Ten years later: ACA consistently proves to be America’s safety net, especially in times of crisis

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Nissa Shaffi

By Nissa Shaffi, NCL Associate Director of Health Policy

Ten years ago, the United States Congress adopted the Affordable Care Act (ACA), after many decades of unsuccessful attempts at achieving universal health care by advocates. For the first time, the ACA provided coverage options for every American across the economic spectrum, expanding Medicaid in many states and offering the self-employed access to insurance on the open exchange. For NCL, the ACA is the safety net program the founders of the League sought to see put in place from the organization’s inception at the turn of the 20th Century.

Today with the rapid spread of the COVID-19 virus across America, patients’ access to health care is more critical than ever. Yet despite the clear need we all have for health care coverage, over the past decade, the ACA has been under attack by conservatives in Congress and survived multiple attempts at repeal. The latest came from the Texas v. United States case – and now it threatens to render the entire ACA unconstitutional, following the repeal of the ACA’s  individual mandate provision. Why conservatives wish to deprive people of health care escapes us at the NCL. In fact, the ACA has transformed the way Americans interact with the healthcare system.

Throughout its short life, the ACA has cemented into law numerous consumer health protections and has expanded access to health coverage for over 20 million people. 37 states have expanded Medicaid, the health care program for low-income Americans. Prioritizing preventive care, the ACA mandated that health insurance providers  cover preventive services for all adults, women, and children – free of cost to the patient. The ACA also made it unlawful for insurers to deny or reduce benefits based on preexisting conditions. These include diagnostic included screenings, vaccines, birth control, and access to certain medications. For the first time, those 26 under could retain their health coverage through their parents’ insurance plans.

Research has shown that ACA Medicaid Expansion has improved access to care, financial security, health outcomes, economic mobility, and have reduced uncompensated care. Despite the progress made by the ACA, there are still 29 million uninsured people in the United States. If the ACA is repealed, 25 million Americans may lose their coverage overnight, without the promise of its replacement. Perhaps the COVID-19 outbreak will change the calculus and bring home how devasting it would be to repeal the ACA. Insurers would no longer be obligated to provide protections offered by the law, allowing plans to deny coverage indiscriminately, leaving millions of families along with low-income and high-risk individuals without care.

The true impact of the ACA will be even more apparent as the national continues to grapple with the COVID-19 pandemic in the coming months. COVID-19 has upended the economy and affected virtually every industry and has caused unemployment to soar. On March 21, unemployment claims reached a record 3.3 million – the highest level of jobless claims in history (the Great Depression saw levels of 24 percent unemployment at its peak but there was no unemployment insurance safety net during the 1930s and thus no jobless claims, just breadlines). Economist Heidi Shierholz of the Economic Policy Institute estimates that by summer, approximately “14 million workers will lose their jobs due to the coronavirus shock.”

A report by FAIR Health estimates that potential treatment for COVID-19, resulting in an average six-day hospital stay, could total to a whopping $73,300 for the uninsured: a devastating prospect in the middle of a global financial collapse. With the increased loss of employer-based health insurance, the ACA proves to be more crucial than ever as individuals and families may turn to the health insurance marketplace to secure coverage. NCL is backing legislation – and the health plans support this too – to move workers losing jobs and health insurance to the COBRA program with heavy subsidies so they can ride out the pandemic –  COVID-19 has exposed so many severe deficiencies in the healthcare system. To learn more about statewide efforts to mitigate the impact of COVID-19, click here.

While the fate of the ACA remains uncertain, it is still the law of the land. If you are concerned about loss of coverage during this time, several state-run health plans have enacted Special Enrollment Periods (SEPs) in response to the COVID-19 outbreak, click here to learn more. NCL believes that healthcare is a right and that protections offered by the ACA make this country a far stronger, more robust nation. We will continue to work diligently to protect universal access affordable and reliable health coverage. To learn more about what’s at stake and how you can help prevent the potential repeal of the ACA, click here.

Idaho Patient Act a model for other states for protecting consumers from medical debt

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I spent a week last month in Boise with two members of the staff of Melaleuca—a company that makes more than 400 nutritional, cleaning, personal care, and cosmetic products—making lobbying visits to the Idaho legislature. Katie Hart and Jay Cobb work for Frank Vandersloot, CEO of Melaleuca. Vandersloot is a highly successful, conservative businessman who is committed to protecting Idaho residents from abusive medical debt collection practices after discovering that one of his employees was hit with thousands of dollars in bills—including hefty lawyers’ fees and court costs—based on a $294 medical debt that she couldn’t even identify. The stark reality is that 50 percent of bankruptcies in America are caused by medical debt. He was championing a bill called the Idaho Patient Act, House Bill 515.

Many people believe federal law provides broad protections for people in debt. While the federal Fair Debt Collection Practices Act (FDCPA), enforced by Federal Trade Commission, makes it illegal for debt collectors to use abusive, unfair, or deceptive practices when they collect debts, it doesn’t address how debts are calculated or curb predatory fees, penalties and court costs.

NCL has worked with Melaleuca for several years, first to fight a bill in Congress that would have essentially legalized pyramid scheme activity. Last October, I flew to Melaleuca headquarters in Idaho Falls to meet nearly half of the state’s legislators who came to town as part of their tour of businesses in Idaho. At that gathering, Vandersloot discussed his hope to pass a bill to address these predatory collection practices, aiming his fire at the practice of ginning up the cost to patients of medical debts with thousands in lawyers’ and court fees; often patients have no idea where the debt is from and debt collectors aren’t required to provide that information to them. The Idaho Patient Act addresses that issue.

Vandersloot also puts his money where his mouth is: not only did he propose a legislative remedy, he and his wife Belinda created a $1 million fund to provide legal counsel to Idahoans who have been hit with these attorney bills. Consumer advocates like NCL have been working for decades to curb the excesses of this industry. But to see  a conservative CEO take on this issue gives the effort a new push.

Sticking up for the little guy is not out of character for Vandersloot. He spoke with the same fervor when we worked together fighting a bill that would have legalized pyramid schemes. In neither case was there any financial reward coming to Melaleuca—Vandersloot took a stand on this issue because he felt it was the right thing to do. Though we may disagree on a host of other matters, on this we are aligned and that is a good thing for vulnerable consumers. Strange bedfellows are a big advantage when it comes to getting things done in the political arena.

Katie Hart has been wisely deployed to live and work in Boise while the legislature is in session and navigate this important bill through the complicated legislative process. She’s a smart and charismatic lawyer—she and Jay Cobb, an expert strategist, could teach Lobbying 101: they’ve met with the Idaho Hospital Association, Idaho doctors, insurance companies, and the Idaho trial lawyers and revised the bill to address their concerns. 

Specifically, the Idaho Patient Act proposes the following:

  1. All health care providers must submit all charges for procedures performed to an insurance carrier within 45 days.
  2. Within 60 days, the patient must receive a summary of services rendered during treatment and recovery, including the names and contact information for all entities that may be billing the patient separately, such as an individual doctor.
  3. All providers must then send a final statement with a total amount owed by the patient after insurance. The bill must correspond with the original list of services.
  4. Health care providers must wait 60 days after sending the final notice before charging a patient interest on an outstanding bill and hiring a collection agency. They must wait 90 days from the final statement before they take “extraordinary collection actions,” which means a lawsuit, or reporting a patient to a credit bureau for failure to pay.
  5. Finally, in medical debt cases that result in litigation, the legislation limits the amount attorney fees and costs that can be shifted to the patient to $350 for uncontested cases and $750 for contested cases. Currently, there is no official cap for fees that can be charged to delinquent patients by collection agencies and their representing lawyers.

In Boise, my first order of business was to register in the Idaho capitol building as a lobbyist, even though I was only going to be there for the day.  We wanted to do everything by the book! For $11 the Secretary of State’s office put me into the system and off we went.

Jay Cobb explained that Idaho is very conservative where rules or regulations are frowned upon. Of the 70 members of the Idaho House, 56 are Republican and some of those lean far right. 14 are Democrats. Of the 35 members of the Senate, only 7 are Democrat. The Governor is Republican, as is the Secretary of State and the Attorney General.

Katie and Jay have been working for months with elected officials, revising the bill without compromising its impact, and last week the measure was  reported favorably from the House Business Committee by a 15-2 vote (after a 5 hour hearing with many witnesses and terribly sad stories). Adding to the challenge of getting this bill enacted the second Vice Chair of the Republican Party in Idaho, and a member of the Idaho legislature were adamantly opposed to the legislation because as their egregious medical debt collection practices were epicenter of the problem.  Now the bill goes to the full House and over to the Senate.

While in the state house, we met with Senator Grant Burgoyne, a democrat who has provided legal representation to the collections industry. His observation? this bill would rein in “bad actors,” and the collections industry as a whole doesn’t oppose it. Senator Michelle Stennett, a democrat from Ketchum, told us about the challenges of getting what she thought were reasonable measures out of committee in Idaho because members are so loathe to pass any laws. The longest serving Democratic House member told us she believes the bill will pass, and the very smart and entertaining newly elected Boise Representative Steve Berch, who ran five times as a democrat in a red district and finally got elected, also predicts a positive outcome for this bill.  

To cap off the day, both U.S. Senators were in the State House and I had the chance to say hello to one of them, Senator James Risch (R-ID) and meet his DC staff.

The calculus changes when a conservative CEO with political clout backs a bill to offer protections to consumers who -through no fault of their own -have medical debt. Thanks to Frank Vandersloot, Katie Hart and Jay Cobb and the whole team at Melaleuca for making their case to the Idaho legislature so persuasively.

We hope this bill gets enacted in Idaho. If it does, the law will become a template for other states to put reasonable guardrails around collection of medical debt and offer some much-needed consumer protections. And maybe we can even hope that Vandersloot’s willingness to use his clout and bully pulpit to speak out on behalf of those who have no voice will be emulated by other CEOs.

Postscript

On March 9, the Idaho Senate passed the Idaho Patient Act 32-1. On March 16 Idaho Governor Brad Little signed the bill into law.

Congratulations to Frank Vandersloot, Melaleuca’s CEO, to his talented team of Katie Hart and Jay Cobb, and to all the members of the Idaho state legislature, who stood up for consumers and understood that one in seven Idahoans struggle with medical debt.

To quote the words on the Hanukkah dreidel, “A great miracle happened there.”

NCL urges caution following HHS drug importation announcement

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December 20, 2019

Media contact: National Consumers League – Carol McKay, carolm@nclnet.org, (412) 945-3242 or Taun Sterling, tauns@nclnet.org, (202) 207-2832

Washington, DC – The National Consumers League (NCL)urges caution in light of this week’s announcement on drug importation from the Department of Health and Human Services. Our primary concerns are that this proposed new rule will put the public at greater risk of counterfeit drugs while not clearly passing on any cost savings on to consumer.

NCL recently launched the Fake Rx Action Center in conjunction with our site Fraud.org, which aims to educate consumers on the risks posed by counterfeit medicines, and how to spot, avoid, and report them should consumers come across any fakes. Counterfeit medicines have already claimed lives across the country, and this proposal further endangers consumer health by undermining the security of the American pharmaceutical supply chain.

Opening the door for states, pharmacies, and distributors to obtain medications beyond U.S. borders means that consumers could more easily fall prey to bad actors from around the globe when being provided medications that have originated outside of the U.S. regulated manufacturing and distribution supply chain. As the World Health Organization has noted regarding the broader counterfeit issue, patients may end up with medications that have the wrong active ingredient, the wrong amount of active ingredient, no active ingredient, or dangerous added ingredients. While we will continue to advocate for access to affordable drugs, it is not clear from the regulations that any potential cost savings from obtaining medications outside the U.S. borders will be passed on to individual consumers. The goal of lowering prices for consumers without a clear assurance of out of pocket cost savings in these regulations is not worth increasing the risk of harm to consumers by exposing them to medications that may not meet the clear standards of U.S. law.

Our organization has put consumers first for more than 100 years. It is our belief that there are safer and more effective ways to provide access to necessary prescription medications than to expose Americans to potentially deadly counterfeits originating outside the United States.

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About the National Consumers League (NCL)

The National Consumers League, founded in 1899, is America’s pioneer consumer organization. Our mission is to protect and promote social and economic justice for consumers and workers in the United States and abroad. For more information, visit www.nclnet.org.

No more surprises: Congress and patients alike sick of surprise billing

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headshot of NCL Health Policy intern Alexa

By NCL Health Policy intern Alexa Beeson

This July, the House Energy and Commerce’s Health Subcommittee passed the No Surprises Act (H.R. 3630) to protect patients from surprise billing. The Senate Health, Education, Labor and Pensions Committee also passed its companion to address surprise billing, the Lower Health Care Costs Act (S.1895). These bills were being considered after a press conference at which President Trump called for reform in surprise billing.

Stakeholder witnesses at the House hearing this June on H.R. 3630 included patient, provider, and insurance payer groups. Reimbursement models were discussed at length, but the unifying theme was that patients should be held harmless in surprise billing situations.

Surprise billing happens mostly in a small subsect of out-of-network providers; the patient has no idea about who’s in or out of network. Some professionals are out-of-network technicians subcontracted by an in-network facility, such as a last-minute anesthesiologist switch for a surgery, or any other non-disclosed provider. To get reimbursed for their services, providers send a bill to the patient for whatever wasn’t covered by the insurance company.

Surprise billing also occurred among patients who should receive reduced prices for care. Johns Hopkins Hospital filed suit on more than 2,400 patients in the last decade, collecting the equivalent of 0.03 percent of its operating revenue. Some of these patients were never told about their right to charity care, and many who qualify never received a discounted rate. These bill collections are inconsequential for Johns Hopkins but could bankrupt a patient.

Legislation to address balance or surprise bills will protect patients, ensuring they will only have to pay in-network rates for out-of-network emergency care. This will help patients avoid bills that can set them back, sometimes, hundreds of thousands of dollars. Although surprise bills only come from a small portion of providers, 1 in 7 insured adults will receive a surprise medical bill from an in-network hospital. The Kaiser Family Foundation found that 70 percent of such patients were not aware that the provider was out-of-network when they received the care.

Panelist Sonji Wilkes, a patient advocate, presented testimony about her struggle with a surprise bill sent after the birth of her son, who was diagnosed with hemophilia. That child was treated by a charitable out-of-network hematologist who did not charge them for her services. However, the NICU that observed the boy was subcontracted to a third-party provider. This meant that the NICU was out-of-network. The Wilkes were sent a $50,000 bill by the hospital that still haunts them 15 years later.

Thomas Nickels, the executive vice president of the American Hospitals Association, claimed that fixed reimbursement rates, such as a median benchmark or percentage of the Medicaid reimbursement value, would disincentivize insurers from maintaining adequate provider networks. Nickels supported the Alternative Dispute Resolutions method, which involves baseball-style arbitration where providers and payers settle on reimbursement value on a case-by-case basis.

Jeanette Thornton, a senior vice president at America’s Health Insurance Plans, argued that the New York model of baseball-style arbitration would create immense clerical burden, resulting in lost time and greater administrative costs. She argued the arbitration reimbursement model would raise costs for patients in the end. Instead, she advocated for the government-dictated fixed reimbursement rates.

Both versions of the bill call for a benchmark to resolve payments between insurance plans and out-of-network providers. This benchmark says health plans would reimburse providers with the median in-network rate already contracted within specific geographic areas. The House bill contains binding arbitration as a fallback in case either the provider or payer decide the payment was an unfair price.

The National Consumers League supports Congress’ tackling of this issue of surprise or balance billing. NCL has taken no position on how these bills are settled between the payer and provider, as long as patients are protected from outrageously expensive bills they can never hope to pay and were never anticipating. In addition, medical debt is the greatest contributor to consumers declaring bankruptcy, and balance billing is a contributor to that troubling consumer issue. The bottom line is that a bill for medical services should never cause bankruptcy, and a patient should never have to choose between medical treatment and food or housing. We are hopeful this issue will be resolved during this Congressional session.

Alexa is a student at Washington University in St. Louis where she studies Classics and Anthropology and concentrates in global health and the environment. She expects to graduate in May of 2020

NCL statement on White House pathway for drug importation

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August 2, 2019

Media contact: National Consumers League – Carol McKay, carolm@nclnet.org, (412) 945-3242 or Taun Sterling, tauns@nclnet.org, (202) 207-2832

Washington, DC—As the nation’s pioneer consumer organization, the National Consumers League (NCL) strongly supports consumer access to safe, effective, and affordable prescription drugs. The recent announcement by the White House to open a pathway for importation of drugs from outside of the United States seems unworkable and poses safety and purity challenges.

Six years ago, the U.S. government enacted a safe system to “track and trace” drugs sold to U.S. consumers through the Drug Supply Chain Security Act. The law required, that by 2023, all drugs sold to U.S. consumers must have both a product identifier and a unique package code to allow Food and Drug Administration (FDA) and any buyer in the supply chain to obtain a comprehensive history of where the drug was manufactured and packaged. This secure supply chain system best ensures consumers are receiving medications that are not counterfeit or substandard.

“The recent announcement by the White House ignores the Drug Supply Chain Security Act and undermines the security of the U.S. pharmaceutical supply chain,” said Sally Greenberg, NCL executive director. “This new pathway for importation could easily lead to counterfeit or substandard drugs finding their way to consumer’s medicine cabinets, thus putting patient health and safety at risk.”

In addition to the safety risks posed by this new policy announcement, there are no guarantees that it will save consumers money. The proposal opens the door for states, pharmacies, and distributors to obtain the medications outside of U.S. borders, but it does not require that any cost savings from obtaining those “lower-priced” medications be passed on to consumers. So, even if safety concerns could be addressed, it is not clear that there will be any direct cost savings benefit to consumers.

The threat to public health is real. Counterfeit medications may contain the wrong active ingredient, the wrong amount of the active ingredient, no active ingredient, harmful ingredients, or even poisons such as mercury, road tar, or antifreeze. Counterfeit medications made with deadly ingredients have been found in more than 40 states across America, posing a significant public health threat.

“Allowing importation will only serve to exacerbate the challenge of preventing counterfeit drugs from reaching American patients,” said Greenberg.

NCL continues to advocate for more responsible strategies to ensure the affordability and accessibility of safe and effective prescription drugs.

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About the National Consumers League

The National Consumers League, founded in 1899, is America’s pioneer consumer organization. Our mission is to protect and promote social and economic justice for consumers and workers in the United States and abroad. For more information, visit www.nclnet.org.

Oral argument for ACA case will determine the fate of millions

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Nissa ShaffiOn Tuesday, July 9, the U.S. Court of Appeals for the 5th Circuit will hear oral arguments that will determine whether or not the Affordable Care Act (ACA) may be overturned. Throughout the course of its life, the ACA has been under the specter of possible repeal. While there have been piecemeal attempts to strike down the legislation over time, none have been as concerning as the most recent Texas v. United States case, which argues that since the individual mandate is no longer enforced, ACA  would be unconstitutional.

The individual mandate requires that most people maintain a minimum level of health insurance or be subject a financial penalty. In 2017 however, the Tax Cuts and Jobs Act (TCJA), set the individual mandate to $0 as of 2019. As a result of this ruling, the Texas v. United States case was filed by 20 Republican state attorneys general and governors. The plaintiffs argue that the ruling rendered the individual mandate futile, as it no longer produces revenue for the federal government, and since Congress declared the individual mandate to be “essential” when enacting the ACA, this would now make the entire law invalid.

In an ideal situation, the court would maintain the ACA as it exists today, absent the individual mandate. If the ACA is repealed along with the protections that come with it, close to 20 million people would lose their health coverage. Those affected will include mostly low-income adults and children with chronic or pre-existing conditions, dependent adult children ages 26 and younger, Medicare and Medicaid enrollees, employer and employee groups, and more.

Repealing the ACA would jeopardize Medicaid expansion, further burdening uncompensated care and provider reimbursement. In addition, repealing the ACA would increase health care costs among the uninsured by $50.2 billion, result in more than 9 million people losing federal subsidies to purchase health insurance via the marketplace, and would endanger consumers’ ability to obtain essential health benefits.

California’s Attorney General, Xavier Beccerra, is leading a coalition of 21 Democratic attorneys general who have intervened to defend the ACA. Advocates interested in joining these efforts can contact izzy@xavierbecerra.com – please do so and sign the petition by July 14. In addition, organizations can participate in the TXvUS Tweetstorm to express their concerns regarding this case, using the hashtags #TXvUS and #WhatsAtStake, on July 9th at 2 pm EST/ 11 am PST.

NCL is a zealous supporter of the ACA and notes that it is still the law of the land. We are following the developments of this case closely and will continue to fight for access to affordable healthcare for all Americans. For more information on developments of this case, please click here.

FDA acts to protect women’s health

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Nissa Shaffi

Last April, the U.S. Food and Drug Administration (FDA) issued a ban on all sales of pelvic surgical mesh products after determining that the manufacturers, Boston Scientific and Coloplast, failed to “demonstrate [a] reasonable assurance of safety and effectiveness.”

The ban comes on the heels of a 2016 reclassification of the product by the FDA, resulting in a class III (high-risk) designation. As a result, the manufacturers were required to undergo meticulous review and obtain premarket approval by the FDA in order to continue sales of their products in the United States.

A surgical mesh is a medical device used to treat urogynecological or pelvic organ issues. Most commonly, surgical mesh has been used to treat pelvic organ prolapse (POP). POP is a type of pelvic floor disorder that occurs when the muscles and tissues supporting pelvic organs become weakened–often resulting in urinary incontinence typically seen as a result of childbirth or advanced age.

A transvaginal surgical mesh is intended to provide additional support to the pelvic floor muscles to reinforce a weakened vaginal wall for treatment of POP. A urethral sling surgical mesh is supposed to provide support to the urethra or bladder to address urinary incontinence. Surgical mesh comes in two forms: synthetic and animal derived. Synthetic surgical mesh remains in the body indefinitely and acts as a permanent implant. Animal derived mesh, made from the intestine or skin of pig or cow, are absorbable and lose durability over time.

The most frequent complications from these devices include vaginal scarring, mesh erosion, increased risk of infection, and painful urination. Nearly 10 million women worldwide have received mesh implants, with about 10 to 15 percent of these women suffering from complications. Following the ban, there are currently no FDA-approved pelvic surgical mesh products available for sale in the United States.

The FDA advises that women who have already received a transvaginal mesh for the surgical repair of POP should continue their routine follow-up care with their provider and need not take any additional action if they are satisfied with their procedure. Patients should notify their provider if they experience any adverse reactions, such as bleeding or pain, following the procedure.

Given the grave injury these devices have caused in women patients, the National Consumers League questions how they ever received FDA approval in the first place. Nevertheless, banning the devices now is better than keeping them on the market. We must expect better from our healthcare regulators. Thankfully, we now have stronger safety standards that have brought an immediate halt to the sale of these unsafe medical devices.

To read the FDA’s full report on transvaginal mesh, click here.

NCL Health Policy Intern Alexa Beeson contributed to this blog.