CBO Deals Blow To Senate Health Bill With Estimate Of 22 Million More Uninsured -AND- Telemedicine Is Wide-Reaching But Doesn't Always Replace Doctor's Touch

CAL/AAEM News Service calaaem.news.service1 at gmail.com
Mon Jul 17 12:47:19 PDT 2017



June 26, 2017


CBO Deals Blow To Senate Health Bill With Estimate Of 22 Million More



-3WxvkoKaxqcfsTZBmxL7NhKxBWFkwLM&_hsmi=53613858> California Healthline



By Mary Agnes Carey and Phil Galewitz and Ana B. Ibarra


Senate Republicans' legislation to overhaul the Affordable Care Act would
leave an additional 22 million people without health care coverage over the
next decade and cut the federal deficit by $321 billion, according to a
Congressional Budget Office analysis released late Monday.


By 2026, an estimated 49 million people would be uninsured, compared with
about 28 million who would lack coverage under current law.


The Senate's bill - the Better Health Care Act, which GOP leaders hope to
put to a vote later this week - comes nearly two months after the House
passed its plan to overhaul the Affordable Care Act. That measure would cut
about $834 billion from Medicaid and leave an additional 23 million people
without coverage in 2026, according to CBO. It would reduce the federal
deficit by $119 billion.


"The CBO score released today confirms that the Senate version is just as
bad" as the House version, state Sen. Ed Hernandez (D-West Covina), chair of
California's Senate Health Committee, said in a statement. "It's still
raising premiums for everyone but the young and healthy. It's still
obliterating Medicaid to give the wealthy a tax cut. It still results in 22
million people losing their health insurance coverage. And it still doesn't
solve a single problem, unless the problem is the rich aren't rich enough.
In other words, it's still mean. Republicans should be ashamed."


Gov. Jerry Brown is expected to join California's two Democratic Senators,
Dianne Feinstein and Kamala Harris, in a media call Tuesday to more
specifically address how the Senate health care bill could affect the state.
In a tweet Monday, Feinstein described the bill as "a lose-lose for
California. I'll do everything in my power to defeat it."


California's Department of Health Care Services said it soon would release
its own analysis of the Senate bill's impact. The agency, which oversees the
state's Medicaid program, previously estimated that the House bill would
cost California $24 billion a year by 2027.


"It continues to be really disheartening . that we continue to see this
attack on older Americans and low-income individuals who would be hit the
hardest," said Sarah de Guia, executive director at the California
Pan-Ethnic Health Network, an advocacy group.


Earlier in the day, before the nonpartisan budget office's score was
released, Senate Majority Leader Mitch McConnell (R-Ky.) described the GOP
plan as preserving "access to care for patients with preexisting
conditions." He also said it would "strengthen Medicaid," give "Americans
more power to control and reduce their medical costs and out-of-pocket
expenses" and give "states significant new tools to drive down premiums."


Yet it was unclear if Republicans, who have a razor-thin Senate majority,
could garner the 50 votes necessary for the measure to pass. The budget
office's findings added to this uncertainly.


Sen. Susan Collins (R-Maine), a moderate who has been on the fence about the
bill, tweeted late this afternoon that she could not support the current
bill based on the CBO score. "I want to work with my GOP and Democratic
colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won't do
it. I will vote no," on bringing the bill to the Senate floor, she


Senate Democrats were also swift to react.


"The CBO report should be the end of the road for Trumpcare," tweeted Senate
Minority Leader Chuck Schumer (D-N.Y.). And, in a statement, Sen. Ron Wyden
(D-Ore.) said it was "abundantly clear [Republicans] are going in the wrong


Sen. Bernie Sanders (I-Vt.) pointed to the analysis and said the GOP plan
was "a cynical and immoral proposal."


Detailing The Medicaid Numbers


Under the GOP measure, federal spending on Medicaid would drop by 26 percent
over current spending projections, or $772 billion, over the next decade,
according to the analysis.


The drop in spending would occur mainly because the Senate plan phases out
federal funds for states to expand Medicaid and it puts annual caps on
federal Medicaid dollars to states. Currently, federal Medicaid matching
payments to states are open-ended.


By 2026, the budget office predicted, 15 million fewer people would be
enrolled in Medicaid than projected under the ACA. Currently, more than 74
million low-income and disabled people are Medicaid beneficiaries.


How Medicaid beneficiaries are affected by these caps depends on how states
respond to them, the CBO notes.


"With less federal reimbursement for Medicaid, states would need to decide
whether to commit more of their own resources to finance the program at
current-law levels or to reduce spending by cutting payments to health care
providers and health plans, eliminating optional services, restricting
eligibility for enrollment through work requirements and other changes,"
according to the analysis.


The Medicaid funding provisions are a key reason several influential health
groups say they cannot support the bill.


"Access to care for some of the most vulnerable members of our society -
including those who require treatment for opioid-use disorder - would be
endangered by the Senate proposal's arbitrary, unsustainable, and
shortsighted formula for funding Medicaid," David Barbe, president of the
American Medical Association, said in a statement posted on the
organization's website.


And even before the CBO report was issued, the National Association of
Medicaid Directors was on record with its concerns. "The Senate bill does
formalize several critical administrative and regulatory improvements, such
as giving Medicaid Directors a seat at the table in the development of
regulations that impact how the program is run, and the pathway to
permanency for certain waiver programs," the group said. "However, no amount
of administrative or regulatory flexibility can compensate for the federal
spending reductions that would occur as a result of this bill."


Other organizations, such as Families USA and the American Public Health
Association, said the CBO's findings show the Senate proposal did
"devastating harm" and would "seriously jeopardize the health of America."


Cost And Coverage


The budget scorekeepers also concluded that, for the individual insurance
market, premium costs would go down under the Senate plan, but so would the
amount of coverage provided.


Because these plans "would pay for a smaller average share of benefits under
this legislation, most people purchasing it would have higher out-of-pocket
spending on health care than under current law," CBO said.


In California's Monterey County,  for example, yearly premiums for the a
silver plan under the BCRA would cost a 40-year-old making $30,000 close to
14 percent of their annual income, according to an analysis by the Kaiser
Family Foundation.  (Kaiser Health News is an editorially independent
program of the foundation.) Under the ACA, premium for a silver plan would
cost this same person 6 percent of their income, the analysis shows.


In 2017, an estimated 12 million people bought health coverage through the
ACA's marketplaces. Most bought silver-level plans, which covered 70 percent
of health care costs.


Under the Senate's plan, the average premiums for an individual in 2020
would be about 30 percent lower. But these policies would cover about 58
percent of costs on average.


According to the CBO, "a combination of factors would lead to that decrease
- most important, the smaller share of benefits paid for by the benchmark
plans and federal funds provided to directly reduce premiums."


The CBO also analyzed the Senate bill provision that would allow states to
use waivers to modify the health law's essential health benefits that
include items like prescription drugs, maternity coverage, mental health and
substance abuse. In states where such waivers were granted, consumers could
experience substantial cost increases for supplemental premiums or
out-of-pocket spending, or choose to forgo services. Nearly half the
population, the CBO estimates, would reside in states that seek these


In addition, the ACA's ban on lifetime and annual limits on covered benefits
would no longer apply to health benefits not defined as essential in a




July 7, 2017


Telemedicine Is Wide-Reaching But Doesn't Always Replace Doctor's Touch 



xvWhojig&_hsmi=53979128> California Healthline



By Elaine Korry


Two years ago, Kimberly Griffiths' week-old daughter, Avery, suddenly became
very ill. "She was turning blue and had very labored breathing," said
Griffiths, who rushed her child to the ER in rural Sonora, Calif.


Doctors there were stumped, and the nearest pediatric specialist was 100
miles away in Sacramento.


Fortunately for Avery, the ER doctors were able to make a two-way, online
video connection to consult with a UC-Davis neonatologist, who viewed
high-resolution images of the infant and her vital-signs monitor. The
specialist suspected a congenital heart condition and prescribed a drug that
stabilized her breathing.


"Without telemedicine, our daughter would have died that night," Griffiths
said. She was relieved that her family's insurance company reimbursed the
cost of the remote services her child received. "Nobody should be denied the
health care they need because of where they live," she said.

Use Our Content

This story can be republished for free (details).


Use of telemedicine is exploding in California and other states as insurers
increasingly cover tests and treatment overseen from afar. Forty-eight
states and Washington, D.C., now provide reimbursement for some form of live
video in Medicaid's fee-for-service model.


Since 2015, Kaiser Permanente in California has served more patients each
year through telehealth - a combination of online contacts and video
conferencing - than through traditional visits. (Kaiser Health News, which
produces California Healthline, is not affiliated with Kaiser Permanente.)


Still, regulators in this state and elsewhere have approached telehealth
with caution.


Only a few states in limited circumstances allow insurance companies to
count telehealth toward fulfilling their requirements for "network adequacy"
- the number of physicians, hospitals and specialists mandated within a
region to ensure the right care can be provided in a timely way within an
acceptable distance. A plan's adequacy needs to be approved before it can
operate in the state, but the state will work with plans that fall short,
according to California regulators.


In California, legislation passed in 2011 recognized telehealth as
appropriate care and qualified some types of care, such as live
videoconferencing, for coverage by insurers and by Medi-Cal, the state
Medicaid program.


But regulators have been "limiting plans from being able to utilize
telehealth to its fullest," said Mario Gutierrez, executive director of the
Center for Connected Health Policy in Sacramento, a nonprofit dedicated to
integrating virtual technologies into the health care system. (The center's
founder and lead funder is the California Health Care Foundation; California
Healthline is an editorially independent service of the foundation.)


Gutierrez said Medi-Cal does not reimburse at all, for instance, for remote
monitoring of biometric measures, such as heart rate or blood pressure.
Plus, Medi-Cal restricts reimbursement for the use of high-definition images
sent online for examination or diagnosis.


Libby Baney, who follows digital health policy for Faegre Baker Daniels
Consulting, said regulators' positions on whether telehealth counts toward
"network adequacy" are inconsistent. "The trend in states at the legislative
level is to create access to telemedicine as a recognized care setting, and
yet you've got regulators lagging behind," she said.


Baney said she believes telehealth services should count toward network
adequacy, but only for settings where it is appropriate, such as providing
access to specialists in remote areas, and not as a "proxy for traditional
in-person care."


Charles Bacchi, president of the California Association of Health Plans,
said that whether to count telemedicine toward network requirements is "a
live debate, something we've been talking about for a couple of years."
Bacchi is hoping for a change in policy from regulators, so that providers
of telehealth already being used by health plans will fulfill network
requirements. For now, that's not the case.


"We cannot in our network filings use those relationships to count as an
actual provider . to satisfy our network adequacy requirements," said


Bacchi said he can't imagine regulators ever allowing insurers to restrict
consumers to using telehealth alone.  "We have to, by law, provide
face-to-face access."


For now, most regulators consider telehealth on a case-by-case basis, as a
helpful strategy in underserved areas. In an email, the state Department of
Managed Health Care, which regulates most of the insurance industry, said it
does this when providers are in short supply. "However, plans are not
permitted to replace accessible brick-and-mortar providers with telehealth


Meanwhile, some providers continue to see tremendous economic opportunity in
telemedicine. They argue it serves busy consumers who value convenience and
can fill gaps as insurance plans increasingly rely on narrower networks of


Dr. Henry DePhillips, chief medical officer of Teladoc, the
direct-to-consumer "virtual care" giant, said its network of providers
includes 3,100 licensed physicians and therapists who are physically present
in all 50 states. They have their own more traditional practices and work
for Teladoc part time. "If you think about the network adequacy question,
these are doctors that are already taking care of Californians today.
They're extending their reach by practicing telemedicine as well, so why
would you not include them in the network adequacy scenario?"


Some patients say they prefer to see their doctors virtually, when feasible.


Gabriel Bruce of Richmond, Calif., is able to log on to the Kaiser
Permanente website and consult directly with his primary care physician
without the hassle of having to visit the doctor's office.


"I don't have a car, so I would have to take BART [public transportation] to
a part of town that I'm not used to," said the 19-year-old student. Access
to the website could have been a little smoother, said Bruce, but otherwise
a recent interaction was a success. "It was very professional, and really
convenient," he said.


Other patients are still wary of telemedicine, fearing it could be used to
cut costs and skimp on care. "They just want to reduce their overhead," said
Michael Barnett, 69, of San Francisco. Studies have differed on whether
virtual health care actually saves insurance companies money. Telemedicine
requires its own infrastructure, plus resources and training to support it,
which can be costly for health plans.


Barnett hasn't used telemedicine, skeptical of the "one-off" kind of
encounter he thinks it amounts to. He prefers a doctor's personal touch.
"Your physician should know your history," he said. "In telemedicine, you're
probably getting someone who doesn't know much about you. They may have
access to it electronically, but it's likely to be very skimpy."


In the right setting, there's nothing wrong with telemedicine per se, said
Anthony Wright, executive director of Health Access California, a statewide
consumer advocacy coalition.


But many people - whether it's a cancer patient receiving chemotherapy or a
child with a broken arm - will need hands-on care, he said.


Wright said advocates fought hard for laws in California requiring health
plans to provide consumers with timely access to treatment. "We want to
safeguard those protections," he said. "We don't see telemedicine as
replacing the need for those standards."




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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