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On Medicare for All and other health plans, candidates should put up or shut up l Opinion

By admin | November 12, 2019

Drew A. Harris, DPM, MPH @drewaharris

Posted: November 11, 2019 – 11:58 AM

The figure is mind-boggling: $20.5 trillion over 10 years. That’s how much presidential candidate Elizabeth Warren says her plan will cost above what the federal government currently spends for health care. Cue the attacks.

So here we go again. Another election in which the question of how best to reform the U.S. health care system will be front and center. Sadly, relying on the media to understand the features of various proposals is like reading a newspaper in a lightning storm—mostly opaque with occasional flashes of illumination.

This piece is not about the relative merits of the various proposals put forth by the presidential candidates. Rather, I want to talk about how we debate health policy and point out the traps set for anyone who proposes a major change. First, a quick discussion about what’s at stake.

Almost one out of every five dollars the U.S. economy generates goes to health care. This is far and above what similarly advanced nations spend, yet U.S. citizens die earlier, are generally sicker and have poorer outcomes when they get care—and it’s predicted to get worse. Our relatively underfunded public health and social service agencies lack the resources to address the major drivers of disease: social factors such as loneliness, depression, anxiety, systemic inequities and community conditions. This is American exceptionalism at its worse.

That fifth of the economy is going somewhere. U.S. hospitals and pharmaceuticals are very expensive compared to peer nations. The system is bloated with non-clinical administrative burdens and costs—on both the provider and payer sides. Some of this is driven by complex regulations and insurance company requirements designed to improve outcomes and contain costs. The unintended consequence of an ever-more burdensome system is clinician burnout and plans for early retirement.

Like an umbrella full of holes on a rainy day, many fully insured families struggle with unaffordable out-of-pocket costs when they get sick. Sad stories abound of parents avoiding huge deductibles and copays by parking outside the emergency department hoping and praying their child doesn’t get worse and need to be seen. Even people lucky enough to have employer coverage pay almost a third of the average $20,576 premium for an employer-sponsored family plan. On top of the premium, 28% of covered workers have a deductible over $2,000, which is just an additional fee you pay when you need care. All together, the average family pays over $12,000 a year out of pocket for health care.

These are the challenges for which the presidential candidates are proposing solutions. Warren’s proposal is the most detailed. Her version of Sen. Bernie Sander’s “Medicare for All” would guarantee and expand coverage for all citizens, cover all providers and eliminate out-of-pocket co-pays and deductibles. Her willingness to explain in detail how she would pay for it sets her apart from her competitors.

Not surprisingly, most of the public discussion about her proposal focuses on overall government costs and taxes, not how it would affect families and individuals or how it would affect spending on medical care overall. The individual impact is framed as “losing” your employer coverage, not as what would be gained in exchange. In reality, people lose their health plan all the time when they change jobs, are laid off, or because the boss switches to a different insurance company. The real threat is losing access to your doctors, which happens a lot when insurance companies reconfigure their provider panels. Saturday Night Live brilliantly described an existing health plan as a “bad boyfriend” you’re afraid to break up with. It’s a case of the devil you know.

I can’t say for certain that Warren’s is the right cure for our nation’s ailing healthcare system. Maybe, an alternative like allowing people to buy into the existing federal Medicare program—the public option—is better. Perhaps, the answer might be some combination of the two.

Any healthcare reform proposal should be judged by objective metrics. Who is covered…and not? How much will people pay out of pocket when they’re healthy or sick? Will businesses benefit from lower costs and a healthier workforce? Will it reward high-quality, cost-effective healthcare providers? How disruptive will the transition to the new plan be? These are the issues people care about, not the political noise.

Any politician criticizing Warren’s effort should provide an equally detailed alternative so we can compare them head to head. At this point in our nation’s decades-long health care debate, we deserve candidates who put up or shut up.

 

Drew Harris is a member of the Inquirer’s Health Advisory Panel, healthcare consultant and assistant professor at the Jefferson University College of Population Health.

 

https://www.inquirer.com/health/expert-opinions/elizabeth-warren-medicare-for-all-20191111.html

 

 

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This Is the Most Realistic Path to Medicare for All

By admin | October 16, 2019

October 15, 2019

This Is the Most Realistic Path to Medicare for All

By J.B. Silvers

Much to the dismay of single-payer advocates, our current health insurance system is likely to end with a whimper, not a bang. The average person simply prefers what we know versus the bureaucracy we fear.

But for entirely practical reasons, we might yet end up with a form of Medicare for All. Private health insurance is failing in slow motion, and all signs are that it will continue. It was for similar reasons that we got Medicare in 1965. Private insurance, under the crushing weight of chronic conditions and technologic breakthroughs (especially genetics), will increasingly be a losing proposition.

As a former health insurance company C.E.O., I know how insurance is supposed to work: It has to be reasonably priced, spread risks across a pool of policyholders and pay claims when needed. When companies can’t do those fundamental tasks and make a decent profit is when we will get single payer.

It’s already a tough business to be in. Right now the payment system for health care is just a mess. For every dollar of premium, administrative costs absorb up to 20 percent. That’s just too high, and it’s not the only reason for dissatisfaction.

Patients hate paying for cost-sharing in the form of deductibles and copays. Furthermore, narrow networks with a limited number of doctors and hospitals are good for insurers, because it gives them bargaining power, but patients are often left frustrated and hit with surprise bills.

As bad as these problems are, most people are afraid of losing coverage through their employers in favor of a government-run plan. Thus inertia wins — for now.

But there’s a reason Medicare for All is even a possibility: Most people like Medicare. It works reasonably well. And what could drive changes to our current arrangement is a disruption — like the collapse of private insurance.

There are two things insurers hate to do — take risks and pay claims. Before Affordable Care Act regulations, insurance companies cherry-picked for lower-risk customers and charged excessive rates for some enrollees.

Those were actually the first indications of market failure. Since the enactment of the Affordable Care Act, insurers have actually had to take these risks as they were supposed to all along and provide rebates of excessive profits.

With insurers under such pressure, we’re now facing another sort of market dysfunction. Insurance companies are doing what they can to avoid paying claims. A recent report says that Obamacare plans average an 18 percent denial rate for in-network claims submitted by providers. Some reject more than a third. This suggests that even in a regulated marketplace like the Obamacare exchanges, insurers somehow manage to dispute nearly one out of every five claims.

These are systemic failures that can and should be fixed by regulation of the exchanges, better information on plan performance and robust competition. Unfortunately, consumers often still can’t make informed choices, and the options they have are limited.

But even if we fix these problems, there are two bigger factors looming that threaten the integrity of the entire system. Insurance at its root assumes that the payout required cannot be determined for each individual but can be estimated for the whole group. We can’t predict who will be affected by trauma or a broken bone, but in the aggregate, it is possible to estimate what will happen to the insured group as a whole. Some will suffer losses while the majority will be fine, and all will pay a fair average premium to cover the expenses that result.

Yet with the increases in chronic conditions and the promise of genetic information, these insurance requirements are not met. Someone with diabetes or rheumatoid arthritis will have the same condition and similar costs in each future year. And the woman with a positive BRCA gene is much more likely to develop breast cancer. In these cases, known costs simply must be paid. Instead of spreading these across all enrolled populations, they must be financed across time for the increasing numbers with such conditions. Loading private insurance companies with these expenses results in uncompetitive rates and market failure.

There is only one solution: pooling and financing some or all of these at the broadest levels. In a nutshell, that is how we get a single-payer government system.

It is how we got Medicare. The cost of care to the elderly was known at the individual level for virtually everyone, so private insurance just wouldn’t work. So we had to finance this largely predictable cost through the government and its enormous pool of taxpayers.

It has been a tremendous, albeit expensive success. For the most part, people on Medicare like it a lot. This is the reason such a disruptive change is even a political possibility.

We will face the same need sometime in the future for the rest of us. Then a form of Medicare for All will look better than the alternative — a failing private insurance system.

J.B. Silvers is a professor of health care finance at the Weatherhead School of Management at Case Western Reserve University.

 

https://www.nytimes.com/2019/10/15/opinion/medicare-for-all-insurance.html?action=click&module=Opinion&pgtype=Homepage

 

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Dr. Olveen Carrasquillo Honored as a ‘History Maker’ for Hispanic Heritage Month

By admin | October 15, 2019

The National Institute on Minority Health and Health Disparities is honoring Olveen Carrasquillo, M.D., M.P.H., professor of medicine and public health sciences and chief of the University of Miami Miller School of Medicine Division of General Internal Medicine, as a “History Maker” in celebration of National Hispanic Heritage Month.

The social media campaign highlights Hispanic researchers who have made important contributions to the Hispanic community and aims to build awareness of minority health and health disparities research in the United States.

Dr. Carrasquillo has more than 20 years of experience leading large National Institutes of Health grants and randomized trials studying diabetes, cardiovascular disease, HIV, cancer and precision medicine. The National Institute on Minority Health and Health Disparities describes him as “a national leader in primary care and health disparities who has conducted extensive research on health insurance and access to care among minority and other vulnerable populations.”

Dr. Carrasquillo is a principal investigator for the SouthEast Enrollment Center of the All of Us research program, leading participant engagement and helping recruit more than 12,000 participants in the first year. All of Us is working to enroll a million or more participants nationally to create a research resource to inform thousands of studies covering a wide range of health conditions and addressing health disparities.

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Puerto Rico’s Looming 2019 Medicaid Fiscal Cliff

By admin | September 26, 2019

Puerto Rico and its residents have experienced numerous crises and shocks in the last decades, including an economic depression dating back to 2006; a public debt crisis resulting in the largest municipal bankruptcy in U.S. history and a federally appointed fiscal oversight board pursuing deep budget cuts; a demographic crisis with population dropping by more than 600,000 residents since peaking at 3.8 million in 2004; and most recently, the devastation and cascading effects left by the hurricanes of 2017. The cumulative effect of these crises has taken a hard toll on the economic and social well-being of its people, disproportionately impacting the most vulnerable populations and communities. These interrelated crises feed on each other, propelling a vicious downward spiral.

Another potential shock is the territory’s imminent Medicaid fiscal cliff, and ensuing public health crisis. In the past, temporary lifelines to Puerto Rico’s Medicaid program have prevented a total system collapse, but by the same token, these short-term extensions of supplemental funding have thwarted efforts to completely reform the system and make it more effective.  The uncertainty caused by this situation is highly detrimental to all stakeholders, especially people whose health and well-being depends on receiving vital care but have few resources to make ends meet in this challenging economic environment.

Differences in Puerto Rico’s Medicaid Program

The U.S. Medicaid program was created to provide vital healthcare services to financially and medically needy populations.  In Puerto Rico, however, that same population that is adversely affected by a disparate and inadequate federal funding structure.  Medicaid programs in the states benefit from an open-ended federal financing structure, receiving federal funds as a function of actual costs and needs. In Puerto Rico, where median household income stood at $19,775 in 2017, compared to $42,009 in Mississippi, the poorest state, and $57,652 in the United States as a whole, the program has been chronically underfunded.  In the poverty-ridden territory, funding limitations further constrain program delivery evidenced in the form of lower eligibility levels, lower federal funding, fewer mandatory benefits, lower provider payments, and lower spending per enrollee.

Lower eligibility levels: To determine income eligibility for participation in Medicaid, Puerto Rico uses the Puerto Rico Poverty Level (“PRPL”) and not the Federal Poverty Level (“FPL”) as in the states, which results in a significantly lower income eligibility threshold. The PRPL is approximately 45% of the FPL for an individual, and 34% for a family of four.

Lower federal funding: Medicaid programs in the U.S. benefit from an open-ended financing structure, receiving federal funds based on actual costs and needs. States with the highest per capita incomes of the U.S. enjoy a Medicaid federal matching rate of 50%, while the poorest, Mississippi, received a Federal Medical Assistance Percentage (“FMAP”) of 76.4% in fiscal year 2019. If Puerto Rico’s FMAP were “calculated by the same statutory formula used for the 50 states and D.C., Puerto Rico’s FMAP would be 83%, although the unbounded FMAP would be 93.34%.” In addition to the lower federal share, Puerto Rico’s Medicaid federal financing is also subject to an annual ceiling or cap, operating effectively as a block grant. Puerto Rico receives an arbitrarily capped allotment, known as the Section 1108 cap, typically resulting in an effective Medicaid federal match rate below 15%. Puerto Rico’s federal funding was capped at $367 million in FY2019, while Medicaid expenditures in the island totaled $2.7 billion. The projected FY2020 cap is expected to be $375.1 million, despite spending projections adding up to $2.8 billion. As per current law, Puerto Rico will also have access to $446 million under the Patient Protection and Affordable Care Act (“ACA”) Section 1323, and $59 million under Social Security Administration (“SSA”) Section 1935(e), also referred to as the Enhanced Allotment Plan (“EAP”), which helps cover prescriptions drugs costs to beneficiaries dually eligible for Medicaid and Medicare, for a total of $880 million in federal spending.

Fewer mandatory benefits: Notwithstanding the great needs and demands for acute and long-term care services – which will likely continue to grow in tandem with the aging population trend and the rising prevalence of chronic health problems – Puerto Rico’s Medicaid program does not cover all mandatory Medicaid benefits. Long-term services, home and community-based services to older adults and people with disabilities with functional limitations and chronic health conditions, are examples of support offered in U.S. states but not available to the residents of Puerto Rico.

Lower provider payments: Disproportionately low provider payment rates and its negative effect on provider availability, and quality and access to care, is a major obstacle for Puerto Rico. The majority of municipalities (i.e. 72 of 78) of Puerto Rico are deemed “medically underserved areas” due to the shortage of medical and healthcare professionals. The Medicaid provider reimbursement rate in Puerto Rico for primary care services from July 2016 to July 2017 was 19% of the Puerto Rico Medicare fee compared to 66% in the U.S. Similarly, maternity services were reimbursed at 50% of the Puerto Rico Medicare fee vs. 81% in the U.S. The substantial differences between Puerto Rico’s Medicaid reimbursement rates and those in the states and the uncertainties regarding the island’s Medicaid financing structure, have played a role in the exodus of physicians and healthcare providers. The number of doctors has decreased from approximately 14,000 in 2006 to currently close to 9,000. There is a particularly acute deficiency of specialty care providers.

Lower Medicaid spending per enrollee: Total Medicaid spending per enrollee is significantly lower in Puerto Rico when compared to all 50 states. According to FY 2020 projections by the Medicaid and CHIP Payment and Access Commission (“MACPAC”), average benefit spending per full year enrollee in Puerto Rico will be $2,144, representing 64% of the lowest per capita spending state ($3,342), 32% of the median ($6,763), and 16% of the highest per capita spending state ($13,429).

Increased Healthcare Needs

Less funding has, in effect, translated to increased needs. The percent of adults reporting fair or poor health in 2017 reached 37.1% in Puerto Rico, compared to 25.3% in Mississippi, and 18.4% in the U.S. The healthiest jurisdiction, according to this indicator, was the District of Columbia reporting 10.8%.  Disparities in chronic health indicators are also significant. Diabetes prevalence in Puerto Rico in 2017 was 17.2%, compared to 10.5% in the U.S.  Asthma and high blood pressure prevalence was 12.2% and 44.7% in Puerto Rico, compared to 9.4% and 32.3% in the U.S, respectively. A robust healthcare system with adequate federal funding could help mitigate the high prevalence of chronic conditions on the island.

Necessary Congressional Action

The chronic underfunding of the island’s Medicaid program has historically placed an undue fiscal burden on Puerto Rico’s budget and prompted federal action. During the last decade, Congress has enacted legislation to provide limited, temporary supplemental funding and avoid a massive healthcare crisis. In 2009, additional federal funds for Puerto Rico’s Medicaid program were appropriated through the American Reinvestment and Recovery Act (“ARRA”), followed by the ACA in 2010, the Consolidated Appropriations Act of 2017, and most recently, through the Bipartisan Budget Act (“BBA”) of 2018 following the devastating 2017 Atlantic hurricane season. In the aftermath of Hurricanes Irma and Maria impacting the island on September 2017, Congress provided an additional $4.8 billion to Puerto Rico’s Medicaid program beyond the annual Section 1108 cap, time-limited funds that were made available from January 1, 2018 to September 30, 2019. The expiration date authorizing the use of that last tranche of funding is soon approaching, and all other temporary federal funds are expected to be exhausted shortly thereafter.

Only prompt Congressional action can help avert a health care crisis in Puerto Rico. If Congress fails to act, it could lead to catastrophic direct and indirect effects. The Medicaid and CHIP Payment and Access Commission (“MACPAC”) estimated that enrollment at the current level of benefits would need to decrease between 36% (455,475) to 53% (669,943) if no new federal funds are made available. The Fiscal Oversight and Management Board for Puerto Rico has warned that “absent action by Congress, by fiscal year 2021, the Commonwealth’s Medicaid costs are projected to comprise roughly 23% of the General Fund’s budget.”

The FMAP that applies to Puerto Rico’s Medicaid program should be computed using the same formula used for the states, considering the average per capita income of Puerto Rico relative to the U.S. national average.  To ensure that the most vulnerable populations of Puerto Rico have access to a more robust, predictable, reliable, and accessible Medicaid healthcare system, Congress must act quickly and remove the federal cap on Medicaid funding altogether and compute the FMAP using the same average per capita income-based formula as done for the states.  Providing Puerto Rico with an adequate level of federal funds for its Medicaid program will also help it return to a path of fiscal stability and economic growth. The urgency of this matter cannot be overstated. Congressional action is promptly needed to stave off another historic humanitarian crisis.

When designing the solution, policy deliberations and prescriptions must be framed within the proper context.  Policymakers must remain keenly aware of the historic critical juncture Puerto Rico is traversing and the larger moral imperatives at play. Puerto Rico’s current dire economic, fiscal, demographic, and post-natural disaster recovery and reconstruction reality must be an essential part of the broader equation. This critical juncture presents an opportunity for Congress to redress a historical wrong, strengthen Puerto Rico’s fragile healthcare system, improve access to critical health services for vulnerable populations, and make headway towards putting Puerto Rico on a stronger fiscal and economic footing.

Further, more than a last-minute temporary fix is needed to provide Puerto Rico with a reliable and sustainable healthcare system.  A permanent, long-term fix to Puerto Rico’s Medicaid program is needed to once and for all guarantee comprehensive, accessible, quality care to low-income families, children, the elderly, and people with disabilities.

https://grupocne.org/2019/09/18/puerto-ricos-looming-2019-medicaid-fiscal-cliff/

 

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Puerto Rico’s next crisis is coming, and only Congress can stop it

By admin | September 26, 2019

BY MICHAEL J. MELENDEZ AND DR. JAIME TORRES, OPINION CONTRIBUTORS

 

 THE HILL–— 09/11/19

  

Congress reconvenes this week and will tackle many issues that are crucial for our country. Among them is the imminent man-made crisis facing Puerto Rico and other U.S. territories when funding from the 2018 Bipartisan Budget Act and the Affordable Care Act runs out at the end of September and December 2019.

For Puerto Rico, this means that starting Oct. 1, 2019, the beginning of FY 2020, the island would only receive an estimated $366.7 million in federal Medicaid matching dollars to cover its Medicaid beneficiaries. To be clear, 1.6 million people in Puerto Rico are reliant upon Medicaid – that is nearly half the entire population of the island. Such a drastic cut in funding would not adequately support the needs of beneficiaries and could worsen health outcomes for the island’s people.

For years, Puerto Rico’s second-class status as a territory of the United States has exacerbated the island’s humanitarian crisis. Because of antiquated policies, such as those on Puerto Rico’s federal funding support for Medicaid, residents’ health care has been gravely limited, which has perpetuated serious, systematic problems.

In recent weeks, we’ve seen the people of Puerto Rico fighting back against the problems plaguing their island. The news stories coming from the island have been surprising yet thrilling. More than half a million people took to the streets demanding an end to government corruption and influence-peddling that culminated in the resignation of the governor. This was democracy in action; nothing short of accountability and transparency from their government would be accepted.

Now is the right time for Congress to address the inherent inequality of Medicaid funding for Puerto Rico and all U.S. territories. Arbitrary and unfair regulatory hurdles set up decades ago by Congress have perpetuated a lack of accountability and transparency and must be changed to meet the needs of the people today.

Critical for advancing this goal, the “Community Health Investment, Modernization, and Excellence Act” (H.R. 2328) includes the Territories Health Care Improvement Act, which would make substantive changes to how Medicaid is administered in territories like Puerto Rico. If approved by Congress, H.R. 2328 could go on to provide $12 billion to secure the Medicaid program on the island for four more years.

The people of Puerto Rico have clearly demonstrated their appetite for transparency and accountability, and the mandatory safeguards written into the law ensure that federal funding would always be used to benefit patients.

H.R. 2328’s robust monitoring mechanism for strict oversight of federal Medicaid funds includes much-needed provisions that would better ensure federal funding dollars for Medicaid are used properly. To start, H.R. 2328 would authorize the Department of Health & Human Services’ Office of Inspector General to perform audits of all federal Medicaid funding on an annual basis, including work plans to monitor and/or investigate contracting practices related to the Puerto Rico Medicaid program. The Centers for Medicaid & Medicare Services would oversee all contracts awarded utilizing Medicaid funding. Puerto Rico itself would establish a system for tracking amounts paid by the federal government, as well as local matching of Medicaid funds, and would have information available with respect to each quarter. Furthermore, the Government Accountability Office would issue a report on contracting oversight and approval for the Puerto Rico Medicaid program no later than two years after the date of enactment.

As is clear after weeks of protests and years of unrest, Puerto Rico can no longer afford to operate under the status quo. Such oversight measures proposed by H.R. 2328 are badly needed to help set the island’s Medicaid program up for success and better serve the millions of residents reliant upon health care. But all of this won’t happen if Congress doesn’t act now.

Puerto Ricans are citizens of this country, and they cannot be held accountable for the egregious actions of elected officials and the contractors working on their behalf. Those actions should be condemned, and the right people prosecuted. But absent any congressional action, it may be the population that is dependent on Medicaid for health care that pays the ultimate price for the wrongdoings of their leaders. If Congress does not pass H.R. 2328, millions of people could become uninsured and sick, further sinking the island into a humanitarian crisis.

Michael J. Melendez, LMSW is Principal of MJM CONTIGO, LLC. and was the former the Associate Regional Administrator of the Center for Medicare & Medicaid Services (CMS) Division of Medicaid and Children’s Health Operations for the New York Regional Office.

Dr. Jaime R. Torres was the former regional director of the US Department of Health & Human Services, Region II—serving New York, New Jersey, Puerto Rico and the US Virgin Islands. They are board members Latinos for Healthcare Equity.

 

https://thehill.com/blogs/congress-blog/healthcare/460926-puerto-ricos-next-crisis-is-coming-and-only-congress-can-stop

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Administration ends protection for migrant medical care

By admin | August 29, 2019

Associated Press

August 26, 2019

Administration ends protection for migrant medical care

By Philip Marcelo

The Trump administration has eliminated a protection that lets immigrants remain in the country and avoid deportation while they or their relatives receive life-saving medical treatments or endure other hardships, immigration officials said in letters issued to families this month.

Critics denounced the decision as a cruel change that could force desperate migrants to accept lesser treatment in their poverty-stricken homelands.

In Boston alone, the decision could affect about 20 families with children fighting cancer, HIV, cerebral palsy, muscular dystrophy, epilepsy and other serious conditions, said Anthony Marino, head of immigration legal services at the Irish International Immigrant Center, which represents the families.

Advocates say similar letters from Citizenship and Immigration Services have been issued to immigrants in California, North Carolina and elsewhere.

“Can anyone imagine the government ordering you to disconnect your child from life-saving care — to pull them from a hospital bed — knowing that it will cost them their lives?” Marino said.

“This is a new low,” Democratic Sen. Ed Markey said. “Donald Trump is literally deporting kids with cancer.”

A Citizenship and Immigration Services spokeswoman said the policy change was effective Aug. 7.

It affects all pending requests, including from those seeking a renewal of the two-year authorization and those applying for the first time. The only exception is for military members and their families.

Going forward, applicants will be able to seek deportation deferrals from a different agency, Immigration Customs and Enforcement, according to the spokeswoman.

Letters sent to Boston-area families last week and reviewed by The Associated Press, however, do not mention that option. They simply order applicants to leave the country within 33 days or face deportation, which can hurt future visa or immigration requests.

Without the discretionary deferrals, immigrant families facing serious health issues have few other options for relief, medical experts in Boston argued Monday.

The deferrals, they added, do not provide families a pathway to citizenship, though they can qualify for government-funded health benefits and receive legal permission to work while their children receive medical treatment.

“They’re not coming for a free ride. They’re coming to save their children,” said Joe Chabot, a director at the Dana-Farber/Boston Children’s Cancer and Blood Disorders Center. “It’s bewildering.”

 

https://www.apnews.com/e27485eced6e480ca10a6a4c1c043f0c

 

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Harris’s Fake Medicare-for-All Plan

By admin | August 5, 2019

The American Prospect

August 1, 2019

Harris’s Fake Medicare-for-All Plan

By Robert Kuttner

In the extensive jousting over Medicare for All, Kamala Harris has evaded scrutiny for the most insidious aspect of her plan: It significantly expands for-profit insurance at the expense of true Medicare by promoting more use of commercial products spuriously known as “Medicare Advantage” and calling that a version of Medicare for All.

One of the successes of Republicans and the insurance industry in recent decades has been to take private, for-profit insurance plans whose business model is based on denying needed care—and brand them as “Medicare.” This tactic, ironically, proves the popularity of universal public programs; Medicare is held in such high regard that private companies feel the need to steal its brand. As the saying goes, hypocrisy is the tribute that vice pays to virtue.

Two examples are the “Medicare” drug benefit, which is purely private, and so-called Medicare Advantage plans, which Harris would dramatically expand.

Unlike true Medicare, Medicare Advantage plans are commercial products offered by private insurers. Medicare’s only role is to collect your taxes and pass them along to these insurance companies.

There are two key differences between Medicare Advantage and standard public Medicare. The first is that a Medicare Advantage plan is an intensely “managed” HMO. The plan dictates what doctors and hospitals you can see, what drugs are covered, which conditions can be treated by which procedures at insurer expense. By contrast, standard Medicare does not limit your choice of doctor and hospital, or what the doctor can order.

Why would patients put up with such restrictions? Because there are some things that standard Medicare doesn’t cover. That’s why more-affluent older people with standard Medicare tend to purchase what’s known as “Medigap” insurance, to cover what Medicare doesn’t—starting at about $4,000 and a lot more for true comprehensive first-dollar coverage.

Medicare Advantage is no more expensive to seniors than standard Medicare—because insurers are so relentless at restricting what’s actually permitted as opposed to what’s nominally covered. But with true Medicare for All, those gaps in what’s covered would be eliminated—and there would be no need for commercial “Medicare Advantage.”

Medicare Advantage insurers use one other sneaky and perverse trick. They try to save costs by targeting their marketing to younger, healthier seniors, less likely to get sick. True Medicare doesn’t need do to that because it is for everyone. With commercial “Medicare Advantage,” insurers make their profits precisely to the extent that they deny care one way or another.

That’s what’s so insidious about Harris’s approach. She would expand the commercial part of the system, falsely branded as a variant of Medicare, and take us further away from true seamless and universal coverage.

Thus the real meaning of “Medicare Advantage.” Advantage: industry. Disadvantage: consumers and patients.

According to some, many seniors like Medicare Advantage, and so it would be folly for Democrats to kill it, just as they supposedly like their employer-provided plans. But this is akin to saying that a refugee “likes” crossing rough seas on a makeshift raft. These plans are popular only given the lack of good alternatives.

In the presidential debates, Harris’s critics have gotten all tangled up in issues of how much her plan would cost and the meaning of the ten-year phase-in. They have missed the single worst thing about it—the reliance on more private insurance. It is a travesty to use the term “Medicare” to characterized this deceptive front for expanding the reach of the commercial insurance industry.

 

https://prospect.org/article/harriss-fake-medicare-all-plan

 

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Congressman Pallone Opening Remarks at Hearing on Medicaid Funding Cliff in the U.S. Territories

By admin | July 22, 2019

Energy and Commerce Chairman Frank Pallone, Jr. (D-NJ) delivered the following opening remarks today at a Health Subcommittee hearing on, ““Strengthening Health Care in the U.S. Territories for Today and Into the Future:”

Today, our Committee continues its efforts to ensure that all Americans have access to health care, whether they live in one of the 50 states or one of the five territories.

The territories are on the verge of a financial and humanitarian crisis.  Experts predict that unless Congress acts, none of the territories will have enough federal funds to support their Medicaid programs next year.  Puerto Rico could potentially spend all its federal funds in a matter of months, facing a shortfall of billions of dollars for the year.

It’s no secret how we got here.  For years, the territories have been operating their Medicaid programs under federal funding caps that haven’t kept up with the needs of the people who live there.  The Affordable Care Act provided increased funding that’s helped the territories for the past decade, but that expires at the end of this year.  Natural disasters in the territories have also put increased strain on their Medicaid programs that required Congress to provide additional support to ensure people didn’t lose access to care.

Medicaid in the territories doesn’t operate like it does in the states.  Each territory only receives a certain amount of federal funds that’s supposed to last them the whole year.  It’s essentially a block grant.  In the states, increases in state Medicaid spending are matched with an increase in federal Medicaid funding.  This means that in times of economic downturn, or in the period following a natural disaster, when state Medicaid spending increases, the state receives an automatic increase in federal Medicaid dollars.  That’s not how it works for the territories.  Once they spend their annual allotment, they have to pay for their Medicaid costs using local funds.  This outdated system forces the territories to pay a substantial amount out of their own pockets to ensure the people there have access to health care.   It’s also a stark reminder of why block grants for Medicaid simply don’t work.

The federal funding shortfall means most of the territories aren’t able to provide the full range of benefits that state Medicaid programs are required to cover.  Payments to doctors and hospitals are so low that providers are leaving the islands for the states.  While Congress has provided some time-limited increases to the territories’ Medicaid funding, we need a longer-term solution.  Doling out federal funds in dribs and drabs has led to uncertainty about the financial future of the programs and calls into question the long-term sustainability of the territories’ Medicaid programs if Congress fails to act.

That’s why we are here today – to discuss the Medicaid cliff facing the territories and what we can do to avert a catastrophe.  As we will hear today, without additional funds, hundreds of thousands of people in the territories could lose their health care coverage.  Some territories have said they would have to stop covering prescription drugs, dental care, durable medical equipment, and community health centers.  Others have said they expect to lose even more providers.

None of this has to happen.  We can all see the cliff coming, but if we work together, we can stop the territories from going off it.  We can ensure that they can continue to provide care to the people who need it the most.  We can stop the flight of doctors and providers from the islands.  And we can provide the certainty and sustainability that the territories deserve.

Several members recently introduced legislation that would provide Puerto Rico with both the amount of federal funds requested by the Governor, and establish a path to help transition its Medicaid program to a full, state-like program.  This would provide sufficient funds to Puerto Rico to ensure its people receive the health care services they need.  I want to thank the Members for their hard work on this bill, especially Rep. Soto on our Committee.  I hope this can potentially be a roadmap to help strengthen the Medicaid program in other territories.

I also want to thank the witnesses for being here today, particularly those that traveled long distances to share your expertise with us.

Thank you.

 

https://energycommerce.house.gov/newsroom/press-releases/pallone-opening-remarks-at-hearing-on-medicaid-funding-cliff-in-the-us

 

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Sanders, Co-sponsors Unveil Legislation to Put Territories on Par with States for Medicaid

By admin | June 11, 2019

WASHINGTON, June 11 – Sen. Bernie Sanders (I-Vt.) along with seven other cosponsors in the Senate, introduced legislation Tuesday to address the immediate humanitarian needs in the territories, including Puerto Rico and the U.S. Virgin Islands.

The Territories Health Equity Act of 2019 (S. 1773) would correct long-standing inequities in federal health care funding for Medicaid and Medicare, and give the nearly four million Americans living in the U.S. territories of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands access to the health care they need. The bill is cosponsored in the Senate by Sens. Jeff Merkley (D-Ore.), Kirsten Gillibrand (D-N.Y.), Richard Blumenthal (D-Conn.), Kamala Harris (D-Calif.), Cory Booker (D-N.J.), Elizabeth Warren (D-Mass.), and Ed Markey (D-Mass.). Rep. Stacey Plaskett (D-V.I.) introduced the companion bill (H.R.1354) together with 37 cosponsors in the House. The Senate version of the bill is endorsed by the American Federation of Teachers, Latinos for Healthcare Equity, BoricuActivate, Boricuas Unidos en la Diaspora (BUDPR), and the International Association of Machinists & Aerospace Workers Union.

Over a year and a half after Hurricane Maria, much of Puerto Rico and the Virgin Islands remain devastated. The vast majority of residents in Puerto Rico—a full 85 percent—report they are worried they will be unable to access health care if they need it. Nearly one in four people living in Puerto Rico report they or a family member have developed a new or worsened health condition as a result of Hurricane Maria, and one in three report they or someone in their home have had trouble accessing medical care. Similarly, in the face of an increased demand for services, the U.S. Virgin Islands has been unable to spend the Medicaid dollars required to secure federal matching funds.

Temporary Medicaid funding for Puerto Rico and the U.S. Virgin Islands expires in September. This funding cliff could be disastrous for the more than 1.5 million people covered by the program. In Puerto Rico alone, an estimated 900,000 people could lose coverage.

The legislation introduced today would provide the territories with the same need-based, open-ended Medicaid funding that is currently available to the fifty states and the District of Columbia by eliminating the arbitrary cap on annual federal Medicaid funding and increasing the federal matching rate for the territories’ Medicaid expenditures. The bill would also address Medicare disparities by updating hospital reimbursements and increasing funding for the territories to provide prescription drug coverage to low-income seniors. Above all, the bill would ensure that Americans living in the territories are eligible for health coverage that is as comprehensive as the coverage available to Members of Congress.

“It is unconscionable that in the wealthiest nation in the world we have allowed our fellow citizens to suffer for so long. The full resources of the United States must be brought to bear on this crisis, for as long as is necessary,” said Sanders. “We must go forward to ensure a strong health care system in all the territories and address inequities in federal law that have allowed the territories to fall behind in almost every measurable social and economic criteria.”

“I would like to thank Senator Sanders for introducing the Senate companion bill to H.R. 1354, Territorial Health Equity Act of 2019. Both bills make improvements to the treatment of the United States territories under the Medicare and Medicaid programs. I am appreciative that Senator Sanders continues to support on matters that are critical to the well-being of residents in the U.S. territories,” Plaskett said.

“Families in Puerto Rico, the U.S. Virgin Islands, and other territories deserve access to the same federal health care programs as families throughout the rest of the United States—no exceptions,” said Senator Warren. “We are introducing the Territories Health Equity Act to end discriminatory double standards in the way Medicare and Medicaid are administered in the U.S. territories.”

“As co-sponsors of the House version of this Bill we are excited to have Senator Sanders joining us in the fight for Territorial healthcare equality. These measures will bring much needed parity in the Medicaid funding levels for Guam and relieve a legacy pressure point that has been choking our healthcare budgets for decades,” said Delegate Michael F.Q. San Nicolas (D-GU-At Large)

“More than 3,000 U.S. citizens died in the wake of Hurricane Maria, largely due to the incompetence and delay of President Trump’s federal response. Instead of being allowed to recover, Puerto Rico is being threatened with cuts, with one million residents at risk of losing their already-insufficient Medicaid coverage in September. I applaud Senator Sanders and his colleagues for introducing the Territories Health Equity Act of 2019 to ensure that Puerto Rico’s vulnerable families receive full, open-ended federal funding for need-based care. This is a vital step in Congress’s recognition that Puerto Rico can no longer be treated as a colony, and moreover, a step toward social justice,” said Carmen Yulín Cruz, Mayor of San Juan, Puerto Rico.

“The U.S. government can no longer turn its back on the American citizens of Puerto Rico, and treat us as second class citizens. That is why we support Senator Sanders’ Territories Health Equity Act of 2019 which will finally result in a permanent fix to the discriminatory and unequal Medicaid and Medicare funding for Puerto Rico, the USVI and all territories. This is more urgent than ever since Puerto Rico faces an upcoming ‘Medicaid cliff’ which, if not funded by the end of 2019, may result in 600,000 Puerto Ricans become uninsured overnight,” said Dr. Jaime R. Torres of Latinos for Healthcare Equity.

“U.S. territories have had to withstand decades of unequal and colonialist treatment. In the last couple of years, they have also had to withstand the increasing impacts of climate change with direct hits from record-setting tropical cyclones. This time, the already suffering and vulnerable people in these U.S. territories face another catastrophic threat, this time to their medical care, which can be easily adverted by the U.S. Congress, if its members decide to put the well-being of its colonial subjects at the same level as those U.S. citizens living in the states,” said Edil Sepúlveda, Co-founder of Boricuas Unidos en la Diáspora.

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OPEN LETTER TO PRESIDENTIAL CANDIDATES

By admin | June 7, 2019

Dear Presidential Candidates:

We, the undersigned organizations, representing millions from the Puerto Rican Diaspora and allies, strongly urge you to publicly support a comprehensive platform addressing the fiscal and economic crises facing the Commonwealth of Puerto Rico.

The people of Puerto Rico, U.S. citizens and residents alike, are still recovering from devastating firsts —including the worst natural disaster and largest bankruptcy proceeding in U.S. history— a depressed economy, and imminent fiscal cliffs in public health, schooling and higher education, public pensions, and nutritional assistance. Many of these challenges are the result of artificial, arbitrary, and often discriminatory decisions made by the federal government in how it treats Puerto Rico. Only bold action spurred by presidential leadership – together with detailed policy prescriptions – can move the needle on these complex issues.

As a presidential candidate, we strongly urge you to publicly support the following policy priorities. Though action is needed on many more fronts, Puerto Rico needs:

A Marshall Plan-type mobilization to fully rebuild and recover after Hurricanes Irma and Maria

Full participation of Island residents in critical federal anti-poverty programs such as:

–        Medicaid

–        Child Tax Credit (CTC)

–        Earned Income Tax Credit (EITC)

–        SNAP

Economic tools such as:

–        Jones Act exemption

–        Fix how federal tax reform law treats the Island and provide tax incentives for job creation, along with improved labor standards

–        Significant public debt relief

Recognition of the right to self-determination of the Puerto Rican people along with a permanent and self-sustained, inclusive, fair and transparent process to end 121 years of U.S. colonialism in Puerto Rico

We stand ready to assist you and your team to answer any questions or provide more in-depth analysis of Puerto Rico issues and look forward to your prompt response as we prepare to periodically report back to the public on the policy positions taken by all presidential candidates.

Sincerely,

Alianza for Progress/Florida
Asociación de Puertorriqueños en Marcha (APM), PA
Americas for Conservation and the Arts
Bay Area Alliance for a Sustainable Puerto Rico, Leadership Committee
Bay Area Boricuas
BoricuActívatEd
Boricua Vota
Boricuas de Corazón, Inc
Boricuas Unidos en la Diáspora
Catalino Productions
Diáspora en Resistencia
El Puente
Faith in Florida
Fort Washington Collegiate Church
Green Latinos
Hispanic Federation
Iniciativa Acción Puertorriqueña
Juan Antonio Corretjer Puerto Rican Cultural Center
La Tertulia Boricua of San Francisco Bay Area
LatinoJustice PRLDEF
Jangueo Boricua
Misión Boricua
National Boricua Human Rights Network
National Conference of Puerto Rican Women
National Puerto Rican Agenda
Organize Florida
Our Revolution Puerto Rico
Parranda Puerto Rico
Puerto Ricans in Action (Los Angeles)
Puerto Rican Arts Alliance
Puerto Rican Alliance of Florida
Puerto Rican Women in Action
Puerto Rico Advocacy Group
Puerto Rico Connect
The Puerto Rican Agenda of Chicago
Women’s March – FL

Signatories as of June 7th, 2019

CASA Maryland
Corazones Unidos Siempre Chi Upsilon Sigma National Latin Sorority, Inc.
Daily KOS
El Centro de Servicios Sociales/Ohio
El Puente Puerto Rico: Enlace Latino de Acción Climática
Florida Immigration Coalition
G-8, Grupo de las Ocho Comunidades Aledañas al Caño Martín Peña, Inc.
Hispanic Roundtable/Ohio
Latino Victory Project
Latinos for Healthcare Equity
MoveOn Political Action
National Urban League
New Florida Majority
Puerto Rican Leadership Council of South Florida
Vieques en Acci?n
Young Latino Network/Ohio
Edgardo Miranda, creator of La Borinqueña
Nilda Medina, Executive Director, Incubadora Microempresa, Bieke, Inc.
Roberto Rabin, Director, Vieques Historic Archives & General Manager of Radio Vieques

 

 

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