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</o:shapelayout></xml><![endif]--></head><body lang=EN-US link="#0563C1" vlink="#954F72"><div class=WordSection1><p class=MsoNormal><span style='font-size:9.0pt;font-family:"Arial",sans-serif'> <img width=623 height=151 id="Picture_x0020_1" src="cid:image001.jpg@01D253B3.08C53900" alt="Description: Description: Description: Description: CAL/AAEM: California Chapter of the American Academy of Emergency Medicine"><o:p></o:p></span></p><p class=MsoNormal><span style='font-size:9.0pt;font-family:"Arial",sans-serif'><o:p> </o:p></span></p><div style='margin-left:15.0pt;margin-top:7.5pt;margin-right:15.0pt;margin-bottom:7.5pt' id=content><div style='border-top:solid #7F7F7F 1.0pt;border-left:none;border-bottom:solid #7F7F7F 1.0pt;border-right:none;padding:4.0pt 0in 4.0pt 0in'><p class=MsoNormal><b><span style='font-size:11.0pt;font-family:"Arial",sans-serif;color:#7F7F7F'>November 15, 2016<o:p></o:p></span></b></p></div><div style='margin-top:11.25pt;margin-bottom:11.25pt'><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'><o:p> </o:p></span></b></p><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'>Calif. Supreme Court says HMOs are on the hook for clients' emergency bills <o:p></o:p></span></b></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0000CC'><a href="http://www.modernhealthcare.com/article/20161115/NEWS/161119951?utm_source=modernhealthcare&utm_medium=email&utm_content=20161115-NEWS-161119951&utm_campaign=financedaily"><span style='color:#0000CC'>Modern Healthcare</span><span style='font-family:"Times New Roman",serif;color:#0000CC'><o:p></o:p></span></a></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>By Erica Teichert<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The California Supreme Court on Monday guaranteed that HMOs will pay for noncontracted emergency services in the state, telling insurers they can't hide behind third-party contracts to avoid paying ER providers.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Two groups of doctors accused several California insurers of refusing to pay them for emergency services provided to the HMOs' planholders because the insurers had delegated the payment responsibility to independent physician associations, or IPAs. But those IPAs—known as La Vida—were in financial trouble and failed to pay those emergency bills.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The California justices unanimously ruled that HMOs must ensure their contracted IPAs are financially sound, and the insurers can't delegate their payment responsibilities to insolvent groups.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The doctor groups alleged that the insurers—including Anthem Blue Cross, Aetna and Cigna Healthcare of California—should have known La Vida was in trouble when it failed to meet the state's solvency rules back in 2007. Although the doctors repeatedly reached out to the HMOs for help when La Vida wouldn't pay for the emergency services, the health plans told the providers to keep submitting their bills to the IPA. La Vida eventually went bankrupt in 2010.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The health plans claimed that state regulations allowed them to shift their financial responsibilities to the IPAs, and the providers should have no recourse to come after them, even if the IPAs were insolvent. But the high court determined the HMOs were negligent and still had a duty to pay the doctors.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>“With this decision, the California Supreme Court has championed the notion that emergency service providers should get paid for their work, and that HMOs cannot simply absolve themselves of their obligations to these providers by delegating payment responsibility to third parties,” said Andrew Selesnick, an attorney with Michelman & Robinson who represented one of the plaintiffs. “As a matter of public policy, we want emergency service providers to deliver excellent care to all who need it, rather than worrying about whether payers are financially distressed or insolvent."<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The cases had originally been tossed based on the health plans' contentions that they weren't liable for the payments. The lawsuits will return to the trial court level for further proceedings.<o:p></o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p></div><div style='border-top:solid #7F7F7F 1.0pt;border-left:none;border-bottom:solid #7F7F7F 1.0pt;border-right:none;padding:4.0pt 0in 4.0pt 0in'><p class=MsoNormal><b><span style='font-size:11.0pt;font-family:"Arial",sans-serif;color:#7F7F7F'>November 16, 2016<o:p></o:p></span></b></p></div><div style='margin-top:11.25pt;margin-bottom:11.25pt'><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'><o:p> </o:p></span></b></p></div><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'>The End of Obamacare <o:p></o:p></span></b></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0000CC'><a href="http://www.nejm.org/doi/full/10.1056/NEJMp1614438?query=TOC"><span style='color:#0000CC'>New England Journal of Medicine</span><span style='font-family:"Times New Roman",serif;color:#0000CC'><o:p></o:p></span></a></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>By Jonathan Oberlander, Ph.D.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Donald Trump’s triumph in the 2016 presidential election marks the beginning of an uncertain and tumultuous chapter in U.S. health policy. In the election’s aftermath, the immediate question is this: Can Republicans make good on their pledge to repeal Obamacare? The Affordable Care Act (ACA) has persisted largely thanks to President Barack Obama’s protection. With Trump in the White House and Republicans maintaining House and Senate majorities, that protection is gone.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Obamacare’s vulnerability reflects not only the 2016 election results, but also its shallow political roots. The ACA has achieved much, including a large reduction in the uninsured population. Still, it lacks strong public support and an organized beneficiary lobby, has encountered significant problems in its implementation, and has been enveloped by an environment of hyperpartisanship.1 If the ACA were more popular and covered a more politically sympathetic or influential population, if its insurance exchanges were operating more successfully and had higher enrollment, and if Democrats and Republicans were not so ideologically polarized and locked in a power struggle, then an incoming GOP administration would probably be talking about reforming rather than dismantling Obamacare.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The Trump administration can do much to undercut the ACA. The insurance exchanges, buffeted in many states by high premium increases, sicker-than-expected risk pools, and insurer withdrawals, require stabilization; simply by doing nothing the GOP could damage them. A Trump administration could also stop reimbursing insurers for the cost-sharing reductions they must give low-income Americans with ACA exchange plans — a move that would severely destabilize insurance marketplaces and lead to insurers’ exiting the exchanges.2 Just as the Obama administration used executive orders to buttress the law, so the Trump administration could reverse those orders and take additional actions to weaken it, including leveraging waivers that enable states to opt out of ACA requirements.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The GOP-led House has already voted to repeal Obamacare dozens of times and will most likely do so again. The situation in the Senate is more complicated. The Republican majority of 51 senators is far less than the 60 votes necessary to overcome a filibuster and thereby pass contested legislation. However, the GOP can use a legislative procedure that requires only a simple majority — budget reconciliation — to overturn Obamacare’s main coverage provisions.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Republicans face challenges in dismantling the ACA. Procedural limits mean that reconciliation can be used to repeal many Obamacare provisions but not the entire law (its insurance market regulations would probably be spared). Moreover, some of its provisions, such as banning insurers from discriminating against people with preexisting conditions and allowing children to stay on their parents’ health plan until 26 years of age, are popular. The GOP could attempt to retain such reforms, which President-elect Trump has expressed interest in maintaining, while eliminating the mandates for individuals to obtain and larger employers to offer insurance coverage or pay penalties, the Cadillac tax on high-cost private plans, and other measures the GOP opposes. Many ACA policies, though, are interconnected: without a requirement that individuals either obtain insurance or pay a penalty, regulations prohibiting insurers from excluding sicker people from coverage or charging them higher premiums are not viable. Picking and choosing to keep only the ACA’s popular provisions is easier said than done.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Furthermore, more than 20 million Americans have gained insurance coverage since the ACA’s enactment, representing a sizable constituency of beneficiaries of Medicaid expansion and subsidized marketplace insurance. Repealing those benefits without adequate replacements would de-insure a substantial share of the U.S. electorate, inviting a political firestorm.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Therein lies the GOP’s chief quandary: talking about repealing the ACA is much easier than actually repealing and replacing it. The GOP could reintroduce a repeal bill, vetoed by Obama, that congressional Republicans passed in 2015 (through budget reconciliation in the Senate) stripping the ACA’s core coverage provisions away.2,3 But with what, if anything, will the GOP replace Obamacare? Trump’s health care platform comprises a handful of bullet points — including allowing the interstate sale of health insurance, expanding the use of health savings accounts, and establishing high-risk pools.4 None of those policies would do anything meaningful to restore the access to health insurance that repealing the ACA would take away from millions of Americans. Trump’s reform vision remains largely a mystery.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Republicans could build on a June 2016 plan released by House GOP leadership, led by Speaker Paul Ryan (WI). The plan shares the above policies with Trump’s platform.5 In addition, it calls for replacing the ACA’s insurance subsidies with tax credits. Insurers could not charge higher premiums to people with preexisting conditions as long as, and only if, those people maintained continuous coverage. The plan would limit the tax exclusion for employer-sponsored insurance that has exempted employer contributions to workers’ insurance from taxation. And it would reform the malpractice system by introducing caps on noneconomic damages.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Yet these policies, too, fall far short of the ACA’s insurance protections and coverage expansion. Under the House GOP plan, more Americans would be uninsured, more would become underinsured, and more would be subject to insurer discrimination. Nonetheless, even that proposal is viewed by some conservatives as an overly ambitious “Obamacare lite.”3 There is no agreed-upon Republican replacement plan; a new health care reform debate could expose divisions within the GOP and between Congress and Trump. If Republicans want to replace the ACA, they must resolve issues such as how ambitious a GOP reform package should be and how to pay for it. Limiting the tax exclusion for employer insurance could generate considerable funds, but many Americans will view that change as an unwelcome tax increase and a cut in their health benefits.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Republicans’ drive for repeal thus brings with it considerable political risks. Americans are profoundly confused about the ACA’s benefits, but the prospect of losing them could prove clarifying. The 32 states, including some governed by Republicans, that have expanded Medicaid do not want to have coverage taken from their residents or to lose large federal payments. Republicans may discover that it is harder to pull the plug on Medicaid expansion than on the insurance exchanges. Other issues await the GOP, such as what to do about the ACA’s measures slowing down Medicare spending growth. Ending those policies would substantially worsen the federal budget deficit. And what becomes of the ACA’s payment and delivery reforms, its expansion of Medicare prescription-drug benefits, and myriad policies affecting medical care and public health that are embedded in the law?<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>A host of health system stakeholders — hospitals, doctors, insurers, and others — will be anxious about the current uncertainty in the health policy landscape and worried about any changes that substantially reduce insurance coverage and adversely affect their bottom lines. Much of the health care industry supported the ACA as part of a broader coalition that included consumer groups. Whether that coalition can reassemble to effectively resist the ACA’s demise is unclear.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Health policy debates could ignite beyond the ACA. Speaker Ryan supports major changes to Medicare and Medicaid. The new Congress and the Trump administration could enact large-scale tax cuts that reduce federal revenues and increase the budget deficit, creating pressures to constrain spending on government insurance programs. The 2015 House GOP plan called for transforming Medicare into a modified voucher system, raising Medicare’s age of eligibility, and converting federal Medicaid payments to states into block grants or per capita allotments. Pursuing those controversial policies, which would shift more costs onto older and lower-income Americans, could trigger a backlash. However, Trump may not support Ryan’s Medicare reform plans (though he has voiced support for block granting Medicaid). The expiration of funding for the Children’s Health Insurance Program also looms in 2017.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.0pt'><span style='font-family:"Arial",sans-serif'>The ACA’s enactment represented a major step toward making health care a right in the United States. Now after another landmark election, health care reform in the United States is headed backward. It is uncertain which parts of the ACA will survive past 2017 and what will follow it. What is certain is that Obamacare as we know it will end.<o:p></o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><strong><span style='font-family:"Arial",sans-serif'>Jeff Wells</span></strong><span style='font-family:"Arial",sans-serif'><br>Deputy Editor, CAL/AAEM News Service<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><strong><span style='font-family:"Arial",sans-serif'>Brian Potts</span></strong><b><span style='font-family:"Arial",sans-serif'> MD, MBA</span></b><span style='font-family:"Arial",sans-serif'><br>Managing Editor, CAL/AAEM News Service<br><br></span><o:p></o:p></p></div><p class=MsoNormal style='background:#D9D9D9'><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>Contact us at: <span style='color:#0000CC'><a href="mailto:calaaem.news.service1@gmail.com"><span style='color:#0000CC'>calaaem.news.service1@gmail.com</span></a></span><br><br>For more articles, visit our <span style='color:blue'><a href="http://www.calaaem.org/news_archives.php"><span style='color:blue'>archives</span></a></span>. <br><br></span><span style='font-size:9.0pt;font-family:"Arial",sans-serif'><a href="mailto:somcaaem@uci.edu"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:black;text-decoration:none'>To</span></a></span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0070C0'><a href="https://maillists.uci.edu/mailman/listinfo/calaaem"><span style='color:#0070C0;text-decoration:none'> </span><span style='color:blue'>unsubscribe</span></a></span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'> from this list, visit our mail server.<br><br>Copyright (C) 2015. The California Chapter of the American Academy of Emergency Medicine (CAL/AAEM).</span> <span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0000CC'><a href="http://www.calaaem.org"><span style='color:#0000CC'>http://www.calaaem.org</span></a></span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>. All rights reserved.<br><br>CAL/AAEM, a nonprofit professional organization for emergency physicians, operates the CAL/AAEM News Service solely as an educational resource for physicians. Dissemination of an article by CAL/AAEM News Service does not imply endorsement, agreement, or recommendation by CAL/AAEM News Service, CAL/AAEM, or AAEM.<br><br><o:p></o:p></span></p><p class=MsoNormal style='background:#D9D9D9'><b><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>Follow CAL/AAEM on Facebook and Twitter:<o:p></o:p></span></b></p><p class=MsoNormal style='background:#D9D9D9'><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='background:#D9D9D9'><a href="http://www.facebook.com/pages/CalAAEM/172577489479442?sk=wall&filter=12" target="_blank"><span style='color:black;text-decoration:none'><img border=0 width=28 height=28 id="Picture_x0020_6" src="cid:image002.jpg@01D253B3.08C53900"></span></a> <a href="https://twitter.com/#!/CALAAEM"><span style='color:windowtext;text-decoration:none'><img border=0 width=30 height=30 id="Picture_x0020_7" src="cid:image003.jpg@01D253B3.08C53900"></span></a> <a href="http://escholarship.org/uc/uciem_westjem"><span style='color:windowtext;text-decoration:none'><img border=0 width=112 height=30 id="Picture_x0020_4" src="cid:image004.jpg@01D253B3.08C53900"></span></a><o:p></o:p></p><p class=MsoNormal style='background:#D9D9D9'><span style='color:black'><o:p> </o:p></span></p></div><br />
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