..congressional Republicans aim to reduce spending on federal health care programs to reduce America’s deficit

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an appearance on Ross Kaminsky’s talk radio show. “… Frankly, it’s the health care entitlements that are the big drivers of our debt, so we spend more time on the health care entitlements — because that’s really where the problem lies, fiscally speaking.”…
Ryan’s remarks add to the growing signs that top Republicans aim to cut government spending next year. Republicans are close to passing a tax bill nonpartisan analysts say would increase the deficit by at least $1 trillion over a decade. Trump recently called on Congress to move to cut welfare spending after the tax bill, and Senate Republicans have cited the need to reduce the national deficit while growing the economy.” (A)

“Healthcare lobbyists are scrambling to win changes in congressional Republican tax legislation, as Senate and House GOP leaders race to merge their separate bills into something both chambers can pass on a party-line vote this month.
But provider, insurer and patient advocacy groups doubt they can convince Republicans to remove or soften the provisions they find most objectionable. They say GOP leaders are moving too fast and providing too little opportunity for healthcare stakeholders to provide input….
Some lobbyists hold out a faint hope that the Republicans’ tax cut effort could collapse as a result of intra-party differences, as did their drive to repeal and replace the Affordable Care Act.
One possibility is that Maine Sen. Susan Collins flips and votes no on the tax cut bill emerging from the conference committee if congressional Republicans fail to pass two bipartisan bills she favors to stabilize the individual insurance market….
Collins conceivably could be joined by Alaska Sen. Lisa Murkowski, who also said she wants to see the market stabilization bills passed. If Tennessee Sen. Bob Corker, who voted no on the tax cut bill over deficit concerns, remains opposed, those three GOP senators could sink the tax bill. “We’d all like to see Collins pull her vote,” Hobson said. “It was always clear that the deal she cut with McConnell won’t fly on the House side.”” (“It appears virtually certain that repeal of the law’s individual mandate to buy coverage will be included in a final tax bill. Two of the moderate senators most likely to defect over that issue — Collins and Lisa Murkowski of Alaska — are okay with getting rid of the mandate, arguing it has been less effective than expected and its associated penalty is paid chiefly by lower-income Americans.
The question is whether Republicans will also manage to pass the two bipartisan measures essentially infusing cash into marketplace plans — a move that analysts say will help insurers lower premiums, which have been spiking across the country.” (B)

“A measure from Alexander and Sen. Patty Murray (D-Wash.) would fund $7 billion in extra cost-sharing discounts; another one from Collins and Sen. Bill Nelson (D-Fla.) would provide $4.5 billion in reinsurance funding. If either one passes, it probably would be as part of a big spending measure.” (C)

“So how’s that working out for you, Senator Collins?
The latest bit of bad news for Collins comes from Avalere Health. According to an analysis the healthcare consulting company released this morning, the reforms sought by Collins, while helpful, are possibly “overshadowed” when the Senate tax bill’s repeal of the individual mandate is taken into account.
The basic problem is that according to the Congressional Budget Office, mandate repeal will cause premiums to spike. The two pieces of legislation that Collins is supporting would try to make up for this. One bill would give insurers $4.5 billion over the next two years to help compensate for the costs of covering sick – read expensive – patients, something known as reinsurance. The other bill would restore payments to insurers — which Trump had stopped — and which would cover the cost of insuring low income people, otherwise known as cost-sharing reductions, or CSRs.
Together, they are supposed to keep down premiums. Caroline Pearson, a senior vice president at Avalere, told The Hill that their study concludes that “From a premium point of view, we do think reinsurance and CSRs probably covers the mandate.”
But this remains unclear. Topher Spiro, a health policy analyst at the liberal Center for American Progress, points out that the analysis actually doesn’t support that conclusion, once you take account of the fact that Trump has already halted the CSRs; restoring them will merely return us to the previous status quo.
What’s more, a number of healthcare wonks recently told Vox that the second of these two bills will not do nearly enough to fix the spiking premium problem.
And finally, the actions sought by Collins only cover a two-year period, and Avalere’s own experts conclude that once they expire, they would do little to deal with spiking premiums. As Elizabeth Carpenter, a senior vice president at Avalere, put it: “Eliminating the requirement to purchase coverage would create additional uncertainty in the market. It is important not to overlook the negative impact of repealing the individual mandate on long-term market stability.” (D)

“Ed Kilgore, writing in New York magazine, said Collins “is an experienced, savvy legislator. She knew when she cut her deals with Trump and McConnell that they would be worthless if the House didn’t go along.”
“She could have demanded assurances from Ryan and conservative leaders, too — certainly she could have demanded the moon at the point where it appeared she might be the decisive vote in the tax bill.
“What this series of events shows is that Collins, like the other alleged ‘holdouts,’ really wanted to ‘get to yes,’ as we kept hearing last week. If that meant securing a promise written in vanishing ink, so be it,” Kilgore said.
Collins’ office released a copy of the agreement reached between McConnell and Collins. Both had signed it. On its face, the ink looks pretty permanent.
In any case, whether Collins got played will be clear within weeks as Congress moves to adopt both the tax bill and a budget measure that Collins expects to include the health care measures she wants.” (E)

“Ms. Collins has released a copy of her agreement with Mr. McConnell in which he pledged to support passage of the two measures before the end of the year. His signature was displayed prominently at the top of the first page. But the deal has landed with a thud in the House, where Republicans appear loath to support legislation that they view as propping up a health law that they have pledged to repeal.
“Our members wince at voting to sustain a system that none of them supported,” said Representative Tom Cole, Republican of Oklahoma.
The Senate could attach the Alexander-Murray legislation to a government funding measure, hoping that Republicans in the House would be willing to swallow it as part of a measure to avoid a government shutdown. But Mr. Cole said House Republicans would be “very offended” at such an approach.
“I don’t think we’re in the mood to be blackmailed by anybody,” he said.
Mr. Brat, a member of the conservative Freedom Caucus, assailed the deal with Ms. Collins as an example of horse trading that is characteristic of the Washington swamp that he said voters had repudiated.
Likewise, Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said of the Alexander-Murray bill, “There’s no appetite for that over here.”
Ms. Collins said on Wednesday that she believed the House would “take a serious look” at the two bills intended to hold down insurance premiums and that Mr. Trump, in several recent meetings, had assured her that he also supported those bills.
“I don’t think this effort is over by any means,” Ms. Collins said.” (F)

“…The open enrollment period for 2017 is significantly shorter this year compared to last. The Trump administration shrunk the sign-up stretch to six weeks instead of three months.
With the December 15 deadline fast approaching, the number of plan selections is well short of the more than 9 million people who signed up on the federal exchange last year….
Matthew Fiedler, a fellow at the Brookings Institution’s Center for Health Policy, said there are a lot of reasons for the enrollment drop-off — but not one that stands out above others.
“My view is that various administration actions — including the shorter enrollment period, the reduction in outreach funding, higher premiums for unsubsidized consumers due to policy uncertainty, and consumer confusion about the ACA’s future — have weighed on enrollment, but the size of each of those effects is uncertain,” Fiedler told Business Insider.
Fiedler said that the decrease in enrollment will likely be detrimental to people enrolled on the exchanges.
“In terms of what the effects of lower enrollment will be, a lower uninsured population will be damaging. The additional uninsured will have worse access to care and be less financially secure,” Fiedler told Business Insider. “Similarly, other individual market enrollees will face higher premiums since the lost enrollees are likely healthier than average, and health care providers will face higher uncompensated care costs.”…
Fiedler said that the Obamacare markets could still “muddle through” even with lower enrollment.
“While bad, enrollment declines are not an existential threat to the individual market,” he said. “The impact of enrollment declines on the risk pool are smaller than sometimes thought. Furthermore, the rate increases insurers implemented for 2018 appear to be large enough to accommodate the deterioration in the risk pool we are likely to see.”” (G)

“A reinsurance program funded with $10 billion or even $15 billion in annual spending could actually offset the price hikes expected to result from individual mandate repeal. But that, of course, costs more money. And again, it doesn’t address what happens after 2020 at all.
This is what experts predicted about the Collins bill. “The Collins-Nelson bill would help mitigate premium increases resulting from repeal of the individual mandate, but it would fall short of completely offsetting the hikes,” Larry Levitt at the Kaiser Family Foundation told Dylan last week.
And at the end of the day, a lot of this debate may be moot. The Collins plan needs 60 votes to move through the Senate (unlike the tax bill, which is being run through the reconciliation process and thus only requires 50 votes). Whether Democrats would want to work with Republicans to pass a bill like this — whether more conservative senators would even get on board — is a big open question.
My takeaway from the Avalere analysis is this: Repealing the individual mandate will cause uncertainty and confusion in the individual market. That much is certain. The Collins plan is a Band-Aid on a much larger problem caused by the Senate bill — one that it just can’t fix.” (H)

“After taking a beating for three years, health plans jacked up their rates for 2017, with the average premium on the most popular products rising more than 20 percent. That created sticker shock for many Obamacare customers while putting many insurers on pace to record profits this year for the first time, according to a POLITICO analysis of 31 regional Blue Cross Blue Shield plans, many of which dominate Obamacare markets in their states.
But the turnaround comes just as Republican efforts to dismantle the health care law are creating new threats to the viability of the marketplaces. That leaves the plans in a bewildering situation, trying to improve their margins while the GOP declares Obamacare a failure and mounts another push to dismantle the system, starting with rolling back the health care law’s individual mandate.
“The political narrative is over a market in crisis, and that’s just not how the market actually looks right now,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, a nonpartisan research group. “At this moment, the individual insurance market looks quite stable and most insurers have achieved profitability.” (I)

“The two core pieces of Obamacare are the subsidies that help middle-class families afford private insurance and the expansion of Medicaid for working-class families. The tax bill doesn’t get rid of either. Instead, it will likely repeal the individual mandate — the requirement that people buy health insurance. As a result, health-insurance markets will suffer some turmoil, and costs for some families will rise.
Most people who want health insurance will still be able to get it, though. And health care advocates can reduce the impact of the mandate’s repeal through public-information campaigns that encourage people to sign up. The elimination of the insurance subsidies and Medicaid expansion would be qualitatively worse.
Many big fights remain. The tax bill’s supporters have a clear vision, and they’ve been surprisingly up front about that vision. The first step is to cut taxes. The second is to cut government programs like Medicare, Social Security, Medicaid and much else.
But this tax bill itself doesn’t accomplish the second step (with the exception of some modest automatic cuts). Republicans will have to pass other bills to shrink programs that benefit the middle class. Democrats are already gearing up to have those debates, as they should be. A McClatchy news headline yesterday: “Dems warn GOP: We’re prepared for class war.” Debates over spending cuts are easier for Democrats to win than debates over tax policy.” (J)

“Sen. Susan Collins (R-Maine) said Thursday that she may change her vote on the final version of the GOP tax-reform bill if her proposed amendments are not included in its final version.
“I would. I’m going to look at what comes out of the conference committee meeting to reconcile the differences between the Senate and House Bill. So I won’t make a final decision until I see what that package is,” Collins told CBS WABI 5 when asked if she would consider changing her vote…
“There’s a real fear that the tax bill is going to trigger a 4 percent cut in Medicare,” Collins added. “I am absolutely certain that 4 percent cut in Medicare that I mentioned will not occur. I have it in writing from both the Speaker of the House Paul Ryan [R-Wis.] and also Sen. Mitch McConnell [R-Ky.].”
Collin expressed optimism that the final bill will adopt her amendments.” (K)

“For the moment, none of this appears to have shaken Collins’s support for the bill. But it has ensured that her second vote for the Trump tax cuts will be more politically painful than her first one. Beyond the collapse of her health-care “deal,” the Republican bill isn’t getting any less (historically) unpopular. And progressive activists in Maine are mobilizing in opposition.
If Collins were to lose her nerve — and Tennessee senator Bob Corker were to retain his opposition to the bill on deficit grounds — then McConnell would only have one vote to spare. Should one of the multiple elderly, Republican senators with ongoing medical problems fall ill — or, should Doug Jones win Alabama’s special Senate election next week — the Trump tax cuts could conceivably fall into jeopardy.” (L)

(A) Ryan says Republicans to target welfare, Medicare, Medicaid spending in 2018, by Jeff Stein, https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.5b3ab0175186
(B) Healthcare lobbyists not optimistic on changing GOP tax bill, By Harris Meyer, http://www.modernhealthcare.com/article/20171206/NEWS/171209899
(C) The Health 202: Senate GOP intensifies push to send more cash to Obamacare marketplaces, By Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/12/07/the-health-202-senate-gop-intensifies-push-to-send-more-cash-to-obamacare-marketplaces/5a28164030fb0469e883fa53/?utm_term=.228c5c6f8672
(D) Susan Collins is getting played. Will she really vote for the tax bill in the end?, by Helaine Olen, https://www.washingtonpost.com/blogs/plum-line/wp/2017/12/06/susan-collins-is-getting-played-will-she-really-vote-for-the-tax-bill-in-the-end/?utm_term=.cb71725eaf59
(E) Despite criticism, Susan Collins is confident that GOP leaders will stand by their word, by Steve Collins, http://www.sunjournal.com/despite-criticism-susan-collins-is-confident-that-gop-leaders-will-stand-by-their-word/
(F) Tax Bill Is Likely to Undo Health Insurance Mandate, Republicans Say, By ROBERT PEAR and THOMAS KAPLAN, https://www.nytimes.com/2017/12/06/us/politics/tax-bill-obamacare-mandate-collins.html?_r=0
(G) It’s looking like Trump’s Obamacare meddling could cause serious problems for the healthcare market, by Bob Bryan, http://www.businessinsider.com/trump-obamacare-enrollment-insurance-market-2017-12
(H) Sen. Collins’s health proposal isn’t going to save Obamacare, by Sarah Kliff, vox.com. Dec 6, 2017
(I) POLITICO survey: Insurers finally making money on Obamacare, by PAUL DEMKO, https://www.politico.com/story/2017/12/07/obamacare-profits-health-care-285258
(J) The Republic Will Survive the Tax Bill, by David Leonhardt, https://www.nytimes.com/2017/12/06/opinion/republican-tax-bill.html
(K) Collins considers changing vote on tax bill over amendments, by JOSH DELK, http://thehill.com/blogs/blog-briefing-room/363891-collins-considers-changing-vote-on-tax-bill-over-amendments
(L) Senate Republicans Made a $300 Billion Mistake in Their Tax Bill, by Eric Levitz, http://nymag.com/daily/intelligencer/2017/12/the-senate-gop-made-a-usd300-billion-mistake-in-their-tax-bill.html

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“…House and Senate Republicans will likely scrap Obamacare’s individual mandate in their final tax bill.”

“Economist Larry Summers said Monday that roughly 10,000 more Americans will die each year if Republican tax-reform legislation passes and includes a repeal of the ObamaCare individual mandate.
“When people lose health insurance, they’re less likely to get preventive care, they’re more likely to defer health care they need, and ultimately they’re more likely to die.”
The Senate passed its tax-reform legislation early Saturday morning. The upper chamber’s bill includes a repeal of the individual mandate, while the House’s tax-reform bill does not.
Summers’s estimate is based on a Congressional Budget Office report that 13 million Americans would opt out of ObamaCare if the individual mandate is repealed.
Summers, who served as former President Clinton’s Treasury secretary and former President Obama’s National Economic Council director, said it’s hard to quantify the number of deaths precisely, but called an estimate that thousands will die because of the bill “very conservative.” (A)

“One clear effect of the GOP tax bill is the provision that medical groups object to most: the repeal of the individual mandate to buy health insurance.
Both the House and the Senate versions of the bill include a repeal of the mandate, which calls for a tax on people who don’t buy health coverage to help make up the cost of care for the uninsured.
While the mandate is unpopular among voters, it was a must-have for health insurance companies. They demanded such a mandate to even take part in the health insurance exchanges set up by the 2010 Affordable Care Act, and without it, many more can be expected to hike premiums or drop out altogether from the Obamacare markets, experts predict.
“If the requirement to carry adequate health insurance disappears, so will the health care coverage of many Americans,” American Heart Association CEO Nancy Brown said in a statement.
“As insurance rolls decrease, premiums will rise an average of 10 percent,” Brown said. “Paying more for health insurance will be a heavy weight to carry if you have a pre-existing condition like heart disease or stroke. We fervently believe this provision should be rejected and removed from the final legislation.”
The Congressional Budget Office (CBO) estimated that repealing the mandate would result in 13 million fewer people being covered by health insurance and would cause insurance companies to raise premiums by 10 percent a year.
“The repeal of the individual insurance mandate destabilizes an essential pillar of the ACA by removing incentives for young and healthy people to purchase insurance,” a coalition of health and consumer groups, including the American Diabetes Association, the American Cancer Society Cancer Action Network and the American Lung Association.” (B)

“Within a year or two of elimination of the mandate, the individual insurance market will resemble the failed pre-Obamacare days when pre-existing conditions and high premiums made access impossible. The difference is that the government will foot a large part of the cost through subsidies. Before the A.C.A., lower-income people who didn’t qualify for Medicaid were priced out of the individual market, but with subsidies, they can now purchase lower-cost plans. If the individual mandate is eliminated, it will be middle-income people without subsidies who lose access.
The continuing high enrollment this fall supports the idea that most people still see the subsidized insurance offerings on the exchanges as a good deal. As a result, the demand side of this unusual market will stay strong for the subsidized customers.
How will the insurance companies react? They will see high demand for subsidized insurance as a tempting market in spite of past and future chaos. The problem for them is that these customers are sicker and less predictable in their needs, which makes it difficult to set a price. This is precisely why the number of insurers this year has dropped so severely. But managing uncertainty is at the core of this business. Any risk is acceptable if the compensation is high enough….
However, the timing of a mandate repeal is central. Eliminating the individual mandate will make little difference to insurers in 2018 if the mandate expires in 2019. But Congress may decide to eliminate the individual mandate immediately. Then insurers, who priced their plans assuming continuation of the same historical enrollee pool, will lose their shirts as healthier enrollees drop out. Changing the rules halfway through the game is not something insurance company C.E.O.s. can anticipate, but it is their biggest challenge now….
Yet as long as the subsidies continue, health plans will offer their policies on the exchanges with very high premiums. While this may allow access for some who otherwise would be left out, the grand purpose of the A.C.A. — to allow affordable care for all — will slip away. Is this any way to do health policy?” (C)

“With one simple move, the tax reform bill passed by Senate Republicans Saturday could herald the beginning of the end of former President Barack Obama’s Affordable Care Act, better known as Obamacare.
The new bill repeals Obamacare’s key requirement that all Americans obtain health insurance. Policy experts say that removing the mandate will force insurance premiums to rise, as young and healthy Americans opt out, leaving millions of Americans without healthcare.”
“It’s going to take a bunch of healthy people out of the insurance market,” Craig Garthwaite , director of the healthcare program at Northwestern University’s Kellogg School of Management, told Reuters.
Obamacare “is going to collapse even more now,” he said.” (D)

“Members of a joint congressional committee will now meet to resolve those differences, conflicts that pit all sorts of special interests against one another. But Republicans are so eager to pass a tax bill — and claim a so-far elusive big win in President Donald Trump’s first year — that compromise is not expected to be too difficult.
Health care mandate: The Senate bill would repeal the requirement in the 2010 Affordable Care Act that most people pay a penalty if they don’t purchase health insurance.
The provision isn’t in the House bill, but is popular among House conservatives. Yet those same conservatives are opposed to health care provisions that would be considered as a result of including the repeal, which might be necessary to delivering critical votes in the Senate.
Sen. Susan Collins, R-Maine, said she expects legislation that would reinstate cost-sharing payments to insurance companies to pass before the tax bill is complete. The provision, authored by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would help lower health insurance premiums, she said.” (E)

“Sen. Susan Collins (R-Maine) has doubled the amount of money she’s requesting in her ObamaCare stabilization bill in exchange for her vote on the GOP’s tax-reform plan.
Collins, a key vote on tax reform, is pushing for the passage of two ObamaCare bills in an attempt to mitigate the effects of the tax bill’s repeal of the individual insurance mandate.
One of those bills — sponsored by her and Sen. Bill Nelson (D-Fla.) — would provide states with $10 billion over two years to establish high-risk pools or reinsurance programs to lower premiums.
That’s more than double the $4.5 billion originally requested in her bill, which she introduced in September.
Senate Majority Leader Mitch McConnell (R-Ky.) said he would support passage of both bills, which could be added to the end-of-year spending deal.” (F)

“In Maine, an estimated 50,000 fewer people could have health coverage by 2025. That’s because insurance rates would rise if, as expected, many healthy young people exercised their option to go without insurance — leaving the pool of insured people older and sicker. And as those rates rise, even more people would be priced out, including some who qualify for subsidies. The budget office estimates that average premiums in the individual market would rise about 10 percent a year for the next decade as a result of repeal. That would be on top of unrelated premium increases….
In 2017, some 79,400 Mainers were covered by individual plans purchased on the state’s insurance marketplace. That an Affordable Care Act provision that allows consumers to make apples-to-apples comparisons between available plans. The majority of the plans purchased in Maine qualified for a premium subsidy, available to enrollees who earn up to 400 percent of the federal poverty limit. That’s about $48,424 for an individual and $98,400 for a family of four. The subsidy takes the form of a tax credit.
In 2015, the most recent year for which information is available, 38,560 taxpayers in Maine qualified for that credit, at a total subsidy value of $184.3 million, according to the Internal Revenue Service. Of those taxpayers, 15,460 had household incomes of between $10,000 to $25,000. Another 13,340 had household incomes between $25,000 to $50,000.
Collins, who earlier this year helped defeat efforts to end the Affordable Care Act, initially said that repealing the individual mandate would destabilize health insurance markets. But in the days leading up to the vote, Collins said she was reassured by Trump’s assertion that other steps will be taken to offset any negative impacts of repeal.” (G)

“But one expert says such efforts are inadequate. Aviva Aron-Dine, senior fellow and senior counselor at the Center on Budget and Policy Priorities, warns that temporary underfunded reinsurance programs are not enough to reverse the impact of the individual mandate’s repeal.
“As a result, it will not meaningfully reduce the risk that insurers will leave the market. Even a much larger reinsurance program would leave insurers in doubt about how to price their insurance products for the state of the overall risk pool: what they should assume, for example, about how many people will leave the market, how much healthier this group is than average, and how quickly the full effects of mandate repeal would be felt,” Aron-Dine wrote.” (H)

CMS Chief Seema Verma:
“Well, first start by saying, I’m not sure that the individual mandate has really been effective. If we look at what’s gone on since Obamacare was implemented, we’ve seen rates go up by over 100%. In some areas of the country, it’s over 200%. While prices have gone up, if we look at the types of plans that are being offered, in many states, right now we have eight states that have only one insurance company. That means that people may not have the choice of doctor. One third of our folks that are using the exchanges will only have one insurer, so our choices are going down.
We’re also hearing from people that the plans that are being offered in and of themselves are high deductible plans or they’re narrow networks. Folks are looking at this and saying, “It’s very expensive, there’s a high deductible, and I don’t want this. I would rather pay the penalty.” If we look at the number of people that are paying the penalty, it’s over seven million people. Out of that seven million, 5.2 million are earning less than $50,000 a year. This is really a tax on low income people, low income people that may not be able to afford coverage and then on top of it they’re paying a penalty. That’s one area of the law, I don’t think that, that in and of itself, is going to address the underlying issues.
From our standpoint, we’re trying to do what we can, making things more flexible, more market friendly, and trying to create more choices, but ultimately, there’s only so much we can do. We need a Congressional, a comprehensive Congressional solution, that’s not only going to provide flexibility for states and empower states, but it’s going to address the underlying reasons of why costs are going up so much.” (I)

“Republicans are also facing the possibility that the $1 trillion tax bill will trigger deep, automatic cuts to Medicare next year unless Congress stops it from happening.
Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) that the cuts required by the “pay-as-you-go” or “pay-go” budgetary rule won’t happen.
Collins was a key holdout, and she said the personal promise from McConnell helped win her support for the legislation.
McConnell on Friday issued a joint statement with Speaker Paul Ryan (R-Wis.) saying the pay-go cuts won’t happen.
“Congress has readily available methods to waive this law, which has never been enforced since its enactment. There is no reason to believe that Congress would not act again to prevent a sequester, and we will work to ensure these spending cuts are prevented,” McConnell and Ryan said.
Lawmakers have voted numerous times in the past to waive the rule, but they need the support of Democrats, who have so far been reluctant to offer it.” (J)

“Speaker Paul Ryan’s (R-Wis.) office told a meeting of congressional leadership offices on Monday that the Speaker is not part of a deal to get ObamaCare fixes passed before the end of the year, according to a source familiar with the meeting.
Senate Majority Leader Mitch McConnell (R-Ky.) made a commitment to Sen. Susan Collins (R-Maine) that he would support passage of two bipartisan ObamaCare bills before the end of the year, a promise that helped win her vote for tax reform.
However, Ryan’s office told a meeting of staff from the four top congressional leadership offices on Monday that he has not made that same commitment, raising further questions about whether the ObamaCare bills, already opposed by House conservatives, can pass the House.
Ryan’s office did not go so far as to say it opposed the bipartisan bills, the source said, and it is still possible the measures could pass before the end of the year. The Senate is expected to add the measures to a government funding bill later this month, which would put pressure on the House to accept it or else risk a government shutdown.” (K)

“The top House tax writer said Tuesday that House and Senate Republicans will likely scrap Obamacare’s individual mandate in their final tax bill.
“Yeah, I believe we will,” House Ways and Means Committee Chairman Rep. Kevin Brady, R-Texas, said when asked if the joint plan would get rid of the provision requiring most Americans to have health insurance or pay a penalty.
Brady’s statement appears to resolve one of the key differences between the separate tax legislation passed by the House and Senate. The Senate bill would effectively repeal the mandate, while the House proposal would not.” (L)

“Republicans appear to be on the brink of striking down the Affordable Care Act’s health-insurance requirement, an ardently sought goal of the law’s opponents. But the fate of a bipartisan bill that centrist Republicans hoped would offset some of the fallout remains uncertain. Some key GOP centrists supported a Senate tax overhaul that repeals the requirement that most people have health insurance, a move experts say will likely drive up premiums, on the condition that it be swiftly accompanied by a bipartisan measure that aims to lower premiums.” (M)

“Repealing the individual mandate means fewer people will sign up for health insurance—13 million according to the Congressional Budget Office (CBO)—and the government will pay out less in premium support. The calculus is clear—tax cuts for the wealthiest Americans will be paid for by providing less support for working families to buy health insurance. Indirectly, however, people who need insurance the most—older, less healthy Americans—will subsidize tax cuts via higher premiums.
Without a mandate, the exchange population will trend older and sicker. Without a balanced risk pool, premiums will spike—at least 10% in most years according to the CBO. Importantly, the ACA’s subsidies will mitigate financial hardship for Americans making under 400% of the federal poverty level, about $98,400 for a family of four. But families above that threshold—who are by no means poor, but certainly not rich—will be thrown to the wolves. Although they will not necessarily be paying higher taxes to support corporate tax cuts, they will be stuck paying higher premiums as a result of the mandate repeal. In many cases, families will be priced out of the insurance market entirely—people can’t choose to buy what they can’t afford.
The GOP tax bill is a bomb lobbed in to the heart of the U.S. health care system. It willingly ignores the dynamics of insurance markets. Under the flag of free markets and consumer choice, the bill guts choice for millions of middle-class Americans to pay for regressive tax cuts.” (N)

“This week, Sen. Orrin Hatch (R-UT) helped push a tax bill through the Senate that will cost about $1 trillion. At the same time, he lamented the difficulties of finding the money to fund the Children’s Health Insurance Program (CHIP), which pays for health care for 9 million children and costs about $14 billion a year — a program Hatch helped create.
A Sunday-morning tweet from MSNBC’s Joe Scarborough quoting Hatch kicked off a dustup on Twitter over the Utah Republican’s take on CHIP. Funding for the program — which was created as a joint effort between Hatch and Democratic Sen. Edward Kennedy in 1997 — expired at the end of September; Congress has yet to reauthorize it. That puts health care for millions of American children at risk.
On Thursday evening, as the Senate debated the Republican tax plan, Sen. Sherrod Brown (D-OH) asked whether there’s “something we can do to get the children’s health insurance program done.”
Hatch’s response, in a nutshell: Yes, we’ll fund the program, but we’re really short on money.
“We’re going to do CHIP; there’s no question about it in my mind. And it’s got to be done the right way,” Hatch said. “But the reason CHIP’s having trouble is because we don’t have money anymore, and to just add more and more spending and more and more spending, and you can look at the rest of the bill for the more and more spending.”” (O)

(A) Economist Larry Summers: 10,000 people will die annually from GOP tax bill, by BRETT SAMUELS, http://thehill.com/policy/healthcare/363152-larry-summers-10000-people-will-die-annually-from-gop-tax-bill
(B) Repeal of health insurance mandate in GOP tax bill could have big effects, by MAGGIE FOX, https://www.nbcnews.com/health/health-care/repeal-health-insurance-mandate-gop-tax-bill-could-have-big-n826441
(C) How the G.O.P. Tax Bill Will Ruin Obamacare, by J. B. SILVERS, https://www.nytimes.com/2017/12/04/opinion/gop-tax-bill-obamacare.html
(D) HOW DONALD TRUMP SHOT DOWN OBAMACARE WITH THE SENATE TAX REFORM BILL, by TOM PORTER, http://www.newsweek.com/senate-tax-reform-bill-could-spell-beginning-end-obamacare-729328
(E) With Senate tax bill passed, deal-making with House to begin, by Ron Johnson, https://www.ohio.com/akron/news/breaking-news-news/with-senate-tax-bill-passed-deal-making-with-house-to-begin
(F) Collins doubles funding ask for ObamaCare bill, by JESSIE HELLMANN, http://thehill.com/policy/healthcare/363130-collins-doubles-funding-ask-for-obamacare-bill
(G) What repealing Obamacare mandate would mean for Maine, by Meg Haskell, https://bangordailynews.com/2017/12/02/health/what-repealing-obamacare-mandate-would-mean-for-maine/
(H) Senate passes tax bill that repeals individual mandate, by David Lim, https://www.healthcaredive.com/news/senate-passes-tax-bill-that-repeals-individual-mandate/512125/
(I) CMS Chief Seema Verma Speaks About Her Top Health Care Policy Priorities, by Avik Roy, https://www.forbes.com/sites/theapothecary/2017/12/05/cms-chief-seema-verma-speaks-about-her-top-health-care-policy-priorities/3/#6eda9c236100
(J) Tax bill could fuel push for Medicare, Social Security cuts, by NATHANIEL WEIXEL, http://thehill.com/policy/healthcare/362866-tax-bill-could-fuel-push-for-medicare-social-security-cuts/
(K) Ryan’s office warning he wasn’t part of deal on ObamaCare, by PETER SULLIVAN, http://thehill.com/policy/healthcare/363306-ryans-office-warning-he-wasnt-part-of-deal-on-obamacare-source
(L) Final GOP tax bill will likely scrap Obamacare individual mandate, top House tax writer Brady says, by Jacob Pramuk, https://www.cnbc.com/2017/12/05/kevin-brady-expects-tax-bill-to-repeal-obamacare-individual-mandate.html
(M) Support Wavers for Senate Bill to Shore Up Health-Insurance Markets, by Stephanie Armour and Kristina Peterson, https://www.wsj.com/articles/support-wavers-for-senate-bill-to-shore-up-health-insurance-markets-1512490052
(N) Obamacare Architect: How Is Trump Paying for Wealthy Tax Cuts? By Kicking People Off Their Health Insurance, by Ezekiel J. Emanuel and Aaron Glickman, http://fortune.com/2017/12/04/tax-reform-bill-2017-explained-obamacare-individual-mandate/
(O) GOP senator says it’s hard to fund $14 billion children’s health care program — then advocates for $1 trillion tax cut, by Emily Stewart, https://www.vox.com/2017/12/3/16730496/orrin-hatch-

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“Concurrent” Surgeries – Is it OK for a surgeon to operate in different ORs at the same time?

Over fifteen years ago a general surgeon at one of our community hospitals left the OR to operate at a competing hospital, and told a nurse to close the incision. He claimed OR nurses could train and be certified as “closers”. Problem was the nurse hadn’t been certified and did not have hospital privileges for this competency. The nurse was fired and the surgeon fought disciplinary action although up to the Board of Trustees. Recollection is that he had been suspended from the medical staff, by me for over six months and that became his penalty as well as a long period of probation.

“Dr. Kirkham Wood arrived in the operating room at Massachusetts General Hospital before 7 one August morning with a schedule for the day that would give many surgeons pause.
Wood, chief of MGH’s orthopedic spine service at the time and a nationally renowned practitioner in his specialty, is a confident, veteran surgeon. He would need all of his talent and confidence this day, and then some, as he planned to tackle two complicated spinal surgeries over the next many hours — two patients, two operating rooms, moving back and forth from one to the other, focusing on the challenging tasks that demanded his special skills, leaving the other work to a general surgeon, who assisted briefly, and two surgeons in training.
In medicine it is called concurrent surgery, and the practice is hardly unique to Wood or MGH. It is allowed in some form at many prestigious hospitals, limited or banned at many others. Hospitals that permit double-booking consider it an efficient way to deploy the talents of their most in-demand specialists while reducing wasted operating room time.” (A)

‘Known as “running two rooms” – or double-booked, simultaneous or concurrent surgery – the practice occurs in teaching hospitals where senior attending surgeons delegate trainees – usually residents or fellows – to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR, but are seeing patients elsewhere.
The decision about whether to allow the practice is left to hospitals, which are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation – and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.” (B)

American College of Surgeons – Overlapping Operations- Statements on Principles (C)
“Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.
The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.
The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.
The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.””

“The Centers for Medicare and Medicaid Services does allow surgeons to bill for concurrent surgeries under certain circumstances but requires that the attending physician is “present during all critical and key portions of both operations.”
Surgeon Matthew Indeck, president of the American College of Surgeons’ central Pennsylvania chapter, said he “certainly would not support [concurrent] cases being done in distant hospitals” or keeping a patient under anesthesia longer than necessary.
But he acknowledged that a line delineating what’s appropriate and what isn’t “is very fuzzy.”” (D)

“……transparency and patient consent. Wrong is the only way to describe the fact that secretaries, nurses, anesthesiologists, residents, and fellows knew but the patient did not. If you defend double-booking, tell the patient. Sometimes I wonder why doctors don’t see themselves as patients. To us, the experienced professional, medical, and surgical practice is rote. It’s hardly so to the person being wheeled onto a narrow table on which they will be cut open. Would any surgeon-patient consent to this practice?” (E)

“Swedish Health has decided to largely prohibit its doctors from conducting overlapping surgeries, responding to the concerns of patients who were troubled by the practice…
Under the new policy, implemented Monday, surgeons must be present for the “substantial majority” of each surgical procedure. They are not required to be present for the very end of the case — closing the surgical incision once the planned procedure is completed — as that can be delegated to a qualified fellow assisting on the case.
Some smaller aspects at the beginning of a surgery, such as the harvesting of healthy blood vessels that would later be used in a coronary-artery bypass surgery, can also be delegated while the attending surgeon is out of the room, according to the policy. There is also flexibility for unexpected emergencies.
Staff will document the times surgeons enter and exit the operating room — something that didn’t previously appear in the records of many surgical patients.” (F)

“Patients whose hip surgeries were performed by surgeons overseeing two operations at once were nearly twice as likely to suffer serious complications as those whose doctors focused on one patient at a time, according to a large Canadian study, the first research to show that overlapping surgery can pose health risks.
The study of more than 90,000 hip operations at some 75 hospitals in Ontario also found that the longer the duration of overlap between surgeries, the more likely patients were to suffer a serious complication within a year, including infections and a need for follow-up surgery.
“If your surgeon is in multiple places, there’s an increased risk of having a complication,” Dr. Bheeshma Ravi, a hip surgeon at Sunnybrook Health Sciences Centre in Toronto and lead author of the study to be published Monday in JAMA Internal Medicine, told the Globe. “I think that just makes sense.”” (G)

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) Clash in the name of Care, by Jenn Abelson, Jonathan Saltzman, Liz Kowalczyk and editor Scott Allen, https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
(B) (B) Is your surgeon double-booked?, by Sandra G. Boodman, http://www.philly.com/philly/health/is-your-surgeon-double-booked-20170712.html
(C) https://www.facs.org/about-acs/statements/stonprin
(D) Senate committee looks at policies on surgeons performing more than one surgery at once, by Steve Twedt, http://www.post-gazette.com/business/healthcare-business/2016/03/28/Senate-committtee-looks-at-hospital-policies-regarding-concurrent-surgeries/stories/201603270074
(E) The Wrongness of a Doctor Being in Two Places at Once, by John Mandrola, http://www.medscape.com/viewarticle/853447
(F) Swedish Health largely bans overlapping surgeries, by Mike Baker, http://www.seattletimes.com/seattle-news/health/swedish-health-largely-bans-overlapping-surgeries/
(G) For the first time, a study finds double-booked surgeries put patients at risk, by PAT GREENHOUSE, https://www.bostonglobe.com/metro/2017/12/04/for-first-time-study-finds-double-booked-surgeries-put-patients-risk/faccZlQYS4bsvz5CDlrwNM/story.html

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“..Conference Committee “may not change a provision on which both houses agree, nor may they add anything that is not in one version or the other,”…

… according to the Congressional Research Service. The final product is a “conference report,” which is passed by the majority of the members in the conference committee and then sent to the full House and Senate floors. Both the House and Senate have to pass the conference report outright for it to be sent to the president’s desk. (A)

“Because the Senate was rewriting its bill till the last minute, only the dealmakers themselves knew what the chamber voted on. There will, no doubt, be many unpleasant surprises as both houses work to pass final legislation for President Trump to sign.
The votes for the bill by Susan Collins of Maine and John McCain and Jeff Flake of Arizona were particularly disheartening. Ms. Collins, who helped sink an effort to effectively repeal the A.C.A. in September, blithely voted for a tax bill that will leave a gaping hole in that law by repealing its requirement that most people have insurance or pay a penalty. She traded away her vote for an inadequate deduction for property taxes and empty promises from Mr. Trump and the majority leader, Mitch McConnell, that they would help shore up the A.C.A., which they have repeatedly tried to sabotage.” (B)

“Left more uncertain is the trade-off Republican leaders made in order to secure support from all but one Senate Republican. Sen. Susan Collins, R-Maine, who voted against GOP efforts to repeal parts of Obamacare this summer, came onboard for the tax plan after promises from leadership that the Senate would bring a bipartisan bill to the floor known as Alexander-Murray. Collins also was able to secure a pledge to bring a two-year, $5 billion-a-year reinsurance fund to the floor, a bill she introduced with Sen. Bill Nelson, D-Fla.
“After securing significant changes, as well as commitments to pass legislation to help lower health insurance premiums, I will cast my vote in support of the Senate tax reform bill,” Collins tweeted Friday.
But Democrats have repeatedly said that passing both bills would not negate the side effects of repealing the mandate. Insurers have warned that without the individual mandate they are likely to raise premiums for the country’s estimated 16 million Obamacare customers, or withdraw from the exchanges where some of these customers can purchase plans that are subsidized by the federal government.
Sen. Patty Murray, D-Wash., who helped author the bill that carries her name and that of Sen. Lamar Alexander, R-Tenn., said that her deal with Alexander wasn’t designed to mitigate mandate repeal.
“Our bill was designed to shore up the existing healthcare system and deal with problems that President Trump and Republicans have already created — not solve the new problems in this awful Republican tax bill,” Murray said on the Senate floor Friday.
Alexander-Murray makes cost-sharing reduction payments to insurers for two years. In exchange, states get more latitude to waive Obamacare insurer regulations. The payments reimburse insurers for a requirement to lower copays and deductibles for low-income Obamacare customers.
Trump ended the payments starting on Oct. 18. In response, many Obamacare insurers raised premiums to offset the costly requirement for lowering out-of-pocket costs for low-income customers.
Murray said the reinsurance bill sponsored by Collins and Nelson won’t offer relief.
“This bill is good policy on its own — but won’t stop the premium increases, coverage losses, and chaos that the Republican tax bill will cause,” she said Friday.” (C)

“Another argument – that the repeal of the individual mandate wouldn’t be the same as throwing people who already have insurance off insurance – is entirely specious. The individual mandate repeal unwinds the exchanges, allowing young and healthy people to stay out of the risk pools, making coverage more expensive and even unaffordable for those who remain. Surely, Collins and Murkowski know this to be the case from the Obamacare repeal debate. Simply put, as the Center on Budget and Policy Priorities found, “Pairing mandate repeal with the Collins-Nelson bill, or a similar approach . . . would not change the fact that repealing the mandate would drive up uninsured rates. That would weaken access to care, health, and financial security for millions of people. It would also substantially raise uncompensated care costs, which would ultimately be borne by providers, other health-care consumers and taxpayers.”
None of this addresses the damage that the bill may do to Medicaid and Medicare. Because of the deficits it creates (an issue that has thrown the entire legislative process into confusion), there may be a $25 billion sequester in Medicaid and Medicare funding in 2018 alone under the so-called pay-as-you-go (PAYGO) rules. Collins has said she’d oppose that, but her colleagues do not show the same concern.” (D)

“But let’s be clear: Repealing the individual mandate would be a big deal. The mandate is a valuable device for stopping free riders. Obamacare mandated that insurance companies offer insurance to everybody who wants it, with only minimal price discrimination based on age and smoking status. But if a healthy person knows they can buy insurance whenever they want for a given price, they may well decide to only purchase it after they get sick and need coverage.
This would be a big problem for insurance markets, as the pool of covered beneficiaries would be an unhealthy and expensive group. That’s why, for example, the CBO forecasts that repealing the individual mandate would cause premiums in nongroup markets to rise significantly.
Additionally, the mandate provides a hard nudge to people on the fence about getting enrolled in health insurance, including those in nongroup markets but also those who have Medicaid or employer-sponsored insurance. The CBO estimates that of the 13 million people who would lose coverage if the mandate is repealed, seven million are dropping out of Medicaid and employer-sponsored plans. In short, the mandate is a very efficient tool for keeping premium increases in check and increasing enrollment in all types of coverage.
Finally, while the individual mandate repeal is the only plank of the tax bill that directly attacks the ACA, Republicans have made no secret of the fact that after this bill passes, they will point at the resulting deficits to justify cuts in Medicaid and Medicare. This is not idle speculation; the House and Senate passed a budget resolution last month with $1.8 trillion in cuts to both of these programs. The battle over health care won’t end with this tax bill—or anytime soon.” (E)

“High-ranking Republicans are hinting that, after their tax overhaul, the party intends to look at cutting spending on welfare, entitlement programs such as Social Security and Medicare, and other parts of the social safety net.
“House Speaker Paul D. Ryan (R-Wis.) said recently that he wants Republicans to focus in 2018 on reducing spending on government programs. Last month, President Trump said welfare reform will “take place right after taxes, very soon, very shortly after taxes.”
As Republicans advocate spending cuts, they have frequently cited a need to reduce the national deficit while growing the economy.
“You also have to bring spending under control. And not discretionary spending. That isn’t the driver of our debt. The driver of our debt is the structure of Social Security and Medicare for future beneficiaries,” Sen. Marco Rubio (R-Fla.) said this week.
While whipping votes for a GOP tax bill on Thursday, Senate Finance Committee Chairman Orrin G. Hatch (R-Utah) attacked “liberal programs” for the poor and said Congress needed to stop wasting Americans’ money.
“We’re spending ourselves into bankruptcy,” Hatch said. “Now, let’s just be honest about it: We’re in trouble. This country is in deep debt. You don’t help the poor by not solving the problems of debt, and you don’t help the poor by continually pushing more and more liberal programs through.”
The GOP tax bill currently under consideration in the Senate would increase the federal deficit by nearly $1.5 trillion over a decade, according to Congress’s official tax analysts and multiple other nonpartisan analysts. When economic growth the measure could create is included in the analysis, Congress’s official tax scorekeeper predicted the bill would add $1 trillion to the deficit over 10 years.
Trump has not clarified which specific programs would be affected by the proposed “welfare reform.”
During the presidential campaign, Trump vowed that there would be “no cuts” to Social Security, Medicare or Medicaid, although the president has reversed many of his economic campaign promises since taking office.” (F)

“In the hours before the Senate’s final vote on the tax overhaul package, McConnell and House Speaker Paul D. Ryan (R-Wis.) sought to tamp down fears of such cuts, issuing a joint statement in which they accused Democrats of “misleading claims” and promised to “work to ensure these spending cuts are prevented.”
The bill itself does not avert them, however. Separate action would be required later and — unlike the parliamentary maneuvers used to adopt the tax plan with only GOP votes — would require support from some Democrats. Republican leaders predict that Democrats would cooperate rather than bear blame for harming health-care funding.
The leaders’ joint statement has its skeptics. “We are aware they say they will waive the paygo, but we have little comfort that they can do this,” said Georges S. Benjamin, executive director of the American Public Health Association. “Why did they not write the bill to address this in the first place?”
The cuts, if they happen, would decrease federal spending on Medicare by 4 percent — amounting to about $25 billion next year, the Congressional Budget Office forecast. Because paygo rules do not allow Medicare benefits to be touched, the funding loss would be spread among payments to doctors, hospitals and others that provide care to the program’s 56 million older and disabled Americans.
Those rules focus only on the mandatory spending within the federal budget and would leave untouched some health-care programs that provide help to low-income Americans, such as Medicaid and the Children’s Health Insurance Program. But it could eliminate nearly $1 billion a year for a Prevention and Public Health Fund, created under the ACA, that now represents 12 percent of the Centers for Disease Control and Prevention’s budget.” (G)

“There are some timing issues that could impact this process. Collins told reporters Tuesday that if she is going to vote on the Senate’s tax bill, she wants to see two Obamacare stabilizations bills passed before the conference report comes out.” (A)

(A) Senate Republicans pass a tax bill giving corporations a massive tax cut and cutting health care. By Tara Golshan, https://www.vox.com/policy-and-politics/2017/12/2/16720052/senate-republicans-pass-tax-bill
(B) A Historic Tax Heist, https://www.nytimes.com/2017/12/02/opinion/editorials/a-historic-tax-heist.html?_r=0
(C) Republicans send Obamacare individual mandate repeal to conference, by Robert King and Kimberly Leonard, http://www.washingtonexaminer.com/republicans-send-obamacare-individual-mandate-repeal-to-conference/article/2642364
(D) Two senators’ inexplicable flip-flop on health care, by Jennifer Rubin, http://www.sfgate.com/opinion/article/Two-senators-inexplicable-flip-flop-on-health-12398430.php
(E) Commentary: The Hidden Victim of Trump’s Tax Plan: Your Health Insurance, by Josh Bivens, http://fortune.com/2017/12/01/trump-senate-tax-bill-vote-individual-mandate/
(F) GOP eyes post-tax-cut changes to welfare, Medicare and Social Security, by Jeff Stein, https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.7430216da035
(G) Senate’s huge tax bill would have potent ripple effects for health-care system, by Amy Goldstein, https://www.washingtonpost.com/national/health-science/senates-massive-tax-bill-would-have-potent-ripple-effects-for-health-care-system/2017/12/02/8e1701b2-d6c3-11e7-a986-d0a9770d9a3e_story.html?utm_term=.ab7093963f

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“The Senate tax bill is really a health care bill with major implications for more than 100 million Americans…..

…who rely on the federal government for their health insurance.
The bill reaches into every major American health care program: Medicaid, Medicare, and the Obamacare marketplaces.
These are expected outcomes based on two key policy changes in the bill. First, the bill repeals the individual mandate, a key piece of Obamacare that requires most Americans get covered. Economists expect its elimination to reduce enrollment in both the Affordable Care Act’s private marketplaces and Medicaid by millions. The money saved will be pumped into tax cuts for the very wealthy.
The bill also includes tax cuts so large that they would trigger across-the-board spending cuts — including billions for Medicare. The last time Medicare was hit with cuts like this, patients lost access to critical services like chemotherapy treatment.
This tax bill deserves a broader name. Its policies will cause millions of vulnerable Americans to lose coverage, disrupt care for the elderly, and potentially change the health care system in other ways we can’t fully predict.” (A)

“Health care became intimately mired in the tax reform debate as Senate Republicans heeded President Trump’s call to tack on a repeal of Obamacare’s individual mandate, one of the health law’s most unpopular measures, into their plan. The mandate requires all Americans to carry insurance (subsidized for the vast majority of people buying individual health insurance plans) or pay a tax penalty.
Trump and the Congressional GOP have long aimed to nix that requirement. But they’ve been unsuccessful to date in part because the CBO has projected that repealing the mandate would lead to millions of fewer insured Americans relative to current law while also hiking rates. And while experts may quibble over the precise magnitude of those effects, the CBO hasn’t equivocated about the overall trend.
“There’s a lot of uncertainty around how effective the mandate has been,” Larry Levitt, senior vice president at the independent health care think tank Kaiser Family Foundation (KFF), told Fortune in an interview. “But CBO has said the direction of the effect is clear. Repealing the mandate would increase premiums, would increase the number of people who are uninsured.”
Just how big of an effect would a mandate repeal have? According to CBO, 13 million fewer people would be insured in 2027 compared with current law while premiums would spike 10%. That’s because, without the policy “stick” of a mandate, healthier and wealthier people would likely drop out of Obamacare’s marketplaces, in turn making individual insurance risk pools more costly by disproportionately leaving them with sicker Americans.” (B)

“President Trump at a closed-door meeting with GOP senators on Tuesday said he would support two proposals meant to stabilize ObamaCare’s insurance markets in exchange for a repeal of the law’s individual mandate, several Republicans in attendance said.
The two bills would fund key ObamaCare insurer payments, and provide billions to help states create reinsurance programs for high-cost patients.
Passage of the measures could prove crucial to winning support for the Senate tax bill, which includes repeal of ObamaCare’s mandate, from Sen. Susan Collins (R-Maine)….
Collins left the meeting feeling she’d been reassured by Trump that he’d support both bills.
“[Trump] said that he understood the need to have something to offset the premium increases and appeared very open” to signing the two bills into law, she said.” (C)

“Sen. Susan Collins (R-Maine) said early Thursday that she expects legislation to lower health-care premiums to pass Congress before senators take a final vote on a $1.5 trillion tax-reform bill that would repeal the Affordable Care Act’s individual mandate….
To mitigate the impact, GOP leaders plan to pass legislation negotiated by Senate Health Committee Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (Wash.) that would reinstate cost-sharing reduction payments to insurance companies.
It will be paired with legislation sponsored by Collins and Sen. Bill Nelson (D-Fla.) that would set up health reinsurance programs for older and sicker individuals.
The measures are likely to be attached to a government stopgap funding bill, Collins said.
“I have met with the president of the United States about this and have gotten his endorsement, I’ve met with the Republican leadership and with the members of the Finance Committee,” she said. “They are most likely to be on the continuing resolution.”
“Assuming the tax bill passes the Senate, we then turn to the CR and those two bills will be put on the CR,” she said.
“While the tax bill is in conference, the CR will presumably become law and then the tax bill come back from conference,” she said. “So I’m going to know whether those provisions made it and that matters hugely to me.”” (D)

“Larry Levitt, an Obamacare expert with the Kaiser Family Foundation, told CNBC that “Alexander-Murray, as it’s currently drafted, wouldn’t really do anything to mitigate the effects of repealing the individual mandate.”
But funding reinsurance programs “could offset any premium increase” resulting from repeal, Levitt said.
Totally offsetting such price hikes from repeal would require some additional funding, and extending reinsurance beyond the two-year span outlined in Collins’ bill, he said.
However, “it wouldn’t do anything to deal with the fact that more people are likely to be uninsured” as a result of the mandate’s repeal, Levitt said.
If the mandate is repealed, the CBO estimates that 13 million more people would become uninsured by 2027 than are currently projected.
“Most of the losses [in insurance coverage] are due to the fact that people are not getting pushed into getting coverage,” Levitt said.
Sen. Patty Murray, D-Wash., who co-authored the Alexander-Murray bill, told The Washington Examiner, “I support reinsurance, but it won’t solve the problem they created,” referring to the mandate repeal.
“The bill we designed has not been written to block the premiums they’re creating,” Murray said.
Republican lawmakers as a group are less likely to be concerned with the increase in the number of uninsured people.
“The premium increases on middle-class consumers is probably the most troubling part of repealing the individual mandate, particularly for Republicans,” Levitt said.
Many middle-income Americans earn too much to qualify for Obamacare subsidies that lower monthly premiums. That means those people bear the full brunt of premium increases.” (E)

“The Senate Republican plan to use tax legislation to repeal the federal requirement that Americans have health coverage threatens to derail insurance markets in conservative, rural swaths of the country, according to a Los Angeles Times data analysis.
That could leave consumers in these regions — including most or all of Alaska, Iowa, Missouri, Nebraska, Nevada and Wyoming, as well as parts of many other states — with either no options for coverage or health plans that are prohibitively expensive.
There are 454 counties nationwide with only one health insurer on the marketplace in 2018 and where the cheapest plan available to a 40-year-old consumer costs at least $500 a month. Markets in these places risk collapsing if Congress scraps the individual insurance mandate.
“It’s very, very concerning to us,” said Denise Burke, healthcare analyst at the Department of Insurance in Wyoming, where the cheapest plan for a 40-year-old consumer in most of the state will cost $586 a month next year.
The precise nationwide impact of the Senate GOP tax plan, which would eliminate the Affordable Care Act’s unpopular mandate penalty, is unclear, as many forces affect how much insurance costs and where insurers sell plans.
But the legislation is widely expected to cause insurers to raise prices or exit markets out of fear that fewer healthy people will buy plans if there is no longer a penalty for going without coverage.
The risk is greatest in places where health insurance is already very expensive and where there are few insurers.” (F)

“But the argument that getting rid of the mandate will improve people’s well-being by allowing them to opt out of coverage without a penalty is weaker than it first sounds, as per this analysis by Aviva Aron-Dine. She draws heavily on the Congressional Budget Office’s estimate that repealing the mandate will lead to 13 million fewer people with coverage and a 10 percent increase in premium costs.
First, the mandate isn’t in the Affordable Care Act just for fun. Health coverage plans with cost controls typically have some version of a mandate to avoid “adverse selection,” wherein the people who buy health coverage tend to be those who need it the most, making it too expensive for others. This undermines health insurance markets, which work through the healthy subsidizing the sick. If that sounds unfair, consider that at some point, you could be either one of those people (i.e., healthy or sick), but you can’t know now which one you’ll be. That’s the problem insurance solves.
Aron-Dine argues that because of this dynamic, “some of the coverage losses from repealing the mandate would not be ‘voluntary’ in any sense.” Instead, they’d be a function of higher premiums due to healthier people leaving the risk pool.
Next, consider that according to the CBO, about half of those budget savings come from fewer people on Medicaid. What’s up with that? After all, Medicaid recipients don’t pay premiums, so why would repealing the mandate affect them either way?
It’s because, as Aron-Dine notes, “the mandate also serves a critical outreach function, leading uninsured people who are unaware of their eligibility for marketplace subsidies or Medicaid to explore their available options and then enroll.” The CBO estimates that this ultimately will lead to 5 million fewer people with Medicaid coverage.
Then there’s the risk that people who don’t get coverage pose to themselves and, through negative spillovers, to the rest of us. Those who decide to forgo coverage are making a bet that they won’t get sick. But some will lose that bet, and when they do, these patients will receive “uncompensated care” because hospitals must treat the sick regardless of their insurance status. And you know who pays for such care, right? The rest of us.” (G)

“Throughout this decadelong healthcare debate, the organization I lead, the National Coalition on Health Care, has urged Congress to pursue bipartisan solutions in healthcare. We have called for reforms that improve our health system and reduce costs through evidence-based policy—but instead, Congress is pursuing across-the-board cuts hidden in a tax bill.
In the individual market today, bipartisan solutions would mean continuing cost-sharing reduction payments and stabilizing premiums—without pushing millions off health coverage. Instead, the Senate tax bill’s repeal of the individual mandate would increase the number of uninsured by 13 million and increase premiums in the nongroup market by about 10%, according to the Joint Committee on Taxation and the Congressional Budget Office.
In Medicaid today, bipartisan solutions would mean fostering state innovation, not shifting the cost burden onto states, beneficiaries or providers. States are already making efforts to transform their care delivery systems by helping beneficiaries remain independent in their homes and integrating care for lower income seniors and disabled individuals enrolled in both Medicare and Medicaid. Targeted federal policy has the ability to improve and expand upon these initiatives. Unfortunately, in this bill much of the savings attributed to the individual mandate repeal would come from a substantial reduction in federal support for state Medicaid programs. An analysis of the mandate repeal published recently by the CBO projected those Medicaid cuts would total $179 billion over 10 years.
In Medicare today, bipartisan solutions would mean improving the quality of care and reducing costs while avoiding indiscriminate cuts that harm beneficiaries. The Senate-passed CHRONIC Care Act is one example of such an effort, providing vital flexibilities to enable providers and health plans to deploy high-tech telehealth and high-touch personal support to improve care for the chronically ill.” (H)

“While the ACA is not perfect, it has provided an important pathway for moving from peril to progress in strengthening America’s health care system. It is important to remember that in 2008, prior to the ACA’s enactment, 82 percent of Americans wanted an overhaul of the U.S. health care system at a time when over 47 million people — or 18 percent of the U.S. population — lacked health insurance. The historic passage of the ACA signed into law by President Obama in 2010 represents the most significant and comprehensive health care legislation since the establishment of Medicare and Medicaid in 1965 and it has transformed the U.S. healthcare system. Through its reforms, the legislation has enabled 20.4 million people to gain insurance coverage by 2016. Medicaid expansion itself covered 11 million people, including nearly two million Americans in rural areas. Furthermore, the ACA’s coverage mandates protect the nearly 129 million Americans with pre-existing conditions — or one in two people — from being charged discriminatorily higher premiums or denied coverage. The ACA’s provisions also put into place payment reforms that incentivized quality care over quantity of medical services provided and fueled a prevention revolution through the provision of preventive services at no cost to consumers in their insurance plans, the establishment of a Prevention and Public Health Fund to support community prevention programs, and the creation of a National Prevention Strategy with the participation many governmental departments and numerous stakeholders.
This is not the time to sabotage the ACA legislation but rather the very moment to strengthen it. Since the establishment of the Affordable Care Act in 2010, much progress has been made to advance America’s health care system in communities, states and nationally. The significant achievements made since the law’s enactment highlight the importance of working together to safeguard, improve, and expand on the ACA’s progress to improve the health of all Americans now and in the years ahead.” (I)

“Gov.-elect Phil Murphy said Wednesday he plans to examine New York Gov. Andrew Cuomo’s efforts to preserve health insurance coverage for residents of his state as a model for New Jersey if parts of the Affordable Care Act are repealed under a new Republican tax bill in Congress….
In June, Cuomo issued emergency regulations requiring any private insurer to guarantee the 10 “essential health benefits” offered under Obamacare, and blocking any insurer that withdraws from New York’s health insurance exchange from participating in Medicaid or its children’s health plan.
But Murphy was adamant that his first priority should be to pressure Congress to preserve the individual mandate to buy health insurance that serves as the Affordable Care Act’s linchpin.
“Make no mistake,” said the governor-elect. “There’s almost nothing the state can do to replace the federal government.”
The current tax reform bill in the U.S. Senate also threatens to slash health insurance for the 900,000 New Jerseyans who’ve gained access to health care under Obamacare by scrapping the the individual mandate requiring people to buy health insurance through a Medicaid exchange or pay a penalty.” (J)

(A) Is it a tax bill or a health care bill?, by Sarah Kliff, VoxCare, November 30. 2017
(B) GOP Tax Plan Would Still Leave 13 Million Without Health Insurance, CBO Says, by Sy Mukherjee, http://fortune.com/2017/11/29/gop-tax-plan-obamacare-cbo/
(C) Trump backs bipartisan fixes to ObamaCare markets, by JESSIE HELLMANN, http://thehill.com/policy/healthcare/362168-trump-backs-bipartisan-fixes-to-obamacare-markets
(D) Collins: Health-care fix will pass before tax bill, by ALEXANDER BOLTON, http://thehill.com/homenews/senate/362537-collins-health-care-fix-will-pass-before-tax-bill
(E) Why a new GOP idea won’t solve biggest problem with repealing Obamacare’s mandate, by Dan Mangan, https://www.cnbc.com/2017/11/28/gop-idea-wont-solve-biggest-problem-with-repealing-obamacare-mandate.html
(F) Republicans’ latest plan to repeal Obamacare’s insurance requirement could wreak havoc in some very red states, by Noam N. Levey, http://www.latimes.com/politics/la-na-pol-insurance-mandate-repeal-20171127-story.html
(G) How the Republican tax cut plan goes after health care, by Jared Bernstein, https://www.washingtonpost.com/news/posteverything/wp/2017/11/27/how-the-republican-tax-cut-plan-goes-after-health-care/?utm_term=.23fcc55219d5
(H) Guest Commentary: Tax reform should mean improving the economy, but not at the expense of our healthcare system, by John Rother, http://www.modernhealthcare.com/article/20171129/NEWS/171129914
(I) Safeguarding America’s Health System from Sabotage, by Susan Blumenthal, M.D. and Alexis Boaz, https://www.huffingtonpost.com/entry/safeguarding-americas-health-system-from-sabotage_us_5a1ecf33e4b0e37da0447b66
(J) Murphy says he’d consider emergency action to save Obamacare for N.J., by By Claude Brodesser-Akner, http://www.nj.com/politics/index.ssf/2017/11/following_cuomo_murphy_will_consider_obamacare_exc.html#incart_river_home

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Facebook users can easily find these drugs – Oxycodone, Hydrocodone, and Percocets

“Gov. Chris Christie’s presidential opioid commission went out of business Wednesday with 56 recommendations on how to address the crisis and an admonition to Congress to spend the money needed….
Among the new recommendations: providing states with more flexibility to use federal funds to address opioid abuse, launching a media campaign to warn about the dangers of opioid abuse, identifying students who may be at risk of using opioids, giving patients information about the risks of opioids and providing guidelines to doctors, and strengthening efforts to intercept packages of fentanyl and other synthetic opioids.
The panel also called for relaxing limits on insurance coverage of drug abuse treatment, including giving new powers to the Labor Department, which oversees health care plans provided by large employers; taking steps to allow emergency medical technicians to administer naloxone, which can combat opioid overdoses; and establishing drug courts 93 federal judicial districts.
The commission attributed the crisis, in part, to unsubstantiated claims that opioids were a non-addictive way to ease patients’ pain, to pharmaceutical company efforts to promote the use of opioids, to unsavory doctors and pharmacists dispensing the drugs, and inadequate Food and Drug Administration oversight.” (A)

“The commission does not say how much funding implementing its recommendations or tackling the opioid crisis will require — leaving a huge question open, even as it argues that “Congress must act” and “appropriate sufficient funds to implement the Commission’s recommendations.” It also does not call for a new, large investment into drug addiction treatment, as some advocates hoped for.
With its final report, the commission ends months of work in which it met with major stakeholders involved in the crisis, from people struggling with addiction to insurers to pharmaceutical companies.
The question now is whether Trump and Congress will listen to the recommendations.
Here are some of the biggest recommendations in the report: Streamline federal funding for drug addiction: Remove barriers to treatment: Open drug courts in all federal jurisdictions: More opioid prescriber training: Stop evaluating doctors based on pain scores: Allow more emergency responders to deploy naloxone: Tougher prison sentences for fentanyl: A media campaign: (B)

“In declaring the opioid epidemic a public health emergency last week, President Trump promised that the federal government would start “a massive advertising campaign to get people, especially children, not to want to take drugs in the first place.” But past efforts to prevent substance abuse through advertising have often been ineffective or even harmful.
Perhaps the most famous American antidrug advertisement featured a sizzling egg in a frying pan to the sound of ominous music and a stern voice-over warning, “This is your brain on drugs.” A sequel to this ad featured Rachael Leigh Cook smashing an egg and the better part of a kitchen to dramatize the impact of heroin….
Why was the original campaign such a failure? In part it suffered from perverse incentives. Congress provided substantial money for the ads and was intensely interested in them at the height of the so-called war on drugs, creating internal pressure to make the ads appealing to members of Congress. But while ads that lectured or scared people about drugs might have seemed compelling to the modal member of Congress (a 60-year-old white male), they did not necessarily dissuade drug use by adolescents. In some cases, this kind of approach may make drugs more attractive as a sign of rebellion. (C)

“Ironically, just as President Trump hypes his announcement, at the same time – in a position drastically at odds with a plan to combat the opioid crisis – he is still pressuring Congress to make extensive cuts to Medicaid. His tax plan, now being debated by Congress, includes a substantial $1 trillion cut to the program by 2026….
If the President succeeds at dismantling Medicaid, the emergency declaration will do little to reverse America’s upward trend of overdose deaths.
Medicaid has given millions of Americans access to substance use disorder treatment, providing health care coverage to some 3 in 10 people with opioid addiction in 2015. The program covers addiction treatment services, including reimbursement for the life-saving medications buprenorphine, methadone and naloxone. It also helps fund other approaches that we know work – including raising awareness and reducing stigma about drug use and distributing naloxone, an emergency medication to reverse overdose. Currently, over half of the states have increased access for Medicaid enrollees to naloxone. This is not just about the urban centers we serve; a cut to Medicaid is going to be felt in other parts of the country where the epidemic is acute, from New Mexico to New Hampshire.” (D)

“In January 2016, St. Joseph’s began a program to try to decrease the use of opioids in the emergency department, Rosenberg said. Instead of using opioids, physicians used alternative treatments for acute pain. For instance, instead of opioids, doctors used nerve blocking injections with some patients. The approach is proving successful: The emergency department has reported a 58 percent reduction in the use of opioids since the initiative started, Rosenberg said.
St. Joseph’s has also launched a program to help patients addicted to opioids. For patients who have opioid use disorder and want help, St. Joseph’s provides recovery coaches, people who are in recovery themselves. These coaches can help guide people trying to stop using opioids through the recovery process. Not every patient with an opioid addiction opts for this help, but of those who do, 86 percent have achieved long-term recovery, meaning they’ve free of opioid use for at least six months.” (E)

“Over the last two decades, opioids have emerged as the default long-term treatment for chronic pain, largely because there has been little incentive to consider alternatives. Every Medicare plan, for instance, covers common opioids and does not require prior approval. Physicians can just write a prescription and provide their patients with immediate relief.
But opioids are not indicated for all chronic pain problems. One comprehensive report from experts at six U.S. universities found that evidence of the long-term benefits of opioids is “scant” and that many opioid users “continue to have moderate to severe pain and diminished quality of life.”
It’s no wonder that the Centers for Disease Control and Prevention recommends that opioids only be used for three days. Yet prescription rates for opioids have skyrocketed, and the overall prevalence of chronic pain in the United States has stayed roughly the same.
Alternative means of treating chronic pain could break this stalemate.
Take “interventional” pain therapies. These non-surgical procedures target the parts of the body that generate chronic pain — and thus could eliminate patients’ desire for opioids. Popular interventional therapies include the application of electric currents to nerve fibers; the injection of steroids or anesthetic into problematic joints, tissue, and nerves; or treatment with an electric spinal-cord stimulator.
Unlike opioids, these procedures are proven to provide long-term relief. In one study, three-quarters of patients who underwent a procedure that stimulated a specific part of the spinal column reported significant improvements in their level of leg pain over the course of a year. (F)

“On Wednesday, Gary Mendell, founder and CEO of Shatterproof; Dr. Thomas McLellan, former deputy director of the Office of National Drug Control Policy; Chris Hocevar, president (strategy, segments and solutions) of Cigna Corporation; and Mary Ann Christopher, vice president (clinical operations and transformation) of Horizon Blue Cross Blue Shield New Jersey, announced that 16 major healthcare payers would adopt eight “National Principles of Care” for the treatment of addiction….
This group includes six of the largest payers in the United States, covers over 248 million patient lives, and has provided letters of commitment and signed a memorandum of understanding to advance the following eight “National Principles of Care”: Universal screening for substance use disorders across medical care settings; Personalized diagnosis, assessment, and treatment planning; Rapid access to appropriate Substance Use Disorder care; Engagement in continuing long-term outpatient care with monitoring and adjustments to treatment; Concurrent, coordinated care for physical and mental illness; Access to fully trained and accredited behavioral health professionals; Access to Food And Drug Administration (FDA)-approved medications; Access to non-medical recovery support services. (G)

“Cardinal Health has unveiled a big push to combat the opioid epidemic in the four Appalachian states that have been hit hardest by it. The Opioid Action plan is a pilot that officials at the Dublin, Ohio-based company said would bring front-line tools to first responders in Ohio, Kentucky, Tennessee and West Virginia, while increasing its investment in education…

The program will see Cardinal Health purchasing roughly 80,000 doses of overdose reversal drug Narcan Nasal Spray or first responders and law enforcement officers. The company said it would also increase support for drug take-back and education programs, building on similar events held in 13 communities in the four states through the Cardinal Health Foundation’s partnership with the Ohio State University College of Pharmacy. The two organizations teamed up to create Generation Rx, an educational program about the dangers of prescription drug misuse.” (H)

“Scientists across America, including myself, are dedicated to finding non-addictive medications for managing chronic pain and as alternatives to the current opioid medications such as methadone, which are narcotic substitution strategies used to manage opioid addiction. Such non-addictive alternatives include natural plant products, vaccines, chemical and molecular modification of pharmaceutical compounds, repurposing medications currently used for treating other diseases, and state-of-the-art techniques that alter brain activity. We are increasingly hopeful about these non-addictive alternatives. We now need to move them to clinical trials to make sure they work and to promote discovery of other novel treatments.
Most non-traditional approaches lack a path for rapid testing outside the normal pipeline for therapeutic development. The bottleneck in the research-to-treatment pipeline is unknown to most people outside of science, no doubt including to the president. It currently takes over two years for a normal research grant to be funded and initiated. Applications with non-traditional approaches often never even make it to the funding stage. If the research strategy is truly novel, the project will require Food and Drug Administration (FDA) approval for clinical research, which can take an additional year. Then completing the clinical trial itself could last up to five years.
We can’t spend so much time getting these research projects off the ground. According to the Centers for Disease Control and Prevention, 45,788 people died from opioids over a 12-month period ending in January 2017.
In issuing his declaration, Trump initiated several federal initiatives to help people with opioid addiction, such as methadone treatment programs and more flexibility for hospitals in hiring substance abuse specialists. However, these are the same treatments that have been used forever. They are not preventative measures nor do they provide new therapeutic options to the large number of people still not served by the current programs. (I)

“Facebook CEO Mark Zuckerberg said what surprised him most about the U.S. was the scope of the opioid crisis, but Facebook is flooded with illegal ads marketing these pain medications.
Sellers in the U.S. and overseas are using Facebook pages and videos to offer drugs that require a prescription by U.S. law, CNBC reported…
The marketing issue, where users can search for Oxycodone, Hydrocodone, and Percocets, among others, persists weeks after President Donald Trump declared the opioid addiction crisis a public health crisis.
CNBC notes that Facebook users can easily find these drugs by searching the name of the drug followed by “for sell,” rather than “for sale.”
These sorts of pages and posts can evade Facebook detection for months at a time.” (J)

“The economic cost of the opioid epidemic was about $504 billion in 2015, more than six times higher than other studies from previous years, according to a newly released analysis from the White House Council of Economic Advisers (CEA).
This figure accounts for roughly 2.8 percent of gross domestic product. The opioid crisis has garnered the national spotlight, as it has led to a significant uptick in overdose deaths since 1999 and, most recently, was declared a national public health emergency by President Trump…
The council noted that data on fatalities underestimate the number of deaths related to opioids. In 2015, there were more than 33,000 reported opioid-related deaths, but because fatalities are underreported, CEA pegged the number closer to about 41,000 deaths. CEA’s analysis on the economic cost is much higher than previous studies, because it adjusted for underreporting of fatalities and accounted for the value of lives lost using a method federal agencies typically use. Also, previous studies only took into account the cost of prescription painkillers, but CEA’s analysis included illicit opioids, like heroin. (K)

“Now, a handful of doctors and hospital administrators are asking, if an opioid addiction starts with a prescription after surgery or some other hospital-based care, should the hospital be penalized? As in: Is addiction a medical error along the lines of some hospital-acquired infections?
Writing for the blog and journal Health Affairs, three physician-executives with the Hospital Corporation of America argue for calling it just that.
“It arises during a hospitalization, is a high-cost and high-volume condition, and could reasonably have been prevented through the application of evidence-based guidelines,” write Drs. Michael Schlosser, Ravi Chari and Jonathan Perlin.
The authors admit it would be hard for hospitals to monitor all patients given an opioid prescription in the weeks and months after surgery, but they say hospitals need to try.
“Addressing long-term opioid use as a hospital-acquired condition will draw a clear line between appropriate and inappropriate use, and will empower hospitals to develop evidenced-based standards of care for managing post-operative pain adequately while also helping protect the patient from future harm,” said Schlosser in an emailed response to questions.” (L)

“It’s a shame that President Trump’s opioid commission said little about demand-side prevention.
It’s a lot less costly (both in dollars and in lives disrupted) to stop opioid misuse before it starts than to deal with its aftermath. And many prevention programs are cost effective, according to an analysis by the Washington State Institute for Public Policy.
The report from the commission last month emphasized limiting supply much more than demand — targeting opioid sources like prescriptions and the black market. That’s important, too.
But among the report’s 56 recommendations, only two aim to prevent people from seeking out opioids for no medical purpose: an advertising campaign and a structured discussion with a health professional. Neither approach has particularly strong science behind it….
There are many evidence-based prevention programs that could be usefully applied to the opioid crisis. The commission’s report mentions some — including many of those described above — but it stops short of recommending any.” (M)

“President Trump’s opioid commission delivered more than 50 specific ideas to help combat the epidemic, involving more than a dozen agencies. But no one’s in charge of implementing that overall plan — which means no one’s accountable for its progress.
Be smart: Policy-specific “czars” can be a bit of a gimmick. But some experts say there’s a strong case for giving one person the authority to spearhead an opioid response that will need to be far-reaching and multifaceted to be successful….
Why now? Looking at the report from Trump’s opioid commission as well as the steps outside experts have recommended, it’s obvious that this will be a complicated solution with a lot of moving parts.
The Centers for Disease Control and Prevention is generally in charge of monitoring epidemics.
The Food and Drug Administration is re-examining its regulatory rules with an eye toward broader use of medication-assisted therapy, like methadone. It also regulates the design and marketing of opioids that are already on the market.
Some of these products are being prescribed or obtained illegally, and people addicted to opioids frequently turn to illegal drugs like heroin, as well. There are roles here not just for health care agencies, but also law enforcement.
And all of that has to be coordinated not just within the federal government, but with the relevant agencies in all 50 states, as well as tribal authorities.” (N)

“As he emerged from the grip of addiction three years ago, Derek saw how complicated recovery would be: programs to navigate, calls to make, forms to fill out, court dates to attend. All that on top of the emotional and physical strain of parting with the heroin and alcohol that had ruled his life for a dozen years.
“But the 32-year-old counts himself lucky to have had a “recovery coach” guiding him on his journey from treatment to sobriety. The coach, Katie O’Leary, offered a deep understanding, and a motivating example of success: She started her own recovery from heroin addiction seven years ago.
O’Leary, who works for the North Suffolk Mental Health Association, belongs to a new profession whose role is expanding amid the opioid crisis. But as the use of recovery coaches grows, so do the questions: Who are they exactly? What qualifies them to do this work? What are the boundaries of their practice?…
Recovery coaches, or “peer support specialists,” have been around for decades, originally as volunteers who had beat addiction and wanted to help others do the same. In recent years, hospitals, treatment centers, municipalities, and courts have started to pay for their services.
They are seen as peers able to guide and mentor, encouraging people to enter treatment or helping them keep on track in recovery. Usually they are not supposed to provide treatment, and most do not have advanced degrees. But there are no firm statewide rules — and insurance companies do not reimburse for peer recovery services, requiring programs that hire recovery coaches to find other sources of funding. No one even knows how many people call themselves recovery coaches, in Massachusetts or nationwide.
Kristoph Pydynkowski, director of recovery management at the Gosnold treatment center on Cape Cod, welcomes the governor’s proposal to credential recovery coaches, part of a wide-ranging plan to battle opioid addiction.
“It’s a like the Wild West,” he said. “We do need to come up with some standards and best practices.”” (O)

(A) Christie sends Trump final report on opioids with this message: ‘Our people are dying’, by Jonathan D. Salant, http://www.nj.com/politics/index.ssf/2017/11/christie_opioid_commission_passes_baton_to_congres.html#incart_river_index
(B) Here’s what Trump’s opioid commission wants him to do, by German Lopez, https://www.vox.com/policy-and-politics/2017/11/1/16589552/trump-opioid-commission-final-report
(C) Just Say No to Opioids? Ads Could Actually Make Things Worse, by AUSTIN FRAKT and KEITH HUMPHREYS, https://www.nytimes.com/2017/11/01/upshot/why-advertising-is-a-poor-choice-to-tackle-the-opioid-crisis.html
(D) President Trump’s Says He Wants to Stop the Opioid Crisis. His Actions Don’t Match, by Dr. Mary T. Bassett, Dr. Julie Morita and Dr. Barbara Ferrer, http://time.com/5008350/donald-trump-opioid-crisis-actions-words/
(E) Innovative Approaches Needed to Attack Opioid Crisis, by Ruben Castaneda, https://www.usnews.com/news/healthcare-of-tomorrow/articles/2017-11-03/innovative-approaches-needed-to-attack-opioid-crisis
(F) THERE’S ONE SURE WAY TO FIX THE OPIOID CRISIS, by PETER STAATS, http://www.newsweek.com/theres-one-sure-way-fix-opioid-crisis-702009
(G) 16 Insurance Companies Make Commitment To Address Opioid Crisis, by Bruce Y. Lee, https://www.forbes.com/sites/brucelee/2017/11/09/16-insurance-companies-make-commitment-to-address-opioid-crisis/#7fad621279de
(H) Cardinal Health kicks off Opioid Action Program, by DAVID SALAZAR, http://www.drugstorenews.com/article/cardinal-health-kicks-opioid-action-program
(I) Commentary: There’s a Better Way to Fight the Opioid Crisis. Why Aren’t We Focusing On It?, by Yasmin Hurd, http://fortune.com/2017/11/09/opioid-crisis-epidemic-addiction-trump-emergency/
(J) Zuckerberg Surprised by Extent of Opioid Crisis, While Multiple Facebook Pages Sell Opioids, by Katelyn Caralle, http://freebeacon.com/culture/zuckerberg-surprised-by-extent-of-opioid-crisis-while-multiple-facebook-pages-sell-these-drugs/
(K) White House: Economic cost of opioid crisis about $504B, by RACHEL ROUBEIN, http://thehill.com/policy/healthcare/361151-white-house-economic-cost-of-opioid-crisis-about-504b
(L) Should Hospitals Be Punished For Post-Surgical Patients’ Opioid Addiction?, by MARTHA BEBINGER, NPR, November 26, 20176:19 AM ET
(M) Where Is the Prevention in the President’s Opioid Report?, by Austin Frakt, https://www.nytimes.com/2017/11/27/upshot/where-is-the-prevention-in-the-presidents-opioid-report.html
(N) Why Trump may need an “opioid czar”, by Sam Baker, https://www.axios.com/why-trump-may-need-an-opioids-czar-2512794498.html
(O) Questions arise over profession spawned by opioid crisis: recovery coaches, by Felice J. Freyer, https://www.bostonglobe.com/metro/2017/11/28/questions-arise-over-profession-spawned-opioid-crisis-recovery-coaches/eZHhpDq6WYNppqcuaCQNeI/story.html

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“The White House is trying kill Obamacare. Americans are throwing it a lifeline.”

For some middle-income families the increased premium from pulling the individual mandate is going to cancel out the tax cut they would get

Sunday Puzzle: “Which Health Plan Is Cheaper?
Doing a thorough comparison of health care plans is difficult.
But there is an imperfect, yet fairly, simple way to check whether a high-deductible plan might qualify for “no-brainer” status, meaning, it enables you to save on health care no matter how often you go to the doctor.
Here’s how to do it: https://www.nytimes.com/2017/11/04/business/which-health-plan-is-cheaper.html ”

“Democrats and other ACA advocates are arguing that eliminating the penalty would hurt lower-income Americans because fewer people would buy coverage overall – about 13 million fewer Americans over a decade, according to the Congressional Budget Office.
But that argument assumes that Obamacare plans aren’t attractive enough for people to keep buying them voluntarily. It seems unlikely that low-income Americans eligible for subsidies would drop their coverage without the mandate — because they’d still be able to access the same subsidies as before. The ACA is designed to make coverage affordable for people in the lower-income brackets by shielding them from the full cost of premiums.
But there is definitely a segment of the population that could suffer without the mandate. The people who are already bearing all the costs of Obamacare plans. These are the people who earn too much to qualify for a subsidy (that is, who earn at least 400 percent of the federal poverty level) and must therefore endure the full brunt of premium hikes.
In the absence of the mandate, some healthy people who don’t feel they need coverage would probably drop out of the market, resulting in higher premiums for everyone else. The CBO has said that average premiums in the individual market would increase by about 10 percent in most years, were the mandate struck from the books.
Collins expressed precisely this fear yesterday on CNN.
“The fact is that if you do pull this piece of the Affordable Care Act out, for some middle-income families, the increased premium is going to cancel out the tax cut they would get,” she said.” (A)

“In the Affordable Care Act and other subsequent reforms, Congress directed the Department of Health and Human Services to test new ways to pay for health care, challenging health care providers, hospitals, and private insurers to provide better care for less money. Under President Trump and former HHS Secretary Tom Price, that work slowed and, in some cases, stopped altogether. With Price out the door, the nominee to replace him, Alex Azar, should commit to righting the ship.
Congress passed payment reforms to test several simple but powerful notions: First, paying doctors and other health care providers for the quality of their care, not just the number of tests they order, ought to improve the health of their patients. Second, keeping patients out of hospitals and other institutions ought to lower costs. Third, preventive strategies should keep people healthier and lower costs. Finally, holding health systems accountable for quality and total cost of care ought to drive innovation.
Achieving those goals would make Americans healthier and help us save on the more than $3 trillion we spend on health care every year. We far outspend the most expensive, universal coverage health care systems in the world, and we aren’t getting better results. Our life expectancy is comparable to Chile and the Czech Republic. More than 250,000 Americans die due to medical errors every year.
Under Price’s leadership, HHS walked away from addressing these problems. He proposed canceling or shrinking Medicare programs to prompt innovation in joint replacements and cardiac care, which could lower costs across the health care system. In September, under Price’s instruction, Medicare chief Seema Verma signaled a “new direction” for the Center for Medicare and Medicaid Innovation, which Congress set up to test promising new ways to improve care and reduce system-wide costs. Instead of vigorously pursuing that mission, the Innovation Center is now looking for ways to loosen protections for Medicare patients, pushing payment systems that would allow unlimited charges for medical services, and even voucherizing the program for seniors. Apparently, the agency’s “new direction” is backwards….
Failing to align incentives in our health care system has real, lasting, life-or-death consequences. Azar needs to convince Congress that he will correct the course that Price set and renew HHS’s commitment to lowering health care costs and improving quality. The American people deserve better than the inefficient and costly system we have today.” (B)

“So the mandate’s repeal leads to a smaller, more expensive insurance market. The mandate is designed, after all, to bring healthier people into the market — without it, we would expect the remaining customers to be sicker and therefore cost more.
Alexander-Murray doesn’t really take any steps to address those problems. The stabilization bill is actually dealing with a whole different set of issues, brought on by Trump’s overt sabotage of the health care law….
Alexander-Murray is best thought of as an attempt to mitigate the damage that Trump has already done to Obamacare’s insurance markets. But repealing the mandate in the tax plan would erode the markets even further, and this other bill doesn’t have any provisions designed to address that new harm.
“The primary benefit of Alexander-Murray would be symbolic. It would be a sign that some bipartisan effort aimed at stabilizing the insurance market is possible, potentially boding well for future efforts,” Larry Levitt, senior vice president at the Kaiser Family Foundation, told me. “But, beyond the symbolism, it really wouldn’t do much to offset the effects of repealing the individual mandate, and could arguably even make things worse.”
That’s because most states and health insurers found a way to price their plans after the loss of cost-sharing reductions so that they actually yielded better deals for many Americans who buy insurance through Obamacare. If Alexander-Murray were passed, it would make those strategies unnecessary, eliminating these cheaper deals for people.
Then when you add in the repeal of the mandate, and the resulting rise in premiums, you have a market that might be even worse off than if Republicans had simply repealed the mandate and not passed Alexander-Murray.
The exact effects can be debated and might be simply unknowable. But what we can conclude, according to these experts, is that passing Alexander-Murray won’t be nearly enough to negate the consequences of repealing the mandate….
Senate Republicans are taking advantage of the superficial logic — repealing the mandate and Alexander-Murray both affect the insurance market, so it makes sense to tackle them at once — to paper over the fact that the tax bill and the stabilization bill are actually dealing with two totally different issues within the health care law.” (C)

“Moderate Republicans like Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska) have said passing Alexander-Murray could help ease their concerns about the destabilizing effects of repealing the mandate in tax reform.
However, Collins said Sunday she wants Alexander-Murray to pass before the tax bill does, which would likely not be the case if the bill waited until the end-of-the-year package.
Experts say that passing Alexander-Murray would not fully offset the effects of repealing the individual mandate, though, which the Congressional Budget Office estimates would increase premiums by 10 percent.” (D)

“Sen. Lisa Murkowski (R-Alaska) said she would support repealing the Affordable Care Act’s individual insurance mandate, giving a potential boost to the Republican effort to pass a massive tax cut package next week.
“I believe that the federal government should not force anyone to buy something they do not wish to buy, in order to avoid being taxed,” Murkowski wrote in an opinion piece published Tuesday by the Fairbanks Daily News-Miner.” (E)

“There are a variety of proposed alternatives to the ACA’s individual mandate to give people incentives to get and stay insured.
One way is to impose a penalty for people who wait to enroll in the form of higher premiums, similar to Medicare Part B. Following that model, the House GOP’s ACA repeal-and-replace bill this year proposed a one-time, 30% premium surcharge for people who enroll following a gap in coverage…
Another approach is to automatically enroll uninsured people in a health plan, giving them the option to drop out…
Other possibilities include requiring people who have not maintained continuous coverage to wait for a set period of time, say six months, before they can enroll in a plan. That was the approach proposed earlier this year in the Senate Republicans’ Better Care Reconciliation Act, which did not pass.
It’s widely agreed that the ACA’s individual mandate penalty—currently $695, or 2.5% of household income, whichever is greater—has not been as effective as hoped in prodding younger and healthier people to buy coverage. But it’s unclear whether any of the alternatives on their own would be as effective as the mandate without costing the federal government significantly more money.
A recent analysis by Wakely Consulting Group found problems with each of the alternative approaches. Several of those models, including late-enrollment penalties and enrollment waiting periods, could actually worsen the risk pool by giving healthier people incentives to put off buying insurance.
Auto-enrollment could boost enrollment among younger people, but it would be logistically difficult to implement because there’s no existing database of those who currently are uninsured…”(F)

“Despite the efforts of President Trump and many congressional Republications to repeal and replace the ACA in 2017, it is still the law of the land. Therefore, marketplace plans are again being offered for 2018.
However, the Trump administration did make some changes that could make it more difficult for consumers to sign up for healthcare coverage or deter them from doing so. This could result in fewer Americans being insured.
Here’s a look at seven specific steps the administration has taken.
1. Shortening the enrollment period.
2. Making changes to qualifying events.
3. Decreasing the amount spent on advertising ACA plans.
4. Decreasing the number of navigators.
5. Planning more maintenance outages on the exchanges.
6. Collecting unpaid premiums.
7. Canceling a subsidy to insurers that lowers consumer costs.” (G)

“Not-for-profit executives are concerned the Senate bill would hurt hospital capital financing by prohibiting advance re-funding of prior tax-exempt bond issues, which made up about 25% of the municipal tax-exempt bond market in 2017. The House GOP tax bill passed earlier this month goes further, eliminating all tax-exempt municipal bond financing starting next year. That’s projected to save the government nearly $40 billion….
Beyond that, healthcare industry groups fear that the Senate bill’s repeal of the Affordable Care Act’s individual mandate would sharply increase the number of uninsured patients. And they foresee Congress later pushing for big Medicare and Medicaid cuts to reduce the $1.5 trillion bump to the deficit that would result from passage of the tax-cut bill.” (H)

“The White House is trying kill Obamacare. Americans are throwing it a lifeline.
Despite the Trump Administration’s promises to “repeal and replace” the Affordable Care Act, enrollment for health insurance under the program is quite healthy with less than a month to go in the current sign-up period, according to the Centers for Medicare & Medicaid Services, a federal agency.
“In week three of Open Enrollment for 2018, 798,829 people selected plans using the HealthCare.gov platform,” the agency reported.
That brings the total number of enrollees in this period to 2.3 million, which is almost 900,000 people — or 64 percent — more than the number of customers who signed up during the first four weeks of enrollment in 2016, according to CNBC.
The figures included more than 566,000 new consumers and 1.7 million renewals, with total Healthcare.gov users exceeding 8.1 million.” (I)

“In a health care system teeming with fine print, here’s an oddity that middle-class people who buy insurance on their own, rather than through an employer, need to know: You might want to take a pay cut next year.
Consider the situation of a 63-year-old married couple with a projected household income of $70,000 next year. The lowest-cost health plan they can buy in Milwaukee County will cost them $24,034.80.
If that couple’s income falls to $60,000, however, the same health plan would cost them $24.
That’s not a typo. It’s the total premium for the year.
The difference: At $60,000, they’ll qualify for a federal subsidy. At $70,000, they won’t.
“The disparity between the cost of health insurance for people eligible for the subsidy and middle-class people who are not is huge,” said Larry Levitt, a policy expert at the Kaiser Family Foundation.” (J)

“Why have Republican leaders set their sights on health care again? They have a serious accounting problem on their hands. Congressional leaders and the Trump administration want to give corporations and wealthy families a giant tax cut, but they have committed to not adding more than (a whopping) $1.5 trillion to the federal deficit over the next decade. So they’re trying to increase revenue by raising taxes on many middle-class families and would compound that harm by cutting spending on things like health care, all in service of further enriching the wealthiest Americans through a plan they’re selling as a break for the middle class. We’d say you can’t make this stuff up, but it turns out they can.” (K)

(A) The Health 202: Republicans are right. The individual mandate is a tax on the poor., by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/11/20/the-health-202-republicans-are-right-the-individual-mandate-is-a-tax-on-the-poor/5a0f2dc030fb045a2e003215/?utm_term=.de5336388219
(B) Alex Azar must commit to ‘righting the ship’ for health care payments, By SHELDON WHITEHOUSE, https://www.statnews.com/2017/11/20/alex-azar-health-care-payments/
(C) The cockamamie health care scheme Senate Republicans are using to pass their tax bill, https://www.vox.com/policy-and-politics/2017/11/21/16679274/senate-republican-tax-plan-alexander-murray
(D) GOP senator: ObamaCare fix could be in funding bill, by BY PETER SULLIVAN, http://thehill.com/policy/healthcare/361218-alexander-bipartisan-obamacare-fix-could-be-in-funding-bill
(E) Republican Sen. Lisa Murkowski announces support for repealing individual mandate, a potential boost to tax overhaul, by Damian Paletta, https://www.washingtonpost.com/news/business/wp/2017/11/21/republican-sen-lisa-murkowski-announces-support-for-repealing-individual-mandate-a-potential-boost-to-tax-overhaul/?utm_term=.1d2a1d95ca98
(F) While axing the ACA mandate, why not replace it with a different coverage incentive?, by Harris Meyer, http://www.modernhealthcare.com/article/20171120/BLOG/171129994
(G) Open enrollment: 7 ways Trump’s actions could impact uninsured rate, by Karen Appold, http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/open-enrollment-7-ways-trump-s-actions-could-impact-uninsured-rate
(H) Looming Senate tax bill vote making healthcare leaders uneasy, by Harris Meyer, http://www.modernhealthcare.com/article/20171121/NEWS/171129971
(I) AMERICANS SIGN UP FOR OBAMACARE IN DROVES AS TRUMP TRIES TO KILL OBAMA LEGACY, by CELESTE KATZ, http://www.newsweek.com/obamacare-affordable-care-act-open-enrollment-repeal-replace-721850
(J) Making an extra $10 could cost you $24,000 more for health insurance, by Guy Boulton, https://www.jsonline.com/story/money/business/health-care/2017/11/24/few-dollars-can-determthe-same-health-plan-can-cost-middle-class-couple-24-034-year-24-year-cost-sam/893295001/
(K) When a Tax Cut Costs Millions Their Medical Coverage, https://www.nytimes.com/2017/11/24/opinion/republican-taxes-healthcare.html?_r=0

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