Trump’s Cancer Panel Says Urgent Action Needed On Rising Drug Cost

Image result for panel on cancer images

Source: The Hill

A White House advisory panel on Tuesday called for urgent action to address the rising cost of cancer drugs.

“Cancer patients should not have to choose between paying for their medications or paying their mortgages. For so many, it is truly a matter of life and death,” said Barbara Rimer, chair of the President’s Cancer Panel, which advises the president on issues related to cancer policy.

“This is a national imperative that will not be solved by any one sector working alone.”

Cancer drugs can enter the market with a price tag of more than $100,000 a year, meaning thousands of dollars in out-of-pocket costs for patients. The White House panel noted that the prices of many drugs don’t reflect their value or health benefit.

“While high prices may be warranted for drugs that significantly extend survival and/or substantially improve quality of life, higher prices are not appropriate for drugs that do little to improve outcomes,” the panel said.

The panel urged President Trump to support policies that propose “sustained, predictable funding” for government agencies that work to provide affordable access to innovative cancer drugs.

The panel also recommended the administration promote pricing of drugs based on the potential value to the patient, stimulate competition in the generic drug markets, ensure the Food and Drug Administration (FDA) has appropriate resources to assess cancer drug safety and efficacy, and invest in research to develop innovative, high-value cancer drugs.

But the White House advisory group did not offer specific steps or actions for the administration to take.

The Trump administration unveiled modest proposals to bring down drug costs, including ones that would put a cap on out-of-pocket spending for enrollees in Medicare’s prescription drug program and cut Medicare payments to remove an incentive for doctors to prescribe higher-priced drugs.

As a presidential candidate, Trump said he would allow the government to negotiate drug prices for Medicare beneficiaries, but so far no action has been taken on that front by the administration.

Health and Human Services Secretary Alex Azar, who also served in that department under George W. Bush, has indicated that he doesn’t support those measures.

FDA Commissioner Says ‘Rigged’ System Raises Drug Costs for Patients, Discourages Competition

Image result for FDA Commissioner imagesSource: The Hill

Scott Gottlieb, commissioner of the Food and Drug Administration (FDA), on Wednesday criticized what he called a “rigged” system that keeps some generic drugs off the market and leaves patients paying high costs.

Complex and secret deals between drug distributors, pharmacies, insurers and other key players have kept less expensive drugs off the market, he argued during a speech at a conference Wednesday for major health insurance companies.

“The rigged payment scheme might quite literally scare competition out of the market altogether,” Gottlieb said.

“I fear that’s already happening.”

Gottlieb said the existing system makes it harder for biosimilars — cheaper versions of complex drugs — to enter the market because older, more expensive drugs are favored.

“The very complexity and opacity of these schemes help to conceal their corrosion on our system – and their impact on patients,” he said. 

“In the long run, the interests of patients, providers, and manufacturers are not well served by these arrangements, precisely because these practices encourage large list price increases to fuel the pricing schemes.”

Gottlieb specifically called out prescription benefit managers (PBMs), which serve as middlemen between insurers and drug manufacturers and work to negotiate prescription drug prices with drug makers. 

But those savings aren’t passed along to patients, Gottlieb said.

“Too often, we see situations where consolidated firms — the PBMs, the distributors, and the drug stores — team up with payers,” Gottlieb said.

“They use their individual market power to effectively split some of the monopoly rents with large manufacturers and other intermediaries rather than passing on the saving garnered from competition to patients and employers.”

Gottlieb also criticized drug rebates, a process in which drug manufacturers give insurers discounts on certain drugs.

Insurers often use these savings to lower premiums for all patients, not passing the discounts on these drugs directly to those buying them, who pay the list price set by manufacturers. 

“Patients shouldn’t face exorbitant out-of-pocket costs, and pay money where the primary purpose is to help subsidize rebates paid to a long list of supply chain intermediaries, or is used to buy down the premium costs for everyone else,” Gottlieb said.

“The big copay or rebate on the costly drug can help offset insurers’ payments to the pharmacy, and reduce average insurance premiums. But sick people aren’t supposed to be subsidizing the healthy.”

A Health Plan ‘Down Payment’ Is One Way States Try Rebooting Individual Mandate

Image result for Health Plan ‘Down Payment’ imagesSource: California Healthline

As President Donald Trump and congressional Republicans tirelessly try to dismantle the Affordable Care Act, a number of states are scrambling to enact laws that safeguard its central provisions.

The GOP tax plan approved by Congress in the last days of 2017 repealed the ACA penalty for people who fail to carry health insurance, a provision called the “individual mandate.” On Jan. 30, in Trump’s first State of the Union address, he claimed victory in killing off this part of the health law, saying Obamacare was effectively dead without it.

But before that federal action kicks in next year, some states are enacting measures to preserve the effects of the mandate by creating their own versions of it.

Maryland is on the cutting edge with legislation moving through both chambers of the Statehouse.

“We’ve been just struggling since Trump became president with how to protect the ACA in our state,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, a nonprofit organization that has been instrumental in pushing the measure.

Proposals have been discussed or advanced in at least nine states, including CaliforniaWashington and Connecticut, and the District of Columbia.

Creating an individual mandate is just one way that states — generally blue states where Democrats control the legislature — seek to ensure what many lawmakers view as key advances made by the ACA don’t disappear.

They’re looking to one another as test cases to see how state-level legislation can either buttress or alter the ACA, according to Trish Riley, the executive director of the National Academy for State Health Policy.

“One state will try one approach, others will try it,” Riley said. “It’s an experiment, and an important one.”

Time is short, since most states have limited legislative calendars and are fast approaching the deadlines for insurers to file their 2019 rate plans.

A bill to create a state-based individual mandate has not been introduced in California, but the trade group that represents the state’s health insurers is among those urging lawmakers to adopt one.

Without a mandate, more Californians would lose their coverage and premiums could spike, said Charles Bacchi, president and CEO of the California Association of Health Plans.

“The requirement to buy coverage is the best method to stabilize California’s health care marketplace,” he said.

But passing and implementing these kinds of measures will be tough, said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “I think there’s still a window of opportunity for states to do something and have an impact on 2019 premiums,” she said.


Maryland’s Take On The Individual Mandate

Maryland’s effort began last April when the state legislature created the Maryland Health Insurance Coverage Protection Commission “both in response to and in anticipation of efforts at the federal level to repeal and replace the ACA,” according to a report by the state’s legislative services department and the commission itself.

The commission, chartered for three years, is charged with studying how federal action could affect the state’s health insurance market and Medicaid program and offering recommendations to mitigate any negative impacts. The panel began meeting months before the Maryland General Assembly started its 90-day session in January.

Based on the commission’s initial recommendations, Sen. Brian Feldman and House Del. Joseline Peña-Melnyk introduced the Protect Maryland Health Care Act of 2018, which lays out a framework for preserving an individual mandate in the state.

The federal individual mandate was put in place to make sure that younger, healthier people joined the insurance risk pool, helping to stabilize the market. The idea is that those relatively healthy customers help cover the insurers’ costs for sicker customers’ care, which keeps premium costs manageable for everyone.

The Congressional Budget Office estimated that 13 million people nationwide would become uninsured without the individual mandate. Some will choose to go without insurance or will not be able to find an affordable plan. Insurers could opt to leave local markets because they could not make money covering only sick patients.

Feldman said insurers and health care experts testified before the commission that Maryland’s insurance exchange would collapse in 2019 if the state didn’t act.

“Because of uncertainty at the federal level, it’s going to be up to states in this arena to pick up the slack and to enact legislation that responds to that uncertainty,” he said.

The federal mandate imposed a tax penalty on people who could afford to but chose not to buy insurance, depositing the money in a general Treasury fund.

In Maryland, the penalty fee will effectively be used, according to advocates, as a “down payment” on an insurance policy.

Beginning in 2020, if someone indicates on their taxes that they’re uninsured, the state would use the fine, plus any tax credits from the federal government, to buy an insurance plan for them.

Maryland would match its residents only with plans that cost nothing more than the fine plus the federal subsidy. So, if such a plan isn’t available in a person’s area, the state will hold on to the money in an interest-bearing account until the next open enrollment season. Then, the person has another chance to buy insurance. If at this time they don’t purchase a plan, the state will deposit the money into an insurance stabilization fund.


Politics And Policy On The Ground

Maryland is fertile ground for such health care experiments. The ACA remains popular within the state. Polling commissioned by DeMarco’s group puts the law’s support at 62 percent.

In addition, about 52 percent of Marylanders favored a state-based individual mandate, to make up for the federal provision that was repealed.

Democrats control the general assembly, but Gov. Larry Hogan, a Republican, has not offered a specific position on the issue — rather, he alluded to health reform efforts in his State of the State address. “Let’s develop bipartisan solutions to stabilize [health insurance] rates,” he said.

Ed Haislmaier, a senior research fellow at the Heritage Foundation, expressed skepticism about whether this approach will make a difference. The people who are targeted, he argued, are younger, healthier and generally lower-income. They don’t have insurance because they don’t want it, he suggested.

Jason Levitis, a senior fellow at Yale Law School’s Solomon Center for Health Law and Policy who has been instrumental in helping states craft their own versions of the individual mandate, warned that Maryland’s approach could face administrative challenges.

States that follow an approach more closely modeled after the federal mandate, he said, will have an easier time implementing it because regulators have already had five years of experience enforcing it.

Still, Levitis praised the Maryland plan: “There’s something attractive about the idea there, that you put this money … towards coverage.”

And a sampling of state proposals highlight a common theme.

“All the mandate efforts are based on the federal one,” Levitis said. “The variations are what you put on top, [how states] individually keep track of the money people pay and use it for health care services.”

He pointed to Connecticut as an example. It has two bills pending in its legislature — one that closely mirrors the federal mandate, but with slightly lower fines, and another in which the fines would be deposited into health savings accounts for the individuals.

In New Jersey, a Senate panel advanced a two-bill approach this week that would collect a fee from residents who opt against buying health insurance. These fines would then be used to help pay the health care claims of people who are catastrophically ill.

In the District of Columbia, a health care working group recommended an individual mandate nearly identical to the federal one. The plan would require City Council and congressional approval to become law.

Washington state has convened a group to study how to enforce a mandate.

Meanwhile, Maryland officials also hope to learn from the experiences of other states.

For instance, lawmakers in Maryland are considering the creation of a state-based, basic, low-cost health plan as well as a fund to help insurers cope with the burden of very high-cost patients.

These efforts also come from the work of the commission.

Stan Dorn, a senior fellow with the pro-Obamacare group Families USA, said Maryland “had the foresight to see threats coming and to try to be proactive about it.”

Senators Push Back On Attacks On Obamacare Bills

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Source: Washington Examiner

A supporter of two Obamacare stabilization bills cited a new analysis showing premiums will decrease due to the legislation amid attacks from outside groups that call the bills “bailouts.”

Sen. Lamar Alexander, R-Tenn., pointed Monday to a new analysis from the consulting firm Oliver Wyman showing the two bills lower premiums by more than 40 percent on the individual market, which is used by people that don’t have insurance through the government or a job and includes Obamacare’s insurance exchanges. Alexander also bristled at the notion the two bills are a “bailout” for insurers, an attack leveled by outside conservative groups Monday.

“I can assure you that President Trump is not about to support anything that is a bailout for insurance companies, nor will I, nor will Sen. Murray,” Alexander said, referring to Sen. Patty Murray, D-Wash., who is a co-sponsor with him on one of the bills.

Alexander and Murray co-sponsored a bill that funds cost-sharing reduction payments for two years in exchange for giving states more latitude to waive Obamacare regulations. Sens. Bill Nelson, D-Fla., and Susan Collins, R-Maine, sponsored another bill that gives states $10 billion over two years to create reinsurance programs that cover the highest claims from Obamacare insurers, who in return lower premiums overall.

The senators behind the bills have sought to put them into a two-year spending bill called an “omnibus,” which congressional negotiators are hammering out now.

“My hope is it will be added to the omnibus,” Alexander said. “That will be up to the Democratic and Republican leaders. I hope they will be.”

But a collection of outside conservative groups including Heritage Action, Club for Growth, and FreedomWorks argued in a letter to Congress Monday for not including the bills in the omnibus.

The groups called the bills taxpayer-funded “bailouts” of Obamacare and sought to downplay whether they will have any impact on federal spending.

Alexander shot back when asked about the “bailout” moniker by pointing to the recent analysis from Oliver Wyman.

The analysis looked at funding cost-sharing payments and providing $10 billion annually for reinsurance in 2019, 2020, and 2021. It found that both bills combined would result in a 40 percent decrease in premiums on the individual market, coupled with 3.2 million more people getting coverage in the market.

The consulting firm used a simulation model to look at the likely effect of the impact of the two bills. It also took into account the additional flexibility for states to relax Obamacare insurer regulations.

“In those states that are not able to obtain a … waiver and take advantage of pass-through savings for 2019, we estimate that premium would decline by more than 20 percent across all metal levels,” the analysis said. “Those estimates include an average 10 percent reduction due to the funding of CSRs, with the remaining reduction coming from the reinsurance program.”

Trump threw his support behind the bills last year in an effort to get Collins on board for tax reform. Senate Majority Leader Mitch McConnell, R-Ky., agreed to bring up both bills for a vote in the Senate.

While the bills have enough support to get through the Senate, there is rampant opposition among House Republicans who believe the bills are propping up a law they say is collapsing.

Alexander said on Monday the bills are needed as a bridge to whatever Congress comes up with on Obamacare.

“What we are trying to do is identify a temporary solution, in the president’s word, to keep people from being hurt over the next few years while Congress decides what to do permanently,” he said.

Covered California Looking at Huge Rate Hikes

Image result for Covered California huge rate hikes imagesSource: San Francisco Chronicle

Across the country, people who buy health insurance on exchanges could see their premiums rise between 12 and 32 percent in 2019, according to an analysis released Thursday by Covered California, the state exchange that sells insurance to 1.2 million residents who don’t receive health coverage through their employers.

Covered California did not break out 2019 projections for California. An analysis last month from the Urban Institute estimated that premiums in California will rise 18 percent in 2019.

“Consumers will see a premium increase show up on notices in September and October for their January 2019 premium,” said Peter Lee, executive director of Covered California.

Prices for insurance will continue to rise after that, Covered California’s analysis predicts. California is among 15 states that are expected to see premiums jump 35 percent by 2021, compared with current rates. Nineteen states could see premium hikes of 50 percent. And 17 states could see a whopping 90 percent increase in insurance premiums.

These rate increases apply to the roughly 10 million Americans who receive federal subsidies to help pay for premiums, as well as the 6 million who do not. The former group may be sheltered somewhat from the price increases because their subsidies should go up as well; the latter group will be hit harder because they earn too much to qualify for this financial assistance.

States like California that have a large number of people enrolled in insurance in the individual market, and a relatively healthy risk pool, are more likely to be in the lower range of the impending increases. California has one of the lowest percentages of people with chronic conditions in its exchange because overall enrollment, including healthy people, is higher than that of most states.

Since 2014, the year Covered California began, insurance premiums rose an average of 4 percent in each of the first two years, 13 percent in 2017 and 12.5 percent in 2018.

The predicted increases are driven by the rising cost of medical care, paired with actions taken by Congress and the White House since 2017 that have injected uncertainty in the insurance market. The individual mandate, the requirement under the Affordable Care Act to buy insurance or pay a tax penalty, will no longer be in effect starting in 2019 because Congress repealed the mandate as part of a tax bill passed in December. The elimination of the mandate will drive premiums up between 7 and 15 percent in 2019, according to Covered California’s chief actuary John Bertko, who wrote the analysis. The underlying medical trend rate accounts for another 7 percent increase each year.

The Trump administration has also loosened regulations around the sale of cheaper, less comprehensive insurance plans. Experts predict this will separate the individual market into two pools: healthy people who will gravitate toward the less expensive, less comprehensive plans, and sick people who will be left paying costlier premiums because they need more protective plans.

Villaraigosa is Right, Single-Payer Healthcare in California is a Political Pipe Dream

Image result for Villaraigosa imagesSource: Los Angeles Times

Antonio Villaraigosa thinks he has a solid weapon to hammer Lt. Gov. Gavin Newsom with as they run for governor. And he probably does.

It’s Newsom’s strong support for creating a state-run, single-payer health insurance program.

That may sound too wonky and eye-glazing for use as campaign ammunition. But it could get attention if more voters learn that the current single-payer bill pending in the Legislature would require a dramatic doubling of state taxes plus Sacramento taking over popular federal Medicare.

It also would necessitate the Trump administration and the Republican Congress cooperating with this state’s liberal leadership. The feds would need to turn over to the state all the Medicare and Medicaid money it spends in California — about $150 billion annually. Fat chance.

In all, a state-operated, single-payer healthcare plan would cost around $400 billion a year, according to objective analysis. Let’s put that in perspective: Gov. Jerry Brown’s total state spending proposal for the next fiscal year is less than half that amount — $190 billion.

So fiscally and politically, the notion of a state single-payer system is a pipe dream.

“They’re selling snake oil,” says Villaraigosa, a former Los Angeles mayor and state Assembly speaker.

Newsom, a former San Francisco mayor, calls Villaraigosa a “defeatist” who lacks political courage and bold leadership. On his campaign website, Newsom promises to “lead the way on a plan to guarantee quality healthcare for everyone financed through a single-payer model like Medicare.”

“Medicare-for-all” is a cause championed by Sen. Bernie Sanders of Vermont. It’s also a holy grail for the politically aggressive California Nurses Assn., which has endorsed Newsom.

Nationally, covering all Americans under Medicare while allowing them to buy supplemental private insurance probably makes sense. But that’s not what is being proposed in California, principally by the nurse’s union.

In fact, the legislation would eliminate Medicare for 6 million senior citizens and place them in a new state plan that covers every California resident. There’d be just one single payer for all healthcare: the state government.

Look, federal Medicare works pretty well. We don’t hear many complaints from beneficiaries. Why would anyone covered by it want the program handed over to Sacramento? And I can’t imagine the federal government agreeing to it.

Villaraigosa challenged Newsom last week to a one-on-one debate over state-run, single-payer healthcare. It’s the issue that provokes the sharpest clash between the two Democratic front-runners to replace the termed-out Brown.

We should be thankful. This is about important substance, not platitudinous fluff. And it might instruct us about how a candidate would govern — not only on this issue, but generally.

Villaraigosa is positioning himself in the race as a center-left moderate and emphasizing that the former San Francisco mayor is, well, a San Francisco liberal.

“Enough with the slogans,” Villaraigosa said. “It’s time to… have a serious in-depth discussion.”

The odds on Newsom agreeing to a debate are practically zilch. But he should. Healthcare is a topic worthy of a separate debate, not just relegated to a one-minute answer in a typical campaign forum. And, of course, the other candidates should be invited too.

Frankly, it’s hard to tell where state Treasurer John Chiang stands on the single-payer bill. The Democrat says he’s for the concept but is leery of the specific legislation. Democrat Delaine Eastin, a former state schools chief, is adamantly for the measure.

At issue is the bill, SB 562, that passed the Senate last year and soon was shelved by Assembly Speaker Anthony Rendon (D-Paramount). “Woefully incomplete,” the speaker said. The nurses’ union started trying to recall him but didn’t get far.

“Incomplete” was an understatement. The measure didn’t have a financing plan, healthcare delivery details or cost controls. But it envisioned medical coverage for everyone, including immigrant adults in the country illegally. There’d be no co-payments or deductibles.

It was one of the most irresponsible major bills to pass a house of the California Legislature in decades.

Most Senate Democrats voted for the bill. Four did not. All Republicans were opposed.

The measure was written by Sen. Ricardo Lara (D-Bell Gardens), who’s running for state insurance commissioner with the nurses’ backing, and incoming Senate leader Toni Atkins (D-San Diego). Atkins acknowledged recently that the bill is unlikely to be passed this year in the Assembly. It’s an election year, after all, and this bill is politically risky.

Studies by the Senate Appropriations Committee and the nonpartisan Legislative Analyst’s Office pegged the annual cost at $400 billion.

Currently, various governments kick in around $200 billion annually for healthcare in California. Of that, the feds spend $150 billion. If all that could be corralled into one Sacramento pot — extremely unlikely — the state would still need to raise another $200 billion.

Private employers could be taxed. They’d no longer have to provide workers with medical insurance. But the state still would need to raise an additional $100 billion in taxes from Californians, give or take.

Newsom continually points to a San Francisco universal healthcare program created when he was mayor as proof that he can make a single-payer plan work for all California. But equating that little San Francisco program with a massive statewide undertaking is like comparing kids’ T-ball to the major leagues.

Villaraigosa says he favors universal healthcare nationally but doesn’t have a clue how a single-payer plan could work in just one state.

“Nobody does,” he says. “That’s a fact.”

Chalk up some points for Villaraigosa.

Buried In The Budget Bill Are Belated Gifts For Some Health Care Providers

Image result for repeal of a limit on Medicare coverage of physical and occupational therapy. images

Source: Kaiser Health News

When President Donald Trump signed the last-minute budget deal into law earlier this month, the news coverage emphasized how the bill boosted military funding, provided tens of billions in disaster aid and raised the debt ceiling.

But buried deep in the 652-page legislation was a repeal of a limit on Medicare coverage of physical and occupational therapy. It received little public attention, but to the American Physical Therapy Association, this headline was decades in the making.

The group had spent 20 years lobbying to reverse a component of the Balanced Budget Act of 1997, which would have limited patients to $2,010 worth of occupational therapy a year, and another $2,010 of physical therapy and speech-language pathology. Each time the limit was about to kick in, APTA managed to postpone its implementation — sometimes for just months, sometimes for another year or so.

Justin Moore, APTA’s CEO, quit his job as a physical therapist in Missouri and moved to Washington, D.C., in 1999 specifically to lobby Congress full time about staving off these so-called therapy caps. He recalls recruiting thousands of physical therapists to protest on Capitol Hill, long hours lobbying in congressional offices and eleventh-hour victories to keep the cap from taking effect.

Just hours after Trump signed the sweeping bill, Moore joked: “I’ve got to figure out what to do next,” celebrating the victory with cupcakes in his Virginia office.

It’s a story of one long-fought battle, marked by legislative twists and convolutions, procrastination and budgeting witchcraft. But it provides a window into the bizarre world of the way much of health care financing gets done in Washington — as an afterthought and via backroom negotiations.

“This is a miniature version of what we also have as the inefficiencies of health policy and health care,” said Thomas Miller, a resident fellow at the conservative American Enterprise Institute, a Washington think tank. “We do a lot of things that burn up resources and energy, and we treat them as a big deal, and that tends to keep you down in the trenches, shooting at things in front of you and not looking at the larger picture.”

In their enthusiasm to pass a budget this month, Congress included permanent dissolution of the therapy caps — 277 pages into the bill. The bill contained several other measures meant to placate medical constituencies by fulfilling their financial requests: for instance, forestalling payment cuts to so-called Disproportionate Share Hospitals, which treat higher proportions of low-income patients, and continuing a payment bump to certain rural home health providers.

The therapy cap came as an amendment to the 1997 budget bill, part of a “big push to reform entitlements,” recalled Katherine Hayes, health policy director at the D.C.-based Bipartisan Policy Center, who worked at the time for Rhode Island Republican Sen. John Chafee, then the chair of the Senate subcommittee on health care.

Its inclusion was somewhat arbitrary — “an assignment … to get some savings in the health sector,” recalls Sen. Ben Cardin (D-Md.), who at the time was a junior member of the House Ways and Means Committee, where the proposal originated.

Others recalled some concern that Medicare was paying too much for physical therapy and a hope that limiting coverage might help control these costs.

Since lawmakers “had to reach the target [for savings], it went into the package. Once it went into the package, it was enacted and became law,” said Cardin, who has introduced numerous bills over the years attempting to repeal the caps.

Almost immediately, backlash came from a small but impassioned therapy contingent, willing to devote the bulk of its lobbying resources to this one issue, with effect. Lawmakers on both sides of the aisle balked when it came to actually implementing the caps.

Over the years, that resistance translated into Capitol Hill rallies, starring speakers such as Maine Republican Sen. Susan Collins, who would wear and remove baseball caps — metaphorically “lifting the cap,” Moore recalled. It also meant full-court-press phone-a-thons from the nation’s physical therapy community, calling on Congress to extend the delay, usually by attaching legislative language to whatever must-pass spending bill or health care funding measure was moving through the pipeline.

The therapy lobby kept the legislative patches going, but efforts always stopped short of a full repeal, many recalled. This solution allowed lawmakers to have it both ways: They did not have to take a generous popular benefit, physical therapy, away from voters. But they continue to support a budget amendment aimed at taming runaway spending.

“For a number of years, we thought [the cap] was not a thoughtful approach,” said Cybele Bjorklund, who worked from 1995 to 2015 as a Democratic staffer in Congress. “Many Republicans also realized pretty early on this was not good policy. But again — nobody wanted to then pay to get rid of it.”

And so, sidestepping imposition of the therapy cap was achieved by adding the delay into a hodgepodge of small health initiatives, known as the “extenders,” which are addressed every few years. In 2006, Congress switched from delaying the cap to simply allowing for easy exceptions for patients who needed therapy beyond the stipulated limits.

On the balance sheet for the budget bill that passed this month, the nonpartisan Congressional Budget Office estimated the permanent therapy cap repeal will cost more than $6 billion over the next decade.

A Few Hiccups And, Ultimately, Repeal

The ups and downs of the therapy cap provision kept APTA in business — providing fodder to mobilize their members and resulting in increasing lawmakers’ interest in a permanent deal, Moore said. Political gamesmanship and partisan bickering resulted in brief lapses — in late 2003, for a month in 2006 and in early 2010 — when lawmakers failed to patch together a bill in time.

Meanwhile, the estimated cost of forestalling or mitigating therapy caps grew more expensive each time around.

An effort to incorporate repeal of the caps into the 2010 Affordable Care Act failed, partially, Bjorklund recalled, because Democrats wanted the sweeping health law as a money saver. That meant every penny counted, and even a few billion dollars represented deadweight.

In 2015, a proposed Senate amendment to a larger bill on doctor paymentsagain would have ended the therapy caps. It was ruled out of order after falling two votes short of a motion to waive concerns about its relevance.

That exhaustive 20-year effort laid the groundwork for this month’s deal. When Bjorkland heard that therapy caps could be on the table for this year’s budget bill?

“I remember saying, ‘Please, just get rid of it, will you? Finish it off!’” she said.

Congress Races The Clock In Quest To Bring Stability To Individual Insurance Market

Image result for stabilize the individual insurance market. imagesSource: Kaiser Health News

Congress is running out of time if members want to come up with legislation to stabilize the individual insurance market.

While Republicans and Democrats still feud over the fate of the Affordable Care Act, a bipartisan group of senators and House members has been working since last summer on measures to keep prices from rising out of control and undermining the individual market where people who don’t get insurance through work or the government buy policies.

They hope to attach a package of fixes to what should be the year’s final temporary spending bill, due in late March.

The lawmakers are up against not just the legislative clock, but also the insurance companies’ timeline. Insurers have until summer to decide if they want to continue to sell policies in the ACA marketplaces, but many start making preliminary decisions as early as April.

In the absence of congressional action, insurers say premiums will go up in 2019 due to the uncertainty — raising costs for consumers and the government.

It is by no means clear whether any package could gain the votes needed in the House and Senate. Most Republicans are loathe to be seen “fixing” Obamacare, although opinion polls clearly show they will be blamed for problems with the law going forward.

The bipartisanship extends beyond Capitol Hill. Last week five governors (three Democrats, one Republican and one Independent) released a blueprint for a health system overhaul that includes several of the stabilization ideas under consideration in Congress.

About 18 million people buy their own policies, both inside and outside the ACA insurance marketplaces.

Lawmakers are looking at two primary fixes, although they could be combined.

One, pushed by Sens. Susan Collins (R-Maine) and Bill Nelson (D-Fla.), is called “reinsurance.” It is a way to guarantee the insurance companies do not face large losses. The idea is that if insurers don’t have to worry about covering the expenses for their highest-cost patients, they can keep premiums lower for everyone.

The ACA actually had a temporary reinsurance program from 2014 to 2016. It was intended to help insurers get started in a market where sick people were able to buy their own insurance for the first time. Prior to the law, most insurers did not cover many people with preexisting health conditions. If they did, it was at an extremely high cost.

Since the federal program ended, several states, including Minnesota and Alaska, have adopted, with some success, their own reinsurance programs in an attempt to hold premiums down.

The other proposal, negotiated by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would guarantee insurers federal reimbursement for so-called cost-sharing reduction subsidies. Those are discounts that the ACA requires insurers to provide to their lower-income enrollees to help reduce their deductibles and other out-of-pocket costs. President Donald Trump cut off federal reimbursement of those payments in October.

Senate Majority Leader Mitch McConnell (R-Ky.) pledged to Collins in exchange for her vote on the GOP tax plan in December that he would support bringing both bills to the floor for debate.

That has not happened, although in a statement, Collins said she is “continuing to have productive discussions” with Senate and House leaders about both bills.

Meanwhile, a lot has changed, including new questions about whether the fixes would work.

For starters, state insurance regulators managed to find a workaround for Trump’s sudden cancellation of the federal cost-sharing payments. Most states allowed insurers to offset the loss of these funds by increasing the premiums for the “silver” level plans that determine how much help enrollees get to pay those premiums. So the increases end up being paid by the federal government anyway, through higher premium subsidies. The result is that most people who get government help pay the same (or, in some cases, less), while insurers are effectively being paid back for the discounts, albeit through a different mechanism.

That means, however, if the cost-sharing reduction payments were reinstated for 2018, as the original legislation called for, insurers would have to give the excess money back to the government.

Analysts agree that would only add to the confusion.

Restoring the federal payments for this year, said Joseph Antos of the conservative American Enterprise Institute, “does not lower premiums this year, so it does absolutely no good to the average person.”

Some advocates have suggested that Congress should guarantee the payments for 2019 and 2020. But Antos said that “also makes no sense, because the insurers would then think ‘Are we going to go through this again?’”  They might raise premiums even more to make up for the uncertainty.

Antos  — and many other analysts — agree that restoring or creating a new reinsurance program would likely do more to control premium increases.

Reinsurance “will protect premiums for the people who are actually most subject to them,” said Sherry Glied, a former Obama administration health official now at New York University. She was referring to those in the individual market who do not get government help and have been footing large premium increases for the past several years. That’s because having protection against the largest bills would allow insurers to lower premiums across the board.

Then there are the political considerations.

Many Republicans in Congress have called the cost-sharing reduction payments in particular a “bailout” to the insurance industry, and are resistant to reinstate the payments.

Republicans seem more amenable to the idea of reinsurance, because they consider it a type of “high risk pool,” which they have been pushing for years. House Speaker Paul Ryan said at an event in Wisconsin in January that “I think there might be a bipartisan opportunity there to get risk pools, risk mechanisms.”

But Republicans have made clear they want something in return for what could be considered a “fix” to the health law they despise.

Health and Human Services Secretary Alex Azar was careful to say in a meeting with reporters last week that the Trump administration has no formal position yet on the stabilization efforts.  But, he said, “I think it would need to be part of an entire set of reforms there that we would want to see.” That would likely include more flexibility for states to opt out of some of the health law’s coverage requirements.

The delay has made Democrats more demanding, too. The repeal of the ACA’s penalties next year for people who don’t have insurance has changed the situation dramatically, said Sen. Murray.

“As I have made clear, the bipartisan bill I originally agreed on with Chairman Alexander will not make up for this latest round of Republican health care sabotage,” she said in a statement. “In fact, there are changes that now need to be made to our bill to ensure it meets its intended goals of keeping premiums down and stabilizing markets.”

But while Congress decides if it will take action, insurers are warning that doing nothing will lead to still higher premiums.

Premium rates for a “benchmark” silver plan could rise by 27 percent in 2019, the Blue Cross Blue Shield Association said earlier this month.

Congressional action on reinsurance and cost-sharing, the association predicted, would help push premium rates 17 percent below this year’s levels.

“Health plans are looking for certainty in the market,” said Justine Handelman, senior vice president in the association’s policy shop.

Ideally, Congress would include the funding in measures adopted in February or March, said Handelman, who spoke with reporters during a briefing at the association’s Washington, D.C., headquarters: “Most plans are filing premium rates by April.”

Democrats Considering A New Strategy To Expand Health Coverage As Frustrations Build With Obamacare

Image result for Democrats Considering A New Strategy health care imagesSource: Los Angeles Times

After spending most of 2017 defending the Affordable Care Act from GOP attacks, a growing number of Democrats believe the law’s reliance on private insurance markets won’t be enough and the party should focus instead on expanding popular government programs like Medicare and Medicaid.

The emerging strategy — which is gaining traction among liberal policy experts, activists and Democratic politicians — is less sweeping than the “single-payer” government-run system that Sen. Bernie Sanders (I-Vt.) made a cornerstone of his 2016 presidential campaign.

Many Democrats still fear such a dramatic change would disrupt coverage for too many Americans, but they have also concluded that the current law’s middle-ground approach to build on the private insurance market — originally a Republican idea — isn’t providing enough Americans with adequate, affordable health coverage.

These Democrats see the expansion of existing public programs as a more pragmatic and politically viable way to help Americans struggling with rising costs and correct the shortcomings of the 2010 law, often called Obamacare.

“What is clear is that the Democratic Party as a whole is coming to the conclusion that stand-alone private market solutions to healthcare do not achieve affordability and coverage for all,” said Chris Jennings, an influential Washington health policy advisor who worked for Presidents Clinton and Obama.

“But there is a recognition that you can’t just snap your fingers and have political consensus. … And one of the lessons learned from 2017 is that you better do your homework.”

Democrats are eager to avoid mistakes made by Republicans, who proved unprepared last year as they struggled unsuccessfully to fulfill their years-long promise to repeal the current health law.

Developing a new healthcare agenda doesn’t promise to be easy, as liberal activists and others in the progressive wing of the Democratic Party remain committed to the single-payer solution championed by Sanders and may resist more incremental steps.

At the same time, even more modest moves to build on Medicare or Medicaid will face opposition from hospitals, drugmakers and others in the industry who fear that government health plans would pressure them to accept lower prices.

And no one expects any Democratic plan to go anywhere as long as Congress remains in Republicans’ hands and Trump holds a veto pen.

But in the wake of widespread public rejection of GOP healthcare proposals last year, Democrats see an opportunity to seize the initiative and advance the party’s long-held dream of universal health coverage.

“We’re on offense on healthcare,” said Brad Woodhouse, campaign director for Protect Our Care, an advocacy group formed last year to fight the GOP effort to roll back the 2010 health law. “We need to make healthcare the No. 1 issue.”

Speaking to a recent conference organized by Families USA, a leading national patients’ rights group, Woodhouse cautioned, however, that Democrats must offer voters more than just a defense of the current law.

In recent months, Democratic lawmakers on Capitol Hill have filed a growing number of bills that would expand eligibility for Medicare or Medicaid, which currently limit coverage to qualifying elderly, disabled or poor Americans. The two mammoth government programs are much cheaper than commercial insurance, in large part because they pay hospitals and other medical providers less.

In January, a group of influential liberal health policy experts gathered in Washington to explore these proposals, which typically would allow younger, wealthier consumers to “buy into” one of the two programs.

At the same time, Democratic leaders in several states, including California, New York and New Mexico are exploring state-based initiatives to expand government health plans.

And last week, the Center for American Progress, a leading liberal think tank, released a plan to open up Medicare to all Americans, while still giving workers the option to stick with coverage offered through an employer.

“Democrats have mostly been trying to keep Republicans from repealing the current law,” said Sen. Tim Kaine (D-Va.). “Now we need to come up with the next set of ideas about how to improve coverage and affordability.”

Kaine and Sen. Michael Bennet (D-Colo.) are cosponsoring yet another proposal — which they call Medicare X — for a new government program based on Medicare, particularly for consumers in parts of the country with limited commercial options.

The renewed interest among Democrats in government health insurance has buoyed the hopes of those who support a more ambitious push to create a single public health plan for everyone.

“What has been happening in the last few years is that millions of working people and young people are getting involved in the party … and the grassroots movement is overwhelmingly clear about what it wants from healthcare,” Sanders said in an interview.

“That means that the debate over Medicare-for-all changes, and I think that is what is happening now.”

Indeed, Sanders’ Medicare-for-all bill, which would create a new government plan like Medicare for everyone, has drawn support from nearly every major Democrat in the Senate who is expected to seek the 2020 presidential nomination.

But many Democrats who aspire to something like Sanders’ proposal still worry about the cost and disruptions that would likely be necessary to create a large new government plan for everyone.

“I share the desire for universal coverage,” said Bennet. “The question is what approach is more practical to achieving that objective.”

Nearly a decade ago, Democratic leaders, concerned about the politics of expanding government health plans too aggressively, created the Obamacare insurance marketplaces, which rely on private insurers to provide coverage for Americans who don’t get health benefits through an employer or through a government program.

Democrats even rejected a proposal for a limited government plan to be sold on the marketplaces as a “public option.”

But the ceaseless GOP attacks on the marketplaces, which had been a conservative idea, and the failure of private health insurers to make more affordable plans available — even before Trump took office — has caused more Democrats to back a bigger role for government.

“That is a huge shift,” said Jacob Hacker, a Yale political scientist who helped develop the public option proposal.

Further emboldening Democrats is growing evidence that the public overwhelmingly supports existing government health plans, especially in the face of GOP threats to scale them back.

Eight in 10 Americans held a positive view of Medicare in a recent nationwide poll by the nonprofit Kaiser Family Foundation.

And majorities of both parties favor allowing more people to buy into the program, the survey found.

Medicaid enjoys similarly broad support, with three-quarters of Americans expressing a favorable view.

By contrast, the GOP proposals to roll back the 2010 health law and slash funding for Medicaid were overwhelmingly unpopular, drawing support from just one in five Americans in several nationwide polls.

Even supporters of this emerging Democratic healthcare agenda acknowledge it will take years to develop and may not be fully debated until the campaign for the 2020 Democratic presidential nomination gets underway next year.

But many say it is not too early to begin planning.

“We saw support for Medicaid [during the 2017 GOP repeal push] that took even many longtime Medicaid advocates by surprise,” said Rep. Ben Ray Lujan (D-N.M.), who is sponsoring a proposal with Sen. Brian Schatz (D-Hawaii) to allow people to buy into the Medicaid program.

“There is an opportunity now to build on that momentum,” Lujan said.

Big Pharma’s Lobbyists Are Losing Despite Their ‘pass the buck’ Campaigns

Image result for big pharma images

Source: The Hill

As policymakers and the administration focus on high drug prices, the brand drugmaker lobby has responded by unleashing millions of dollars in an attempt to shift blame.

They’ve blamed price gouging scandals on a “broken system” and claim to want to reform. They bankroll more than 1,400 lobbyists along with many “patient groups” and so-called “experts” to carry these messages to the media outlets and politicians on whom they lavish millions in advertising dollars and campaign contributions.

However, their polling numbers remain as low as before their advertising blitz began as Americans have overwhelmingly negative views of drugmakers and the pricing schemes of “Pharma Bro” Martin Shkreli and others who increased drug prices simply because they found that they could.

The response from the drugmaker lobby has been to rollout slick public relations slogans like “Share the Savings” and “Let’s Talk About Cost” that use fancy infographics in an attempt to move the conversation away from those setting the price of the drug (drug companies) to everyone else who uses or pays for their products, like employers, hospitals, pharmacy benefit managers, insurers, and others.

This isn’t surprising and certainly not unpredictable, but ignores the basic challenge facing drug companies: no amount of money can change the fact that Republicans and Democrats know the problem is high drug prices and that drugmakers alone set those prices.

So despite all this overwhelming lobbying and financial firepower, the question remains: Why are drugmakers losing?

In the recent budget bill, drugmakers were singled out by both parties to pay billions more in discounts to help seniors in the Medicare prescription drug benefit “donut hole.”

This comes as states across the country are taking a harder look at drugmaker pricing schemes and passing legislation in California and Nevada that faced significant pushback from drug companies (and their surrogates).

Like the emperor who wore no clothes, drugmakers have confused politician’s fear of speaking out against them with support for their pricing practices. It appears that most politicians will tolerate, but not believe in the drug lobby’s messages or goals.

Drug manufacturers have a number of options to alter public perception of their pricing strategies. They can assert that their products are a great value at any price but there is definitely a level where that argument fails. They can also compete on price and refrain from automatic pricing increases that obviously impact healthcare affordability.

Instead, they peddle distracting narratives and government mandates that undermine federal programs and result in huge industry profit windfalls. One recent example would be to prevent brand discounts and rebates from being used to lower premiums for seniors.

According to the White House’s budget proposal, this mandate alone would cost the government about more than $42 billion and lead to higher premiums for Medicare beneficiaries.

This is yet another distraction from the real problem of excessive drug pricing. If the drugmakers were truly concerned about affordability, the drug companies would simply reduce their prices. That would have a direct impact on the cost of health care to every American consumer.

Simply put, drugmakers have failed to give policymakers the one thing they need: real solutions that reduce costs. They’ve offered no solutions that score savings — in fact, they all raise costs.

Their relentless, ongoing PR blitz is simply an effort to pass the buck and direct attention away from their pricing strategies. The drug lobby has underestimated the one politician, with whom their money and power doesn’t carry much weight: President Trump. It was only last year that he said drugmakers were “getting away with murder.”

If the record is any indicator, he still thinks Big Pharma is one of the creatures lurking in the swamp he intends to drain.

Last Updated 03/14/2018

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