Expand search form

Featured, Health Policy, Healthcare Reform, Law, Politics

Legislative Update: AHCA edition

1 Comment

In this edition of Legislative Update, Marilyn Singleton, MD, JD dissects AHCA. We know what’s in the House version, but what will the Senate come up with?

The American Health Care Act, H.R. 1628—passed by the House with one vote to spare on May 4—is a budget reconciliation bill that is part of the 2017 federal budget process. It lowers both government spending and tax revenue. Reconciliation status means it can avoid filibuster in the Senate and pass with a simple majority of votes.

Please be advised: the Senate has promised to change this bill and is already looking to side-step major provisions of AHCA, claiming they might not meet requirements for reconciliation. “What we have to do is build a consensus … to get to a compromise we can agree to,” stated Senate Majority Whip John Cornyn, a member of a 12-person Senate “working group” said to be developing an alternate bill.

Some argue that the bill was put together too quickly without conferring with stakeholders while Obamacare was drafted and discussed for over a year. Of course, I don’t recall the Obama administration contacting AAPS for our opinion.

It seems to me, the Republicans have had a solid 6 years to horse-trade and come up with something that should have been ready on day one for a vote.

There were not enough votes to pass the bill at the end of March. The centrist Tuesday Group and the Freedom Caucus kissed and made up with the MacArthur Amendment and the Upton Amendment at the end of April. The MacArthur amendment allows states to apply for a waiver allowing insurers to further increase the ratio of premiums charged to enrollees in their 50s and early 60s versus younger enrollees. It also allows states to waive essential health benefits and certain sections of the community rating program that would permit insurers to charge people significantly more if they have a pre-existing condition, as long as the state creates a program to ameliorate the costs to enrollees and/or insurers. The Upton Amendment adds an additional $8 billion in assistance to lower costs for enrollees with pre-existing conditions.

The bill has equal opportunity opposition: AARP, AMA, American Hospital Association, Association of American Medical Colleges, among others. Additional critics include Heritage Action, the Cato Institute, Americans for Prosperity, FreedomWorks, Tea Party Patriots, MoveOn.org, and the Center for American Progress and many other liberal groups.

What Was “Repealed”

  • The AHCA eliminates (by reducing to $0) the individual mandate penalty for not having ACA-qualified “coverage.”
  • The AHCA reverses the ACA’s Medicaid expansion in 2020 (32 states opted in). Anyone enrolled prior to 2020 would stay enrolled.
  • The AHCA eliminates the ACA’s expanded required benefits mental health and addiction benefits under Medicaid.
  • The AHCA eliminates fines for large employers who don’t provide health plans
  • Under current law, state Medicaid programs are guaranteed federal matching funds for qualifying expenditures. The bill establishes targeted spending caps for each state, on federal funding for state Medicaid programs beginning in 2020 based on 2016 Medicaid expenditures. States could also choose a block grant and institute work requirements for Medicaid enrollees.
  • Small business tax credits end in 2020.
  • Health insurance premium limits are adjusted. Under the ACA, older persons could be changed up to three times that of younger folks. This is changed to to five times.
  • The platinum, silver and bronze levels are eliminated.
  • Taxes are eliminated: 3.8% tax on investment income and 0.9% additional Medicare tax on high income folks. Also, the 10% tanning services and 2.3% medical device tax.
  • The 40% Cadillac tax is suspended until 2024.
  • The threshold for receiving a tax deduction form medical expenses is returned to 7.5% of adjusted gross income from the ACA’s 10%.

Added by last minute amendment:

  • States may opt-out of providing the ACA’s essential health benefits. (This requirement was already dropped in the bill for Medicaid but not for the individual market.)
  • Pre-existing conditions: States may opt-out of requiring premiums to be the same for all people of the same age, so while individuals with pre-existing conditions must be offered health insurance there is no limit on the cost of that insurance. New funds would help lower premiums for these individuals.
  • States may opt-out of limiting premium differences based on age. The 3 to 1 limit is changed to 5:1 federally. States may apply for a waiver to choose a different ratio above 5:1.

Keepers

  • Guaranteed issue
  • The AHCA would keep the ACA’s requirement that dependents can stay on their parents’ plan until they are 26.
  • The ACA’s federal and state-run exchanges which listed individual and small business health insurance plans, would continue unchanged.
  • The AHCA would continue to provide subsidies for premiums that are based on income although the formula would be completely different and the subsidy would likely be much less for young, low-income Americans.
  • Although the individual mandate is reduced to $0 (essentially repealing it), the AHCA would instead impose a 30% surcharge when purchasing a policy after a lapse in coverage.

Expanded Benefits

  • Increased contributions to Health Savings Accounts. Increase annual tax free contribution limit to equal the limit on out-of-pocket cost sharing under qualified high deductible health plans ($6,550 for self only coverage, $13,100 for family coverage in 2017, indexed for inflation). – Tax penalty for HSA withdrawals used for non-qualified expenses is reduced from 20% to 10%.
  • Federal subsidies can assist with premiums for insurance purchased off the exchanges (but not grandfathered plans).
  • $123 Billion authorized for various state-based initiatives to “to improve affordability and access to coverage.”

Additional resources:

Full text bill (126 pages) and amendments: https://rules.house.gov/bill/115/hr-1628

Congressional Research Service Summary: https://www.govtrack.us/congress/bills/115/hr1628/summary#libraryofcongress

Kaiser Family Foundation Summary: http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act

CBO Scoring: https://www.cbo.gov/publication/52486

AAPS White Paper on Repeal and Replace: http://aapsonline.org/white-paper-repealreplacement-affordable-care-act/

Health Policy, Healthcare Reform, Law, Politics

Legislative Update – March 15, 2017

No Comments

“Beware of the Ides of March as both parties slowly kill us all off!” ~Marilyn Singleton, MD, JD reports on the latest battles in health care legislation on Capitol Hill.

Revisions to the ACA
Revisions to the ACA continued to pile in even as the “repeal and replace” was in progress. What was on their minds? These bills seem like an exercise in futility while negotiations over a major health care “system” overhaul are occurring. These revisions will likely be ignored while our congresspersons mull over the American Health Care Act (AHCA). At least these bills will be written when nothing happens to the ACA and we are still stuck with it.
I include some alternative bill to the American Health Care Act since they, like the AHCA, maintain provisions of the ACA.

 

The American Health Care Act (AHCA – working bill; no official bill yet)
The bill would repeal and replace various tax-related provisions of the ACA. Rep. Paul Ryan indicates that this bill is designed as the first phase of a three-step process. By focusing on taxes, the bill can be introduced using the reconciliation process. (Reconciliation allows for expedited consideration of certain tax, spending, and debt limit legislation. In the Senate, reconciliation bills aren’t subject to filibuster and the scope of amendments is limited). This summary is based on the House Ways and Means Committee majority summary. The bulk of the proposed bill repeals and replaces health-related tax policy:

(1) Recapture Excess Advance Payments Of Premium Tax Credits
The amount a household is required to pay towards their premiums is based on income. If a household’s income increases during the tax year, excess premium tax credits may result. Under the ACA, for households with incomes less than 400 percent of the federal poverty level there are certain limits on the amount the household is required to repay the federal government for the excess premium tax credits. For tax years 2018 and 2019, any individual who was overpaid in premium tax credits must repay the entire excess amount, regardless of income.

(2) Additional Modifications To Premium Tax Credit
Under the ACA, qualified health plans must meet certain requirements for households to be eligible for the premium tax credit. This section: (a) amends those requirements to make available premium tax credits for the purchase of “catastrophic-only” qualified health plans and certain qualified plans not offered through an Exchange; (b) prohibits premium tax credits from being used to purchase plans that offer elective abortion coverage; (c) revises the schedule under which an individual’s or family’s share of premiums is determined by adjusting for household income and the age of the individual or family members.

(3) Premium Tax Credit
This section repeals the ACA’s premium tax credit beginning in 2020.

(4) Small Business Tax Credit
This section repeals the ACA’s small business tax credit beginning in 2020. Between 2018 and 2020, under the proposal, the small business tax credit generally is not available with respect to a qualified health plan that provides coverage relating to elective abortions.

(5) Individual Mandate
This section would reduce the penalty to zero for failure to maintain minimum essential coverage. The bill would provide retroactive relief to those impacted by the penalty in 2016.

(6) Employer Mandate
This section would reduce the penalty to zero for failure to provide minimum essential coverage. The bill would provide retroactive relief to those impacted by the penalty in 2016.

(7) Repeal Of The Tax On Employee Health Insurance Premiums And Health Plan Benefits
The ACA imposed a 40 percent excise tax on high cost employer-sponsored health coverage (“Cadillac plans”). The tax will go into effect in 2020. This section changes the effective date of the tax until December 31, 2024.

(8) Repeal Of The Tax On Over-The-Counter Medications
This section repeals the ACA exclusion of over-the-counter medications from the definition of qualified medical expenses.

(9) Repeal Of Increase Of Tax On Health Savings Accounts
Distributions from an HSA or Archer MSA that are used for qualified medical expenses are excludible from gross income. Distributions that are not used for qualified medical expenses are includible in income and are generally subject to an additional tax. The ACA increased the percentage of the tax on distributions that are not used for qualified medical expenses to 20 percent. This section lowers the rate to pre-ACA percentages, effective for distributions after December 31, 2017.

(10) Repeal Of Limitations On Contributions To Flexible Savings Accounts
This section repeals the ACA limits the amount an employer or individual may contribute to a health Flexible Spending Account (FSA) to $2,500, indexed for cost-of-living adjustments, effective December 31, 2017.

(11) Repeal Of Medical Device Tax
This section repeals the ACA’s 2.3 percent medical device excise tax beginning after December 31, 2017.

(12) Repeal Of Elimination Of Deduction For Expenses Allocable To Medicare Part D Subsidy
This section re-instates the pre-ACA business-expense deduction for retiree prescription drug costs without reduction by the amount of any federal subsidy, beginning after December 31, 2017.

(13) Repeal Of Increase In Income Threshold For Medical Expense Deduction
The ACA increased the AGI percentage threshold from 7.5 percent to 10 percent if the taxpayer or spouse was aged 65 or older. This section restores the pre-ACA AGI percentage threshold to 7.5-percent for all taxpayers beginning in 2018 and extends the special rule for those aged 65 or older through this year.

(14) Repeal of Medicare Tax Increase
This section repeals the ACA’s Medicare Hospital Insurance (HI) surtax based on income at a rate equal to 0.9 percent of an employee’s wages or a self-employed individual’s self-employment income, beginning in 2018.

(15) NEW: Refundable Tax Credit For Health Insurance
This section creates an advanceable, refundable tax credit for the purchase of state-approved, major medical health insurance and unsubsidized COBRA coverage. To be eligible, generally, an individual must not have access to government health insurance programs or an offer from any employer; and be a citizen, national or qualified alien of the United States, and not incarcerated. The credits are adjusted by age, increasing from $2,000 for those under age 30 to $4,000 to those over age 60. The credits are additive for a family and capped at $14,000.

(16) Increase Maximum Contribution Limit To Health Savings Accounts
This section increases the basic limit on aggregate Health Savings Account contributions for a year to equal the maximum on the sum of the annual deductible and out-of-pocket expenses permitted under a high deductible health plan. Thus, the basic limit will be at least $6,550 in the case of self-only coverage and $13,100 in the case of family coverage beginning in 2018.

(17) Allow Both Spouses To Make Catch-Up Contributions
This section would effectively allow both spouses to make catch-up contributions to one HSA beginning in 2018.

(18) Special Rule for Certain Medical Expenses Incurred Before Establishment of HSA
This section sets forth certain circumstances under which HSA withdrawals can be used to pay qualified medical expenses incurred before the HSA was established. Starting in 2018, if an HSA is established during the 60-day period beginning on the date that an individual’s coverage under a high deductible health plan begins, then the HSA is treated as having been established on the date coverage under the high deductible health plan begins for purposes of determining if an expense incurred is a qualified medical expense.

Other Provisions
*Repeal of ACA’s 10% indoor Tanning Tax, beginning 2018.

*Repeal Of ACA’s Net Investment Tax
This section repeals the ACA’s 3.8% net investment tax on individuals, estates, and trusts with incomes above certain amounts, starting in 2018.

*Remuneration From Certain Insurers – While this marks a return to free capitalism, it is also a gift to the insurers who appear to be driving all health care “reform.”
Generally, employers may deduct the remuneration paid to employees as “ordinary and necessary” business expenses. The ACA added a limitation for certain health insurance providers that exceeds $500,000 paid to an officer, director, or employee. This section repeals the limit on the deduction of a covered health insurance provider for compensation attributable to services performed by an applicable individual starting in 2018.

*Repeal of Tax on Prescription Medications
This section repeals the ACA’s annual fee (tax) on brand pharmaceutical manufacturers such that the tax would not apply for years beginning after December 31, 2017.

*Repeal Of Health Insurance Tax
This section repeals the ACA’s annual fee (tax) on health insurers beginning after December 31, 2017.

Full text: http://www.foxnews.com/politics/interactive/2017/03/06/text-american-health-care-act/

 

Other ACA “Replacements”:

On January 23, 2017, S. 191, the Patient Freedom Act of 2017,(73 pages) was introduced by Sen. Bill Cassidy, MD (R-LA) and referred to the Senate Finance Committee. The legislation aims to shift the question of repeal to states by allowing them to continue to use the ACA as is or move to state-specific plans that rely on health savings accounts and decreased financial support from the federal government.

The bill eliminated from the ACA:
(1) the individual mandate, the employer mandate
(2) mandated benefit packages

The bill maintains the ACA’s:
(1) rules allowing children to stay on their parents’ health insurance plans until age 26
(2) preventing denial of coverage based upon pre-existing conditions
(3) prohibiting both annual and lifetime limits by health insurance companies.

Each state would have one of three choices:
(1) re-adopt the ACA on a state level,
(2) create a new state-designed plan with federal assistance but less money than the ACA provided, or
(3) create a new state-designed plan with no federal assistance at all.

An article in The Federalist, “4 Ways the Patient Freedom Act Is Worse Than Obamacare,” notes that the bill would expand taxpayer funding for abortions (by providing federal funding for states as a workaround to the ban on federally funding abortions), could increase total federal expenditures by increasing Medicaid funding even for states choosing not to expand the program, perpetuates government-mandated price controls, and creates a “big government” automatic enrollment program.

Full text: https://www.govtrack.us/congress/bills/115/s191/text.

 

On January 24, 2017, S. 222, the Obamacare Replacement Act (149 pages) was introduced by Sen. Rand Paul, MD (R-KY) and referred to the Senate Finance Committee. While the American Health Care Act is what is on the table, Rand Paul is fighting for his proposals. The basis for his proposals are personal freedom saving money for individuals and the federal government. But it does not repeal the ACA, leaves many taxes in place, and
The bill eliminates many of the parts of the ACA:
(1) the employer mandate, the individual mandate, Medicaid expansion.
(2) most of federal regulations that mandate what health plans are required to cover, mandatory birth control coverage, community rating.
(3) ban on insurer discrimination on the basis of a patient’s preexisting condition. Sen. Paul’s bill returns to pre-ACA rules from HIPAA which provides that individuals cannot be denied eligibility or benefits based on certain “health factors” when enrolling in a health plan. Additionally, they may not be charged more than similarly situated individuals based on any health factors.
The bill adds new provisions which would:
(3) allow insurance to be sold across state lines
(4) encourages health savings accounts (HSAs) by providing a tax credit of up to $5,000 (vs the current $3,400 per individual).
(5)provide uncapped deduction for individual-provided health insurance.
(5) provide refundable tax credit for health insurance premiums, but the refundable portion of the credit only applies up to the limit of an individual’s payroll taxes paid.
(6) allow the IRS to give doctors a tax deduction equal to the amount they would otherwise charge for charity care, up to 10 percent of a doctor’s income for the year.

Full text: https://www.govtrack.us/congress/bills/115/s222/text.

 

Repeal the IPAB
On February 1, 2017, S. 260, the Protecting Seniors’ Access to Medicare Act of 2017, was introduced by Sen. John Cornyn (R-TX) and referred to the Senate Finance Committee. This bill repeals the Independent Payment Advisory Board (IPAB) and any provision of law amended by such sections is hereby restored as if such sections had not been enacted into law.
Full text: https://www.govtrack.us/congress/bills/115/s260/text.

On February 1, 2017, S. 251, the Protecting Medicare from Executive Action Act of 2017, was introduced by Sen. Ron Wyden (D-OR) and referred to the Senate Finance Committee. The bill repeals section 3403 of the Affordable Care Act – the IPAB – and any provision of law amended by such sections is hereby restored as if such sections had not been enacted into law.

Full text: https://www.govtrack.us/congress/bills/115/s251/text.

 

Repeal of Other Tax-Related ACA Provisions
On February 14, 2017, H.R. 1051, the Halt Tax Increases on the Middle Class and Seniors Act, was introduced by Rep. Martha McSally (R-AZ) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to roll back the increased income threshold for determining the amount of the tax deduction for medical expenses. Currently, individual taxpayers may only deduct those medical expenses that exceed 10% of their adjusted gross income. This bill reduces that percentage to 7.5%.

Full text: https://www.govtrack.us/congress/bills/115/hr1051/text.

On February 16, 2017, H.R. 1150, Tanning Tax Repeal Act of 2017, was introduced by Rep. George Holding (R-NC) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to repeal the 10% excise tax on indoor tanning services.

Full text: https://www.govtrack.us/congress/bills/115/hr1150/text.

On February 17, 2017, H.R. 1204, the Responsible Additions and Increases to Sustain Employee Health Benefits Act of 2017, was introduced by Rep, Steve Stivers (R-OH) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code, with respect to the tax exclusion for distributions from health flexible spending arrangements provided under a cafeteria plan, to: (1) increase the annual limit on employee salary reduction contributions to $5,000, with an additional $500 for each additional employee dependent above two dependents that has not been taken into account by another person for the year; (2) revise the adjustment for inflation after 2017; and (3) allow a carryforward into the next year for unused amounts in such plans.

Full text: https://www.govtrack.us/congress/bills/115/hr1204/text.

 

Expansion of Religious Exemptions
On February 17, 2017, H.R. 1201, the Equitable Access to Care and Health Act (EACH Act), was introduced by Rep. Rodney Davis (R-IL) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to expand the religious conscience exemption under the Patient Protection and Affordable Care Act to exempt individuals who rely solely on a religious method of healing and for whom the acceptance of medical health services would be inconsistent with their religious beliefs from the requirement to purchase and maintain minimum essential health care coverage.

Full text: https://www.govtrack.us/congress/bills/115/hr1201/text.

 

Physician Practice Issues

On February 2, 2017, S. 284, the End Surprise Billing Act of 2017, was introduced by Sen. Sherrod Brown (D-OH) and referred to the Senate Finance Committee. Its sister bill, H.R. 817, introduced by Rep. Lloyd Doggett (D-TX). This bill amends the Medicare law to require a critical access hospital or other hospital to comply, as a condition of participation in Medicare, with certain requirements related to billing for out-of-network services. The justification for the bill is that the ACA does not limit what emergency-care providers may balance bill patients beyond the amounts that health plans allow. To fully protect patients, federal law should prohibit any balance billing by providers for emergency services, also including ambulance services. In addition, a comprehensive solution should cover the totality of a patient’s treatment after coming to the emergency room, including any care during an ensuing hospital admission (either at the same or a transfer hospital). This requirement could be imposed, similar to EMTALA, as a condition of providers participating in Medicare.

With respect to an individual who has health benefits coverage and is seeking services, a hospital must provide notice to individuals with any type of health insurance as to:
(1) whether the hospital, or any of the providers furnishing services to the individual at the hospital, is not within the health care provider network or otherwise a participating provider with respect to the individual’s health care coverage; and
(2) if so, the estimated out-of-pocket costs of the services to the individual.
At least 24 hours prior to providing those services, the hospital must document that the individual: (1) has been provided with the required notice, and (2) consents to be furnished with the services and charged an amount approximate to the estimate provided. Otherwise, the hospital may not charge the individual more than the individual would have been required to pay if the services had been furnished by an in-network or participating provider.
With respect to such an individual who is seeking same-day emergency services, a hospital may not charge more than the individual would be required to pay for such services furnished by an in-network or participating provider.

Full text (Senate): https://www.govtrack.us/congress/bills/115/s284/text.
Full text (House): https://www.govtrack.us/congress/bills/115/hr817/text.

Medical Education
On February 16, 2017, H.R. 1167, Enhancing Opportunities for Medical Doctors Act of 2017 was introduced by Rep. Mia Love and referred to the House Energy and Commerce and Ways and Means Committees. The bill would amend the Medicare law to redistribute unused residency positions for which graduate medical education costs are paid under Medicare. Specifically, the Centers for Medicare & Medicaid Services must: (1) reduce a hospital’s resident limit by a specified amount if the hospital has unused residency positions and is not a rural hospital with fewer than 250 acute care inpatient beds, and (2) increase the resident limit for each qualifying hospital that applies for an increase. In aggregate, the number of increased positions shall equal the number of reduced positions.

Full text: https://www.govtrack.us/congress/bills/115/hr1167/text.

Use of Unapproved Medical Products by Patients with a Terminal Illness
On January 24, 2017, S. 204, the Trickett Wendler Right to Try Act of 2017, was introduced by Sen. Ron Johnson (R-WI) and referred to the Senate Health, Education, Labor, and Pensions Committee. This bill requires the federal government to allow unrestricted manufacturing, distribution, prescribing, and dispensing of experimental drugs, biological products, and medical devices that are: (1) intended to treat a patient who has been diagnosed with a terminal illness, and (2) authorized by state law. The federal government must allow unrestricted possession and use of such treatments by patients certified by a physician as having exhausted all other treatment options.
A manufacturer, distributor, prescriber, dispenser, possessor, or user of such a treatment has no liability regarding the treatment.

The outcome of manufacture, distribution, prescribing, dispensing, possession, or use of such a treatment may not be used by a federal agency to adversely impact review or approval of the treatment.

The treatment must: (1) have successfully completed a phase 1 (initial, small scale) clinical trial; (2) remain under investigation in a clinical trial approved by the Food and Drug Administration; and (3) not be approved, licensed, or cleared for sale under the Federal Food, Drug, or Cosmetic Act or the Public Health Service Act.

Full text: https://www.govtrack.us/congress/bills/115/s204/text.

Expansion of duties of Mid-levels
On February 16, 2017, H.R. 1155 was introduced by Rep. Lynn Jenkins (R-KS) ad referred to the House Energy and Commerce and on Ways and Means Committees. The bill would amend the Medicare law to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary rehabilitation programs.

Full text: https://www.govtrack.us/congress/bills/115/hr1155/text.

Will Physicians Be On the List?
On February 15, 2017, H.J. Res. 42, introduced by Kevin Brady (R-TX), passed the House (236 – 189). The resolution disapproves and nullifies the rule issued by the Department of Labor on August 1, 2016, defining the occupations eligible for drug testing of unemployment compensation applicants. “Occupations” listed by the Department that may regularly require drug testing are only jobs that require carrying a firearm, aviation flight crews, air traffic controllers, commercial drivers, railroad crews, pipeline crew members, and commercial maritime crew members. This list is considered too narrow and the rule generally considered too prescriptive and overly constraining of states.
Full text: https://www.govtrack.us/congress/bills/115/hjres42/text.

On February 16, 2017, S.J. Res. 23, a joint resolution disapproving the rule submitted by the Department of Labor relating to drug testing of unemployment compensation applications, was introduced by Sen. Ted Cruz (R-TX) and referred to the Senate Committee on Finance Committee.

Full text: https://www.govtrack.us/congress/bills/115/sjres23/text.

 

Abortion-Related Bills

On January 30, 2017, S. 241, the Protect Funding for Women’s Health Care Act, was introduced by Sen. Joni Ernst (R-IA) and referred to the Senate Health, Education, Labor, and Pensions Committee. This bill prohibits federal funding of Planned Parenthood Federation of America or its affiliates, subsidiaries, successors, or clinics.

Full text: https://www.govtrack.us/congress/bills/115/s241/text.

On January 31, 2017, H.R. 771, the Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act of 2017, was introduced by Rep. Barbara Lee (D-CA) and referred to House Energy and Commerce and Oversight and Government Reform Committees. This bill is in response to H.R. 7, the No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act passed by the House in February 2017. That bill made permanent the ban of federal funding for abortions as set forth in the Hyde Amendment which Congress has passed every year since 1976.

This bill, H.R. 771, requires the federal government: (1) to ensure coverage for abortion care in public health insurance programs including Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP); (2) as an employer or health plan sponsor, to ensure coverage for abortion care for participants and beneficiaries; and (3) as a provider of health services, to ensure that abortion care is made available to individuals who are eligible to receive services.
The federal government may not prohibit, restrict, or otherwise inhibit insurance coverage of abortion care by state or local governments or by private health plans. State and local governments may not prohibit, restrict, or otherwise inhibit insurance coverage of abortion care by private health plans.

Full text: https://www.govtrack.us/congress/bills/115/hr771/text.

Doctors, Medical Ethics, Medicine, Op-eds, Politics

The Oath of Hypocrisy—and the Politicians’ “Disease”

No Comments

By Marilyn M. Singleton, MD, JD

As I physician, I proudly recited and adhere to the Oath of Hippocrates, which commands physicians to “use treatment to help the sick according to [their] ability and judgment … and [to] abstain from all intentional wrong-doing and harm.” Physicians don’t all think alike—medically or politically—but when a patient’s health is at stake, we find a way to work together for the patient’s best interest.

In 2016 a bipartisan Congress passed the 21st Century Cures Act, ostensibly designed to speed up research and drug approvals. They should have legislated a cure for a highly contagious disease that infects politicians in staggering numbers: chronic, relapsing, terminal hypocritical churlishness (the “Disease”).

The current acrimonious and vitriolic hyper-partisan rhetoric is making our country sick.

When the Republicans did not support the Affordable Care Act they were heartless dunderheads who wanted to see women and children suffer. It was irrelevant that the law had serious flaws that have now fully manifested themselves. In a tit-for-tat fashion, the Democrats have made it clear that they will obstruct President Trump’s efforts irrespective of whether doing so harms the American citizenry. There is no question that the value of a two-party system is exposure to a spectrum of ideas and opinions. However, dissent for the purpose of partisan posturing must not blind our legislators to novel solutions in America’s best interest.

In honor of Black History Month, let’s look at the different responses to racial insensitivity. Joe Biden was rewarded with the vice-presidency for his ringing endorsement of Obama: “I mean, you got the first mainstream African-American who is articulate and bright and clean and a nice-looking guy.” Part of former Senate majority leader Harry Reid’s assessment of candidate Barack Obama’s chances to win the presidency was that he was “light-skinned” and had “no Negro dialect”? Was he censured? No. Did he have to resign? No.

At the 100th birthday party for Strom Thurmond, a 1948 (anti-integration) Dixiecrat presidential candidate, former Senate Republican leader Trent Lott praised him, saying South Carolina proudly voted for him. He was forced to resign his position. However, Democrats heaped praise upon Hillary Clinton’s “friend and mentor,” Robert Byrd who was unanimously elected the top officer in the local Ku Klux Klan unit. Bill Clinton dismissed the Klan membership, saying “he was only trying to get elected.” In December 1944, Byrd wrote to Senator Theodore G. Bilbo, “I shall never fight in the armed forces with a negro by my side … Rather I should die a thousand times… than to see this beloved land of ours become degraded by race mongrels.” Moreover, he launched a 14-hour filibuster and voted against the Civil Rights Act of 1964. (Republican Senator Everett Dirksen is credited with rallying enough senators to allow the bill’s passage.)

The Democrats tout themselves as the advocates for black people, but have allowed politics to trump exploring new ideas. Although the large majority of black parents support increased educational options, including traditional public, public charter, and opportunity scholarships to attend private schools, the Democrats thrashed Secretary of Education nominee Betsy DeVos for her support of school choice. Senator Cory Booker while Newark’s mayor promoted Ms. DeVos’s ideas on school choice to improve Newark’s failing schools. Stricken with the Disease, he conveniently had a change of heart.

In 2016, Senator Booker felt “blessed and honored to have partnered with Sen. Sessions” to pass legislation honoring those who participated in the 1965 Voting Rights March from Selma to Montgomery, Alabama, with the Congressional Gold Medal. But a year later, Booker chose to testify against Sessions’s nomination for Attorney General. Senator Tim Scott’s endorsement of Sessions netted him being called (among many other N-words) a “house negro” and “a big ‘Uncle Tom’ piece of fertilizer,” and “a black man who is racist.”

Senator Elizabeth Warren expressed her peace, love, and teamwork by tweeting, “If Jeff Sessions makes even the tiniest attempt to bring his racism, sexism & bigotry into the Justice Department, he’ll hear from all of us.” Senator Charles Schumer ungraciously said that Sessions’s confirmation “turned my stomach.” Kerry Kennedy of the Robert Kennedy Center for Human Rights said that the Senators who voted for Jeff Sessions absolutely were racists.

It is unsettling that “racist” has become the new synonym for a political foe, or simply someone with whom one disagrees. Derisive name-calling is an unprincipled substitute for honest discussion.

The apparent game plan to cut the new administration off at the knees may backfire. We don’t want to discover that their operation was a success, but the patient died.

Featured, Health Policy, Healthcare Reform, Law, Medicare, Medicine

Legislative Update February 6, 2017

No Comments

As we enter the second month of the 115th Congress, Marilyn Singleton, MD, JD is out with her review of the latest medical care related proposals on Capitol Hill, from full ACA repeal to Medicare for all and everything in between.

 

Full Repeal of the Affordable Care Act

On January 9, 2017, H.R. 370, a bill to repeal the patient Protection and Affordable Care Act and health care-related provisions in the Health Care and Education Reconciliation act of 2010, was introduced by Rep. Bill Flores (R-TX) and referred to the House Appropriations, House Committee on Education and the Workforce Committee, and 7 other committees. The bill would repeal the Patient Protection and Affordable Care Act and the health care provisions of the Health Care and Education Reconciliation Act of 2010. The repeal is effective on January 1, 2020. Provisions of law amended by the repealed provisions are restored.

The budgetary effects of this bill must not be entered on the PAYGO scorecards maintained by the Office of Management and Budget.

Full text: https://www.govtrack.us/congress/bills/115/hr370/text.

On January 12, 2017, S. 106, the ObamaCare Repeal Act, was introduced by Sen. Ted Cruz (R-TX) and referred to the Senate Finance Committee. The bill repeals the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 and restores provisions of law amended by those Acts, effective January 1, 2018.

Full text: https://www.govtrack.us/congress/bills/115/s106/text.

Some of the Latest “Replacement” Plans and News

We mentioned Sen. Rand Paul’s “ObamaCare Replacement Act” in our last update, and since then the full bill, S. 222, has been released. Read a summary here and the full text here.

Rep. Darrell Issa appears to be set to reintroduce his “Access to Insurance for All Americans Act.” It was know as H.R. 138 in the 114th Congress and would “offer Federal employee health benefits plans to individuals who are not Federal employees.”

Senators Cassidy and Collins are back with S. 191, the “Patient Freedom Act of 2017.” It would be a partial repeal tied to provisions that allow states to keep ACA on a state-by-state basis or fund state-based market-oriented reforms.

Amid the replacement plans there are reports that the GOP is shifting from “Repeal and Replace” to “Repair” as well as reminders that, “Yes, We Can Repeal Every Word of ObamaCare.”

Also there’s talk of extending the repeal time frame and discussion about how soon-to-be HHS head Dr. Tom Price “will have plenty of room to singlehandedly shift health care toward a free-market system… .”

Changes to the Affordable Care Act

There is much repetition in these bills. It seems everyone wants to get in on the ACA changes. What this telegraphs is that the ACA will likely not be repealed any time soon.

On January 10, 2017, H.R. 407, the Tax Free Health Insurance Act of 2017, was introduced by Rep. Steve King (R-IA) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to allow an individual taxpayer a deduction from gross income of insurance premiums paid for the health care coverage of the taxpayer and the taxpayer’s spouse and dependents. The bill makes the deduction available whether or not the taxpayer itemizes other deductions.

Full text: https://www.govtrack.us/congress/bills/115/hr407/text.

On January 12, 2017, H.R. 499, the No Exemption for Washington from Obamacare Act, was introduced by Rep. Ron DeSantis (R-FL) and referred to the House Energy and Commerce and House Administration Committees, and 2 other committees. The bill amends the Patient Protection and Affordable Care Act to extend the requirement for participation in a health insurance exchange to the President, Vice President, executive branch political appointees, and employees of congressional committees and leadership offices of Congress. Currently, this requirement applies to Members of Congress and their staff.

The government is prohibited from contributing to or subsidizing the health insurance coverage of officials and employees subject to this requirement

Full text: https://www.govtrack.us/congress/bills/115/hr499/text.

On January 13, 2017, H.R. 521, Protection from Insurance Exchange Monopolies Act, was introduced by Rep. Mark Amodei (R-NV) and referred to the House Ways and Means Committee. This one page bill would amend the Internal Revenue Code of 1986 to provide an exemption to the individual mandate to maintain health coverage for individuals residing in counties with fewer than two health insurance issuers offering plans on an Exchange.

Full text: https://www.govtrack.us/congress/bills/115/hr521/text.

On January 13, 2017, H.R. 537, Budget Process Accountability Act, was introduced by Rep. Andy Biggs (R-AZ) and referred to the House Energy and Commerce and House Administration Committees, and 2 other committees. The bill would amend the Internal Revenue Code to exempt individuals from the requirement to maintain minimum essential health care coverage if they reside in a county where fewer than two health insurers offer insurance on the health insurance exchange. This bill amends the Patient Protection and Affordable Care Act to extend the requirement for participation in a health insurance exchange to the President, Vice President, executive branch political appointees, and employees of congressional committees and leadership offices of Congress. Currently, this requirement applies to Members of Congress and their staff.

The government is prohibited from contributing to or subsidizing the health insurance coverage of officials and employees subject to this requirement

Full text: https://www.govtrack.us/congress/bills/115/hr537/text.

On January 13, 2017, H.R. 563, the Unaffordable Care Act, was introduced by Rep. Luke Messer (R-IN) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to exempt from the requirement to maintain minimum essential health coverage an individual who: (1) resides in a location with fewer than two qualified health plans offered through an exchange established under the Patient Protection and Affordable Care Act, or (2) was covered under minimum essential coverage for the last month of the preceding year and the premium is at least 125% percent of the premium for that month.

Full text: https://www.govtrack.us/congress/bills/115/hr563/text.

On January 24, 2017, H.R. 633, the Patient Fairness and Relief Act of 2017, was introduced by Rep. Gregg Harper (R-MS) and referred to the House Energy and Commerce and House Ways and Means Committees. The bill would authorize health insurance issuers to continue to sell health insurance coverage that was offered in the individual market before the enactment of the Affordable Care Act in satisfaction of the minimum essential health benefits.

Full text: https://www.govtrack.us/congress/bills/115/hr633/text.

On January 24, 2017, H.R. 661, the Employee Fairness and Relief Act of 2017, was introduced by Rep. Brett Guthrie (R-KY) and referred to the House Energy and Commerce and Ways and Means Committees. The bill would authorize health insurance issuers to sell previously available health insurance coverage in the small group market in satisfaction of the minimum essential health insurance coverage requirement.
Full text: https://www.govtrack.us/congress/bills/115/hr661/text.

On January 13, 2017, H.R. 562, Obamacare Regressive Tax Relief Act, was introduced by Rep. Luke Messer (R-IN) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code of 1986 to return the penalty to 1 percent of the excess of the taxpayer’s household income that is above the yearly tax filing requirement (gross income of at least $10, 350 (individuals), $20,700 (married filing jointly). Currently the law increased the penalty to 2.5 percent as of 2015.

Full text: https://www.govtrack.us/congress/bills/115/hr562/text.

On January 17, 2017, S. 147, the Obamacare Taxpayer Bailout Prevention Act, was introduced y Sen. Marco Rubio (R-FL) and referred to the Senate Health, Education, Labor, and Pensions Committee. The bill repeals the provision of the Patient Protection and Affordable Care Act that directs the Department of Health and Human Services to establish a program of risk corridors for 2014, 2015, and 2016 under which qualified health plans must participate in a payment adjustment system based on the ratio of a plan’s allowable costs to its premiums. (Qualified health plans are sold on health insurance exchanges, are the only plans eligible for premium subsidies, and fulfill an individual’s requirement to maintain minimum essential coverage.)

Full text: https://www.govtrack.us/congress/bills/115/s147/text.

On January 27, 2017, H.R. 710, the Health Coverage State Flexibility Act of 2017, was introduced by Rep. Bill Flores (R-TX) and referred to the House Ways and Means Committee. The bill amends the ACA to better align the grace period required for non-payment of premiums before discontinuing coverage with the grace periods provided for under State law.

Full text: https://www.govtrack.us/congress/bills/115/hr710/text.

Independent Payment Advisory Board (IPAB)
On February 1, 2017, S.J. Res. 16 regarding the Independent Medicare Advisory Board was introduced by Sen. Ron Wyden (D-OR) and referred to the Senate Finance Committee. The resolution approves the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899A of the Social Security Act.

The resolution also requests that Congress approves the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board.

Full text: https://www.govtrack.us/congress/bills/115/sjres16/text.

On February 1, 2017, S.J. Res. 17 regarding the Independent Medicare Advisory Board was introduced by Sen. John Cornyn (R-TX) ad referred to the Senate Finance Committee. (Exact wording as S.J. Res 16). The resolution approves the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899A of the Social Security Act.

The resolution also requests that Congress approves the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board.

Full text: https://www.govtrack.us/congress/bills/115/sjres17/text.

On January 31, 2017, H.J. Res 51 regarding the Independent Medicare Advisory Board was introduced by Rep. David Roe (R-TN) and referred to the House Energy and Commerce and Ways and Means Committees. Exact wording as S.J. Res 16). The resolution approves the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899A of the Social Security Act.

The resolution also requests that Congress approves the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board.

Full text: https://www.govtrack.us/congress/bills/115/hjres51/text.

Health Savings Accounts
On January 4, 2017, S. 28, the Health Savings Account Expansion Act of 2017, was reintroduced by Sen. Jeff Flake (R-AZ). The House companion bill, H.R. 247 was introduced by Rep. Dave Brat (R-VA). This bill amends the Internal Revenue Code to modify the requirements for health savings accounts (HSAs) to increase the maximum contribution amounts, permit the use of HSAs to pay health insurance premiums and direct primary care expenses, repeal the restriction on using HSAs for over-the-counter medications, eliminate the requirement that a participant in an HSA be enrolled in a high deductible health care plan, and decrease the additional tax for HSA distributions not used for qualified medical expenses.

Full text (Senate): https://www.govtrack.us/congress/bills/115/s28/text
Full text (House): https://www.govtrack.us/congress/bills/115/hr247/text

On January 10, 2017, S. 85, the Restoring Access to Medication Act of 2017, was introduced by Sen. Pat Roberts (R-KS) and referred to the Senate Finance Committee. The sister bill in the House, H.R. 394, was introduced on January 10th by Rep. Lynn Jenkins (R-KS) and referred to the House Ways and Means Committee. These bills would repeal provisions of the Internal Revenue Code, as added by the Patient Protection and Affordable Care Act, that limit payments for medications from health savings accounts, medical savings accounts, and health flexible spending arrangements to only prescription drugs or insulin (thus allowing distributions from such accounts for over-the-counter drugs).

Full text (Senate): https://www.govtrack.us/congress/bills/115/s85/text.
Full text (House): https://www.govtrack.us/congress/bills/115/hr394/text.

Contraception/Abortion-Related

On January 13, 2017, H.R. 7, the No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2017, was introduced by Rep. Christopher Smith (R-NJ). The bill passed in the House on January 24, 2017 and goes to the Senate next for consideration. Title I–Prohibiting Federally Funded Abortions (Sec. 101). This section makes permanent the prohibition on the use of federal funds, including funds in the budget of the District of Columbia, for abortion or health coverage that includes abortion. The prohibitions in this bill, and current prohibitions, do not apply to abortions in cases of rape or incest, or where a physical condition endangers a woman’s life unless an abortion is performed.

Abortions may not be provided in a federal health care facility or by a federal employee.

Title II–Application under the Affordable Care Act (Sec. 201). This section amends the Internal Revenue Code and the Patient Protection and Affordable Care Act to prohibit qualified health plans from including coverage for abortions. (Qualified health plans are sold on health insurance exchanges, are the only plans eligible for premium subsidies and small employer health insurance tax credits, and fulfill an individual’s requirement to maintain minimum essential coverage.) Currently, qualified health plans may cover abortion, but the portion of the premium attributable to abortion coverage is not eligible for subsidies.

Sec. 202 revises notification requirements for qualified health plans regarding abortion coverage and charges for abortion coverage.

In the 114th Congress, similar legislation (H.R.7) passed the House by a vote of 242-179.

Full text: https://www.govtrack.us/congress/bills/115/hr7/text.

On January 10, 2017, S. 93, Allowing Greater Access to Safe and Effective Contraception Act was introduced by Sen. Joni Ernst (R-IA) and referred to the Senate Finance Committee. The sister bill, H.R. 421 was introduced by Rep. Mia Love (R-UT) and referred to the House Energy and Commerce and Ways and Means Committees.

This bill requires the Food and Drug Administration (FDA) to prioritize review of supplemental drug applications (applications to modify the approved use of a drug) for contraceptive drugs intended for routine use that would be available to individuals aged 18 and older without a prescription. The FDA must waive user fees for such supplemental drug applications. Any drug that is eligible for this priority review must be a prescription drug for individuals under age 18.

This bill repeals provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 to allow health savings accounts and health flexible spending accounts (HFSAs) to be used to pay for medicine without a prescription and to remove the limit on salary reduction contributions to a HFSA under a cafeteria plan, effective as if the provisions had never been enacted.

Full text (Senate): https://www.govtrack.us/congress/bills/115/s93/text.
Full text (House): https://www.govtrack.us/congress/bills/115/hr421/text.

Medicaid
On January 6, 2017, H.R. 352, State Health Flexibility Act of 2017, was introduced by Rep Todd Rokita (R-IN) and referred to the House Appropriations, House Committee on Education and the Workforce Committee, and 6 other committees. The bill amends the Social Security Act (SSAct) to replace federal requirements for Medicaid and the Children’s Health Insurance Program (CHIP) with health care block grants to states. A state may use block grant funds to: (1) provide health care services to indigent individuals; (2) fund risk adjustment mechanisms for the purpose of subsidizing the cost of private health insurance for the high-risk population; and (3) support other welfare-related programs, as specified by the bill.

In addition to repealing titles XIX (Medicaid) and XXI (CHIP) of the SSAct, the bill repeals: (1) the Patient Protection and Affordable Care Act, and (2) the Health Care and Educational Reconciliation Act of 2010.

With respect to an alien not lawfully admitted for permanent residence in the United States, a state may use grant funds to provide only emergency health care services, as specified by the bill.
The bill limits the authority of any federal agency to supervise a state’s use of funds received under the block grant program.

Full text: https://www.govtrack.us/congress/bills/115/hr352/text.

Changes to Medicare
On January 5, 2017, S. 41, Medicare Prescription Drug Price Negotiation Act of 2017, was introduced by Sen. Amy Klobuchar (D-MN) and referred to the Senate Finance Committee. This bill amends title XVIII (Medicare) of the Social Security Act to require the Centers for Medicare & Medicaid Services (CMS) to negotiate with pharmaceutical companies regarding prices for drugs covered under the Medicare prescription drug benefit. Current law prohibits CMS from doing so.

Full text: https://www.govtrack.us/congress/bills/115/s41/text.

On January 10, 2017, H.R. 409, the Putting Patients and Providers Ahead of Compressed Regulatory Timelines Act of 2017, was introduced by Rep. Steve King (R-IA) and referred to the House Energy and Commerce and Ways and Means Committees. The bill would amend title XVIII (Medicare) of the Social Security Act to eliminate provider penalties for failure to comply with electronic health records (EHR) use requirements.

Under current law, certain hospitals, Medicare Advantage organizations, and professionals participating in Medicare are subject to negative payment adjustments if they fail to comply with established requirements for EHR use. The bill eliminates these penalties and requires the Centers for Medicare & Medicaid Services to reimburse such providers for payments that they would have received within a specified timeframe had such penalties not been applied.

Full text: https://www.govtrack.us/congress/bills/115/hr409/text.

On January 10, 2017, H.R. 410, Protecting Life Until Natural Death Act, was introduced by Rep. Steve King (R-IA) and referred to the House Energy and Commerce and House Committee on Ways and Means Committees. The bill amends title XVIII (Medicare) of the Social Security Act to exclude from Medicare coverage advanced planning services, with the exception of certain hospice-related services that may include advising on end-of-life or advanced care planning.

Full text: https://www.govtrack.us/congress/bills/115/hr410/text.

On January 12, 2017, H.R. 508, Seniors Have Eyes, Ears, and Teeth Act of 2017, was introduced by Rep. Lucille Roybal-Allard (D-CA) and referred to the House Energy and Commerce and Ways and Means Committees. The bill amends title XVIII (Medicare) of the Social Security Act to expand Medicare coverage to include eyeglasses, hearing aids, and dental care.

Full text: https://www.govtrack.us/congress/bills/115/hr508/text.

On January 27, 2017, H.R. 707, the Health Care Choices for Seniors Act, was introduced by Rep. Marsha Blackburn (R-TN) and referred to the House Energy and Commerce and House Ways and Means Committees. The bill amends title II (Old Age, Survivors, and Disability Insurance) (OASDI) of the Social Security Act to require the Department of Health and Human Services (HHS) to establish the Medicare Alternative Voucher (MAV) Program, under which a voucher may be used as a contribution into a health savings account and for the payment of enrollment premiums under a high-deductible health plan. HHS must establish a procedure under which an individual otherwise entitled to Medicare benefits may waive such entitlement and be automatically enrolled in the MAV Program.

Additionally, the bill amends the Internal Revenue Code to increase the amount of the deduction from gross income for health savings accounts by the amount of the MAV that is contributed to an individual’s health savings account.

The bill also suspends Medicare late enrollment penalties for an individual between ages 65 and 70.

Full text: https://www.govtrack.us/congress/bills/115/hr707/text.

Medicare for All!?
On January 24, 2017, H.R. 676, the Expanded and Improved Medicare for All Act, was reintroduced by Rep. John Conyers (D-MI) and referred to the House Energy and Commerce and Natural Resources Committees. Conyers has introduced this bill in every session of Congress since 2003.

This bill aims to establish the Medicare for All Program to provide all individuals residing in the United States and U.S. territories with “free” health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.

Only public or nonprofit institutions may participate. Nonprofit health maintenance organizations (HMOs) that deliver care in their own facilities may participate. Patients may choose from participating physicians and institutions.

Health insurers may not sell health insurance that duplicates the benefits provided under this bill. Insurers may sell benefits that are not medically necessary, such as cosmetic surgery benefits.

The bill sets forth methods to pay institutional providers and health professionals for services. Financial incentives between HMOs and physicians based on utilization are prohibited.

The program is funded: (1) from existing sources of government revenues for health care, (2) by increasing personal income taxes on the top 5% of income earners, (3) by instituting a progressive excise tax on payroll and self-employment income, (4) by instituting a tax on unearned income, and (5) by instituting a tax on stock and bond transactions. Amounts that would have been appropriated for federal public health care programs, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), are transferred and appropriated to carry out this bill.

The program must give employment transition benefits and first priority in retraining and job placement to individuals whose jobs are eliminated due to reduced clerical and administrative work under this bill.

The Department of Health and Human Services must create a confidential electronic patient record system.

The bill establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability. The Indian Health Service must be integrated into the program after five years. Congress must evaluate the continued independence of Department of Veterans Affairs health programs.

Full text: https://www.govtrack.us/congress/bills/115/hr676/text.

Health Policy, Healthcare Reform

Legislative Update: January 17, 2017

1 Comment

Marilyn Singleton, MD, JD is back with her first legislative update for the 115th Congress. 

The 115th United States Congress has convened with the introduction of numerous health care bills. Most bills we looked at last year have “died in a previous Congress.” Bills are not carried forward from Congress to Congress. They have two years to make it into law.

Senate Sets Stage for Reconciliation Bill: First Step in Repealing ACA

On January 12, 2017, the Senate voted 51-48 along party lines (with a lone Republican “NAY” by Rand Paul) for the resolution – S.Con.Res. 3 –  that will start the reconciliation process. The House followed with its approval in a 227-198 vote on January 13. Reconciliation allows for expedited consideration of certain tax, spending, and debt limit legislation. A reconciliation measure cannot be filibustered and the Senate can pass such a bill with a simple majority. This is the same procedure used to pass the ACA. Under the resolution, the House and Senate committees must come up with repeal legislation by January 27th.  Under this process, however, only certain taxing/spending-related provisions of the ACA would be repealed, but would not repeal the entire law. For example, pre-existing condition mandates for insurers would remain.

Additionally, House Speaker Paul Ryan said he would like a “concurrent” replace and repeal.

 

Another Step Toward Interstate Licensure

Jan 9, 2017, H.R. 302, the Sports Medicine Licensure Clarity Act of 2017, was introduced by Brett Guthrie (R-KY). This was a re-introduction of the same 2016 bill. On January 9, 2017, the bill passed the House and was referred to Senate Committee on January 10th. The bill protects sports medicine professionals to who have malpractice insurance and provide services to an athlete in a Secondary State pursuant to a contract, the insurance shall cover the professional. If the professional is licensed in the Primary State, they are presumed to have satisfied licensure requirements for licensure in the Secondary State (where services were rendered). This bill’s language is another step in opening the door for interstate licensure.

Full text: https://www.govtrack.us/congress/bills/115/hr302/text.

 

Just What We Don’t Need: Another Commission

On January 5, H.R. 309, the National Clinical Care Commission Act, was introduced by Rep. Pete Olsen (R-TX).  On January 9, 2017, the House passed the bill.  This bill amends the Public Health Service Act to establish within the Department of Health and Human Services (HHS) a National Clinical Care Commission to evaluate and recommend solutions regarding better coordination and leveraging of federal programs that relate to supporting clinical care for individuals with complex metabolic or autoimmune disease, diabetes, or complications caused by such diseases.

The duties of the commission include: evaluating HHS programs regarding the utilization of preventive health benefits, identifying current activities and gaps in federal efforts to support clinicians in providing integrated care, making recommendations regarding the development and coordination of federally funded clinical practice support tools, recommending clinical pathways for new technologies and treatments, evaluating and expanding education and awareness activities provided to health care professionals, and reviewing and recommending methods for outreach and dissemination of educational resources. The commission must submit an operating plan to HHS and Congress within 90 days of its first meeting. The commission is terminated after it submits a final report, but not later than the end of FY2021.

Full text: https://www.govtrack.us/congress/bills/115/hr309/text.

 

On Jan 9, 2017, H.R. 315, the Improving Access to Maternity Care Act, was introduced by Rep. Michael Burgess (R-TX). On January 9, 2017, the bill passed the House and was referred to Senate Committee on January 10th. This bill amends the Public Health Service Act to require the Health Resources and Services Administration (HRSA) to identify areas within health professional shortage areas that have a shortage of maternity care health professionals, for purposes of assigning maternity care health professionals to those areas.

Full text: https://www.govtrack.us/congress/bills/115/hr315/text.

 

A Batch of Health Care Related Bills: Awaiting the Text

Ted Cruz introduced a bill to repeal the ACA in its entirety. This may end up being the only relevant bill. Multiple bills were introduced that chipped away at the Affordable Care Act. These may be posturing for the congressperson’s constituency or they honestly believe the ACA will not be repealed.  Rand Paul has tweeted out the first page of “THE Obamacare Replacement Plan,” which he says will be released in full soon.  He shared some details in an interview with CNN.

Senate:

On January 4, 2017, S. 28, the Health Savings Account Expansion Act of 2017 was reintroduced by Sen. Jeff Flake. It is a bill “to amend the Internal Revenue Code of 1986 to expand the permissible use of health savings accounts to include health insurance payments and to increase the dollar limitation for contributions to health savings accounts, and for other purposes.”  The House companion bill is H.R. 247, introduced by Rep. Dave Brat.

On January 5, 2017, S. 41, A bill to amend part D of title XVIII of the Social Security Act to require the Secretary of Health and Human Services to negotiate covered part D drug prices on behalf of Medicare beneficiaries was introduced by Sen. Amy Klobuchar (D-MN) and referred to the Senate Finance Committee.

On January 10, 2017, S. 85, a bill to amend the Internal Revenue Code of 1986 to repeal the amendments made by the Patient Protection and Affordable Care Act which disqualify expenses for over-the-counter drubs under health savings accounts and health flexible spending arrangements was introduced by Sen. Pat Roberts (R-KS) and referred to the Senate Finance Committee. The sister bill in the House, H.R. 394, was introduced on January 10th by Rep. Lynn Jenkins (R-KS) and referred to the House Ways and Means Committee.

On January 10, 2017, S. 93, a bill to allow women greater access to safe and effective contraception was introduced by Sen. Joni Ernst (R-IA) and referred to the Senate Finance Committee. The sister bill, H. R. 421 was introduced by Rep. Mia Love (R-UT) and referred to the House Energy and Commerce and Ways and Means Committees.

On January 12, 2017, S. 106, a bill to repeal the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 in its entirety was introduced by Sen. Ted Cruz (R-TX) and referred to the Senate Finance Committee.

On January 12, 2017, S. 109, a bill to amend title XVIII of the Social Security Act to provide for coverage under the Medicare program for pharmacist services was introduced by Sen. Charles Grassley (R-IA) and referred to the Senate Finance Committee.

House:

On January 6, 2017, H.R. 352, a bill to amend the Social Security Act to replace the Medicaid program and the Children’s Health Insurance program with a block grant to the States was introduced by Rep Todd Rokita (R-IN) and referred to the House Appropriations, House Committee on Education and the Workforce Committee, and 6 other committees.

On January 9, 2017, H.R. 370, a bill to repeal the patient Protection and Affordable Care Act and health care-related provisions in the Health Care and Education Reconciliation act of 2010, was introduced by Rep. Bill Flores (R-TX) and referred to the House Appropriations, House Committee on Education and the Workforce Committee, and 7 other committees.

On January 10, 2017, H.R. 407, a bill to amend the Internal Revenue Code of 1986 to allow a deduction for premiums for insurance which constitutes medical care, was introduced by Rep. Steve King (R-IA) and referred to the House Ways and Means Committee.

On January 10, 2017, H.R. 408, a bill to amend the Internal Revenue Code of 1986 to expand health savings accounts was introduced by Rep. Steve King (R-IA) and referred to the House Ways and Means Committee.

On January 10, 2017, H.R. 409, a bill to amend title XVIII of the Social Security Act to sunset certain penalties relating to meaningful electronic health records use by Medicare eligible professionals and hospitals was introduced by Rep. Steve King (R-IA) and referred to the House Energy and Commerce and Ways and Means Committees.

On January 10, 2017, H.R. 410, a bill to amend title XVIII of the Social Security Act to exclude coverage of advance care planning services under the Medicare program was introduced by Rep. Steve King (R-IA) and referred to the House Energy and Commerce and House Committee on Ways and Means Committees.

On January 12, 2017, H.R. 499, a bill to require members of Congress and congressional staff to abide by the Patient Protection and Affordable Care Act with respect to health insurance coverage was introduced by Rep. Ron DeSantis (R-FL) and referred to the House Energy and Commerce and House Administration Committees, and 2 other committees.

On January 12, 2017, H.R. 508, a bill to expand Medicare coverage to include eyeglasses, hearing aids, and dental care was introduced by Rep. Lucille Roybal-Allard (D-CA) and referred to the House Energy and Commerce and Ways and Means Committees.

On January 13, 2017, H.R. 521, a bill to amend the Internal Revenue Code of 1986 to provide an exemption to the individual mandate to maintain health coverage for individuals residing in counties with fewer than two health insurance issuers offering plans on an Exchange was introduced by Rep. Mark Amodei (R-NV) and referred to the House Ways and Means Committee.

On January 13, 2017, H.R. 537, a bill to amend the Internal Revenue Code of 1986 to provide an exemption to the individual mandate to maintain health coverage for individuals residing in counties with fewer than two health insurance issuers offering plans on an Exchange; to require members of Congress and congressional staff to abide by the Patient Protection and Affordable Care Act with respect to health insurance coverage was introduced by Rep. Andy Biggs (R-AZ) and referred to the House Energy and Commerce and House Administration Committees, and 2 other committees.

On January 13, 2017, H.R. 562, a bill to amend the Internal Revenue Code of 1986 to flatline the individual mandate penalty was introduced by Rep. Luke Messer (R-IN) and referred to the House Ways and Means Committee.

On January 13, 2017, H.R. 563, a bill to amend the Internal Revenue Code of 1986 to exempt certain individuals from the individual health insurance mandate was introduced by Rep. Luke Messer (R-IN) and referred to the House Ways and Means Committee.

 

Only My Opinion

There a bill from the last Congress that I am glad is dead. Sen. Ron Wyden (D-OR) introduced Senate Resolution 590, a resolution commemorating 100 years of health care services provided by Planned Parenthood, “affirm[ing] that Planned Parenthood remains an essential thread in the fabric of society.” My objection is that Planned Parenthood’s founder, Margaret Sanger is quite controversial. She supported eugenics, noting, “Eugenics suggests the reestablishment of the balance between the fertility of the “fit” and the “unfit.” In The Pivot of Civilization (1922) she referred to immigrants and poor people as “reckless breeders,” “spawning…human beings who never should have been born.”  No matter what one’s views on today’s Planned Parenthood or abortion are, Planned Parenthood’s advocates should include a denunciation of its founder’s extreme views alongside its praise for the present-day organization.

Doctors, Health Policy, Healthcare Reform, Medicine

The Surprise in California’s Medical Bill Law

No Comments

by Marilyn M. Singleton, M.D., J.D.

These days, in order to keep costs down the vast majority of insurance plans use the model that limits the hospitals or physicians from whom patients can get medical services. The “covered services” are determined by the insurer. The plans involve contracts between the insurer and the patient, and the insurer and the “health care providers.” The parties agree upon and know in advance who must pay for medical care—with the amount to be determined by the insurer.

The insurer develops its “provider network” by negotiating discounted prices with hospitals, laboratories, radiology facilities, and physicians. The value to the service providers and physicians is that in exchange for reduced fees, they might have an increased volume of patients.

On the patient’s end, the incentive for using the network personnel is the “discounted” price. After receiving in-network medical treatment, the patient expects to pay out of pocket any co-payment or co-insurance fee, and any deductible that the plan requires. If the patient uses out-of-network services, the insurer generally imposes higher cost sharing. Also, the out-of-network provider can bill the patient the difference between the customary or “market” rate and the in-network contracted rate for the same service or procedure (“balance billing”).

One downside to the networks is that patients may not have access to the care they need because some hospitals lack sufficient in-network hospital-based specialists. Because hospitals fill the gaps with out-of-network physicians, a patient could unknowingly receive care from an out-of-network physician or service at an in-network facility.

No one—particularly your physician—wants to see patients suffer financially. California’s newly-minted solution to “surprise medical bills” is Assembly Bill 72. Under this law, if a plan’s patient obtains medical care at an in-network facility but receives treatment or services from a non-contracted out-of-network provider, the patient would only pay for such services as if they were in-network. (This is already the case for some emergency services.)

Problem solved—no surprise bill.

It’s also no surprise that yet again insurers get the brass ring. Insurers can pay the non-contracted out-of-network physician the same amount they pay the physician on contract with the insurer. And if the doctors don’t like the payment, they can go to arbitration at their expense to seek their usual fee. It is a remedy in name only as the legal costs would outweigh any benefit.

Note: AAPS has filed suit to stop AB 72. Details at http://StopAB72.com

Dr. Singleton is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) Board member. She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law.  She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.

Health Policy, Healthcare Reform, Law, Politics

They’re Baaack! Legislative Update – October 7, 2016

No Comments

Marilyn Singleton, MD, JD summarizes recent healthcare-related legislative activity on Capitol Hill.

It was a slow summer as our Congresspersons took their highly coveted 7-week vacation.

Even as premiums skyrocket and ACA co-ops fail, health care reform has been below the fold during much of this presidential campaign.

Thanks to Bill Clinton, the ACA is gaining the attention it deserves. The former president while shilling for his wife in Flint, Michigan, called Obamacare “the craziest thing in the world.”  He said, “you’ve got this crazy system where all of a sudden 25 million more people have health care and then the people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half.”

He continued, “on the other hand, the current system works fine if you’re eligible for Medicaid, if you’re a lower-income working person; if you’re already on Medicare, or if you get enough subsidies on a modest income that you can afford your health care. . . But the people that are getting killed in this deal are small business people and individuals who make just a little too much to get any of these subsidies.”

For example, the largest approved premium hikes on individual market plans for 2017 are: (1) Tennessee, Blue Cross, Blue Shield, 62%; (2) Kentucky, Golden Rule Insurance Co., 47%; (3) Iowa, Wellmark, 42%; (4) Nebraska, Medica, 39%; (5) Maryland, CareFirst, Blue Cross, Blue Shield, 31%.

 

More Fixes to the ACA

The CO-OP Consumer Protection Act, H.R. 954 which was introduced by Rep. Adrian Smith (R-NE) in February 2016, passed the House on September 22nd. The legislation was in response to the fact that only 6 of the 23 ACA Co-ops have not failed. This bill temporarily exempts from penalties for failing to purchase and maintain minimum essential health care coverage (i.e., individual mandate penalty) individuals whose coverage under a plan offered by a qualified nonprofit health insurance issuer receiving funds through the Consumer Operated and Oriented Plan program was terminated or otherwise discontinued.

Full text: https://www.govtrack.us/congress/bills/114/hr954/text.

 

On September 13, 2016, H.R. 6019, the Relief from Obamacare Mandate Act of 2016 was introduced by Rep. Todd Young (R-IN) and referred to the House Ways and Means Committee. The bill would to provide an exemption to the individual mandate to maintain health coverage for certain individuals whose premium has increased by more than 10 percent.

Full text: https://www.govtrack.us/congress/bills/114/hr6019/text.

 

On September 14, 2016, S. 3322 was introduced by Sen. Jeff Flake (R-AZ) and referred to the Senate Finance Committee. The bill would modify the ACA’s hardship exemption to the individual mandate to maintain health coverage for certain individuals residing in service areas with no health insurance issuers offering plans on an Exchange.

Full text: https://www.govtrack.us/congress/bills/114/s3322/text.

 

On September 15, 2016, H.R. 6049, the Protection from Insurance Exchange Monopolies Act was introduced by Rep. Joseph Heck (R-NV) and referred to the House Ways and Means Committee. This bill amends the Internal Revenue Code to exempt from the requirement to maintain minimum essential health coverage any individual residing in a county with fewer than two health insurance issuers offering qualified health plans on an exchange.

Full text: https://www.govtrack.us/congress/bills/114/hr6049/text.

 

On September 19, 2016, H.R. 6067, the Relief from Obamacare Exchange Failures Act was introduced by Rep. Diane Black (R-TN) and referred to the House Ways and Means Committee. The bill would amend the Internal Revenue Code to provide an exemption from the individual mandate for certain individuals without access to Exchange coverage.

Full text: https://www.govtrack.us/congress/bills/114/hr6067/text.

 

On July 6, 2016, H.R. 1270, the Restoring Access to Medication Act of 2015 was passed in the House and was sent to the Senate for consideration. This bill repeals provisions of the Internal Revenue Code, added by the Patient Protection and Affordable Care Act, that limit payments for medications from health savings accounts, medical savings accounts, and health flexible spending arrangements to only prescription drugs or insulin (thus allowing distributions from such accounts for over-the-counter drugs).

Full text: https://www.govtrack.us/congress/bills/114/hr1270/text.

 

On May 25, 2016, H.R. 5324, Health Savings Account Expansion Act of 2016 was introduced by Rep. Dave Brat (R-VA) and referred to the House Ways and Means Committee. This bill amends the Internal Revenue Code to modify the requirements for health savings accounts (HSAs) to:

increase the maximum contribution amounts, permit the use of HSAs to pay health insurance premiums and direct primary care expenses, repeal the ACA’s restriction on using HSAs for over-the-counter medications, eliminate the requirement that a participant in an HSA be enrolled in a high deductible health care plan, and decrease the additional tax for HSA distributions not used for qualified medical expenses.

Full text (House): https://www.govtrack.us/congress/bills/114/hr5324/text.
Full text (identical Senate): https://www.govtrack.us/congress/bills/114/s2980/text.

 

On Sep 15, 2016 Senate Resolution 561, a resolution supporting efforts to increase competition and accountability in the health insurance marketplace, and to extend accessible, quality, affordable health coverage to every American through the choice of a public option, was introduced by Sen. Jeff Merkley (D-OR) and referred to the Senate Health, Education, Labor, and Pensions Committee.

This resolution expresses support for efforts to build on the ACA by adding the public option. The resolution posits that the public option would (1) lead to increased competition and reduced premiums; (2) cut wasteful spending on administration, marketing, and executive pay; and (3) ensure that consumers have the affordable choices they deserve; and (4) save taxpayers billions of dollars according to the Congressional Budget Office.

Full text: https://www.govtrack.us/congress/bills/114/sres561/text

 

Tax Relief for Consumers

On Jun 29, 2016, S. 3111, the Seniors Tax Hike Prevention Act of 2016 was introduced by Sen. Rob Portman (R-OH) and referred to the Senate Finance Committee. This bill amends the Internal Revenue Code to extend through 2018, the rule that permits individuals who are 65 and older to deduct certain medical expenses that exceed 7.5% of adjusted gross income. (Under current law, the rule that reduces the 10% threshold for the medical expense deduction to 7.5% if a taxpayer or a taxpayer’s spouse is 65 or older expires at the end of 2016.)

Full text: https://www.govtrack.us/congress/bills/114/s3111/text.

 

Support for Direct Pay Practices

On September 13, 2016, H.R. 6015, the Primary Care Enhancement Act was introduced by Rep. Erik Paulson (R-MN) and referred to the House Ways and Means Committee. (Identical bill in Senate, S 1989). This bill amends the Internal Revenue Code to: (1) permit an individual to pay primary care service arrangement costs from a health savings account; (2) allow an eligible taxpayer enrolled in a high-deductible health plan to take a tax deduction for cash paid into a health savings account, even if the taxpayer is simultaneously enrolled in a primary care service arrangement; and (3) for purposes of certain tax-deductible expenses for medical care, expand the definition of “medical care” to include periodic provider fees and pre-paid services. A “primary care service arrangement” is an exchange of ongoing primary care services for a fixed periodic fee which is not billed to any third party on a fee-for-service basis.

The bill also amends title XI of the Social Security Act to require the Center for Medicare and Medicaid Innovation (CMI) to test a primary care medical home model for payment and service delivery. Under this type of model, qualified direct primary care medical home practices are reimbursed a periodic fee for serving Medicare enrollees. In selecting qualified direct primary care medical home practices to participate, CMI shall give priority to practices seeking to enroll dual-eligible individuals.

Full text House version: https://www.govtrack.us/congress/bills/114/hr6015/text.
Full text Senate version: https://www.govtrack.us/congress/bills/114/s1989/text.

 

Pro-Physician Volunteer Legislation

On June 27, 2016, S. 3101, the Good Samaritan Health Professionals Act of 2016 was introduced by Sen. Bill Cassidy (R-LA) and referred to the Senate Health, Education, Labor, and Pensions Committee. This bill amends the Public Health Service Act to shield a health care professional from liability under federal or state law for harm caused by any act or omission if: (1) the professional is serving as a volunteer in response to a disaster; and (2) the act or omission occurs during the period of the disaster, in the professional’s capacity as a volunteer, and in a good faith belief that the individual being treated is in need of health care services.

This protection from liability does not apply if: (1) the harm was caused by an act or omission constituting willful or criminal misconduct, gross negligence, reckless misconduct, or a conscious flagrant indifference to the rights or safety of the individual harmed; or (2) the professional rendered the health care services under the influence of alcohol or an intoxicating drug.

Full text: https://www.govtrack.us/congress/bills/114/s3101/text

 

More Control Over Physicians as Part of the Opiate Wars

On July 13, 2016, S. 3209, the Prescription Drug Monitoring Act of 2016 was introduced by Sen. Amy Klobuchar (D-MN) and referred to the Senate Health, Education, Labor, and Pensions Committee. The bill would require the use of prescription drug monitoring programs and to facilitate information sharing among States.

Full text: https://www.govtrack.us/congress/bills/114/s3209/text.

 

Legalized Physician Assisted Suicide Is On the March

Attempting to join Washington, Oregon, Vermont, Montana, California, on October 4, 2016, a Washington, D.C. city council panel voted 3-2 to advance a bill allowing physician-assisted suicide. One of the dissenters said she feared low-income people who have less access to health care would be pushed to end their lives early. Another felt this should be done through a ballot initiative to give voters their say.

 

And Why Do We Need Laws to Mandate Administrative Common Sense

On September 22, 2016, H.R. 5320, the Social Security Must Avert Identity Loss (MAIL) Act of 2016 passed the House by 414-0. This bill directs the Social Security Administration to ensure that no document it sends by mail includes a complete Social Security account number unless necessary.

Full text: https://www.govtrack.us/congress/bills/114/hr5320/text.

 

On July 14, 2016, H.R. 5880 was introduced by Rep. Cedric Richmond (D-LA) and referred to the House Ways and Means Committee. This bill directs the Department of Health and Human Services to establish cost-effective procedures to ensure that a Social Security account number (or a derivative) is not displayed, coded, or embedded on Medicare cards. If you remember, 20 years ago HIPAA mandated that insurance cards would not have Social Security numbers, but Medicare could not figure out how to do it.

Full text: https://www.govtrack.us/congress/bills/114/hr5880/text.

 

On September 13, 2016, H.R. 6011, the ACA Premium Verification Act, was introduced by Rep. Gus Bilirakis (R-FL) and referred to the House Energy and Commerce and Ways and Means Committees. To require that the Centers for Medicare & Medicaid Services has in place adequate verification procedures to ensure that advance payments under the Patient Protection and Affordable Care Act are made for only enrollees under qualified health plans who have paid their premiums

Full text: https://www.govtrack.us/congress/bills/114/hr6011/text.

Doctors, Elections, Health Policy, Healthcare Reform, Medical Ethics, Medicare, Medicine, Op-eds, Politics

The Dry Tortugas and Being a Deplorably Good Physician

1 Comment

By Marilyn Singleton, MD, JD

Hillary Clinton recently said that half of Donald Trump supporters belonged in the “basket of deplorables” and were irredeemable. Many believe that Dr. Samuel Mudd, the physician who treated John Wilkes Booth, was deplorable. While some say he was merely being a good doctor, setting a broken leg for a man in pain, others argued that he knew of the conspiracy to assassinate President Abraham Lincoln. After a speedy trial, he was sentenced to life imprisonment at Fort Jefferson on the Dry Tortuga Island off the Florida coast.

An 1867 outbreak of yellow fever took the lives of prisoners and the prison doctor. Dr. Mudd took over and saved some 1000 lives. Conspirator, maybe. I’d like to believe he sought redemption and his physician better angel emerged and he did what he was trained to do: take care of patients. After laudatory letters from the prison and continued local advocacy, Dr. Mudd was pardoned by President Andrew Johnson in 1869.

Over the last few years we have seen the deplorable consequences of the Affordable Care Act. Most of the newly “insured” are folks placed on Medicaid. There is a reason Clinton calls for “Medicare for all” and not Medicaid for all. Then there’s the lack of choice in insurance policies and the consequent lack of choice of physicians; unaffordable premiums and sky-high deductibles for virtually unusable insurance, and mergers of major insurance companies, further lessening choice.

A new study looking at California hospitals shows that as more hospitals become part of large chains, the prices go up – as much as 25 percent. As more hospitals consolidate, this trend is likely to be replicated across the county. Again, less choice and competition have their consequences.

With regard to medications, competition in stores like Walmart some ten years ago caused cash prices to be much lower than deductibles. But now many pharmacists are barred from discussing the cash price under terms set by contracts between them and the middlemen-insurers.

And as for that doctor that you liked but couldn’t keep, the government has doubled down on the red tape to receive compensation for treating Medicare patients. The 962-page Merit-Based Incentive Payment System (MIPS) forces your doctor to complete reams of paperwork showing compliance with complex metrics or they will get a downward “adjustment” of their Medicare payments.

Particularly troubling is the “Resource Use,” measurement which begins as 10% of the score and increases to 30% in 5 years. This metric measures the cost per beneficiary based on the government’s review of claims submitted. But this metric does not address the fact that patients have different needs. Some patients may require more visits for the same illness.

Worse yet, the new system spells the demise of our beloved solo practitioner. The Center for Medicare and Medicaid Services estimated that 87 percent of solo practitioners would be penalized.

Government regulation has reached the tipping point. Even the citizenry of progressive Seattle, Washington had their limit. The city authorized a plan to impose a $1 fine on residents each time their garbage cans were filled with more than 10 percent food, compostable waste and paper products. Trash collectors were forced to snoop through the garbage to ensure compliance. A lawsuit was filed and the ordinance was deemed unconstitutional.

The regulatory escalation confirms that the ACA and its progeny were about control, not improving medical care. As more patients complain about unaffordability and inaccessibility, the answer from the social engineers is to say we have to just make health care free! But experience with human nature shows that paid products carry more value. Physicians want patients to value their health. Physicians want to care for patients, not become paper-pushing robotic “providers.”

There is another answer. Physicians can break out of the third party payer trap. We have learned the hard way that if you take their money, you follow their rules, no matter how restrictive or onerous. The majority of patients would pay for routine care, the cost of which is far less than the current insurance premiums. Remove the ACA’s restrictions on insurance policies for catastrophic illnesses. These policies were inexpensive and available to all. Finally, let physicians get back to delivering unfettered charity care.

Remember, the core of Mrs. Clinton’s 1993 Health Security Act was to “put the common good, the national interest ahead of individuals.” Mrs. Clinton’s plan massively expanded the health care fraud definitions and penalties. Physicians faced $50,000 penalties for rendering care outside of the system or seeking payment for care that did not comply with her National Health Board’s medical necessity standards.

In Clinton’s eyes, if you are a patient seeking individualized care or a private physician, your name is Mudd.

Dr. Singleton is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) Board member. She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.

Close Menu