Friday, January 6, 2017

Turning the clock back on health care

A new year is usually a time to look forward to better things.

For health care though, 2017 is looking more and more like it will be a year of turning back.  Assuming, that is, that the GOP-controlled Congress and incoming Trump administration are able to enact their plan to repeal, delay and replace the Affordable Care Act.

Full repeal of the ACA will mean turning back to a time when millions more people were uninsured, and when insurance companies routinely denied coverage or limited benefits to people who were sick. 

It would mean going back to the days when more than 20 percent of Americans were uninsured because they did not qualify for Medicaid and other safety-net programs, and couldn’t afford private insurance, compared to fewer than 10 percent who are without insurance today. 

It would mean going back to the days when women were charged higher premiums than men for no other reason than that they were women.  

It would mean going back to a time when insurers were not required to offer coverage for preventive services, contraception, maternity care, mental health, and many other essential benefits, and if they did offer them, they were often subject to deductibles and co-payments.

It would mean going back to the days when insurance companies were allowed to impose annual and lifetime dollar caps on benefits, which often meant bankruptcy for people with expensive conditions like cancer.

The GOP has already started the process of repealing the ACA, scheduling a vote next week on a budget resolution that instructs congressional committees to come up with legislation to repeal as much of the ACA as they can through a process called budget reconciliation, which can be passed by a simple majority vote, no Democrats needed. The budget resolution would put Congress on the path to repealing the ACA in stages, an approach that has been called “repeal, delay and replace.”  (The New York Times has a good primer on how repeal, delay and replace would play out legislatively). 

While the GOP argues that “repeal, replace and delay” will allow people to keep their current coverage while Congress comes up with a “better” replacement, it isn’t likely to work out that way.  More likely, millions will begin losing coverage as early as later this year, as I argued in my recent Annals commentary, something that even many well-respected conservatives are starting to acknowledge.

Still, the GOP congressional leadership seems committed to rolling back the ACA in stages, disregarding the fact that that only 20 percent of the public supports repeal, delay and replace, the warnings about the chaos it will introduce into insurance markets, and the near-impossibility that the GOP will be able to (eventually) craft a replacement that will cover as many as the ACA, with comparable benefits and consumer protections, that can also win Democratic votes.   This means that at some point, most likely starting a few months from now, and certainly by the time when delayed ACA repeal would actually take place in 2018 or 2019, we will go back to the bad old days, before the ACA became law in 2010, when millions more people were uninsured, and when insurance companies routinely denied coverage or limited benefits to people who were sick. 

It doesn’t have to be this way, though.  ACP is doing everything we can to persuade Congress not to move forward with ACA repeal, delay and replace; all it takes is 3 Republican Senators to say no repeal especially without being offered a viable replacement for consideration.  Here are some of the things we are doing:
  • ACP joined with the American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetrics and Gynecology, in a letter urging the Senate to vote no on a resolution that would start the process of repealing the ACA.  Collectively, our organizations represent nearly 400,000 physician and medical student members.
  • ACP sent its own letters to the Senate and House of Representatives opposing the repeal resolution.
  • ACP has developed advocacy resources to help make the case against repeal, delay and replace,  including my December 15 blog post on “There must be 50 ways you can lose your health insurance (if Obamacare is repealed);  a fact sheet on the impact of repeal;  a table showing the impact in each state on the number of uninsured, people with pre-existing conditions, and uncompensated care costs;  and an at-a-glance profile of the impact for each state.
  • We sent an urgent alert to the 19,000 ACP members who have volunteered to be an Advocate for Internal Medicine, asking them to call their Senators to urge a no vote on the repeal resolution.
  • Next week, we will be communicating with Congress about the key questions that should be asked of any proposals to amend, improve, or replace the ACA, to ensure that patients are not harmed.  The letter will be posted on ACP Online on Monday.
  • ACP has been using social media to draw attention to our concerns about repeal, delay and replace; you can follow me on Twitter at @bobdohertyACP, the Advocates for Internal Medicine network at @AdvocatesIM, and the ACP Public Affairs department @ACPInternists.

The encouraging news is that our concerns are being widely reported by the press and not just through social media, including an opinion piece by New York Times columnist Nicolas Kristof, the Los Angeles Times (same story also published in The Chicago Tribune, San Diego Union-TribuneOrlando SentinelBaltimore Sun and Charlotte Observer), Forbes, Politico, Washington Examiner, and the Providence Journal.

But ACP won’t be successful in stemming the drive to repeal the ACA unless thousands of physicians raise their voices directly with members of Congress.  The Senate is expected to vote on the resolution to start ACA repeal next Wednesday, January 18. We need every doctor who does not want to see nearly 60 million people lose coverage to call your Senators, 202-224-3121, between today and Wednesday to urge them to vote against repeal.

If you don’t act, Congress may very well take us back to the pre-ACA days, when millions more were uninsured and insurers routinely denied coverage or limited benefits for sick people.  We must not let that happen.

Today’s question:  have you called your Senators to urge them to vote against ACA repeal?


Thursday, December 15, 2016

There must be 50 ways to lose your health insurance (if Obamacare is repealed)

The Republican congressional leadership appears to be determined to move forward with a high-risk “repeal, delay and replace” plan, very early in the new 115th Congress to repeal (at least on paper) the Affordable Care Act’s key coverage provisions—Medicaid expansion, subsidies to make private insurance sold through the exchanges affordable, the individual and employer mandates, and the taxes to pay for coverage—by a simple majority vote, while delaying when the repeal would go into effect to give them time to come up with a replacement. 

The problem is that this isn’t likely to work, not without disrupting care for millions.   As I point out in a commentary The Demise of the Affordable Care Act?  Not So Fast, published online on Tuesday in the Annals of Internal Medicine, I think it is magical thinking to believe that one can repeal the ACA, delay the repeal from going into effect, avoid loss of coverage, and then replace the ACA with something that keeps the popular parts while jettisoning the unpopular ones.

Much more likely, according to many independent and non-partisan studies, the result of “repeal, delay and replace” will be that many millions of Americans will lose their coverage as early as 2017, and many more if the ACA is full repealed without an alternative that offers comparable coverage. 

So many, in fact, that I found from the studies that there must be at least 50 ways you could lose your health insurance if the ACA is repealed (my apologies to songwriter Paul Simon).  Under ACA repeal, you could lose coverage if:

  1. You are the one of nearly 59 million who would lose coverage if the ACA is fully repealed.
  2. You are one of the 7.1 million who would lose coverage because of an expected “near collapse”  of the individual insurance market while Congress tries to come up with a replacement.
  3. You are one of the 4.3 million who would lose coverage as early as 2017, because “if Congress eliminates the individual and employer mandates immediately, in the midst of an already established plan year, significant market disruption would occur.”
  4. You are one of the 52 million people, 1 out of every 4, with a pre-existing medical condition, because insurers may once again be allowed to turn you down or charge you more for coverage.
  5.  You have a specific “declinable” medical conditionlike asthma, diabetes, cancer, or hepatitis C—that could become ineligible for coverage in the individual insurance market.
  6. You live in one of 11 states, most of them red (Republican-leaning) states in the South, where at least 3 in 10 non-elderly adults have a pre-existing “declinable” medical condition.
  7. You have a “declinable” pre-existing condition and lose your employer-based coverage, say because of a lay-off, and then find that no insurer in the individual market will cover it.
  8. You are a miner, baggage handler, EMT first-responder, off-shore oil driller, or one of dozens of other occupations that places you at risk of suffering job-related injuries needing medical attention.  Before the ACA, many people in such higher-risk occupations could be turned down for coverage.
  9. You are a woman, because insurers would again be allowed to treat being female as a pre-existing condition, allowing them to charge you higher premiums.
  10. You are a woman having a baby, because insurers could again begin to deny coverage for maternity care and breastfeeding support, supplies, and counseling.
  11. You are a woman using contraceptives, because insurers would again be allowed to deny coverage for contraception.
  12. You are a survivor of domestic or sexual violence, which often was counted as a pre-existing condition before the ACA, making you ineligible for coverage. You could also lose the ACA-mandated coverage for interpersonal domestic violence screening and counseling.
  13. You are a pregnant woman who has a medical need for gestational diabetes screening, an ACA-required benefit that could be taken away.
  14. You are a sexually active woman who benefits from the ACA-required coverage of STI counseling on sexually transmitted infections (STIs), which can reduce risk behaviors in patients; for high-risk human papillomavirus (HPV) DNA testing every three years, regardless of Pap smear results; for HIV screening and counseling; and for contraceptive counseling.
  15. You are a sexually active man who benefits from HIV screening and counseling and STD screening, benefits which may no longer be offered if the ACA is repealed.
  16. You are or have a child who gained coverage from the ACA and now might lose it, doubling  the number without health insurance, like the 67,000 children in New York state alone who would are at risk of being dropped. 
  17. You are one of the 12.3 million people who live in a state that has expanded Medicaid under the ACA and could be dropped from coverage if it is repealed.
  18. You are a low-wage person who lives in a red state that was considering expanding Medicaid, and are now likely to put the brakes on expanding eligibility.
  19. You are one of the 14 million who would lose their Medicaid coverage, or no longer gain coverage in the future, if the ACA’s Medicaid expansion is replaced with block grants to the states.
  20. You are in a red state that has expanded Medicaid because ACA repeal could cut off funding for the “more than 2.5 million people in GOP-represented states [who were] were enrolled in Medicaid through the expanded eligibility” created by the ACA.
  21. You are one of the 60 million people suffering from a mental or behavioral health condition or substance use disorder who could lose your coverage because “full repeal  of the health law would gut major benefits and protections . . .”
  22. You are one of the 1.4 million young adults who get coverage from their parents’ plan but could lose it.
  23. You are an entrepreneur with a pre-existing condition who may have to give up your start-up to get a regular job that offers coverage.
  24. You have a pre-existing condition and end up being stuck with a job you don’t like—job lock—because you might not be covered if insurers in the individual market can again turn you down or charge more for coverage. 
  25. You are one of the 10.7 million seniors or disabled persons under Medicare who to date have saved $10.8 billion on prescription drugs because the ACA phases-out the “doughnut hole” in Part D coverage.
  26. You are one of the over 39 million seniors who have received no-cost preventive services  guaranteed by the ACA, like “flu shots, tobacco cessation counseling, as well as no-cost screenings for cancer, diabetes and other chronic diseases” and “annual wellness visits wellness visit so they can talk to their doctor about any health concerns” at no out-of-pocket cost to you.
  27. You are a senior enrolled in Medicare who would likely see higher premiums, deductibles, and cost sharing for Medicare-covered services.
  28. You are white working class person because 56 percent of those at risk of losing coverage from ACA repeal are white, most of who are from the working class.
  29. You are Latino or Hispanic because 22% of those who could become uninsured from repeal are Hispanic, a disproportionately large share of those at risk.
  30. You are African-American because 12% of those who have gained coverage under the ACA are black, and now are at risk of losing it if the law is repealed.
  31. You are one of the 7 million people who are eligible for cost-sharing subsidies under the ACA; if these subsidies are repealed, your maximum out-of-pocket costs will increase substantially.
  32. You are one of the 9 million people who make between 100 and 400% of the Federal Poverty level who receive ACA’s premium subsidies to make insurance affordable.
  33. You are older but not yet Medicare age, because if insurers are again allowed to charge older people 5 or 6 times more than younger ones (the ACA limits it to no more than 3 times more), your premiums in the individual market will go up.
  34. You are one of the 133 million people with at least one chronic health condition who could find yourself again turned down for coverage or charged more.
  35. You are one of the millions of patients who are, or will sometime in the future, be diagnosed with cancer and who now benefit from the ACA’s prohibition against excluding or charging more to patients with pre-existing conditions, no-cost coverage of preventive and screening tests, and a ban on annual and lifetime limits on coverage, leaving many cancer patients “frantic and scared” about loss of coverage.
  36. You are one of the 137 million people (55.6 million women, 53.5 million men, and 28.5 million children) who have received no-cost coverage for preventive services from private insurers since the ACA’s required coverage of such services went into effect.
  37. You are one of the millions of Americans who received combined $2.4 billion in refunds from your insurers because they spent too much on administration and too little on direct patient care; protections that would go away if the ACA was repealed.
  38. You are a gun violence victim, because the ACA “has brought coverage to tens of thousands of previously uninsured shooting victims, often young African-American men, who, once stabilized in emergency rooms, missed out on crucial follow-up care and have endured unremitting effects of nerve injuries, fractured bones, intestinal damage and post-traumatic stress disorder.”
  39. You are one of the 105 Million Americans, many of whom are middle class, who could again be subjected to lifetime limits on coverage under ACA repeal.
  40. You are LGBT, because the ACA protects you from discrimination in coverage.
  41. You live in a “red” (Republican leaning) state because you are more likely to be at risk of losing coverage under the ACA and your state will have fewer state resources to help you keep it, compared with “blue” [Democratic-leaning] states that have fewer people at risk, and more resources to maintain coverage for those who are.
  42. You don’t have a college degree, since an estimated 80 percent of adults at risk of becoming uninsured if the ACA is repealed do not have at least an associate degree.
  43. You are one of the millions of non-elderly veterans who have gained coverage since the ACA was enacted, reducing the uninsured rate among veterans from 12% in 2011 to 8.6% as of 2015.
  44. You are one of the approximately 15 million people with incomes below 200% of the federal poverty level, approximately 48,000 for a family of four in 2016, who would lose coverage under full ACA repeal.
  45. You are one of the 700,000 who would lose coverage from your employer.
  46. You are insured and end up paying more for your hospital care, because hospitals are forced to cost-shift to you the $166 billion in losses that would result from ACA repeal.
  47. You are one of the 1.7 million non-seniors who live in Florida and have signed up for Obamacare coverage sold by private insurers, the most of any state, and would stand to lose it if the law is repealed.
  48. You live in California, the state that “has the most to lose” if the ACA is repealed.
  49. You live in any of the 50 states or the District of Columbia, all of which would see big losses in coverage; it’s just a matter of degree.
  50. You one of the 36,000 Americans who could die each year if the ACA is repealed.
To be clear, you can’t add up all of the numbers above, because people at risk of losing coverage could fall in multiple categories.  But no matter how you slice and dice it, ACA repeal, particularly without an alternative that would cover as many with comparable benefits and protections, will lead to massive losses in coverage, touching just about everyone in some way, in some fashion.  Yes, there are at least 50 ways you could lose your health insurance if the ACA is repealed, and probably, many more.

Today’s question: What is your reaction to the data on how many could lose coverage and benefits, and in what way, if the ACA is repealed?



Wednesday, December 7, 2016

Preparing ACP for the post-election political environment

It’s often said that elections have consequences, and this is especially true of the 2016 election. The election of Donald S. Trump, combined with continued GOP control of Congress, will rock the health care world, starting with the GOP pledge to begin to repeal and replace the Affordable Care Act early in the new Congress. 

But it’s not just the ACA: the Trump administration may try to privatize the VA, end U.S. commitments to reduce emissions contributing to climate change, reverse Obama’s executive actions on firearms violence prevention, convert Medicare into a defined contribution (voucher) program rather than an open-ended entitlement, and much, much more.  While these are highly concerning to ACP, we believe that there will be many opportunities to find common ground on improving access to mental health, healing the opioids epidemic, reducing barriers to chronic care management, reforming the medical liability system, and especially, reducing regulatory burdens on physicians and their patients.

In order for ACP to be effective, we have to start by stepping back and assessing what the impact of the elections will likely be on our priorities, recalibrating as needed to achieve our objectives.  To be clear, this does not mean stepping back on our commitment to issues like universal coverage, mitigating the public health impacts of climate change, reducing gun violence, and ensuring access to care for all persons without regard to race, religion, ethnicity, gender and gender identity, and sexual orientation; these are overarching core principles and policy commitments the College has made to the public, they can’t be negotiated away.  But we can and will assess how best to advance or defend them given the changed political circumstances.

Here is what your ACP advocacy team in Washington has been doing to help ACP prepare for the new administration and Congress:
  • We provided suggestions to ACP President Dr. Nitin S. Damle on his November 17 email to all ACP members, U.S. and international, on the implications of the 2016 election.
  • We are working with Dr. Damle on responding to several dozen e-mails from members in response to his letter.
  • We are doing a comprehensive staff assessment of all of our key public policy priorities; for each of them, we are evaluating whether there is a threat or opportunity or threat and opportunity, whether it’s from Congress, the Executive Branch, or both; and whether we need new or revised policy direction from the ACP policy committees, regents and governors.
  • In particular, we are examining how the GOP may use a “repeal, delay, and replace” legislative strategy to undo as much of the ACA as possible through budget reconciliation, which requires a simple majority vote, while delaying for a couple of years the date(s) when those provisions would expire, which in theory gives them a time to develop a replacement plan (which is much easier said than done, which I will address in a future post).
  • For some of our priorities, we are doing a much deeper policy dive; for instance, examining possible GOP alternatives to the ACA overall and specific elements of it; the impact of possible efforts to privatize the VA system; implications of turning Medicaid into a block grant program; potential threats to Graduate Medical Education funding; and policies affecting women’s health access, among others.
  • Our regulatory affairs team is preparing specific recommendations to the new administration and Congress on changes in federal regulations, quality measurement, EHRs and “meaningful use” requirements, documentation guidelines, and on other ways to ease administrative burdens on physicians.
  • We are reaching out to other health-advocacy organizations, not just within the medical profession, but with business leaders, hospitals, insurers, and consumer groups, to see where our interest may align and where we may differ; and how we might work together when we are in agreement.
  • We are continuing to encourage members to sign up to participate in our grass roots Advocates for Internal Medicine (AIMn) program while making enhancements to it.  The strength of this program will to a large extent determine how effective we can be advocating with the new Congress.

Even as we are devoting so much of our time to prepare for the new administration and Congress, we are ensuring that ACP’s voice is heard now, as the lame-duck 114th Congress completes work on several outstanding health care bills, including the CURES Act and a temporary resolution to fund the federal government into early next year.  We are also providing extensive comments to the outgoing Obama administration on the 2017 Medicare physician fee schedule final rule and the MACRA final rule.  Oh, and we are developing new and updated resources and tools to help members be successful as Medicare’s new Quality Payment Program (created by MACRA) begins to be rolled out on January 1. 

In my view, ACP advocacy is more important now than ever before.  On issues ranging from ensuring  that internists’ patients don’t lose their health insurance coverage, easing the regulatory burden on physicians,  protecting GME from budget cuts, ensuring that women don’t lose access to care, supporting the many ACP members in the VA system and the veterans they serve from ill-advised “reforms’,  advocating for medical liability reforms,  opposing policies that would be discriminatory against LGBTQ persons, and continuing to advocate for policies to reduce the health consequences of climate change,  ACP will be there, ensuring that internists’ voices are heard in this tumultuous time for American (and global) health care. 

Today’s question: What policies do you think are most important for ACP to advocate with the new Trump administration and Congress?