PNHP

Copayments can kill

Copayments can kill

Weatherford teacher dies from flu effects

By Christin Coyne and Jelani Gibson
Weatherford Democrat, February 5, 2018

A second grade teacher at Ikard Elementary School, 38-year-old Heather Holland, died Sunday due to complications of the flu.

In addition to a classroom of second graders, Holland left behind husband Frank Holland, a 10-year-old daughter, and a 7-year-old son.

Holland fell ill about a week ago and planned to pick up flu medication but felt the $116 copay was too high, her husband said.

Frank Holland bought the prescription himself when he found out, but things worsened.

“Friday night, things escalated and she ended up in the ICU,” Holland said. “The doctors got the blood cultures back and they had to put her on dialysis early Saturday.” 

Heather Holland died Sunday morning.

“I have to be strong for the kids but it’s still surreal, it hasn’t all set in,” Holland said. “We’ve been together a long time, over half my life. She’s my best friend, my soulmate, my everything.”

http://www.weatherforddemocrat.com…

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Comment:

By Don McCanne, M.D.

It is difficult to discuss policy issues in the face of tragedies such as this. Heather Holland’s husband, children and students come first. A moment of silent contemplation seems appropriate here.

***

We will never know whether earlier initiation of her flu medication could have improved her outcome. Evidence suggests that the medication shortens duration of symptoms, but reduction of complications is not quite so clear.

What we do know is that treatment was available, but it was delayed because of a $116 copayment. We do know that erecting financial barriers to care such as cost sharing through deductibles, copayments and coinsurance reduces access to care and can result in adverse outcomes – suffering and sometimes even death.

In this case we would have much preferred to have never heard about this tragedy because taking medication, getting well, and going back to work is not a newsworthy story. Again, we will never know for sure.

One of the most fundamental principles of a national health program such as the model supported by PNHP is that the financing of health care and the delivery of health care are totally separated. People should have health care when they need it without a need to arrange personal finances as a condition of accessing that care. Instead, the entire health care system should be financed in advance of need through equitable taxes based on ability to pay.

This concept is so simple, yet across the political spectrum voices tell us that patients need to fulfill their personal financial responsibilities before they access care. In a well designed single payer national health program they have already done that by paying their taxes. All of our policies should be oriented to helping people get the care they need when they need it. Why do we make that so complicated?

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Stephen Miller has to go

Letter to the White House: Stephen Miller must be removed

National Council of Jewish Women

On February 8, 17 Jewish organizations sent a letter authored and organized by NCJW to White House Chief of Staff General John Kelly expressing our deep concern that Senior Policy Advisor Stephen Miller does not belong in national leadership due to his extreme viewpoints and advocacy of racist policies.

February 8, 2018

General John F. Kelly
White House Chief of Staff
The White House
1600 Pennsylvania Avenue
Washington, DC 20500

Dear General Kelly:

We, the undersigned Jewish agencies and organizations, are writing to share our deep concern that Senior Policy Advisor Stephen Miller does not belong in national leadership due to his extreme viewpoints and advocacy of racist policies.

As Jews, we are in solidarity with immigrants and refugees and believe that our nation must be a refuge and welcoming home for new Americans. Our people have been persecuted too many times in history for us to do otherwise. Not only our history but our holy texts teach us this: we are commanded by the Torah to welcome the stranger, for we were once strangers in the land of Egypt. We believe that we are all made b’tzelem Elohim, or “in the image of God.” Every person is deserving of a dignified and safe life, regardless of race, religion, nationality or any other identity.

Stephen Miller’s views on immigration are extreme and dangerous, and he has been an obstacle to passing widely-supported, bipartisan, popular, badly-needed immigration policy changes throughout his time in the administration. There will be no forward motion for immigrants and refugees while he advises the president, despite bipartisan support, to the detriment of all who live and work in this country. Immigrants are a vital part of American society and crucial to our country’s businesses. They are also human beings deserving of a decent life, out of the shadows.

Miller’s views are anathema to our Jewish and American values. They’re outside the mainstream, and they have no place in the White House. Throughout his professional career, Miller has made no secret of his belief that immigration should be restricted and that immigrants are bad for our country. With then-Senator Sessions, Miller helped orchestrate the defeat of comprehensive immigration reform in 2014. He worked closely with Breitbart Media, a platform for the alt-right and white supremacist movements, and was a reliable media presence to comment on anti-immigrant and nativist policies. During the 2016 election, Miller was a frequent warm-up act at Trump’s campaign rallies, revving up the crowd by invoking the image of immigrants as criminals, telling rally attendees “We’re going to build [the wall] out of love for every family who wants to raise their kids in safety and peace.”

During his time in the White House, Miller’s hard line stance against immigrants has informed and even directed the administration’s policies. Miller was the architect of the first and second Muslim and Refugee bans, which blocked people from seven Muslim-majority countries from entering the US. He orchestrated cuts to the refugee program, resulting in the lowest admissions number in modern history during the worst refugee crisis since World War II. Miller helped author the now infamous list of the administration’s immigration priorities, which include building a border wall, defunding sanctuary cities, eliminating the diversity visa program, and changing the nation’s entire immigration system from one based on family unification to one based on speaking English and being light-skinned. These priorities have been cited as a prerequisite to any immigration negotiations. They are grotesquely anti-immigrant, and against the values of most Americans and certainly the Jewish community which our organizations represent.

Miller’s racist views should be enough to disqualify him from the White House, and his sway over President Trump has made it nearly impossible for Congress to move forward on a bipartisan deal to protect Dreamers — which 70-80% of Americans support. Senator Lindsey Graham held up Miller as an outlier even within their own party, and other Members of Congress point to Miller as a barrier to any type of agreement on immigration.

Our organizations, and the millions of Jews we represent, are in solidarity with immigrants and refugees as a reflection of our Jewish values and our American values. When our nation opens its doors, our families, communities, schools, and congregations thrive. Unlike Miller, we believe that the Statue of Liberty, by which so many of our own families passed during their journeys to the United States, is a potent symbol of the best our country has to offer — welcome and hope.

Stephen Miller opposes the beliefs we hold dear, and while he advises President Trump there will be no forward movement on immigration — to the detriment of this great nation founded by immigrants. We urge you to remove Miller from your team and the White House as soon as possible.

Sincerely,

Ameinu
American Jewish World Service
Americans for Peace Now
Bend the Arc Jewish Action
Habonim Dror North America
IK AR
J Street
Jewish Community Action
Jewish Council on Urban Affairs
Jewish Labor Committee
Jews for Racial & Economic Justice (JFREJ)
Jews United for Justice
Keshet
National Council of Jewish Women
Open Hillel
T’ruah: The Rabbinic Call for Human Rights
The Workmen’s Circle

https://www.ncjw.org…

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The National Council of Jewish Women (NCJW) is a grassroots organization of volunteers and advocates who turn progressive ideals into action. Inspired by Jewish values, NCJW strives for social justice by improving the quality of life for women, children, and families and by safeguarding individual rights and freedoms.

NCJW believes that the moral test of a nation is how it treats its most vulnerable members. In recent years, the United States has failed that test, cutting the budgets of human needs programs and diverting critical federal dollars to military spending. Federal investments must ensure that human needs programs are fully funded including health care, lifelong education, opportunities to work, income supplements when work is not possible, and affordable necessities, including food, housing, and caregiving for children, seniors, and people with disabilities.

https://www.ncjw.org

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Trump takes immigration cues from ‘Pres. Stephen Miller’

By Paul Begala
CNN, January 23, 2018

In a remarkable bipartisan meeting on January 9, the President said he would sign what Sen. Dianne Feinstein, D-California, called “a clean DACA bill,” which would allow the Dreamers to stay with no strings attached. After that, he said, we would move to “Phase Two, which would be comprehensive immigration reform. … But I think we need to do DACA first.”

In that January 9 meeting, President Trump promised to take the heat and sign a bipartisan immigration reform bill. Acting on his urging, Senators Graham and Dick Durbin, D-Illinois, hammered out a compromise. At 10:15 a.m. on January 11, Durbin phoned the President and said they had a deal. He was receptive and invited the senators to brief him.

By the time Durbin and Graham came to the White House at noon, the President’s tone had changed radically. Surrounded by hardline staffers like Mr. Miller, and bolstered by anti-immigration Republicans like Senator Tom Cotton, R-Arkansas, and Rep. Bob Goodlatte, R-Virginia, the President launched into a racist tirade, saying he wanted more immigrants from overwhelmingly white Norway, rather than black and brown immigrants from “shithole countries” in Africa, the Caribbean and Central America.

“Every time we have a proposal, it is only yanked back by staff members,” Graham said. How can it be that the President, who ran as a deal-maker, is being overruled by a young man who seems to want to upend every deal?

https://www.cnn.com…

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This two and one-half minute video from BBC reveals Stephen Miller’s character

http://www.bbc.com…

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Comment:

By Don McCanne, M.D.

Although this is an unusual selection for a blog on single payer it is very apropos since Stephen Miller is one of the most influential advisors to President Trump and is a primary source of his speeches and some of his inflammatory rhetoric. Although the NCJW letter targets Miller’s “extreme viewpoints and advocacy of racist policies,” in a larger sense it represents a protest against the warped mores he brings to the White House that negatively impact other issues of social justice, including our issue of health care justice.

Our president needs help in making this a better nation. Stephen Miller “opposes the beliefs we hold dear.” He has to go.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Why Internists Might Want Single-Payer Health Care

By Paul Sorum, M.D., Ph.D.
Annals of Internal Medicine, Feb. 13, 2018
 
Single-payer health care is back in the news thanks to the efforts of the president and Republicans to cripple if not kill the Patient Protection and Affordable Care Act and Bernie Sanders’ introduction of a new Medicare for All bill in the Senate. I aim to explain why internists in particular should consider working for a single-payer health care system.

Physicians and their staff are experiencing increasingly high levels of dissatisfaction and burnout. Much of this burnout is caused by the administrative burdens and other frustrations caused at least in part by our incoherent, inefficient, and inequitable multipayer system.

Continue reading:
http://annals.org…

Health care documentary in Flat Rock looks to heal a broken system

By Sammy Feldblum
Mountain Xpress (Asheville, N.C.), Feb. 13, 2018

Dr. Marsha Fretwell addressed a crowd of 25 in blunt terms Monday in Flat Rock: “We need to get for-profit health insurance out of the marketplace.”

Fretwell, a former geriatric physician and a member of Healthcare for All Western North Carolina, crystallized the thesis of the documentary Fix It: Health Care at the Tipping Point, which had finished a double feature at Flat Rock Cinema. The film, sponsored by the Henderson County chapter of Our Revolution, the progressive political organization spun off from Bernie Sanders’ presidential campaign, made a businesscentric case for single-payer health care.

With dark musical undertones thrumming, the documentary opened with the story of Richard Master, the increasingly distressed owner of a framing business. He described watching his employees’ premiums double over 10 years, even as his margins thinned, and worried what that price tag meant for the business.

Master was not alone. The documentary bounced among academics, economists and business executives who trotted out a series of grim and disturbing statistics about the cost and effectiveness of health care in the United States. More than 60 percent of bankruptcies in the United States are connected to medical bills, the documentary warned, before showcasing a man whose hemophilia medications cost him $50,000 a month. At that number, the audience let out an audible gasp.

The numbers piled up: In 1971, health care in the United States accounted for 7 percent of the country’s total economic activity; now, it accounts for 18 percent. (In other industrialized countries, that number hovers around 10 percent.) The increase, we learn, corresponds with the rise of for-profit health insurance companies’ control of the marketplace. Those health insurance companies, said Michael Lighty, director of public policy for National Nurses United, act like “an invisible force in the room,” directing health care decisions for patients instead of health care professionals doing so, inevitably worsening care.

When the documentary mentioned single-payer health care, its score turned buoyant, and the onscreen scenery took on a decidedly brighter tone — grass began to grow around sick cartoon stick figures. Canadian practitioners raved about their experience with single-payer in stark contrast to their harrowed American counterparts. In perhaps the most striking interview of the documentary, Wendell Potter, a former CIGNA executive, told the audience, “I regret what I did…I misled people.” Now, he works toward universal health care.

A Republican lawmaker, Dave Steil of Pennsylvania, urged the business-minded toward single-payer, noting that it would save money for both the country and for businesses — who would not have to pay expensive premiums for employees. The single-payer supporters were ahead by a landslide when the lights came up, so when Fretwell asked,“How many people are already convinced that we need health care reform?” every hand in the room shot up.

But Dr. Becky Love, a family physician based in Shelby, had concerns. She wondered what a transition to a national single-payer system might look like since powerful industry interests will surely oppose such a move. “Bernie says: ‘Drop Medicare to people 50 and over,’” Fretwell responded. “And, actually, if I were queen, that’s what I would do too.”

Love, though, invoked monthslong delays in payment by Medicare, which gave her pause. Her proposal for a transition involved putting a single-payer option on the Affordable Care Act’s insurance marketplace, offering a cheaper option for primary care. If it worked for a subset of the population, she suggested, it could be expanded accordingly.

Fretwell stressed that health care is not a political issue but a health and moral issue. “We need to get together on this as a country,” audience member Jim Kane said to Xpress. “If North and South Korea can go to the Olympics together…”

Still, the politicians in attendance were Democrats. Amy Donaldson, wife of Hendersonville urologist Scott Donaldson, who is running for Mark Meadows’s 11th District House of Representatives seat, told a story about a relative getting a year of treatment for lymphoma in Korea for the same amount that each of his annual follow-ups now costs in the United States (and stumped for her husband a bit in the aftermath). Sam Edney, a hopeful for the state House of Representatives in North Carolina’s 113th District, showed up as well. His main health care focus, he said, was expanding Medicaid, which he described as urgent thanks to rampant middle-income job loss in his district.

“We’re sending, this year, $3 billion to states that did expand Medicaid,” Edney told Xpress. “Arizona, Kentucky, Ohio: John McCain, Mitch McConnell, John Kasich. So why did we get all the dumb Republicans? We’re doing the exact opposite of what we should be doing, because of the ideologues in Raleigh.”

But Kyra Moore of Hendersonville, who organized the event, has a plan to reach across the aisle. “We’re going to take this into all the churches around here,” she said, her ubiquitous dog, Dusty, hanging placidly at her ankles. “Then we’re going to take this film into the conservative areas. And we’re the type of people that when we say we’re going to do something, we’re going to do it.”

https://mountainx.com…

Are Medicaid work requirements legal?

Experimenting On The Health Of The Poor: Inside Stewart v. Azar

By Sara Rosenbaum
Health Affairs Blog, February 5, 2018

As the complaint in Stewart v. Hargan (now Stewart v. Azar), filed on January 24 in federal district court in Washington D.C. makes abundantly clear, both the work experiment solicitation and the approval of Kentucky’s 1115 waiver in its wake are remarkable for the clarity of their intent to use punishment—in the form of denial or loss of health insurance coverage—to promote work. It doesn’t take a wealth of empirical research to conclude that people who are healthy probably are more likely to hold jobs and work more. Furthermore, there is actual empirical research that suggests that the very act of providing access to health care under the ACA expansion has had a positive effect on health and work. There simply is no evidence to support any reasonable hypothesis that health can be promoted by threatening the future and stability of health care for people whose health is worse to begin with and who—owing to the concentrated nature of poverty in the U.S.—tend to live in communities with higher unemployment and reduced job prospects.

Every dimension of the Kentucky demonstration is in play, with no hypothesis other than the assumption that people are healthier when they work. The evidence regarding how Medicaid actually promotes work is not even acknowledged.

This design combines work requirements with new program features that, according to the state, reflect the far less forgiving world of commercial health insurance. In this version of Medicaid, its core objective becomes the inverse of its statutory aim: to limit access as much as possible so that people will stop relying on it.

These hoops are multiple: Work requirements with few, poorly defined exemptions; lengthy loss of coverage for failure to follow additional reporting requirements; stripping away essential benefits with little hope of regaining them; using Medicaid to expose people to the limits of commercial insurance through escalating premiums, delayed enrollment, and elevated cost-sharing; and selectively withholding benefits from people considered undeserving.

(To better understand the lawsuit, an explanation of the plaintiffs’ legal arguments, omitted here, can be accessed at the link below.)

The Limits Of 1115

Medicaid’s core features, essential structure, and express prohibitions on certain types of experiments essentially put the brakes on how far 1115 experiments can go. Furthermore, as the complaint notes, 1115 as an experimental statute has its own brakes. Its agency powers can be invoked only for experiments that further program objectives.

Kentucky’s Aim: Selectively Culling The Eligible Population

Given the fact that federal law bars states from selecting winners and losers among the eligibility groups they cover, what is so striking about the Kentucky experiment is the lengths to which the state and its federal partner have gone to come up with a strategy, under the guise of experimentation, for selectively culling the Medicaid population.

Final Thoughts

Despite its historic role in shaping Medicaid policy, however, 1115 is a statute that grants limited powers. At its heart, 1115 is designed to fulfill a specific purpose: to enable Medicaid to better achieve its objectives. What makes the January 11 Medicaid work solicitation and the Kentucky approval such outliers is the singular absence of an experiment that promotes Medicaid’s core objectives. The relationship between work and health is axiomatic but this axiom alone cannot serve as the basis for threatening insurance coverage for people who cannot fulfill work requirements.

Indeed, so far afield from Medicaid’s objectives are the Administration’s work experiments that, in its solicitation, the Administration makes clear that it will permit no federal funds to be claimed for costs associated with work supports, nor will it permit states to keep savings attributable to the loss of eligibility for reinvestment in other Medicaid activities. These two fundamental caveats drive home the degree to which the Trump Administration has essentially admitted that, rather than advancing policy goals involving health care for the poor, Medicaid work experiments undermine them.

https://www.healthaffairs.org…

For another opinion on the legality of Medicaid work requirements, by Nicholas Bagley, JD:
https://jamanetwork.com…

Nicolas Bagley writes, “But the courts have not been moved by the argument—true though it may be—that Congress never meant for section 1115 to be a vehicle for the adoption of sweeping, controversial, and partisan reforms to Medicaid. Instead of winning in court, the opponents of work requirements may need to win some elections.”

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Comment:

By Don McCanne, M.D.

Medicaid was established to help low-income individuals receive the health care that they need. Section 1115 waivers were established to allow states to make modifications within the Medicaid program to better achieve that goal. The Trump administration is now undermining that goal by using the waivers to punish Medicaid beneficiaries by denying health care if unemployed. The legality is being challenged.

In her full article Sara Rosenbaum describes the legal principles and how HHS/CMS is undermining them. Nicholas Bagley also discusses the legal issues while making the very important point that the moral foundation ultimately is determined by our action as voters. We get what we choose.

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BMJ: Failing health of the United States

The role of challenging life conditions and the policies behind them

By Steven H Woolf, Laudan Aron
BMJ, Editorial, February 7, 2018

Life expectancy in the US has fallen for the second year in a row. This is alarming because life expectancy has risen for much of the past century in developed countries, including the US. The decline in US health relative to other countries, however, is not new; it has been unfolding for decades. In 1960, Americans had the highest life expectancy, 2.4 years higher than the average for countries in the Organisation for Economic Cooperation and Development (OECD). But the US started losing ground in the 1980s. US life expectancy fell below the OECD average in 1998, plateaued in 2012, and is now 1.5 years lower than the OECD average.

A joint panel of the National Research Council and Institute of Medicine investigated the US health disadvantage in 2013. It found that Americans had poorer health in many domains, including birth outcomes, injuries, homicides, adolescent pregnancy, HIV/AIDS, obesity, diabetes, and heart disease. It also found that many factors contribute to the health disadvantage; for example, Americans are more likely to engage in unhealthy behaviors (such as heavy caloric intake, drug abuse, and firearm ownership), live in cities designed for cars rather than pedestrians or cyclists, have weaker social welfare supports, and lack universal health insurance.

The panel reported high death rates in the US from drugs, a problem that has grown over time. Between 2000 and 2014, the rate of fatal drug overdoses rose by 137%, a crisis fueled by the growing use of highly addictive opioid drugs. In 2015 alone, more than 64 000 Americans died from drug overdoses, exceeding the number of US casualties in the Vietnam war. Drug addiction is devastating families and the social fabric of communities. The country is belatedly scrambling to reduce access (with, for example, prescription drug monitoring and drug take back programs), improve emergency responses to reverse overdoses (such as naloxone programs), and enhance access to effective addiction treatment (such as medication assisted treatment).

But the opioid epidemic is the tip of an iceberg, part of an even larger public health crisis in the US: death rates from alcohol abuse and suicides have also been rising. Between 1999 and 2014, the suicide rate rose by 24%. These “deaths of despair,” as some have called them, are disproportionately affecting white Americans, especially adults aged 25-59 years, those with limited education, and women. The sharpest increases are occurring in rural counties, often in regions with longstanding social and economic challenges.

Why white Americans are dying at higher rates from drugs, alcohol, and suicides is unclear, complex, and not explained by opioids alone. The answer—likely some combination of factors in American life—must explain why the rise in mortality is greatest in white, middle aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, the erosion of social cohesion and greater social isolation, economic hardship, and distress among white workers over losing the security their parents once enjoyed. By contrast, greater resilience might explain why black Americans—who have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality—have not experienced a surge in drug deaths or suicides.

Other data are also enlightening. Over the three decades in which survival advances slowed in the US, educational performance weakened, social divides (including income inequality) widened, middle class incomes stagnated, and poverty rates exceeded those of most rich countries. The US is rich, but its wealth is not inclusive. Its social contract is weaker than in other countries—those in need have less access to social services, healthcare, or the prevention and treatment of mental illness and addiction. The “American dream” is increasingly out of reach, as social mobility declines and fewer children face a better future than their parents.

In theory, policy makers jolted by the shortening lifespan of Americans would hasten to correct these conditions. They would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems. But the pro-business policy agenda favored by elected officials rarely prioritizes these needs. On the contrary, recent legislation and regulations may prolong or intensify the economic burden on the middle class and weaken access to healthcare and safety net programs.

Ironically, leaders are outspoken about ending the opioid epidemic and bemoan spiraling and unsustainable healthcare costs. Solutions to both problems—which involve investment to support struggling families and communities and thereby improve public health—are often rejected, usually by leaders with competing self interests or ideological objections. The consequences of these choices are dire: not only more deaths and illness but also escalating healthcare costs, a sicker workforce, and a less competitive economy. Future generations may pay the greatest price.

http://www.bmj.com…

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Comment:

By Don McCanne, M.D.

This editorial states that lack of universal health insurance is one cause of declining health and life expectancy in the United States, especially when contrasted with the superior performance of other OECD nations. But it is only one cause. We have much more that we need to do to reverse the increasing disparities and their unwelcome outcomes.

The people of the United States need an epiphany – the realization that we need to join together to improve understanding of our deficiencies and then to resolve to work together to fix them. The solutions lie primarily in the public arena. That means we need national political leadership that is dedicated to this cause. But that also means that the people will have to fire the obstructionist partisans. That would be easy except for the plethora of obstructionist partisan voters who are immune to epiphanies.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Seema Verma’s policies can kill people

Trump Administration Says States May Impose Work Requirements for Medicaid

By Robert Pear
The New York Times, January 11, 2018

In a speech to state Medicaid officials in November, (CMS Administrator Seema) Verma indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid. And she criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.

“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”

https://www.nytimes.com…

CMS letter to Medicaid Directors; “Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries” (10 pages):
https://www.medicaid.gov…

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State Waivers As A National Policy Lever: The Trump Administration, Work Requirements, And Other Potential Reforms In Medicaid

By Billy Wynne and Taylor Cowey
Health Affairs Blog, February 6, 2018

Despite repeat campaign promises from then presidential candidate Donald Trump that he had no interest in altering Medicaid and other entitlements, it was evident from the start of his administration that there would be big plans in the works for the low-income insurance program. This was evident, most notably, in his appointment of health policy consultant Seema Verma—architect of the uniquely conservative Medicaid expansion waiver in Indiana—to run the Centers for Medicare and Medicaid Services (CMS). Now, one year into the Trump presidency, after Congress’s attempts to cut and restructure Medicaid through legislation have proved unsuccessful, the administration has begun in earnest to pursue a regulatory pathway to state-by-state Medicaid reform grounded in Verma’s approach to Section 1115 Medicaid waiver design.

Alignment with the program’s purpose—defined in statute (42 US Code Section1396) as “to furnish medical assistance on behalf of families … and … individuals … whose income and resources are insufficient to meet the cost of necessary medical services”—is a key requirement for waiver approval. CMS’s newly stated criteria no longer places an emphasis on coverage levels. Instead, it focuses on Medicaid’s sustainability over the long term, upward mobility, greater independence and beneficiary engagement, incentive structures and “responsible decision-making,” and commercial health insurance design features to “facilitate smoother beneficiary transition” off of Medicaid.

At the outset of the administration’s second year, CMS has unveiled highly anticipated guidance on how states can implement work, education, and job training requirements through Section 1115 waivers. Shortly after, HHS announced the approval of the first work requirement demonstrations in Kentucky and Indiana.

Pending Waivers to Watch

Work Requirements

Besides Kentucky and Indiana, eight other states—Arkansas, Arizona, Kansas, Maine, Mississippi, New Hampshire, Utah, and Wisconsin—have waivers pending at CMS that would impose a work requirement on Medicaid expansion or traditional adult Medicaid populations. As a feature of their proposed work requirements, some of these states are seeking to impose specific time limits on how long beneficiaries may stay enrolled in Medicaid coverage if they fail to meet engagement requirements.

Lifetime Caps

Several states, including Arizona, Kansas, and Utah, have gone a step beyond time limits tied to work and have proposed lifetime limits on Medicaid coverage for able-bodied adults, ranging from three to five years. If approved in Medicaid, it would constitute another monumental shift of the program design away from being a vehicle for health care and toward being treated as a conditional welfare program.

Lockouts

Time-limited periods of Medicaid ineligibility, or “lockouts,” resulting from nonpayment of premiums were previously approved by the Obama administration for certain expansion adults in only a small number of states. However, with approval of the Kentucky HEALTH waiver, premiums and lockouts may now apply to the traditional population as well. These policies present an additional administrative burden for states and create a yearly hurdle for enrollees to retain their coverage, which could lead to increased disenrollment and churn.

Hospital Presumptive Eligibility

Under the ACA, hospitals gained the option to make presumptive eligibility determinations for patients in need of immediate care. The policy provides greater access to Medicaid benefits for low-income individuals and protects participating hospitals from a percentage of uncompensated care costs. Where some states have previously been allowed to waive presumptive eligibility enrollment and retroactive coverage for pregnant women and children, it has not yet allowed a state to eliminate presumptive eligibility conducted by hospitals, as Maine and Utah are currently proposing to do.

Partial Expansion

Arkansas, which expanded its Medicaid program in 2014, has proposed to reduce eligibility for its expansion population down from the 138 percent of federal poverty level dictated by the ACA to 100 percent of poverty, while still maintaining the enhanced expansion funding for those who remain. Massachusetts later included a similar provision in its own pending waiver. Critics worry that approval of this “partial expansion” would set a precedent with budgetary and coverage consequences for low-income individuals in other states.

Exclusion Of Planned Parenthood

Separately from its actions on 1115 waivers, CMS recently issued a letter to state Medicaid directors rescinding previous guidance issued by the Obama administration regarding the “Free Choice of Provider” requirement in Medicaid, particularly in relation to providers of family planning and abortion services. The guidance had clarified that states may not exclude family planning providers from Medicaid reimbursement “solely because they separately provide family planning services or the full range of legally permissible gynecological and obstetric care, including abortion services.” This was widely understood to be in response to certain states seeking to prevent Medicaid dollars from going to Planned Parenthood. Citing “legal issues under the Administrative Procedure Act,” CMS has removed this guidance and opened the door to states that were previously seeking to exclude the organization.

Medicaid Drug Formularies

In response to the rising cost of prescription drugs, Massachusetts has proposed adopting a closed formulary for its Medicaid population. This would involve a waiver of the statute that otherwise requires Medicaid coverage of Food and Drug Administration-approved outpatient drugs provided the manufacturer participates in the Medicaid Drug Rebate Program.

Conclusion

From a state perspective, the Medicaid landscape has grown ever more complex as the program is increasingly found at the nexus of partisan debate and made the subject of major reform efforts that swing with the party controlling the White House or Congress.

With its solicitation of work requirement proposals and the other waiver reforms implemented in 2017, Verma and the Trump administration have decidedly swung the pendulum once more. Many states are responding in kind and ushering in an era of profound change for the decades-old program. But it remains to be seen if we will truly see work requirements and related reforms tested in the states as the legal and regulatory framework upon which this new paradigm is built is called into question in the courts. At the heart of the matter, as always, will be the question of how our nation views the core objectives of the Medicaid program—as health care or welfare for the nearly 70 million Americans enrolled.

https://www.healthaffairs.org…

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After approving Medicaid work requirements, Trump’s HHS aims for lifetime coverage limits

By Tony Pugh
Lexington Herald-Leader, February 5, 2018

After allowing states to impose work requirements for Medicaid enrollees, the Trump administration is now pondering lifetime limits on adults’ access to coverage.

The move would continue the Trump administration’s push to inject conservative policies into the Medicaid program through the use of federal waivers, which allow states more flexibility to create policies designed to promote personal and financial responsibility among enrollees.

“I think you have to be very thoughtful here in a way that’s quite different from cash assistance,” said Gail Wilensky, a senior fellow at Project HOPE who ran the Medicaid program from 1990 to 1992 under President George H.W. Bush. “It depends on what the safeguards and defaults are in a program like this. Otherwise it does not make a lot of sense and seems to be cruel and inappropriate.”

http://www.kentucky.com…

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Comment:

By Don McCanne, M.D.

CMS Administrator Seema Verma is critical of the Obama Administration because it used the Medicaid program to help low-income people receive the health care that they needed, just as the law requires. Referring to this as the “soft bigotry of low expectations,” Verma is encouraging states to apply for waivers that would use the deprivation of Medicaid benefits as a whip to move individuals out of poverty and into jobs. Instead of looking at Medicaid as a health care program that should be expanded to all who need it, she looks upon it as a welfare program that needs to be ratcheted down (presumably to reduce taxes for the benefit of the rich).

It is not only the work requirements that would reduce access to care for Medicaid eligible individuals; Verma is also considering other policies that would further reduce access. As the article by Billy Wynne and Taylor Cowey indicates, CMS also encourages lifetime caps that would arbitrarily throw individuals off of the program based simply on a time limit rather than on need; they would require premiums which could be a hardship for these vulnerable individuals; they would use lockouts perhaps as punishment for failure to comply with all details of the application process; they would eliminate presumptive eligibility prohibiting individuals from receiving coverage in an emergency even though obviously eligible; they would allow states to reduce their Medicaid expansion programs, keeping otherwise eligible individuals out of the program; they would allow states to exclude family planning and preventive services provided by Planned Parenthood, and they would allow closed drug formularies preventing individuals from obtaining excluded medications.

Obstructing the path to health care results in financial hardship, physical suffering, and sometimes even death.

Not even all of the conservatives can stomach this. Gail Wilensky, head of HCFA (precursor of CMS) under President George H.W. Bush, recognizes the difference between capping “cash assistance” welfare and capping a program designed to help people get the health care they need. As she says, a program capping health care “does not make a lot of sense and seems to be cruel and inappropriate.”

It’s true. Either actively or passively denying health care to anyone does not make a lot of sense and seems to be cruel and inappropriate. We need a well designed single payer national health program that takes care of everyone.

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How to create American jobs-health insurance for small business

By Jack Bernard
The Newnan (Ga.) Times-Herald, February 8, 2018

I’m a retired SVP with a publicly held health care corporation.

I now work as a volunteer with a wonderful non-profit organization, SCORE, which provides free mentoring to small businesses throughout the nation, including Georgia. It’s a fine program that I would recommend to anyone either starting a small business or expanding an existing one.

I strongly believe in the benefits of capitalism and have mentored hundreds of start-ups. Small business is the engine driving job creation in our nation…not tax cuts under the GOP tax proposal that primarily benefit international businesses, corporate officers and affluent investors like me. Per their own admission, these large corporations have no intention of adding jobs as a result of the GOP tax cut.

There are many, many obstacles in starting a new small business, among them health care insurance. The average health insurance cost for a family of four is now over $15,000 annually. If entrepreneurs have families with health issues, they may find themselves in an untenable position, seeking expensive insurance without government financial subsidies.

This is one key reason why the subsidies under the Affordable Care Act – ACA – Obamacare are so important.  Furthermore, Obamacare prohibits excluding coverage on the basis of pre-existing conditions. Thus, the ACA makes insurance more affordable for many of these entrepreneurs.

But, for those not getting the subsidies due to income restrictions – i.e. upper and upper middle- income wage earners, the choice is a stark one. They can follow their passion and start a business…or they can stay put on their current job, playing it safe and keeping health insurance.

This is not a choice entrepreneurs in other developed nations face, a competitive advantage for them. These nations have single payer, expanded Medicare to cover all or something like it.

The Commonwealth Fund recently (7-17) did an analysis of health care in 11 wealthy nations, all having full coverage except the USA. All were much less expensive than our country and had significantly better mortality and morbidity. For example, our cost per capita is over $9,000 annually. Italy is one-third that figure.

Short-term, the ACA is needed to help both entrepreneurs and others. And, the majority of Americans support it.

But, long-term we must have a comprehensive national health plan to control expenses while providing care for all citizens, creating high quality jobs for Americans as a result. Polls have shown that more and more Americans are coming to this point of view. Detailed information regarding Medicare for All, including funding specific sources, can be found on the website of Physicians for a National Health Plan at www.pnhp.org.

Interestingly, Trump was all for single payer decades ago, advocating for it frequently both in interviews and in writing. He even said during the campaign that it would be the best option if we were starting from scratch here.

Mr. President, are you now saying that you are unwilling to fight the entrenched drug and insurance interests and their lobbyists? What happened to draining the swamp?

Mr. President, with 12 percent of our population still uncovered – up from 9 percent because of health insurance market instability… purposefully created by you and Congress –  including many budding entrepreneurs, single payer is still the best option for both better health results and long-term small business job creation. Furthermore, with expansion of insurance will come the creation of more good paying jobs in the health care sector and related support services.

If you are really interested in job creation, and I believe that you are, it is past time to have Medicare for All in America.
 
Jack Bernard of Fayette County, a retired corporate executive, was a two-term county commissioner and former county Republican Party chairman in Jasper County.

http://times-herald.com…

Dr. Paul Song on ‘Rising Up With Sonali’

PNHP national board member Dr. Paul Song appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on February 8, 2018. He discussed the newly formed United States of Care organization, its reluctance to even utter the phrase “universal coverage,” and the ongoing need for single-payer reform.

Can Andy Slavitt keep politics out of ‘United States of Care’?

United States of Care, Accessed February 7, 2018

The mission of United States of Care is to ensure that every single American has access to quality, affordable health care regardless of health status, social need, or income.

A new non-partisan non-profit, we are building and mobilizing a movement to achieve long-lasting solutions that make health care better for everyone. United States of Care will help make it happen by working with Americans from across the country, policymakers, physicians and other clinicians, caregivers, and business, civic, and religious leaders.

We must change the conversation and create a new narrative that puts health care over politics by redefining the goal in human, not political terms, and supporting a positive, practical, and lasting approach.

United States of Care’s principles are:

* Affordable Source of Care: Every American should have an affordable regular source of care for themselves and their families

* Protection from Financial Devastation: All Americans should be protected from financial devastation because of illness or injury

* Political and Economic Viability: Policies to achieve these aims must be fiscally responsible and win the political support needed to ensure long-term stability

Board of Directors

Andy Slavitt, Former acting Administrator of the Centers for Medicare and Medicaid Services

Steve Beshear, Former Governor of Kentucky (Democrat)

Kristie Canegallo, Former Deputy White House Chief of Staff to President Obama

Jim Douglas, Former Governor of Vermont (Republican)

Dave Durenberger, Former United States Senator from Minnesota (Republican)

William Frist, M.D., Former United States Senate Majority Leader from Tennessee (Republican)

Rhonda Medows, M.D., Executive Vice President, Providence St. Joseph Health

For the 52 members of the Founder’s Council, use this link:
https://unitedstatesofcare.org/about-us/

United States of Care
https://unitedstatesofcare.org

***

Comment:

By Don McCanne, M.D.

“The mission of United States of Care is to ensure that every single American has access to quality, affordable health care regardless of health status, social need, or income.” That can be accomplished by enacting a well designed single payer national health program. In contrast, building on our current dysfunctional system will always fall short.

In establishing this organization, Andy Slavitt says that we must put “health care over politics.” Yet the several politicians involved are either Republicans (majority) or conservative neo-liberal Democrats (minority). The 52 members of the Founder’s Council (link to list above) include many strong supporters of the Affordable Care Act. There are many representatives of the health care industry. There are many outspoken opponents to single payer reform, aka Medicare for all. Yet there is not one individual who has taken a prominent stance in favor of single payer, even though a majority of Americans do support Medicare for All.

This organization that professes to place itself above politics is already smothered in anti-single payer politics and is doomed to fail. Sad.

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Amazon’s health care experiment shows exactly why we need Medicare for All

We have to remove profit from the health care equation, just like Amazon, Berkshire Hathaway and JPMorgan Chase intend to do.

By Richard Master
USA Today, Feb. 7, 2018

Amazon, Berkshire Hathaway and JPMorgan Chase announced last week that they would be forming a new company aimed at reducing employee health care costs. This decision was a response to what small, mid-sized and large business owners and CEOs have known for a long time: The private insurance system is strangling the U.S. economy.

As the founder and CEO of a mid-sized company that employs 180 people in the United States, I know this well. In 2018, we will pay $2.8 million to insure our workers and their families. Year after year, we have wrestled with the costs of our health care plans. And despite trying every trick in the book, our per-employee costs have tripled over the past 14 years.

A family plan in 2018 will cost us $27,000, which is higher than the annual salary of one-third of all working Americans. To put it another way, we are paying $13.50 per hour per employee just to cover the health care benefit. It’s a model that’s completely unsustainable, and needs to change.

According to their statement, this new health care company will pursue technology solutions to provide health care and lower costs. The real game-changer is that the company will be “free from profit-making incentives and constraints.”

They’re inches away from a major revelation: The way to fix health care for all people — not just those who are employed by monolithic corporations — is to de-commercialize the health insurance system.

In announcing the new partnership, Berkshire Hathaway Chairman Warren Buffett called the costs of healthcare “a hungry tapeworm on the American economy.” He’s right. But, combined, these three companies employ about 1.1 million people. Even accounting for dependents, this new company will, at best, serve 1% of the population. I’m looking for a solution that would help the other 99%: Medicare for All.

In the United States, we rely on private, for-profit insurance companies to finance our health care system. Over 157 million Americans are getting their coverage from employer based plans. Another 21.9 million have purchased insurance individually.

In theory, an insurance company exists to help negotiate with providers, and minimize the amount that patients and families are paying for healthcare. However, health insurance executives have the same motivation as the leader of any other company: profit.

That motivation is holding patients, workers and every other sector of our economy hostage to high premiums, and large out of pocket expenses. It is no coincidence that while health insurance companies are using hundreds of billions annually for their own sales and marketing, administrative overhead and profits, we are suffering under the most complex and expensive system in the world.

This is an existential threat to our businesses and our economy.

The high costs of health care, fueled by the profit motivation in the private insurance system, can be directly linked to the decreased take-home pay for workers; businesses not having capital to expand to new markets, create new jobs, or invest in new technologies; and medical bills as the number one cause of bankruptcy in the United States.

While some companies have the resources to do what Berkshire Hathaway, Amazon and JPMorgan Chase are doing, most don’t.

I certainly couldn’t do it for my employees, even though I wish I could. That’s why, if we are going to achieve an improved system for all of our citizens, what we really need is Medicare for all. Whether they know it or not, the leadership of these three companies made a strong case for removing profit from our health care system, and I hope our politicians are listening.

Richard Master is founder and CEO of MCS Industries, executive producer of multiple documentaries on the U.S. health care system, and founder of the Business Initiative for Health Policy.

https://www.usatoday.com…

Single payer at play in Germany’s talks to build a coalition government

Parties enter final round of talks to build new German coalition government

Deutsche Welle, February 4, 2018

More than four months after holding general elections, Germany remains in political limbo without a new government.

Negotiations between the CDU/CSU (Christian Democrats and Christian Social Union) and the SPD (Social Democratic Party) have entered what many hope could be the final round, with a number of issues still unsettled between the parties.

The parties managed to reach agreement on energy and agriculture issues as well as on the divisive issue of refugee family reunifications, but there’s still no consensus, especially over healthcare reforms. The conservative CDU/CSU bloc have squarely rejected SPD calls for introducing sweeping changes to Germany health insurance system which would see the country’s universal multi-payer health care system replaced by a national single-payer model.

“We’ll have to negotiate very, very intensively on these issues today and I think agreements are possible but they still haven’t been reached,” (SPD leader Martin) Schulz told reporters.

http://www.dw.com…

***

Germany’s divided SPD: the ultimate grand coalition decider

Deutsche Welle, February 4, 2018

After German reunification in 1990, the Social Democratic Party (SPD) boasted nearly a million members. These days, that figure is just over 440,000. But the members that remain are set to play a crucial role in the future of the center-left party.

The Christian Democrats (CDU), the Christian Social Union (CSU) and the SPD have set a Sunday deadline for concluding coalition talks, though party leaders have agreed to a two-day grace period in the event they have yet to overcome key differences.

But without the consent of SPD party members, Germany will not be governed by a so-called grand coalition. Once talks have concluded, a copy of the coalition treaty will be sent to each of them for review. When going over the document, the key issue will be: Does the proposed government agenda bear the stamp of the Social Democrats in a clearly perceptible manner, or were the SPD’s negotiators shortchanged by their conservative counterparts?

As was the case four years ago, it’s the SPD that has the last word when it comes to signing a coalition treaty with Chancellor Angela Merkel’s CDU and their Bavarian sister party, the CSU.

In contrast to negotiations to form Germany’s previous government in 2013, which 76 percent of the SPD’s members approved, dissenting voices in the party have the opportunity to derail the current grand coalition at an early stage. Many Social Democrats already feel that some of their key demands are being overlooked.

http://www.dw.com…

***

Germany’s grand coalition talks enter second period of extra-time

Deutsche Welle, February 6, 2018

German officials remained positive on Tuesday morning that Chancellor Angela Merkel’s conservative bloc and the Social Democrats (SPD) would strike a deal to forge a new coalition government by the evening.

As she headed into the final round of talks, Merkel called on all sides to make the necessary concessions and strike a deal that would end months of political limbo.
“Each of us will still have to make painful compromises,” the chancellor said. “I am prepared to do that if we can be sure in the end that the advantages outweigh the disadvantages,” she added.

SPD leader Martin Schulz also said today’s decisive stalks were “about nothing less than building stable, lasting government in one of the largest industrialized countries in the world.”

However, the sides still remain divided on several issues, most notably labor and healthcare policy.

The CDU and its Bavarian sister party, the Christian Social Union (CSU), continue to reject any sweeping changes to Germany’s health insurance system. The SPD, meanwhile, wants to see Germany’s two-tier health system reformed with a new system that closes the care gap between citizens with private and statutory insurance.

The CDU’s Klöckner said her party wanted to see welcome changes to Germany’s healthcare model but warned that a “one-size-fits-all” system would be too expensive.

http://www.dw.com…

***

Comment:

By Don McCanne, M.D.

Germany has a multi-payer system for health care composed of competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”) in the compulsory statutory health insurance (SHI) system, and those with higher incomes can choose private health insurance (PHI). PHI is especially attractive for young people with good incomes, as insurers may offer them contracts with more extensive ranges of services and lower premiums. Thus Germany has a two-tiered system with a “care gap between citizens with private and statutory insurance.”

Four months after their election, talks may finally conclude today on formation of a coalition government. One of the major issues still to be decided is whether or not the parties will agree to close the gap in their two-tiered system by replacing it with a national single payer model. Although the conservative opposition has not yet yielded, the success in forming a coalition government may be at stake. We may know the results later today.

The issue for us is that more egalitarian European systems, such as that in Germany, may still be inequitable if people are allowed to buy up out of the compulsory system. The fact that single payer has become a major negotiating issue in Germany shows that their citizens understand that as well. Although the divide is between center-left and conservative politicians, just as in the United States, is that where the people are? Or would they prefer that the politicians move past the polarization and adopt a fully egalitarian system?

(As of Feb. 6, 9:00 PM, Central European Time, there are no further media reports on the progress of the negotiations.)

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