Short-Term Health Plans Hold Savings For Consumers, Profits For Brokers And Insurers (KHN)
By Julie Appleby, Kaiser Health News Sure, they’re less expensive for consumers, but short-term health policies have another side: They’re highly profitable for insurers and offer hefty sales commissions. Driven by rising premiums for Affordable Care Act plans, interest in short-term insurance is growing, boosted by Trump administration actions to ease Obama-era restrictions and possibly make federal subsidies available to consumers to purchase them. That’s good news for brokers, who often see commissions on such policies hit 20 percent or more. On a policy costing $200 a month, for example, that could translate to a $40 payment each month. By contrast, ACA plan commissions, which are often flat dollar amounts rather than a percentage of premium, can range from zero to $20 per enrollee per month. “Customers are paying less and I’m making more,” said Cindy Holtzman, a broker in Woodstock, Ga., who said she gets 20 percent on short-term plan commissions. Large online brokers also are eagerly eyeing the market. Ehealth, one such firm, will “continue to shift our focus to selling short-term plans and non-ACA insurance packages,” CEO Scott Flanders told investors in October. The firm saw an 18 percent annual jump in enrollment in short-term plans this year, he added. Insurers, too, see strong profits from plans because they generally pay out very little toward medical care when compared with the more comprehensive ACA plans. Still, some agents like Holtzman have mixed feelings about selling the plans, because they offer skimpier coverage than ACA insurance. One 58-year-old client of Holtzman’s wanted one, but he had health problems. She also learned his income qualified him for an ACA subsidy, which currently cannot be used to purchase short-term coverage. “There’s no way I would have considered a short-term plan for him,” she said. “I found him an ACA plan for $360 a month with a reduced deductible.” (A federal district court judge in Texas issued a ruling Dec. 14 striking down the ACA, which would among other things impact the requirements of ACA coverage and subsidies. The decision is expected to face appeal.) Short-term plans can be far less expensive than ACA plans because they set annual or lifetime payment limits. Most exclude people with medical conditions, they often don’t cover prescription drugs, and policies exclude in fine print some conditions or treatments. Injuries sustained in school sports programs, for example, often are not covered. (These plans can be purchased at any time throughout the year, which is different than plans sold through the federal marketplaces. The open enrollment period for those ACA plans in most states ends Dec. 15.) Consequently, insurers providing short-term plans don’t have to pay as many medical bills, so they have more money left over for profits. In forms filed with state regulators, Independence American Insurance Co. in Ohio shows it expects 60 percent of its premium revenue to be spent on its enrollees’ medical care. The remaining 40 percent can go to profits, executive salaries, marketing and commissions. A 2016 report from the National Association of Insurance Commissioners showed that, on average, short-term plans paid out about 67 percent of their earnings on medical care. That compares with ACA plans, which are required under the law to spend at least 80 percent of premium revenue on medical claims. Short-term plans have long been sold mainly as a stopgap measure for people between jobs or school coverage. While exact figures are not available, brokers say interest dropped when the ACA took effect in 2014 because many people got subsidies to buy ACA plans and having a short-term plan did not exempt consumers from the law’s penalty for not carrying insurance. But this year it ticked up again after Congress eliminated the penalty for 2019 coverage. At the same time, the premiums for ACA plans rose on average more than 30 percent. “If I don’t want someone to walk out of the office with nothing at all because of cost, that’s when I will bring up short-term plans,” said Kelly Rector, president of Denny & Associates, an insurance sales brokerage in O’Fallon, a suburb of St. Louis. “But I don’t love the plans because of the risk.” The Obama administration limited short-term plans to 90-day increments to reduce the number of younger or healthier people who would leave the ACA market. That rule, the Trump administration complained, forced people to reapply every few months and risk rejection by insurers if their health had declined. This summer, the administration finalized new rules allowing insurers to offer short-term plans for up to 12 months — and gave them the option to allow renewals for up to three years. States can be more restrictive or even bar such plans altogether. Administration officials estimate short-term plans could be half the cost of the more comprehensive ACA insurance and draw 600,000 people to enroll in 2019, with 100,000 to 200,000 of those dropping ACA coverage to do so. And recent guidance to states says they could seek permission to allow federal subsidies to be used for short-term plans. Currently, those subsidies apply only to ACA-compliant plans. Granting subsidies for short-term plans “would mean tax dollars are not only subsidizing commissions, but also executive salaries and marketing budgets,” said Sabrina Corlette of Georgetown University Center on Health Insurance Reforms. No state has yet applied to do that. For now, brokers are focusing on getting their clients into some kind of coverage for next year. Commissions on both ACA and short-term plans are getting their attention. After several years of declining commissions for ACA plans — with some carriers cutting them altogether a couple of years ago — brokers say they are seeing a bit of a rebound. Among Colorado ACA insurers, “it’s gone from about $14 to $16 per enrollee [a month] to $16 to $18,” said Louise Norris, a health policy writer and co-owner of an insurance brokerage. Rector, in Missouri, said an insurer that last year paid no commissions has reinstated them for 2019 coverage. For her, that doesn’t really
Healthcare Is Where The Jobs Are. But What Kind Of Jobs? (KHN)
By Rachel Bluth, Kaiser Health News More Americans are now employed in healthcare than in any other industry. The Bureau of Labor Statistics, which tallies job creation, says that for most of this year the health sector outpaced the retail industry. Only government, on all levels, employs more people. One of the consistent features of the BLS reports is that healthcare has reliably added thousands of jobs to the economy each month. November was no different. The healthcare industry created 32,000 jobs, adding to the 328,000 healthcare positions created since early 2017. But what kinds of jobs? Were they highly paid doctors and hospital executives or were they positions on the other end of the pay scale, such as nursing home aides and the people who enter data for billing in hospitals and clinics? It’s hard to know for sure, because the BLS monthly data measure industries not occupations and what information it does have on occupations is overly broad. For instance, it says hospitals accounted for about 13,000 jobs in November. Another 19,000 jobs were for “ambulatory” care, which is a broad term for services delivered outside of hospital systems, like in clinics and private doctors’ offices. But another set of BLS data offers additional insights. Every two years, BLS puts out a wonky set of numbers called “industry-occupation matrices,” which more finely slices job categories and predicts which will grow or shrink over the next 10 years. The most recent, from 2016, still provides a pretty accurate snapshot, according to Joanne Spetz, a professor at the University of California-San Francisco’s Institute for Health Policy Studies. Registered nurses are the fastest-growing occupation. They account for more than 25 percent of jobs in hospitals. If that share remained the same last month, 3,289 of the new hospital jobs added in November went to RNs. [protected-iframe id=”afd374bef04176b4120013d3f73733ab-7618883-99279322″ info=”//datawrapper.dwcdn.net/XoirU/5/” width=”100%” height=”500″ frameborder=”0″ scrolling=”no”] It’s likely that many of the hospital jobs went to medical assistants, who currently make up only 1.5 percent of the industry. Medical assistants are usually the people taking your vitals and helping the doctor take notes. The BLS expects about a 16 percent increase in these jobs in the next decade. “There will be a fair amount of growth in physician and surgeon employment in the next decade, but so many more medical assistants than physicians,” Spetz said. The national median pay of a registered nurse is $70,000 a year, according to more BLS data. For medical assistants, it is $32,480. Doctors’ median pay is more than $200,000. Far more of those medical assistants found work outside the hospital in the ambulatory sector: almost 1,300. There is also a good chance that in these ambulatory settings many of the newly created jobs were filled by non-medical staff. As of 2016, fewer than 30 percent of staff in ambulatory settings were workers whom Spetz calls “paper pushers.” If the trend held up, around 5,700 of the hires in November, or 30 percent of ambulatory jobs, fall into these categories. These jobs can pay as much as medical assistants. The BLS says the median income of “medical record and health information technicians” is about $39,000 a year. BLS is predicting around a 20 percent increase in “information and record clerks” and another 22 percent increase in “secretaries and administrative assistants.” But the idea that hospitals and doctors’ offices are hiring only lower-paid support staff might be overblown. The BLS figures “healthcare practitioners and technical occupations” still make up more than 37 percent of the ambulatory industry, and “health diagnosing and treating practitioners” are almost 23 percent. So nearly 70 percent of ambulatory hires last month were probably physicians or other skilled professionals like registered nurses, licensed practical nurses, social workers and personal care aides. “What we have seen over the past couple years is with the job growth in health it is not dominated by back office,” said Ani Turner, an economist who focuses on health sector labor trends with Altarum, a nonprofit health research and consulting organization. Another thing hiding in the numbers? A dissipating distinction between ambulatory and hospital care. Traditionally, hospital jobs were pretty straightforward; they referred to the doctors, nurses and support staff who worked in hospitals. But as business models shift, more care is given outside of hospital walls, something not reflected in employment numbers that split health into two distinct categories. Employees who staff the clinics, surgery centers, labs and imaging centers run by hospitals are counted as hospital staff, Turner said, though they work in outpatient settings. So those 13,000 new hospital jobs the BLS cited last month may not reflect real-world trends about where hiring happens. “Whether in physicians’ offices, free-standing clinics or hospital outpatient clinics, you’ll see it as the two separate settings, but the same trend,” Turner said. This story originally appeared on Kaiser Health News. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Need Health Insurance? The Deadline Is Dec. 15 (KHN)
By Michelle Andrews The woman arrived at the University of South Florida’s navigator office in Tampa a few weeks ago with a 40-page document describing a short-term health insurance plan she was considering. She was uncomfortable with what the broker had said about the coverage, she told Jodi Ray, a health insurance navigator who helps people enroll in coverage, and she wanted help understanding it. The document was confusing, according to Ray, who oversees Covering Florida, the state’s navigator program. It was hard to decipher which services would be covered. “It was like a bunch of puzzle pieces,” she said. Encouraged by her wife, the woman eventually opted instead for a marketplace plan with comprehensive benefits. The annual open-enrollment period for people who buy their own insurance on the Affordable Care Act’s marketplaces ends Dec. 15 in most states. Enrollment in states that use the federal healthcare.gov platform has been sluggish this year compared to last. From Nov. 1 through Dec. 1, about 3.2 million people had chosen plans for 2019. Compared with the previous year, that’s about 400,000 fewer, or a drop of just over 11 percent. The wider availability of short-term plans is one big change that has set this year’s apart from past sign-up periods. Another is the elimination of the penalty for not having health insurance starting next year. The Congressional Budget Office has estimated that as many as 3 million people who buy their own coverage may give it up when they don’t face a tax penalty. But experts who have studied health insurance enrollment say that surveys so far indicate that the penalty hasn’t typically been the pivotal factor in people’s decision on whether to buy insurance. They also caution against reading too much into the preliminary enrollment totals. “There typically is a surge in enrollment at the end,” said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms. “It’s hard to know whether it will make up for the shortfall.” If they don’t pick a new plan, people who are enrolled in a 2018 marketplace plan may be automatically re-enrolled in their current plan or another one that is similar when the open-enrollment period ends. About a quarter of people who have marketplace plans are reassigned in this way. Another factor that may be affecting enrollment is tighter federal funding for the health insurance navigators, like Jodi Ray in Tampa, who guide consumers through the complicated process. With fewer experts available to answer questions and help fill out the enrollment forms, consumers may fall through the cracks. Across the country, funding for navigators dropped from $36 million in 2017 to $10 million this year. In Florida, federal funding for the Covering Florida navigator program was slashed to $1.25 million this year from $4.9 million last year, Ray said. The program was the only one to receive federal funding in the state this year. The Covering Florida program reduced the number of open-enrollment navigators to 59 this year, a nearly 61 percent drop, Ray said. Navigators this year are available in only half of Florida counties; the organization is offering telephone assistance and virtual visits to people in counties where they can’t offer in-person help. “It’s all we can do,” Ray said. So far, the group’s navigators have enrolled about half the number of people this year as they had last year. It’s unclear the extent to which the Trump administration’s efforts to reduce health care costs by expanding access to short-term plans is affecting marketplace plan enrollment. These plans, originally designed to cover people who expected to be out of an insurance plan for a short time, such as when they change jobs, can be less expensive. Unlike marketplace plans, short-term plans don’t have to provide comprehensive benefits or guarantee coverage for people who have preexisting medical conditions. The Obama administration limited short-term plans to a three-month term. But in August, the federal government issued a rule that allowed their sale with initial terms of up to a year, and the option of renewal for up to three years. Ten states either ban short-term plans or restrict them to terms of less than three months, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities. Many people are seemingly not focused on their options this open-enrollment season, however. According to a recent survey, about half of adults under age 65 who were uninsured or who buy their own coverage said they planned to buy a plan for 2019. But only 24 percent of people in that age group said they knew what the deadline was to enroll in health insurance, according to the Kaiser Family Foundation’s November health tracking poll. This story originally appeared on Kaiser Health News. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
In Grandma’s Stocking: An Apple Watch To Monitor Falls, Track Heart Rhythms
By Rachel Bluth, Kaiser Health News For more than a decade, the latest Apple products have been the annual must-have holiday gift for the tech-savvy. That raises the question: Is the newest Apple Watch on your list — either to give or receive — this year? At first glance, the watch appears to be an ideal present for Apple’s most familiar market: the hip early adopters. Its promotional website is full of svelte young people stretching into yoga poses, kickboxing and playing basketball. But when Apple unveiled its latest model in September — the Series 4, which starts at $399 — it was clear it was expanding its target audience. This Apple Watch includes new features designed to detect falls and heart problems. With descriptions like “part guardian, part guru” and “designed to improve your health … and powerful enough to protect it,” the tech giant signaled its move toward preventive health and a much wider demographic. “The health care market is obviously important to Apple,” Andy Hargreaves, an Apple analyst with KeyBanc Capital Markets, wrote in an email. The fall prevention and electrocardiogram apps are a “play to sell people more stuff” and bring health-monitoring apps beyond just “fitness people” to baby boomers who want to keep themselves and their parents healthy, he added. This watch could be a perfect present for those older people, said Laura Martin, a senior analyst with Needham. “People who wore watches their whole lives, plus fall monitoring?” Martin said. “Voilà! It creates another on-ramp for another consumer in the Apple ecosystem.” The Inner Workings The fall-monitoring app uses sensors in the watchband, which are automatically enabled for people 65 and older after they input their age. These sensors track and record the user’s movements, and note if the wearer’s gait becomes unsteady. If a fall is detected, the watch sends its wearer a notification. If the wearer doesn’t respond within a minute by tapping a button on the watch to deactivate this signal, emergency services will be alerted that the wearer needs help. That minute also gives the wearer time to prevent false alarms, such as a dropped watch. Many geriatricians and medical experts agree that this app could help older consumers. Falls can cause fractured hips and head injuries, but even fear of falling can prevent older people from living on their own or participating in activities. Fall deaths in the U.S. increased 30 percent for older adults in the past decade, and 3 million older people go to the emergency room for fall injuries each year, according to the Centers for Disease Control and Prevention. Dr. Armin Shahrokni, an internist with Memorial Sloan Kettering Cancer Center who describes himself as “tech-savvy,” is excited that older patients might get into wearable technology. “In older cancer patients, my area of expertise, all the chemo can make them fall more,” he said, making detecting falls and balance important. The other app, the ECG monitoring app, also uses sensors in the wristband to monitor a patient’s heartbeat and send alerts if it gets too fast or too slow. Specifically, the app is meant to detect atrial fibrillation, which is a type of arrhythmia, also described as a problem with the speed or rhythm of the heartbeat. Here is how the app works: The watch’s sensors can detect a heart rhythm in 30 seconds, creating a “waveform” readout. It also allows the user to note how they are feeling — lightheaded, winded, full of energy — at that moment. This combination, according to Apple, will help people have better conversations with their doctors about symptoms and heart patterns. The Food and Drug Administration cleared this function for people 22 or older. However, it’s rare for anyone younger than 50 to be diagnosed with atrial fibrillation, noted Eric Topol, a cardiologist at the Scripps Research Institute. Doctors have expressed concern that scores of panicked Apple Watch users would flood emergency rooms with every heart rhythm notification and blip. “It’s mass use of a tool, and with that is going to come lots of unintended consequences,” Topol said. “It’ll lead to a lot of anxiety and expense and additional testing, and even then some people will get blood thinners inappropriately,” he added. “This is the opposite of individualized medicine, where you are using something on exactly, precisely the right person,” Topol said. Wearables Unleashed The watch represents the beginning of what analysts agree will be a wave of new health apps and wearable health trackers. Consumers can expect more ways to track vital signs, like blood sugar, and more apps that will use those numbers to help people prevent medical emergencies, said Ross Muken, an analyst with Evercore ISI. While health tracking isn’t a new concept, putting that data into an algorithm to help change behavior and get ahead of a health crisis is the next big frontier for wearable health technology products. Experts caution, though, that while the FDA “cleared” these new apps, it hasn’t actually “approved” them, which is a bureaucratic distinction that means they haven’t faced as much rigorous testing as something that has gained the agency’s formal OK. For example, there are no findings from studies or trials that offer evidence of the fall prevention or ECG apps’ benefits, Topol said. “We don’t have any data to review. These are unknowns.” Someday, he added, he expects the “medicalized smartphone” to be more common, cheaper and accessible to seniors. Right now we’re seeing the very beginning of this technology be put into use. “Technology is way ahead of medical practice,” Topol said. This story originally appeared on Kaiser Health News Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
In Throes Of Turkey Salmonella Outbreak, Don’t Invite Illness To Your Table
By JoNel Aleccia, Kaiser Health News As Americans prepare to cook and consume nearly 50 million turkeys on Thanksgiving Day, an ongoing outbreak of salmonella poisoning linked to the poultry means food safety at home is more critical than ever. Federal health officials have identified no single source of the outbreak of Salmonella Reading, which has sickened at least 164 people in 35 states during the past year. As of Nov. 5, the bacterial strain has led to 63 hospitalizations and, in California, one death. Many who fell ill reported preparing or eating such products as ground turkey, turkey parts and whole birds. Some had pets who ate raw turkey pet food; others worked at turkey processing plants or lived with someone who did. Late Thursday, Jennie-O Turkey Store Sales LLC of Barron, Wis., recalled more than 91,000 pounds of raw ground turkey products that may be connected to the illnesses. There is no U.S. requirement that turkeys or other poultry be free of salmonella — including antibiotic-resistant strains like the one tied to the outbreak — so prevention falls largely to consumers. That means acknowledging that the Thanksgiving turkey you lug home from the grocery store is likely contaminated, said Jennifer Quinlan, an associate professor in the Nutrition Sciences Department at Drexel University. “They absolutely should assume there’s a pathogen,” she said. Last year, right after the holiday season, Quinlan and her colleagues surveyed more than 1,300 U.S. consumers about their turkey-handling habits. Most, they found, fail to follow safe practices, despite decades of public health warnings. Ninety percent of those surveyed washed raw birds in the sink, even though that can spread dangerous bacteria. Fifty-seven percent reported always or sometimes stuffing a turkey before cooking instead of baking dressing separately, and 77 percent said they left a cooked bird in a warm oven or at room temperature. Such practices can allow the growth not only of salmonella but other bad bugs, such as campylobacter and Clostridium perfringens, she said. “All of these illnesses could have been prevented. There’s either cross-contamination going on in the home, or there’s not thorough cooking.” Other experts contend that simply telling consumers to handle food properly is unfair and ineffective. Regulators and industry should be responsible for preventing contamination in the first place. “They ought to be going after these guys like gangbusters,” said Carl Custer, a food safety microbiology consultant who spent decades at the U.S. Department of Agriculture. “This is a seriously virulent strain.” This month, Custer renewed calls for pathogenic strains of salmonella to be declared “adulterants” in poultry, which would require the USDA to test products and recall those contaminated with the bacteria. The USDA classified E. coli O157:H7 as an adulterant in ground beef after the deadly 1993 Jack in the Box hamburger outbreak. After that, the rate of those E. coli infections plummeted. Since then, the agency has named six additional strains as adulterants in certain beef products. Efforts to ban drug-resistant salmonella from meat and poultry have stalled, however, despite years of demands from consumer advocacy groups and lawmakers. In February, USDA officials rejected a 2014 petition from the group Center for Science in the Public Interest to declare certain strains of drug-resistant salmonella to be adulterants, saying the group failed to distinguish strongly enough between resistant and non-resistant salmonella. In 2015, Democratic congresswomen Rosa DeLauro of Connecticut and New York’s Louise Slaughter introduced a bill that would have defined resistant and dangerous salmonella as adulterants and given USDA new power to test and recall tainted meat, poultry and eggs. It was not enacted. “It’s very hard to get attention to food safety issues in this current political climate,” said Sarah Sorscher, CSPI’s deputy director of regulatory affairs. Outside observers said there’s little political will for taking on the nearly $5 billion-a-year U.S. turkey industry, as well as regulators. “I don’t see a lot of traction for making it an adulterant right now,” said Kirk Smith, director of the Minnesota Integrated Food Safety Center of Excellence. “Salmonella is still common enough that it would be hugely impractical and costly to make it an adulterant,” he added. “It would double the cost of poultry.” In a sharply worded statement, USDA officials refused to publicly name the producers, suppliers and brands linked to the turkey outbreak, saying it would be “grossly irresponsible and reckless” when no definite source of illness has been identified. Because the outbreak strain of salmonella has been found at turkey-processing plants, in workers and in a wide range of food products, it will take a broad effort to detect and eradicate the source, said Smith, the Minnesota food safety expert. “It should be a whole-system approach, starting with controls on the farm, all the way through to educating consumers as best we can,” he said. This story originally appeared on Kaiser Health News Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Multiple Hospitals Evacuate As California Wildfires Spread
Multiple hospitals evacuated patients this week as the Camp Fire continued to spread across California, according to the state’s Department of Public Health. More than 300 patients across three general acute care hospitals, three skilled nursing facilities and six intermediate care facilities have evacuated since Nov. 10. Some facilities, like Los Robos Regional Medical Center in Thousand Oaks, have started repopulating their hospitals with evacuee patients, but most of the facilities remain non-operational, according to the Department of Public Health. The blaze forced Adventist Health Feather River Hospital to evacuate on Nov. 8, and damaged the lower level of the hospital, the chiller and utility area and most of the other outbuildings, according to the hospital’s website. Full damage from the fire is still being assessed, but in the meantime evacuated patients are staying at Enloe Hospital in Chico and Oroville Hospital in Oroville. A majority of Adventist Health’s staff have lost their homes, a representative for the hospital told Bloomberg News. The Camp Fire, which started on Thursday, Nov. 8 near Camp Creek Road in Butte County, has been recorded as the deadliest and most destructive wildfire in California history. The fire has killed 63 people and destroyed thousands of homes and commercial structures, according to the most recent Butte County Camp Fire Incident Update on Nov. 16 Camp Fire Incident Update 11.16.18 AM#CampFire #ButteCounty @ButteSheriff @CountyofButte @townofparadise @chicofd @chicopolice @CHP_Valley @CHP_Oroville @CHP_Chico #ButteCounty @CAL_FIRE pic.twitter.com/5DL7vSd6gZ — CAL FIRE Butte Unit/Butte County Fire Department (@CALFIRE_ButteCo) November 16, 2018 View the current status of active California wildfires on the map below:
Midterm Election Boosts Medicaid Expansion, But Challenges Remain
By Phil Galewitz, Kaiser Health News Medicaid — which has been a political football between Washington and state capitols during the past decade — scored big in Tuesday’s election. Following the vote, nearly 500,000 uninsured adults in five states are poised to gain Medicaid coverage under the Affordable Care Act, advocates estimate. Three deep-red states passed ballot measures expanding their programs and two other states elected governors who have said they will accept expansion bills from their legislatures. Supporters were so excited by the victories they said they will start planning for more voter referendums in 2020. Medicaid proponents also were celebrating the Democrats’ takeover of the House, which would impede any Republican efforts to repeal the ACA and make major cuts to the federal-state health insurance program for low-income people. “Tuesday was huge for the Medicaid program,” said Katherine Howitt, associate director of policy at Community Catalyst, a Boston-based advocacy group. “The overall message is that the electorate does not see this as a Democrat or GOP issue but as an issue of basic fairness, access to care and pocketbook issue. Medicaid is working and is something Americans want to protect.” But health experts caution that GOP opposition won’t fade away. David Jones, an assistant professor in the Department of Health Law, Policy and Management at Boston University, said ballot organizers now have a blueprint on how to expand Medicaid in states that have resisted. “I see this as a turning point in ACA politics,” he said. Still, he added‚ “it’s not inevitable.” Medicaid is the largest government health program, insuring at least 73 million low-income Americans. Half of them are children. To date, 32 states and the District of Columbia have expanded it under the ACA. Before that law, Medicaid was generally limited to children, sometimes their parents, pregnant women and people with disabilities. The ACA encouraged states to open the program to all Americans earning up to 138 percent of the poverty level ($16,753 for an individual in 2018). The federal government is paying the bulk of the cost: 94 percent this year, but gradually dropping to 90 percent in 2020. States pay the rest. GOP opposition has left about 4.2 million low-income Americans without coverage in various states. “It’s not over until it’s over is the story of Medicaid expansion and the Affordable Care Act as the politics never ends and the opportunity for obstruction never ends,” said Jones. “But the trend overall has been to increasing implementation and increasing coverage.” Montana Fails To Endorse Funding Two years after President Donald Trump carried Idaho, Nebraska and Utah by double-digit margins with a message that included repeal of the ACA, voters in those states approved the ballot referendums Tuesday. Together, the states have about 300,000 uninsured adults who would be eligible for the program. In addition, Democrats secured the governor’s offices in Kansas and Maine, which will increase the likelihood those states pursue expansion. Legislatures in both states have previously voted to expand, only to have GOP governors block the bills. Maine voters also passed a referendum in 2017 endorsing expansion, but Republican Gov. Paul LePage again refused to accept it. Current and incoming Republican governors in Utah and Idaho said they wouldn’t block implementation of the effort if voters approved it. Nebraska Gov. Pete Ricketts said Wednesday he would follow the will of the voters but would not support paying for it with a tax increase. It wasn’t a clean sweep, however, for Medicaid on Tuesday. In preliminary results, a ballot issue to fund Montana’s Medicaid expansion — which is already in place and slated to expire next July — was failing. Tobacco companies had mounted a campaign to stop the measure, which would have partially financed the expansion with taxes on tobacco products. The Montana legislature and the Democratic governor are expected to address the issue in the session that starts in January. No state has reversed its Medicaid expansion, even though GOP governors in Kansas and Arkansas have threatened to do so. Nearly 100,000 Montana residents have received Medicaid since its expansion, twice as many as expected. Nancy Ballance, the Republican chairwoman of the Montana House Appropriations Committee who opposed the bill that expanded Medicaid in 2015, said she is confident the state legislature will extend the program past July. But she expects the legislature to put some limits on the program, such as adding an asset test and work requirements. “There are some people in the state who may not have disabilities but need some help to access coverage,” she said. “I think we can pass something without people having a gap in coverage. … That will be a priority.” “It was never our intent to simply sunset the expansion and have it go away,” she said. Rather, the legislature put the sunset provision in to revisit the provision to make any changes. Chris Jacobs, a conservative health policy analyst in Washington, D.C., said the Montana results showed that when voters are given a choice of having to pay for Medicaid expansion through a new tax they were not willing to go along. But in Utah, voters did agree to fund their state plan by adding 0.15 percent to the state’s sales tax, just over a penny for a $10 purchase. Fernando Wilson, acting director of the Center for Health Policy at the University of Nebraska Medical Center, said the vote on the state’s ballot question indicated many people wanted to help 80,000 uninsured Nebraskans gain coverage. “I think it showed there was a clear need for it,” he said. The legislature likely won’t block the expansion, Wilson said, though it may try to add a conservative twist such as adding premiums or other steps. Sheila Burke, a lecturer in health policy at Harvard Kennedy School, said voters approved Medicaid expansion not just because it would help improve health coverage for their residents but to help stabilize their hospitals, particularly those in rural areas. Hospitals have said this step helps their bottom
Question 1: Massachusetts Nurse-To-Patient Ratio Ballot Initiative Defeated
Massachusetts’ Question 1, a ballot initiative that would have established mandatory nurse-patient ratios in hospitals was defeated during the general election Tuesday. The Massachusetts Nurses Association, a union representing nurses in 51 acute care hospitals across the state, conceded defeat around 9 p.m. Tuesday evening. At approximately 10:20 p.m., the initiative had 969,400 votes against and 416,720 votes in favor, with more than 50 of precincts reporting, according to the preliminary results. “We are all disappointed by tonight’s results and the impact this will have on the patients we care for every day,” MNA President Donna Kelly-Williams said in prepared remarks. “We know that right now – as I speak to you here – there are nurses caring for too many patients and those patients are unnecessarily being put in harm’s way. And the problem continues to grow every year. The status quo is not a solution here.” The outcome was a victory for the Massachusetts Health and Hospital Association, who opposed the initiative for fear that it would dramatically increase state healthcare costs. The association represents 70 hospitals across the state. “This is the beginning of a conversation, not the end,” MHA President and CEO Steve Walsh said in a statement to Mass Live. “Question 1 forced some difficult and necessary discussions about the future of healthcare and the future of our workforce going forward. These conversations with our care teams and in our communities have been critically important and will continue in bargaining sessions, legislative debates, board rooms and newspapers.” An independent study conducted by the state’s Health Policy Commission found that implementing the mandate would cost an estimated $676-949 million per year and potentially save $34-47 million. The study also found that hospitals would need to hire 2,286 to 3,101 additional full-time equivalent nurses to meet the mandate.
The Election’s Impact On Healthcare: Some Bellwether Races To Watch
By Julie Rovner, Kaiser Health News Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many. But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions and state legislatures around the country. All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen — or not happen — over the next two years. For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not. Here are three big health issues that could be dramatically affected by Tuesday’s vote. 1. The Affordable Care Act Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans and the generic drug approval process, among other things. Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law. This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect. Polls suggest Cramer has a healthy lead in that race, but if Heitkamp pulled off a surprise win, health care might well get some of the credit. And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care. It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and two GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general — Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey — are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016. The attorneys general are running against Democratic incumbents — Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit. Although Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts. But in the end, the fate of the ACA depends less on an individual race than on which party winds up in control of Congress. “If Democrats take the House … then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health. Conservative healthcare strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday. “Republicans, if they maintain the majority in the House, will have a margin of a half dozen seats — if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently, there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017. And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so a change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there. 2. Medicaid expansion The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138 percent of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94 percent in 2018, gradually dropping to 90 percent in 2020. Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid. McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said. Four states — Nebraska, Idaho, Utah and Montana — have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs. In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov.
Tobacco Tax Battle Could Torch Montana Medicaid Expansion
By Eric Whitney, Montana Public Radio Montana legislators expanded Medicaid by a very close vote in 2015. They passed the measure with an expiration date: It would sunset in 2019, and all who went onto the rolls would lose coverage unless lawmakers voted to reapprove it. Fearing legislators might not renew funding for Medicaid’s expanded rolls, Montana’s hospitals and health advocacy groups came up with a ballot measure to keep it going — and to pay for it with a tobacco tax hike. If ballot initiative I-185 passes Tuesday, it will mean an additional $2-per-pack tax on cigarettes and levy a tax on e-cigarettes, which are currently not taxed in Montana. The tobacco tax initiative has become the most expensive ballot measure race in Montana history — drawing more than $17 million in opposition funding from tobacco companies alone — in a state with fewer than 200,000 smokers. Amanda Cahill works for the American Heart Association and is a spokeswoman for Healthy Montana, the coalition backing the measure. She said coalition members knew big tobacco would fight back. “We poked the bear, that’s for sure,” Cahill said. “And it’s not because we were all around the table saying, ‘Hey, we want to have a huge fight and go through trauma the next several months.’ It’s because it’s the right thing to do.” Most of the $17 million has come from cigarette maker Altria. According to records from the National Institute on Money in Politics, that’s more money than Altria has spent on any state proposition nationwide since the center started keeping track in 2004. Meanwhile, backers of I-185 have spent close to $8 million on the initiative, with most of the money coming from the Montana Hospital Association. “What we want to do is — No. 1 — stop Big Tobacco’s hold on Montana,” Cahill said. Also, she continued, it’s imperative that the nearly 100,000 people in Montana who have gotten Medicaid under the expansion will be able to keep their health care. Cahill said I-185 will allocate plenty of money to cover the expansion, though some lawmakers say the state can’t afford the expansion even with higher taxes. Nancy Ballance, a Republican representative in the Montana state Legislature, opposes the measure. “In general I am not in favor of what we like to refer to as ‘sin taxes,’ ” Ballance said. “Those are taxes that someone determines should be [levied] so that you change people’s behavior.” Ballance also isn’t in favor of ballot initiatives that, she said, try to go around what she sees as core functions of the Legislature: deciding how much revenue the state needs, for example, or where it should come from, or how it should be spent. “An initiative like this for a very large policy with a very large price tag — the Legislature is responsible for studying that,” Ballance said. “And they do so over a long period of time, to understand what all the consequences are — intended and otherwise.” Most citizens, she said, don’t have the time or expertise to develop that sort of in-depth understanding of a complicated issue. Montana’s initiative to keep Medicaid’s expansion going would be a “double whammy” for tobacco companies, said Ben Miller, the chief strategy officer for the nonprofit Well Being Trust. “People who are covered are more likely to not smoke than people who are uninsured,” said Miller, who has studied tobacco tax policies for years. He notes research showing that people with lower incomes are more likely than those with higher incomes to smoke; and if they’re uninsured, they’re less likely to quit. Federal law requires Medicaid to offer beneficiaries access to medical help to quit smoking. Plus, Miller added, every time cigarette taxes go up — thereby increasing the price per pack — that typically leads to a decrease in the number of people smoking. And that, he said, works against a tobacco company’s business model, “which is, ‘you need to smoke so we can make money.’ ” Ballance agrees that tobacco companies likely see ballot initiatives like I-185 as threats to their core business. But, she said, “for anybody who wants to continue smoking, or is significantly addicted, the cost is not going to prohibit them from smoking.” The U.S. Centers for Disease Control and Prevention says tobacco use is the leading cause of preventable disease and death in the U.S. Montana’s health department says that each year more than 1,600 people in the state die from tobacco-related illnesses. This story is part of a reporting partnership with Montana Public Radio, NPR and Kaiser Health News. This story originally appeared on Kaiser Health News. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.