Now we know…

The Republicans have just floored their health care reform bill. You can read the details all over the internet. But it’s a disaster for rural hospital districts like ours. We have the oldest population of any county in the State and  rely heavily on Medicare reimbursement. We also have a huge poor population, which relies on Medicaid. Let’s just set aside the number of people who come to the food bank weekly.

Our reliance on  Medicare and Medicaid patients being reimbursed from the federal government at rates that make it worthwhile to do the work of caring for them, make it important not to lose what ground has been gained. Before Obamacare we were running a deficit that the taxpayers of this county paid for. Since Obamacare we are running a surplus. Not much, but not in the red. Now this. Who’s going to pay?The general attitude that I hear all the time from acquaintances and on the Internet is that they don’t want more taxes. The poor will come into the emergency rooms regardless if they are covered or not. But if the Feds don’t pay for them, it will be on us. You and I. Or the hospital could eventually close. Just ponder the words of a Kaiser Family Foundation study published in 2016 (JHC is  a 25 bed hospital):

In 2012-2013, rural hospitals had an average of 50 beds and a median of 25 beds. They had an average daily census of 7 patients and 321 employees, and they were 10 years old on average. Compared to urban hospitals, rural hospitals are more likely to be in counties with an elderly and poor population.9 According to The North Carolina Rural Health Research Program (NC RHRP) at the Cecil G. Sheps Center for Health Services Research, which tracks rural hospital closures, there were 72 rural hospital closures between January 2010 and April 2016, compared to 42 closures between 2005 and 2009, and since the 2008-2009 recession, the annual number of closures has increased each year.10 More than half of all rural hospital closures since 2010 were in the South and few Southern states have expanded Medicaid under the ACA.

The expectations are that we are in for some very hard times in the years ahead. It will take a lot of effort to keep our hospital running efficiently and staffed appropriately. Even now, we are having a hard time retaining quality medical staff even though we offer competitive salaries to Seattle, according to the hospital administration. Unfortunately, we have not done a great job at looking at foreign trained medical professionals, which are in wide spread use at Harrison and other nearby medical facilities. We also are behind the curve in the use of less expensive mid-levels, ARNPs and PAs. To the hospital district’s credit, the number of those mid-levels is up recently, probably due more to federal requirements and an inability to retain physicians, more  than anything else.

Perhaps if the Democrats win back the House and Senate and eventually the Presidency we can hope for fixes to this awful proposal which was created by a cabal of men behind closed doors. No women, even of their own party, were asked to work with them. It was despicable back room politics of the worse kind. They have even screwed their own constituents in places like Spokane and Wenatchee, as rural hospitals there are even farther from urban centers.  You have to wonder just who they represent? Or maybe we already know and this next four years will finally drive that home to their supporters in places throughout the rural west and south. Or maybe those voters and non-voters are so tuned into Fox News that they can’t connect the dots anymore.

We can only hope that we will get through the next four years without seeing a collapse of our hospital and the services it is offering, even though prices are already causing people who are aware of the high charges to drive closer into Seattle to seek competitive rates for services.

Now more than ever we need engaged, knowledgeable people in the role of Hospital District Commissioner, which is an election that is happening now. We don’t need a rubber stamp for the hospital district administration, we need deeply knowledgeable people who can roll up their sleeves and help, challenge the administration when needed and go advocate for the hospital district in the State and Federal arenas.

We need leadership from skilled medical professionals who have spent time in the trenches, understanding  both the issues of health care administration and the needs of our neighbors because they have sat in the rooms with these patients as they poured out their hearts to them about their medical conditions and their ability to pay for treatment or drugs. People who held them as they cried. Who may have given them free treatment rather than walked away. Who might have sometimes given them hard news. People who know what we have to fight for and can help guide the hospital district administration and our elected officials forward through this coming dark night.

Medicaid is for everyone – New York Times

The war on the poor in America continues. As the Republicans work in secrecy to come up with a healthcare bill to serve someone other than the average American,  The New York Times ponders the destruction of Medicaid, high on the Republicans list. If ever there was a rich vs. poor issue, this is it. If this gets implemented as the Republicans and Trump want, it will have disastrous consequences for Jefferson and Clallam Counties. Both of them have high levels of both Medicaid and Medicare beneficiaries and our hospitals budgets are based on those reimbursals being available. It is the calm before the storm here.

First to lose Obamacare? The sickest county in the state – Seattle Times

The Seattle Times has a good article about the outcome of the Republican led move to sow uncertainty and doubt about Obamacare’s future. Gray’s Harbor joins the growing ranks of county’s without healthcare insurance for over 2200 of it’s residents. And if the Republicans in Washington get their way, there will be over 7000 more joining them soon. Oddly, out of all this, we may end up getting single payer, due to the Republicans apparently hell bent on committing political suicide by alienating their base of white rural lower to middle class voters. 47 counties nationwide now don’t have health insurance companies serving them, most of the counties voted Republican. Read it and weep. Because counties like ours, which are largely using Medicare and Medicaid to supply us with health coverage are next up on the Republicans chopping block.

Obamacare is starting to crack, starting in our state’s sickest spot, Grays Harbor County. But the plan isn’t to fix it. It’s to make it dramatically worse.

Trump Makes His First Big Changes To Obamacare – Huffington Post

This is a very important read for any of us tracking the Administration’s attack on healthcare.

The overall consequence of the new rules is that health insurance will be harder to buy in 2018, especially for people whose circumstances change during the year, enabling them to buy policies outside the annual sign-up period. The length of that sign-up period is also cut in half.

Thank you to the Huffington Post for making this news digestible to almost anyone that knows how to read. Read the whole article here:

Trump Makes His First Big Changes To Obamacare

Thoughts on Trump’s approach to Healthcare

From Diane Jones:Here is what I hear from the healthcare advocates group I connect with:
1. What changes will the Trump Administration attempt to make through rulemaking?


Republicans have talked about a three-pronged strategy for ACA repeal and replace: (1) enact the American Health Care Act (AHCA) through the budget reconciliation process; (2) make changes through the regulatory process; and (3) enact follow-up legislation through normal order (i.e., not through the budget reconciliation process). They have emphasized within their own caucus that they can do a lot through the second prong. According to Politico, President Trump’s budget director, Mick Mulvaney, even went so far as to present the Freedom Caucus “a letter from Trump outlining all the Obamacare regulations his administration would repeal on its own” as part of the last-ditch effort to win over its members last Thursday night.


Presumably, the administration will still move forward with a major portion of these planned rule changes. HHS had already begun using the rulemaking process to make change before the AHCA was even unveiled. On February 17, HHS issued a proposed rule billed by the Department as aimed at improving market stabilization, though its primary elements were in fact directed at making it more difficult for individuals to purchase coverage, opening the door to lower-value plans, and lowering the amount of federal premium tax credits. (The AFL-CIO comments on the proposed rule are attached.) The IRS also reportedly is softening enforcement of the individual shared responsibility penalty. There are many other areas the administration could pursue. Back in January, Nicholas Bagley and Adrianna McIntyre at the Incidental Economist had a good run down of potential changes: Executive Actions Trump Could Take to Change the ACA. We discuss a few potential avenues for change in the questions below.


2. Does the Trump Administration go along with Congress in stopping cost sharing subsidy reimbursements to insurers participating in the marketplaces?


It is widely recognized that a surefire way to tank the ACA individual marketplaces quickly would be to halt reimbursement of insurers for cost-sharing subsidies they are required to provide enrollees with household incomes below 250 percent of the federal poverty level. That’s why resolution of an ongoing lawsuit between congressional Republicans and the federal government over whether the government has the authority to reimburse insurers absent a congressional appropriation is so important. The Trump Administration and congressional Republicans need to decide whether to pay up or create havoc.


3. What will happen to Medicaid?


Medicaid still has a huge target on its back. The House Republican plan would have cut $839 billion Medicaid spending over 10 years, not only rolling back the ACA Medicaid expansion but also ending the half-century-old federal Medicaid funding guarantee through per capita caps (or optional block grants for some beneficiaries) among other changes. Republicans will be tempted to make another run at Medicaid in subsequent budget reconciliation legislation, since cuts to it could be used to pay for tax cuts.


Also, as we noted last week, HHS secretary Tom Price and CMS administrator Seema Verma recently sent a letter to governors signaling that HHS and CMS are now open for business when it comes to waivers (known as Section 1115 waivers). They would like to allow states to make significant changes to their Medicaid programs, like imposing work requirements for certain enrollees (which the failed House Republican plan would have permitted by statute).


4. How will HHS try to use state innovation waivers to reshape the ACA?


The ACA comes with a built-in tool for trying alternative approaches to achieving the ACA’s coverage and affordability goals, through state innovation waivers under Section 1332 of the Act. The Trump Administration has expressed some initial interest in using these waivers.On March 13, HHS secretary Tom Price sent a letter to governors soliciting state innovation waiver applications, with an emphasis on applications that include high-risk pools or state-operated reinsurance programs. More broadly, conservatives have expressed interest in using these waivers in combination with Medicaid Section 1115 waivers, as a way to devolve control to states. See, for example, the Manhattan Institute’s State Waivers: A Federalist Rx for Obamacare Ills. HHS likely will issue new agency guidance and possibly use the rulemaking process to give states more leeway under Section 1332.


5. What will happen to Value-Based Payment Models with Tom Price in charge of HHS?


On March 21, HHS and CMS issued an interim final rule (IFR) announcing a further delay of two mandatory bundled payment programs under Medicare for heart attack treatment and bypass surgery, a delay of the Cardiac Rehab Incentive Payment Model and a delay in the expansion of the mandatory Comprehensive Care for Joint Replacement Model. The IFR solicits comments on the delay as well as a further delay. This raises questions about the future of many of the on-going efforts to improve care and reduce costs through alternative payment models. HHS Secretary Tom Price does not support much of this work and considers the Center for Medicare and Medicaid Innovation (CMMI)—the ACA-created entity that develops new models for delivering and paying for care under certain government programs—to be an incursion into Congressional authority and oversight. This is despite CBO’s view that CMMI reduces federal spending. Questioning value-based payment models may also lead to changes under MACRA and impact physician payments under Medicare.


6. How will health care come up in tax reform?


President Trump and congressional Republicans say they soon will turn to tax reform. Health care is likely to come up in several ways. The biggest question is whether Republican tax reform plans will go after the tax exclusion for workplace health plans. Leaders like House Ways & Means Committee chairman Kevin Brady (R-TX) made it clear early in the ACA repeal and replace debate that they really would like to cap the tax exclusion. The leaked version of the House health bill capped it at the premium for the 90th percentile plan, before the drafters removed it in favor of a straight-up delay in “Cadillac tax.” Other things to keep an eye on include HSA changes (especially big increases in the contribution limits) and restoring the medical expense deductibility threshold at its pre-ACA level (7.5% of income).


7. What’s next for the “Cadillac tax”?


The excise tax on high-cost health plans is scheduled to go into effect beginning in 2020. Failure of the Republican health plan may lead Treasury and IRS to restart the regulatory process and move toward issuing a proposed rule. On the other hand, Treasury and IRS may slow walk things if they believe Congress is likely at least to delay the effective date again before it goes into effect. The last version of the House bill would have delayed the tax until 2026. As noted above, Congress may also try to replace the tax with a cap on the tax exclusion as part of comprehensive tax reform.


8. Will Congress try to move smaller pieces of legislation?


House Republicans have teed up several health care bills separate from their ACA repeal and replace plan. For example, the House passed theSmall Business Health Fairness Act (H.R. 1101) on Wednesday. (See the AFL-CIO letter opposing this bill attached to this e-mail.) At the moment, it seems unlikely this bill, which authorizes so-called association health plans, will move in the Senate, but Republicans could try to show some progress on health care with smaller pieces of legislation like this bill.


9. What will President Trump do, if anything, about prescription drug prices?


President Trump has repeatedly gone after prescription drug manufacturers because of high drug prices and has said he supports government drug price negotiating authority. However, he has sent very mixed signals about his intentions. The day before he met with Rep. Elijah Cummings (D-MD) and Rep. Peter Welch (D-VT) to discuss their draft legislation to give HHS price negotiating authority for Medicare, President Trump tweeted:


President Trump previously met with PhRMA’s leaders and struck a conciliatory tone toward drug manufacturers, indicating that he saw regulatory barriers and the slow drug approval process as the major problems. So, any action on drug prices is TBD.


10. Will single payer proposals or legislation building on the ACA’s basic structure, such as a public option, gain momentum now?


Sen. Bernie Sanders (D-VT) has announced that he soon will introduce a “Medicare for All” bill, which Rep. Peter Welch (D-VT) also will introduce in the House of Representatives. This is in addition to the Expanded and Improved Medicare for All Act (H.R. 676) that Rep. John Conyers (D-MI) has introduced in successive congresses. A Sunday Washington Postarticle quotes Sen. Jack Reed (D-RI) and Rep. Jim Langevin (D-RI) also calling for single payer, and their colleague Sen. Sheldon Whitehouse (D-RI) endorsing the public option.


11. Will Republicans try to engage Democrats around alternative ACA replacement ideas?


Legislation introduced by Sen. Bill Cassidy (R-LA) and Sen. Susan Collins (R-ME) in January, the Patient Freedom Act of 2017 (S. 191), garnered a lot of attention as something that might build a bridge for some Democratic support. That’s partly because this bill would give individual states the option of keeping some elements of the basic ACA structure (individual and employer shared responsibility requirements, marketplaces, and ACA premium tax credits and cost-sharing subsidies at somewhat lower levels), though the emphasis would be on alternatives that are heavy on block grants and state control. There are lots ofproblems with the bill, but it’s worth paying attention to whether Republicans try to engage centrist Democrats around this kind of approach

Health leaders in Washington state seek improvements in existing health care law – Yakima Herald

Good original article by the Yakima Herald’s Molly Rosbach. Especially useful is it’s point on the use of Electronic Health Records, the bain of many physicians.

“Physicians don’t want to get rid of their EHRs; they understand the value, they just want to make sure it works in a way that’s natural to their work flow,” rather than a series of mindless boxes to check off, said Jennifer Hanscom, executive director of the state Medical Association. “It would be great if we could sit down with the folks at (Health and Human Services) in particular to kind of walk through that, and keeping the lens of a physician on all those regulations.”

A big area where documentation regulations appear at odds with the broader transition from fee-for-service to value-based purchasing is in prior authorization, Hanscom said: Why do insurers still require prior authorization, a extra step for patients and doctors, if doctors are already using the best evidence-based guidelines to make decisions about what services the patient needs?”

Read the whole story here: