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  • Why is it difficult for children to get a bed at pediatric hospitals? It’s more complicated than you think | CNN

    Why is it difficult for children to get a bed at pediatric hospitals? It’s more complicated than you think | CNN

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    CNN
     — 

    Effie Schnacky was wheezy and lethargic instead of being her normal, rambunctious self one February afternoon. When her parents checked her blood oxygen level, it was hovering around 80% – dangerously low for the 7-year-old.

    Her mother, Jaimie, rushed Effie, who has asthma, to a local emergency room in Hudson, Wisconsin. She was quickly diagnosed with pneumonia. After a couple of hours on oxygen, steroids and nebulizer treatments with little improvement, a physician told Schnacky that her daughter needed to be transferred to a children’s hospital to receive a higher level of care.

    What they didn’t expect was that it would take hours to find a bed for her.

    Even though the respiratory surge that overwhelmed doctor’s offices and hospitals last fall is over, some parents like Schnacky are still having trouble getting their children beds in a pediatric hospital or a pediatric unit.

    The physical and mental burnout that occurred during the height of the Covid-19 pandemic has not gone away for overworked health care workers. Shortages of doctors and technicians are growing, experts say, but especially in skilled nursing. That, plus a shortage of people to train new nurses and the rising costs of hiring are leaving hospitals with unstaffed pediatric beds.

    But a host of reasons building since well before the pandemic are also contributing. Children may be the future, but we aren’t investing in their health care in that way. With Medicaid reimbursing doctors at a lower rate for children, hospitals in tough situations sometimes put adults in those pediatric beds for financial reasons. And since 2019, children with mental health crises are increasingly staying in emergency departments for sometimes weeks to months, filling beds that children with other illnesses may need.

    “There might or might not be a bed open right when you need one. I so naively just thought there was plenty,” Schnacky told CNN.

    The number of pediatric beds decreasing has been an issue for at least a decade, said Dr. Daniel Rauch, chair of the Committee on Hospital Care for the American Academy of Pediatrics.

    By 2018, almost a quarter of children in America had to travel farther for pediatric beds as compared to 2009, according to a 2021 paper in the journal Pediatrics by lead author Dr. Anna Cushing, co-authored by Rauch.

    “This was predictable,” said Rauch, who has studied the issue for more than 10 years. “This isn’t shocking to people who’ve been looking at the data of the loss in bed capacity.”

    The number of children needing care was shrinking before the Covid-19 pandemic – a credit to improvements in pediatric care. There were about 200,000 fewer pediatric discharges in 2019 than there were in 2017, according to data from the US Department of Health and Human Services.

    “In pediatrics, we have been improving the ability we have to take care of kids with chronic conditions, like sickle cell and cystic fibrosis, and we’ve also been preventing previously very common problems like pneumonia and meningitis with vaccination programs,” said Dr. Matthew Davis, the pediatrics department chair at Ann & Robert H. Lurie Children’s Hospital of Chicago.

    Pediatrics is also seasonal, with a typical drop in patients in the summer and a sharp uptick in the winter during respiratory virus season. When the pandemic hit, schools and day cares closed, which slowed the transmission of Covid and other infectious diseases in children, Davis said. Less demand meant there was less need for beds. Hospitals overwhelmed with Covid cases in adults switched pediatric beds to beds for grownups.

    As Covid-19 tore through Southern California, small hospitals in rural towns like Apple Valley were overwhelmed, with coronavirus patients crammed into hallways, makeshift ICU beds and even the pediatric ward.

    Only 37% of hospitals in the US now offer pediatric services, down from 42% about a decade ago, according to the American Hospital Association.

    While pediatric hospital beds exist at local facilities, the only pediatric emergency department in Baltimore County is Greater Baltimore Medical Center in Towson, Maryland, according to Dr. Theresa Nguyen, the center’s chair of pediatrics. All the others in the county, which has almost 850,000 residents, closed in recent years, she said.

    The nearby MedStar Franklin Square Medical Center consolidated its pediatric ER with the main ER in 2018, citing a 40% drop in pediatric ER visits in five years, MedStar Health told CNN affiliate WBAL.

    In the six months leading up to Franklin Square’s pediatric ER closing, GBMC admitted an average of 889 pediatric emergency department patients each month. By the next year, that monthly average jumped by 21 additional patients.

    “Now we’re seeing the majority of any pediatric ED patients that would normally go to one of the surrounding community hospitals,” Nguyen said.

    In July, Tufts Medical Center in Boston converted its 41 pediatric beds to treat adult ICU and medical/surgical patients, citing the need to care for critically ill adults, the health system said.

    In other cases, it’s the hospitals that have only 10 or so pediatric beds that started asking the tough questions, Davis said.

    “Those hospitals have said, ‘You know what? We have an average of one patient a day or two patients a day. This doesn’t make sense anymore. We can’t sustain that nursing staff with specialized pediatric training for that. We’re going to close it down,’” Davis said.

    Registered nurses at Tufts Medical Center hold a

    Saint Alphonsus Regional Medical Center in Boise closed its pediatric inpatient unit in July because of financial reasons, the center told CNN affiliate KBOI. That closure means patients are now overwhelming nearby St. Luke’s Children’s Hospital, which is the only children’s hospital in the state of Idaho, administrator for St. Luke’s Children’s Katie Schimmelpfennig told CNN. Idaho ranks last for the number of pediatricians per 100,000 children, according to the American Board of Pediatrics in 2023.

    The Saint Alphonsus closure came just months before the fall, when RSV, influenza and a cadre of respiratory viruses caused a surge of pediatric patients needing hospital care, with the season starting earlier than normal.

    The changing tide of demand engulfed the already dwindling supply of pediatric beds, leaving fewer beds available for children coming in for all the common reasons, like asthma, pneumonia and other ailments. Additional challenges have made it particularly tough to recover.

    Another factor chipping away at bed capacity over time: Caring for children pays less than caring for adults. Lower insurance reimbursement rates mean some hospitals can’t afford to keep these beds – especially when care for adults is in demand.

    Medicaid, which provides health care coverage to people with limited income, is a big part of the story, according to Joshua Gottlieb, an associate professor at the University of Chicago Harris School of Public Policy.

    “Medicaid is an extremely important payer for pediatrics, and it is the least generous payer,” he said. “Medicaid is responsible for insuring a large share of pediatric patients. And then on top of its low payment rates, it is often very cumbersome to deal with.”

    Pediatric gastroenterologist Dr. Howard Baron visits with a patient in 2020 in Las Vegas. A large portion of his patients are on Medicaid with reimbursement rates that are far below private insurers.

    Medicaid reimburses children’s hospitals an average of 80% of the cost of the care, including supplemental payments, according to the Children’s Hospital Association, a national organization which represents 220 children’s hospitals. The rate is far below what private insurers reimburse.

    More than 41 million children are enrolled in Medicaid and the Children’s Health Insurance Program, according to Kaiser Family Foundation data from October. That’s more than half the children in the US, according to Census data.

    At Children’s National Hospital in Washington, DC, about 55% of patients use Medicaid, according to Dr. David Wessel, the hospital’s executive vice president.

    “Children’s National is higher Medicaid than most other children’s hospitals, but that’s because there’s no safety net hospital other than Children’s National in this town,” said Wessel, who is also the chief medical officer and physician-in-chief.

    And it just costs more to care for a child than an adult, Wessel said. Specialty equipment sized for smaller people is often necessary. And a routine test or exam for an adult is approached differently for a child. An adult can lie still for a CT scan or an MRI, but a child may need to be sedated for the same thing. A child life specialist is often there to explain what’s going on and calm the child.

    “There’s a whole cadre of services that come into play, most of which are not reimbursed,” he said. “There’s no child life expert that ever sent a bill for seeing a patient.”

    Low insurance reimbursement rates also factor into how hospital administrations make financial decisions.

    “When insurance pays more, people build more health care facilities, hire more workers and treat more patients,” Gottlieb said.

    “Everyone might be squeezed, but it’s not surprising that pediatric hospitals, which face [a] lower, more difficult payment environment in general, are going to find it especially hard.”

    Dr. Benson Hsu is a pediatric critical care provider who has served rural South Dakota for more than 10 years. Rural communities face distinct challenges in health care, something he has seen firsthand.

    A lot of rural communities don’t have pediatricians, according to the American Board of Pediatrics. It’s family practice doctors who treat children in their own communities, with the goal of keeping them out of the hospital, Hsu said. Getting hospital care often means traveling outside the community.

    Hsu’s patients come from parts of Nebraska, Iowa and Minnesota, as well as across South Dakota, he said. It’s a predominantly rural patient base, which also covers those on Native American reservations.

    “These kids are traveling 100, 200 miles within their own state to see a subspecialist,” Hsu said, referring to patients coming to hospitals in Sioux Falls. “If we are transferring them out, which we do, they’re looking at travels of 200 to 400 miles to hit Omaha, Minneapolis, Denver.”

    Inpatient pediatric beds in rural areas decreased by 26% between 2008 and 2018, while the number of rural pediatric units decreased by 24% during the same time, according to the 2021 paper in Pediatrics.

    Steve Inglish, left, and registered nurse Nikole Hoggarth, middle, help a father with his daughter, who fell and required stiches, inside the emergency department at Jamestown Regional Medical Center in rural North Dakota in 2020.

    “It’s bad, and it’s getting worse. Those safety net hospitals are the ones that are most at risk for closure,” Rauch said.

    In major cities, the idea is that a critically ill child would get the care they need within an hour, something clinicians call the golden hour, said Hsu, who is the critical care section chair at the American Academy of Pediatrics.

    “That golden hour doesn’t exist in the rural population,” he said. “It’s the golden five hours because I have to dispatch a plane to land, to drive, to pick up, stabilize, to drive back, to fly back.”

    When his patients come from far away, it uproots the whole family, he said. He described families who camp out at a child’s bedside for weeks at a time. Sometimes they are hundreds of miles from home, unlike when a patient is in their own community and parents can take turns at the hospital.

    “I have farmers who miss harvest season and that as you can imagine is devastating,” Hsu said. “These aren’t office workers who are taking their computer with them. … These are individuals who have to live and work in their communities.”

    Back at GBMC in Maryland, an adolescent patient with depression, suicidal ideation and an eating disorder was in the pediatric emergency department for 79 days, according to Nguyen. For months, no facility had a pediatric psychiatric bed or said it could take someone who needed that level of care, as the patient had a feeding tube.

    “My team of physicians, social workers and nurses spend a significant amount of time every day trying to reach out across the state of Maryland, as well as across the country now to find placements for this adolescent,” Nguyen said before the patient was transferred in mid-March. “I need help.”

    Nguyen’s patient is just one of the many examples of children and teens with mental health issues who are staying in emergency rooms and sometimes inpatient beds across the country because they need help, but there isn’t immediately a psychiatric bed or a facility that can care for them.

    It’s a problem that began before 2020 and grew worse during the pandemic, when the rate of children coming to emergency rooms with mental health issues soared, studies show.

    Now, a nationwide shortage of beds exists for children who need mental health help. A 2020 federal survey revealed that the number of residential treatment facilities for children fell 30% from 2012.

    “There are children on average waiting for two weeks for placement, sometimes longer,” Nguyen said of the patients at GBMC. The pediatric emergency department there had an average of 42 behavioral health patients each month from July 2021 through December 2022, up 13.5% from the same period in 2017 to 2018, before the pandemic, according to hospital data.

    When there are mental health patients staying in the emergency department, that can back up the beds in other parts of the hospital, creating a downstream effect, Hsu said.

    “For example, if a child can’t be transferred from a general pediatric bed to a specialized mental health center, this prevents a pediatric ICU patient from transferring to the general bed, which prevents an [emergency department] from admitting a child to the ICU. Health care is often interconnected in this fashion,” Hsu said.

    “If we don’t address the surging pediatric mental health crisis, it will directly impact how we can care for other pediatric illnesses in the community.”

    Dr. Susan Wu, right, chats with a child who got her first dose of the Pfizer-BioNtech Covid-19 vaccine at Children's Hospital Arcadia Speciality Care Center in Arcadia, California, in 2022.

    So, what can be done to improve access to pediatric care? Much like the reasons behind the difficulties parents and caregivers are experiencing, the solutions are complex:

    • A lot of it comes down to money

    Funding for children’s hospitals is already tight, Rauch said, and more money is needed not only to make up for low insurance reimbursement rates but to competitively hire and train new staff and to keep hospitals running.

    “People are going to have to decide it’s worth investing in kids,” Rauch said. “We’re going to have to pay so that hospitals don’t lose money on it and we’re going to have to pay to have staff.”

    Virtual visits, used in the right situations, could ease some of the problems straining the pediatric system, Rauch said. Extending the reach of providers would prevent transferring a child outside of their community when there isn’t the provider with the right expertise locally.

    • Increased access to children’s mental health services

    With the ongoing mental health crisis, there’s more work to be done upstream, said Amy Wimpey Knight, the president of CHA.

    “How do we work with our school partners in the community to make sure that we’re not creating this crisis and that we’re heading it off up there?” she said.

    There’s also a greater need for services within children’s hospitals, which are seeing an increase in children being admitted with behavioral health needs.

    “If you take a look at the reasons why kids are hospitalized, meaning infections, diabetes, seizures and mental health concerns, over the last decade or so, only one of those categories has been increasing – and that is mental health,” Davis said. “At the same time, we haven’t seen an increase in the number of mental health hospital resources dedicated to children and adolescents in a way that meets the increasing need.”

    Most experts CNN spoke to agreed: Seek care for your child early.

    “Whoever is in your community is doing everything possible to get the care that your child needs,” Hsu said. “Reach out to us. We will figure out a way around the constraints around the system. Our number one concern is taking care of your kids, and we will do everything possible.”

    Nguyen from GBMC and Schimmelpfennig from St. Luke’s agreed with contacting your primary care doctor and trying to keep your child out of the emergency room.

    “Anything they can do to stay out of the hospital or the emergency room is both financially better for them and better for their family,” Schimmelpfennig said.

    Knowing which emergency room or urgent care center is staffed by pediatricians is also imperative, Rauch said. Most children visit a non-pediatric ER due to availability.

    “A parent with a child should know where they’re going to take their kid in an emergency. That’s not something you decide when your child has the emergency,” he said.

    Jaimie and Effie Schnacky now have an asthma action plan after the 7-year-old's hospitalization in February.

    After Effie’s first ambulance ride and hospitalization last month, the Schnacky family received an asthma action plan from the pulmonologist in the ER.

    It breaks down the symptoms into green, yellow and red zones with ways Effie can describe how she’s feeling and the next steps for adults. The family added more supplies to their toolkit, like a daily steroid inhaler and a rescue inhaler.

    “We have everything an ER can give her, besides for an oxygen tank, at home,” Schnacky said. “The hope is that we are preventing even needing medical care.”

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  • Democrats Seek To Expand Access To Home And Community Services For Disabled People

    Democrats Seek To Expand Access To Home And Community Services For Disabled People

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    Democrats in the House and Senate reintroduced legislation this week that would expand access to home- and community-based services (HCBS) and address barriers faced by millions of disabled people nationwide who use these services.

    The Home and Community Based Services Access Act, initially introduced in 2021 with the support of disability organizations, would mandate the services as a Medicaid benefit and increase funding for them. It would also incentivize states to expand these programs and eliminate long waitlists. In conjunction with the Better Care Better Jobs legislation, wages would be increased for care givers.

    The bill was introduced by Sen. Bob Casey (D-Pa.) in the Senate and co-sponsored by 16 other members of the Democratic caucus. Rep. Debbie Dingell (D-Mich.) introduced the House version, which is co-sponsored by Rep. Jamaal Bowman (D-N.Y.).

    The legislation would also work toward improving the stability, availability and quality of direct care providers, which could help boost the economy after a decades-long workforce shortage crisis exacerbated by the coronavirus pandemic.

    The bills arrive in the same week as President Joe Biden’s proposed budget, which would allocate $150 billion for Medicaid HCBS over the next 10 years.

    Following the deinstitutionalization movement and the landmark Olmstead case barring segregation of disabled people from community life, HCBS provided support to disabled people that allows them to live in their communities rather than in institutional settings.

    According to the Kaiser Foundation, most people 65 and older and disabled people younger than 65 have Medicare, but it doesn’t cover most long-term support and services. Medicaid is required to cover long-term care and services in institutional settings, such as nursing homes, but the Medicaid HCBS benefits are not mandatory.

    Optional waivers are available to allow individual states to provide Medicaid HCBS rather than solely offering long-term care services in institutional settings, along with other benefits.

    The waivers and programs differ state by state, David Goldfarb, director of long-term supports and services policy at disability nonprofit The Arc of the United States, told HuffPost, as do eligibility requirements. Many are placed on waitlists for these services, and, even if they do receive them, they might not get the exact services they need. According to the Kaiser Foundation, 656,000 people in the U.S. were on waiting lists for services in 2021, although the foundation notes that data is an “incomplete measure of unmet need” due to states’ differing eligibility screenings for waitlists and other factors.

    “It’s potentially more because many people may have given up, they may be in an institution,” Goldfarb said. “There’s likely more people that would benefit if we ended these waitlists. But hundreds of thousands of people want to receive care at home, and they are often in an institution and not able to participate in society the way they’d like to.”

    Maura Sullivan, a Massachusetts resident and single mom of two autistic young adults, has been affected by these shortages. Sullivan’s eldest son, Neil, 21, attends a residential school in Massachusetts and visits home on the weekend, more often than usual due to staffing shortages at the school. Her younger son, Tyler, 19, lives at home.

    Her family was lucky to have had access to school-based services for her kids during the pandemic, she said. But with the intensifying workforce crisis, home support outside of school hours has not been consistently available, which has limited her sons’ abilities to be involved in the community.

    “Direct-support professionals have to learn … a whole new communication system [for my sons]. They need to learn augmentative communication and nonverbal communication, and, through that, take the time to bond and develop trust,” Sullivan told HuffPost.

    “When that happens, and when there’s someone available to do that, it’s beautiful. And when they leave just a couple of months after learning all of that because they don’t get a living wage, it’s devastating, and it’s so hard on my sons,” she said, emphasizing that increasing pay for HCBS workers is critical.

    Sullivan is in the process of supporting Neil in the transition to adult HCBS, which she describes as a “very scary time” because of staff shortages. She also worries for her younger son, who will likely live at home for the foreseeable future and might not have access to day programs and community services. Sullivan said she’s concerned because many of the programs have closed in their area, and community services and other opportunities have long waitlists.

    “Even if we raise rates now, it will take time to reopen 20-plus day programs that have closed and consolidated here in Massachusetts [and] to get thousands of individuals back into services and support,” she said. “So I see this as such a long term-problem that I know my sons will be right in the middle of as they’re moving into adulthood.”

    Goldfarb notes that states often view HCBS as extra since they are already mandated in nursing homes. And, in states where they are offered, the services often aren’t fully funded. Expanding Medicaid might be difficult with the current divided Congress, Goldfarb said, adding that Republicans are focusing on not raising the debt ceiling.

    “This is very much a long-term project to work on,” Goldfarb said. “There’s a continuing effort to try to provide access, and we’re really excited about this one.”

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  • Millions of children are at risk of losing Medicaid coverage starting in April | CNN Politics

    Millions of children are at risk of losing Medicaid coverage starting in April | CNN Politics

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    CNN
     — 

    The majority of American children now receive their health insurance through Medicaid and the Children’s Health Insurance Program, according to a new report published Wednesday by the Georgetown Center for Children and Families.

    But that could change starting this spring. As many as 6.7 million children are at risk of losing that coverage once states restart their reviews of recipients’ eligibility, according to Georgetown.

    Medicaid enrollment ballooned during the pandemic thanks to an early Covid-19 pandemic relief provision passed by Congress that barred states from involuntarily disenrolling beneficiaries in exchange for higher federal matching funds. But lawmakers voted late last year to end that continuous enrollment provision on April 1, freeing states to start winnowing ineligible recipients.

    More than 42 million children were covered by Medicaid and CHIP as of August, up 17.5% from February 2020, just before the pandemic started.

    Ten states plus the District of Columbia have more than 60% of their children insured through the public programs, according to Georgetown. New Mexico leads the nation with more than three-quarters of its kids covered by Medicaid and CHIP.

    By contrast, fewer than a quarter of children in Utah are enrolled in the programs.

    The number of children who gained Medicaid and CHIP coverage during the pandemic varied by state. Indiana had the largest surge, with a nearly 45% increase. Wyoming, North Dakota, Missouri and Georgia saw their child enrollment grow by roughly a third.

    On the flip side, Vermont experienced less than an 8% growth in child enrollment in Medicaid and CHIP.

    More than 83 million people, including more than 34 million children, were covered by Medicaid as of August. And another 4 million children were enrolled in Medicaid financed by CHIP. All will have their eligibility reviewed, and in some cases, the children will continue to qualify even if their parents do not.

    “If they’re getting the message that they’re losing their own coverage, a lot of times a parent understandably thinks that their child is also losing coverage,” said Joan Alker, executive director of the Georgetown Center for Children and Families.

    A total of roughly 15 million people could be dropped from Medicaid when the continuous enrollment requirement ends, according to an analysis the Department of Health and Human Services released in August. About 8.2 million folks would no longer qualify, but 6.8 million people would be terminated even though they are still eligible, the department estimated.

    When states reevaluate families’ eligibility, they need to look separately at adults and children, Alker said. Officials should work with pediatricians, schools, child care centers and others to explain the situation to parents and make sure the children retain coverage if they continue to qualify.

    Nearly three-quarters of the children projected to be dropped will remain eligible for Medicaid but will likely lose coverage because of administrative issues, such as their parents not submitting the necessary paperwork or procedural errors, according to Georgetown.

    Although states have 14 months to complete the unwinding process, some will look to do so more quickly.

    “My concern is that a large number of children could become uninsured in states that do not take their time and pay particular attention to the unique needs of children,” Alker said.

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  • Rick Scott: From embattled health care executive to Biden’s top foil | CNN Politics

    Rick Scott: From embattled health care executive to Biden’s top foil | CNN Politics

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    CNN
     — 

    Florida Sen. Rick Scott has emerged as Joe Biden’s top Republican foil in the days since the president’s State of the Union address, with the White House seizing on a year-old Scott proposal that even GOP leaders recognized at the time as politically toxic.

    As a spending fight looms in Washington and Biden moves toward his 2024 reelection bid, the White House is attempting to make Scott the poster child for the president’s accusations that Republicans are seeking to cut entitlement programs, including Social Security and Medicare.

    Scott has responded by accusing Biden of lying, airing a misleading ad that alleges Biden cut Medicare and lambasting the president in a barrage of television interviews.

    Biden traveled Thursday to Florida – where Scott was a health care executive and two-term governor – on the latest leg of his post-State of the Union tour.

    The trip was designed in part to stoke a fight with Scott after Biden in his speech Tuesday night seized on the first-term senator’s proposal to sunset all federal programs – including Social Security and Medicare – every five years unless Congress extends those programs.

    Biden’s assertion that some Republicans are seeking to change entitlement programs was met with jeers from Republican lawmakers, who have said spending cuts should be part of any proposal to raise the debt ceiling.

    The president continued pressing that message Wednesday in Wisconsin, telling union workers, “A lot of Republicans, their dream is to cut Social Security and Medicare.” He waved a pamphlet with Scott’s proposal as he spoke.

    Ahead of Biden’s speech Thursday in Tampa, White House aides placed copies of Scott’s proposal on every seat.

    In an interview with CNN’s Kaitlan Collins on Thursday, Scott said Biden has misrepresented the proposal he put forward ahead of the 2022 midterm elections while serving as head of the National Republican Senatorial Committee, the campaign arm of the Senate GOP.

    “Nobody believes that I want to cut Medicare or Social Security. I’ve never said it,” Scott said.

    Scott said his proposal is intended to eliminate wasteful spending and help ensure the government can “figure out how to start living within our means.”

    “I want to make sure we balance our budget and preserve Medicare and Social Security, and I’ve been clear all along. So what I want to do is get rid of wasteful programs that we never review up here,” he said.

    But Scott’s proposal would sunset all federal legislation – including the two entitlement programs – every five years and require Congress to pass them again.

    Long before he was a US senator, Scott had first-hand experience dealing with America’s federal health care programs – and it became the source of much criticism as he entered the political arena.

    In the 1980s, Scott founded Columbia Hospital Corporation by purchasing a pair of distressed Texas hospitals. He later merged his company with Hospital Corporation of America to create Columbia/HCA, becoming the largest for-profit hospital chain at the time and gaining notoriety on Wall Street for what appeared like cost-cutting in an industry with ballooning expenses.

    In 1997, federal agents unveiled a sweeping investigation into Columbia/HCA that would roil the company for years. On the day the FBI swooped in to seize records from 35 of its hospitals across six states, Scott shrugged off the probe. “It’s not a fun day, but … government investigations are a matter of fact today in health care,” he said on CNN.

    The investigation would unearth what the US Department of Justice later called the “largest health care fraud case in U.S. history.” According to a press release, Columbia/HCA schemed to defraud Medicare, Medicaid and TRICARE, the military’s health care program, of hundreds of millions of dollars. The company pleaded guilty to criminal conduct, including charges related to fraudulent Medicare billing and paying kickbacks to doctors, and it ultimately agreed to pay $1.7 billion in fines, damages and penalties.

    Scott was pushed out as CEO amid the turmoil. He was never charged with a crime, though much of the alleged financial abuses took place during his watch. His time in the corporate world made Scott a wealthy individual, which he would lean on in 2010 when he decided to kickstart a political career by entering the race for Florida governor.

    Scott’s time at the helm of Columbia/HCA was the subject of negative ads from both Republicans and Democrats, but he fended them off with a self-funded campaign that flooded the airwaves with a jobs-focused message. He told the St. Petersburg Times that “mistakes were made” at his former company and that he had “learned hard lessons,” but he also said during a debate that he was “proud of the company I built.” Regardless of the controversy, the little-known Scott defeated a GOP favorite for his party’s nomination, and Floridians narrowly elected him governor that fall.

    During his eight years leading Florida, Scott fought off attempts to extend safety net benefits to Floridians. He frequently challenged the Obama administration over the Affordable Care Act and blocked expansion of Medicaid in Florida. In his first year as governor, he signed a bill to cut unemployment payments and tied benefits to the state’s unemployment rate.

    Democrats continued to make Scott’s time at Columbia/HCA an issue, to no avail. Scott eked out a reelection victory in 2014. He then narrowly unseated longtime Democratic Sen. Bill Nelson in 2018 after spending more than $70 million of his own money on his campaign.

    Marching to the beat of his own drum, Scott declined to be sworn in with his class in January 2019. Instead, he waited until his term as governor had ended and flew to Washington for a separate ceremony. For a time, it made him the country’s most junior senator, but he nevertheless soon found himself in party leadership.

    Scott and other Republicans are aggressively pushing back against Biden’s assertions that the GOP is seeking to cut spending on entitlement programs.

    However, Republican leaders have long recognized Scott’s proposal to sunset all federal programs after five years as rocky political terrain.

    The tense relationship between Scott and Senate Minority Leader Mitch McConnell burst into public view during the 2022 election cycle as Republicans sought to retake the Senate.

    Scott, as NRSC chairman, released a platform called “Rescue America,” which would have subjected all federally elected officials to a term limit of 12 years and closed the Department of Education, amid a slew of other initiatives. It would also have required millions of low-income and middle-class Americans to pay income taxes, which was later dropped in a revised version of the plan.

    And, in what Democrats immediately recognized as an opening to accuse Republicans of attempting to undercut popular programs, Scott’s plan proposed sunsetting all federal legislation in five years – unless Congress extended it.

    McConnell quickly disavowed Scott’s plan, seeking to make clear that the Florida senator did not speak for Senate Republicans.

    “Let me tell you what would not be a part of our agenda,” McConnell said at a news conference last March. “We will not have as part of our agenda a bill that raises taxes on half the American people, and sunsets Social Security and Medicare within five years.”

    Their frosty relationship did not improve as the 2022 election cycle continued, as the two battled over which candidates to support in primaries and in the general election, and Republicans ultimately fell short of winning a majority.

    After the election, Scott challenged McConnell for the top Senate Republican post but lost.

    The Florida senator said last week that he saw McConnell’s decision to remove him from the Senate Commerce Committee as retribution.

    “He didn’t like that I opposed him because I believe we have to have ideas – fight over ideas,” Scott said on “CNN This Morning.”

    When pressed Thursday by CNN’s Collins about why his proposal left open the opportunity for the government to cut funding for Social Security and Medicare, Scott repeatedly referenced a policy proposal from then-Sen. Biden in 1975 to sunset federal legislation periodically.

    Scott said Biden’s old proposal does less to protect entitlements for seniors than the senator’s plan from last year because “he proposed it year after year after year to reduce Medicare and Social Security. Year after year. I’ve never done that. I don’t believe in that.”

    Asked Thursday about the 1975 proposal mentioned by Scott, White House press secretary Karine Jean-Pierre said, “A bill from the 1970s is not part of the president’s agenda.”

    “The president ran on protecting Medicare and Social Security from cuts. And he reiterated that in the State of the Union,” she said.

    A new ad from Scott released this week in advance of the president’s visit to Florida says that “Joe Biden just cut $280 billion from Medicare” – a claim that was previously debunked when Scott and the NRSC made it in 2022.

    Biden’s Inflation Reduction Act is expected to reduce Medicare prescription drug spending by the federal government by $237 billion, according to the most recent Congressional Budget Office estimate, because the law allows the government to spend less money to buy drugs from pharmaceutical companies and not because it cuts benefits to seniors enrolled in Medicare. The law makes Medicare’s prescription drug program substantially more generous to seniors while also saving them money.

    Scott, in his interview with Collins, also defended his recent call for Biden to resign, labeling him “a complete failure.” He said his resignation calls did not specifically stem from Biden’s use of his proposal as an avenue to attack Republicans but expressed his displeasure with the president’s repeated references to his plan.

    “He lies about what I want to get done, and I don’t appreciate it,” Scott said.

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  • Biden intends to end Covid-19 and public health emergencies on May 11 | CNN Politics

    Biden intends to end Covid-19 and public health emergencies on May 11 | CNN Politics

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    CNN
     — 

    President Joe Biden intends to end the Covid-19 national and public health emergencies on May 11, the White House said Monday.

    The White House, in a statement of administration policy announcing opposition to two Republican measures to end the emergencies, said the national emergency and public health emergency authorities declared in response to the pandemic would each be extended one final time to May 11.

    “This wind down would align with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the (public health emergency),” the statement said.

    The statement added, “To be clear, continuation of these emergency declarations until May 11 does not impose any restriction at all on individual conduct with regard to COVID-19. They do not impose mask mandates or vaccine mandates. They do not restrict school or business operations. They do not require the use of any medicines or tests in response to cases of COVID-19.”

    The statement came in response to a pair of measures before the House that would end the public health emergency and the Covid-19 national emergency.

    The White House weighed in because House Democrats were concerned about voting against the Republican legislation to end the public health emergency that is coming to the floor this week without a plan from the Biden administration, a senior Democratic aide told CNN.

    “Democrats were concerned about the optics of voting against Republicans winding down the public health emergency, absent an understanding of whether and how we intended to do so from the White House,” the aide said. “As soon as we saw this bill, it obviously concerns the White House. So, it was important for them to weigh in.”

    The administration argues that the bills are unnecessary because it intends to end the emergencies anyway. The White House also noted the passage of the measures ahead of May 11 would have unintended consequences, such as disrupting the administration’s plans for ending certain policies that are authorized by the emergencies.

    The White House said it would extend the Covid-19 emergencies one final time in order to ensure an orderly wind-down of key authorities that states, health care providers and patients have relied on throughout the pandemic.

    A White House official pointed to a successful vaccination campaign and reductions in Covid cases, hospitalizations and deaths as a rationale for lifting the emergency declarations. The official said a final extension will allow for a smooth transition for health care providers and patients and noted that health care facilities have already begun preparing for that transition.

    The administration is actively reviewing flexible policies that were authorized under the public health emergency to determine which can remain in place after it is lifted on May 11.

    The aide told CNN that it will be up to every member to decide what is best for their district and how they will vote on the legislation this week. Declaring an end to the public health emergency will also end the border restriction known as Title 42, which will also likely set up a showdown on Capitol Hill.

    The public health emergency has enabled the government to provide many Americans with Covid-19 tests, treatments and vaccines at no charge, as well as offer enhanced social safety net benefits, to help the nation cope with the pandemic and minimize its impact.

    “People will have to start paying some money for things they didn’t have to pay for during the emergency,” said Jen Kates, senior vice president at the Kaiser Family Foundation. “That’s the main thing people will start to notice.”

    Most Americans covered by Medicare, Medicaid and private insurance plans have been able to obtain Covid-19 tests and vaccines at no cost during the pandemic. Those covered by Medicare and private insurance have been able to get up to eight at-home tests per month from retailers at no charge. Medicaid also picks up the cost of at-home tests, though coverage can vary by state.

    Those covered by Medicare and Medicaid have also had certain therapeutic treatments, such as monoclonal antibodies, fully covered.

    Once the emergency ends, Medicare beneficiaries generally will face out-of-pocket costs for at-home testing and all treatment. However, vaccines will continue to be covered at no cost, as will testing ordered by a health care provider.

    State Medicaid programs will have to continue covering Covid-19 tests ordered by a physician and vaccines at no charge. But enrollees may face out-of-pocket costs for treatments.

    Those with private insurance could face charges for lab tests, even if they are ordered by a provider. Vaccinations will continue to be free for those with private insurance who go to in-network providers, but going to an out-of-network providers could incur charges.

    Covid-19 vaccinations will be free for those with insurance even when the public health emergency ends because of various federal laws, including the Affordable Care Act and pandemic-era measures, the Inflation Reduction Act and a 2020 relief package.

    Americans with private insurance have not been charged for monoclonal antibody treatment since they were prepaid by the federal government, though patients may be charged for the office visit or administration of the treatment. But that is not tied to the public health emergency, and the free treatments will be available until the federal supply is exhausted. The government has already run out of some of the treatments so those with private insurance may already be picking up some of the cost.

    The uninsured had been able to access no-cost testing, treatments and vaccines through a different pandemic relief program. However, the federal funding ran out in the spring of 2022, making it more difficult for those without coverage to obtain free services.

    The federal government has been preparing to shift Covid-19 care to the commercial market since last year, in part because Congress has not authorized additional funding to purchase additional vaccines, treatments and tests.

    Pfizer and Moderna have already announced that the commercial prices of their Covid-19 vaccines will likely be between $82 and $130 per dose – about three to four times what the federal government has paid, according to Kaiser.

    The public health emergency has also meant additional funds for hospitals, which have been receiving a 20% increase in Medicare’s payment rate for treating Covid-19 patients.

    Also, Medicare Advantage plans have been required to bill enrollees affected by the emergency and receiving care at out-of-network facilities the same as if they were at in-network facilities.

    This will end once the public health emergency expires.

    But several of the most meaningful enhancements to public assistance programs are no longer tied to the public health emergency. Congress severed the connection in December as part of its fiscal year 2023 government funding package.

    Most notably, states will now be able to start processing Medicaid redeterminations and disenrolling residents who no longer qualify, starting April 1. They have 14 months to review the eligibility of their beneficiaries.

    As part of a Covid-19 relief package passed in March 2020, states were barred from kicking people off Medicaid during the public health emergency in exchange for additional federal matching funds. Medicaid enrollment has skyrocketed to a record 90 million people since then, and millions are expected to lose coverage once states began culling the rolls.

    A total of roughly 15 million people could be dropped from Medicaid when the continuous enrollment requirement ends, according to an analysis the Department of Health and Human Services released in August. About 8.2 million folks would no longer qualify, but 6.8 million people would be terminated even though they are still eligible, the department estimated.

    Many who are disenrolled from Medicaid, however could qualify for other coverage.

    Food stamp recipients had been receiving a boost during the public health emergency. Congress increased food stamp benefits to the maximum for their family size in a 2020 pandemic relief package.

    The Biden administration expanded the boost in the spring of 2021 so that households already receiving the maximum amount and those who received only a small monthly benefit get a supplement of at least $95 a month.

    This extra assistance will end as of March, though several states have already stopped providing it.

    Congress, however, extended one set of pandemic flexibilities as part of the government funding package.

    More Medicare enrollees are able to get care via telehealth during the public health emergency. The service is no longer limited just to those living in rural areas. They can conduct the telehealth visit at home, rather than having to travel to a health care facility. Plus, beneficiaries can use smartphones and receive a wider array of services via telehealth.

    These will now continue through 2024.

    This story has been updated with additional details.

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  • First on CNN: Biden administration to strengthen Obamacare contraceptive mandate in proposed rule | CNN Politics

    First on CNN: Biden administration to strengthen Obamacare contraceptive mandate in proposed rule | CNN Politics

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    CNN
     — 

    The Biden administration wants to make it easier for women to access birth control at no cost under the Affordable Care Act, reversing Trump-era rules that weakened the law’s contraceptive mandate for employer-provided health insurance plans.

    The proposed rule, unveiled Monday by the departments of Health and Human Services, Labor and Treasury, would remove an exemption to the mandate that allows employers to opt out for moral convictions. It would also create an independent pathway for individuals enrolled in plans offered by employers with religious exemptions to access contraceptive services through a willing provider without charge.

    The proposed rule would leave in place the existing religious exemption for employers with objections, as well as the optional accommodation for contraceptive coverage.

    The administration crafted the proposed rule keeping in mind the concerns of employers with religious objections and the contraceptive needs of their workers, a senior HHS official told CNN.

    “We had to really think through how to do this in the right way to satisfy both sides, but we think we found that way,” the official said, stressing that there should be no effect on religiously affiliated employers.

    Students at religiously affiliated colleges would have access to the expanded accommodation, just like workers in group health plans where the employer has claimed the exemption.

    Now that the proposed rule has been announced, the public will have the opportunity to comment during the next few months. Officials expect there to be many thousands of public comments, and it will be “many months” before the rule could be finalized.

    HHS expects the proposal would affect more than 100 employers and 125,000 workers, mainly through providing the proposed independent pathway for employees to receive no-cost contraception.

    Women using that pathway would obtain their birth control from a participating provider, who would be reimbursed by an insurer on the Affordable Care Act exchanges. The insurer, in turn, would receive a credit on the user fee it pays the government.

    “If this rule is finalized, individuals who have health plans that would otherwise be subject to the ACA preventive services requirements but have not covered contraceptive services because of a moral or religious objection, and for which the sponsoring employer or college or university has not elected the optional accommodation, would now have access,” Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure said in a news release.

    How many people benefit, however, would depend on whether women and their health care providers know the independent pathway exists and whether providers and insurers are willing to set it up.

    “We’ll just have to see how widely that information is spread and in what way to providers and individuals,” said Laurie Sobel, associate director for Women’s Health Policy at the Kaiser Family Foundation, noting that the proposed rule would not require data collection to show the pathway’s takeup.

    But the Planned Parenthood Federation of America cheered the initiative.

    “Employers and universities should not be able to dictate personal health care decisions and impose their views on their employees or students,” said Alexis McGill Johnson, the group’s CEO. “The ACA mandates that health insurance plans cover all forms of birth control without out-of-pocket costs. Now, more than ever, we must protect this fundamental freedom.”

    The requirement to provide no-cost contraception is not in the Affordable Care Act itself. Instead, HHS under former President Barack Obama included it as one of the women’s preventive services that all private insurance plans must offer without charge.

    The mandate was controversial from the start, sparking lawsuits from religiously affiliated employers and closely held companies that said it violated their beliefs. Exemptions and accommodations have been available for such employers.

    The Trump administration, however, weakened the mandate. Under the rules issued in 2018, entities that have “sincerely held religious beliefs” against providing contraceptives are not required to do so. That provision also extends to organizations and small businesses that have objections “on the basis of moral conviction which is not based in any particular religious belief.”

    The rules also include an optional accommodation that lets objecting employers and private universities remove themselves from providing birth control coverage while still allowing their workers and dependents access to contraception. But the employer or university has to voluntarily elect the accommodation, which risks leaving many without access.

    The Trump administration changes were temporarily blocked after a Pennsylvania district court judge issued a nationwide injunction in 2019. But the following year, the Supreme Court ruled that the administration could expand exemptions for employers who have religious or moral objections to covering contraception.

    At the time, the National Women’s Law Center estimated that the ruling would impact about 64.3 million women in the United States with insurance coverage that included birth control and other preventive services without out-of-pocket costs.

    Employers are not required to notify HHS if they have a moral objection. The agency estimates about 18 employers have claimed that exemption and around 15 employees are affected.

    Still, if the rule is finalized, senior HHS officials say it is “plausible” there could be potential lawsuits brought by religiously affiliated employers – similar to what has been seen in the past.

    “There’s no new obligation on them to participate in any sort of process. This is simply an additional channel for employees in those employer health plans to receive access to contraceptive services,” another senior HHS official said.

    The contraceptive mandate has taken on increased importance now that the Supreme Court has overturned Roe v. Wade, allowing many states to impose severe restrictions on abortion access.

    The Biden administration in turn has focused on continuing access to birth control at no cost. The Health, Labor and Treasury department secretaries last year met with health insurers and issued guidance underscoring Obamacare’s contraceptive coverage requirements for private insurance under the Affordable Care Act.

    “Now more than ever, access to and coverage of birth control is critical as the Biden-Harris Administration works to help ensure women everywhere can get the contraception they need, when they need it, and – thanks to the ACA – with no out-of-pocket cost,” HHS Secretary Xavier Becerra said in a news release.

    This story has been updated with additional information.

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  • Senior citizens will soon get that big hike in their Social Security benefits | CNN Politics

    Senior citizens will soon get that big hike in their Social Security benefits | CNN Politics

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    CNN
     — 

    Senior citizens and other Social Security recipients will start getting a heftier monthly benefit next month due to an 8.7% annual cost-of-living adjustment aimed at helping them cope with high inflation.

    The increase, the largest in more than 40 years, will boost retirees’ monthly payments by more than $140 to an estimated average of $1,827 for 2023.

    The adjustment is the highest that most current beneficiaries have ever seen because it is based on an inflation metric from August through October, which was also around 40-year highs. Inflation has cooled somewhat since then, though prices remain elevated.

    “I’m sure everyone is anxiously awaiting because prices are still high,” said Mary Johnson, a Social Security and Medicare policy analyst at The Senior Citizens League, an advocacy group. “Just shopping for food to feed people during the holidays is going to be a huge challenge.”

    Roughly 70 million people will receive the increase, which follows a 5.9% adjustment for 2022.

    Many senior citizens depend heavily on Social Security. Some 42% of elderly women and 37% of elderly men rely on the monthly payments for at least half their income, according to the Social Security Administration.

    Just when the beefed-up payment will arrive depends on recipients’ ages and birth dates. Those who received Social Security before May 1997 get their monthly benefit on the 3rd of each month. For more recent retirees, those whose birth dates are the 1st through the 10th of the month receive it on the second Wednesday, while those born on the 11th to 20th and the 21st to 31st of the month are paid the third and fourth Wednesdays, respectively.

    Even though recipients received a sizable adjustment for this year, inflation ate away at the boost.

    The increase fell short of actual inflation by an average of more than $42 – or 46% – every month or roughly $508 for the year, Johnson said.

    Many retirees have been forced to turn to their savings or public assistance. One-third of seniors reported signing up for food stamps or visiting a food pantry over the past 12 months, compared with 22% in 2020, according to recent surveys by The Senior Citizens League. Also, 17% have applied for assistance with heating costs, compared with 10% in 2020.

    This is not a new problem. Benefits have not kept up with the rising cost of living for years, even with the annual adjustments.

    As of March, inflation has caused Social Security payments to lose 40% of their buying power since 2000, according to a study released earlier this year by the league. Monthly benefits would have to increase by $540 to maintain the same level of buying power as in 2000.

    Senior citizens will also see their Medicare Part B premiums drop in 2023, the first time in more than a decade that the tab will be lower than the year before, the Centers for Medicare and Medicaid Services announced in the fall. It’s only the fourth time that premiums are declining since Medicare was created in 1965.

    The standard monthly premiums will be $164.90 in 2023, a decrease of $5.20 from 2022.

    The reduction comes after a large spike in 2022 premiums, which raised the standard monthly premium to $170.10, up from $148.50 in 2021. A key driver of the 2022 hike was a projected jump in spending due to a costly new drug for Alzheimer’s disease, Aduhelm. However, since then, Aduhelm’s manufacturer cut the price and the Centers for Medicare and Medicaid Services limited coverage of the drug.

    Also, spending was lower than projected on other Part B items and services, which resulted in much larger reserves in the Part B trust fund, allowing the agency to limit future premium increases.

    The big annual adjustment could end up hurting some seniors, Johnson said.

    For instance, the resulting increase in income could push them above the thresholds for certain government benefits, such as Medicare Extra Help, Medicaid, food stamps and rental assistance, leaving them eligible for less or no aid. Or they could have to pay more for their Medicare Part B premiums, which are adjusted for income.

    Also, they could have to start paying taxes – or owe higher levies – on their Social Security benefits if their income rises above a certain level.

    Further, the increase could leave Social Security’s finances on even shakier ground. The combined trust funds that pay benefits to retirees, survivors and the disabled will be depleted by 2035 and only able to distribute roughly three-quarters of promised payments unless Congress addresses the program’s long-term funding shortfall, according to the most recent Social Security trustees’ report.

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  • House investigation says FDA approval process of Alzheimer’s drug was ‘rife with irregularities’ | CNN

    House investigation says FDA approval process of Alzheimer’s drug was ‘rife with irregularities’ | CNN

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    CNN
     — 

    A congressional investigation found that the US Food and Drug Administration’s “atypical collaboration” to approve a high-priced Alzheimer’s drug was “rife with irregularities.”

    The report, released Thursday, was the result of an 18-month investigation by two House committees. It is sharply critical of Biogen, maker of the medication Aduhelm.

    The report says Biogen set an “unjustifiably high price” for Aduhelm to “make history” for the company, and thought of the drug as an “unprecedented financial opportunity.” Biogen priced Aduhelm at $56,000 per year, even though its actual effects on a broad patient population were unknown.

    More than 6.5 million people in the US live with Alzheimer’s, and that number is expected to grow to 13.8 million by 2060, according to the Alzheimer’s Association. The disease is the sixth leading cause of death in the United States. There is no cure, and effective treatments are extremely limited. Before Aduhelm’s approval in June 2021, the FDA had not approved a novel therapy for the condition since 2003.

    The investigation found that Biogen planned an aggressive marketing campaign to launch the drug, intending to spend more than $3.3 billion on sales and marketing between 2020 and 2024 – more than 2½ times what it spent to develop Aduhelm.

    Dementia, including Alzheimer’s, is one of the “costliest conditions to society,” according to the Alzheimer’s Association. In 2022 alone, Alzheimer’s and other dementias cost the US $321 billion, including $206 billion in Medicaid and Medicare payments, the association says.

    Aduhelm’s cost to patients and to Medicare would be significant, the new report says. It was one of the key factors behind a big increase in Medicare premiums in 2022, according to the Centers for Medicare and Medicaid Services.

    In anticipation of “pushback” from providers and payers, the report says, Biogen also prepared a narrative to sell the value of the drug.

    The Committee on Oversight and Reform and the Committee on Energy and Commerce found that the collaboration between the FDA and Biogen in the approval process of the drug “exceeded the norm in some respects.”

    Biogen had initially discontinued Aduhelm’s clinical trials in March 2019 after an independent committee found that it probably would not slow the cognitive and functional impairment – the decline in memory, language and judgment – that comes with Alzheimer’s. But in June 2019, the FDA and Biogen started a “working group” to see whether the effort could be saved.

    The investigation found that the FDA and Biogen engaged in at least 115 meetings, calls and substantive email discussions from July 2019 to July 2020, including 40 meetings to guide Aduhelm’s potential approval. There may have been even more meetings, but the committees say the FDA failed to follow its own documentation protocol.

    The agency then collaborated with Biogen to draft a document used to brief an independent advisory committee that met in November 2020. The trial results were mixed, with only one showing a small benefit to patients.

    At that meeting, none of the committee’s members voted to say that the studies presented strong evidence that the drug was effective at treating Alzheimer’s.

    The meeting was unusual, according to one former FDA adviser who had sat on the committee for several years. Dr. Aaron Kesselheim told CNN in 2021 that the relationship between the FDA and the company was out of the ordinary.

    “There was a strange dynamic compared to the other advisory committee meetings I’ve attended,” the professor at Harvard Medical School said. “Usually, there’s some distance between the FDA and the company, but on this one, the company and the FDA were fully in line with each other in support of the drug.”

    When the FDA approved the drug, Kesselheim and two other members of the advisory committee resigned in protest. He later labeled it “probably the worst drug approval decision in recent US history.”

    The FDA often follows the independent committee’s recommendations, but in this case, it changed course and used its accelerated approval pathway, which sets a different standard of proof that a treatment could work.

    The committee members said senior FDA leadership told them that the shift in how the drug would be approved came after an FDA expert council meeting in April 2021 provided “unfavorable feedback” for the traditional approval process, according to the new report.

    The FDA also approved the drug for “people with Alzheimer’s disease,” a far broader population than was studied in Biogen’s clinical trials.

    Internal documents from the company said that Biogen accepted this broader indication “despite internal reservations about the lack of evidence of clinical benefit for patients at disease stages outside of the clinical trials and an unknown safety profile,” the report says. Leaders expressed concern that the company could lose credibility, and it developed a communications strategy to deal with the “anticipated fallout,” the report says.

    The committees recommended that the FDA document all of its meetings with drug sponsors, establish a protocol for briefing documents and advisory committees, and update its guidance for how Alzheimer’s drugs are developed and reviewed.

    The committees also recommended that companies clearly communicate safety and efficacy concerns to the FDA and consider the value assessments made by outside experts when setting drug prices.

    “The American people rely on FDA for assurance on the safety and efficacy of the medications they take. The number of patients and families impacted by Alzheimer’s disease will continue to increase, and it is crucial that FDA and drug companies adhere to established procedures and conduct themselves with the transparency necessary to earn public trust,” the report says.

    The FDA said in a statement that its “decision to approve Aduhelm was based on our scientific evaluation of the data contained in the application, which is described in the approval materials.”

    The agency says it is reviewing the committees’ findings and recommendations and says its own review found that the interactions with Biogen were appropriate.

    “It is the agency’s job to frequently interact with companies in order to ensure that we have adequate information to inform our regulatory decision-making. We will continue to do so, as it is in the best interest of patients. That said, the agency has already started implementing changes consistent with the Committee’s recommendations.”

    Biogen said in a statement Thursday that it has been working “cooperatively” with the investigation.

    “Biogen has been committed to researching and developing treatments for Alzheimer’s disease for more than a decade. We have been focused relentlessly on innovation to address this global health challenge, and have adapted to both successes and setbacks,” it said. “Biogen stands by the integrity of the actions we have taken.”

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  • More Mixed Signals On The Housing Economy

    More Mixed Signals On The Housing Economy

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    I grew up in the 80s, a period of time when inflation and recession were common language. At the end of the 70s inflation was raging and so the Federal Reserve dialed up interest rates, a recession followed. My memory of 1982 includes endless reports about layoffs and economic hardship and big midterm wins for Democrats. Then things turned around. Today, the story isn’t so simple, and it never is as events are unfolding. The Ringer has a great podcast called Plain English and I found their episode The Housing Recession is Coming informative and interesting. I speculated last month on what’s happening with the housing economy, but the podcast got me thinking again about what might happen to housing in 2023.

    Host Derek Thompson starts with the weird signals coming from data sources reporting on various economic trends especially housing. Some measures show housing prices and rents falling beginning earlier this year while the so called “headline inflation rate,” the one reported by the government shows inflation up, driven largely by increased housing costs. A broad category called “shelter” is a third of the CPI calculation, and when that indicator gets hot, then overall inflation goes up. Meanwhile, in the broader economy, Gross Domestic Production (GDP) is down and has been two quarters in a row, yet employment numbers are holding strong.

    Thompson hosts Mark Zandi of Moody’s Analytics to tap his brain on what’s going on, especially with housing. First, there is a good conversation on methodology. The rent tracking platforms like Zillow are must faster with their surveys of rent data, while the Bureau of Labor Statistics lags, using a survey instrument that uses a unique sampling methodology. The point Zandi makes is that the BLS numbers lag behind other measures of rent, so rents actually probably, overall, started falling early in the year and continue to fall or flatten. Those changes won’t show up in the BLS tallies until later, perhaps easing inflation toward the end the year.

    Zandi takes on the Thompson’s question about whether “this is 2007 again,” with housing teetering on the edge of a precipitous crash. I found Zandi’s answer sensible. Probably not. We are not on the verge of crash but more of a correction; because of lagging production of housing over the last decade, supply still has not caught up after the 2008 housing crash. Therefore, even though prices for housing did rise steeply, the lack of supply creates a ceiling. He echoes my point about people that may have bought houses in places like Boise and Austin at the top of the market with cheap money, but now are seeing the market value of their purchase falling back to earth.

    He also echoes my concern that if there is a real and sustained recession, those households who went all in on buying housing may face big challenges. If a Fed driven recession hits in early 2023 to correct for inflation, and hours are cut or jobs are lost, the mortgage payment might be more difficult to make, leading to foreclosures. This all depends on how deep and lasting any recession may be, and Zandi posits that we’re not in a recession now and because of strong job numbers, may not really tip into a deep and lasting one in 2023.

    To Thompson’s question about the construction industry and whether jobs will evaporate there, Zandi bets on multifamily housing construction to keep that sector at least flat since that housing type seems to be doing well even while single-family construction is lagging. I’m skeptical for no good reason about Zandi’s view of multifamily other than I think it remains to be seen what happens with job growth and income and growth.

    And that’s where I’ll jump in with my own thoughts as we move toward the end of 2022. I’m no economist of course, but I’d revise my early thoughts and guess that we will be entering a period of recession in 2023, one that will see many of the housing purchases of 2021 seem like a big mistake. I also think that building of multifamily projects, especially townhomes, which are for-sale products, will see high vacancy rates. Many townhomes and condominiums will be sitting on the market for months before they get pulled off the market or sold at big discounts. Interest rates are high, and I think people – investors and buyers – are going to stay out of the game through the first quarter of 2023.

    The psychology of 2023 is going to be key as it always is an economy. Will people feel happy that we made it through a relatively Covid-free 2022, and will that lead to an exuberance that will keep production high? Won’t that lead to more inflation and thus more pressure from the Fed on interest rates? How will those things work in combination? How will all this impact housing policy, something I know much more about that economics?

    That last question depends on something Thompson and Zandi discuss, the nature of our measures of monthly housing costs. Unlike gasoline, prices for housing don’t go up and down perceptibly on a daily, weekly, or even monthly basis. Generally speaking, if the news reports big spikes in rents, most people’s rent stays the same. And mortgages don’t move at all. If the market remains volatile, with “corrections” or “collapses” or “spikes” (choose your adjective or adverb), people will have to compare their own experience with signals in the economy.

    I’ve often thought we’d be better off if rent and mortgages were paid on a weekly or even daily bases, or withheld from each pay check. This might ease the sting of fluctuations in prices, making them less perceptible. If people had to write a check for their taxes every month or every quarter like small business owners do, attitudes about taxes might be different. I wonder if people would be less panicked and thus less inclined to call for rent control if they didn’t have to write a huge rent or mortgage check every month. Right now, broad economic volatility in the housing economy doesn’t feel abstract; it makes people worry and crave things like rent control.

    Volatility in the housing economy is going to continue well into 2023, and depending on the outcome of the election, there will continue to be pressure on policy makers to regulate the ups and downs out of the market. Whether that pressure pushes us further toward more and more government intervention or better policy will depend on whether policy makers can keep their heads and whether they can find better alternatives like less regulation and more efficient subsidies.

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    Roger Valdez, Contributor

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  • Five takeaways from the Georgia Senate debate | CNN Politics

    Five takeaways from the Georgia Senate debate | CNN Politics

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    CNN
     — 

    When Democratic Sen. Raphael Warnock and Republican Herschel Walker met to debate in the already contentious Georgia Senate race, all the focus was on how personal allegations against Walker would roil the first – and likely only – debate in the campaign.

    The allegations that Walker paid for a woman to terminate her pregnancy and then, two years later, encouraged the same woman to have the procedure a second time, however, were just a blip in the hour-long contest, which instead centered on Warnock’s ties to President Joe Biden, the vast differences between the two candidates on abortion and even, however briefly, Walker’s use of what appeared to be a sheriff’s badge.

    Walker continued to deny the allegations about him – calling them “a lie” – and Warnock, as he has on the campaign trail, did not engage on the controversy, instead choosing to question his Republican opponent’s relationship to the truth.

    “We will see time and time again, as we have already seen, that my opponent has a problem with the truth,” Warnock said. “And just because he says something doesn’t mean it’s true.”

    For Walker, the debate was as much about touting his own candidacy as it was about tying Warnock to Biden, who was invoked early and often. His effort, in the closing moments, to assuage fence-sitting voters about his readiness to serve also included a jab at Warnock and Biden.

    “For those of you who are concerned about voting for me, a non-politician, I want you to think about the damage politicians like Joe Biden and Raphael Warnock have done to this country,” Walker said.

    Here are five takeaways from Friday’s debate:

    Biden wasn’t on the stage Friday night, but Walker tried repeatedly to convince viewers that the Democratic President was ostensibly there with his Democratic opponent.

    From the outset of the event, Walker repeatedly invoked Biden, hoping to tie his Democratic opponent to the President’s low approval ratings.

    “This race isn’t about me. It is about what Raphael Warnock and Joe Biden have done to you and your family,” Walker said at the top of the debate.

    Later, when pressed on voter fraud in the 2020 election, he added, “Did President Biden win? President Biden won, and Sen. Warnock won. That’s the reason I decided to run.”

    He then synthesized his point: “I am running because he and Joe Biden are the same.”

    Warnock did little to distance himself from Biden, even at times touting the legislation he passed with the President’s help. But during a question on foreign policy, he took the chance to note a specific time he stood up to the Biden administration.

    “I am glad we are standing up to Putin’s aggression and we have to continue to stand up, which is why I stood up to the Biden administration when it suggested we should close the Savanah Combat Readiness Training Center,” Warnock said. “I told the President that was the exact wrong thing to do at the exact wrong time. … We kept that training center open.”

    Walker went back to his message in response: “He didn’t stand up. He had laid down every time it came around.”

    “It is evident,” said a somewhat exasperated Warnock, “that he has a point that he tried to make time and time again.”

    Headed into the debate, the focus was on how Walker – and arguably less predictably, Warnock – would address the accusations that the Republican candidate allegedly paid for a woman to terminate her pregnancy and then, two years later, encouraged the same woman to have the procedure a second time.

    Walker did what he has done repeatedly as the allegations roiled an already contentious Senate race: Label the allegations a lie.

    “As I said, that is a lie,” Walker said in response to a question from the moderator. “I put it in a book, one thing about my life, I have been very transparent. Not like the senator, he has hid things.”

    Walker added: “I said that is a lie and I am not backing down. And we have Sen. Warnock, people that would do anything and say anything for this seat. But I am not going to back down.”

    CNN has not independently verified the allegations about Walker.

    Warnock, as he has done previously, did not address the allegations, instead choosing to let Walker fight them off without pushing them himself.

    Instead, the senator took a broad approach, focusing on Walker’s “problem with the truth” and less on the specific allegations.

    The candidates also clashed on abortion rights more generally, with Walker insisting he did not support a federal ban, in contrast to past statements, and pointing to the state’s restrictive “heartbeat” law. The law prohibits abortions as soon as early cardiac activity is detectable, which can be as early as six weeks, before many women know they are pregnant.

    “On abortion, I’m a Christian. I believe in life. Georgia is a state that respects life,” Walker said.

    The Georgia law makes exceptions for cases of rape or incest, pending a timely police report, and in some cases where the pregnant person’s health is at risk.

    Before the Supreme Court’s ruling overturning Roe v. Wade, state law had allowed abortions up to 20 weeks.

    Warnock, who supports abortion rights, repeated an argument he’s made on the trail: “A patient’s room is too narrow and small and cramped for a woman, her doctor and the US government. … I trust women more than I trust politicians.”

    Walker then shot back, invoking Warnock’s support for the Black Lives Matter movement against police brutality.

    “He told me Black lives matter… If Black lives matter, why are you not protecting those babies? And instead of aborting those babies, why aren’t you baptizing those babies?,” Walker said.

    Warnock, as he did throughout the debate, didn’t directly answer Walker’s provocation. Instead, he repeated his position.

    “There are enough politicians piling into the rooms of patients,” the senator said, “and I don’t plan to join them.”

    Georgia is one of 12 states not to expand Medicaid and currently has an estimated 1.5 million uninsured residents.

    Walker, when asked by the moderator if the federal government should step in to make sure everyone has access to health care, began a confusing non-response.

    “Well, right now, people have coverage for health care. It’s according to what type of coverage do you want. Because if you have an able-bodied job, you’re going to have health care,” he said. “But everyone else – have health care is the type of health care you’re going to get. And I think that is the problem.”

    Walker continued to say that Warnock wants people to “depend on the government,” while he wants “you to get off the government health care and get on the health care he’s got.”

    To note: Warnock, as a US Senator, is on a government health care plan.

    Walker also gave a puzzling response to Warnock’s attack on his opposition to federal legislation capping the price of insulin for people with diabetes.

    “I believe in reducing insulin, but at the same time, you have to eat right,” Walker said. “Unless you have eating right, insulin is doing you no good. So you have to get food prices down and you got to get gas prices down so they can go and get insulin.”

    Warnock responded by telling viewers who require the drug that Walker was, in effect, blaming them for their struggles accessing it.

    Warnock, on the subject of his pledge to close the Medicaid gap, was asked how he would pay for it.

    “This is not a theoretical issue for me,” he replied, invoking the story of a nurse in a trauma ward who lost coverage when she became sick and, as he put it, died “for lack of health care.”

    “Georgia needs to expand Medicaid,” Warnock continued. “It costs us more not to expand. What we’re doing right now is we’re subsidizing health care in other states” – a reference to the state’s refusal to accept federal funds that residents already pay into.

    The debate within the debate over Warnock’s support for police, in which the senator pointed to his support for legislation that backed smaller departments, was briefly derailed when Walker pulled out what appeared to be a police badge.

    The moderator quickly admonished Walker, reminding him that props were not allowed onstage.

    “You have a prop,” the surprised moderator said. “That is not allowed, sir.”

    Moments earlier, Warnock – in response to Walker’s claims that he has “called (police officers) names” and caused “morale” to plummet – said that his opponent “has a problem with the truth.”

    Warnock then hit Walker with a callback to a more than two-decade-old police report in which the Republican discussed exchanging gunfire with police and a subsequent false claim from Walker that he previously served in law enforcement.

    “One thing that I haven’t done is I haven’t pretended to be a police officer and I’ve never, ever threatened a shootout with police,” he said.

    Warnock also argued that his support for greater scrutiny of police didn’t undermine his support for law enforcement.

    “You can support police officers, as I’ve done, through the COPS program, through the invest-to-protect program, while at the same time, holding police officers, like all professions, accountable,” he said.

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  • Here’s what you can do if you lose Medicaid coverage | CNN Politics

    Here’s what you can do if you lose Medicaid coverage | CNN Politics

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    CNN
     — 

    Though millions of Americans are expected to be kicked off of Medicaid in coming months, they don’t all have to be left uninsured.

    But it could take some work to regain health coverage.

    “For a lot of people, this can be a very disruptive period of time,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “There is a significant time and paperwork burden being placed on families – a lot of them very low income, a lot of them medically vulnerable.”

    States are now free to terminate the Medicaid coverage of residents they deem ineligible. States had been barred from involuntarily removing anyone for the past three years as part of an early congressional Covid-19 pandemic relief package, causing enrollment in Medicaid and the Children’s Health Insurance Program to balloon to more than 92 million people.

    Of the roughly 15 million people who could lose Medicaid coverage over the next 14 months, about 8.2 million would no longer qualify, according to a Department of Health and Human Services analysis released in August.

    Some 2.7 million of these folks would qualify for enhanced federal subsidies for Affordable Care Act policies that could bring their monthly premiums to as low as $0.

    Another 5 million are expected to secure other coverage, mainly through employers.

    Some 6.8 million people, however, will be disenrolled even though they remain eligible for Medicaid.

    Check out Obamacare policies: Folks who lose their Medicaid coverage can shop for health insurance plans on the Affordable Care Act exchanges.

    Those whose annual incomes remain below 150% of the federal poverty level – $20,385 for a single person and $41,625 for a family of four in 2023 – can obtain enhanced federal assistance to lower their premiums to as little as $0 a month. That beefed-up subsidy is in place through 2025.

    Many people with higher incomes can find subsidized policies for $10 or less.

    State Medicaid agencies are tasked with easing residents’ transfer from Medicaid to the Obamacare marketplaces, but the smoothness of the process will vary greatly by state. Once someone is determined to no longer qualify for Medicaid, the agency must assess his or her eligibility for Affordable Care Act coverage and transfer the resident’s information to the exchange.

    Some states that run their own Obamacare exchanges are taking extra steps to ensure their residents remain covered. Rhode Island, for instance, is automatically enrolling certain people in marketplace coverage. It’s also paying the first two months of premiums for some residents who actively select policies.

    Those who lose Medicaid coverage and live in the 33 states covered by the federal marketplace, healthcare.gov, can apply for Affordable Care Act policies through a special enrollment period that runs through July 2024. State-based exchanges have their own deadlines, with some mirroring the federal exchange and others providing much shorter windows.

    Navigators and insurance brokers can help consumers select plans.

    Historically, very few people who lose Medicaid coverage wind up in Obamacare plans. About 4% of adults who were terminated from Medicaid enrolled in exchange policies in 2018, according to the Medicaid and CHIP Payment and Access Commission.

    The coverage differs too. Those that switch to the marketplace may have to find other doctors that are in their insurers’ networks and may face out-of-pocket costs.

    Consider job-based coverage: A number of people who are terminated from Medicaid may already be covered by their employers, particularly those who started new jobs during the pandemic. Others have the option of obtaining coverage through work, though it will almost certainly be more expensive than Medicaid since it will likely entail premiums, deductibles and copays.

    Workers may find they can afford coverage for themselves but not for their families. If the premiums for family policies cost more than 9.12% of household income, spouses and children may be able to get subsidized coverage on the Affordable Care Act exchanges.

    Employees should contact their human resources departments to sign up. Typically, they’ll have to enroll within 60 days of losing Medicaid, but those who are terminated from the program between now and July 10 will have until early September to sign up.

    See if you or your children remain eligible for Medicaid: Millions of Americans who still qualify for Medicaid may lose coverage for procedural reasons. For example, they may have moved so they don’t receive the redetermination notices. Or they may not return the necessary paperwork to prove their eligibility.

    So it’s crucial that folks update their contact information with their state agencies and reply to the letters they receive about renewing their Medicaid eligibility.

    “When you get that packet in the mail, respond to it promptly,” Corlette said.

    Those who are dropped have 90 days to submit their renewal paperwork to their state agency, which is required to reinstate them if they are found eligible. Beyond that time period, people may reapply. In most states, your coverage can be made retroactive for up to three months if you were eligible and received Medicaid-covered services.

    Parents who no longer qualify and are terminated should check if their children remain eligible. As many as 6.7 million kids are at risk of losing Medicaid coverage, according to Georgetown’s Center for Children and Families.

    Nearly three-quarters of the children projected to be dropped will remain eligible for Medicaid or CHIP but will lose coverage mainly because of administrative issues. Black and Latino children and families are more likely to be erroneously terminated, according to the center.

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  • Biden administration moves ahead with Medicare drug price negotiations amid industry lawsuits | CNN Politics

    Biden administration moves ahead with Medicare drug price negotiations amid industry lawsuits | CNN Politics

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    CNN
     — 

    Undeterred by a growing number of lawsuits, the Biden administration on Friday released revised guidance for Medicare’s new drug price negotiation program.

    The latest guidance outlines how the Centers for Medicare and Medicaid Services will negotiate with drugmakers to reach agreement on a maximum fair price for a selected medicine, the agency said. It was informed by public input on the initial guidance the agency released in March, which explained how it will select the drugs and how the negotiations will be conducted.

    The program, which was authorized by the Inflation Reduction Act that congressional Democrats passed last year, has prompted a fierce backlash from the pharmaceutical industry. Two drug manufacturers and two industry groups have filed lawsuits, arguing the measure is unconstitutional.

    But the administration is not backing down from implementing its historic new power. It intends to keep its timeline of announcing the first 10 drugs that will be selected for negotiation by September 1. CMS and the drugmakers will negotiate during 2023 and 2024. The prices will be effective starting in 2026.

    “The Biden-Harris Administration isn’t letting anything get in our way of delivering lower drug costs for Americans,” Secretary of Health and Human Services Xavier Becerra said in a statement. “Pharmaceutical companies have made record profits for decades. Now they’re lining up to block this Administration’s work to negotiate for better drug prices for our families. We won’t be deterred.”

    The initial set of drugs will be chosen from the top 50 Part D drugs that are eligible for negotiation that have the highest total expenditures in Medicare. CMS will consider multiple factors when developing its initial offer, including the drugs’ clinical benefits, the price of alternatives, research and development costs and patent protection, among others.

    If drugmakers don’t comply with the process, they will have to pay an excise tax of up to 95% of the medications’ US sales or pull all their drugs from the Medicare and Medicaid markets. The pharmaceutical industry contends that the true penalty can be as high as 1,900% of sales.

    CMS said it received more than 7,500 comments on its initial guidance from patient groups, drug companies, pharmacies and others.

    The changes it is making are aimed at improving transparency while keeping confidentiality in mind, as well as fostering “an effective negotiation process,” the agency said.

    They include revising the confidentiality process to state that CMS will release information about the negotiations when it publishes the explanations of the prices. Also, drug companies may publicly discuss the negotiations – the prior secrecy requirement had been a point of contention among manufacturers that was mentioned in the lawsuits. And they won’t be required to destroy data relating to the negotiations.

    In addition, CMS will hold patient-focused listening sessions to provide drug companies and the public more opportunities to engage with the agency. The sessions – which will give patients, caregivers and others the chance to share input on how a medication addresses unmet needs, how it impacts specific populations and what therapeutic alternatives exist – will be held in the fall for the first round of drugs.

    Merck, Bristol Myers Squibb, the Pharmaceutical Research and Manufacturers of America, known as PhRMA, and the US Chamber of Commerce have all recently filed lawsuits in federal courts across the US. They each argue the program is unconstitutional in various ways.

    The challengers also say that the negotiation provision will harm innovation and patients’ access to new drugs.

    Among the arguments are that the program violates the Fifth Amendment’s “takings” clause because it allows Medicare to obtain manufacturers’ patented drugs, which are private property, without paying fair market value under the threat of serious penalties.

    Plus, the negotiations process violates the First Amendment, the challengers say, because it coerces manufacturers into saying that they agree to the price that the government has dictated and that it’s fair.

    Another argument is that the process violates the Eighth Amendment by levying an excessive fine if drugmakers refuse to negotiate and continue selling their products to the Medicare market.

    Merck expects its diabetes drug Januvia to be among the drugs named in September and its blockbuster cancer treatment Keytruda and diabetes drug Janumet to be subject to negotiation in the future. Bristol Myers Squibb believes its blood thinning medication, Eliquis, will be subject to negotiations this year, and its cancer medication, Opdivo, will be selected in a subsequent round.

    The changes in the revised guidance did not allay the complaints of the pharmaceutical industry. PhRMA said that transparency remains “severely limited,” patients’ views are not being taken into account and Medicare beneficiaries could have less access to drugs.

    “The very few substantive changes to the final guidance demonstrate CMS saw this as a box checking exercise, not an opportunity to mitigate the negative impacts this price setting policy will have on patients or the broader health care sector,” PhRMA said in a statement.

    “The approach CMS took in this final guidance confirms what we claimed in our lawsuit – Congress’ unconstitutional shortcuts taken in the law have given the administration far too much flexibility to set prices at their whim without any oversight or accountability to anyone,” the group continued.

    The Biden administration will “vigorously defend” the drug price negotiation program, said CMS Administrator Chiquita Brooks-LaSure.

    “We feel the law is on our side,” she said in a call with reporters Friday.

    This story has been updated with additional information.

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  • These 5 states will be the first to kick residents off Medicaid starting in April | CNN Politics

    These 5 states will be the first to kick residents off Medicaid starting in April | CNN Politics

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    CNN
     — 

    Millions of Americans are at risk of losing their Medicaid coverage in coming months, but residents in Arizona, Arkansas, Idaho, New Hampshire and South Dakota will be the first to bear the brunt of the terminations.

    States have been barred by Congress from winnowing their Medicaid rolls since the Covid-19 pandemic began. That prohibition ends on Saturday, and some states are moving much more swiftly than others to kick off those deemed ineligible for the public health insurance program for low-income Americans.

    That worries advocates, who say speed will result in eligible residents being incorrectly terminated. Also, it could hamper shifting those who no longer qualify to other types of coverage.

    “This is the fable of the tortoise and the hare,” said Joan Alker, executive director of the Georgetown University Center for Children and Families. “Taking time is absolutely going to result in a better outcome for eligible children and families to remain covered. So speed is a big concern.”

    The five states will start cutting off coverage in April, followed by 14 more states in May and 20 additional states plus the District of Columbia in June. All states must complete their redeterminations over the next 14 months.

    Around 15 million people could be dropped from Medicaid, according to various estimates, though several million folks could find coverage elsewhere. Others may still be eligible but could be terminated for procedural reasons, such as not completing renewal forms. Those at risk include at least 6.7 million children, according to a Georgetown analysis.

    Medicaid enrollment has ballooned since March 2020, when lawmakers passed the Families First Coronavirus Response Act, which prevented states from involuntarily removing anyone from coverage. In exchange, Congress boosted states’ federal Medicaid match rates by 6.2 percentage points.

    The provision was initially tied to the national public health emergency, but lawmakers changed that as part of the federal spending bill that passed in December. In addition to being able to start conducting terminations in April, states will receive an enhanced federal match through the rest of this year, though it will phase down over time.

    More than 92 million Americans were enrolled in Medicaid and the Children’s Health Insurance Program in December, up 31% since February 2020, according to the most recent data available from the Centers for Medicare and Medicaid Services.

    Reviewing the eligibility of all those enrollees will be a monumental task for state Medicaid agencies, many of which are also contending with slim staffing. To gear up, they are hiring new employees, temporary workers or contractors or bringing back retirees, according to a recent survey conducted by Georgetown and the Kaiser Family Foundation.

    Most states can automatically renew coverage for at least some of their enrollees using other data, such as state wage information. But agencies must get in touch with others in their Medicaid programs, which proved challenging even prior to the pandemic. Most states are using multiple methods to update enrollees’ contact information, including working with insurers that provide Medicaid coverage to residents.

    If notices sent by mail are returned, states must make good faith attempts to contact enrollees through at least two other methods before cutting them off. And states have to adhere to additional requirements to continue to qualify for the enhanced match. If they don’t, CMS also could suspend their terminations, require they take corrective action or impose monetary penalties.

    Of the roughly 15 million people who could lose Medicaid coverage, about 8.2 million will no longer qualify, according to a Department of Health and Human Services analysis released in August. Some 2.7 million of these folks would qualify for enhanced federal subsidies for Affordable Care Act policies that could bring their monthly premiums to as low as $0.

    Some 6.8 million people, however, will be disenrolled even though they remain eligible.

    Though the federal government has given states more than a year to conduct the eligibility reviews and terminations, some plan to move much more quickly.

    Idaho, which has been monitoring enrollees’ eligibility throughout the pandemic, plans to complete its reevaluations by September, which it touts as one of the fastest timelines in the country.

    Of the nearly 450,000 Idahoans in the program, about 150,000 of them either don’t qualify or haven’t been in touch with the state in the past three years. The state began sending notices in February to those who face termination. People have 60 days to respond before they are removed.

    Those that are not eligible have 60 days from their termination date to enroll in Idaho’s state-based Obamacare exchange, Your Health Idaho. The exchange receives information nightly from the state Medicaid agency about residents who no longer qualify for public coverage but may be eligible for federal subsidies for Affordable Care Act policies.

    The exchange is reaching out to those folks weekly while they still have Medicaid and then every 15 days during the two-month special enrollment period via various methods, including mail, email and text messages, said Pat Kelly, Your Health Idaho’s executive director.

    The exchange works with 900 agents, brokers and enrollment counselors who can help folks sign up for policies. And it plans to start an advertising campaign this month highlighting the hefty subsidies.

    “We have to really help Idahoans know and understand that low-cost options are available, and most importantly, that it’s comprehensive health insurance that they can get for $0 a month,” Kelly said.

    Still, advocates in Idaho are concerned that the state’s push to unwind quickly will result in eligible residents losing coverage.

    Many people are not aware that they once again need to prove that they qualify, and the state agency is understaffed and underfunded, said Hillarie Hagen, health policy associate at Idaho Voices for Children. Renewal letters may not make it to enrollees, and those who need help may not be able to get through to customer service.

    “We are very concerned about families, and particularly children, losing health coverage without their knowledge – that they will find out when they show up to the doctor,” Hagen said.

    Aware that many people don’t know they’ll have to renew their eligibility, Arizona’s Medicaid agency last summer sent text messages and letters and made robocalls to enrollees, asking them to update their contact information. It is also working with community partners, health care providers, pharmacies and insurers. And it’s ramping up another text campaign since the prior one was so successful, said Heidi Capriotti, public information officer for the Arizona Health Care Cost Containment System.

    While the state can automatically redetermine the eligibility of about 75% of its Medicaid participants, it still has to connect with about 670,000 residents who could lose coverage because they are no longer eligible or they haven’t responded to the agency’s requests. The state plans to take 12 months to assess whether its enrollees still qualify.

    South Dakota will start terminating Medicaid enrollees in April, though some low-income adults may become eligible again in July, when the state’s Medicaid expansion program begins.

    Voters approved the broadening of Medicaid to low-income adults at the ballot box in November, over the objections of the Republican governor and legislature.

    Nearly 152,000 residents were enrolled in Medicaid in January, an increase of more than 30% from March 2020, according to the state’s Department of Social Services. But more than 22,000 people appear to be ineligible currently.

    The agency said in an FAQ that it will prioritize reviewing folks who are most likely to be ineligible because they no longer meet a coverage group or their income has increased, among other reasons.

    Those who are not eligible will be disenrolled with 10-days’ notice. If they appear eligible for expansion in July, they’ll receive a notice about it when they are terminated and sent a reminder in June. The agency is encouraging any enrollees who are determined to be ineligible to reapply after Medicaid expansion takes effect.

    But that three-month gap can wreak havoc on low-income residents’ health, said Jen Dreiske, deputy director of South Dakota Voices for Peace, which is working with the state’s immigrants and refugees to inform them of the unwinding. These folks may have to go without their heart medication or their cancer treatment. They may also be afraid to go to the doctor because of the cost.

    “Why can’t we just wait until July 1?” Dreiske said. “Our concern is that people are going to get sick or die because they’re not going to be able to access the health care that they so desperately need.”

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  • Mako Medical Laboratories Launches New Mobile App Aimed at Lowering Pharmacy Cost

    Mako Medical Laboratories Launches New Mobile App Aimed at Lowering Pharmacy Cost

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    Mako Medical is releasing a new mobile app that will help patients know exactly what the true cost of medications is

    Press Release
    –


    updated: Feb 12, 2020


    DALLAS, February 12, 2020 (Newswire.com)
    –
    A new pharmacy program called MakoRx was launched by Mako Medical Laboratories in an effort to tackle one of the biggest challenges Americans are facing —  prescription cost. MakoRx will be led by Dr. Vinay Patel, who has spent his career building new pharmacy models. 

    Extensive research from self-funded employers, independent providers, wholesalers, and independent pharmacies has provided the basis for this new disruptive model being launched by Mako Medical Laboratories.  “Every one of us has a family member or knows someone that is struggling with the cost of medication. The problem is — no one knows why they cost so much,” says Chad Price, President of Mako Medical. “You can find the cost of a car, house, or book a cruise online but we still have no idea what prescriptions cost or where the best place to buy them is.”

    MakoRx’s tech team has developed a proprietary mobile app that will allow users to search a drug, see the cost of medication, and know exactly where to go to get it. To address rural markets and access issues, delivery is available and partnerships with independent pharmacies will be leveraged. 

    Mako Medical Laboratories said that the MakoRx platform will provide a new pricing model using a “cost-plus” basis so that families know the true cost — not the inflated retail amount often published on other sites. The MakoRx platform will allow patients to get the same price from all locations, unlike the other online options that list different prices at different pharmacies. 

    MakoRx will also offer a loyalty card that can be used by families that have insurance and prescription coverage but struggle with high deductibles and out-of-pocket costs. The loyalty card could also be used by those with no health benefits. The goal is to drastically lower costs for every family in America and to simplify the process. Self-funded employer plans have also been struggling to lower pharmacy costs and control spend. 

    Mako Medical said that the MakoRx app is set to be released at the end of the first quarter and will be the tool people need to understand exactly what the cost of these medications is. 

    Mako Medical is known for its extensive community service and for hiring military veterans and supporting Christian missionaries. Mako Medical has won numerous awards for innovation and quality.  

    CONTACT: Vpatel@makomedical.com

    Source: Mako Medical Laboratories

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  • TSBS Announces New Executive Leadership Team With Focus on Driving Innovation and Client Satisfaction

    TSBS Announces New Executive Leadership Team With Focus on Driving Innovation and Client Satisfaction

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    Press Release
    –


    updated: Jul 16, 2019


    KYLE, Texas, July 16, 2019 (Newswire.com)
    –
    TSBS, a leader in consultative and billing services within the school health and related services program (SHARS), has announced several enhancements to the company’s senior management team. 

    Appointed as President is Robert Ewen, who most recently served as VP of Finance and Human Resources.  With over 15 years working within the Medicaid program through public, private and volunteer-based organizations, Robbie has been a critical driver of TSBS’ push to radically improve its client-based services. Key innovations to its client-facing technology have created a far better user experience for school practitioners and administrators. “I’m proud to lead TSBS into its third decade by creating even stronger bonds with our clients and continuing to break new ground on positive experiences, cutting-edge technology and unmatched customer service.”

    Amber Paige, a longtime TSBS team member, has been elevated to VP of Operations and Client Relations.  Amber has been a pillar of strength and stability within TSBS for over 11 years, most recently serving as Performance Manager and Program Director. Amber’s stellar mentoring skills, drive for advanced operational management and appetite for personal and professional growth place her in the ideal position to help strengthen TSBS’ standing as an industry leader. “I’m honored to be part of an organization that places so much emphasis on integrity, client relationships and innovation,” says Amber. “We are embarking on an exciting new era at TSBS and I am excited to work with this team to generate new and creative solutions that benefit our clients.”

    Joining TSBS as VP of Business Development and Collaborative Strategy is Kandi Schmidt. With Kandi comes over 25 years of experience with organizational structure, change management, consulting and business development. “I am proud to work for a company that began in Texas and was built on integrity back when a handshake meant something,” states Kandi. “Those values ring true today with everything we do, and it is truly inspiring.  Joining such an exceptional team of talented people is both humbling and exciting!”

    “These enhancements to our organization reflect TSBS’ vigorous commitment to the development of forward-thinking, innovative solutions, enhanced compliance and excellent client services that address key pain points for Special Education Programs in Texas,” adds Robbie Ewen. 

    About TSBS:

    TSBS was founded in 1998 in Austin, Texas to provide SHARS services specifically to Texas school districts.  Since then, it has become an industry leader providing a full-service billing and consultative SHARS package to maximize Medicaid reimbursements while minimizing the workload for school districts and ensuring the highest levels of compliance with federal and state regulations. For additional information, visit www.tsbs.cc.

    Media Contact: 
    Mariah Herrera
    ​Phone: 877.897.8283
    Email: mariah@tsbs.cc

    Source: Texas State Billing Services, Inc.

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  • Behavioral Health Center of Excellence Awarded Contract With Utah Medicaid for Applied Behavior Analysis Coverage Policy Evaluation

    Behavioral Health Center of Excellence Awarded Contract With Utah Medicaid for Applied Behavior Analysis Coverage Policy Evaluation

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    Press Release
    –


    updated: Nov 14, 2018


    SALT LAKE CITY, November 13, 2018 (Newswire.com)
    –
     The Behavior Health Center of Excellence (BHCOE) was recently awarded a contract with Utah Medicaid to conduct an independent evaluation of Utah’s autism-related services coverage policy and implementation, and assist with identifying quality care providers in the state.

    The Behavior Health Center of Excellence is the only accrediting body specific to Applied Behavior Analysis, or ABA therapy, and has set a national standard for quality care. To assure the proper administration of the autism spectrum disorder (ASD)-related services program and the quality of services provided to Medicaid members, BHCOE will provide an independent evaluation of coverage policies and implementation practices.

    BHCOE looks forward to working collaboratively with the state and the ABA service providers in the region to identify areas in which Utah Medicaid can better serve the autism population.

    In addition to the general evaluation of current policy and practices, BHCOE will assist Utah Medicaid in defining the quality of services and provider qualifications beyond individual providers of ABA services and recommend standards for the companies who are responsible to hire, train, and supervise multiple individuals who provide ABA services.

    Utah Medicaid began covering ABA therapy as a benefit under the Early Periodic Screening Diagnosis and Testing (EPSDT) program on July 1, 2015. Because Medicaid coverage of ASD–related services was a newly emerging policy, Utah employed research and analysis to develop coverage policy for these services. Now that coverage has been in place for nearly three years, Utah Medicaid contracted with BHCOE to conduct an independent evaluation of its coverage policy and implementation. 

    “We are thrilled that this partnership will help to enhance the quality of care for families receiving services through Utah Medicaid,” said Sara Gershfeld Litvak, CEO of Behavioral Health Center of Excellence. “BHCOE looks forward to working collaboratively with the state and the ABA service providers in the region to identify areas in which Utah Medicaid can better serve the autism population.”

    The rising prevalence of autism, as well as increased insurance coverage for applied behavior analysis, or ABA therapy, is driving increased interest in autism services. Although autism advocates welcome an expansion of services, they also caution that unchecked growth could cause lapses in training or oversight. The Center of Excellence process is the first attempt at standardizing the quality of care for ABA therapy and has been widely adopted by therapy providers and payers across the United States.

    For additional information about the project, please visit the BHCOE website (www.bhcoe.org).

    Source: Behavioral Health Center of Excellence

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  • Senior Planning Services Partners With Ocrolus to Improve Medicaid Application Processing

    Senior Planning Services Partners With Ocrolus to Improve Medicaid Application Processing

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    Press Release
    –


    updated: May 31, 2017


    New York, NY, May 31, 2017 (Newswire.com)
    –
     Ocrolus, the emerging leader in bank statement review automation, today announced its partnership with Senior Planning Services, a nationally recognized Medicaid application processor. The partnership will enable Senior Planning Services (SPS) to more efficiently conduct bank statement reviews for large nursing home chain clients and others. Medicaid-Genius, a software product powered by Ocrolus, will now be an embedded part of the SPS workflow.  

    The Medicaid application process can be daunting for families who have loved ones in need of long-term care. Senior Planning Services streamlines and simplifies this process from A-Z, offering a turnkey solution to healthcare facilities, elder law attorneys and families. The eligibility process includes a federally mandated “five-year lookback” in which hundreds or thousands of pages of bank statements must be reviewed for each applicant. With Ocrolus providing 99+% accurate, automated bank statement analysis, SPS will be able to scale more efficiently.

    “Senior Planning Services is a pioneer in the Medicaid world, providing a one-stop shop for anyone who wishes to have their Medicaid applications completed professionally and quickly at an affordable rate,” said Victoria Meakin, President and Co-founder of Ocrolus. “We are excited to accelerate the application process for SPS, which will in turn enable families in need to be awarded healthcare benefits sooner.”

    The partnership with Senior Planning Services is another step forward for Ocrolus in the Medicaid space, as Medicaid-Genius has already been employed by elder law attorneys and government entities who process applications. In tandem with SPS, Ocrolus will now help nursing homes streamline Medicaid reimbursement cycles through automation.

    “Ocrolus technology will help us scale to new heights,” said Ben Mandelbaum, COO and Managing Partner of Senior Planning Services. “With Ocrolus automating the most laborious part of the financial review process, our team will be able to complete more applications than ever before.”

    About Ocrolus

    Ocrolus is a technology company that automates the review of bank statements. The Company’s products, PerfectAudit and Medicaid-Genius, analyze statements from every financial institution with 99+% accuracy, generating account information, summary analytics and a comprehensive database of transactions. By replacing the tedious and error-prone manual process of analyzing bank statements with hyper-accurate automation, Ocrolus boosts efficiency for professionals in a number of industries.

    Additional information about Ocrolus is available at www.ocrolus.com.

    About SPS

    Senior Planning Services is the leading Medicaid application company in the health care industry. Planning and applying for Medicaid is a grueling task and applicants are often unaware of the pitfalls that lay ahead. SPS has successfully guided thousands of individuals through the complex Medicaid process, earning a stellar reputation throughout the long-term care community.

    Additional information about SPS is available at www.senior-planning.com.

    Ocrolus Contacts:

    Sam Bobley
    CEO
    sbobley@ocrolus.com
    o: 646.850.9090 Ext. 1
    c: 516.233.4293

    Victoria Meakin
    President
    vmeakin@ocrolus.com
    o: 646.850.9090 Ext. 2
    c: 917.941.5388

    Source: Ocrolus

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  • New Partnership and Grant Helps Caregivers With Resources, Coverage, and Support Throughout NYC

    New Partnership and Grant Helps Caregivers With Resources, Coverage, and Support Throughout NYC

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    Medicaid Advisory Group has partnered with PSS Circle of Care, a New York-based nonprofit that will provide free resources, training, assistance, and guidance to caregivers who need it most.

    Press Release
    –

    Jun 22, 2016


    New York, NY, June 22, 2016 (Newswire.com)
    –
    Medicaid Advisory Group has announced a formal partnership with the New York nonprofit, PSS Circle of Care, that will provide free resources, training and assistance to caregivers who need it most.

    PSS Circle of Care was recently awarded $7.5 million as part of New York Governor Andrew Cuomo’s Alzheimer’s Caregiver Support Initiative. The award will bring training, online resources, support groups, assistance and information to caregivers who are struggling to take care of aging loved ones.

    “Caregivers frequently tell us they are tired, exhausted, stressed and sometimes just need a little time for themselves. This partnership will help these caregivers a support network to help them through this difficult time.”

    Ginalisa Monterroso, CEO, Medicaid Advisory Group

    Every year, thousands of eligible Medicaid recipients struggle financially, even though many of these patients qualify for free healthcare assistance. In surveys, most caregivers say they are unaware of the application and eligibility process to Medicaid, while others say the application process is complex, confusing and stressful. Most caregivers don’t have the time, energy nor the healthcare expertise to research whether or not their aging parents, grandparents or disabled family members are eligible for Medicaid.

    This new partnership between Medicaid Advisory Group and PPS Circle of Care brings together a network of personal caregivers across all five boroughs, providing other caregivers with an easy way to access free caregiving resources through PSS and obtain Medicaid consultation services.

    Medicaid Advisory Group guides and represents seniors during the complex, stressful Medicaid application process, without expensive legal costs. PSS Circle of Care offers free training, online resources, support groups, assistance, and information to the caregivers who need it most.

    “Caregivers frequently tell us they are tired, exhausted, stressed and sometimes just need a little time for themselves. This partnership will help these caregivers a support network to help them through this difficult time,” said Ginalisa Monterrosa, the CEO of Medicaid Advisor Group. “It will also provide these caregivers with new resources, so they won’t spend hours of their own time searching for answers.”

    ABOUT MEDICAID ADVISORY GROUP

    Ginalisa Monterroso has more than 25 years in the healthcare industry. As the founder of Medicaid Advisory Group, she and her team of social workers help navigate the complicated healthcare system. Medicaid Advisory Group provides patients and caregivers with easy access to Medicaid assistance and coverage, saving them time, money, and stress during the most critical time of their lives.

    ABOUT CIRCLE OF CARE

    In New York City alone, nearly half a million caregivers look after their parents every day. Circle of Care offers the resources and experience caregivers and patients need. It also provides access to private and public meeting spaces for local caregivers and their patients. Circle of Care was recently awarded $7.5 million as part of New York Governor Andrew Cuomo’s Alzheimer’s Caregiver Support Initiative, allowing them to further connect and support New Yorkers.

    For more information, you can contact:
    (646) 745-9122
    ​info@medicaidadvisorygroup.com

    Source: Medicaid Advisory Group

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