Category: From California Healthline.org

Julie Rovner, chief Washington correspondent for KHN, participated in a discussion on KQED’s “Forum” about the arguments before the Supreme Court on Tuesday in a case that is challenging whether the Affordable Care Act is constitutional. You can hear the conversation and listeners’ questions here.

Can’t see the audio player? Click here to listen.

Family physician Maxwell Self is doing his same old job for a new employer. For two decades he was a doctor with Mercy Hospital. But when Mercy packed up and left, a federally qualified health center moved to town — into the hospital building itself — and hired Dr. Self.

The Community Health Center of Southeast Kansas does things differently.

“What CHC says really has teeth and they’re solid,” Self said. “There’s real follow-through. And I have a lot more, I feel like, freedom to take care of people the way I want to and to get them what they need.”

With nutrition counseling and mental health and addiction services, and even things like arranging rides for patients, the center offers people what they need to be healthy, clinic executives said — not only health care for when they’re sick.

In the final chapter of the podcast, we also meet Sherise Beckham, 31, who lost work as a dietitian at Mercy when the hospital closed — just as she was expecting her second child.

“Initially, I cried a lot because I would be losing my job as well as losing a place to have my baby,” Beckham said.

Beckham helps explain how much more difficult it can be to have a baby when a town loses full-service maternity care. Then, later when she gets a job at — where else? — the new CHC clinic, Beckham gives us a front-row seat to the new vision for health care in Fort Scott.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

SACRAMENTO — Of any state, California has the most to lose if the U.S. Supreme Court overturns the Affordable Care Act.

Health care coverage for millions of people is at stake, as are billions in federal dollars. Yet Democratic California leaders don’t have a plan to preserve the broad range of health care programs the state has adopted since it aggressively implemented Obamacare — including initiatives that go far beyond the federal health care law.

“We have made great strides and we don’t want to go back,” said Katie Heidorn, executive director of the nonprofit Insure the Uninsured Project. “This is real and we have to get our ducks in a row.”

The Supreme Court hears arguments Tuesday in the case, now known as California v. Texas. Texas and 18 Republican attorneys general, with backing from President Donald Trump and his administration, argue that Obamacare is unconstitutional because the law cannot stand without the tax penalty that accompanies the individual mandate, which is the requirement to have health coverage. The Republican-controlled Congress zeroed out the mandate’s tax penalty as part of the 2017 tax bill, which the Republican attorneys general say rendered both the mandate and the rest of the law unconstitutional.

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California Attorney General Xavier Becerra is leading the defense and says the law can stand without the mandate.

Legal experts predict the court is unlikely to rule until spring 2021, at the earliest. It could strike down the law entirely or keep parts of it, such as the ability for states to expand Medicaid to more adults, which has brought health insurance to roughly 12 million Americans. Or, the justices could preserve the law as is.

Even as legal experts say the addition of three Trump-nominated justices to the Supreme Court since the last time it weighed in on the law amounts to a legal wild card, Becerra is optimistic.

“We feel pretty confident that, as in the past, when the justices look to the fundamentals of the Affordable Care Act, they’re going to find that it is constitutional,” Becerra told California Healthline. “It would be near impossible right now to keep a state’s head above water without the Affordable Care Act.”

Democratic Gov. Gavin Newsom’s administration agreed the situation would be “catastrophic” for California if the law, or core parts of it, are overturned.

The state enthusiastically embraced Obamacare, and it gets more money than any other state under the law. It expanded its Medicaid program, called Medi-Cal, adding nearly 4 million enrollees as of June. It was the first to create a health insurance exchange, Covered California, which offers tax credits to help qualified Californians pay for coverage. Currently, about 1.5 million people are enrolled.

Since 2014, when the major provisions of the law took effect, California has cut its uninsured rate to historic lows — down to about 7% from 17% — and health insurance premiums for those buying coverage on the individual market are rising slower than before. The statewide average premiums for Covered California plans in 2020 and 2021 have increased less than 1%.

But if the court finds the law unconstitutional, about 5 million residents could lose health coverage, and the state stands to lose an estimated $27 billion in federal funds annually.

Of that, Medi-Cal would lose $20 billion and Covered California would lose nearly $7 billion, according to the state Department of Finance. Public health agencies, which also receive federal Obamacare funding, would also take a nearly $50 million hit.

California also offers much more than Obamacare provides, such as state subsidies to help low-income and middle-class families pay for their Covered California plans. It also covers full Medicaid benefits for unauthorized immigrants up to age 26. And as the Trump administration cut funding for outreach and enrollment, Covered California has continued to plow more money — $157 million this year — into such efforts.

Should Obamacare be struck down during a deepening financial and public health crisis, Newsom administration officials and lawmakers say California could not afford to continue its Medicaid expansion on its own. Millions of other low-income residents on Medi-Cal could face cuts to their benefits and insurance markets could be destabilized, sending insurance premiums soaring, state lawmakers warn.

And Covered California would be in peril, said Covered California Executive Director Peter Lee.

Lee told lawmakers in October that coming up with a replacement strategy would be a waste of time because the state couldn’t make up for such a monumental loss in funding.

“Talking about contingency plans is like talking about adding a few lifeboats to the Titanic,” he said. “We are not spending time on contingency plans, I’ll be really frank about that.”

Instead, Democratic lawmakers say they’d be forced to make painful health care cuts because, unlike the federal government, states can’t operate with budget deficits. And legislative leaders say they wouldn’t be able to finance the far more ambitious health care agenda they are eyeing under a Joe Biden-Kamala Harris administration.

“Peter Lee is right. I don’t know how we’d pivot and replace resources that should be coming to us from the federal government, because we’re in a budget crisis brought on by the pandemic,” Senate President Pro Tem Toni Atkins told California Healthline.

“We’ve gone from a $26 billion budget reserve and surplus in March to a $54 billion deficit, so this would put us in an impossible situation to continue to move forward creating more access from a health care perspective,” Atkins said.

Powerful lawmakers who lead the health committees in the state Senate and Assembly said they fear California would have to rescind programs approved just last year, including the state subsidies for low- and middle-income Californians.

To date, roughly 40,000 low- and middle-income people have benefited from those subsidies, expected to cost $240 million this year, according to Covered California.

Most likely, lawmakers said, the state would no longer be able to afford its 2019 expansion of Medi-Cal to unauthorized immigrants between ages 19 and 25, which is expected to cost roughly $100 million per year. About 75,000 unauthorized immigrants in that age group signed up for the program this year, according to the Department of Health Care Services.

California has codified other parts of Obamacare into state law that don’t require major state spending. These laws would preserve protections for some Californians should the federal law be invalidated.

For instance, state-regulated plans must cover dependents up to age 26, and this year Newsom approved laws prohibiting them from imposing annual or lifetime coverage limits. Also, state-regulated insurers are required to cover preventive care such as mammograms and vaccines.

But millions of Californians in plans regulated by the federal government would lose those protections.

“We’ve passed some bills that do a little patchwork, but it’s a fraction of what’s needed,” said state Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee. “People with preexisting conditions are going to be in big trouble.”

Because the Supreme Court likely won’t issue its ruling for months, Newsom administration officials and lawmakers said they have time to come up with a plan should Obamacare be deemed unconstitutional. If necessary, they could call a special legislative session and Democratic lawmakers, with a supermajority in the legislature, could enact emergency legislation.

Dr. Robert Ross is a member of the Healthy California for All Commission, which is studying the feasibility of enacting a state-based single-payer system. He said the commission, with deep health policy expertise, also could be well poised to respond.

“All the lofty aspirations to do something that transformative turn to dust if the Affordable Care Act is blown up,” said Ross, president of the California Endowment, a foundation that focuses on expanding health care access among Californians. “We’d be having an entirely different, sobering conversation, and I’d hope our commission could put ideas in front of the governor for consideration.”

Samantha Young of California Healthline contributed to this report.

In Ethiopia, health clinics for teenagers once supported by U.S. foreign aid closed down. In Kenya, a decades-long effort to integrate HIV testing and family planning unraveled. And in Nepal, intrepid government workers who once traversed the Himalayas to spread information about reproductive health were halted.

Around the world, countries that depend on U.S. foreign aid have scrapped or scaled back ambitious public health projects, refashioning their health systems over the past four years to comport with President Donald Trump’s sweeping anti-abortion restrictions that went further than any Republican president before him.

The effects have been profound: As groups scrambled to meet the administration’s strict ideologically driven rules, they severed ties with health care providers that discuss abortion in any way, deleted references to abortion on websites and in sexual education curricula, and stopped discussing modern contraception for fear of forfeiting vital American aid.

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President-elect Joe Biden has pledged to reverse the policy when he takes office, and he campaigned on a promise to enshrine abortion rights in federal law. But for many foreign aid groups, the changes may be permanent.

“The U.S. has lost its position as a leader and lost its credibility,” said Terry McGovern, of Columbia University’s Mailman School of Public Health who has overseen research of the Trump policy in multiple countries.

Since Ronald Reagan, Republican presidents have barred foreign aid organizations from using U.S. global health funds to counsel women about abortion or refer them to a safe abortion provider. But the Trump administration vastly expanded those anti-abortion restrictions, known as “the global gag rule” by opponents. Under Trump, the rule applies to some $9 billion of aid touching nearly every facet of global health funding, including groups working on HIV, malaria, tuberculosis and water sanitation. Under President George W. Bush, the policy applied to a fraction of that, $600 million in foreign aid.

The Trump administration proudly touted these efforts to protect “the unborn abroad,” but the rules have left international aid groups deeply skeptical of U.S. promises and deepened the nation’s rift with European countries that have long viewed abortion access as vital to women’s health and safety.

Some major organizations opted out of any U.S. funding rather than comply with the new strictures, including Marie Stopes International and International Planned Parenthood Federation, among the largest providers of reproductive health care in the developing world. Untold numbers of front-line health care workers — in large cities and remote villages alike — have been confused by what seem like sudden swings in American policy.

And that trepidation may not be quick to dissipate even with a Democrat in the White House.

“Biden and Trump may seem radically different to Americans,” said Jennifer Sherwood, a policy manager at Amfar, the Foundation for AIDS Research. “But if you’re a small organization in sub-Saharan Africa, you may not understand what this new [Biden] administration means and if you can trust the United States.”

The restrictions intentionally constrict the activities of foreign aid groups, many of which have worked in close coordination with American counterparts for decades. The rules also have a ripple effect on their funding: U.S. funding to foreign groups is contingent on their not accepting money from other countries, or even private foundations, to underwrite abortion-related services. They are not allowed to subcontract with other organizations that run separate abortion-related projects.

Trump telegraphed the worldwide anti-abortion gains in appeals to evangelical Christians. In early October, Secretary of State Mike Pompeo touted the policy during a speech to the Florida Family Policy Council, a conservative anti-abortion group, calling it an “unprecedented defense of the unborn abroad.”

“Our administration has drawn on our first principles to defend life in our foreign policy like no administration in all of history,” said Pompeo, who is an evangelical Christian.

The hard-right policies of the Trump administration stand in stark contrast to the steady liberalization of abortion laws in countries around the world over the past two decades. Since 2000, more than two dozen countries have eased abortion laws, including Ireland, South Korea, the Democratic Republic of Congo and Ethiopia.

Even in countries where abortion is forbidden, the rules are having an impact on reproductive health care. In Madagascar, where abortion is illegal with no exceptions, the largest provider of contraception, Marie Stopes, turned down U.S. money, endangering its ability to offer unfettered medical care to women, ending support for nearly 200 public and private facilities.

Mamy Jean Jacques Razafimahatratra, a researcher at the Institut National de Santé Publique et Communautaire in Antananarivo, found that led to shortages of contraception, in a poor country where travel to nearby towns is difficult.

“The women asked us, ‘What is the cause of this rupture?’” said Razafimahatratra. “We tried to explain to them the reason, and [they say], ‘But that regulation is for abortion, so we don’t understand why we are also penalized?’”

Researchers at Amfar and Johns Hopkins, in a study published in Health Affairs, found the anti-abortion policies could have deadly consequences, specifically in preventing the spread of HIV/AIDS. Sherwood said young African women face the highest risk of HIV and many clinics had combined HIV testing and treatment with family planning services.

But, fearing they would run afoul of the Trump policy and thus forfeit funding, clinics have curtailed family planning for patients, reducing the number of women seeking care in African countries.

“A lot of the times, they want contraception,” said Sherwood. “That is what’s on their mind, and HIV is the secondary thing, something we can tack on to meet their needs all at once.”

Jennifer Kates, director of global health and HIV policy at KFF said, “I have no doubt some groups are going to say, ‘We are not going to play there anymore.’” (KHN is an editorially independent program of KFF.)

The practical challenges of restarting these programs are steep: rehiring staff, reopening clinics, retraining employees, rewriting curricula.

“You can imagine being a health care worker that was under threat of losing their funding for counseling a patient on abortion,” Sherwood said. “To us, it’s like a light switch that can turn off and on, but to them, this is a very opaque and confusing process. It’s not how health systems work. You can’t just change the way they work overnight.”

SACRAMENTO — When the U.S. Supreme Court hears a case Tuesday that could decide the fate of the Affordable Care Act, California will be leading the defense to uphold the federal law that touches nearly every aspect of the country’s health care system.

It’s usually the federal government’s job to defend a federal law, but President Donald Trump’s administration wants this law, also known as Obamacare, to be overturned.

So California Attorney General Xavier Becerra, backed by more than 20 other states, is defending the law against the challenge brought by a coalition of Republican state officials two years ago.

Becerra has been one of Trump’s most formidable adversaries, taking the administration to court scores of times over its policies, ranging from immigration and birth control to climate change. He is considered one of the leading contenders to fill the Senate vacancy that will open now that Sen. Kamala Harris of California has been elected vice president.

“Just as vigorously as a president and his administration are fighting to destroy the Affordable Care Act, we are fighting to save it for every American,” Becerra told reporters in a press conference Monday.

Should the court overturn the entire law, the impact would be felt widely. The law provides health insurance to more than 23 million Americans. It allows qualified people to buy subsidized insurance through federal or state insurance exchanges; permits states to expand their Medicaid programs to more people; prevents insurance companies from denying coverage to people with preexisting medical conditions; bans lifetime limits on coverage; adds benefits to Medicare; and allows children to stay on their parents’ plans up to age 26.

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At issue in California v. Texas is the federal tax penalty for not having health insurance, as the law requires. The Republican-led Congress in 2017 zeroed out the penalty but kept the rest of the health law intact, a move Becerra and some other legal experts say shows congressional intent to support the law. The Republican state officials, however, say the loss of the tax invalidates the mandate to have insurance — as well as the entire law.

Becerra said it’s possible the court may determine that the challengers don’t have standing to sue the government because no one has been harmed by a zero-tax penalty.

Although the court has twice upheld the federal health care law, the composition of the court has changed since its last ACA ruling in 2015. Trump has appointed three conservative judges since then. Two replaced other conservatives, but Amy Coney Barrett, who was confirmed in late October, took the seat of a liberal icon, Justice Ruth Bader Ginsburg.

Abbe Gluck, faculty director of the Solomon Center for Health Law and Policy at Yale Law School, said that if the court believes the health insurance requirement is unconstitutional without the penalty, it should just hold that section of the law invalid but not overturn the entire law.

But “I have learned that you can never predict what happens in court when it comes to the Affordable Care Act,” Gluck said. “And that is why there is this heightened sense of concern, because the statute has become so fundamentally important to one-fifth of our economy and the health care of virtually all Americans.”

Becerra talked to California Healthline’s Samantha Young about his defense of Obamacare and the far-reaching influence of the law. The interview has been edited for length and clarity.

Q: What are the chances the Supreme Court could overturn the Affordable Care Act?

We’re confident they will see not just the legal logic behind it, but the wisdom and the practical success of the Affordable Care Act — all of which weigh heavily in favor of the justices recognizing that it’s not only legal but indispensable. When the justices look to the fundamentals of the Affordable Care Act, they’re going to find that it is constitutional.

Q: The makeup of the U.S. Supreme Court has changed since it last ruled on the ACA. Why do you think these justices will rule the same way?

That shouldn’t change the fact that the fundamentals of the law have remained the same. The fundamentals of the ACA are grounded, they’re solid, and they work. I would hope that nine justices reviewing the same law would look at that precedent.

Q: What should the public pay attention to during the oral arguments?

One thing interesting to watch is how the court interprets the actions taken by Congress in 2017 when they passed the tax break bill and zeroed out the individual mandate fee or penalty. Now, we’re looking at a president and at least one house in Congress that’s prepared to defend the Affordable Care Act. How might the court look at the fact that another Congress could reinstitute part of that mandate?

What does that do to the legal argument that having zeroed out the mandate somehow triggered the unconstitutionality of the entire law? I think that’s a question the court will have to examine.

Q: What happens if the U.S. Supreme Court declares the Affordable Care Act unconstitutional?

The worries return. Preventative care under Medicare would be gone. The days when Americans don’t have to worry about going personally bankrupt for having visited a hospital would pretty much be gone.

I’ve got three daughters. There was a time when all three of them as adults were on our health care coverage. That would be gone because the provision that allows adult children under the age of 26 to remain on a parent’s coverage would disappear. I could go on and on.

Q: Could states, including California, afford to step in on their own?

I don’t know if there’s any state who has the capacity to replace what the Affordable Care Act does. It’d be almost insurmountable. Part of that is because we can’t replicate some of the things that the federal government can do. We don’t have that federal jurisdiction, we don’t have that breadth and depth of reach.

Q: If the court overturns the ACA, can’t Congress pass piecemeal protections that have Republican support, such as coverage for preexisting conditions?

We have heard Republicans say “repeal and replace” for more than 10 years, and it’s been empty rhetoric from the beginning. I’ve gotta tell you that for parents who have children with preexisting medical conditions, it is no comfort to have someone promise you that they will replace a right that you know you now have for your child to visit a hospital. And, why would you throw that away for an empty promise that’s 10 years old?

Most Americans would say, Keep building on the Affordable Care Act. Let’s make it better, but don’t scrap what’s worked.

Q: How do you know the Affordable Care Act is working?

My former congressional district in Los Angeles ranked among the most uninsured congressional districts in the nation. In a matter of years, once the Affordable Care Act took place, the uninsured rate in that congressional district had gone down by 50%. It was just astronomical.

The Affordable Care Act made it possible for working families to secure coverage and that’s huge. That’s the kind of burden that’s lifted off your soul.

Q: Do you think having a President Joe Biden and a Vice President Kamala Harris in the White House will lead to an improved Affordable Care Act?

As a candidate for president, Joe Biden said that he would build on the success of the Obama-Biden presidency and make sure that we continue to increase the number of Americans who have access to affordable health care. The good thing is you finally have someone at the top of the totem pole who says we’re going to make it better. And that’s why this election was so important.

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Sacramento.- Cuando la Corte Suprema de los Estados Unidos esté escuchando el martes 10 un caso que podría decidir el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), California liderará la defensa de la ley federal que impacta en casi todos los aspectos del sistema de salud del país.

Por lo general, es tarea del gobierno federal defender una ley federal, pero la Administración Trump quiere que ACA, también conocida como Obamacare, se revoque.

Por eso, el fiscal general de California, Xavier Becerra, respaldado por más de 20 estados, defiende la ley contra el desafío presentado hace dos años por una coalición de funcionarios estatales republicanos.

Becerra ha sido uno de los adversarios más formidables de Trump: ha llevado a la administración a los tribunales decenas de veces por sus políticas, que van desde la inmigración y el control de la natalidad hasta el cambio climático. Se le considera uno de los principales contendientes para llenar la vacante del Senado que se abrirá ahora que la senadora por California Kamala Harris ha sido elegida vicepresidenta.

“Tan enérgicamente como un presidente y su administración están luchando para destruir la Ley de Cuidado de Salud a Bajo Precio, nosotros estamos luchando para salvarla para todos los estadounidenses”, dijo Becerra a los periodistas en una conferencia de prensa el lunes 9.

Si el tribunal anula toda la ley, el impacto se sentiría ampliamente. La ley proporciona seguro médico a más de 23 millones de estadounidenses. Permite a las personas que califican comprar seguros a través de los mercados estatales y el federal, y recibir subsidios.

También ha recomendado  a los estados expandir sus programas de Medicaid a más personas; previene que las compañías de seguros nieguen cobertura a personas con afecciones médicas preexistentes; prohíbe los límites de por vida en la cobertura; agrega beneficios a Medicare; y permite que los hijos permanezcan en los planes de sus padres hasta los 26 años.

El tema central en California vs. Texas es la multa fiscal federal por no tener seguro médico, como exige la ley. En 2017, el Congreso liderado por los republicanos redujo esta multa a cero, pero mantuvo intacta al resto de la ley, una medida que, según Becerra y otros expertos en leyes, muestra la intención del Congreso de apoyarla.

Sin embargo, funcionarios estatales republicanos dicen que la pérdida de la penalidad invalida el mandato de tener un seguro, así como toda la ley.

Becerra dijo que es posible que el tribunal determine que los impugnadores no tienen legitimidad para demandar al gobierno porque nadie ha sido perjudicado por una multa que cuesta cero.

Aunque la corte ha ratificado dos veces esta ley, la composición de la corte ha cambiado desde su último fallo sobre ACA en 2015. Desde entonces, Trump ha nombrado a tres jueces conservadores. Dos reemplazaron a otros conservadores, pero Amy Coney Barrett, quien fue confirmada a fines de octubre, ocupa el asiento de un ícono liberal, la jueza Ruth Bader Ginsburg.

Abbe Gluck, directora del Centro Salomón de Derecho y Políticas de Salud de la Escuela de Derecho de Yale, dijo que si el tribunal cree que el requisito del seguro médico es inconstitucional sin la penalidad, debería simplemente declarar inválida esa sección de la ley, pero no anularla por completo.

Pero “he aprendido que nunca se puede predecir lo que sucede en la corte cuando se trata de la Ley de Cuidado de Salud a Bajo Precio”, dijo Gluck. “Por eso hay más preocupación, porque el estatuto se ha vuelto tan fundamentalmente importante para una quinta parte de nuestra economía y para la atención médica de prácticamente todos los estadounidenses”.

Becerra habló con Samantha Young de California Healthline sobre su defensa del Obamacare y el enorme alcance de la influencia de la ley. La entrevista ha sido editada por extension, y para mayor claridad.

¿Cuáles son las posibilidades de que la Corte Suprema derogue la Ley de Cuidado de Salud a Bajo Precio?

Confiamos en que no solo verán la lógica legal detrás de esto, sino también la sabiduría y el éxito práctico de la Ley de Cuidado de Salud a Bajo Precio, lo cual pesa mucho a favor de que los jueces reconozcan no solo que es legal, sino indispensable. Cuando los jueces examinen los fundamentos de la Ley de Cuidado de Salud a Bajo Precio, encontrarán que es constitucional.

La composición de la Corte Suprema de los Estados Unidos ha cambiado desde la última vez que se pronunció sobre ACA. ¿Por qué cree que estos jueces decidirán de la misma manera?

Eso no debería cambiar el hecho de que los fundamentos de la ley siguen siendo los mismos. Los fundamentos de ACA son sólidos y funcionan. Espero que nueve jueces que revisan la misma ley observen ese precedente.

¿A qué debe prestar atención el público durante los argumentos orales?

Algo interesante de observar es cómo la corte interpreta las acciones tomadas por el Congreso en 2017, cuando aprobaron el proyecto de ley de exención de impuestos y redujeron a cero la tarifa o multa por el mandato individual. Ahora, estamos ante un presidente y al menos una cámara en el Congreso que está preparada para defender la Ley de Cuidado de Salud a Bajo Precio. ¿Cómo podría considerar el tribunal el hecho de que otro Congreso podría restablecer parte de ese mandato?

¿Cómo se relaciona esto con el argumento legal de que haber reducido a cero el mandato de alguna manera provocó la inconstitucionalidad de toda la ley? Creo que es una cuestión que el tribunal tendrá que examinar.

¿Qué pasará si la Corte Suprema de los Estados Unidos declara inconstitucional la Ley de Cuidado de Salud a Bajo Precio?

Volverán las preocupaciones. La atención preventiva de Medicare desaparecería. Los días en que los estadounidenses no tenían que preocuparse por la bancarrota por haber pisado un hospital prácticamente se esfumarían.

Tengo tres hijas. Hubo un tiempo que, como adultas, las tres estaban en nuestra cobertura de atención médica. Eso desaparecería porque la disposición que permite que los hijos adultos menores de 26 años permanezcan en la cobertura de los padres desaparecería. Y podría seguir y seguir.

¿Podrían los estados, incluido California, darse el lujo de intervenir por su cuenta?

No sé si hay algún estado que tenga la capacidad de reemplazar lo que hace la Ley de Cuidado de Salud a Bajo Precio. Es casi imposible. Parte de eso se debe a que no podemos replicar algunas de las cosas que puede hacer el gobierno federal. No tenemos esa jurisdicción federal, no tenemos esa amplitud y profundidad de alcance.

Si el tribunal anula ACA, ¿el Congreso no puede aprobar protecciones parciales que cuenten con el apoyo de los republicanos, como la cobertura de afecciones preexistentes?

Hemos escuchado a los republicanos decir “revocar y reemplazar” durante más de 10 años, y ha sido una retórica vacía desde el principio. Para los padres que tienen hijos con afecciones médicas preexistentes, no es reconfortante que alguien les prometa que reemplazarán un derecho que saben que ahora tienen para que sus hijo vayan al hospital. Y, ¿por qué desecharías eso por una promesa vacía que ya lleva 10 años?

La mayoría de los estadounidenses dirían: sigue construyendo sobre la base de la Ley de Cuidado de Salud a Bajo Precio. Mejorémosla, pero no descartemos lo que ha funcionado.

¿Cómo sabe que la Ley de Cuidado de Salud a Bajo Precio está funcionando?

Mi antiguo distrito congresional en Los Ángeles se encontraba entre los distritos congresionales con más cantidad de personas sin seguro de salud de la nación. En cuestión de años, una vez que entró en vigor la Ley de Cuidado de Salud a Bajo Precio, la tasa de personas sin seguro en ese distrito se redujo en un 50%. Fue simplemente astronómico.

La Ley de Cuidado de Salud a Bajo Precio hizo posible que las familias trabajadoras pudieran obtener cobertura y eso es enorme. Ese es el tipo de carga que se quita del alma.

¿Cree que tener a Joe Biden como presidente y a Kamala Harris como vicepresidenta en la Casa Blanca llevará a una mejora en la Ley de Cuidado de Salud a Bajo Precio?

Como candidato a presidente, Joe Biden dijo que se basaría en el éxito de la presidencia de Obama-Biden y se aseguraría que sigamos aumentando el número de estadounidenses con acceso a una atención médica asequible. Lo bueno es que finalmente tienes a alguien en la parte superior del tótem que dice que lo vamos a mejorar. Por eso esta elección fue tan importante.

If they’ve been listening to President Donald Trump, seniors may be expecting a $200 debit card in the mail any day now to help them pay for prescription drugs.

He promised as much this month, saying his administration soon will mail the drug cards to more than 35 million Medicare beneficiaries.

But the cards — if they are ever sent — would be of little help. Policy experts say that what Medicare beneficiaries really need, as well as younger Americans, are sweeping federal changes to close the gap between what their health insurance pays and what drugs cost them.

The nation’s 46.5 million enrollees in Medicare’s Part D prescription drug program — except for those who qualify for low-income subsidies — face unlimited out-of-pocket exposure to drug costs even though the Affordable Care Act finally closed the infamous “doughnut hole.” After Part D enrollees have spent $6,550 and reached the catastrophic threshold in a given year, they still must pay 5% coinsurance on the list price of their drugs.

Congress was considering legislation to lower drug prices and cap out-of-pocket costs until early this year, when the COVID-19 pandemic took center stage. But partisan disagreement, federal budget concerns and opposition from drug manufacturers and other health care industry groups hampered the efforts.

Many observers question the value, timing and legality of Trump’s drug card plan, with the promise coming just ahead of an election in which the president wants to shore up the support of older voters.

“A $200 card is better than a sharp stick in the eye, but it won’t be that meaningful,” said Tom Scully, the Medicare chief under President George W. Bush who in 2004 implemented a two-year, $1,200 drug card program passed by Congress as part of the law creating the Part D prescription drug benefit.

Two hundred dollars won’t go very far. One million Part D plan enrollees have out-of-pocket drug spending way above the program’s catastrophic coverage threshold, with average annual costs exceeding $3,200, according to KFF. (KHN is an editorially independent program of KFF.) Last year, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to a 2019 JAMA study.

“A lot of people don’t have $2,000 or $3,000 to pay out-of-pocket when they go to the pharmacy,” said Stacie Dusetzina, a drug policy expert at Vanderbilt University.

Steven Hadfield, 68, of Charlotte, North Carolina, has a rare blood cancer requiring treatment with Imbruvica, with a list price of $132,000 a year. He also needs two different medications for Type 2 diabetes, including insulin at $300 a bottle, a blood pressure drug and a muscle relaxer to relieve leg cramps.

He continues to work at Walmart and holds three part-time jobs. He pays more than $4,000 a year for his drugs, out of his $12-an-hour wages and monthly $1,100 Social Security check. The only way he can afford Imbruvica is through the manufacturer’s copay cards.

If he left his Walmart health plan and signed up for Medicare Part D drug coverage, he would have to pay thousands of dollars more because, under Medicare rules, he would no longer be able to use copay cards. “My whole Social Security check would go to drugs, and I’d have nothing left for my car or anything,” he said.

Asked about Trump’s $200 drug card, Hadfield said, “I’d be happy to get anything, but they need to do more. Our representatives need to create some kind of program to lower prices.”

The Republican-controlled Senate refused to consider a sweeping drug cost bill passed by House Democrats a year ago that would have capped Part D out-of-pocket costs at $2,000 a year, penalized drugmakers for raising prices above inflation rates and let Medicare negotiate drug prices. Trump threatened to veto it.

In addition, Senate Republican leaders wouldn’t take up a bipartisan bill backed by the White House capping Part D out-of-pocket costs at $3,100 and also imposing penalties for price hikes above inflation.

The lack of action hasn’t stopped Trump from claiming, mostly inaccurately, that he has implemented policies that have reduced drug prices and saved seniors lots of money.

“Day after day I’m fighting to defend seniors from Big Pharma,” Trump said Oct. 16 in a Florida speech promising drug price cuts of 50% to 80%. “We have this terrible system that’s taken years and years to rig.”

The president’s centerpiece proposal is to index the drug prices paid by Medicare to lower prices paid by foreign countries. But his administration has not yet issued a rule to carry that out, and any such rule would face a strong legal challenge from drugmakers.

Joe Biden’s drug cost platform includes allowing Medicare to negotiate prices with drug manufacturers, limiting launch prices for new drugs, capping price increases at the inflation rate and letting consumers buy cheaper medicines from other countries. His plan would also likely spark opposition from drug companies.

Trump’s $200 drug card appears to be in trouble within his own administration. White House chief of staff Mark Meadows said last week that details will be finalized shortly and that the cards will be mailed to seniors in November or December.

But the general counsel of the Department of Health and Human Services warned in an internal memo the plan could violate election law. Congressional Democrats have called for an investigation, saying Trump is “attempting to buy votes.”

In a draft document obtained by Politico, the White House set the cost of the drug card plan at nearly $8 billion. To avoid having to seek congressional approval for the expenditure, Trump’s advisers want to call it a demonstration project, testing whether lowering Medicare patients’ out-of-pocket drug costs boosts their compliance in taking medications.

It’s also unclear whether the Office of Management and Budget will approve the plan because Medicare demonstrations must be designed so they do not increase the federal budget deficit. Yet the money would have to come from the government’s general revenues or Medicare payroll taxes or premiums, likely causing a negative budget impact.

“It will be difficult to learn anything from this demonstration project that we do not already know from other studies,” Dusetzina said.

“It’s a whole lot of money that would be more effectively focused on people with cancer and serious chronic illnesses who are struggling with high out-of-pockets,” said Daniel Klein, CEO of the Patient Access Network Foundation, which provides grants to help patients with drug costs.

Maureen Allen, 80, a retired marketing specialist who lives in Talking Rock, Georgia, said she could apply the $200 card to her annual cost of more than $2,000 for the anti-blood clot drug Eliquis and other medicines.

“It would help me with one month of Eliquis,” she said. “We’ll take the card because we need the money. But don’t think for a moment it will have the slightest impact on my vote.”

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Nursing homes, small physician offices and rural clinics are being left behind in the rush for N95 masks and other protective gear, exposing some of the country’s most vulnerable populations and their caregivers to COVID-19 while larger, wealthier health care facilities build equipment stockpiles.

Take Rhonda Bergeron, who owns three health clinics in rural southern Louisiana. She said she’s been desperate for personal protective equipment since her clinics became COVID testing sites. Her plight didn’t impress national suppliers puzzled by her lack of buying history when she asked for 500 gowns. And one supply company allows her only one box of 200 gloves per 30 days for her three clinics. Right now, she doesn’t have any large gloves on-site.

“So in the midst of the whole world shutting down, you can’t get PPE to cover your own employees,” she said. “They’re refilling stuff to larger corporations when realistically we are truly the front line here.”

More than eight months into the pandemic, health care leaders are again calling for a coordinated national strategy to distribute personal protective equipment to protect health care workers and their patients as a new wave of disease wells up across most of the country. The demand for such gear, especially in hot spots, can be more than 10 times the pre-pandemic levels. While supply chains have adjusted, and the availability of PPE has improved dramatically since the mayhem of the spring, limited factories and quantities of raw materials still constrain supply amid the ongoing high demand.

In this free-market scramble, larger hospitals and other providers are stockpiling what they can even while others struggle. Some facilities are scooping up supplies to prepare for a feared wave of COVID-19 hospitalizations; others are following new stockpiling laws and orders in states such as California, New York and Connecticut.

“They’re putting additional strain on what’s still a fragile hospital supply chain,” said Soumi Saha, vice president of advocacy for Premier Inc., a group-purchasing organization that procures supplies for over 4,000 U.S. hospitals and health systems of various sizes. “We want available product to go to front-line health care workers and not go into a warehouse right now.”

Over a quarter of nursing homes in the country reported a shortage of items such as N95 masks, gloves or gowns from Aug. 24 through Sept. 20. A recent survey from the American Medical Association found 36% of physician offices reported having a difficult time securing PPE. And about 90% of nonprofit Get Us PPE’s recent requests for help with protective gear have come from non-hospital facilities, such as nursing homes, group homes and homeless shelters.

“I can completely understand that large health systems don’t want to find themselves short on PPE,” said Dr. Ali Raja, co-founder of Get Us PPE and executive vice chairman of emergency medicine at Massachusetts General Hospital. “Smaller places simply not only can’t stockpile but also can’t get enough for their day-to-day usage.”

From the outset of the pandemic, the fight for PPE has been about who has had the most money and connections to fly supplies in from China, sweet-talk suppliers or hire people who could spend their time chasing down PPE. At various points, hospitals with sufficient supplies have shared their wealth, as has California, which sent millions of masks to Arizona, Nevada, Oregon and Alaska this summer.

But the fight for PPE is becoming even more challenging as states, such as California, pass stockpiling requirements, Saha said. Premier asked California Gov. Gavin Newsom to veto a bill that requires hospitals, starting in April, to have stockpiles of three months’ worth of PPE, or face $25,000 fines. However, Newsom signed the bill into law in September, and Saha worries it could become model legislation for other states.

For an average hospital, a 90-day supply is $2 million worth of equipment filling about 14 truckloads, said Chaun Powell, Premier’s group vice president of strategic supplier engagement — or about a football field and a half of warehouse space.

Traditional supply chains were ill equipped to handle the onslaught of demand caused by the pandemic, which has led to the frantic search for PPE. When distributors face such shortages, they rely on past orders to allocate who gets what share of their existing products, so no single buyer buys up everything. Nursing homes and clinics never used this much protective gear in the past, so they lack an ordering history and get put at the back of the line. That has forced many of them to rely on lower-grade masks like KN95s and other workarounds, Saha said.

Shortages of PPE put facilities’ workers and patients at risk, while also limiting their ability to treat their communities. At least 1,300 U.S. health care workers have died of COVID-19.

In Kirksville, a college town in northern Missouri, Twin Pines Adult Care Center Administrator Jim Richardson said his nursing home is running low on gowns. It also is reusing N95s after staffers treat them with UV light. Although major medical supplier Medline Industries has supplied him with extra products at times, he’s still had to turn to eBay.

“I’m a little-bitty facility and I’m bidding against a Life Care nationwide,” he said. “Guess who Medline is going to take care of?”

COVID-19 cases are rising in Kirksville following the students’ return to campus, Richardson said. Visitors are starting to return to the nursing home, and flu season is beginning.

Dr. Michael Wasserman, immediate past president of the California Association of Long Term Care Medicine, said the lack of supplies for smaller providers like nursing homes speaks to the nation’s priorities when it comes to caring for older adults.

“Here we are in October, and the fact that there is not an abundance of PPE for every nursing home in the country is a literal abomination,” he said. “Without PPE, you lose to this virus.”

Stuart Almer, president and CEO of Gurwin Jewish Nursing & Rehabilitation Center, has managed to scavenge the 60-day stockpile required by New York state law for his facility on Long Island, but it’s come at a great financial cost. And he worries that as long as hot spots and stockpiling persist, massive price fluctuations and delivery concerns will continue.

He learned early on no one was coming to save him. Even deliveries from the Federal Emergency Management Agency, which he appreciated, were too small in quantity and not always easy to use. The heavy floor-length gowns it provided needed to be trimmed.

“Really, we’re on our own,” he said.

American Medical Association President Dr. Susan Bailey said in an emailed statement that federal officials need to step in: “We urge the administration to pull every lever to ramp up PPE production — for N95 masks, gowns, and testing supplies — and coordinate distribution.”

Get Us PPE’s Raja argued for a more fair, robust, centralized and transparent allocation process that doesn’t rely on donations to fill gaps. What good does it do a community to have a hospital stockpile, he asked, when the nursing home down the street has no PPE?

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Johnathon Talamantes, of South-Central Los Angeles, broke his hip in a car accident on Oct. 22 and underwent surgery five days later at a public hospital near downtown.

His post-op recovery will keep him in the hospital, L.A. County+USC Medical Center, beyond Election Day, and as he prepared himself for the surgery, he wondered what that would mean.

“One of the first things I asked my nurse this morning was, ‘Oh, how am I going to vote?’” Talamantes, 30, said from his hospital bed the day before the operation.

He initially thought of asking his mom to rummage through a pile of papers at the home he shares with her and bring him the mail-in ballot that he, like all registered California voters, received for this election.

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But then staffers at LAC+USC told him about another option: They could help him get an emergency ballot and cast his vote without having to get out of bed. So Talamantes told his mom not to bother.

“I don’t want her coming down here, because of the COVID restrictions,” he said.

California law protects the rights of voters who are in the hospital or other care facilities, or confined at home. It allows them to get help from anyone they choose — other than an employer or a union representative — and to cast an emergency ballot.

At least 37 other states allow emergency voting for medical reasons, according to the National Conference of State Legislatures. But practices vary.

In some states, only family members can assist hospitalized patients with voting from the hospital.

In California, New York and several other states, hospital employees and volunteers can help a patient complete an emergency ballot application. They can pick up the ballot for the patient and deliver the finished ballot back to the election office or deposit it in an official drop box.

In North Carolina, by contrast, it is a felony for a health care worker to assist a patient with voting.

In 18 states, the law allows local election boards to send representatives directly to patients’ bedsides, though six of those states have canceled that service this fall because of the COVID-19 pandemic, said Dr. Kelly Wong, founder of Patient Voting, a nonpartisan organization dedicated to increasing turnout among registered voters unexpectedly hospitalized around election time.

The group’s website features an interactive map of the United States with state-by-state information on voting while in the hospital. It also allows patients to check whether they are registered to vote.

Wong, an emergency room resident at Rhode Island Hospital in Providence, recalled that when she was a medical student working in an ER, patients who were about to be admitted to the hospital would tell her, “‘I can’t be admitted; I have let the dogs out, or I’m the sole caretaker of my grandmother.’” Then during the election of 2016, she heard, “‘I can’t stay. I have to go vote.’”

“That really caught my attention,” Wong said. She did research and learned patients could vote in the hospital using an emergency ballot — something none of her co-workers knew. “Our patients don’t know this, she said. “It should be our job to tell them.”

Some U.S. hospitals have been assisting patients with voting in major elections for two decades or more, part of a broader tendency in the health care industry toward civic engagement.

Community clinics register voters in their waiting rooms or at public registration drives. In an increasing number of ERs, patients and their families are offered the chance to register. Many hospitals, including LAC+USC, this year will have mobile voting units on-site, open to staff members, patients who are well enough to walk, and their families.

These efforts come against the backdrop of health care’s starring role in the nation’s heated political drama: COVID-19 has become a top presidential campaign issue, while the U.S. Supreme Court, its conservative majority fortified this week, prepares to hear a case — one week after the election — that could be the death knell for the Affordable Care Act.

The pandemic has made inpatient voting a challenge because of tight restrictions at hospitals and the many employees furloughed, laid off or working at home. And a significant increase in early voting and the use of mail-in ballots in many states may reduce the number of patients who need help.

“The majority of our patients, I am hoping, will have voted already, because that will alleviate the stress — for them, it’s one less thing to worry about,” said Camille Camello, associate director of volunteer services at the nearly 900-bed Cedars-Sinai Medical Center in Los Angeles, which has a program to help inpatients vote. In past elections, she said, over 200 patients have requested ballots.

At LAC+USC, administrators have been trying to ensure patients know they can get help voting. Posters line the walls of common spaces and staffers are handing out flyers with voting information to every patient who is admitted, said Gabriela Hernandez, the hospital’s director of volunteer services.

Hernandez said she and about 25 volunteers have been walking the halls in the inpatient units of the hospital for the past month, asking patients if they want help voting.

Patients who say yes get emergency ballot applications, which the hospital has been sending to the L.A. County Registrar-Recorder for verification. The ballot applications will continue to be made available to patients up to the morning of Election Day.

Hernandez and her team will collect the ballots and distribute them to patients, then return them to the registrar before the 8 p.m. deadline on Election Day.

Other hospitals have a more collapsed timeline.

At St. Jude Medical Center in Fullerton, California, hospital staffers will start asking patients Monday if they want voting assistance and bring them ballots on Election Day, said Gian Santos, manager of volunteer services at the hospital. In the 2016 election, only about seven or eight patients voted that way, Santos said.

St. Joseph Hospital in Orange, California, plans to do everything — applications and ballots — on Election Day.

For big hospitals, inpatient voting can be a massive undertaking. People often require assistance in multiple languages, and the hospitals frequently contract with translation services to accommodate them.

Many hospitals receive patients from numerous counties — and across state lines.

Lenox Hill Hospital in Manhattan plans to assist as many as 200 patients from nine counties in New York state and three in New Jersey, said Erin Smith, an obstetrical nurse navigator who, along with fellow OB nurse navigator Lisa Schavrien, is leading the effort.

The hospital will assign one or two “runners” to each of the 12 county election boards, Smith said. For her, enabling vulnerable patients to exercise their right to vote is worth the effort.

“If we’re not helping them do it, how many thousands of people are not voting in elections because they were in a car accident, because they had appendicitis, because they had unexpected brain surgery?” Smith asked.

“If we’re not making it happen in the hospital, it kind of feels to me like voter suppression.”

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White House chief of staff Mark Meadows said this week that “we’re not going to control the pandemic,” effectively conceding that the administration has pivoted from prevention to treatment. But COVID-19 cases are rising rapidly in most of the nation, and the issue is playing large in the presidential campaign. President Donald Trump is complaining about the constant news reports about the virus, prompting former President Barack Obama to say Trump is “jealous of COVID’s media coverage.”

Meanwhile, as the case challenging the constitutionality of the Affordable Care Act heads to the Supreme Court on Nov. 10, open enrollment for individual health insurance under the law begins Sunday.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Anna Edney of Bloomberg News.

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Among the takeaways from this week’s podcast:

• Whichever candidate wins the presidency next week will have a heavy lift in mounting a strong public response to battle COVID-19. Polls suggest about a third of people do not believe some of the basic science about the virus or its prevention, such as that using masks can help stem transmission.
• Dr. Scott Gottlieb, who once served as Food and Drug Administration commissioner under Trump, called for a temporary national mask mandate in his column in The Wall Street Journal. He suggested that masks should not be a political issue.
• Gottlieb’s column has been supported by other commentators who suggest that masks need to become a social and cultural norm and compare the debate over their use to similar debates in the past about seat belts, smoking bans and harsh punishments for driving while intoxicated. Those measures all faced opposition from people who complained about civil liberties but gradually became accepted. The difference now is that public health advocates are looking for a quick acceptance of masks.
• Part of the resistance to wearing face masks is that many people don’t understand their purpose and presume masks are for their own protection. But public health officials advocate masks as a way to protect others, especially vulnerable people, from any virus a mask wearer might shed, often without even realizing it.
• Drugmakers and health experts are rolling back expectations about the timing of a COVID vaccine as the trials seek more data. One issue may be that not enough people in the placebo groups have contracted the coronavirus. That could be because people who volunteer for such an endeavor may be more aware of health issues and cautious about the disease.
• Once a vaccine is approved, FDA and other federal health officials will face a number of complicating issues. Among them: How should trials of other vaccine candidates continue and how should the vaccine be distributed?
• Enrollment for insurance plans on the Affordable Care Act’s marketplaces begins Sunday, but many consumers could be forgiven for not knowing that. There is precious little marketing or advertising for the plans, and some people think the Supreme Court is going to overturn the ACA, anyway, and its plans will go away. That’s not known yet and it may well be summer 2021 before there is an answer on that.

Also this week, Rovner interviews KHN’s Anna Almendrala, who reported the latest NPR-KHN “Bill of the Month” installment, about a patient who did everything right and got a big bill anyway. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New York Times’ “A Chance to Expand Medicaid Rallies Democrats in Crucial North Carolina,” by Abby Goodnough

Joanne Kenen: The New Yorker’s “A President Looks Back on His Toughest Fight,” by Barack Obama

Tami Luhby: KHN’s “Florida Fails to Attract Bidders for Canada Drug Importation Program,” by Phil Galewitz

Anna Edney: The Wall Street Journal’s “Health Agency Halts Coronavirus Ad Campaign, Leaving Santa Claus in the Cold,” by Julie Wernau, James V. Grimaldi and Stephanie Armour

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