Thursday, April 27, 2017

How to make a terrible, horrible, no good, very bad bill even worse

It’s BACK—the terrible, horrible, no good, very bad bill to repeal and replace the Affordable Care Act (ACA).  Last month, I blogged about how the bill, called the American Health Care Act, was the worst legislation for health care of any that I have seen in 38 years of advocacy for doctors and patients.  While it was good that this bill was pulled by House Speaker Paul Ryan on March 24 due to a lack of support among Republican lawmakers, he may bring it back for a vote as early as this Friday, April 28. Only, this time, believe it or not, with changes designed to win support from hard-right conservatives that make the original bill even worse for patients.  I guess we will have to call this version the even more terrible, horrible, no good, very bad, bill for patient care. 

On Tuesday, ACP was able to confirm that the House GOP leadership and Trump administration were close to reaching a deal with 20 or so of the most conservative lawmakers, the self-described “Freedom Caucus.” Unfortunately, as explained in a detailed letter that we sent to all members of Congress later that day, the proposed “compromise”  would gut existing law protections for people with preexisting medical conditions and requirements that insurers cover essential benefits by allowing states to opt-out of such requirements.  And today, we joined in a coalition letter with 5 other physician membership organizations, collectively representing over 560,000 physician and medical student members, expressing our combined opposition to the “compromise” bill. 

Let me be clear why the compromise makes a terrible bill even worse:

It would allow states to obtain “waivers” to opt-out of the ACA’s prohibition on insurers charging more to people with preexisting conditions.  That’s right, the “compromise” would return us to the pre-ACA days when states often allowed insurers to charge whatever they wanted to people with conditions like asthma, diabetes or dozens of other conditions that were considered to be “declinable” by insurers.  As ACP explained in its letter to Congress, “Before the ACA, insurance plans sold in the individual insurance market in all but five states typically maintained lists of so-called "declinable" medical conditions—including asthma, diabetes, arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer in the past 10 years. Even if a revised bill would not explicitly repeal the current law’s guaranteed-issue requirement—which requires insurers to offer coverage to persons with pre-existing conditions like these—guaranteed issue without community rating allows insurers to charge as much as they believe a patient’s treatment will cost. The result would be that many patients with pre-existing conditions would be offered coverage that costs them thousands of dollars more for the care that they need, and in the case of patients with expensive conditions like cancer, even hundreds of thousands more.”

The bill does say that states would have to set up or participate in high risk pools for people with preexisting conditions in order to be approved for a waiver.  But we know from experience that underfunded high-risk pools, which were common before the ACA, typically had very high premiums and deductibles, long wait lists, and limited benefits, making the coverage unaffordable for those who need it most. And the amended AHCA does not provide anywhere near the amount of money that could make high risk pools viable, and does not set any standards or funding levels that states must meet to ensure that coverage under the pools are affordable and benefits are adequate.

It would allow states to obtain “waivers” to opt-out of the ACA’s requirement that all insurers cover 10 categories of essential medical care services.   We know from the pre-ACA days what this could mean for patients: in many states, insurers will once again be allowed to decline coverage of needed benefits like physician and hospital visits, maternity care and contraception, mental health and substance use disorder treatments, preventive services, and prescription drugs. “Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance-use disorder services, 18% did not have mental-health services and 9% did not have coverage for prescription drugs,” ACP wrote to Congress.  “A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 more for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care. Such increased costs would make it practically impossible for many patients to avail themselves of the care they need. The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.”

And repeal of the essential benefit requirements would mean that insurers would no longer be required to cover substance use disorder treatments.  “Allowing states to eliminate the [Essential Health Benefits] will threaten our nation’s fight against the opioid epidemic,” ACP told Congress. “A study concluded that with repeal of the ACA, ‘approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.’”

And the “compromise” would even gut the ACA’s ban on insurers imposing annual or lifetime limits on coverage, because under current law insurers are only banned from imposing dollar limits on services that are included in the mandatory essential health benefits package.   If a state, for example, decided that chemotherapy was no longer an essential benefit in your state, there would be nothing stopping insurers from putting a $100,000 lifetime dollar limit (if even that much) on coverage for your cancer treatment.  After that, sorry, you’d be on your own, forcing choices like lose your house, or lose your health care, you decide. 

The bill’s gutting of prohibition on annual and lifetime coverage limits would affect not only people who get coverage  through health plans sold through the ACA’s marketplaces, but also the vast majority of people who get coverage from their employer, as analyst Tim Jost explains today in a Health Affairs blog.  “Since the ACA’s prohibitions of lifetime and annual limits and cap on out-of-pocket expenditures also only apply to essential health benefits, states granted a waiver would be able to define these protections as well. The changes to the lifetime and annual limits and to the out-of-pocket caps could potentially apply as well to large group and self-insured employer plans.” Jost also observes that although the amendment says that “’nothing in this Act shall be construed as permitting insurers to limit access to health coverage for individuals with preexisting conditions,” but that is precisely what health status underwriting [which could return in states that obtain waivers] does. Health status underwriting could effectively make coverage completely unaffordable to people with preexisting conditions.”  

And remember, even before the proposed compromise made the AHCA even worse, the original bill was unacceptable because it cut, capped, and block granted Medicaid, ended funding for Medicaid expansion, and replaced the ACA’s income-based premium and cost-sharing subsidies with regressive age-based ones that would make premiums and deductibles unaffordable for older and sicker patients, resulting in 24 million more uninsured persons, according to the Congressional Budget Office.

So if politicians tell you that people with preexisting conditions are protected by the amended AHCA, don’t believe them.  They are either lying, or more charitably, don’t understand what is being proposed.  And if they say premiums will be lower, keep in mind that while this might be true for some young and healthy people, it would be at the expense of making health care unaffordable for older and sicker patients.

Yet Speaker Ryan is counting votes right now in the hope of bringing the bill to a vote by Friday so it can be passed by the House of Representatives during President Trump’s first 100 days.

Don’t let Speaker Ryan and President Trump bring their even more terrible, horrible, no good, very bad bill back from the dead.  Call your member of Congress today, especially if he or she is a moderate Republican or one in a competitive district, at 202-224-3121 and help us put a nail in the AHCA’s coffin.  (And even if you have called before, they need to hear from you again).  Don't put this off, tomorrow could be too late.  Patients are depending on you.

Today’s question: did you make your call to Congress to urge them to vote no on the even more terrible, horrible, no good, very bad AHCA!

Thursday, March 23, 2017

In 38 years advocating for doctors, patients I've never seen a bill that will do more harm to health

When I tweeted this on Monday morning about the House GOP bill to “repeal and replace” the Affordable Care Act, I had no idea that it would result in me appearing on MSNBC’s Last Word with Lawrence O’Donnell or that it and my other tweets would be referenced by NBC News, a New York Times editorial, or for that matter, a retweet from singer-songwriter John Legend!


I mention all of this not for reasons of self-promotion, but to share with readers of this blog why I firmly believe that the GOP “repeal and replace” bill, expected to be voted on later today in the House of Representatives, will, if enacted, do more harm to health than any I have seen in nearly four decades of advocacy on behalf of internal medicine.

Here are my reasons:

First, never before I have I seen legislation advanced to the floor of either the House or Senate that would take health insurance coverage and consumer protections away from tens of millions of Americans; not once, not ever.  In fact, I doubt there is any time in history where Congress is being asked to vote to take health care away from so many.  Instead, the trajectory has been to expand health insurance coverage, not take it away: from enactment of Medicare and Medicaid in 1965, to the bipartisan Children’s Health Insurance Program becoming law in 1997; to creation of the Medicare Part D prescription drug program, signed into law by President George W. Bush on December 8, 2003; to the Affordable Care Act becoming law on March 23, 2010, exactly seven years ago.   Up until now, no President of either political party, and no Congress, has championed a measure that would result in a wholesale rollback of coverage and access to care for people who have gained it under prior laws.

Second, and most importantly, the American Health Care Act would do incalculable harm to the health of tens of millions of Americans.  This is not a political assessment, it’s based on what the bill actually proposes to do and evidence (from independent and non-partisan researchers) on how patients will be affected.

  • It makes radical changes to the Medicaid program’s structure and financing; the non-partisan Congressional Budget Office (CBO) estimates that 14 million low-income kids, adolescents and adults will lose their Medicaid coverage as a result. By putting a per-enrollee cap on the federal contribution to Medicaid, or offering states a “block grant” option (both of which means that the states are left having to make up any difference between the federal contribution and the costs of providing benefits to Medical enrollees), and phasing out the higher federal contribution for states that have expanded Medicaid to persons with incomes up to 138% of the Federal Poverty Level (FPL), the CBO found that the total federal contribution would be cut by $890 billion over the next decade, a whopping 25% cut!  Because most states are required by law to balance their budgets, a reduction in and/or a cap on federal matching funds will necessarily require them to greatly reduce benefits and eligibility and/or impose higher cost-sharing for Medicaid enrollees, most of whom cannot afford to pay more out of pocket—or alternatively and concurrently, reduce payments to physicians and hospitals (including rural hospitals that may be forced to close), enact harmful cuts to other state programs or raise taxes.  The phase-out of funding for Medicaid expansion, and the retroactive (to March 1) freeze on providing enhanced funding to any additional states that might have expanded the program, will eliminate one of the most effective programs ever in driving down the uninsured rate to historic lows.  Some Republicans surely recognize the importance of preserving funding for Medicaid expansion in their states: just yesterday, Michigan (GOP) Governor Rick Snyder wrote to the state’s congressional delegation urging them to vote against the AHCA.

  • It would reward states with higher federal funding if they impose punitive work or job search requirements on certain Medicaid enrollees.  If states adopt such requirements, current Medicaid enrollees (or those seeking to enroll) would not be eligible for the program if they are unable to prove to state Medicaid officials they have a job or are in job-training, or that they meet the conditions specified in the statute to be exempted from the requirement.  Medicaid is not a cash assistance or job training program; it is a health insurance program and eligibility should not be contingent on whether or not an individual is employed or looking for work.  While an estimated 80% of Medicaid enrollees are working, or are in working families, there are some who are unable to be employed because they have behavioral and mental health conditions, suffer from substance use disorders, are caregivers for family members, do not have the skills required to fill available positions, or there simply are no suitable jobs available to them.  Skills- or interview-training initiatives, if implemented for the Medicaid population, should be voluntary, not mandatory.  ACP’s Ethics, Professionalism and Human Rights Committee has stated that it is contrary to the medical profession’s commitment to patient advocacy to accept punitive measures, such as work requirements, that would deny access to coverage for people who need it.

  • Although not final, it’s been widely reported that Speaker of the House Paul Ryan will add to the version of the bill being voted on today a repeal of the ACA requirement that private insurers in the individual insurance market must cover 10 categories of essential services including physician and hospital visits, prescription drugs, cancer screening tests and other preventive services, mental health treatment, and many other services.  Even before this change, the AHCA repeals the requirement that Medicaid programs cover such benefits.  Any reduction in Medicaid coverage for substance use disorder treatments would exacerbate the grave opioid misuse epidemic that is devastating individuals, families and communities across the country.  Women’s access to health care would particularly be at risk, because the AHCA eliminates required coverage for childbirth and maternity and for contraception. 

  • Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance use disorder services, 18% did not have mental health services and 9% did not have coverage for prescription drugs. A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care.  Such increased costs would make it practically impossible for many patients to avail themselves of the care they need.  The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.

  • The AHCA’s regressive age-based tax credits, combined with changes that will allow insurers to charge older people much higher premiums than allowed under current law, will make coverage unaffordable for poorer, sicker, and older persons, as well as for persons who live in high health care cost regions. The AHCA replaces the ACA’s income-based and cost-sharing subsidies with age-based advance refundable tax credits worth only $2,000 to $4,000 for an individual.  These subsidies will be inadequate for most people to be able to buy affordable coverage, and would especially put vulnerable persons at risk, including low-income families and children, children and adults with special health care needs, and older persons with chronic illnesses who are not yet eligible for Medicare.  Indeed, a study based on the value of these tax credits determined that only 34% of a beneficiary’s medical costs would be covered. This is much less than the ACA, which ranges from about 60% to 94%, depending on the level of plan. By repealing the current law cost-sharing subsidies for persons with incomes up to 250% of the FPL, the AHCA would make out-of-pocket costs too high, and health care unaffordable, for many poorer patients. Without cost-sharing reductions, enrollees will be exposed to higher deductibles, co-payments and other cost sharing, potentially discouraging patients with limited financial means from seeking medically necessary care.  The AHCA also establishes a set amount for the tax credits per individual, without any adjustment for differences in the cost of care by locality.  This will result in the tax credits being insufficient to make coverage affordable for patients in high health care cost areas, especially older, poorer  and sicker ones.

  • The AHCA discriminates in the awarding of federal grant funds and/or Medicaid and Children’s Health Insurance Program funding to women’s health clinics that are qualified under existing federal law for the provision of evidence‐based services including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.  This provision, targeted at Planned Parenthood, reduces women’s access to evidence‐based services offered through the clinics including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.

  • The AHCA eliminates funding for Prevention and Public Health Fund, which provides billions in dollars to the Centers for Disease Control and Prevention to prevent and control the spread of infectious diseases like flu, Zika, and epidemics and pandemics.  

I could go on and on with other reasons why Congress should vote down the American Health Care Act but I think (hope) you get the point: this bill is a monstrous and unprecedented assault on coverage and access to care for many millions of Americans, and especially, the most vulnerable of our neighbors: those who are older, poorer and sicker.  It is by far the worst piece of health-related legislation I have seen since I first started working for the American Society of Internal Medicine (which merged with ACP in 1998) when Jimmy Carter was president.  It must be stopped, now.

Today’s questions: What do you think of the AHCA, and what are you doing about it?

Wednesday, February 22, 2017

Mr. President: are foreign-born doctors and sick children “bad people”?

President Trump argues through his Twitter posts that his administration’s travel ban on immigrants and refugees from 7 majority-Muslim countries, currently on hold because of court rulings against it, is about keeping “bad people” out of the country.  Commenting on the initial ruling by a federal judge suspending the ban, which was then upheld by a 10-1 ruling by a federal appeals court, President Trump tweeted: 

“The judge opens up our country to potential terrorists and others that do not have our best interests at heart. Bad people are very happy!” 

“Because the ban was lifted by a judge, many very bad and dangerous people may be pouring into our country. A terrible decision.”

“What is our country coming to when a judge can halt a Homeland Security travel ban and anyone, even with bad intentions, can come into U.S.?”

Rather than continuing to fight it out in court, though, the administration has announced that it will issue a revised executive order this week, one that it believes will pass muster with the courts. We will see what the new order says and if the courts agree.

From the standpoint of what’s best for health care, though, ACP believes that it is essential that the revised order discontinue the policy of discriminating against foreign-born physicians and medical students, especially Muslims, from the 7 designated countries, and thousands of refugees from them seeking shelter in the United States.

The fact is that rather than keeping out “bad people” who want to do us harm, President Trump’s executive order denied travel to many physicians who live in the United States with valid visas, physicians who provide care to hundreds of thousands of patients.  Among them are:

Dr. Chalak Berzing, an Iraqi Muslim immigrant physician/cardiologist who has won the trust of an overwhelmingly conservative, working class town in Appalachia. President Trump, is Dr. Berzingi among the “bad people” you want to keep out?

Dr. M. Ihsan Kaadan, a Syrian doctor who treated patients suffering from the horrors inflicted on the civilians of Aleppo, Syria; he later was granted a visa to enter the United States to continue his studies at Brandeis and his internal medicine residency training at Massachusetts General.  “In hopes that leaders and politicians around the world reconsider any plans to ban refugees who seek to escape brutal wars and other human tragedies” Dr. Kaadan recently wrote of his experiences:

“I am a Muslim and I am from Syria, I came here fleeing a brutal war that has killed more than 400,000 men, women, and children. I have the features that make me look like what some people think of as terrorist. But I am not a terrorist. In fact, I’m the opposite — I am a patriot for America and for Syria. I want to serve the country that opened its doors to me and also help my home country.” 

President Trump, Is Dr. Kaadan among the “bad people” you want to keep out?

Drs. Kaadan and Berzing are hardly alone.  There are 15,000 physicians from across the United States that are from the 7 countries subject to the travel ban, many of whom are providing care to Americans in underserved communities.  Even if the executive order would allow them to remain in the U.S. as long as they had valid visas, the travel ban placed them at risk of not being able to reenter the U.S. if they traveled home to see their families—say to see an ailing aged parent. In fact, there were at least three physicians in U.S. internal medicine residency programs, ACP members, who were traveling abroad at the time the executive order was issued and were turned away from re-entering the United States. And, according to the Association of American Medical Colleges, there are currently 260 applicants from the affected countries among the 35,000 people seeking residency and fellowship positions in this country. 

President Trump, are these 15,000 physicians seeking to train in the U.S. and provide care to the most underserved Americans among the “bad people” you want to keep out?

Let’s also not forget the sick refugee kids and their families, already vetted and approved for visas, who were denied entry to U.S. borders, including tens of thousands of Syrian children and their families seeking shelter from horrible violence, deprivation and death, and babies like this four-month-old Iranian child in urgent need of brain surgery who was turned away when the executive order went into effect. 

President Trump, are these children among the “bad people” you want to keep out?

The American College of Physicians has taken a firm stance against discrimination in immigration policy based on religion and in strong opposition to the President’s executive order, and in support of comprehensive policies to reform immigration laws and policies to allow physicians and medical students with approved visas to travel freely to and from the United States, to protect “Dreamers” from deportation, and to expand the number of refugees accepted into the United States, particularly those with urgent medical needs. We have also joined with 11 other internal medicine membership organizations to urge the Department of Homeland Security to immediately implement changes to lift restrictions on travel for physicians and medical students with approved visas and to prioritize admitting refugees who need medical care.

The Trump administration still has a chance to get things right this time in its revised executive order, by lifting discriminatory travel restrictions on Muslim physicians and medical students and refugees who have been thoroughly vetted and approved for visas to travel to and from the United States.  Let’s hope it does, because maintaining the current policy in some other form is bad for health care, bad for medical education, and bad for the millions of patients who get their care from foreign-born physicians—and for many refugees, it’s a matter of life and death. 

Today's question: What do you think of President Trump's travel and immigration ban and ACP's advocacy to overturn it? 

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?