Pelosi Drug Plan Saves $345B but Could Reduce Flow of New Drugs

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Source: FierceHealthcare

House Speaker Nancy Pelosi’s drug prices plan would reduce Medicare spending by $345 billion over a seven-year period but could also impact the number of new drugs entering the market, according to an analysis from the Congressional Budget Office.

The analysis centers only on how the bill, which gives Medicare the power to negotiate lower drug prices, will save money on Medicare Part D. The bill would enable Medicare to negotiate for a lower drug price that is 120 times an average paid by other countries.

“The largest savings would come from the lower prices for existing drugs that are sold internationally, for which the price ceiling would be binding in most but not all cases,” said the CBO analysis, which was released late Friday.

Pelosi’s plan would also require drug companies to offer the negotiated Medicare price to commercial plans.

While CBO acknowledges that the bill could force drug companies to pull out of the U.S. market entirely, the nonpartisan congressional scorekeeper speculated that would be unlikely for all drugs being sold in the U.S.

“Manufacturers would initially set list prices of some new drugs in the U.S. higher than under existing law, although the net prices paid by consumers over time could be lower in many cases,” the CBO said.

However, CBO also estimates that any cut in manufacturer revenue “would result in lower spending on research and development and thus reduce the introduction of new drugs.”

That estimate would be welcome news to the pharmaceutical industry, which has said that Pelosi’s bill would stifle innovation. Impact on R&D funding is a common defense the industry uses to attack drug pricing policies.

CBO’s preliminary estimate said that a reduction in revenue of $500 billion to $1 trillion “would lead to a reduction of approximately eight to 15 new drugs entering the market the next 10 years.”

The Food and Drug Administration on average approves about 30 new drugs a year, so CBO estimates that about 300 drugs might be approved over the next 10 years.

“The overall effect on health of families in the United States that would stem from increased use of prescription drugs but decreased availability of new drugs is unclear,” the agency added.

It remains unclear whether Pelosi’s bill would make it through Congress. Lawmakers return from a two-week recess on Tuesday and a top Pelosi health aide has said he expects the bill to be voted on by the end of the month.

But the bill is likely to face a steep challenge in the GOP-controlled Senate, where Majority Leader Mitch McConnell has called it a Socialist proposal.

However, President Trump has previously shown a desire to let Medicare negotiate drug prices and his administration has issued a proposal that would tie the prices for certain Medicare Part B drugs to those paid by other countries.

Support Drops for ‘Medicare for All’ but Increases for Public Option

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Source: The Hill

Support is dropping for Sen. Bernie Sanders “Medicare for All” health care plan, according to a poll released Tuesday.

The Kaiser Family Foundation tracking poll found that 51 percent of those surveyed in October favored Medicare for All, a proposal in which all Americans would get their insurance from a single government plan, compared to the 53 percent who said they supported it last month.

Conversely, 47 percent of those surveyed said they opposed Medicare for All, an increase of 2 percentage points from September.

Support for Medicare for All has dropped 5 percentage points since April in the Kaiser Family Foundation tracking poll, and opposition has grown by 8 points.

Medicare for All has been a source of contention among Democrats running for president and it is likely to come up again during Tuesday’s debate in Ohio.

While Sanders and Sen. Elizabeth Warren (D-Mass.) support the plan, former Vice President Joe Biden and other moderates oppose it, arguing it would eliminate choice for Americans who prefer private health insurance.

Biden has opted for a more moderate proposal that would create a public option to compete with private insurance companies.

The Kaiser Family Foundation tracking poll found support for a public option is growing: 73 percent said they supported the proposal in October, compared to the 69 percent who said the same in September.

Independent and Republican respondents were more likely to support a public option than Medicare for All.

While only 28 percent of Republicans polled said they support Medicare for All, 58 percent said they support a public option, indicating Biden’s plan might fare better in a general election.

Meanwhile, 50 percent of independents polled said they support Medicare for All, but 73 percent said they support a public option.

The tracking poll has a margin of sampling error of 3 percentage points and was conducted Oct. 3-8 among a nationally representative sample of 1,205 adults.

More Middle-Income Californians Can Now Get Health Insurance Subsidies

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Source: San Francisco Chronicle

Open enrollment for Covered California, the state marketplace that sells subsidized health insurance to Californians who do not get insurance through their employer, begins Tuesday and ends Jan. 31.

Those who sign up by Dec. 15 will have their health coverage take effect Jan. 1. Those who sign up from Dec. 16 to Jan. 31 will have coverage take effect Feb. 1.

About 235,000 middle-income Californians will be newly eligible for financial assistance in 2020 because California will be providing state subsidies for the first time. Until now, people bought plans with the help of federal subsidies, which are available for individuals who make roughly $17,000 to $50,000 a year, or 138% to 400% of the federal poverty level.

The new state subsidies will be available for people who earn $50,000 to $75,000 per person, or 400% to 600% of the federal poverty level. The exact amount a person gets in subsidies is tied to income; the higher the income, the lower the subsidy.

About 1 million Californians currently receive federal subsidies to buy insurance. About 663,000 of them are now eligible to receive an additional state subsidy, but the exact amount will depend on their age and how much health care costs in their region. Covered California officials estimate that the average state subsidy this group will receive is $15 per household per month, on top of the federal subsidy they currently receive.

The state subsidies will cost California about $429 million in 2020, and officials expect much of that amount — $317 million — to come from new tax penalties paid by people who don’t buy health insurance.

California has a state individual mandate, which takes effect in 2020, requiring people to buy insurance or pay a penalty of $695 per adult and $347.50 per child, or 2.5% of annual household income, whichever is higher, to the Franchise Tax Board. The move is in response to Congress repealing the federal individual mandate, required under the Affordable Care Act, in 2017.

Average premiums for Covered California health plans are expected to rise less than 1% in 2020.

Think ‘Medicare For All’ Is The Only Democratic Health Plan? Think Again

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Source: Kaiser Health News

If you tuned in for the first five nights of the Democratic presidential debates, you might think “Medicare for All” and providing universal care are the only health care ideas Democrats have.

With four months to go before the Feb. 3 Iowa caucuses, proposals on issues like the opioid epidemic have attracted less attention.

That is because big-ticket policy ideas ― like enrolling all U.S. residents into a Medicare-style program and eliminating private insurance ― can help candidates stand out in the eyes of voters during a primary, said Robert Blendon, a professor of health policy and political analysis at Harvard University and director of the Harvard Opinion Research Program.

But Blendon said he has not seen polling suggesting voters have an appetite for another major health care debate. Voters are more concerned with how much they have to pay for medical care, like prescription drugs ― “very practical, pocketbook issues,” he said.

“So it’s just my belief that whoever wins is going to have to switch back to pocketbook issues,” Blendon said of the eventual Democratic nominee.

A new poll echoes that. Democratic voters are eager to hear more from the candidates about other health care issues, according to a Kaiser Family Foundation poll released Tuesday. The results show 58% of Democrats and Democratic-leaning independents believe the candidates are not spending enough time talking about women’s health, including access to reproductive health services, for instance. And more than half said the candidates were spending too little time discussing surprise medical bills and ways to lower the costs people pay for care. (KHN is an editorially independent program of the foundation.)

The next Democratic presidential debate on Oct. 15 will give 12 of the candidates a fresh chance to talk about their ideas beyond sprawling health care reform. Let us walk you through a few proposals they have championed, plus what President Donald Trump is offering.

Sanders’ Plan To Cancel Medical Debt 

Sen. Bernie Sanders of Vermont rolled out a sweeping proposal last month to overhaul medical debt collection with a headline-catching promise: to wipe clean the roughly $81 billion Americans owe in past-due medical debt.

And the issue is ubiquitous since polls show voters are deeply concerned about their out-of-pocket costs. Raymond Kluender, an assistant professor at Harvard Business School who researches medical debt, said about 20% of households have medical bills in collections.

Kluender said Sanders’ plan targets debt that is rarely repaid anyway, noting that only about 8% of what is sent to collection agencies is ever repaid. Although some limited research suggests debt forgiveness may have mental health benefits, Kluender said, the effect Sanders’ move would have “is hard to know.”

Here are highlights of Sanders’ proposal: 

  • * Empower the federal government to negotiate, then pay off past-due medical bills that have been reported to the credit agencies. To calculate how much that debt is, the Sanders campaign points to a 2018 study that showed 1 in every 6 Americans has a past-due medical bill on their credit report, with debt totaling about $81 billion.
  • * Curb “abusive and harassing” debt collection tactics, including enforcing statutes of limitation that generally run from three to six years, depending on the state; limiting how often debt collectors can contact those who owe; requiring debt collectors to verify whether the information they have is accurate before attempting to collect; restricting the seizures of assets and garnishing of wages.
  • * Task the Internal Revenue Service with examining nonprofit hospitals to ensure they meet the “charitable care standards” for facilities with nonprofit tax status.
  • * Reform the bankruptcy court system to help those in debt. 

Biden’s Plan To Curb Gun Violence 

Former Vice President Joe Biden announced a plan this month to reduce gun violence, an issue that has become a must for most Democratic voters.

In addition to outlining his proposal to ban the manufacture and sale of assault weapons and require universal background checks, Biden took the opportunity to talk about his legislative history on guns: In 1993, he helped pass the law that established the background check system, and in 1994, he helped secure the 10-year assault weapons ban that has since lapsed.

He also drew attention to his newer ideas to change the system, including a push toward transitioning to “smart guns.”

But Biden’s plan does not go as far as that of some of his opponents ― including Sen. Cory Booker (N.J.), who would require a license to own a firearm.

Here is what Biden has said he would do on gun control: 

  • * Ban the manufacture and sale of assault weapons and high-capacity magazines, and otherwise regulate and buy back existing weapons.
  • * Require background checks for all sales, and close certain loopholes, including those that allow people with mental health issues and hate crime convictions to have firearms.
  • * Reward states that set up firearm licensing programs, require owners to safely store their weapons, and crack down on “straw purchasers” who buy firearms for those who cannot pass a background check. 

Buttigieg’s Plan To Strengthen Mental Health Care

Mayor Pete Buttigieg of South Bend, Ind., introduced a wide-ranging, $300 billion proposal in August to improve treatment for mental health and substance abuse.

Few disagree on the need to increase access to mental health care in the United States, making the issue one that is unlikely to move voters on its own, Blendon said. But Buttigieg’s plan stands out for tripling the investments proposed by other Democratic candidates, including Massachusetts Sen. Elizabeth Warren.

True to his mayoral roots, Buttigieg adopts a locally driven approach. Among other strategies in his 19-page plan, he would give communities “most affected” by mental illness and addiction $10 billion annually for 10 years to address prevention and care.

His campaign claims the plan would enable about 10 million more people to access care over the first four years of the program. Here are some ways Buttigieg said he would do that:

  • * Enforce mental health parity in coverage, including under Medicare and Medicaid.
  • * Expand access to addiction treatments, including by deregulating buprenorphine, a medication-assisted treatment proven effective for opioid use disorder.
  • * Reduce related incarceration, in part by decriminalizing all drug possession and expunging past convictions.
  • * Hold drug companies “accountable” for their role in the opioid epidemic, including by supporting state-level lawsuits.
  • * “Combat the epidemic of social isolation and loneliness,” including through a national service program that would pair older and younger Americans. 

Warren’s Plan To End The Opioid Crisis 

Warren unveiled an aggressive plan to combat the nationwide opioid epidemic last spring, proposing to spread $100 billion across the country to help state, local and tribal governments respond to the crisis.

And unlike Buttigieg and his $300 billion mental health and addiction plan, Warren outlined how she would pay for it ― with a tax on the richest 75,000 families.

“This crisis has been driven by greed, pure and simple,” she wrote in a Medium post detailing her plan.

Here is some of what her plan would do: 

  • * Prioritize and allocate money for public health departments, first responders and others in “front-line” communities.
  • * Give states incentives to cover addiction services through state Medicaid programs.
  • * Expand surveillance, research and access to treatment, including naloxone, the overdose reversal drug. 

Trump’s Efforts On Medicare, Public Health And Drug Price

President Donald Trump caused a stir this year when he declared the Republican Party would become “the party of health care” and suggested he was working on another proposal to replace the Affordable Care Act.

But he has said little on the subject since then, and a Washington Post report last month said the White House has abandoned that effort in favor of damage control should the 5th Circuit Court of Appeals strike down the Affordable Care Act.

Instead, the Trump administration has picked up on a series of often disparate health issues, including changes to how the government pays for care, investments in public health crises and steps intended to pressure drugmakers to lower prices.

One of his latest moves came on Oct. 3, when Trump signed an executive order making a variety of changes to Medicare, including expanding the private Medicare Advantage plans available to seniors and changing the enrollment process. He took the opportunity to pan the progressive push toward a single-payer health care system as “socialist,” framing his changes as protections for seniors.

In addition to an ambitious plan to end HIV/AIDS introduced in February, the Trump administration unveiled a kidney care initiative in July that adjusts payment incentives to encourage preventive care, home dialysis and transplants. And last month, the administration said it was preparing to ban the sale of flavored e-cigarettes amid a public health scare over vaping and concerns about widespread use among teens.

And after promising to lower drug prices, Trump has struggled to make changes amid disagreements with the pharmaceutical industry and even fellow Republicans.

The administration has tasked the Department of Health and Human Services to work on other policies, including requiring hospitals to disclose prices and laying out a framework to allow, for the first time, the legal importation of prescription drugs from overseas.

California’s New Transparency Law Reveals Steep Rise In Wholesale Drug Prices

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Source: California Healthline

Drugmakers fought hard against California’s groundbreaking drug price transparency law, passed in 2017. Now, state health officials have released their first report on the price hikes those drug companies sought to shield.

Pharmaceutical companies raised the “wholesale acquisition cost” of their drugs — the list price for wholesalers without discounts or rebates — by a median of 25.8% from 2017 through the first quarter of 2019, according to the Office of Statewide Health Planning and Development. (The median is a value at the midpoint of data distribution.)

Generic drugs saw the largest median increase of 37.6% during that time. By comparison, the annual inflation rate during the period was 2%.

Several drugs stood out for far heftier price increases: The cost of a generic liquid version of Prozac, for example, rose from $9 to $69 in just the first quarter of 2019, an increase of 667%. Guanfacine, a generic medication for attention deficit hyperactivity disorder (ADHD), on the market since 2010, rose more than 200% in the first quarter of 2019 to $87 for 100 2-milligram pills. Amneal Pharmaceuticals, which makes Guanfacine, cited “manufacturing costs” and “market conditions” as reasons for the price hike.

“Even at a time when there is a microscope on this industry, they’re going ahead with drug price increases for hundreds of drugs well above the rate of inflation,” said Anthony Wright, executive director of the California advocacy group Health Access.

The national debate over exorbitant prescription drug prices — and how to relieve them — was supposed to take center stage in recent weeks, as House Speaker Nancy Pelosi released a plan to negotiate prices for as many as 250 name-brand drugs, including high-priced insulin, for Medicare beneficiaries. Another plan under consideration in the Senate would set a maximum out-of-pocket cost for prescription drugs for Medicare patients and penalize drug companies if prices rose faster than inflation.

President Donald Trump has highlighted drug prices as an issue in his reelection campaign. But lawmakers’ efforts to hammer out legislation are likely to be overshadowed, for now, by presidential impeachment proceedings. In Nevada, health officials in early October fined companies $17 million for failing to comply with the state’s two-year-old transparency law requiring diabetes drug manufacturers to disclose detailed financial and pricing information.

California’s new drug law requires companies to report drug price increases quarterly. Only companies that met certain standards — they raised the price of a drug within the first quarter and the price had risen by at least 16% since January 2017 — had to submit data. The companies that met the standards were required to provide pricing data for the previous five years. In its initial report, the state focused its analysis on drug-pricing trends for about 1,000 products from January 2017 through March 2019.

California’s transparency law also requires drugmakers to state why they are raising prices. Over time, that information, in addition to cost disclosures, could create “one of the more comprehensive and official drug databases on prices that we have nationwide,” Wright said. “That, in itself, is progress, so that we can get better information on the rationale for drug price increases.”

But the data does not reflect discounts and rebates for insurers and pharmacy benefit managers and bears little resemblance to what consumers actually pay, said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America. The group filed a lawsuit seeking to overturn the California legislation that has not yet been resolved.

“If transparency legislation only looks at one part of the pharmaceutical supply chain, without getting into the various middlemen like insurers and pharmacy benefit managers that ultimately determine what patients have to pay at the pharmacy counter, it won’t help patients access or afford their medicines,” VanderVeer said in an email.

State Sen. Richard Pan (D-Sacramento), a pediatrician who chairs the Senate health committee, agrees — up to a point.

“Transparency always has value,” Pan said. But policymakers need more data on how much insurers and consumers are spending on prescription drugs, he said.

And he wonders why the price of generic drugs, including those with plenty of competition, rose at higher rates.

His concerns were echoed by University of Southern California policy researchers, who recently published a study that concluded most state-level drug-transparency laws are “insufficient” to reveal the true transaction prices for prescription drugs, or where in the distribution system excessive profits lie.

“The question is, why are these prices going up? Typically, there are competing stories for that,” said Neeraj Sood, vice dean of the University of Southern California’s School of Public Policy and an author of the study. “Maybe cost of production is going up,” he said. “Maybe there’s a drug shortage, or some competitors got eliminated. This reporting of [wholesale acquisition cost] data doesn’t really tell us which of these stories is true.”

For now, California’s new data is not likely to be of much help to consumers, Pan said. But he said it might help state officials in their bid to overhaul the way the state purchases drugs for 13 million people served by Medi-Cal, the state’s Medicaid program for low-income residents. Gov. Gavin Newsom’s controversial plan to have the state, rather than individual Medi-Cal managed-care plans, negotiate directly with drugmakers would save the state an estimated $393 million a year by 2023, according to the administration.

Governor Newsom Signs AB 824 to Lower Prescription Drug Costs in First Health Care Bill Signing Event

Source: Health Access

California Governor Gavin Newsom today signed the biggest prescription drug price bill of the year, intended to lower prescription drug prices for California consumers by hundreds of millions of dollars a year. During the first-ever health care bill signing event under the new Administration, Newsom signed AB 824, authored by Assemblymember Wood and sponsored by Attorney General Xavier Becerra, to deter harmful “pay-for-delay” practices by pharmaceutical and generic drug manufacturers.

Health Access was proud to join Governor Newsom for the bill’s signing, along with many of the health, consumer, senior, labor, and other groups that supported the bill throughout the legislative session, which together overcame well-financed opposition from prescription drug companies which sought to weaken the legislation.

With Governor Newsom’s signing of AB 824, anti-competitive “pay-for-delay” practices by prescription drug companies will be under greater scrutiny. These harmful “pay-for-delay” deals occur when brand name pharmaceutical companies pay generic drug makers to slow down or stop lower-cost alternative medications from entering the marketplace. While this drives up profits for drug companies, consumers were being left to pay artificially high prescription drug costs. In 2010, the Federal Trade Commission estimated Americans pay $3.5 billion a year more for medications because of these “pay-for-delay” practices, and that figure has likely gone up significantly since that finding.

By signing AB 824, California consumers will see lower price alternatives come to the market sooner, easing the burden on people who need these medications to survive. It will be that much harder for brand-name and generic drug companies to engage in shady back-room deals that drive up their profit in secret, at the expense of consumers.

Governor Newsom’s signature also puts California at the forefront of efforts to prevent the problematic, price-gouging practices by prescription drug companies, and will hopefully provide momentum for further action that is desperately needed at the federal level. Consumers ultimately need Congress to act to lower drug prices for Americans, but California is leading the way.

The bill will go into effect on January 1, 2020.

Californians Must Have Health Insurance In 2020, Or Face Penalty

A mother and daughter wait to meet with an enrollment counselor to sign up fo...

Source: KPBS

A new state law going into effect Jan. 1 requires Californians to have health insurance in 2020 or face a penalty on their state taxes.

This follows the repeal of the individual mandate at the federal level, which took effect in 2019. California’s individual mandate is part of a state budget deal struck by Democratic legislative leaders and Gov. Gavin Newsom over the summer.

Covered California was created in 2014 to offer state residents subsidized health insurance under the Affordable Care Act. Covered California’s enrollment period for health coverage in 2020 starts Tuesday and runs through Jan. 31.

FDA’s Proposed Rules On Drug Importation: What to Know

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Source: BenefitsPRO

The Food and Drug Administration recently announced an action plan for allowing prescription drugs to be imported from Canada and other countries. However, employer plan sponsors and plan administrators must heed caution at this time as this is just the announcement that proposed rules are coming.

While this is a signal of where the FDA thinks it will go, these ideas are not even proposed (let alone final) rules yet and, it is noteworthy to mention that this initiative was not one of those listed as part of the Trump Administration’s blueprint to reduce prescription drug costs.

The FDA action plan describes two paths it intends to propose. They are:

  • * Pathway 1: The FDA would allow states, drug wholesalers, and pharmacists to import drugs from Canada. These would be Canadian versions of FDA-approved drugs. This would be a pilot program with an unspecified time limit. In other words, this would get a trial run for a while to see if it works. The FDA action plan lists several controls that would be designed to make sure the drugs are safe and not counterfeit. The FDA anticipates that certain drugs would not be eligible for this pathway, such as controlled substances, biological products, infused drugs, intravenously injected drugs, drugs inhaled during surgery, and certain other parenteral/injectable drugs.
  • * Pathway 2: The FDA would allow drug manufacturers to import U.S. versions of drugs they sell in foreign countries. The drugs would be given a new National Drug Code to allow them to be priced differently than the current U.S. version. This was in response to claims by manufacturers that they could not reduce prices on U.S. versions because of contractual obligations in their supply chains.

The FDA has reason to believe that manufacturers might use Pathway 2 as an opportunity to offer Americans lower cost versions of their own drugs. In recent years, multiple manufacturers have stated (either publicly or in statements to the Administration) that they wanted to offer lower cost versions but could not readily do so because they were locked into contracts with other parties in the supply chain. Pathway 2 would highlight an opportunity for manufacturers to use importation to offer lower-cost versions of their drugs.

Notably, employer plan sponsors (other than states) are not listed among the parties that will be eligible for either pathway. Even for states, the proposal is expected to require them to work through a wholesaler or pharmacist to take advantage of Pathway 1. This means most employers will likely need to rely on their insurers and pharmacy benefit managers to earn, and pass along any discounts, once these are part of finalized regulations.

Again, at this point the FDA’s initiative is interesting, but without proposed or final regulations, nothing is final yet. There is no change in the law, so employer plan sponsors and plan administrators will need to wait for proposed and then final rules before making any plan changes.

Finally, in the current political and regulatory environment, and based on many new health care initiatives, it is reasonable to expect that these rules will be challenged in court. In fact, the FDA anticipates this in the action plan. The action plan says that, if any part of the Pathway 1 rules is invalidated by a court, the proposal will require that all of Pathway 1 be invalidated. Therefore, even if these rules are proposed, and subsequently finalized, they may never become available in any event.

Taking all this into account, employers should keep an eye on these types of FDA initiatives. However, any relief from prescription drug costs that these rules may provide is still a long distance away.

Medi-Cal’s Outdated Computer Enrollment Systems Can Leave Patients Without Coverage When They Need It Most, Experts Say

Image result for Medi-Cal Outdated Computer Enrollment Systems Can Leave Patients Without Coverage When They Need It Most, Experts Say images

Source: The Fresno Bee

Sylvia Valenzuela was in bed for two months early in her pregnancy because of severe nausea and vomiting caused by a rare condition. At a time when she desperately needed ongoing medical care, the Fresno resident says she suddenly lost her Medi-Cal coverage through no fault of her own.

The 32-year-old mother of three, who comes from the Pascua Yaqui Tribe in Arizona, tried to stop herself from crying as she recalled the “difficult” and “unfair” process of trying to obtain Medi-Cal, California’s Medicaid program for low-income residents.

Medi-Cal informed Valenzuela, now eight months pregnant, in a letter in late August that she was indeed eligible based on her family income and that her coverage was retroactive to February, when she had first applied

But the delay in processing her original application and apparent error in dropping her coverage in July left Valenzuela without medical insurance during a significant stretch of her pregnancy, when she became sicker and sicker. Experts and government officials say problems such as this continue to occur throughout the state, and are often connected to outdated and disparate computer enrollment systems.

“It was pretty upsetting,” Valenzuela said. “I don’t know how they got tangled up, but (the Medi-Cal representative) was calling to tell me they made a mistake on my case.”

A county health care official declined to discuss the specifics of Valenzula’s case but did acknowledge that there had been “issues” related to Medi-Cal’s enrollment systems that might have affected her coverage, and that she had been eligible for pregnancy-related coverage all along.

In many instances, a statewide system will show cases as discontinued or puts them on hold, “but in reality cases are still open and approved,” according to Chester Prince, program manager at the Fresno County Department of Social Services, which oversees Medi-Cal in the county.

People who believe their coverage has been wrongly dropped or denied should contact a county caseworker to review their eligibility, Prince said.

“Historically, there have been issues with enrollment that have been caused by the state and county IT systems not talking to each other well,” said Laurel Lucia, health care program director at the UC Berkeley Center for Labor Research and Education.

Valenzuela says she first discovered that her Medi-Cal coverage had been dropped when her benefits card was denied at an ultrasound appointment in July. When she called, she was told she had been dropped from Medi-Cal after having been approved in May.

Prince asked for a patient consent form signed by Valenzluela in order to discuss the details of her case further. When provided with the form, he said he couldn’t discuss her case after all, citing confidentiality laws.

Prince did say the problem was caused mainly by inconsistencies in Valenzuela’s information across Medi-Cal enrollment systems. That has since been addressed, he said.

“She’s been eligible from the beginning,” Prince said. But he would not confirm whether Valenzuela’s coverage had indeed been dropped during her pregnancy, citing confidentiality laws, and directed a reporter to ask her.

That’s what the Center for Health Journalism News Collaborative did.

Valenzuela says she can’t count the number of times she called Medi-Cal. She says she first applied sometime in February, when she was nearly two months pregnant.

“I even cried to (a Medi-Cal staffer), and told him my situation, spoke to numerous supervisors, and all they could tell me is that they had a heavy load,” she said.

Paperwork error, medical nightmare

Valenzuela had been receiving primary care through an Indian Health Service clinic, but she applied for Medi-Cal because she needed to see an OB-GYN and specialty care wasn’t available to her through the IHS-tribal clinic. She began experiencing symptoms similar to her previous pregnancies, when she had a condition known as hyperemesis gravidarum, or HQ, which causes extreme nausea and vomiting.

During her previous pregnancy, she required a nurse at home to administer IV fluids.

While she waited for months for Medi-Cal to process her application, Valenzuela says, she spent two months in her room, unable to get out of bed and sometimes vomiting up to 50 times a day. She lost about 50 pounds in four weeks, she said

“I can’t even remember how my children lived. I couldn’t care for my children,” she said. “Even to get up and go to the restroom, I had to wait for my husband or wait for my mom to get me there. That’s how weak I was. I couldn’t move. I couldn’t stand on my own two feet.”

Valenzuela also ended up at the hospital twice — once with a bladder infection and again when she started bleeding and feared she was having a miscarriage. The bleeding was caused by a condition called placenta previa, which results when the baby’s placenta covers the mother’s cervix.

When she was almost four months pregnant, she says, her husband couldn’t take seeing her like that anymore and sought out an OB-GYN, and she received some limited care.

Given that she has a high-risk pregnancy, Valenzuela was concerned she could go into early labor during this period when she lacked insurance.

Medi-Cal errors, delayed care

Valenzuela says that after initially applying for Medi-Cal in February, her coverage finally began in May, when she was almost five months pregnant. But she says her coverage lasted only about a month and a half before she was notified she no longer qualified based on her income.

She didn’t get any prenatal care for the critical first four months of her pregnancy. Despite the gains in health care coverage since the implementation of the Affordable Care Act, Valenzuela’s situation is far from unique. From 2015-17, one in three women nationally who became pregnant experienced a disruption in health insurance from preconception to postpartum, researchers recently reported in a HealthAffairs blog post.

Regular Medi-Cal applications must be processed within 45 days, but if someone has an immediate need for care, counties can process the application to allow the person to access medical care the same day, said Anthony Cava, spokesman for the California Department of Health Care Services.

Her husband, the only worker in the household, makes about $70,000 a year, and provides for the couple and their three children, ages 4, 5 and 16. Although that family income is typically too high to qualify for standard Medi-Cal coverage, women can obtain medically necessary pregnancy-related services if their family income is at or below 213% of the federal poverty line.

In Valenzuela’s case, based on the number of children, including her unborn child, and adults in her immediate family, that means she would be eligible as her income was below the threshold of $73,677. The coverage is active throughout the pregnancy and 60 days after birth.

Her husband, a correctional officer for Fresno County, looked into the possibility of enrolling the family in his employer’s insurance, according to Valenzuela, but found that the most economical plan would cost around $400 every two weeks, with a $6,000 annual deductible.

That’s something they couldn’t afford, she said. “There’s no way we could have made ends meet.”

Systems not on the same page

In California, Medi-Cal enrollment increased by 35% between 2013 and 2014 as a result of its expansion under the Affordable Care Act, according to a 2015 study. At that time, issues with the various enrollment systems came to light.

Counties use three systems to determine eligibility and manage cases, UC Berkeley’s Lucia said. Two of those systems feed into a third statewide system, which consolidates all information and tracks who’s enrolled. But the integration has been uneven, creating problems like Valenzuela’s.

“The state is in the process of moving toward a single consolidated system, CalSAWS (Statewide Automated Welfare System),” she said. “I think there has been acknowledgement that there needs to be improved communication between different IT systems in the state.”

Neighborhood Legal Services of Los Angeles filed two lawsuits over wrongful Medi-Cal terminations across the state, in 2015 and 2016.

“We do hear from time to time that something goes wrong,” said Jen Flory, a policy advocate at the Western Center on Law and Poverty, adding that a “county worker can’t always figure out what’s going on.”

Her organization recommends that people go to a local nonprofit legal service agency if they are concerned that their cases are being mishandled. Problems navigating the enrollment systems could mean delayed access to care.

California Uncovered

About this series: This project results from an innovative reporting venture — the USC Center for Health Journalism News Collaborative — which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capitol Public Radio.

As Medicare Enrollment Nears, Popular Price Comparison Tool Is Missing

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Source: Kaiser Health News

Millions of older adults can start signing up next week for private policies offering Medicare drug and medical coverage for 2020. But many risk wasting money and even jeopardizing their health care due to changes in Medicare’s plan finder, its most popular website.

For more than a decade, beneficiaries used the plan finder to compare dozens of Medicare policies offered by competing insurance companies and get a list of their options. Yet after a website redesign six weeks ago, the search results are missing crucial details: How much will you pay out-of-pocket? And which plan offers the best value?

That’s because the plan finder can no longer add up and sort through the prescription costs plus monthly premiums and any deductibles for all those plans. A mere human can try, but it is a cumbersome process fraught with pitfalls. One plan might have the lowest premium but not the lowest drug prices. Another could exclude a plan’s preferred pharmacy that offers lower prescription prices.

“We can’t guarantee you that you’re going to be in the best plan or the cheapest plan anymore,” said Howard Houghton, the former Fairfax County coordinator for the Virginia Insurance Counseling and Assistance Program who still helps with enrollment as a volunteer.

Using the old plan finder produced big savings. Counselors at Passages, the Senior Health Insurance Information Program (SHIP) serving five counties in Northern California, said in August they used it to save one woman $8,400 for this year and more than $5,000 when helping another client.

Medicare officials say the total cost calculator will be fixed in time for the annual enrollment season, which starts nationwide Oct. 15 and runs through Dec. 7. But they have yet to address multiple other issues raised by the Medicare Rights Center and industry groups.

“The new tool will provide more enhanced price and quality information” to assure informed health care decisions, Seema Verma, administrator at the Centers for Medicare & Medicaid Services, said when she unveiled the redesign in August.

During open enrollment, beneficiaries can sign up for Medicare Advantage plans, the alternative to traditional Medicare that offer drug coverage and often more benefits than the government program does. About a third of the 64 million people in Medicare choose this option. Next year, the average Medicare Advantage monthly premium is expected to drop 14% compared with 2019 to an estimated $23, according to CMS. 

This is also the only time most people in traditional Medicare can sign up for a drug plan, also known as Part D, to help cover their prescription costs. It’s a good idea to review plans every year since costs and covered drugs can change from year to year. Estimated average monthly premiums for these policies will be $30 next year, about 8% less than in 2019, CMS has reported.

Medicare Advantage plans next year are allowed to offer new additional benefits for people with certain chronic diseases, such as dementia, diabetes or heart disease. That’s on top of the non-medical benefits that are not tied to a person’s health problems they were allowed to add this year, such as home-delivered meals after a hospitalization, transportation to medical appointments and minor home improvements, such as grab bars to prevent falls in the bathroom.

Next year, the additional services some Advantage plans will offer hardly sound like insurance benefits: pest control, dog food for service animals, home-delivered meals and discounted groceries.

“It’s really shifting from reactive care to preventative care,” said Martin Esquivel, vice president for Medicare product management at Anthem, which will offer those and other new perks to some of its more than a million Medicare Advantage members.

Smaller Medicare Advantage plans have also expanded benefits. The 60,000 Alignment Healthcare members in some California, Florida and North Carolina plans will have access to free transportation to doctor appointments from Uber or Lyft.

To address social isolation, some California members who also have certain chronic diseases can receive visits from “Grandkids On-Demand,” college students who can help with light housekeeping and provide companionship for up to two hours a day. Humana and Aetna will also offer the service in some plans.

But most insurers are not embracing the opportunity to add extra benefits.

“Of those Medicare Advantage plans affected by the new rules, 10% (or about 500) offered new supplemental benefits in 2020 for people with serious chronic illnesses, such as in-home services, palliative care, respite support for people’s caregivers or adult day care,” said Robert Saunders, research director for payment and delivery reform at Duke University’s Margolis Center for Health Policy. He is still analyzing the other categories of extra benefits.

UnitedHealthcare, which controls 26% of the Medicare Advantage market, is focused“on providing the core medical benefits, which is why people purchase health insurance in the first place,” said Steve Warner, vice president of the UHC Medicare Advantage product team.”Most consumers don’t want to buy a plan that’s been loaded up with ancillary benefits that they don’t think they’re going to use.”

Instead, the insurer is offering more plans that do not restrict members to a network of health care providers and introducing specialized plans for people with diabetes or dementia, among other changes.

Because new extra benefits will not be accessible in every county, seniors may need to do some detective work to find out what’s available. Using the plan finder, it’s possible to narrow down the Medicare Advantage choices only to those plans that offer hearing, vision, dental, fitness and transportation coverage.

Bonnie Burns, a consultant to California Health Advocates, recommends that customers call insurers to confirm details before signing up.

Among the improvements in the new plan finder is the ability to compare estimated costs of Medicare Advantage plans against coverage under traditional Medicare with a separate drug plan and one of 11 kinds of Medigap supplement plans, which cover all or some of the out-of-pocket costs Medicare doesn’t pay for.

But the monthly premiums listed for Medigap policies ― at least in some areas ― are wildly off course. According to the plan finder, a senior in San Francisco can buy a Medigap plan for as little as $20.83 a month. Yet such a plan is not included in the rate chart published by the California Department of Insurance, which lists the cheapest bare-bones policy for a 65-year-old at four times more.

With a more complicated, slower enrollment process, it’s likely that older adults will need more help. And help may be scarce.

“It means fewer people that we get to see because we’re giving each one more time,” said Alicia Jones, administrator of the state SHIP program at Nebraska’s Department of Insurance.

Last Updated 10/17/2019

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