Medicare, Medicaid, and health insurance



Frequently asked questions

Frequently asked questions (Centers for Medicare & Medicaid Services). You'll find a wealth of questions and answers in the online CMS booklet: Medicare & You (with a handy index of frequently asked questions and topics at the front)
What is the difference between Medicare and Medicaid? (Medicare Interactive, Medicare Rights Center) Medicare is a federal program that provides health coverage if you are 65 or older or have a severe disability, no matter your income. Medicaid is a state and federal program that provides health coverage if you have a very low income.
• ****My Medicare Matters (National Council on Aging). Provides a free self-assessment tool self to guide you through the Medicare process, what's involved, add-ons (Parts C and D), and so on.
---What is Medicare Part A & B or Original Medicare? Original Medicare is made up of 2 parts: Part A, which covers mostly inpatient care, including most medically necessary hospital care and care in skilled nursing facilities; and Part B, which covers mostly outpatient care (most medically necessary doctors’ services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services. (Thanks to neighbor Robert Huyck for explaining this, based on his experience helping his parents.)
---What is Medicare Part C or Medicare Advantage? Medicare Part C plans must cover all the same things as Medicare Part A and B, but can do so with different rules, costs, and coverage restrictions. You also typically get Part D as part of your Medicare Advantage benefits package. Many different kinds of Medicare Advantage Plans are available. They also may cover services that Original Medicare does not pay for. You may pay a monthly premium.
---What Are Medicare Part D Plans? Basics Medicare offers prescription drug coverage, or Part D, to everyone with Medicare. To get Part D, you must join a plan run by an insurance company or other private company approved by Medicare.
---What is Medicare Gap?
Get Answers (Medicare Interactive, Medicare Rights Center) Scroll down and find questions you didn't know enough to ask!
Medigap vs. Medicare Advantage (Consumer Reports) Know the difference before you choose
Frequently Asked Questions about Health Reform (Kaiser Family Foundation)
Disaster aftermath: Helping people to ensure Medicare benefits continue (Liz Seegert, Covering Health, AHCJ, 10-19-16) What happens to Medicare beneficiaries stranded by disaster, without medications or prescriptions, or at an airport and in need of dialysis, for example.
AARP on Medicare and Medicaid
Ask Ms. Medicare archives (AARP's Patricia Barry's responses to important questions)
What are long-term care hospitals (LTCHs)? (PDF, Centers for Medicare & Medicaid Services)
Health Insurance: How Does It Work? (Yonatan Zunger, Health Care in America, Medium, 2-15-17) Four Questions to Ask About Health Care Reform. Three different things get bundled under the misleading name “health insurance:” (1) Ordinary health insurance , which splits up the cost of your expected lifetime medical bills over time; (2) Catastrophic health insurance , which splits up the cost of rare expenses so big that people couldn’t pay them across everyone; and (3) Access to the health care system itself . How does a system spread out risks and costs? How are pre-existing conditions handled? What are the various options? An excellent explanatory piece.
10 FAQs: Medicare’s Role in End-of-Life Care (Kaiser Family Foundation)
Q1: What is “end-of-life care” and does Medicare cover it? Q2:
What is “advance care planning” and does Medicare cover it?
Q3: Are policymakers, such as CMS or Congress, considering changes in Medicare’s coverage of advance care planning?
Q4: What are “advance directives”? Are health care facilities, such as hospitals or skilled nursing facilities, required to keep records of Medicare patients’ advance directives?
Q5: Does Medicare cover hospice care? How many Medicare beneficiaries use hospice?
Q6: What is “palliative care” and does Medicare cover it?
Q7: How much does Medicare spend on end-of-life care, and for which services?
Q8: Did the Affordable Care Act (ACA) affect Medicare coverage for end-of-life care or advance care planning?
Q9: Has the Institute of Medicine (IOM) made any recommendations regarding advance care planning and end-of-life care?
Q10: How does the public feel about advance care planning and Medicare’s role in end-of-life preferences?

Medical Loss Ratio (MLR) Information "The medical loss ratio is a calculation that divides the total dollars a plan spends on health care by the total dollars a plan receives in premiums. The result is the medical loss ratio or MLR." The ACA requires that health insurers "spend specific target amounts of the premiums they receive on payments for the health care members utilize, as well as for projects that improve the quality of care members receive. When insurance companies spend less than those target amounts, the Affordable Care Act requires that those companies refund the difference between the amount that was spent and the specific target amount."
“America's health care system is neither healthy, caring, nor a system.” ~Walter Cronkite
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The Affordable Care Act (ACA)
(often called Obamacare, originally by its opponents)


On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The eight basic consumer protections the Obama White House wants health care reform to cover:
(1) No discrimination for pre-existing conditions,
(2) No exorbitant out-of-pocket expenses, deductibles or co-pays,
(3) No cost-sharing for preventive care,
(4) No dropping of coverage if you become seriously ill,
(5) No gender discrimination,
(6) No annual or lifetime caps on coverage,
(7) Extended coverage for young adults,
(8) Guaranteed insurance renewal so long as premiums are paid.
For more about the White House plans for health care, see
http:/​/​www.whitehouse.gov/​healthreform .

Various sites, articles, judicial arguments (etc.) of interest:
Summary of the Affordable Care Act (Kaiser Family Foundation). Many other ACA-related resources here, too.
Affordable Care Act (Commonwealth Fund). Many more ACA-related resources.
Wrong Prescription? (Trudy Lieberman, Harper's, July 2015) The failed promise of the Affordable Care Act. "The A.C.A. was sold to the public on the pledge of “affordable, quality health care....The A.C.A.’s greatest legacy may finally be the fulfillment of a conservative vision laid out three decades ago, which sought to transform American health care into a market-driven system. The idea was to turn patients into shoppers, who would naturally look for the best deal on care — while shifting much of the cost onto those very consumers. In other words, Rooney and his G.O.P. allies (with, it should be said, Democratic acquiescence) moved American health insurance in a direction contrary to that taken by most every other nation in the developed world. It is also contrary to the needs of those unlucky enough to get sick."
Churning, Confusion And Disruption — The Dark Side Of Marketplace Coverage (Jay Hancock, KHN, 12-7-17) The ACA increased the number of Americans with health insurance by 20 million and cut the uninsured rate to about 9 percent. But the task of finding new insurance annually often undermines the continuity of care for people with ongoing medical needs or chronic conditions. That challenge is immeasurably harder this year as policies change under the Trump administration, spurring unstable networks and turmoil in many state and local markets.
Dead Man Walking (Michael Stillman and Monalisa Tailor, New England Journal of Medicine 2013) 'Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation. As his wife sobbed next to him in our examination room, he recounted his months of weight loss, the unbearable pain of his bowel movements, and his gnawing suspicion that he had cancer. “If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”'
Equitable Access to Care — How the United States Ranks Internationally (Karen Davis and Jeromie Ballreich, NEJM, 10-23-14) "The United States has been unusual among industrialized countries in lacking universal health coverage. Financial barriers to care — particularly for uninsured and low-income people — have also been notably higher in the United States than in other high-income countries. As more Americans become insured as a result of the Affordable Care Act (ACA), differences in access to care between the United States and other countries — as well as among income groups within the United States — may begin to narrow."
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Mississippi, Burned (Sarah Varney, Political magazine, Nov./​Dec. 2014). " In Mississippi, America’s most down-and-out state, a full 20 percent of the population doesn’t graduate from high school, 22 percent lives in poverty—and even more than that, a quarter of the state, goes without health care coverage. In a state stricken by diabetes, heart disease, obesity and the highest mortality rate in the nation, President Barack Obama’s landmark health care law has barely registered, leaving the country’s poorest and most segregated state trapped in a severe and intractable health care crisis. ...Why has the law been such a flop in a state that had so much to gain from it? ...bumbling errors and misinformation; ignorance and disorganization; a haunting racial divide; and, above all, the unyielding ideological imperative of conservative politics."
Landmark: The Inside Story of America's New Health-Care Law—The Affordable Care Act—and What It Means for Us All (Public Affairs Reports, staff of Washington Post)
Health Insurance Marketplace Calculator (Subsidy Calculator) (Kaiser Family Foundation) provides estimates of health insurance premiums and subsidies for people purchasing insurance on their own in health insurance exchanges (or “Marketplaces”) created by the Affordable Care Act (ACA). With this calculator, you can enter your income, age, and family size to estimate your eligibility for subsidies and how much you could spend on health insurance. You can also use this tool to estimate your eligibility for Medicaid. Here's an explanation of how it works (KFF)
Deciphering The Health Law’s Subsidies For Premiums (Julie Appleby, Kaiser Health News, 7-24-13)
• The Kaiser Family Foundation's summary of the law (pdf), and of changes made to the law by subsequent legislation, focuses on provisions to expand coverage, control health care costs, and improve health care delivery system. Kaiser also posts the implementation timeline for health reform , an interactive tool designed to explain how and when the provisions of the Affordable Care Act will be implemented over the next several years.
Frequently Asked Questions about Health Reform (Kaiser Family Foundation)
HHS basic information on the coming health insurance marketplaces.
HHS interactive state-by-state map.
Obamacare’s Secret Success (Paul Krugman, NY Times Opinion page, 11-28-13) The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums; t was also about “bending the curve” — slowing the seemingly inexorable rise in health costs. Follow the bending cost curve and you will find that the slowdown in health costs has been dramatic.
Obama's Deal, long, fascinating transcript of Frontline special on the deal-making that went into health care reform. You can also Watch the Frontline program. "Those deals can be pretty smelly."
Why Republicans can't come up with an Obamacare replacement (Ezra Klein, Vox, 1-16-15) Making "sure poor people have health insurance is politically popular, at least in the abstract. But the plans that achieve it tend to be in tension with both broad tenets of conservatism — it raises taxes, it redistributes wealth, and it grows the government — and with key factions of the conservative coalition....It is ironic that the law Republicans loathe most is actually based on ideas they developed, and that their most recent presidential nominee actually implemented."
Supreme Court Case May Be A Wake-Up Call For Republicans (Julie Rovner, KHN, 2-23-15) About Obamacare: "“Republicans are united around repeal. And they’re united around replace. But obviously they’re not united around ‘replace with what...’”
Obamacare: The Rest of the Story (Bill Keller, Opinion Page, NY Times, 10-13-13) "You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable. What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system. " An interesting account of "accountable care organizations" (ACOs), which are springing up all around the country.
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Medicaid Expansion in Red States (Drew Altman, WSJ's Think Tank, 12-18-14) "In the struggle between pragmatism and ideology over Medicaid expansion in red states, pragmatism may slowly be winning."
Majority Favors the Affordable Care Act’s Employer Mandate, But Opinion Can Shift When Presented With Pros and Cons (Kaiser Family Foundation, 12-18-14) Recent news stories on the health law did not attract most Americans’ attention, and many are unaware of details and implications of the developments
Three Words and the Future of the Affordable Care Act (PDF, Nicholas Bagley, draft accepted for publication in Journal of Health Politics, Policy and Law, 2014, open access)
Medicine’s Top Earners Are Not the M.D.s (Elisabeth Rosenthal, Sunday Review, NY Times 5-12-14) The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries. (There are more doctors than administrators, so she's talking about individual, not total, salaries for a group.)
Feds Target Health Law Loophole That Allows Large Employers To Offer Plans That Don’t Cover Hospitalization (Kaiser Health News, 11-4-14) The administration intends to disallow plans that “fail to provide substantial coverage for in-patient hospitalization services or for physician services,
Medical Loss Ratio (MLR) Information "The medical loss ratio is a calculation that divides the total dollars a plan spends on health care by the total dollars a plan receives in premiums. The result is the medical loss ratio or MLR." The ACA requires that health insurers "spend specific target amounts of the premiums they receive on payments for the health care members utilize, as well as for projects that improve the quality of care members receive. When insurance companies spend less than those target amounts, the Affordable Care Act requires that those companies refund the difference between the amount that was spent and the specific target amount."
A death blow for Obamacare? (Laurence H. Tribe, Boston Globe, 7-18-14) "The moment the Affordable Care Act was enacted in 2010, it became a litigation magnet. The lawsuits threatening to derail it were initially dismissed as ridiculous but became deadly serious by the time Chief Justice John Roberts’s decisive fifth vote two years later barely upheld the law’s individual mandate, while the Court’s decisive 7-2 vote left the health law’s Medicaid expansion in tatters. Last month, the court struck a second blow to the ACA by allowing some for-profit corporations to opt out of offering contraceptive coverage they deemed religiously offensive. And even House Speaker John Boehner is joining in the litigation..."
The Piecemeal Assault on Health Care(NY Times editorial, 11-22-14) "Now that they will dominate both houses of Congress, Republicans are planning to dismantle the Affordable Care Act piece by piece instead of trying to repeal it entirely....All of the provisions they are targeting should be retained — they were put in the reform law for good reasons."
Hospitals and health law (Opinion, NY Times, 12-7-14) "The American people aren’t the only ones who will suffer from the systematic dismantling of the Affordable Care Act. It’s also bad news for America’s hospitals."
Another Baseless Attack on Health Law (NY Times editorial, 12-12-14) A suit filed by the "Republican-dominated House aims to block another important subsidy: federal payments to insurance companies to keep deductibles, co-payments and other cost-sharing low for the poor. ... If the federal government cannot assist, a lot of other individual policyholders may have to pay more."

A closer look: Did the ACA result in more canceled plans? (Joanne Kenen, Covering Health, AHCJ, 4-29-14)
Warren: It's too soon to call Obamacare — or Obama — a failure (James Warren, Daily News, 12-1-13) There was a lot of melodrama over Saturday's 'sort-of deadline' for repairing HealthCare.gov. Though Obama's approval ratings are tanking and the Obamacare website had early missteps, the President and his health care plan shouldn't be written off so quickly.
Safety Leaders. Actor Dennis Quaid's family is joining forces with the Texas Medical Institute of Technology (TMIT) to raise public awareness about our broken medical system, to eliminate human error, and to make caregivers aware that patients have the right to know all information that could have an impact on their health and well-being, with major focus on increasing awareness of the dangers of medication errors. See also Preventable Medical Malpractice: Revisiting the Dennis Quaid Medication/​Hospital Error Case (Rick Schapiro, The Legal Examiner 8-9-10).
Bringing local, national perspectives to report on ACA in rural Kentucky (Joanne Kenen, Covering Health, AHCJ, 6-17-14)
The AP downplays its Obamacare scoop (Trudy Lieberman, Columbia Journalism Review 4-11-14). AP calls "minor' a change in legislation that shifts costs to consumers by raising deductibles.
Preventive Services Covered by Private Health Plans under the Affordable Care Act (Kaiser Foundation 10-28-14) A key provision of the ACA is the requirement that private insurance plans cover recommended preventive services without any patient cost-sharing. Full discussion.
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The Great Cost Shift comes into focus (Trudy Lieberman, CJR, 12-24-14). "Consumers, even consumers who have insurance, are paying a larger share of their healthcare costs. This shift has been in the works for years, but provisions in the ACA have made it more visible."
Rooting for Failure (Timothy Egan, NY Times Opinion page, 11-28-13) It's hard to remember a time when a major political party and its media arm were so actively hoping for fellow Americans to lose. Tim Egan's unvarnished take on the shamelessness of the anti-Obamacare creed.
Challenges For The New Health Insurance Exchanges (transcript for Diane Rehm show, with guests Susan Dentzer of The Robert Wood Johnson Foundation, Louise Radnofsky of The Wall Street Journal, Jon Kingsdale of the Wakely Consulting Group, who led the agency that implemented the Massachusetts health insurance exchange, and David Simas, speaking from the White House, 10-16-13).
Special Investigation: How Insurers Are Hiding Obamacare Benefits from Customers (Dylan Scott, Talking Points Memo, 11-4-13). "By warning customers that their health insurance plans are being canceled as a result of Obamacare and urging them to secure new insurance plans before the Obamacare launched on Oct. 1, these insurers put their customers at risk of enrolling in plans that were not as good or as affordable as what they could buy on the marketplaces."
Middle class families wary of higher premiums Carla K. Johnson, AP story in Portland Press Herald, 9-13-13). "The new Affordable Care Act health exchanges won't offer any bargains for higher-income families, who fear that their current health insurance policies may get more expensive under the new law's requirements. As many as nine in 10 Texans buying health insurance on the new federally run exchange will get a break on costs, according to federal health officials. Steve and Maegan Wolf won't be among them."
Medical Device Industry Fears Health Care Law’s Tax on Sales (Barry Meier, Tracking the Affordable Care Act, NY Times, 10-1-13)
Questionable design blamed for healthcare website woes (Carla K. Johnson and Ricardo Alonso-Zaldivar, AP, 10-8-13)
A decision by the Obama administration to require that consumers create online accounts before they can browse health overhaul insurance plans appears to have led to many of the glitches that have frustrated customers, independent experts say.
How Obamacare’s medical device tax became a top repeal target (Sarah Kliff, Wonkblog, WashPost, 9-28-13). See also:
In Need of a New Hip, but Priced Out of the U.S. (Elisabeth Rosenthal, NY Times, 8-3-13) Paying Till It Hurts: A Trip Abroad. Part of an excellent series on what's wrong with American health care.
How can I get an estimate of costs and savings on Marketplace health insurance? (Healthcare.gov)
Kaiser Family Foundation information site on the Affordable Care Act (extremely helpful)
LocalHelp.HealthCare.gov (for state-specific information)
ACA-Mandated Insurance Quick Tips (Bob Rosenblatt, Aging Today) /ib_marketplace_premiums.cfm"target="_blank">Health Insurance Marketplace Premiums for 2014 (HHS, Assistant Secretary of Planning and Evaluation)
The Affordable Care Act Will Work (Sen. Jay Rockefeller, Reader Supported News, 10-3-13)
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Where Poor and Uninsured Americans Live (interactive map, NY Times, 10-2-13). The 26 Republican-dominated states not participating in an expansion of Medicaid are home to a disproportionate share of the nation’s poorest uninsured residents. Eight million will be stranded without insurance.
Little Evidence Obamacare Is Costing Full-Time Jobs (Kaiser Health News' Daily Report, 10-23-13) Roundup of stories from WSJ, NYTimes, Reuters, Wash Post, Politico and others.
States Are Focus of Effort to Foil Health Care Law (Sheryl Gay Stolberg, NY Times, Politics, 10-18-13) In Virginia, conservative activists are pursuing a hardball campaign as they chart an alternative path to undoing “Obamacare” — through the states.
New York State of Health: The Official Health Place
Covered California, the new marketplace for affordable private health insurance
Millions of Poor Are Left Uncovered by Health Law ( Sabrina Tavernise and Robert Gebeloff, NY Times, 10-2-13)
A Nevada Health Plan -- Without The Insurance (Pauline Bartolone, Kaiser Health News, Capital Public Radio, NPR, 9-14-13) An unusual Nevada nonprofit that helps connect 12,000 uninsured residents to doctors and hospitals who are willing to accept a lower-cost, negotiated fee for their services. Giving care to the uninsured before they require urgent care helps lower costs by keeping their members out of the ER.
Health Reform D-Day? Or not for a few more months? (Joanne Kenen, Covering Health, AHCJ, 10-1-13). See also Tracking exchange activity.
Shutdown Din Obscures Health Exchange Flaws (Robert Pear, NY Times, 10-4-13)
What's in a name? Lots when it comes to Obamacare/​ACA (Steve Leisman, CNBC, 9-26-13) In CNBC's third-quarter All-America Economic Survey, we asked half of the 812 poll respondents if they support Obamacare and the other half if they support the Affordable Care Act. And 30% of those polled don't know what ACA is, vs. only 12% when asked about Obamacare; 29% support Obamacare compared with 22% who support ACA; and 46% oppose Obamacare and 37% oppose ACA. "So putting Obama in the name raises the positives and the negatives." Republicans coined the term Obamacare as a pejorative, but not everyone perceives it that way.
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A British Woman Spent Three Days in a U.S. Hospital. Here's What She Learned About Obamacare. (Eleanor Margolis, New Republic, 10-18-13. First appeared in New Statesman) "I begin to wonder how the Republicans have managed to convince even those in the very midst of a system that punishes the poor, that the slightest implementation of state-funded healthcare is an evil, communist conspiracy. ...As a foreigner with travel insurance, I’m lucky enough to observe American healthcare from a safe distance. But to someone fully enmeshed, like Carmen, Obamacare is a tiny drop in the murkiest of quagmires."
Health Care Reform: What It Is, Why It's Necessary, How It Works by Jonathan Gruber (clear explanations in graphic novel format of the Affordable Care Act, by an MIT economist, and one of the architects of both RomneyCare and ObamaCare). Here's YouTube version, in short.
C-Span is a good place to find various town hall discussions, hearings, wonderful links. For example: Supreme Court Determining the Constitutionality of Health Care Act and Supreme Court Hears Argument on Individual Mandate Provision
Understanding the Right’s Obamacare Obsession (Joshua Holland, What Matters Today, Moyers.com, 9-2-13) Excellent overview.
Church Insurance Improvements To Obamacare Threatened By Partisan Fighting (Sarah Pulliam Bailey, Religion News Service, 8-9-13)
The Republican party's 'defund Obamacare' disorder (Michael Cohen, The Guardian, 8-25-13) In denial of political reality thanks to its Tea Party fringe, the GOP is revving up for a debt ceiling showdown it can only lose.
How the ObamaCare defunding fight became a political showdown (Sam Baker, HealthWatch, 8-29-13)
Ten Titles: Understanding the Affordable Care Act (pdf, John McDonough, Hunter College, October 2010)
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Frequently asked questions about health care insurance and the Affordable Care Act

Health Care Fact Sheets (U.S. Dept of Health & Human Services, HHS)
HHS basic information on the health insurance marketplaces.
HHS interactive state-by-state map.
Frequently Asked Questions About Health Reform (Kaiser Family Foundation)
Frequently Asked Questions (HealthCare.gov)
Fact Sheets and Frequently Asked Questions (FAQs) about Medicare and Medicaid (Centers for Medicare and Medicaid Services)
Health Insurance Marketplace Calculator (Subsidy Calculator) (Kaiser Family Foundation) provides estimates of health insurance premiums and subsidies for people purchasing insurance on their own in health insurance exchanges (or “Marketplaces”) created by the Affordable Care Act (ACA). With this calculator, you can enter your income, age, and family size to estimate your eligibility for subsidies and how much you could spend on health insurance. You can also use this tool to estimate your eligibility for Medicaid. Here's an explanation of how it works (KFF)
Resources for Agents and Brokers in the Health Insurance Marketplaces (The Center for Consumer Information & Insurance Oversight, Centers for Medicare and Medicaid Services)
Kaiser Family Foundation information site on the Affordable Care Act (extremely helpful)
LocalHelp.HealthCare.gov (for state-specific information)

ACA-Mandated Insurance Quick Tips (Bob Rosenblatt, Aging Today)

Health Coverage and Federal Income Taxes (HHS)

Health Insurance and Mental Health Services (HHS) How does the Affordable Care Act help people with mental health issues? How do I find out if my health insurance plan is supposed to be covering mental health or substance use disorder services in parity with medical and surgical benefits? What do I do if I think my plan is not meeting parity requirements? Does Medicaid cover mental health or substance use disorder services? Does Medicare cover mental health or substance use disorder services?

Breast Pumps and Insurance Coverage: What You Need To Know (HHS)

The Affordable Care Act and Immunization (HHS)

Deciphering The Health Law’s Subsidies For Premiums (Julie Appleby, Kaiser Health News, 7-24-13)

• The Kaiser Family Foundation's summary of the law (pdf), and of changes made to the law by subsequent legislation, focuses on provisions to expand coverage, control health care costs, and improve health care delivery system. Kaiser also posts the implementation timeline for health reform , an interactive tool designed to explain how and when the provisions of the Affordable Care Act will be implemented over the next several years.
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Medicare and Medicaid: History and legislation

Medicare and Medicaid were established in 1965, under President Lyndon B. Johnson. The Affordable Care Act (ACA, 2010), or Obamacare, called for its expansion, but the Supreme Court later ruled it optional. Eventually, 32 states widened coverage. See Health care debate shines light on Medicaid (Susan Heavey, Covering Health, AHCJ, 7-19-17) "Republicans, who control the House and the Senate as well as the White House, proposed drastic changes to the program, exposing the split among senators from U.S. states that chose to adopt Medicaid expansion under the ACA and those that did not. While some moderates expressed concerns over cutting the program, more conservative Republicans backed reining it in.
Hiding the true cost of Medicare prescription drug legislation (Charles S. Lewis, Investigative Reporting Workshop, 10-18-16) "In 2003, Bush administration officials withheld important cost projection data from members of Congress before they voted on the biggest overhaul to the Medicare program since it began in 1965. Among other things, the Medicare Prescription Drug, Improvement and Modernization Act provided a prescription drug benefit for Medicare users and prevented the government from negotiating drug prices with pharmaceutical companies, a contested provision at the time....Weeks after the bill narrowly passed in the House in late November 2003 — during a highly unorthodox and controversial voting session held at 3 a.m. that reportedly included major arm-twisting by the bill’s main architects and last-minute vote changes — the White House announced the bill would indeed cost over $100 billion more than they had told Congress and the American people. Soon thereafter, Scully and at least 14 other staffers, officials and members of Congress closely involved with getting the bill passed resigned or left their positions for highly lucrative jobs in the pharmaceutical industry, which benefitted hugely from the new measure." See also Inquiry Confirms Top Medicare Official Threatened Actuary Over Cost of Drug Benefits (Robert Pear, NY Times, 7-7-2004) Administration hid true cost until after legislation passed.
How the GOP Turned Against Medicaid (Joshua Zeitz, Politico, 6-27-17) It began as a modest, bipartisan program to help poor children. But as America’s economy hollowed out, Medicaid grew—and Republicans came to oppose it. An interesting discussion of the history of liberal and conservative views of post-World War II entitlements and of their growth. "Though many conservative Republicans agreed with Reagan that Medicare represented 'a short step to all the rest of socialism,' a large number of moderate and liberal GOP members openly supported government health care for the oldest and poorest Americans."
The Governor Blocked Medicaid Expansion. Now Maine Voters Could Overrule Him. (Abby Goodnough, NY Times, 10-27-17) Gov. Paul LePage, a Republican, has five times vetoed expanding access to the program under the Affordable Care Act. Next month, voters here will be the first in the nation to decide the issue by referendum. Maine is one of 19 states whose Republican governors or legislatures have refused to expand Medicaid under Obamacare, and the other holdouts — particularly Utah and Idaho, where newly formed committees are working to get a Medicaid expansion question on next year’s ballot — are closely watching the initiative, whose outcome may offer clues about the salience of the issue in next year’s midterm congressional elections. Turnout may be the biggest challenge for the advocacy groups leading the effort. Under the Affordable Care Act, the federal government picked up the entire cost of new enrollees under Medicaid expansion for the first three years and will continue to pay at least 90 percent. The law allows any citizen with income up to 138 percent of the poverty level — $16,642 for an individual, $24,600 for a family of four — to qualify. The main arguments for expanding the program here are that it would help financially fragile rural hospitals, create jobs and provide care for vulnerable people who have long gone without it. Canvassers for the measure have found one of the biggest obstacles is lack of knowledge about the issue, even among those who would benefit. “I’ve lived in other countries where nobody’s going to let you fall all the way down,” said Mr. Miller, a jazz drummer. “We buy into the American legend of, ‘You can take care of yourself anywhere, kid.’ That’s a bad lesson to teach everybody.”
Veterans Helped By Obamacare Worry About Republican Repeal Efforts (Stephanie O'Neill, Shots, Morning Edition, NPR, 6-28-17)
Medicare Unveils Far-Reaching Overhaul of Doctors' Pay (Ricardo Alonso-Zaldivar, AP via ABC News, 10-14-16) "The goal is to reward quality, cost-effective care instead of just paying piecemeal for services. The complex regulation is nearly 2,400 pages long and will take years to fully implement. It's meant to carry out bipartisan legislation that was passed by Congress and signed by President Barack Obama last year. Whether it succeeds or fails, it's one of the biggest changes in Medicare's 50-year history."
CMS History (great links to timeline and various aspects of Centers for Medicare and Medicaid Services history)
Kaiser Family Foundation. KFF's excellent links to facts, infographics, and stories about Medicaid.
Medicare and Medicaid a tarnished triumph (Robert J. Samuelson, Wash Post, 7-24-15) "The 1965 legislation, writes scholar Paul Starr, “created two moral frameworks” for coverage — superior for the elderly, inferior for the poor. Medicare benefits were (and are) uniform and considered sacrosanct. By contrast, Medicaid benefits vary state to state, and reimbursement rates are often so low that many doctors have “refused to take Medicaid patients.” "Costs were another problem. To soften resistance from doctors and hospitals, the legislation “failed to impose any cost restraint on health-care providers.” ...The system's manifold complications tempt providers to game or defraud the system.
Insights from the Top: An Oral History of Medicare and Medicaid National Academy of Social Insurance, March 2016) Available online as part of the CMS program history, along with other historic material.
The Real Reason Medicare Is a Lousy Drug Negotiator: It Can’t Say No ( Margot Sanger-Katz, The Upshot, NY Times, 2-2-16) Right now, the program is O.K. at negotiating, saving as much as 30 percent off the list price of drugs, according to government reports. But Medicare still pays much, much more than government health systems in other countries. The government does have one program that can say “no” to drug companies, and it gets much better deals than Medicare. The Department of Veterans Affairs negotiates hard with drugmakers. But it is also bound by fewer rules than Medicare, and one result is that it covers far fewer drugs. “To negotiate prices any further, the government would need to impose access or coverage restrictions on medicines,” said Doug Elmendorf, testifying before Congress in 2009. None of the candidates currently talking about allowing Medicare to negotiate for drugs have endorsed allowing Medicare to say no more often.
The GOP Civil War over Medicaid Expansion in the States (Alexander Hertel-Fernandez, Theda Skocpol, Scholars Strategy Network, Oct. 2015) In "states where Republicans control the governorship and both chambers in the legislature, or two out of three, have gone one way or another in decisions about Medicaid expansion in significant part because of the balance of capacities and pressures between these two dueling factions. Where mainstream business interests operating through Chambers of Commerce endorsed expansion and commanded the upper hand over the conservative networks, states tended to move ahead. But when businesses stood on the sidelines or were poorly equipped to lobby state governments, the best-established conservative networks with relatively substantial resources have managed to stymie expansion efforts."
JAMA's special issue: Medicare and Medicaid at 50 (Journal of the American Medical Association, Vol. 314, No. 4, 7-28-15)
Medicare at 50: Lessons and Challenges (Tricia Neuman and John Rother. Generations, American Society on Aging, 6-3-15)
Is There a Bright Future for Medicare? (read this special issue of Generations online, American Society on Aging, 6-3-15)
The Story of Medicare: A Timeline (video, Kaiser Family Foundation. A visual timeline of Medicare’s history, including the debate that led to its creation in 1965 and subsequent changes, such as: the passage and repeal of the Medicare Catastrophic Coverage Act in the late 1980s, the Medicare Modernization Act in 2003, and the Affordable Care Act in 2010. The video also highlights the program’s impact on the 55 million elderly and disabled Americans it covers today, as well as the fiscal challenges it faces in ensuring its long-term sustainability. (Quick overview of things you've probably forgotten, if you knew)
The Future of Medicare (National Academy of Social Insurance)
Medicare reform’s slow progress (Charles Lane, Wash Post, 3-4-13) "Part of the problem was Medicare’s lax screening of suppliers, which attracted hundreds of swindlers to the business. But the real scandal was how much you could charge Medicare legally. Congress drew up the DMEPOS reimbursement schedule in 1989 based on mid-1980s economics and left it unchanged thereafter, except for sporadic inflation adjustments. In short, the law required Medicare to overpay." "Congress should accelerate the planned introduction of nationwide competitive bidding on DMEPOS to 2014, and extend it to medical devices, lab tests and advanced imaging services by 2015, as recommended in a recent Center for American Progress report. The savings could total $38 billion over the next decade. Medicare is supposed to be a health-care program for seniors, not a cash cow."
The Lowdown on the 52 Percent Medicare Premium Increase ( Bob Rosenblatt, Next Avenue, 10-21-15) Who'd be affected, how to lessen the pain and what might stop it.
Common health care acronyms (National Health Policy Forum)
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Medicare: What you need to know

Turning 65? 9 Tips For Signing Up For Medicare. (Carolyn Mayer, Kaiser Health News, 10-7-14) Failing to sign up can be costly. Part A of traditional Medicare covers inpatient hospital services, skilled nursing home care and hospice, among other things. Part B of traditional Medicare helps cover preventive care and physician and outpatient services, among other things. Part D plans are private insurance plans covering prescription drug costs. Medicare Advantage is an alternative to traditional Medicare. In this program, private insurance plans are paid by the federal government to provide coverage that is equivalent to original Medicare. Tools for helping you figure out what to sign up for include:
---My Medicare Matters
---AARP's Medicare Question and Answer Tool
---Consumer Fact Sheets (Medicare Rights Center)
---Fact sheets and FAQs (Centers for Medicare & Medicaid Services, CMS)
---Is my test, item, or service covered by Medicare?
---Managing Medicare (Consumer Reports) Get the most from this comprehensive health insurance option for seniors
---Where to get free Medicare advice (Consumer Reports) Take advantage of your state's one-on-one counseling program.
A Few Pointers To Help Save Money And Avoid The Strain Of Medicare Enrollment (Susan Jaffe, KHN, 10-17-17) Most beneficiaries have from Oct. 15 through Dec. 7 to decide which of dozens of private plans offer the best drug coverage for 2018 or whether it’s better to leave traditional Medicare and get a drug and medical combo policy called Medicare Advantage. (Jaffe points out some pros and cons.) Individual assistance is free from the federally funded Senior Health Insurance Information Program (www.shiptacenter.org), the Medicare Rights Center (800-333-4114 and its website Medicare Interactive (a href="https://www.medicareinteractive.org/"target="_blank">www.medicareinteractive.org) as well as from Medicare’s plan finder website and helpline (www.medicare.gov/​, 800-633-4227).
Paying for the doctor when you have Original Medicare There are three categories of Medicare doctors: Participating, Non-Participating, and Opt-Out. Be sure to always ask your doctor if he/​she accepts Medicare before you get care. In addition, you can learn whether your doctor accepts Medicare and takes assignment by going online and visiting Medicare’s Physician Comparetool. Psychiatrists are more likely than any other type of provider to opt-out of Medicare.
Medicare Rights (Getting Medicare right)
Between ACA and Medicare, some Americans may have too much health coverage (Susan Jaffe | Kaiser Health News, WaPo, 10-11-16) “In most cases you won’t want to keep your Marketplace plan because once your Medicare coverage starts, you’ll no longer be eligible for any premium tax credits or other cost savings you may be getting."
Medicare and You (the official U.S. government Medicare handbook--with index at back/​bottom).
CMS Prepares for New Medicare ID Number (Ken Terry, Medscape Medical News, 10-7-16) Replacing our social security number with an 11-digit alpha-numeric code has practical implications that will need to be ironed out.
Moops?: A Roadmap To MIPS (Bill Wynne and Max Horowitz, Health Affairs, 2-26-16) The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) permanently reformed Medicare physician payments and (finally) put to rest what had become a dreaded perennial legislative ritual of blocking reimbursement cuts. MACRA replaced the Sustainable Growth Rate with annual 0.5 percent payment increases for each of the next five years, and creates two tracks for physician payment after that. Under one track, MACRA streamlines certain Medicare quality initiatives that affect reimbursement under a unified system known as the Merit-Based Incentive Payment System (MIPS). MIPS is the subject of this post.
Under the other track, physicians can get bonus payments/​incentives if they receive a “significant share” of their revenue through an alternative payment model (APM). Physicians who receive payment through their participation in an APM above a certain threshold will not be subject to payment adjustments under MIPS. (Article goes into detail and gives full explanation.)
How to Opt Out of Medicare (a guide for physicians) (Association of American Physicians and Surgeons, AAPS). This is why your physician who does not accept Medicare may ask you to sign something indicating you acknowledge that s/​he does not participate.
The Real Reason Medicare Is a Lousy Drug Negotiator: It Can’t Say No (Margot Sanger-Katz, The Upshot, NY Times, 2-2-16) Medicare beneficiaries wanted the program to cover most drugs that older people would want to use. So Congress put in place rules that strengthen the hand of the drug companies in negotiations....The Congressional Budget Office has examined several proposals to allow the government to negotiate on drug prices, and it has repeatedly said that the savings would be “negligible” without other major policy changes (to impose access or coverage restrictions on medications). The government does have one program that can say “no” to drug companies, and it gets much better deals than Medicare. The Department of Veterans Affairs negotiates hard with drugmakers. But it is also bound by fewer rules than Medicare, and one result is that it covers far fewer drugs....The trade-offs between price and generosity are real and wrenching.
Behind the Scenes on Those Enormous Medicare Billing Numbers (Kevin Drum, Mother Jones, 4-10-14). "Medicare is flatly forbidden from approving certain drugs but not others. As long as Lucentis works, Medicare has to pay for it. That's great news for Genentech, but not so great for the taxpayers footing the bill." And "Medicare pays doctors a percentage of the cost of the drugs they use," a disincentive to use the lower-cost drug that is equally effective.

CMS Special Open Door Forums
Medicare Savings Programs (Medicare.gov) If you have income from working, you may qualify for these 4 programs even if your income is higher than the income limits listed.
Accountable Care Organizations, Explained (Jenny Gold, Kaiser Health News, 9-14-15)
CMS online manuals (Centers for Medicare & Medicaid Services, or CMS)
Medicare Plan Finder
Medicare & Medication information (also CMS)
Benefits Coordination & Recovery Center (BCRC) (CMS.gov -- Centers for Medicare and Medicaid Services)
Prescription Assistance Programs (Partnership for Prescription Assistance)
Together RX Assistance '
How Much Medicare Pays for Your Doctor’s Care (NY Times interactive graphic based on database of Medicare payments).
Beware of Shifting Options Within Medicare Plans (Tara Siegel Bernard, NY Times, 10-3-14)
Look out for Medicare drug plans’ bait-and-switch pricing tactics (Philip Moeller, PBS NewsHour, 2-18-15)
How to Complain to Medicare (Paula Span, NY Times, 8-28-14) Besides explaining problems in the complaint process, Paula Span lists helpful contact information, including Claims and Appeals (Medicare.gov) and Who to Contact to Appeal a Discharge (the state by state guide that the United Hospital Fund has posted.)
Health overhaul confuses Medicare beneficiaries (Kelli Kennedy, Philly.com, 9-12-13). In late 2013, roughly 50 million Medicare beneficiaries will get a handbook in the mail with a prominent Q&A that stresses Medicare benefits aren't changing. "We want to reassure Medicare beneficiaries that they are already covered, their benefits aren't changing, and the marketplace doesn't require them to do anything different," said Julie Bataille, spokeswoman for the Centers for Medicare and Medicaid Services.

Are you a hospital inpatient or outpatient? If you have Medicare, ask! (PDF, Medicare) From a story by Stacey Singer DeLoye in the Palm Beach Post: Outpatient vs Inpatient. For Medicare beneficiaries, it matters. Here's why:
----Inpatients have better coverage under Medicare Part A. There's a one-time deductible of $1,184 for up to 60 days' care.
----Outpatients' bills are covered under Medicare Part B. Patients must pay both their deductible and 20 percent of doctors' charges. They'll probably also have to cover the hospital's charges for medications.
----Medicare only pays its nursing home benefit following a "qualifying hospital stay." That requires a three-day inpatient stay; any time spent in observation doesn't count toward the three days. Plus, the day of discharge doesn't count toward the three days.
----Note: Rules may differ for beneficiaries with a Medicare Advantage plan.

Observation Status & Bagnall v. Sebelius Increasingly, hospital patients are finding that they have been considered "Observation Outpatients," although they have been cared for in the hospital for many days and nights. On November 3, 2011, the Center for Medicare Advocacy, and co-counsel National Senior Citizens Law Center, filed a nationwide class action lawsuit to challenge this illegal policy and practice. Bagnall v. Sebelius (No. 3:11-cv-01703, D. Conn) states that the use of observation status violates the Medicare Act, the Freedom of Information Act, the Administrative Procedure Act, and the Due Process Clause of the Fifth Amendment to the Constitution. (The problem: Medicare doesn't cover observation status.)
Hospital Surprise: Medicare’s Observation Care (Francis Ying, Thu Nguyen, and Lynne Shallcross, KHN, 8-29-16) Video on the issue, for which transcript is available here.
Medicare tries to limit the use of observation status (The Advisory Board, 5-6-13) Proposed rule would limit the length of observation stays.

FAQs about health reform (Kaiser Family Foundation, or KFF) Marketplace eligibility, enrollment periods, plans and premiums; individual mandate; minimum essential coverage; etc.
Medicare Rights
Health-care bill in retirement: $240,000 (Elizabeth O'Brien, Retire Well, MarketWatch, 11-15-12) How to budget for what Medicare doesn’t cover
Medicaid.gov
Medicaid Denies Nearly Half Of Requests For Hepatitis C Drugs: Study (Michelle Andrews, Kaiser Health News, 11-20-15) People with hepatitis C who sought prescriptions for highly effective but pricey new drugs were significantly more likely to get turned down if they had Medicaid coverage than if they were insured by Medicare or private commercial policies, a recent study found. The drugs included Sovaldi, Harvoni and Viekira Pak, and others that are part of the treatment regimen. A 12-week course of treatment for one patient can reach more than $90,000....because of their hefty price tag, insurers often restrict access by limiting the availability to people whose livers show serious signs of damage, among other criteria.
My Medicare.gov (Sign in to view plan enrollment and quality information for your Prescription Drug, Medicare Advantage, and other insurance plans. Compare health and drug plans based on quality measures and estimated costs.)
ElderLaw answers about Medicare and Medicaid
Quick Facts About Payment for Outpatient Services for People with Medicare Part B
(PDF, Center for Medicare Advocacy)
Nursing Home/​Skilled Nursing Facility Care (Center for Medicare Advocacy)
Spreading The Word: Obamacare Is For Native Americans, Too (Anna Gorman, Shots, NPR, 9-2-15)
Self Help Packets , including self-help packets for expedited appeals (Center for Medicare Advocacy)
StopFraud.gov (The Financial Fraud Enforcement Task Force's advice on how to protect yourself from health/​medicare fraud, identity theft, and other risks)
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Medicare issues and Medicare reform (and reform proposals)

Medicare Delivery System Reform: The Evidence Link (Kaiser Family Foundation). KFF’s Evidence Link is a central source of information and data about Medicare accountable care organizations (ACOs), medical home models, and bundled payment models—all developed by the Centers for Medicare and Medicaid Services (CMS) under the Affordable Care Act (ACA). Provides the most up-to-date evidence on Medicare’s efforts to reduce the growth in health care spending and improve patient care through new payment and delivery reform models. New findings, released by CMS, show mixed and modest gains in Medicare savings for ACOs in 2016—currently accounting for care provided to over 11 million Medicare beneficiaries (almost 20 percent of the Medicare population). See The Evidence Link: A Tutorial (video), for a walk-through of the site’s content and features.
Ban on bargaining, campaign cash keeps Medicare prescription drug costs high (Stuart Silverstein, Investigative Reporting Workshop, 10-18-16) When the Republican-controlled Congress approved a landmark program in 2003 to help seniors buy prescription drugs, it slapped on an unusual restriction: The federal government was barred from negotiating cheaper prices for those medicines. Instead, the job of holding down costs was outsourced to the insurance companies delivering the subsidized new coverage, known as Medicare Part D. The ban on government price bargaining,justified by supporters on free market grounds, has been derided by critics as a giant gift to the drug industry....But critics say it’s no mystery, given the enormous financial influence of the drug industry, which rivals the insurance industry as the top-spending lobbying machine in Washington.
10 Essential Facts About Medicare’s Financial Outlook (Juliette Cubanski and Tricia Neuman, Kaiser Family Foundation, 2-2-17) Go to that page to read the details and support, but here are the main points:
1. Medicare isn’t “going broke” even though it does face financial challenges.
2. The aging of the U.S. population, along with higher health care costs, are contributing to the growth in Medicare spending over time.
3. The Affordable Care Act helped to reduce Medicare spending growth in the years following its enactment.
4. Repealing the ACA, including all Medicare provisions, would increase Medicare spending.
5. Medicare spending was 15 percent of the federal budget in 2016.
6. Medicare spending is projected to increase gradually as a share of the federal budget and the nation’s economy over the next 10 years.
7. Medicare spending is projected to increase at a faster rate in the coming years than in the five years following enactment of the ACA.
8. Spending on Part D prescription drug coverage is expected to grow faster than spending on other Medicare-covered benefits over the next 10 years.
9. Medicare spending is projected to increase as a share of the economy over the long run, but the ACA helped to moderate the long-range projections.
10. Medicare benefits are funded mainly by a combination of general revenues, payroll taxes, and premiums paid by beneficiaries.
Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute (Susan Jaffe, NPR and Kaiser Health News, 1-30-17) Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away. Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer’s or Parkinson’s diseases, stroke, and spinal cord or brain injuries. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until they got worse and were eligible again for coverage. “There was a long-standing kind of mythical policy that Medicare contractors put into place that said Medicare only pays for services if the patient could progress,” said Roshunda Drummond-Dye, director of regulatory affairs for the American Physical Therapy Association. “It takes extensive effort to erase that.”
Medicare and Medicare Spending (National Health Policy Forum) Four YouTube videos from the Forum's 101-style briefings designed to get new (and returning) congressional staff up to speed on health policy topics. They provide an overview of national spending trends as well as a detailed review of the Medicare program, which provides health care coverage to over 55 million Americans. See Briefing Book 2015

Fraud And Billing Mistakes Cost Medicare — And Taxpayers — Tens Of Billions Last Year (Fred Schulte, Kaiser Health News, 7-19-17) "Federal health officials made more than $16 billion in improper payments to private Medicare Advantage health plans last year and need to crack down on billing errors by the insurers, a top congressional auditor testified... the “largest contributors” to billing mistakes in standard Medicare were claims from home health care and inpatient rehabilitation facilities....CMS official Morse...said that improper payments are “most often payments for which there is no or insufficient supporting documentation to determine whether the service … was medically necessary.”
Medicare Advantage Money Grab (Fred Schulte, David Donald and Erin Durkin, Center for Public Integrity, June 2014) "Congress created private Medicare Advantage health plans 11 years ago to help control health care spending on the elderly. But a Center for Public Integrity investigation found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a “risk score.” The formula is supposed to pay health plans more for sicker patients and less for healthy people, but often it pays too much. The government has for years missed opportunities to corral tens of billions of dollars in overcharges and other billing errors tied to abuse of risk scores. Meanwhile, the growing power of the Medicare Advantage industry has muzzled many critics in Congress, and turned others into cheerleaders for the program."
Is Paul Ryan already eyeing Medicare cuts? (Mike DeBonis, WaPo, 11-11-16)
CMS launches largest-ever multi-payer initiative to improve primary care in America (Centers for Medicare & Medicaid Services. 4-11-16)
Comprehensive Primary Care Plus (CPC+) Fact Sheet (CMS, 4-11-16)
Will House Republican Health Proposal and Trustees’ Report Make Medicare a Factor in Election? (Drew Altman, Wall Street Journal, 6-24-16) Kaiser Family Foundation polling on whether Medicare should continue as structured or shift to a 'premium support' system. Large shares think Medicare should continue as it is today; about a quarter prefer fixed premium support system.
The Birth and Increasingly Troubled Life of Medicare (Richard Peck, Medpage Today, 7-30-15) Years of 'socialized medicine' swept aside, but cost concerns eventually overtake program. First of a four-part series looking back, and ahead, at Medicare. Worth signing in for.
---Part 2: Medicare Physician Payment: Seeking Control (7-30-15) Efforts to rein in costs become ever more convoluted; "sustainable growth rate" formula proves no help.
---Part 3: Medicare at 50: Run to Value Out goes fee-for-service, in comes -- what? For the transition to value-based reimbursement to succeed, much needs to be done in developing quality measures that are accurate, comprehensive, and transparent, with physicians at least generally understanding the official definitions of quality and value and the rewards and penalties for dealing with them.
---Medicare at 50: View from the Trenches (Richard Peck, Medpage Today, 7-30-15) Physicians (including a former CMS administrator) talk about their experiences with Medicare.

The top 10 Medicare billers explain why they charged $121M in one year (Jason Millan, Wonkblog, 4-9-14) "Some doctors said they were just passing through the payment to drug companies. But the Medicare payment system also incentivizes physicians to choose more expensive drugs, since they’re reimbursed for the average price of the drug plus 6 percent."
Data uncover nation’s top Medicare billers ( Peter Whoriskey, Dan Keating and Lena H. Sun, Washington Post, 4-9-14). "Jonathan S. Skinner, a Dartmouth economist..."there are people who are operating in the gray area of health care who are causing Medicare to spend enormous amounts on health care that may be harmful to their patients.'”
Texas Judge Upends Effort To Limit Charity Funding For Kidney Care (Michelle Andrews, NPR Shots, 2-14-17) Third-party payments by nonprofit groups, health care providers and others are controversial. The federal government has expressed concern that health care providers and organizations they're affiliated with might be inappropriately "steering" patients to marketplace plans instead of Medicare or Medicaid, for which they are often eligible. The public programs reimburse for the dialysis services at lower rates than most private plans. The efforts by charities have also long been a sore spot with health insurers, who say they encourage sick patients who have expensive health care needs to opt for private coverage. Insurers suffered a setback recently when a federal judge temporarily blocked a new rule from the Department of Health and Human Services that was set to go into effect Jan. 13. It would require that dialysis centers inform insurers if the centers are making premium payments either directly or indirectly through a third party for people covered by marketplace plans. Insurers would then have the option of accepting or denying the payment. In granting the preliminary injunction in late January, U.S. District Court Judge Amos Mazzant in Sherman, Texas, criticized the government's administrative process for establishing the regulation and said it hadn't considered the benefits of private individual insurance or the fact that the rule would leave thousands of patients without coverage."
How Does Your Doctor Get Paid? The Controversy Over Capitation (Mark Hagland, Frontline). Being an educated, discerning and assertive consumer is becoming more and more important in interactions with time-pressured (and sometimes financially pressured) physicians.
11 Myths About Health Care Reform (Beth Howard, AARP, Sept 2012) The hype about the law, including its impact on Medicare, is confusing — and scary. Here’s the truth
U.S. legislators join call for Medicare to cover hearing aids (Steve Twedt, Pittsburgh Post-Gazette, 6-24-16)
Fraud and Other Threats to Medicare (NY Times editorial, 7-28-16) Obamacare provided additional funding for detecting fraud. "The law also toughened sentencing for Medicare fraud, in part, by clarifying that prison terms are to be based on the falsely billed amounts, not the amount actually paid out before the fraud was detected. To date, some 2,000 of 2,900 defendants charged with felony health care fraud in strike force cases have been convicted. Most have been sentenced to prison, not merely probation....Medicare fraud is a scourge. But those who would weaken the health care system for ideological reasons are an even bigger problem."
Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute ( Susan Jaffe, NPR and KHN, 1-30-17) Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical therapy and other skilled care simply because their condition is not improving, patients are still being turned away.
Signed Out Of Prison But Not Signed Up For Insurance, Inmates Fall Prey To Ills ( Jay Hancock, Kaiser Health News, and Beth Schwartzapfel, The Marshall Project, KHN, 12-6-16) "Before he went to prison, Ernest killed his 2-year-old daughter in the grip of a psychotic delusion. When the Indiana Department of Correction released him in 2015, he was terrified something awful might happen again. He had to see a doctor. He had only a month’s worth of pills to control his delusions and mania. He was desperate for insurance coverage. But the state failed to enroll him in Medicaid, although under the Affordable Care Act Indiana had expanded the health insurance program, making most ex-inmates eligible. Left to navigate an unwieldy bureaucracy on his own, he came within days of running out of the pills that ground him in reality. The health law was expected to connect Ernest and almost all other ex-prisoners for the first time to Medicaid coverage for the poor, cutting expensive visits to the emergency room, improving their prospects of rejoining society and reducing the risk of spreading communicable diseases that flourish in prisons. But Ernest’s experience is repeated millions of times across the country, an examination by The Marshall Project and Kaiser Health News shows." "Failure to link emerging inmates to health insurance is a missed opportunity to improve health and save money by cutting recidivism as well as visits to the hospital emergency room, advocates say. Studies have showed Medicaid access in Florida and Washington cut return trips to jail among the mentally ill by 16 percent."
Sicker Patients Seem at a Disadvantage With Medicare Advantage (Austin Frakt, The Upshot, NY Times, 4-4-16) New evidence suggests Medicare Advantage may not serve some sicker Medicare beneficiaries as well as it does healthier ones. Though some evidence suggests Medicare Advantage plans offer higher quality and greater efficiency than traditional Medicare, that may not benefit some sicker people — like those needing hospitalization, home health care or nursing home care — or those with certain mental illnesses, like depression.
Target Of Medicare Insider Trading Case Boasted He Was Unstoppable ‘Beast’ (Christina Jewett and Melissa Bailey, KHN, 5-30-17) Federal prosecutors announced an indictment against consultant David Blaszczak "and three co-defendants, including an executive-level Medicare employee, for allegedly turning confidential government information into windfall profits on Wall Street....Political intelligence workers track countless decisions Medicare and the Food and Drug Administration make each month about which hospital beds, heart valves, surgical techniques or drugs will rise or fall in value — or if the government will pay for them at all. It’s a Washington, D.C., industry that reflects the big business of U.S. health care...." In this case, information fed to hedge fund operators " led to short sales by the hedge-fund firm," bets in favor of stocks tanking when bad news from Medicare was made public.
Get ready for big changes in Medicare drug pricing (Philip Moeller, PBS NewsHour, 3-16-16) Medicare is prohibited from directly negotiating drug prices with pharmaceutical companies. This was one of the “free enterprise” provisions that Republicans insisted upon when Medicare’s Part D prescription drug program was enacted in 2003 (the actual Part D plans did not begin until 2006). Preventing Medicare from directly using its powerful leverage to influence drug prices has been a major (but hardly the only) cause of what is now a runaway epidemic of higher drug prices....Medicare announced a test program last week that would change the way some providers are paid for the drugs they prescribe in Part B of Medicare which covers drugs — many expensive ones — that are administered in doctors’ offices or by caregivers in an outpatient setting. The test will last for five years and be mandatory and providers (and Medicare beneficiaries) in 75 percent of the country will face pricing changes (including reduced commissions to prescribers). "Many medical groups, particularly those treating cancer patients and others who take expensive drugs, have issued unusually strong statements of opposition to these changes, saying they will hurt and not help patients by forcing doctors to prescribe less expensive and less useful drugs. The notion that doctors would sacrifice patient welfare for financial gains doesn’t go over so well either."
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Medicaid: What you need to know

Plan on Growing Old? Then the Medicaid Debate Affects You (Ron Lieber, NY Times, 6-30-17) ". One in three people who turn 65 end up in a nursing home at some point. Among the people living in one today, according to the Kaiser Family Foundation, 62 percent cannot pay the bill on their own. And when that happens, Medicaid pays. The very Medicaid program that stands to have hundreds of billions of dollars less to spend if anything like the health care bills on the table in Washington come to pass....Reality forces our hand, however, when the first nursing home bills arrive."
10 Things to Know about Medicaid: Setting the Facts Straight (Julia Paradise, Kaiser Family Foundation, 6-9-17) 1. Medicaid is a cost-effective program, providing health coverage for low-income Americans at a lower per-person cost than private insurance could. (Read the whole article, to get the evidence behind the assertions.)
Medicaid Covers All That? It’s The Backstop Of America’s Ailing Health System (Phil Galewitz, Kaiser Health News, 9-25-17). "A recent survey by the Kaiser Family Foundation showed three-fourths of the public, including majorities of Democrats (84 percent) and Republicans (61 percent), hold a favorable view of Medicaid. That’s nearly as high as Americans’ views on Medicare. (Kaiser Health News is an editorially independent program of the foundation.) But it may still have a bull’s-eye on its back. “The fact that the House passed a bill to cut $800 billion from Medicaid and it came one vote short to passing the Senate shows Medicaid is stronger than maybe many Republican leaders anticipated,” said Oberlander. “But politically it is still in a precarious position.”
Medicaid Covers All That? It’s The Backstop Of America’s Ailing Health System (Phil Galewitz, KHN, 9-25-17)
From Birth To Death, Medicaid Affects The Lives Of Millions (Alison Kodjak, Shots, NPR, 6-27-17) Why Medicaid takes up one-tenth of the federal budget. Children and adults make up the largest share of Medicaid enrollees, but most spending goes to seniors and people with disabilities. It pays for half of all births in the United States. It pays for most people in nursing homes. If you or your loved one are disabled, you may qualify. And the expansion of Medicaid is one of the only paths to treatment for the many, many people who are addicted to opioids. Several studies have credited the expansion of Medicaid to better access to medication-assisted treatment, which is the most successful treatment for substance abuse.

2. Medicaid bolsters the private insurance market by acting as a high-risk pool.
3. Federal Medicaid matching funds support states’ ability to meet changing coverage needs, such as during economic downturns and public health emergencies.
4. Medicaid is a major spending item in state budgets, but also the largest source of federal funds for states.
5. States have broad discretion in designing key aspects of their Medicaid programs.
6. Medicaid beneficiaries have robust access to care overall, although access to certain types of specialists is an ongoing challenge for Medicaid and all payers.
7. Medicaid keeps coverage and care affordable for low-income Americans.
8. Evidence of Medicaid’s impact on health outcomes is growing.
9. Medicaid is the primary payer for long-term care for seniors and people with disabilities.
10. Medicaid is popular with the American public as well as with enrollees themselves.
Who's covered under Medicaid (Reuters graphic). Roughly 70 million people in the United States get their coverage through Medicaid--here, that amount is broken down by category.
Medicaid Benefits (by state) (Benefits.gov)
Medicaid and Long-Term Services and Supports: A Primer (Erica L. Reaves and MaryBeth Musumeci, Kaiser Family Foundation, 12-15-15) Millions of Americans – children, adults, and seniors – need to access long-term services and supports as a result of disabling conditions and chronic illnesses. Long-term services and supports are expensive, with institutional care costs exceeding costs for home and community-based services and supports. Medicaid is the primary payer for institutional and community-based long-term services and supports. Medicare coverage of long-term services and supports for seniors, nonelderly people with disabilities, and people with certain chronic conditions is limited. As of 2011, almost 10 million beneficiaries – known as “dual eligibles” – were enrolled in both Medicaid and Medicare, with Medicaid paying for the majority of their long-term services and supports costs. Private long-term care insurance is typically inaccessible to all with current or future care needs often due to high premium prices. People with long-term services and supports needs may qualify for Medicaid based solely on their low incomes or they may qualify at slightly higher incomes if they also meet disability-related functional criteria. Within the Medicaid program, there has been a historical structural bias toward institutional care.
Medicaid Financing: The Basics (Robin Rudowitz, Kaiser Family Foundation,12-22-15) Medicaid represents $1 out of every $6 spent on health care in the US and is the major source of financing for states to provide coverage to meet the health and long-term needs of their low-income residents. Medicaid is administered by states within broad federal rules and jointly funded by states and the federal government. President-elect Trump and other GOP proposals have put forth fundamental changes in Medicaid financing. This brief examines the following 3 key Medicaid financing questions: How does Medicaid financing work now? How much does Medicaid cost and how are funds spent? What is the role of Medicaid in federal and state budgets?
In Health Bill’s Defeat, Medicaid Comes of Age (Kate Zernike, Abby Goodnough, and Pam Belluck, NY Times, 3-27-17) "When it was created more than a half century ago, Medicaid almost escaped notice. Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills.
"But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.
"Medicaid, so central to the country’s health care system, also played a major, though far less appreciated, role in last week’s collapse of the Republican drive to repeal and replace the Affordable Care Act...In the Senate, many Republicans, echoing their states’ governors, had worried about jeopardizing the treatment of people addicted to opioids, depriving the working poor, children and people with disabilities of health care and in the long run reducing funding for the care of elderly people in nursing homes.
"Still, last week’s defeat reflected how hard it is to take away an entitlement. It also showed the broad and deep reach of Medicaid, which covers about six times as many people as the private marketplaces created under the A.C.A."
Medicaid’s Role for Seniors (Kaiser Family Foundation). KFF's infographic explains Medicaid’s role for millions of Americans age 65 and older. Because of their complex health needs and high use of services, the 6.4 million seniors on Medicaid account for 9 percent of the program’s enrollment but 21 percent of its spending. The infographic shows that Medicaid funds over half of long-term care in the U.S. and helps pay for other services not covered by Medicare, including assistance with self-care such as bathing and dressing, and household activities such as preparing meals. Medicaid also helps make Medicare affordable for seniors with low incomes by helping with premiums and cost sharing. The 47.5 million Americans age 65 and older make up 15 percent of the population, numbers that are expected to grow as the U.S. population ages in coming decades.
New York Times stories about Medicaid
The Ethics of Adjusting Your Assets to Qualify for Medicaid (Ron Lieber, NY Times, 7-21-17)
How the Medicaid Debate Affects Long-Term Care Insurance Decisions (Ron Lieber, Your Money, NY Times, 7-14-17) "Medicaid is the backstop for retirees who run out of money but still need home-based care or must move into a nursing home. Medicare generally doesn’t cover those costs, and they are high enough that even people with many hundreds of thousands of dollars can end up spending everything they have the years before they die. The money for Medicaid comes from both the federal government and the states, and this week, the Bipartisan Policy Center in Washington had this to say about what the future holds: “States will not be able to sustain spending for long-term services and supports as baby boomers begin to need these services and supports.”...Most insurers have left the long-term care market, and many of the rest have raised prices significantly, both on existing policyholders and newcomers. READ THIS ARTICLE AND PAY ATTENTION TO YOUR FEDERAL POLITICIANS!
MedicaidSecrets. Learn how to protect your assets from nursing home costs. You may want to buy the book: How to Protect Your Family's Assets from Devastating Nursing Home Costs by K. Gabriel Heiser
One Woman’s Slide From Middle Class to Medicaid (Ron Lieber, Your Money, NY Times, 7-7-17)
With Medicaid, Long-Term Care of Elderly Looms as a Rising Cost (Nina Bernstein, NY Times, 9-6-12)
Medicaid and CHIP Briefing Book (National Health Policy Forum). This briefing focused on Medicaid and the Children’s Health Insurance Program (CHIP) which provided health coverage to 72 million and 8 million individuals, respectively, in FY 2013. The session began with background information about how Medicaid differs from other payers and high-level descriptions of beneficiaries, spending levels, and projections.
Medicaid’s Role in Meeting Seniors’ Long-Term Services and Supports Needs (KFF, 8-2-16)
State Variation in Medicaid Per Enrollee Spending for Seniors and People with Disabilities (MaryBeth Musumeci and Katherine Young, KFF issue brief, 5-1-17) This issue brief explains the variation in Medicaid spending per enrollee for seniors, nonelderly adults with disabilities, and children with disabilities compared to other populations as well as variation in per enrollee spending for these populations among states. It also provides a snapshot of state choices about optional eligibility pathways and covered services important to many seniors and people with disabilities.
Medicaid and Children with Special Health Care Needs (MaryBeth Musumeci, KFF, 1-31-17) An estimated 11.2 million children, or 15% of all children in the U.S., have special health care needs, based on the most recent data available from 2009-2010. Their needs result from a range of conditions, such as Down syndrome, cerebral palsy, and autism. Medicaid, CHIP, and other public health insurance programs cover nearly half (44%) of children with special health care needs. Some children with special health care needs qualify for Medicaid based solely on their family’s low income. Other children with special health care needs qualify for Medicaid through a disability-related pathway. Nearly all states choose to expand Medicaid financial eligibility for children with special health care needs without regard to family income through optional disability-related pathways
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Medicaid issues and Medicaid reform

10 Essential Facts About Medicare and Prescription Drug Spending: A Slideshow (Kaiser Family Foundation analysis)
Medicaid: What We Learned From the Recent Debate and What to Watch for in September 2017 (Robin Rudowitz, KHN, 9-5-17) An excellent summary and analysis, of which these are only the main points:
1. More than half of the states have a strong stake in continuing the ACA Medicaid expansion as it has provided coverage to millions of low-income residents and produced net fiscal benefits.
2. While most states favor enhanced flexibility, financing caps through a block grant or per capita cap may not be a good deal for many states.
3. Uncertain future health care costs and needs as well as variation across states make it difficult to implement a pre-set growth rate for Medicaid under a capped financing structure.
4. The proposals to cap federal funding could lock-in current state spending patterns that reflect historic Medicaid policy choices.
5. Medicaid has broad support and also strong support among the many special populations that rely on Medicaid.
Election Results Invigorate Medicaid Expansion Hopes (Abby Goodnough and Margot Sanger-Katz, NY Times, 11-8-17) The election results in Maine and Virginia have energized supporters of expanding Medicaid under the Affordable Care Act in several holdout states. After months of battling Republican efforts to repeal the law, they now see political consensus shifting in their direction. Groups in Idaho and Utah are already working through the process of getting Medicaid expansion initiatives on next year’s ballots, hoping to follow Maine’s path after failing through the legislative route.
Healthcare, for years a political winner for GOP, now powers Democratic wins (Noam N. Levey, Los Angeles Times, 11-8-17) he polarizing issue of healthcare, which has dragged down Democrats since passage of the Affordable Care Act in 2010, emerged from Tuesday’s state elections as a potentially formidable new force in the party’s efforts to regain power in next year’s congressional elections. “There has been a major change here,” said Robert Blendon, an expert on public opinion about healthcare at Harvard’s Kennedy School. “Democrats for years wouldn’t talk about healthcare. … Now, the implication is that if you are a Democrat running in 2018, you can talk about protecting healthcare for millions of Americans.”
To Insure More Poor Children, It Helps If Parents Are on Medicaid (Shefali Luthra, Kaiser Health News, 9-5-17) Efforts by Republican lawmakers to scale back Medicaid enrollment could undercut an aspect of the program that has widespread bipartisan appeal — covering more children, research published Tuesday in the journal Health Affairs suggests. The study focuses on the impact of Medicaid’s “welcome-mat” effect — a term used to describe the spillover benefits kids get when Medicaid eligibility is extended to their parents. Children were more likely to be enrolled in public health insurance programs — specifically Medicaid, which in some states is administered as an expansion of the federal-state Children’s Health Insurance Program — if their parents were also able to enroll. The findings highlight an underlying tension and a key relationship — parents’ insurance status and that of their kids — as Congress moves in coming weeks to reauthorize CHIP, before its funding expires at September's end. “There’s no doubt that it’s the combination effect; when parents find out they’re eligible, it brings in the kids,” said Tricia Brooks, a senior fellow at Georgetown University’s Center for Children and Families." “Public coverage for children … increased as the Affordable Care Act took effect,” said Benjamin Sommers, an associate professor of health policy and economics at Harvard University’s public health school.
The War on Medicaid Is Moving to the States (Greg Kaufman, Moyers & Company, 9-5-17) Recent congressional proposals to repeal and replace the Affordable Care Act would have reduced Medicaid enrollment by up to 15 million people, and, despite being defeated, congressional Republicans aren’t done yet: It’s likely they will attempt to gut the program during the upcoming budget debate. Meanwhile, more than half a dozen conservative governors are trying to take a hatchet to the program — at the open invitation of the Trump administration — through a vehicle known as a “Medicaid waiver.”
Medicaid Financing: An Overview of the Federal Medicaid Matching Rate (FMAP) (Kaiser Commission on Medicaid and the Uninsured. Which refers to the Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier
What Medicaid Recipients And Other Low-Income Adults Think About Medicaid Work Requirements (Jessica Greene, Health Affairs blog, 8-30-17) "Arguments for and against work requirements have been made repeatedly in the media, particularly since the beginning of the Trump administration. Those who support work requirements claim they create a culture of work, provide a pathway out of poverty, reduce reliance on public programs, and ultimately improve people’s health. Those who oppose work requirements argue that few able-bodied recipients are not working, that health is a precondition for work, that the policy would hurt the most vulnerable, and that it is a thinly veiled strategy to reduce the number of Medicaid recipients." Greene asked Medicaid recipients what they thought. The working poor are still poor and still qualify for Medicaid. Paying premiums will challenge both those working and those not working. Paying premiums is unlikely to reduce people's need for Medicaid. Overall, focus group participants thought that Kentucky HEALTH would not address the absence of affordable private insurance or the lack of support during the transition from Medicaid to private coverage. Participants wanted a bridge between Medicaid and employer-sponsored coverage. Their experiences highlight an underacknowledged problem with the ACA—that low-income people become ineligible for premium or cost-sharing assistance once they are offered employer-sponsored coverage. They offered several specific suggestions.
Health care debate shines light on Medicaid (Susan Heavey, Covering Health, 7-19-17) One result of the ongoing health care reform debate is a renewed look at Medicaid by both journalists and the public. It does not cover only low-income Americans. It also provides coverage for pregnant women, many children, many disabled people, U.S. military veterans in areas with no Veterans Affairs coverage, and nursing home care for some seniors. Rural hospitals depend heavily on Medicaid dollars. It covers some 70 million people.
One child, a $21-million medical bill: How a tiny number of patients poses a huge challenge for Medi-Cal (Soumya Karlamangla, Los Angeles Times, 7-16-17) Medi-Cal, which is jointly funded by the federal and state governments, provides health coverage to 13.5 million Californians, or a third of state residents. State data show that the most expensive 1% of patients in Medi-Cal account for 23% of the program’s spending. Ten percent of patients create 63% of total costs. Medi-Cal patients incurring the absolute highest costs tend to have severe genetic disorders such as cystic fibrosis, hemophilia, Duchenne muscular dystrophy and sickle cell disease. Some of those people may be addicted to drugs or have a mental health condition that contributes to their high healthcare expenses. They may overuse the emergency room because they don’t know how to navigate the healthcare system or find a primary care doctor. They’re concerned about the Senate healthcare bill, which would scale back federal funding.
The Back Story on Trump and Medicaid (NY Times video, Retro Report) During his campaign Trump supported Medicaid; in office he has changed his tune. Under Clinton, welfare funds and responsibilities were shifted to the states, but states vary in how and how well they use that money.
5 Challenges Facing Medicaid at 50 (Phil Galewitz, Kaiser Health News, 7-30-15) 1. Controlling costs: Medicaid is one of the largest items in state budgets, although its beneficiaries lack political clout. 2. Getting states to expand income eligibility under Obamacare: The Supreme Court's 2012 ruling that states could decide whether to participate in the health law's Medicaid expansion impaired Democrats' efforts to expand eligibility nationwide. 3. Better oversight of managed care: More than half of Medicaid enrollees now get care through private managed care companies... 4. Ensuring access to doctors and dentists: Studies show people enrolled in Medicaid can get primary and preventive care as easily as those with private coverage, but have a harder time finding specialists and dentists who are willing to treat them. 5. Meeting growing demand for long term care.
Cuts Leave Patients With Medicaid Cards, but No Specialist to See (Robert Pear, NY Times, 4-2-11)
The Unmentioned Problems in ‘Medicaid for All’ (Jim Geraghty, The Corner, from Morning Jolt, 3-14-17)
Best Health-Care Plan for Republicans? Wait (Megan McArdle, Bloomberg, 3-13-17) There are no good outcomes at this point.
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MACRA

Medicare Access & CHIP Reauthorization Act (MACRA).
MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015. The Children’s Health Insurance Program (CHIP) provides provided health coverage to 8 million individuals in FY 2013. Medicaid provided coverage for 72 million adults in the same period.

MACRA: A look at the final rule on physician quality payments and EHR transition(Rebecca Veseley, Covering Health, AHCJ, 11-9-17) The federal government released its final rule for 2018 on a law that governs physicians’ adoption of electronic health records and rewards them for meeting quality measures when treating Medicare patients. However, the final rule includes some changes that mean that fewer physicians will be required to participate. One prominent physician group said that the rule will slow the transition to value-based care. The law, the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA, created the Quality Payment Program (QPP). This QPP reimburses physicians who treat Medicare beneficiaries based on meeting quality benchmarks and their continued transition to electronic health records. Under the QPP, providers can choose two tracks: one is the Merit-Based Incentive Program (MIPS), and the other is the Advanced Alternative Payment Model (APM). Most physicians fall under MIPS. An explanation for journalists with links to additional resources.
Children’s health advocates anxious that CHIP funding will slip through the cracks (Mary Otto, Covering Health, 9-20-17) Amid the ongoing debate over the fate of the Affordable Care Act, another landmark federal health care program faces an uncertain future. Funding for the Children’s Health Insurance Program (CHIP), which provides medical and dental coverage to nearly nine million children of the working poor, runs out Sept. 30, and unless a divided and distracted Congress takes action to renew it, state CHIP programs could start running out of money later this year.
State Plans for CHIP as Federal CHIP Funds Run Out (Kaiser Family Foundation, 12-6-17)
Comparison of Key Provisions in the Senate and House CHIP Bills (Kaiser Family Foundation, Nov. 2017)
Medicaid and CHIP Income Eligibility Limits for Children as a Percent of the Federal Poverty Level (Kaiser Family Foundation, 1-1-17)
You’ve heard of Brexit? Here’s what they call doctors who are leaving. (Niran S. Al-Agba, MD, KevinMD, 4-25-17) "Sean MacStiofain said, “most revolutions are caused … by the stupidity and brutality of governments.” Regulation without legitimacy, predictability, and fairness always leads to backlash instead of compliance. Here’s a prediction for you: If something is not done to stop MACRA implementation, more physicians will opt-out of Medicare and Medicaid than is fathomable....The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is destructive to the physician-patient relationship because it prevents physicians from prioritizing patient care....Enter stage left, MACRA, known as the “permanent doc fix,” which was passed concurrently with the sustainable growth rate formula repeal legislation. This was the original “repeal and replace.”
How MACRA will decimate the private practice physician (Niran S. Al-Agba, MD, KevinMD, 7-20-16) "Small, independent private practices are closing, increasing numbers of physicians are retiring, and fewer medical school graduates are choosing primary care....MACRA proposed reimbursement will decimate rural care as we know it....This plan will penalize 7 out of 10 small 1 to 2 physician practices in this country. Why? Because we will be overwhelmed complying with statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients."

Breaking Down The MACRA Proposed Rule (Billy Wynne, Katie Pahner, and Devin Zatorski; Health Affairs blog, 4-29-16) The mother ship has landed. On Wednesday, April 27, the Centers for Medicare and Medicaid Services (CMS) released the highly anticipated proposed rule that would establish key parameters for the new Quality Payment Program, a framework that includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These policies were established by the latest, permanent ‘doc fix,’ the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
What is MACRA and what do reporters need to know about it? (Rebecca Vesely, Association of Health Care Journalists tip sheet,
Medicare's New Physician Payment System (Health Policy Briefs, Health Affairs, 4-21-16) "For more than two decades Congress and the federal government have wrestled with how to pay physicians in the Medicare program, which covers forty-seven million Americans....The primary challenge of physician payment is determining fair fees for physicians and other clinicians. But, just as important, the challenge extends to paying physicians in a way that promotes efficient, effective, and safe care; does not incentivize excessive and unnecessary care; and fosters the judicious use of medical resources since physicians order and direct the care that constitutes the lion's share of total Medicare spending."
"MACRA creates a payment system for physicians that will accelerate Medicare's transition from fee-for-service to payment based on performance metrics, patient experience, and patient outcomes. But three years of complex MACRA rulemaking lie ahead amid a still-entrenched fee-for-service system, continued political rancor over the ACA, and a change in administrations and a new Congress. The trajectory of health care spending over the next few years could also affect the urgency and design components of MACRA implementation. The hundreds of comments on CMS's request for information signal many areas of tension but also areas of agreement. The major question is whether MACRA will succeed at improving quality, reducing unnecessary care, and lowering cost growth where past efforts have lagged or failed outright."
RNC: Physician Payment Reform Still Needs Tweaking (Joyce Frieden, Medpage Today, Washington Watch, 7-19-16) MACRA is progress, and physician payment reform is slowly moving in the right direction, but it has a long way to go. Too many and conflicting quality measures make the cost of compliance too high. Plus too little $$ and attention is paid to prevention (such as getting people to eat right and exercise more).
Last Year's Medicare 'Doc Fix' Is Already Breaking Down--Here Are Some New Fixes (John Graham, Forbes, 7-21-16) "Advertised by Republican and Democratic leaders as a permanent solution to the flawed way Medicare paid doctors, the Medicare Access and CHIP Reauthorization Act (MACRA) was actually Republican politicians’ first vote for Obamacare....The MACRA was largely pushed the professional societies which claim to represent physicians. Unfortunately, practicing physicians who see patients all day were too busy to pay attention to how the federal government was going to impose itself even more on their practices....That blissful ignorance is dissipating, in the wake of a lengthy rule proposed by the Centers for Medicare & Medicaid Services (CMS) last March. Just the first step in implementing the many technical requirements necessitated by MACRA, the rule has been described as “962 pages of gibberish” by Margalit Gur-Alie, a leading healthcare consultant." A report proposes two changes.
Understanding Medicare Payment Reform (MACRA) (AMA)
Brave New World: Medicare’s Advanced Payment Models (Billy Wynne and Max Horowitz, Health Affairs blog, 4-4-16) Under Medicare’s traditional fee-for-service reimbursement approach, providers are paid based on the volume of services delivered. By now we all seem to understand that rendering more care is not the same as rendering high-quality care, and the policy conversation has increasingly focused on tying payment to the value of the services rendered. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a new framework for Medicare physician payment. Under the law, beginning in 2019, health care professionals participating in the program will come to a crossroads on their path to reimbursement.
"In one direction—the default direction—they will be subject to the Merit-Based Incentive Payment System (MIPS), a revamp of Medicare’s fee-for-service (FFS) payment system that consolidates existing quality programs into a unified reimbursement component.
"Those who receive a certain share of their revenue through alternative payment models (APMs) are exempt from MIPS requirements. The law further encourages participation in APMs by providing incentive payments during the first few years of implementation and steeper increases to their base reimbursement rate later on." This post tries to explain what an APM under MACRA really is, discuss the provider incentives under this path, and clarify what we know so far about efforts underway to create and implement them.
CMS timeline for MACRA implementation
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Health insurance, ACA, and the marriage glitch

What Happens When Marriage Makes Health Insurance Unaffordable (Sammy Mack, Health News Florida, 12-2-15) The “family glitch”: when you get married and lose your subsidy to buy insurance in the individual marketplace. "Under the Affordable Care Act, if one person in a family has a job that offers health insurance to the rest of the family then nobody can get subsidies on the federally run exchanges. A recent study from the Kaiser Family Foundation estimates that more than 400,000 Floridians went without health coverage—even when they could have gotten it through work....Big employers have to offer “affordable” health insurance options to employees to avoid federal tax penalties. An affordable plan for the employee can’t cost more than 9.5 percent of her household income. But the rules don’t apply to family members of the employee....As health insurance costs keep rising, the family benefit is one of the places employers can shift costs without getting fined. And, says Ullmann, there’s reason to believe more families will find themselves in this situation."
When the partner over 65 picks up Medicare (and a secondary insurer), the under-65 person is left out in the cold, says one member of Association of Health Care Journalists, through whom I learn much of what you find here).

The Hidden Marriage Penalty in Obamacare (Garance Franke-Ruta, The Atlantic, 11-5-13) Childless couples and empty nesters pay more. Much more. The Obamacare subsidies "are more generous to single people and one- or two-parent families with children in the house than to couples who lack children. They were designed to help single moms and struggling middle-class families with children, not married creative-class millennials in pricey cities who have not yet settled into well-paid work, or barring that, work for a single employer."
"Any married couple that earns more than 400 percent of the federal poverty level—that is $62,040—for a family of two earns too much for subsidies under Obamacare. "If you're over 400 percent of poverty, you're never eligible for premium" support, explains Gary Claxton, director of the Health Care Marketplace Project at the Kaiser Family Foundation."

Some Face Marriage Penalty In Obamacare Subsidies (Robert Calandra, The Philadelphia Inquirer and Kaiser Health News, 12-4-13) Some couples are complaining that "the law has a hidden marriage penalty. Here’s why: Say a couple has a household income of $70,000 with one spouse making $30,000 and the other $40,000. Combined, they are ineligible for a subsidy. But if they were just living together, each would be eligible for a subsidy." “We’ve known all along that some people will do better in this market and some people will do worse,” said one expert. "The ACA, like the tax code, is complicated, and it sometimes provides a marriage subsidy and a penalty, said Mark Duggan, a health economist at the University of Pennsylvania’s Wharton School." Changing "the way health insurance is delivered in America is a huge undertaking.... the country will have to break a few eggs to make this omelet."

Resources for Agents and Brokers in the Health Insurance Marketplaces (The Center for Consumer Information & Insurance Oversight, CCIIO, CMS)

Why The GOP’s ‘Marriage Penalty’ Is A Myth (Igor Volsky, ThinkProgress, 10-27-11) Issue one: "since the majority of the uninsured are not married and marrying lowers uninsurance rates, providing more subsidies to individuals is a better way of targeting affordability credits to those who need them most....to expand the affordability definition and allow more people to take advantage of the tax credits within the exchanges would cost the government “an extra $50 billion a year” — spending Republicans would surely oppose....Republican health care prescriptions — look to the Boehner alternative introduced in the House for an example — don’t provide subsidies to anyone — married or unmarried and it’s actually their efforts to repeal the ACA and do little to nothing for health care spending that would significantly strain families and their economic well being."
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Helpful blogs, websites, organizations, and citizen lobbies about Social Security, Medicare, and pension rights

Health policy essentials (National Health Policy Forum, essential information about Medicare, Medicaid, health insurance & the uninsured, CHIP, the Safety Net, pharmaceuticals, public health, aging & long-term care, and workforce issues, in a variety of formats)
The Medicare Blog (the official blog for the U.S. Medicare program)
Center for Medicare Advocacy ("occasionally sues Medicare for certain policies")
The Commonwealth Fund. See, for example, AHCA Would Affect Medicare, Too ("One-third of all Medicaid spending is for people covered by Medicare.")
National Medicare Advocates Alliance provides Medicare advocates with a collaborative network to share resources, best practices, and developments of import to Medicare beneficiaries throughout the country. The Alliance is supported by the Atlantic Philanthropies
National Committee to Preserve Social Security & Medicare (trusted, independent, effective).
The Medicare Payment Advisory Commission (MEDPAC), a nonpartisan legislative branch agency that provides the U.S. Congress with analysis and policy advice on the Medicare program
The Medicare Daily Report (news and commentary on the politics of Medicare)

Beat the Press (Center for Economic and Policy Research, or CEPR)
Entitled to Know
Health Care Policy and Marketplace Review (Bob Laszewski's health care reform blog, covering the latest developments in federal health policy, health care reform, and marketplace activities in the health care financing business
Justice in Aging (fighting senior poverty through law)
Kaiser Health News (easiest way to stay on top of health and medical news). See KHN on Medicare and on Medicaid, among other topics
My Elder Advocate
Notes on Social Security Reform (occasional comments on the economics and politics of Social Security policy by Andrew Biggs)
OWL (The Voice of Midlife and Older Women)
Pension Rights Center blog
The People's Pension (separating fact from superstition about Social Security, social insurance, and mutual aid)
Squared Away (financial behavior: work, save, retire -- Center for Retirement Research at Boston College)
WISER (Women's Institute for a Secure Retirement)

GROUPS THAT SUPPORT MEDICAL INDUSTRIES
whose interests often conflict with those of patients, and are often lobbied for when legislation is being negotiated
American Medical Association (AMA)
AdvaMed (Advanced Medical Techology Association)
PhRMA (represents 48 pharmaceutical companies)
American Hospital Association (AHA)

WHO and WHAT HAVE I MISSED???
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How Medicare and Medicaid fall short
End-of-life talks and other issues


Whistleblowers: United Healthcare Hid Complaints About Medicare Advantage (Fred Schulte, KHN, 7-28-17) United Healthcare Services Inc., which runs the nation’s largest private Medicare Advantage insurance plan, concealed hundreds of complaints of enrollment fraud and other misconduct from federal officials as part of a scheme to collect bonus payments it didn’t deserve, a newly unsealed whistleblower lawsuit alleges. The suit, filed by United Healthcare sales agents in Wisconsin, accuses the giant insurer of keeping a “dual set of books” to hide serious complaints from customers about its services and of being “intentionally ineffective” at investigating misconduct by its sales staff. About 19 million have chosen to enroll in Medicare Advantage plans as an alternative to standard Medicare.
Curing Medicare: One doctor's view of how our health care system is failing the elderly and how to fix it by Andy Lazris. Don't have the book yet? Read the blog: An Inside Look at Health Care for the Elderly and Medicare
Streamlining Medicaid Home and Community-Based Services: Key Policy Questions ( Mary Sowers, Henry Claypool, and MaryBeth Musumeci, Kaiser Family Foundation briefs, 3-11-16)

Part 1: 2 million kids. $24 billion battle. (Maggie Clark's excellent Herald Tribune series). Malik Staton’s story shows holes in Florida Medicaid. Other stories in this series follow:
---Part 2: A double-edged sword (Maggie Clark) Fighting the stigma, fighting for care
---Part 3: An impossible choice Doctors are torn between patients and the Medicaid system
---Part 4: Medicare dental debate leaves out kids
---Part 5: Sound at stake A hearing clinic trying to balance financial reality with needs of children on Medicaid reaches out for community support.
---Shattered smiles (Maggie Clark, Part 6. Florida kids face dental crisis)
---
---What you need to know about Medicaid (card 1, FAQs)

Medicare Kills (Paul Burke, post on Citizen Oversight, 9-27-13). Burke's father's death from insufficient care is the story behind this investigative search of data. "[D]octors who advise Medicare patients against treatment can sign up to keep half the savings as a kickback....hospitals which talk Medicare patients into hospice, or out of coming back to a hospital, keep as much as $265,000 for each readmission they avoid." See also Hospitals Punished for Followup Care (PR Newswire release posted on The Business Journals 5-30-14).
Imagine a Medicare ‘Part Q’ for Quality at the End of Life (Katy Butler, NY Times, 12-9-15) At the "tail end of life, Medicare continues to pay well for fix-it treatments focused unrealistically on cure and underpays for care and desperately needed home support." In his last six years, it paid more than $80,000, all told, for treatments for Katy Butler's father. "But it paid very little for home health aides to give my mother respite and cut off, far too soon, the speech and physical therapies that helped maintain his ability to function and take pleasure in life. Under fee-for-service medicine, Medicare paid to patch him up after he fell but not to keep him from falling." Medicare as currently organized is fine for the “young old” – those in the 65- to 80-year-old range who are active. "Medicare’s also not bad for those with swiftly fatal diseases: a hospice benefit covers those with less than six months to live. But for those in between, there’s a terrible gap." Medicare pays poorly for primary care and supportive services except within hospice, says health policy expert Muriel Gillick of Harvard, who writes that Medicare “shapes the way we die” by funneling us toward a high-tech hospital death.
Medicare Penalties on US Hospitals, and Effects on Patients (Paul Burke's site, Globe1234.info). Medicare's policy is to penalize repeated admissions to hospitals--to "save money by reducing treatment." He proposes cost-saving alternatives in Medicare Costs, Premiums, and Alternatives. You can find more Medicare-related articles on Burke's watchdog site Globe1234.info.
Supreme Court Battle Brewing Over Medicaid Fees (Phil Galewitz, Kaiser Health News, 1-12-15). In December 2014, ruling in a lawsuit brought by the state’s pediatricians and patient advocacy groups, a federal district judge in Miami determined that a 7-year-old in severe pain from a sinus infection had an “unreasonable” wait to get medical attention and that Florida’s Medicaid program was failing him and nearly 2 million other children by not paying enough money to doctors and dentists to ensure the kids have adequate access to care.
The Secretive Group Behind Medicare Reimbursements (Kate Pickert, Time magazine, 7-29-13)
Attacking the main myth of Medicare and more (Paul Mulshine, Star Ledger, 12-5-13) If the Republicans were honest they would try to repeal Medicare before repealing Obamacare....They keep accusing the Democrats of wanting to turn Obamacare into a single-payer system - while at the same time defending that single-payer system known as Medicare.
The ACA and High-Deductible Insurance — Strategies for Sharpening a Blunt Instrument (J. Frank Wharam and other, New England Journal of Medicine, 10-17-13)
Fewer Doctors Treating Medicare Patients, CMS Says (Kaiser Health News, 7-28-13)
Gaps in Medicare (National Academy of Social Insurance)
How Medicare Fails the Elderly (Jane Gross, Sunday Review, NY Times, 10-15-11) Fee-for-service doctors and Big Pharma benefit from Medicare, but it does not cover some of the things elders need, including certain diagnostic tests and long-term care by home aides at home.
Poor oversight of Medicaid managed care programs takes toll on patients (Jenni Bergal, Association of Health Care Journalists, 8-22-13)
A Process with Promise; How the New Integration Demonstrations May Align Care for Dual Eligibles (Diane Justice, Generations, ASA, 2013) Dual eligibles, individuals who are enrolled in both the Medicare and Medicaid programs, have the most complex needs of participants in each program—yet they often receive fragmented care. The low-income participants, who often have multiple chronic conditions and functional support needs, must navigate a confusing maze of multiple program structures to access care. A partnership between federal and state governments is needed to advance reforms.
CMS admits underpaying dual-eligible health plans (Virgil Dickson, Modern Healthcare, 11-5-15) The CMS has revealed that it underpays health plans that enroll large numbers of people who are dually eligible for Medicare and Medicaid, and the agency plans to modify its risk-adjustment model to make up for the underpayment...
In Oregon, Medicaid Now Covers Transgender Medical Care (Kristian Foden-Vencil, NPR, 1-10-15)
Kaiser Health News is a good site for catching up and keeping up with health care issues, whether you are part of the press or just a thoughtful citizen.
Medicare’s open enrollment period is health care’s Groundhog Day (Philip Moeller, PBS NewsHour, 10-15-14)
The Medicare Miracle (Paul Krugman, NY Times, 8-31-14) "...it turns out that incremental steps to improve incentives and reduce costs can achieve a lot, and covering the uninsured isn’t hard at all. When it comes to ensuring that Americans have access to health care, the message of the data is simple: Yes, we can."
STOP Medicare Fraud (US HHS and Department of Justice)
Medicare Can Afford a Bit of Fraud (Megan McArdle, Bloomberg View, 6-10-14). A good explanation of why it's not worth catching the penny-ante fraud in the system.

Data uncover nation’s top Medicare billers ( Peter Whoriskey, Dan Keating and Lena H. Sun, Washington Post, 4-9-14). "Jonathan S. Skinner, a Dartmouth economist..."there are people who are operating in the gray area of health care who are causing Medicare to spend enormous amounts on health care that may be harmful to their patients.'”'
The top 10 Medicare billers explain why they charged $121M in one year (Jason Millan, Wonkblog, 4-9-14) "Some doctors said they were just passing through the payment to drug companies. But the Medicare payment system also incentivizes physicians to choose more expensive drugs, since they’re reimbursed for the average price of the drug plus 6 percent."
Manufactured Medicare outrage (Charles Lane, Opinion, Wash Post, 3-18-15) "Last fall, the Department of Health and Human Services released a comprehensive analysis showing that MA costs grew faster than they would have under fee-for-service between 2004 and 2013 — and that only upcoding, not patient demographics or other neutral factors, could explain this.
Medicare Advantage Money Grab (David Donald and Erin Durkin, series byThe Center for Public Integrity, June 2014). Congress created private Medicare Advantage health plans 11 years ago to help control health care spending on the elderly. But a Center for Public Integrity investigation found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a “risk score.” The formula is supposed to pay health plans more for sicker patients and less for healthy people, but often it pays too much. The government has for years missed opportunities to corral tens of billions of dollars in overcharges and other billing errors tied to abuse of risk scores. Meanwhile, the growing power of the Medicare Advantage industry has muzzled many critics in Congress, and turned others into cheerleaders for the program. (Sign up for the Center's Watchdog email.) Specific stories include
---Why Medicare Advantage costs taxpayers billions more than it should (Fred Schulte, David Donald, Erin Durkin, 6-4-14) Regulators have kept problems secret, and there's no fix in sight.
--- Health insurers have their way with regulators (Fred Schulte, 6-9-14) Billions in Medicare Advantage overcharges likely gone for good
---Home is where the money is for Medicare Advantage plans (Fred Schulte, 6-10-14) Feds wanted to ban costly 'house calls,' but backed off due to lobbying blitz
---Whistleblower suit says health plan cheated government out of more than $1 billion (Fred Schulte, 6-4-14) Company says former Bush health official simply a 'disgruntled employee'
---Medicare Advantage lobbying machine steamrolls Congress (Fred Schulte, 6-10-14) Fear of senior voters turns critics into champions
---Audit: Feds overpaid for half of patients in UnitedHealth Medicare Advantage plan (Fred Schulte, 6-19-15) Giant insurer disputed 2012 findings in secret legal proceeding
---How risk scores work (Chris Zubak-Skees, 6-4-14)
---Some Medicare Advantage plans overcharged the government by billions of dollars and got away with it (Fred Schulte, 12-18-15) Senate Judiciary chair Grassley says government has to 'get it right' and pursue full refunds for overpayments.
---Fraud case puts spotlight on Medicare Advantage plans (Fred Schulte, 2-13-15) Florida doctor indicted in suspected $2.1 million scheme
---Yet another whistleblower alleges Medicare Advantage fraud (Fred Schulte, 3-14-16) Florida doctor claims Humana knew of inflated bills, but did nothing, even though misleading diagnoses could harm patients
---Audit: Feds overpaid for half of patients in UnitedHealth Medicare Advantage plan (Fred Schulte, 6-17-15) Giant insurer disputed 2012 findings in secret legal proceeding
Treatment Tracker (Lena Groeger, Charles Ornstein, and Ryann Grochowski Jones, ProPublica, 5-15-14) The Doctors and Services in Medicare Part B. which covers services as varied as office visits, ambulance mileage, lab tests, and the doctor’s fee for open-heart surgery. Use this tool to find and compare providers.
The Crushing Cost of Care (Janet Adamy and Tom McGinty, Wall Street Journal 7-6-12) A small percentage of challenging cases, often at the end of life, make up the great bulk of Medicare spending on hospital care. Are we anywhere close to containing the costs?
Medicare and the $716 billion bogeyman (Trudy Lieberman, CJR, 8-22-12). Will a new version of a half-truth work for the GOP?
Medicare Uncovered: the pain from ‘skin in the game’ (Trudy Lieberman, CFJ, 1-8-13). A report puts a hole in the plan to make people pay more
The federal debt debate: Boomers vs. millennials (David Rogers, Politico, 3-11-15). A worker retiring at 70 can qualify for benefits worth about 75 percent more than if he or she had chosen early retirement at 62." Among other things. A big-picture look at what's wrong with our retirement and disabilities payment systems.
I love old people, but I will not accept Medicare (Pamela Wible, KevinMD, 8-7-14)
Groups Scrutinize White House Plan to Cut Drug Costs in Medicare (Robert Pear, NY Times, Politics, 3-9-16). Under a proposal to try a half-dozen new ways of paying for prescription drugs in Part B of Medicare, for the first time Medicare payments would be linked to the effectiveness of a drug and the cost of comparable medications — factors not normally considered in the current reimbursement formula, which is based on the average sales price of drugs, with an additional 6 percent allowance for storage and handling costs. "Prices for new cancer drugs often exceed $100,000 a year, and it is not unusual to see television commercials and magazine advertisements promoting such treatments."
Use Medicare’s Muscle to Lower Drug Prices (NY Times editorial, 9-21-15) One way to reduce drug costs for older patients on Medicare -- who often live on modest incomes, are in poor health, and take four or more prescription drugs -- is to reverse the policy set by the 2003 Medicare Modernization Act, which created Medicare’s prescription drug program.
"At Republican insistence, that law barred the federal government from negotiating with drug manufacturers. ...Congressional Republicans would no doubt balk at having the federal government negotiate Medicare drug prices, but the public is clamoring for action, and it’s the right thing to do."
Part D for Drug Coverage — and Drudgery (Jane Gross, New Old Age, NY Times, 12-1-14) "[A] ny “benefit’’ that twins the insurance industry with Big Pharma can’t really have the public interest at heart." A "Kaiser Family Foundation study had found 87 percent of Part D policyholders between 2006 and 2010 made no change, even when they knew they were overpaying, because [researching fees and doing the math] was too hard. Kaiser went so far as to say that the Part D plans had observed and responded to this behavior, offering reasonable rates one year and over-the-moon rates the next in a classic bait-and-switch." See also D Is for Dazed (Jane Gross, NY Times, 7-13-12). The "government cannot expect an elderly person with cognitive, visual or other deficits to manage this task —and it cannot assume that everyone has a daughter who can." And see Part D Gains May Be Eroding (Paula Span, NY Times, 8-21-14).
D Is for Dazed (Jane Gross, NY Times, 7-13-12)."I spent three days picking a Medicare drug plan. I'm praying I got the right one." Gross says "the government cannot expect an elderly person with cognitive, visual or other deficits to manage this task [of figuring out which Medicare Part D plan is best for them] —and it cannot assume that everyone has a daughter who can."
Observation stays over hospital admissions drives up costs for some Medicare patients (press release about study by Robyn A. Smith and Raina Kulkarni of University of Pennsylvania School of Medicine and Susannah G. Cafardi of the Centers for Medicare & Medicaid Services) Increasing use of observation stays may lead to financial liability for Medicare patients. The Penn team found that the number of patients with multiple observation visits within a 60-day period rose by 22 percent between 2010 and 2012. See more on problems with observation status under Medicare and Medicaid: What you need to know
Aid-in-Dying Laws Are Just a Start (Katy Butler, Opinionator, NY Times, 7-11-15) "Medicare currently pays meagerly for palliative care, hospice and home nursing....a quarter of Medicare payments go for treatment in the last year of life, often last-ditch attempts at cure rather than care. But in a positive change, Medicare is currently selecting hospices for a pilot program that will let some patients receive palliative care without requiring them to forgo what are typically considered curative treatments. And Medicare’s new willingness to pay for discussions of end-of-life options is another good step. Such programs may start to reduce the widely recognized problem of overly aggressive medical treatment, and attendant suffering, near the end of life."
U.S. Finds Many Failures in Medicare Health Plans (Robert Pear, NY Times, 10-12-14) Federal officials say they have repeatedly criticized, and in many cases penalized, Medicare health plans for serious deficiencies, including the improper rejection of claims for medical services and unjustified limits on coverage of prescription drugs.
When Medicare Falls Short (Jane Gross, NY Times, 10-16-08) Click here for more NY Times stories tagged "Medicare."
White House Takes Aim At Medicare And Medicaid Billing Errors (Fred Schulte, Shots, NPR, 9-3-15)
Medicare to Cut Payments to Some Doctors, Hospitals (Melinda Beck, Wall Street Journal, 12-18-14) More than 257,000 U.S. doctors will see their Medicare payments cut by 1% next year because they didn’t meet federal goals for using electronic medical records, said the Centers for Medicare and Medicaid Services.
The Longevity Insurance Dilemma (Frank Armstrong III, Forbes, 8-14-14) Let's say y0u plunk down $125,000 to purchase an annuity from a name brand major company that promises to pay you $79,987.50 for life if you live to 85. Good deal for them; probably not worth the gamble to you.
Obama Returns to End-of-Life Plan That Caused Stir (Robert Pear, NY Times, 12-25-10) "The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit. Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves."
Feds to Consider Paying for End-of-Life Planning (Michael Ollove, Pew Charitable Trust, 5-30-14)
Can We Have a Fact-Based Conversation About End-of-Life Planning? (Brendan Nyhan, The Upshot, NY Times, 9-10-14) "Although the claim has been repeatedly proved false, polls have consistently shown that more than a third of Americans believe the Affordable Care Act created a government panel to make decisions about end-of-life care for people on Medicare"--the "death panel" Sarah Palin invoked. Maybe end-of-life consultation coverage will be added to Medicare, when common sense prevails.
Coverage for End-of-Life Talks Gaining Ground (Pam Bellack, NY Times, 8-30-14). The issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as 2015.
Your Medicare Coverage: Preventive visit & yearly wellness exams (accessed 6-20-14)
Sliver of Medicare Doctors Get Big Share of Payouts (Reed Abelson and Sarah Cohen, NY Times, 4-9-14)
Fast-tracking the truth in IPAB coverage (Brendan Nyhan, CJR, 1-14-13). How to cover a key provision of the Affordable Care Act without making misinformation worse. "Unfortunately, one key element of the ACA—the Independent Payment Advisory Board (IPAB)—has become entangled with the 'death panel'” myth about the legislation, making it an important test case for whether we can have a fact-based debate about whether and how to reduce the explosive growth of healthcare costs."
No Easy Answers on Financing Long-Term Care (Judith Graham, New Old Age, NY Times, 9-19-13) "The federal Long-Term Care Commission published its full report on Wednesday, but it did little to change the perception that substantial relief for caregivers will be a long time coming." Geriatrician Joanne Lynne "believes that it’s a mistake to separate long-term care from broader reforms of Medicare and the health care delivery system." " The two primary financing options considered by the commission share “some commonalities,” said the commission chairman, "including agreement on the need for strong public programs and a role for the private sector." “If you look carefully at these two perspectives, you can begin to see a way forward.”
Medi-Cal Long-Term Care: Safety Net or Hammock? (PDF of report from Pacific Research Institute with Center for Long-Term Care Reform)
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Health care reform and the Affordable Care Act (ACA)

Often called Obamacare, originally by its opponents)

On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The eight basic consumer protections the Obama White House wants health care reform to cover:
(1) No discrimination for pre-existing conditions,
(2) No exorbitant out-of-pocket expenses, deductibles or co-pays,
(3) No cost-sharing for preventive care,
(4) No dropping of coverage if you become seriously ill,
(5) No gender discrimination,
(6) No annual or lifetime caps on coverage,
(7) Extended coverage for young adults,
(8) Guaranteed insurance renewal so long as premiums are paid.
For more about the Obama White House plans for health care, see http:/​/​www.whitehouse.gov/​healthreform .

Various sites, articles, judicial arguments (etc.) of interest and often helpful:
Repealing The Affordable Care Act Could Be More Complicated Than It Looks (Julie Rovner, Kaiser Health News, 11-9-16). President-elect Donald Trump has pledged to end the Affordable Care Act. But promising to make the law go away, and actually figuring out how to do it, are two very different things. Interesting analysis.
Health Care Reform: What It Is, Why It's Necessary, How It Works by Jonathan Gruber (clear explanations in graphic novel format of the Affordable Care Act, by an MIT economist, and one of the architects of both RomneyCare and ObamaCare). Here's YouTube version, in short.
Ten Titles: Understanding the Affordable Care Act (pdf, John McDonough, Hunter College, October 2010)
Equitable Access to Care — How the United States Ranks Internationally (Karen Davis and Jeromie Ballreich, NEJM, 10-23-14) "The United States has been unusual among industrialized countries in lacking universal health coverage. Financial barriers to care — particularly for uninsured and low-income people — have also been notably higher in the United States than in other high-income countries. As more Americans become insured as a result of the Affordable Care Act (ACA), differences in access to care between the United States and other countries — as well as among income groups within the United States — may begin to narrow."
Are More Americans Benefiting From Obamacare Than Realize It? (Drew Altman, Wall Street Journal, 5-20-15) The ACA guarantees coverage despite pre-existing conditions (previously denied coverage), requires a range of preventive services (without co-pays), eliminates lifetime caps on insurance coverage. Many Americans don't realize that that free flu shot is one benefit that resulted. "...gradually, more people may become aware of the popular benefits the ACA provides beyond expanding coverage for the uninsured."
• The Kaiser Family Foundation's summary of the law (pdf), and of changes made to the law by subsequent legislation, focuses on provisions to expand coverage, control health care costs, and improve health care delivery system. Kaiser also posts the implementation timeline for health reform , an interactive tool designed to explain how and when the provisions of the Affordable Care Act will be implemented over the next several years.
Frequently Asked Questions about Health Reform (Kaiser Family Foundation)
Medicare’s Rush To Risk: Confounding Theory And Practice, Leaving ACOs Vulnerable (David Introcaso and Clifton Gaus, Health Affairs blog, 6-19-15) It's hard to summarize this piece, which is well worth reading. While tying payment to value makes perfect sense, transforming the Medicare program without the evidence that explains how to do this does not.
HHS interactive state-by-state map.
Preventive Services Covered by Private Health Plans under the Affordable Care Act (Kaiser Foundation 10-28-14) A key provision of the ACA is the requirement that private insurance plans cover recommended preventive services without any patient cost-sharing. Full discussion.
The Great Cost Shift comes into focus (Trudy Lieberman, CJR, 12-24-14). "Consumers, even consumers who have insurance, are paying a larger share of their healthcare costs. This shift has been in the works for years, but provisions in the ACA have made it more visible."
The ‘unmitigated disaster’ of Obamacare in Mississippi (Trudy Lieberman, Columbia Journalism Review, 11-5-14). Sarah Varney and Jeffrey Hess report the heck out of a grim, ominous healthcare story. The story: Mississippi, Burned: How the poorest, sickest state got left behind by Obamacare. (Sarah Varney with Jeffrey Hess, Politico, Oct. 2014).
Obamacare’s Secret Success (Paul Krugman, NY Times Opinion page, 11-28-13) The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums; t was also about “bending the curve” — slowing the seemingly inexorable rise in health costs. Follow the bending cost curve and you will find that the slowdown in health costs has been dramatic.
Feds Target Health Law Loophole That Allows Large Employers To Offer Plans That Don’t Cover Hospitalization (Kaiser Health News, 11-4-14) The administration intends to disallow plans that “fail to provide substantial coverage for in-patient hospitalization services or for physician services,
A death blow for Obamacare? (Laurence H. Tribe, Boston Globe, 7-18-14) "The moment the Affordable Care Act was enacted in 2010, it became a litigation magnet. The lawsuits threatening to derail it were initially dismissed as ridiculous but became deadly serious by the time Chief Justice John Roberts’s decisive fifth vote two years later barely upheld the law’s individual mandate, while the Court’s decisive 7-2 vote left the health law’s Medicaid expansion in tatters. Last month, the court struck a second blow to the ACA by allowing some for-profit corporations to opt out of offering contraceptive coverage they deemed religiously offensive. And even House Speaker John Boehner is joining in the litigation..."
Another Baseless Attack on Health Law (NY Times editorial, 12-12-14) A suit filed by the "Republican-dominated House aims to block another important subsidy: federal payments to insurance companies to keep deductibles, co-payments and other cost-sharing low for the poor. ... If the federal government cannot assist, a lot of other individual policyholders may have to pay more."

A closer look: Did the ACA result in more canceled plans? (Joanne Kenen, Covering Health, AHCJ, 4-29-14)
Warren: It's too soon to call Obamacare — or Obama — a failure (James Warren, Daily News, 12-1-13) There was a lot of melodrama over Saturday's 'sort-of deadline' for repairing HealthCare.gov. Though Obama's approval ratings are tanking and the Obamacare website had early missteps, the President and his health care plan shouldn't be written off so quickly.
Safety Leaders. Actor Dennis Quaid's family is joining forces with the Texas Medical Institute of Technology (TMIT) to raise public awareness about our broken medical system, to eliminate human error, and to make caregivers aware that patients have the right to know all information that could have an impact on their health and well-being, with major focus on increasing awareness of the dangers of medication errors. See also Preventable Medical Malpractice: Revisiting the Dennis Quaid Medication/​Hospital Error Case (Rick Schapiro, The Legal Examiner 8-9-10).
Bringing local, national perspectives to report on ACA in rural Kentucky (Joanne Kenen, Covering Health, AHCJ, 6-17-14)
The AP downplays its Obamacare scoop (Trudy Lieberman, Columbia Journalism Review 4-11-14). AP calls "minor' a change in legislation that shifts costs to consumers by raising deductibles.
Rooting for Failure (Timothy Egan, NY Times Opinion page, 11-28-13) It's hard to remember a time when a major political party and its media arm were so actively hoping for fellow Americans to lose. Tim Egan's unvarnished take on the shamelessness of the anti-Obamacare creed.
Challenges For The New Health Insurance Exchanges (transcript for Diane Rehm show, with guests Susan Dentzer of The Robert Wood Johnson Foundation, Louise Radnofsky of The Wall Street Journal, Jon Kingsdale of the Wakely Consulting Group, who led the agency that implemented the Massachusetts health insurance exchange, and David Simas, speaking from the White House, 10-16-13).
Special Investigation: How Insurers Are Hiding Obamacare Benefits from Customers (Dylan Scott, Talking Points Memo, 11-4-13). "By warning customers that their health insurance plans are being canceled as a result of Obamacare and urging them to secure new insurance plans before the Obamacare launched on Oct. 1, these insurers put their customers at risk of enrolling in plans that were not as good or as affordable as what they could buy on the marketplaces."
Middle class families wary of higher premiums Carla K. Johnson, AP story in Portland Press Herald, 9-13-13). "The new Affordable Care Act health exchanges won't offer any bargains for higher-income families, who fear that their current health insurance policies may get more expensive under the new law's requirements. As many as nine in 10 Texans buying health insurance on the new federally run exchange will get a break on costs, according to federal health officials. Steve and Maegan Wolf won't be among them."
Medical Device Industry Fears Health Care Law’s Tax on Sales (Barry Meier, Tracking the Affordable Care Act, NY Times, 10-1-13)
Questionable design blamed for healthcare website woes (Carla K. Johnson and Ricardo Alonso-Zaldivar, AP, 10-8-13)
A decision by the Obama administration to require that consumers create online accounts before they can browse health overhaul insurance plans appears to have led to many of the glitches that have frustrated customers, independent experts say.
How Obamacare’s medical device tax became a top repeal target (Sarah Kliff, Wonkblog, WashPost, 9-28-13). See also:
In Need of a New Hip, but Priced Out of the U.S. (Elisabeth Rosenthal, NY Times, 8-3-13) Paying Till It Hurts: A Trip Abroad. Part of an excellent series on what's wrong with American health care.
How can I get an estimate of costs and savings on Marketplace health insurance? (Healthcare.gov)
Kaiser Family Foundation information site on the Affordable Care Act (extremely helpful)
LocalHelp.HealthCare.gov (for state-specific information)
ACA-Mandated Insurance Quick Tips (Bob Rosenblatt, Aging Today)
2015 Marketplace health insurance plans and prices right now (HHS, Assistant Secretary of Planning and Evaluation)
New York State of Health: The Official Health Place
Covered California, the new marketplace for affordable private health insurance
Millions of Poor Are Left Uncovered by Health Law ( Sabrina Tavernise and Robert Gebeloff, NY Times, 10-2-13)
A Nevada Health Plan -- Without The Insurance (Pauline Bartolone, Kaiser Health News, Capital Public Radio, NPR, 9-14-13) An unusual Nevada nonprofit that helps connect 12,000 uninsured residents to doctors and hospitals who are willing to accept a lower-cost, negotiated fee for their services. Giving care to the uninsured before they require urgent care helps lower costs by keeping their members out of the ER.

Health Reform D-Day? Or not for a few more months? (Joanne Kenen, Covering Health, AHCJ, 10-1-13). See also Tracking exchange activity.
Shutdown Din Obscures Health Exchange Flaws (Robert Pear, NY Times, 10-4-13)

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Health insurance (general)

How health insurance works (TurboTax)
Health Insurance Explained (Kaiser Family Foundation, YouToons)
Health insurance explained (KFF). YouTunes video explains key terms: copay, coinsurance, deductible, out-of-pocket maximum, drug formulary, PPO, provider network.
Many Flexible Health Plans Come With A Costly Trap (Julie Appleby, Shots, NPR, 12-3-15) An increasing number of the preferred provider plans, or PPOs, offered under the federal health law have no ceiling at all for out-of-network costs. Consumers who choose them face unlimited financial exposure, similar to what more restrictive and often less expensive types of coverage, such as health maintenance organizations, impose on people who use services outside their networks. This year, 14 percent of existing silver-level PPO plans have no annual ceiling on out-of-network care.
How to Save Money on Your Federal Health Insurance (Walton Francis, FedSmith, For the Informed Fed, 11-23-15) Every year Washington Consumer’s CHECKBOOK publishes a detailed comparison of the Federal Employee Health Benefit Program (FEHB) plans for federal employees and annuitants. The Guide provides cost comparisons among health plans taking into account both premiums and likely out-of-pocket expenses. The results are worth studying.
PriceCheck: Across the nation, community-built health cost guides (Jeanne Pinder, Clear Health Costs, 12-23-16). See also Is it cheaper to pay cash than to use your insurance? Maybe.
For some Louisiana health insurers, explanations of benefits are anything but (Jed Lipinski, Nola.com/​Times Picayune, Cracking the Code, 5-3-17) "In their explanation of benefits statements, or EOBs, Blue Cross informs patients of the "service date," the "total amount charged," the "member discount amount," and what Blue Cross paid the provider, among other information. But perhaps the most important details - a specific description of what was done to the patient's body and the corresponding code - is nowhere to be found....The lack of clarity in EOBs from some of the state's largest insurers is especially troubling, experts say, because of the likelihood that the documents contain mistakes that could cost patients hundreds or even thousands of dollars."
Blue Cross launches SmartShopper to let customers shop online, compare prices for common medical procedures (Baton Rouge, Aug. 2017) SmartShopper lets the insurer’s customers see and compare cost ranges for procedures in more than 300 categories, powered by information from Blue Cross’ claims data.
Anthem Offers Money to Educated Consumers (Frank Diamond, Managed Care, Jan. 2013) The health plan’s New Hampshire subsidiary rolls out its Compass SmartShopper program to small employers. In Compass SmartShopper, patients can earn up to $500 just for doing a little shopping around before getting that MRI or infusion therapy.
Sales of Short-Term Health Policies Surge (Anna Wilde Mathews, WSJ, 4-10-16) A type of limited health coverage with features largely banned by the Affordable Care Act is flourishing, consumers saying it is cheaper than conventional plans, but such plans may not cover pre-existing conditions, a limitation no longer allowed in full health coverage. The short-term policies can offer far higher profit margins for insurers than ACA plans. Insurers typically pay little in claims on them. (Emphasis added.)
Banning Benefits for Bad Behavior: Unraveling the Illegal Act Exclusion (Crystal M. Patterson, American Bar Association, from May/​June 2009 issue of Probate & Property Magazine) PDF download. The Illegal Acts Exclusion allows insurers to deny coverage when an insured party commits an illegal act, such as crashing into a tree while driving drunk or getting hurt while attempting a robbery. There are some gray areas, where, for example, you are not charged for driving while intoxicated, but when you get to the hospital blood tests reveal a high blood alcohol level.
What will it take to make sense of medical bills? (Don Sapatkin, Philadelphia Inquirer, 11-15-15) Nearly a third of Americans with private insurance were surprised by a bill for which their insurer paid less than expected in the last two years, according to a Consumer Reports survey. "Out-of-network surprises are most common with anesthesiologists, radiologists, and pathologists. They often involve services that are critical to the outcome of a procedure - interpreting a scan, for instance - but may not take place in the operating room. The hospital might normally use a radiologist on staff; if that person is out, no one is going to ask the replacement if he or she is part of one patient's network.... Emergency departments, where physicians often are independent contractors, are among the most common source of surprise out-of-network bills, and patients brought in on stretchers obviously can't do much about it even if they knew. There is one level of protection for emergencies: Insurers must pay the in-network equivalent. But patients may still be on the hook for the difference between the in-network payment and the out-of-network charge." Paying $25 a month on medical debts will fend off collection agencies.
Even In High-Deductible Plans, Some Service May Be Covered Without Cost To You (Michelle Andrews, Kaiser Health News, 11-3-15) Under the health law, most plans have to cover preventive care that’s recommended by the U.S. Preventive Services Task Force without charging consumers anything out of pocket -- such as any cancer screenings that are advised for someone at a particular age. Services that plans may exempt from the deductible include generic and brand name drugs, primary care visits and specialist visits among other things. “Some plans exempt almost everything from the deductible except hospitalization,” Dave Chandra says. Consumers are finally learning that there’s often a trade-off between a low monthly premium and a high deductible.
As HMOs Dominate, Alternatives Become More Expensive (Julie Appleby and Jordan Rau, Kaiser Health News, 11-25-15) Preferred provider organizations, or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians. They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts. The price gap between PPOs and HMOs is growing in many places where both are offered. Examples Appleby and Rau provide help clarify differences.
Cancer Meds Often Bring Big Out-Of-Pocket Costs For Patients, Report Finds (KHN) Cancer patients shopping on federal and state insurance marketplaces often find it difficult to determine whether their drugs are covered and how much they will pay for them, the advocacy arm of the American Cancer Society says in a report that also calls on regulators to restrict how much insurers can charge patients for medications. Most insurance plans in the six states that were examined placed all or nearly all of the 22 medications studied into payment “tiers” that require the biggest out-of-pocket costs by patients. Those drugs include some well-known treatments, such as Gleevec for certain types of leukemia and Herceptin for breast cancer, and even some generics. Often, that tier means patients pay a percentage of the cost of the drugs, rather than a flat dollar amount, which is more common for drugs placed into lower cost-sharing categories. Read full article.
Why Consumers Often Err in Choosing Health Plans (Austin Frakt, The New Health Care, NY Times, 11-1-15) Evaluating health insurance plans can be daunting and confusing, and most people don’t get much guidance, research shows.

Health insurance exchange and marketplaces (and ACA)


HealthCare.gov December 15, 2015, is the deadline for coverage that starts on January 1, 2016. each plan you find on HealthCare.gov is required to include a set of preventive services at no additional cost to you. Everyone enrolled has access to services like cancer screenings, vaccines, tobacco cessation and well-child visits -- you don’t even have to meet your deductible or pay a co-pay to use these services. The downside: In moving from a segregated plan group (healthy, few health risks, well-educated, well-employed, hard to qualify to participate in the plan, etc.) to a plan that is part of the general population pool, as you are doing with the health exchanges, chances are your monthly premium rate may go up.
Health Insurance Literacy (Consumer Reports Health). Baffled by premiums, deductibles and out-of-pocket maximums? Watch Understanding Health Care Costs, in three parts.
Frequently Asked Questions about the Affordable Care Act (Kaiser Health News, or KHN)
Preventive Services Covered Under the Affordable Care Act (HHS) "f you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider."
Uninsured Quiz (KHN)
Finding a Health Insurance Plan That Travels With You (Stephanie Rosenbloom, The Getaway, NY Times, 9-28-15) "If your health insurance is not comprehensive, if you have a pre-existing condition, or if you are an adventure traveler, or if you will be going someplace where the hospitals are questionable, budget for health and medical evacuation insurance. Your body and your bank account are worth it." International Association for Medical Assistance to Travellers (Iamat) provides health advice about countries worldwide (necessary vaccinations, food and water conditions). Don’t rely on a tour or cruise company to present you with insurance options. Insure My Trip "sells coverage from multiple carriers, allowing users to comparison shop." "The State Department website, travel.state.gov/​content/​passports/​english/​go/​health/​insurance-providers.html (Insurance Providers for Overseas Coverage), is a fine place to begin shopping. Here you’ll find a list of some insurance and medical evacuation providers, including veterans such as Travel Guard and MedjetAssist. (Also available: insurance for trip cancellation.)
Most Health Savings Account Owners Stick With Conservative Options (Michelle Andrews, Shots, NPR, 9-3-15) Only a tiny fraction of the growing number of people with health savings accounts invests the money in their accounts in the financial markets, a recent study finds. The vast majority leave their contributions in savings accounts instead where the money may earn lower returns.


Makeover Coming for HealthCare.gov (Robert Pear, NY Times, 10-12-15) The Obama administration plans major changes to HealthCare.gov this year to make it easier for shoppers to find health insurance plans that include their doctors and to predict their health care costs for the coming year.
Many Say High Deductibles Make Their Health Law Insurance All but Useless (Robert Pear, NY Times, 11-14-15) "But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage." Republicans, who criticize the ACA, "once pushed high-deductible health plans in the belief that consumers would be more cost-conscious if they had more of a financial stake or skin in the game." "All plans must cover preventive services like mammograms and colonoscopies without a deductible or co-payment. Some plans may help pay for some items, like generic drugs or visits to a primary care doctor, before patients have met the deductible. Under the Affordable Care Act, health plans must have an overall limit on out-of-pocket costs, to protect people with serious illness against financial ruin.""In addition, people with particularly low incomes can obtain discounts known as cost-sharing reductions, which lower their deductibles and other out-of-pocket costs if they choose midlevel silver plans."
HHS basic information on the coming health insurance marketplaces.
Consumers who lack health coverage that meets Affordable Care Act standards can face penalties. Fees represent the larger of each pair of options:
2016: $695 per adult or 2.5% of household income
Additional fees can be assessed for children; households’ annual total fees are subject to certain caps.
Health Insurance Marketplace Calculator (Subsidy Calculator) (Kaiser Family Foundation) provides estimates of health insurance premiums and subsidies for people purchasing insurance on their own in health insurance exchanges (or “Marketplaces”) created by the Affordable Care Act (ACA). With this calculator, you can enter your income, age, and family size to estimate your eligibility for subsidies and how much you could spend on health insurance. You can also use this tool to estimate your eligibility for Medicaid. Here's an explanation of how it works (KFF)• Deciphering The Health Law’s Subsidies For Premiums (Julie Appleby, Kaiser Health News, 7-24-13)
SHIPtalk . The State Health Insurance Assistance Program, or SHIP, a national program that offers one-on-one counseling and assistance to people with Medicare and their families
Health insurance marketplaces are not for seniors (Susan Jaffe, Kaiser Health News, USA Today, 8-25-13). Medicare is taking steps to help seniors understand that their benefits won't be affected by the Affordable Care Act's Health Insurance Marketplace.
What's the real cost of health insurance on the Illinois exchange? (Kristen Schorsch and Andrew L. Wang, Crain's Chicago Business 12-9-13). "Policies with low premiums require consumers to pay higher out-of-pocket costs in the form of deductibles and co-payments. Depending on the size of annual medical bills, policies with higher monthly premiums may be better bargains." Do your homework! Read Joseph Burns on Using state exchange data, Chicago journalists estimate the true cost of health insurance (Association of Health Care Journalists)
Where insurance premiums are highest, new health law's subsidies are, too (Christopher Snowbeck and MaryJo Webster, Pioneer Press, 3-1-14). Click on U.S. map to see where premium costs, after tax credits are applied, vary even within the same state. See also Analysis looks at which consumers get better deal in the health insurance exchanges (MaryJo Webster and Christopher Snowbeck, Association for Health Care Journalists, 3-24-14). "Experts told us some of these disparities might be quirks resulting from this being the first year of enrollment under the ACA. Insurers might have set premiums higher or lower than usual because of uncertainty about who would purchase plans through the exchanges. As a result, it’s likely we’ll see an entirely different picture at the end of this year when rates are set for 2015 insurance policies."
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The politics and policy issues of health care (insurance) reform and the Affordable Care Act (ACA)


C-Span is a good place to find various town hall discussions, hearings, wonderful links. For example: Supreme Court Determining the Constitutionality of Health Care Act and Supreme Court Hears Argument on Individual Mandate Provision
Medicare Payment Plan on Cancer Drugs Sparks Furious Battle (Ricardo Alonso-Zaldivar, ABC News, 4-10-16) A Medicare proposal to test new ways of paying for chemotherapy and other drugs given in a doctor's office has sparked a furious battle, and cancer doctors are demanding that the Obama administration scrap the experiment. At issue are some of the most expensive drugs for treating life-changing diseases. The question isn't whether those drugs are fairly priced, but whether Medicare's current payment policy encourages doctors to prescribe the costliest medications so they can make more money. Injected and infused drugs for such conditions as macular degeneration, rheumatoid arthritis and Crohn's disease are also affected.
"The new formula announced last month combines a 2.5 percent add-on (as opposed to 6 percent) with a flat fee for each day the drug is administered. A control group of doctors and hospitals would continue to be paid under the current system. "A second wave of experimentation would try to link what Medicare pays for a given drug to how well it works." "Specialist doctors, drugmakers and some patient advocacy groups are trying to compel Medicare to drop the plan. Primary care doctors, consumer groups representing older people, and some economic experts want the experiment to move ahead."
UnitedHealth Warns Of Marketplace Exit – Start Of A Trend Or Push For White House Action? (Julie Appleby, Kaiser Health News, 11-20-15) UnitedHealthGroup laid out a litany of reasons Thursday why it might stop selling individual health insurance through federal and state markets in 2017 — a move some see as an effort to compel the Obama administration to ease regulations and make good on promised payments. “Disproportionately, the sick are signing up and the healthy are dropping out,” said former insurance executive and consultant Robert Laszewski, adding that alternative plans with fewer benefits but lower costs should be made available.
Core topic: Insurance (invaluable resource page, Association of Health Care Journalists). See, for example, Glossary; key concepts; resource links; multimedia archive.
Safety net programs for the poor.
Repairing Medicare (Wash Post, 1-6-13) "There are two major reasons for Medicare’s rising costs. The first is the program’s design, often tweaked but left fundamentally intact since its creation in 1965, which basically pays doctors and hospitals fixed fees for whatever they do. The ultimate solution is structural: to limit growth in expenditures per beneficiary. Easier said than done. he current Medicare program includes a hodgepodge of cost-sharing requirements that neither give participants clear incentives to limit consumption of services nor shield them from catastrophic expenses. "
Medicine’s Top Earners Are Not the M.D.s (Elisabeth Rosenthal, Sunday Review, NY Times 5-12-14) The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries. (There are more doctors than administrators, so she's talking about individual, not total, salaries for a group.)
Remembering What Matters About the Affordable Care Act (Paul Waldman, American Prospect, 1-30-14) On the Affordable Care Act front today, there's very good practical news, and not-so-good political news. That gives us an excellent opportunity to remind ourselves to keep in mind what's really important when we talk about health care.
GOP Views of Medicaid Expansion Differ From Conventional Wisdom (Drew Altman, WSJ blog, 11-4-15) Many Republicans in states that have not expanded Medicaid are favorable toward expansion. "That even a slim majority of Republicans favor expansion is notable given the tone of debate on this issue on the campaign trail, where expansion has become like a third rail for GOP candidates. ...But Medicaid may not be as unpopular with Republicans overall as the conventional wisdom suggests, and other issues may be more salient for Republican voters in primary and general elections across the country than opposition to Medicaid expansion."
Bernie Sanders, Hillary Clinton, and Medicare for All (Drew Altman, WSJ blog, 12-20-15) A skirmish broke out recently between Hillary Clinton and Bernie Sanders about the merits of single-payer health care, an idea that Mr. Sanders has long advocated. Most Democrats either strongly favor (52%) or somewhat favor (24%) the general idea of Medicare for all. Meanwhile, 62% of Republicans either strongly or somewhat oppose the idea. In his advocacy of Medicare for all, a policy that he recognizes cannot be achieved any time soon, Mr. Sanders is signaling his outside-the-box approach to policy and politics, while in opposing the idea Mrs. Clinton may have been signaling her more practical and incremental approach to achieving policy change.
Health Insurance Is Not a Favor Your Boss Does For You (Paul Waldman, American Prospect, 7-9-14) Everyone seems to have forgotten that insurance is a form of compensation, no less than your salary. Click here for more Waldman stories on health care and insurance.
The Tennessean pushes for better healthcare (Trudy Lieberman, Columbia Journalism Review, 12-1-14) on how one reporter's (Tom Wilemon's) stories show readers the effect of state government policy on real people. For example, Twin babies' $200K hospital bill illustrates TennCare flaws (10-4-14), Thousands caught in TennCare limbo await hearings (11-14-14), TennCare patients on ventilators face cuts in home care (11-9-14), and TennCare point system leaves some seniors fending for themselves (video and print story on TennCare's scoring system, under which those who have difficulty walking and eating still may not qualify for nursing home care) 2-16-14).
Behind the Scenes on Those Enormous Medicare Billing Numbers (Kevin Jones, Mother Jones, 4-10-14)
A British Woman Spent Three Days in a U.S. Hospital. Here's What She Learned About Obamacare. (Eleanor Margolis, New Republic, 10-18-13. First appeared in New Statesman) "I begin to wonder how the Republicans have managed to convince even those in the very midst of a system that punishes the poor, that the slightest implementation of state-funded healthcare is an evil, communist conspiracy. ...As a foreigner with travel insurance, I’m lucky enough to observe American healthcare from a safe distance. But to someone fully enmeshed, like Carmen, Obamacare is a tiny drop in the murkiest of quagmires."
What's in a name? Lots when it comes to Obamacare/​ACA (Steve Leisman, CNBC, 9-26-13) In CNBC's third-quarter All-America Economic Survey, we asked half of the 812 poll respondents if they support Obamacare and the other half if they support the Affordable Care Act. And 30% of those polled don't know what ACA is, vs. only 12% when asked about Obamacare; 29% support Obamacare compared with 22% who support ACA; and 46% oppose Obamacare and 37% oppose ACA. "So putting Obama in the name raises the positives and the negatives." Republicans coined the term Obamacare as a pejorative, but not everyone perceives it that way.
Understanding the Right’s Obamacare Obsession (Joshua Holland, What Matters Today, Moyers.com, 9-2-13) Excellent overview.
Why Republicans can't come up with an Obamacare replacement (Ezra Klein, Vox, 1-16-15) Making "sure poor people have health insurance is politically popular, at least in the abstract. But the plans that achieve it tend to be in tension with both broad tenets of conservatism — it raises taxes, it redistributes wealth, and it grows the government — and with key factions of the conservative coalition....It is ironic that the law Republicans loathe most is actually based on ideas they developed, and that their most recent presidential nominee actually implemented."
Supreme Court Case May Be A Wake-Up Call For Republicans (Julie Rovner, KHN, 2-23-15) About Obamacare: "“Republicans are united around repeal. And they’re united around replace. But obviously they’re not united around ‘replace with what...’”
Obamacare: The Rest of the Story (Bill Keller, Opinion Page, NY Times, 10-13-13) "You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable. What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system. " An interesting account of "accountable care organizations" (ACOs), which are springing up all around the country.
Americans' Top Health-Care Priorities for the President and Congress (Drew Altman, WSJ, 5-4-15) Surprising results of the Kaiser Family Foundation’s April 2015 Health Tracking Poll. #1 priority: Making sure that high-cost drugs for chronic conditions are available at affordable costs.
Medicaid Expansion in Red States (Drew Altman, WSJ's Think Tank, 12-18-14) "In the struggle between pragmatism and ideology over Medicaid expansion in red states, pragmatism may slowly be winning."
Majority Favors the Affordable Care Act’s Employer Mandate, But Opinion Can Shift When Presented With Pros and Cons (Kaiser Family Foundation, 12-18-14) Recent news stories on the health law did not attract most Americans’ attention, and many are unaware of details and implications of the developments.
Three Words and the Future of the Affordable Care Act (PDF, Nicholas Bagley, draft accepted for publication in Journal of Health Politics, Policy and Law, 2014, open access)
The Piecemeal Assault on Health Care(NY Times editorial, 11-22-14) "Now that they will dominate both houses of Congress, Republicans are planning to dismantle the Affordable Care Act piece by piece instead of trying to repeal it entirely....All of the provisions they are targeting should be retained — they were put in the reform law for good reasons."
Hospitals and health law (Opinion, NY Times, 12-7-14) "The American people aren’t the only ones who will suffer from the systematic dismantling of the Affordable Care Act. It’s also bad news for America’s hospitals."
The Affordable Care Act Will Work (Sen. Jay Rockefeller, Reader Supported News, 10-3-13)
Where Poor and Uninsured Americans Live (interactive map, NY Times, 10-2-13). The 26 Republican-dominated states not participating in an expansion of Medicaid are home to a disproportionate share of the nation’s poorest uninsured residents. Eight million will be stranded without insurance.
Church Insurance Improvements To Obamacare Threatened By Partisan Fighting (Sarah Pulliam Bailey, Religion News Service, 8-9-13)
Little Evidence Obamacare Is Costing Full-Time Jobs (Kaiser Health News' Daily Report, 10-23-13) Roundup of stories from WSJ, NYTimes, Reuters, Wash Post, Politico and others.
States Are Focus of Effort to Foil Health Care Law (Sheryl Gay Stolberg, NY Times, Politics, 10-18-13) In Virginia, conservative activists are pursuing a hardball campaign as they chart an alternative path to undoing “Obamacare” — through the states.
The Republican party's 'defund Obamacare' disorder (Michael Cohen, The Guardian, 8-25-13) In denial of political reality thanks to its Tea Party fringe, the GOP is revving up for a debt ceiling showdown it can only lose.
How the ObamaCare defunding fight became a political showdown (Sam Baker, HealthWatch, 8-29-13)
as part of a whole section on
Health Care Reform, Medical Error, and the Affordable Care Act, including one section on What you need to know about long-term care insurance.
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Faith-based alternatives to health insurance plans

A Christian Alternative to Health Insurance (Kimberly Leonard, The Atlantic, 7-20-12) Exempt from regulation, taxation, and the individual mandate, Christian collectives called health care sharing ministries are paying for the care of their neediest members -- if they approve of the morality of their needs. As nonprofits, health care sharing ministries aren't required to follow the same state and federal regulations as health insurance companies. The Affordable Care Act has a section that exempts members of health care sharing ministries from purchasing insurance. The Amish, Mennonite, and Indian tribe communities also are exempt from the penalty that will be incurred on Americans who fail to purchase health insurance by 2014. Since the law was passed in 2010, membership for Medi-Share and Samaritan Ministries has risen by about 40 percent.
Faith and Its Limits (Ann Neumann, Virginia Quarterly Review, 11-28-16) An essay about the Clinic for Special Children in Lancaster, Pennsylvania, which serves the Amish and Mennonite communities. They largely abstain from insurance for theological reasons. "Donated machines keep the costs low; donations, auctions, fund-raisers, discounted fees for visits. The clinic is sustained by patients’ families. It looks and feels holistic—pure, advanced, sustainable."
For some Christians, sharing medical bills is a godly alternative (Bob Smietana, Religion News Service, WaPo, 1-23-14) "Every month Eddinger deposits about $400 — known as a share — into an account set up through Medi-Share, a Florida-based nonprofit that has about 70,000 members nationwide. If Eddinger’s family has medical bills — like those for the birth of his youngest son last year — other members deposit their monthly share into Eddinger’s account. Otherwise Eddinger’s $400 goes to another family that has medical bills....Health-sharing ministry members sign a statement of beliefs, along with a code of conduct that bans smoking, extramarital sex and excessive drinking. They also pray for other families in the group, along with sending money. Health-sharing plans don’t cover abortion or contraception."
Opponents of health-care law turn to faith-based nonprofits to cover medical expenses (Sandhya Somashekhar, WaPo, 6-5-14) "Susan Tucker is one of millions of Americans who dislike the health law and want nothing to do with it. Tucker dropped the private health plan she had carried for more than a decade and joined Christian Healthcare Ministries, a faith-based nonprofit in which members pool their money to pay for one another’s medical needs — and promise to adhere to biblical values, such as attending church and abstaining from sex outside marriage. “When all this came up with the ACA, I just realized I don’t want to be a part of any of this,” said Tucker, who views the Affordable Care Act as the government meddling in her personal health care. The Christian Healthcare program is not as comprehensive as insurance — she has to pay for her preventive care, for example — but the monthly payment of $150 can’t be beat, she said....Tucker is part of a small but growing group of Americans whose opposition to the Affordable Care Act is spurring them to seek out alternatives, choosing once-fringe methods to pay for their medical care in an effort to skirt the many requirements the law imposes on the private health insurance market."
Onward, Christian Health Care? (Molly Worthen, New York Times, 1-31-15) When Theresa Bixby, 63, learned that she had breast cancer four years ago, she reacted as many Americans do. “One of my first thoughts was, ‘will they pay?’ ” she said. She lost her conventional health care coverage when she left her full-time position for part-time work at her church in Greenville, S.C. She was worried about the program that she had joined six months earlier: Christian Healthcare Ministries. Christian Healthcare Ministries is not an insurance company. It is a nonprofit “health care sharing ministry” based in Barberton, Ohio. The cost of membership is far lower than the rates of traditional insurance policies — $45 a month for the cheapest plan — but the ministry makes no guarantees of payment. Members send their monthly “gift” to an escrow account, which disburses payments for eligible medical bills, excluding costs like routine physicals, continuing treatment for pre-existing conditions or procedures that members have voted to exclude, like care for pregnancies outside wedlock. Christian Healthcare Ministries assigned her case to a “member advocate,” who negotiated discounts on her fees. These counted toward Ms. Bixby’s $5,000 deductible, so she paid out of pocket only for office visits. In the end, the ministry persuaded the hospital to lop $220,900 off a bill of $301,540 and reimbursed or paid directly the remaining $80,640.
Maryland Muslim doctor offers free clinics (Vickie Connor | AP, WaPo, 12-8-16) The 64-year-old Muslim Dr. Ashraf Meelu and a few volunteers spend Friday mornings providing flu shots, measuring blood pressure and offering other health treatments at a Guatemalan consulate in Silver Spring, Maryland. Patients file in, one after another, for the Pakistan native’s treatments.
How People Are Using Religion to Circumvent Obamacare (Claire Zillman, Fortune, 1-4-16) The Affordable Care Act has had one largely unanticipated consequence: it’s driven the growth of faith-based health insurance ministries. The ministries, which provide cost-sharing services to consumers with similar religious beliefs, have boomed in large part because of an exemption to the ACA that allows participants in the ministries to avoid being fined for not purchasing health insurance elsewhere. Membership in the ministries—many of which are run by Amish or Mennonite communities or individual churches—has reached an estimated 500,000, up from 200,000 prior to the passing of the ACA, according to The Wall Street Journal."
More People Turn to Faith-Based Groups for Health Coverage ( Stephanie Armour, Wall Street Journal, 1-4-16) Some insurance commissioners say health-care ministries could put consumers at risk. (Available to subscribers only.)
‘Christians are just healthier': One family’s cost-sharing alternative to Obamacare (Danielle Paquette, Washington Post, 8-29-14) Health-care sharing gives some Americans a faith-based support system -- as long they pledge to refrain from sin. Samaritan bills itself as non-insurance — and has therefore avoided regulation. It works like this: When illness strikes, Samaritan members can file a request for aid. To Duff, it’s a way to preserve some personal liberties while giving up the ones he won’t miss.
The Lowdown on Medical Sharing Plans (Tamara E. Holmes, Black Enterprise: Wealth for Life, 8-30-12) There are reasons consumers should think twice about signing up for such plans. For example, you won’t have consumer protections offered by your state insurance department, which regulates insurance companies that operate in your state. You risk hurting your credit if the medical sharing plan refuses to pay or pays slowly.
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