HR1458 and S565

[plugger]

I noticed S565 and HR1458, the federal bills to extend Medicare payment for transplant drugs, are still languishing in committee in Washington.  I thought it would be a good idea to gather a list of representatives with their contact info and post it on the web, so I did:

Senate bill S565
http://dialysisethics2.org/forum/index.php?topic=554.0

House bill HR1458
http://dialysisethics2.org/forum/index.php?topic=553.0

I've written most of the reps and already have a couple of responses I posted.

[Bill Peckham]

The Health Care Overhaul Bill does not include the coverage extension but doesn't it take the issue off the table by eliminating the preexisting condition exclusion? S565 and HR1458 would only have extended immunosuppressant drug coverage, fixing the system to eliminate the preexisting exclusion does a lot more.

If it is signed into law you could get the immunosuppressant coverage along with the insurance coverage that you'll need for other parts of your medical care.

Karol posted my blog post on health care over haul and the CKD advocacy agenda
http://ihatedialysis.com/forum/index.php?topic=18224.0
 

[Zach]

While eliminating the pre-existing condition exclusion is a good thing, insurance companies will not be required to include immunosuppressant drug coverage in their formularies.  And if they include only generic versions, is that a good thing?

[Bill Peckham]

While eliminating the pre-existing condition exclusion is a good thing, insurance companies will not be required to include immunosuppressant drug coverage in their formularies.  And if they include only generic versions, is that a good thing?

 

I think the base coverage would encompass most immuno drugs. The exchange has pretty high standards compared to some of the junk policies being sold today. Part of what this bill does is define what is minimally needed to call something acceptable insurance, routine Tx drugs would fit under there.

[Zach]

Part of what this bill does is define what is minimally needed to call something acceptable insurance, routine Tx drugs would fit under there.

"Trust but verify."
 

[Bill Peckham]

Part of what this bill does is define what is minimally needed to call something acceptable insurance, routine Tx drugs would fit under there.

"Trust but verify."
 

Da

Твоё здоровье!
 

[plugger]

I have no great love for the health insurance companies and don't mind it when they get stuck actually having to pay for health care.  However, I can see the scenario where an employer, especially a small company, might be reluctant to hire someone with a transplant and possibly risk having their insurance premiums go up. 

Then when lay-offs come, who might get laid-off first?  Possibly someone causing a greater expense for the company?

I actually would like to see a Medicare-for-all single-payer program, but that doesn't look like that is going to happen anytime soon.

[plugger]

I don't know, maybe I need to read the health care bill more (ugh).  But I'm also wondering about the scenario where a person has an individual catastrophic policy with a high deductible.  Are they going to still be driven broke if they come down with kidney disease and go on dialysis or get a transplant?

[plugger]

Ok, I went to a source I trust, Physicians for a National Health Program to see what they had to say about the latest health care reform:

"Millions of middle-income people will be pressured to buy commercial health insurance policies costing up to 9.5 percent of their income but covering an average of only 70 percent of their medical expenses, potentially leaving them vulnerable to financial ruin if they become seriously ill. Many will find such policies too expensive to afford or, if they do buy them, too expensive to use because of the high co-pays and deductibles."
http://pnhp.org/news/2010/march/pro-single-payer-doctors-health-bill-leaves-23-million-uninsured

It is sounding to me like bills S565 and HR1458 are still needed.

[Bill Peckham]

Ok, I went to a source I trust, Physicians for a National Health Program to see what they had to say about the latest health care reform:

"Millions of middle-income people will be pressured to buy commercial health insurance policies costing up to 9.5 percent of their income but covering an average of only 70 percent of their medical expenses, potentially leaving them vulnerable to financial ruin if they become seriously ill. Many will find such policies too expensive to afford or, if they do buy them, too expensive to use because of the high co-pays and deductibles."
http://pnhp.org/news/2010/march/pro-single-payer-doctors-health-bill-leaves-23-million-uninsured

It is sounding to me like bills S565 and HR1458 are still needed.

Another way of saying this is that millions of middle income people will finally have the option to buy health insurance for no more than 9.5% of their income.

The calculus is: will it be worth $1,300 (yearly Part B Medicare premiums) - in addition to the the insurance premiums you will be buying through the exchanges, to have 80% coverage of transplant drugs, for people with kidney transplants.

Only kidney patients will be spending extra for the Medicare extension? That just does not make sense to me. People with liver/heart/lung transplants will be in the exchanges. The policies will necessarily cover their immunosuppressants.

Remember the bills extend immunosuppressant coverage, people will still need to buy health insurance through the exchanges.

[plugger]

I did see Senator Richard Durbin from Illinois did try to get an amendment added to the big health care reform bill that would have extended Medicare coverage for transplants (The Durbin Kidney Immuno Drug Amendment in the Senate’s health care reform bill, S.Amdt. 3102 to H.R. 3590).  As far as I can tell, it didn't make it on the final bill.

However, I was curious to see what it might cost to get and maintain a kidney transplant.  I found this from Rand:

"H.R. 3590 expands the insurance options available to potential new purchasers by establishing Health Benefit Exchanges.  The Exchanges will offer four basic plans with different actuarial values: Bronze (60%), Silver (70%), Gold (80%), and Platinum (90%).  The actuarial value of a health plan is defined as the percentage of the “allowed charges” of a medical bill that the health plan will pay, on average, for a standardized population. Plans with higher actuarial values have higher premiums and lower deductibles and copayments."
http://www.rand.org/pubs/research_briefs/2010/RAND_RB9514.pdf

Last I saw it takes about $17,000 a year to maintain a transplant - plus about $100,000 for the surgery.  A person would be paying at least anywhere from $1700 (platinum program) to $6800 (bronze program) dollars a year for the transplant, plus whatever the insurance premiums would be.  And I'm assuming there would be costs from the surgery.

Maybe with the new bill things will be better than they were, but from what I'm seeing so far there might still be some disincentive to get a transplant.

[Bill Peckham]

The Affordable Care Act's out-of-pocket costs for those with incomes up to 400% Federal Poverty Level are limited to the following levels:

o  100-200% FPL: one-third of the HSA limits ($1,983/individual and $3,967/family);
o  200-300% FPL: one-half of the HSA limits ($2,975/individual and $5,950/family);
o  300-400% FPL: two-thirds of the HSA limits ($3,987/individual and $7,973/family).

As far as upper limits the basic package level (Bronze) must have specified “essential benefits” and will limit cost-sharing to no more than federal HSA limits ($5,950/ individual or $11,900/family in 2010).

The effect of extending Medicare immunosuppressant drug coverage would vary by a person's demographic data but in general, I think the extension would benefit people who have incomes over 400% of the FPL and copays in the year less than $5,950 (for an individual). That would be a pretty narrow band of people.

Rather than helping people who need immunosuppressants by extending Medicare why not directly subsidize premiums? Or provide tax credits for copays?

Is extending Medicare the most efficient option? That seems unlikely.

[plugger]

Bill,

Thanks for your help with all this!  I try to read and sort through this mess until my head wants to explode, it is good to have someone to share the pain with.  It also does help me remember why I so hate private health insurance companies.

I did find a nice Kaiser analysis that had this to say about premiums:

• Provide refundable and advanceable premium credits to eligible individuals and families with incomes
between 133-400% FPL to purchase insurance through the Exchanges. The premium credits will be tied
to the second lowest cost silver plan in the area and will be set on a sliding scale such that the premium
contributions are limited to the following percentages of income for specified income levels:

Up to 133% FPL: 2% of income
133-150% FPL: 3 – 4% of income
150-200% FPL: 4 – 6.3% of income
200-250% FPL: 6.3 – 8.05% of income
250-300% FPL: 8.05 – 9.5% of income
300-400% FPL: 9.5% of income
http://www.kff.org/healthreform/upload/8061.pdf

I'm trying to come up with a worst case scenario and see how all this applies.  Say we have someone getting older, has kidney disease and has been cutting back on work, so they are making $10,000 a year (about 100% of Federal Poverty Level).  So that the figures in this post apply, the person is on a individual silver health care plan and is thinking about a transplant.  However, first the person wants to see what it is going to cost.

Our friend sees the following:

Premiums: $200 a year

out-of-pocket per year(co-pays, deductibles): $1983 (your post)

Transplant surgery: $30,000 (insurance pays $70,000)

The person is looking at paying $2183 a year for health care and would have bill for $30,000 for the surgery.  I was wondering if you agree with these figures so far?  Might be more help with all this, but I haven't seen it yet.  And I'm not sure how all this reform applies to dialysis.

[Bill Peckham]

I think the out of pocket cap includes deductibles, copayments, and coinsurance. That $30,000 is a copayment so it would fall under the cap.

Also if the person has income less than 133% of the FPL then they would qualify for Medicaid and 0 copays.

The way I think of it you start with Medicaid which is basically zero out of pocket and as income goes up you pay more and more out of pocket - potentially. Where you're talking at less then 200% of FPL the cost to the sick is much less than the tens of thousands of dollars.

[plugger]

That $30,000 is a copayment so it would fall under the cap.

That is a relief to hear!  Thanks again for helping me get this all straight.  It seemed ridiculous to have a bill of $30,000, but then our health system has been rather ridiculous - so it seemed possible.  I guess it is going from ridiculous to semi-ridiculous.

[plugger]

Or maybe I should say our health care system is going from utterly ridiculous to ridiculous.  I did some more digging around and did find a online Kaiser premium calculator and the section of the bill that limits out-of-pocket that Bill mentioned.  I thought it would be nice to figure out what is coming and I came up with the following numbers, they seem to closely jive with numbers I've seen elsewhere:

YEARLY INCOME             TOTAL EXPENSES (premiums and out-of-pocket)    PERCENT OF INCOME
$15,000                         $2482                                                                16.5%
$20,000                         $3102                                                                15.5%
$30,000                         $5625                                                                18.8%
$40,000                         $7760                                                                19.4% 

Kaiser premium calculator:
http://healthreform.kff.org/Subsidycalculator.aspx

Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans. The standard out-of-pocket maximum limits ($5,950 for individuals and $11,900 for families) would be reduced to one-third for those between 100-200 percent of poverty, one-half for those between 200-300 percent of poverty, and to two-thirds for those between 300-400 percent of poverty.
http://dpc.senate.gov/healthreformbill/healthbill49.pdf

So it looks to me someone making less than $40,000 a year is going to be asked to payout anywhere from ~16% to 20% of their income for health care (worst case) - that looks like a huge burden to me.  I don't know if extending Medicare is the answer or not, but it sure looks like something more is needed.  And I trust private insurance only to try and keep the money; I would favor some sort of government help.

(used the example of someone 60 years old on an individual policy)

[Bill Peckham]

Or maybe I should say our health care system is going from utterly ridiculous to ridiculous.  I did some more digging around and did find a online Kaiser premium calculator and the section of the bill that limits out-of-pocket that Bill mentioned.  I thought it would be nice to figure out what is coming and I came up with the following numbers, they seem to closely jive with numbers I've seen elsewhere:

YEARLY INCOME             TOTAL EXPENSES (premiums and out-of-pocket)    PERCENT OF INCOME
$15,000                         $2482                                                                16.5%
$20,000                         $3102                                                                15.5%
$30,000                         $5625                                                                18.8%
$40,000                         $7760                                                                19.4% 

Kaiser premium calculator:
http://healthreform.kff.org/Subsidycalculator.aspx

Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans. The standard out-of-pocket maximum limits ($5,950 for individuals and $11,900 for families) would be reduced to one-third for those between 100-200 percent of poverty, one-half for those between 200-300 percent of poverty, and to two-thirds for those between 300-400 percent of poverty.
http://dpc.senate.gov/healthreformbill/healthbill49.pdf

So it looks to me someone making less than $40,000 a year is going to be asked to payout anywhere from ~16% to 20% of their income for health care (worst case) - that looks like a huge burden to me.  I don't know if extending Medicare is the answer or not, but it sure looks like something more is needed.  And I trust private insurance only to try and keep the money; I would favor some sort of government help.

(used the example of someone 60 years old on an individual policy)

Politically I don't think it possible, right now (or for the next couple of cycles) to give more of a subsidy - paying $8,000 is not much of a burden compared to facing illness without health insurance. That person making $40,000 (no dependents) is a lot better off in 2014, than under current conditions.

But more to the point, given the new framework, that 60 year old (with a transplant I assume) will have to have insurance after 2014  so the question is: what do their expenses look like with and without HR1458 and S565? I don't think HR1458 and S565 would have much effect.

I think in 2014 someone who is 60 years old, living with a transplant, not working for a large employer, will happily take advantage of the opportunity to buy decent health insurance through the exchange (I expect that someone with a severe medical condition, earning $40,000 a year would opt for the gold or platinum plan). Given that, why would they sign up for duplicative coverage through Medicare?

[plugger]

I guess I see it more as another choice, than duplicative.  It could be something like the public option we were promised.  I get a bit concerned when I read things such as the following:

"The much-vaunted insurance regulations - e.g. ending denials on the basis of pre-existing conditions - are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. Older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017."
http://www.pnhp.org/

Politically I don't think it possible, right now (or for the next couple of cycles) to give more of a subsidy

Don't know what is possible now or tomorrow.  Know if we give up now trying to get a better deal, it will be harder in the future.

 - paying $8,000 is not much of a burden compared to facing illness without health insurance. That person making $40,000 (no dependents) is a lot better off in 2014, than under current conditions.

That person making $15,000 is even less well off.  %16 just seems ludicrous!

[paul.karen]

To say paying 20% of your paycheck on top of tax's isn't a much of a burden is ludicrous at best.  What if the person is healthy and not in need of healthcare like we here are?

To have faith that the government wont totally screw this up is a joke.
They run the post office-medicare-Social security and so many other entities so poorly, yet they will manage healthcare keep costs down help more people with less doctors all while dropping wait times.

I suppose the VAT tax will be a happy day for one and all.

For a FRACTIN of the trillion we are being charged we could have coverd ALL the people without healthcare while letting people who already had it alone.

All this and there are still going to be Millions of people in the US who arnt covered.  And that doesn't include the illegal alien population.

Full trust in Government  Not for me sorry....  But I'm glad some think the government is great and has all the answers, this is what makes the world go around.

 

[Bill Peckham]

PK you're making the choice of reacting to only half a sentence, there isn't really anything I can discuss if that's your choice.

Plugger HR1458 and S565 would add over $1,300 in premiums to the total cost columns without providing additional medical care - that's duplicative. If the legislation would extend full Medciare benefits to people post transplant that would be an entirely different matter but HR1458 and S565 extends only immunosuppressant coverage.

I can imagine legislation that would be more supportive of transplants but HR1458 and S565 isn't it. What I am calling for is a reassessment of the situation. The worst course is to ask the many transplant advocates to lobby for something that won't help.

[plugger]

Full trust in Government  Not for me sorry....  But I'm glad some think the government is great and has all the answers, this is what makes the world go around.
 

I trust big business even less when it comes to health insurance.  I'm not sure what qualms you have with Medicare (might be legitimate), but it looks pretty good to me when compared to private health insurance:

"Private insurers take, on average, 13% of premium dollars for overhead and profit. Overhead/profits are even higher, about 30%, in big managed care plans like U.S. Healthcare. In contrast, overhead consumes less than 2% of funds in the fee-for-service Medicare program, and less than 1% in Canada’s program."  http://www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_system.php

I remember when my daughter was in the clinic for dialysis.   My recollection was my private insurance was getting gouged and it looked like it was Medicare trying to hold down costs.  Seems backwards, but then I realized Medicare was paying for most of the dialysis in this country and private insurance is so fragmented, they have no real clout - another reason I would like to see a Medicare-for-all type program in this country, but that is another subject.

However, if you are interested in that sort of thing, Physicians for a National Health Program has some nice FAQs and articles:

http://www.pnhp.org/facts/single-payer-faq

http://www.pnhp.org/news/articles-of-interest

Plugger HR1458 and S565 would add over $1,300 in premiums to the total cost columns without providing additional medical care - that's duplicative. If the legislation would extend full Medciare benefits to people post transplant that would be an entirely different matter but HR1458 and S565 extends only immunosuppressant coverage.

I can imagine legislation that would be more supportive of transplants but HR1458 and S565 isn't it. What I am calling for is a reassessment of the situation. The worst course is to ask the many transplant advocates to lobby for something that won't help.

Bills morph and change - maybe these will, or maybe new bills will have to be started.
 
 I guess what I would like to see is if someone started out with Medicare drug coverage and liked it, they could stay with Medicare.  And if someone found their private health insurance lacking, they should have the option of dropping their current drug coverage and picking up with Medicare.  I have serious trust issues with private insurance.  As I pointed out earlier, there already are loopholes for pre-existing conditions, hard telling what is in store for drug coverage.

"The much-vaunted insurance regulations - e.g. ending denials on the basis of pre-existing conditions - are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation." http://www.pnhp.org/

And thanks Bill for pointing out the bills in their present form will probably have to be tweaked!

[Zach]

Here's an interesting podcast from the American Society of Nephrology:
http://www.asn-online.org/publications/kidneynews/podcast.aspx

Expansion of Immunosuppressive Drug Coverage - An Imperative Reform
Tue, 18 May 2010 12:02:00 EDT

Transplant nephrologists David Cohen, MD, and Bryan Becker, MD, discuss immunosuppressive legislative debate and next steps.

Duration: 00:24:01

~~~~~~~~

No need to download anything, just press the "Listen" button.

[Bill Peckham]

Here's an interesting podcast from the American Society of Nephrology:
http://www.asn-online.org/publications/kidneynews/podcast.aspx

Expansion of Immunosuppressive Drug Coverage - An Imperative Reform


Tue, 18 May 2010 12:02:00 EDT

Transplant nephrologists David Cohen, MD, and Bryan Becker, MD, discuss immunosuppressive legislative debate and next steps.

Duration: 00:24:01

~~~~~~~~

No need to download anything, just press the "Listen" button.

 

Here's my DSEN post on the podcast:

The kidney transplant community's stabbed in the back narrative

By Bill Peckham

On Friday RenalWEB linked to an American Society of Nephrology podcast that is deeply frustrating.

Expansion of Immunosuppressive Drug Coverage - An Imperative Reform, presents the National Kidney Foundation's and the American Society of Transplantation's explanation of how the transplant advocacy community failed to achieve their objective of extending immunosuppressant drug coverage, under Medicare Part B, to certain kidney transplant recipients. The podcast is a companion to editorials published in the Clinical Journal of the American Society of Nephrology (ASN hopefully will make the CJASN editorials freely available).

The story according to the podcast set-up (the fist minute) is that there is "bipartisan support for extending immunosuppressant benefits for the life time of the transplant", that such an extension makes "good clinical and economic sense" however, the narrative continues, in the process of passing healthcare reform "the Senate removed" from the House's healthcare bill a provision that would have extended immunosuppressant coverage.

Given that starting point, the editorials and podcasts present two explanations for events. Bryan N. Becker, MD, the President of the National Kidney Foundation, describes events as manifesting "A Conflict of Responsibility": the NKF couldn't support the House's approach to extending benefits because the pay for would disadvantage people on dialysis. David J. Cohen, MD, American Society of Transplantation Board member, gives what I take to the be the transplant community's explanation of events: the NKF's objection to the legislation is baseless and the root motivation was profits. Cohen's charge is that the dialysis industry (aka Kidney Care Partners), sacrificed a clear benefit for transplant patients on the altar of financial gain.

Where to begin. This is wrong on so many levels. First and foremost, there is no acknowledgment that immunosuppressant drug coverage under Medicare Part B has ALWAYS been a suboptimal solution to the problem. People need more than a few medications to successfully live with a transplant. The AST and NKF are continuing to advocate for legislation that would not even cover the doctor visits needed to maintain those prescriptions. This isn't what people need.

What people living with a transplant really need is access to health insurance. Affordable health insurance which would provide access to all the medical service they need including immunosuppressant drugs. Wouldn't that be nice - access to health insurance without having to find a way into a large Employer Group Health Plan.

The idea of providing access to health insurance, including access for people with preexisting conditions, should sound familiar because the bill under discussion, the one that didn't extend immunosuppressant drug coverage, that bill did extend health insurance access to people living with a transplant.

It's always disappointing to hear nefarious motives ascribed to those who advocate for optimal dialysis but what I find frustrating is the central complaint: that a redundant half measure wasn't passed. Get over it. On January 1, 2011 we will enter a new era.

After January 1 someone on dialysis, with Medicare primary, who gets a transplant - they will have full Medicare access for 36 months and then when that is up they will have access to insurance through the new public Exchanges (if they haven't found their way into a large employer group). That's a big change. That change represents a huge win for kidney patients. Advocates should now be working to make sure the Exchange policies, and the high risk pool policies during the 2011-1014 transition period, meet the needs of those with a transplant. January 1 is less than 7 months away, the NKF and AST should be working on new messaging to spread the good news that the future is bright.

[Zach]

Bill,
I thought you'd find the podcast interesting.

[plugger]

I decided to have some more fun with math!  Some members of my church have been studying the new health care bill and told me about another clause in the bill that changes some of the numbers I mentioned earlier:

Cost-sharing subsidies (page 2) • Provide cost-sharing subsidies to eligible individuals and families. The cost-sharing credits reduce the cost sharing amounts and annual cost-sharing limits and have the effect of increasing the actuarial value of the basic benefit plan to the following percentages of the full value of the plan for the specified income level:

100-150% FPL: 94%

150-200% FPL: 87%

200-250% FPL: 73%

250-400% FPL: 70%
http://www.kff.org/healthreform/upload/8061.pdf

Also Kaiser updated their calculator to reflect 2014 dollars.


And my church friends gave me a worksheet to figure all this out.  Anyway, if anybody wants the long version of how to figure health care costs due to the new bill, here it is:
                                                                                                                             # 1                 # 2
                                                                            Benefit                                       Out-of-           Out-of-
                                                        Benefit        Cost Limit               Prem Cost        Pocket            Pocket
                        Out-of-Pocket             Cost          (of $17,000)            After                Limits             Limits (b)
Ann'l Inc.           Ann'l Max (a)               Limit (%)        ($)(b)                 Credits (c)        (a) + (c)          + (c)

$16,000             $2083                         6%               $1020                 $537                $2620               $1557
$20,000             $2083                        13%              $2210                $1019               $3102               $3229
$25,000             $3125                        27%              $4590                $1726               $4851               $6316
$30,000             $3125                        30%              $5100                $2509               $5634               $7609
$40,000             $4167                        30%              $5100                $3800               $7967               $8900
------------------------------------------------------------------------------------------------------------------------

(continued)
Total est.          Health Expenses
Out-of-Pocket    % of income
Limit (Lessor      (premiums+
of #1 or #2)       out-of-pocket)
   
$1557                 9.7%
$3102               15.5%
$4851               19.4%
$5634               18.8%
$7967               19.9%