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The latest news on Obamacare from Business Insider

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    paul ryan

    Republicans take full control of the government on Jan. 20, and their biggest problem may be the calendar.

    Their agenda is expansive — repealing Obamacare, pushing through tax cuts and rolling back a host of President Obama’s regulations — and some elements have a time limit attached.

    Between those deadlines and the Senate’s procedural penchant for grinding everything to a halt, Republicans may not be able to accomplish all their goals.

    That’s why they’re trying to create a kind of legislative trash compactor that mushes a bunch of bills into one package. That could be the only way for them to maximize their rollback of the Obama regulatory state.

    The scheme would streamline a clunky existing law that allows lawmakers to overrule federal agencies. The Congressional Review Act (CRA) of 1996, a priority of Newt Gingrich’s Contract with America, gives Congress the ability to overturn any executive branch rule within 60 legislative days of it being finalized in the Federal Register.

    Congress can introduce a resolution of disapproval, which only requires a majority vote in the House and Senate, to vanquish the rule, and force any future rule of that type to get explicit congressional authorization.

    Because presidents don’t really appreciate having Congress cancel out their priorities, this gambit has worked exactly once in the 20 years since enactment, to overturn an Occupational Safety and Health Administration rule on ergonomics in March 2001. But those circumstances mirror the situation today: a new Republican president replacing a Democrat, with Republican control of both houses of Congress.

    This Congress has designs on much more than one rule. Under the 1996 law, Congress can consider any rule finalized within 60 days of the end of the legislative session. Legislative days only count if Congress is in session, a rare event in 2016.

    The Congressional Research Service estimates that any rule submitted to Congress after May 30 of this year would be available for overturning. The Congressional Research Service lists 48 major rules that could be wiped off the books; the Wall Street Journal identifies 180 in all. That doesn’t include several others scheduled for completion between now and the end of Obama’s term.

    mitch mcconnell

    Plus, if Congress adjourns sooner than anticipated, it would be able to upend more rules, which is critical. Republicans desperately want to block a Department of Labor rule that doubles the salary threshold for workers eligible for overtime. That rule was finalized May 23, so the GOP could conceivably move back adjournment long enough to give them the opportunity to nuke it.

    The idea here is to block “midnight regulations,” passed in secret before a changeover of power. But a midnight lasting from May to January doesn’t exist anywhere on the planet, not even the North Pole. The CRA stretches the definition of “midnight” so anti-government conservatives can nullify months of rulemaking, sometimes on regulations that took several years to shape.

    But the clock is ticking, albeit slowly. As every observer of Congress knows, passing legislation eats up time. The CRA limits Senate debate but doesn’t eliminate it: Senators still must hold multiple votes, and the minority still gets 10 hours to discuss each resolution. There are opportunities to reduce that, but in general terms Democrats would still have enough tools to limit CRA resolutions to about one per day.

    You cannot assume that all of the first 60 legislative days of the new Congress would be spent on rolling back Obama rules. The Senate has Donald Trump’s entire cabinet to confirm, and if Congress passes a short-term funding bill sometime in the next few weeks as expected, it will to complete another budget bill next spring, which will take up much more floor time.

    In short, it doesn’t seem metaphysically possible to kill all the rules Republicans desire in the specified time.

    barack obama

    That’s where a new bill called the Midnight Rules Relief Act comes in. Devised by California Republican Darrell Issa, who may not make the next Congress (he’s up 4,200 votes in his re-election race, with several thousand left to count), the bill would allow multiple CRA resolutions to be combined into one big ball of disapproval. This eliminates the timing problem by vanquishing all the rules Republicans want with one resolution rather than dozens. In the name of efficiency, it creates a process to erase the work of the last several months of the Obama presidency.

    With support from the Chamber of Commerce, the House passed the Midnight Rules Relief Act last week, inexplicably getting three conservative Democrats (Henry Cuellar, Collin Peterson and Kyrsten Sinema) to vote for it. Of course, Obama promised a veto, calling it unnecessary and arbitrary. But President Trump would eagerly sign this; reversing the thrust of Obama administration goals appeals to him. And Issa (or if he’s gone, someone else) plans to reintroduce the bill after the inauguration.

    Unlike the CRA, the Midnight Rules Relief Act is an ordinary bill, meaning that it’s subject to the filibuster. So 41 committed Senate Democrats out of the 48 in the next Congress could prevent this from passing. That would seem likely, but Republicans could promise to shield certain coveted regulations or include others disfavored by moderate Senate Democrats to reach the 60-vote threshold. With 10 Democrats from states won by Trump up for re-election in 2018, it’s not out of the question.

    If the Issa bill passes, one vote would wipe out the efforts of thousands of executive branch bureaucrats and millions of hours of public input and review. It would effectively shorten the term of office of a president, much like the Senate did when it refused to even schedule a hearing for Obama’s Supreme Court nominee, Merrick Garland. If you want three-year terms for president and one year of paralysis, write a constitutional amendment. But the proliferation of end-runs to artificially limit the power of a particular branch of government are dangerous.

    Because our 18th-century governing structure is ill-suited to a partisan age, you get these aggressive power grabs. Democracies only work when there are clear lines of accountability, when everyone knows that their vote translates into decisions made on their behalf. When you lose that, voting becomes nothing more than an exercise in picking your favorite celebrity.

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     obamaThe pledge by President-elect Donald Trump and congressional Republicans to swiftly repeal the Affordable Care Act -- followed by months or even years of deliberation over a replacement – is no doubt troubling news to many of the roughly 20 million Obamacare beneficiaries.

    House Speaker Paul Ryan (R-WI) and Senate Majority Leader Mitch McConnell (R-KY) have vowed to jam through legislation as early as January to dismantle the heart of President Obama’s signature 2010 health insurance program, while leaving the question of precisely how they would replace it and when that new system would be put in place unanswered.

    But the GOP’s crusade to finally destroy Obamacare has the health care industry in an uproar, with strong indications that major insurers could accelerate their departure from the ACA exchanges. At the same time, hospital administrators are in a panic, fearing that they will incur massive financial losses if millions of Americans lose their health care coverage under Obamacare or expanded Medicaid.

    To be clear, Obamacare already is reeling from a high profile exodus of major insurers, including Aetna, UnitedHealthcare and Blue Cross-Blue Shield, which suffered millions of dollars in losses during the first few years of the program’s operation. But health care experts and state insurance administrators say that insurers would have even less incentive to stick around beyond the upcoming 2017 season without knowing precisely what to expect at the end of the transition.

    "The discussion right now about repeal and replacement is making the market very, very nervous," Washington Insurance Commissioner Mike Kreidler, a Democrat, said at a press conference last week organized by the liberal Center for American Progress. "I would not be surprised to see the potential for a stampede to exit the market."

    CAP officials contend that even if the Republicans delay the effective date of repeal as part of expedited budget legislation in January, that approach would still cause “massive disruption and chaos” in the individual market for health insurance and a “complete unraveling” of the market by the end of 2017.

    Demonstrators in favor of Obamacare gather at the Supreme Court building in Washington March 4, 2015.  REUTERS/Jonathan Ernst

    Health and Human Services Secretary Sylvia Mathews Burwell predicted in an interview with The Huffington Post on Monday that health insurers would abandon the Obamacare markets in droves by 2018 if they don’t know how Republicans intend to replace the system.

    She said that the GOP leadership’s current strategy of postponing the effective date of the repeal to give the incoming Trump administration and Republicans time to devise an alternative would do nothing to calm the insurance companies jittery nerves. “This idea of repeal and wait two years to replace – that is repeal,” Burwell said. “The uncertainty that gets created for consumers, for insurers, for states by having that is very, very damaging.”

    While major insurers may continue to retreat from the Obamacare market to avoid more losses down the road, the biggest loser may be the hospital industry, which counted on a major expansion in business with a flood of newly insured patients under Obamacare and Medicaid.

    Charles Kahn, chief executive of the Federation of American Hospitals, told Kaiser Health News this week that his industry was caught by surprise by Trump’s victory over Democrat Hillary Clinton and that the “working assumption” had been that “we had a program that wasn’t going anywhere.”

    As part of the negotiations that led to passage of Obamacare, hospitals agreed to substantial cuts in Medicare and Medicaid reimbursement for seniors and the poor, with the expectation that those cuts would be more than offset by increases in the volume of paying customers who were newly insured.

    If that expanded insurance coverage now begins to fade away, Kahn indicated, those cuts in Medicare and Medicaid reimbursements will have to be restored or else the hospitals will take a substantial financial beating.

    Obamacare protest

    Sheryl R. Skolnick, director of research at Mizuho Securities USA, warned clients Tuesday to avoid investing in hospitals because of the growing uncertainty over the future of the health care system. She said in a note that the combination of a repeal of Obamacare and a likely GOP overhaul of Medicare and Medicaid makes hospitals “dangerous ground for investing.”

    Even as they have pressed for over six years to undermine Obamacare, House and Senate Republicans have been unable to come close to agreement on a replacement package. Trump, Ryan and House Budget Committee Chair Tom Price (R-GA) have offered differing approaches that rely largely on market forces, tax credits, enhanced inter-state competition and encouraging more employers to provide coverage.

    Trump said recently that he would favor preserving portions of Obamacare, including keeping children on their parents’ policies until they turn 26 and the ban on insurers discriminating against people with chronic health problems. But some, including Sen. Lamar Alexander (R-Tenn.), chair of Health, Education and Labor Committee, warn that it will take many more years – perhaps beyond Trump’s first term – to finally reach a consensus on the future of the U.S. health care system.

    Joseph Antos, a health care expert with the American Enterprise Institute, said Wednesday that insurers and hospital administrators may be jumping the gun in their angst-ridden reaction to an emerging GOP policy. “It’s premature,” Antos said. “Trump hasn’t named his chief health people yet, so until that happens, we really would have a hard time doing anything other than speculate about what might happen.”

    “All of this talk about a quick repeal and then waiting two years to replace leaves out what happens during the intervening two years,” he added. “And the one thing Trump has actually said is he doesn’t want to have any gaps. So that implies to me,  at least, pretty much a steady-as-you-go in terms of financing health insurance until the new system – whatever that specifically means – is ready to go on line.”

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    Jan Brewer

    PHOENIX (AP) — Former Arizona Gov. Jan Brewer fought her own Republican party in the state Legislature for months to push through a Medicaid expansion under the Affordable Care Act.

    That was three years ago. Now, as an early Donald Trump supporter who has his ear, Brewer hopes one of the pillars of President Barack Obama's health care law can be saved as Trump pushes to dump much of the overhaul.

    "I don't know how much of that, and I mean it sincerely, is going to be affected," she told The Associated Press in an interview. She said she's encouraging Trump's administration to look at Arizona's model because it is so cost-effective.

    Brewer said the low-income population that the Medicaid expansion was designed to cover was one of the main drivers of the law, and she's not prepared to see that group go without care. Nearly 400,000 Arizonans have gained Medicaid insurance since Brewer's proposal took effect in 2014.

    Arizona is one of 31 states that expanded Medicaid, many of them run by Democrats. Republicans have blocked expansion in the remaining 19 states.

    Among the GOP-led states that expanded Medicaid, many officials are like Brewer, strong proponents of the program that has brought insurance to about 9 million low-income Americans who can't possibly afford to buy it themselves. Before the expansion, those people had little access to regular health care, and when they got sick, hospitals were forced to treat them without compensation.

    States that strongly oppose Medicaid expansion, however, continue to do so.

    Mississippi's three top Republican leaders have said consistently for years that they believe the state cannot afford expansion, as have Idaho's GOP leaders.

    Florida Gov. Rick Scott called for a complete repeal of Obama's overhaul a week after the Nov. 8 election. Scott has been vague, however, about what should be done about the 20 million Americans who got health insurance through the overhaul, nearly half of them though Medicaid expansion his state rejected.

    If he doesn't completely dump the program, Trump will be under pressure to allow changes to it to give states more control.

    medicaid expansion

    Current Arizona Gov. Doug Ducey last year proposed a work requirement for healthy Medicaid recipients, premiums and co-pays and a five-year limit on coverage. The Obama administration approved limited co-pays but nixed the work requirement and the five-year limit. Michigan, Indiana and Iowa also have been allowed to charge premiums or fees, but broader changes requested by some states have been rejected.

    Vice president-elect Mike Pence told Republican governors meeting in Florida on Nov. 14 that Trump would replace traditional Medicaid funding to states with block grants that "encourage innovation that better delivers health care to eligible residents," according to a statement from the Trump transition team.

    Pence, Indiana's governor, expanded Medicaid in his state but got waivers from the Obama administration to implement plans that kick healthy people off the program for six months if they fail to pay premiums.

    Arkansas Gov. Asa Hutchinson said he hopes Trump's election means the state will have more flexibility in how it spends Medicaid money. More than 300,000 people are enrolled in the state's hybrid Medicaid expansion, which uses federal expansion money to buy private insurance for low-income residents.

    "This election means we're going to have an administration that wants to give more flexibility to the states," Hutchinson, a Republican, said recently. "So this is good news in our ability to get waivers to implement the reform we want in terms of work requirements, in terms of cost-sharing, in terms of other elements of reform that encourages employer-based insurance."

    Hutchinson stopped short of saying whether he'd like some form of coverage for those on the expanded Medicaid program to continue if Trump and congressional Republicans repeal the Affordable Care Act.

    But Ducey, Arizona's governor, said recently the discussion is "not only about repeal but replace."

    "We want to see all of our citizens have access to affordable health care," Ducey told reporters in response to a question about the future of Medicaid expansion. "That was the objective. That's not where we are. We've got a new president and a new Congress, and a fresh start."

    A spokesman for Republican Michigan Gov. Rick Snyder said he plans to work with the new administration to tout the successes and advantages of his state's Medicaid expansion.

    "How we continue that success is important, and he's willing to discuss how to do that with anyone who has other ideas to consider," Ari Adler said.

    As for Arizona's former governor, she said her state's Medicaid program is among the nation's best in terms of costs and provider choice. The program contracts with private insurers to provide care on a per-patient basis.

    "I don't know how you could deliver that population any more services better, more cheaply, than what we've already done here," Brewer said.

    ___

    Associated Press writers David Eggert in Lansing, Michigan, Gary Fineout in Orlando, Florida, and Andrew DeMillo in Little Rock, Arkansas contributed to this report.

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    coal miner

    Again and again, President-elect Donald Trump presented himself as the coal miners' candidate. During the campaign, he promised to bring coal back into the economy, and jobs back into struggling Appalachian towns.

    But now some in coal country are worried that instead of helping, Trump's first actions will deprive miners — and their widows and children — of the compensation they can receive if they are disabled by respiratory problems linked to breathing coal mine dust.

    That's because buried in the Affordable Care Act are three sentences that made it much easier to access these benefits. If Trump repeals Obamacare — as he vowed to do before the election — and does not keep that section on the books, the miners will be back to where they were in 2009, when it was exceedingly difficult to be awarded compensation for "black lung" disease.

    "You couldn't ever win back then," said Sue Toler, a coal miner's widow in Huntsville, Tenn., of claims for black lung benefits. "It didn't matter what kind of evidence you had."

    Of the 27 years her husband Arvis worked for Eastern Associated Coal in Kopperston, W.Va., 16 of them were spent underground. When he had to stop working because of breathing trouble, a doctor ordered chest X-rays and saw the telltale dark scars on his lungs. His doctor's diagnosis, his widow said, was coal workers' pneumoconiosis — or black lung.

    That was in 1993. Five years later, after two appeals and innumerable examinations with doctors chosen by the coal company, Toler was denied benefits, in part because he'd smoked cigarettes before his diagnosis.

    At the time, to qualify for benefits, miners had to prove not only that they were disabled because of breathing problems, and that they had coal workers' black lung, but that their disability was caused by their years in the mine.

    Coal mine

    It was "almost impossible," said Phil Smith, a spokesman for the United Mine Workers of America. "The vast majority of people were denied benefits. People would take these cases through the black lung court system and they would be denied because the companies could sow the shadow of a seed of a doubt."

    The Affordable Care Act changed that. Under "Miscellaneous Provisions" is a small section sponsored by a self-proclaimed"child of the Appalachian coalfields," the late West Virginia Democratic Senator Robert Byrd.

    The Byrd Amendments shifted the burden of proof from the miners onto the mining companies. If a miner has spent 15 years or more underground and can prove respiratory disability, then it is presumed to be black lung related to mine work, unless the company can prove otherwise.

    "Often the person whose job it is to do the convincing loses," said Evan Smith, a lawyer for the nonprofit Appalachian Citizens' Law Center, who represents many miners affected by black lung. That change had a significant impact: In 2009, 19 percent of claims for black lung benefits were successful; in 2015, that percentage had jumped to 28.

    The Byrd Amendments also had a huge effect on the families relying on that compensation. Before their enactment, when a miner died, his widow would keep getting compensation only if she could prove that her husband died because of black lung — a process that often took years, if it was successful.

    coal miners

    Now, with a bit of paperwork, she keeps getting a portion of the money the family got when her husband was alive. The amount changes according to the number of family members dependent on the coal miner or widow. At the top end, a beneficiary with three or more dependents gets $1,289 a month, while a single beneficiary gets $644.50.

    These changes in the Affordable Care Act not only meant that Arvis Toler ended up being awarded benefits shortly before he died in 2015, but also that his 70-year-old widow, Sue, has continued to receive compensation every month.

    The coal industry opposes these rules. "Our concern back then, which continues today is that … compensation is not based on occupational disease, but rather this is becoming a supplemental pension program, and that was not what it was ever intended to be," said Bruce Watzman, vice president of the National Mining Association.

    But, he said, industry representatives have other priorities than undoing Byrd's changes, such as reversing what he called "Obama's war on coal."

    Even so, many coal miners and their advocates are concerned that their fates are tied to a piece of legislation that has, in a certain sense, just lost an election, especially in coal-producing states such as Kentucky and West Virginia. Lawyers working on this issue are worried that repeal of the ACA could mean no compensation for new claimants and the potential loss of benefits for anyone who won them since the law passed.

    The Trump transition team did not respond to STAT's request for comment. Since the election, though, Trump has softened his rhetoric about completely doing away with Obamacare, and miners have advocates in the House and the Senate. "Repealing and replacing Obamacare will be a top priority for the new Congress, but Congressman Rogers has advocated for a piecemeal approach … many Members of Congress have acknowledged that some portions of the law are worthy of continuation, such as critical protections for coal miners," said a spokesperson for US Representative Hal Rogers, a Kentucky Republican who chairs the powerful House Appropriations Committee.

    The offices of Democratic Senators Joe Manchin of West Virginia and Bob Casey of Pennsylvania said they would fight any attempt to remove these protections from coal miners. A spokesperson for Kentucky Republican and Senate Majority Leader Mitch McConnell said by email that the senator has no "announcements on any legislative action for next Congress."

    coal miner

    Evan Smith, the attorney, warned against complacency. "I want to make sure that coal country doesn't assume that they are going to be taken care of just because a lot of our political leaders have voiced support for our region," he said. "I wish I could be more optimistic that they truly would keep their promise."

    Dr. Cecile Rose, director of the Miners Clinic of Colorado and a professor at National Jewish Health in Denver, noted that black lung benefits can be especially vital for the many former miners who don't have pensions. "Retired miners, a lot of them have also lost their pensions because of the bankruptcies that many of the coal mines have declared," she said. "They may be hanging on by a thread."

    The uncertainty about these benefits is even more worrisome to her because of evidence showing an increase in both the prevalence and severity of black lung cases.

    Sue Toler takes issue with Trump's way of talking, and she isn't sure about his plan to get miners back to work. "I've got mixed feelings about that … I watched my husband suffer," she said. "But if it's good for the country, then I'm all for it."

    To her, though, it would be sad if black lung benefits like her husband's got taken away after the 22 years of suffering that preceded his death.

    "He couldn't breathe, and that just kept getting worse. He just died a little bit every day, and there was nothing you could do about it," she said. "Words can't describe what somebody goes through when they are dealing with black lung."

    Her brother-in-law is "dealing with that now," she added. "I've seen him walk through the house when it looked like he was going to draw his last breath, and I had held my own breath until he was able to set down."

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    donald trump

    Any Republican attempt to replace the Affordable Care Act must address Medicaid, which has literally become the 800-pound gorilla in the health-care policy room.

    Simply rolling back the ACA’s Medicaid expansion would spike the number of uninsured Americans and expose Congress and the Trump administration to withering criticism.

    On the other hand, leaving Medicaid unchanged exposes the federal budget to the program’s unsustainable cost trajectory: Federal Medicaid spending has doubled over the past decade.

    While the debate over Obamacare normally focuses on the health-care exchanges, the law’s impact on Medicaid has been even more consequential.

    About 10.4 million individuals were covered under a health-care exchange plan in early 2016, but Medicaid enrollment increased by 14.5 million between the Affordable Care Act’s implementation and late 2015 (this and other Medicaid statistics I cite include the closely related Children’s Health Insurance Plan).

    By August 2016, Medicaid enrollment totaled 73.1 million people — over 22 percent of the nation’s population. Medicaid’s recent growth is attributable both to the expansion of eligibility under Obamacare and greater enrollment among individuals who were already eligible.

    As documented by Brian Blase of the libertarian-leaning Mercatus Center, Obamacare’s Medicaid expansion has cost much more than expected: In 2015, the cost per expansion-eligible enrollee was $6,366, more than $2,000 above projections.

    In fiscal year 2016, the federal government spent around $368 billion on Medicaid, with states kicking in roughly $220 billion more.

    While the federal government sets many program rules, it is the states that manage Medicaid on a day-to-day basis. And this creates perverse incentives. Every time a state reimburses a provider for Medicaid services, its spending is matched at least one for one by a federal grant.

    Since states pay only a fraction of the budgetary cost of Medicaid reimbursements, they can enrich powerful health-care provider constituencies at a low budgetary cost to the state.

    U.S. President Barack Obama signs the Affordable Care Act, dubbed Obamacare, the comprehensive healthcare reform legislation during a ceremony in the East Room of the White House in Washington, U.S., March 23, 2010. REUTERS/Jason Reed/File Photo

    This effect was on display during this election season in California. Television viewers were bombarded by advertisements for Proposition 52, a measure that extends a temporary state fee on hospitals.

    Revenues the state collects from imposing the fee are dedicated to the state’s Medicaid program, known as Medi-Cal. Hospitals and other health-care interests spent more than $60 million in campaign contributions to get the measure approved.

    It may seem odd that hospitals would fight so hard to have a state fee imposed upon them until one realizes that the fee is simply a device for extracting more federal money through Medicaid — money that then flows back to hospitals.

    California is not alone in doing this; almost every stateuses these financial gimmicks. Vice President Joe Biden has referred to these fees as a scam that should be scrapped.

    This perversion of state fiscal policy is usually justified as a necessary evil in pursuit of providing health care to the poor.

    But a lot of the money is captured by hospital executives. For example, Patrick Fry, the CEO of northern California hospital group Sutter Health received $6.3 million in total compensation in 2014; Kaiser Foundation Health Plan Chairman George Halvorson pocketed $10.4 million the same year.

    Both Kaiser and Sutter obtain hundreds of millions of dollars in Medicaid funds annually. Runaway hospital executive compensation has also become a concern for organized labor: The Service Employees International Union prepared a measure limiting pay to $450,000 annually, but was ultimately persuaded against placing it on the California ballot.

    Much of the federal money not paid out to executives falls to the hospitals’ bottom lines. In California, overall hospital revenues exceeded expenses by $7.9 billion during 2014. Although most hospitals are technically not-for-profit, it is still easy for stakeholders other than patients to harvest this windfall.

    The gains can finance future executive compensation or can be plowed into sparkling new facilities, which may be unnecessary, or unnecessarily opulent, for the care provided.

    Paul Ryan

    Hospitals are not the only provider group enriched by the Medicaid program. Provider reimbursement data from the state’s Department of Health Care Services (DHCS), which is available online (after by being obtained through a FOIA request), show several doctors receiving over $1 million annually from the state’s Medi-Cal program, including a couple of obstetricians who have mostly negative reviews on Yelp.

    With most of its funds coming from the federal government, DHCS has less incentive to monitor physicians receiving these large payouts.

    To encourage states to properly manage Medicaid spending, Congress should replace the federal matching scheme with a different funding mechanism. Earlier this year, House Republicans suggested moving to either block grants or per capita allotments.

    A block grant is a fixed sum of money allocated to each state to support its Medicaid spending, while a per capita allotment would provide states a fixed amount of funding per Medicaid beneficiary. In either case, annual federal funding would grow at a slower rate than it does now, but states would have much more flexibility in the way they use federal Medicaid grants, enabling them to provide services in a more cost-effective manner.

    For example, Ohio would like to implement health savings accounts for Medicaid beneficiaries, asking them to contribute a small amount (not to exceed $8.25 per month) to these accounts, so that they have “skin in the game.” Ohio’s program was rejected by Health and Human Services but could be implemented if Congress moves to a block grant or per capita allotment framework.

    A federal funding mechanism that eliminates perverse state incentives promises to provide better care for our less fortunate neighbors at lower taxpayer cost. While this solution may not be ideal for highly compensated hospital executives and unscrupulous physicians, it will be a win for the rest of us.

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    Chairman of the House Budget Committee Tom Price (R-GA) announces the House Budget during a press conference on Capitol Hill in Washington on March 17, 2015.      REUTERS/Joshua Roberts

    President-elect Donald Trump has selected Rep. Tom Price of Georgia to lead the Department of Health and Human Services.

    That's according to a person familiar with the decision, which is expected to be announced Tuesday morning.

    Price, a Republican, has been a leading critic of President Barack Obama's signature healthcare law. Trump has vowed to repeal the measure, though he has been unclear about exactly what he hopes to replace it with.

    The person familiar with the decision insisted on anonymity because the person was not authorized to discuss the nomination publicly ahead of Tuesday's announcement.

    Trump adviser Newt Gingrich has tweeted his approval, calling Price "the right leader to help Congress replace Obamacare."

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    tom price

    Rep. Tom Price of Georgia on Tuesday was nominated as the new secretary of health and human services by President-elect Donald Trump.

    A former orthopedic surgeon, Price has an impressive record in the healthcare field. He is also a vocal critic of the Affordable Care Act, the healthcare law better known as Obamacare, and his appointment perhaps signals Trump's seriousness in intending to dismantle the law.

    "The Trump administration's mantra has been that the ACA is a disaster and the only way to fix it is to repeal and replace it, and this appointment seems to confirm that idea,"Timothy Jost, a law professor and health-policy expert at Washington and Lee University who supports the ACA, told Business Insider.

    Price has been at the forefront of congressional fights to repeal and replace President Barack Obama's signature legislation.

    While Trump's own details on how to replace the law have been spotty, Price has written legislation called the Empowering Patients First Act, which would repeal most of the sections of Obamacare and shift toward what Republicans call a "market-based" approach.

    How it would work

    Price's plan would significantly restructure the benefits given to Americans without health insurance through their employer or the government. Price's plan structures tax credits based on age brackets — $1,200 for people ages 18 to 35 and up to $3,000 for those 50 and older. This is different from the ACA, which bases its tax credits on the income of the patient.

    Another key aspect of Obamacare — one Trump has said he would consider keeping — that prevents insurers from denying coverage based on a preexisting condition, would change. Under Price's proposal, people would be able to continue coverage if they shifted from the employer market to the individual market, but only if they have no interruptions in coverage. Thus, a break in care would allow insurers to deny coverage to people with an illness.

    For those who do not maintain that care, Price's plan would institute state-level high-risk pools to help cover them. The Price plan would provide $1 billion in federal funding to help control costs for these pools. The Commonwealth Fund, however, a nonpartisan health-policy think thank, estimates that these pools would require well over $170 billion a year in federal funding to cover those who today have ACA-based plans.

    Additionally, such high-risk pools typically have premium costs double those of normal individual-market plans.

    The expansion of Medicaid under Obamacare would also be rolled back under Price's plan, shifting roughly 15 million people from the government-sponsored insurance to the individual marketplace. The expansion provided coverage for those making roughly $16,490 and below annually. Questions loom over, even with a subsidy, how affordable it will be for those people to obtain plans on the individual market.

    In total, Price's proposal bears much of the same hallmarks of plans from Republican other congressional leaders, such as House Speaker Paul Ryan, who called Price the "absolute perfect choice" for the position in Trump's Cabinet.

    "We could not ask for a better partner to work with Congress to fix our nation's healthcare challenges," Ryan said in a statement.

    barack obama sad frown

    'Asking the fox to guard the hen house'

    The appointment of Price has drawn criticism from Democrats and advocates of the Affordable Care Act. Sen. Chuck Schumer of New York, the incoming Senate minority leader, said Price's healthcare proposals were "far out of the mainstream of what Americans want."

    "Nominating Congressman Price to be the HHS secretary is akin to asking the fox to guard the hen house," Schumer's statement said.

    Jost said Price's proposals would, incidentally, end up hurting many of the people who elected Trump to the White House.

    Price's plan "shows where we're heading," Jost told Business Insider. "It will help wealthier people and does nothing to help the working-class people who actually voted for Trump."

    Critics point to potential rollbacks of provisions in the ACA that compel insurance companies to provide certain types of care, meaning insurance companies could exclude comprehensive coverage needed by sick people. For older individuals, Price's plan would take away the provision linking what insurers can charge young people compared with seniors, providing the potential for insurers to increase rates for older people with chronic-care needs.

    Even the majority of Americans who get their insurance through their employer, Jost said, might see their costs increase under a Price-type plan. Those with insurance through their workplace currently do not pay federal taxes on premiums and other health-related payments — such as health savings accounts and health reimbursement arrangements — paid to these plans.

    Price's plan would cap the amount of healthcare spending that is non-taxable at $20,000 for a family and $8,000 for an individual. While such a provision could hurt affordability for those with employer-based insurance, according to the Tax Policy Center, the exemption cost the federal government $250 billion in lost taxes in 2015.

    Jost also suggested many of the provisions in Price's plan — such as state-level tribunals for malpractice cases and limitations on what patients may use in cases as evidence against a doctor — are designed to guard physicians from patients.

    "The bill should probably be called 'Empowering Doctors First,'" Jost told Business Insider. "He's a doctor, and it's clear he is trying to shield doctors."

    SEE ALSO: Obamacare is close to death after Trump's election

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    Coal Miner

    Donald Trump made a major play for coal miners and producers throughout the 2016 campaign, loudly denouncing the “anti-coal” policies of the Obama administration and Hillary Clinton.

    He promised to reopen abandoned mines and rejuvenate the declining industry.

    "We're going to get those miners back to work ... the miners of West Virginia and Pennsylvania … and Ohio,” Trump said last spring.  “They are going to be proud again to be miners."

    The number of coal mining jobs has declined, falling from 84,600 shortly after President Obama took office in March 2009 to just 56,700 early this year, according to the Department of Labor. Trump’s plea to voters in major mining states paid off handsomely and helped him to score critical wins in the battleground states of Pennsylvania and Ohio, while coasting to victory in Kentucky, West Virginia and the rest of coal country. 

    Whether Trump and the GOP are capable of reversing trends that are hurting the coal industry – including natural gas production from fracking that is driving down energy costs, increased mechanization of coal production that eliminates jobs, and strict government regulations on carbon emissions — remains to be seen.

    In the short term, however, Republican policy making could have an adverse effect on rank and file coal miners, retired miners, and their families. While the issues at hand are relatively narrow, they are critically important to tens of thousands of mining families throughout Appalachia who are struggling to make ends meet.

    coal miners trump supporters

    Black lung disease. For years, coal miners and their families were rebuffed by mining companies in attempting to collect compensation for disabilities associated with respiratory problems developed by inhaling coal mine dust. The biggest problem was that by law the burden of proof fell to the disabled miners, their families or survivors to demonstrate that the miners’ respiratory problems were real and directly related to years of work in company mines.

    But as the health and science website STAT reported Monday, that all began to change with enactment of the Affordable Care Act in 2010. Under an obscure miscellaneous provision added by the late Democratic Sen. Robert C. Byrd of West Virginia, the burden of proof was abruptly shifted from the disabled miners to the mining companies themselves.

    In effect, if a miner had spent 15 years or more working underground for a company and could prove that he or she had developed a respiratory disability, then it was presumed to be black lung associated with employment at the mine. And unless the company could somehow prove otherwise, it would be responsible for providing disability benefits to the miner or his survivors.

    Coal mine

    “Often the person whose job it is to do the convincing loses,” Evan Smith, a lawyer for the nonprofit Appalachian Citizens’ Law Center who has handled many black lung cases, told STAT. In 2009, just prior to enactment of Obamacare, 19 percent of claims for black lung benefits were successful. By last year, the share had jumped to 28 percent.

    Now, however, many in coal country may have reason to worry. Trump and House and Senate GOP leaders have vowed to make the repeal of Obamacare one of their first acts in January. If the Republicans carry through, Byrd’s black lung provision would likely be washed away along with the provisions for subsidized health insurance plans and expanded Medicaid for low-income Americans.

    The Miners Protection Act. Congress is trying to address the crisis of failing pension and health benefits in the coal mining industry before the end of the year, but a clash of views between Senate Majority Leader Mitch McConnell (R-KY) and Senate Democrats may jeopardize enactment of the legislation.

    Those benefit plans were severely underfunded as a result of the Great Recession and a major downturn in the industry, as coal companies declared bankruptcy and reneged on their obligations to current and former employees. In the latest bit of bad news, the benefit fund of Patriot Coal informed 12,500 retirees last month that their health coverage would end on Dec. 31, according to Sen. Joe Manchin (D-WV), a chief sponsor of the emergency rescue legislation.

    coal miner

    More than 10,000 other retirees are likely to experience a similar fate next year, according to Manchin and 27 other Democratic co-sponsors of the legislation.Additionally, the pension fund that these miners and their widows rely on for life’s basic necessities will reach the point of no return shortly thereafter,” the lawmakers said in a letter earlier this year.

    The proposed emergency legislation cleared the Senate Finance Committee by a vote of 18 to 8 in September. It would borrow from a mine cleanup program created by the Surface Mining Control and Reclamation Act to boost union health and retirement plans with an estimated $220 million a year.

    But the legislation has run into a serious roadblock after McConnell, the Republican majority leader and champion of Appalachian coal companies, questioned why the emergency funding would be targeted exclusively to unionized coal workers, and not to non-union miners, as The New York Times editorial page reported Monday.

    The current version of the bill would transfer funds from the abandoned mine land program to the United Mine Workers of America 1974 Pension Plan to prevent its insolvency. That would protect an estimated 89,000 pensioned miners and family members and 22,000 workers.

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    barack obama smile

    Though the future of the law is in doubt, the number of people signing up for health-insurance plans under the Affordable Care Act, better known as Obamacare, is crushing the pace of enrollments in previous years.

    According to the Centers for Medicare and Medicaid Services, which oversees the public Obamacare marketplaces, 2,137,717 Americans have signed up for plans through the various provisions of the ACA in November.

    "Over 2.1 million people have selected plans using the Healthcare.gov platform since Open Enrollment began on November 1, including over half a million new consumers and 1.6 million consumers renewing their coverage," the release from CMS said.

    The Department of Health and Human Services expects 13.8 million people to sign up for plans during open-enrollment season, which runs from November 1 through January 31.

    The number of sign-ups is higher than it was over the same period in previous years, according to CMS.

    "Enrollments for these two weeks represent an increase of 167,000 plan selections versus the third and fourth weeks of Open Enrollment last year," the release said. "In addition, the total number of plan selections at this point exceeds last year by over 97,000, even though this year's totals include two fewer days."

    The sign-up data comes just two days after President-elect Donald Trump nominated Rep. Tom Price as his pick for secretary of the HHS. Price is a longtime critic of Obamacare and has vowed to repeal and replace the law.

    SEE ALSO: Trump's new Cabinet pick wants to destroy Obamacare

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    doctor patient pacemaker

    While the out of pocket costs of healthcare have increased for many in recent years due to shifts in the insurance market, it appears fewer Americans are struggling with medical bills than in previous years.

    According to the U.S. Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), and the National Center for Health Statistics (NCHS), the percentage of Americans under 65 who reported that their family had trouble paying medical bills in the past 12 months was down to 16.2% in the first half of 2016.

    This is down from 16.4% in 2015 and 21.3% from 2011, just five years prior.

    According to the NCHS, the drop in the number of people having trouble with their bills coincides with the drop in the rate of Americans without health insurance, which hit is lowest rate ever in the first half of 2016.

    "During this time period, there have been changes in the prevalence of uninsured persons," said the report from the NCHS."In the first 6 months of 2016, 28.1 million (10.4%) persons under age 65 were uninsured at the time of interview—17.8 million fewer persons than in 2011 (17.3%) but only 0.3 million fewer persons than in 2015 (a non-significant difference)."

    The drop off has also occurred since the passage of the Affordable Care Act, better known as Obamacare.

    Screen Shot 2016 11 30 at 12.36.09 PM

    Now since this is simply bills, it does not include premium payments for insurers, which have gone up.

    The data is part of the broader National Health Interview Health Survey, which interviewed nearly 600,000 Americans in a national representative sample and is generally considered the best data on the state of healthcare.

    The decrease also came across the board, regardless of age and sex. Of note, the struggle to pay medical bills has decreased for people with all types of coverage: private insurance, public insurance, or no insurance at all.

    Thus, this could be a combination of increased coverage as well as the generally improving labor market. With unemployment down and wage increasing at their fastest pace since the financial crisis, the income boost may be helping manage bills.

    Screen Shot 2016 11 30 at 12.43.24 PM

    The decline was also most striking for those on the lower end of the income spectrum. According to the survey, the percentage of people living under the poverty threshold that have reported problems paying medical bills has decreased from 32.1% in 2011 to 23.0% in the first six months of 2016.

    For those considered "near poor" by the NCHS — for 2016 this would be a single person earning between $11,770 and $23,540 annually — the measure has decrease from 34.6% in 2011 to 24.9% this year.

    For the near poor, the extension of Medicaid under the ACA may have played a role in the decrease.

    In terms of ethnicities, all groups saw their inability to pay medical bills decrease since 2011. Interestingly, however, the percentage of non-Hispanic blacks reporting trouble with bills ticked up slightly between 2015 and 2016.

    Screen Shot 2016 11 30 at 12.52.56 PM

    SEE ALSO: The number of people signing up for Obamacare is soaring

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    tightrope

    Republicans are about to play a game of chicken with 20 million Americans' healthcare.

    GOP lawmakers are planning to repeal the Affordable Care Act, better known as Obamacare, in 2017 but delay the the rollback by up to three years to draft a replacement plan, according to Politico.

    Republicans have long wanted to repeal the ACA, and now with Donald Trump headed to the White House, they'll likely get their wish.

    The problem is that many parts of the law — such as the provision that insurers can't deny coverage based on a preexisting condition — are popular with Americans, and nearly 20 million people have accessed healthcare plans through the ACA.

    To avoid political repercussions from doing away with those popular aspects, GOP lawmakers, with the support of the Trump administration, are planning to set a three-year time frame on the repeal and replacement of the ACA, according to Rachael Bade and Burgess Everett at Politico.

    The clock set by the Obamacare repeal law would, much like the so-called fiscal cliff in 2013, put pressure on lawmakers to compromise on a new healthcare bill. If no compromise is found, the repeal would happen and leave the 20 million people who currently have insurance through the ACA without coverage.

    The thinking is that this would not only give impetus to Republicans to streamline various existing replacement proposals, but also put political pressure on Democrats to sign onto a replacement or put 20 million out of coverage. It also allows Republicans to pin any failure to pass a replacement on Democrats for not going along with their plan.

    House Majority Leader Kevin McCarthy told Politico the three-year delay makes sense because when there's "a date certain that something's going away … you know you have to have something done."

    Republicans could immediately repeal the parts of the law dealing with the budget, such as funding for the Medicaid expansion and state exchanges, with a simple majority vote.

    Of note, this would also push the repeal date past the midterm elections in 2018, avoiding any political fallout if a replacement is not found in time.

    The promises of House Speaker Paul Ryan, Senate Majority Leader Mitch McConnell, and Trump to repeal Obamacare on "Day One" may come with some caveats.

    SEE ALSO: The number of people signing up for Obamacare is soaring

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    doctor patient pacemaker

    When Donald Trump this week tapped a surgeon-turned-congressman to run the Department of Health and Human Services, the nation’s largest physicians group swiftly endorsed the choice.

    The blowback started almost at once.

    Liberal doctors peppered the American Medical Association with furious tweets decrying the group’s endorsement of Representative Tom Price as a betrayal of patients and physicians. 

    And by Wednesday night, 500 doctors had signed an online open letter titled “The AMA Does Not Speak For Us” started by the Clinician Action Network, a left-leaning advocacy group.

    The outpouring of anger has exposed the bitter political rifts dividing doctors these days. Price is an AMA member, but he also belongs to a conservative doctors’ group that publishes a journal which has advanced discredited theories, such as the notions that abortions cause breast cancer, vaccines cause autism, and HIV does not cause AIDS.

    The same group shot into the spotlight during the presidential campaign by promoting conspiracy theories about Hillary Clinton’s health, including speculation that she’d had a seizure or a stroke.

    There are left-leaning alternatives to the AMA, too, including one that has long advocated for gun control, pushes physicians to cut all financial ties with drug companies — and expressed dismay that any doctors group would back Price.

    The AMA remains by far the biggest and most visible lobbying force representing doctors and medical students. The group spent $15 million just in the first nine months of this year to lobby Congress and the executive branch on everything from marijuana research to opioid prescribing to telemedicine, as well as traditional issues such as reimbursement and billing, according to federal filings.

    But physicians are increasingly using social media to push back against the organization.

    Donald Trump

    “The AMA is generally a force for the status quo in health care, a physicians’ guild in the old-school style of wheeling, dealing, and horse-trading to keep the billing flowing like a mighty stream into MDs’ coffers,” Dr. Zackary Berger, an internist at Johns Hopkins, said in an email. Berger, who is also the founder of Doctors Against Trump, has never belonged to the AMA.

    The AMA has about 250,000 members, including doctors and medical students. Roughly 15 percent of practicing doctors in the US are full dues-paying members of the AMA, according to a 2011 estimate published in the journal of the Canadian Medical Association.

    The organization has a lot at stake when a new administration comes to town: Working with Congress, the executive branch can shape everything from health insurance markets to hospital ratings systems to how much money doctors receive for treating patients on Medicaid and Medicare.

    Back in 2009, when President Obama first nominated Kathleen Sebelius to run HHS, the AMA put out a statement within hours praising her “leadership skills.”

    Within six hours of Trump officially nominating Price, the AMA urged quick confirmation in a tweet expressing strong support for the Georgia congressman, a former orthopedic surgeon. In a statement on its website, the group praised Price as “a leader” in developing “market-based solutions” to health policy and reducing “excessive regulatory burdens.”

    The AMA didn’t mention that Price has been a vocal opponent of the Affordable Care Act. Or that he’s called for restructuring and sharply cutting federal aid to Medicaid, which primarily serves poor people. Or that he’s proposed controversial changes that could cut benefits to seniors under Medicare. Or that he has a 0 percent rating from Planned Parenthood and has opposed efforts to give women free access to birth control.

    tom price

    The endorsement infuriated some doctors.

    Other physicians said they were glad they had cut ties with the AMA before the endorsement. “I left when I realized they certainly were not speaking for me,” said Dr. Jen Gunter, a Bay area OB-GYN who was an AMA member for a few years in the 1990s.

    Gunter told STAT she found the AMA too slow to speak up in defense of reproductive health, too weak on promoting primary care physicians, and too slow to promote female leaders. Even so, she said she was “stunned” that the organization endorsed Price.

    The outcry among doctors didn’t escape the notice of Sebelius, who served as HHS secretary for five years during the development and implementation of Obamacare (and who took heavy criticism from anti-abortion groups after her nomination).

    “I wasn’t surprised to see some pushback” from doctors on Price’s nomination, Sebelius told STAT in a phone interview. She noted that the AMA has supported Medicaid expansion and been involved in outreach around the Affordable Care Act — and “clearly, this nominee does not share those views.”

    Even Dr. Steven Croft, a Texas neurologist who is a member of the same right-wing physicians group as Price, said he was “shocked” — and pleased — to see the AMA back Trump’s nominee, given the group’s support for Obamacare.

    “It seems that they switched sides (for the better),” Croft said in an email.

    Dr. Patrice Harris, who chairs the AMA’s board of trustees, said the group’s endorsement stems from its “relationship with Dr. Price going back decades.”

    The AMA has not always agreed with Price on “important policy issues,” Harris wrote in an emailed statement, but he has “consistently recognized the many challenges facing patients and physicians, and he has been willing to listen” to the group’s concerns.

    And the blowback from doctors? “We understand that our diverse membership will never agree on every position the AMA takes,” Harris wrote.

    Obamacare protest

    The AMA wasn’t the only medical group to back Price.

    “A strong choice,” said the Association of American Medical Colleges.

    “An indispensable voice,” said the American Academy of Orthopaedic Surgeons.

    America’s Essential Hospitals lauded Price’s health care background. The Advanced Medical Technology Association said “we look forward” to his confirmation.

    Meanwhile, the National Physicians Alliance, which identifies as nonpartisan but generally backs liberal policies, put out a statement taking those other groups to task: “We are dismayed that other large physician organizations have endorsed Dr. Price without consideration of the harm his policies would inflict on our collective patients.”

    The group’s president, Dr. Manan Trivedi, told STAT that he believes many physicians share his sense that they have been betrayed by “organizations that they thought represented them and patients but in fact were focused on personal pocketbook issues.”

    His view of Price? “No [health secretary] nominee in recent memory has been such a threat for basic health care for our patients,” Trivedi said.

    Price’s congressional office did not respond to a request for comment. Neither did Trump’s transition team.

    Dylan Scott contributed reporting from Washington.

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    Obamacare protest

    Donald Trump won the White House on a platform that includes repealing the Affordable Care Act, aka Obamacare. That's mostly good news for big insurers that have lost hundreds of millions of dollars selling plans through Obamacare's exchanges, paying its fees, and adhering to its consumer-centric regulations.

    However, a repeal isn't all good news for the industry. A complete repeal of Obamacare could result in a steep drop in the number of people enrolled in Medicaid, and if that happens, it could significantly reduce revenue at private insurers that manage state Medicaid programs. 

    The good news

    Before explaining the how a rollback in Medicaid could hurt insurers, let's spend a moment considering the potential benefits to insurers that could stem from Obamacare's repeal.

    If Obamacare disappears, large insurers such as UnitedHealth Group(NYSE:UNH) will no longer have to figure out how to price and manage marketplace plans that have been losing them money.

    UnitedHealth Group's losses on Obamacare plans could reach $650 million this year, and those losses have both weighed down earnings and forced management to reduce its exposure to the exchanges. In 2016, UnitedHealth Group sold Obamacare plans in more than 30 states, but next year, it's offering plans in only a handful of states.

    Dismantling Obamacare could also eliminate the health insurance industry tax. Last year, that tax cost insurers a combined $11.3 billion, and the industry is expected to pay the IRS a similar amount this year. UnitedHealth Group's share of that tax bill was $1.8 billion last year, and the company expects its share to be $1.9 billion this year.

    Removing restrictions that limit the ratio of premiums charged to insure older Americans to younger Americans could also support earnings. Obamacare limits that ratio to 3:1, but historically, the ratio of healthcare costs for these two patient populations has been closer to 6:1. Removing this restriction would give insurers more flexibility to bring patient premiums more in line with their costs of care. 

    Further, insurers' profitability would benefit from the removal of Obamacare's requirement that insurers spend at least 80% of their premiums on member healthcare. Today, insurers that spend less than 80% on healthcare have to send members rebate checks. If this rule disappears, insurers could deliver more money to their bottom lines by reducing what they spend on medical costs.

    The bad news

    Deregulation would give insurers profit-friendly tailwinds, but it could negatively impact their revenue from state Medicaid programs. 

    Obamacare includes provisions allowing states to opt into Medicaid expansion, and more than 30 states have chosen to do so. According to the Centers for Medicare and Medicaid Services, Medicaid enrollment has grown by 15.4 million people to 72.8 million people since Obamacare's launch, and most of that membership growth took place in the expansion states. 

    Surging membership has been a boon to Medicaid insurers, both big and small. UnitedHealth Group makes most of its money selling employer-sponsored plans, but its Medicaid enrollment has grown significantly over the past three years. In the past 12 months alone, its Medicaid enrollment grew by 485,000 to 5.8 million people, and as a result, revenue at the company's community and state insurance segment jumped 12% year over year to $8.3 billion in the third quarter. For perspective, consider that UnitedHealth Group's Medicaid membership in the third quarter of 2013 -- the last full quarter before Obamacare's launch -- totaled 3.95 million people, and its community and state segment revenue was $4.6 billion.

    Smaller insurers that get most of their revenue from running state Medicaid programs could be hit hardest. For example, Molina Health served 1.9 million people through its various products prior to Obamacare's enactment. Today, it serves 4.2 million members. In Q3 2013, Molina's earnings per share were $0.17. Last quarter, they were $0.85. While Medicaid expansion isn't the only reason for Molina's success, it has been a big contributor to it.

    Looking ahead

    President-Elect Trump has said that he might be willing to keep some aspects of Obamacare in place, such as allowing children to stay on their parents' health insurance plans until age 26. He's also indicated that he prefers free-market solutions, such as competing across state lines, to curb premiums in the future. However, Trump hasn't offered up a comprehensive blueprint for replacing Obamacare, and until he does, investors are left guessing at how his repeal and replace plans will shake out for insurers. For now, repealing Obamacare should be a net win for big insurers like UnitedHealth Group, but it could be a net loss for smaller, niche players that have a lot of exposure to Medicaid.

    SEE ALSO: Republicans are planning to play a dangerous game of chicken with Obamacare

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    Obamacare protest

    As President-elect Donald Trump and congressional Republicans begin a perilous drive to overhaul the nation’s health care system, the gravity of dismantling the Affordable Care Act and devising a politically acceptable replacement is beginning to sink in with GOP lawmakers and many of those who voted for Trump.

    Trump blithely asserted recently on CBS’s 60 Minutes that he and his allies on Capitol Hill will be able to simultaneously repeal and replace Obamacare early next year without wreaking havoc on the 20 million or more Americans who currently get their health care insurance through the program.

    However, senior House and Senate Republicans said this week that it could take as long as two to three years to hammer out a bipartisan replacement plan that could muster the necessary majorities in the House and Senate.

    Prominent GOP lawmakers including House Majority Leader Kevin McCarthy of California, Senate Majority Whip John Cornyn of Texas and Sen. Lamar Alexander of Tennessee, the chair of the Senate Health, Education and Labor Committee, told reporters that reaching consensus on a replacement plan without stripping millions of Americans of the security of health care insurance will take a number of years to achieve.

    “We’re talking about a three-year transition now that we actually have a president who is likely to sign the repeal into law,” Cornyn told reporters Wednesday, according to Politico.“People are being, understandably cautious, to make sure nobody’s dropped through the cracks.”

    McCarthy told reporters on Tuesday that once Obamacare is repealed and the consequences begin to sink in, that “you will have hopefully fewer people playing politics” and more policymakers in both parties willing to come together to write replacement legislation. He added that when there is a “date certain” that Obamacare will disappear, “you know you have to have something done.”

    Obamacare Protest

    Joseph Antos, a health care expert with the conservative-leaning American Enterprise Institute, said on Thursday that Republican leaders may be kidding themselves if they think they can get by with an open-ended deadline or replacing the Affordable Care Act.

    “In the end, a two or three-year timeline is the same as saying nothing will ever happen,” he said in an interview. “In my view, they have a year. If they don’t pass a replace plan by let’s say December of 2017, then I think the reasonable view of Democrats in the Senate will be, well, they couldn’t get their act together, so why should we think we should help them?”

    But if the Republicans could manage to both repeal and replace Obamacare within a year or so, he added, “That’s serious. It shows they really are going to do something. It matters.”

    Repealing Obamacare will be the easy part for Republicans who are tentatively targeting mid-January for action, right around the time that Trump takes the oath of office as president.  The Republicans already had a dress rehearsal for such action last January, when the GOP-controlled House and Senate used arcane “reconciliation” budget rules to ram repeal legislation through Congress and send it to the president’s desk. President Obama vetoed the legislation, but Trump is certain to sign a similar bill when it reaches his desk in the Oval Office.

    The Republicans won’t need a single Democratic vote to accomplish their reprise of the Obamacare repeal legislation, which provided for a two-year wait before implementation.  But crafting a replacement for the Affordable Care Act is a much different challenge and one that will require the acquiescence of some Democrats in order to achieve a needed 60-vote “super majority” to pass major legislation in the Senate.

    The Republicans are far from agreeing among themselves on the details of new Trumpcare legislation to succeed Obamacare. House Speaker Paul Ryan (R-WI) has outlined an alternative in his “Better Way” proposals and House Budget Committee Chair Tom Price (R-GA), who has been chosen by Trump to become Secretary of Health and Human Services, has prepared a very detailed free-market style plan.

    Trump has said that he is inclined to keep the “good parts” of Obamacare, including provisions that allow parents to keep their children on their health care policies until they turn 26 and a ban on insurance companies denying coverage to consumers with pre-existing chronic health problems. But beyond that, the Republicans’ approach to replacing Obamacare is very much a work in progress.

    Although a new Kaiser Family Foundation tracking survey shows that the public is still divided over Obamacare, many of the ACA’s major provisions continue to be quite popular with people, even across party lines.

    Moreover, while half of those who voted for Trump favor repealing the law, the public more generally is more divided over the issue.  Just a quarter of the voters surveyed since the election favor repealing the entire law, while 17 percent would scale it back, 30 percent would expand it and 19 percent would leave it as it is.

    public's view of obamacare

    It took Obama, the Democrats and special interest groups nearly two years to forge a compromise on the current health insurance program before it was passed and signed into law in March 2010.  Because of the size of their majorities in the Senate and House in 2010, the Democrats were able to pass Obamacare without a single Republican vote. However, the Republicans won’t have that luxury and will likely need at least eight or nine Democrats to join with them.

    Republicans have spent so many years bashing Obama and his Democratic allies for the many shortcomings in the Affordable Care Act – especially numerous technical problems with its online insurance exchanges, soaring premiums and out-of-pocket costs, and the collapse of nearly two dozen non-profit cooperatives – that Democrats are likely to relish the GOP’s challenges and headaches in finally offering a serious alternative of their own.

    Ryan, Senate Majority Leader Mitch McConnell (R-KY), Price and other GOP leaders will be challenged to assemble a coalition including the insurance industry, hospitals and doctors, the pharmaceutical industry, consumer advocates and others who will be needed to assure passage of new legislation. “We know that to correct [Obamacare] is going to take some time, it’s just that simple,” Senate Finance Committee Chair Orrin Hatch (R-UT), told The Washington Post.

    However, Senate Democratic Leader Chuck Schumer of New York and other Democrats appear to be enjoying the Republicans’ discomfort as they inherit responsibility for Obamacare and other major health care programs including Medicare and Medicaid. Already there have been reports that UnitedHealthcare, Aetna, Blue Cross-Blue Shield and other major insurers are likely to accelerate their withdrawal from the Obamacare program over the next year or two as uncertainty grows over the program’s fate.

    As the Republicans begin to wade into the political quagmire of health care, Schumer likened it to “the dog that caught the bus.” Now that they essentially own health care policy, Republicans may face voter resentment and backlash in the 2018 mid-term elections.

    “They’re stuck and that’s why they don’t have a solution,” he told reporters.

    SEE ALSO: Obama explains why it’s going to be harder for Republicans to repeal Obamacare than they think

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    Obamacare Protest

    The Kaiser Family Foundation released a new poll showing that Americans haven’t exactly gotten more enthused with the idea of getting rid of Obamacare since Trump’s election. From NPR:

    One-fourth, or 26 percent, of Americans favor a full repeal of the health care law, while 17 percent say scale it back, according to the Kaiser poll. On the other hand, 30 percent favor expanding the law and another 19 percent want lawmakers to move forward with the law as it is.
    The poll was conducted one week after the 2016 presidential election. In its aftermath, President-elect Donald Trump and Republican lawmakers have signaled their intention to follow through on their campaign promise to repeal President Obama's landmark health care legislation. Republican lawmakers have voted to repeal Obamacare dozens of times.

    The poll also shows that Republicans have softened on the idea of repealing the law. In October, 69 percent of Republicans said they wanted to eliminate the law entirely. Now that their guy has been elected and is ready to roll on the repeal, only 52 percent do. “Similarly, in October,” NPR’s Richard Gonzales writes, “just 11 percent of Republicans said they wanted the law scaled back but not eliminated. In November, that percentage increased to 24 percent.” Scaling the law back would mean keeping its most popular features, like allowing young people to be on their parents’ plans until they’re 26, which is supported by a full 85 percent of Americans.

    The poll additionally shows that 77 percent of Americans who favor repealing the law would continue to do so even if it meant that 20 million Americans who had gained coverage through Obamacare would lose their health insurance. Even so, a plurality of them—42 percent—believe that the GOP should figure out a replacement plan before repealing. As Politicowrote Thursday, Republicans on the Hill plan on passing a repeal early next year that won’t go into effect for as many as three years—giving them time, in theory, to come up with a passable replacement. This, in effect, would set up an “Obamacare cliff”:

    They’re crossing their fingers that the delay will help them get their own house in order, as well as pressure a handful of Senate Democrats—who would likely be needed to pass replacement legislation—to come onboard before the clock runs out and 20 million Americans lose their health insurance. The idea is to satisfy conservative critics who want President Barack Obama’s signature initiative gone now, but reassure Americans that Republicans won’t upend the entire health care system without a viable alternative that preserves the law’s popular provisions.

    It’s unclear, though, whether Americans will be “reassured” by a process that guarantees another round of political brinkmanship over a fairly popular law that provides health care to tens of millions. We’ll soon find out.

    SEE ALSO: Obama explains why it’s going to be harder for Republicans to repeal Obamacare than they think

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    obama trump obamacare thumb

    WASHINGTON (Reuters) - A federal appeals court on Monday agreed to put on hold until after U.S. President-elect Donald Trump takes office in January the Obama administration's appeal of a judge's ruling favoring a Republican challenge to a key part of the Obamacare law.

    The action by the U.S. Court of Appeals for the District of Columbia Circuit was a victory for the Republican-led U.S. House of Representatives, which filed the challenge to the 2010 law and asked the court for the delay. Trump favors repealing and replacing the Affordable Care Act, President Barack Obama's signature domestic policy achievement.

    The court said both sides should provide an update on the status of the case by Feb. 21. Trump is due to be sworn in as Obama's replacement on Jan. 20.

    The House Republican challenge targets government reimbursements to insurance companies to compensate them for reductions that the law requires them to make to customers' out-of-pocket medical payments.

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    Donald Trump smile

    Many academic economists must be perplexed by the last three weeks’ financial news, having confidently opined that a Trump presidency would spell economic disaster.

    Let’s hope that they are feeling a little embarrassed by the stock market’s surge, by sharply rising inflation expectations, and by accelerating growth forecasts.

    Interestingly, many voters saw what economic “experts” did not: an utter contempt for economic growth by the Obama Administration and the Clinton campaign.

    That contempt was visible constantly over the past eight years – in the refusal to allow the XL Pipeline, in the shutting down of the coal industry in West Virginia, in the lack of any serious prioritization of tax reform.

    Obama and Clinton had a tin ear for anything but the priorities of the progressive elite, and consequently focused on redistribution, battling global warming, expanding health care coverage on unsustainable financial footings, and punishing bank lending.

    Within 24 hours of Trump’s election, the markets not only expressed confidence in a pro-growth Trump agenda; more importantly, they told us how easy it would be to create growth if the political class is willing to do so. So much for the silly “secular stagnation” theories of the left, which were a transparent attempt to deflect blame for slow growth onto the purported absence of innovation, or a list of other purported ills of the market – anything but the costly growth-killing policies of the Obama Administration.

    It remains to be seen whether the President-Elect will realize the growth aspirations that are within his reach or be distracted by growth-destroying policies such as vague and indefensible allegations of Chinese currency manipulation, or the mass deportation of non-criminal illegal aliens, or “shovel-ready” Keynesian pyramid building.

    The markets are betting that Trump will not be sidetracked from a pro-growth agenda, despite his campaign rhetoric. That belief likely to some extent reflects confidence that congressional Republicans will push back against ill-advised policies. President Trump might secretly welcome that opposition, which would exonerate him from failing to fulfill some ill-advised campaign promises. 

    A pro-growth policy agenda that focuses on lower tax rates for corporations and individuals, reduced tax deductions to finance some of the tax revenue foregone, smart and properly targeted growth-supporting reforms of Obamacare and Dodd-Frank, and modest, value-creating and carefully chosen (not hurried, “shovel ready”) infrastructure spending would leave Democrats with even less voter support in two years, clearing the way for further Republican policy initiatives in many other areas, especially education and entitlement reform.

    donald trump

    Is it possible to quickly identify and implement well-targeted healthcare and financial reforms? House Finance Committee Chairman Jeb Hensarling (R-TX) and others in Congress have already identified the low-hanging fruit of potential reforms of Dodd-Frank. Most importantly, they have articulated the key principles that should guide those reforms: restoring rule of law to the regulatory process and allowing banks to regain control of their own lending and other business decisions so long as they are credibly taking risks with their own funds rather than relying on the protection of taxpayers. Rising interest rates (which finally appear likely) will strengthen bank profits and provide a tailwind to encourage more lending.

    With respect to Obamacare, the key principles guiding reform in existing Republican proposals are restoring consumer choice and strengthening market competition, while avoiding high premiums for preexisting conditions and ensuring coverage for the lowest-income Americans. The political challenge is finding a way to reduce the size of government subsidies so that coverage can be financially sustainable, and individuals will have the incentive to exercise cost-saving healthcare choices. Although such medicine may not be popular with some voters, it will be much easier for voters to swallow in light of skyrocketing health care costs, diminished choice, and the general understanding that Obamacare is currently fundamentally dysfunctional.

    The Obama Administration’s gift to Mr. Trump is the opportunity to substantially spur growth primarily through a combination of targeted changes in tax and regulatory policy. A growth boost need not rely on expensive short-term fixes (such as an overly ambitious infrastructure spending package), and here too, the good news is that the Republican Congress likely will not approve a $1 trillion spending spree on infrastructure.  To succeed, Republicans must avoid the hubris of believing that they can achieve growth by magical thinking. Mass deportations, trade wars, or pyramid building will produce economic and political failure, profiting Elizabeth Warren, but not the average blue collar voter or the Republicans.

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    doctor patient pacemaker

    The pace of U.S. health care spending picked up slightly last year, reaching a total of $3.2 trillion or $9,990 per person in the country.

    While a number of factors were at play, the increase was largely due to expanded coverage of individuals who signed up for Obamacare or who took advantage of a major expansion of Medicaid, according to a new study released on Friday. 

    The new analysis from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) estimated that health care spending grew at a rate of 5.8 percent in 2015, less than a percentage point increase from the previous year.

    Viewed as a share of the entire U.S. economy, health care spending last year constituted 17.8 percent of Gross Domestic Product, up from 17.4 percent in 2014.  

    “Coverage expansions that began in 2014 as a result of the ACA helped increase the percentage of the population with health insurance from 86.0 percent in 2013 to 90.9 percent in 2015,” according to a summary of the report. “This expansion of coverage continued to affect health spending growth in 2015.” 

    The findings were  published online by the journal Health Affairs

    The report comes at a time when President Obama’s signature health care program is under its greatest threat yet. President-elect Donald Trump and House and Senate Republican leaders have vowed to push through legislation in January to repeal much of Obamacare and replace it in the coming years.

    GOP critics have long denounced the subsidized health insurance program for being too costly, for driving up premiums and out of pocket and for imposing onerous regulations and mandates on individuals and businesses.

    The new report acknowledges that while overall health care costs have increased after five years of historically low growth, Obamacare has substantially raised the rate of insured Americans from 86 percent in 2013 to 90.9 percent in 2015. The expansion of Obamacare coverage, including millions who acquired insurance for the first time through an expansion of the Medicaid program in more than 30 states and the District of Columbia, continued to impact health spending growth in 2015.

    doctors

    According to the report, the biggest driver of rising health care cost was accelerated spending for private health insurance, which climbed by 7.2 percent to $1.1 trillion. At the same time, hospital care costs rose by 5.6 percent to $1 trillion and clinical services costs rose by 6.3 percent to $635 billion.

    Moreover, Medicare spending on the elderly reached $646.2 billion, a 4.5 percent increase over the previous year. Meanwhile, Medicaid expenditures for the poor totaled $545.1 billion in 2015, a 9.7 percent increase.

    Amid concern about soaring prescription drug prices and gouging by manufacturers, the report found that spending on prescription drugs rose 9 percent to $324 billion last year. That constituted one out of every 10 dollars spent on healthcare.

    “Although the 2015 spending growth of 9.0 percent was slower than the rate of 12.4 percent in 2014, growth in prescription drug spending was faster than that of any other service in 2015,” the report stated. “Recent rapid growth is attributed to increased spending on new medicines, price growth for existing brand-name drugs, increased spending on generics, and a decrease in the number of expensive blockbuster drugs with expiring patents.”

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    Donald Trump

    President-elect Donald Trump has called for allowing health insurers to sell coverage across state lines to encourage competition and provide consumers with greater choice of individual plans.

    The proposal is part of Trump’s health care alternatives to Obamacare posted on his presidential transition website, and he talked about it frequently throughout the 2016 campaign.

    "We have to get rid of the artificial lines around the states, where we stop insurance companies from coming in and competing," Trump said during the second presidential debate with Democrat Hillary Clinton in St. Louis in October.

    The current system under Obamacare, in which every state and the District of Columbia establishes its own government-operated insurance market, “gives the insurance companies essentially monopolies,” Trump explained. "We want competition."

    The 2010 Obamacare law carefully prescribes ground rules for insurers participating in the subsidized health insurance program, including a prohibition against taking into account a person’s pre-existing medical conditions before determining whether to accept an applicant.

    The insurers can only consider an applicant’s age and location in setting premium prices, and they are obliged to offer every applicant a basic menu of coverage and benefits.

    Trump’s idea – echoed by House Speaker Paul Ryan (R-WI) and House Budget Chair Tom Price (R-GA), who has been nominated to be the next secretary of Health and Human Services -- is that by cutting through detailed regulations tied to state insurance regulations, insurance companies will be able to offer national plans with lower premiums and reduced administrative costs.

    That presumably would expand consumers’ choices as well as generate lower premiums and out-of-pocket costs.

    In effect, insurance companies large and small could market their individual plans to consumers in any state as long as they are licensed in their home states and adhere to their home-state regulations.

    Rep. Tom Price, R-Ga.

    But as The Wall Street Journal has reported, Trump’s interstate insurance marketing ideas are meeting resistance from state insurance regulators, the health insurance industry and independent health care analysts who say the approach has been tried before on a limited basis and is far from a panacea.

    Edmund Haislmaier, a senior research fellow at the conservative Heritage Foundation, said that while interstate sales might carry regional benefits, “No one should be under the illusion you can dramatically lower the cost of insurance in Los Angeles if you buy an Arkansas policy.” Moreover, state insurance commissioner have long challenged the efficacy of the concept as more myth than reality.

    “Some have suggested that allowing interstate sales of health insurance policies will make coverage more affordable and available,” the National Association of Insurance Commissioners said in a statement. “In reality, interstate sales of insurance will allow insurers to choose their regulator, the very dynamic that led to the financial collapse that has left millions of Americans without jobs. It would also make insurance less available, make insurers less accountable, and prevent regulators from assisting consumers in their states.”

    The indictment of Trump’s approach, which has been endorsed by House Speaker Paul Ryan (R-WI) and other GOP lawmakers and governors, is four-fold.

    Paul Ryan

    First, state officials complain that federal legislation to authorize insurance sales across state lines would undercut the state’s traditional role in regulating the insurance industry. If an insurer licensed, say, in Indiana  decided to offer its policies to consumers in Michigan or Wisconsin, it would be under no obligation to conform to the rules of Michigan or Wisconsin, provided it followed Indiana’s insurance regulations.

    In some ways, this would constitute even more invasive government big-footing by the federal government than the current law the Republicans want to get rid of.

    Second, critics warn that as insurers invariably flock to states with the most limited requirements and standards, the result would be for insurance companies to offer consumers cheap policies but often without some of the most basic health care and prescription drug coverage.

    The National Association of Insurance Commissioners argue that “interstate sales will start a race to the bottom by allowing companies to choose their regulators.”

    The state commissioners say that allowing insurers to pick and choose among markets in which to sell coverage is tantamount to allowing banks to choose their own regulators, a surefire way to create a financial crisis.

    Insurance companies would seek the state regulations “that allow them to most aggressively select the healthiest risk,” resulting in a situation in which the healthiest, youngest policy holders pay the least expensive premiums while older, sicker people would be confronted with steep premiums – provided they could find coverage at all.

    Third, while some major health insurers already have experimented in recent years in selling coverage across the country, they nonetheless have had to meet state regulatory requirements. If insurers were free to sell their policies in states where they were unlicensed, the possibility of cheating, fraud or other irregularities would be substantially increased.

    Obama doctors Obamacare

    Finally – and perhaps most importantly – insurance premiums are closely linked to underlying health care costs, such as rate levels paid to local or regional doctors and hospitals and the projected health needs of the policy holders. In order to sell an insurance policy in a particular state, the insurer would have to have a local network of allied doctors, hospitals and other health care providers in order to make the system financially feasible.

    The liberal-leaning Center on Budget and Policy Priorities said in an analysis of the GOP health care proposals released Monday that, “The few states that tried to open their markets to out-of-state insurers prior to health care reform generally had little to show for it, as insurers had problems establishing networks of providers outside their own states.”

    However, if insurers did succeed in entering other state’s markets, “the out-of-state plans would likely attract healthier-than-average people with low health care costs, because such people have much less need for consumer protections such as requirements to cover certain benefits or limits on insurers’ ability to charge higher premiums based on age or gender,” wrote Judith Solomon, an analyst with the non-partisan research organization.”

    Consequentially, the study said, those who remain in the plans offered by the in-state insurers would become less healthy as a group, and their premiums would rise accordingly.

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    opioid addiction heroin crisisAs one of its last acts of 2016, Congress could drop about $1 billion on America’s drug problem by approving the 21st Century Cures Act.

    The bipartisan bill, which includes funds to help states combat opioid addiction and overdoses, is up for final approval in the Senate, and President Obama wants to sign it into law before he leaves office.

    But even if the legislation is approved as expected, Obama won’t be around to decide exactly how the money is spent.

    That responsibility falls to President-elect Donald Trump and the conservative ex-surgeon from Georgia he picked to lead the Department of Health and Human Services, Rep. Tom Price. Trump and Price have both vowed loudly and repeatedly to repeal the Affordable Care Act, widely known as Obamacare, which some experts feel would worsen an already dire crisis.

    Trump hasn’t offered many specifics about how he’ll tackle the opioid epidemic and the 78 fatal overdoses per day that come with it. The situation is especially bad in many of his stronghold states, but he gave only one speechabout the issue on the campaign trail.

    His remarks largely focused on reducing the supply of drugs — a strategy that has failed the U.S. for decades — but he also pledged to “dramatically expand access to treatment slots and end Medicaid policies that obstruct inpatient treatment.”

    At the same time, however, Trump and Price want to repeal Obamacare which gave 1.2 million people in 31 states access to addiction treatment under its expansion of Medicaid. At least another least 1.1 million people with substance abuse disorders live in states that declined to opt-in to Obamacare’s Medicaid expansion. Obamacare also made substance abuse coverage an essential health benefit, requiring insurers to pay for the services.

    Price, a Tea Party Republican from the Atlanta suburbs, has proposed a replacement to  Obamacare, but it would not require insurers to cover addiction treatment. Both he and Trump also want to give states greater control over Medicaid spending, an approach that raises concern among some public health experts.

    “Health insurers have even more sway on a state level than the federal level, and the likelihood that they’ll mandate things that are beneficial to people is low,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University School of Law. “Taking mandates away and decreasing regulation will make it harder to ensure that people can get appropriate care for their substance use issues.”

    Even with increased coverage since 2010, only one in five opioid addicts receive treatment, according a recent landmark report on addiction by the Surgeon General. The report strongly urged the expansion of medically-assisted treatment programs that use drugs like methadone and Suboxone.

    Local health officials from 11 major cities have already urged the Trump administration to increase access to these treatments, and “ensure that addiction is addressed as the disease that it is.”

    Obamacare

    The current lack of access to treatment is partly the result of conservative states refusing to embrace medically-assisted therapies, even though the methods have been proven effective, because they’re sometimes viewed as swapping one addictive substance for another.

    Price’s home state of Georgia, for instance, recently placed a moratorium on opening new substance abuse centers that use medically-assisted treatment. The move came despite the fact that overdose deaths are up 10 percent in Georgia, with more than 1,200 fatalities reported in 2014, the most recent year that data is available. The situation is worse elsewhere: Florida, which has twice the population of Georgia, has only 69 treatment centers, one fewer than its northern neighbor. Tennessee  has just 14 for the entire state.

    The federal government —  specifically the Substance Abuse and Mental Health Services Administration, which Price will soon oversee — can push for the expansion of medically-assisted treatment. It’s unclear whether that will be on the agenda though, and states will have wiggle room regardless, since they are responsible for licensing clinics.

    Price will also likely push to privatize public health as much as possible, according to Charles Bullock, an expert on Southern politics at the University of Georgia. “Whatever he comes up with in regard to opioid addiction, it’s going to have more a market-oriented approach than you’d get under the Obama administration or any other administration,” Bullock said.

    The concern, the political science professor added, is that drug addicts are risky and expensive to cover, making insurers reluctant. With the repeal of Obamacare, insurers would be able to deny coverage for pre-existing conditions, like substance abuse, which would make finding help harder and more expensive for addicts.

    opioid treatment

    “It would be much more the individual shopping in the market and seeing what’s offered, rather than a guarantee that your provider ensures you have access,” Bullock said. “It might be that treatment is available but at a price they can’t afford, particularly if their drug abuse problems are such that they’re not earning much.”

    Even funding to alleviate the opioid crisis will be a question mark under Trump and Price. The $1 billion set aside by the impending 21st Century Cures Act is supposed to bankroll initiatives included in another bill, the Comprehensive Addiction and Recovery Act, a sweeping response to the opioid crisis that Congress passed in July — but failed to fund. Critics of 21st Century Cures Act, such as Massachusetts Sen. Elizabeth Warren, who worries that the bill’s provision for yearly reauthorization won’t hold up in a Republican-controlled Congress.

    “This final deal has only a tiny fig leaf of funding for NIH and for the opioid crisis,” Warren said. “And most of that fig leaf isn’t even real. Most of the money won’t be there, unless future Congresses pass future bills in future years to fund those dollars.”

    While Trump has expressed support for the Comprehensive Addiction and Recovery Act, Price is a hardline deficit hawk who may seek to cut public spending and push people to the private sector to get treatment. And with no guarantee of substance abuse coverage after the expected repeal of Obamacare, experts like Beletsky are concerned for the future.

    “Even with the Affordable Care Act, we’ve done too little to get quality prevention and quality treatment, but it’s certainly positive and there’s promising trends,” he said. “Dismantling that system and replacing it with something that’s less robust is something that will almost certainly fuel the opioid crisis.”

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