All posts by Jason White

Feds Order More Weekend Inspections Of Nursing Homes To Catch Understaffing

The federal government announced plans Friday to crack down on nursing homes with abnormally low weekend staffing by requiring more surprise inspections be done on Saturdays and Sundays.

The federal Centers for Medicare & Medicaid Services said it will identify nursing homes for which payroll records indicate low weekend staffing or that they operate without a registered nurse. Medicare will instruct state inspectors to focus on those potential violations during visits.

“Since nurse staffing is directly related to the quality of care that residents experience, CMS is very concerned about the risk to resident health and safety that these situations may present,” the agency said in a notification to state inspection offices.

The directive comes after a Kaiser Health News analysis found there are 11 percent fewer nurses providing direct care on weekends on average, and 8 percent fewer aides.

Residents and their families frequently complain the residents have trouble getting basic help — such as assistance going to the bathroom — on weekends. One nursing home resident in upstate New York compared his facility to a weekend “ghost town” because of the paucity of workers.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan, welcomed the new edict but said it was only necessary because state inspectors have not been properly enforcing the rules already on the books.

“The basic problem is the states don’t take this seriously,” Mollot said. “How many studies do we have to have, year after year, decade after decade, saying it all comes down to staffing, and there are very few citations for inadequate staffing and virtually all of them are identified as not causing any resident harm?”

CMS said it will identify potential violators by analyzing payroll records that nursing homes are now required to submit. Those records, which became public this year, showed lower staffing than what facilities had previously told inspectors during their visits, according to the KHN analysis.

“CMS takes very seriously our responsibility to protect the safety and quality of care for our beneficiaries,” CMS Administrator Seema Verma said in a statement.

The nursing home industry criticized the heightened scrutiny.

“Unfortunately, today’s action by CMS will enforce policies that makes it even more difficult to meet regulatory requirements and hire staff,” said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an industry trade group, in a written statement. “Rather than taking proactive steps to address the national workforce shortage long-term care facilities are facing, CMS seems to be focusing on a punitive approach that will penalize providers and make it harder to hire staff to meet the shared goal of increasing staffing.”

Currently, a tenth of inspections must occur during “off hours,” which can be either a weekend, or during a weekday before 8 a.m. or after 6 p.m. But for facilities that Medicare identifies as having lower weekend staffing, half of those off-hour inspections—or 5 percent of the total — must be performed on Saturdays or Sundays.

Medicare requires nursing homes to have a registered nurse on site for at least eight hours every day, but according to the payroll records, a quarter of nursing homes reported no registered nurses available at least one day during a three-month period. Since July, Medicare’s Nursing Home Compare website for consumers has highlighted homes that lack sufficient registered nurses and lowered their star ratings. Nursing Home Compare has downgraded ratings for 1,402 of 15,600 facilities for gaps in registered nurse staffing, records show.

The new directive instructs inspectors to more thoroughly evaluate staffing at facilities Medicare flags. The edict does not mean a flurry of sudden inspections. Instead, Medicare wants heightened focus on those nursing homes when inspectors come for their standard reviews, which take place roughly once a year for most facilities.

But what may appear to be staffing scarcities in payroll records may instead be clerical problems in which nurse hours are not properly recorded, say some nursing home officials.

Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services, said in a statement that some homes are still struggling to adapt to the new data collection rules.

“We’ve been voicing our concerns to CMS and will continue to do so,” she said.


KHN’s coverage of these topics is supported by
John A. Hartford Foundation and
The SCAN Foundation

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Podcast: KHN’s ‘What The Health?’ Reading The Tea Leaves In Blue Wave’s Wake

This week, “What the Health?” panelists discuss, among other things, how the House Democrats’ leadership battle could affect the congressional health policy agenda.

The panelists are Mary Agnes Carey of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Ollstein of Politico and Anna Edney of Bloomberg News.

As the post-election dust settles on Capitol Hill, the Democrats — soon to be in control of the House of Representatives — have begun the process of choosing their leadership team. How this shakes out will have a lot to do with how health policy agenda takes shape in the lower chamber.

House Democrats nominated Rep. Nancy Pelosi (D-Calif.) to retake the speaker’s gavel, but she still needs to win over more of her colleagues to secure the speaker post in January.

But all the action this week wasn’t focused on Congress. Food and Drug Administration Commissioner Scott Gottlieb unveiled a proposed overhaul of the FDA’s decades-old medical device approval process, and the Trump administration announced proposals it said would reduce Medicare prescription drug costs. Critics fear those changes could mean that some people with chronic diseases like AIDS or cancer might not have access to the drugs they need.

Among the takeaways from this week’s podcast:

  • House Democrats nominated Rep. Nancy Pelosi (D-Calif.) to retake the speaker’s gavel this week along with the rest of its leadership slate, Reps. Steny Hoyer of Maryland and Jim Clyburn of South Carolina. This is only the first step, though. The leadership positions will not be filled officially until January, when they are voted on by the full House. Although Pelosi is still wrangling for the support needed to earn her the required 218 votes, most insiders expect the Democrat’s leadership team to look much as it did the last time Democrats ruled the House chamber in 2010, when the Affordable Care Act became law. That means the House will likely be laser-focused on the necessary steps to protect the ACA. There may also be hearings on single-payer health insurance — a concept that is increasingly gaining interest and support within the caucus, and especially among some of its newest members.
  • In the background, the Texas lawsuit that could overturn the ACA’s protections for people with preexisting conditions is still pending. That decision could come any day. Keep in mind, though, that whatever the court rules, it is likely to be appealed immediately and move up the legal ladder. And, in the interim, House Democrats may still move forward with legislation to strengthen those ACA safeguards. Such a measure could get some GOP support because many Republicans seeking re-election this year said they wanted to ensure that patients with preexisting medical conditions would not lose coverage.
  • The FDA unveiled a proposed overhaul of its decades-old medical device approval system. Among its provisions, the plan includes steps to ensure that new medical devices reflect current safety and effectiveness features. Critics of the current system say it has failed to detect problems with some implants — like hip replacements that failed prematurely or surgical mesh that has been linked to pain and bleeding. The changes, if approved, could take years to implement and some might require congressional approval.
  • The Trump administration proposed a series of changes to reduce the number of prescription drugs that all Medicare drug plans must cover. The proposal focuses on drugs in six “protected classes” and involves medications such as antidepressants, antipsychotic medicines, cancer drugs and antiretrovirals to treat HIV/AIDS. Administration officials have said the proposal could cut costs for Medicare, but patient advocacy groups say it could reduce patients’ access for much-needed treatments. The proposed changes would not occur until 2020, and Congress could intervene to stop them.

Also this week, Julie Rovner interviews KHN senior correspondent Jay Hancock, who investigated and wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a single mother from Ohio who received a wrongful bill for her multiple sclerosis treatment. You can read the story here.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Mary Agnes Carey: The New York Times’ “This City’s Overdose Deaths Have Plunged. Can Others Learn From It?” by Abby Goodnough

Margot Sanger-Katz: NPR’s “Rethinking Bed Rest for Pregnancy,” by Alison Kodjak

Anna Edney: The Washington Post’s “Overdoses, Bedsores, Broken Bones: What Happened When a Private-Equity Firm Sought to Care for Society’s Most Vulnerable,” by Peter Whoriskey and Dan Keating

Alice Ollstein: Wired.com’s “The Science Is Clear: Dirty Farm Water Is Making Us Sick,” by Elizabeth Shogren and Susie Neilson

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher or Google Play.

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Chronically Ill, Traumatically Billed: The $123,000 Medicine For MS

Shereese Hickson’s multiple sclerosis was flaring again. Spasms in her legs and other symptoms were getting worse.

She could still walk and take care of her son six years after doctors diagnosed the disease, which attacks the central nervous system. Earlier symptoms such as slurred speech and vision problems had resolved with treatment, but others lingered: she was tired and sometimes still fell.

This summer, a doctor switched her to Ocrevus, a drug approved in 2017 that delayed progression of the disease in clinical trials better than an older medicine did.

Genentech, a South San Francisco-based subsidiary of Swiss pharma giant Roche, makes Ocrevus. It is one of several drugs for multiple sclerosis delivered intravenously in a hospital or clinic. Such medicines have become increasingly expensive as a group, priced in many cases at well over $80,000 a year. Hospitals delivering the drugs often take a cut by upcharging the drug or adding hefty fees for the infusion clinic.

Hickson received her first two Ocrevus infusions as an outpatient two weeks apart in July and August. And then the bill came.

Patient: Shereese Hickson, 39, single mother who worked as a health aide and trained as a medical coder, living in Girard, Ohio. Because her MS has left her too disabled to work, she is now on Medicare; she also has Medicaid for backup.

Total Bill: $123,019 for two Ocrevus infusions taken as an outpatient. CareSource, Hickson’s Medicare managed-care plan, paid a discounted $28,960. Hickson got a bill for about $3,620, the balance calculated as her share by the hospital after the insurance reimbursement.

Medical Service: Two Ocrevus infusions, each requiring several hours at the hospital.

Service Provider: Cleveland Clinic, a nonprofit, academic medical center in Ohio.

What Gives: Hickson researched Ocrevus online after her doctor prescribed the new medicine. “I’ve seen people’s testimonies about how great it is,” on YouTube, she said. “But I don’t think they really go into what it’s like receiving the bill.”

That was particularly shocking because, covered by government insurance for her disability, she’d never received a bill for MS medicine before.

“I have a 9-year-old son and my income is $770 a month,” said Hickson. “How am I supposed to support him and then you guys are asking me for $3,000?”

Even in a world of soaring drug prices, multiple sclerosis medicines stand out. Over two decades ending in 2013, costs for MS medicines rose at annual rates five to seven times higher than those for prescription drugs generally, found a study by researchers at Oregon Health & Science University.

“There was no competition on price that was occurring,” said Daniel Hartung, the OHSU and Oregon State University professor who led the study. “It appeared to be the opposite. As newer drugs were brought to market, it promoted increased escalation in drug prices.”

With Ocrevus, Genentech did come up with a price that was slightly less than for rival drugs, but only after MS medicines were already extremely expensive. The drug launched last year at an annual list price of $65,000, about 25 percent lower than that of other MS drugs, Hartung said. MS drugs cost about $10,000 per year in the 1990s and about $30,000 a decade ago.

“We set the price of Ocrevus to reduce price as a barrier to treatment,” said Genentech spokeswoman Amanda Fallon.

It was also probably a response to bad publicity about expensive MS drugs, Hartung said. “Now companies are very aware at least of the optics of releasing drugs at higher and higher prices,” he said.

Patients starting Ocrevus get two initial infusions of 300 milligrams each and then 600 mg twice a year. Cleveland Clinic charged $117,089 for Hickson’s first two doses of Ocrevus — more than three times what hospitals typically pay for the drug, said John Hennessy, chief business development officer at WellRithms, a firm that analyzes medical bills for self-insured employers.

As is typical of government programs such as Medicare, the $28,960 reimbursement ultimately collected by the Cleveland Clinic was far less — but still substantial.

“We kind of got ourselves in a pickle here,” he said. “We’re more excited about the discount than we are about the actual price.”

Hickson’s nearly $3,620 bill represented the portion that Medicare patients often are expected to pay themselves.

Shereese Hickson, diagnosed with multiple sclerosis in 2012 and unable to work, supports herself and her son, Isaiah, on $770 a month.(Shane Wynn for KHN)

Last year, the Institute for Clinical and Economic Review, an independent nonprofit that evaluates medical treatments, completed a detailed study on MS medicines. It found that Ocrevus was one of three or four medicines that were most effective in reducing MS relapses and preventing MS from getting worse. But it also found that patient benefits from MS drugs “come at a high relative cost” to society.

At the same time, deciding which MS drug — there are about a dozen — would best suit patients is something of a shot in the dark: The science showing the comparative effectiveness of MS drugs is not as strong as it could be, researchers say.

“In general, there’s a real lack of head-to-head studies for many of these drugs,” said Hartung. The FDA has no required comparison standard for MS drugs, an agency spokeswoman said. Sometimes they’re rated against placebos. With everyone able to charge a high price, the companies have little incentive to see which works better and which worse.

Resolution: After Hickson questioned the charges over the phone, the billing office told her to apply to the hospital for financial assistance. Hickson had to print a form, provide proof of her disabled status, mail it and wait.

Hospital officials told her in October she qualified for assistance based on her income through a state program funded by hospital contributions and federal money. Cleveland Clinic wiped out the $3,620 balance.

“I’m grateful that they approved me for that, but not everybody’s situation is like that,” she said. She was worried enough about being billed again for her next Ocrevus infusion that she considered switching back to her old medicine. But her doctor wants her to give it more time to gauge its effects.

The Takeaway: Always ask about charity care or financial assistance programs. Hospitals have different policies and wide discretion about how to apply them, but often do not even tell patients such programs exist.

Because health care costs are so high, you may be eligible even if you have a decent salary. Cleveland Clinic gives free care to everybody below a certain income, said spokeswoman Heather Phillips. But it wasn’t until Hickson called that the hospital agreed to erase the charge.

While there are multiple new drugs to treat serious chronic conditions, they have often not been tested against one another. Moreover, your doctor may have no idea about their relative prices. He or she should. For newer drugs, all options may well be very expensive.

Keep in mind that drugs which must be infused often come with facility fees and infusion charges, which can leave patients with hefty copayments for outpatient treatment. Ask about oral medicines or those you can self-inject at home.

NPR produced and edited the interview with Elisabeth Rosenthal for broadcast. Marlene Harris-Taylor, from member station Ideastream in Cleveland, provided audio reporting.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.


KHN’s coverage of these topics is supported by
The David and Lucile Packard Foundation and
Laura and John Arnold Foundation

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Podcast: KHN’s ‘What The Health?’ Health Nerd Books For The Holidays

The Food and Drug Administration took some serious steps toward curbing teen use of tobacco and nicotine products this month, including proposing a virtual ban on most flavors of the liquid used in e-cigarettes.

Meanwhile, open enrollment continues for individual coverage under the Affordable Care Act and Medicare. ACA sign-ups are slightly lagging behind last year’s. It is unclear why, but it’s still early in the six-week open-enrollment period.

And the new Democratic majority in the U.S. House faces big decisions about whether to pass a “Medicare-for-all” bill when it assumes control in January. First, the coalition must choose a speaker. Rep. Nancy Pelosi (D-Calif.), whose deal-making skills as speaker were instrumental in getting the ACA passed in 2010, is facing challenges from both wings of the party, although no single candidate has emerged to try to replace her.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Joanne Kenen of Politico and Anna Edney of Bloomberg News.

Among the takeaways from this week’s podcast:

  • Several factors may have contributed to the drop in marketplace enrollment over last year’s tally. The midterm elections may have distracted customers, the government is doing less consumer outreach, the labor market is very tight so more people may be getting coverage through work, and people will not face a tax penalty in 2019 for not having coverage.
  • There’s also another open enrollment occurring: Medicare plans. Although seniors’ coverage is not on the line, they have a wealth of choices that can be confusing.
  • In both ACA and Medicare enrollment periods, it is important for consumers to check out their choices, because the best option may have changed.
  • As the FDA weighs new rules for tobacco products, it is walking a tightrope. E-cigarettes may be an important tool for adults who are looking to wean themselves from cigarettes, but officials are wary of the thrill they may hold for young people.
  • The push among progressive Democrats in the House to pass a bill to implement a “Medicare-for-all” plan may cost the party support in the critical suburban districts that members depended on this month for victory.

Plus, for extra credit this holiday week, the panelists recommend some of their favorite health policy books:

“The Heart of Power: Health and Politics in the Oval Office,” by David Blumenthal and James A. Morone

“Bad Blood: Secrets and Lies in a Silicon Valley Startup,” by John Carreyrou

“Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” by Jonathan Cohn

“Dreamland: The True Tale of America’s Opiate Epidemic,” by Sam Quinones

“An American Sickness: How Healthcare Became Big Business and How You Can Take It Back,” by Elisabeth Rosenthal

“The Immortal Life of Henrietta Lacks,” by Rebecca Skloot

“The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry,” by Paul Starr

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher or Google Play.

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Trumpeted New Medicare Advantage Benefits Will Be Hard For Seniors To Find

For some older adults, private Medicare Advantage plans next year will offer a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars or air conditioners for asthma sufferers.

But the new benefits will not be widely available, and they won’t be easy to find.

Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.

That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.

Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent. Despite that enthusiasm, a full listing of the new services is not available on the web-based “Medicare Plan Finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options.

Even if people sign up for those plans, they won’t all be eligible for all the benefits. Advantage members will need a recommendation from a health care provider in the plan’s network. Then they may need to have a certain chronic health problem, a recent hospitalization or meet other eligibility requirements.

Medicare counselors from California to Maine say key details are not included on the government’s website. In some cases, if insurers offer the new benefits, the plan finder “will indicate ‘yes’ or ‘no,’” said Georgia Gerdes a health care choices specialist at AgeOptions, the Area Agency on Aging in Oak Park, Ill., outside Chicago. That’s hardly enough, she said.

“There is a lot of information on the plan finder, but there is a lot of information missing that requires beneficiaries to do more research,” said Deb McFarland, Medicare services program supervisor at the Southern Maine Agency on Aging.

Nonetheless, officials say the added benefits will help Advantage members prevent costly hospitalizations. Federal approval of additional benefits is “one of the most significant changes made to the Medicare program,” Seema Verma, the head of the Centers for Medicare & Medicaid Services, told an insurers’ meeting last month. She said she expects plans to expand services in coming years.

Medicare Advantage plans, which are an alternative to traditional Medicare, serve 21 million beneficiaries and limit their out-of-pocket expenses. But they also restrict members to a network of doctors, hospitals and other medical providers. They often offer benefits not available in traditional Medicare, such as dental and vision care, hearing aids and gym memberships.

The federal government pays a set amount to the plans to help cover the cost of each member. The Trump administration gave insurers more money to spend on benefits next year — an average pay raise of 3.4 percent, seven times more than the rate of increase in 2018.

Enrollment is underway for Medicare Advantage plans, as well as for people in traditional Medicare who want to buy a policy for drug coverage. The deadline for choosing either type of plan is Dec. 7.

Among the new benefits that some Medicare Advantage plans said they will offer are:

  • Trips to the pharmacy or fitness center in addition to doctor’s appointments for plan members, depending on where they live or their health conditions.
  • A monthly or quarterly allowance for over-the-counter pharmacy products such as cold and allergy medications, eye drops, vitamins, supplements and compression stockings.
  • House calls by doctors or other health care providers, under certain conditions.
  • A home health care aide for a limited number of hours to help with dressing, eating and other daily activities, possibly including household chores and light housekeeping.

However, plans offering these and other services will likely have only some of the options and will have different eligibility criteria and other limitations. The same services likely won’t be available in every county the plan serves.

For example, next year an estimated 150,000 Humana Medicare Advantage members in Texas and South Florida — two of the 43 states Humana serves — who cannot be left alone at home will be able to get a free in-home personal care aide for up to 42 hours a year, so that their regular caregiver can get a break. And more than half of the members in Cigna-HealthSpring Advantage plans will have access to free transportation services in all but five of the 16 states and the District of Columbia where the company sells coverage.

To find these supplemental benefits, seniors can use the online plan finder. After they enter their ZIP code and get a list of plans available locally, they can click on a plan name. That will take them to another page that offers more details about coverage, including a tab for health and drug plan benefits. That page might say whether the new services are offered.

But often the website will simply indicate that specific benefits are available — and perhaps not name them — and advise consumers to contact the plan for more information. A Medicare spokesperson confirmed that there is currently not an indicator on the plan finder for plans offering these expanded health-related supplemental benefits.

In addition to extra benefits, other variables should be considered when choosing an Advantage plan, such as which health care providers and pharmacies participate in a plan’s network, which drugs are covered and the costs.

Where available, several insurers say the new services will be free with no increase in monthly premiums.

“We certainly believe that all of the ancillary benefits we provide will help keep our members healthy, which is good for them, and it’s good for us in the long run,” said Steve Warner, head of the Medicare Advantage product team at UnitedHealthcare, which insures about 5 million seniors or 1 in 4 Medicare Advantage members.

Insurers are betting that services will eventually pay for themselves.

Dawn Maroney, consumer president at Alignment Healthcare, which serves eight counties in Southern California, said it’s much cheaper to give an air conditioner to someone with congestive heart failure to keep that patient healthy than to pay for more expensive medical treatment.

But if the new benefits are such a good idea, they should be available to the majority of older adults in traditional Medicare, said David Lipschutz, a senior policy attorney at the Center for Medicare Advocacy.

For free help with Medicare Advantage and drug plan enrollment, contact the federally funded State Health Insurance Assistance Program (www.shiptacenter.org), the Medicare Rights Center, 800-333-4114 or its website, www.medicareinteractive.org. The Medicare Plan Finder website is available at https://www.medicare.gov/find-a-plan/questions/home.aspx or call 800-633-4227.

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Midterm Results Show Health Is Important To Voters But No Magic Bullet

[UPDATED at 1:50 p.m. ET]

Health care proved important but apparently not pivotal in the 2018 midterm elections on Tuesday as voters gave Democrats control of the U.S. House, left Republicans in charge in the Senate and appeared to order an expansion of Medicaid in at least three states long controlled by Republicans.

In taking over the House, Democrats are unlikely to be able to advance many initiatives when it comes to health policy, given the GOP’s control of the Senate and White House. But they will be able to deliver an effective veto to Republican efforts to repeal the Affordable Care Act, convert the Medicaid health care system for low-income people into a block grant program and make major changes to Medicare.

One likely development is an expansion of Medicaid in several of the 18 states that had so far not offered coverage made available by the Affordable Care Act. Voters in Idaho and Nebraska easily approved ballot measures calling for expansion. A similar measure was leading in Utah based on incomplete returns.

In Montana, voters are deciding if the existing expansion should be continued and the state’s expenses covered by raising tobacco taxes. In preliminary results, opponents outnumbered supporters, but key counties were not expected to release their tallies until Wednesday.

Medicaid might also be expanded in Kansas, where Democratic gubernatorial candidate Laura Kelly defeated GOP Secretary of State Kris Kobach. The Kansas legislature had previously passed Medicaid expansion, but it was vetoed in 2017 by former GOP Gov. Sam Brownback. Kobach had not supported the ACA expansion.

And in Maine, where voters approved Medicaid expansion in 2017 but GOP Gov. Paul LePage refused to implement it, Democrat Janet Mills was victorious. She has promised to follow the voters’ wishes. LePage was not running.

The abortion issue was also on the ballot in several states. In Alabama and West Virginia, voters approved state constitutional amendments that would make it easier for the states to ban abortion entirely if the Supreme Court were to overturn Roe v Wade. Oregon voters, on the other hand, defeated a measure that would have restricted public funding of abortion and insurance coverage for abortion.

The mixed results allowed both sides of the polarized abortion debate to claim victory.

“This election is a major victory … for everyone in this country who cares about access to health care and access to reproductive health care,” Deirdre Schifeling, executive director of Planned Parenthood Votes, told reporters in a conference call.

Said Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List: “Yesterday was a clear victory for the pro-life movement. The Senate once again has a pro-life majority — a ringing affirmation of President Trump’s pro-life agenda from the American people, who have seen him deliver on a key promise by appointing two outstanding Supreme Court justices.”

In exit polling, as in many earlier surveys in 2018, voters said that health care, particularly preserving protections for people with preexisting conditions, was their top issue. But health care remained more important to Democrats than to Republicans.

Those who urged Democrats to emphasize health care this year took credit for the congressional successes. “The race for the House was a referendum on the Republican war on health care. You know it, I know it, and the Republican incumbents who shamefully tried to cover up their real record on health care and lost their seats know it,” said Brad Woodhouse of the advocacy group Protect Our Care.

But the issue was not enough to save some of the Senate Democrats in states won by President Donald Trump in 2016. Sen. Claire McCaskill (D-Mo.) was defeated by GOP Attorney General Josh Hawley, who is a plaintiff in a key lawsuit seeking to declare the Affordable Care Act unconstitutional. Sens. Heidi Heitkamp (D-N.D.) and Joe Donnelly (D-Ind.), who also campaigned hard on health care, were defeated.

Nonetheless, Sen. Joe Manchin (D-W.Va.) beat Republican Patrick Morrisey, the state’s attorney general who is also a plaintiff in the lawsuit seeking to upend the ACA.

Rep. Nancy Pelosi (D-Calif.), the leader of the House Democrats who would be first in line to take over as speaker, told supporters gathered in Washington for a victory celebration that her caucus would make health care a key legislative issue.

“It’s about stopping the GOP and [Senate Majority Leader] Mitch McConnell’s assault on Medicare, Medicaid and the Affordable Care Act and the health care of 130 million Americans living with preexisting medical conditions,” she said. She pledged that Democrats would take “very, very strong legislative action” to lower the cost of prescription drugs.

In a wide-ranging news conference on Wednesday, Trump struck something of a conciliatory tone toward the new Democratic majority in the House.

“I believe Nancy Pelosi and I can work together to get a lot of things done,” Trump said. “I suspect [House Democrats] will come up with some fantastic ideas that I can support … including prescription drug prices.”

Among the many new faces in the House is at least one with some significant experience in health policy. Former Health and Human Services Secretary Donna Shalala, who ran the department for all eight years of the Clinton administration, won an open seat in Florida.

Several members of the House and Senate were reelected despite serious ethical and legal troubles. Among them was Rep. Chris Collins (R-N.Y.), who was charged in August with violating insider trading laws while promoting Innate Immunotherapeutics, a small Australian biotech company.

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Beyond The Buzz: What Do Americans Mean By ‘Medicare-For-All’?



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Kaiser Health News Editor-in-Chief Elisabeth Rosenthal discussed “Medicare-for-all” and how the U.S. health system differs from others around the world on a recent episode of KERA’s “Think,” a public affairs radio talk show in Dallas. The wide-ranging interview with KERA’s Krys Boyd touched on the ideas Rosenthal and KHN correspondent Shefali Luthra wrote about in a news analysis piece co-published by The New York Times. Times readers, including several physicians, also wrote interesting responses to the analysis.

KHN’s Samantha Young also explored why many voters say they’re “just confused” as politicians across the country toss around health care catchphrases, sometimes interchangeably.

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The Election’s Impact On Health Care: Some Bellwether Races To Watch

Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many.

But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions and state legislatures around the country.

All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen — or not happen — over the next two years.

For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not.

Here are three big health issues that could be dramatically affected by Tuesday’s vote.

1. The Affordable Care Act

Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans and the generic drug approval process, among other things.

Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law.

This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect.

Polls suggest Cramer has a healthy lead in that race, but if Heitkamp pulled off a surprise win, health care might well get some of the credit.

And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care.

It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and two GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general — Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey — are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016.

The attorneys general are running against Democratic incumbents — Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit.

Although Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts.

But in the end the fate of the ACA depends less on an individual race than on which party winds up in control of Congress.

“If Democrats take the House … then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health.

Conservative health care strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday.

“Republicans, if they maintain the majority in the House, will have a margin of a half dozen seats — if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017.

And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there.

2. Medicaid expansion

The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138 percent of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94 percent in 2018, gradually dropping to 90 percent in 2020.

Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid.

McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said.

Four states — Nebraska, Idaho, Utah and Montana — have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs.

In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov. Butch Otter, who is retiring after three terms, endorsed it Tuesday.

But the issue is in play in other states, too. Several non-expansion states have close or closer-than-expected races for governor where the Democrat has made Medicaid expansion a priority.

In Florida, one of the largest states not to have expanded expanded Medicaid, the Republican candidate for governor, former U.S. Rep. Ron DeSantis, opposes expansion. His Democratic opponent, Tallahassee Mayor Andrew Gillum, supports it.

In Georgia, the gubernatorial candidates, Democrat Stacey Abrams and Republican Brian Kemp, also are on opposite sides of the Medicaid expansion debate.

However, the legislatures in both states have opposed the expansion, and it’s not clear if they would be swayed by arguments from a new governor.

3. Medicare

Until recently, Republicans have remained relatively quiet about efforts to change the popular Medicare program for seniors and people with disabilities.

Their new talking point is that proposals to expand the program — such as the often touted “Medicare-for-all,” which an increasing number of Democrats are embracing — could threaten the existing program.

“Medicare is at significant risk of being cut if Democrats take over the House,” Rep. Greg Gianforte (R-Mont.) told the Lee Montana Newspapers. “Medicare-for-all is Medicare for none. It will gut Medicare, end the VA as we know it, and force Montana seniors to the back of the line.”

Gianforte’s Democratic opponent, Kathleen Williams, is proposing another idea popular with Democrats: allowing people age 55 and over to “buy into” Medicare coverage. That race, too, is very tight.

Meanwhile, back in Washington, congressional Republicans are more concerned with how Medicare and other large government social programs are threatening the budget.

“Sooner or later we are going to run out of other people’s money,” said Chris Jacobs.

Senate Majority Leader Mitch McConnell suggested in an Oct. 16 interview with Bloomberg News that entitlement programs like Medicare are “the real driver of the debt by any objective standard,” but that bipartisan cooperation will be needed to address that problem

Republican Jacobs and Democrat McDonough think that’s unlikely any time soon.

“Why would Democrats give that up as an issue heading into 2020?” asked McDonough, especially because Republicans in recent years have been proposing deep cuts to the Medicare program.

Agreed Jacobs, “Trump may not want that to be the centerpiece of a re-election campaign.”

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GOP’s Latest Campaign Punch On Health Care Relies On Classic Hook: Medicare

Once again, Medicare is front and center in this fall’s campaigns.

Democrats throughout the election season have been hammering Republicans over votes and lawsuits that would eliminate insurance protections for preexisting conditions for consumers.

But now Republicans are working to change the health care conversation with a tried-and-true technique used by both parties over the years: telling seniors their Medicare coverage may be in danger.

It’s not yet clear, however, whether these dependable voters are responding to the warning.

Republicans charge that Democrats’ support for expanding Medicare would threaten the viability of the program for the seniors who depend on it.

“The Democrats’ plan means that after a life of hard work and sacrifice, seniors would no longer be able to depend on the benefits they were promised,” wrote President Donald Trump in a guest column for USA Today on Oct. 10. “Under the Democrats’ plan, today’s Medicare would be forced to die.”

In a speech to the National Press Club on Oct. 8, House Speaker Paul Ryan said almost exactly the same thing. “Democrats call it ‘Medicare-for-all,’ because it sounds good, but in reality, it actually ends Medicare in its current form,” Ryan said.

It’s a sentiment being expressed by Republicans up and down the ballot. In New Jersey, where Republican Assemblyman Jay Webber is running for an open U.S. House seat, he enlisted his elderly father in one of his ads. After the candidate notes that his opponent is “interested” in Medicare-for-all, Webber’s father, Jim Webber, says, “That would end Medicare as we know it.”

Fact-checkers have repeatedly challenged these claims. Health insurance analyst Linda Blumberg of the Urban Institute told PolitiFact that suggesting Medicare-for-all would disrupt current enrollees’ coverage is a “horrible mischaracterization of the proposal.” Glenn Kessler of The Washington Post’s “Fact Checker” column noted that a leading proposal “in theory would expand benefits for seniors.”

Furthermore, in New Jersey, Webber’s Democratic opponent, Mikie Sherrill, is not one of the many Democrats who have specifically endorsed the idea of Medicare-for-all. In fact, how to assure health coverage for all Americans remains a point of contention among Democrats. They are far from united on the topic of expanding Medicare.

But Republicans have pushed the issue this fall, said Harvard public health professor and polling expert Robert Blendon, because “people over 60 are very high-turnout voters,” particularly in non-presidential election years like 2018.

Issues involving Medicare and Social Security can motivate those older voters even more, said Blendon, “because they are so dependent on [those programs] for the rest of their lives. Retirees are very scared about outliving their benefits.”

Medicare is often a rallying cry for politicians from both parties. And it can be critical in both presidential and off-year elections.

In 1996, Democrats in general, and President Bill Clinton in particular, campaigned on the early GOP attempts to rein in Medicare spending. Republicans coined the term “Mediscare” to describe Democrats’ attacks. But in the 2010 midterm contests, just after the passage of the Affordable Care Act, Republicans zoomed in on the billions of dollars of Medicare payment reductions to health providers to help pay for the rest of the law, sparking protests against Democrats around the country.

The irony is that after Republicans regained control of the House in that election, Ryan, then head of the House Budget Committee, opted to call for a repeal of everything in the ACA except the Medicare reductions the GOP had so strongly campaigned against.

Democrats in 2018 have hammered back, noting that both Trump and the GOP Congress have proposed even more cuts in Medicare and that under Republican leadership the insolvency date of the Medicare trust fund has gotten closer.

According to Democrats, Senate Majority Leader Mitch McConnell also misstepped when, in an interview with Bloomberg News, he blamed higher deficit numbers on Medicare and other entitlement programs rather than the GOP’s tax cuts from 2017.

“We can’t sustain the Medicare we have at the rate we’re going, and that’s the height of irresponsibility,” he said.

That came after Trump’s economic adviser Larry Kudlow suggested that the administration will push for larger entitlement cuts in 2019.

“First they passed a tax bill that gave a huge windfall to corporations and the wealthy, despite warnings from nonpartisan scorekeepers that it would explode the deficit,” said a statement from Oregon Sen. Ron Wyden, the top Democrat on the Senate Finance Committee. “Then, before the ink was even dry the knives came out for Medicare, Medicaid and Social Security.”

Despite the coordinated talking points, it is unclear whether this year’s GOP attacks on Democrats over Medicare will work. That is not just because Democrats have ammunition to throw back, but also because seniors don’t seem particularly threatened by the idea that expanding insurance to others could jeopardize their own coverage.

In a poll conducted by the Kaiser Family Foundation in September 2017, seniors were no more likely than younger respondents to say they thought health care costs, quality and availability would get worse if the U.S. instituted a national health plan. Fewer than a third of respondents overall, as well as those 65 and older, said they thought national health insurance would worsen their own coverage. (Kaiser Health News is an editorially independent program of the foundation.)

In addition, pollster Geoff Garin, president of Hart Research, said in a conference call with reporters Oct. 15 that the attacks on Medicare-for-all had not shown up in polls yet. But he said he’s skeptical of how much impact they could have.

“The basic idea of expanded health care in America is generally pretty popular,” he said.

Still, Harvard’s Blendon said he understands why Republicans are trying: “Seniors are critical for Republicans to maintain their majority.”


KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

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