New research center in East Tennessee aims to figure out how to break generational cycle of poor rural health

"A new rural health research center with a multi-million-dollar annual budget will focus on breaking the cycle of inter-generational behavior that contributes to poor health," Liz Carey reports for The Daily Yonder. "The center will also work to become a source for policymakers – providing the data from which those in government and other policy making organizations can make decisions to help improve the health of those in rural and nonurban communities."

East Tennessee State University in Johnson City announced the creation of the new Center for Rural Health Research on July 16. Randy Wkyoff, dean of ETSU's College of Public Health, said those inter-generational cycles of "poor health, lack of education and persistent poverty" are among the greatest health challenges in the region, and that interrupting them is paramount, Carey reports.

"One of the first things Wykoff said he’ll focus on is perinatal care – the period just before and after childbirth. Emphasizing this period will empower women to provide the best care they can to protect their babies from harm," Carey reports. "He also hopes to look at how to get healthcare to those in rural areas." Wykoff said he hopes the center's ideas will help other states besides Tennessee.

The center is getting ample funding. Tennessee Gov. Bill Lee promised the center a first-year $1.5 million grant and $750,000 annually for ongoing operations, and regional health care system Ballad Health has promised $15 million over the next 10 years, the largest gift in the university's history.

Rural hospitals alarmed at Graham-Cassidy bill; interactive map shows Medicaid impact by county

UPDATE, 2:08 p.m.: Arizona Sen. John McCain announced that he would vote against the Graham-Cassidy bill, dealing it "a potentially decisive blow," The Washington Post reports. That puts the focus on Alaska Sen. Lisa Murkowski and Maine Sen. Susan Collins, the other Republicans who voted against the last bill, and Sen. Rand Paul of Kentucky, who voted for it but says he will oppose this one.

"Leaders of cash-strapped rural hospitals worry that the latest proposal to repeal and replace the Affordable Care Act could destroy them," Dave Barkholz reports for Modern Healthcare. Many rural hospitals are already on the ropes. "Of the nation's 1,160 rural hospitals, 41 percent are operating at a financial loss. Eighty-two have already closed since 2010. And one in three of the survivors is considered at risk of closing," Barkholz reports.

"If you want to watch a rural community die, kill its hospital," Lauren Weber and Andy Miller report for the Huffington Post from three counties in rural Georgia that are struggling to keep their hospitals alive. Georgia is one of the 15 states that did not expand Medicaid under the ACA, which has generally boosted rural hospitals elsewhere. The bill would end the Medicaid expansion in 2020. Because rural areas have far higher rates of Medicaid patients, rural hospitals would be disproportionately hurt and many might have to close. The Daily Yonder reports on an analysis of that by Headwaters Economics, which includes an interactive map showing how much of each county's personal income is Medicaid benefits. Here's a screenshot of the version showing counties at 10 percent or more (click image for larger version):

The bill also doesn't address the federal cost-sharing subsidies that help insurers offer cheaper plans for people with low incomes. President Trump has threatened to withhold those payments, sparking concern -- and withdrawal from rural markets -- by many insurers. Maggie Elehwany, vice president of governmental affairs at the National Rural Health Association, said that rural hospitals would be hit especially hard by legislation that "increases the uninsured, boosts deductibles for patients or threatens already shrinking Medicare payments."

Under the Graham-Cassidy bill, the individual and employer insurance mandates would be repealed, states would be given more leeway to change rules, and nearly $1.2 trillion in ACA subsidies would be distributed to states through block grants. "If state block grants end up cutting funding to health care, patients who can afford insurance may end up with higher deductibles, leaving hospitals struggling to collect payments," said Megan Neuberger, team head for health care at Fitch U.S. Corporate Ratings.

Charts predict how your state's federal health-care funding would change under last-ditch repeal plan

How would your state fare under Senate Republicans' last-ditch bill to repeal the Patient Protection and Affordable Care Act, which could pass Congress next week? The Kaiser Family Foundation has some figures, and so does The New York Times. UPDATE, Sept. 21: The Trump administration released its state-by-state estimates. "The predicted loss is less than that forecast by three independent analyses of the bill’s impact in recent days, but the internal numbers show a similar checkerboard of states that would be big winners and equally big losers," The Washington Post reports.

Kaiser says in a Sept. 20 report that the Graham-Cassidy proposal would:

• Repeal the Medicaid expansion and subsidies for individual insurance—including premium tax credits, cost-sharing reductions, and the basic health program—in 2020.
• Put the money into a new block-grant program to states in 2020-26. States could use the funds "to cover the cost of high-risk patients, assist individuals with premiums and cost-sharing, pay directly for health care services, or provide health insurance to a limited extent to people eligible for Medicaid," Kaiser reports.
• Cap state-by-state federal funding of the traditional Medicaid program for the poor and disabled.
• Repeal the mandates requiring individuals to have health insurance and employers to offer it, and let states waive required benefits and community rating, which prevents insurers from charging higher premiums to people with pre-existing conditions.

The changes would reward the 15 states, controlled by Republicans, that did not expand Medicaid to people in households with incomes up to 138 percent of the federal poverty threshold. Kaiser explains the complex formula and reduces its effect to a simple chart:

State by state, Kaiser defines the extremes: "Five states would see a reduction in federal funds of 30% or more from 2020 to 2026: New York (-35%), Oregon (-32%), Connecticut (-31%), Vermont (-31%), and Minnesota (-30%). Six states would see at least 40% more in federal funds under the proposal: Tennessee (44%), South Dakota (45%), Georgia (46%), Kansas (61%), Texas (75%), and Mississippi (148%). . . . Because actual state allotments under the block grant may vary based on state-specific factors and the secretary’s authority to further adjust the formula, actual state experiences under the block grant may differ. It is uncertain how additional adjustments would be used to alter states’ allotments up or down."

Kaiser's report has three state-by-state tables, showing the projected differences in federal spending for ACA coverage, the total change in federal spending due to the block-grant program and the limit on Medicaid; and the projected loss of federal funds due to those factors.

The New York Times showed the funding changes per person, in charts that were color-coded: first by states that expanded Medicaid (in green), then by states (in orange) with senators who voted against one of the Obamacare repeal bills in July:

How the ACA affected every state, in 51 graphs

The Washington Post has offered a real treat for data wonks with a story compiling how the Patient Protection And Affordable Care Act affected each state in 51 graphs--one graph per state. The 51st graph highlights how the percentage of uninsured Americans has dropped more in states that expanded Medicaid, though the rate dropped in both groups.

Washington Post graphic

Philip Bump points out interesting trends in the data, such as how Delaware had a slower rate of decline in its uninsured rate than other states, but that may be because it had a lower rate of uninsured people to begin with: "In only three of the above graphs did the lines go up between years: South Dakota had an increase in 2015, and D.C. and Nebraska had increases in 2016. Every other year in every other state, the rate of the uninsured fell."

Anthem leaves Nevada, stays in rural Georgia after state threat; here's a good Q and A on Obamacare

UPDATE: Anthem Blue Cross Blue Shield, "one of the largest marketplace insurers in 2017, continues to scale back," Bloomberg News reports on its continually updated page that tracks insurance markets for 2018. "The Nevada Division of Insurance announced today that Anthem will leave the state entirely after initially planning to remain in three counties. Anthem is also leaving the 74 Georgia counties that have other marketplace options, while remaining in the 85 mostly rural counties where it is the only insurer. According to Jay Florence, Georgia’s deputy insurance commissioner, the company initially proposed leaving all counties except one. The state’s insurance department said it would respond by banning Anthem from re-entering the market for five years, so the company chose to continue offering plans in some counties."

Bloomberg News map; click on it to view a larger version

If Congress doesn't put forth legislation to repeal or replace the Patient Protection and Affordable Care Act, President Trump has said that he would "let Obamacare fail." A Q&A from Cynthia Cox and Larry Levitt of the Kaiser Family Foundation examines the possible short-term consequences, and also what would happen if the ACA remains the law. The foundation has long been a source of reliable, detailed information about health, health care and health insurance.

Is the ACA is failing, as critics say? The short answer is no, but rural markets are fragile, and insurance may become too expensive for some people who buy individual insurance on government marketplaces because they make too much (about $95,000 for a family of four) to qualify for subsidized plans. When people talk about the ACA failing, they're usually referring to the marketplace exchanges for individual insurance. Some insurance companies have left the exchanges, and premiums have increased, but the "structure of the ACA’s premium subsidies – which rise along with premiums and cap what consumers have to pay for a benchmark plans a percentage of their income – prevents the market from deteriorating into a 'death spiral.' However, premiums could become unaffordable in some parts of the country for people with incomes in excess of 400 percent of the poverty level, who are ineligible for premium assistance," Cox and Levitt say. Insurer pullouts have left one in three U.S. counties, mostly rural, with only one insurer on the exchange. At the state level, individual market competition is relatively stable.

Kaiser Family Foundation chart

How could actions by the Trump administration affect market stability? "Despite signs that the individual insurance market is generally stabilizing on its own, certain administrative actions could cause the market to destabilize again." The administration could weaken the market if it stops enforcing or weakens the individual mandate, scales back outreach and consumer assistance, or stops making cost-sharing subsidy payments. "The combined effect of these policy changes could cause some insurers to raise premiums on some plans by as much as 40 percentage points higher than they otherwise would." Because insurers are unsure about the future, some have already raised premiums, left some markets, or made plans to exit the marketplace altogether.

What happens if the market fails? Some rural areas are at risk of having no insurer offering marketplace plans in 2018. "If no exchange insurer ultimately moves into some of these counties, people buying their own insurance will not be able to get subsidies and would have to pay full price for insurance. Paying for unsubsidized insurance would be particularly difficult for low-income and older adults living in high-cost areas like many rural parts of the country. Our subsidy calculator can show the difference in cost," Cox and Levitt note. Some people may be left without full-price insurance options if insurers exit the regular market in their as well as the marketplace.

What could be done to strengthen the marketplace? "One possible policy response that could receive bipartisan support would be to re-establish a reinsurance program. Reinsurance programs provide funds to insurers that enroll high-cost (sicker) individuals and can work to lower premiums. The Affordable Care Act included a reinsurance program, but it was temporary and phased out in 2016. Republicans in Congress and the administration have also signaled a willingness to establish reinsurance programs; both the House and Senate repeal bills included stability funds for reinsurance," Cox and Levitt note.

Bipartisan groups of governors, House members propose fixes for subsidized health insurance

Congress has tried and so far failed to repeal or replace the Patient Protection and Affordable Care Act, so a bipartisan group of governors is trying to repair it. The seven Democrats and six Republicans in the Governors' Bipartisan Health Reform Learning Network have crafted a slew of proposals: They want "federal money to stabilize the ACA’s health insurance marketplaces, and greater power to manage them," Michael Ollove reports for Stateline. "They argue it should be easier for states to customize Medicaid, the joint federal-state health insurance for the poor, and they want new tools to curb fast-rising drug prices. And they insist that states should continue to regulate the health policies sold within their borders."

The group, which was assembled by the National Governors Association in March, released a list of its ideas in June. They plan to continue meeting for the next 18 months to distill their ideas into policy proposals that, they hope, will be enacted through congressional legislation or Cabinet-issued regulations. The states in the governors' group are: California, Delaware, Kentucky, Minnesota, Montana, Pennsylvania, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington and Wyoming.

In Washington, a bipartisan group of House members called the Problem Solvers Caucus has also proposed some fixes: "permanently funding extra Obamacare subsidies for cost-sharing discounts, repealing the ACA’s medical device tax, giving states greater flexibility to manage their marketplaces and creating a federal fund to help cover the costs of the sickest, most expensive patients," Paige Winfield Cunningham reports for The Washington Post. "Yet Republicans face ongoing, heavy pressure from the White House to revisit their partisan repeal-and-replace effort, largely via a string of tweets from President Trump blasting them for failing to pass a bill and threatening to hold hostage extra Obamacare subsidies for insurers that could help stabilize the marketplaces." Those cost-sharing discounts are especially important to rural areas.

Analysis shows local TV coverage of health bills surged after first Senate bill was released

Senate Republicans have so far failed to accomplish their stated goal of repealing and replacing the Patient Protection and Affordable Care Act, for many reasons. Might one be increased news coverage once they released their bill after weeks of secrecy?

Most Americans get the bulk of their information about the issue from the news media, and local television news has a larger overall audience than cable and network news. Local TV coverage of the issue skyrocketed after Republican senators released the first version of their health-insurance bill, and it seems safe to presume that coverage in other local media did, too.

"That drumbeat of coverage in their home districts during Senate debates may have made some GOP senators think twice about angering constituents — including those of their own party," researchers Erika Franklin Fowler and Sarah Gollust write for The Washington Post. Fowler is an associate professor of government at Wesleyan University in Middletown, Conn.; Gollust is associate professor of health policy and management at the University of Minnesota.

To show the jump in coverage after the Senate bill was released, Fowler and Gollust mapped the average mentions of the issue before and after (click on image for larger version):

Researchers looked for key words in closed captioning of local news broadcasts in the 201 U.S. media markets from early March, when House Republicans released their bill. While no firm conclusions can be drawn from the increased coverage, Fowler and Gollust have a hunch that the coverage attention to parts of the ACA that were popular but hadn't been well-covered, such as a ban on denying coverage for pre-existing conditions. "If our hunch is right, and local media drew attention to what might be lost . . . then that would help explain why the ACA has grown more popular, and the AHCA less so, the more citizens learned what one did, and the other would not contain," they write.

Fowler and Gollust caution that their research doesn't say how local TV covered the issue, but "a look at the drop in public approval of efforts to repeal the ACA suggests that local TV coverage cannot have made things easier for wary GOP senators."

Some rural hospitals hang by a Medicaid thread

Lincoln Community Hospital (NPR photo)

Lincoln Community Hospital in Hugo, Colo., is exemplary of rural hospitals across the country. Residents are proud of their hospital, but changes to the Medicaid program could reduce its funding and force it to cut back services, reports John Daley of NPR.

"From the outside, Lincoln Community Hospital looks more like a small 1960s-era apartment building," Daley reports. "But it has all the essential high-tech health care equipment: modern imaging machines, tele-medicine links — even an AirLife helicopter. Rachel Smith, the assistant director of nursing, says the thing that really sets the hospital apart is the quality of its care."

Smith said, "It's definitely not treat 'em and street 'em. It's definitely somebody you're going to see — maybe even later that day, later that week."

Half of the hospital's patients are covered by Medicare, according to Daley. "One chronic problem for the hospital is that its reimbursement from Medicare doesn't cover the full cost of the services it provides. The hospital also receives — and depends on — Medicaid payments, and that program is facing deep cuts under the Senate health bill now under consideration," Daley writes.

Making the financial puzzle pieces fit is tricky for rural hospitals. "As Congress works to change the health system once more, many small town facilities like Lincoln Community Hospital are on thin ice," Daley says.

Conservative news and opinion media are focusing less on health debate in Congress

Recent actions by conservative media and politicians, who tend to hold sway in rural areas, seem to reflect ebbing voter interest in repealing the Patient Protection and Affordable Care Act, writes David Weigel of The Washington Post. 

Fox News and conservative talk radio hosts such as Rush Limbaugh largely ignored Senate Republicans' decision to delay voting on an ACA replacement, Weigel reports: "The lack of 'Obamacare repeal' coverage, unthinkable just six months ago, reflected a general decline of conservative interest in what united Republicans for seven years. Conservative grass-roots groups have either ignored the latest health-care details, like Americans for Prosperity, or lobbied against the bill, like the Club for Growth."

To the extent that Fox covers the issue, the network frames it as President Trump himself, and not necessarily Republicans in Congress, waging war against Democrats. Some on the network have criticized Congress for failing to get the job done. 

Republicans in Congress may be acting cautiously in light of reduced voter interest and support, Weigel suggests. A recent Quinnipiac University poll shows 37 percent of Republican voters favor the ACA repeal. A USA Today poll released today shows only 12 percent of Americans in general support the Senate's health-care plan, while 53 percent say "Congress should either leave the law known as Obamacare alone or work to fix its problems while keeping its framework intact."

The proposed health-care bills from both the House and Senate would negatively impact many rural Americans, since the subsidy cuts would fall disproportionately on older and lower-income populations, according to an analysis by the Kaiser Family Foundation. A set of maps by the Post illustrates the various impacts; here's an example (click on it to enlarge; click on link for the rest):

Critics of Senate health bill call it 'anti-rural'

Senate Majority Leader Mitch McConnell (Associated Press photo)

Critics of the Senate's newly released Better Care Reconciliation Act, the potential replacement of the Patient Protection and Affordable Care Act, say the bill will hit rural America especially hard, writes Tim Marema of The Daily Yonder.

Alan Morgan, chief executive officer of the National Rural Health Association, told Marema that the organization will oppose the Senate bill because the legislation will hurt rural America. "In its current form, this bill is anti-rural," Morgan said. The bill contains several provisions that would hit especially hard in rural areas, Marema says. "Among these are deep cuts in Medicaid spending and an end to Medicaid expansion. About 45 percent of rural children use Medicaid, compared with 38 percent in metropolitan areas, according to a Georgetown University study. The bill would reduce funding for treatment of opioid addiction, another issue for rural America," Marema writes.

The rate of opioid overdose deaths is 45 percent higher in rural counties, according to the NRHA. The Senate bill provides $2 billion to fight opioid addiction in 2018, while the House version of the bill would have provided $45 billion over 10 years.

Rural hospitals will continue to be at risk of closure under the new bill, Marema writes. One analysis finds that 673 rural hospitals are vulnerable to closure. Since 2010, 79 rural hospitals have closed, according to tracking by the University of North Carolina.

"Morgan also noted one part of the bill that probably won’t attract much attention but ought to," Marema writes. "The bill zeroes out the Public Health and Prevention Fund, which has been used to fight the zika virus, a mosquito-borne disease that can cause severe birth defects. " Morgan said, "There is a real concern that zika is going to reemerge this summer in rural communities along the southern border. From a rural public health standpoint it’s a real problem."

"This bill is going to hit rural America like a wrecking ball," Sen. Ron Wyden (D-Ore.) said at a hearing Wednesday.

The Washington Post has a side-by-side comparison of the two bills and the Patient Protection and Affordable Care Act.

Medicaid cuts would hit rural hospitals hardest

Pemiscot Memorial Hospital in one of Missouri's
poorest counties (Side Effects Public Media photo)

For the hundreds of rural hospitals struggling to stay in business, health-policy decisions made in Washington, D.C., could make survival a lot tougher, Bram Sable-Smith reports for NPR.

"Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing," Sable-Smith notes. "These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding."

House Republicans' bill would cut Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities — by as much as $834 billion, Sable-Smith reports. "The Congressional Budget Office has said that would result in 23 million more people being uninsured in the next 10 years. Even more could lose coverage under the budget proposed by President Trump, which suggests an additional $610 billion in cuts to the program."

The House bill would end the Medicaid expansion in 2020; the Senate bill revealed Thursday would phase it out by 2024, but after that would tighten the funding formula in a way that would likely force states to limit eligibility or cut benefits, or both. All those would be problems for small rural hospitals that depend on Medicaid. A rural hospital closure goes beyond people losing health care, Sable-Smith explains. Jobs, property values and local schools can suffer.

"Relief for rural hospitals is not what is being debated in Washington right now." he says. "Under the GOP House plan, even states like Missouri that did not expand Medicaid could see tens of thousands of residents losing their Medicaid coverage."

Foundation says 44 counties, so far, are at risk of having no Obamacare insurers in 2018

One reason many Republicans in Congress give for repealing and replacing "Obamacare" is that the health-insurance system created by the 2010 law is collapsing as companies withdraw from the marketplaces for federally subsidized insurance, threatening to leave many Americans unable to buy such policies. "The status quo is simply unsustainable," Senate Majority Leader Mitch McConnell said today.

That threat may be overstated, but more complete information is coming, according to research by the Kaiser Family Foundation. At the precipice of the June 21 deadline for insurers to submit rates for the marketplace, the foundation released a map that will continue to track counties at risk of having no health insurers that offer plans in the 2018 marketplace.

To date, only 44 counties are at risk of having no marketplace insurers, representing 31,268 estimated enrollees, according to a foundation news release. Those counties are a mix of metropolitan and rural counties throughout Ohio (from which insurer Anthem Inc. recently withdrew) and western Missouri, plus a rural county in southern Washington.

"Compiled from a foundation analysis of insurer filings and news reports, the map charts the counties at risk of having no insurers based on current public announcements, along with the name of the 2017 participating insurer and the number of enrollees in 2017," the release says. "The map also includes a tally of the number and share of counties at risk, and the number and share of enrollees that could be affected. . . . Foundation experts will continue updating the map until insurer participation in 2018 is finalized in the fall of 2017."

If a county has no marketplace insurer, consumers would not be able to purchase plans subsidized by federal tax credits and cost-sharing reductions. "Tax credits make coverage more affordable throughout the year by lowering consumers’ monthly premium costs; cost-sharing reductions help lower out-of-pocket costs," Kaiser explains. "In 2017, 8.7 million people (84 percent of all marketplace enrollees) received tax credits to cover a share of their premium and 5.9 million people (57 percent of all marketplace enrollees) received cost-sharing reductions."

Interactive map, tables show changes by state in health coverage and financing under Obamacare

Screenshot of interactive map shows partial data for Arizona; for a larger version,
click on the image. For the actual interactive map, click on the link below.

The Kaiser Family Foundation launched an interactive map Friday that provides a look at changes in health-insurance coverage and financing in each state under the Patient Protection and Affordable Care Act.

The ACA, enacted in 2010, increased enrollment in health insurance by financing expansion of Medicaid in states that chose to do so, offering tax credits for low- and middle-income people to buy private insurance, and reforming insurance-market rules. For example, it required insurance companies to cover people with pre-existing health conditions.

Users can scroll over each state to see a detailed breakdown of ACA-related data, as described by the foundation's Katie Smith:

• The number of people enrolled in plans in the ACA marketplace, the number of enrollees receiving advance premium tax credits to help them buy insurance, and the total amount of money in the form of such credits received by marketplace enrollees in the state.
• The number of enrollees in Medicaid, with a break out of the number of Medicaid expansion enrollees in the 31 expansion states and Washington D.C., as well as total federal Medicaid spending and Medicaid expansion spending in the state;
• The reduction in the number of people without health coverage in each state between 2013 and 2015, as well as the estimated number of people in the state with pre-existing health conditions.

"The map also shows the political party affiliations of U.S. senators in each state," Smith adds. "Replacement legislation under consideration in Congress has the potential to affect every state’s Medicaid program and individual health insurance market."

Maine's rural nature creates health issues, but state also has some examples to use in reforms

If Congress passes a health law this year, Maine could be one of the states most affected because it is one of the most rural states, with an unusual number of jobs tied to seasonal industries such as fishing, agriculture and tourism, reports Jennifer Steinhauer of The New York Times.

About 22 percent of Mainers hold part-time jobs; the national average  is 17 percent. "As a result of their short-term spike in income, many of Maine’s working class will likely lose some or all of their health-insurance subsidy, a feature of the federal health-care law, which has been a complicated blessing for the citizens of Maine," Steinhauer reports.

Sen. Susan Collins (NYT photo by Yoon Byun)

U.S. Sen. Susan Collins of Maine, who "once oversaw Maine's insurance bureau," told Steinhauer that he has spent a lot of time on the health-care issue because Maine is "disproportionately affected." The state also has a median age of 43, highest in the nation, and is relatively poor, Steinhauer notes.

Senate Majority Leader Mitch McConnell "omitted" Collins from a working group of senators he picked to draft the Senate bill, but she "has formed a bipartisan working group that may help build a foundation for future changes should Senate Republicans fail on their own, which seems increasingly likely," Steinhauer writes.

Maine could be a model for some reforms. It was one of a handful of states that included a “guaranteed issue” policy of health insurance, regardless of pre-existing medical conditions, has one of the few remaining health-insurance cooperatives, and formed high-risk pools to help sick people buy insurance, while stabilizing the markets. Collins says the House bill doesn’t fund high-risk pools anywhere near the level that Maine has.

Drug and mental-health treatment in Medicaid expansion would be optional under House plan

House Republicans' replacement for Obamacare would repeal in 2020 the requirement that substance abuse and mental-health care be covered under Medicaid expansion. That could have a disproportionate impact in rural areas, where such services tend to be less accessible already.

"The proposal would also roll back the Medicaid expansion under the act — commonly known as Obamacare — which would affect many states bearing the brunt of the opiate crisis, including Ohio, Kentucky and West Virginia. Thirty-one states and the District of Columbia expanded Medicaid under the ACA," report Katie Zezima and Christopher Ingraham of The Washington Post. "Advocates and others stress that mental-health disorders sometimes fuel drug addiction, making both benefits essential to combating the opioid crisis. . . . Republicans on the committee argue that the change would give states additional flexibility in coverage decisions, and believe they would continue to provide addiction and mental-health coverage to Medicaid recipients if needed."

However, President Trump has vowed to expand drug treatment, and "Several Republican senators expressed concern about removing the benefits. Sens. Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) sent a letter to Senate Majority Leader Mitch McConnell (R-Ky.), stating that the plan does not 'provide stability and certainty' for individuals and families enrolled in Medicaid expansion programs, or flexibility for states," the Post reports.

The reporters note, "Nearly 1.3 million people receive treatment for mental-health and substance abuse disorders under the Medicaid expansion, according to an estimate by health care economists Richard G. Frank of the Harvard Medical School and Sherry Glied of New York University."

Frank told the Post that dropping addiction treatment services for low-income people is especially harmful, because they are more likely to abuse drugs. "He said Medicaid recipients who are covered for addiction treatment and maintain their coverage through 2020 would not lose the benefit under the GOP proposal. But, he added, because addiction is a chronic-relapse disease, people may get clean, relapse, stop working and need to go back on Medicaid," the Post reports.

House health-care draft suggests a plan that could leave rural areas short of coverage

Photo from The Atlantic

A 100-page draft of a House Republican plan to repeal the Patient Protection and Affordable Care Act suggests that "millions of people in rural areas where it’s already hardest to find doctors might no longer be able to afford health insurance in a few years," Van R. Newkirk II writes for The Atlantic.

"The basics of that plan, which was unveiled by House Speaker Paul Ryan two weeks ago, and the rough shape of which has the support of new health secretary Tom Price and the Trump administration, are known," Newkirk reports. "The plan removes the individual and employer mandates to purchase and provide insurance, respectively, and it would also repeal most of the taxes that fund Obamacare. It would roll back funding for the Affordable Care Act’s Medicaid expansion and dramatically restructure the Medicaid program’s funding. Further, the plan would replace the Affordable Care Act’s cost-sharing subsidies and premium tax credits with an age-rated tax credit, all while keeping Obamacare’s popular pre-existing conditions ban."

The draft was leaked to Politico last week. It "specifies that Obamacare’s Medicaid expansion for low-income able-bodied adults won’t be completely eliminated, but the eligibility and funding will be rolled back after 2020. The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation," Newkirk says.

The draft plan repeals the tax-based individual mandate and replaces it with an incentive to maintain continuous health-insurance coverage. "For people not covered by employers or public insurance who have to purchase insurance on individual, small group, or exchange markets, this proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months, and also for young adults who don’t enroll in coverage as soon as they age out of their parents’ plans, a surcharge that would not be remitted as taxes to sustain the system, but would be paid as profits to insurers. The effects of this potential measure on individuals’ pockets are potentially limited by a reduction of federal oversight over what can be considered health-insurance coverage, which would allow people to avoid penalties by purchasing barebones coverage," Newkirk explains. (Read more)

GOP senators from Medicaid expansion states want to delay ACA repeal until a replacement is enacted

Republican senators who want to delay President-elect Donald Trump's plans to immediately repeal the Patient Protection and Affordable Care Act, until a suitable replacement can be enacted, are mostly from states that expanded Medicaid under the law, Sy Mukherjee reports for Fortune. About 20 million Americans stand to lose coverage if the law is repealed and not replaced.

GOP senators from Alaska, Louisiana, Maine, Ohio and Maine"signed on to an amendment Monday that would essentially delay (although non-bindingly) the repeal process by about a month to give congressional committees more time to craft an alternative," Mukherjee writes, noting that Alaska, Louisiana and Ohio have expanded Medicaid. Other Republican senators from Arizona, Kentucky (expansion states) and Tennessee (where the legislature blocked the governor's expansion plan) "recently warned against a hasty Obamacare repeal sans a replacement."

Mukherjee notes, "A number of red states have ardently refused to go along with the expansion, but Kentucky, Arkansas, Louisiana, Alaska, and other Medicaid expansion states have all seen massive drops in their uninsured rates after adopting it, providing a boon in rural regions where many hospitals regularly see patients who can't afford their care. There's also significant evidence that this newfound coverage has allowed previously uninsured people to access all sorts of basic medical treatments that they never used before, according to the Kaiser Family Foundation." (Kaiser graphic: States that have expanded Medicaid, as of October 2016, are in blue)

Repealing health reform could kill struggling rural hospitals, many in areas Trump carried

If Congress repeals the health-reform law, struggling rural hospitals, many in regions that strongly supported Donald Trump, could be in danger of shuttering, Shefali Luthra reports for Kaiser Health News. The Patient Protection and Affordable Care Act "threw a number of life-savers to these vital but financially troubled centers. And its full repeal, without a comparable and viable replacement, could signal their death knell."

Best Places map

Luthra's example is Highlands Hospital in Connellsville, a poor rural town in Southwest Pennsylvania, which has struggled with the loss of coal mining and manufacturing jobs. Trump won Fayette County with 64 percent of the vote. Without Obamacare's expansion of Medicaid, the 64-bed hospital, the town's second largest single employer, could close, costing the town hundreds of local jobs.

"In Pennsylvania, 625,000 people enrolled in the expanded Medicaid program," Luthra writes. "Close to 300,000 came from rural areas, said Andy Carter, president of the Hospital and Health System Association of Pennsylvania. As of October, about 42,700 of Fayette’s residents had Medicaid, according to state data, an increase of about 8 percent from 39,460 in June 2015. (Pennsylvania‘s Medicaid expansion took effect in January of that year.) That’s close to one-third of the county’s population."

"Rural hospitals have long operated on the edge," Luthra writes. "In the past six years, more than 70 such facilities have closed, citing financial duress. Almost 700 more have been deemed at risk of following the same path. Meanwhile, the need for reliable health care remains pressing. Conditions such as heart and lung disease are widespread in rural areas. Addiction to the prescription painkillers known as opioids is acute. Nationally, the Medicaid expansion offered a bit of stability for some rural hospitals at risk of closure. Researchers say it disproportionately benefited such facilities—particularly here and other states with large rural populations, such as Illinois, Kentucky and Michigan."

New Democratic N.C. governor wants to expand Medicaid before Trump gets in; GOP says illegal

The Obama administration said Monday it will act quickly on plans by North Carolina's recently elected Democratic Gov. Roy Cooper to expand Medicaid in the state, William Douglas and Lesley Clark report for McClatchy Newspapers. President-elect Donald Trump has said repealing federal health reform, of which Medicaid expansion is the most expensive part, is one of his first priorities after taking office at noon Jan. 20.

Cooper last week sent a letter to federal officials "alerting them of his intention to expand Medicaid, which currently covers 1.9 million North Carolinians and costs $14 billion a year," reports McClatchy Newspapers. "Two-thirds of the expense is paid for by the federal government."

North Carolina Republicans in the House and state legislature responded with "a letter to Centers for Medicare & Medicaid Services Acting Administrator Andrew Slavitt, urging him to reject Cooper’s expansion plan," McClatchy reports. They "said Cooper’s move was illegal because a 2013 state law prevented the governor from seeking expanded Medicaid coverage without the state legislature’s support." They wrote: “Any governor of North Carolina does not have the legal authority to submit a Medicaid expansion plan to CMS. Such actions would commit the state to approximately $600 million in new spending each year."

Interstate health insurance? It's more complicated than it sounds, and might be bad for rural buyers

The idea of letting insurance companies sell across state lines seems simple, but in practice it wouldn't be, and it might disadvantage rural areas and states, reporter Jackie Farwell writes for the Bangor Daily News.

President-elect Donald Trump has proposed interstate health insurance, "a perennial favorite of Republicans," Harwell notes. Maine, Georgia and Wyoming have tried it, but no insurance companies took them up on their offers. "Trump’s proposal is different, aimed at allowing sales of health plans across all 50 states instead of just a few. And he has released no specifics about how it would work," Farwell notes. "But Maine’s experience reveals some of the problems with this general approach."

First, insurers need networks of health-care providers to "keep costs down, by negotiating lower prices with providers in their networks, which should lead to more affordable monthly premiums for consumers. Networks also allow insurers to select doctors and hospitals that meet certain safety and quality standards," Farwell writes. "But networks are expensive to set up. Insurers have to pay lawyers to draw up contracts, spend time negotiating rates and so on. That’s part of why even in states with lax insurance regulations, you don’t see 20 insurers competing for business. Allowing the sale of insurance across state lines wouldn’t make forming networks any easier."

Also, "Health-care costs vary from state to state . . . because of the relative age and health of residents and other factors. That’s reflected in different monthly premiums in each state," Farwell notes. "Under Trump’s proposal, a wide swath of America’s population would presumably become the customer pool for health insurers. States with cheaper health care would likely end up subsidizing customers in other states," which could suppress premium increases. "But health insurers would have to grow even bigger to serve such a big customer base. Is that in consumers’ best interests?" she asks, noting antitrust lawsuits against big insurance mergers.

The National Association of Insurance Commissioners, which has a "Myth vs. Reality" sheet about interstate insurance, "warns of a 'race to the bottom,' in which insurers cherry-pick the healthiest customers in each state, who are the cheapest to insure. That would leave everyone else — the older, sicker and more expensive — to face steep premium hikes, if those people can even find a plan to cover them," Farwell writes. Rural areas and states have older populations.

"Proponents point out that the proposals pushed by Trump’s pick for HHS secretary, Tom Price, and House Speaker Paul Ryan would require insurers to provide a minimum level of benefits in order for consumers who buy them to qualify for tax credits. And Trump has said that health plans would have to comply with regulations in each state," Farwell writes. "But if that’s the case, it’s difficult to envision how the benefits of his proposal would be realized. They’re built, at least theoretically, on doing away with a lot of those regulations." (Read more)