Tag: Affordable Care Act

How to make America healthy again
Adam Gaffney writes for In These Times about how to make America healthy again: A universal single-payer system. President-elect Donald Trump and the Republican-led Congress is set to defund many health care programs and policies, including making large cuts to Medicaid and possibly eliminating income-based subsidies for people receiving coverage through the Affordable Care Act.

To “Make America Healthy Again” (MAHA), Robert F. Kennedy, Jr., president-elect Trump’s pick to head the US Department of Health and Human Services (HHS), is planning a number of initiatives that will only make us sicker, writes Gaffney. He agrees with Trump and Kennedy that the US health care system is flawed in a variety of ways, leading to lower life expectancy than every other wealthy country, an opioid epidemic, as well as millions of uninsured Americans and unaffordable health care for tens of millions more Americans.

One in four working Americans cannot afford their health care. Twenty-five million Americans are uninsured. In total, nearly half of working-age Americans are either uninsured or underinsured. But, the upcoming Trump administration is hell-bent on a path forward that is most likely to boost profits for UnitedHealth and other big health corporations, drive up health care costs, and increase the number of Americans who cannot afford their health care, while contaminating the air we breathe and the water we drink.

Americans who oppose this path should support “a bold, populist progressive healthcare vision.” RFK Jr. continues to promote an anti-vaccine agenda that is likely to be seriously harmful to people around the world; he also denies AIDS. He appears to support a healthy eating agenda, but that is less likely to have legs in the next administration.
RFK, Jr. claims that seed oils are “poisoning” Americans. But, there’s no data to support his claim. On the other hand, air pollution is responsible for 48,000 needless deaths each year in the US. And, if Trump sticks to his first-term agenda, he will allow weaker automobile emission standards and power plant pollution standards. The Environmental Protection Agency projects that weakening standards could add as many as 1,200 needless deaths and 1,900 asthma cases each year.

Childhood poverty is another serious issue in the US, leading to childhood obesity and disease. Policy reforms are critical, but they are not on the Trump administration agenda. Instead of improving the nutritional value of school lunches, the first Trump administration permitted fewer fruits and vegetables and an increase in poor quality food.

RFK Jr. wants to end direct-to-consumer advertising of prescription drugs, which is a good idea. But, it is unlikely the Supreme Court would allow this, supporting what the Supreme Court will claim are the first amendment rights of pharmaceutical companies over the value of consumer protections. RFK Jr. also correctly called out the malfeasance of the FDA for approving drugs that have little or no benefit to mollify industry. But, again, Trump is unlikely to address this issue, and RFK’s views on certain drugs are unfounded in science and dangerous to the public health.

As bad as RFK Jr., Jim O’Neill, a biotech investor whom president-elect Trump has proposed as deputy secretary of HHS, does not believe the FDA should weigh drug efficacy when deciding whether to approve drugs. And, Mehmet Oz, whom Trump has proposed to head the Centers for Medicare and Medicaid Services (CMS), has a history of promoting supplements and other products that have no value whatsoever. Oz’s own Columbia University colleagues have condemned his views, expressing “dismay” that he is on the faculty there.

Advances in health care treatments are only beneficial for those who can afford them. The Trump administration is ready to make these treatments even less affordable than they already are, among other things, planning to cut the Medicaid budget dramatically. Such a move will mean tens of thousands more preventable deaths. During his first presidency, President Trump attempted to repeal the Affordable Care Act. Had it succeeded, it would only have increased the number of preventable deaths.

As Sen. Bernie Sanders has proposed, what we need to “Make America Healthy Again” is a very different agenda from Trump’s–one that promotes guaranteed affordable access to care, clean air and clean water.

Here’s more from Just Care:
January 15, 2025
What will happen to ACA subsidies in 2025?
The Trump administration, in partnership with the next Congress, will determine whether or not subsidies will continue for people getting health insurance through the state health insurance exchanges under the Affordable Care Act. Axios reports on the state of play.

Republicans in Congress, who will be the majority in both the House and the Senate, will spark a lot of rage among millions of people in the state health insurance exchanges, if they do not extend the subsidies. They will force millions of people to lose their insurance because, without the subsidies, they won’t be able to afford it. Without subsidies, the Republicans will force others to pay far higher health insurance premiums. Of note, the premium subsidies are most helpful to residents of Republican states that have not expanded Medicaid. So, Republicans in Congress could pay a big price if they eliminate the subsidies.

But, as of now, the Republicans are not biting. They would not agree to a Democratic proposal to extend the ACA subsidies for one year.

The Senate Finance Committee’s new Chairman, Mike Crapo (R-Idaho), is considering whether to include the subsidies in the budget reconciliation process that will happen in early 2025. He has not taken the subsidies off the table.

However, Republicans in the House are saying that they do not support the subsidies. Jodey Arrington, who chairs the House Budget Committee, does not see an extension of the subsidies in the future. His response, when asked about extending the subsidies, was “hell no.” But, who knows?

What would be the consequences of not extending the subsidies? Without the ACA subsidies in 2026, 2.2 million Americans are projected to lose their health insurance. In 2027, 3.8 million would lose their health insurance. People in the state health insurance exchanges would see their premiums rise 4.3 percent in 2026 and 7.7 percent in 2027.

As of yet it is unclear what the Republicans in Congress would do for the millions of uninsured Americans, particularly if they end the ACA subsidies.

Here’s more from Just Care:
December 17, 2024
Medicare stronger than expected, per person spending has barely grown since 2010
A new review of Medicare spending over the last several decades shows a leveling off in Medicare spending per person since 2010, reports The New York Times. No one knows why exactly. Given that the government overpays Medicare Advantage plans–health plans administered by corporate health insurers–tens of billions of dollars a year, this slow-down in the rate of per person spending has made Medicare stronger than expected.

In 2011, Medicare spent $13,159 per enrollee. Passage of the Affordable Care Act in 2010 appears to have controlled per person spending since then. If this spending had continued to grow at the same rate as it had been growing, Medicare would spend an average of $22,006 per person today. Instead, it is spending less, $12,459 per person on average.

Medicare spent about $3.9 trillion less than projected since 2010. Part of the explanation for the reduction in spending is that Congress reduced payments to hospitals and to Medicare Advantage plans through the Affordable Care Act. But, that can hardly be all of it as our government is overpaying Medicare Advantage plans some $75 billion a year at this point.

The Times suggests that spending has leveled off in part because older adults are experiencing fewer heart attacks, possibly because more of them are taking cholesterol and blood pressure medicines. The Times also suggests that there are few blockbuster costly new drugs to drive up spending. But. Aduhelm is now available to people with Alzheimer’s and is incredibly expensive. And, if Medicare approves coverage of Ozempic for weight loss, that would also drive up Medicare spending.

Some argue that Medicare spending per person has barely increased in more than a decade because hospitals and other health care providers are focused on cost-containment. But, that focus could be denying people access to needed treatments. Life expectancy among older adults is falling.

Of course, Covid-19 also kept people out of the hospital and from getting other costly care. So, the pandemic also contributed to savings. And, while the New York Times story does not say so, high out-of-pocket costs keep a lot of people from getting Medicare services they otherwise would be getting.

Here’s more from Just Care:
September 4, 2023
Health insurers increasingly deny coverage for critical care
Elisabeth Rosenthal writes for The Washington Post on the rising rate of health insurance denials. High denial rates are not surprising given that health insurers generate greater revenues on each claim they deny. Consequently, they often use proprietary computer algorithms to deny claims in a systematic fashion, with no regard for people’s medical needs.

Since the Affordable Care Act, health insurers can no longer refuse to cover people with pre-existing conditions in many instances. Instead, to maximize profits, they find ways to deny care. Rosenthal highlights how one insurance company literally has as a job title “denial nurse.”

Although the US Department of Health and Human Services is charged with overseeing insurance company denials, it has not undertaken its oversight responsibilities in a meaningful way. Rather, too often, patients are faced with care denials and the obligation to pay for their care themselves or skip getting care altogether.

The Kaiser Family Foundation (KFF) recently reported that, in 2021, one in six claims for in-network care in the state health insurance exchanges were denied, 17 percent. In one case, the insurer denied half of all claims, 49 percent! Worse still, another insurer denied four in five claims, 80 percent. And, while insurers reverse the majority of denials when people appeal, patient appeal rates are extremely low–one in 500.

At times, denials are not only medically incomprehensible but nonsensical. For example, one patient with arrhythmia had his insurer’s approval for a heart procedure, but he was denied coverage “for injections into nerves in your spine,” which he had not received. The insurer had not paid the claim many months later, notwithstanding endless attempts to fix the error.

In another instance, the insurer wrote a newborn to let the baby know that his neonatal care was denied because the baby could drink from a bottle and breathe on his own. Of course, the baby could not read the denial! And, an insurer denied coverage for epinephrine and steroids received in the emergency room to treat a young man with a deadly anaphylactic allergic reaction, which the insurers claimed was medically unnecessary. Though the patient’s mother has appealed, she still has not gotten the insurance to cover the services.

Increases in insurer denial rates are likely a product of a computer system, PXDX, which I wrote about here, that allows insurers’ medical claims-review staff to deny 50 claims in ten seconds. This system saves insurers billions of dollars a year, at the expense of the health and well-being of their enrollees.

To add insult to injury, claims can be denied because an insurer does not have a contract with a particular drug or device manufacturer. It doesn’t matter that the patient needs the treatment.

Of course, these denials are also happening in Medicare Advantage plans. And, the Centers for Medicare and Medicaid Services (CMS) is not reporting plan denial rates to enable people to avoid plans with high denial rates. In fact, most likely, those plans are getting four and five-star ratings, because the rating system is such a farce! (You can read about why the Medicare Advantage star-ratings are a farce here.)

The Affordable Care Act gives health insurer oversight responsibilities to HHS and requires HHS to collect and publicly report denial rates among corporate health insurers in the state health exchanges. But, HHS has not undertaken this data collection and reporting, as required. So, after more than a decade of failed government oversight, the insurers continue to deny claims with impunity.

Here’s more from Just Care:
May 18, 2023
Joe Biden will build a strong public health infrastructure
Atul Gawande makes the case for electing Joe Biden President in the New Yorker. He argues that a Biden administration will build a strong public health infrastructure to control the pandemic, which will begin the reforms necessary to fix our broken health care system. At the same time, Gawande appreciates that the Biden administration will not deliver us the guaranteed health care we so desperately need.

No question that a President Biden will make controlling the pandemic a priority. And, there’s also no question that doing it well will move us towards a better health care system. The only question is whether Biden and a Democratic Congress will do it as well as it should be done.

Vice-President Biden and House Speaker Nancy Pelosi have already made clear that they do not have any interest in automatically guaranteeing everyone access to affordable health care through Medicare for All. But, continuing our fragmented private health care system means no good real-time data of what’s happening with the pandemic and, more generally, with people’s health care. It also means premiums and out-of-pocket costs will continue to rise. There’s good reason to believe many people will skip testing and treatment because of the cost.

Without a single public health care system, the federal government will have little ability to make system improvements that will help. Just look at how poorly hospitals and insurers responded to the Congressional mandate that COVID-19 testing be free. People continue to see big bills, and as a result, many people are not getting tested or treated when they should.

If there’s good news, it’s that Vice-President Biden and a Democratic Congress will trust the science and available evidence. They will be forthright about what is happening in the country and what people need to do to protect themselves and their community. They will also appropriate and disburse at least some of the funds needed to keep the economy from sinking. And, they will offer help to people and hospitals in need. How much help they will provide businesses and individuals is still an open question.

In stark contrast, President Trump and his administration and Congress have lied to the American people about the dangers of the virus, denied the science, and done precious little to fight the virus. For example, they should have imposed a national mask mandate. Instead, their actions have led to the needless death of countless older adults, health care workers, working people and their children. They have failed to ensure adequate supplies of personal protective equipment for health care workers and other essential workers, including a disproportionate number of Americans who are Black, Latino and low-income.

The number of reported COVID-19 deaths is unconscionably high at 220,000; and the Trump administration likely has underreported these deaths; more than 300,000 people have died this year than at the same time last year. The Trump administration also has failed to ensure that people have access to free tests with timely results or that health care workers have the personal protective equipment they need.

Pandemic management must start with the federal government, not with the states, as Vice-President Biden acknowledges. It must include universal health care coverage. But, pre-pandemic, 45 percent of working Americans were uninsured or underinsured, with unaffordable out-of-pocket costs.

Moreover, as the pandemic has made clear, we must end the tie between work and health care coverage if we are to ensure Americans access to needed health care. Tying health insurance to people’s jobs puts them at severe health risk when the economy turns and the job market shrinks.

If we don’t fix health care, we can’t fix financial or racial inequality. Yet, Gawande recognizes that a Biden administration has not yet committed to take the bold steps we will need to guarantee everyone access to care. Biden wants to build on the Affordable Care Act, which tends to offer health plans with few high-quality specialists and high out-of-pocket costs. Time will tell whether Biden’s version of a public health insurance option will guarantee people the reliable and affordable coverage they need.

Here’s more from Just Care:
October 21, 2020
Pharma doesn’t have your back
You might think that Pharma is doing more good than harm, but, watch out, it does not put your interests first; it doesn’t have your back. Stat News reports that the pharmaceutical industry has given $1.5 million in the last election cycle to Republican State Attorneys General working to repeal the Affordable Care Act. As always, Pharma’s focus is only on its bottom line, driving profits for shareholders.

Pharmaceutical companies must see more benefits for themselves from overturning the Affordable Care Act than in keeping it. What’s interesting is that the ACA generates a lot of revenue for the pharmaceutical industry. The ACA insures millions of people. And with that coverage comes prescription drug benefits. So, it makes sense that Pharma’s support of the State Attorneys General working to repeal the ACA stems from its belief that it will generate greater revenue from its repeal.

The state health insurance exchange health plans tend not to offer particularly good access to care, and they are very expensive. But, they are still a way better option than going without insurance for the millions of Americans who need it. And, the majority of Americans (58 percent) do not want to see the ACA repealed.

With their support of Republican State Attorneys General, drug corporations are undermining the needs of more than 20 million Americans who depend on coverage from their state health insurance exchanges. Pharmaceutical companies are endangering their health and, in the process, tarnishing the industry’s image. In addition, in the short term, the pharmaceutical companies will lose revenue, if the ACA is repealed.

But, states can confer lots of additional benefits on the pharmaceutical industry, including tax waivers. States can also fail to enact regulations that would lower drug prices. Pharma does not want states regulating drug prices or otherwise forcing them down. So, it appears that Pharma has chosen to play this long game.

Of course, Pharma claims it never intended to support the ACA’s repeal. That’s hard to believe. There’s a lot that pharmaceutical companies could be doing now to demonstrate support for the ACA if the pharmaceutical companies so chose. Their inactions speak louder than words.

Here’s more from Just Care:
October 19, 2020
Blame President Trump if people with pre-existing conditions lose their health insurance guarantee
In an op-ed for the New York Times, former Administrator of the Centers for Medicare and Medicaid Services, Andy Slavitt, and Nicholas Bagley explain how President Trump will be to blame if the new Supreme Court overturns the Affordable Care Act. With Ruth Bader Ginsburg’s passing, extra benefits for people with Medicare very well might fall away as might the guaranteed right to health insurance for people with pre-existing conditions.

President Trump is supporting a lawsuit challenging the constitutionality of the Affordable Care Act. His Supreme Court nominee easily could be the deciding vote eliminating the law. If overturned, nearly 15 million people who have Medicaid as a result of the ACA’s expansion of the Medicaid income limit would lose it. And, more than 11 million people who have coverage through the state health insurance exchanges would lose that. People with Medicare Part D would have to spend a lot more for their prescription drugs.

All Americans with health insurance would lose the guarantee of preventive care services with no deductible or copay, a protection in the ACA. They would also lose the guarantee of no lifetime limits on their coverage. And, children would not be able to get coverage through their parents’ policies until the age of 26.
The Supreme Court case challenging the ACA is based on the nonsensical claim that because people can no longer pay a penalty as an alternative to buying health insurance–a federal appeals court struck down the penalty provision in the law–the law forces people to buy health insurance, which is unconstitutional. The plaintiffs claim that without a penalty on people who don’t buy health insurance, the language in the law that says people “shall” buy health insurance has no meaning. Of course, eliminating the penalty actually makes it less costly to decide to go without health insurance and was never meant to force people to buy health insurance.

Plaintiffs further claim that if one part of the law is unconstitutional, the whole law is unconstitutional. This is yet another ridiculous argument. But, President Trump stands behind it. In the meantime, he has made it harder for people to get and stay on Medicaid by requiring people to complete more paperwork.

Congress could fix the ACA. It could put a $1 financial penalty on people who don’t get health insurance. Or, it could eliminate the “shall” language from the law, so that it can’t be argued that people must buy health insurance. But, these fixes are only possible if the Democrats win control of the Senate and the presidency.

Here’s more from Just Care:

Medicare Part D drug coverage in 2020

Seven reasons commercial insurance cannot meet our health care needs

Ten ways Medicare Advantage plans differ from traditional Medicare

Medicare ratings of Medicare Advantage plans a farce

Don’t be seduced by Medicare Advantage bells and whistles
September 30, 2020
Take advantage of Medicare’s annual wellness visit
Take advantage of Medicare’s annual wellness visit. During this visit, Medicare covers a series of preventive care services to detect health risks. If you’d like, you can also discuss end-of-life wishes with your doctor. It should help you and the people you love stay healthy and out of the hospital.

The annual wellness visit is different from a physical in that it is intended for the doctor to understand your medical history and current health risks. The doctor will check your weight, vision and blood pressure. And, your doctor will do a screening for depression as well as for cognitive impairment, check to make sure you’ve had all necessary vaccines and other preventive care services, and speak with you about your safety at home. The doctor will assess your ability to bathe, feed and dress yourself.

If appropriate, the doctor might recommend nutrition counseling, smoking cessation counseling, weight-loss counseling, all of which Medicare covers.

Medicare does not cover an annual physical. So, if you would like the Medicare wellness visit, be sure to ask specifically for it to avoid being surprised by a bill for services Medicare does not cover.

To ensure that you have no out-of-pocket costs:
- If you are enrolled in traditional Medicare, the visit is covered in full so long as you see a doctor who takes assignment
- If you are enrolled in a Medicare Advantage plan, the visit is covered in full so long as you see an in-network doctor
But, keep in mind that if you ask the doctor to treat a specific condition during your visit, the doctor can charge separately for that care.

Here’s more from Just Care:
January 27, 2020
Retirement security is not improving
Except for the wealthiest Americans, retirement security is not improving. Mark Miller reports for the New York Times on the plight of most older adults since the great recession. Although many parts of the economy have recovered, middle and low-income Americans have largely not seen meaningful growth in their retirement income.

In fact, evidence from the Federal Reserve shows that, at best, middle and lower-income families have managed to recover their retirement savings. And, many middle and lower-income families have not managed to recover their retirement savings.

In addition, Social Security benefits are replacing a lower proportion of people’s retirement income, even though benefits have adjusted up a bit for inflation. The longer wait to reach Social Security’s full retirement age—once 65 and now increasing to 67 for people born in 1960 or later—also operates as a benefit cut. And, Medicare costs are going up.

It is getting harder for baby boomers and GenXers to have adequate resources in retirement. The wealthiest households are doing a lot better today and should be in good shape when they retire. But, middle-income households have as good a chance of success in retirement as of failure. Meanwhile, people with low incomes have a much lower chance of having the resources they will need in retirement.

People who were out of work during the recession also often were without health insurance. Those people who were not yet eligible for Medicare could sign up for coverage through the Affordable Care Act, but at a significant cost. Today, 9.4 percent of people between 50 and 65 are uninsured. That’s largely because 14 states opted not to expand Medicaid.

Medicare spending has risen considerably, in large part as a result of private Medicare Advantage plans, which have been overbilling the federal government and taxpayers for their services. The question is whether Republicans in Congress will succeed at shifting more costs onto older and disabled Americans with Medicare to reduce spending or whether Democrats will succeed at enacting laws that end Medicare Advantage abuses that drive up spending as well as rein in health care prices. Speaker Nancy Pelosi’s prescription drug bill, H.R.3, would save Medicare tens of billions of dollars a year in lower prescription drug costs alone.

The official unemployment rate for people over 55 is at 2.6 percent. But, if you include people who were unsuccessful at finding jobs and have stopped looking for work, the unemployment rate goes up to 5.5 percent. Moreover, wages are not up in the last decade for older people who are working. They are at $872 a week, as compared with $861 ten years ago.

Nearly 80 percent of older adults have equity in their homes that they may be able to draw on if they need money. But, since the recession, fewer older adults own their homes. And, there has been a significant drop in the proportion of people under 65 who now own their homes. They are at serious risk of not having adequate resources to pay for health care and housing costs as they grow older. Today, almost five million older people who own their homes are paying at least half their income on housing costs, forcing them to spend less on food and health care.

Here’s more from Just Care:
December 18, 2019
What would Warren do to improve access to health care through executive power?
If elected President, Medicare for All will only become law if both the US House of Representatives and the Senate pass Medicare for All legislation. If that does not happen, Presidents can use their executive powers to improve access to health care. Margot Sanger-Katz reports for the New York Times on how Elizabeth Warren says she would use that power.

Warren‘s first priority is limiting corporate influence over Congress. That takes legislation. She says she would pursue anti-corruption reforms against health insurers and pharmaceutical companies. She wants to tax “excessive lobbying” by these companies and restrict their ability to effectively bribe members of Congress through campaign contributions. She would also use her power to protect people with pre-existing conditions.

With her executive authority, Warren would undo many of President Trump’s executive actions on health care. She would strengthen the Affordable Care Act and she would expand premium tax credits to help people buy insurance coverage. She would restore funding to Planned Parenthood. She would end work requirements for people with Medicaid. And, she would limit corporate health insurance companies’ ability to sell health plans that do not cover all essential health benefits, “short-term health plans.”

People with health insurance would have greater benefits and protections. Warren would cover dental care for people with Medicare. And, states would have the ability to expand Medicaid coverage. Warren would also expand mental health and substance abuse coverage.

Warren would give more people help to pay for their health insurance, such as families of working people and legal immigrants who are not citizens. Transgender people and women who had had abortions would regain civil rights protections.

To lower the cost of prescription drugs, Warren would use her executive authority to have HHS cancel pharmaceutical company patents on drugs developed with government funding. And, in the case of public health emergencies, she would use federal authority to have the government manufacture some prescription drugs, including insulin, antibiotics and hepatitis C medicines.

Here’s more from Just Care:
December 4, 2019