U.S. Healthcare, Obamacare 2017-19

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See previous posts on Affordable Care Act aka Obamacare

Understanding the bipartisan Senate Finance prescription drug reform package
Loren Adler, Paul B. Ginsburg, and Steven M. Lieberman
(Brookings) Today’s prescription drug system is characterized by several problems. The first —and the one that gets the most attention— is the high prices paid for prescription drugs, particularly those offering limited value, by both patients and health plans.
Many studies have shown that other high-income nations achieve both lower list and actual (“net”) prices for almost all prescription drugs and limit the utilization of lower-value drugs (that is, drugs that are expensive but result in limited clinical impact compared to lower-cost competitors), resulting in significantly lower spending. As a result, the U.S. accounts for an estimated 64 to 78 percent of all worldwide pharmaceutical profits. This raises questions about the value of our drug spending, and high U.S. prices lead to access and affordability issues while resulting in significant costs to taxpayers.
On July 25, the Prescription Drug Pricing Reduction Act (PDPRA) of 2019 was approved by the Senate Finance Committee by a
19-9 vote, with small modifications to the initial Chairman’s mark. Taken together, the legislation seeks to address many issues with prescription drug markets and coverage that affect Medicare and its beneficiaries, focusing on lowering drug prices, improving the benefit design of Medicare’s outpatient prescription drug benefit (Part D), and eliminating myriad impediments to competition.
The Congressional Budget Office (CBO) estimates that the package would reduce deficits by more than $100 billion over ten years, beneficiary cost-sharing in Part D by $25 billion, and Part D premiums by $6 billion, while also somewhat reducing the cost of commercial prescription drug coverage (due to spillover effects from the Part D inflation rebate policy).

19 September
Nancy Pelosi’s Drug Plan Pits Trump’s Base Against GOP Orthodoxy
(New York) Unlike the bulk of the House Democrats’ legislative proposals this year, the prescription-drug package is not purely a messaging device. Due the breadth and intensity of public outrage over soaring pharmaceutical prices, along with the popularity of “big government” action for driving down drug costs, some Republican senators have embraced a more modest package of reforms. Meanwhile, Donald Trump has mulled a variety of more radical actions. For these reasons, it’s not inconceivable that some version of Pelosi’s bill could make it into law.

17 April
60 doctors, pharmacists charged in largest US opioid prescription bust
(MSN) Some of the doctors are accused of trading drugs for sex, giving prescriptions to Facebook friends without proper medical exams and unnecessarily pulling teeth to justify writing pain pill prescriptions.
The list of indicted medical professionals includes podiatrists, orthopedic specialists, dentists, general practitioners and nurse practitioners.
Prosecutors said the specialties and methods varied among the accused, but the result in every case was the same: People addicted to pain medication received dangerous amounts of opioids, including oxycodone, methadone and morphine.

2 April
Trump abandons plan for pre-election vote on health care after talking to McConnell
Bloomberg: It’s an issue that has bedeviled Donald Trump since he took office.
Two years ago Speaker Paul Ryan, lacking support from his fellow Republicans, was forced to pull a Obamacare rollback measure from the House floor. Now, the president’s renewed effort undo his predecessor’s signature legislative achievement on healthcare has proved short-lived.
Trump said late last night that Republicans – who, unlike two years ago, don’t enjoy a House majority – would wait until after the 2020 election to hold a vote on an Obamacare replacement.
The abrupt decision to abandon the push, which he began last week during a rhetorical victory lap following the conclusion of Special Counsel Robert Mueller’s 22-month investigation, underscores the trepidation that Republicans feel about injecting the healthcare law into the poll debate.
Nine years on, Obamacare – passage of which helped spark the Tea Party movement that swept Republicans into control of the House in 2010 – has achieved widespread popularity in opinion polls, with some Democrats even advocating an expansion.
So most congressional Republicans are in no mood to return to the battlefield. The question is whether an unpredictable commander-in-chief will keep step – or get out of line again.
Kathleen Hunter

30 March
For Trump’s ‘Party of Healthcare,’ there is no health-care plan
(WaPo) Republicans have no intention of heeding President Trump’s urgent demands for a new health-care plan to replace the Affordable Care Act, fearing the potential political damage that such a proposal could cause in 2020 and hoping he will soon drop the idea, according to interviews with numerous GOP lawmakers, legislative staffers and administration aides.
Not only is there no such health-care overhaul in the works on Capitol Hill — there are no plans to make such a plan.
Senate Republicans, who were caught off guard by Trump’s rapid shift to focus on health care last week, said the White House would need to make the first move by putting forward its own proposal. But administration officials said nothing firm is in the works.

29 March
‘Clearly an end-run’: Federal judge rejects Trump’s health-care plan to go around Obamacare
(WaPo) A federal judge in Washington ruled late Thursday that the Trump administration’s push to make health insurance plans available outside the Affordable Care Act that avoid the requirements of the health-care law was illegal, calling the efforts “clearly an end-run around the ACA.” The 43-page ruling, submitted by U.S. District Judge John D. Bates of the District of Columbia, blocks new rules from the Trump administration overseeing “association health plans,” which would allow small businesses to combine their forces to offer plans outside the ACA that would both be less expensive and provide fewer health protections.

27 March
Democrats Move to Defend Obamacare From Trump, Again
(New York) In what was either serendipity or an extremely rapid response, House Democrats unveiled a new bill that shored up elements of the Affordable Care Act that the Trump administration has been messing with, with excellent timing, as Dylan Scott reports:
House Democrats are rolling out a plan to strengthen the Affordable Care Act that would expand federal insurance subsidies and reverse the Trump administration’s attacks on the health care law — but avoids the party’s internal fight about more ambitious proposals to extend health coverage.
Democrats released the bill the day after the Trump administration said it wanted the entire health care law thrown out by the courts, underscoring the striking divide between the two parties on an issue at the top of voters’ minds.
The legislation covers a number of perceived weaknesses that have appeared in the structure of Obamacare, including some engineered by the administration:

25 March
DOJ Moves to Strike Down Entire Affordable Care Act
The Department of Justice is moving to strike down the Affordable Care Act, according to a Monday legal filing cited by Axios. The move marks a significant legal change in the DOJ’s position: After a federal judge deemed the entire ACA unconstitutional in December, the Justice Department maintained that only certain parts of the law—including the individual mandate and the requirement to cover people with pre-existing conditions—had to be thrown out. But in the new filing, the department sided with the attorneys general who brought the initial lawsuit, arguing that the law needed to be scrapped entirely. Axios notes that dismantling the ACA would cause serious upheaval and would deprive millions of people of health insurance. The move is just the latest in a series of legal attacks on the law.

23 February
A highly complicated issue that will require summaries by independent authorities accompanied by  comparative charts of what each proposal means to how many Americans as well as to the industries/professions concerned.
Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’
(NYT) Doctors, hospitals, drug companies and insurers are intent on strangling Medicare for all before it advances from an aspirational slogan to a legislative agenda item.
They also demonstrate how entrenched the Democrats’ last big health care victory, the Affordable Care Act, has become in the nation’s health care system.
In a daily fusillade of digital advertising, videos and Twitter posts, the coalition, the Partnership for America’s Health Care Future, says that Medicare for all will require tax increases and give politicians and bureaucrats control of medical decisions now made by doctors and patients — arguments that echo those made to stop Medicare in the 1960s, Mrs. Clinton’s health plan in 1993 and the Affordable Care Act a decade ago.
The lobbyists’ message is simple: The Affordable Care Act is working reasonably well and should be improved, not repealed by Republicans or replaced by Democrats with a big new public program. More than 155 million Americans have employer-sponsored health coverage. They like it, by and large, and should be allowed to keep it.
The Democrats’ proposals could radically change the way health care providers do business and could drastically shrink the role and the revenues of insurers, depending on how a single-payer system is devised.
When members of Congress unveiled legislation to let people age 50 to 64 buy into Medicare, the coalition conflated it with proposals to put all Americans into Medicare.
Under the Affordable Care Act, insurers can increase premiums with a person’s age, and older people who do not qualify for subsidies face the highest premiums on the insurance exchange. For a 60-year-old in Charlotte, N.C., the average premium for a mid-level silver plan is more than $1,100 a month; in Phoenix, it is nearly $1,000 a month.
The coalition … also has a positive agenda. It wants to expand Medicaid under the Affordable Care Act in Texas, Florida and other states that have yet to do so. It wants to expand federal subsidies under the health law so insurance will be affordable to more people. And it wants to stabilize premiums by persuading states to set up reinsurance programs, using a combination of federal and state funds to help pay the largest claims.
… “Proposals on the left and the right, in Congress and on the campaign trail, could blow up the employer-based health care system that has worked pretty well for more than 60 years.”
The version of Medicare for all proposed by Mr. Sanders in 2017 could disrupt that coverage. It would expand the list of items and services covered by Medicare and would prohibit employers from duplicating any of those benefits.
… Yet another Democratic proposal, allowing states to create a Medicaid buy-in program for all their residents, regardless of income, has won support from 23 senators

3 January
House Democrats plan to hold hearings on Medicare for All
(WaPost) The new Democratic majority in the House will hold the first hearings on Medicare-for-All legislation, a longtime goal of the party’s left, after Speaker-designate Nancy Pelosi lent her support for the process.
“It’s a huge step forward to have the speaker’s support,” said Rep. Pramila Jayapal (D-Wash.), who will be the House sponsor of the legislation, usually denoted as HR 676. “We have to push on the inside while continuing to build support for this on the outside.”
Some version of universal health care has been a Democratic goal for decades. The Expanded and Improved Medicare for All Act, first introduced in 2003 by then-Rep. John Conyers Jr. of Michigan, has become the vehicle for Democrats who want to bring single-payer, Canada-style health care to the United States.
That legislation was typically sidelined, even when Democrats had power; in 2009 and 2010, when the House passed the Affordable Care Act, the “Medicare-for-All” package was not part of the discussion.
Polling has found support for Medicare for All at anywhere from 58 to 70 percent, though critics point out that support dips depending on how the costs and changes to private insurance are described.


14-15 December
GOP feels heat in wake of Obamacare ruling: ‘It’s all the downsides’
The decision spells bad news for Republicans by allowing Democrats to replay a potent health care message that helped them flip 40 House seats.
(Politico) The midterm elections took repeal off the table, and Democrats were gearing up for a party-defining fight over “Medicare for all.” But Friday night’s ruling by a federal judge in Texas that the Affordable Care Act must be scrapped once again puts the law front and center as Democrats prepare to take back the House just weeks from now.
Federal judge in Texas rules entire Obama health-care law is unconstitutional
(WaPost) A federal judge in Texas threw a dagger into the Affordable Care Act on Friday night, ruling that the entire health-care law is unconstitutional because of a recent change in federal tax law.
The opinion by U.S. District Judge Reed O’Connor overturns all of the sprawling law nationwide.
The ruling came on the eve of the deadline Saturday for Americans to sign up for coverage in the federal insurance exchange created under the law. If the ruling stands, it would create widespread disruption across the U.S. health-care system — from no-charge preventive services for older Americans on Medicare to the expansion of Medicaid in most states, to the shape of the Indian Health Service — in all, hundreds of provisions in the law that was a prized domestic achievement of President Barack Obama.
… calling the opinion “misguided and wrong,” America’s Health Insurance Plans, the industry’s main trade group, sought to reassure consumers that their health coverage would remain “strong and stable” while the ruling is appealed.
Since the lawsuit was filed in January, many health-law specialists have viewed its logic as weak but nevertheless have regarded the case as the greatest looming legal threat to the 2010 law, which has been on the GOP’s whipping post ever since and assailed repeatedly in the courts.
(NYT & Politico) Texas Judge Strikes Down Obama’s Affordable Care Act as Unconstitutional: “At issue was whether the health law’s insurance mandate still compelled people to buy coverage after Congress reduced the penalty to zero dollars as part of the tax overhaul that President Trump signed last December.”
“When the Supreme Court upheld the mandate as constitutional in 2012, it was based on Congress’s taxing power. Congress, the court said, could legally impose a tax penalty on people who do not have health insurance. But in the new case, the 20 plaintiff states, led by Texas, argued that with the penalty zeroed out, the individual mandate had become unconstitutional — and that the rest of the law could not be severed from it.”
A federal judge in Texas struck down the entire Affordable Care Act on Friday on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it.
The ruling was over a lawsuit filed this year by a group of Republican governors and state attorneys general.  … On Friday night, a spokeswoman for Xavier Becerra, the California attorney general, said California and the other defendant states would challenge the ruling with an appeal in the United States Court of Appeals for the Fifth Circuit in New Orleans …  it will almost certainly make its way to the Supreme Court, threatening the survival of the landmark health law and, with it, health coverage for millions of Americans, protections for people with pre-existing conditions and much more.

24 November
Can House Democrats really protect Obamacare?
They face a tough time turning campaign rhetoric into reality.
with the Senate and White House still in Republican hands, Democratic leaders have only one surefire weapon in their arsenal: a resolution to jump into the court fight over Obamacare’s consumer protections. That would empower the House Counsel to intervene in the lawsuit brought by 20 conservative state attorneys general that threatens to abolish the health care law.
“There’s a clear picture that the thing we will definitely do quickly is intervene in the lawsuit” to defend the law, a Democratic leadership aide told POLITICO.

10 October
Jonathan Chait: Trump’s Op-ed Accidentally Points Out He Broke His Health-Care Promise
(New York) “As a candidate, I promised that we would protect coverage for patients with preexisting conditions and create new health-care insurance options that would lower premiums,” writes President Trump in a USA Today op-ed – or, I should say, “writes,” since the text is not nearly digressive or incoherent enough to have sprung from the man’s own pen. “I have kept that promise, and we are now seeing health insurance premiums coming down.”
The first line, you might notice, contains a hyperlink. If you click it, it takes you to a Washington Post fact-checking story which explains that Trump’s administration is supporting a lawsuit to eliminate protections for patients with preexisting conditions. “With no explanation or warning, the president now supports an effort to nullify the provisions that make it possible for millions of people to purchase affordable insurance,” the article says, concluding, “Thus this new position, directly contradicting his repeated stance as a candidate and as president, qualifies as a flip-flop.”
… He hasn’t covered everybody. He hasn’t proposed, let alone enacted, a “terrific” health-care plan. If protections for people with preexisting conditions remain in place, it will be only because his administration loses its legal fight to eliminate them. Whether Trump is more than dimly aware of any of these facts is an open question. The most perfectly emblematic fact about Trump’s health-care record is that he has written an op-ed pointing out that he has broken his own promises.

7 July
Trump administration takes another major swipe at the Affordable Care Act
Drawing swift protest from the health-insurance industry, the administration halted billions of dollars in annual payments required under the law to even out the cost to insurers whose customers need expensive medical services.
(WaPost) Risk adjustment is one of three methods built into the 2010 health-care law to help insulate insurance companies from the ACA requirement that they accept all customers for the first time — healthy and sick — without charging more to those who need substantial care.
The other two methods were temporary, but risk adjustment is permanent. … This idea of pooling risk has had significant practical effects: encouraging insurers to participate in the insurance marketplaces the ACA created for Americans who cannot get affordable health benefits through a job.

26 February
Study: ObamaCare premiums to rise 18 percent from GOP-backed changes
(The Hill) ObamaCare premiums will rise an average of 18.2 percent next year due to GOP-backed changes to the health law, according to a study from the left-leaning Urban Institute released Monday.
The study finds that the combination of repealing ObamaCare’s individual mandate and expanding access to cheaper, skimpier health plans known as short-term plans will lead to the premium increase.
Both of those actions have the effect of leaving fewer healthy people in ObamaCare plans, which drives up premiums for the remaining group of sicker enrollees.
The flip side of the expansion of short-term plans, announced by the Trump administration last week, is that some people, particularly those who make too much to qualify for financial assistance and are facing high costs, will be able to find cheaper coverage.
The study finds 4.2 million people will enroll in the new short-term plans, with 1.7 million of those being otherwise uninsured.
But this new coverage is primarily attractive to healthy people because it does not need to follow ObamaCare rules, can deny coverage to those with pre-existing conditions and leave out coverage of certain services.
See full report from the Urban Institute: The Potential Impact of Short-Term Limited-Duration Policies on Insurance Coverage, Premiums, and Federal Spending

30 January
Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care
(NYT) Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they would form an independent health care company for their employees in the United States.
The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies.
Each tech company is taking its own approach, betting that its core business strengths could ultimately improve people’s health — or at least make health care more efficient. Apple, for example, has focused on its consumer products, Microsoft on online storage and analytics services, and Alphabet, Google’s parent company, on data.


26 December
How Big Tech Is Going After Your Health Care
(NYT) … as consumers, medical centers and insurers increasingly embrace health-tracking apps, tech companies want a bigger share of the more than $3 trillion spent annually on health care in the United States, too. The Apple Heart Study reflects that intensified effort.
The companies are accelerating their efforts to remake health care by developing or collaborating on new tools for consumers, patients, doctors, insurers and medical researchers. And they are increasingly investing in health start-ups.

20 December
Trump Falsely Claims to Have ‘Repealed Obamacare’
(NYT) President Trump celebrated the tax bill that Congress approved on Wednesday by characterizing it as a two-for-one victory, falsely claiming that it also made good on his promise to repeal the Affordable Care Act.
“When the individual mandate is being repealed, that means Obamacare is being repealed,” Mr. Trump said in a cabinet meeting. “We have essentially repealed Obamacare, and we will come up with something that will be much better.”
Mr. Trump’s suggestion that he kept two key campaign promises with one bill is not accurate.
Effectively, the tax bill does repeal the individual mandate beginning in 2019. The mandate is a core component of the Affordable Care Act and fines people who do not have health insurance. But the tax bill leaves every other vital part of the current health care law intact.
“The A.C.A. is far more than the mandate, and the repeal of the mandate is by no means a fatal blow. Most of the A.C.A. survives, and most of its coverage gains will remain,” said Timothy Jost, an emeritus professor at Washington and Lee University School of Law and a contributing editor for the journal Health Affairs.
Republicans repeatedly and unsuccessfully tried to repeal the Affordable Care Act over the summer. The individual mandate was one of 12 key elements of the health care law, which also included provisions that addressed access to insurance, requirements for insurance policies and costs of coverage.

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