Millones podrían perder el Medicaid bajo el plan de Trump

Millones de personas de bajos ingresos que tienen Medicaid podrían perder su cobertura de salud si el presidente electo Donald Trump y el Congreso controlado por los republicanos siguen las propuestas del partido para cortar el financiamiento del programa federal gerenciado por los estados.
El mayor riesgo para los beneficiarios del Medicaid proviene de las promesas de Trump y otros republicanos de revocar la Ley de Cuidado de Salud Asequible (ACA), que proporciona fondos federales a los estados para ampliar la elegibilidad de Medicaid desde el 2014. Treinta y un estados y Washington, DC lo hicieron, sumando 15,7 millones de personas al programa, según el gobierno.
Alrededor de 73 millones están inscriptas en el Medicaid, y cerca de la mitad son niños.

Una de las metas de Trump y del nuevo Congreso será reducir el número de personas en el Medicaid, asegurándose que sólo los más necesitados —como los niños o las embarazadas— permanezcan elegibles, dijo Brian Blase, investigador principal del conservador Mercatus Center en la George Mason University en Virginia.
“Si no tenemos menos personas en el Medicaid en cuatro años, entonces no hemos reformado la política de salud en una buena dirección”, dijo.
Pero hay obstáculos para los planes de los republicanos. El Medicaid, una de las iniciativas de la “Gran Sociedad” del presidente Lyndon Johnson, que fue creado en 1965, es el principal programa de seguro de salud de la nación para personas de bajos ingresos.
La revisión es políticamente difícil debido al daño potencial a los beneficiarios, así como a las consecuencias financieras para los estados, hospitales, médicos y otros proveedores de salud, quienes podrían no recibir el pago por sus servicios si los pacientes no tienen cobertura.
En el año fiscal 2015, el gasto total del Medicaid fue de $532 mil millones, con un 62 por ciento de esa cifra financiada por el gobierno federal.
Un cambio importante respaldado por el presidente Trump y por el líder de la Cámara de Representantes, Paul Ryan (republicano de Wisconsin) transformaría al Medicaid de un programa “por derecho” a un programa de subvención en bloque.
Ésta es la diferencia: En un programa por derecho, la cobertura está garantizada para todos los que son elegibles. El compromiso del gobierno federal para ayudar a los estados a cubrir los costos es abierto. La obligación de los estados es cubrir a ciertos grupos de personas y proporcionar beneficios específicos. Por ejemplo, los niños y las mujeres embarazadas que cumplan con criterios específicos de ingresos deben ser cubiertos.
Esa fórmula cambiaría si los fondos federales fluyen a los estados a través de subvenciones en bloque. Los estados tendrían más flexibilidad para ejecutar sus programas de Medicaid como lo desean, incluyendo la reducción de beneficios y elegibilidad. Y los que proponen esto dicen que permitiría al gobierno federal gastar menos en el Medicaid y hacer que los estados sean responsables de cubrir costos más allá de sus asignaciones federales.
Convertir al Medicaid en un programa de concesión en bloque se ha discutido por más de 25 años, pero la idea siempre ha encontrado resistencia por parte de algunos estados, proveedores de salud, defensores del cuidado médico y demócratas. Incluso con una mayoría republicana en el Congreso y Trump en la Casa Blanca, el plan todavía se enfrentaría a una batalla legislativa cuesta arriba.
El gobierno federal rara vez otorga poder a los estados, y no todos los estados quieren estar en mayor riesgo financiero por el programa.
“Las subvenciones en bloque del Medicaid se enfrentan a un futuro muy incierto”, dijo Joel Cantor, director del Center for State Health Policy en la Rutgers University en New Jersey.
Otra opción para redefinir la financiación del Medicaid, similar a una subvención en bloque, se conoce como un tope per capita. Se les daría a los estados una cantidad fija de dinero por afiliado, lo que aumentaría cada año, pero los críticos temen que probablemente no se mantenga al día con los crecientes gastos de salud. Ese método ayudaría a los estados a lidiar mejor con el aumento de la matrícula porque la financiación también aumentaría.
Incluso sin la ayuda del Congreso, la administración Trump podría cambiar el Medicaid usando el poder del Ejecutivo para aprobar las solicitudes de los estados para las exenciones de las reglas federales. Eso podría permitir que Trump apruebe los cambios propuestos por los gobernadores republicanos que la administración Obama ha rechazado, incluyendo los requisitos de trabajo para los afiliados del Medicaid, y las primas mensuales y otros costos compartidos.
Trump también podría terminar con algunas exenciones que ampliaron el Medicaid y enviaron miles de millones en nuevos fondos federales a algunos estados que transformaron la atención de salud.
Cualquier cambio al Medicaid por parte del Congreso el próximo año probablemente incluiría negociaciones sobre el Programa de Seguro de Salud para Niños (CHIP), otro programa federal-estatal que provee cobertura a niños y jóvenes cuyas familias tienen ingresos algo más altos de lo que la elegibilidad para el Medicaid requiere.
El programa caduca si no se reautoriza el 30 de septiembre del 2017. Según la Kaiser Family Foundation, aproximadamente 8 millones de niños reciben cobertura a través del CHIP, un programa que ha tenido apoyo republicano y demócrata.
Después de que Trump asuma el cargo, puede darse cuenta que es más difícil de lo que pensaba derogar el Obamacare y jugar con el Medicaid, porque cortar la cobertura de millones de personas podría causar muchas consecuencias políticas, dijo Joan Alker, directora ejecutiva del Center for Children and Families de la Georgetown University.
Por ejemplo, el gobernador republicano Matt Bevin de Kentucky tomó una táctica similar el año pasado haciendo campaña en contra del Obamacare y prometiendo eliminar la expansión del Medicaid, observó Alker. Desde entonces ha propuesto cambios importantes al Medicaid, pero aún no ha actuado para impedir su expansión.
Sin embargo, Alker dijo que la victoria de Trump pone la idea de la concesión de bloque en el frente y centro (de la discusión) en enero. Y un acuerdo para hacerlo podría dar flexibilidad a los estados para hacer recortes en los beneficios actualmente requeridos por el gobierno federal, tales como exámenes de salud para bebés y niños.
“Estaría muy preocupado por lo que podría suceder”, dijo Alker.

Concerned About Losing Your Marketplace Plan? ACA Repeal May Take Awhile

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President-elect Donald Trump has promised that he’ll ask Congress to repeal the Affordable Care Act on Day One of his administration. If you’re shopping for coverage on the health insurance marketplace, should you even bother signing up? If everything’s going to change shortly after your new coverage starts in January anyway, what’s the point?
While it’s impossible to know exactly what changes are coming to the individual market and how soon they’ll arrive, one thing is virtually certain: Nothing will happen immediately. Here are answers to questions you may have.
Q. How soon after Trump takes office could my marketplace coverage change?

A. It’s unlikely that much, if anything, will change in 2017.
“It’s a complex process to alter a law as complicated as the ACA,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. It seems unlikely that congressional Republicans could force through a repeal of the law since Democrats have enough votes to sustain a filibuster blocking that move. So Congress might opt to use a budget procedure, called “reconciliation,” that allows revenue-related changes, such as eliminating the premium tax credits, with simple majority votes. Yet even that process could take months.
And it wouldn’t address the other parts of the health law that reformed the insurance market, such as the prohibition on denying people coverage if they’re sick. How some of those provisions of the law will be affected is still quite unclear.
“It will likely be January 2019 before any new program would be completely in place,” said Robert Laszewski, a health care industry consultant and long-time critic of the law.
The current open enrollment period runs through January 2017. Shop for a plan, use it and don’t focus on what Congress may do several months from now, Rosenbaum advised.
Q. Will my subsidy end next year if the new administration repeals or changes the health law?
A. Probably not. Mike Pence, the vice president-elect, said on the campaign trail that any changes will allow time for consumers receiving premium subsidies to adjust.
Timothy Jost, an emeritus professor at Washington and Lee University School of Law in Virginia who is an expert on the health law, also predicts a reasonable transition period.
Congress and the new administration are “not eager to have a bunch of angry, uninsured voters,” Jost said.
Theoretical conversations about changing the health law are one thing, but “I think that Congress may be less willing to just wipe the subsidies out if a lot of people are using them,” Rosenbaum said. More than 9 million people receive subsidies on the marketplace, according to the federal Department of Health and Human Services.
Q. Can my insurer drop out once the new administration takes over, even if the law hasn’t been repealed?
A. No, insurers are generally locked in contractually for 2017, according to experts. But 2018 could be a whole different story, said Laszewski.
Many insurers are already losing money on their marketplace offerings. If they know that the health insurance marketplaces are being eliminated and replaced by something else in 2019, why would they stick with a sinking ship?
“The Trump administration could be left with a situation where Obamacare is still alive, the subsidies are still alive, but not the insurers,” said Laszewski. To prevent that, the Trump administration might have to subsidize insurers’ losses during a 2018 transition year, he said.
Q. My state expanded Medicaid to adults with incomes up to 138 percent of the federal poverty level (about $16,000). Is that going to end if Obamacare is repealed?
A. It may. Trump has advocated giving block grants to finance the entire Medicaid program on the theory that it provides an incentive for states to make their programs more cost-effective. But that strategy could threaten the coverage of millions of Americans if the block grants don’t keep pace with costs, Jost said.
So far, 31 states and the District of Columbia have expanded Medicaid under the health law. Republican governors in these states may play a key role in arguing against taking the expansion money away, Rosenbaum said.
Q. I have a heart condition. Does this mean I’m going to have a hard time finding coverage?
A. It’s possible. The health law prohibits insurers from turning people away because they’re sick and may be expensive to insure.
Republicans have generally promised to maintain that guaranteed insurability, but what that would look like is unclear. Some of their plans would require people to remain continuously insured in order to maintain that guarantee, said Laszewski.
“I would advise people who are sick to get good coverage now and hang onto it,” said Jost.
Q. Since Republicans have pledged to repeal the law, can I ignore the law’s requirement that I have health insurance?
A. The individual mandate, as it’s called, is one of the least popular elements of Obamacare. As long as it’s the law, you should follow it, experts said.
Insurers have argued that the requirement that they take all comers who apply for health insurance only works if there’s a coverage mandate or other mechanism that strongly encourages people to have insurance. Otherwise why would they bother unless they were sick?
For the past few years, Republicans have been pushing hard to eliminate the mandate, Laszewski noted.
“One of the easy things they could do is just not enforce it,” he said.
Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Genetically Engineered Mosquitoes Split A Straw-Poll Vote In The Florida Keys

Voters in one Florida county were at odds on a ballot referendum Tuesday about whether to allow the first trial of “Frankenflies” — mosquitoes genetically engineered to reduce populations of the species that spreads Zika.
That species, the Aedes aegypti, lives in homes and is difficult to root out with insecticides. In addition to Zika, they spread yellow fever, dengue and chikungunya.
In Key Haven, the town where the trial could be staged, more than 65 percent of voters rejected the plan. In Monroe County, which encompasses Key Haven, more than 57 percent of voters said yes to it.
The ballot measure, sometimes referred to as a “straw poll,” is non-binding. A final decision on the question will be made by the Florida Keys Mosquito Control District Board, which is scheduled to meet Nov. 19 to discuss the poll results as well as the results of five other surveys the county has conducted.
The outcome of these deliberations could encourage further exploration of the technology, which its manufacturer and charity benefactors describe as a silver bullet to curbing mosquito-borne illnesses, but detractors say is an expensive and risky business opportunity.

“While we did not win over every community in the Keys, Oxitec appreciates the support received from the community and is prepared to take the next steps with the Florida Keys Mosquito Control Board,” said CEO Hadyn Parry in a statement. Oxitec, the company that developed the “Frankenflies,” is owned by Intrexon Corporation, a biotechnology firm with a portfolio focused on synthetic biology.
If the trial moves forward, the British-based company’s mosquitoes would be released three times a week over the small peninsula. Key Haven is home to just 1,000 residences and a single gas station. The native mosquito population is insulated by seawater and the island’s main highway, making for a perfect trial location, the company said.
If the trial goes as planned, those mosquitoes will breed with native females, the ones that bite. Both the genetically engineered insects and their offspring carry a fatal gene, and die quickly. Over time, the population will thin out.
“We’re very happy with the results,” Mosquito Control Board Chairman Phil Goodman said of the Monroe County vote. He thought [Key Haven] voters got bad information about the safety of the trial and anticipates the board will choose to go forward, but find another site in the county.
But the referendum has implications beyond this tiny section of the Florida Keys. Miami-Dade County, Florida’s most populous county, has been watching closely and is considering using the genetically modified mosquitoes as well. But the small enclave of Key Haven is a vastly different place than the bustling tourist destination of Miami-Dade, home to 2.7 million people.
A company representative said he could not discuss pricing until the product is sold commercially — as opposed to in a trial period. But in the past, Oxitec has charged based on number of people benefiting from the technology’s use. In Brazil, the tab ran $7.50 per resident. Company officials, however, have told Monroe County that its costs will not be more than it already budgets to control Aedes in the lower keys — about $1.2 million annually, Goodman said.
Trial skeptics raise additional red flags. For instance, since the genetically engineered mosquitoes do not by design produce offspring, the company would have to continually pump them into the environment.
“If you want to implement a male sterilization program, there are other ways to do that,” said Durland Fish, a Yale University professor of microbial diseases as well as forestry and environmental studies, who questions the plan. “This is a business opportunity. This is expensive. And you can’t stop doing it.”
Some vocal Monroe residents have raised environmental concerns and even circulated an online petition.
The Food and Drug Administration determined in August that the trial would have “no significant impact” on the environment, paving the way for mosquitoes’ release. And the World Health Organization and Pan American Health Organization have tentatively recommended expanding trials, with the caveat that more clinical data is needed.
But it may not be so straightforward, said Fish. Eliminating Aedes from one ecosystem could lead to a reinvasion, or an invasion of another disease-carrying species, like Aedes albopictus, he added.
Luke Alphey, who engineered the mosquitoes and cofounded Oxitec, has a very different view. “Part of the motivation for this research was using modern genetics to provide the striking benefits of this kind of approach [sterilizing mosquitoes],” including the avoidance of insecticides and being able to target a specific species without harming others.

How To Spend Your Final Months At Home, Sweet Home

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There’s no mystery about what older adults want when they become seriously ill near the end of their lives.
They want to be cared for at home. For as long as possible.
It’s easy to understand why. Home represents familiarity, safety and identity — the place where we belong.
Yet health systems aren’t rewarded financially for making “time at home” a priority like they are for reducing the number of patients readmitted to hospitals.
Researchers from the Dartmouth Institute for Health Policy and Harvard Medical School argued that should change recently in the New England Journal of Medicine.
Health systems should focus on “outcomes that matter to patients,” they wrote, citing a new national analysis of terminally ill patients.
Where these patients — most of them older adults — spent their last 180 days varied significantly across the country. People had the most time at home in Mason City (145.82 days) and Waterloo, Iowa (144.61 days), and the least time at home in Idaho Falls, Idaho (118.83), and Shreveport, La. (119.15 days).

Multiple factors contributed, including the availability of medical and social services and seniors’ financial and caregiving resources.
Do a few more weeks spent at home matter? Yes, if what patients truly value is taken seriously, the researchers asserted.
They describe a patient who had been in the hospital six weeks and finally returned home accompanied by a family member. “Just to see familiar photos on the wall made us feel we could breathe again,” that family member said.
What’s needed to make care at home possible during the last six months of life? We asked several experts:
Reallocating resources. “We have to reallocate resources within the healthcare system to the home setting,” said Dr. Diane Meier, a geriatrician and director of the Center to Advance Palliative Care in New York City.
This is already happening, to some extent. Medicare is testing the feasibility of bringing comprehensive medical services directly to frail, ill seniors through its Independence at Home demonstration project, now in 14 locations.
And house call programs that send physicians into seniors’ homes are beginning to expand across the country. To find a program near you, check this web site sponsored by the American Academy of Home Care Medicine.
Clarifying priorities. If staying at home at the end of life is a priority, this has to be communicated – clearly and frequently — to your family, caregivers, and physicians, said Dr. Thomas Lee, co-author of the New England Journal of Medicine study and chief medical officer at Press Ganey, a firm that tracks patients’ experiences with care.
Tradeoffs have to be part of this discussion.
Lee gives the example of his 89-year-old mother, who lives by herself in a condominium in Boston’s Beacon Hill neighborhood. Though she’s fallen several times, she’s refused to consider moving to assisted living or having a paid caregiver come in to help.
Being safe isn’t his mother’s foremost goal; independence is, Lee said. And that means accepting the risk that she could fall again or hurt herself.
Every time he sees a frail elderly patient, Dr. Thomas Cornwell asks “do you want to go to the hospital if you get sicker or do you want to stay at home?”
“If a crisis occurs, let’s say an exacerbation of congestive heart failure, and your values haven’t been discussed, you’ll generally end up in a hospital and, at least temporarily, in a nursing home,” said Cornwell, who has made over 32,000 house calls and is affiliated with Northwestern Medicine in metropolitan Chicago.
Making medical decisions. Take advantage of services designed for people with serious illnesses who need help at home.
One is home-based palliative care, which addresses worrisome symptoms such as pain or nausea that otherwise could send a vulnerable older adult to a hospital. In this model, a doctor, nurse and social worker join together to address a patient’s needs after a comprehensive assessment.
Home-based palliative care is still relatively new and not widely available. To learn more about programs in your area, go to www.getpalliativecare.org. Contact a few and ask if they offer these services or know of another organization that does.
Hospice care is similar in its approach, but only for people expected to live six months or less. The vast majority receive care in their homes. Unfortunately, most adults wait to sign up for hospice services until the last several weeks of life, missing out on potentially valuable assistance.
Getting needed help. Meier worries that an emphasis on home-based care for people with terminal illness could translate into more work for family caregivers who shoulder the burden of this care, not more support.
Currently, caregivers patch together services as best they can. Medicare doesn’t pay for aides who help frail, ill seniors bathe, dress, toilet, take their medications, keep their house clean, and prepare breakfast, lunch, or dinner. Low-income seniors can qualify for help from Medicaid, but the amount of assistance available is limited and varies by state.
There’s no easy solution to this “how can I get the help I’ll need?” dilemma. Be realistic about the cost of care (about $10 per hour, on average, with wide geographic variation) and the resources you have available. Also, be realistic about other elements of caring for someone at home, including the skills that will be required and whether the environment can support this challenge.
“Are the bedroom, the bathroom, and the kitchen on the same floor?,” asked Cornwell. “If not, you’re going to have a problem.”
Building community. “You’re going to need support” from family, friends or other social contacts if you’re trying to manage a serious illness at home, said Laura Connors, executive director of Beacon Hill Village in Boston.
Her organization sends volunteers into seniors’ homes to help in various ways on an as-needed basis. Older adults pay an annual fee to participate in the community’s social events and qualify for discounted home care services.
As with children, it “takes a community” to care for vulnerable older adults, Connors said, and you need to know “who’s going to be there for you.”

Obamacare ‘Replacement’ Might Look Familiar

The Affordable Care Act transformed the medical system, expanding coverage to millions, injecting billions in tax revenue, changing insurance rules and launching ambitious experiments in quality and efficiency.
Less of that might disappear under President-elect Donald Trump’s pledge to “repeal and replace Obamacare” than many believe, say policy analysts. Republicans promising change might not quickly admit it, but in some respects Obamacare’s replacement may look something like the original.
“It gets into a questions of semantics,” said Mark Rouck, an insurance analyst for Fitch Ratings. “Are they really repealing the act if they replace it with new legislation that has some of the same characteristics?”
Problems that helped give rise to the health law — rising costs, an aging population, mediocre medical results — haven’t gone away. The ACA pushed insurers, hospitals and employers to launch their own reimbursement reforms, which are largely unaffected by who runs Washington.
Even fierce health-law opponents may pause at the political risk of taking benefits from millions who gained coverage since its implementation. Subsidies for the middle class to buy insurance may remain — even if they’re not the Obamacare tax credits applied through online marketplaces, said Joseph Antos, a health economist at the American Enterprise Institute.
“The idea that they’re just going to wipe that money away is pretty unlikely,” he said. “They don’t want to be in a position of saying they’re just kicking millions of people out in the street.”
Others disagree.

“I think they go away,” said Ana Gupte, a health care analyst for Leerink Partners. “The subsidies … are at risk” along with the ACA’s requirement that everybody have health coverage, she said.
Topping the list of ACA provisions likely to survive under Trump is the requirement that employers cover workers’ children up to the age of 26, analysts said. The measure is widely popular and not especially expensive.
A health law crafted by Republicans might also retain the ACA’s protections for people with preexisting illness seeking coverage, said Glenn Melnick, a health economist at the University of Southern California.
That could include relaxing the ACA’s limit on how much insurers can charge and allowing them to adjust premiums based on an individual’s health, he said. However, that might put the price of insurance out of reach for many.
The health law’s payment reforms might also survive in some form. The ACA prompted hundreds of experiments to control costs by rewarding doctors for efficiency and fixing payments for episodes of care or treating entire populations.
“Part of what I would expect to hear from [the new administration] is we want more value out of the entire system,” said Daniel Steingart, a hospital analyst at Moody’s Investors Service. “All of that jibes pretty closely” with ACA payment experiments by the Department of Health and Human Services, he said. “I can foresee a scenario where they gradually expand all those programs.”
Republicans have criticized HHS’s innovation lab, which presides over accountable care organizations and many other payment tests. But they may find it more appealing under their own supervision, said Rodney Whitlock, a strategist and former top Republican health advisor in the Senate.
“You can really want to curtail it — until maybe you’re in charge,” he said. “Then maybe you would like it.”
In any case private insurance companies, employers and hospitals are likely to continue their own payment reforms, analysts said.
“Private industry is really taking that and running with it,” said Gupte. To be sure, health policy and financing are likely to look substantially different in a Trump administration, experts said.
The ACA’s biggest coverage expansion came through the Medicaid program for the poor and disabled, which added more than 15 million people. Trump has suggested giving states fixed federal grants for Medicaid, which could lead to a substantial reduction in coverage or benefits.
Even partial cuts in Medicaid funding and subsidies for private plans would hurt hospitals, which have benefited from the health law’s revenue infusion.
“If you’re running a health system and you now have more insured people through a Medicaid expansion or exchange customers — if even a portion of those go away, that might be your [profit] margin for the year,” said Benjamin Isgur, who heads the Health Research Institute at PwC, a consultancy.
On the other hand, hospitals and insurers represent a powerful lobby seeking to maintain something that looks like the status quo.
“There’s a bigger role [hospitals] can play, a much more cost-effective role we can play if we have a long-term strategy” as part of a consistent health reform program, said Bill Ryan, a spokesman for the Einstein Healthcare Network, a Philadelphia-based hospital system. “And stopping and starting seems to be a crazy way to do this.”
Other aspects of health care will probably stay the same in the near future no matter what Congress does, analysts said.
Health costs continue to grow faster than the economy’s ability to pay for them. Partly as a result, high deductibles — what patients pay before insurance kicks in — have become widespread in employer and individual plans alike. Neither have much to do with the health law, said Don Berwick, who was acting Medicare administrator early in the Obama administration.
Republicans “managed to make the public think Obamacare was causing all the trouble. That is absolutely wrong,” he said. “They could repeal it tomorrow and still have a broken delivery system and costs would continue to go up.”
Now Republicans face the same challenge, said Mark McClellan, who ran Medicare in the George W. Bush administration.
“It’ll be a different path, but the urgency of finding ways to transform health care — to give care that’s more personalized in prevention and less costly and more accessible, especially to people of limited means — the pressure to do that is not going to go away,” he said. “It’s going to increase.”
KHN Senior Correspondents Julie Appleby and Jordan Rau contributed to this story.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Millions Could Lose Medicaid Coverage Under Trump Plan

Millions of low-income Americans on Medicaid could lose their health coverage if President-elect Donald Trump and a Republican-controlled Congress follow through on GOP proposals to cut spending in the state-federal insurance program.
The biggest risk for Medicaid beneficiaries comes from pledges by Trump and other Republicans to repeal the Affordable Care Act, which provided federal funding to states to expand Medicaid eligibility starting in 2014. Thirty-one states and Washington, D.C. did so, adding 15.7 million people to the program, according to the government. About 73 million are now enrolled in Medicaid — about half are children.
Reducing the number of people in Medicaid while ensuring that only the most needy — such as children and pregnant women — remain eligible will be a goal for Trump and the new Congress, said Brian Blase, senior research fellow at the conservative Mercatus Center at George Mason University in Virginia.

“If we do not have fewer people in Medicaid in four years, then we have not reformed health policy in a good direction,” he said.
But there are obstacles to the Republicans’ plans. Medicaid, one of President Lyndon Johnson’s “Great Society” domestic programs that was created in 1965, is the nation’s main health insurance program for low-income people.
Overhauling it is politically difficult because of the potential harm to recipients as well as the financial consequences to states, hospitals, doctors and other health providers, who might not get paid for their services if patients don’t have coverage. Total Medicaid spending was $532 billion in fiscal 2015, with about 62 percent funded by the federal government.
One major change endorsed by both Trump and House Speaker Paul Ryan (R-Wis.) would transform Medicaid from an entitlement program into a block grant program.
Here’s the difference. In an entitlement program, coverage is guaranteed for everyone who’s eligible. The federal government’s commitment to help states cover costs is open-ended. The states’ obligation is to cover certain groups of people and to provide specific benefits. Children and pregnant women who meet specific income criteria must be covered, for example.
That formula would change if federal funds flow to states through block grants. States would have more flexibility to run their Medicaid programs as they wish — including cutting benefits and eligibility. And proponents say it would allow the federal government to spend less on Medicaid and make states responsible for covering costs beyond their federal allotments.
Turning Medicaid into a block grant program has been discussed for more than 25 years, but the idea has always met resistance from some states, health providers, health care advocates and Democrats. Even with a Republican majority in Congress and Trump in the White House, the plan would still face an uphill legislative battle.
The federal government rarely shifts power to the states and not all states want to be at increased financial risk for the program.
“Medicaid block grants face a very uncertain future,” said Joel Cantor, director of the Center for State Health Policy at Rutgers University in New Jersey.
Another option to redefine Medicaid funding, similar to a block grant, is known as a per capita cap. States would be given a set amount of money per enrollee, which would increase each year but critics fear likely not keep up with rising health expenses. That method would help states better deal with growing enrollment because funding would rise, too.
Even without help from Congress, Trump’s administration could change Medicaid using the executive branch’s power to approve states’ requests for waivers from federal rules. That could allow Trump to approve changes proposed by Republican governors that the Obama administration has rejected, including work requirements for Medicaid enrollees and monthly premiums and other cost-sharing.
Trump could also end some waivers that expanded Medicaid and sent billions in new federal funding to some states that transformed care.
Any congressional changes to Medicaid next year would likely include negotiations about the Children’s Health Insurance Program, another federal-state program that provides coverage to youngsters whose families are slightly over the Medicaid eligibility. The program expires if not reauthorized by Sept. 30, 2017. According to the Kaiser Family Foundation, about 8 million children get coverage through CHIP, which has had Republican and Democratic support.
After Trump is in office, he may find it’s harder than he realized to repeal Obamacare and tinker with Medicaid because cutting off coverage for millions of people could bring plenty of political fallout, said Joan Alker, executive director of the Center for Children and Families at Georgetown University.
Republican Gov. Matt Bevin of Kentucky took a similar tack last year, she observed, running against Obamacare and vowing in his campaign to eliminate the expansion. He has since proposed major changes to Medicaid, but he has not yet moved to kill the expansion.
Still, Alker said Trump’s win puts the block grant idea front and center in January. And an agreement to do it could give states flexibility to make cuts in federally required benefits, such as health screenings for infants and children.
“I would be very concerned about what could happen,” Alker said.

California Lends Its Weight To Wider Marijuana Acceptance

Twenty years ago, California became the first state in the nation to approve the use of marijuana for medical purposes.
On Tuesday, Californians voted to legalize it for recreational use — a move expected to reduce drug arrests, raise up to $1 billion in new tax dollars for the state and regulate a growing industry that has largely gone unchecked.
California was one of four states to approve recreational marijuana Tuesday, along with Nevada, Maine and Massachusetts. Four other states — Montana, Florida, Arkansas and North Dakota — voted to allow marijuana for medical use.
The number of states with laws permitting marijuana consumption underscores a national cultural shift toward wider acceptance of the drug, despite the existing federal prohibition and limited evidence on the public health impacts of legalization.
“More and more states are going to be passing these,” said Kevin P. Hill, an assistant professor of psychiatry at Harvard Medical School. “It is not an issue that is going away. … But we really need to address it in way that results in good policy.”
A Gallup poll last month showed that 60 percent of Americans believe marijuana should be legalized, up from 31 percent in 2000.
Consumption of marijuana has also increased steadily over the past decade, with more than 22 million Americans reporting they had used it in the previous month, according to the National Institute on Drug Abuse. It is the most commonly used illicit drug in the United States, and many Americans don’t believe it is harmful, according to the U.S. Substance Abuse and Mental Health Services Administration.

“There is no question that a majority of Americans now think that marijuana prohibition no longer makes sense,” said Ethan Nadelmann, executive director of the Drug Policy Alliance, which promotes legalization initiatives nationwide.
Nadelmann predicted the votes in California and elsewhere could accelerate the momentum to end marijuana prohibition federally, provided the incoming administration under Donald Trump doesn’t challenge state laws.
Opponents of legalization, including Kevin Sabet, an assistant professor of psychiatry at the University of Florida, have said the marijuana industry is profiting from addiction. Sabet said Wednesday that his organization, Smart Approaches to Marijuana, would explore legal options against the industry. Legalization opponents have also raised money for a project to hold the industry accountable and empower cities to ban stores and cultivation sites.
With passage of the new ballot initiatives, there are now seven states, along with Washington, D.C., that allow marijuana for recreational use. Colorado, Washington, Oregon and Alaska already had permitted it before Tuesday’s election.
Beau Kilmer, a senior policy researcher at the RAND Corporation in Santa Monica, said states are taking advantage of the Obama administration’s decision not to enforce the federal ban where it conflicts with local and state laws. The federal government has said it generally wouldn’t challenge state and local laws or prosecute marijuana businesses following those laws.
“You have got an administration that is willing to tolerate these experiments at a state level even though it’s illegal at a federal level,” Kilmer said.
Trump has indicated some support for medical use of marijuana, but he has not made clear what he thinks about states approving it for recreational use.
California’s initiative, Proposition 64, allows adults aged 21 and over to grow, buy and possess small amounts of marijuana for personal use. The initiative also regulates recreational marijuana businesses and imposes taxes, which will help pay for drug education and prevention programs. And the measure allows people serving time for certain marijuana convictions to petition for their sentences to be reduced.
The new law does include some restrictions, in addition to the age limit. It prohibits using marijuana in public and driving under the influence of it — though opponents of the measure noted that no reliable test for marijuana-related DUIs yet exists. California residents can begin growing up to six plants immediately, but the state is not expected to begin licensing recreational marijuana businesses for more than a year.
Proposition 64 supporters argued the law would create a safe and legal system for adults to use marijuana while still protecting youths. Critics maintained that legalizing marijuana could increase traffic accidents, expand the black market and lead to widespread smoking ads on television.
California is considered a linchpin in the fight for legalization around the country, in part because of its large population, Nadelmann of the Drug Policy Alliance said. The fact that California voters approved it is “really monumental,” he said. “California is a national policy innovator and leader in the country.”
He said the California measure is unlike any other, because it integrates sentencing reform, social justice, youth protection, tax revenue allocation and public health. “It is hopefully a model for others nationwide,” he said.
The passage of Proposition 64 is not expected to increase the use of marijuana dramatically. Cannabis consumption is already largely mainstream and the rules governing the use of medical marijuana have been lax, said John Hudak, senior fellow at the Brookings Institution.
“Because marijuana use is so pervasive for those who want to use it regularly, I can’t imagine Proposition 64 really changing that,” Hudak said. “Whoever wanted to access marijuana through a legal market [before the measure passed] … could do so.”
Mike Bertolina, 39, who lives in Los Angeles, got a medical marijuana card about a year and a half ago. He said the process was easy — and seemed a bit like “a joke.”
“The doctor had a stack of certificates on his desk,” said Bertolina. “He just basically stamped it and said, ‘Here you go.’” Bertolina said he primarily uses marijuana to relieve aches and pains.
He said he voted for Proposition 64 because he believes in the decriminalization of marijuana and in the tax revenue that it will bring to the state.
Public health officials and experts plan to monitor and study the impact of the new state law, paying attention to youth consumption, traffic safety and addiction.
So far, many of the public health and safety fears have not materialized where recreational marijuana is legal, said Hill, the Harvard Medical School professor who is author of the book, “Marijuana: The Unbiased Truth about the World’s Most Popular Weed.” He added that, “a lot of people predicted doomsday scenarios that haven’t really played out.” For example, there wasn’t a statistically significant increase in use by adolescents in Colorado after that state legalized marijuana, Hill said.
There has been a small spike in emergency department visits among children, he said, but the state addressed that by changing labeling and packaging to discourage accidental consumption.
Driving under the influence is still a concern for many people, as more states pass recreational marijuana laws. A report by the AAA Foundation for Traffic Safety found earlier this year that fatal crashes among drivers who recently used marijuana doubled in Washington after legalization. But Hill said there is no evidence that the drug led to the accidents. With increased use overall, it’s not surprising that more people in accidents have marijuana in their system, he said.
Hudak, the Brookings fellow, said states need to take safety and public health concerns into consideration, though they might not get their policies right on the first try. “It is incumbent on the state to recognize the risks,” he said. “Having a regulated system in place … is not necessarily a cure-all.”
Proponents of pot legalization say the medical marijuana movement has paved the way for lifting the ban on recreational use. More than two dozen states now allow patients to possess marijuana for medical purposes.
San Diego resident Starlight Mundy has held a medical marijuana card for the last two years, and she regularly uses cannabis to reduce anxiety and “take the edge off” after a long day, she said. Mundy voted for Proposition 64, saying she believes pot should be allowed not only for people with medical conditions.
Mundy hopes California’s new law will continue increasing acceptance of marijuana.
“This is not the finish line,” Mundy said. “But it is a big step that affects a lot of people who are not patients.”

California Faces Major Reversal If Trump, Congress Scrap Health Law

California has a lot to lose if President-elect Donald Trump and the Republican-led Congress fulfill their campaign pledge to repeal Obamacare.
The Golden State fully embraced the Affordable Care Act by expanding Medicaid coverage for the poor and creating its own health insurance exchange for about 1.4 million enrollees. Supporters held California up as proof the health law could work as intended.
But now President Barack Obama’s signature law is in serious jeopardy and California officials are left wondering what Republicans in Washington may put in its place.
“There is no doubt that Obamacare is dead,” said Robert Laszewski, a health care consultant and expert on the California insurance market. “The only question is just exactly how Republicans will get rid of it.”
Health policy experts don’t expect Republicans to immediately kick millions of people off their insurance policies. Instead, they predict lawmakers may repeal parts of the law and allow for some transition period for consumers while a replacement plan is put together.
Still, the personal and financial impact for the state could be jarring. The number of uninsured Californians would more than double to 7.5 million people if the Affordable Care Act was repealed, according to a recent study by the Urban Institute.

Researchers also said California stands to lose an estimated $15 billion annually in federal funding for Medicaid expansion and insurance subsidies — more than any other state. That loss of federal money would make it difficult for California to pursue health reform on its own.
State Sen. Ed Hernandez, (D-West Covina), chairman of the Senate Health Committee, said it’s difficult to predict what the next iteration of the Affordable Care Act may look like.
“Will there be federal subsidies? Will the state legislature pay for subsidies to ensure Californians have coverage? Those are open questions,” Hernandez said. “I will do everything I can to make sure California continues to take the lead on this issue.”
Congress already has voted to eliminate funding for Medicaid expansion and premium tax credits to dismantle two key pillars of the health law. Obama vetoed that legislation earlier this year, but Trump made the repeal of Obamacare a centerpiece of his campaign.
If repeal goes through, state leaders and consumer advocates may look to the ballot box, asking voters to fund expanded health coverage through higher taxes or fees. In Tuesday’s election, Californians backed the extension of a hospital fee to help pay for Medi-Cal, the state’s Medicaid program.
State officials could aim even higher and try for a government-funded single-payer health system at the state level. But that’s expensive, disruptive to the current system and a tough sell to the public. Colorado voters soundly rejected a state single-payer initiative during Tuesday’s election.
Some Republican lawmakers in California would applaud a reversal on Medi-Cal expansion. They have argued that state and federal spending increases on the program are unsustainable.
The state’s Medi-Cal program now covers about a third of all Californians. The health law’s Medicaid expansion has added about 3.5 million Californians to the program since January 2014 and total enrollment stands at more than 13 million.
Molina Healthcare, a Long Beach-based insurer, is a major player in Medicaid managed care nationwide and also covers about 600,000 people through exchanges in California and eight other states. The company’s chief executive, Dr. J. Mario Molina, said he thinks Covered California and other exchanges will become a smaller part of health reform under a Republican plan and coverage expansion will shift more to Medicaid.
Molina said Republicans in Congress could grant governors more flexibility on Medicaid benefits to keep costs down while maintaining guaranteed access to coverage regardless of preexisting conditions, a popular provision of the health law.
“Republicans have the benefit of looking back at the experiment of Obamacare and seeing what worked and what didn’t work,” Molina said in an interview. “I think the Republicans will negotiate a deal where Medicaid gets expanded with more state control and exchanges will play a different role. The most cost effective way to do coverage expansion is through Medicaid.”
Consumer advocates acknowledged the financial challenges posed by repeal but also encouraged Californians to keep signing up for coverage in the meantime.
“Californians should continue to enroll in Covered California this open enrollment season, in Medi-Cal, and all the benefits they are still entitled to–and then fight like hell to keep them,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group.
But some Covered California policyholders expressed concern about what a Trump administration might mean for their coverage.
“I worry it will be gone, and I don’t know what I will do for insurance,” said Jane Henning Childress, 61, who lives in Calaveras County.
Taking into account her federal subsidy, she said she pays about $135 a month for her exchange plan. Earlier this year, she used it to help cover surgery for an ovarian cyst. “It sure helped me out,” she said.
Even before the election, some major health insurers were pulling out of the exchange market nationally and premiums shot up 22 percent, on average, for state and federal exchanges for 2017.
In the Covered California exchange, the average rate increase was 13.2 percent for next year. That’s higher than the 4 percent average rate increases that California negotiated its first two years. Open enrollment started Nov. 1.
Health insurers in California and nationwide face plenty of uncertainty as well from the election outcome. Some analysts said more insurers may exit state marketplaces rather than wait for them to unravel and risk getting stuck with too many expensive patients.
Four big insurers, led by Anthem Inc. and Blue Shield of California, account for about 90 percent of Covered California’s enrollment.
“The unthinkable has happened,” said Ana Gupte, a senior health care research analyst at Leerink Research. “With a Republican sweep of the White House, Senate and the House, we are looking ahead to a 2017 filled with much change and uncertainty in the health care markets.”
This post is being periodically updated.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

After Colorado, ‘Right To Die’ Movement Eyes New Battlegrounds

Fortified by a victory in Colorado Tuesday, a controversial campaign to let terminally ill patients access life-ending medication is moving on to other battlegrounds across the country.
By an overwhelming vote Tuesday, Coloradans approved a ballot initiative allowing physicians to prescribe lethal drugs to mentally fit, terminally ill adults who want to end their lives. Colorado is the sixth state to allow the practice, following Oregon, Washington, Montana, Vermont and California. Washington, D.C., is poised to approve similar legislation as soon as this month.

Colorado’s ballot initiative proposal met resistance from religious groups with moral objections and disability advocates leery of abuse of power. Opponents raised over $2.6 million, the bulk of which came from the Archdiocese of Denver. Supporters, who argued that terminally ill patients deserve the option to “die with dignity,” raised over $5.4 million, mostly from the Compassion & Choices Action Network.
“Colorado demonstrates what we have been saying: Voters want medical aid-in-dying laws because they want to have all possible options at the end of life,” said Toni Broaddus, acting national director of political affairs and advocacy at Compassion & Choices, which has been pushing for these laws across the country.
Advocates took the matter directly to voters after Colorado legislators rejected a similar bill last year. When all ballots were counted Wednesday, the ballot measure had won by a margin of nearly 2-1.
“When you pass a bill by such a significant majority,” Broaddus said, “it just demonstrates the non-partisan nature of this issue, and the widespread support.”
Colorado was one of 19 states to consider right-to-die laws this year. While many legislative sessions have ended, Broaddus said she is hopeful about pending legislation in New Jersey, and expects a bill in New York to be reintroduced in January.
Broaddus said Compassion & Choices has staff on the ground and networks of volunteers ready to work, in New Jersey, New York, Maryland, Minnesota, Hawaii, New Mexico and Massachusetts. That may be just the beginning: “Close to half” of the states will consider similar legislation in 2017, she predicted.
These efforts have gained steam since Brittany Maynard, an eloquent 29-year-old with terminal brain cancer, became the public face of the movement in 2014. Because her home state of California would not allow it at the time, Maynard moved to Oregon to acquire the lethal prescription that she used to end her life. Maynard’s husband, Dan Diaz, has spent the last two years urging other states to give patients that option.
The momentum also comes at a time when baby boomers are aging, confronting end-of-life planning for their parents and themselves, and seeking to “make sure we don’t have unwanted medical care,” Broaddus said.
In addition to its legislative efforts, Compassion & Choices is pushing courts to clarify state law in Massachusetts, New York and Vermont. That approach proved effective in Montana, where the state supreme court ruled in 2009 that state law protects physicians from prosecution if they help terminally ill patients die, effectively legalizing the practice.
These efforts across the country have sent opponents scrambling.
“Those who favor this are targeting every state,” said Rita Marker, executive director of the Patient Rights Council, which opposes such measures.
In Washington, D.C., her group has been working with African-American churches and low-income senior citizens who fear the laws will put disadvantaged patients at risk.
Colorado’s new law, based on Oregon’s 1997 law, requires patients to make two verbal requests 15 days apart, and one written request observed by two witnesses, to obtain lethal medication. Two doctors must affirm that the patient has six months or less to live.
While no malicious deaths have been reported since Oregon legalized the process nearly 20 years ago, Marker said the safeguards aren’t strong enough to prevent coercion by doctors, relatives or heirs. These laws require patients to self-administer the drugs, but Marker noted there’s no requirement that a physician witness the death.
“All of these safeguards stop when the so-called prescription is filled,” she said.
Diane Coleman, president of a national disability advocacy group called Not Dead Yet, said the laws create a dangerous financial dynamic in which insurance companies may deny expensive treatments but cover lethal drugs.
“Will insurers do the right thing or the cheap thing?” she asked.
Coleman also said a faulty diagnosis could prompt patients to end their lives earlier than need be. Her group, which has only three paid staff members, is working with networks of disability advocates to fight legislation across the country.
“Wherever the bills are brought up, we will be giving our best efforts,” she said.
KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.