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Medicare, Medicaid, and health insurance

 

Medicare: What you need to know
Medicare (and others') coverage of hospitalization
Medicare coverage of prescription drugs (Part D)
Medicare's power to control drug prices (new)
Original Medicare vs. Medicare Advantage
Medigap vs Medicare Advantage
Medicare Compare search pages and other rating sites
Medicare issues and Medicare reform
MACRA (Medicare Access & CHIP Reauthorization Act)

Frequently asked questions about Medicare and Medicaid


Medicare and Medicaid: History and legislation
How Medicare and Medicaid fall short
Helpful blogs, organizations, and citizen lobbies about Medicare, Social Security, pension rights

Medicaid: What you need to know

     (including 'Medicaid's Unwinding')
Medicaid issues and Medicaid reform
Spotting and fighting Medicare and Medicaid fraud

 

Health insurance basics
Health insurance exchanges
Dealing with health insurance denial
Politics, policy issues, and problems with health care insurance and reform
Faith-based health ministries as alternatives to health insurance
Health insurance, ACA, and the marriage glitch
Trump and health care  
The Affordable Care Act (ACA, also called Obamacare, originally by its opponents)
Frequently asked questions about health insurance and the ACA (Obamacare)

 

SEE ALSO


The benefits pharmacy benefit managers manage do not usually benefit consumers
Reforming the U.S. health care system
Why U.S. medical costs are so high and where the system needs fixing

Single payer and other models for health care financing
Pros and cons of a single payer system

Gradual and modified approaches to single payer system
Retainer or concierge medicine and other new models for paying doctors
Dealing with physician (and other healthcare professional) shortages

Repeal, Reform, or Replace ("inside the sausage factory" and Republican efforts to get rid of 'Obamacare')


Health insurance (general)


U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Issue Brief, Commonwealth Fund, 1-21-23)
---Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage.
---The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest
---The U.S. has the highest rate of people with multiple chronic conditions and an obesity rate nearly twice the OECD average.
---Americans see physicians less often than people in most other countries and have among the lowest rate of practicing physicians and hospital beds per 1,000 population.
---Screening rates for breast and colorectal cancer and vaccination for flu in the U.S. are among the highest, but COVID-19 vaccination trails many nations.


KFF Survey of Consumer Experiences with Health Insurance (Karen Pollitz, Kaye Pestaina, Alex Montero, Lunna Lopes, Isabelle Valdes, Ashley Kirzinger, and Mollyann Brodie, KFF, 6-15-23) "Monitoring how coverage works for people who are sick is particularly important in gauging how well our health insurance system works when people need it the most. The KFF Survey of Consumer Experiences with Health Insurance finds that most consumers experience problems when they try to use their coveragerelated to denied or mishandled claims, provider network issues, pre-authorization requirements and others. Among high utilizers of health care, and people who use mental health care, about three in four people experience problems with their insurance.
      "The types of problems people experience vary depending on the type of coverage they have. For example, people in Marketplace and Medicaid are more likely to experience provider network problems compared to people with traditional Medicare. People with Marketplace and ESI coverage more often experience claims denials than people with public coverage, though Medicaid enrollees report problems with pre-authorization denials more often than consumers with any other type of coverage. In addition, affordability of health insurance premiums and out-of-pocket costs is a particular concern for people with private (ESI and Marketplace) coverage.
       "Challenges using health insurance are particularly acute for those who describe their mental health as “fair” or “poor,” with 45% rating their coverage negatively for the availability of mental health providers. Also, a sizable share (37%) of this population, who said that they did not get needed mental health care in the last year, say it was because their insurance did not cover the care. At a time when most US adults say mental health is a crisis in the U.S., such insurance barriers to mental health care are cause for concern.
      "People who encounter problems using their insurance often can’t fix them. About half of consumers with problems said they were able to resolve the problem to their satisfaction. One in six consumers who experienced health insurance problems in the past year said they were not able to access recommended care as a direct result; one in six also said their health status declined as a direct result; and about one in four said they ended up paying more out of pocket for care. Most consumers (60%) don’t understand they have legal rights when problems arise, and most (76%) do not know what government agency to call if they need help."


How Your In-Network Health Coverage Can Vanish Before You Know It (Elisabeth Rosenthal, KFF Health News and Washington Post, 3-15-24) "One of the most unfair aspects of medical insurance, in a system that often seems designed for frustration, is this: Patients can change insurance only during end-of-year enrollment periods or at the time of “qualifying life events,” such as a divorce or job change. But insurers’ contracts with doctors, hospitals and pharmaceutical companies (or their arbiters, so-called pharmacy benefit managers) can change abruptly at any time.
     "That is particularly galling for patients because, whether obtaining insurance through an employer or buying it on the marketplace, they generally choose a policy based on whether it covers their desired doctors and hospital or an expensive drug they need. Turns out that particular coverage could evaporate at any time during the policy term."
      "State and federal regulators have the authority to regulate insurers’ networks and could end the practice, Hoffman said. But until now “there hasn’t been federal regulation about continuity of coverage,” particularly how to define it. She suspects that the apparent surge in contract disputes between insurers and providers stems from hospital price transparency regulations that took effect in 2021 and have allowed hospitals to compare reimbursement rates with one another."

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Another Year of Record ACA Marketplace Signups, Driven in Part by Medicaid Unwinding and Enhanced Subsidies (Jared Ortaliza, Cynthia Cox, and Krutika Amin, KFF Health News, 1-11-24) The number of people with Marketplace coverage has grown significantly each year under the Biden Administration, with enhanced subsidies in the American Rescue Plan Act and the Inflation Reduction Act making coverage more affordable for enrollees, and increased marketing, outreach, and enrollment assistance also playing a role.


*** Know your (new) rights under the No Surprises Act (Dan Weissmann, First Aid Kit, 1-19-22)

The No Surprises Act addresses a widespread scam called “surprise bills.” 

1. The No Surprises Act pretty much only applies to hospitals. Anywhere else you go, you’re out of luck.

2. Beware the “Surprise Billing Protection Form.” If you sign it, you’re actually consenting to be treated by out-of-network providers and to pay their rates. Which could be sky-high. 

3. What to do if you're being screwed with. (In ER and forced to sign a form.)

4. Put this number in your phone: 1-800-985-3059. It’s the federal hotline for reporting violations of the No Surprises Act.

5. Don’t just ask “Do you take my insurance?”  Ask “Are you in my insurance plan’s network?” 

6. Oh, also: Ambulances. They're not covered.

7. Finally: Watch the mail. Watch for a bunch of statements from your insurance company called an Explanation of Benefits, or EOB for short. Anything on a bill is supposed to also show up on those EOBs — which are supposed to “explain” what your insurance is paying and what you’re on the hook for. Your goal is to verify nobody’s charging you more than your insurance thinks you’re responsible for.  
Health Insurance Coverage in the United States: 2020 (U.S.Census Bureau)

    "In 2020, 8.6 percent of people, or 28.0 million, did not have health insurance at any point during the year.
    "The percentage of people with health insurance coverage for all or part of 2020 was 91.4.
    "In 2020, private health insurance coverage continued to be more prevalent than public coverage at 66.5 percent and 34.8 percent, respectively. Of the subtypes of health insurance coverage, employment-based insurance was the most common, covering 54.4 percent of the population for some or all of the calendar year, followed by Medicare (18.4 percent), Medicaid (17.8 percent), direct-purchase coverage (10.5 percent), TRICARE (2.8 percent), and Department of Veterans Affairs (VA) or Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) coverage (0.9 percent)."

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Mary Lou Retton’s Explanation of Health Insurance Takes Some Somersaults (Julie Appleby, KFF Health News, 1-12-24) The gold-medal gymnast’s explanation of why she remained uninsured has health policy experts doing mental gymnastics — because it makes little sense. Under the Affordable Care Act, which has offered coverage through state and federal marketplaces since 2014, insurers are barred from rejecting people with preexisting conditions and cannot charge higher premiums for them, either.

      The ACA also includes subsidies that offset all or part of the premium costs for the majority of low- to moderate-income people who seek to buy their own insurance. An estimated “four out of five people can find a plan for $10 or less a month after subsidies on HealthCare.gov.”

      "Those subsidies are one of the reasons cited for record enrollment in 2024 plans, with more than 20 million people signing up so far. To be sure, there are also many Americans whose share of the premium cost is still a stretch, especially those who might be higher on the sliding subsidy scale.

      "The ACA does offer subsidies to offset deductible costs for people on the lower end of the income scale. For those with very low incomes, the law expanded eligibility for Medicaid, which is a state-federal program. However, 10 states, including Texas, where Retton lives, have chosen not to expand coverage, meaning some people in this category cannot get either Medicaid or ACA subsidies."
Uncovered: How the Insurance Industry Denies Coverage to Patients (ProPublica series, 2023)  Click here for links to the whole series.
---Find out why your health insurer denied your claim. ProPublica’s Claim File Helper lets you customize a letter requesting the notes and documents your insurer used when deciding to deny you coverage.
---Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment After Robert “Skeeter” Salim was diagnosed with stage four throat cancer, his health insurance, Blue Cross and Blue Shield of Louisiana, refused to pay for proton therapy, recommended by Salim’s doctor. Salim, named one of the country’s top litigators, fought back.
---How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them (Patrick Rucker, The Capitol Forum, and Maya Miller and David Armstrong, ProPublica,3-25-23) Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said. Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said. Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection.
---Health Insurers Have Been Breaking State Laws for Years States have passed hundreds of laws to protect people from wrongful insurance denials. Yet from emergency services to fertility preservation, insurers still say no.
---I Set Out to Create a Simple Map for How to Appeal Your Insurance Denial. Instead, I Found a Mind-Boggling Labyrinth. (Cheryl Clark for ProPublica, 8-31-23) I spoke with more than 50 insurance experts, patients, lawyers, physicians and consumer advocates about building a tool anyone could use to navigate insurance appeals. Nearly everyone said the same thing: Great idea. But almost impossible to do. Co-published with The Capitol Forum 
---Health Insurance Claim Denied? See What Insurers Said Behind the Scenes Learn how to request your health insurance claim file, which can include details about what your insurer is saying about you and your case.
---How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said.
---UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings. After a college student finally found a treatment for ulcerative colitis that worked, the insurance giant decided it wouldn’t pay for the costly drugs. His fight to get coverage exposed the insurer’s hidden procedures for rejecting claims.
---How Often Do Health Insurers Say No to Patients? No One Knows. Insurers’ denial rates — a critical measure of how reliably they pay for customers’ care — remain mostly secret to the public. Federal and state regulators have done little to change that.

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Family Health Insurance Is No Longer Affordable Through Small Employers (Drew Altman, KFF Health, 11-28-23) Workers employed by small firms—those with fewer than two hundred employees—would need to pay $8,334 on average towards the premiums each year for family coverage. Employers pay the difference on premiums that average $23,621 for family coverage. But enrolling a family at these firms can often be much more– a quarter of covered workers at small firms must pay $12,000 annually or more to enroll in family coverage. Covered workers at small firms on average must pay a larger share of family premiums than those at larger firms.
---2023 Employer Health Benefits Survey (KFF) Annual premiums for employer-sponsored family health coverage reached $23,968 this year, with workers on average paying $6,575 toward the cost of their coverage. The average deductible among covered workers in a plan with a general annual deductible is $1,735 for single coverage. Workers at smaller firms on average contribute $2,445 more toward the cost of family coverage than workers at smaller firms. This year’s report also looks at employers’ experiences and views about abortion coverage, mental health and substance use services, and wellness programs.

       For more details, do read the article.

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FAQs: Health Insurance Marketplace and the ACA (Kaiser Family Foundation) Browse FAQs by Topic
If You’ve Lost Your Health Plan in the COVID Crisis, You’ve Got Options (Julie Appleby, KHN, 6-12-2020) But some of those options, like special enrollment periods, are time-sensitive.
What Are My Options Outside of OEP and AEP? (Caroline Darr, broker LIG Solutions, 1-10-22) The Open Enrollment Period (OEP, for those under 65 years old) and the Annual Enrollment Period (AEP, for Medicare beneficiaries) are not the only times in the year where you can sign up for health coverage. There are, for OEP, for example, Special Enrollment Periods (SEP) for various occasions (change in household or residence or eligibility, loss of coverage, supplemental insurance (dental etc.). A good list of options available for various circumstances.
HealthCare.gov 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.
Finding Health Insurance (USA.gov)
Health Sherpa Find your most affordable health plan. Compare quotes from multiple insurance companies. Enroll in under 10 minutes.

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They Thought They Were Buying Obamacare Plans. What They Got Wasn’t Insurance. (Bram Sable-Smith, KHN, 6-7-22) Some consumers who think they are signing up for Obamacare insurance find out later they actually purchased a membership to a health care sharing ministry. But regulators and online advertising sites don’t do much about it. See Healthcare Navigator (Healthcare.gov) To find a health insurance plan, visit the federal marketplace, healthcare.gov, or call 800-318-2596. See Find Local Help (healthcare.gov).
Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win by investigative journalist Marshall Allen. Everything you need to know to deal with health insurance companies and health care providers, explaining what to do when faced with an invoice for out-of-pocket expenses. Says one reader "It is not only about purposeful fraud, it is also about purposeful incompetence on the part of those in healthcare facilities for creating and submitting the claims."

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An Arm and a Leg podcast: We Spend 12 Million Hours a Week on the Phone With Insurers (Dan Weissmann, KHN, 10-18-21) After Stanford professor Jeffrey Pfeffer got back surgery years ago, he kept a file folder labeled “Blue Shield Troubles.” Then he teamed up with Gallup on a study of time spent talking to health insurers and learned: "If you get your insurance through work, your employer probably “self-insures.” (That’s true for about two-thirds of all workers, and more than 90% of people who work for companies with more than 1,000 employees.) But it isn’t obvious if your job self-insures. You’ll have an insurance card that says Cigna or United or Aetna etc. But you’re operating in a different universe."

       Laurie Todd, author of Fight Your Health Insurer and Win, says "no appeal was ever meant to lead to an approval. Your employer is paying Blue Cross or Aetna or whoever a fee to act as what's called a Third Party Administrator. They actually process the claims. You are paying that organization 20% to move money from one pocket to another. Self-funded plans are governed by federal law, so your state insurance commission can’t step in and help. Pfeffer, Karen Pollitz, and Leslie Walker report that when companies are playing their role in “self-insured” setups, they can get up to some shady practices. And the employers they’re working for — even big, powerful outfits — often don’t exercise a lot of oversight or even have a lot of leverage. Read the details in this transcript of the Arm and a Leg podcast. "When you're in a "self-funded plan," you're actually in a whole different legal situation from if you've got INSURANCE-insurance." Your state insurance commission can't help you at all if it's federal health insurance." Part 2 to follow in a week.
He Bought Health Insurance for Emergencies. Then He Fell Into a $33,601 Trap. (Jenny Deam, ProPublica, 5-8-21) Since the Trump administration deregulated the health insurance industry, there’s been an explosion of short-term plans that leave patients with surprise bills and providers with huge revenue. And check out How they did it: Reporting on junk health insurance plans (Joseph Burns, Covering Health, 6-15-21) An excellent example for any journalist looking to cover the complex world of health insurance plans that do not comply with the requirements of the Affordable Care Act (ACA), otherwise known as Obamacare.
Understanding Health Insurance (Medical Billing and Coding)
Understanding Health Insurance for College Students (USA.gov)

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Short-term, limited-duration health plans assailed in Congressional Democrats’ report (Joseph Burns, Covering Health, AHCJ, 7-21-2020) "Short-term, limited-duration insurance plans threaten the health and financial well-being of American families, according to a recent staff report from Congressional Democrats on the Committee on Energy and Commerce (E&C). The report is a result of an investigation that staff conducted into nine health insurers, including UnitedHealth Group and Anthem, and five insurance company brokers that sell these plans for insurers. “These plans are simply a bad deal for consumers, and oftentimes leave patients who purchase them saddled with thousands of dollars in medical debt,” according to Shortchanged: How the Trump Administration’s Expansion of Junk Short-Term Health Insurance Plans is Putting Americans at Risk. The committee’s investigation into how these plans operate outlines what the report calls “the deeply concerning industry practices” of STLDI plans and the insurance brokers who sell them.
"Short-term limited duration insurance plans spend less than half of consumers’ premiums on medical care, while insurance plans that comply with the rules of the Affordable Care Act spend 80 percent to 85 percent of premium income on medical care, according to a recent congressional staff report."
What Options Exist If You’ve Lost Job-based Health Insurance? (2-minute video, KFF, 6-17-2020) As unemployment skyrockets due to the COVID-19 pandemic, tens of millions of people are at risk of losing their job-based health insurance. However, the majority of people are eligible for other forms of health insurance coverage. Watch this 2-minute video to learn about the options: Medicaid, job-based coverage from a spouse or parent, ACA marketplace coverage, COBRA and short-term insurance plans.
Navigating Healthcare for the Uninsured (Medical Billing and Coding)
State Health Facts (Kaiser Family Foundation) State facts in terms of Demographics and the Economy, Disparities, Health Costs & Budgets, Health Coverage & Uninsured, Health Insurance & Managed Care, Health Reform, Health Status, HIV/AIDS, Medicaid & CHIP, Medicare, Providers & Service Use, Women's Health.
Women’s Health Insurance Coverage (Kaiser Family Foundation)
How health insurance works (TurboTax)
Health Insurance Explained (Kaiser Family Foundation, YouToons)

 

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An Arm and a Leg (Episodes list and links) A podcast about the cost of health care that’s more entertaining, empowering, and occasionally useful than enraging, and terrifying and depressing.
I’m a health-care reporter. Here’s how I shop for health insurance. (Sarah Kliff, Vox, 10-15-15) "You buy insurance so you're covered in the case of rare but financially catastrophic events.... There's typically a direct relationship between how much you pay upfront for a plan and how much it will cover....It's impossible to predict your medical costs...understanding the concept of co-insurance is especially crucial to understanding the type of coverage you're buying."
The Guide to Keeping Your Home Through Debilitating Disease (Mortgage Calculator)
It’s Not Just You: Picking Health Insurance Is Hard. (Dan Weissmann, KHN, 12-9-19) Choosing the best plan is tricky whether you have to buy insurance on your own or just figure out which plan to sign up for at work. Here’s what you need to know. en years ago on Christmas Eve, the Senate passed its version of Obamacare. The 2010s began with the United States taking its most significant steps toward universal health coverage in a generation.
How the 2010s changed health care (Dylan Scott, Vox, 12-23-19) The decade brought America closer to universal coverage. But there’s still a long way to go. As the Affordable Care Act’s approval with the public slowly started to improve, public opinion on something else was changing in parallel: Americans had broadly come to believe (after a significant dip when the law first passed) the government had a responsibility to make sure everybody had health coverage. That belief is reflected most directly in the strong support for the ACA’s ban on insurers denying coverage based on preexisting conditions, which nearly 75 percent of people now say should be maintained.
Obamacare has been hobbled along the way. Medicaid expansion was undercut by the Supreme Court by making it optional for states, a decision that has left more than 2 million people in poverty without coverage. The law’s financing for health insurers has been blocked by congressional Republicans and Trump. The administration has sought to implement Medicaid work requirements to trim the number of people covered by Medicaid expansion and taken numerous other steps to undermine the ACA’s private insurance markets. And today, right now, the Trump administration and Republican-led states are still trying to get Obamacare overturned by the courts. The fight isn’t over.
When you get as sick as I did, you realize how critical health coverage is for everyone (Trudy Lieberman, Remaking Health Care, Center for Health Journalism, 3-24-18) Four months in the hospital with $3.6 million in bills reminds a journalist why everyone needs health coverage. "Is it okay for the government to subsidize employers for providing health insurance, but it’s not okay for state governments to subsidize health care through Medicaid programs so poor women can get coverage?...Requiring that people work in order to qualify for medical care, a basic right in other developed countries, is cruel, especially when we don’t require millions of spouses of workers covered by employer-provided insurance to work. Perhaps the worker in the household is enough to make the connection to the workplace. But that gets into the thorny territory of work-based health coverage, the bedrock of the U.S. system."

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Why you (and I) will likely pick the wrong health-insurance plan (Arm and a Leg, Season One, episode 4, 11-20-18) A useful primer and the source of several more links below.
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.
Why Your Health Insurer May Owe You Money (Donna Rosato, Consumer Reports, 9-17-19) When insurers set premiums too high they're supposed to send you a rebate, but millions go unclaimed every year. Check it out.
How can Checkbook's Guide to Health Plans for Federal Employees help me? (Consumers' Checkbook) A really good Q&A section about FEHB plans.
Find the best FEHB plan for you and your family at the right price. (Consumers Checkbook) 2020 health plan data will be released on the first day of Open Season, November 11th.
FEHB Program Handbook (contents listed along right side link you to specific topics)
Insurance FAQs (OPM, 2019)
How to Save Money on Your Federal Health Insurance Washington Consumer’s CHECKBOOK's annual detailed comparison of the Federal Employee Health Benefit Program (FEHB) plans for federal employees and annuitants--buy online access or the print book. The Guide provides cost comparisons among health plans taking into account both premiums and likely out-of-pocket expenses. The results are worth studying. See also How to Save Money on Your Federal Health Insurance (Walton Francis, FedSmith, 11-23-15) Explains principles that aren't dated, such as lower doctor's fees if paid out of a Flexible Spending Account.
BBBS #8: For Your Health (Anna Jo Beck, For Your Health, ISSUU, 10-29-17) A how-to zine on American health insurance: how it works, how to pick a plan, and the author's opinions on the entire healthcare economy in the United States, and several moments of cute, heartwarming distraction to keep you from wanting to totally give up hope.

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The most confusing words in your health insurance forms, explained (Sara Kliff, Vox, 11-14-14)
My company offers free health insurance — here’s why I decided to spend $1,000 more on a better plan (Zachary Tracer, Business Insider, 11-4-18)
How to Pick a Health Insurance Plan (Roni Caryn Rabin, NY Times, 10-18-16) Going through my choice structure (David Anderson, Balloon Juice, 10-18-18) How one family weighed their risks and options.
Employer-based coverage is unaffordable for low-wage workers (Drew Altman, Axios, Kaiser Family Foundation, 9-26-19) Employer-based health insurance isn’t a monolith — the cost and generosity of that coverage varies widely. And that likely affects how open workers would be to “Medicare for All” or a public insurance option. Democrats’ health care plans would offer a better deal to many low-wage workers than to their higher-wage counterparts. Just 33% of workers at lower-wage firms offering health benefits are covered by their employer’s health benefits, well below the 63% share at other firms offering coverage. These low-wage workers pay an average of $7,000 per year just toward the premium for a family plan. Workers in low-wage firms also face much higher deductibles: a $2,679 annual single deductible, while at other firms, the average is $1,610. That is the definition of unaffordable. And family coverage isn’t even available to these workers much of the time.
The $30 Spooky Health Plan You Probably Don’t Want (Lillian Karabaic Oh My Dollar!, 10-31-18) Downsides of short-term health insurance plans--also known as junk plans.
A place where they do health care more cheaply and effectively. (And yes, it’s in the U.S.) (An Arm and a Leg podcast, 7-31-19). Count your blessings if there's such a clinic near you.
How to pick the best health insurance plan for you (Policy Advisor, ISSUU, 3-9-16) Picking a Best health Insurance plan will be sophisticated. we will assist you to perceive the way to compare Best Health plans and select one that is right for you. So, just how do you pick a health insurance plan? Here are 5 quick tips to help when choosing a plan. Four factors influence cost: Age, location, number of people in your family, tobacco use.

Ghost networks of psychiatrists make money for insurance companies but hinder patients’ access to care (Jack Turban, STAT, 6-17-19) More than a month after it was published, this opinion piece about "ghost networks" of mental health providers — insurers' out-of-date or fraudulent provider lists — continues to elicit outrage from readers who have experienced this dodge or who worry that people are not getting access to the care they need. "In a recent study, researchers called 360 psychiatrists on Blue Cross Blue Shield’s in-network provider lists in Houston, Chicago, and Boston. Some of the phone numbers on the list were for McDonald’s locations, others were for jewelry stores. When the researchers actually reached psychiatrists’ offices, many of the doctors didn’t take Blue Cross Blue Shield insurance or weren’t taking new patients."

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Health Insurance Hustle: The Confounding Way We Pay for Care (ProPublica series) Americans pay insurance companies to make sure their medical needs are covered — and at a cost they can afford. But games, side deals and hidden incentives often result in higher costs, delays in care or denials of treatment.
Pieces in the Health Insurance Hustle series:
---Behind the Scenes, Health Insurers Use Cash and Gifts to Sway Which Benefits Employers Choose (Marshall Allen, ProPublica and NPR Shots, 2-20-19) The insurance industry gives lucrative commissions and bonuses — from six-figure payouts to a chance to bat against Mariano Rivera — to the independent brokers who advise employers. Critics call the payments a “classic conflict of interest” that drive up costs.
---In Montana, a Tough Negotiator Proved Employers Don’t Have to Pay So Much for Health Care (Marshall Allen, ProPublica and NPR, 10-2-18) With its employee health plan in financial crisis, Montana hired a former insurance insider who pushed back against industry players with vested interests in keeping costs high. She proved, essentially, that bargaining down health care prices works. Bartlett understood something the state officials didn’t: the side deals, kickbacks and lucrative clauses that industry players secretly build into medical costs. Everyone, she’d observed, was profiting except the employers and workers paying the tab. The way health care works in America, most employers cede control of health care costs to their health insurers, to the hospitals that treat their employees and to the companies they pay to manage their benefits. And so Bartlett pitched a bold strategy. Step one: Tell the state’s hospitals what the plan would pay. Take it or leave it. Step two: Demand a full accounting from the company managing drug costs. If it wouldn’t reveal any side deals it had with drugmakers, replace it. Read what happened when Bartlett pushed for change in Montana.
---Why Your Health Insurer Doesn’t Care About Your Big Bills (Marshall Allen, NPR and ProPublica, 5-25-18) Patients may think their insurers are fighting on their behalf for the best prices. But saving patients money is often not their top priority. Just ask Michael Frank.
---You Snooze, You Lose: Insurers Make The Old Adage Literally True (Marshall Allen, ProPublica and NPR, 11-21-18) Millions of sleep apnea patients rely on CPAP breathing machines to get a good night’s rest. Health insurers use a variety of tactics, including surveillance, to make patients bear the costs. Experts say it’s part of the insurance industry playbook.
---Your Medical Devices Are Not Keeping Your Health Data to Themselves (Derek Kravitz and Marshall Allen, ProPublica, 11-21-18) CPAP units, heart monitors, blood glucose meters and lifestyle apps generate information that can be used in ways patients don’t necessarily expect. It can be sold for advertising or even shared with insurers, who may use it to deny reimbursement.
---Health Insurers Are Vacuuming Up Details About You — And It Could Raise Your Rates (Marshall Allen, ProPublica and NPR, 7-17-18) Without any public scrutiny, insurers and data brokers are predicting your health costs based on data about things like race, marital status, how much TV you watch, whether you pay your bills on time or even buy plus-size clothing.
---Do You Work in the Health Insurance Field? ProPublica and NPR Are Investigating the Industry and We’d Like Your Help. (Marshall Allen, 5-25-18)

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Buyers Of Short-Term Health Plans: Wise Or Shortsighted? (Anna Gorman, KHN, 11-20-18) Policyholders reason that their health is good — for now — and they don’t see the need for costly comprehensive coverage. Detractors say the plans undermine the Affordable Care Act, and agents advise reading the fine print. Some plans have exclusions that could blindside consumers, such as not covering hospitalizations that occur on a Friday or Saturday or any injuries from sports or exercise. The plans can exclude people with preexisting conditions such as cancer or asthma and often don’t cover the “essential benefits” required under the health law, including maternity care, prescription drugs or substance abuse treatment. They also can have ceilings on what they will pay for any type of care. Insurers offering such plans can choose to cover — or not cover — what they want. Critics fear healthy people may abandon the ACA-compliant market to buy cheaper short-term plans, leaving sicker people in the insurers’ risk pool, which raises premiums for those customers. But some agents said the policies may be good for healthy people as they transition between jobs, near Medicare eligibility or go to college — despite significant limitations. Agents also get a higher commission on the plans, providing them with more of an incentive to sell them. But he advises clients that if they do have a chronic illness, they may face denials for coverage. “This is old-world insurance,” he said. “You basically have to be in perfect health.”
Patient Groups Condemn Short-term Insurance Plans Final rule on short-term insurance plans will leave people with pre-existing conditions with high costs, less coverage. In the past, short-term plans provided transitional coverage for up to three months and were not an alternative to comprehensive health insurance. "Short-term health insurance plans are basically 'junk' health insurance plans," says Kim Calder, senior director of health policy at the National Multiple Sclerosis Society. "They are cheaper than other options for a reason – they don’t cover much and they exclude people with pre-existing conditions, including people living with MS." In response, the Society joined patient and consumer groups to condemn these cheaper "junk" insurance plans that will siphon off younger, healthier individuals, causing premiums for more comprehensive plans to rise for people with pre-existing conditions.
Tracking 2019 Premium Changes on ACA Exchanges (Rabah Kamal, Cynthia Cox, Michelle Long, Ashley Semanskee, and Larry Levitt, KFF, 6-6-18) Insurers submit filings every year to state regulators detailing their plans to participate in the Affordable Care Act marketplaces (also called exchanges). These filings include information on the premiums insurers plan to charge in the coming year and which areas they plan to serve.
Health Insurance Marketplace Calculator 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). You can also use this tool to estimate your eligibility for Medicaid.
The Health Insurance Hustle (Pro Publica) The way we pay for medical care is confounding. Americans pay insurance companies to make sure their medical needs are covered—and at a cost they can afford. But games, side deals and hidden incentives often result in higher costs, delays in care or denials of treatment.
---Why Your Health Insurer Doesn’t Care About Your Big Bills (Marshall Allen, Pro Publica, 5-25-18) Patients may think their insurers are fighting on their behalf for the best prices. But saving patients money is often not their top priority. Just ask Michael Frank.
---Do You Work in the Health Insurance Field? ProPublica and NPR Are Investigating the Industry and We’d Like Your Help. (Marshall Allen, Pro Publica, 5-15-18) We need your perspective on the health insurance hustle.

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HSA vs. FSA: Differences and How to Choose (NerdWallet, 9-12-19) Both HSAs and FSAs provide tax savings on health costs, but you'll have to buy a medical plan that pays few costs upfront to qualify for an HSA, and not everybody should. Scroll down for comparison chart.
PriceCheck: Across the nation, community-built health cost guides (Jeanne Pinder, Clear Health Costs). See also Pinder's Is it cheaper to pay cash than to use your insurance? Maybe. (2014) and See a Doctor Out of Network and Pay Less Than the In-Network Rate (Harry Sit, The Finance Buff, 5-7-19) Paying cash to see a doctor out-of-network can sometimes save money because 1) insurance is seen as having deeper pockets than individuals and 2) self-paying customers have choices and price is a factor.
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.)

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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 (under the ACA)


HealthCare.gov 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 Sherpa Find your most affordable health plan. Compare quotes from multiple insurance companies. Enroll in under 10 minutes.
Buying your own health insurance? Healthcare.gov. Full stop. (Dan Weissmann, First Aid Kit, 11-30-21) Health insurance you can buy on healthcare.gov is crappy in the usual ways. Everything else is worse.
New Health Plans Offer Twists on Existing Options, With a Dose of ‘Buyer Beware’ (Julie Appleby, KHN, 11-4-21)
This Open Enrollment Season, Look Out for Health Insurance That Seems Too Good to Be True ( Bram Sable-Smith, KHN, 11-1-22)
HHS To Allow Insurers’ Workaround On 2019 Prices (Julie Rovner, KHN, 6-7-18) Federal officials will not block insurance companies from again using a workaround to cushion a steep rise in health premiums caused by President Donald Trump’s cancellation of a program established under the Affordable Care Act, Health and Human Services Secretary Alex Azar announced Wednesday. The technique — called “silver loading” because it pushed price increases onto the silver-level plans in the ACA marketplaces — was used by many states for 2018 policies. But federal officials had hinted they might bar the practice next year. States moved to silver loading after Trump in October cut off federal reimbursement for so-called cost-sharing reduction subsidies that the ACA guaranteed to insurance companies.
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)
Exchange plans may have limited provider networks, but that doesn't equal poorer quality care (Kellie Schmitt, Remaking Health Care, Center for Health Journalism, 6-4-15) As more consumers buy health insurance plans on federal or state exchanges, patients and advocacy groups have criticized some of those marketplace options for offering overly limited health provider networks, or “narrow networks.” But a Health Affairs study examined California hospital networks under marketplace plans and evaluated their size, patient access and quality. It is true that marketplace plans have narrower networks than their commercial counterparts, the study found. But that doesn’t equate to differences in access or the quality of care. Authors sought to broaden the debate about narrow networks to include access and quality instead of merely counting the number of hospitals. As for hospitals, “It seems plausible that insurers are deliberately excluding some hospitals that have not been designated as top performers,” the authors wrote. “More surprisingly, depending upon the measure of hospital quality employed, the marketplace plans have networks with comparable or even higher average quality than the networks of their commercial counterparts.”
More Insured, but the Choices Are Narrowing (Reed Abelson, NY Times, 5-13-14No matter what kind of health plan consumers choose, they will find fewer doctors and hospitals in their network — or pay much more for the privilege of going to any provider they want. These so-called narrow networks, featuring limited groups of providers, have made a big entrance on the newly created state insurance exchanges, where they are a common feature in many of the plans. Many critics, remain wary about narrowing networks. A concern is that insurers will limit access to specialists or certain hospitals.
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.
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.
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.
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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Original Medicare vs. Medicare Advantage

Including bogus sales tactics with Medicare Advantage

 

Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by private insurance companies and benefits them, not the insured. AARP Bulletin covers this topic well, particularly in the article below by Dena Bunis.
Bill Suggests Prison Time For Corporate Greed Crimes In Health Care (Morning Brekaout, KFF Health News). A roundup of stories related to this: Sens. Warren, Markey propose bill that would lead to prison time for 'corporate greed' in health care ( Landon Mion Fox News, 6-12-24) The Corporate Crimes Against Health Care Act would create a new criminal penalty that could land executives in prison for up to six years
Older Americans Say They Feel Trapped in Medicare Advantage Plans (Sarah Jane Tribble, KFF Health News, 1-5-24) You may sign on to MA because an agent tells you its plans offer less expensive and broader coverage (including vision and dental) that are funded largely by the government but administered by private insurance companies. If you run into bigger health issues, though, that MA plan will probably mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. That makes getting care more difficult, and at that point you probably can't switch back to traditional, government-administered Medicare. To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage. (Do read the whole article if you have to choose between the two.)
Son of Medicare: Attack of the Medicare Machines (An Arm and a Leg, 4-10-24) Listen or scroll down and click on transcript. "This 30-minute episode of “An Arm and a Leg” sounds like a real horror movie. It uses one of Hollywood’s favorite tropes: machines taking over. And the machines belong to the private health insurance company UnitedHealth Group. Herman tells Weissmann that some of UnitedHealth’s own employees say the algorithm creates a “moral crisis” in which care is unfairly denied.
      "Traditional Medicare does have limits on nursing home care — but if you need “post-acute care” — help getting back on your feet after leaving a hospital traditional Medicare pays in full for 20 days– pretty much no questions asked. One of the selling points of Medicare Advantage — like selling points to policy nerds and politicians — was that it could cut waste, by asking those kinds of questions.... NaviHealth and its algorithm were designed to help Medicare Advantage plans ask those questions in a smart way. But Medicare Advantage's denial-by-algorithm appeal system is designed in such a way that people will give up after having claims denied."
Will Original Medicare Survive the Medicare Advantage Boom? (Dena Bunis, AARP, 9-27-23) I quote liberally from this excellent article, without enclosing things in quote marks, and the boldface is added. The sentences are rearranged and edited to condense and shrink the whole. Do read the original before making a decision between the two plans. I've shortened and condensed its content here, to lay out the main factors to consider, and have omitted an important long section toward the end about what Congress should do (but probably won't, until the very last minute).
       New enrollees have an immediate big decision to make: Should they enroll in original Medicare (also referred to as traditional Medicare) or sign up for the private insurance managed care alternative, Medicare Advantage (MA)? The two options not only differ in how they operate but increasingly in what coverage and services they provide.
      Original Medicare’s biggest draw remains the freedom enrollees have to go to any doctor or hospital in the country that takes Medicare. Original Medicare is managed entirely by the federal government. Under it you can go to any doctor, lab or hospital in the U.S. that participates in the program (about 90 percent of medical professionals do).

     In MA plans, enrollees mostly must go to providers within the plan’s network, and these networks are highly regionalized. Going out of network means facing a much higher copay for each visit. In some cases, the care may not be covered at all.
      Medicare Advantage plans can feel more familiar, as they closely resemble the managed care plans offered by many employers, often in the form of a health maintenance organization (HMO) or preferred provider organization (PPO). An MA plan is the one-stop-shopping alternative that bundles hospital, doctor and prescription drug coverage. Most offer extra benefits not in original Medicare. MA plans also cap how much beneficiaries must pay out of pocket each year, something original Medicare does not. Advantage plans are operated by private and often for-profit organizations that get flat-rate payments from the government to provide health care to an enrollee. By managing costs and a patient’s care carefully, they can — in theory — provide all needed services and still have money left over for their bottom line. MA’s promise of extra benefits and lower premiums has been effective. Based on current patterns, it won’t be long before enrollment in MA plans substantially overtakes enrollment in original Medicare.
       Until they enroll, many Americans don’t realize how costly and complicated Medicare can be. That is especially true if you choose original Medicare. Most original enrollees must make three regular insurance payments: one for basic Part B coverage, one for a Part D prescription plan, and one more for a Medigap policy to cover some or all of the expenses that Medicare doesn’t. And there are other expenses on top of the premiums; for example, original Medicare Part B has an annual deductible ($226 in 2023); there’s also a deductible for every hospital visit, which in 2023 is $1,600. Those charges take a heavy financial toll. An important dividing line when choosing a Medicare path is whether a beneficiary can afford to pay the added monthly costs of a Medigap policy to supplement original Medicare coverage, as well as for a separate Part D prescription plan.
      High-income earners can usually afford what is typically a few hundred dollars a month premium for a Medigap policy. Others might have subsidized Medigap coverage as part of a retiree benefit. And there’s government help for people on the low end of the economic scale: People with the lowest incomes might qualify for Medicaid, which would pick up their out-of-pocket costs, or they could be eligible for a Medicare Savings Plan (MSP) that pays for some, or all, of a low-income consumer’s costs. People in original Medicare usually don’t need referrals to see specialists, and as long as Medicare covers a test or treatment a doctor orders, except in a few situations, Medicare will pay for it.
       By contrast, an Advantage plan enrollee usually has just one recurring payment: It includes the government-mandated Part B coverage cost and, in some cases, a small additional premium, which varies by what plan you choose and where you live. You pay various copays and deductibles for your services and doctor visits, but the rest is fully covered by the plan, and you know going in what the copay is for the different providers. Costs under MA can also add up, though, especially if you need hospital care; most plans have a per-day hospital charge. “Denials may be more frequent in Medicare Advantage plans than in traditional Medicare for people who have serious health problems.”
       Not a fair fight. The difference in “choice” between original Medicare and an MA plan isn’t simply which doctor you can see. In an MA plan, the care you need is likely to be more scrutinized than in an original plan. Insurers that run MA plans often require what’s called prior authorization before paying for your tests and procedures; that means a doctor must get approval for recommended care from internal reviewers before the treatment will be covered. Some plans also require referrals to specialists. The networks of doctors and facilities that treat MA patients are almost always based geographically. So older adults who travel a lot or who live in different places during the year most often find that if they need nonemergency medical care while away from home, their MA plan won’t cover it.
       On the other hand, most MA plans have benefits that original Medicare does not. The out-of-pocket cap is a big benefit; in 2023, MA enrollees know they won’t have to pay more than $8,300 in total annual health costs, although many plans have lower out-of-pocket limits than that. Most MA plans cover basic dental, vision and hearing services. Some provide what are called Medicare flex cards that beneficiaries can use to pay for over-the-counter medications and other drugstore items, as well as healthy food.
      The primary concern with Advantage plans, besides their geographic boundaries, is the quality of care they deliver when a member has serious health issues. Advocates and patients agree that MA plans seem fine as long as you’re healthy. But too often, beneficiaries with serious illnesses find it more difficult to get the care they say they need. When people first enroll in Medicare, they may not be able to predict what kind of care they may need years down the road.
      Original Medicare may have another disadvantage: it doesn't do television ads. Throughout the year, but most prominently during Medicare open enrollment season each fall, ads for Medicare Advantage plans blanket broadcast and cable television stations.
      Each year, Medicare mails a “Medicare & You” handbook to beneficiaries that more objectively details how the types of Medicare compare. Only a small percentage of people actually look at it. CMS announced a crackdown this year on misleading Medicare ads. The agency ordered that MA commercials must disclose what insurance plan is being advertised and that television pitches can’t misuse the Medicare logo or card to lead consumers to believe celebrity endorsers represent the federal government. Consumers also should know that there is a financial incentive for insurance agents and brokers to steer clients to Advantage plans.
      “When we did focus groups with brokers, many said they are paid more to put people into Medicare Advantage plans, sometimes much more,” said Gretchen Jacobson, VP of Medicare at the nonpartisan Commonwealth Fund. But “if they were going into Medicare tomorrow, most of them said they would choose to be in traditional Medicare.” These brokers do not get any commission for helping someone enroll in original Medicare.
      What comes next? Ultimately, Congress sets the rules for Medicare. Here, too, the playing field for MA versus original isn’t level. Allowing MA plans to offer extra benefits isn’t as politically charged a move as it would be to pass a law allowing original Medicare to offer the dental, vision and hearing coverage that most MA plans do. That’s because Advantage plans use part of the fixed amount they get per patient from the federal government to fund these extra services. But expanding original Medicare’s benefits would likely require putting more taxpayer dollars into the program.   

       AARP fights to strengthen Medicare benefits. Specifically, AARP is working to add a dental benefit to original Medicare and has supported a legislative package that would add vision and hearing coverage.  

       Then there’s solvency. In their latest report, the Medicare trustees, which gauge the fiscal health of the program, say the trust fund that helps pay for the Part A hospital care portion of Medicare will be depleted by 2031, meaning payments to health care providers would be much reduced. Other than maintaining the program’s solvency, lawmakers have historically been loath to make major changes to Medicare, which could land them in political peril.

       MedPAC and other Medicare watchers have urged Congress to do more to level the playing field between original and Advantage. Ever since its inception in 1997, MA and its plans have been paid more to take care of Medicare beneficiaries than original Medicare pays. Early on, the idea was to give insurers a profit incentive to create and sustain MA plans. Now many experts say it’s time to stop those extra payments, something health insurers have strongly opposed.
Medicare Advantage Increasingly Popular With Seniors — But Not Hospitals and Doctors (Julie Appleby, KFF Health News, 11-29-23) A hospital system in Georgia. Two medical groups in San Diego. Another in Louisville, Kentucky, and nearly one-third of Nebraska hospitals. Across the country, health care providers are refusing to accept some Medicare Advantage plans — even as the coverage offered by commercial insurers increasingly displaces the traditional government program for seniors and people with disabilities. As of this year, commercial insurers have enticed just over half of all Medicare beneficiaries — or nearly 31 million people — to sign up for their plans instead of traditional Medicare. The plans typically include drug coverage as well as extras like vision and dental benefits, many at low or even zero additional monthly premiums compared with traditional Medicare.
       But "increasingly, according to experts who watch insurance markets, hospital and medical groups are bristling at payment rates Medicare Advantage plans impose and at what they say are onerous requirements for preapproval to deliver care and too many after-the-fact denials of claims.... People whose preferred doctors or hospitals refuse their coverage may have to switch Medicare Advantage plans or revert to the traditional program, although it can be difficult or even impossible when switching back to obtain what is called a “Medigap” policy, which covers some of the traditional plan’s cost-sharing requirements.
       Studies show that Medicare Advantage costs taxpayers more per beneficiary than the traditional program. But the plans enjoy the backing of many lawmakers, especially Republicans, because of their popularity. The Health and Human Services Department’s inspector general reported last year that some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules."
Uncle Sam Wants You … to Help Stop Insurers’ Bogus Medicare Advantage Sales Tactics (Susan Jaffe, KFF Health News, 11-30-23) "Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.
     "People with traditional government Medicare coverage can add or change a prescription drug plan or join a Medicare Advantage plan that combines drug and medical coverage. Although private Advantage plans offer extra benefits not available under the Medicare program, some services require prior authorization and beneficiaries are confined to a network of health care providers that can change anytime. Beneficiaries in traditional Medicare can see any provider."
Tiny, Rural Hospitals Feel the Pinch as Medicare Advantage Plans Grow (Sarah Jane Tribble, KFF Health News, 10-23) More than half of seniors are enrolled in private Medicare Advantage plans instead of traditional Medicare. Rural enrollment has increased fourfold and many small-town hospitals say that threatens their viability.

    "Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare. The plans have become dubious payers for many large and small hospitals, which report the insurers are often slow to pay or don’t pay. Private plans now cover more than half of all those eligible for Medicare.
    "Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.
CMS Proposes Rule to Limit Medicare Advantage Plan Sales Commissions (Cheryl Clark, MedPage Today, 11-7-23) No more golf parties or free trips to brokers who "steer" beneficiaries to higher-paying plans.

     "To stop Medicare Advantage (MA) and Part D plan marketing agents from steering beneficiaries into plans that pay the agents the highest commissions -- rather than the plans that best suit the patients' needs -- the Centers for Medicare & Medicaid Services (CMS) proposed a rule Monday that would limit the amount they'd receive on sales to $632 for the 2025 plan year.
     "Currently, agents can receive far more than the current national commission cap of $601, even as high as $1,300 on one sale for 1 year's enrollment, because of "add-on" or "incentive fees," according to recent Senate committee hearing testimony. CMS called the practice "anti-competitive steering" since larger plans are usually paying the most, putting smaller, potentially better plans at a disadvantage."
     "If a hospital or provider does not contract with a Medicare Advantage plan, then a patient may have to pay for out-of-network care. That generally wouldn’t happen with traditional Medicare, which is widely accepted."
Shady Medicare Advantage Plan Tactics Blasted at Senate Hearing (Cheryl Clark, MedPage Today, 10-19-23) A dozen U.S. Senators and three witnesses sharply criticized Medicare Advantage (MA) marketing schemes during a Senate Finance Committee hearing yesterday. Participants blasted the "unscrupulous," "deceptive," and "rip-off" tactics and high commissions that enroll seniors in plans that don't meet their healthcare needs. Sen. Ron Wyden (D-Ore.) pointed to federal investigators' findings that "marketing middlemen are the latest set of sleazy private-sector scoundrels targeting seniors on Medicare Advantage."
    Hearing witness Krista Hoglund, who is the CEO of a small MA plan in Wisconsin covering 60,000 lives, said MA companies now pay $1,300 or more to an agent for enrolling a new beneficiary -- far above the CMS-approved cap of $611. "Unfortunately, we know some large firms and third-party marketing organizations leverage their influence for financial gain rather than what's in the best interest of the consumer," Hoglund said. While many plan agents are trustworthy, many are not, she said.
     "It's outrageous. It's a rip-off and it's got to stop," said Wyden.
     Although millions of beneficiaries use brokers to find the right plan, the problem is that "brokers are not required to put consumers first. I think that needs to change," said Cobi Blumenfeld-Gantz, CEO of Chapter, a New York City-based counseling program for seniors. Congress and CMS should also require plans to publish data now held secret so that seniors and their helpers can get the information to make the right choice, he said.

     Sen. James Lankford (R-Okla.) noted that many of the rural hospitals in his state "just won't take Medicare Advantage period. They just cut everybody off and said, we can't do it because we can't afford the constant chasing after all the denials."

     Ghost networks are also a pet peeve of Sen. Michael Bennet (D-Colo.)  Bennet's constituents with MA plans "consistently tell my office that their surgeries are delayed often for months, or that they were lied to about their level of coverage, or that their plan was too expensive and that their claims are denied when they're told the service should have been or would have been covered."

Sen. Maggie Hassan (D-N.H.) said her constituents complain of "unscrupulous marketing" of plans' prescription coverage -- a big reason many beneficiaries choose MA plans -- but then don't actually cover the drugs patients need, or change the tier or price category or stop covering them altogether during the plan year.


8 Things Medicare Doesn’t Cover (Dena Bunis, AARP, 5-24-22) 1. Opticians and eye exams, 2. Hearing aids, 3. Dental work, 4. Overseas care, 5. Podiatry, 6. Cosmetic surgery, 7. Chiropractic care, 8. Nursing home care.
Understanding Medicare’s Options: Parts A, B, C and D (Dena Bunis, AARP, 11-15-21) Making sense of the alphabet soup of health care choices.
---Part A — Hospital coverage
---Part B — Doctor and outpatient services
---Part C — Medicare Advantage
---Part D — Prescription drugs

 

Which to Choose: Medicare or Medicare Advantage? (Paula Span, NY Times, 11-11-22) Open enrollment for Medicare plans ends Dec. 7. Here’s what you need to know about shopping for them.
---Why the marketing barrage?

The biggest providers of Advantage plans are Humana and United Healthcare, and they and others market aggressively to persuade seniors to sign up or switch plans. A new U.S. Senate report found that some of these Advantage plan practices are deceptive; for example, some marketing firms sent Medicare beneficiaries mailers made to look like government websites or letters.
---Which is better: Medicare or Medicare Advantage? Advantage enrollees may also be drawn to the plan by benefits that traditional Medicare can't offer. "Vision, dental and hearing are the most popular," Mr. Lipschutz said, but plans may also include gym memberships or transportation.

       "We caution people to look at what the scope of the benefits actually are," he added. "They can be limited, or not available, to everyone in the plan. Dental care might cover one cleaning and that's it, or it may be broader." Most Advantage enrollees who use these benefits still wind up paying most dental, vision or hearing costs out of pocket.

---What are the downsides to Medicare Advantage?

One big downside is that these insurers require "prior authorization," or approval in advance, for many procedures, drugs or facilities. Advantage participants who are denied care can appeal, and those who do so see the denials reversed 75 percent of the time, but only about 1 percent of beneficiaries or providers file appeals. Before signing up for a Medicare Advantage plan, understand that anytime you want care other than an emergency, the plan has to approve it. So "think very carefully before you switch out of traditional Medicare, which lets you see just about any doctor or go to any hospital." 
---So maybe I should just go with traditional Medicare?

"Medicare does not have any limit on what you can spend out of your own pocket. The bills can mount up quickly, especially if you need costly treatments such as outpatient chemotherapy.

     "The Kaiser literature review found that traditional Medicare beneficiaries experienced fewer cost problems than Advantage beneficiaries if they had supplementary Medigap policies — but if they didn't, they were more likely to report problems like delaying care for cost reasons or having trouble paying medical bills."
---What should I know about drug plans?

Unlike most Medicare Advantage plans, traditional Medicare does not include drug coverage. For that, you must buy a separate Part D plan. "If you're the person who doesn't take many medications or only uses generics, the best strategy might be to sign up for the plan with the lowest premium," Dr. Cubanski said. "But if you take a lot of medications, the most important thing is whether the drugs you take, especially the most expensive ones, are covered by the plan."

      Different plans cover different drugs 
---After I pick a plan, can I switch if I don’t like it?

"Switching from traditional Medicare to an Advantage plan can cause a major problem: You relinquish your Medigap policy, if you had one. Then, if you later grow dissatisfied and want to switch back from Advantage to traditional Medicare, you may not be able to replace that policy. Medigap insurers can deny your application or charge high prices based on factors like pre-existing conditions.
---Where can I find help with these decisions?

"Switching from traditional Medicare to an Advantage plan can cause a major problem: You relinquish your Medigap policy, if you had one. Then, if you later grow dissatisfied and want to switch back from Advantage to traditional Medicare, you may not be able to replace that policy. Medigap insurers can deny your application or charge high prices based on factors like pre-existing conditions."

    
More Retiree Health Plans Move Away From Traditional Medicare (Mark Miller, NY Times, 3-10-23) Retirees whose former employers offer health coverage are being shifted to privately run Medicare Advantage, often against their wishes. The change saves millions for employers. Retirees who are shifted into Medicare Advantage plans may not fully understand the major differences from traditional Medicare. These include the requirement to use physicians and hospitals in their plan’s narrower network, and reduced access to care in some instances. A federal investigation concluded last year that tens of thousands of people in Medicare Advantage plans were denied necessary care that should be covered. See Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds (Reed Abelson, NY Times, 4-28-22) Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.
Coalition for Medicare Choices (Warning from Source Watch) A project of America's Health Insurance Plans, a lobbying group that represents the interests of companies that sell health insurance The group opposes health care reform. In a press release in 2009 it described itself only as "a rapidly growing organization of Medicare Advantage beneficiaries" and "a grassroots organization of more than 2 million Americans who are covered by Medicare Advantage.

     Health insurance companies "benefit financially from the Medicare Advantage because they get extra federal subsidies that are supposed to pay for extra services the Medicare Advantage beneficiaries get. The study the press release cited was commissioned by the Blue Cross and Blue Shield Association." It des=
Medicare Made Easy (AARP booklet, PDF) "A What-to-Do Guide for Americans Approaching Age 65" Your essential questions answered: When to enroll. How the program works.Your menu of choices. What you'll pay. Where to get help.
Medicare Eligibility: Do You Qualify? (AARP)
How Much Does Medicare Cost? (Dena Bunis, AARP, 11-15-21) Monthly premiums, other out-of-pocket expenses can add up.
The Big Choice: Original Medicare vs. Medicare Advantage (Dena Bunis, AARP, 10-12-21) What you need to know:  Which path you take will determine how you get your medical care — and how much it costs. What does each cover? What doesn't it cover? Are there other costs? How does it compare with Medicare Advantage? Who prefers original Medicare?
Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges (Fred Schulte and Holly Hacker, KHN, 11-21-22). Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average. Taxpayers had to foot the bills for care that should have cost far less, according to records released after KHN filed a lawsuit under the Freedom of Information Act. The government may seek to recover up to $650 million as a result.

     Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage. “From the outside, it seems pretty smelly,” he said. A slew of government reports and whistleblower lawsuits are alleging that Medicare Advantage plans routinely have inflated patient risk scores to overcharge the government by billions of dollars.
Lawsuit by KHN Prompts Government to Release Medicare Advantage Audits (Fred Schulte, KHN, 10-14-22) The lawsuit was filed three years ago to learn about vast overcharges by the popular health plans that are detailed in audits the government refused to release to the public.
The Medicare Advantage Trade-Off: Saving Money, Losing Access (Cheryl Clark, MedPage Today, 10-13-22) Beneficiaries may spend less on premiums, but care delays are common. Do worse outcomes follow? "We're seeing this all the time – people who have been taken in by advertising that changes their Medicare benefits to a Medicare Advantage plan to the detriment of their medical outcomes," Weil said. (Medical News Special Reports > Exclusives The Medicare Advantage Trade-Off: Saving Money, Losing Access)
     Beneficiaries may spend less on premiums, but care delays are common. Do worse outcomes follow? With beneficiaries rapidly joining MA plans by the millions each year, more than half of those eligible will be in MA plans rather than traditional Medicare as soon as next year. They are wooed by ads promising low- or no-cost premiums, money added to their Social Security checks, free dentistry, home meals, prescriptions, and rides to the doctor. There is a greater, and less well-publicized, problem with MA plans -- denial of physicians' referrals for care.
      "They can't see their doctors that they had been going to, and they have to work up all the tests and everything has to be redone with new providers. We continue to see clients who have been harmed by brokers who switch them to a plan that doesn't work for them. They just sign them up for the highest commission that they'll be paid."
How seniors can avoid Medicare Advantage marketing scams, care denials and medical underwriting (Joseph Burns, Covering Health, AHCJ, 10-21-22)
CMS Puts the Kibosh on Misleading Medicare Advantage Sales Pitches (Cheryl Clark, MedPage Today, 10-21-22) "Secret shoppers" found that 80% of agent calls with clients were inaccurate or insufficient.
‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions (Reed Abelson and Margot Sanger-Katz, NY Times, 10-8-22) By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud. Check out the information chart.
Biggest Medicare Changes for 2022 (Dena Bunis, AARP, 5-4-22) Look for higher premiums and deductibles in the new year, but also more help with insulin, mental health.
Pros and Cons: Exploring the Differences in Medicare Coverage (Sari Harrar, AARP, 10-12-21) An excellent outline of some key differences between original Medicare and Medicare Advantage (MA) plans as to coverage for chronic conditions (diabetes, arthritis, heart disease, etc.), weight-loss help, a case of the flu, an emergency appendectomy, a screening colonoscopy, ongoing pain, hearing decline.

     How beneficiaries get their care differs depending on the option they choose. Medicare covers most medical services that beneficiaries need but there are differences in how those needs are covered, including which providers you can see, what hospitals and other facilities you can access and how you pay for care. This section explains some key differences between original Medicare and Medicare Advantage (MA) plans.
8 Reasons to Change Your Medicare Coverage During Open Enrollment (Tamara Lytle, AARP, 10-12-21) Reviewing your plan every year can save you money and help you avoid headaches. Read the article for reasons and details on the 8 items below.
1. My prescription costs have jumped.
2. I’ve decided to spend my winters (or summers) in a different state.
3. I need surgery and prefer a specific doctor.
4. I’m super healthy and rarely need a doctor.
5. I’ve been diagnosed with a chronic condition.
6. My income has dropped sharply.
7. My former employer is changing its retiree health benefits.
8. My regular doctor is no longer in network for my plan.

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Medicare: What you need to know

 

Official information from Medicare.gov and/or HHS:
Medicare and You 2023 The official U.S. government Medicare handbook (online)
Accessible Communications: Medicare provides free auxiliary aids and services, including information in accessible formats like braille, large print, data or audio files, relay services and TTY communications. If you request information in an accessible format, you won’t be disadvantaged by any additional time necessary to provide it. This means you’ll get extra time to take any action if there’s a delay in fulfilling your request.


To request Medicare or Marketplace information in an accessible format you can:
1. Call us:
For Medicare: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
2. Send us a fax: 1-844-530-3676
3. Send us a letter:
Centers for Medicare & Medicaid Services
Offices of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop S1-13-25
Baltimore, MD 21244-1850
     Attn: Customer Accessibility Resource Staff


Your request should include your name, phone number, type of information you need (if known), and the mailing address where we should send the materials. We may contact you for additional information.

      Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan, contact your plan to request its information in an accessible format.
Get Started with Medicare (Medicare.gov) Important facts, category by category. Read it online or get a printed version of the booklet from Medicare.gov.

     Note: Failing to sign up can be costly.

Get Medigap Basics (Medicare.gov)

     Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private insurance company to help pay your share of costs in Original Medicare.  Important: You get a 6 month “Medigap Open Enrollment” period, which starts the first month you have Medicare Part B and you’re 65 or older. During this time, you can enroll in any Medigap policy and the insurance company can’t deny you coverage due to pre-existing health problems. After this period, you may not be able to buy a Medigap policy, or it may cost more. Your Medigap Open Enrollment Period is a one-time enrollment. It doesn’t repeat every year, like the Medicare Open Enrollment Period.


Medicare Costs (Medicare.gov)
Your Medicare Rights (Medicare.gov)
Medicare and Medicaid: Frequently asked questions (U.S.Dept. of Health & Human Services, or HHS)
Who is eligible for Medicare (HHS) Generally, Medicare is for people 65 or older. You may be able to get Medicare earlier if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also called Lou Gehrig’s disease). Medicare has four parts: Part A (Hospital Insurance) Part B (Medicare Insurance) Part C (Medicare Advantage Plans Part D (Drug Coverage)
What does Medicare cost? (Medicare.gov) Details costs for Medicare Parts A, B, and D.
Without Medicare Part B’s Shield, Patient’s Family Owes $81,000 for a Single Air-Ambulance Flight (Tony Leys, Bill of the Month, KFF Health News, 2-27-24)

Debra Prichard was a retired factory worker who was careful with her money, including what she spent on medical care. She had Medicare Part A but not Part B.

     Then the rural Tennessee resident suffered a devastating stroke and several aneurysms. One of her trips to the Nashville hospital was via helicopter ambulance. . Her daughter had heard such flights could be pricey, but she didn’t realize how extraordinary the charge would be — or how her mother’s skimping on Medicare coverage could leave the family on the hook, for $81,739.40, none of which was covered by insurance.

     "Prichard was enrolled only in Medicare Part A, which is free to most Americans 65 or older. That section of the federal insurance program covers inpatient care, and it paid most of her hospital bills, her daughter said. But Prichard declined other Medicare coverage, including Part B, which handles such things as doctor visits, outpatient treatment, and ambulance rides. Her daughter suspects she skipped that coverage to avoid the premiums most recipients pay, which currently are about $175 a month."

For Medicaid, contact your State Medical Assistance (Medicaid) office.
A Snapshot of Sources of Coverage Among Medicare Beneficiaries (Nancy Ochieng, Gabrielle Clerveau, Juliette Cubanski, and Tricia Neuman, KFF Health, 12-13-23) Coverage of Medicare benefits is provided through either traditional Medicare or Medicare Advantage private plans. Many people with Medicare also have other coverage, such as Medicaid, Medigap, and employer coverage, which may pay some or all of their Medicare cost-sharing requirements and may also provide benefits that Medicare does not cover. This brief analyzes the different types of coverage that people with Medicare have and the demographic characteristics of Medicare beneficiaries with these different coverage types.
   In 2021, more than three million people with traditional Medicare, mostly low to modest-income beneficiaries, had no supplemental coverage, placing them at risk of facing high out-of-pocket spending or going without needed medical care due to costs.

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Types of Medicaid for people with Medicare (Medicare Rights, Medicare Interactive) If you are eligible for Medicare and have a sufficiently low income, you may qualify for help from certain Medicaid programs in your state. Whether you qualify will depend on:
   Your earned and unearned income, including wages and Social Security payments
   Your assets, including checking accounts, stocks, and some proper

   Your nursing care and long-term care needs
   You must meet your state’s functional eligibility criteria (standards for assessing your need for help with activities of daily living, such as, toileting, bathing, and dressing). Each state sets its own standards.
---How Medicaid works with Medicare
---Aged, blind, and disabled Medicaid eligibility
Medicaid and Medicare Part D overview

 

Find a Medigap policy that works for you (Medicare.gov) In Original Medicare, you generally pay some of the costs for approved services. Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company that helps pay your share of costs.

• How does Medigap differ from Medicare Advantage?

A Medigap policy is different from a Medicare Advantage Plan (Part C).

A Medicare Advantage Plan (unofficially "Part C") is another way to get your Medicare coverage besides Original Medicare.

A Medigap policy is a supplement to Original Medicare coverage.

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What is Medicare Part C? (U.S. Dept. of Health & Human Services)
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.
       If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Compare the five types of Medicare Advantage Plans (a chart)
   Health Maintenance Organization (HMO)
   Preferred Provider Organization (PPO)
   Medicare Savings Account (MSA)
   Private Fee for Service Plan (PFFS)
   Special Needs Plan (SNP).

Chart presents answers for these questions:
   Do these plans charge a monthly premium?
   Do these plans offer Medicare prescription drug coverage (Part D)?
   Can I use any doctor or hospital that accepts Medicare for covered services?
   Do I need to choose a primary care doctor?
   Do I have to get a referral to see a specialist?


Find Medicare Plans Near You (Healthline) Choose your state, from this map, to see what medicare plans are available.

• Medicare Open Enrollment FAQs (KFF, The independent source for health policy research, polling, and news)

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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.

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Observation status and other Medicare rule

 

• Here Are Some Rules About Medicare That You Need to Know (Debra Schuster, ElderCare Matters, 4-23-19) Medicare allows hospitals to place Medicare beneficiaries on “observation status” for up to 48 hours if the hospital believes Medicare will not pay for inpatient care. (If you are in the hospital 3 days you are no longer on 'observation status.') The financial consequences of not being admitted as an inpatient can be devastating. Some of the rules about Medicare can be challenging to understand, including those governing stays in nursing facilities.
FAQs about health reform (Kaiser Family Foundation, or KFF) Marketplace eligibility, enrollment periods, plans and premiums; individual mandate; minimum essential coverage; etc.  This list of Frequently Asked Questions (FAQs) about the Medicare Open Enrollment period covers a range of topics related to enrollment, including Medicare Advantage, Part D, Medigap, and more.  A Spanish-language version and additional FAQs about Medicare and the Marketplace are also available.
Medicare Rights
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. (The problem: Medicare doesn't cover observation status.) 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.
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.
Understanding Medicare Observation Status (Howard Gleckman, Forbes, 1-2-19) "No issue generates more anger and confusion among Medicare recipients than observation status—that hospital stay that really isn’t a hospital stay.... While reimbursements differ depending on a patient’s condition, Medicare pays hospitals roughly one-third less for an observation stay than for an admission....Some hospital critics say there is a second, more self-serving reason why hospitals treat patients in observation instead of admitting them: to avoid readmission penalties. In recent years, Medicare has been cutting payments to hospitals that readmit certain patients within 30 days."

Medicare tries to limit the use of observation status (The Advisory Board, 5-6-13) Proposed rule would limit the length of observation stays.

Medicare-Medicaid Coordination (CMS.gov, or Centers for Medicare & Medicaid Services)


    

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*** More Retiree Health Plans Move Away From Traditional Medicare (Mark Miller, NY Times, 3-10-23) Retirees whose former employers offer health coverage are being shifted to privately run Medicare Advantage, often against their wishes. The change saves millions for employers. Retirees who are shifted into Medicare Advantage plans may not fully understand the major differences from traditional Medicare. These include the requirement to use physicians and hospitals in their plan’s narrower network, and reduced access to care in some instances. A federal investigation concluded last year that tens of thousands of people in Medicare Advantage plans were denied necessary care that should be covered.


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 (hospital insurance) of traditional Medicare covers inpatient hospital services, skilled nursing home care and hospice, among other things.

Part B (medical insurance) of traditional Medicare helps cover preventive care and physician and outpatient services, among other things.

Part D (prescription drug coverage) plans are private insurance plans covering prescription drug costs.

Medicare Advantage (Part C) is an alternative to traditional Medicare, in which  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:
---What's Medicare? (Medicare.gov) New to Medicare? Learn how to get started.
---Medigap vs. Medicare Advantage: What's the Difference? (Investopedia) "Medicare has four basic parts: A, B, C, and D. Taken together, Parts A (hospital care), B (doctors, medical procedures, equipment), and D (prescription drugs) provide basic coverage for Americans 65 and older. What's relevant for this article is what these parts don't cover, such as deductibles, co-pays, and other medical expenses that could wipe out your savings should you become seriously ill. That's where Part C comes in. Also known as Medicare Advantage, it's one of two ways to protect against the potentially high cost of an accident or illness. The other option is Medicare Supplement Insurance, also called Medigap coverage." Explains the differences between Medigap and Medicare Advantage.(One of the clearest overall explanations I've read.)
---Find a Medicare Plan for 2020 Try Medicare's redesigned Plan Finder.
---Mind the Calendar (AARP) Enrolling on time or pay a penalty. Miss that deadline and it'll cost you — potentially for the rest of your life. Your Initial Enrollment Period (IEP) is the time you MUST sign up to avoid hassles. It spans seven months —from three months before you turn 65 until three months after. Part B, for example, "covers doctor visits and other outpatient services, like blood tests, X-rays, etc. If you don't have health insurance and don't sign up for Part B during your IEP, you'll pay almost $6,500 more in premiums over the next 20 years based on this year's $135.50 monthly premium. That's because Medicare will increase your premium by a 10 percent penalty for every 12 months you don't enroll when you should have." Miss your IEP on Part D (which helps pay for prescription drugs) and "your monthly premium may be 1 percent higher for each month you aren't enrolled. The average monthly Part D premium for 2019 is $31.83. So, if you don't have good drug coverage and wait 24 months to sign up, you'll pay almost $8 a month more for your prescription drug plan for as long as you have drug coverage." (But see next entry.)
---Understanding the Medicare Late Enrollment Penalty (My Medicare Matters) Another clear explanation of the penalties for enrolling late in Medicare Parts A, B, and D. It also explains Special Enrollment Periods (SEPs) that apply when you are able to delay your enrollment in Medicare Parts A, B, C & D. These SEPs are only available for certain circumstances. You might qualify for a SEP if you had health insurance through your job or your spouse's job when you were first eligible to sign up for Medicare Part B.

---Download Medicare and You (the official and excellent U.S. government Medicare handbook, available in various formats, including audio and braille--with index at back/bottom). To get a paper handbook, call 1-800-MEDICARE (1-800-633-4227).
---eMedicare Read "Medicare and You, 2020" online.
---My Medicare Matters (excellent detailed explanations of various aspects of Medicare coverage)
--- Understanding Medicare’s Options (Dena Bunis, AARP, 9-23-19) What you need to know about Parts A, B, C and D. "First you have to decide whether to go with Original Medicare or a Medicare Advantage plan.If you select to go with Original Medicare, your buffet will include Parts A and B and probably Part D. If you decide to go with Part C, a Medicare Advantage plan, it will be more like a sit-down meal, since a private insurer bundles together parts A and B and most likely D into one comprehensive plan." A good big-picture explanation. Be sure to watch the video about Original Medicare vs. Medicare Advantage plans (the pros and cons of each).
---AARP's Medicare Question and Answer Tool
---Is my test, item, or service covered by Medicare? (Medicare). Type in the name of your test, etc., or look at the list of preventive and screening services covered by Medicare.
---Medicare Materials & Trainings Catalogue (Medicare Rights Center)  Look through the titles here just to see what issues you might not know about -- and then search for online explanations for that issue.
---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.
---How to Avoid Medicare Late Enrollment Penalties (My Medicare Matters) This article is specific and very helpful.
---Savvy Medicare Planning for Boomers (Horse's Mouth) A pitch to financial planners about a training course. Scroll down to course outline (a helpful list of what you should know about) See also Courses available to become a Medicare pro (Mary Beth Franklin, Investment News,4-12-17)

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An Overview of Medicare (Kaiser Family Foundation, 2-13-19)
Medicare's Challenging Relationship with Hospitals (Globe1234.com) Important information.
Learning Medicare’s ABCDs (Kate Yandell, Cancer Today, 9-18-20) Medicare was established to help provide affordable health care coverage for older Americans. But Medicare beneficiaries with cancer can still face financial burdens related to their care.
Data.cms.gov Provider summaries by type of service (probably too much in the weeds for most of us to understand).
Quick Guide to Medicare (Triage Cancer)
Plan year 2020 Medicare enrollment dates at a glance (MedicareResources.org)

---The plan-year 2020 Medicare open enrollment period starts October 15.
---The annual five-star Medicare Advantage enrollment period is December 8-November 13
---The Medicare Advantage open enrollment is January 1 – March 31.
---The Part A / Part B general enrollment period is January 1 – March 31.
Medicare’s Open Enrollment Is Open Season for Scammers (Susan Jaffe, KHN and Washington Post, 11-11-21)
Medicare and Medicare Advantage enrollment guide (scroll down for state-by-state links)

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Prescription Assistance Programs for Seniors (National Council on Aging) State Pharmaceutical Assistance Programs (SPAPs) are state-run programs that assist low-income seniors and adults with disabilities in paying for their prescription drugs. SPAP coverage varies by state, but the programs generally provide Part D “wraparound” coverage, meaning that they pay costs that Medicare Part D does not pay.
State Health Insurance Assistance Programs (SHIPs) (Medicare) SHIPs offer local, personalized counseling and assistance to people with Medicare and their families. SHIPs can help you with things like:
---Your Medicare questions, including your benefits, coverage, premiums, deductibles, and coinsurance
---Complaints and appeals
---Joining or leaving a Medicare Advantage Plan (such as an HMO or PPO), any other Medicare health plan, or Medicare Prescription Drug Plan (Part D)
Did you know that each state may call its SHIP by a different name — such as HICAP in California, or APPRISE in Pennsylvania? See Find your State’s State Health Insurance Assistance Program (SHIP) (Seniors Resource Guide).
Medicare Savings Programs (MSPs) If you have limited income and resources, you can get help from your state paying some or all of your Medicare premiums, deductibles, and coinsurance.
Guide to get the most out of medicare (Consumer Reports)
57 must-know caregiver tips, stats, and facts (Medicare PlanFinder)
Medicare Interactive (the Medicare Rights Center's online reference tool) Click on section you have questions about, such as this one about Medicare Part D coverage.
What Are Medicare Part D Plans? (My Medicare Matters)
Medicare Plan F vs Plan G (Medicarefaq.com) These are the two most popular Medicare Supplement plans among beneficiaries today. The plan that’s best for you will depend on how often you go to the doctor and your budget and whether you want coverage when traveling. (Plan F, which covers the Part B deductible, is no longer available in some areas, such as Montgomery County, MD; Plan G is an alternative -- Plan F minus coverage of the Part B deductible.)
Medicare Plan F vs Plan G vs Plan N (Boom Benefits) Scroll down to see the chart, which shows Plan N not covering excess charges.
Best Medicare Supplement Plans and Companies (Retirement Living, 10-28-19) You can click on reviews of Medicare Supplement plans. Top-rated were AARP by UnitedHealthcare, Mutual of Omaha, and United Medicare Advisors.
Moving and Medicare (United Medical Care Advisors) What to do if you have Medicare and a Medicare Supplement plan and are moving to a new address.
Medicare’s Wellness Visit Isn’t the Same as an Annual Physical (Michelle Andrews, KHN, 3-20-19) Medicare does not cover an annual physical exam. Patients who get them may be on the hook for the entire amount. “It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit.’” If a wellness visit veers beyond the bounds of the specific covered preventive services into diagnosis or treatment — whether at the urging of the doctor or the patient — Medicare beneficiaries will typically owe a copay or other charges. Meanwhile, some Medicare Advantage plans cover annual physicals for their members free of charge.
Your Guide to Medicare Preventive Services

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4 Simple Steps to Understanding Medicare (Boomer Benefits, an insurance agency's fairly helpful explanation)
CMS is mailing new Medicare cards.
10 Essential Facts About Medicare and Prescription Drug Spending: A Slideshow(Kaiser Family Foundation analysis)
Data.CMS.gov (various pages flash by--to click on for more info: Part D Prescriber Lookup Tool, Medicare Revalidation List, Medicare Physician and Supplier Lookup Tool, Market Saturation and Utilization, Qualifying APM Participant (QP) Lookup Tool, Opt Out Affidavits, Order and Referring.
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, as well as from the online Medicare Plan Finder and Medicare's helpline (www.medicare.gov/, 800-633-4227). [WARNING: The $11 Million Dollar Medicare Tool That Gives Seniors the Wrong Insurance Information (Akilah Johnson, ProPublica,11-25-19) The federal government recently redesigned a digital tool that helps seniors navigate complicated Medicare choices, but consumer advocates say it’s malfunctioning with alarming frequency, offering inaccurate cost estimates and creating chaos in some states during the open enrollment period. Look here to compare drug plans (Part D) and Medicare Advantage (Part C)
Readers and Tweeters Find Disadvantages in Medicare Advantage (Letters to the Editor, KHN, 11-12-21) See also Medicare Plans’ ‘Free’ Dental, Vision, Hearing Benefits Come at a Cost (Phil Galewitz, KHN, 10-27-21)
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 Compare tool. 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."
Does Medicare pay for assisted living? Understand what’s covered—and your other options (Liz Seegert, Fortune, 7-17-23) Medicare covers the medical services that people in assisted living need, just as they would if you were still at home, but does not pay for housing, room, food or other fees. It also won’t pay for aides or personal care services, with limited exceptions. “If they have low income and assets they might qualify for Medicaid or a state-funded program that might cover this. But for everyone else, they must pay for this help entirely themselves or rely on friends and family for help.”

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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, but your Social Security number will be better protected.
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.

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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 & 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.)

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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.

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
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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Medigap vs. Medicare Advantage

Be sure to read this!


The Truth About Those Medicare Advantage TV Commercials (Richard Eisenberg, Next Avenue, 11-5-21) Some of what you hear on those Medicare Advantage TV ads is true, but the fine print shows that "free" isn't really "free." When the commercials say "zero premium, zero deductible and zero co-pay," that's not the whole story.Savage said that due to the Medicare program's rules, Medicare Advantage enrollees could wind up paying out of pocket as much as $7,500 a year; more than $11,000 a year if you use out-of-network health care providers. Before signing up for a Medicare Advantage plan, understand that anytime you want care other than an emergency, the plan has to approve it. So, Savage advised, "think very carefully before you switch out of traditional Medicare, which lets you see just about any doctor or go to any hospital."
The Pros and Cons of Medicare Advantage (Penelope Wang, Consumer Reports, 11-3-22) Popular Advantage plans come with some risks. Here’s how to weigh your options.
      It’s easy to see the appeal: Original Medicare requires piecing together care from what’s called Part A, for in-patient hospital and skilled nursing care, and Part B, for doctor services. That typically costs about $165 a month (with the cost deducted from your Social Security check). Plus, many people pay extra for Medigap, to cover copays and other out-of-pocket costs, as well as a Part D plan for drugs.
       Advantage plans (also called Part C), on the other hand, provide the benefits of Parts A, B, and often D, usually for about the same amount, with lower copays, so there’s no need for Medigap. Some also offer benefits not in Original Medicare, such as fitness classes or some vision and dental care. Sounds good—but be wary.

       “Some people in Medicare Advantage end up paying unexpectedly high costs when they become ill or find their network lacks the providers they need,” says Tricia Neuman, senior vice president at Kaiser. If you have chronic conditions or significant health needs, you may want to think twice. For one thing, with Original Medicare you can see any provider that accepts Medicare, which is most of them.

       "Medicare Advantage plans typically require that you get care from a more limited network of providers, and you may need pre-authorization to see specialists, says Melinda Caughill, a co-founder of 65 Incorporated, a firm that provides Medicare enrollment guidance.

      "A recent Kaiser study found that about half of all Medicare Advantage enrollees would end up paying more than those in traditional Medicare for a seven-day hospital stay.

      "Medicare Advantage plans may be especially problematic for people in rural areas.

      There is a chart comparing features, which makes Medicare Advantage look pretty good.


Medigap & Medicare Advantage Plans (Medicare.gov)
Medicare Plans’ ‘Free’ Dental, Vision, Hearing Benefits Come at a Cost (Phil Galewitz, KHN, 10-27-21) Medicare beneficiaries are inundated each autumn during the open enrollment period — by marketing from Medicare Advantage plans touting low costs and benefits not found with traditional Medicare. Dental, vision and hearing coverage are among the most advertised benefits. While people in traditional Medicare paid on average about $992 for dental care in 2018, those in Medicare Advantage plans paid $766, according to the study. For vision, people with traditional Medicare paid $242, compared with $194 for those covered by a Medicare Advantage plan. The differences are not as large as one might expect...
     Seniors typically can choose from more than 30 Medicare Advantage plans sold by several insurers. The choice is so daunting that fewer than a third of seniors bother to shop and compare during the open enrollment window — even though costs and benefits change every year. And for those who want to shop around, comparisons are not easy. The Medicare.gov website doesn’t offer a comparison of which doctors, dentists or hospitals are in the Medicare Advantage network or provide details about limits on dental, hearing and vision care. For that information, consumers must go to each insurer’s website and read through a summary of benefits that can be dozens of pages long. Jenny Chumbley Hogue, an insurance broker near Dallas and an analyst at medicareresources.org, which helps seniors navigate the program, said consumers should choose a plan based on whether their doctor is in that network or their drugs are covered at the lowest cost.
No Gaps In Understanding: Here’s Your Primer On Medigap Coverage (Judith Graham, Kaiser Health Network, 7-26-18) [KHN is an editorially independent program of the foundation.] Every year, older adults can opt out of a Medicare Advantage plan and opt in to original Medicare during open enrollment season, which begins on Oct. 15. But unexpected problems can arise with this change. Seniors often don’t realize that private insurers are required to offer Medigap policies, or supplemental insurance, only when people first sign up for Medicare. Seniors who later want to return to original Medicare might not be able to purchase Medicare supplemental insurance, also known as Medigap coverage. Medigap covers some or all of the out-of-pocket costs associated with Medicare (deductibles, copayments and coinsurance), minimizing the financial risk to seniors. Under original Medicare, there is no limit to an individual’s out-of-pocket liability. (By contrast, Medicare Advantage plans limit out-of-pocket costs to a maximum $6,700 a year.) “People think they can choose Medicare Advantage one year and traditional Medicare another year, and go back and forth without difficulty,” said Tricia Neuman, senior vice president at the Kaiser Family Foundation and a co-author of a new report on consumer protections in Medigap. “But in states that don’t guarantee supplemental coverage, this might not be a realistic option.”) Only four states require insurers to issue Medicare supplemental policies to adults age 65 and older, regardless of their health status: Connecticut, Massachusetts, Maine, and New York.

Medicare Advantage (Medicare Part C) (Paying for Senior Care) Scroll down for specific information on topics such as dental coverage, hearing coverage, vision coverage, etc., as well as what Medicare Advantage doesn't cover (e.g., room and board at an assisted living facility).
What is Medicare Advantage? (My Medical Matters) Medicare Part C (Medicare Advantage 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. But you also lose some important benefits.
Types of Medicare Advantage Coverage (Medicare Interactive) Basics, cost and coverage, and comparisons with alternatives for Medicare Health Maintenance Organizations (HMOs), Medicare Preferred Provider Organizations (PPOs), Medicare Private Fee-for-Service (PFFS) plans, Medicare Special Needs Plans (SNPs), Medicare Medical Savings Account (MSA) plans.
Special Needs Plans and the Coordination of Benefits and Services for Dual Eligibles (David C. Grabowski, Health Affairs, Jan-Feb 2009) "Special Needs Plans (SNPs) are a new type of Medicare Advantage plan with the potential to coordinate Medicare and Medicaid benefits and services for dually-eligible beneficiaries. However, experience to date suggests that SNPs have not greatly expanded the number of dual eligibles enrolled in joint Medicare-Medicaid products. Importantly, SNPs need to have some contractual relationship with state Medicaid plans to add value to dual eligible beneficiaries beyond traditional Medicare Advantage plans."
What's Medicare Supplement Insurance (Medigap)? and 8 things to know about Medigap policies (Medicare.gov) A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn't cover, such as copayments, coinsurance, deductibles. Medigap policies are sold by private companies.
Medigap vs. Medicare Advantage (Consumer Reports) Know the difference before you choose. Study CR's chart to understand the difference between these two options. "Medicare does not have any limit on what you can spend out of your own pocket. The bills can mount up quickly, especially if you need costly treatments such as outpatient chemotherapy. You may have a retiree or TRICARE plan that helps pick up some or all of those costs. If not, you have two options for limiting your exposure to excessive out-of-pocket costs:

1. Medicare Supplement (Medigap) plans. Private supplemental coverage that pays all or most Part A & B out-of-pocket costs.) Part D not included.

2. Medicare Advantage. Private health plans that provide Part A & B benefits directly in place of Original Medicare. Most plans include Part D coverage.
How to choose the best medicare advantage plan for you (Consumer Reports, Oct. 2014) You have lots of tools to help with your choice
Medigap & Medicare Advantage Plans (Medicare.gov) Medigap policies can't work with Medicare Advantage Plans. If you have a Medigap policy and join a Medicare Advantage Plan (Part C), you may want to drop your Medigap policy. Your Medigap policy can't be used to pay your Medicare Advantage Plan copayments, deductibles, and premiums. If you want to cancel your Medigap policy, contact your insurance company. If you leave the Medicare Advantage Plan, you might not be able to get the same, or in some cases, any Medigap policy back unless you have a "trial right." See
Guaranteed issue rights Guaranteed issue rights (also called "Medigap protections") are rights you have in certain situations when insurance companies must offer you certain Medigap policies. In these situations, an insurance company:
---Must sell you a Medigap policy
---Must cover all your pre-existing health conditions
---Can't charge you more for a Medigap policy because of past or present health problems
In most cases, you have a guaranteed issue right when you have other health coverage that changes in some way, like when you lose the other health care coverage. In other cases, you have a "trial right" to try a Medicare Advantage Plan (Part C) and still buy a Medigap policy if you change your mind. In other cases, you have a "trial right" to try a Medicare Advantage Plan (Part C) and still buy a Medigap policy if you change your mind.
Medigap or Medicare Advantage? ( Patricia Barry, AARP Bulletin, April 2014) People often confuse the two plans, but their differences are great. Here's what you need to know
Medicare Savings Programs (Center for Medicare Advocacy) QMB, SLMB, and QI, explained. The Qualified Medicare Beneficiary program (QMB), Specified Low-Income Medicare Beneficiary program (SLMB), and Qualified Individual program (QI), help Medicare beneficiaries of modest means pay all or some of Medicare’s cost sharing amounts (ie. premiums, deductibles and copayments). To qualify an individual must be eligible for Medicare and must meet certain income guidelines which change annually. Covering some of the same territory: Health Care Cost Assistance Guide Medicare, Medicaid, and State Assistance Programs. (Medicare Advantage)
CareSet Becomes First Organization with Research Access to Medicare Advantage Data (Bryan Lang, CareSet Systems, 7-26-18) “For the first time, the marketplace will have transparent insight into what healthcare looks like when it is administered by private plans.”

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Medicare coverage of hospitalization


Inpatient hospital care (Medicare.gov) Medicare Part A (Hospital Insurance) covers inpatient hospital care if you meet both of these conditions:
---You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury
---The hospital accepts Medicare. (Find out ahead of time if hospital does. Not all do.)

"Medicare Part A will sometimes cover hospitalization if you don’t meet these conditions provided the hospital’s utilization review committee approves your stay during your admission."

 
Medicare Part A coverage–hospital care

Does Medicare Cover Hospital Stays? (Roberta Pescow, NerdWallet, 10-3-23) Medicare covers hospital stays, but there are limitations on the number of days and you may have to pay coinsurance. How much does hospital coverage cost with Medicare Part A?
Medicare Part A has a deductible of $1,600 in 2023 for each benefit period. Once your deductible is met, here’s how coverage and coinsurance works:
   Days 1-60 of hospitalization: You owe $0 coinsurance.
   Days 61-90 of hospitalization: You owe $400 per day in 2023 for each benefit period.
   Days 91 and after: You owe $800 in 2023 for each of your “lifetime reserve days” after day 90 for each benefit period, of which you have 60 to use over the course of your lifetime.
   Days after lifetime reserve is used up: No coverage. You owe full cost.

 

Be aware of exclusions that Medicare doesn't cover: :
Private rooms (unless they’re medically necessary). 
In-room TV or phone (if the hospital charges separately for these services). 
Private-duty nurses.
Personal care items, such as socks or razors.


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 (hospital insurance) of traditional Medicare covers inpatient hospital services, skilled nursing home care and hospice, among other things. Part B (medical insurance) of traditional Medicare helps cover preventive care and physician and outpatient services, among other things. Part D (prescription drug coverage) plans are private insurance plans covering prescription drug costs. Medicare Advantage (Part C) is an alternative to traditional Medicare, in which  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:
---What's Medicare? (Medicare.gov) New to Medicare? Learn how to get started.
Medicare's Challenging Relationship with Hospitals (Globe1234.com) Important information.
Here Are Some Rules About Medicare That You Need to Know (Debra Schuster, ElderCare Matters, 4-23-19) Medicare allows hospitals to place Medicare beneficiaries on “observation status” for up to 48 hours if the hospital believes Medicare will not pay for inpatient care. (If you are in the hospital 3 days you are no longer on 'observation status.') The financial consequences of not being admitted as an inpatient can be devastating. Some of the rules about Medicare can be challenging to understand, including those governing stays in nursing facilities.


Understanding Medicare Observation Status (Howard Gleckman, Forbes, 1-2-19) "No issue generates more anger and confusion among Medicare recipients than observation status—that hospital stay that really isn’t a hospital stay.... While reimbursements differ depending on a patient’s condition, Medicare pays hospitals roughly one-third less for an observation stay than for an admission....Some hospital critics say there is a second, more self-serving reason why hospitals treat patients in observation instead of admitting them: to avoid readmission penalties. In recent years, Medicare has been cutting payments to hospitals that readmit certain patients within 30 days."


Here Are Some Rules About Medicare That You Need to Know (Debra Schuster, ElderCare Matters, 4-23-19) Medicare allows hospitals to place Medicare beneficiaries on “observation status” for up to 48 hours if the hospital believes Medicare will not pay for inpatient care. (If you are in the hospital 3 days you are no longer on 'observation status.') The financial consequences of not being admitted as an inpatient can be devastating. Some of the rules about Medicare can be challenging to understand, including those governing stays in nursing facilities.
Understanding Medicare Observation Status (Howard Gleckman, Forbes, 1-2-19) "No issue generates more anger and confusion among Medicare recipients than observation status—that hospital stay that really isn’t a hospital stay.... While reimbursements differ depending on a patient’s condition, Medicare pays hospitals roughly one-third less for an observation stay than for an admission....Some hospital critics say there is a second, more self-serving reason why hospitals treat patients in observation instead of admitting them: to avoid readmission penalties. In recent years, Medicare has been cutting payments to hospitals that readmit certain patients within 30 days."


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.

 

See also How Medicare and Medicaid fall short

For example:
Hospitals Said They Lost Money on Medicare Patients. Some Made Millions, a State Report Finds. (Fred Clasen-Kelly, KHN, 10-25-22) For the same year that Atrium’s website says it recorded the $640 million loss on Medicare, the hospital system claimed $82 million in profits from Medicare and an additional $37.2 million in profits from Medicare Advantage in a federally required financial document... The lack of clarity about whether health systems like Atrium gain or lose money treating Medicare recipients reflects how loosely the federal government regulates the way hospitals calculate their community benefits. br />• Medicare Fines for High Hospital Readmissions Drop, but Nearly 2,300 Facilities Are Still Penalized (Jordan Rau, KHN, 11-1-22)“Covid has been a tremendously disruptive force for all aspects of health care, most certainly CMS’ quality measurement programs,” Demehin said. “It’s probably going to be a couple of volatile years for readmission penalties.”
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.

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Medicare's power to control drug prices


Legal fights and loopholes could blunt Medicare's new power to control drug prices (Leslie Walker, Dan Gorenstein, Shots, Health News from NPR, 9-15-22) In August, "the White House celebrated the passage of the the Inflation Reduction Act, a sweeping climate, tax and health care package passed in August. Among other measures, it grants Medicare historic new powers to control prescription drug prices.

     "...for the people faced with putting this law into practice, the work is just beginning. Now, federal government employees and pharmaceutical companies begin a new round in the fight over how much the massive Medicare program pays for prescription drugs. This round is shaping up to be a bureaucratic brawl over the new law's fine print, its loopholes and its legality. Here's what's at stake and what stands in the way of Medicare benefiting from the new measures.
      Two of the biggest battlegrounds will be a pair of new powers that lawmakers gave Medicare: Medicare's new powers to cut and cap prescription drug prices. One of the new powers lets the federal government negotiate deep discounts directly with drugmakers for some of the drugs that cost Medicare the most. This provision is unprecedented — and one that the pharmaceutical industry fought for decades. To be eligible for negotiation, drugs must be among the 100 products costing Medicare the most money,have been on the market at least several years, lack generic competition, and be unaffected by several other exemptions in the law.
      The other new power lawmakers gave Medicare is known as the inflation rebate. It allows Medicaid to claw back any price increases that exceed the rate of inflation, and has significantly lowered Medicaid's spending.


Medicare Begins to Rein In Drug Costs for Older Americans (Paula Span, NY Times, 1-14-23) Reforms embedded in the Inflation Reduction Act will bring savings to seniors in 2023. Already some Republican lawmakers are aiming to repeal the changes.

      "Out-of-pocket insulin costs for 2023 drop, to a $35 monthly cap on insulin, which will affect more than a million insulin users who have Part D through Medicare Advantage plans or free-standing plans purchased along with traditional Medicare.The legislation establishes other requirements to lower drug prices for Medicare beneficiaries, about three-quarters of whom have Part D plans. Medicare has begun a one-time special enrollment period through the end of 2023, allowing insulin users to drop, add or change Part D plans. Beneficiaries have to call the 1-800-MEDICARE number to make a switch. Counselors at State Health Insurance Assistance Programs (SHIPs) can also help with the decision.
      "In the second major change, adult vaccines covered by Part D, typically offered at pharmacies, are now free, without deductibles or co-pays, just as the flu and pneumonia vaccines (covered by Part B) have been. That will in particular improve access to the shingles vaccine, the most expensive adult vaccine.
        "The third major change: When prices for drugs covered under Part D, and some under Part B, increase faster than the inflation rate, the law now requires drug manufacturers to pay rebates or face stiff penalties."
       "Probably the most significant policy change is that the new law requires Medicare to begin bargaining with drug manufacturers, “the first time the federal government is not just allowed but required to negotiate prices on behalf of Medicare beneficiaries,” Dr. Cubanski said. "Republicans in Congress, nearly all of whom voted against the Inflation Reduction Act, have already introduced legislation to repeal the measures intended to lower drug prices, and supporters are braced for court challenges, too."


What Are the Prescription Drug Provisions in the Inflation Reduction Act? (KFF, Charts and Slides, 3-17-23)
How Will the Prescription Drug Provisions in the Inflation Reduction Act Affect Medicare Beneficiaries? Juliette Cubanski, Tricia Neuman, Meredith Freed, and Anthony Damico, KFF, 1-24-23) The Inflation Reduction Act of 2022 includes a broad package of health, tax, and climate change provisions. "The law includes several provisions to lower prescription drug costs for people with Medicare and reduce drug spending by the federal government. These provisions will take effect beginning in 2023 (see table showing schedule of changes. This brief examines the potential impact of these provisions for Medicare beneficiaries nationally and by state.
The Public Weighs In On Medicare Drug Negotiations (Ashley Kirzinger, Audrey Kearne, Mellisha Stokes, Liz Hamel, and Mollyann Brodie, KFF, 10-12-21) One-third of the public say the argument from those opposed to drug price negotiations is convincing compared to a large majority (84%) who say they found the argument from those in favor convincing. Neither President Biden nor members of either party in Congress has gained the full confidence of the public to do what’s right for the country on prescription drug pricing.
HHS Releases Initial Guidance for Historic Medicare Drug Price Negotiation Program for Price Applicability Year 2026 (HHS Press Release, 3-15-23)
VoxCare: Big Pharma’s legal fight to stop cheaper Medicare drugs, explained (VoxCare newsletter, 6-15-23), subscription required (free). "For the foreseeable future, the pharma industry's lawsuits attempting to stop Medicare from negotiating prescription drug prices, as authorized under the Inflation Reduction Act, are going to be a big health care story.
      Today's newsletter (6-15-23) is intended to give you the gist of the legal arguments being made and the long-term implications if pharma's legal arguments were to prevail. (Worth reading.)
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."

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How Medicare and Medicaid fall short (End-of-life talks and other issues)


Hospitals Said They Lost Money on Medicare Patients. Some Made Millions, a State Report Finds. (Fred Clasen-Kelly, KHN, 10-25-22) For the same year that Atrium’s website says it recorded the $640 million loss on Medicare, the hospital system claimed $82 million in profits from Medicare and an additional $37.2 million in profits from Medicare Advantage in a federally required financial document... The lack of clarity about whether health systems like Atrium gain or lose money treating Medicare recipients reflects how loosely the federal government regulates the way hospitals calculate their community benefits.
They could lose the house — to Medicaid (Tony Leys, Shots, NPR, 3-1-23) "Federal law requires all states to have "estate recovery programs," which seek reimbursements for spending under Medicaid, the joint federal and state health insurance program mainly for people with low incomes or disabilities. The recovery efforts collect more than $700 million a year...
     "Iowa's Medicaid program had spent $226,611.35 for Ruhl's health care, and the government was entitled to recoup that money from her estate, including nearly any assets she owned or had a share in. If a spouse or disabled child survived Ruhl, the collection could be delayed until after their death, but the money would still be owed. "The notice said the family had 30 days to respond.
      "Supporters say the clawback efforts help ensure people with significant wealth don't take advantage of Medicaid.
      "Critics say families with resources, including lawyers, often find ways to shield their assets years ahead of time — leaving other families to bear the brunt of estate recoveries. For many, the family home is the most valuable asset, and heirs wind up selling it to settle the Medicaid bill. "The 2021 federal advisory report urged Congress to bar states from collecting from families with meager assets, and to let states opt out of the effort altogether.       "The program mainly recovers from estates of modest size, suggesting that individuals with greater means find ways to circumvent estate recovery and raising concerns about equity," the report says."
Government Watchdogs Attack Medicare Advantage for Denying Care and Overcharging (Fred Schulte, KHN, 6-29-22) The Government Accountability Office and the Health and Human Services inspector general’s office say seniors enrolled in the program are suffering and taxpayers are getting bilked for billions of dollars a year.
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
Medicare Fines for High Hospital Readmissions Drop, but Nearly 2,300 Facilities Are Still Penalized (Jordan Rau, KHN, 11-1-22)“Covid has been a tremendously disruptive force for all aspects of health care, most certainly CMS’ quality measurement programs,” Demehin said. “It’s probably going to be a couple of volatile years for readmission penalties.”
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.
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.
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."
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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Help spot and fight Medicare and Medicaid fraud

When you get your new Medicare card, don’t throw your old one in the trash. Instead, put it through a shredder or “spend time cutting it up with a pair of scissors” to make sure the part showing your Social Security number is destroyed, said Amy Nofziger, a fraud expert for AARP.
       If you suspect fraud, report it to the FTC, AARP's fraud help line, 1-877-908-3360, or your local Senior Medical Patrol. Senior Medicare Patrols--SMPs--empower and help Medicare beneficiaries, their families, and caregivers prevent, detect, and report health care fraud, errors, etc.
The System Feds Rely On to Stop Repeat Health Fraud Is Broken (Sarah Jane Tribble and Lauren Weber, KHN, 12-12-22) Patients for Profit: How Private Equity Hijacked Health Care. A months-long KHN examination of the system meant to bar fraudsters from Medicaid, Medicare, and other federal health programs found gaping holes and expansive gray areas through which banned individuals slip to repeatedly bilk taxpayer-funded programs. Part of an excellent series.
Careless (Tim Evans, Emily Hopkins, and Tony Cook, Indianapolis Star, 3-11-20) An IndyStar investigation found at least $1 billion in supplemental Medicaid funding meant for nursing homes has been diverted to the state’s county hospitals since 2003. More than 20 county hospitals, including Columbus Regional, had acquired almost all of Indiana's nursing homes — at least on paper — to access enhanced Medicaid payments available only to publicly owned nursing homes. But the hospitals diverted much of the money away from the nursing homes to pad their own bottom lines, even as nursing home residents languished in poorly staffed facilities. Columbus Regional, for example, collected nearly $123 million in enhanced Medicaid nursing home payments from its eight nursing homes from 2013 to 2020. It then diverted about $55 million of that money to the hospital, while nursing homes such as Wedgewood remained among the most poorly staffed in America.
How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions (Fred Schulte and Holly K. Hacker, KHN,12-12-22) Facing rare scrutiny from federal auditors, some Medicare Advantage health plans failed to produce any records to justify their payments, government records show. The audits revealed millions of dollars in overcharges to Medicare over three years.
Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges (Fred Schulte and Holly K. Hacker, KHN, 11-21-22) Taxpayers had to foot the bills for care that should have cost far less, according to records released after KHN filed a lawsuit under the Freedom of Information Act. The government may seek to recover up to $650 million as a result.
Medicare Fraud (Senior Medicare Patrol) with links to various types of fraud schemes.
Help fight Medicare fraud (Medicare.gov)
How Medicare Stole My Mother’s Health and Life Savings: A Medicare loophole left her destitute and unhealthy (Cat Stone, Covey Club) My very independent mom was aging right. Until she checked into the hospital. When a doctor at the hospital told her that she had to sign the paperwork or leave, she signed. She told us that she was doing so well after the fracture that the hospital was just keeping her “under observation” and that she was relieved not to be “admitted.” So my mother accidentally signed away her future because the papers she initialed said she understood Medicare’s special rule: that patients “under observation” do not qualify for skilled nursing care.
Everything You Need to Know About the New Medicare Cards (But Beware of Scams) (Judith Graham, KHN, 3-15-18) Cards were sent to people covered by Medicare on a rolling basis over a 12-month period ending in April 2019. When you get your new Medicare card, don’t throw your old one in the trash. Instead, put it through a shredder or “spend time cutting it up with a pair of scissors” to make sure the part showing your Social Security number is destroyed, said Amy Nofziger, a fraud expert for AARP.
      If you suspect fraud, report it to the FTC, AARP's fraud help line, 1-877-908-3360, or your local Senior Medical Patrol. Senior Medicare Patrols--SMPs--empower and help Medicare beneficiaries, their families, and caregivers prevent, detect, and report health care fraud, errors, etc.

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Frequently asked questions (FAQs) about Medicare and Medicaid

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)
Medicare-Medicaid Coordination (CMS)
Medicare Open Enrollment FAQs (KFF) This list of Frequently Asked Questions (FAQs) about the Medicare Open Enrollment period covers a range of topics related to Medicare enrollment, including Medicare Advantage, Part D, Medigap, and more.
Medicare costs at a glance (Medicare.gov) Part A premium, Part A hospital inpatient deductible and coinsurance, Part B premium, Part B deductible and coinsurance, Part C premium (Compare costs for specific Part C plans), Part D premium (Compare costs for specific Part D plans).
7 Things to Do Before You Enroll in a Medicare Plan (Amy Schultz, Next Avenue, 11-15-17) A 7-step checklist to find the right Medicare plan for you.
Coordination of Medicare and FEHB Benefits: FAQs (OPM.gov)
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 (not always) 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. See Medicare Part D (prescription drug coverage).
---What is Medigap? (My Medicare Matters) Medigap is a supplemental insurance you can get on top of your Medicare Parts A & B. Medicare covers many healthcare costs, but it does not pay for every expense. You are responsible for these costs, sometimes called the “gaps” in Medicare coverage. Medigap helps pay for the gaps, much like retiree insurance.
---How to compare Medigap policies Medigap policies are standardized. Find a Medigap Policy in your area. (Medicare.gov).
Latest Kaiser Health News stories about Medicare Most recent stories first. An invaluable way to keep up with relevant news on the topic.
Get Answers (Medicare Interactive, Medicare Rights Center) Scroll down and find questions you didn't know enough to ask!
How to Avoid Medicare Late Enrollment Penalties (My Medicare Matters) This article is specific and very helpful.
How Do You Change Medicare Plans? (My Medicare Matters, National Council on Aging) Specifically helpful answers to a number of questions.
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?

Open Door Forum Podcasts and Transcripts. See archive of forums about ambulances; employers; home health, hospice & DME (durable medical equipment)/Quality (HHH/DME); hospitals; long-term services & supports; low income health access; new Medicare card; physicians, nurses, and allied health professionals; rural health; safety-net providers; skilled nursing facility (SNF) and long term care (LTC); special; First Friday Call, clinical outreach meeting; quality payment program.
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."
Ways to apply for 2019 health insurance (Healthcare.gov)
The new ecosystem of health data keeps getting BIGGER (Charlie Ornstein, ProPublica, 4-2018) This Google-docs tip sheet for journalists offers both very broad data sources, as well as more granular ones. None of the data sets cover individual claims-level data, which require special permissions and often cost a lot of money. Examples:
---CMS Fast Fact Sheets (Centers for Medicare and Medicaid Services)
---Medicare and Medicaid Statistics ("top level, super useful," revised annually)
---Medicaid & CHIP Enrollment Data (Medicaid.gov)
---How much doctors are paid by Medicare and what they do for that money (as translated from jargon). See ProPublica's Treatment Tracker
---What drugs doctors prescribe most (again, as translated from data talk).

America's health care system is neither healthy, caring, nor a system.” ~Walter Cronkite
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Medicare coverage of prescription drugs (Part D)

What Are Medicare Part D Plans? (My Medicare Matters) "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. Each plan can vary in cost and the drugs covered, and plans can change from year to year. A plan that covers your prescriptions this year might change and not cover them next year.

...If you choose not to enroll in Part D, you may face a late penalty, depending on your circumstances, and have to pay higher monthly premiums for the rest of the time you have drug coverage from Medicare. Learn more about Part D penalties you might face if you enroll late.

Many states have low-cost Part D plans that can act as a safety net in case your health situation changes. Consider this if you don’t take prescription drugs now." Read about examples of prescription drug coverage you may currently have that could count as creditable coverage. If "you do not have creditable coverage and delay your enrollment in Part D, you will have to pay a penalty for the life of your Part D plan coverage."
Medicare names first 10 drugs up for price negotiations with government (Berkeley Lovelace Jr, MSN.com, 8-28-23)
Eliquis, a blood thinner
Xarelto, a blood thinner
Januvia, a diabetes drug
Jardiance, a diabetes drug
Enbrel, a rheumatoid arthritis drug
Imbruvica, a drug for blood cancers
Farxiga, a drug for diabetes, heart failure and chronic kidney disease
Entresto, a heart failure drug
Stelara, a drug for psoriasis and Crohn's disease
Fiasp and NovoLog, for diabetes

Millions of Medicare Part D Enrollees Face Increases in Premiums and Other Costs in 2020 if They Do Not Switch Plans During Open Enrollment (Chris Lee, KFF, 11-14-19) Among the 20 stand-alone Part D plans available nationwide, average premiums will range sixfold, with the two lowest-premium plans charging $13 per month (Humana Walmart Value Rx) and $14 per month (WellCare Wellness Rx) and the two highest-premium plans charging $79 per month (AARP MedicareRx Preferred) and $83 per month (Express Scripts Medicare Choice).
How to Avoid Medicare Late Enrollment Penalties (Margie Johnson Ware, My Medicare Matters, 2-14-18). Scroll down for section on penalties for late enrollment in Part D, as well as circumstances in which you might be able to avoid the penalties.
Will the Medicare Formulary Cover My Drugs? (My Medicare Matters) Each Medicare Prescription Drug Plan will have a list of drugs it covers, called the plan’s formulary. The formulary (which will include both generic and brand name drugs) will tell you the names of the drugs the plan covers, how much you would pay for each drug and if there are limits or restrictions on your ability to get a drug.
How Much Does Medicare Part D Cost? (My Medicare Matters) "Medicare will pay part of the costs of prescription drug coverage for everyone who enrolls in a plan. How much you pay will depend on which prescription drug plan you choose and whether or not you qualify for Extra Help (Medigap) which helps cover the costs of this coverage."
Medicare Part D: A First Look at Prescription Drug Plans in 2020 (Juliette Cubanski and Anthony Damico, KFF, 11-4-19)
GoodRx for Medicare A good site for finding and comparing drug costs from various sources.
'Extra Help.' Lower prescription costs on Medicare If you meet certain income and resource limits, you may qualify for a Medicare program called Extra Help to pay the prescription costs, premiums, deductibles, and coinsurance of Medicare prescription drug coverage.Find your level of 'Extra Help' (Part D)
Extra Help basics (Medicare Interactive) for low-income Medicare participants.
The Part D donut hole, explained (Medicare Interactive) "You enter the donut hole when your total drug costs—including what you and your plan have paid for your drugs—reach a certain limit. For most plans in 2019, this amount is $3,820. You generally pay more for your drugs during the coverage gap. However, as a result of health reform, there are federally funded discounts that help you pay for your drugs during the donut hole. In 2019, there is a 75% discount for most brand-name drugs, paid for by the manufacturer and the federal government. This means you pay the remaining 25% of the cost for brand-name drugs. Similarly, the government provides a 63% discount for generic drugs. This means you pay the remaining 37% of the cost for generics."

How do you get out of the donut hole? "In all Part D plans, after you have paid $5,100 in 2019 in out-of-pocket costs for covered drugs (this amount is just the amount you have paid, not the total drug costs that you and your plan have paid), you leave the donut hole and reach catastrophic coverage. During this period, you pay significantly lower copays or coinsurance for your covered drugs for the remainder of the year."
Why You Need Part D (Danielle Kunkle Roberts, Boomer Benefits, 6-5-12) Part D has a catastrophic coverage limit, and it is the best part of the coverage. It protects Medicare beneficiaries from massive drug spending in any given calendar year.
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 benefited 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.
What drugs doctors prescribe most (in data talk!)
As Medicare Enrollment Nears, Popular Price Comparison Tool Is Missing (Susan Jaffe, Kaiser Health News, 10-8-19)
Much more information on drugs and drug prices (including Who's responsible for high drug prices and who (and who not) benefits from price gouging)

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Medicare and Medicare Advantage issues and proposed reform

Core healthcare issues and political football


Younger Medicare Beneficiaries with Disabilities Experience More Problems Using Their Coverage than People with Medicare Ages 65 and Up Majorities of beneficiaries in both age groups rate Medicare positively, but people with Medicare who are under 65 with disabilities experience more problems using their Medicare coverage, including access and cost-related problems, than beneficiaries who are 65 and older, a KFF survey analysis shows. The survey shows that 70 percent of Medicare beneficiaries under 65 with disabilities - a group that represents 12 percent of all beneficiaries - reported having a problem with their Medicare coverage in the last year, compared to 49 percent of beneficiaries ages 65 and older. This includes a larger share of those under age 65 with disabilities who say they experienced denials or delays in getting prior approval (27% vs. 9%) or insurance not paying for care they received that they thought was covered (24% vs. 8%).

      Younger beneficiaries with disabilities were also more likely to report delaying or going without specific health care services due to cost, such as dental care (42% vs. 24%), prescription drugs (18% vs. 10%), and doctor visits (14% vs. 4%). Read the article for more details.
Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need (Casey Ross and Bob Herman, Stat Investigation, Stat News,3-13-23) A Pulitzer series finalist.
---How UnitedHealth’s acquisition of a popular Medicare Advantage algorithm sparked internal dissent over denied care (7-11-23)
---UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients’ rehab care (11-14-23)
---UnitedHealth used secret rules to restrict rehab care for seriously ill Medicare Advantage patients (12-18-23)
How seniors could lose in the Medicare political wars (Julie Rovner, NPR and KHN, 2-16-23) "Republicans have repeatedly warned they would hold raising the federal debt ceiling hostage unless Democrats negotiated changes to Medicare, Medicaid, and Social Security. The three programs together, along with funding for the Affordable Care Act and Children's Health Insurance Program, account for nearly half of the federal budget.
      "In 2010, Republicans turned the tables, using what they described as "Medicare cuts" in the Affordable Care Act to sweep back to power in the House. (Those "cuts" were mostly reductions in payments to providers; beneficiaries actually got extra benefits through the ACA.) The reality is that Medicare's value as a political weapon also sabotages any effort to come together in a bipartisan way to solve the program's financing problems.
      "Many Republicans want Medicare to shift from a "defined benefit" program — in which beneficiaries are guaranteed a certain set of services and the government pays whatever they cost — to a "defined contribution" program, in which beneficiaries would get a certain amount of money to finance as much as they can — and would be on the hook for the rest of their medical expenses.This would shift the risk of health inflation from the government to seniors. And while it clearly would benefit the taxpayer, it would disadvantage both providers and the people on Medicare.
       "Republicans are correct about this: Medicare and Social Security can't be "fixed" until both sides lay down their weapons and start talking.
GOP leaders demand answers from Medicare on alleged $2B catheter fraud (Dan Diamond, Washington Post, 3-6-24) At least 10 companies are linked to an unexplained surge in bills for intermittent urinary catheters, low-cost devices used to relieve urinary incontinence. HHS alert: “Scammers are targeting Medicare enrollees through phone calls, internet ads, and text messages with offers of free services, medical equipment, or gift cards upon confirming their personal information and eligibility for specific Medicare services,” the agency’s alert reads. “Once the scammers obtain the enrollee’s personal information, monthly billing to Medicare will begin for medically unnecessary urinary catheters that may or may not actually be sent to the enrollee.”
---CMS Officials Pressed on Catheter Fraud Issue at Accountable Care Meeting (Joyce Frieden, MedPage Today,4-12-24)
House Weighs Medicare Pay Reforms For Doctors, But Costs Not Assessed (KFF Morning Breakout, 10-23) A House Energy & Commerce health subcommittee hearing Thursday discussed 23 bills or drafts that address how Medicare pays providers. Lawmakers face an end-of-year expiration when Medicare will cut payments to doctors in certain rural areas and labs. Lawmakers brought up 23 different bills on the topic, many of which are drafts that haven’t been introduced.
What President Biden and Republicans are saying about funding Medicare Michel Martin, NPR, and Julie Rovner, Health Care News, 3-12-23, discuss the politics of Medicare ahead of debt ceiling talks in Washington.

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Fixing Social Security and Medicare: Where the Parties Stand (Mark Miller, Business, NY Times, 2-18-23) A noisy exchange — provoked by Mr. Biden’s charge that some Republicans want to “sunset” Medicare and Social Security — may have left viewers wondering where politicians stand on fixing these critical programs, which face financial problems in the years ahead. Most Democrats are unified behind proposals that would raise new taxes on the wealthy and expand benefits; Republicans are less united, but conservatives have outlined changes that would shrink benefits and reduce eligibility. Republicans and Democrats have starkly different visions for how to avert insolvency for the trust funds.
Another Problem on the Health Horizon: Medicare Is Running Out of Money (Julie Rovner, HealthBent, KHN, 7-22-2020) In April, Medicare’s trustees reported that the Part A Trust Fund, which pays for hospital and other inpatient care, would start to run out of money in 2026, but their projections did not include the impact of COVID-19 on the trust fund. There are two ways the Trust Fund can get into trouble: Either the money flowing in is too little, or the payments going out for care are too much. Money comes into the fund largely from the 1.45% payroll tax paid by employees and employers. With so many people out of work due to pandemic-related shutdowns, cash flowing in has dropped dramatically. As for costs, read the article.
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. BUT SEE NEWS FLASH: No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices (Susan Jaffe, KHN, 10-10-18) "For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off. When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret. President Donald Trump is scheduled to sign two bills Wednesday that ban “gag order” clauses in contracts between pharmacies and insurance companies or pharmacy benefit managers — those firms that negotiate prices for employers and insurers with drugstores and drugmakers. Such provisions prohibit pharmacists from telling customers when they can save money by paying the pharmacy’s lower cash price instead of the price negotiated by their insurance plan."

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The Large Hidden Costs of Medicare’s Prescription Drug Program (Austin Frakt, NY Times, 8-13-18) Premiums have risen very little in the years since Medicare Part D was introduced. But the same cannot be said of the burden on taxpayers. 'In 2007, Part D cost taxpayers $46 billion. By 2016, the figure reached $79 billion, a 72 percent increase....Much of this increase is a result of growing enrollment — it has doubled in the past decade to 43 million — and higher drug prices. But there is also a subtle way in which the program’s structure promotes cost growth....when enrollees’ drug spending surpasses a certain catastrophic threshold — set at $5,000 in out-of-pocket spending in 2018 — 80 percent of drug costs shifts to a government program called reinsurance. This gives people in charge of private insurance plans an incentive to find ways to push enrollees into the catastrophic range, shifting the vast majority of drug costs off their books. For example, they could be less motivated to negotiate for lower drug prices for certain types of drugs if doing so would tend to keep more enrollees out of the catastrophic range....Changing the extent to which manufacturer’s contributions count as enrollee out-of-pocket spending is one potential reform of the program. Other solutions include increasing the liability of insurance company plans in the catastrophic range and decreasing the liability of taxpayers.This would have the effect of bringing premiums more in line with program spending. Doing so would “return Part D to the market-based program it was intended to be,” Ms. Jung said.'
Panelists explore what’s missing from Medicare (Liz Seegert, Covering Health, Association of Health Care Journalists, 12-17-18) Many beneficiaries are surprised to learn that Medicare does not cover dental care, hearing aids or eyeglasses. Many pensions don’t cover these services either. “Yet there is increasing evidence between oral health and systemic health. Now more than ever, they need access, especially those with comorbid illnesses,” Dr. Michèle J. Saunders (professor of medicine, dentistry and dental hygiene) said. Tooth loss has been associated with increased mortality and higher prevalence of heart disease, Type 2 diabetes, and aspiration pneumonia.Closing huge gaps in coverage ­– some might argue chasms – could improve public health, reduce hospitalizations, help support cognitive function, maintain quality of life and save the health system millions of dollars. But it will literally take an act of Congress for anything to really change. 'Hearing aids cost from $4,700 to $12,000 a pair. Surprisingly, fewer than 20 percent of people who own hearing aids actually use them – even the newer, less expensive, over-the-counter models. “It’s an access issue,” said Reed. “Proper fitting and fine tuning require multiple specialist visits and there’s no Medicare coverage whatsoever.” The 2017 Over-the-Counter (OTC) Hearing Aid Act allows these devices to be marketed and sold without a prescription. The FDA has until 2020 to produce regulations. But there’s still a disconnect, Reed said. “Medicare Part B covers one hearing exam a year if ordered by a physician for medical reasons. However, the exam cannot be related to a hearing aid, despite the fact that to fit a hearing aid, you have to have a hearing exam.”'
Medicare Part B Offers a Way Forward for Dental Coverage (Melissa Burroughs, Families USA, 8-18-18) Medicare dental coverage would keep seniors and people with disabilities healthier and more financially stable, Medicare dental coverage is a needed, wise, and popular investment, reports this study.
Drilling Down on Dental Coverage and Costs for Medicare Beneficiaries (Meredith Freed, Tricia Neuman, and Gretchen Jacobson, Kaiser Family Foundation, 3-13-19) Almost two-thirds of Medicare beneficiaries do not have dental coverage and many go without needed care, a new KFF analysis finds. Medicare does not cover routine preventive dental care or more expensive dental services that are often needed by older adults. Lack of dental care can lead to delayed diagnosis of serious health conditions, preventable infections and complications, chronic pain, and costly emergency room visits.
Can we fix Medicare in time? (Stephen Heuser and Maura Reynolds, The Agenda: Future of Medicare, Politico, 9-12-18) America’s most popular entitlement is straining under an older population and swelling costs. POLITICO looks at where the new ideas will come from.
---Three Obamacare tweaks that both parties can love (Lanhee J. Chen and James C. Capretta, Politico, 2-12-19) Divided government doesn’t have to mean political stalemate on health care. A Compromise on Medicaid, Market Stabilization and State Flexibility, Controlling Costs and Improving Value.
---The one big winner of the Obamacare wars (Joanne Kenen, Politico, 7-7-18) The Affordable Care Act was a bonanza for health consultants. So is Trump’s attempt to take it down.
Once Upon A Time, Republicans Wanted Nothing More Than To Reform Medicare. A Look At How That’s Changed. (KHN, 10-10-18) One of the main health care promises featured in Republican campaign ads this cycle is that theirs is the party that will protect Medicare as it is -- even though entitlement program changes have long been desired by GOP leadership.

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How eight years – and President Trump – have changed the GOP's tune on Medicare (David Weigel, WaPo, 10-9-18) 'Four weeks from today, Republicans will try to hold on to the House of Representatives with a message that buries the tea party movement deep underground: Keep us in charge, and we won't touch Medicare or Social Security. In attack ads, the National Republican Congressional Committee warns that Democrats "support cutting $800 billion from Medicare."

     In debates, Republican candidates argue that Democrats who favor Medicare-for-all would bring about "Medicare for None." That was the same phrase Democrats, citing the Wall Street Journal, used to describe Ryan's old plan to turn Medicare from an entitlement into a "premium support" program....

     "Donald Trump changed the Republican Party in a number of ways; the most impactful was, arguably, his insistence that there was no need to change Medicare, Medicaid or Social Security. This year, Republicans have largely abandoned the idea that the entitlements need to be restructured to cut the debt.' [Bernie Sanders' 'Medicare for All' campaign seems to have shifted the goal line.]
Feds Settle Huge Whistleblower Suit Over Medicare Advantage Fraud (Fred Schulte, KHN, 10-1-18) One of the nation’s largest dialysis providers will pay $270 million to settle a whistleblower’s allegation that it helped Medicare Advantage insurance plans cheat the government for several years....Medicare Advantage plans, which now enroll more than 1 in 3 seniors nationwide, have faced growing government scrutiny in recent years over their billing practices. At least a half-dozen whistleblowers have filed lawsuits accusing the insurers of boosting payments by overstating how sick patients are.
Feds Want to Force Anthem to Comply with Medicare Billing Investigation (Shelby Livingston, Modern Healthcare, 8-21-18) Health insurer Anthem has refused to comply with the U.S. Justice Department's investigation into its Medicare Advantage billing practices, according to federal court documents filed Tuesday. So the Justice Department this week asked the U.S. District Court for the Southern District of New York to force Anthem to comply with a civil investigative demand issued in March to provide testimony .... The Justice Department asked for Anthem's testimony as part of an investigation into whether Anthem unlawfully obtained hundreds of millions of dollars in Medicare Advantage risk-adjustment payments in violation of the False Claims Act by submitting inaccurate patient diagnosis codes to the CMS.
Medicare Could Save $2.8 Billion in a Single Year If Prices Could Be Negotiated (Ed Silverman, STAT, 8-1-18) By allowing the federal government to negotiate with drug makers, Medicare and its beneficiaries could save an estimated $2.8 billion in a single year for the top 20 most commonly prescribed medicines, according to a new analysis by Democrats on the Senate Homeland Security and Governmental Affairs Committee. In crunching the numbers, the committee staff found that other government agencies that are permitted to negotiate with drug companies — such as the Department of Veterans Affairs and the Department of Defense — were able to secure pricing that rose at “significantly lower rates” than wholesale prices for the most widely prescribed brand-name drugs in Medicare Part D

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Using technology to monitor patients at home gets boost from Medicare (Rebecca Vesely, Covering Health, AHCJ, 7-6-18) Remote patient monitoring – using technology to keep track of a patient’s health between doctor visits – is gaining traction as our population ages and a health care workforce shortage persists.
Are we spending too much on the dying? New research challenges this widely held view (Orly Nadell Farber, STAT News, 6-28-18) Have you heard these stats: "The U.S. spends too much money on the dying. Every year, 5 percent of Medicare beneficiaries die, but one-quarter of spending occurs in the last year of life." A study published in the journal Science, pushes back on this notion. The study team found in their new estimate that patients with the highest one-year mortality risk account for less than 5 percent of spending, much less than the original one-quarter claim. Implicit in the dialogue about wasting money in the last year of life is the assumption that there is a good way to distinguish the sick and dying patient from the sick patient who will survive.
Increases in Reimbursement for Brand-Name Drugs in Part D (Office of Inspector General, U.S. Dept of Health & Human Services) Recent increases in prescription drug prices have drawn the attention of Congress, made headlines in major media outlets, and raised concerns in Government agencies that reimburse for these drugs. Some studies also have shown that certain therapeutic classes of drugs—i.e.,groups of drugs that treat specific conditions such as diabetes and heart disease—are becoming more expensive. Drugs in these therapeutic classes are typically maintenance drugs, which means they are usually prescribed for chronic conditions. Therefore, increasing costs for these drugs may have a long-term financial impact on Part D and its beneficiaries.
Subtle but consequential changes to Medicare's handbook (Bob Herman, Axios, 5-24-18) The Trump administration is promoting policies that are favorable for the health insurance industry and private doctors through a set of new, discreet changes to the annual Medicare handbook. Three Medicare consumer groups wrote to the federal government to say that describing prior authorizations as benefits "twists the facts beyond recognition." Those groups also criticized the administration for broadly suggesting Medicare Advantage is less expensive than traditional Medicare. Health insurers and doctors wouldn't mind these changes because they could make their plans and practices sound more appealing to Medicare enrollees — potentially boosting their income.
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.

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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 [in 2017] “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)

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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)
Genomics Rising, Charlatans Circling (Lisa Suennen, MedPage Today, 4-4-18) " CMS announced that it will now pay for diagnostics tests that tell us the genetic make-up of solid tumors in advanced cancer patients. CMS, the agency that oversees Medicare and Medicaid, "said it finalized plans to cover FDA-approved tests that scan tumors for a range of genetic mutations" and further agreed that CMS "will also immediately cover tests cleared by the FDA as companion diagnostics, as long as there are approved drugs on the market that clinicians can direct their patients to as a result." The cost is high and "a majority of drugs prescribed don't have the desired impact."
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.

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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."

Cracking the Code: How doctors and hospitals have collected billions in questionable Medicare fees

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Insurance marketplace under Obamacare, after Obama


U.S. signs up more than 14.5 million people for Obamacare health insurance (Reuters, 3-23-22) More than 14.5 million Americans signed up for Obamacare health insurance for 2022, a 21% jump over last year and the highest since the Affordable Care Act was signed 12 years ago, the U.S. government said on Wednesday. About 10.3 million people enrolled from the 33 U.S. states that use the online marketplace funded by the federal government and about 4.3 million people from states that sell the insurance directly to their residents.
Frequently Asked Questions about Health Reform (Kaiser Family Foundation)
Frequently Asked Questions about the Affordable Care Act and the health insurance Marketplace, (Kaiser Family Foundation) Marketplace eligibility, enrollment periods, plans and premiums. 300+ Q&As.
Separating Obamacare Facts From Fiction (Frank Addessi, The Simple Dollar, 8-28-15)
Best Health Insurance Companies of 2019 (Saundra Latham, The Simple Dollar, 9-12-19)
It’s Obamacare Sign-Up Time: How to Untangle Coverage Choices (Tara Siegel Bernard, NY Times, 11-1-18) Must-read, if you have to make decisions. The insurance marketplace created by the Affordable Care Act is still here, but Republican efforts to hobble the law have yielded new options, and some potential pitfalls, now that open enrollment has begun.
Republicans Put In Bind Over Preexisting Conditions (Nathaniel Weixel, The Hill, 11-3-18) New actions from the Trump administration are complicating efforts of vulnerable Republicans to show their support for pre-existing condition protections heading into Tuesday's midterm elections. The Trump administration moved last week to allow states to waive certain ObamaCare requirements and pursue conservative health policies that were previously not allowed under the Obama administration.
GOP Candidates Are Hearing It From Constituents With Pre-Existing Conditions (Emily Kopp, Roll Call, 11-2-18) Outspoken patients feel like they’re collateral damage in the battle over ‘repeal and replace.’ Republicans have tried to contain the damage of their “repeal and replace” push as they defend their majorities in the midterm elections. In order to pull that off, the campaigns have had to find ways to discredit the sympathetic voices of people with complex medical needs who opposed their votes. These health care advocates include people who got engaged in advocacy for the first time because of Republicans’ attempts to dismantle the law. They are patients with serious health conditions who are covered through the law’s marketplaces and patients who rely on Medicaid. They worry that without the law they could go into bankruptcy or go without care.
2019 Open Enrollment is here – and ends Dec 15 (Healthcare.gov, Nov. 2018)
Exchange (Healthcare.gov) Another term for the Health Insurance Marketplace, a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance. The Marketplace is accessible through websites, call centers, and in-person assistance.
The Marketplace in your state (Healthcare.gov)

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The Affordable Care Act (ACA)


(often called Obamacare, originally by opponents)


About 5 Million Uninsured People Could Get ACA Marketplace Coverage Without a Monthly Premium – But They Would Have to Enroll Soon (KFF Newsroom, 1-10-23) KFF has an online calculator that estimates the tax credits and premiums available to individuals and families based on their age, income, and location, and maintains more than 300 frequently asked questions about open enrollment, the health insurance marketplaces and the ACA.
Featured Affordable Care Act Resources (Kaiser Family Foundation)
Understanding the Affordable Care Act (Medical Billing and Coding)
ACA Plans Are Being Switched Without Enrollees’ OK (Julie Appleby, KFF Health News and , 4-2-24) "Some consumers covered by Affordable Care Act insurance plans are being switched from one plan to another without their express permission, potentially leaving them unable to see their doctors or fill prescriptions. Some face large IRS bills for back taxes.
      "Unauthorized enrollment or plan-switching is emerging as a serious challenge for the ACA, also known as Obamacare. Brokers say the ease with which rogue agents can get into policyholder accounts in the 32 states served by the federal marketplace plays a major role in the problem, according to an investigation by KFF Health News.
      "Wu did not answer specific questions about whether two-factor authentication or other safeguards would be added to the federal website, though he wrote that CMS is “actively considering further regulatory and technological solutions to some of these problems.”
By a Wide Margin, Democratic Voters Now Care More About the Affordable Care Act Than Republican Voters Do, And Voters Trust Democrats More Than Republicans to Handle Its Future. (KFF Health Tracking Poll, 12-1-23) The future of the Affordable Care Act, an issue that was once a key health care issue for Republican voters, is now more important to Democratic voters, a new KFF Health Tracking Poll finds. About half (49%) of voters say it is a “very important” issue for the candidates to discuss, including more than twice the share of Democratic voters (70%) than Republican voters (32%).
Legislators Who Built Obamacare Look Back and Ahead one-hour video, Ideas Health panel, Aspen Ideas Festival, Summer 2018) One-hour video of Sens. Max Baucus (D-Mont.) and Chris Dodd (D-Conn.) and former Reps. Henry Waxman (D-Calif.) and George Miller (D-Calif.) and retiring Rep. Sander Levin (D-Mich.) looking back on the ACA, and ahead. As summed up in As ACA turns 10, some top supporters look back (Joanne Kenen, Covering Health, AHCJ, 2-17-2020) The former chairs reflected on the partisanship in Congress (which has gotten even worse) and the differences between the earlier failed health care efforts of the Bill Clinton presidency and now.

     "That the Democrats had trouble explaining a complicated law made it easier for the GOP to demagogue about it, particularly after the botched implementation of the Healthcare.gov website in the fall of 2013....The five all said they wished they could have gone even further than what the ACA ultimately achieved — but all described it as a historic achievement that protected people with pre-existing conditions and enabled millions of Americans to get health coverage. All saw it as a structure that could be built on in the future.They acknowledged that the Democrats, and the Obama presidency, paid a political price for finally achieving a health care objective that had eluded them for decades. Yet none of them had any regrets."
Trump administration suffers another Obamacare blow in court (Paul Demko, Politico, 3-28-19) 'A federal judge ruled late Thursday in Washington that the administration’s efforts to expand the availability of health plans that don’t meet the coverage rules of the Affordable Care Act is a deliberate and illegal “end run“ around the federal health care law. The ruling addressed insurance known as “Association Health Plans,” which cost less than many Obamacare plans but can also provide fewer health benefits....The ruling by U.S. District Court Judge John Bates, a George W. Bush appointee, comes just one day after another federal judge rejected the Trump administration’s embrace of work requirements for people on Medicaid, concluding that those new rules in Kentucky and Arkansas violate the program’s primary goal of delivering health care coverage to low-income Americans....The Trump administration’s moves infuriated many Republican lawmakers, still smarting from failed repeal efforts in 2017. They would prefer to attack Democrats for efforts to pass “Medicare for All," which they deride as socialized medicine that will eliminate all private insurance coverage.'
The GOP's Health Problem: They Like Big Chunks of the Affordable Care Act (Drew Altman, Kaiser Family Foundation, Axios, 12-18-18) Now that a Texas judge has ruled that the entire Affordable Care Act is unconstitutional — all because of its individual mandate — Republicans may find themselves wishing for a different outcome. Democrats will now use the 2020 campaign to paint Republicans as threatening a host of popular provisions in the ACA, including protection for pre-existing conditions. Even Republicans favor many provisions of the ACA. The individual mandate was by far the least popular part of the law and gave them something to crow about. Now, they may have bought more than they bargained for.
Trump Administration Steps Up Obamacare Attack, Asks Court To Overturn Law. Democrats Pounce as Trump Administration Ratchets Up Attack on Obamacare (Reuters, 3-16-19) Democrats said the move to overturn Obamacare would overshadow Republican President Donald Trump's claim of victory following the conclusion of Special Counsel Robert Mueller's probe of Russian interference in the 2016 presidential election. The legal filing gave Democrats a natural opening to focus on an issue they say is more important to voters than the Mueller investigation. "We always felt that the issues that affect average Americans - healthcare, climate change, jobs - (are) far more important to them, and to us, than what happens in an investigation," Senate Minority Leader Chuck Schumer told reporters. See Democrats Delighted By Trump’s Pivot To Health Care As Republicans, Caught Off Guard, Are Put In Awkward Position For 2020 (KHN, 3-27-19) Democrats have largely viewed health care as a winning topic, and President Donald Trump's renewed focus on the issue--right before House Speaker Nancy Pelosi (D-Calif.) announced a plan to shore up the health law marketplaces--gives them an easy talking point as election season draws ever nearer. For Republicans, it shifted the spotlight from a topic that was a political victory for them--the Mueller investigation--onto one where they've repeatedly stumbled in the past two years. A roundup of news stories on the topic. including NY Times: Democrats Pivot Hard to Health Care After Trump Moves to Strike Down Affordable Care Act )3-26-19) The Trump administration’s decision to ask a federal appeals court to invalidate the Affordable Care Act has given House Democrats a new opening to pursue what they see as a winning political strategy: moving past talk of impeachment to put kitchen-table issues like health care front and center.
• 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.) about the original Affordable Care Act:
Summary of the Affordable Care Act (Kaiser Family Foundation). Many other ACA-related resources here, too.
ACA Signups.net (a potpourri of ACA information, explanations, and updates)
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


Frequently Asked Questions about the Affordable Care Act and the health insurance Marketplace, (Kaiser Family Foundation) Marketplace eligibility, enrollment periods, plans and premiums. 300+ Q&As.
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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Trump and the two parties on health care

Health Care Crowds Out Jobs, Taxes in Midterm Ads ( Brian McGill and Julie Bykowicz. Wall Street Journal, 10-9-18) Eight years ago, the newly passed Affordable Care Act was so widely criticized that it contributed to Democrats losing control of the House of Representatives. But in this midterm election, health care is the party’s most-mentioned topic in advertising—far above anything else, including opposition to President Trump. Meanwhile, Republicans—who have made repealing the Affordable Care Act one of their top advertising messages since the 2010 election—are barely mentioning it this year, after the GOP-led Congress tried unsuccessfully to overturn the law last year. The party has instead turned its attention to touting the tax legislation Mr. Trump signed into law late last year
AP FACT CHECK: Trump Distorts Democrats' Health Care Ideas (Assoc. Press, New York times, 10-9-18) Forget "Obamacare." President Donald Trump has found a new target when it comes to ideas from the Democrats for the nation's health care system. In rallies for the November midterm elections, Trump is going after "Medicare for All," the rallying cry of Sen. Bernie Sanders, the Vermont independent who caucuses with Senate Democrats. Trump is trying out attack lines echoed by other Republicans that a government-run system would wreck the existing and enormously popular Medicare program for seniors and disabled people. There definitely are serious questions about "Medicare for All," including the massive tax increases that would be needed to pay for it and longstanding differences in society about the proper function of government. But Trump omits any mention of improved benefits for seniors that Sanders and other Democrats promise. And he implies that Democrats are all lined up behind the idea, when they are not. THE FACTS: "Medicare for All" means different things to different Democrats. For Sanders, it's a "single-payer" system in which the government substitutes for private insurers and employers, paying for almost all medical care with tax money instead of premiums. But for others, "Medicare for All" means allowing people to buy into a new government plan modeled on Medicare, while leaving private insurance in place.
Trump’s losing fight against Obamacare (Paul Demko and Adam Cancryn, Politico, 8-1-18) . President Donald Trump can't kill Obamacare, no matter how hard he tries. His administration's latest threat to the law, unveiled Wednesday, expands the availability of short-term health plans that critics deride as “junk” insurance. The health care law is proving surprisingly resilient to the administration’s efforts to tear it down. Public support for Obamacare has skyrocketed since congressional Republicans made ill-fated repeal attempts last year.
Trump’s Sabotage of Obamacare Is Illegal (law professors y Nicholas Bagley and Abbe R. Gluck, Op Ed, New York Times, 8-14-18) When Congress declined to repeal the Affordable Care Act, as Mr. Trump had requested, he said that he was taking on that job himself: “So we’re going a little different route.” A president doesn’t have the right to dispense with laws he dislikes. Never in modern American history has a president so transparently aimed to destroy a piece of major legislation.
‘Short Term’ Health Insurance? Up To 3 Years Under New Trump Policy (Robert Pear, NY Times, 8-1-18) 'The Trump administration issued a final rule on Wednesday that clears the way for the sale of many more health insurance policies that do not comply with the Affordable Care Act and do not have to cover prescription drugs, maternity care or people with pre-existing medical conditions. President Trump has said that he believes that the new “short-term, limited-duration insurance” could help millions of people who do not want or need comprehensive health insurance providing the full range of benefits required by the health law. The new plans will provide “much less expensive health care at a much lower price,” Mr. Trump said. The prices may be lower because the benefits will be fewer, and insurers do not have to cover pre-existing conditions or the people who have them.' Another way of putting it: Trump Administration Widens Availability of Skimpy, Short-Term Health Plans (Amy Goldstein, WashPost, 8-2-18) "Buyers take note: Plans will carry a disclaimer that they don’t meet the ACA’s requirements and safeguards. And there’s no federal guarantee short-term coverage can be renewed."
What to Know Before You Buy Short-Term Health Insurance (Margot Sanger-Katz, NY Times, 8-1-18) "They are also less costly and will be marketed extensively....But the plans are cheaper for a reason: They tend to cover fewer medical services than comprehensive insurance, and they will charge higher prices to people with pre-existing health problems, if they’ll cover them at all."
New York Pushes Back Against Insurance Premium Increases (Kate King, WSJ, 8-1-18) New York Gov. Andrew Cuomo is pushing back against health insurers that want to raise premiums after the federal repeal of financial penalties for those who lack insurance, while New Jersey officials said they avoided such hikes by making the coverage mandate state law. On Monday, Mr. Cuomo directed the state Department of Financial Services to reject the portion of insurers’ proposed rate increases that are tied to the federal changes, saying the companies are seeking to “gain windfall profits” from changes to the Affordable Care Act under President Donald Trump.

Trump's previous promises on health care (Dylan Stafford, CNN, 6-24-17) "I'm going to take care of everybody." "I'm not going to cut Social Security like every other Republican. And I'm not going to cut Medicare or Medicaid."
A Closer Look at Trump’s Proposed Medicare, Medicaid Cuts (Nick Blumberg, Chicago Tonight, WTTW, 2-13-18) "in that plan, the Trump administration wants an almost complete reworking of Medicare and Medicaid, reducing spending by $554 billion over the next decade....Amanda Starc, associate professor at Northwestern’s Kellogg School of Management who studies health insurance and economics, agrees that the Medicaid cuts are the more significant....“If you look at the set of people on Medicaid we could actually expect to work a full-time job, it’s actually quite small.” And, she thinks it will cost states more to enforce the work requirements than it’ll save them. “The juice is not worth the squeeze.”
Why the Trump administration made it easier for Virginia Republicans to expand Medicaid (WashPost, 5-31-18) In becoming the first state in nearly two years to open Medicaid to more of its poor residents, Virginia lawmakers found political buffering and momentum in a recent conservative health policy shift in Washington. Three of four Republican state senators who defected from their caucus’s long-held opposition to expanding Medicaid cited the fact that the Trump administration is allowing states to impose work requirements for the first time in the half-century history of this central piece of the nation’s social safety net.
The Trump Administration’s Newest Strategy For Excluding Planned Parenthood From Medicaid (Sara Rosenbaum, Health Affairs, 1-25-18) Medicaid has been ground zero in the war against Planned Parenthood, given the program’s outsize position as a source of health care financing for low-income and at-risk populations. Now the Trump administration has opened a new front, this time with a relatively obscure, but highly consequential, policy guidance that effectively invites states to try, once again, to push Planned Parenthood out of the program.
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.”
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.
Trump Hits Obamacare Again, Nearly Wiping Out Funds For Outreach ( Jeffrey Young and Jonathan Cohn, Huff Post, 7-10-18) It will probably mean less help for the very people who need Affordable Care Act coverage the most.
Trump administration takes another major swipe at the Affordable Care Act (Amy Goldstein, WashPost, 7-7-18) "The Trump administration took another major swipe at the Affordable Care Act, halting billions of dollars in annual payments required under the law to even out the cost to insurers whose customers need expensive medical services...the Centers for Medicare and Medicaid Services said it will stop collecting and paying out money under the ACA’s “risk adjustment” program, drawing swift protest from the health insurance industry. Risk adjustment is one of three methods built into the 2010 health-care law to help insulate insurance companies from the ACA requirement that they accept all customers for the first time — healthy and sick — without charging more to those who need substantial care."
Trump Administration Freezes Payments Required By The Affordable Care Act (Maggie Penman, Morning Edition, 7-8-18) "When the rules of the game change after the fact – insurers don't necessarily see the federal government as a particularly reliable partner right now," Levitt says. "This is one of several steps the Trump administration has taken to undermine the ACA." "When the rules of the game change after the fact – insurers don't necessarily see the federal government as a particularly reliable partner right now," Levitt says. "This is one of several steps the Trump administration has taken to undermine the ACA." "The executive order the president signed, not long after he got to the White House after the [Inaugural] Parade was effectively, 'We're declaring war on the Affordable Care Act.'" Whitlock says, the goal has been to make the marketplace as inhospitable as possible for participating plans, and this is just one more step in that direction.
What's in Trump's health care executive order? (Tami Luhby, Money, CNN, 10-13-17)
Here’s How Trump’s New Policy Would End Medicaid As We Know It (Rebecca Vallas, Talk Poverty, 1-11-18) 'Adding so-called “work requirements” to Medicaid has long been on GOP leaders’ wish list....at their core, work requirements are premised on a set of myths about poverty. First, that “the poor” are some stagnant group of people who “just don’t want to work.” Second, that anyone who wants a well-paying job can snap her fingers to make one appear. And third, that having a job is all it takes to not be poor. Reinforcing these myths is core to Trump’s divide-and-conquer playbook. That’s why he’s so keen to smear Medicaid and other popular programs as “welfare”—a term with a deeply racially charged history, evoking decades of racial stereotypes about who is poor in this country.'
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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.
4 ways the Trump administration wants to change Medicare (CNN, 8-22-18) After unsuccessfully trying to overhaul Obamacare and Medicaid, the Trump administration is now trying to put its stamp on Medicare. The Centers for Medicare and Medicaid Services has issued a slew of proposed rules in recent weeks. They would change how doctors and hospitals are paid for treating senior citizens and give insurers in the Medicare Advantage program more control over the medications doctors can prescribe. Here's what the administration wants to do (in summary--read the article!)"
Change how doctors are paid for office visits
Limit payments to hospitals for outpatient visits
Give Medicare Advantage plans more control over medications
Curb Accountable Care Organizations
The proposed changes would shake up the ACO industry. The agency projects that just over 100 -- or roughly one-fifth -- would drop out of the program. But the industry group for ACOs say that number would be much higher.
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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Medicaid and Medicaid's Unwinding: What you need to know

If you don't know what can go wrong, you can't act to prevent it.

 


Medicaid.gov The official site.


10 Things to Know About Medicaid (Robin Rudowitz, Alice Burns, Elizabeth Hinton, and Maiss Mohamed, KFF, 6-30-23)
Medicaid and CHIP (Healthcare.gov)
Oregon Equips Medicaid Patients for Climate Change (Samantha Young, California Healthline, 4-30-24) At least 20 states, including California, Massachusetts, and Washington, already direct billions of Medicaid dollars into programs such as helping homeless people get housing and preparing healthy meals for people with diabetes, according to KFF. Oregon is the first to use Medicaid money explicitly for climate-related costs, part of its five-year, $1.1 billion effort to address social needs, which also includes housing and nutrition benefits.
      State and federal health officials hope to show that taxpayer money and lives can be saved when investments are made before disaster strikes.

Unwinding and Returning to Regular Operations after COVID-19 (Medicaid) The expiration of the continuous enrollment condition authorized by the Families First Coronavirus Response Act (FFCRA) presents the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act. Medicaid continuous enrollment ends on March 31, 2023. States will soon resume normal operations, including restarting full Medicaid and CHIP eligibility renewals and terminations of coverage for individuals who are no longer eligible. Beginning April 1, 2023, states are able to terminate Medicaid enrollment for individuals no longer eligible. States will have up to 12 months to return to normal eligibility and enrollment operations.

    This page includes links to many fact sheets.
10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision (Jennifer Tolbert and Meghana Ammula, KFF, 6-9-23)
Status of State Medicaid Expansion Decisions: Interactive Map (KFF, 3-20-24) SOURCE: KFF analysis of state actions related to adoption of the ACA Medicaid expansion.
Medicaid Recipients Struggle To Stay Enrolled (An Arm and a Leg, KFF Health News, 6-4-24. Listen or read transcript.) Medicaid — the state-federal health insurance program for low-income and disabled Americans — has cut more than 22 million recipients since spring 2023.Medicaid — the state-federal health insurance program for low-income and disabled Americans — has cut more than 22 million recipients since spring 2023. Many families lost their Medicaid coverage in the “unwinding” of protections that had barred states from dropping people for years during the covid pandemic.

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Halfway Through ‘Unwinding,’ Medicaid Enrollment Is Down About 10 Million (Phil Galewitz, KFF Health News, 2-7-24) While more Medicaid beneficiaries have been purged in the span of a year than ever before, enrollment is on track to settle at pre-pandemic levels. Since last April, states have removed more than 16 million people from the programs in a process known as the “unwinding,” according to KFF estimates compiled from state-level data.

      "While many beneficiaries no longer qualify because their incomes rose, millions of people have been dropped from the rolls for procedural reasons like failing to respond to notices or return paperwork. But at the same time, millions have been reenrolled or signed up for the first time....about two-thirds of the 48 million beneficiaries who have had their eligibility reviewed so far got their coverage renewed. About one-third lost it....There are big differences between states....The big question, Levitt said, is how many of the millions of people dropped from Medicaid are now uninsured."
Medicaid’s ‘Unwinding’ Can Be Especially Perilous for Disabled People (Rachana Pradhan, KFF Health,11-28-23) Beverly Likens thought she’d done everything she needed to do to keep her Medicaid. Then came an unwelcome surprise: Ahead of surgery to treat chronic bleeding, the hospital said her insurance was inactive, jeopardizing her procedure. Likens had just been diagnosed with severe anemia and given a blood transfusion at the emergency room.
1 in 3 People Dropped by Utah Medicaid Left Uninsured, a ‘Concerning’ Sign for Nation (Phil Galewitz, KFF Health, 11-22-23) About a third of the 130,000 people Utah has dropped from Medicaid this year say they now lack health insurance. It’s a glimpse into the fate of people caught up in Medicaid’s “unwinding.”
How Will Rural Americans Fare During Medicaid Unwinding? Experts Fear They’re on Their Own (Jazmin Orozco Rodriguez,KFF Health News, 9-20-23) A lack of access to navigators in rural locales to help Medicaid enrollees keep their coverage or find other insurance if they’re no longer eligible could exacerbate the difficulties rural residents face. Navigators help consumers determine whether they’re eligible for Medicaid or CHIP, coverage for children whose families earn too much to qualify for Medicaid, and help them enroll. If their clients are not eligible for these programs, navigators help them enroll in marketplace plans.
Medicaid To Be Reinstated For Nearly 500,000 People Mistakenly Removed (KFF Health News Morning Briefing, 9-22-23)

    Now 29 states and D.C. are scrambling to fix a computer system error that improperly evaluated people’s Medicaid eligibility, CMS announced Thursday. The glitch led to nearly 500,000 people, including many children, losing their insurance coverage. Links to various news articles.

    Earlier, we were told: If your state says you're no longer eligible for Medicaid or CHIP coverage, you can re-apply through your state to find out if you still qualify. (In all states, Medicaid and CHIP offers health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities.)

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When Medicaid Comes After the Family Home (Paula Span, The New Old Age, NY Times, 3-16-24) Federal law requires states to seek reimbursement from the assets, usually homes, of people who died after receiving benefits for long-term care. Medicaid estate recovery means surviving family members may have to sell the home of a loved one to repay Medicaid, or the state may seize the property.'
They could lose the house — to Medicaid (Tony Leys, Shots, NPR, 3-1-23) Selected quotes:

"Federal law requires all states to have "estate recovery programs," which seek reimbursements for spending under Medicaid, the joint federal and state health insurance program mainly for people with low incomes or disabilities.

      "Supporters say the clawback efforts help ensure people with significant wealth don't take advantage of Medicaid, a program that spends more than $700 billion a year nationally.

     "Critics say families with resources, including lawyers, often find ways to shield their assets years ahead of time — leaving other families to bear the brunt of estate recoveries. For many, the family home is the most valuable asset, and heirs wind up selling it to settle the Medicaid bill.

      "Henry Ruhl, 83, wanted to leave the house to Coghlan, but since his wife was a joint owner, the Medicaid recovery program could claim half the value after his death.

      "Some of the Medicaid money went to Coghlan for helping care for her mother. She paid income taxes on those wages, and she says she likely would have declined to accept the money if she'd known the government would try to scoop it back after her mother died."
Nearly 4 million in U.S. cut from Medicaid, most for paperwork reasons (Amy Goldstein, WashPost, 7-28-23) "Most of those people have been dropped from Medicaid for reasons unrelated to whether they actually are eligible for the coverage, according to KFF, a health-policy organization, which has been compiling this data. Three-fourths have been removed because of bureaucratic factors. Such “procedural” cutoffs — prompted by renewal notices not arriving at the right addresses, beneficiaries not understanding the notices, or an assortment of state agencies’ mistakes and logjams — were a peril against which federal health officials had cautioned for many months as they coached states in advance on how best to carry out the unwinding."
       Every day, people arrive for appointments or for medicine at clinics, unaware that their Medicaid coverage has stopped..
Lost Your Medicaid? Here’s What to Do Next (Jordan Means, Health Care Insider, 2-28-23) If you lose your Medicaid eligibility, you qualify for a Special Enrollment Period for a subsidized ACA plan. Short-term health insurance also offers temporary stop-gap coverage. You could also reapply for Medicaid although time limits apply.
     "No matter the reason for denying your Medicaid, states must provide you with an opportunity to appeal the decision. If you do happen to receive a denial letter, you must submit your appeal no more than 90 days after the date of the denial letter. Applying for Medicaid occurs at the state level, so you must follow the procedures provided by your state. It may be useful to submit the appeal in person and in writing and have it date-stamped."
Medicaid: State Overviews (Medicaid.gov)

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Why millions may be kicked off Medicaid in 2023 and what to do if you lose coverage (Amanda Seitz, Associated Press, PBS, 2-26-23) Roughly 84 million people are covered by the government-sponsored program, which has grown by 20 million people since January 2020, just before the COVID-19 pandemic hit.
    But as states begin checking everyone’s eligibility for Medicaid for the first time in three years, as many as 14 million people could lose access to that health care coverage.
Medicaid: State Overviews (Medicaid.gov)
A look at why so many people may no longer qualify for the Medicaid program over the next year and what you need to know if you’re one of those people who relies on the program.
As Medicaid Purge Begins, ‘Staggering Numbers’ of Americans Lose Coverage (Hannah Recht, KFF Health News, 6-1-23) In what’s known as the Medicaid “unwinding,” states are combing through rolls to decide who stays and who goes. But the overwhelming majority of people who have lost coverage so far were dropped because of technicalities, not because officials determined they are no longer eligible
Medicaid & Assisted Living: State by State Benefits & Eligibility (Paying for Senior Care) As of 2022, 47 states and Washington, D.C., offer some level of assistance for individuals in assisted living or other forms of non-nursing home, residential care through their Medicaid programs.
Staying covered if you lose Medicaid or CHIP (HealthCare,gov) Re-apply if you lost or will soon lose Medicaid or CHIP If your state says you’re no longer eligible for Medicaid or CHIP coverage, you can re-apply through your state to find out if you still qualify. (In all states, Medicaid and CHIP offers health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities.) Check with your employer about job-based coverage. Your employer may offer health insurance. If they do, find out how to decide between job-based or Marketplace coverage.
How Will Rural Americans Fare During Medicaid Unwinding? Experts Fear They’re on Their Own (Jazmin Orozco Rodriguez, KFF Health News, 9-20-23) As states review their Medicaid rolls after the expiration of a pandemic-era prohibition against kicking recipients off the government insurance program, experts say the lack of help available to rural Americans in navigating insurance options puts them at greater risk of losing health coverage than people in metropolitan areas.
Get Marketplace coverage if you lose or are denied Medicaid or CHIP coverage (Healthcare.gov)
As early as February 1, 2023, your state may be re-starting the renewal process to check if you're still eligible to keep Medicaid or Children's Health Insurance Program (CHIP). Your state will reach out to you if they need more information. To prepare:
---Update your contact information with your state.
---Check your mail for a letter from your state.
---Complete and submit any forms your state asks for right away.
If your state finds that you no longer qualify, you may lose your Medicaid or CHIP coverage. Explains how to explore your health care options.
Thousands Face Medicaid Whiplash in South Dakota and North Carolina (Arielle Zionts, KFF Health News, 5-18-23) Thousands of South Dakotans are being knocked off Medicaid, only to be eligible to requalify several months later. Even more enrollees are likely to experience a temporary loss of coverage in North Carolina.
More States OK Postpartum Medicaid Coverage Beyond Two Months (Matt Volz, KFF Health News, 6-1-23) Montana, Alaska, Mississippi, Missouri, South Dakota, Texas, Utah, and Wyoming are among the latest states moving to provide health coverage for up to a year after pregnancy through the federal-state health insurance program for low-income people.

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The Debt Ceiling Deal Takes a Bite Out of Health Programs. It Could Have Been Much Worse. (Julie Rovner, KFF Health News, 6-1-23) A bipartisan deal to raise the government’s borrowing limit dashed Republican hopes for new Medicaid work requirements and other health spending cuts. Democrats secured the compromise by making relatively modest concessions, including ordering the return of unspent covid funds and limiting other health spending.
15 Million Americans May Soon Lose Medicaid Coverage. Here’s How to Prepare. (Dani Blum, NY Timers, 3-31-23) As pandemic protections expire, states are redetermining which people are eligible for the health insurance program. The federal government has estimated that about 15 million people will lose coverage in the coming months, including nearly seven million people who are expected to be dropped from the rolls even though they are still eligible.

Medicaid and the Children's Health Insurance Program have ballooned to cover roughly 90 million people, or more than one in four Americans — up from about 70 million people at the start of the pandemic. The guaranteed coverage amounted to an extraordinary reprieve for patients, preserving insurance for millions of vulnerable Americans and sparing them the hassles of regular eligibility checks.

      Hundreds of thousands of people could end up in the so-called coverage gap in states that have not expanded Medicaid under the Affordable Care Act, with incomes too low for subsidized coverage through those marketplaces but too high to qualify for Medicaid.
Understanding Medicaid (Medical Billing and Coding)
Privatized Medicaid is worst prank ever (Andie Dominick, Des Moines Register, 4-1-17) Privatizing administration of Medicaid was supposed to provide state budget predictability in Medicaid spending. Instead, "Iowa is being taken for a ride by experienced, for-profit insurers that will continue to try to milk every penny they can from government the way they have done in other states."            "Home-bound, disabled people who rely on daily visits from caregivers have lost access to health services."

    "The managed care companies have underpaid or not paid many health care providers."

     "The public is getting the exact opposite of the “unprecedented transparency" that was promised. Insurers refuse to explain why claims are denied and providers are not paid." This piece won a Pulitzer for Editorial Writing.
The nightmarish Supreme Court case that could gut Medicaid, explained (Ian Millhiser, Vox, 11-3-22) Health and Hospital Corporation v. Talevski is the single greatest threat to America’s social safety net since Paul Ryan. Should the defendants prevail, tens of millions of patients could effectively be stripped of legal safeguards intended to guarantee them a certain quality of care. Rather than litigating whether they did or didn't violate the laws protecting nursing home patients, the defendant is asking the Supreme Court to strip Medicaid patients of their ability to bring such lawsuits entirely. 

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Families With Sick Kids on Medicaid Seek Easier Access to Out-of-State Hospitals (Harris Meyer, KHN, 4-5-21) "Making top-quality care accessible at out-of-state children’s hospitals for kids with complex medical needs has long vexed families, providers and Medicaid programs. The choice of an out-of-state hospital can be a matter of convenience for patients and their families, and it may also mean ensuring state-of-the-art care, since only a limited number of hospitals and physicians in the country have the skills and experience to best treat children with certain conditions."
Commentary: A breakthrough model in care for America's sickest children (Dr. Kurt Newman, Modern Healthcare, 6-26-19) "Two-thirds of children with complex medical conditions have health insurance through Medicaid. Although they represent just 6% of the pediatric population served by Medicaid, these children account for 40% of Medicaid's spending on children's care. Concern for these families, and a growing body of research on children with complex medical conditions led to a three-year, $23 million project called CARE—Coordinating All Resources Effectively—supported by a federal grant from CMS' Center for Medicare and Medicaid Innovation, part of HHS. With little fanfare, CARE created a new model for caring for the estimated 3 million kids who are considered medically complex.
Coordinating Care From Out-of-State Providers for Medicaid-Eligible Children With Medically Complex Conditions (Federal Register) A Proposed Rule by the Centers for Medicare & Medicaid Services on 01/21/2020.
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 Most Common Myths About Medicaid (Shana Siegel, ElderCare Matters, 5-24-19)

Medicaid laws and regulations are complicated and subject to change.

Timing is important.

Because private payment rates are higher than Medicaid rates, the nursing home has no incentive to assist clients in protecting assets and often will give incorrect information.

The filing of a Medicaid application is comparable to filing an income tax return that you know will be audited. Consult an eldercare attorney (writes this eldercare attorney).

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CMS expands popular home and community-based program (Liz Seegert, Covering Health, AHCJ, 8-30-22) The Centers for Medicare and Medicaid is funding five additional states and territories to expand access to home and community-based services through Medicaid’s Money Follows the Person (MFP) demonstration program. MFP supports state efforts for rebalancing their long-term services and supports system so that individuals have a choice of where they live and receive services. From the start of the program in 2008 through the end of 2020, states have transitioned over 107,000 people to community living under MFP. MFP programs are designed to support Medicaid Long Term Care beneficiaries moving out of nursing homes (or other institutionalized settings) and back to their home in the community. The MFP programs give beneficiaries access to the same type of care in the community that they received in the institution and help them pay for moving expenses.
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.”
Compare Long Term Care Costs Across the United States (Carescout, for the Genworth Cost of Care Survey)

Medicaid Long Term Care Guide: Eligibility By State (Senior Planning's excellent map and information) Every state has individual programs and eligibility requirements for their Medicaid long term care. Medicaid long term care is a partnership between the state and federal government with the goal of taking care of each state’s aged, blind, or disabled populations. Click your state for a comprehensive look at available programs and eligibility qualifications.
Medicaid Spending by Drug (Centers for Medicare & Medicaid Services Data)

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Medicaid planning: Beware of the look-back period before applying (Ronald Fatoullah, ElderCare Matters, 6-4-19) Workers are entitled to Medicare because they have paid it for through payroll withholding. Medicaid is a needs-based program that has specific income and asset requirements. There is a five-year, look-back period for Medicaid. Anything you gave away through a transfer of assets or a gift during the 60 months prior to the application will be looked at and can trigger penalties that can put a serious damper on the assistance you receive.
Qualifying for Medicaid and Protecting the Family Home (Stephen J. Silverberg, ElderCare Matters, 5-15-19) While you generally don’t have to sell your home in order to qualify for Medicaid coverage of nursing home care, it is possible the state can file a claim against your house after you die, so you may want to take steps to protect your house....The home is not counted as an asset for Medicaid eligibility purposes if the equity is less than $585,000 (in 2019) ($878,000 in some states)."
4 Ways to prove that a transfer of assets was not made for Medicaid purposes (Ronald Fatoullah, ElderCare Matters, 5-7-19)
Medicaid Is Rural America’s Financial Midwife ( Shefali Luthra, KHN and Kentucky Standard, 4-13-18) Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly. As hospital treatments have become increasingly sophisticated and expensive, health care has become inextricably linked to Medicaid in rural areas, which are often home to lower-income and more medically needy people. Medicaid pays the tab for close to 45 percent of all U.S. births annually, and about 51 percent of rural births. Medicaid payments allow struggling hospitals to maintain vital costly services such as maternity care.
State by State Guide to Medicaid Coverage for Assisted Living Benefits (Paying for Senior Care)
Medicaid Coverage of Adult Foster Care for Seniors – State by State Programs & Eligibility (Paying for Senior Care)
Self-Directed Medicaid Options With these, participants, or their representatives if applicable, have decision-making authority over certain services and take direct responsibility to manage their services with the assistance of a system of available supports. The self-directed service delivery model is an alternative to traditionally delivered and managed services. See the State Waivers List Section 1115 demonstrations and waiver authorities in section 1915 of the Social Security Act are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP).
Medicaid and Nursing Homes (Skilled Nursing Facilities) Information about Medicaid and nursing home care. For more information, contact your local Area Agency on Aging, Department on Aging, or the Ombudsman office in your city or community.

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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.

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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.

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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?
Do Medicaid and Medicare Offer Dental Insurance? (Area Dentist)
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."

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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.

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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


As Pandemic-Era Medicaid Provisions Lapse, Millions Approach a Coverage Cliff (Phil Galewitz, KHN, 2-2-23) The upheaval, which begins in April, will put millions of low-income Americans at risk of losing health coverage, threatening their access to care and potentially exposing them to large medical bills. It will also put pressure on the finances of hospitals, doctors, and others relying on payments from Medicaid, a state-federal program that covers lower-income people and people with disabilities. With the rate of uninsured Americans at an all-time low, 8%, the course reversal will be painful.
After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates (Tony Leys, KHN, 3-2-23) States take drastically different approaches to recovering Medicaid money from deceased participants’ estates. Demands for repayment of Medicaid spending can drain the assets a person leaves behind, depending on where they lived. "Iowa’s Medicaid program had spent $226,611.35 for Ruhl’s health care, and the government was entitled to recoup that money from her estate, including nearly any assets she owned or had a share in. If a spouse or disabled child survived Ruhl, the collection could be delayed until after their death, but the money would still be owed."

     "Supporters say the clawback efforts help ensure people with significant wealth don’t take advantage of Medicaid, a program that spends more than $700 billion a year nationally. Critics say families with resources, including lawyers, often find ways to shield their assets years ahead of time — leaving other families to bear the brunt of estate recoveries. For many, the family home is the most valuable asset, and heirs wind up selling it to settle the Medicaid bill."

     Medicaid paperwork may not clearly explain that the government might seek reimbursement for properly paid benefits. People might decline to accept Medicaid support if they knew the government would try to scoop it back after a patient dies. (States vary in how diligently and how much they try to recover.) “The program mainly recovers from estates of modest size, suggesting that individuals with greater means find ways to circumvent estate recovery and raising concerns about equity,” the report said.

       'Medicaid is the only major government program that seeks reimbursement from estates for properly paid benefits. Medicare, the giant federal health program for seniors, covers virtually everyone 65 or older, no matter how much money they have. It does not seek repayments from estates."
How the North Carolina GOP Completely Changed Its Mind On Medicaid Expansion (Jonathan Cohn, HuffPost, 3-28-22) When they had an opportunity to open up the program to anybody with income below or just above the poverty line, Republicans in North Carolina passed it up, arguing that the existing Medicaid program was too expensive and too broken. They used to be extremely skeptical of offering the health care program to more low-income residents. That officially changed this week.
       "It was mostly reliably blue states like California and Maryland that expanded Medicaid initially. More came around over time, starting with a group of swing states where GOP governors touted the economic benefits and (in the notable case of Ohio Gov. John Kasich) biblical obligations to help the poor.
     "More recently, even some deeply red states like Idaho, Missouri and South Dakota have expanded Medicaid, though in those cases it was via ballot referendum. Medicaid expansion has always polled well; even staunchly conservative voters value the program and the chance to get health care.
Path Cleared for Georgia to Launch Work Requirements for Medicaid (Andy Miller and Sam Whitehead, KHN, 11-18-22) Georgia is set to become the only state to have work requirements for Medicaid coverage. Republican Gov. Brian Kemp’s reelection — and a surprising Biden administration decision not to appeal a federal court ruling — have freed the state to introduce its plan that would allow for a limited increase in the pool of low-income residents eligible for Medicaid.

       Questions remain about the rollout of Kemp’s plan. But it would set up Georgia as a test case for a work provision that has been proposed by several states and struck down in federal courts and by the Biden administration. The Kemp plan would be more expensive per enrollee (at least three times higher than under a regular Medicaid expansion) and would cover a fraction of the people who would get Medicaid under a full expansion.

       The new Georgia eligibility program would require a minimum of 80 hours of work or volunteering a month. Full-time caregivers, people with mental health conditions or substance use disorders, and people unable to work but who have not yet qualified for disability coverage would find it hard to qualify, said Laura Colbert, executive director of the consumer advocacy group Georgians for a Healthy Future. Other challenges could include a lack of transportation that makes it hard for enrollees to get to work and, for potential enrollees, limited access to computers to sign up.
In Tennessee, a Medicaid Mix-Up Might Land You on a ‘Most Wanted’ List (Blake Farmer, Nashville Public Radio and KHN, 2-22-23) Tennessee posts the names and photos of people arrested for alleged Medicaid fraud on a government website and social media. Some people even wind up on a “most wanted” list. Michele Johnson, executive director of the Tennessee Justice Center, said policing fraud among TennCare beneficiaries takes time and money that otherwise could be spent on something more helpful.
A Montana Addiction Clinic Wants to Motivate People With Rewards. Then Came a Medicaid Fraud Probe. (Katheryn Houghton, KHN and U.S. News & World Report, 12-19-22) A complaint was filed with the state against an addiction treatment provider that wants to use rewards — an effective but largely unregulated tool — to help people stay in recovery. The tug of war over the effective but largely unregulated tool is playing out in the northwestern Montana town of Kalispell, where a local government grant is financing rewards for people who stick with treatment provided by the outpatient clinic Oxytocin.

     Research shows that motivational incentives, called contingency management, can reduce the number of days someone takes illicit stimulants, such as methamphetamines, and can promote abstaining from other substances, such as opiates, by reinforcing healthy behavior with prizes, privileges, or cash. But clinicians are wary of running afoul of a 1972 federal anti-kickback statute that prohibits offering something of value to a federal beneficiary, such as a Medicaid recipient, to induce them to select a particular provider. KHN obtained a copy of a complaint filed against Oxytocin. In addition to the allegations of Medicaid fraud, it accuses Oxytocin of having several providers who offer services outside of their area of expertise or without a license.
Texas Says It Cares About Mothers, but Its Medicaid Postpartum Coverage Lags Behind Most Other States (Lomi Kriel, ProPublica and The Texas Tribune, 7-20-22) Gov. Greg Abbott claimed Texas provides expectant mothers “necessary resources so that they can choose life for their child,” but it is now one of a dwindling number of states not to offer Medicaid coverage for a full year after residents give birth. Texas lags behind at least 33 states, including 11 led by Republican governors, as well as the District of Columbia, all of which have already expanded or are working with the federal government to extend postpartum Medicaid benefits for a full year after giving birth.
Medi-Cal Makeover (Bernard J. Wolfson and Angela Hart, award-winning California Healthline series, Sept.-Dec. 2021)
---Layers of Subcontracted Services Confuse and Frustrate Medi-Cal Patients
---Mattresses and Mold Removal: Medi-Cal to Offer Unconventional Treatments to Asthma Patients
---California’s Reboot of Troubled Medi-Cal Puts Pressure on Health Plans
---Billions in Public Money Aimed at Curing Homelessness and Caring for ‘Whole Body’ Politic


‘Somebody Is Gonna Die’: Medi-Cal Patients Struggle to Fill Prescriptions (Samantha Young, California Healthline, 2-9-22) Problems with California’s new Medicaid prescription drug program, Medi-Cal Rx, are preventing thousands of patients from getting their medications. It didn’t anticipate that calls to its help center would take so long, and a large number of its call center workers have been sickened during the omicron surge. “Somebody is gonna die if they haven’t already,” added Dr. James Schultz, chief medical officer of Neighborhood Healthcare, which operates 17 clinics in Riverside and San Diego counties. Schultz said some of his clinics’ patients have experienced delays getting life-saving medications such as antibiotics or those used to prevent seizures and blood clots. “That’s why we’re fighting so hard.”
California Inks Sweetheart Deal With Kaiser Permanente, Jeopardizing Medicaid Reforms (Bernard J. Wolfson and Angela Hart and Samantha Young, KHN, 2-3-22) Gov. Gavin Newsom’s administration has negotiated a secret deal to give Kaiser Permanente a special Medicaid contract that would allow the health care behemoth to expand its reach in California and largely continue selecting the enrollees it wants, which other health plans say leaves them with a disproportionate share of the program’s sickest and costliest patients. The deal, hammered out behind closed doors between Kaiser Permanente and senior officials in Newsom’s office, could complicate a long-planned and expensive transformation of Medi-Cal, the state’s Medicaid program, which covers roughly 14 million low-income Californians. (Editor’s note: KHN is not affiliated with Kaiser Permanente.)
A Switch to Medicaid Managed Care Worries Some Illinois Foster Families (Christine Herman, Side Effects Public Media, KHN, 4-21-2020) Illinois is moving thousands of children into its Medicaid managed-care program. Proponents say the approach can cut costs while increasing access to care. But after a phase-one rollout of the new health plans caused thousands to temporarily lose coverage, some question whether it's the right move.
How they did it: Reporters find dire problems with Texas’ Medicaid system (Chloe Reichel, The Journalist's Resource, 3-7-19) Journalists reveal failures of Texas' managed care system through public records requests, statewide door-knocking efforts and data analysis. The move to shift Texas’ Medicaid program from a state-run system to a managed care system was intended to cut costs and improve the coordination of sick Texans’ care. Instead, it cost the state billions while patients lost access to critical care, journalists J. David McSwane and Andrew Chavez discovered in their “Pain and Profit” multi-part investigation for the Dallas Morning News. See ; Pain&Profit: Part 1: The preventable tragedy of D’ashon Morris "Doctors described him as “happy and playful” and told his foster mother he would be healthy by the time he went to kindergarten. That was before a giant health care company made a decision that saved it as much as $500 a day — and cost D’ashon everything." The first article in a series.
A job-scarce town struggles with Arkansas’s first-in-nation Medicaid work rules(Amy Goldstein, WaPo, 3-27-19) Nearly 10 months ago, Arkansas became the first place in the nation to impose work requirements on the part of Medicaid that expanded under the Affordable Care Act. This community — scarce on jobs and among the poorest in a poor state — provides an early reality check on how hard it is to carry out President Trump’s vision of a social safety net that requires most able-bodied people to work, or try to work, in exchange for government health benefits. “I am a big fan of work and people working,” said Rep. Reginald Murdock (D), a veteran state legislator from Marianna. But with jobs so scarce here, even at a time of low unemployment statewide, “threatening people with their insurance wasn’t a proper way to do it.” “What the state is doing is kicking tens of thousands of people off health care, under the guise of an experiment that they aren’t even collecting any data about, let alone analyzing it,” said Kevin De Liban, a Legal Aid lawyer in northeast Arkansas who is active in the federal lawsuit against the program. Evidence is scanty, too, of whether the requirements are leading people to get help in training for a job or searching for one. And the systems for keeping track of people with exemptions appear to be unreliable.
TennCare's revised Medicaid block grant plan: The feds get it first, then the public (Brett Kelman, Nashville Tennessean, 10-28-19) "State officials will make some revisions to a plan to overhaul TennCare after sharp criticism at public hearings this month, but the public won't find out what those changes are until after the plan is in the hands of the federal government.... The block grant plan would fundamentally transform how the federal government pays for TennCare, which insures about 1.4 million Tennesseans, most of whom are children from low-income families. Under the proposal, the state will gain more authority over TennCare and keep half the savings if the program operates at a lower cost. TennCare officials have promised not to reduce enrollment or services, but many worry that's exactly how the state will lower costs and reap the rewards....The first version of the block grant plan, revealed in mid-September, was heavily criticized in public hearings held earlier this month. During more than 130 comments at five hearings, only one person spoke in favor of the proposal."
New tip sheet explains ‘partial Medicaid expansion’ – and why it hasn’t happened (yet) ( Joanne Kenen, Covering Health, AHCJ, 1-6-2020) 'Politically, it’s a way for conservative states to cover more people with more federal dollars without fully adopting “Obamacare.” Generally they’d cover people up to the poverty line – while the Affordable Care Act envisioned Medicaid coverage up to 138 percent of the federal poverty line. The states would put people in the 100-138 percent income bracket in the ACA exchanges – where subsidies are fully federally funded, with no state matching contributions....both the Obama and Trump administrations have rejected partial expansions but for different reasons. “Democrats shunned partial expansions because they wanted states to fully expand their programs as the ACA intended,” she writes. “The Trump administration has rejected partial expansions because it creates the appearance of a broader state acceptance of the ACA.” Read more on the tip sheet, for AHCJ members only.
The Trump Administration Cracked Down on Medicaid. Kids Lost Insurance. (Lexi Churchill, ProPublica, 10-31-19) Weeks before 4-year-old Paul Petersen’s surgery to close a hole in his stomach, he lost coverage. The administration’s latest enforcement of the Affordable Care Act burdened many Idaho Medicaid recipients, as a million kids nationwide lost coverage.

Locked Out of Medicaid (Benjamin Hardy, Arkansas Times, 11-19-18) Arkansas's work requirement strips insurance from thousands of working people.
Pain & Profit (Dallas News, 2018: "Your tax money may not help poor, sick Texans get well, but it definitely helps health care companies get rich") The move to shift Texas’ Medicaid program from a state-run system to a managed care system was intended to cut costs and improve the coordination of sick Texans’ care. Instead, it cost the state billions while patients lost access to critical care, journalists J. David McSwane and Andrew Chavez discovered in their prize-winning “Pain and Profit” multi-part investigation for the Dallas Morning News.
Medicaid Won The Midterms. Here’s Why That Could Save Lives (Amal Trivedi and Benjamin Sommers, CommonHealth, WBUR, 11-8-18) "Under the Affordable Care Act, 32 states and Washington, D.C., have thus far expanded Medicaid, leading to coverage for more than 15 million low-income adults. On Tuesday, Idaho, Nebraska and Utah voted via ballot referenda to expand Medicaid, with as many as 300,000 residents in these states poised to gain coverage.The Medicaid expansion makes things much simpler: Any American with an income below 138 percent of the federal poverty level — roughly $35,000 for a family of four — can qualify....Meanwhile, a larger, population-based study of three states that expanded Medicaid coverage in the early 2000s found significant reductions in mortality in the five years following expansions....Although most of the nearly 500,000 Americans that receive regular dialysis are eligible for Medicare coverage, for those under age 65, there is typically a three-month waiting period after starting dialysis before coverage begins. Because of this, 20 percent of patients younger than age 65 with kidney failure lacked coverage at the time of starting dialysis....Furthermore, economic analysis reveals that Medicaid expansion is cost-effective, an investment with a better health return than many other policy changes. Overall, our study shows that the health effects of insurance coverage are likely to be concentrated among individuals with serious chronic illnesses, like those with kidney failure....Our calculations suggest that for every 17 individuals with end-stage kidney failure gaining Medicaid coverage, one life was saved each year."
Medicaid Expansion Boosts Hospital Bottom Lines — And Prices (Phil Galewitz, KHN, 3-27-19) Medicaid expansion was a boon for St. Mary’s Medical Center, the largest hospital in western Colorado. Since 2014, the number of uninsured patients it served dropped by more than half, saving the nonprofit hospital more than $3 million a year. But the Grand Junction hospital’s prices did not go down. The average hospital profit per each patient discharge rose to $1,359 in 2017, twice the amount in 2009. And some insurers have not passed along savings to customers that hospitals give them, said Julie Lonborg, a spokeswoman for the Colorado Hospital Association. Colorado is the first state to analyze whether hospital cost-shifting — often referred to as a “hidden tax” on health plans — dropped following Medicaid expansion. “Not only did [it] fail to deliver on the promises of alleviating the hidden healthcare tax, it allowed urban hospitals to increase charges on private payers dramatically,” said a report from the Phoenix-based Goldwater Institute. Edmond Toy, a senior adviser for the nonprofit Colorado Health Institute, noted health experts have long debated whether the higher prices hospitals charge people with private insurance are designed to make up for the losses they take on with Medicare, Medicaid and uninsured patients. He said the state report shows how hospitals in heavily consolidated markets don’t have to cut prices as their bottom lines improve. “They can charge whatever the market will bear.”
How Medicaid broke through in three deep-red states, and could do the same in more (Noam N. Levey, LA Times, 11-16-18) "Nebraska state Sen. Adam Morfeld, like healthcare advocates in many conservative states, was beginning to lose hope last year that his poorest constituents would ever get health coverage through the Affordable Care Act. “After seven years of losing in the Legislature, it was apparent that passing Medicaid expansion just wasn’t politically feasible here,” he recalled....With funding from the Fairness Project, however, advocates in Nebraska, Idaho and Utah were able to fan out across their states and collect more than enough signatures [to get on the ballot measures to expand Medicaid eligibility]. They also honed a message that spotlighted the working people who would benefit, and they drew voters’ attention to the tax money the states were sending to Washington and not getting back....

     Equally important, the three Medicaid campaigns worked to ensure that Medicaid expansion was not seen as a Democratic Party issue. That also proved critical. Surveys by Fairness Project shortly before election day showed solid support for the measures by Republican voters. In Nebraska, GOP women supported it by 13 points, according to the polling.
Status of State Action on the Medicaid Expansion Decision
Meet the group funding the fight to expand Medicaid in red states (Jessie Hellmann, The Hill, 8-2-18) Voters in Idaho, Nebraska and Utah may have the chance to achieve something their Republican state lawmakers oppose: expand Medicaid to thousands of residents. After years of being told “no” by GOP-controlled state legislatures, health-care advocacy groups have spent much of 2018 leading campaigns to put the question on the ballot in November.
After Prison, Many People Living With HIV Go Without Treatment (Heather Boerner, Shots, NPR, 10-9-18) Boerner examined the fate of people who live without treatment for their HIV after they leave prison. In addition to providing an in-depth perspective from several experts, Boerner also tells the story of Bryan C. Jones, who had left a prison in Ohio and almost immediately ditched his HIV drugs because he knew they were no longer working. A study published in PLOS One showed that people with HIV often are lost to care once they leave the monitoring and services provided in prison. "But Jones was one of the lucky ones. A few weeks after his release, he returned to his old HIV doctor, paid for with Ryan White Care Act funds while he waited for his Medicaid to be approved." A case manager connected him to permanent housing. That "made all the difference," Jones recalls. That made it easier to take meds. Many states cancel Medicaid enrollment, requiring recently incarcerated people to navigate reapplying. Other states have extremely limited eligibility for Medicaid that might exclude adults without disabilities. If we want to control (even end) HIV/AIDS, this is clearly a group that should be targeted for Medicaid expansion.
Medicaid & CHIP Scorecard (Medicaid.gov)The Centers for Medicare & Medicaid Services (CMS) developed its Medicaid and Children's Health Insurance Program (CHIP) Scorecard to increase public transparency about the programs’ administration and outcomes. The Scorecard includes measures voluntarily reported by states, as well as federally reported measures in three areas:
---State Health System Performance
---State Administrative Accountability
---Federal Administrative Accountability
Like Medicaid and CHIP beneficiaries, information in the Scorecard spans all life stages. This first version of the Scorecard includes information on selected health and program indicators. It also describes the Medicaid and CHIP programs and how they operate.
Finally, Some Answers on the Effects of Medicaid Expansion (By Aaron E. Carroll, NY Times, 7-2-18) The Medicaid logjam appears to be breaking. When the Affordable Care Act first invited states to make more low-income people eligible for Medicaid, pretty much all the blue states said yes, but many red ones said no. Now, the Maine Legislature seems poised to overcome Gov. Paul LePage’s opposition to expanding the program. Just weeks ago, Virginia voted to expand Medicaid as well. They would join 32 states that have already expanded the program, and three others actively considering it. Community health centers have long provided primary care to millions of patients in underserved areas across the United States, both urban and rural. Because most of their patients are poor or uninsured, they were expected to benefit from the Medicaid expansion.
Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence (Robin Rudowitz and Larisa Antonisse, Kaiser Family Foundation, 5-16-18) States that have expanded Medicaid under the Affordable Care Act generally have seen gains in coverage, improvements in access to and affordability of health care, and net fiscal benefits, a growing body of research and data show. At the same time, Medicaid expansion has not diverted coverage from traditional groups or significantly reduced state spending on other programs, the research shows, contrary to assertions by some critics of Medicaid expansion. For example, data do not support a relationship between states’ expansion status and Medicaid community-based long-term care services waiver waiting lists. These are the key findings in a new issue brief from the Kaiser Family Foundation that summarizes the existing research as the debate intensifies over the costs and benefits of Medicaid expansion. Some studies look at 2014-2016, when expansion costs were 100 percent financed by the federal government, so savings estimates could change, but other studies anticipate net fiscal gains even after states begin to pay the state share of the expansion costs. Several more states are considering expanding Medicaid to cover low-income adults (some through ballot initiatives), joining 32 states and Washington D.C. that have already adopted Medicaid expansion.

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States Question Costs Of Middlemen That Manage Medicaid Drug Benefits (Alison Kodjak, Shots, NPR, 8-8-18) "For example, Ohio paid the PBM $273.50 per unit for the generic version of Gleevec, a drug that treats leukemia and other cancers, while pharmacies reported the wholesale price of the drug was $83.69. In other words, the PBM charged the state more than the three times the price of the drug....If the analysis is released, it will offer an unprecedented look into the opaque world of pharmacy benefit managers and the mechanics of drug pricing....West Virginia last year stopped using pharmacy benefit managers altogether. And Kentucky is also doing an analysis of its costs while lawmakers consider legislation that would require pharmacy benefit managers that contract with Medicaid to report details of their costs to the state and ensure they pay independent pharmacies a fair price."
A Public Health Crisis in Puerto Rico Unfolds as a New Hurricane Season Nears (Listen on The Takeaway, 5-31-18) Omaya Sosa, co-founder of Puerto Rico’s Center for Investigative Journalism, and Carmen Heredia, reporter for Kaiser Health News, join The Takeaway to discuss the structural problems with health care on the island.Puerto Rico had been facing a major Medicaid funding crisis before Hurricane Maria made landfall, with nearly 1 million people at risk for losing their coverage. Medicaid is the main source of insurance for low-income families, pregnant women, children, and people with disabilities. About half of Puerto Rico's 3.4 million residents receive it. But because the island is a U.S. territory and not a state, it doesn’t receive the same federal support that states do, putting residents at higher risk for losing coverage and forcing them to overhaul their system.
What Expanding Medicaid Means For Healthcare In Virginia (Matt McCleskey, WAMU, NPR, with Kaiser Health News, 5-31-18). Listen or read. Virginia Reverses Course On Medicaid Expansion. Virginia lawmakers Wednesday voted to expand the state’s Medicaid program, ending several years of bitter fights with Democratic governors and providing coverage for an estimated 400,000 people. Julie Rovner, Kaiser Health News’ chief Washington correspondent, discusses the development with WAMU anchor Matt McCleskey. Virginia lawmakers Wednesday voted to expand the state’s Medicaid program, ending several years of bitter fights with Democratic governors and providing coverage for an estimated 400,000 people. Julie Rovner, KHN's chief Washington correspondent, discusses the development with WAMU anchor Matt McCleskey.

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How work might worsen health (Chloe Reichel, Journalist's Resource, 1-24-18) Proponents of work requirements as an eligibility condition for Medicaid often cite the beneficial health effects of employment as rationale. Though the employed tend to enjoy better health, it might be the case that the poorer health of some unemployed people explains precisely why they cannot work. In fact, a body of literature supports this notion. Further, research suggests that for healthy and unhealthy people alike, some forms of work might worsen health. Links to numerous articles, study results.
The Trump Administration’s Newest Strategy For Excluding Planned Parenthood From Medicaid (Sara Rosenbaum, Health Affairs, 1-25-18) Medicaid has been ground zero in the war against Planned Parenthood, given the program’s outsize position as a source of health care financing for low-income and at-risk populations. Now the Trump administration has opened a new front, this time with a relatively obscure, but highly consequential, policy guidance that effectively invites states to try, once again, to push Planned Parenthood out of the program.
Hate Paperwork? Medicaid Recipients Will Be Drowning in It (Margot Sanger-Katz, NY Times, 1-18-18) Kentucky’s new Medicaid waiver will ask low-income people to jump over hurdles to keep their coverage. Evidence suggests that many will fail.

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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.

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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.”

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When States Make It Harder to Enroll, Even Eligible People Drop Medicaid (Margot Sanger-Katz, NY Times, 1-18=18) Kentucky’s new Medicaid waiver will ask low-income people to jump over hurdles to keep their coverage. Evidence suggests that many will fail.
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.

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A Preventable Cancer Is on the Rise in Alabama (Eyal Press, New Yorker, 3-30-2020) The state’s refusal to expand Medicaid is causing poor women to miss out on lifesaving screenings. 'Jeff Sessions, who is running for his former Alabama Senate seat, aired a campaign ad accusing Democrats of plotting to provide “free health care for illegal immigrants.” In fact, undocumented immigrants are ineligible for Medicaid, but it’s not hard to imagine how such a claim might arouse indignation among poor voters in Alabama, where the income requirements for Medicaid are more stringent than in any state except Texas....Cervical cancer is now viewed by most physicians as preventable, and in more affluent parts of the country it is correspondingly rare. But in the poorer pockets of less wealthy states it remains disturbingly common.'
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)
One Woman’s Slide From Middle Class to Medicaid (Ron Lieber, NY Times, 7-7-17) Recently widowed, she had a net worth of roughly $600,000 as of 1998. Her health was excellent, and she dutifully purchased a long-term care insurance policy that would cover three years of nursing home costs should she ever need help. Watching over it all was her daughter, a medical social worker, and her son-in-law, a financial planner. By the time she died at the age of 94 last year, however, all of the money was gone after a diagnosis of dementia and five and a half years in a nursing home. Like so many people who never see it coming, she’d gone from being financially comfortable to qualifying for Medicaid. This is the same Medicaid that our representatives in Washington are aiming to cut right now.

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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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Medicaid issues and Medicaid reform

Trump wants to bypass Congress on Medicaid plan (Rashana Pradhan and Dan Diamond, Politico, 1-11-19) Block grants for states would achieve conservative dream on health program for poor. "The Trump administration is quietly devising a plan bypassing Congress to give block grants to states for Medicaid, achieving a longstanding conservative dream of reining in spending on the health care safety net for the poor. Three administration sources say the Trump administration is drawing up guidelines on what could be a major overhaul of Medicaid in some states. Instead of the traditional open-ended entitlement, states would get spending limits, along with more flexibility to run the low-income health program that serves nearly 75 million Americans, from poor children, to disabled people, to impoverished seniors in nursing homes. Capping spending could mean fewer low-income people getting covered, or state-designated cutbacks in health benefits — although proponents of block grants argue that states would be able to spend the money smarter with fewer federal strings attached." "During the Obamacare repeal debate in 2017, Republican proposals to cap and shrink federal Medicaid spending helped galvanize public opposition, with projections showing millions would be forced off coverage."
Providers Walk ‘Fine Line’ Between Informing And Scaring Immigrant Patients (Ana B. Ibarra, KHN, 1-15-19) 'While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.... The proposed “public charge” rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants’ use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people.'
Locked Out of Medicaid (Benjamin Hardy, Arkansas Times, 11-19-18) Arkansas's work requirement strips insurance from thousands of working people.
States Try a Gentler Approach to Getting Medicaid Enrollees to Work (Phil Galewitz, KHN,10-28-19) Under pressure from the Republican-controlled Pennsylvania legislature to require Medicaid recipients to work as a condition for coverage, state health officials have devised a gentler approach to getting beneficiaries into jobs--asking them if they want job training assistance. Despite the focus on getting Medicaid enrollees into jobs, studies show most people on Medicaid already work, and many of the rest have some disability, go to school or are caring for a family member.
Unsolved mystery: Why 700,000 Ohioans were removed from Medicaid coverage (Catherine Candisky, Columbus Dispatch, 1-12-19) More than 700,000 Ohioans were removed from the state’s Medicaid program in just the first 10 months of 2018.Franklin County had the most disenrollments, with nearly 90,000 losing the health-care coverage from January through October, the most recent data available show. But no one quite knows why such a huge shift took place in the state-federal program for low-income Ohioans.
Coverage Denied: Medicaid Patients Suffer As Layers Of Private Companies Profit (Chad Terhune, KHN and Los Angeles Times, 1-3-19) Marcela Villa isn’t a big name in health care — but she played a crucial role in the lives of thousands of Medicaid patients in California. Her official title: denial nurse. Each week, dozens of requests for treatment landed on her desk after preliminary rejections. Her job, with the assistance of a part-time medical director, was to conclusively determine whether the care — from doctor visits to cancer treatment — should be covered under the nation’s health insurance program for low-income Americans. MVilla says her managers kept pressuring her to deny expensive claims. “If it was a high-dollar case, they tried to deny it,” she says. “I told them you can’t deny it just because it’s going to cost $20,000."
Medicaid Won The Midterms. Here’s Why That Could Save Lives (Amal Trivedi and Benjamin Sommers, CommonHealth, WBUR, 11-8-18) "Under the Affordable Care Act, 32 states and Washington, D.C., have thus far expanded Medicaid, leading to coverage for more than 15 million low-income adults. On Tuesday, Idaho, Nebraska and Utah voted via ballot referenda to expand Medicaid, with as many as 300,000 residents in these states poised to gain coverage.The Medicaid expansion makes things much simpler: Any American with an income below 138 percent of the federal poverty level — roughly $35,000 for a family of four — can qualify....Meanwhile, a larger, population-based study of three states that expanded Medicaid coverage in the early 2000s found significant reductions in mortality in the five years following expansions....Although most of the nearly 500,000 Americans that receive regular dialysis are eligible for Medicare coverage, for those under age 65, there is typically a three-month waiting period after starting dialysis before coverage begins. Because of this, 20 percent of patients younger than age 65 with kidney failure lacked coverage at the time of starting dialysis....Furthermore, economic analysis reveals that Medicaid expansion is cost-effective, an investment with a better health return than many other policy changes. Overall, our study shows that the health effects of insurance coverage are likely to be concentrated among individuals with serious chronic illnesses, like those with kidney failure....Our calculations suggest that for every 17 individuals with end-stage kidney failure gaining Medicaid coverage, one life was saved each year."
How to treat Wisconsin's opioid epidemic by expanding Medicaid (Anne Stumpf, Journal Sentinel, 1-2-19) Experts and the evidence agree, medication-assisted therapy is a key to fighting addiction, and Medicaid expansion would improve access, writes a fourth-year UW medical student. It is the largest source of funding for treatment.
How Medicaid broke through in three deep-red states, and could do the same in more (Noam N. Levey, LA Times, 11-16-18) "Nebraska state Sen. Adam Morfeld, like healthcare advocates in many conservative states, was beginning to lose hope last year that his poorest constituents would ever get health coverage through the Affordable Care Act. “After seven years of losing in the Legislature, it was apparent that passing Medicaid expansion just wasn’t politically feasible here,” he recalled....With funding from the Fairness Project, however, advocates in Nebraska, Idaho and Utah were able to fan out across their states and collect more than enough signatures [to get on the ballot measures to expand Medicaid eligibility]. They also honed a message that spotlighted the working people who would benefit, and they drew voters’ attention to the tax money the states were sending to Washington and not getting back....Equally important, the three Medicaid campaigns worked to ensure that Medicaid expansion was not seen as a Democratic Party issue. That also proved critical. Surveys by Fairness Project shortly before election day showed solid support for the measures by Republican voters. In Nebraska, GOP women supported it by 13 points, according to the polling.
Status of State Action on the Medicaid Expansion Decision
Medicaid Plans Cover Doctors’ Visits, Hospital Care — And Now Your GED (Phil Galewitz, KHN, 1-7-19) 'Medicaid health plans are starting to pay for non-traditional services such as meals, transportation, housing and other forms of assistance to improve members’ health and reduce medical costs....AmeriHealth Caritas CEO Paul Tufano said studies show people with lower educational levels tend to be in poorer health. “Helping members attain their GED can be incredibly consequential for them to live the kind of life they want to live,” he said. But Tufano acknowledged that only a small fraction of people who need the assistance reach out for it. About 1,000 members have started GED training through the insurer in Pennsylvania, Louisiana, South Carolina and Delaware.'
Meet the group funding the fight to expand Medicaid in red states (Jessie Hellmann, The Hill, 8-2-18) Voters in Idaho, Nebraska and Utah may have the chance to achieve something their Republican state lawmakers oppose: expand Medicaid to thousands of residents. After years of being told “no” by GOP-controlled state legislatures, health-care advocacy groups have spent much of 2018 leading campaigns to put the question on the ballot in November.
Medicaid & CHIP Scorecard (Medicaid.gov) Scorecard

The Centers for Medicare & Medicaid Services (CMS) developed its Medicaid and Children's Health Insurance Program (CHIP) Scorecard to increase public transparency about the programs’ administration and outcomes. The Scorecard includes measures voluntarily reported by states, as well as federally reported measures in three areas:
---State Health System Performance
---State Administrative Accountability
---Federal Administrative Accountability
Like Medicaid and CHIP beneficiaries, information in the Scorecard spans all life stages. This first version of the Scorecard includes information on selected health and program indicators. It also describes the Medicaid and CHIP programs and how they operate.
Finally, Some Answers on the Effects of Medicaid Expansion (By Aaron E. Carroll, NY Times, 7-2-18) The Medicaid logjam appears to be breaking. When the Affordable Care Act first invited states to make more low-income people eligible for Medicaid, pretty much all the blue states said yes, but many red ones said no. Now, the Maine Legislature seems poised to overcome Gov. Paul LePage’s opposition to expanding the program. Just weeks ago, Virginia voted to expand Medicaid as well. They would join 32 states that have already expanded the program, and three others actively considering it. Community health centers have long provided primary care to millions of patients in underserved areas across the United States, both urban and rural. Because most of their patients are poor or uninsured, they were expected to benefit from the Medicaid expansion.
Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence (Robin Rudowitz and Larisa Antonisse, Kaiser Family Foundation, 5-16-18) States that have expanded Medicaid under the Affordable Care Act generally have seen gains in coverage, improvements in access to and affordability of health care, and net fiscal benefits, a growing body of research and data show. At the same time, Medicaid expansion has not diverted coverage from traditional groups or significantly reduced state spending on other programs, the research shows, contrary to assertions by some critics of Medicaid expansion. For example, data do not support a relationship between states’ expansion status and Medicaid community-based long-term care services waiver waiting lists. These are the key findings in a new issue brief from the Kaiser Family Foundation that summarizes the existing research as the debate intensifies over the costs and benefits of Medicaid expansion. Some studies look at 2014-2016, when expansion costs were 100 percent financed by the federal government, so savings estimates could change, but other studies anticipate net fiscal gains even after states begin to pay the state share of the expansion costs. Several more states are considering expanding Medicaid to cover low-income adults (some through ballot initiatives), joining 32 states and Washington D.C. that have already adopted Medicaid expansion.

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States Question Costs Of Middlemen That Manage Medicaid Drug Benefits (Alison Kodjak, Shots, NPR, 8-8-18) "For example, Ohio paid the PBM $273.50 per unit for the generic version of Gleevec, a drug that treats leukemia and other cancers, while pharmacies reported the wholesale price of the drug was $83.69. In other words, the PBM charged the state more than the three times the price of the drug....If the analysis is released, it will offer an unprecedented look into the opaque world of pharmacy benefit managers and the mechanics of drug pricing....West Virginia last year stopped using pharmacy benefit managers altogether. And Kentucky is also doing an analysis of its costs while lawmakers consider legislation that would require pharmacy benefit managers that contract with Medicaid to report details of their costs to the state and ensure they pay independent pharmacies a fair price."
A Public Health Crisis in Puerto Rico Unfolds as a New Hurricane Season Nears (Listen on The Takeaway, 5-31-18) Omaya Sosa, co-founder of Puerto Rico’s Center for Investigative Journalism, and Carmen Heredia, reporter for Kaiser Health News, join The Takeaway to discuss the structural problems with health care on the island.Puerto Rico had been facing a major Medicaid funding crisis before Hurricane Maria made landfall, with nearly 1 million people at risk for losing their coverage. Medicaid is the main source of insurance for low-income families, pregnant women, children, and people with disabilities. About half of Puerto Rico's 3.4 million residents receive it. But because the island is a U.S. territory and not a state, it doesn’t receive the same federal support that states do, putting residents at higher risk for losing coverage and forcing them to overhaul their system.
What Expanding Medicaid Means For Healthcare In Virginia (Matt McCleskey, WAMU, NPR, with Kaiser Health News, 5-31-18). Listen or read. Virginia Reverses Course On Medicaid Expansion. Virginia lawmakers Wednesday voted to expand the state’s Medicaid program, ending several years of bitter fights with Democratic governors and providing coverage for an estimated 400,000 people. Julie Rovner, Kaiser Health News’ chief Washington correspondent, discusses the development with WAMU anchor Matt McCleskey. Virginia lawmakers Wednesday voted to expand the state’s Medicaid program, ending several years of bitter fights with Democratic governors and providing coverage for an estimated 400,000 people. Julie Rovner, KHN's chief Washington correspondent, discusses the development with WAMU anchor Matt McCleskey.

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Privatized Medicaid is worst prank ever (Andie Dominick, Des Moines Register, 4-1-17) Privatizing administration of Medicaid was supposed to provide state budget predictability in Medicaid spending. Instead, "Iowa is being taken for a ride by experienced, for-profit insurers that will continue to try to milk every penny they can from government the way they have done in other states." "Home-bound, disabled people who rely on daily visits from caregivers have lost access to health services." " The managed care companies have underpaid or not paid many health care providers." "The public is getting the exact opposite of the “unprecedented transparency" that was promised. Insurers refuse to explain why claims are denied and providers are not paid." This piece won a Pulitzer for Editorial Writing.
How work might worsen health (Chloe Reichel, Journalist's Resource, 1-24-18) Proponents of work requirements as an eligibility condition for Medicaid often cite the beneficial health effects of employment as rationale. Though the employed tend to enjoy better health, it might be the case that the poorer health of some unemployed people explains precisely why they cannot work. In fact, a body of literature supports this notion. Further, research suggests that for healthy and unhealthy people alike, some forms of work might worsen health. Links to numerous articles, study results.
The Trump Administration’s Newest Strategy For Excluding Planned Parenthood From Medicaid (Sara Rosenbaum, Health Affairs, 1-25-18) Medicaid has been ground zero in the war against Planned Parenthood, given the program’s outsize position as a source of health care financing for low-income and at-risk populations. Now the Trump administration has opened a new front, this time with a relatively obscure, but highly consequential, policy guidance that effectively invites states to try, once again, to push Planned Parenthood out of the program.
Hate Paperwork? Medicaid Recipients Will Be Drowning in It (Margot Sanger-Katz, NY Times, 1-18-18) Kentucky’s new Medicaid waiver will ask low-income people to jump over hurdles to keep their coverage. Evidence suggests that many will fail.

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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.

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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.”

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When States Make It Harder to Enroll, Even Eligible People Drop Medicaid (Margot Sanger-Katz, NY Times, 1-18=18) Kentucky’s new Medicaid waiver will ask low-income people to jump over hurdles to keep their coverage. Evidence suggests that many will fail.
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.

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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)

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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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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)
Senior websites Medicare links to Access America for Seniors, Administration on Aging, AARP, Benefits Check Up, Healthy Aging for Older Adults, Medicare Interactive, NIH SeniorHealth.
Other government websites (many more Medicare links)

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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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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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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The politics, policy, and business issues of health care insurance

Dealing with denials of health care claims


Dealing with health insurance denial. Scroll down a few entries for ProPublica series. 
Biden and Sen. Bernie Sanders join forces to promote lower health care costs, including for inhalers (Darlene Superville, AP News, 4-3-24) Biden and Sanders fought for the lower health care costs that come through the Democrats’ sweeping climate, health care and tax package that Biden signed into law in 2022. It caps various health care costs for those on Medicare, including $35 a month for insulin and $2,000 a year for prescription drugs. No Republican lawmakers voted for the law. Both Biden and Sanders supported pressuring most major inhaler manufacturers to cap the costs of the devices to no more than $35 a month. Otherwise, the purchase price of inhalers ranges somewhere between $200 to $600 without insurance.
Denials of Health Insurance Claims Are Rising — And Getting Weirder (Elisabeth Rosenthal, KFF Health News, 5-26-23)The Department of Health and Human Services is tasked with monitoring denials both by Obamacare health plans and those offered through employers and insurers. As insurers’ denials become more common, they sometimes defy not just medical standards of care but sheer logic. Why hasn’t the agency fulfilled its assignment?
Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need (Casey Ross and Bob Herman, STAT News, 3-13-23) "An algorithm, not a doctor, predicted a rapid recovery for Frances Walter, an 85-year-old Wisconsin woman with a shattered left shoulder and an allergy to pain medicine. In 16.6 days, it estimated, she would be ready to leave her nursing home. On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the [artificial intelligence] algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone.

      "It would take more than a year for a federal judge to conclude the insurer's decision was "at best, speculative," and that Walter was owed thousands of dollars more for more than three weeks of treatment." [Only subscribers can read the full article.]
KFF Survey of Consumer Experiences with Health Insurance (Karen Pollitz, Kaye Pestaina, Alex Montero, Lunna Lopes, Isabelle Valdes, Ashley Kirzinger, and Mollyann Brodie, KFF, 6-15-23) A KFF 'survey shows that the sheer complexity of insurance is as big a problem as affordability, particularly for those with the greatest needs,” KFF President and CEO Drew Altman said. “People report an obstacle course of claims denials, limited in-network providers, and a labyrinth of red tape, with many saying it prevented them from getting needed care.” Among those with the greatest mental health needs, many adults across insurance types find their coverage lacking and report forgoing needed care. About six in ten (58%) insured adults report having experienced a problem with their health insurance in the past 12 months, including majorities of those with ESI (60%), Medicaid (58%) and Marketplace coverage (56%) and about half of adults with Medicare (51%).
Core topic: Insurance (invaluable resource page, Association of Health Care Journalists). See, for example, Glossary; key concepts; resource links; multimedia archive.

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Uncovered How the Insurance Industry Denies Coverage to Patients (ProPublica)

     Health insurers reject millions of claims for treatment every year in America. In ProPublica's excellent investigation and exposé, corporate insiders, recordings and internal emails expose the system and its harm. Read the whole series here.
---How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them  (Patrick Rucker, Maya Miller and David Armstrong, ProPublica, 3-25-23)

     Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said. “It takes all of 10 seconds to do 50 at a time.” Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.
---Health Insurance Claim Denied? See What Insurers Said Behind the Scenes (Maya Miller, with Patrick Rucker and David Armstrong, ProPublica, 5-10-23)

     Learn how to request your health insurance claim file, which can include details about what your insurer is saying about you and your case. When a health insurance company is deciding whether to pay for your medical treatment, the company generates a file around your claim. You have a right to see this file. Health insurers rarely advertise that people can access their claim files.
     "What’s the difference between a health insurance claim file request and an appeal? After you receive a denial, you can submit an appeal. This means you are asking the health insurance company to reconsider its decision. "When you submit a claim file request, you are asking the insurer to send you all of the records generated around your claim. Patients and lawyers said they found it helpful to submit these requests before an appeal."

---Big Insurance Met Its Match When It Turned Down a Top Trial Lawyer’s Request for Cancer Treatment  (T. Christian Miller, ProPublica, 11-7-23)
      'Blue Cross and Blue Shield denied payment for the proton therapy Robert “Skeeter” Salim’s doctor ordered to fight his throat cancer. But he was no ordinary patient. He was a celebrated litigator. And he was ready to fight.
     'In his decades as a plaintiff’s lawyer, Salim had relied upon consumer protection laws and billion-dollar judgments to make companies fix their bad practices. But now he stood on different terrain, facing a 1970s-era federal law that deprived patients of tools to fight, let alone change, abuses by the insurance industry.
     'And interviews, court documents and previously confidential emails and records from Blue Cross, its contractors and MD Anderson would expose the inner workings of a large insurer and an unnerving truth: To overcome a system tilted heavily in favor of the insurance industry, you need money, a dogged doctor and a friend with unusual skills.'
---I Set Out to Create a Simple Map for How to Appeal Your Insurance Denial. Instead, I Found a Mind-Boggling Labyrinth. (Cheryl Clark for ProPublica, 8-31-23)

     "I spoke with more than 50 insurance experts, patients, lawyers, physicians and consumer advocates about building a tool anyone could use to navigate insurance appeals. Nearly everyone said the same thing: Great idea. But almost impossible to do."
---How Often Do Health Insurers Say No to Patients? No One Knows. (Robin Fields, ProPublica, 6-28-23)

    Insurers’ denial rates — a critical measure of how reliably they pay for customers’ care — remain mostly secret to the public. Federal and state regulators have done little to change that.
---Health Insurance Claim Denied? See What Insurers Said Behind the Scenes  (Maya Miller, with Patrick Rucker and David Armstrong, ProPublica, co-published with The Capitol Forum, 5-10-23)

    Learn how to request your health insurance claim file, which can include details about what your insurer is saying about you and your case.
---UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings. (David Armstrong, Patrick Rucker and Maya Miller, ProPublica, 2-2-23)

     After a college student finally found a treatment that worked, the insurance giant decided it wouldn’t pay for the costly drugs. His fight to get coverage exposed the insurer’s hidden procedures for rejecting claims.
      Insurers have wide discretion in crafting what is covered by their policies, beyond some basic services mandated by federal and state law. They often deny claims for services that they deem not “medically necessary.”
      When United refused to pay for Christopher McNaughton's treatment for ulcerative colitis for that reason, his family did something unusual. They fought back with a lawsuit, which uncovered a trove of materials, including internal emails and tape-recorded exchanges among company employees. Those records offer an extraordinary behind-the-scenes look at how one of America's leading health care insurers relentlessly fought to reduce spending on care, even as its profits rose to record levels.
---Do You Have Insights Into Dental and Health Insurance Denials? Help Us Report on the System. (David Armstrong, Patrick Rucker and Maya Miller, ProPublica, 8-18-22)

    "Insurers deny tens of millions of claims every year. ProPublica is investigating why claims are denied, what the consequences are for patients and how the appeal process really works. 

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A Windfall in Health Insurance Rebates? It’s Not as Crazy as It Sounds (Julie Appleby, KFF Health News, 6-7-23) The billion-dollar amount cited by former Sen. Al Franken, while an estimate, is likely very close to what insurers will owe this year under a provision of the Affordable Care Act that compels rebates when insurers spend too little on actual medical care. “Americans will get $1.1 B in rebates from health insurance companies this year cuz of a provision I wrote in the ACA.”
50 ways to lose your coverage (Louise Norris, Healthinsurance.org, 10-25-19) You don't know what you've got until it's gone. Here's a helpful list of what you'd lose if the ACA is overturned
Why Do Short-Term Health Insurance Plans Have Lower Premiums Than Plans That Comply with the ACA? (Larry Levitt, Rachel Fehr, Gary Claxton, Cynthia Cox, and Karen Pollitz, KFF, 10-31-18) Short-Term Health Insurance Plans Charge Less than Half as Much in Premiums as ACA Plans By Excluding Pre-Existing Conditions and Severely Limiting Benefits
How a Medical Recoding May Limit Cancer Patients’ Options for Breast Reconstruction (Rachana Pradhan and Anna Werner, CBS News and Leigh Ann Winick, CBS News, KFF Health News, 5-31-23) The federal government’s arcane process for medical coding is influencing which reconstructive surgery options are available, creating anxiety for breast cancer patients.
Mental Health ‘Ghost Networks’ — And a Ghostbuster (Dan Weissmann, An Arm and a Leg, KFF Health News, 5-11-23) What should you do when your search for an in-network mental health care provider comes up empty? Abigail Burman has some expertise to share.
---For more details, read Laying Ghost Networks to Rest: Combatting Deceptive Health Plan Provider Directories (Abigail Burman, Yale Law & Policy Review) Errors in health plans' provider directories, also known as "ghost networks," are a  pernicious feature of the American health care system, with some studies showing that more than half of all directory entries contain errors. These errors disrupt patients' access to care, can lead to large, unexpected bills, and undermine the regulatory structure of the entire health insurance market. They also exacerbate existing structural inequalities.

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To get more kids health care, train their neighbors to navigate insurance maze (Adam Hoffman, STAT News, 3-17-16) Paying low-income parents to help other low-income parents navigate the red tape of public insurance programs turns out to be a surprisingly effective, and cost-efficient, way to get more kids enrolled in health care,
Pence calls for Social Security reform, private savings accounts (Tom LoBianco, Yahoo News, 2-3-23) Privatizing Social Security is his plan to address the growing national debt by cutting expenditures, at least in domestic spending.
---Heather Cox Richardson (2-3-23) Republicans like Pence believe the federal government should stay out of economic affairs, letting individuals make their own decisions in free markets (although the concept of a “free market” has always been more theoretical than real). Any federal attempts to regulate business or provide a social safety net are “socialism,” they claim, although they have largely forgotten how that argument was established in the United States. '

     "This argument is what gives us the story Kayode Crown reported yesterday for the Mississippi Free Press: thirty-eight of Mississippi’s rural hospitals, more than half of them, are in danger of collapsing because Governor Tate Reeves refuses to allow the state to accept an expansion of Medicaid. The hospitals are required to treat all patients who need care, but since many patients are uninsured, without the expansion of Medicaid the hospitals don’t get paid."

     "On Monday, Reeves warned Republican lawmakers not to "cave under the pressure of Democrats and their allies in the media who are pushing for the expansion of Obamacare, welfare, and socialized medicine." "Instead, seek innovative free-market solutions that disrupt traditional health-care delivery models, increase competition, and lead to better health outcomes for Mississippians." Last month, in a poll from Mississippi Today/Siena College, about 80% of Mississippi voters wanted Medicaid expansion. 

---As Mississippi Hospitals Fail, Leaders Kill Medicaid Expansion Efforts Again (Kayode Crown, Mississippi Free Press,2-2-23) Standing inside a shuttered hospital’s abandoned emergency room in Newton County, Miss., on Monday night, Democratic candidate for governor Brandon Presley blamed Gov. Tate Reeves for the fact that more than half of the state’s rural hospitals are in danger of closing. “This is the reality that Tate Reeves has chosen to put us in. Make no mistake, he made this choice,” Presley, a public service commissioner who hopes to unseat Reeves in this year’s elections, said in a video he released on YouTube Monday night.
        Earlier that day, Reeves had delivered his annual State of the State address on the Capitol steps in Jackson, where he reiterated his opposition to expanding Medicaid—a policy that many state health-care leaders, Democrats, and some Republicans say would save lives and prevent more ailing hospitals from closing.

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Trump’s Legacy Looms Large as Colorado Aims to Close the Hispanic Insurance Gap (Rae Ellen Bichell and Markian Hawryluk, KHN, 6-23-22) Hispanic residents have long been among the least likely to have health insurance — in Colorado and across the country — in part because of unauthorized immigrants. The state is expanding coverage to some of them, although the change runs up against lingering fears about the use of public benefits. Some Hispanic patients are afraid to make claims on health insurance because of Trump administration immigration policies, including its changes to the public charge rule. The long-standing rule determines when someone can be denied a green card or a visa because they are deemed likely to depend on or are already using government benefits. The Trump administration expanded the types of benefits that could be used to deny someone immigration status, adding food stamps, nonemergency Medicaid, and housing subsidies.
The big difference in 2020 health plans isn’t among Democrats (Dylan Scott, Vox, 10-28-19) "Republicans want to roll back Obamacare as Democrats debate Medicare-for-all....Democrats are debating whether to have the federal government provide health insurance to every American or just to many more of them than it does now. Republicans want to shrink both the federal government’s obligation to ensure coverage and its spending to support it....The stark differences between the two parties were laid bare in a new white paper last week from the Republican Study Committee, an internal think tank for House Republicans. The paper laid out the conservative agenda for health care reform: roll back Obamacare’s insurance rules requiring comprehensive health insurance and replace them with high-risk pools and tax breaks for individual health care expenses. Fewer people would have comprehensive health insurance. The protections for preexisting conditions would be weaker. More of the responsibility for paying for health care would fall on individuals and the states....The Republican vision for American health care is a lot less government spending and regulation — but that comes with consequences."
‘An earthquake’: The deal that changed Montana’s insurance market (Katheryn Houghton, Bozeman Daily Chronicle, 1-26-2020) Two decades ago, four Montana hospitals wanted to challenge what they described as Blue Cross Blue Shield of Montana’s “dominating presence.” So they founded insurer New West Health Services in 1998 to cover hospital employees and whoever else they could pick up. Blue Cross remained the lead by far, but those watching the industry said New West lowered prices for Montanans as insurers’ competition intensified. It worked, and then it ended. By 2011, the hospitals’ leadership wanted out of the insurance business and made a deal that deflated New West and boosted Blue Cross, the insurer it was formed to compete against. See Montana journalist explains how one deal years ago changed the state’s insurance market (Katheryn Houghton, How I Got That Story, Covering Health, AHCJ, 7-21-2020) Her tips are a reminder that there is a wealth of untouched stories in places where health reporters are few, so it's important to keep local newspapers strong.
What you need to know about proposed actions to reduce the cost of prescription drugs KFF’s research, analysis and public opinion data, as well as Kaiser Health News’ journalism, about prescription drugs and their costs -- discussions range from sweeping changes in the health care system to targeted initiatives that could affect Medicare, Medicaid and private insurance. Links to analysis of many important issues.

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Going Down Fighting: Dying Activist Champions ‘Medicare For All’ (Anna Almendrala, California Healthline, 8-14-19) Santa Barbara lawyer-turned-activist Ady Barkan, 35, who has amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig’s disease, watched from his wheelchair as Massachusetts Sen. Elizabeth Warren described how he and his family had to raise money online to help pay for roughly $9,000 a month in health care costs not covered by his private health insurance. "His fight for better access to health care began in 2017, when he protested the GOP tax cut bill on the grounds that removing that revenue from the federal government would make it more difficult to fund disability and Medicaid payments....Q: What did you think about the debate, especially the portion in which candidates were asked about raising taxes on the middle class to pay for Medicare for All? When I saw the moderate candidates argue that Medicare for All will never pass because Republicans are going to call us socialists, or attack us for raising taxes, that makes me sad. It’s an argument that doesn’t give voters enough credit. Yes, Medicare for All will probably mean a new tax, but that tax will be less, way less, than how much we’re spending on health care bills. Let’s make that argument and treat voters like adults....One thing I think candidates haven’t had to do so far is make a case for why private insurance companies are good, how they actually make life better for doctors or patients."
Analysis: Choosing a Plan from the Impossible Health Care Maze (Elisabeth Rosenthal, KHN, 12-5-19) 'As prices spiraled upward, insurers (backed by economists) imposed copayments and coinsurance so patients would have “skin in the game,” to encourage them to use health care more sparingly, more wisely. But with prices in medicine now so high, the skin-in-the-game theory now means many patients live with debilitating symptoms, delay needed treatment or don’t get treated at all. I’m a medical doctor and have spent years as a journalist covering health care. But I am grateful that my company chooses my PPO health plan — not just because it’s good, but also because it means I don’t have to try to decide between hundreds of options when there is no good way to make a rational choice.'
Why Doesn’t America Have Universal Health Care? One Word: Race (Jeneen Interlandi, The 1619 Project, NY Times, 8-14-19) 'One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.'
Establishment looks to crush liberals on Medicare for All (Adam Cancryn, Politico, 12-10-18) The coalition that fought Obamacare repeal has fragmented as the Democratic party tries to follow through on campaign promises. Deep-pocketed hospital, insurance and other lobbies are plotting to crush progressives’ hopes of expanding the government's role in health care once they take control of the House. The private-sector interests, backed in some cases by key Obama administration and Hillary Clinton campaign alumni, are now focused on beating back another prospective health care overhaul, including plans that would allow people under 65 to buy into Medicare. This sets up a potentially brutal battle between establishment Democrats who want to preserve Obamacare and a new wave of progressive House Democrats who ran on single-payer health care.
How to Build a Medicare-For-All Plan, Explained by Somebody Who’s Thought About It for 20 Years Dylan Scott interviews Jacob Hacker (who explains Medicare for America) for Vox (1-28-19). See the full section on Single payer and other models for health care financing
Flurry of Health Movement in Blue States May Act as ‘Test Balloons’ for Wider Marketplace (KHN Morning Briefing, 1-14-19) With a divided Congress, there may not be much forward progress on health care issues at a national level, but states led by Democratic lawmakers are already taking steps to fulfill campaign promises for more expanded options. CQ: "States are picking up the slack, with new governors signing executive orders and proposing plans to drastically increase coverage or confront rising prescription drug prices." NY Times : "Gavin Newsom dived into the highly charged debate over prescription drug prices in his first week as California’s governor, vowing action on a topic that has enraged the public but has proved resistant to easy fixes. His idea: Find strength in numbers. Within hours of taking office on Monday, Mr. Newsom signed an executive order proposing a plan that would allow California to directly negotiate with drug manufacturers."
Blue states buck Trump to expand health coverage (Nathaniel Weixel, The Hill, 1-13-19) Democratic governors are experimenting with new ways to expand health care, testing out progressive ideas that could go national if their party wins the Senate or White House in 2020. The policies run counter to the Trump administration's ideas and are only now possible after a Democratic wave in the House helped secure the future of ObamaCare.

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What a French Doctor’s Office Taught Me About Health Care (Erica Rex, NY Times, 1-2-19) "I am an accidental European. I developed breast cancer in 2009. With no continuing medical coverage in the United States, and in desperate need of it, I moved to Britain. Under the sponsorship of an acquaintance, I was granted “indefinite leave to remain” and received care through the National Health Service. When I moved to France four years ago, the French system quickly took over covering me. It has taken me nine years to grow accustomed to the idea that my health care won’t suddenly evaporate at the whim of a new government. Doctors here often ask how I landed in Europe. When I tell them, they shake their heads. American values are deranged, they say."
Young invincibles like me should pay our fair share for health care (Jonathan Fried, Philadelphia Inquirer, 1-2-19) "I should have the freedom to buy and drive a car, and with that freedom comes the responsibility to purchase car insurance, just in case I crash my car into yours and can’t pay for your repairs. My decision to become uninsured is like choosing to rear-end the guy in front of me on the turnpike, because it increases his health-insurance premium, and yours, too. In that sense, it’s just as reasonable to require me to buy health insurance as it is to require me to have car insurance."
1,495 Americans Describe the Financial Reality of Being Really Sick (Margot Sanger-Katz, The Upshot, NY Times,10-17-18) “Do you pay the hospital bill or do you pay the utility bill?” Don’t count on your health insurance for serious illnesses, a new survey warns. Health insurance provides little help for people who have to cut back on work because of their own illness or that of a family member. If you lose work because of illness and your income falls, financial difficulties may be compounded by medical costs. And people with complex medical conditions may not always be able to negotiate complicated medical insurance systems.
Implications of “Medicare for All” and “Public Plan” Strategies: New Brief and Interactive Tool Summarize Legislative Proposals and Key Issues (Tricia Neuman, Karen Pollitz, and Jennifer TolbertKFF, 10-9-18) As policymakers debate next steps for expanding health insurance coverage and lowering health costs, some have introduced legislation that would broaden the role of public programs, such as Medicare and Medicaid. During the 115th Congress, eight such proposals were introduced, ranging from bills that would create a new national health insurance program for all U.S. residents, replacing virtually all other sources of public and private insurance (Medicaid-for-All), to more incremental approaches that would create a new public plan option, as a supplement to private sources of coverage and public programs.

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McCain’s Complicated Health Care Legacy: He Hated the ACA. He Also Saved It. (Emmarie Huetteman, Kaiser Health News, 8-25-18) The six-term Arizona senator, who died Saturday, took on some of health care’s goliaths, such as the tobacco industry and insurance companies, in addition to the health law. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990 ("the country’s first comprehensive civil rights law that addressed the needs of those with disabilities"), most of the health initiatives he undertook failed after running afoul of traditional Republican priorities--often involving more government regulation and increased taxes. He fought the Affordable Care Act (Obamacare) because " extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs." But his "late-night thumbs-down vote halted his party’s most promising effort to overturn" the ACA, for which Trump treated him as an enemy. "While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace" Obamacare with something better. What bothered McCain more, though, was "his party’s strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory." “I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare,” McCain wrote. “That had not been my goal.”
Huetteman's summary of McCain's other efforts at health care legislation reads like a to-do list for Congress to consider should it ever go back to considering the "little guy" above all--to being willing to "work across the aisle," across parties. "McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients’ bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies....The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed."
One plan he supported "would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued [that] employer-provided plans were driving up costs, as well as keeping salaries lower." That triggered “a total freakout." "McCain’s health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate’s Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans’ care measures he undertook."
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
Recommended Actions for States to Protect Their Health Insurance Markets (Jeanne Lambrew, Aviva Aron-Dine, Sam Berger, Matthew Fiedler, and Jason Levitis, Health Affairs blog, 1-22-18)
Listen: Why Red States Challenging ACA Tread Precariously on a Popular Protection (KHN, 8-2-18) States seeking to overturn the Affordable Care Act must do a delicate dance. That’s because most of them have higher-than-average rates of residents with preexisting conditions — a group specifically protected under the ACA. The 2010 health law prohibits insurers from charging more or denying coverage for such conditions, and that provision remains popular across the country and party lines. Twenty GOP state attorneys general and governors filed a challenge to the constitutionality of the ACA in February. Last month, the Department of Justice under Attorney General Jeff Sessions sided with them and decided not to defend key portions of the ACA, including the preexisting conditions provision.
Most experts don’t expect any immediate changes, since the lawsuit will take a considerable amount of time to work its way through the courts. Should the GOP-led states ultimately prevail, the impact of losing the protection for preexisting conditions would vary by state. In some states, there is no similar protection to replace the federal one afforded by the ACA. Other states do have such protections.
Prior authorization rules: Yet another way the health insurance system frustrates physicians and patients (Joseph Burns, Covering Health, AHCJ, 8-9-18) "For patients and physicians, many aspects of the health care and health insurance systems are frustrating and appear to be needlessly complex.
One of the most frustrating processes is prior authorization, the mother-may-I approach health insurers use to ensure that procedures, medications and even certain care processes are appropriate and worthy of coverage. AHCJ members can access a tip sheet on covering this topic.
Why Your Health Insurer Doesn't Care About Your Big Bills (Marshall Allen, NPR Shots and ProPublica, 5-25-18) Michael Frank couldn't believe his co-pay for a partial hip replacement: $7,088 for a grossly inflated $70,000 surgical procedure. As Frank eventually discovered, once he had signed on for surgery, a secretive system of pre-cut deals came into play that had little to do with charging him a reasonable fee. The Affordable Care Act kept profit margins in check by requiring companies to use at least 80 percent of the premiums for medical care. That's good in theory, but it actually contributes to rising health care costs....Making a 3 percent profit is better if the company spends more....Patients, of course, don't know how the behind-the-scenes haggling affects what they pay. By keeping costs and deals secret, hospitals and insurers dodge questions about their profits, said Dr. John Freedman, a Massachusetts health care consultant. Cases like Frank's "happen every day in every town across America. Only a few of them come up for scrutiny."
"After the hearing, Nugent said a technicality might have doomed their case. New York defendants routinely lose in court if they have not contested a bill in writing within 30 days, he said. Frank had contested the bill over the phone with NYU Langone and in writing within 30 days with Aetna. But he did not dispute it in writing to the hospital within 30 days." "The system," he said, "is stacked against the consumer."

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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."
The Growing Power of Some Providers to Win Steep Payment Increases from Insurers Suggests Policy Remedies May Be Needed (Robert A. Berenson, Paul B. Ginsburg, Jon B. Christianson, and Tracy Yee, Health Affairs, May 2012) "In the constant attention paid to what drives health care costs, only recently has scrutiny been applied to the power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers. Interviews in twelve US communities indicated that so-called must-have hospital systems and large physician groups—providers that health plans must include in their networks so that they are attractive to employers and consumers—can exert considerable market power to obtain steep payment rates from insurers."
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.

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The promise and perils of ‘invisible’ risk pools (Joanne Kenen, Covering Health, AHCJ, 1-2-18) Among the many items on Congress's January to-do list is legislation to stabilize the Affordable Care Act markets, such as the bill Sens. Susan Collins (R-ME) and Bill Nelson (D-FL) introduced last fall. It would provide $4.5 billion in federal reinsurance payments over two years, 2018 and 2019. The idea is to compensate insurers for taking on costly patients to prevent shifting all that cost to higher premiums for everyone in the exchanges. There are several ways for states to construct reinsurance. The idea is a bipartisan one, with both blue and red states looking at various mechanisms. Alaska, for example, already has begun one under an ACA waiver.
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."

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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.

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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)

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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

Health-care sharing ministries
Priced Out Of Health Insurance, Americans Rig Their Own Safety Nets (John Tozzi, Bloomberg, 8-22-18) Consumers frustrated by high costs are bypassing the bureaucracy with patchwork plans. The number of people joining so-called health-care sharing ministries—religion-based cost-sharing plans—rose 74 percent from 2014 to 2016, according to the latest Internal Revenue Service data. An alliance for the groups said that more than 1 million people now participate in such programs. Similarly, primary-care clinics like the one Julie Gunther started in 2014 have grown to almost 900 from just a handful in the early 2000s, according to the Direct Primary Care Coalition, a trade group for the clinics.
Direct Primary Care Coalition
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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