IMAGE: (L-R) U.S. President Donald J. Trump, Vice President Mike Pence, and U.S. House Speaker Paul Ryan greet one another on stage during the 2017 “Congress of Tomorrow” Joint Republican Issues Conference in Philadelphia, Pennsylvania, U.S. January 26, 2017. REUTERS/Mark Makela
IMAGE: U.S. Speaker of the House Paul Ryan (R-WI) holds a copy of his party’s “A Better Way” reform agenda at a news conference on Capitol Hill in Washington, DC, U.S. September 29, 2016. REUTERS/Gary Cameron
By Tony Pugh, McClatchy Washington Bureau (TNS)
WASHINGTON — With more than 50 congressional repeal votes, a near-death Supreme Court experience, and a botched marketplace debut to its credit, the Affordable Care Act has had a tortured five-year existence as the Republican Party’s legislative enemy Number One.
And since President Barack Obama signed the health care measure into law on March 23, 2010, its troubled legislative history isn’t close to being fully written.
Yet another Supreme Court case threatens to topple one of the law’s main pillars, there’s bipartisan support in Congress to eliminate the tax on medical devices — one of the law’s primary funding mechanisms — and a slight majority of Americans still have negative views of the sprawling legislation.
But despite the political headwinds, experts say Obama’s legacy-defining law is quietly accomplishing the goals it was created to achieve.
The nation’s uninsured rate has plummeted as more Americans enroll in Medicaid or in federal and state marketplace coverage.
The law’s consumer protections and insurance-benefit requirements have improved the quality of coverage for millions of people who get health insurance outside the workplace.
Premiums for marketplace health insurance have largely been reasonable and have increased only moderately thus far. Long-term cost estimates for providing coverage under the law have been falling.
Early Congressional Budget Office projections showed the law would trim the federal budget deficit by $124 billion from 2010 to 2019, while its repeal would increase the deficit by more than $100 billion from 2013 to 2022. The CBO can’t update the law’s projected impact on the deficit because of forecasting difficulties.
While it’s too soon to declare a summary judgment on the law, its early success usually would quiet most naysayers.
“Most of the dire predictions made by the critics of the ACA have not come to pass,” said Drew Altman, president and CEO of the Kaiser Family Foundation.
But the law may never overcome the bitter politics that surrounded its enactment and that partly define its legacy.
Long viewed as a government overreach, the health care law has been problematic for those who want the private insurance market to dictate who gets health insurance and what it should cost.
Fiscal conservatives argue that the federal government can’t afford the roughly $1.2 trillion it will cost to subsidize health care for millions of Americans under the law from 2016 to 2025, according to CBO estimates.
Moreover, the law’s requirement that most Americans have health insurance is seen as an infringement on individual freedom. The Supreme Court ruled in June 2012 that the so-called individual mandate didn’t violate the Constitution.
As the poster child for the nation’s partisan divide, the law has eclipsed its health care roots, Altman said, and become “a symbol for its critics of bigger things they’re upset about.”
“They don’t like the president. They don’t like the direction the country is moving in. They don’t like the role of government,” Altman said. “At this point, I think we can ask the American people whether they think the ACA will take us to Mars or solve the climate change problem and we would get a perfect split between Democrats and Republicans.”
That split has come to define not only the politics of the law but also its implementation.
Twenty-eight states and Washington, D.C., have used the law’s Medicaid expansion to widen program eligibility for more low-income adults and children. For states that do so, the federal government pays 90 percent of the new enrollees’ medical expenses in 2015 and 2016 and no less than 90 percent thereafter.
Most of the states that haven’t adopted the Medicaid expansion are led by Republican governors or majority-GOP legislatures. But public and fiscal pressure to accept the federal Medicaid funding is prompting more GOP governors to soften their opposition.
Convincing Republican-majority state legislatures to do the same, however, has proved a tougher sell. Red-state politicians say they’re leery of the federal government’s long-term promise to pay 90 percent of new enrollees’ care.
Even with 22 states not participating, enrollment in Medicaid and the Children’s Health Insurance Program has grown by nearly 11 million people, or 18.6 percent, since just before the health insurance marketplaces opened in October 2013.
And 11.7 million people have re-enrolled or signed up for marketplace coverage this year, according to the latest government figures.
The national average cost of premiums for the lowest-priced marketplace “silver” plan –which covers at least 70 percent of medical expenses– increased just 2.9 percent this year, according to a new report from the Urban Institute, a centrist research center.
But storm clouds are brewing. The U.S. Supreme Court will decide in the coming months whether subsidies to help purchase marketplace coverage can be provided only in the 16 states — and the District of Columbia — that set up their own insurance marketplaces.
The plaintiffs in the King v. Burwell case cite a section of the health law that says the tax credits can be applied only to coverage purchased “through an exchange established by the State.” The Obama administration maintains that a full reading of the law makes clear that Congress intended to provide the credits in all states.
If the court sides with the plaintiffs, an estimated 9.3 million people in the 34 states that use the federal health insurance marketplace at HealthCare.gov would lose their tax credits next year, according to the Urban Institute. The ripple effect could undo much of the progress the health law has made in cutting the nation’s uninsured rate.
The Gallup-Healthways Well-Being Index survey found that the nation’s uninsured rate fell from 16.3 percent in the first quarter of 2010, when the Affordable Care Act was signed into law, to 12.3 percent for the first two months of 2015.
That works out to roughly 9.7 million fewer uninsured people, said Dan Witters, research director for the Gallup-Healthways survey.
Over the next decade, the CBO expects the health law to further reduce the number of uninsured Americans by “24 million to 25 million in most years relative to what would have occurred under prior law.”
If the plaintiffs prevail in King v. Burwell, an estimated 6.3 million people would probably become uninsured next year in the 34 states that would lose the subsidies, the Urban Institute predicts.
In Congress, support is building to repeal the ACA’s medical-device tax. The medical device, insurance, and pharmaceutical industries face new taxes and fees under the health law because they’ll see substantial new revenue as more Americans are required to buy health insurance or face tax penalties. The Senate Republican budget proposal for 2016 would repeal the medical device tax.
Aggressive industry lobbying and the sprinkling of device makers across a wide swath of states have fostered support for the tax-repeal measure among several Democrats, such as Senators Al Franken and Amy Klobuchar of Minnesota and Elizabeth Warren of Massachusetts.
Repealing the tax would create a $30 billion funding shortfall for the health law and require Congress to come up with the money from another source.
Industry lobbying has already cut the tax in half, from 4.6 percent to 2.3 percent. And because the excise tax can be deducted from a company’s income taxes, the true impact will be more like 1.4 percent instead of 2.3 percent. A research and development tax credit of nearly two percent further eases device companies’ tax burden.
The device industry claims the tax will hurt the industry’s job growth, but a recent analysis by the Congressional Research Service found “fairly minor effects, with output and employment in the industry falling by no more than two-tenths of one percent.”
The analysis, however, did say the tax was “challenging” to justify since excise taxes are typically designed to discourage undesirable activities, such as tobacco use.
“These justifications do not apply, other than weakly, to the medical device case,” the report says.
As the health care law hits age five, it’s way too early to pass judgment on its effectiveness, said health care blogger Robert Laszewski. The law’s main provisions have been in place for only about 18 months, Laszewski said. Marketplace insurers are still being subsidized by the federal government, and only about half of the estimated 22 million marketplace plan members the CBO envisions in coming years have purchased coverage.
“I would rate Obamacare, 18 months after implementation, as incomplete,” Laszewski said. “Anybody who wants to look at Obamacare and talk about whether it’s a success or a failure, call me in 2017.”
Photo: Nancy Pelosi via Flickr
By Tony Pugh, McClatchy Washington Bureau (TNS)
WASHINGTON — As the nation’s largest private health care provider, Hospital Corporation of America owns 155 hospitals, 112 surgery centers and three psychiatric facilities across the country.
Their 37,000 affiliated staff physicians and 75,000 nurses handled 7.5 million emergency room visits, 1.8 million inpatient admissions and 1.4 million surgeries last year.
Nearly 90 percent of the corporation’s facilities are in states that use the federal health insurance marketplace at HealthCare.gov.
That puts the Nashville, Tenn.-based health care giant at the center of a potential financial catastrophe known as King v. Burwell.
The Supreme Court case will decide whether consumers in the 34 states that use the federal marketplace can continue to receive tax credits to help pay for their coverage. Plaintiffs argue that the subsidies can go only to people in the 16 states, plus Washington, D.C., that operate their own health insurance marketplaces.
If the plaintiffs prevail, an estimated 5.6 million people will lose their tax credits next year in the 15 HealthCare.gov states where Hospital Corporation of America has facilities, according to the Urban Institute, a centrist research center.
Nearly 4.9 million of these people would ultimately become uninsured, the institute predicts. Without coverage, most of these low- to moderate-income people would struggle to pay their medical bills and become prime candidates for hospital charity and uncompensated care.
That money-losing scenario after a plaintiff victory has sent a chill through HCA’s corporate coffers and the hospital industry as a whole.
“It’s kind of a perfect storm of all things bad,” said Jimmy Lewis, CEO of HomeTown Health LLC, a trade association of roughly 50 rural hospitals in Georgia and Florida. “Anything that increases the uninsured puts rural hospital providers at an even greater risk for distress or closure.”
Under the Affordable Care Act, Congress has cut hospital reimbursements for uncompensated care by $36.1 billion over 10 years. Lawmakers also cut hospitals’ Medicare payments and inflation adjustment rates by an estimated $233 billion.
Hospitals were expected to recoup the money through an influx of newly insured patients, courtesy of the marketplace tax credits, expanded Medicaid eligibility and the requirement that most Americans have health insurance.
But 13 of the 15 HealthCare.gov states with HCA facilities haven’t expanded their Medicaid programs. This limits the number of insured patients treated at HCA hospitals and hurts the company’s ability to offset the funding cuts.
In fact, only 11 of the 34 states that use the federal marketplace have expanded coverage under Medicaid. That lost revenue stream would deepen the financial hole for hospitals in non-expansion states if tax credits are eliminated in the Burwell case.
“An ACA without subsidies would leave hospitals unable to make up the loss in their funding,” a group of hospital organizations wrote in their friend-of-the-court brief in the Burwell case. “That could imperil some hospitals, and will make it more difficult for others to carry out their missions, including effectively serving their communities.”
In its own court brief, HCA said patients with coverage through HealthCare.gov paid an average of $390 in out-of-pocket expenses when they visited an HCA facility, while 90 percent of its uninsured patients paid nothing.
HCA’s uninsured patients are also half as likely to seek cost-effective outpatient care and three times more likely to get expensive emergency room treatment than its patients with federal marketplace coverage.
Because they pay more, use the emergency room less and utilize cheaper outpatient services more frequently, patients with coverage through HealthCare.gov have helped HCA weather $600 million in federal funding cuts under the Affordable Care Act.
Last year, the company generated roughly $250 million from previously uninsured patients who obtained coverage through HealthCare.gov. That revenue is just beginning to offset the federal funding cuts that HCA has absorbed under the health care law.
“This was exactly what Congress intended when it sought to have every stakeholder in the health care system share the costs and benefits of achieving universal coverage,” HCA wrote in its brief.
HCA officials declined to discuss the Burwell case, but its corporate concerns and experiences are shared by scores of other hospitals in the 34 states where the tax credits could be eliminated.
Last year, Bothwell Regional Health Center in Sedalia, Mo., treated 589 patients who had federal marketplace insurance.
Forty-four percent — or 260 of them — were previously uninsured, a population that had paid an average of 3 cents for every dollar of care they received, said Jimmy Robertson, Bothwell’s chief financial officer.
After getting coverage through HealthCare.gov, these 260 patients generated $935,000 in additional revenue, which shaved 5.5 percent off the hospital’s $17 million uncompensated-care costs.
“That’s a huge impact,” Robertson said. “We were, quite frankly, a little amazed at what we saw, but pleasantly surprised.”
And like the HCA’s patients with marketplace insurance, Bothwell’s newly insured began to use other hospital services, relying less on emergency room care.
“A lot of the hype that we heard before the exchange opened is actually coming true,” Robertson said.
If the Burwell plaintiffs prevail and the tax credits are eliminated, Robertson said, he expects all 589 of the hospital’s marketplace plan members to drop their coverage.
Texas hospitals spend $5.5 billion each year to treat the estimated 25 percent of state residents without health insurance, said Ted Shaw, CEO of the Texas Hospital Association. Killing the tax credits would drive Texas’ uninsured rate — already the nation’s highest — even higher.
“If we add another million people to that uninsured population, you’re going to see the costs to hospitals of Texas skyrocket at least another $1 billion to ($1.5) billion dollars,” Shaw said at a recent news briefing.
In Florida, hospitals that treat high numbers of the uninsured are already facing a $1.8 billion funding loss due to the pending expiration of a state-federal program that provides medical care for low-income residents. A plaintiff victory in Burwell is projected to add more than 1 million people to Florida’s uninsured ranks next year, according to the Urban Institute.
That would “only add to the uncertainty” of hospitals that care for Medicaid and uninsured patients, said Ron Bartlett, spokesman for the Safety Net Hospital Alliance of Florida, an advocacy group for 23 hospitals that provide 41 percent of Florida’s charity care.
Lewis, of HomeTown Health, said economically distressed consumers hadn’t been following the Burwell case closely.
“I believe that they’re so consumed with the trials of living day to day that they haven’t even thought about this,” Lewis said. “There may be a large part of the population that doesn’t really get this or understand this until the day it happens. The day their insurance goes away.”
AFP Photo/Karen Bleier
By Tony Pugh, McClatchy Washington Bureau (TNS)
WASHINGTON — When Indiana Governor Mike Pence (R-IN) agreed to expand eligibility for his state’s Medicaid program, he made sure to call it “reform” rather than “expansion.”
The change reflects both the unique, conservative features of Indiana’s Medicaid plan as well as a complex political dynamic for Pence, a conservative Republican with rumored presidential aspirations.
By embracing a key pillar of the Affordable Care Act, Pence’s Medicaid plan could tarnish his conservative bona fides with large swaths of GOP voters and opinion makers.
So with party leaders in Washington calling for the repeal and replacement of Obamacare, Medicaid “reform” sounds and looks a lot better to GOP hardliners than the dreaded E-word.
“This has been a long process, but real reform takes work,” Pence said when the deal was done.
His careful wording is part of an awkward political dance that’s being performed nationwide as more Republican governors push for Medicaid expansion, despite tepid support from GOP state lawmakers and a continuing assault on the health care law by Republicans in Congress.
The governors’ efforts have muddied what had been one of their party’s clearest and strongest political messages — their universal disdain for the health care law.
“It’s always a mixed message when one group is doing something and the other’s not. There’s a political element behind all of this,” said Senator Richard Shelby (R-Ala).
But Republican strategist Keith Appell said the conflicting interests on the state and national levels haven’t created intra-party political tension.
“I haven’t seen anything that demonstrates that at all,” Appell said.
The health care law allows states to cover non-elderly adults earning up to 138 percent of the federal poverty level through Medicaid, the state-federal health plan for low-income Americans.
The federal government will pay all medical costs for the newly eligible enrollees through 2016 and no less than 90 percent of their costs thereafter.
To date, 28 states have implemented the Medicaid expansion. This includes 10 with Republican governors whose initial opposition gave way to pressure from voters, hospitals, and patient advocates to grab the federal Medicaid dollars and the new jobs that come with it.
In his recent State of the State speech, Republican North Carolina Governor Pat McCrory called on state lawmakers to join the expansion movement.
“Last session, we came close to passing Medicaid reform, but progress stalled on the one-yard line,” McCrory said. “Let’s run it up the middle and win a victory for families across North Carolina.”
By crafting an expansion that embodies conservative principles, Indiana’s Medicaid plan could become the template for other Republican governors wrestling with the politics of expansion.
It requires most Indiana Medicaid recipients to pay a small monthly premium for coverage that includes dental and vision benefits.
Those who earn below the poverty level won’t have to pay premiums. But if they don’t, they get no vision or dental benefits and must make co-payments toward their care.
Higher-earning enrollees who don’t pay their monthly premiums would lose their coverage in Indiana and couldn’t re-enroll for six months.
While the Obama administration rejected Indiana’s proposed work requirement for Medicaid enrollees, “they were willing to explore some of these more experimental provisions, to see what works and to compromise with these governors that want these folks to have more skin in the game,” said Caroline Pearson, vice president with Avalere Health, a Washington consulting firm.
Any North Carolina expansion plan would likewise “require personal and financial responsibility from those who would be covered,” McCrory said.
Appell said Indiana’s plan is “perhaps the best approach you can take as a conservative.”
“It’s a gutsy call on his part,” Appell said of Pence, “because he also gets some flack.”
Nina Owcharenko, director of the Center for Health Policy Studies at the Heritage Foundation, a conservative Washington think tank, said Indiana’s Medicaid deal takes one step forward by incorporating a number of personal responsibility provisions, “but two steps backwards” by expanding a broken program to new enrollees.
“It doesn’t make sense to me that to reform a program you expand it,” Owcharenko said. “Why would you add more people to something and then say, ‘And now we’re going to figure out how to fix it?’ The boat has a hole in it. It’s sinking, but let’s add more people so it sinks faster?”
Republican Governors Bill Haslam of Tennessee (R-TN), Gary Herbert of Utah (R-UT), and Matt Mead of Wyoming (R-WY) also have called for new Medicaid enrollees to pay premiums. But Haslam’s and Mead’s expansion proposals died earlier this month amid resistance from Republican state lawmakers.
Lobbying by Americans for Prosperity, an influential conservative political advocacy group funded by the billionaire Koch brothers, helped kill Haslam’s proposal in Tennessee. The group opposes the Affordable Care Act.
“Governor (Bill) Haslam was trying to create an independent version of Medicaid expansion, and so far he hasn’t been able to persuade the legislature to do it,” said Senator Lamar Alexander (R-TN).
In Utah, Herbert’s Medicaid plan cleared a state Senate committee vote this week and will soon be debated by the full Senate.
Photo: Medill DC via Flickr
By Tony Pugh, McClatchy Washington Bureau (TNS)
WASHINGTON — When New York state Attorney General Eric Schneiderman recently sought authority to investigate and prosecute cases that involve police killings of unarmed civilians, it was a watershed moment for Vincent Warren.
The executive director of the Center for Constitutional Rights, a nonprofit legal group that grew out of the civil rights movement, Warren has long called for independent investigations when there are questions about the use of lethal force by police.
Local prosecutors are ill-suited for the investigations, Warren said, because their cozy working relationships with local police can be a conflict of interest. But as he and other activists in the police accountability movement had called for change, their proposals were ignored as a solution in need of a problem.
With little support from politicians, prosecutors and the police themselves, Warren and others were largely dismissed as criminal-justice critics too eager to assume foul play when disputed police encounters weren’t adjudicated to their liking.
That perception changed with Eric Garner’s death in July after an aggressive chokehold and bodily restraint by New York City police officers.
When a Staten Island grand jury decided not to indict the officers, despite video footage of the incident, an eruption of nationwide protests and an erosion of public trust pushed Schneiderman to seek what Warren had called for all along.
New York Gov. Andrew Cuomo is considering Schneiderman’s call for independent police investigations. Warren is keeping his fingers crossed.
“I’m gratified that Attorney General Schneiderman has proposed a sensible solution to this long-standing problem,” Warren said recently. “Amidst all the hand-wringing and soul-searching on this issue, this is very much a step in the right direction.”
Warren said jurisdictions nationwide should consider similar measures, such as appointing special prosecutors, as questionable police shootings of black men created uncertainty about local prosecutors’ ability and willingness to police the police.
“Before special prosecutors were used at the federal level, there was a lot of state experience with them, and it’s not unusual to use some kind of model where, if there’s a perception of bias, you create a special prosecutor’s office” or provide another avenue for outside investigation, said Katy Harriger, a professor of politics and constitutional law at Wake Forest University in Winston-Salem, N.C.
John Malcolm, the director of the Edwin Meese III Center for Legal and Judicial Studies at the conservative Heritage Foundation, said he was unsure what was prompting Schneiderman’s call for special investigative authority.
“If it is done to give the public confidence that such investigations are being carried out thoroughly and in an unbiased fashion, that’s a good thing,” Malcolm said. “If he’s doing it just to second-guess how a particular investigation was run, then I would say that is not a good thing.”
In the police-involved deaths of Garner and of Michael Brown in Ferguson, Mo., local prosecutors investigated the cases and presented evidence to the grand juries. The veracity of their investigations, , however, has come under scrutiny after the grand juries didn’t indict the police in either incident.
By 50 to 37 percent, most Americans think the grand jury made the right decision in the Ferguson case, according to a recent survey by the Pew Research Center and USA Today. In the Garner case, 57 percent thought the grand jury erred by not indicting police, compared with 22 percent who thought the jurors got it right.
Public opinion about the failure to locally prosecute the Garner and Brown deaths has differed along racial lines, however.
While a majority of whites and blacks thought Garner’s death called for prosecution, 80 percent of blacks thought the grand jury erred in not charging police in Brown’s death. Sixty-four percent of whites thought no charges were warranted, Pew found.
Most blacks — 64 percent in the Brown case and 62 percent in the Garner case — say race was a major factor in the grand jury’s decisions. Only 16 percent of whites agreed in the Brown case and just 18 percent in Garner’s.
The numbers surely reflect some blacks’ long-standing perceptions of bias in the criminal justice system. It’s unclear whether outside investigations would alter that dynamic.
“The true answer is to have diversity among the attorneys in prosecutors’ offices, and for prosecutors’ offices to continue working on their relationship with the communities they serve, so that there is trust and transparency in the justice process,” said Melba Pearson, the president of the National Black Prosecutors Association.
While an independent prosecutor may be a useful tool in some circumstances, “it isn’t necessarily the answer for all police shooting cases,” she said.
Some state prosecutors already have units or individual prosecutors dedicated to public officials, including police officers, who have allegedly committed crimes.
“This may be a good option to expand upon,” Pearson said.
In light of the video of Garner’s arrest, Warren, of the Center for Constitutional Rights, said the New York prosecutors were either incompetent in presenting their case to the grand jury or simply didn’t want the officers charged.
“And if the prosecutor is giving the police officer more of the benefit of the doubt than the average criminal defendant, then that is a built-in conflict,” he said.
Malcolm, of the Heritage Foundation, said, “It all depends on how broadly you define ‘conflict of interest.’ ”
Because police arrest and question suspects, collect evidence and typically become key prosecution witnesses, they, by necessity, have a “very, very close” and trusting relationship with prosecutors, said Malcolm, a former federal prosecutor.
“But I do think that there are ethical prosecutors who don’t like police corruption or overzealous police officers who will unnecessarily harm the public, and who could do a thorough, competent and unbiased job with these investigations,” he said.
Still, Malcolm said, when the public questions — rightly or wrongly — the integrity of a grand jury ruling because of the relationship between the police and prosecutors, as in the Garner case, having the state attorney general’s office investigate “would remove that taint or at least minimize the likelihood that that taint might follow a decision not to prosecute.”
While independent investigations would improve public confidence in the criminal justice system, said Harriger of Wake Forest, they were no magic bullet and would address only one symptom of deeper problems in the system.
She said more police training on the use of force and multicultural communications would also help. Scrapping the election of local prosecutors should also be considered as a way to eliminate the appearance of conflicts, Harriger said.
“The criminal justice system is a very complex organism, and if you just poke at one part of it, you can’t really get at the problems,” she said. “You need to look at it across the board and all the ways it works.”
AFP Photo/Mat Hayward
By Tony Pugh, McClatchy Washington Bureau (TNS)
WASHINGTON — America spent more than $2.9 trillion on health care in 2013, or about $9,255 per person, according to a government report released Wednesday.
The 3.6 percent increase — from roughly $2.8 trillion in 2012 — was the smallest annual percentage hike since the data was first tracked in 1960, according to the Department of Health and Human Services.
It also marked the fifth straight year that total public and private health care spending has grown at historically low levels, mainly because of the effects of the Great Recession.
“The key question is whether health spending growth will accelerate once economic conditions improve significantly. Historical evidence suggests it will,” said Micah Hartman, an HHS statistician and lead author of the report.
Because slower health spending and modest economic growth typically follow a severe recession, the share of the national economy devoted to health care remained at 17.4 percent for the fifth consecutive year in 2013.
After increasing 4.1 percent from 2011 to 2012, national health spending slowed by half a percentage point in 2013. That was because of slower growth in private health insurance premiums and benefits, and less spending for medical equipment and facilities. Also contributing was slower growth in Medicare spending driven by sluggish enrollment growth, federal budget sequestration and provisions of the Affordable Care Act.
The health law helped lower medical spending in 2013 by adjusting Medicare fee-for-service payments; reducing base payment rates for Medicare Advantage, which offers the government insurance program through the private market; increasing Medicaid prescription drug rebates; and requiring insurers to spend at least 80 percent of premium revenue on medical claims and improvements in health care quality.
The controversial law also increased government spending for health care by enhancing Medicare prescription drug coverage, expanding eligibility for Medicaid, temporarily increasing payments to Medicaid care providers and imposing new fees on prescription drug makers.
As a result, Medicaid expenditures grew 6.1 percent to $449.4 billion in 2013, accounting for 15 percent of all health spending.
Medicaid enrollment grew 2.7 percent in 2013, and per-enrollee costs increased 3.3 percent last year.
After increasing 4 percent in 2012, private health insurance premiums increased just 2.8 percent, totaling $961.7 billion in 2013. The slowdown resulted from low enrollment growth, greater enrollment in lower-cost, high-deductible health plans and rate hike reviews required by the health care law.
At $585.7 billion, Medicare spending increased 3.4 percent last year, compared with a 4 percent increase in 2012. Spending for hospital services reached $937 billion in 2013, but the 4.3 percent increase was down from a 5.7 percent hike in 2012. Hartman said the slowdown was because of less use of hospital services and slower growth in prices.
Spending for prescription drugs topped $271 billion last year, up 2.5 percent after growing just 0.5 percent in 2012, when a number of blockbuster drugs became available in generic form.
Price increases for brand name and specialty drugs, greater drug usage and increased spending on new medicines drove the 2013 increase in drug spending, Hartman said.
At 28 percent, U.S. households accounted for the largest share of national health spending in 2013 followed by the federal government at 26 percent, Hartman said in a briefing with reporters. Private employers paid 21 percent, while state and local governments financed 17 percent.
Since 2010, the federal government’s share of total health spending has fallen 2 percentage points while the share paid by states and local governments has increased by 1 percentage point, as enhanced federal Medicaid payments provided under the economic stimulus law expired in 2011.
AFP Photo/Robyn Beck
By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — In his 30 years as director of the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci has seen his share of public health scares.
When AIDS exploded in the 1980s among gay men, Fauci recalls that some people didn’t want gay waiters to serve them in restaurants. And during the anthrax scare that followed the 9/11 terrorist attacks, many were afraid to open their mail.
But when it comes to Ebola, “This one’s got a special flavor of fear,” Fauci said at the recent Washington Ideas Forum, sponsored by The Atlantic magazine and the Aspen Institute, a nonpartisan policy group.
The growing death toll in West Africa has helped create “an epidemic of fear” in the U.S., Fauci said, even though most experts feel the likelihood of a widespread outbreak in this country is minimal.
James Colgrove, a public health professor at Columbia University, said the chances of an outbreak in this country are “extremely remote.” Pamela Cipriano, president of the American Nurses Association, went even further. “What we know right now would suggest that there is no risk of an epidemic,” she said.
Enhanced screenings of West African visitors allow U.S. health officials to “very quickly identify and sequester and evaluate and care for anyone who shows any type of risk,” Cipriano said. “That’s a very high level of control.”
Even in Dallas, where Liberian Ebola patient Thomas Eric Duncan triggered the nation’s first potential outbreak, only two nurses contracted the virus after direct contact with Duncan while he was desperately ill. That’s out of 70-plus health care workers and 48 family and community members who interacted with him.
Despite the flawed federal and local response, the Dallas episode proved what Fauci and other experts have said all along: Ebola is tough to catch and even tougher to spread when contact tracing, patient isolation and quarantines are in place.
But rather than validate experts’ calls to trust the science and impose public health precautions that reflect actual risk, the Dallas scare triggered a policy backlash driven by fear. Individual states imposed mandatory quarantines for all health care workers returning from Ebola-stricken West Africa, even if they had no symptoms and weren’t contagious.
Kaci Hickox, a Doctors Without Borders nurse who treated Ebola patients in Sierra Leone, was, upon returning, kept in an isolation tent for a weekend by New Jersey officials, even though she showed no symptoms of the virus.
She was permitted to return home to Maine, where officials tried to legally quarantine her. A judge ruled in her favor, requiring only that Hickox monitor herself for signs of Ebola for 21 days, which ended Monday night.
“The fear is trumping science,” said Dr. Georges Benjamin, executive director of the American Public Health Association.
Lawmakers continue to call for outright travel bans from West Africa, which, experts say, would only cause people to seek alternative entry while discouraging U.S. caregivers from helping out in Africa.
Fauci said the severe responses are simply good-faith efforts by politicians to protect fearful constituents.
“You have to respect the fear of people,” he said. “You can’t denigrate it and say, ‘Why are you afraid?’ You’ve got to try and explain to them and you’ve got to do it over and over. … It’s just that as a health person, as a physician and a scientist, I would say you look at the data, and it tells you what the risk is.”
Ebola is only transmitted by direct contact through broken skin or mucous membranes with the body fluids of infected people. Airborne transmission of the virus — through tiny, dry particles that float through the air — does not occur.
But if larger saliva or mucous droplets from an infected person are expelled by coughing or sneezing and come in contact with another’s eyes, nose or mouth, that person could become infected. No such infections, however, have ever been documented.
Americans’ lingering fears about the disease stem partly from health officials’ misstatements about the nation’s readiness to fight it.
Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, originally said hospitals in this country were ready to care for Ebola patients. Many, in fact, were not.
The agency then had to revise its outdated and insufficient guidance on personal protective equipment to ensure the safety of Ebola caregivers. The CDC also provided contradictory information about whether people being monitored for Ebola symptoms should be allowed on public transportation.
“Some of the missteps have eroded some of the trust that the public has had,” said Cipriano, the nurses association president. “I think that it certainly has added to the sense of, ‘Well, who do we trust?’ ”
Colgrove said Frieden’s mistakes were surprising, because the CDC director had always excelled in the art of communicating risk. Frieden used to refer to public health in an epidemic as “the art of controlled hysteria,” Colgrove said.
“You want people to be worried enough that they give you the resources that you need to do the job,” explained Colgrove, the Columbia professor, “but you don’t want them to be so worried that they do stupid things. It’s a very, very delicate balance that he has to walk. That any public health official has to walk.”
With a lull in the number of new Ebola cases, many are hoping the U.S. has seen the worst of the deadly virus. But Benjamin, of the American Public Health Association, knows better.
“I always remain skeptical and vigilant,” he said. “So while I’m hoping that we have, I still believe that we have to keep a high index of suspicion.”
AFP Photo/Chip Somodevilla
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By Tony Pugh, McClatchy Washington Bureau (MCT)
WASHINGTON — The Obama administration expects fewer than 10 million people to enroll in marketplace health coverage next year, far below the 13 million people that the Congressional Budget Office has projected.
The 2015 enrollment season for marketplace health insurance begins Saturday, and consumers can expect more coverage choices, a better functioning network and an easier enrollment process for most new first-time users, according to the Obama administration.
After last year’s disastrous rollout of the HealthCare.gov website, the U.S. Department of Health and Human Services spent the past year upgrading, simplifying and fully testing the glitch-prone process that serves 36 states. Officials expect the redesigned and more muscular system to handle more than 125,000 concurrent users.
The CBO projected marketplace enrollment to reach 13 million in 2015, 24 million in 2016 and a “steady rate” of 25 million in 2017 as the program is fully implemented.
That aggressive growth assumed a significant decline over the next two years in both employer-based insurance and non-marketplace individual coverage. But a new HHS analysis suggests the CBO projections may be unrealistic.
Senior administration officials say there’s “mixed evidence” and “considerable uncertainty” about the CBO’s expectation of a large two-year movement away from job-based coverage and individual coverage purchased outside the marketplace.
Those uncertainties and the history of slower enrollment growth in programs like Medicaid and the Children’s Health Insurance Program suggest it could take four to five years — until 2019 — for the state and federal marketplaces “ramp up” to 25 million enrollees.
As a result, the Obama administration expects only 9 million to 9.9 million people to enroll in marketplace coverage by the end of 2015. This year’s enrollment period, which begins Nov. 15, will run for just three months, through Feb. 15, instead of six months like last year.
Officials are promising an improved user experience when open enrollment begins, with a streamlined application process that will allow 70 percent of first-time HealthCare.gov enrollees to complete their coverage applications by navigating through just 16 computer screens, instead of 76.
The remaining 30 percent whose household characteristics are more complex will use the traditional application process.
Consumers returning to HealthCare.gov already have received notices in the mail and in their HealthCare.gov accounts explaining the re-enrollment process. When they begin, 90 percent of their online application already will be filled out.
To ensure new coverage is effective on Jan. 1, 2015, applicants must complete the enrollment process no later than Dec. 15.
People who don’t re-enroll for 2015 will be auto-enrolled in the same plan with the same premium tax credits as last year. Those who want to change plans must do so by Feb. 15. For those that do, their new plan coverage will begin on the first day of the next month or, depending on when they enroll, the second month.
The HealthCare.gov website also has been optimized for mobile usage, so people with smartphones or tablets can better navigate the site and shop for coverage.
Users will find some of the most frustrating aspects of the online application process have been eliminated. The new system allows users to browse and compare health plans without creating a user account. And a backward navigation function lets applicants correct information on previous screens without having to start all over.
Shoppers on HealthCare.gov will find 57 more insurers — 248 compared with 191 last year.
That’s a 30 percent increase over 2014. Among states using the federal marketplace, Texas, Michigan and Ohio are projected to have the most insurers, with 16. Pennsylvania and Wisconsin are next with 15, followed by Florida with 14.
As of Oct. 20, Colorado, Maryland, New York, Ohio, Oregon, Rhode Island, Vermont and the District of Columbia had approved rates for individual coverage purchased both on and off the state and federal marketplaces, according PricewaterhouseCoopers’ Health Research Institute.
In those states, premiums have increased by an average of just 3.5 percent from 2014, while the average 2015 premium is $344, PricewaterhouseCoopers found. The average premium increase across all 41 reporting states was 6 percent and the average premium was $381.
As of mid-October, 7.1 million people were enrolled in marketplace health plans, down from 7.3 million in September. About 110,000 people lost coverage for not providing the proper information about their income or citizenship and immigration status, officials said.
The administration expects 83 percent of the 7.1 million plan members — 5.3 million — to renew their coverage. Many of the 1.8 million others are expected to move to job-based coverage or Medicaid.
The number of uninsured working-age adults has fallen by 10.3 million, or 26 percent since 2013, due mainly to the Affordable Care Act’s coverage mandates and Medicaid expansion. Of the estimated 32 million remaining uninsured Americans, roughly 17 million are thought to be eligible for Medicaid, leaving an estimated 15 million who could purchase marketplace coverage.
Another 8 million to 12 million have individual coverage purchased outside the marketplace. Many of them also could become marketplace buyers in 2015. HHS expects 75 percent to 80 percent of new marketplace enrollees in 2015 to be previously uninsured.
AFP Photo/Joe Raedle
By Tony Pugh, McClatchy Washington Bureau (MCT)
WASHINGTON — A New York City physician who recently returned from treating Ebola patients in West Africa has become the nation’s latest Ebola patient.
Dr. Craig Spencer 33, is in isolation at Bellevue Hospital Center, which is one of eight hospitals in New York state that were recently designated to treat Ebola patients.
Spencer was transported to the hospital Thursday morning by a Hazardous Material Tactical Unit of the city fire department.
Three of Spencer’s friends, including his fiancee, will now be quarantined for 21 days — the incubation period for Ebola infection — after being in contact with Spencer while he was potentially contagious.
In a Thursday evening news briefing, New York Mayor Bill de Blasio said the hospital staff was “battle tested” and well prepared for an Ebola patient.
He said the city had been preparing for months for a possible Ebola case and that New Yorkers “are not at all at risk” for catching the deadly virus.
Officials from the U.S. Centers for Disease Control and Prevention were already at the hospital when Spencer arrived, said CDC Director Tom Frieden. They were inspecting the hospital’s newly constructed Ebola treatment unit, which is a self-contained space with a dedicated blood lab.
“They were prepared just for this moment,” said New York Gov. Andrew Cuomo, who urged city residents not to panic because Ebola is a tough virus to contract, requiring direct contact with body fluids of an infected, contagious person.
“I know it’s a frightening situation,” Cuomo said. “New York is a dense place, a lot of people on top of each other, but the more facts you know, the less frightening,” it becomes.
Spencer apparently contracted the virus while treating Ebola patients in Guinea for the humanitarian group, Doctors Without Borders.
He left Guinea on Oct. 12 and boarded his return flight from Europe to JFK Airport on Oct. 14. He showed no symptoms of illness during the trip.
Spencer, who had been limiting his personal contacts since returning to the U.S. on Oct. 17, had gone for a three-mile jog on Thursday morning before he notified Doctors Without Borders that he had developed a fever.
“Doctors Without Borders, in the interest of public safety and in accordance with its protocols, immediately notified the New York City Department of Health & Mental Hygiene,” said a statement from the group.
Health care workers in full protective gear facilitated an “orderly removal” of Spencer from his apartment, said Dr. Mary Travis Bassett, New York City’s health commissioner.
Officials are awaiting blood-test results from the CDC to confirm the infection, but the agency already has an Ebola response team on the way to New York, Frieden said.
Spencer had gone bowling with friends on Wednesday at “The Gutter,” a Brooklyn bowling alley that has since been closed pending examination and cleaning by health officials, Bassett said.
Spencer took several subway trains, but because he wasn’t symptomatic — only fatigued — Bassett said he likely posed no threat to other riders. Spencer only began having Ebola symptoms, such as high fever and gastrointestinal problems, Thursday morning.
“He did not have a stage of disease that creates a risk of contagiousness on the subway,” Bassett said. “We consider that it is extremely unlikely, the probability being close to nil, that there would be any problem related to his taking the subway system.”
Officials will be checking Spencer’s recent travels, including to a local restaurant, to make sure there are no other people who may be at risk for infection, Bassett said.
If necessary, the health department will isolate and quarantine known contacts of Spencer.
“The chances of the average New Yorker contracting Ebola are extremely slim,” said a city health department statement.
City and state officials are also working closely with the hospital to ensure that all staff follow new CDC guidelines designed to prevent health care workers from contracting Ebola.
The virus is spread by direct contact with the bodily fluids of an infected person.
“You cannot be infected simply by being near someone who has Ebola,” the health department advised.
Photo: Martin Wippel via Flickr
By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — A breach in safety protocol at a Dallas Hospital has caused a female health-care worker to become infected with Ebola after having extensive contact with Ebola patient Thomas Eric Duncan.
The development — the first known case of the deadly disease transmitted in the United States — stunned health officials who had not included the woman in the group of 48 people being monitored for the disease because she was thought to be of low risk for infection because she had worn protective equipment while caring for Duncan.
But the woman developed symptoms on Friday, and preliminary diagnostic tests came back positive late Saturday — a reminder of the risk that nurses, doctors and other hospital workers face treating Ebola patients. More than 400 health-care workers, the vast majority in West Africa, have contracted Ebola. Fifty-eight percent of those have died, according to the most recent report from the World Health Organization.
Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, said the CDC still must confirm the diagnosis, but that there was little doubt that there had been a failure of the supposedly rigid precautions that health workers are to take when caring for patients with the highly contagious disease.
“We don’t know what occurred in the care of (Duncan), but at some point, it was a breach in protocol and that breach in protocol resulted in this infection,” Frieden said in a briefing on Sunday. “If this individual was exposed, which they were, it is possible that other individuals were exposed,” Frieden said.
All health-care workers who treated Duncan are now being monitored for possible infection. Previously, those monitored included family members and others who had come into contact with Duncan before he was hospitalized Sept. 28. Four family members are being checked twice a day and are being guarded to ensure they remain isolated. The 21-day incubation period for most of the 48 ends on Oct. 19.
As the epidemic has swept the West African nations of Liberia, Guinea and Sierra Leone, health-care workers, unaware that they were treating people with the disease, are thought to have played a role in its spread. Texas officials said only one person is believed to have had contact with the new Dallas patient after she began to show symptoms. That person will now be monitored for 21 days.
The CDC now is recommending that the Dallas hospital, Texas Health Presbyterian, keep the number of workers treating possible Ebola patients to an “absolute minimum,” Frieden said. The agency also wants the hospital to provide a full-time infection control officer to ensure that safety measures are followed with Ebola patients.
The hospital announced Sunday that its emergency department had stopped until further notice accepting patients brought by ambulance “because of limitations in staffed capacity,” a step known as “diversion.'”
“While we are on diversion we are also using this time to further expand the margin of safety by triple-checking our full compliance with updated CDC guidelines,” the hospital said. “We are also continuing to monitor all staff who had some relation to Mr. Duncan’s care even if they are not assumed to be at significant risk of infection.”
The infected woman sought care immediately after her symptoms developed and was placed in isolation at the hospital, Frieden said.
Frieden said the worker had extensive contact on multiple occasions with Duncan during his care, but currently had a low level of the virus.
President Barack Obama asked federal authorities take more steps to ensure that hospitals and health-care providers are ready to follow proper procedures in dealing with Ebola patients. The White House also says Obama has asked the CDC to move as quickly as possible in investigating the apparent breach of procedures.
The CDC is investigating whether the new infection occurred during kidney diaIysis or respiratory intubation procedures that Duncan underwent “as a desperate measure to try to save his life,” Frieden said.
“Both of those procedures may spread contaminated materials and are considered high risk,” Frieden said. Duncan died of complications from Ebola on Wednesday.
The CDC is recommending that the hospital perform only “essential procedures” on Ebola patients to limit workers’ possible exposure to the virus. Under that guideline, Duncan would not have received the kidney dialysis and respiratory intubation treatments.
Officials will also examine whether the infection occurred during the removal of the worker’s protective equipment. The full-body suits, gloves and masks worn by Ebola caregivers are designed to protect them from infected body fluids, which spread the disease.
But removing the gear is a “major potential area of risk,” Frieden said.
If done improperly, a person could accidentally put their skin in contact with soiled or contaminated protective equipment, leaving them potentially exposed to the virus. Frieden said proper equipment removal to avoid infection is “critically important and not easy to do right.”
“It requires meticulous and scrupulous attention to infection control,” he said. “And even a single, inadvertent innocent slip can result in contamination.”
For that reason, “putting more on isn’t always safer,” Frieden said. “It may make it harder to provide effective care.”
A nursing assistant in Madrid, Spain who became infected after treating Ebola patients, has suggested her infection may stem from hand-to-face touching as she removed her protective equipment. Spanish authorities are monitoring 16 people who came in contact with the nursing assistant who is critical condition.
The CDC will examine the use of protective equipment and will look to develop better guidelines to assure its proper use, Frieden said.
Because the newly infected woman was thought to be at low risk for infection like other health-care workers who treated Duncan after he was placed in isolation on Sept. 28, she was self-monitoring her condition when she developed Ebola symptoms.
A hazardous materials crew from Fort Worth, Texas, arrived Sunday afternoon to begin decontaminating the worker’s apartment. Brad Smith with Fort Worth-based CG Environmental Cleaning Guys says a crew of about 15 on Sunday was to start scrubbing the exterior of the apartment building. Smith says he expects to begin work inside on Monday.
His company decontaminated the Dallas apartment where Duncan stayed before he was hospitalized and also cleaned parts of the hospital where he was treated.
Dallas County officials hurried early Sunday to reassure residents that they were not in danger.
“While this was obviously bad news, it is not news that should bring about panic,” Dallas County Judge Clay Jenkins said at a Sunday morning news conference at the hospital.
“That health-care worker is a heroic person,” Jenkins said. “Let’s remember that as we do our work that this is a real person who is going through a great ordeal, and so is that person’s family.”
The new infection is the latest in a series of problems at the hospital since Duncan first showed up for care on Sept. 24.
After telling hospital staff he had recently traveled from Liberia, where Ebola is raging, Duncan was sent home that day with only antibiotics after doctors failed to properly screen him as a possible Ebola patient.
After Duncan returned four days later and was placed in isolation with the disease, the hospital offered several different accounts about why Duncan was initially released.
At first it said nurses didn’t provide Duncan’s travel history to other staffers. Then it blamed a computer glitch for the error.
The hospital later retracted that account, saying the information was available to all Duncan’s caregivers. No further explanation has been provided.
Dr. Daniel Varga, chief clinical officer of Texas Health Resources, which oversees Texas Health Presbyterian, declined to place blame for whatever lapse led to the new infection.
“This individual was following full CDC precautions,” Varga said. “Gown, glove, mask and shield.” Asked how concerned he was that even after those precautions, the worker tested positive, he replied, “We’re very concerned.”
(Kathy Vetter and Judy Wiley of the Fort Worth Star-Telegram contributed to this report. )
Photo: A barrel for disposal of hazardous waste sits outside the residence at 5740 Marquita, where reportedly a person diagnosed with Ebola lived, on Sunday, Oct. 12, 2014, in Dallas. (Louis DeLuca/Dallas Morning News/MCT)
By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — Roughly 700,000 of the more than 8 million people who enrolled in marketplace health insurance plans have lost their coverage, Medicare administrator Marilyn Tavenner testified Thursday before Congress.
Her surprise disclosure came during a House Oversight and Government Reform Committee hearing in which Republicans blasted Tavenner about a lack of transparency and ongoing data security problems with the HealthCare.gov website created under the Affordable Care Act.
After a disastrous rollout that saw the federal insurance marketplace crash only minutes after its Oct. 1 debut, HealthCare.gov underwent a massive repair job by a team of private-sector computer experts from Silicon Valley.
By Thanksgiving 2013, the website was functioning properly and more than 8 million people signed up during an extended enrollment period that ended in May. Since then, Tavenner and other officials at the Department of Health and Human Services have been unable to say how many of the new enrollees have lost coverage because of non-payment.
After mentioning in Thursday’s testimony that 7.3 million Americans were covered by marketplace plans, committee chairman Darrell Issa (R-CA) asked Tavenner what happened to the other 700,000.
“Individuals may have either gotten employer-sponsored insurance, they may have found that they were eligible for Medicaid instead of the marketplace, and some individuals may have decided not to go forward and pay,” said Tavenner, who heads HHS’ Centers for Medicare and Medicaid Services.
When asked by Issa how many of the 700,000 were dropped because they didn’t pay their premiums, Tavenner said she didn’t know and added, “I don’t think you’ll know that until the end of the year.”
Even with the loss of nearly 10 percent of enrollees, Tavenner said she was pleased with what appears to be a 90 percent retention rate for marketplace sign-ups thus far.
“This is a brand new program. This has never been done before,” Tavenner testified. “I expect in some cases (some of the 700,000) may have moved. They may have gotten married. They may have gotten insured. They may have lost their income and gone on Medicaid or into the uninsured ranks. We will only know that as we look back. And we’re careful not to look back too early.”
Earlier this week, the Government Accountability Office released a report that criticized her department for information security and privacy weaknesses that compromise the personal information of HealthCare.gov users.
In testimony Thursday, Gregory Wilshusen, GAO’s director of information security issues, said HHS officials were slow to release documents and unnecessarily restricted GAO’s access to others, citing concerns about the security of the information.
The GAO report said the Centers for Medicare and Medicaid Services accepted increased security risks by allowing HealthCare.gov to launch on Oct. 1 when the system had not been fully tested. The investigative arm of Congress, the GAO also found problems in HealthCare.gov’s technical controls that protect the confidentiality, integrity and availability of data maintained in the system.
“CMS has not fully addressed security and privacy management weaknesses, including having incomplete security plans and privacy documentation, conducting incomplete security tests, and not establishing an alternate processing site to avoid major service disruptions,” the report said.
“Until these weaknesses are addressed, increased and unnecessary risks remain of unauthorized access, disclosure, or modification of the information collected and maintained by HealthCare.gov and related systems or the disruption of service provided by the systems,” the GAO report found.
The GAO report recommended 22 improvements to resolve technical weaknesses in security controls and six others to improve security and privacy controls.
Tavenner said the Centers for Medicare and Medicaid Services has implemented 19 of the 22 GAO recommendations so far and will comply with each of its six recommendations before the 2015 open enrollment period begins on Nov. 15.
She also said “end-to-end” testing of the entire federal marketplace will occur later this month or in October.
AFP Photo/Joe Raedle
By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — If the 23 states that have rejected expanding Medicaid under the 2010 health-care law continue to do so for the next eight years, they’ll pay $152 billion to extend the program in other states — while receiving nothing in return.
This exodus of federal tax dollars from 2013 through 2022 would pay 37 percent of the cost to expand Medicaid in the 27 remaining states and Washington, D.C., over that time.
Most of the money, nearly $88 billion, would come from taxpayers in just five nonexpansion states: Texas, Florida, North Carolina, Georgia, and Virginia.
The findings are part of a McClatchy analysis of data from the Urban Institute, a nonpartisan research center that’s advised states on implementing the health-care law, the Affordable Care Act.
Non-expansion states would see direct benefits from their $152 billion only if they reversed course and expanded eligibility for Medicaid, the state and federal health program for low-income Americans. The health-care law provides financial incentives for states to extend Medicaid coverage to adults who earn up to 138 percent of the federal poverty level.
If the non-expansion states did so, they’d still have to pay the $152 billion. But the 23 states also would split nearly $386 billion in federal Medicaid funding from 2013 to 2022, according to Urban Institute estimates.
The money would cover all medical costs for newly eligible Medicaid enrollees from 2014 through 2016, and no less than 90 percent of their costs thereafter.
“Here is money that is pretty much there for the asking, and these states are turning it down. And in the meantime, their taxpayers are paying taxes that fund expansions in states that are moving forward. It just doesn’t make any sense,” said Sherry Glied, the dean of the Robert F. Wagner Graduate School of Public Service at New York University.
The federal funding under Medicaid expansion also would stimulate economic activity, boost tax revenue, and create hundreds of thousands of jobs in the non-expansion states, experts say.
“This additional use of medical services not only brings more federal dollars, but hospitals, physicians, and pharmacies would likely hire more people, keep longer hours, and probably raise wages. All of which leads to indirect spending and subsequent rounds of spending that generate tax revenues and, in general, the expansion of the economy within states,” said Michael Morrisey, a health economics professor at the University of Alabama at Birmingham.
Expansion opponents doubt the federal government’s long-term ability to fund 90 percent of the cost for new enrollees. They also worry that their states can’t afford the increased Medicaid costs that come with expansion.
“We’re already struggling as a state, financially, to find the money to support our existing Medicaid system,” said Georgia Republican state Rep. Jason Shaw. “It’s really tough times for the state. It just wouldn’t be fair to the taxpayers if we just accepted the expansion.”
Some critics think the expansion encourages government dependency by providing free and low-cost health coverage for some while requiring those with higher incomes to pay full price. Those concerns have made expansion a tough sell in the holdout states, where Republican lawmakers want to curb enrollment growth in Medicaid no matter how sweet the financial incentives may be.
Last week, Pennsylvania became the ninth state with a Republican governor to accept the expansion. Like Arkansas and Iowa, Pennsylvania won approval from the Obama administration to bypass the Medicaid program and use the federal funding to help low-income residents buy private coverage instead.
Indiana and Utah, two other states with Republican governors, also are working with the Obama administration to enact their own versions of the Medicaid expansion. Many experts think that kind of federal flexibility will help Medicaid expansion work in most red states one day.
But in the run-up to the first midterm elections since the health law was fully implemented, expansion remains a hot-button issue. While polls show the Affordable Care Act remains largely unpopular, Democratic candidates in Republican-led states are campaigning for the expansion, citing the financial benefits.
Medicaid is a key element of the Affordable Care Act’s goal to provide near-universal coverage for millions of Americans. Since last October, more than 7.2 million people have gained Medicaid coverage, largely through the expansion.
In the 27 expansion states, single adults who earn up to $16,105 a year are eligible for Medicaid coverage, as are families of four that earn up to $32,913.
Expanding Medicaid coverage in the 23 remaining states would increase their state budget costs by $28.8 billion from 2013 through 2022, the Urban Institute reports. Expansion in Georgia, for instance, would hike its expenses by $2.5 billion over the 10 years, according to the institute.
“We simply cannot afford the $2.5 billion in new spending that expansion would require,” said Sasha Dlugolenski, a spokeswoman for Gov. Deal. “I think everyone can agree on one thing: The expansion costs money the state does not have.”
But experts say the increased revenue a state would see from expansion would more than make up for the state’s additional Medicaid spending.
Revenue gains for Alabama and Mississippi would exceed their expansion costs by $935 million and $848 million, respectively, according to a study co-authored by Morrisey, of the University of Alabama.
Those kinds of projections have led Republican state Rep. Steve Clouse, the chairman of the Alabama Legislature’s Ways and Means General Fund Committee, to support expanding Medicaid, even though he favors repealing and replacing the Affordable Care Act.
“We’ve got to deal with the hand we’ve been dealt by the feds,” Clouse said.
AFP Photo/Brendan Smialowski
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By Tony Pugh, McClatchy Washington Bureau
The Director-General of the World Health Organization on Friday declared the West African Ebola outbreak a “Public Health Emergency of International Concern,” and called for both affected and unaffected countries to implement a coordinated international response that features a wide range of new safety measures, including travel restrictions for some and a plan to return infected health workers to their home countries.
One of the highest-level emergency declarations that the WHO can issue was made by Dr. Margaret Chan following a two-day conference in Geneva, Switzerland, where a panel of health experts unanimously recommended the action after hearing reports from the West African nations of Guinea, Liberia, Sierra Leone, and Nigeria where the outbreak is centered.
Growing numbers of health experts had been calling for a firm international response to the worst Ebola crisis in history, which has claimed 932 lives and likely infected more than 1,700 people.
The WHO has asked all countries to take a series of varied actions with the most stringent recommendations reserved for countries where the disease is actively being transmitted and those that either have a potential or confirmed case of Ebola or share a border with either of the four affected West African nations.
In those four countries, WHO recommends exit screening for all people attempting to leave the country at international airports, seaports, and major land crossings. The screenings should include at the minimum, a series of questions, body temperature measurements and a risk assessment of whether any high fever is caused by Ebola. “Any person with an illness consistent with Ebola should not be allowed to travel unless the travel is part of an appropriate medical evaluation,” according to WHO press statement.
Similar international travel restrictions are recommended for Ebola patients and persons who were in contact with infected people. Confirmed Ebola cases should be isolated at treatment centers with no national or international travel until two diagnostic tests conducted at least 48 hours apart are negative. People in contact with infected persons, excluding properly protected health workers and laboratory staff who have had no unprotected exposure, should be monitored daily with restricted national travel and no international travel for three weeks after exposure.
The WHO also calls on the leaders of affected West African countries to declare a national emergency and personally address the nation about the crisis. Health ministers in these countries are urged to meet regularly with affected communities and visit Ebola patient treatment centers.
For unaffected countries that share borders with the four West African nations, WHO recommends surveillance to find clusters of unexplained fever or deaths, providing access to labs qualified to test for Ebola and establishing “rapid response teams” to investigate and manage suspected and confirmed Ebola cases. Any such findings should be treated as medical emergencies with action taken in the first 24 hours to stop a potential outbreak.
The WHO recommends that all other countries should not impose a general ban on international travel or trade, but should implement WHO’s suggested travel precautions for Ebola patients and their contacts. All countries should also provide travelers to at-risk areas with information about the inherent health risks, how to minimize those risks and advice on how to manage a potential exposure.
All countries should also be “prepared to detect, investigate, and manage Ebola cases, provide access to labs that screen for Ebola “and, where appropriate, provide the capacity to “manage travelers” from infected areas who arrive with unexplained symptoms of the disease. The WHO also calls on all countries to facilitate the evacuation and repatriation of their citizens, particularly health workers, who have been exposed to the disease.
AFP Photo/Zoom Dosso
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By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — Only four days after the Pungo District Hospital in Belhaven, N.C., closed its doors for good on July 1, Portia Gibbs suffered a heart attack in neighboring Hyde County, which has no doctors or hospitals.
Residents of Hyde, a sprawling, rural county in eastern North Carolina, had long relied on Pungo for emergency medical care. Now the nearest emergency room was 75 miles away.
More than an hour after a Medevac helicopter was called, Gibbs, 48, died just as the chopper arrived to airlift her to a hospital.
“Before, she would have been given nitroglycerin, put in the back of an ambulance and been to a hospital in about 25 minutes,” said Belhaven Mayor Adam O’Neal. “In that hour that she lived, she would have received 35 minutes of emergency room care and she very well could have survived.”
The memory of Portia Gibbs was alive and well for O’Neal on Monday as he completed a grueling 273-mile walk from his hometown to the U.S. Capitol, where he met with reporters to share his town’s story of losing its only hospital.
O’Neal’s two-week trek was equal parts politics and public relations. In a long-shot bid to reopen Pungo, he was hoping that his shoe-leather odyssey and Gibbs’ compelling story would help him get a meeting with, and assistance from, the Obama administration. The White House did contact O’Neal, but no meeting has been scheduled.
“I’m just praying and hoping that there will be some government official that has the power to stop this,” he said.
To help trumpet his cause, O’Neal used his “march” to highlight the growing problem of rural hospital closures across America and to make the case for Medicaid expansion, which North Carolina and 23 other states have refused to implement.
Medicaid, the federal-state health insurance plan for low-income Americans, would be open to adults who earn up to 138 percent of the federal poverty level under the expansion offered by the Affordable Care Act.
Since last year, 22 rural hospitals in the U.S. have closed up shop, according to the National Rural Health Association. Twenty were in states that blocked Medicaid expansion due to strong opposition from Republican governors or Republican-controlled legislatures.
In Georgia, where four rural hospitals have closed since 2012, Republican state Rep. Jason Shaw said the state simply couldn’t afford the long-term costs of covering higher-income people through Medicaid.
“Obviously, it’s a tough decision,” said Shaw, who chairs Georgia’s legislative rural caucus. “But I think it’s the right thing to do as far as protecting the state and the taxpayers.”
O’Neal, a conservative Republican, disagrees. He strongly supports expanding Medicaid and said the Pungo hospital would probably still be open if North Carolina had done so.
That would have sent more insured patients to the hospital and cut its uncompensated charity care, which helped fuel a $1.8 million operating loss last year.
But expanding Medicaid in North Carolina isn’t an option right now, especially since the program has faced a $1.8 billion shortfall over the last four years, said Kirsti Clifford, a spokeswoman for the North Carolina Department of Health and Human Services.
“The Medicaid budget must first be stabilized,” she said in a statement. “Once we fix the current system, North Carolina can then consider expanding Medicaid eligibility.”
O’Neal plans to meet with North Carolina Democratic Senator Kay Hagan to discuss the hospital closure.
He’s hoping they’ll introduce legislation that would require the U.S. Health and Human Services secretary to sign off on all closures of rural critical-access hospitals, such as Pungo, that are at least 35 miles from other hospitals. O’Neal also wants to require critical access hospitals to provide a year’s notice before closing their doors.
His unorthodox campaign hasn’t won many friends in his party. His letter seeking help from North Carolina’s Republican governor, Pat McCrory, went unanswered. But Virginia Governor Terry McAuliffe, a Democrat who’s trying to expand Medicaid in his state, met with O’Neal for 40 minutes recently.
That’s what happens when a conservative Republican pushes for a prized Democratic policy initiative.
“But this is something that’s above politics,” O’Neal told a group of supporters Friday in Fredericksburg, Va., as he passed around Portia Gibbs’ photo. “This is not about Republican or Democrat. We’ve got to leave that behind. We’ve got to make sure that people like Portia don’t die.”
America’s rural hospitals were struggling long before expanding Medicaid became an issue. But the changing health care environment has made things tougher, said Brock Slabach, a senior vice president at the National Rural Health Association.
Because they treat higher rates of poor, uninsured and under-insured patients, rural hospitals typically provide large amounts of charity care without compensation. It’s a big reason that the average rural hospital operates at an 8.3 percent loss, Slabach said.
Advances in health care delivery that cut patient volumes and shortened hospital stays have also hurt rural facilities, which already serve a smaller pool of patients, limiting their revenue potential.
Throw in funding cuts due to federal budget reductions, increased costs for new technology and reimbursement cuts for Medicaid and Medicare, which typically account for 60 to 80 percent of rural hospital revenues, and it’s easy to see why rural hospitals are struggling.
Medicaid expansion would go a long way toward easing the financial burden, said Paul Taylor, the CEO of Ozarks Community Hospital in Springfield, Mo., which is cutting 60 employees because of financial problems. The reductions will mean fewer beds for the hospital’s growing number of psychiatric patients.
“Had they expanded Medicaid, we would have increased bed capacity to deal with that population,” Taylor said. “But they didn’t, so I’ve got to go in a different direction.”
One-third of Ozarks’ emergency room patients are uninsured, resulting in about $3 million a year in uncompensated care, Taylor said. Nearly all the uninsured patients would qualify for Medicaid under the expansion, but he said state lawmakers wouldn’t budge.
“I call it political posturing,” Taylor said, “because, honestly, when I go to these guys and I say, ‘Let’s talk about Medicaid expansion,’ they just say ‘Aww, it’s Obamacare. We’re not going to talk about it.’ Well, at least talk about it. Come on, let’s take a serious look at it. But because it’s Obamacare, it’s just off the list. It can’t be discussed.”
In Georgia, Governor Nathan Deal, a staunch opponent of Medicaid expansion, has formed a Rural Hospital Stabilization Committee to try to help. The committee won’t consider expanding Medicaid, because a new state law requires legislative approval for any expansion.
Through a change in hospital licensing rules, Deal has offered Georgia’s struggling rural hospitals the opportunity to offer downsized services, including an emergency department.
“It’s not the answer for everything, but I think we’ll find that some of the hospitals that have closed, at least now we’ve allowed a way for them to scale down some services and keep some emergency care available,” said Rep. Shaw.
But Slabach said that without a definitive funding stream, these “freestanding emergency departments” would also struggle.
“Emergency departments are typically the most expensive and (unprofitable) department of any rural hospital,” he said, “so it’s hard to understand how they would sustain this program.”
Photo: Pete Marovich/MCT
By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — After declaring in 2000 that measles had been eliminated from the U.S. through a successful vaccination program, government officials now say the number of confirmed cases has reached a 20-year high as people who get the disease abroad bring it back to America.
Unvaccinated residents in the U.S. and foreign visitors who traveled to the Philippines, Europe, Africa, Asia and the Pacific are the main culprits in a growing spike of measles cases in this country that began several years ago and exploded this year.
To date, 288 cases have been reported in 18 states, the highest year-to-date total since 1994 when 963 cases were reported by year’s end.
The overwhelming majority of U.S. cases are among people who have chosen to go unvaccinated for personal, religious or philosophical reasons, said Dr. Anne Schuchat, director of the National Center for Immunizations and Respiratory Diseases at the U.S. Centers for Disease Control and Prevention.
In Ohio alone, 138 cases have been linked to Amish communities where several members had traveled to the Philippines, which is experiencing its own measles outbreak with more than 32,000 cases and 42 deaths this year, Schuchat said.
Fifteen outbreaks, involving three or more related cases, have occurred in places like New York City and in California, where six outbreaks were reported in six counties. Forty-three people have been hospitalized nationally, but no deaths have yet been reported, she said.
Health officials are urging people to get vaccinated for measles, especially prior to international travel.
A highly contagious viral respiratory disease that grows in cells at the back of the throat and lungs, measles is spread through the air by coughing, sneezing and even breathing. It can cause fever and cold-like symptoms, along with a stubborn body rash.
About 10 percent of children who get the disease also get an ear infection and about 5 percent develop pneumonia. About one in 1,000 measles patients contract encephalitis and one or two out of 1,000 die.
Prior to the U.S. measles vaccination program, which began in 1963, three to four million people in the U.S. developed measles each year, leading to 48,000 hospitalizations and 400 to 500 deaths.
As measles vaccinations took off in the 1960s, the rate of transmission steadily declined, prompting health officials to declare in 2000 that the indigenous spread of the disease had been eradicated in the United States.
It’s re-emergence through imported cases is a troubling development for health officials. Measles patients in the U.S. range in age from two weeks old to age 65, with more than half being over age 20.
About 164,000 people around the world die from measles each year. Measles also can cause women to miscarry or to give birth prematurely.
Photo via Wikimedia commons
By Tony Pugh, McClatchy Washington Bureau
WASHINGTON — The Obama administration reversed itself on Monday, announcing that private health plans that provide Medicare benefits will receive a slight increase in government payments next year, rather than the reduction that was proposed earlier.
Congressional Democrats, many facing tough re-election campaigns, recently joined Republicans in asking that the private health plans, known as Medicare Advantage, be spared from payment cuts next year, even though they receive an average of 6 percent, or $8 billion, more this year to cover their enrollees than it would cost under the traditional Medicare program.
The administration had proposed a 2 percent cut in Medicare Advantage payment rates in February under the Affordable Care Act, to help bring the payments more in line with the regular Medicare program.
The reduced payments would cause some plans to reduce benefits, but they would still have to provide all the benefits covered by traditional Medicare.
A February report from Barclay’s projects that advantage plans “have ample room to adjust benefits downward while maintaining benefit levels that are better for their members than the traditional (Medicare) fee for service program.”
But a series of attack ads by the insurance industry and Republican-backed groups claimed that the Medicare Advantage cuts would reduce benefits for seniors, cause premiums to increase and force some plans to pull out of certain markets altogether, making access to coverage more difficult.
The ads helped Republican David Jolly narrowly defeat Democrat Alex Sink in a House race in the Tampa, Fla., area last month that was largely viewed as an early test of how health care could affect the November mid-term elections.
Senate Democrats, including Al Franken of Minnesota and Chuck Schumer of New York, joined House Democrats like Reps. John Barrow of Georgia and Patrick Murphy of Florida in asking that Medicare Advantage payment rates remain untouched next year.
They got their wish on Monday when Jonathan Blum, principal deputy administrator at the government’s Centers for Medicare and Medicaid Services, announced an average payment increase of about 0.4 percent next year. Actual payment rates will vary by plan based on location, a plan’s quality rating and other factors, Blum said.
Many Democrats expressed relief.
“This proposed cut would have been disproportionate, hurting seniors who would lose doctors or pay more,” Schumer said in a statement on Monday. “We’re glad the administration heeded our call and reversed the policy.”
Not everyone, however, was pleased with the decision. Max Richtman, president and chief executive of the National Committee to Preserve Social Security and Medicare, called the move “bad policy and bad economics for the Medicare program.”
“Since 2003, all seniors in Medicare (including those not even enrolled in Medicare Advantage) have paid higher premiums to help fund the billions in government overpayments to private Medicare Advantage insurance companies,” Richtman said in a written statement. “This annual drama with private insurers in Medicare proves, once again, that when private Medicare Advantage plans are unwilling to compete on a level playing field with traditional Medicare, seniors will ultimately pay the price.”
House Speaker John Boehner said the policy change does little to address ongoing conerns about the Affordable Care Act.
“We have called on the president and his Cabinet to develop a plan to help American seniors deal with the consequences, both now and in the future, of this destructive law. Thus far we’ve seen no such plan,” Boehner said in a written statement.
Nearly 16 million seniors, about 30 percent of Medicare’s 52 million beneficiaries, are enrolled in Medicare Advantage plans, up from 14.6 million enrollees in 2013, according to Avalere Health, a health-care consulting firm.
The Medicare Advantage program allows private managed care plans, typically HMOs and PPOs, to provide hospital coverage and physician services for Medicare enrollees. Rather than bill Medicare for each medical service, the plans receive a flat monthly sum to cover each patient and a separate payment to provide prescription drug benefits. The plans typically provide extra benefits like coverage for eyeglasses, hearing aids and gym memberships.
The extra benefits have helped fuel the funding disparity between Medicare Advantage plans and the traditional Medicare program.
To address these concerns, the Affordable Care Act, passed in 2010, changed the formula for paying Medicare Advantage plans, with the goal of saving more than $130 billion over 10 years. The law phases in payment reductions to the Medicare Advantage plans that bring them more in line with payments for services under the traditional Medicare program.
That plan has worked. Medicare Advantage used to cost 14 percent more to care for enrollees than the traditional program. That payment disparity is now down to 6 percent, according to the Medicare Payment Advisory Commission, an independent congressional agency that advises Congress about Medicare.
Blum said the trajectory of lower payments will continue in spite of the slight payment increase next year. He said overall program costs won’t rise as quickly in coming years as healthier, less costly baby boomers continue to join the program.
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