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Lamb's Victory a Win for Social Security, Medicare, and Working Americans Everywhere


Not only is Democrat Conor Lamb’s victory in Pennsylvania’s special Congressional election a rebuke to President Trump, it is an affirmation that voters want Social Security and Medicare to be vigorously protected.  Last month, the National Committee endorsed Lamb, a U.S. Marine and former federal prosecutor who champions Americans’ retirement and health security.

 “Our nation needs his leadership, vision and determination to fight for working families and older Americans.  Conor Lamb understands and supports the critical roles that Social Security and Medicare play in the lives of our nation’s older citizens and their families.  We look forward to working with Conor Lamb to protect – if not expand – Americans’ earned benefits.”” - National Committee president and CEO Max Richtman.

On Wednesday, President Trump and House Speaker Paul Ryan twisted themselves into knots trying to spin Lamb’s victory as a win for conservatism. Though Lamb took a few conservative positions (as well he might in a historically Republican district), his support for programs benefitting working families was rock solid.

 *He promised to boost Social Security benefits and expand Medicare to cover hearing, vision, and dental care – and to protect both programs from GOP attempts to cut and privatize them.

 *He opposed the Trump/GOP tax scam, calling it a “giveaway” to the wealthy, advocating instead for a tax cut truly aimed at “working and middle class people” without adding to the debt.

 *He railed against GOP attempts to repeal and undermine Obamacare, promising to work to “help people with pre-existing conditions, improve the quality of care, and reduce premiums, out-of-pocket costs, and prescription drug prices.”

On issue after issue, Lamb is unabashedly on the side of working Americans.  This election was a test of voters commitment to these issues – and the results were clear. The fact that Lamb earned more votes – albeit by a razor-thin margin – in a deep red district where the Democrats didn’t even field a candidate in the previous two elections proves that voters want to protect working people’s interests. 

Health care, in particular, was voters’ top-ranking concern in Pennsylvania’s special election, according to an exit poll released yesterday. As The Hill newspaper reports, “For 52 percent of voters, health care [was the] top issue when deciding who to vote for, while 19 percent said it wasn’t at all important to them.” 

 The poll also found that 53 percent disapprove of Republican efforts to repeal Obamacare, while 39 percent approve. This is leading some Democrats to think health care could be a winning issue for them in the 2018 midterms, when they hope to retake seats in Congress. – The Hill newspaper, 3/15/18

For more than a year, President Trump and Congressional Republicans have engaged in a war against the programs that working Americans rely on for basic income and health security – while passing trillions of dollars in tax breaks for the wealthy and big corporations.  Working people’s well-being hinges on electing more defenders of Social Security, Medicare, Medicaid, and Obamacare to Congress this Fall.  With the 2018 Congressional elections drawing closer, Conor Lamb’s victory is a positive harbinger for those who fight for the working class, and a warning to those who don’t.

Watch our live analysis of Conor Lamb's win on "Behind the Headlines" via Facebook Live. 

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Bipartisan Budget Bill a Pretty Good Deal for Seniors

The bipartisan budget bill passed by Congress early this morning is, on balance, good news for seniors and the federal programs that provide them with financial and health security. 

“Seniors will feel these changes in their pocketbooks and even in the way they feel physically. We have been fighting for these measures for quite some time and are happy to see Congress take action on a bipartisan basis.” - Max Richtman, National Committee president 

On the positive side, the budget bill:

*Closes Medicare Part D “donut hole” in 2019.  The prescription drug coverage gap embedded in the original law, which the Affordable Care Act has been gradually closing, will be altogether eliminated one year early. This will save seniors thousands of dollars in out-of-pocket prescription drug costs.

*Repeals Medicare therapy caps.  The bill scraps arbitrary caps on physical, speech, language and occupational therapies that have cost seniors money – or delayed care at crucial times.  Beneficiaries will now find it easier – and more affordable – to get the therapies they need without undue interruption. 

*Lifts non-defense domestic spending caps, allowing Congress to appropriate more adequate funding for the Social Security Administration’s operating budget. The SSA has suffered from draconian budget cuts since 2011 which have impinged on customer service, even as 10,000 Baby Boomers retire every day.  This badly-needed (but yet unspecified) higher level of funding should allow SSA to improve customer service for the program’s 67 million beneficiaries.

On the negative side, the bill increases Medicare premiums for some individuals by further expanding Medicare means-testing. 

“Congress continues to expand Medicare means-testing, and they will not stop until middle-class seniors are burdened with higher Medicare premiums.” - Max Richtman.

Here is a more detailed summary of the budget bill’s implications for seniors. 

For more on this story, view our Behind the Headlines broadcast live from Capitol Hill here

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Medicare Therapy Caps: It's Time for a Permanent Repeal

Many of us have loved ones who’ve heard those dreaded words “Medicare won’t approve any more physical therapy (or occupational therapy or speech therapy) for you this year” – or have been told the same thing ourselves.  Whether recovering from a stroke, heart attack, serious fall or myriad other conditions, few things are more frustrating for convalescing seniors than being informed they have hit a coverage limit in the midst of medically necessary therapy.

Congress imposed caps on outpatient therapies for Medicare Part B beneficiaries in 1997 as part of the Balanced Budget Act.  Since then, the National Committee and other Medicare advocates have been shouting from the rooftops that therapy caps are bad policy.

Realizing the hardship these caps would cause patients, subsequent Congresses enacted - and continually renewed – an exceptions process for exceeding the caps.  Under this process, beneficiaries could get coverage for therapy beyond the caps until they hit a higher threshold (currently $3700 per year), after which Medicare would manually review every claim before deciding whether to pay.  

However, the current Congress failed to extend the exceptions process, meaning that as of January 1st, all Medicare beneficiaries are subject to a hard, annual cap of $1,980 on physical therapy – and the same for occupational therapy.

In a letter to Congress, the Legislative Council of Aging Organizations (of which the National Committee is a member) says the therapy caps are random – and harmful.

“These arbitrary caps are aimed at federal cost-savings rather than providing clinically appropriate service and disproportionately impact the most vulnerable Medicare beneficiaries who require ongoing therapy services.” – LCAO letter to Congress

Christina Metzler, Chief Public Affairs Officer at the American Occupational Therapy Association (AOTA), says Congress has left the Medicare community in the lurch by failing to at least renew the exceptions process:

“Consumers and practitioners are in a very difficult spot right now.  While few people will hit the cap right away, if you have a severe injury or are just getting out of the hospital, your outpatient visits are going to start piling up.” – Christina Metzler, AOTA, 1/5/18

The Centers for Medicare and Medicaid Services (CMS) has issued zero guidance for providers or patients on how to handle the situation, opening the door for potential confusion and denial of proper care.

Ironically, there already is a bipartisan solution to this problem.  Last fall, Republicans and Democrats on key Senate and House committees agreed on a policy to make the exceptions process permanent – and less onerous for patients and providers.

As Metzler describes it, the bipartisan policy would result in:

*Elimination of therapy caps

*A nimbler process for obtaining coverage beyond cost thresholds

*Greater clarity for beneficiaries and providers

“The benefit of this approach is that there are no caps.  Instead, we’d have a new and different methodology for documenting and reviewing therapy claims. Patients would be assured of a permanent policy, and we wouldn’t be in a situation of confusion where beneficiaries and providers are in the dark.”  - Christina Metzler, AOTA, 1/5/18

The National Committee, AOTA, and other advocacy groups are calling on Congress to attach the bipartisan measure to pending legislation without delay.  Some Hill-watchers believe that reauthorization of the Children’s Health Insurance Program (CHIP) funding is the most likely vehicle.  (Congress would have to act on CHIP by January 19th before some states run out of money for children’s health insurance.)

“Anything less than a permanent fix that finally allows patients to receive medically necessary therapies without interruption or financial worry would be a disservice to everyone who relies on Medicare.” - National Committee president and CEO Max Richtman, 1/8/18

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Here's One Way You May be Overpaying for Prescription Drugs - And How to Avoid It

Did you know that when you lay down $10, $20, or $30 for a copay at the pharmacy that you may be overpaying for the prescription itself --- and a third party may be pocketing the difference?  Or that you might save money by not going through insurance at all and paying a reduced cash price for the medication?  Such is the head-spinning – and sometimes unethical – world of prescription drug benefits in the second decade of the 21st century.

Middlemen called Pharmacy Benefit Managers (PBMs) can skim extra profit by overcharging for medications.  The PBMs’ ostensible purpose is to negotiate favorable pricing with pharmaceutical companies on behalf of insurers, including Medicare.  But sometimes, especially with cheaper generic medicines, PBMs excessively mark up those prices and keep the remainder for themselves –  causing consumers to pay more than they should. Unfortunately, this practice is especially costly for older Americans living on fixed incomes. 

Unsuspecting customers are particularly vulnerable when paying co-pays at their local pharmacy, where PBMs can “claw back” excess profits.  Here’s how it works:

 A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager “claws back” the remainder. – Bloomberg, 2/24/17

(See also the graphic at the bottom of this post for a more detailed explanation of clawbacks.)

Though most customers are unaware of this practice, Bloomberg news reports that it is disturbingly common.  More than 80% of independent pharmacists surveyed said that they have experienced clawbacks from PBMs at least 10 times a month. 

In some cases, there is a simple way for customers to protect themselves from clawbacks. They can simply ask the pharmacist for the cash price of the prescription.  If the cash price is lower than the co-pay, the customer can elect to pay it and bypass the insurance coverage for that medication.  Consumers can also use prescription drug apps to determine the cash price (and available discounts) for various medications.

Unfortunately, PBMs do what they can to keep customers ignorant of this option.  In fact, many PBMs (including one called OptumRx) contractually forbid pharmacists from educating customers about potential alternatives.  

 Pharmacists who contract with OptumRx in 2017 could be terminated for “actions detrimental to the provider network,” doing anything that “disparages” it or trying to “steer” customers to other coverage or discounted plans… - Bloomberg, 2/24/17

Some PBMs further restrict customers’ rights by mandating that enrollees in certain insurance plans use mail order and specialty pharmacies that they own, creating a conflict of interest.

Up to now, PBMs have operated with little transparency, so that no one really knows the inner workings of their deals with the drug companies or the details of their pricing structures.  But pressure has been building on Capitol Hill.  After all, the federal government is the largest health care provider in the country and is motivated to keep prescription drug costs under control.  Hence, a bipartisan bill called the Prescription Drug Price Transparency Act (H.R. 1316) seeks to strengthen oversight of PBMs in the Medicare, Medicaid, and Federal Employee Health Benefit programs.  

Three other bills – one in House and two in the Senate – have been introduced requiring greater transparency and accountability for PBMs. Meanwhile, New York State (under the leadership of Governor Andrew Cuomo) has unveiled new regulations for PBMs, and other states may do the same.

PBMs have also become the target of lawsuits (16 of them since October of last year) and have invited scrutiny from the U.S. Justice Department, which has alleged that the industry “is rife with conflicts of interests and undisclosed arrangements entered into at customers’ expense.”

Of course, the nascent clampdown on PBMs has to be seen in the context of soaring prescription drug prices overall, which are the main driver of rising medical costs.  President Trump pledged to bring down drug prices, but so far has not delivered.  Incremental measures to crack down on pricing abuses by PBMs are a good start. But until consumers receive actual deliverance from prescription price gouging, they will have to try their best to protect themselves.  


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Two Paths Forward on Obamacare: One Reasonable, the Other Perilous

Newly back from summer recess, Senators are taking two divergent paths on healthcare after the Republicans’ spectacular failure to repeal and replace the Affordable Care Act (ACA).  For Americans who rely on the ACA for health insurance, one path is encouraging; the other, fraught with peril. 

On the encouraging side, the Republican and Democratic leaders of the House Education, Labor, and Pensions (HELP) committee are working on a bi-partisan plan to stabilize the ACA insurance markets, recognizing that the healthcare of millions of Americans hangs in the balance.  In fact, Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) are up against a hard deadline.  Insurers need to know the level of federal support for the ACA marketplaces before they set premiums for 2018 at the end of September.

The legislation they devise will likely beef up cost-sharing payments to insurers who waive certain out-of-pocket costs for lower income patients, as well as re-insurance payments to help insurers cover high-risk populations.  While President Trump and hardline conservatives in Congress have indicated they would be content to let the Affordable Care Act languish, Senator Alexander wisely recognizes that the public will hold Republicans accountable if Americans lose healthcare.  In other words, the GOP will own the ACA, whether they like it or not. 

Unlike the Senate and House leadership during the repeal and replace debacle, the HELP committee has been holding hearings (imagine that!) to get input from outside of Congress on possible fixes to the ACA.  Last week, a group of Republican and Democratic governors of widely different ideologies sang from the same hymnal:  the ACA marketplaces must be stabilized.

Senators Alexander and Murray must finish their hearings, mark-up the bill, pass it out of committee, and hope that it reaches the Senate floor.  If Senate leadership feels the bill has bipartisan support, it may come to a vote.  Whether all of that can happen by the end of September is anyone’s guess.

On the discouraging side, Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) just won’t let go of the repeal and replace agenda.  Undaunted by the GOP’s failure to get rid of the Affordable Care Act, Senators Cassidy and Graham are working on legislation to try, try again.  The Cassidy-Graham amendment is just as bad as - if not worse than - the failed Senate repeal bill last summer, and retains many of the most objectionable parts of the House-passed legislation.  Among other things, Cassidy-Graham:

*Ends the ACA’s Medicaid expansion  

*Cuts hundreds of billions of dollars in Medicaid spending

*Imposes per capita caps on Medicaid payments to the states

*Ends ACA subsidies and replaces them with inadequate block grants

*Leaves older and poorer Americans with no guarantee of affordable or adequate coverage

Were Senators Cassidy and Graham not paying attention when Americans at town halls across the nation expressed outrage at the GOP repeal and replace plans, including drastic cuts to Medicaid and more than 20 million people losing health coverage?  Did they not take seriously the Congressional Budget Office reporting on the negative impacts of repeal and replace on everyday Americans?  Apparently not. 

Fortunately for seniors – and all Americans who need healthcare – Senators Cassidy and Graham are running out of time.  Under Senate rules, their amendment cannot pass with a simple majority vote after the fiscal year ends on September 30th.  If they wanted to keep pushing for passage after that, they’d need 60 votes under regular order – a threshold they are not likely to meet.

Of course, it is premature for supporters of the ACA to declare victory.  We have seen seemingly dead repeal and replace bills suddenly spring back to life.  The legislative rollercoaster of last Spring and Summer are fresh in our memories.  Advocates and everyday Americans must keep the pressure on their elected representatives to work in a bipartisan fashion (like Sens. Alexander and Murray) to strengthen the Affordable Care Act– and reject repeal and replace once and for all.

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