Questions for Martha McSally re: health care

Below is some recent reporting on health care to help you formulate your questions for Rep. Martha McSally for her “chicken bunker” tele-town hall tonight.

The largest health insurance companies in the United States reaped historically large profits in the first quarter of this year, despite all the noise you hear surrounding the Affordable Care Act’s individual marketplaces. Profits are booming at health insurance companies:

Aetna, Anthem, Cigna, Humana and UnitedHealth Group — the big five for-profit insurers — cumulatively collected $4.5 billion in net earnings in the first three months of 2017. That was by far the biggest first-quarter haul for the group since the ACA exchanges went live in 2014. Other major insurers, such as the Blue Cross and Blue Shield company Health Care Service Corp., also are improving their ACA operations.

Aetna lost money only because it had to pay Humana a $1 billion break-up fee after their merger failed; otherwise it would have been in the black. Some other things to keep in mind:

• The ACA exchanges represent a small amount of the insurance market, and most of the for-profit carriers have bailed on those plans.
• Employer-based coverage is a profit center, but insurers continue to invest more in Medicare Advantage and Medicaid.
• Congress suspended the ACA’s health insurance industry fee for 2017, which is creating a temporary windfall.
• The first quarter of the year is usually good for health insurers. Deductibles are reset, leaving people on the hook for a lot of their out-of-pocket medical expenses. The fourth quarter usually is the worst, since people often reach their deductibles by the end of the year.

Uncertainty over the future of health care for millions of Americans grew deeper Monday after the administration and House Republicans asked an appeals court for a 90-day extension in a case that involves federal payments to reduce deductibles and copayments for people with modest incomes who buy their own policies. Insurers seek stability as Trump delays health care decision:

The fate of $7 billion in “cost-sharing subsidies” remains under a cloud as insurers finalize their premium requests for next year.

Hours before the filing, a major insurer group released a framework for market stability that relies in part on a continuation of such subsidies.

The BlueCross BlueShield Association represents plans that are the backbone of insurance markets under the Affordable Care Act, or ACA, and would also be the mainstay with a Republican approach.

As the GOP-led Congress works on rolling back major parts of the Obama law, the BlueCross BlueShield plan called for:

—Continued protections for people with pre-existing medical conditions and sustained federal funding to offset the cost of care for the sickest patients.

—More leeway for states to experiment with health insurance benefits, with a basic floor of federal standards.

—Preserving ACA consumer safeguards including no lifetime caps on benefits, no higher premium for women based on gender, and a requirement that insurers spend a minimum of 80 cents of every premium dollar on medical care.

—Penalties such as waiting periods for people who fail to maintain their coverage. Republicans want to repeal the Obama-era tax penalties on uninsured people deemed able to afford coverage.

—Significant federal funding to subsidize premiums and out-of-pocket costs.

“There needs to be sustained federal funding,” said Justine Handelman, policy chief for the insurer group. “It’s critical to ensuring overall affordability.”

About 20 million Americans purchase individual health insurance policies, with more than half using the ACA’s markets, which offer income-based subsidies for premiums and out-of-pocket costs.

The Trump administration has sent mixed signals, and the White House is now saying it needs more time to decide on the cost-sharing money. Without those subsidies, experts say, premiums could jump about 20 percent in 2018. Another round of sharp premium increases and insurer exits seems possible.

The cost-sharing money is embroiled in a lawsuit originally filed by House Republicans [House v. Price]. Democrats call the whole thing a cynical ploy.

“In merely delaying their suit, Republicans cynically continue to sow uncertainty in the health coverage of millions of Americans,” House Democratic leader Nancy Pelosi of California said in a statement. “At a critical period when insurers are deciding premiums for next year, Republicans are pouring uncertainty into the health insurance marketplaces.”

House v. Price is on appeal after a lower court ruled that the government lacks constitutional authority to make the payments because Congress failed to specifically approve them in the Obama-era health overhaul legislation. Democrats argue that is based on a faulty reading of the law. They also argue that House Republicans have no legal standing to even bring the case.

Even though during the 2016 campaign Donald Trump said pharmaceutical companies are “getting away with murder,” his first budget for the Department of Health and Human Services does nothing to change how prescription drugs are priced. Trump’s budget doesn’t touch drug pricing:

Trump didn’t include ideas he mentioned on the campaign trail, like allowing Medicare to negotiate drug prices. There’s also no mention of mandating Medicaid-type rebates for low-income people on Medicare.

What they’re saying: “The lack of any mention in the budget makes us question whether this is truly an issue of importance to the administration.” — Spencer Perlman, managing partner at Veda Partners

Or as Dylan Scott covers in-depth at Vox.com, Who knew bringing down drug prices could be so complicated.

Candidate Trump promised to “end the opioid epidemic in America.” President Trump may make it worse. Trump’s budget makes it official: he’s doing little to nothing about the opioid epidemic:

Tens of thousands of people will likely die of drug overdoses under President Donald Trump’s watch, as America’s horrific opioid epidemic continues. Yet with his first big policy document — the 2018 budget proposal — Trump is proving that he’ll do little to nothing about the crisis.

If anything, Trump’s proposal could make the opioid epidemic worse. Where the budget does anything of significance regarding the epidemic, it comes through cuts to the office in charge of coordinating drug policy, Medicaid, public health programs, and more. And there is nothing in the budget to balance out the cuts — leaving a crater in the government’s response to a crisis that led to more than 33,000 opioid overdose deaths and more than 52,000 total drug overdose deaths in 2015.

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[Advocates] hoped Trump, who on the campaign trail promised to “end the opioid epidemic in America” and “spend the money” on drug treatment, would bring a bigger commitment.

It’s not just [Trump’s] budget plan. The spending proposal also fits the pattern we’ve seen with Trump on the opioid epidemic so far: Despite all his talk and promises on the campaign trail, this is an issue in which Trump is doing little to nothing as president — and the little his administration is doing will very likely prove counterproductive.

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Trump, at the very least, doesn’t propose cutting overall drug treatment spending this year, based on ONDCP’s figures. But he suggests other cuts to public health and anti-drug programs that completely outweigh the tiny gains that ONDCP claims.

For one, the budget proposal slashes drug prevention programs across all federal agencies by about 11 percent — from about $1.5 billion to more than $1.3 billion.

Some drug policy advocates see ONDCP as somewhat problematic, given its history of supporting ineffective “tough on drug” policies. But they argue the office should be reformed and propped up to lead the response to the opioid epidemic, not cut back.

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Trump also proposes a 47 percent cut to Medicaid over the next 10 years. This would rob millions of people of the one affordable source of health insurance that they have — to pay for, in part, drug treatment. According to a 2014 study by Truven Health Analytics researchers, Medicaid paid for a quarter, or $7.9 billion of $31.3 billion, of projected public and private spending for drug treatment in 2014. As a patient using Medicaid to pay for drug addiction care at a New Jersey facility told me earlier this year, “If it wasn’t for insurance, I wouldn’t be here.”

The budget further asks for nearly $400 million in cuts to the Substance Abuse and Mental Health Services Administration, hundreds of millions in cuts to mental health block grants, and billions in cuts altogether to the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA). This funding didn’t all go specifically to drug treatment, but these agencies and programs in part help address the opioid epidemic and drug addiction in general.

Advocates are already sounding the alarm over these cuts. The Baltimore City Health Department, for example, said in a statement, “At a time of a public health emergency around opioids, with unprecedented numbers of Marylanders dying from overdose, this proposal could deprive millions of the care that they need.”

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The rest of Trump’s opioid policy isn’t much better. Generally, it can be described as the opposite of what Trump said on the campaign trail — instead of allocating more funding to deal with the epidemic as a public health issue, he’s often undercutting such efforts.

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Instead of doing any of this, Trump has proposed cutting public health programs and Medicaid, and he’s pushed to repeal Obamacare without a replacement that would cover Americans’ health insurance needs.

More broadly, Trump has done nothing to address the structural issues behind drug addiction — the poverty, joblessness, deteriorating communities, and other common contributors to despair that lead to drug addiction. “If you look at overall public health trends, there are a lot of things like alcohol use and suicide that have increased in concert with opioid use,” said Leo Beletsky, a professor of law and health sciences at Northeastern University. “That speaks to underlying, larger problems.”

“It’s not unusual for Trump to make a promise and do the opposite. But in this case, people’s lives are quite literally at stake — and his administration is at best dawdling and at worst taking steps that will make a very deadly crisis even deadlier.”