includes officials from the White House National Economic Council, Domestic Policy Council, Health and Human Services, the FDA, the Federal Trade Commission, the Department of Commerce, the Office of the U.S. Trade Representative and the Department of Justice.

According to the documents — the latest of which is dated June 1— the working group focused on the following “principles” and “talking points”:

  1. Extending the patent life of drugs in foreign markets to “provide for protection and enforcement of intellectual property rights.” This will ensure “that American consumers do not unfairly subsidize research and development for people throughout the globe.”

Extending monopoly protections for drugs overseas has been one of the pharmaceutical industry’s top priorities since the Trans-Pacific Partnership was defeated last year.

That policy would push up global drug prices, according to Médecins Sans Frontières.

  1. Promoting competition in the U.S. drug market — both by “modernizing our regulatory and reimbursement systems” and limiting “barrier to entry, including the cost of research and development,” according to the documents.

The working group also discussed two broad policy ideas that have been championed by the pharmaceutical industry, according to sources familiar with the process:

  1. Value-based pricing, when pharmaceutical companies keep the list prices of drugs unchanged but offer rebates if patients don’t improve. It’s unclear who would audit the effectiveness of the drugs, what criteria they would use to evaluate them and who would receive the rebates. Grogan invited Robert Shapiro — an adviser for Gilead and former secretary of Commerce under President Bill Clinton — to brief the working group on value-based pricing on May 18. Shapiro is the chairman and co-founder of Sonecon LLC, a Washington, D.C., firm that consulted with Gilead, Amgen and PhRMA, according to his curriculum vitae.
  1. Grogan and Shapiro also discussed issuing 10-year U.S. Treasury bonds to drug manufacturers to pay for expensive, hepatitis C drugs like Sovaldi and Harvoni under Medicare and Medicaid, to avoid rationing drugs to the sickest patients. The 2015 Senate investigation, for example, found that though Medicaid spent more than $1 billion on Sovaldi, just 2.4 percent of Medicaid patients with hepatitis C were treated.

After the working group’s first meeting on May 4, Grogan distributed detailed policy recommendations on expediting generic drug approvals, creating a new tax credit “of up to 50 percent” for investments in generic drug manufacturing, distribution and research and development. The documents also propose scaling back the 340B program, which requires drug manufacturers to provide some medicines at a discount to hospitals that treat low-income patients.

Most of these policies would not ease patient costs, and at least one would increase prices, say experts who reviewed the documents at the request of Kaiser Health News.

“This six-page document contains the kind of solutions to the cost-of-drugs problem that you would get if you gathered together all the executives of pharma and asked them ‘What sort of token gestures can we do?’ ” said Vinay Prasad, a professor of medicine at Oregon Health and Sciences University who studies the costs of cancer drugs.

The pharma-friendly recommendations appear to clash with earlier press reports indicating that OMB Director Mick Mulvaney was considering requiring drugmakers to pay rebates to Medicare patients, a measure the pharmaceutical lobby fiercely opposes.

Brand-name drug prices — which account for 72 percent of drug spending — go untouched in the handouts, said Fiona Scott Morton, a Yale economics professor and former attorney with the Justice Department’s antitrust division.

“The changes to generic markets to promote competition look helpful, but there need to be some more ideas to create more competition for branded drugs or consumers aren’t really going to notice this,” Scott Morton said.

Some of the text in the document is cribbed directly from policy papers published by the pharmaceutical industry’s powerful lobby — Pharmaceutical Research and Manufacturers Association (PhRMA).

Under the subtitle, “Encourage Use of 21st Century Tools for Drug Evaluation, Review and Approval,” one handout proposes the FDA use less rigorous clinical trial standards to speed drug approvals.

The handout cites a PhRMA paper from March 2016 that includes an identical subtitle, “Encourage Use of 21st Century Tools for Drug Evaluation, Review and Approval,” and recommends the FDA implement less rigorous clinical trial standards.

These recommendations would not lower drug prices, experts say.

Such measures “would be like a firefighter spraying gasoline on your burning garage,” Prasad said.

Another section — which recommends giving the FDA more discretion to evaluate generic copies of complex drugs — closely resembles a National Law Review article written by two lobbyists in the pharmaceutical division of Foley & Lardner, whose clients include generic drugmakers.

The handouts further recommend allowing drugmakers to supply data and off-label information to insurers and pharmacy benefit managers during the clinical trial period, before they secure FDA approval.

That’s a “terrible idea,” said Jerry Avorn, a professor at Harvard Medical School and the chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital. “That’s why we have the whole approval process, to determine what’s actually true,” he said.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Descent Into Secrecy: Senate Health Talks Speak To Steady Retreat From Transparency

KFF Health News, June 15, 2017

People are outraged over the lack of transparency and the loss of regular order. But both Democrats and Republicans have laid the track on which this train is rolling.

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

By Julie Rovner

Congress struggling to finish a huge budget reconciliation bill. A GOP president pushing a major overhaul of federal payments for health insurance that could transform the lives of sick patients.

Sound familiar? The year was 1986. I was a rookie health reporter on Capitol Hill and watched a Medicare bill move from introduction, to hearings, to votes in subcommittees, to full committees and then to the entire House — an operation that took months and was replicated in the Senate, before the two chambers got together to iron out their differences for final passage. Everything was published in the official Congressional Record in almost excruciating detail for everyone to see — as long as they could read really tiny type.

Since then, in three decades of reporting, I’ve had a front-row seat to Congress’ slow, stuttering retreat from such step-by-step transparency, a process known as “regular order.”

It has now culminated in the Senate GOP leadership’s top-secret process to try to write a health bill that could change the formula for nearly one-fifth of the nation’s economy, with a vote they want to cast by July 4. In fact, a GOP Senate aide told the news site Axios on Monday that no details would be forthcoming until the bill is finished, adding, “We aren’t stupid.” That means bypassing the debate that traditionally went into lawmaking, in order to achieve consensus.

The extreme secrecy is a situation without precedent, at least in creating health law. Still, it’s not hard to see how we got here — and there is plenty of bipartisan blame to go around.

Since 1986, I have chronicled the passage (and repeal) of the Medicare Catastrophic Coverage Act, the fight over President Bill Clinton’s health proposal, passage of the Medicare prescription drug bill and passage of the Affordable Care Act, in addition to a dozen budget reconciliation measures that altered health care, often in fundamental ways.

Despite promises from incoming Democratic and Republican leaders over the past decade to restore a time-honored process, regular order has not returned. In fact, not only has it become increasingly rare, but the legislative process itself has become ever-more truncated, with Congress skipping steps it deemed inconvenient to partisan ends, particularly as leaders have “end run” the committees that are supposed to do the lion’s share of legislative work.

So long as there is bipartisan agreement, regular order can still prevail. A major bill completed in 2015 to reconfigure how Medicare pays doctors was the product of 15 months of work by Democrats and Republicans in the House and Senate, and passed three committees in open session by unanimous roll call votes.

But it has become progressively — and distressingly — more acceptable to set transparency aside in lawmaking over the years.

In the 1980s, Rep. Bill Natcher (D-Ky.) routinely closed the subcommittee markup of the spending bill to fund the Departments of Labor, Health and Human Services, and Education, even when there was no particular controversy to avoid. Reporters got to see the bill for the first time at the full Appropriations Committee markup.

Markups at the House Ways and Means Committee under Chairman Dan Rostenkowski (D-Ill.) also were frequently closed to the press and public, mostly for tax bills. Still, once I personally held up a health subcommittee markup for nearly a half-hour because the vote to close the session required a majority of members present. I refused to leave until a couple of committee members could be located and brought to the room to vote in person and kick me out.

Even meetings open to the press were sometimes less than revealing. In House-Senate conference meetings, members would frequently refer to what they were talking about using numbers on notes that were not shared with the audience, including reporters. So they basically spoke in code, and if you didn’t have the key you were just out of luck.

Of course, today there are fewer and fewer formal conference committees, places the two sides hammer out their differences in the public eye. Often the final versions of contentious bills are worked out behind closed doors, often without all of the members of the conference committee. In 2003, House Ways and Means Committee Chairman Bill Thomas (R-Calif.) retreated with all the Republican conferees and two of seven Democrats into his Capitol hideaway office in a group he called “the coalition of the willing.” They wrote the final bill in secret while reporters and lobbyists stood outside in the hall for weeks on end. (Sitting in the Capitol is considered civil disobedience and is strictly forbidden.) We were there so long and got to know one another so well that on my birthday someone got all the conferees in the room to sign a birthday card for me.

The final version of that bill was the one that passed the House in the dead of night – Republicans purposely scheduled the vote to begin at 1 a.m. (on the theory it would be easier to get wavering members to vote yes if only to go home to bed). The vote didn’t end until nearly 6 a.m., after President George W. Bush reportedly got the last few members to switch, via phone calls.

In 2009, creation of the Affordable Care Act was both open and closed. There were hundreds of hearings and markups that lasted days, or, in the case of the Senate Health, Education, Labor and Pensions Committee, months. But the unsuccessful effort by Senate Finance Committee Chairman Max Baucus (D-Mont.) to bring Republicans into the fold consisted of weeks of closed-door discussions, and the Senate bill that would ultimately become the foundation of the ACA was written in Senate Majority Leader Harry Reid’s office before being debated on the Senate floor for almost a month.

We got a sneak preview of how the GOP might shepherd its health bill through in 2015, when Republicans — who by then controlled Congress — orchestrated a “dress rehearsal” ACA repeal bill that was vetoed (as they knew it would be) by President Barack Obama. The bill was prewritten by leadership, approved by the relevant House committees, passed by the House and sent to the Senate. The Senate passed it with small changes (and without committee consideration). Rather than having a conference, the amended Senate bill was then simply approved by the House and sent to Obama for his veto.

That secretive process is being reiterated now. Only this time a Republican, Donald Trump, is president and the potential for change is real. People are outraged over the lack of transparency and the loss of regular order. But both Democrats and Republicans have laid the track on which this train is rolling.

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