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Date: February 15, 2018 at 6:46:46 AM MST
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Subject: The Health 202: Alex Azar's first big test: Will he enforce
Obamacare?
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Alex Azar's first big test: Will he enforce Obamacare?
BY PAIGE WINFIELD CUNNINGHAM
with Paulina Firozi
THE PROGNOSIS
Idaho Gov. C.L. "Butch" Otter is allowing insurers in his state to sell plans
that don't fully comply with the Affordable Care Act. (AP Photo/Otto
Kitsinger, File)
Alex Azar is facing his first big Obamacare test in his new role as Health
and Human Services secretary: Will he enforce the Affordable Care Act even as
some Republicans try to duck its requirements?
If Azar cracks down on Idaho for its recent bold and unprecedented move to
sidestep ACA insurance regulations, he’ll send the message that the law of
the land comes first — even if he privately supports efforts by Congress to
repeal Obamacare. But if the new secretary shrugs off Idaho’s actions, it
could embolden more GOP-led states to thumb their noses at the health-care
law and let off the hook more insurers from its consumer protections.
It was unclear yesterday, however, exactly what approach Azar would take as
he faced questions in a congressional hearing about how he’ll respond to
Idaho, a state whose Republican governor, C.L. “Butch” Otter, announced last
month that insurers can sell non-ACA-compliant plans.
Asked about the Idaho move during a House Ways and Means Committee hearing,
Azar said that “there are rules and there’s a rule of law that we need to
enforce.”
But Azar also didn’t indicate that he has issued warnings to the state. “I’m
not aware that our opinions or views have been solicited,” he told lawmakers.
ThinkProgress's Amanda Michelle Gomez tweeted a response from Azar's new
department:
On Wednesday, Blue Cross of Idaho became the first insurer to take Otter up
on the offer, announcing it would sell five “Freedom Blue” plans that include
limits on annual medical spending and charge higher premiums to people with
preexisting medical conditions — all policies that are specifically
prohibited under the ACA.
Indeed, there’s little dispute among experts that Idaho is violating the text
of the ACA and some of its key tenets to make insurance coverage more
comprehensive. A major part of the health-care law is requiring that
individual market plans cover 10 categories of “essential health benefits”
and ensuring that people with preexisting conditions don’t have to pay higher
monthly premiums than healthy people.
“It is, I think, a clear-cut violation of the Affordable Care Act,” Joel
Ario, who directed the Office of Health Insurance Exchanges under the Obama
administration, told me.
Andy Slavitt, former Centers for Medicare and Medicaid Services administrator
under Obama:
Aviva Aron-Dine, a senior fellow at the liberal Center on Budget and Policy
Priorities and a former member of Obama’s administration:
Kaiser Family Foundation senior VP Larry Levitt:
So, what could the Centers for Medicare and Medicaid Services do to enforce
the law? If the agency determines Idaho has failed substantially to enforce
part of the ACA, it could wield a pretty big stick by fining the plans $100
per day for every customer, which could add up to $36,500 per year.
There are possible legal ramifications, too. Plans ducking the ACA face the
risk of lawsuits from patients who buy noncompliant coverage only to later
realize their plan doesn’t cover certain mandated benefits that they might
need.
Given those possible risks, it could seem surprising that any state would
give insurers such license. But if CMS doesn’t take a firm stance in the
Idaho situation, it’s possible to imagine other Republican-led states
following suit, especially those that have resisted other elements of the ACA
such as its Medicaid expansion.
Health and Human Services Secretary Alex Azar testifies before the House Ways
and Means Committee on Wednesday. (AP Photo/Jacquelyn Martin)
Expect states and insurers to be carefully watching Azar’s moves in the
coming weeks as they start thinking about the marketplaces for 2019.
Marketplace insurers are working on setting rates for next year, and in a few
months they’ll need to start submitting plans to the administration for
approval.
“I do suspect if Idaho goes forward and approves the plans and they’re
actually sold — and there isn’t any consequence against them — I do think
you’ll see other states take a closer look at that strategy,” Ario said.
Just look at how more than a half dozen states legalized recreational use of
marijuana under the lenient Obama-era policy that kept federal authorities
from enforcing a federal ban against it. A similar domino effect could occur
with health plans -- once one state shows it's possible to duck the ACA,
other states might try to do the same, said Nicholas Bagley, a professor at
the University of Michigan Law School.
"I think Azar has got to be worried that, if Idaho presses ahead, other
states will follow," Bagley told me. "Once they know the cop is off the beat,
why wouldn't they?"
To justify their actions, Otter and Blue Cross have both pointed to rising
insurance premiums on Idaho’s individual market as reasons they’re ignoring
parts of the ACA. Idaho officials said the aim is to allow these cheaper
plans to be sold off the state’s marketplace to attract younger and healthier
consumers.
Yesterday, Idaho Blue Cross CEO Charlene Maher said Idaho’s marketplace
“isn’t affordable” for middle-class families. “Our new state-based plans are
a response to Gov. Otter’s executive order, which begins to solve the issues
that have kept middle-class Idahoans from buying health insurance,” she said
in a statement.
Idaho’s move is also raising the ire of many health-care advocates and
stakeholders who had bristled at Republican efforts in Congress to repeal
some of the ACA’s insurance requirements but then breathed easier when those
efforts dramatically failed. Now, they have to worry about whether the Trump
administration will enforce a law that remains on the books.
A group of 15 medical associations wrote to Azar yesterday, urging him to
ensure plans would continue providing the full range of benefits required
under the ACA and maintain its consumer protections.
“We urge you to make clear that Idaho cannot authorize the issuance of health
insurance coverage that violates federal law, and that any insurer that
issues such plans risks enforcement action and serious penalties,” says the
letter, signed by the Cancer Action Network, the American Heart Association
and the American Lung Association, among others.
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Here's what we know about the Florida high school shooting
— The latest on the Florida shooting: At least 17 people were killed when a
19-year-old gunman opened fire Wednesday on the South Florida high school
from which he was expelled. Nikolas Cruz had been kicked out for
“disciplinary reasons,” and was captured following a manhunt in the aftermath
of the shooting, The Post’s Moriah Balingit, William Wan, Mark Berman and
Lori Rozsa report. Cruz was booked into Broward County Jail early Thursday
and charged with 17 counts of premeditated murder, per the Associated Press.
Officials said another 14 people have been treated at hospitals, per the AP.
The terror unfolded at Marjory Stoneman Douglas High, a 3,000-student school
named after an icon of the South Florida environmental movement and located
in an affluent suburb northwest of Fort Lauderdale. It was the 18th school
shooting in the nation just 45 days into the year, according to pro-gun
control group Everytown for Gun Safety. President Trump has tweeted three
times about the shooting, expressing his “prayers and condolences” to
victims’ families. “So many signs that the Florida shooter was mentally
disturbed, even expelled from school for bad and erratic behavior,” the
president tweeted Thursday morning. “Neighbors and classmates knew he was a
big problem. Must always report such instances to authorities, again and
again!”
Sen. Chris Murphy (D-Conn.) took to the Senate floor on Wednesday to call out
Congress for not doing enough to address gun violence. "This epidemic of mass
slaughter, this scourge of school shooting after school shooting," Murphy
said. “It only happens here not because of coincidence, not because of bad
luck, but as a consequence of our inaction. We are responsible for a level of
mass atrocity that happens in this country with zero parallel anywhere else."
AHH, OOF, OUCH
Medical bottles bearing tracking codes in the McKesson medical distribution
center in Delran, N.J. (AP Photo/Brian Branch-Price, File)
AHH: Prescription drug spending is projected to grow faster than any other
major medical good or service over the next decade, The Post's Carolyn Y.
Johnson reports. The analysis out yesterday from the Centers for Medicare and
Medicaid Services, published in the journal Health Affairs, estimates that by
2026, national health spending will climb to $5.7 trillion, or nearly a fifth
of the economy.
While data was released in December showing a 1.3 percent increase in
spending on prescription drugs in 2016 — a small fraction of the increases in
previous years -- the new analysis suggests the low rate of increase will not
last. Future spending is forecast to grow at 6.3 percent per year, on
average, between 2017 and 2026, according to the CMS analysis.
"CMS actuaries said the secret rebates that manufacturers negotiate with
health plans have helped temper the growth of prescription drug prices and
spending in recent years but will not contribute as much in the future,"
Carolyn writes. "The new data suggests that while rebates have helped to rein
in prescription drug spending, the effect will attenuate over the next
decade. The spending growth will also be driven by a shift toward specialty
drugs, which cost more and often do not carry the same generous rebates."
A nurse prepares a flu shot at the Salvation Army in Atlanta. (AP Photo/David
Goldman)
OOF: This flu season has gotten so bad -- partly because the vaccine is less
effective than in previous years -- that patients seeking care have surged to
levels not reported since 2009's swine flu peak. My colleagues Darla Cameron
and Dan Keating have put together an interesting graphic showing flu-related
hospitalizations by year, illustrating just how intense this year's flu
season is.
It's worth noting President Trump hasn't said anything about the flu. And
it's not as though he doesn't ever address epidemics: Since his inauguration,
Trump has called out three 'epidemics' on his Twitter feed: An “epidemic” of
human trafficking; an epidemic of crime in Chicago; and, of course, the
opioid epidemic, The Post's Philip Bump notes. Trump hasn’t promoted the flu
vaccine, either through his personal Twitter account, the White House account
or the @POTUS account -- although former President Obama didn’t do so from
his personal account as president, either, despite flu epidemics in 2013 and
2015.
Dee Clarke, 60, of Portland, Me., says Trump's proposal to cut Medicaid, food
stamps and other social services would hurt poor people. (Tristan Spinski for
The Washington Post)
OUCH: Anti-poverty advocates say the social safety net cuts and restructuring
proposed in Trump's budget — substituting “food boxes” for food stamps and
introducing work requirements for subsidized housing — could make life more
precarious for 90 million low-income Americans who rely on at least one of
those programs, potentially pushing millions off the programs and reducing
benefits for the ones who are left, The Post's Caitlin Dewey and Tracy Jan
report.
The budget proposal, released Monday, would slash nearly half a trillion
dollars over the next 10 years from the three main pillars of the social
safety net: Medicaid, federal housing assistance and the Supplemental
Nutrition Assistance Program, better known as food stamps. The proposal is
unlikely to become law, but it reflects the priorities of Trump and his
administration, who say dramatically curtailing spending on these programs
can shrink the deficit and focus benefits on the truly needy.
But anti-poverty advocates charge the cuts put vulnerable low-income families
at risk of hunger or homelessness — particularly if they, like an estimated
5.7 million Americans, depend on all three of the targeted programs, Caitlin
and Tracy write. “Is that making America great — by making it unbearable for
people who are U.S. citizens to even live here?” asked Daisy Franklin, a
60-year-old grandmother in Norwalk, Conn., whose household of four relies
upon Medicaid, a federal housing voucher and more than $300 a month in food
stamps. “It sounds like Trump is trying to turn the clock back.”
HEALTH ON THE HILL
Sen. Tammy Duckworth (D-Ill.) says a bill to amend the ADA could hurt those
with disabilities. (Photo by Alex Wong/Getty Images)
--Today the House is expected to approve a bill that removes incentives for
business owners to comply with the Americans With Disabilities Act mandating
equal access to public accommodations, The Post's Mike DeBonis reports.
Advocates for the disabled fear the measure would weaken the 27-year-old law,
while proponents contend the legislation would stem a tide of “drive-by
lawsuits” brought by predatory lawyers seeking to collect payouts from
noncompliant business owners without actually improving access for those with
disabilities.
The ADA Education and Reform Act which is supported by House GOP leaders and
a handful of Democrats, would require those who sue businesses in federal
court to first deliver a specific written notice to that business detailing
the illegal barrier to access, and then give that business 60 days to come up
with a plan to address the complaints and an additional 120 days to take
action. "That, the bill’s supporters say, would keep small-business owners
from being targeted for legal shakedowns. But the bill’s opponents say it
would in effect gut the ADA by removing any incentives businesses have to
comply with the law before a complaint is filed," Mike writes.
More than 200 disability-rights groups have signed a letter opposing the
bill, and tensions over the bill have run high at times. Activists
interrupted a House Rules Committee meeting on Tuesday chanting “Don’t take
our rights away. Hands off the ADA!” Capitol Police arrested 10 people after
they refused an order to leave the premises. Five were in wheelchairs, Mike
reports.
AGENCY ALERT
Surgeon General Jerome Adams. (AP Photo/Darron Cummings, File)
--Surgeon General Jerome Adams says he would “politely disagree” that efforts
to combat opioid abuse should move away from law enforcement and toward
addiction treatment. “We have to help law enforcement have a public
health-informed approach to the way they tackle addiction, but we will never
be able to remove law enforcement from the equation,” Adams said yesterday at
an event hosted by The Hill. “We’ve got to figure out ways to better partner
with them.”
Adams also said connecting people with support services, such as food and
housing, should be a key part of the effort to fight the opioid epidemic. But
he stressed the money Congress recently allocated should be spent in ways
that produce results.
“That’s what I want Congress to know, that’s what I want policymakers to know
— we’re not throwing good money after bad; we’re actually getting a return on
investment by wrapping people with the support services they need to be
successful in recovery," Adams said.
--A few more good reads from The Post and beyond:
Veterans Affairs chief Shulkin, staff misled ethics officials about European
trip, report finds
A senior VA official altered an email to make it appear that David J. Shulkin
was receiving an award from the Danish government, then used the award to
justify paying for his wife’s travel, an inspector general found.
Lisa Rein • Read more »
MEDICAL MISSIVES
FDA clears insulin dose calculator that's connected to a smartphone app
The Food and Drug Administration has approved Glooko's Mobile Insulin Dosing
System.
CNBC • Read more »
INDUSTRY RX
A surprise no one wants: Big medical bill even with coverage
This winter’s nasty flu season may smack patients with a financial side
effect: surprise medical bills. People who wind up in the emergency room or
need an ambulance can be blindsided by hefty, unexpected charges.
AP • Read more »
STATE SCAN
Ohio wants to require those on Medicaid to get a job
Thousands of Ohioans soon might need to find a job or lose their Medicaid
health insurance.
Columbus Dispatch • Read more »
OPIOID OPTICS
How a Police Chief, a Governor and a Sociologist Would Spend $100 Billion to
Solve the Opioid Crisis
Treatment foremost, but also support for a host of other solutions, including
more interdiction.
New York Times • Read more »
How best to treat opioids' youngest sufferers? No one knows
The opioid abuse surge has outpaced the science, and no one knows the best
way to treat the opioid epidemic’s youngest patients.
AP • Read more »
DAYBOOK
Coming Up
The USC-Brookings Schaeffer Initiative for Health Policy holds an event on
patient cost sharing for prescription drugs on Friday.
SUGAR RUSH
Sen. Chris Murphy (D-Conn.) told his fellow lawmakers Wednesday's shooting at
a South Florida high school is the “consequence of our inaction:"
Murphy: Fla. shooting is ‘consequence of our inaction’
Former FBI agent Philip Mudd broke down while talking about Wednesday's
school shooting on CNN:
Ex-FBI agent breaks down over Florida school shooting
The White House's claims surrounding the domestic violence allegations
against Rob Porter were challenged by FBI Director Christopher A. Wray:
Wray vs. the White House on Porter
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