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News Article | June 30, 2017

How The Senate GOP Health Care Bill Could Affect The Midterms And Beyond One provision of the Senate's health care bill stands to be quite popular: the Better Care Reconciliation Act would eliminate the Affordable Care Act's individual mandate. That would be repealed immediately. Another would likely please the Republican base: defunding Planned Parenthood for a year. Those funds would disappear right away, too. Another would threaten health care coverage for millions of Americans: a rollback to the Medicaid expansion. That change wouldn't start until 2021. Repealing Obamacare may be Senate Republicans' main goal, but it's also easy to see how the BCRA could benefit the GOP in coming elections. The provisions that stand to be more popular (and less harmful to many Americans) are front-loaded, occurring before the 2018 midterms. Cuts to premium subsidies and Medicaid come after that, and many of them are delayed until after the 2020 presidential election. To better see how this bill could affect future politics, we've put together a timeline of when major BCRA changes would go into effect in relation to the dates of coming elections. We've also explained the potential effects of the bill, as reported by the Congressional Budget Office and other health care experts, to try to game out how those effects could affect voters' choices. So here's what goes into effect when: Prior to this point, the individual mandate — one of the most unpopular parts (maybe the most unpopular part) of Obamacare — will have been repealed. That could make midterm voters happy — and inclined to vote for Republicans — despite the fact that Obamacare has, in general, gained in popularity since Trump took office. According to the Congressional Budget Office, the elimination of the individual mandate would lead to 15 million more uninsured people in 2018 alone. In addition, several Obamacare taxes will have been repealed by now, overwhelmingly benefiting the highest-income Americans. Those changes could please a crucial group of GOP supporters. Not only that, but the bill will not have yet removed cost-sharing subsidies — payments to insurers that help lower-income customers afford coverage — and it will not have yet kicked in the (generally) less-generous premium support subsidies. The Medicaid expansion likewise will not have yet been rolled back. That rollback will eventually affect millions — by 2026, it would mean 15 million more people would be off the Medicaid rolls than there would be under current law, according to the CBO. In short, many of the potentially less-popular provisions of this law — provisions that would lead to higher premiums or deductibles (which could in turn lead to more people choosing not to buy coverage), as well as lower Medicaid enrollment — wouldn't go into effect for a while and could save the GOP some pain at the ballot box. However, it could cause some hardship for some Americans — specifically, those who rely on Planned Parenthood for services. Government funds currently account for 40 percent of Planned Parenthood's revenue, with much of that coming from Medicaid (but none of that going toward abortions, except in cases of rape, incest and when the mother's life is in danger). Cutting those funds could mean clinic closures or fewer services, as FiveThirtyEight explained in March. Around 15 percent of people in areas where there aren't other options for low-income people to get care would be affected, and the reduction in family planning services would mean the number of Medicaid births would go up by "several thousand." Midterm turnout tends to be low, however — much lower than in presidential election years. So the bill could make a difference to the extent that it affects the views of many people who would vote anyway. But then, if people's experiences with it are particularly negative or positive, it could inspire them to turn out as well. Of course, how this affects the election at all depends not only on what else is going on but also which party people blame or praise for any changes in the health care system. By now, some pain may have kicked in for some Americans. Some who were formerly eligible for tax credits for individual market insurance premiums — that is, those between 350 and 400 percent of the federal poverty level — will no longer be eligible. The cost-sharing reduction payments that benefit lower-income people on the exchanges will also end. That could lead to lower-income people paying premiums near where they are now, but also having much higher deductibles, the CBO reported this week. In other words, health care would be more expensive for many lower-income people in the individual markets, so many may simply choose not to purchase insurance. And the amount the federal government spends to reimburse states for Medicaid will be dropping by then. If states want to maintain current levels of coverage, they will have to spend more and more of their own money. Otherwise, as the CBO wrote, states would cut spending in a number of ways: Furthermore, some older Americans would by now paying more for their health insurance, though some younger Americans could be seeing smaller premiums. But then, the number of people on the exchanges in the first place is small — around 6.4 million right now. If people on the exchanges are getting less care for more money, and if it affects their votes (that is, if those people vote), it may not be a huge bloc of voters. And the effects of these changes may be slow in coming. "Those changes do start in 2020 and could be a problem for the election [for Republicans], but I think those market effects would be more gradual," said Caroline Pearson, senior vice president for policy and strategy at Avalere Health. Still more factors could affect these elections, particularly Medicaid cuts. These could be getting sharper in many states, with "churn" in the system having taken people off the rolls who now won't be able to get back on, with the expansion dialing back. The federal spending on the Medicaid expansion would be gone entirely by now — states could maintain the expansion if they had enough money, but for many states, that's unlikely. As the left-leaning Center on Budget and Policy Priorities reports, some states would have to up their spending by 400 percent in 2024 to maintain the expansion. Medicaid per capita growth now pegged to a lower inflation rate (meaning lower spending in the future) By now, Medicaid will be drastically changed from what it was before the bill, with work requirements in some states, caps on spending (meaning it won't adjust for recessions, for example), and much lower enrollment in general. In addition, by now, premiums in the marketplaces will have shifted sharply. Older adults in particular could face some massive increases in premiums, as the CBO report showed.

News Article | July 25, 2017

"For more than a half-century, long before the Affordable Care Act (ACA) and long before the health care debate was poisoned by partisanship, the United States has protected kids in need of healthcare," said Bill Lindsay, chairman of the board at Children's Hospital Colorado. "Senator Gardner has been an eloquent spokesman for the need to protect children on Medicaid, and now he has the opportunity to act on those principles." The Medicaid expansion in the ACA did not primarily benefit children. Now, the current version of the BCRA goes far beyond simply repealing the ACA and would actually slash longstanding coverage for children that goes back to the creation of Medicaid in 1965. Children's Colorado strongly opposes the BCRA. An Avalere analysis estimates the bill would cut kids' Medicaid funding by $43 billion over 10 years. The amendment Children's Colorado is pushing would limit the deep cuts to children's funding in the bill, though funding would still be reduced relative to current law. "We urge Senator Gardner to put forward an amendment to the BCRA to limit the bill's harm to children. Colorado's kids are counting on Cory," said Jena Hausmann, president and CEO of Children's Hospital Colorado. Editorial boards across the state – from The Gazette in Colorado Springs to the Pueblo Chieftain and The Daily Sentinel in Grand Junction-- have called on Congress to protect the essential safety net for children's medical coverage. Voters across Colorado agree. A public opinion survey by leading Republican polling firm The Tarrance Group found that, regardless of their political affiliation, 85% of Colorado voters agreed that "regardless of whether Obamacare is ultimately repealed or replaced, Congress should maintain the longstanding benefits that Medicaid has guaranteed children since 1965." Last month, a bipartisan group of 39 business, community, and political leaders sent a letter to Colorado's U.S. Senators Gardner and Michael Bennet (D – Colo.), urging them to ensure that Medicaid coverage for children is not impacted by efforts to repeal and replace the ACA. About Children's Hospital Colorado Children's Hospital Colorado (Children's Colorado) has defined and delivered pediatric health care excellence for more than 100 years. Founded in 1908, Children's Colorado is a leading pediatric network entirely devoted to the health and well-being of children. Continually acknowledged as one of the nation's outstanding pediatric hospitals by U.S. News & World Report, Children's Colorado is known for both its nationally and internationally recognized medical, research, education and advocacy programs, as well as comprehensive everyday care for kids throughout Colorado and surrounding states. Children's Colorado is the winner of the 2015 American Hospital Association-McKesson Quest for Quality Prize, and is a 2013-2017 Most Wired hospital according to Hospitals & Health Networks magazine. Children's Colorado also is recognized for excellence in nursing from the American Nurses Credentialing Centers and has been designated a Magnet® hospital since 2005. The hospital's family-centered, collaborative approach combines the nation's top pediatric doctors, nurses and researchers to pioneer new approaches to pediatric medicine. With urgent, emergency and specialty care locations throughout Metro Denver and Southern Colorado, including its campus on the Anschutz Medical Campus, Children's Colorado provides a full spectrum of pediatric specialties. For more information, visit and connect with Children's Colorado on Facebook, Twitter and Pinterest. Children's Hospital Colorado complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

News Article | July 8, 2017

Senate Health Bill Could Both Boost And Undercut Mental Health Funding A little-discussed provision in the Senate health care bill is designed to boost the number of hospital beds for psychiatric care, providing a long-sought victory for mental health advocates. The provision would amend an obscure rule regarding Medicaid funding — a rule that has sharply limited the number of beds for those with schizophrenia, bipolar disorder or other mental illnesses. Yet leading advocacy groups on mental health issues say they see no reason to celebrate. That's because the Senate bill would also wring out $772 billion from Medicaid — the joint state-federal insurance program that is the single-largest provider of care for people with serious mental illness. The nonpartisan Congressional Budget Office has said that the Senate bill, drafted by Republicans as a replacement for the Affordable Care Act, would reduce overall Medicaid spending by 26 percent by 2026, and by 35 percent the following decade. The loss of those funds would devastate health care services for people with mental illness, who are some of the most vulnerable and disadvantaged people in the country, said Bethany Lilly, deputy director of policy and legal advocacy at the Bazelon Center for Mental Health Law, an advocacy group. "Medicaid is the safety net for people with serious mental illness," said Ronald Honberg, senior policy adviser at the National Alliance on Mental Illness. Without decent mental health care and support services, people who have a psychotic disorder can quickly deteriorate, Honberg said, ending up in overcrowded emergency rooms, jail and prison cells or dangerous city streets. "This bill is a prescription for making all these problems worse." Republicans who crafted the Senate bill have noted that Medicaid spending will still increase under their plan — just at a rate lower than currently projected. The Senate bill will make Medicaid spending more sustainable, said Julia Lawless, a spokeswoman for the Senate Finance Committee, one of the Senate committees that oversees health legislation. "Even before Obamacare's unprecedented Medicaid expansion," Lawless said, "the program was plagued by quality issues. States were barred from using innovative solutions to improve patient care and both federal and state Medicaid spending was growing at unprecedented, unsustainable levels." The Senate bill will reverse this course, she said, and slow the growth of Medicaid "without cutting actual benefits." The Medicaid program has traditionally refused to pay for inpatient stays in large, freestanding psychiatric facilities, making exceptions for patients under age 21 and facilities with 16 beds or fewer. The rule, which has changed little since Medicaid was created five decades ago, was aimed at preventing the federal government from paying for long-term care in psychiatric institutions. But that Medicaid rule also has contributed to a severe shortage of psychiatric beds for people in crisis, said John Snook, executive director of the Treatment Advocacy Center, a nonprofit that focuses on people with serious mental illness. Mental health advocates have called for changing the rule for decades. Last year, the Centers for Medicare & Medicaid Services eased the policy, paying for up to 15 days of inpatient hospital care for patients enrolled in Medicaid managed-care plans. But in a letter to the Medicaid program last year, the National Association of Medicaid Directors noted that some patients with mental illness or substance abuse disorders might need closer to a month of inpatient care. The current draft of the Senate bill, dubbed the Better Care Reconciliation Act, would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year. This suggested change in Medicaid funding was included in the Republican bill because several senators have voiced concern that patients haven't had enough access to hospital care for mental illness and addiction, according to a GOP Senate aide who was authorized to speak only on condition of anonymity. The legislators involved, according to the aide, included Sen. Orrin Hatch, R-Utah, and Sen. Rob Portman, R-Ohio. Honberg said he would welcome such a change except that reducing overall Medicaid spending could force closures of rural hospitals and institutions that serve as "safety nets" — providing free care to people who are uninsured or poor. If these hospitals go out of business, Honberg said, the total number of hospital beds available to people with mental illness could shrink, not expand. Medicaid, he pointed out, pays for a wide variety of supportive services for people with schizophrenia and other serious mental illnesses — beyond doctor's visits and medications. States can use Medicaid funds to pay for case managers; transportation of patients to and from doctor's appointments; supportive housing, which helps people with serious mental illness live independently; supported employment, which provides job training and other services; and teams of professionals who assist people who need intensive, comprehensive help navigating the health system and social services. Kaiser Health News, a nonprofit health newsroom, is an editorially independent part of the Kaiser Family Foundation. Follow KHN's enterprise reporter Liz Szabo on Twitter @LizSzabo.

News Article | September 28, 2017

Internists Urge President Trump to 'Consider Taking Additional Actions' to Provide Relief in Puerto Rico and U.S. Virgin Islands Letter offers solutions to prevent situation from becoming greater public health crisis Washington, September 28, 2017 --The American College of Physicians (ACP) today sent a letter? urging President Trump "to consider taking additional actions to provide immediate assistance and relief to the American citizens in Puerto Rico and the U.S. Virgin Islands currently recovering from the aftermath of Hurricane Maria." Sent by Jack Ende, MD, MACP, president of ACP, on behalf of the 152,000-member organization, the letter acknowledges and expresses appreciation for the administration's decision to temporarily waive the Jones Act for Puerto Rico, which will help alleviate shortages of basic necessities on the island, as well as the decision to deploy needed military resources to the island. Yet ACP recommended that President Trump and his administration work with Congress to provide additional resources to address an urgent public health crisis on the islands. "As millions continue to live without reliable access to food, water, fuel, and electricity, we ask that you consider taking additional actions, as recommended in this letter, to accelerate and improve the response and recovery on the ground, and prevent the situation from turning into an even greater public health and humanitarian crisis," Dr. Ende continued. Dr. Ende noted that ACP is not an expert on how best to provide the necessary recovery assistance. However, he pointed out six steps that have been recommended by those with such expertise that merit consideration: ACP already has begun promoting hurricane relief resources to its membership and invites the Trump administration to partner with ACP and other medical organizations on how they can most effectively help, such as by identifying volunteer opportunities for ACP members and serving as a clearinghouse for information. "As each day passes without adequate access to basic necessities and health care services, the public health crisis in Puerto Rico and the U.S. Virgin Islands will continue to become more dire," Dr. Ende concluded. "We respectfully urge your administration to consider taking additional actions to address the unfolding humanitarian crisis threatening the lives and livelihood of millions of American citizens affected by Hurricane Maria."

News Article | September 14, 2017

(Reuters Health) - After the Affordable Care Act (ACA) helped reduce the number of uninsured Americans, more low-income adults got cancer diagnosed when it was less advanced and potentially easier to treat, a recent study suggests. Researchers examined data on 1.7 million adults under age 65, of all income levels, who were newly diagnosed with cancer between 2011 and 2014. About 907,000 participants lived in states that expanded Medicaid, the government-sponsored insurance for the poor, under the ACA. Another 811,000 people lived in states that didn’t expand Medicaid. The effect of expanded Medicaid was most pronounced for low-income patients. Before the ACA took effect, in the states that subsequently added to their Medicaid rolls, 9.6 percent of low-income people newly diagnosed with cancer were uninsured. Afterward, only 3.6 percent of poor, newly diagnosed cancer patients lacked health coverage in these states. The decline in the proportion of newly diagnosed patients without insurance was much less pronounced in states that didn’t expand Medicaid. In these states, the proportion of low-income newly diagnosed cancer patients without insurance dropped from 14.7 percent before the ACA to 13.3 percent afterward. In Medicaid expansion states, there was also a small but statistically meaningful increase in the proportion of patients newly diagnosed with colorectal, lung, breast, pancreatic and melanoma cases that were caught when tumors were in the early stages of development. “Although the increase in the percent of patients diagnosed with early-stage diseases in Medicaid expansion states is small, it has significant clinical implications,” said lead study author Ahmedin Jemal, vice president of surveillance and health services research at the American Cancer Society in Atlanta. “Patients diagnosed with early-stage diseases are more likely to be treated successfully and to be cured and to have better quality of care,” Jemal said by email. “Furthermore, the increase in detection of cancers at early stage has societal implications by avoiding premature deaths when individuals are in the workforce, raising children and supporting other family members.” These results suggest a need for additional expansion of access to care, especially for low-income populations, the authors conclude in the Journal of Clinical Oncology. To assess the impact of the ACA and the expansion of Medicaid programs, researchers examined data from the National Cancer Data Base. For a picture of what happened before the ACA took effect at the beginning of 2014, they looked at data from 2011 through the third quarter of 2013. To see what happened afterward, they examined data from the second to fourth quarter of 2014 They looked at changes in insurance and in early-stage diagnosis for 15 leading cancers in men and women. The study wasn’t a controlled experiment designed to prove that the ACA or Medicaid expansion directly caused more low-income people to be diagnosed with cancer sooner. The study also didn’t follow people to determine if this resulted in better survival odds or other benefits. Researchers also didn’t follow people beyond the first year of Medicaid expansions. Previous research has found that coverage gains, access to care and health benefits of expanding Medicaid increase over time, said Dr. Benjamin Sommers, a health policy and economics researcher at the Harvard T. H. Chan School of Public Health and Brigham and Women’s Hospital in Boston. “However, coverage expansion on its own may not necessarily lead to more early stage cancer (diagnoses), especially cancers for which we don’t have effective screening tests,” Sommers, who wasn’t involved in the study, said by email. And it’s too soon to expect to see dramatic changes in survival rates, said Dr. Ernest Hawk of the University of Texas MD Anderson Cancer Center. “Nevertheless, the reduction in the number of newly diagnosed cancer patients in conjunction with the downward stage-shift documented in this study is a promising step towards helping to address the disparities in cancer outcomes, including survival,” Hawk, who wasn’t involved in the study, said by email.

Shaw F.E.,Centers for Disease Control and Prevention | Asomugha C.N.,MediCaid | Conway P.H.,MediCaid | Rein A.S.,Centers for Disease Control and Prevention
The Lancet | Year: 2014

The Patient Protection and Affordable Care Act, which was enacted by the US Congress in 2010, marks the greatest change in US health policy since the 1960s. The law is intended to address fundamental problems within the US health system, including the high and rising cost of care, inadequate access to health insurance and health services for many Americans, and low health-care efficiency and quality. By 2019, the law will bring health coverage-and the health benefits of insurance-to an estimated 25 million more Americans. It has already restrained discriminatory insurance practices, made coverage more affordable, and realised new provisions to curb costs (including tests of new health-care delivery models). The new law establishes the first National Prevention Strategy, adds substantial new funding for prevention and public health programmes, and promotes the use of recommended clinical preventive services and other measures, and thus represents a major opportunity for prevention and public health. The law also provides impetus for greater collaboration between the US health-care and public health systems, which have traditionally operated separately with little interaction. Taken together, the various effects of the Patient Protection and Affordable Care Act can advance the health of the US population.

The Affordable Care Act established the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models. The goal is to reduce program expenditures while preserving or improving the quality of care provided to beneficiaries of Medicare, Medicaid, and the Children's Health Insurance Program. Central to the success of the Innovation Center is a new, rapid-cycle approach to evaluation. This article describes that approach-setting forth how the Rapid Cycle Evaluation Group aims to deliver frequent feedback to providers in support of continuous quality improvement, while rigorously evaluating the outcomes of each model tested. This article also describes the relationship between the group's work and that of the Office of the Actuary at the Centers for Medicare and Medicaid Services, which plays a central role in the assessment of new models. © 2013 Project HOPE-The People-to-People Health Foundation, Inc.

Hamilton T.E.,MediCaid
Current Opinion in Organ Transplantation | Year: 2013

PURPOSE OF REVIEW: This article conveys early findings with respect to changes in patient and graft survival since Centers for Medicare & Medicaid Services (CMS) regulations for Medicare coverage of solid organ transplantation became effective on 28 June 2007. RECENT FINDINGS: Programmes cited by CMS for subpar outcomes have strong incentives to improve performance and have risen to the challenge. Adult kidney programmes that entered into System Improvement Agreements or were approved for mitigating factors by CMS, for which there is a 2-year postsurvey tracking period (N =  15), improved their standardized mortality ratio (SMR) for 1-year posttransplant patient survival from 2.05 to 1.17 on average. Volume in some of those programmes tended to decline, whereas national volume increased. Nationally, average donor risk across U.S. adult kidney transplant programmes increased approximately 6% from CY2001 through CY2010. Average recipient risk also increased. Despite increased risk profiles, national survival rates for all organ types continued to increase from 2007 through 2010. SUMMARY: People who receive transplants from programmes cited by CMS for subpar outcomes tend to have much improved prospects for posttransplant survival. Individuals waitlisted in those programmes may face lower odds of receiving a transplant, at least temporarily, due to the tendency of such programmes to reduce volume as they regroup to improve their outcomes. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Lochner K.A.,MediCaid
Preventing chronic disease | Year: 2013

The increase in chronic health conditions among Medicare beneficiaries has implications for the Medicare system. The objective of this study was to use the US Department of Health and Human Services Strategic Framework on multiple chronic conditions as a basis to examine the prevalence of multiple chronic conditions among Medicare beneficiaries. We analyzed Centers for Medicare and Medicaid Services administrative claims data for Medicare beneficiaries enrolled in the fee-for-service program in 2010. We included approximately 31 million Medicare beneficiaries and examined 15 chronic conditions. A beneficiary was considered to have a chronic condition if a Medicare claim indicated that the beneficiary received a service or treatment for the condition. We defined the prevalence of multiple chronic conditions as having 2 or more chronic conditions. Overall, 68.4% of Medicare beneficiaries had 2 or more chronic conditions and 36.4% had 4 or more chronic conditions. The prevalence of multiple chronic conditions increased with age and was more prevalent among women than men across all age groups. Non-Hispanic black and Hispanic women had the highest prevalence of 4 or more chronic conditions, whereas Asian or Pacific Islander men and women, in general, had the lowest. The prevalence of multiple chronic conditions among the Medicare fee-for-service population varies across demographic groups. Multiple chronic conditions appear to be more prevalent among women, particularly non-Hispanic black and Hispanic women, and among beneficiaries eligible for both Medicare and Medicaid benefits. Our findings can help public health researchers target prevention and management strategies to improve care and reduce costs for people with multiple chronic conditions.

Public substance abuse treatment services have largely operated as an independent part of the overall health care system, with unique methods of administration, funding, and service delivery. The Affordable Care Act of 2010 and other recent health care reforms, coupled with declines in state general revenue spending, will change this. Overall funding for these substance abuse services should increase, and they should be better integrated into the mainstream of general health care. Reform provisions are also likely to expand the variety of substance abuse treatment providers and shift services away from residential and standalone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is more medically based and person-centered. © 2011 Project HOPE-The People-to-People Health Foundation, Inc.

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