Darlin Kpangbah receives free health insurance through Medicaid and is grateful for the coverage in case of accidents, such as when she tore a ligament in her leg a few years ago. “I feel like I’m injury-prone,” said Kpangbah, 20, who lives in Sacramento, Calif. Without insurance, she said, the injury “would’ve been huge to pay for.”
Young adults like Kpangbah were among the biggest beneficiaries of Obamacare, which helped reduce the rates of uninsured millennials to record lows and provided millions of Americans with access to free or low-cost insurance as well as maternity care, mental health treatment and other services.
Now, Senate Republicans have proposed overhauling the Affordable Care Act — a move that could help some young adults by lowering the cost of their premiums in the private insurance marketplaces but could hurt others who gained insurance through a massive expansion to Medicaid. A Congressional Budget Office analysis of the bill released Monday estimated that 22 million Americans could lose coverage under the Senate bill, which could change significantly before an expected vote before July 4.
The proposed legislation also would retain a popular Obamacare provision that allowed young adults up to age 26 to stay on their parents’ insurance. But the bill in its current form also could dramatically reduce health coverage and care for other young adults, according to the bill’s many critics, which include the American Medical Association and the American Hospital Association.This story also ran in the Teen Vogue. It can be republished for free (details).
“Don’t be fooled,” said Jen Mishory, executive director of the advocacy organization Young Invincibles. “This is going to be a bad deal, particularly for the most vulnerable young people.”
Mishory said one of the biggest concerns is that states could opt out of requiring insurers to provide benefits such as maternity care, mental health care and prescription drugs — all commonly used among young adults. “You will see a lot of young people not getting the kind of coverage they need,” she said.
The proposed changes in the marketplaces, however, could make coverage more attractive to young people. The Congressional Budget Office reports that the Senate bill would result in a larger number of younger people paying lower premiums to buy private plans. The proposal would allow insurers to charge older people up to five times more than others, which could mean lower premiums for younger people.
At the same time, the Senate bill shifts the amount people who qualify for subsidies must pay toward their own premiums, meaning that people under age 40 might pay a smaller portion of their income toward coverage than they do under Obamacare.
But young adults could face other cost increases because of larger deductibles and less help with out-of-pocket expenses. Some no longer would qualify for subsidies at all, because the bill would reduce the income threshold for eligibility.
Millions of young adults have enrolled in coverage through the insurance exchanges, in part because of a coordinated push to get as many healthy, young people into the marketplace to balance out older, sicker consumers who were eager to sign up right away.
About 27 percent of the 12.2 million consumers who enrolled in health insurance through the exchanges across the nation in 2017, were 18 to 34 years old. In California, 37 percent of 2017 enrollees were in that age group, according to Covered California, the state’s insurance exchange.
Steven Orozco, who lives in Los Angeles, is among them. He, his wife and 2-year-old daughter have a plan through Covered California. Orozco, who is a real estate agent, said they are all healthy so they don’t use it often, but he has it just in case of broken arms or other unexpected health needs.
Orozco, 32, said that he is concerned about what could happen in Washington and how that might affect his coverage, which currently costs about $450 a month.
Despite potential benefits to young adults in the private marketplace, the most damaging changes under the Senate proposal would be for young adults covered by Medicaid, said Walter Zelman, chairman of the public health department at Cal State-Los Angeles.
In addition to phasing out the expansion of Medicaid, the Senate bill also would result in reduced funding for the program, he said.
“The biggest impact on young people is the dismantling of Medicaid,” Zelman said.
Since the Affordable Care Act took effect, about 3.8 million young adults have gained coverage through the expansion of Medicaid, according to Young Invincibles.
In California alone, Zelman said, hundreds of thousands of young people won’t be able to access Medi-Cal, California’s version of Medicaid, if the expansion is phased out. Zelman, who worked to enroll California State University students into health coverage under Obamacare, said that historically the highest percentages of uninsured people have been young adults, low-income residents, part-time workers and Latinos.
“Those are my students,” he said. “And, more generally, those are young people overall. … Anything that threatens [their] access to health is bad for them,” he said.
It’s unclear whether the proposed Republican overhaul would result in more or fewer young enrollees.
Uninsured Sacramento resident Sydney Muns, 27, works at a nonprofit that doesn’t offer health coverage, and she earned too much money to qualify for Medi-Cal or receive Obamacare subsidies. Muns said she hopes premiums and out-of-pocket costs will decline in the future so she can get coverage.
“It’s just not affordable,” said Muns, who faces $50,000 in college loan debt. “I don’t know anyone my age who has insurance.”
But Chyneise Dailey, 24, said she plans to purchase health care whether or not she is required to do so. Dailey, who works at Sacramento State, remains on her parents’ Blue Cross health insurance plan, but knows she has only a couple of years before she has to buy her own coverage.
“You never know what can happen. You get into a car accident, you’re in the ER — do you want to pay full rate or do you want to pay your copay?” Dailey said. “I’d just rather be safe than sorry.”
Under both the Senate and House plans to overhaul Obamacare, young women who go to Planned Parenthood for reproductive health and other medical services could be hurt because of a provision to ban federal funding of the organization for a year.
That concerns Niki Kangas, 35, who frequently visits Planned Parenthood clinics even though she has job-based coverage from Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.) Kangas, of Sacramento, said she is “pissed off” that the Senate’s proposed bill would impose a one-year ban on federal funding to the organization, which is a frequent target for conservatives.
“I’ve used Planned Parenthood a lot, either in between jobs or sometimes it’s just more convenient than going out to Kaiser, like if I just need birth control,” said Kangas, a project manager at a design agency. “I think for people who don’t have insurance through their work that it’s a resource they depend on.”
Mary Agnes Carey, Julie Appleby and Barbara Feder Ostrov contributed to this report.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN’s coverage in California is funded in part by Blue Shield of California Foundation.
The Villages Regional Hospital did not sweat its decision to add hyperbaric oxygen therapy in 2013.
Hyperbaric treatment, increasingly given to diabetics — many of them elderly with persistent wounds — involves breathing pure oxygen inside a pressurized air chamber typically for two hours each weekday, often for more than a month. Twenty outpatient sessions can bring a hospital $9,000 in revenue.
Villages serves a central Florida retirement community that supplied nearly half of the hyperbaric patients at another hospital 30 minutes away. Hospital officials knew their clientele preferred their medical appointments only a golf-cart’s ride from home.
“Wound care was a service line we saw as low-hanging fruit,” said Todd Powell, who oversees hyperbaric therapy at Villages hospital.This KHN story also ran in The Washington Post. It can be republished for free (details).
Many hospitals seem to agree. Enticed by healthy Medicare payments — about $450 for a two-hour session — and for-profit management companies that do much of the work, nearly 1,300 U.S. hospitals have installed hyperbaric facilities. That’s triple the number that an industry group says offered the service in 2002, when Medicare first decided to pay for the therapy for certain diabetic wounds.
Medicare — the largest payer of hyperbaric services — has flagged evidence of overuse in at least some parts of the country. Medicare officials declined to comment for this story, but they have retained coverage for more than 15 years, even as studies have questioned the therapy’s effectiveness.
The American Diabetes Association does not recommend the treatment. After an ADA committee of experts in diabetes care reviewed the available research last year, it concluded there was “not enough supporting data on the efficacy of this treatment to recommend its use,” said William Cefalu, the association’s chief medical officer.
Some experts say hyperbaric therapy’s increased use for diabetic wounds owes more to hospitals’ pursuit of Medicare revenue than to the treatment’s proven value.
“The science remains poor to support its use, but it is being widely used [in the United States], and one possible explanation to this may be related to reimbursement,” explained Dr. Andrew Boulton, an internationally recognized expert on hyperbaric therapy, and a professor of medicine at University of Manchester medical school in Great Britain.
“Some folks are chasing the money. It’s seen as a money grab because reimbursement has been favorable,” acknowledged John Peters, executive director of the Undersea & Hyperbaric Medical Society, which accredits 200 hyperbaric oxygen facilities nationally and has inspected 500 for accreditation in the past 15 years.
Offered at a handful of hospitals in the last decades of the 20th century, hyperbaric chambers were a niche treatment for deep-sea divers suffering with the bends — a painful and potentially fatal condition where gas bubbles accumulate in the bloodstream during too-rapid ascents from depth. In 2002 — after industry lobbying and some suggestive research — Medicare approved hyperbaric therapy for certain diabetic wounds that did not respond to conventional treatments.
That decision drove a building boom in outpatient wound care centers over the next half-decade, featuring hyperbaric therapy. Medicare covers the treatment for more than a dozen conditions in which skin fails to heal, such as failing grafts and tissue damage from anti-cancer from radiation, but the USA’s rising diabetic population supplies much of the demand.
It costs about $500,000 to install a hyperbaric unit with two chambers. With Medicare’s lucrative reimbursement policies, “hospitals can generate cash almost immediately,” Peters said. During hyperbaric sessions, patients merely lie on a bed in a glass-enclosed tube containing high-pressure oxygen under a physician’s supervision.
The business model is so compelling that management companies typically pay for the equipment and staff. Hospitals provide space for the chamber, make patient referrals and handle billing. The companies and the hospitals split revenue from insurers.
Because of poor blood circulation, diabetics are susceptible to developing ulcers in their lower legs and feet that heal poorly and can sometimes lead to amputations. Hyperbaric oxygen therapy, in theory, works by stimulating the body’s creation of new blood vessels and aiding the formation of new skin around a wound. Side effects are uncommon but include ear and sinus pressure, paralysis and air embolisms.
In 2015, Medicare imposed stricter billing procedures in three states where its expenses for hyperbaric services were 21 percent above the national average — possible evidence of overuse or overbilling. Providers in Illinois, Michigan and New Jersey must get regulators’ preauthorization of expenses before treating Medicare patients for the most commonly approved conditions in non-emergency cases. Elsewhere, Medicare requires documentation supporting hyperbaric therapy’s need only after services begin.
Signs of abusive industry practices predate the 2015 action. A critical report by the Health and Human Services Department’s inspector general in 2000 disclosed that Medicare was billed millions of dollars for non-diabetic wound care treatments that were inappropriate or excessive. The office has promised a follow-up report before Oct. 1 — its first since 2000.
The Justice Department alleged fraud or other wrongdoing involving hyperbaric therapy in at least five cases from 2008 to 2014. It has won more than $11 million in penalties and restitution — along with some jail sentences — in court rulings and settlements.
(The FDA warned in 2013 about some treatment centers’ falsely promoting the therapy for unapproved uses, including as a cure for cancer, autism and diabetes.)
Medicare’s crackdown on billing in three states saved $5.3 million in its first 13 months, the government said in November. Medicare’s total spending on hyperbaric therapy — including all approved conditions — in 2015 fell about 10 percent to $230 million. That was the first annual decline in a decade.
Debates about the utility of the treatment continue despite decades of use.
In fact, few large, controlled studies have explored hyperbaric oxygen therapy for diabetic wounds — and nearly all were done outside the United States.
Some studies have found the treatment benefits certain patients while others have concluded it neither increases a wound’s chances of healing nor prevents amputations. The problem is knowing which wounds would have healed over time on their own.
Businesses and individuals invested in the facilities remain unalloyed boosters. The treatment “used to be considered voodoo medicine. But today more doctors have been swayed, and it’s now seen as mainstream therapy,” said Marc Kaiser, owner of Precision Health Care, which manages hyperbaric centers at five hospitals in New York and Connecticut.
Based on studies and anecdotal experience, Dr. Geoffrey Gurtner, a plastic surgeon who helped establish the Stanford University Wound Care Center in 2014, believes the therapy has some merit. But he said that research is needed to understand how the treatment works, which patients need it and the right number of sessions for each wound.
And, critics say, companies are profiting from and abusing the current state of uncertainty. Medicare pays for hyperbaric therapy for diabetic wounds that have not healed after 30 days of standard treatments. If hospitals provide more than 30 treatments, they must document that patients’ wounds are improving.
Twenty to 30 sessions of hyperbaric therapy should heal diabetic wounds, but radiation-damaged skin might require 40 treatments, said Dr. Phi-Nga Jeannie Le, a Houston physician.
“The problem is, we see these financially motivated centers keep doing the treatment into the hundreds of visits,” she said.
Also, Medicare pays nearly double the standard rate when the treatment is performed at hospital-affiliated facilities, which can add on a “facility fee.” Because of this quirk in the rules, hyperbaric management companies tend to court hospitals to install their devices.
April Hall underwent 50 sessions of hyperbaric oxygen therapy at MedStar Good Samaritan Hospital in Baltimore last summer.
Stretched out in one of the hospital’s four hyperbaric chambers, wrapped in blankets with her head propped up to watch television, Hall breathed pure oxygen for two hours at a time.
One wound on the bottom of her left foot healed. The other did not.
“I did what I had to do to save my foot,” said Hall, 50, who is on Medicare disability.
Sometimes even dozens of treatments do not avert amputations, as diabetic William Padgett Jr., 65, of Culpeper, Va., can attest. He lost his right leg in 2013 after nearly 90 hyperbaric sessions failed to heal a wound.
Last year, he tried hyperbaric oxygen again to close a wound on his left leg, taking about 80 sessions over four months at a hospital in Arlington, Va. The wound healed. “It’s been a slow process … but well worth the time,” he said.
In any one case, it is hard to say whether the treatment was key to success.
A 2014 federal whistleblower lawsuit against Healogics, which manages about half — 750 — of the nation’s hospital-owned wound-care and hyperbaric centers, raised other concerns. Two doctors and a third employee who worked for Healogics alleged a company conspiracy to defraud the federal government by billing it for unnecessary wound care and hyperbaric services.
Healogics denied the claims in its court-filed responses, and a judge dismissed the case for lack of detail. It is under appeal.
The lawsuit alleged Healogics “actively targeted each and every [wound care] patient for conversion” to hyperbaric therapy and set benchmarks for each center on the amount of hyperbaric care that would be provided.
According to Healogics, 5 percent of its 326,000 patients last year had hyperbaric treatment. Only 2 percent of those received more than 50 sessions.
WHEN Senate Majority Leader Mitch McConnell broke the news Tuesday afternoon, all the nervous buildup around the Senate health care bill vanished faster than a sticky, summer day in Washington, D.C. after a thunderstorm. Could McConnell really push the bill through the Senate before senators left town for the holiday? How many senators were balking now? Those and other questions disappeared — for now — when McConnell announced the Better Care Reconciliation Act would get no floor vote until after July 4.
GOP senators were just leaving their Tuesday afternoon policy lunch about 2 p.m. ET as word about a delay circulated before McConnell confirmed it. Many wanted nothing to do with the sea of reporters that waited outside the room where the senators meet for lunch. Sen. John Cornyn (R-Texas) slipped quickly into an elevator, taking no questions. Sen. Rob Portman (R-Ohio) — head down, shoulders hunched — practically sprinted past microphones into the Senate chamber.
ONE of the few who stopped to talk was Sen. Marco Rubio (R-Fla.), who expressed hope that a bill would get through the Senate and the House before the August recess. Reporters showered him with attention.Use Our ContentThis KHN story can be republished for free (details).
Once Republican leadership emerged to explain why the vote was being delayed, they defaulted to a familiar script: bashing the Affordable Care Act. “The schedule may have changed a little bit, but one thing that hasn’t is that Obamacare is collapsing,” said Sen. John Thune (R-S.D.), the Republican Conference chairman. McConnell told reporters the delay wasn’t an indictment of the bill, but the outcome of more discussions and senators asking for more time. “It’s complicated,” he said.
MINORITY Leader Chuck Schumer, looking visibly annoyed that reporters were still in a scrum around Thune and not at his mic, said Democrats aren’t counting the delay as a victory. “No matter what tweaks they may add in the next week and a half, no matter how the bill changes around the edges, it is fundamentally flawed at the center,” he said.
LATER in the afternoon, three dozen or so people stood on the grass outside the Capitol, chanting, banging drums, delivering speeches and waving signs that read, “AHCA=Death” and “Survival of the Richest.” The group represented LGBTQ and HIV/AIDS advocacy groups. Though their tone was happy and elevated in the wake of the health care bill vote’s delay, it wasn’t victorious. “We got complacent with the House bill,” one speaker said. Organizers announced phone banks and letter writing campaigns every week in opposition to the Senate proposal.
THEY say a picture is worth a thousand words and Senate Democrats tried out that advice in in a media photo op on the Capitol steps early Tuesday afternoon. About two dozen senators held foam posters decorated with large photos of constituents who had reported they would be hurt by Trumpcare. What the cameras didn’t show were the posters’ backsides where the name of the senator who was supposed to be holding that poster was written in marker. Many also had their constituent’s story printed out and taped on the back. As each senator left the second floor of the Capitol building to descend the stairs to waiting cameras, staffers handed out the posters and quickly prepped their bosses, almost like stage parents reminding a child how to perform a dance routine before a recital. As one lawmaker darted through the double doors to join the others, a staffer handed him his poster and said, “Here’s your constituent, senator, isn’t she a beauty?”
Senate Majority Leader Mitch McConnell is well aware of the political peril of taking health benefits away from millions of voters. He also knows the danger of reneging on the pledge that helped make him the majority leader: to repeal Obamacare.
Caught between those competing realities, McConnell’s bill offers a solution: go ahead and repeal Obamacare, but hide the pain for as long as possible. Some of the messaging on the bill seems nonsensical (see: the contention that $772 billion squeezed out of Medicaid isn’t a cut). But McConnell’s timetable makes perfect sense — if you are looking at the electoral calendar.
Here are a few key dates in McConnell’s “Better Care Reconciliation Act” (BCRA) that seem aimed more at providing cover for lawmakers than coverage for Americans:
2019: First major changes and cuts to the Affordable Care Act exchanges happen after the 2018 midterm cycle, allowing congressional Republicans to campaign on a “fixed” health system, even though Obamacare is still largely in place next year.
2019: States share $2 billion in grants to apply for waivers under a much looser process through this fiscal year. These waivers could allow insurers to sell skimpy plans that have low price tags but don’t take adequate care of people with preexisting conditions. None of those waivers has to go into effect, however, until after 26 Republican governors face re-election in 2018.This KHN story also ran in The Daily Beast. It can be republished for free (details).
2020: Stabilization cash that makes the markets more predictable and fair for insurers flows through the congressional midterm cycle and the 2020 presidential cycle. Then it disappears. Medicaid expansion funds hold steady through this crucial political window, too.
2024: States enjoy their last few sips of Medicaid expansion cash at the end of 2023 — just as, perhaps, a second Republican presidential term is ending.
2025: The bill changes the formula for the entire Medicaid budget (not just the Obamacare expansion), dramatically reducing federal funding over time. That starts eight years and two presidential election cycles from now.
McConnell insists everything about the bill has been aboveboard and transparent.
“Nobody’s hiding the ball here. You’re free to ask anybody anything,” McConnell said on June 13.
But he and his working group did literally hide the bill from Democrats and most Republicans, crafting it behind closed doors until there was just a week left before his goal to secure a vote on it. (That timing was thrown off Tuesday with the announcement the vote was delayed, but the dealmaking is just beginning.)
Meanwhile, at least two policy details in the bill may obscure the effects for several years and make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.
One is a stipulation that compels the federal government, for two years, to pay the cost-sharing reduction payments to insurance companies that President Donald Trump has threatened to end. The payments are part of the Affordable Care Act, and they flow to insurers on behalf of low-income marketplace customers to cover their out-of-pocket health expenses. Republicans had sued to stop the payments, adding considerable instability to ACA marketplaces next year. McConnell ends that uncertainty for two years.
On top of that cash infusion, the BCRA proposes a “Short-Term Stabilization Fund” that would also aim to help lower premium costs and could attract a few more insurers into counties that are sparsely covered now. It would dish out $50 billion to insurers — $15 billion per year in 2018 and 2019 and $10 billion per year in 2020 and 2021.
The money would make up for the billions that the Republican-led Congress has refused to appropriate for insurance companies under the ACA’s risk corridors program. Risk corridors aimed to offset losses for insurers whose costs were more than 103 percent of expected targets. Congress has so far paid only 12.6 cents on the dollar of those obligations and faces lawsuits from insurers that were stiffed.
In short, the two pots of money would go a long way toward addressing the instability in Obamacare created by the Republican-led Congress, but only through the next presidential cycle in 2020.
Beyond timing, the legislation’s features allow senators to make truthful arguments that disguise negative effects.
Perhaps the key claim is that the Senate bill would increase access to insurance. It might, in that insurance companies in states that waive standards would be free to offer much cheaper plans. But those plans would be cheaper because they wouldn’t cover essential health benefits or adequately cover preexisting conditions. Lower-income Americans might be able to buy a plan — possibly a $6,000 deductible for someone who makes less than $12,000 a year.
A spokesman for McConnell did not answer a request for comment. But Democrats are keenly aware of the electoral machinations in the bill.
“Everything about this legislation, from the process to the effective dates of many of the provisions, is driven by political expediency,” said Brian Fallon, a Democratic consultant and former lead spokesman for Hillary Clinton’s campaign. “Mitch McConnell only cares about getting the ‘win,’ not about the substance of the bill.”
Senate Democratic aides who spoke on background were not sure that the steps the bill takes to shore up markets for the next two elections would work when insurance companies can see what lies ahead. But they agreed the timing and short-term fixes might help McConnell twist the arms of reluctant Republican senators.
“I think it will be enormously helpful to McConnell in a room with a moderate Republican who wants to be told, ‘Hey, a lot of this stuff that’s going to happen in this bill that you’re hearing about, that’s worrisome is past your re-elect, it’s past 2018, it’s past 2020,’” one senior aide said. “‘Just vote for it, it’ll be fine, we’ll figure the rest out later.’”
Democrats said McConnell’s hide-the-ball strategy will not work with voters, and they want Republican senators to know that before they vote.
“The polling already shows that, based on the fact that they control every aspect of government, Trump and the Republicans own everything that happens from now on in the health care system,” Fallon said.
Sen. Patty Murray (D-Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee who has the task of leading the arguments against the GOP bill, thinks senators will imperil their political futures if they buy McConnell’s arguments.
“Sen. McConnell is doing everything he can to persuade Senate Republicans that Trumpcare won’t be devastating for the people they serve, but the facts are that Trumpcare is going to cause families to pay more, gut Medicaid, and take coverage away from millions of people,” Murray said. “Any Senate Republican who votes for Trumpcare and believes patients and families won’t hold them accountable is being sold a bill of goods.”
Still, McConnell knows how to work a legislative calendar. Expect a July full of closed-door dealmaking with reluctant senators, leading up to maximum leverage before the August recess.