Counting On Medicaid To Avoid Life In A Nursing Home? That’s Now Up To Congress.

Ten years ago, a driver ran a stop sign as Jim McIlroy rode into the intersection on his motorcycle. Serious injuries left McIlroy paralyzed from the chest down. But, after spending some time in a nursing home, he returned to his home near Bethel, Maine.

McIlroy does most of his own cooking since Maine’s Medicaid program paid for a stovetop that he can roll his wheelchair underneath to reach the food-prep area. His new kitchen sink has the same feature. Wheelchair-friendly wood flooring has replaced McIlroy’s wall-to-wall carpeting.

The alterations plus a personal care aide — all paid for by Medicaid — enable McIlroy to stay in his house that he and his wife, who has since died, “worked really hard to own,” he said. The arrangement also saves Medicaid roughly two-thirds of what it would cost if he lived in a nursing home.

McIlroy depends on the federal-state program’s growing support of home-based care services — along with 2 million elderly or disabled Americans who rely on them to live at home for as long as possible.

However, that crucial help could face severe cuts if congressional Republicans eventually succeed in their push to sharply reduce federal Medicaid funds to states.

States can choose whether to offer Medicaid services at home, but nursing home coverage, which is more expensive, is a required benefit. Optional benefits like home services would likely be first to go if states face budget troubles, the Center on Budget and Policy Priorities (CBPP) warned in an analysis in May.

Esther Ellis holds an emergency call button she wears as a pendant around her neck provided by Partners in Care, a Medicaid-funded home-care service that helps her live at home and avoid nursing home care. “If it wasn’t for them, I don’t know what I would do,” she says. (Heidi de Marco/KHN)

Children with special health needs, older adults and people with disabilities greatly value home- and community-based assistance, said Sen. Susan Collins (R-Maine), who chairs the Senate Select Committee on Aging.

“That’s why I am deeply concerned with proposals that would significantly cut Medicaid, forcing governors and state legislators to confront difficult budget choices, including how to maintain these critical, but optional, services,” said Collins, one of three Republicans whose votes early Friday helped defeat the Senate’s “skinny repeal” measure that would have scuttled the Affordable Care Act.

While home services are not a required part of Medicaid, they represent a large share of Medicaid spending. Medicaid expenses for long-term care consumed a third of the Medicaid budget nationwide in 2015, and more than half of that amount went to optional home-based care, according to a government report. Nursing homes got the rest.

Jim McIlroy, 73, grows cucumbers, peppers and tomatoes on the deck of his house. Ten years ago, a driver hit him as he rode his motorcycle, leaving McIlroy paralyzed from the chest down. (Courtesy of Judy Gould)

“Staying at home is so incredibly important,” said McIlroy, 73, who grows cucumbers, peppers and tomatoes on the deck of his house. “You can do what you want to do when you want to do it, and you don’t have to share a room with somebody else and have your meals brought to you.”

Yet demand for home-based services is outpacing supply. In Maryland, more than 20,000 people were on a registry awaiting openings for Medicaid home-based services last month. About 160,000 older or disabled people across the country were waiting for home services in 2015, according to a Kaiser Family Foundation report last year. (Kaiser Health News is an editorially independent program of the foundation.)

Esther Ellis, who lives outside Los Angeles, received a new mattress this year from Partners in Care Foundation, a nonprofit that runs four of the 38 sites in California’s Multipurpose Senior Service Program and provides Medicaid-funded home services.

The mattress helps relieve her back problems after surgery. Partners also provided a couch, a microwave and an emergency call button to summon help that she wears as a pendant around her neck.

“If it wasn’t for them, I don’t know what I would do,” said Ellis, 79.

Home-based Medicaid benefits and eligibility vary by state and can include:


Home health and personal care aides, a visiting nurse, psychotherapy, automatic medication dispensers, pest control services


  • Emergency call buttons, motion detectors that alert emergency responders
  • Kitchen, dining:

    • Microwave ovens, air conditioners, food processors, stabilizing forks and spoons for people with hand tremors, automatic shut-off devices for electric stoves
    • Home modifications: 

      • Ramps, stair lifts and widened doorways for wheelchair access, bathroom grab bars, automatic door openers for walk-in showers
      • Outdoors:

        • Snow removal

Advocates argue that home-based services can make a big difference for health. “It’s all well and good to discharge people from the hospital with a list of medications to take,” said Camille Dobson, deputy executive director of the National Association of States United for Aging and Disabilities, which represents state departments of aging. “But if they go home to a refrigerator that doesn’t work so that they can’t store their medications or have no way to get to their appointments, all of that great medical intervention goes for naught.”

Medicaid home services usually include a visiting nurse or nurse practitioner, a home health aide or someone to help with dressing, eating and other daily activities, light housekeeping and transportation to doctor’s appointments. But that’s just the beginning.

The programs also pay for home modifications, which include minor renovations such as grab bars in the bathroom to prevent falls and wider door frames to accommodate wheelchairs. To overcome potentially treacherous stairs, states may provide wheelchair ramps and some — including California and Ohio — will install a stair glider or chairlift.

Carolyn Gilliland, 81, has lived in her home in central Ohio’s farm country since she was 4. She receives home-based services to help with chronic health problems through a Medicaid managed-care plan called MyCare Ohio. It provides two weekly visits from a nurse, a personal care aide and a chairlift to reach her second-floor bedroom. Until it was installed in April, she couldn’t go upstairs.

“It relieves the stress on my knees,” she said.

Home health services, plus any appliances, electronics and other items, must be medically necessary and part of an individual care plan. Recipients must receive Medicaid, and in most cases must be sick enough to qualify for nursing home care.

Among them is Cynthia Dutil, 60, who lives near Waterville, Maine. Because she has cerebral palsy, she depends on a personal care aide for help with dressing and other daily activities. Maine’s home-based services program also provided a small food processor to puree her foods, a large-print keyboard for her computer and a two-sided toothbrush.

Dutil said she’s living life on her terms. She began to explain why she prefers that to living in a nursing home, but stopped midsentence. “How much time do you have?”

For more information about Medicaid home-based services, go to or call 1-800-677-1116.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation and its coverage of aging and long-term care issues is supported by The SCAN Foundation.

Categories: Aging, Medicaid, Repeal And Replace Watch, The Health Law

Tags: Disabilities, Nursing Homes

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Trump aims at insurers in battle over healthcare subsidies

WASHINGTON/NEW YORK (Reuters) – U.S. President Donald Trump on Monday took aim at the nation’s health insurers in an escalating threat to cut the healthcare subsidy payments that make Obamacare plans affordable, one day after urging Republican senators to continue working to undo his Democratic predecessor’s healthcare law.

“If ObamaCare is hurting people, & it is, why shouldn’t it hurt the insurance companies & why should Congress not be paying what public pays?” Trump, a Republican, wrote on Twitter.

Trump, frustrated that he and Republicans have not been able to follow through on their campaign promises to repeal and replace Obamacare, has repeatedly threatened to let it implode. So far, the administration has continued to make the monthly subsidy payments, and withholding them is just one way they could make good on Trump’s threat that could weaken the law.

The president’s latest comments echoed his weekend tweets targeting the federal government’s cost-sharing reduction subsidies to insurers that lower the price of health coverage for the poor under the Affordable Care Act, known as Obamacare.

Kellyanne Conway, a senior counselor to Trump, told “Fox News Sunday” Trump would decide this week whether to end the cost sharing reduction (CSR) payments.

Insurers have asked the government to commit to making the $8 billion in payments for 2018. Trump could cut off the monthly payments for this year’s plans as soon as September.

“Beyond that is a sea of uncertainty,” analysts for Capital Alpha Partners wrote in a research note on Monday.

If the subsidies end, insurers have said they will raise premium rates by another 20 percent in 2018 to make up for losing them. They face an Aug. 16 deadline to submit 2018 rates for Obamacare plans.

Kristine Grow, spokeswoman for health insurer lobby America’s Health Insurance Plans, declined to comment on Trump’s latest tweet but said subsidies are a federally mandated part of the individual insurance market and that health plans do not profit from them.

Insurers that sell individual plans incorporating subsidies include Anthem Inc (ANTM.N), Molina Healthcare Inc (MOH.N) and Centene Corp (CNC.N). Anthem shares fell 0.5 percent to $186.80, Molina fell 2.2 percent to $68.45 and Centene fell 3.4 percent to $79.86 in morning trading.

The subsidy question looms after Republicans last week failed to push through their latest healthcare plan through the Senate, despite having a majority in the chamber.

A bipartisan group of 43 House lawmakers in a letter on Monday called for Congress to quickly stabilize the individual insurance market by appropriating money for the payments and creating a stability fund for states.

Reporting by Susan Heavey, Caroline Humer and Susan Cornwell; Editing by Jeffrey Benkoe and Bill Trott

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AstraZeneca fights back in cancer with new hires, fast drug status

LONDON (Reuters) – AstraZeneca hired two senior scientists to bolster its cancer drug work on Monday, signaling confidence in its oncology portfolio despite last week’s big setback in a lung cancer clinical trial.

The company said Jean-Charles Soria, previously a professor at South-Paris University, had joined the MedImmune biotech unit as head of oncology innovative medicines, while Geoffrey Kim would lead work on late-stage immunotherapy drug combinations.

Kim was most recently at the U.S. Food and Drug Administration (FDA), where he worked on the evaluation and regulation of medicines for a variety of cancers.

“Our ability to attract these recognized experts in the fast-developing field of immuno-oncology speaks to our exciting pipeline of innovative cancer treatments,” said MedImmune head Bahija Jallal.

AstraZeneca also announced its immunotherapy drug Imfinzi had been granted “breakthrough” designation by U.S. regulators for treating non-metastatic lung cancer following the success of the so-called Pacific trial.

The FDA decision paves the way for a speedy regulatory review and confirms the drug’s potential in earlier stage disease, despite its initial failure in the key Mystic trial, which targeted the bigger advanced cancer market.

Reporting by Ben Hirschler; editing by David Clarke

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Trump tells Republicans to get back on healthcare bill

WASHINGTON (Reuters) – U.S. President Donald Trump and members of his administration on Sunday goaded Republican senators to stick with trying to pass a healthcare bill, after the lawmakers failed spectacularly last week to muster the votes to end Obamacare.

For the second day running, the Republican president tweeted his impatience with Congress’ inability to deliver on his party’s seven-year promise to replace the Affordable Care Act, President Barack Obama’s signature healthcare bill commonly known as Obamacare. Members of his administration took to the airwaves to try to compel lawmakers to take action.

But it was unclear whether the White House admonishments would have any impact on Capitol Hill, where Republicans who control both houses signaled last week that it was time to move on to other issues.

Republicans’ zeal to repeal and replace Obamacare was met with both intra-party divisions between moderates and conservatives and also the increasing approval of a law that raised the number of insured Americans by 20 million.

Polling indicates a majority of Americans are ready to move on from healthcare at this point. According to a Reuters/Ipsos poll released on Saturday, 64 percent of 1,136 people surveyed on Friday and Saturday said they wanted to keep Obamacare, either “entirely as is” or after fixing “problem areas.” That is up from 54 percent in January.

With the U.S. legislative branch spinning its wheels, the executive branch pledged to look at rewriting Obamacare regulations. Health and Human Services Secretary Tom Price told ABC’s “This Week” that he would change those regulations that drive up costs or “hurt” patients.

Price sidestepped questions about whether there were administration plans to waive Obamacare’s mandate that individuals have health insurance, saying “all things are on the table to try to help patients.”

But Price also told NBC he would implement Obamacare because it is the “law of the land.”

That Obamacare was still law clearly angered Trump, who has no major legislative accomplishments to show for his first half-year in office. “Don’t give up Republican Senators, the World is watching: Repeal & Replace …” the president said in a tweet on Sunday morning.

Not ‘Time to Move on’

On Friday, Senate Republicans failed to collect enough votes to repeal even a few parts of Obamacare. That capped a week of failed Senate votes on whether to simply repeal, or repeal and replace, the 2010 law, while Trump repeatedly berated lawmakers in a late attempt to influence the legislation.

“The president will not accept those who said, quote, ‘it’s time to move on,'” Kellyanne Conway, a senior counselor to Trump, said on Fox News Sunday. Senate Majority Leader Mitch McConnell, a Republican, had made exactly that comment before dawn on Friday morning after the failed healthcare vote.

The White House budget director, Mick Mulvaney, said on Sunday lawmakers should stay in session to get something done on healthcare – even if this means postponing votes on other issues such as raising the debt ceiling.

“So yes. They need to stay. They need to work. They need to pass something,” Mulvaney said on CNN.

The House of Representatives has already gone home for its August break and the Senate is expected to do the same by mid-August.

Mulvaney also said Trump was seriously considering carrying out threats he tweeted about on Saturday, when the president said that “if a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”

That tweet appeared to be referring to the approximately $8 billion in cost-sharing reduction subsidies the federal government pays to insurers to lower the price of health coverage for low-income Americans.

The Saturday tweet also appeared to be a threat to end the employer contribution for members of Congress and their staffs, who were moved from the normal federal employee healthcare benefits program onto the Obamacare insurance exchanges as part of the 2010 healthcare law.

“What he’s saying is, look, if Obamacare is hurting the American people – and it is – then why shouldn’t it hurt insurance companies and more importantly, perhaps for this discussion, members of Congress?” Mulvaney said on Sunday on CNN.

Some Republicans have said they are trying to find a way forward on healthcare. Senate Republican Susan Collins, one of three Republicans who voted against repealing parts of Obamacare on Friday, told NBC that Congress should produce a series of bills with bipartisan input on healthcare, including appropriating the cost-sharing subsidies.

The Senate has one vote scheduled when it reconvenes on Monday afternoon: whether to confirm a U.S. circuit court judge. Senate aides said they had no guidance for the agenda beyond that vote.

Additional reporting by Sarah N. Lynch, Roberta Rampton, and Caren Bohan; Editing by Phil Berlowitz and Mary Milliken

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Trump threatens to end insurance payments if no healthcare bill

WASHINGTON (Reuters) – U.S. President Donald Trump threatened on Saturday to end government payments to health insurers if Congress does not pass a new healthcare bill and goaded them to not abandon their seven-year quest to replace the Obamacare law.

In a Twitter message on Saturday, Trump said “if a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”

The tweet came a day after Senate Republicans failed to muster enough votes to repeal parts of the Affordable Care Act, President Barack Obama’s signature healthcare bill commonly known as Obamacare.

The first part of Trump’s tweet appeared to be referring to the approximately $8 billion in cost-sharing reduction subsidies the federal government pays to insurers to lower the price of health coverage for low-income Americans.

The second part appeared to be a threat to end the employer contribution for Congress members and their staffs, who were moved from the normal federal employee healthcare benefits program onto the Obamacare insurance exchanges as part of the 2010 healthcare law.

Trump has previously threatened to suspend the payments to insurers, which are determined by the Department of Health and Human Services. In April, he threatened to end the payments if Democrats refused to negotiate over the healthcare bill.

Responding to Saturday’s tweet, Senate Democratic leader Chuck Schumer said that if the president carried out that threat, “every expert agrees that (insurance) premiums will go up and health care will be more expensive for millions of Americans.”

“The president ought to stop playing politics with people’s lives and health care, start leading and finally begin acting presidential,” Schumer said in a statement.

Trump later urged Senate Republicans to try again on a healthcare vote. The Senate is in session for another week before it is scheduled to begin an August recess.

“Unless the Republican Senators are total quitters, Repeal & Replace is not dead! Demand another vote before voting on any other bill!” Trump said in a subsequent tweet.

Many insurers have been waiting for an answer from Trump or lawmakers on whether they will continue to fund the annual government subsidies. Without assurances, many plan to raise rates an additional 20 percent by an Aug. 16 deadline for premium prices.

With Republican efforts to dismantle Obamacare in disarray, hundreds of U.S. counties are at risk of losing access to private health coverage in 2018 as insurers consider pulling out of those markets.

   In response, Trump on Friday again suggested his administration would let the Obamacare program “implode.” He has weakened enforcement of the law’s requirement for individuals to buy insurance, threatened to cut off funding and sought to change plan benefits through regulations.

Meanwhile, some congressional Republicans were still trying to find a way forward on healthcare.

Senator Lindsey Graham said in a statement issued late on Friday that he and two other Republican senators, Dean Heller and Bill Cassidy, had met with Trump after the defeat to discuss Graham’s proposal to take tax money raised by Obamacare and send it back to the states in the form of healthcare block grants.

Graham said the move would end Democrats’ drive for a national single-payer healthcare system by putting states in charge.

“President Trump was optimistic about the Graham-Cassidy-Heller proposal,” Graham added. “I will continue to work with President Trump and his team to move the idea forward.”

However, a majority of Americans are ready to move on from healthcare at this point. According to a Reuters/Ipsos poll released on Saturday, 64 percent of 1,136 people surveyed on Friday and Saturday said they wanted to keep Obamacare, either “entirely as is” or after fixing “problem areas.

When asked what they think Congress should do next, most picked other priorities such as tax reform, foreign relations and infrastructure. Only 29 percent said they wanted Republicans in Congress to “continue working on a new healthcare bill.”

Asked what they think Congress should do next, most respondents picked other priorities such as tax reform, foreign relations and infrastructure. Only 29 percent said they wanted Republicans in Congress to “continue working on a new healthcare bill.”

Additional reporting by David Lawder in Washington; Editing by Jonathan Oatis and James Dalgleish

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Even Without Congress, Trump Can Still Cut Medicaid Enrollment

After the Senate fell short in its effort to repeal the Affordable Care Act, the Trump administration is poised to use its regulatory powers to accomplish what lawmakers could not: shrink Medicaid.

President Donald Trump’s top health officials could engineer lower enrollment in the state-federal health insurance program by approving applications from several GOP-controlled states eager to control fast-rising Medicaid budgets.

Indiana, Arkansas, Kentucky, Arizona and Wisconsin are seeking the administration’s permission to require adult enrollees to work, submit to drug testing and demand that some of their poorest recipients pay monthly premiums or get barred from the program.

Maine plans to apply Tuesday. Other states would likely follow if the first ones get the go-ahead.

Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said absent congressional action on the health bill “the administration may be even more proactive in engaging with states on waivers outside of those that are already planning to do so.”

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The hope, he added, is that fewer individuals will be on the program as states figure out ways “to transition able-bodied enrollees into new jobs, or higher-paying jobs.” States need to shore up the program to be able to keep meeting demands for the “truly needy,” such as children and the disabled, he added.

To Medicaid’s staunchest supporters and most vocal critics alike, the waiver requests are a way to rein in the $500 billion program that has undergone unprecedented growth the past four years and now covers 75 million people.

Waivers have often been granted in the past to broaden coverage and test new ways to deliver Medicaid care, such as through private managed-care organizations.

But critics of the new requests, which could be approved within weeks, said they could hurt those who are most in need.

The National Health Law Program “is assessing the legality of work requirements and drug testing and all avenues for challenging them, including litigation,” said Jane Perkins, the group’s legal director.

The administration has already said it favors work requirements and in March invited states to suggest new ideas.

Before taking the top job at the Centers for Medicare & Medicaid Services, Seema Verma was the architect of a Kentucky waiver request submitted last year.

Not all states are expected to seek waivers, because Medicaid enjoys wide political support in many states, particularly in the Northeast and West.

Medicaid, the nation’s largest health insurance program, has seen enrollment soar by 17 million since 2014, when Obamacare gave states more federal funding to expand coverage for adults. It’s typically states’ second-largest expense after education.

This year, Senate and House bills tried to cap federal funding to states for the first time. Since the program began in 1965, federal Medicaid funding to states has been open-ended.

Health experts say allowing the waiver requests goes beyond the executive branch’s authority to change the program without approval from Congress.

“The point of these waivers is not for states to remake the program whole-cloth on a large-scale basis,” said Sara Rosenbaum, a health policy expert at George Washington University who chairs a Medicaid group that advises Congress.

Rosenbaum noted that states received waivers for different purposes under the Obama administration.

In Iowa, state officials won the authority to limit non-emergency transportation. Indiana received approval to charge premiums and lock out enrollees with incomes above the federal poverty level if they fell behind on paying premiums.

“Now there is concern these more extreme measures would hurt enrollees’ access to care,” Rosenbaum said.

Three states seeking waivers today are home to three key GOP players in the Senate health debate: Majority Leader Mitch McConnell (Kentucky), Sen. John McCain (Arizona) and Vice President Mike Pence (Indiana).

If states add premiums, as well as work and drug testing requirements, the result would be fewer people enrolling and staying in Medicaid, said David Machledt, senior policy analyst for the National Health Law Program.

“How does that serve the purpose of the Medicaid program and what are the limits of CMS waiver authority?” he asked.

Wisconsin, where Republican Gov. Scott Walker wants his state to become the first to require some Medicaid enrollees to undergo drug testing, is a prime waiver candidate.

State officials stress the effort is not to deter drug users from the program but to help provide treatment for drug users.

Wisconsin is also one of five states seeking a waiver to add a work requirement. People could meet the mandate through volunteering, job training or caring for an elderly relative.

In addition, Wisconsin wants to limit enrollees’ Medicaid benefits to 48 consecutive months, unless the beneficiary is working.

Enrollees with incomes from 50 percent to 100 percent of the federal poverty level, or between $6,030 and$12,060, would have to pay an $8 monthly premium.

All of these rules would apply to about 12 percent of people currently enrolled in Medicaid — adults who are not disabled and don’t have dependent children.

Wisconsin Medicaid Director Michael Heifetz said the main goal of the proposed changes is not to shrink the size of Medicaid but to get people into the workforce.

“The proposal is not designed to have folks leave the program except for positive reasons,” he said.

If the waiver is approved, the state anticipates annual savings of nearly $50 million and a drop in enrollment of 5,102 over five years.

Wisconsin now spends $7 billion on Medicaid and has 1.2 million recipients.

Asked why childless adults — not parents — are the focus of the waivers, Heifetz said Wisconsin wanted to test the provisions on a smaller population first and focus on adults who should be able to find work.

But the Wisconsin effort has sparked broad outrage from hospitals, doctors and advocates for people with disabilities.

The Wisconsin Council of Churches said the state would be punishing the poor with its waivers — and undermining the vitality of communities.

“We are concerned the proposed changes to the program will be detrimental for the health of our most vulnerable neighbors … and undermine the social fabric and vitality of our state,” said Peter Bakken, public policy coordinator for the group in Sun Prairie, a suburb of Madison.

Categories: Cost and Quality, Medicaid, Repeal And Replace Watch, States

Tags: Arizona, Arkansas, CMS, Indiana, Kentucky, Maine, Trump Administration, U.S. Congress, Wisconsin

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Remote Coaching Plus Cash Boosts Activity After Knee Replacement

Action Points

  • Note that this randomized trial found that a combination of financial incentives plus telephone-based coaching had a modest effect on increasing step counts among those after total knee replacement.
  • It is not clear how the increase in step counts translates into functional or long-term outcomes.

Health coaching by telephone integrated with financial incentives led to an increase in physical activity in patients following total knee replacement (TKR) for osteoarthritis (OA).

In a randomized trial involving 202 TKR patients, those assigned to the combined intervention increased their mean number of steps/day at 6 months by 1,808 compared with an increase of 680 in a control arm, reported Elena Losina, PhD, from Brigham and Women’s Hospital, Boston, and co-authors. In addition, the amount of time spent doing physical activity increased by 25 minutes/week compared with the controls.

“While surgery usually restores function and improves pain, previously sedentary individuals also require substantial behavior modification to change their post-operative physical activity,” they wrote in Arthritis Care & Research. “With recent moves to shift healthcare financing from paying for volume to value, expenditure of resources to improve physical activity will become increasingly attractive, given that physical activity is among the most important drivers of quality of life in OA.”

For the study, the authors screened patients 40 years and older with knee OA who were scheduled to undergo a primary, unilateral TKR at Brigham and Women’s Hospital. Patients wore an activity tracker for at least 5 days within a 7-day period prior to surgery and again during follow-up. Following surgery, patients were randomized to one of four groups: attention control; telephone health coaching; financial incentives; and telephone health coaching plus financial incentives.

Those randomized to attention control and financial incentives only received calls conveying general health messages, with conversations focused on general aspects of recovery and rehabilitation.

The telephone health coaching arm received periodic calls made by research staff trained in motivational interviewing techniques. These calls focused on the participants’ short- and long-term physical activity goals.

Patients assigned to financial incentives were given an escrow account of $105, from which they received $5 for completing at least five of seven daily (postoperative weeks 2 to 8) physical activity logs or a weekly (postoperative weeks 9 to 23) log. Bonus payments of $15 were awarded if the patients increased their self-reported minutes of physical activity by at least 10% from the preceding week. At 6 months, they were eligible to receive an additional $50 payment if they either increased their daily step count by at least 50% compared with the 3 months prior or met physical activity guidelines of ≥150 minutes of moderate-to-vigorous physical activity per week. Participants could earn a maximum of $305.

Mean patient age was 65 years, with 57% women. Prior to TKR, they walked a mean of 5,032 steps/day.

Some 74% wore the accelerometer for at least 4 days at both time points and formed the analytic cohort for the complete case analysis. Adjusting for the baseline step count, the average daily step count at 6 months ranged from 5,619 in the telephone health coaching arm to 7,152 in the telephone health coaching plus financial incentives arm. The control arm and financial incentives had similar step counts.

The mean increase in daily step count from baseline to 6 months was 680 in the control arm, 274 in the telephone health coaching arm, 826 in the financial incentives arm and 1,808 in the telephone health coaching plus financial incentives arm. The difference in the change in average daily steps over the 6-month period between the telephone health coaching plus financial incentives arm and the control arm was 1,128 (95% CI 14-2,241).

Patients in the telephone health coaching plus financial incentives arm increased their weekly mean MVPA between baseline and 6 months by 39 minutes. This increase was 25 minutes greater than the increase in patients in the control arm, which fell short of statistical significance (P=0.0967).

Results were similar in a sensitivity analysis using multiple imputation to augment missing data for 32 patients who provided baseline but not 6 month accelerometer data.

Potential limitations include the modest sample size, the limited duration of intervention, the lag time between increasing physical activity and financial rewards and the ability of patients to view same day step counts, which may have acted as motivation rather than simply a measurement device for research.

Losina disclosed being a statistical consultant to TissueGene.

This study was funded by National Institute of Arthritis and Musculoskeletal and Skin Diseases.

  • Reviewed by
    F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner


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By the Numbers: Getting to Know U.S. Pain Patients

Normally in this spot, we highlight a single finding from a recent study. This time around, we thought we’d take a different tack. We dug into the 2016 National Health Interview Survey — 805 questions asked of 33,000 Americans — and in particular the data on pain.

Nearly 1 in 7 respondents last year reported they felt pain every single day in the past six months. While the current wisdom is that pain is overtreated, we thought it would be worth taking a closer look at other ways this fairly large group differs from other respondents.

Bottom line: people who report chronic pain are older, in poorer health, more likely to be on depression or anxiety medication, and more financially troubled. They’re also slightly more responsible patients.

Age, of course, played a role. The median age of those who report daily pain was 59, which is 7 years older than the group as a whole. More than a third were over age 65 — a group that accounted for only a quarter of overall survey respondents.

No matter how you slice it, the group with daily pain had more health problems than survey respondents overall. They had more hypertension, more depression, more diabetes, and their average BMI was 29, compared with 27 for all respondents.




While the survey covers race, age, weight, and other questions you can’t ask in polite society, it doesn’t directly cover income. There are indications that those with daily pain tend to be at an economic disadvantage. Specifically, the group responded to a handful of questions about the stress from paying bills at a higher rate than respondents overall.

Despite that, those with daily pain were slightly more likely than all respondents to see a doctor regularly, and not just in emergency situations. Two-thirds reported getting regular preventive care, about 3 percentage points higher than the overall group of respondents.


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Analysis: GOP Failure To Replace The Health Law Was Years In The Making

This story was originally published on July 18.

After a week of high drama, culminating in a one-vote loss for a last-ditch bill, Senate Republicans conceded defeat early Friday morning in their seven-year push to “repeal and replace” the Affordable Care Act.

The failure, at least for now, breaks one of the key promises Republicans have made to their voters since 2010, when the ACA first became law.

“This has been a very challenging experience for all of us,” Senate Majority Leader Mitch McConnell (R-Ky.) told reporters Tuesday afternoon. “It’s pretty clear that there are not 50 Republicans at the moment to vote for a replacement for Obamacare.”

Monday night’s declaration of opposition by conservative Sens. Mike Lee (R-Utah) and Jerry Moran (R-Kan.) effectively scotched even the chance to start debate on the version of a bill unveiled July 13.

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McConnell added that the Senate would vote early the following week on a plan, originally approved in 2015 and vetoed by President Barack Obama, that would repeal parts of the health law. That approach would delay the effective date for two years to give lawmakers time to come up with a replacement.

However, the opposition of moderate Sens. Susan Collins (R-Maine), Shelley Moore Capito (R-W.Va.) and Lisa Murkowski (R-Alaska) ensured that vote would fail, too.

“To just say ‘repeal and trust us, we’re going to fix it in a couple of years,’ that’s not going to provide comfort to the anxiety a lot of Alaskan families are feeling right now,” Murkowski told reporters.

In retrospect, Republicans’ inability to overhaul the health law should not come as much of a surprise. Here are some of the reasons:

1. It’s hard to take things away from people.

Once launched, federal programs that provide people with benefits they find important and valuable are very difficult to rescind. In the case of health care, people’s lives can be at stake. In the current debate, patients who feared what would happen to their health coverage made their concerns known — loudly — to lawmakers.

2. Republicans have long been divided on health care.

Republicans’ dirty little secret the past seven years is that the only thing they fundamentally agreed on when it comes to health care was the slogan “repeal and replace.” There’s a reason they failed to have a plan ready when Donald Trump was elected president — all efforts to reach a consensus had thus far failed.

“I did not come to Washington to hurt people,” said Capito in a statement. “I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia’s decision to expand Medicaid.”

But the more conservative members, notably Sen. Rand Paul (R-Ky.), have other priorities. “All of us promised we would repeal Obamacare,” Paul told reporters Tuesday. “If you’re not willing to vote the way you voted in 2015, then you need to go back home and you need to explain to Republicans why you’re no longer for repealing Obamacare.”

3. Presidential leadership on hard issues is important.

President Trump has been all over the place in what he said he wanted from a health bill. It was his original insistence that “repeal and replace” happen simultaneously that moved Congress away from its 2015 strategy of repealing first and replacing later. He hosted a celebration in the White House Rose Garden when the House passed its bill, then subsequently called the measure “mean” during a strategy meeting with senators.

When it became clear Monday night that the Senate effort was foundering, Trump tweeted: “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate.” But within hours he instead suggested, “As I have always said, let ObamaCare fail and then come together and do a great healthcare plan.”

The president “gave them an impossible assignment with his promises (more, better, cheaper for all) and neither policy nor bully pulpit help at crunch time,” said Len Nichols, a professor of health policy at George Mason University. “And now he’ll blame them for failing.”

Added Thomas Miller, of the conservative American Enterprise Institute: “We now have a randomized clinical trial that proves one cannot lead and govern via Twitter.”

4. Health care is complicated. Really.

Health care has not traditionally been a major voting issue for Republicans, and thus it has been a low priority — compared with issues like taxes and trade — for the officials they elect.

Adding to the complexity is that the Republicans’ bench is nowhere near as deep as the Democrats’ when it comes to health policy expertise. Democrats have toiled on these issues for years. Even before the Affordable Care Act, many had served in Congress for decades and learned from the mistakes that were made on efforts like the failed health bill under President Bill Clinton.

5. Some parts of the ACA really are popular, even among Republicans.

The requirement for most people to have insurance or else pay a fine — the individual mandate — has consistently been unpopular among voters of all political stripes. But many other major provisions of the health law, such as guaranteeing coverage for people with preexisting conditions, remain broadly popular.

In fact, in recent months, the Affordable Care Act has been growing in popularity. Most polls show it’s more than twice as popular as GOP efforts to overhaul it.

“Republicans have to admit that some of the things in the ACA we actually liked,” said Murkowski.

That left a huge gap between Republicans who wanted to maintain the popular benefits and those who wanted to repeal the law entirely. A gap that, so far, Republicans have been unable to bridge.

Rachel Bluth contributed to this story.

Categories: Repeal And Replace Watch, States, The Health Law

Tags: Legislation, U.S. Congress

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5 Ways White House Can Use Its Muscle To Undercut Obamacare

This story was originally published on July 24.

About an hour after the Senate’s dramatic third attempt to repeal Obamacare fell short — and after almost eight months of repeated congressional attempts to dismantle it — President Donald Trump tweeted that it was only a matter of time before the law fell apart on its own.

“As I said from the beginning, let ObamaCare implode, then deal. Watch!” the president wrote.

Independent analyses have concluded that such spontaneous disintegration isn’t happening. But the White House has the power to make it so. In a number of ways, the Trump administration’s policies are already pushing Obamacare into the vortex.

Reports from Standard & Poor’s, the Congressional Budget Office and the Kaiser Family Foundation all suggest that the exchanges — where people can shop for coverage, often with the help of a government subsidy — are stabilizing. (Kaiser Health News is an editorially independent program of the foundation.)

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But Obamacare faces a difficult political reality: Its marketplaces require active maintenance and federal support.

The White House can take a number of behind-the-scenes steps to sabotage the exchanges and hasten their undoing. It has been deploying some of those tactics for weeks now — even prompting a review from the Government Accountability Office to see if these actions are legal.

Meanwhile, in a statement issued after Friday’s early-morning vote, Health and Human Services Secretary Tom Price reiterated the administration’s commitment to “provide relief to Americans who are reeling from the status quo.

This will be an area to watch.

“The administration has a lot of power to undermine the markets and make them dysfunctional,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, who specializes in private insurance markets.

Here’s a look at five ways the White House is working to weaken the health law, and what that means for consumers.

‘Cost-Sharing Reductions’

Under the ACA, when someone’s income falls between 100 and 250 percent of the federal poverty level — up to about $29,000 for an individual or around $61,000 for a family of four — marketplace carriers must offer a plan with “cost-sharing reductions” (CSRs) that reduce consumers’ out-of-pocket expenses.

Reducing cost-sharing — generally copayments and deductibles — makes plans more expensive for the insurers. The Obama administration used its rule-making power to set up direct payments to carriers to help offset this burden. The Trump White House has inherited that responsibility but also has the power to end the payment program.

The nonpartisan Congressional Budget Office estimated CSR subsidies in 2017 would total about $7 billion. Without that money, analysts say, more insurers might choose to exit, limiting options for consumers, and letting the insurers who remain charge higher prices.

Trump has been committedly noncommittal, publicly indicating he would like to halt the subsidies, but so far — on a month-to-month basis — letting them continue.

The uncertainty makes insurance companies skittish about participating, analysts noted. It’s also one reason some plans say they have had to increase their rates, noted Charles Gaba, a Michigan-based blogger who tracks ACA sign-ups. For instance: When filing plans for the 2018 marketplace, carriers on average raised premiums by about 34 percent — with about 20 points stemming from CSR uncertainty, Gaba said, based on an analysis of 21 states’ initial rate filings. Dropping the subsidies altogether would be even more damaging.

Weaken The Mandate

The White House has already signaled it does not want to enforce the individual mandate — the health law’s requirement that all people have coverage and one of the main targets of the Senate Republican’s so-called “skinny repeal” plan. And administration officials have repeated that position.

Meanwhile, in January, it issued an executive order that encouraged U.S. agencies to grant exemptions and waive or defer health law provisions that could put financial strain on companies or individuals — which could also be applied to the individual mandate.

For 2016 tax returns, though, the Internal Revenue Service continued to impose a financial penalty on people who didn’t have health insurance and who didn’t qualify for an exemption.

But enforcement may be waning. This year, the IRS was supposed to reject tax returns if people didn’t indicate whether they had coverage, flagging them for a potential penalty. Instead, it continued processing them, citing Trump’s executive order.

If the IRS has already processed any tax refunds for consumers, then they “don’t have much leverage” when attempting to collect the mandate fee, said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform.

Enforcement of the mandate enforcement, economists note, is crucial to ensuring that enough healthy people buy coverage to balance the costs of sicker beneficiaries.

But even with the mandate in effect, the efforts to defang it bring confusion.

“A lot of people believe the Trump administration is not enforcing it,” Jost said.

As a result, healthy people may become less likely to buy insurance, even as sick ones continue seeking it. That means higher prices, and a shakier pool.

“If they don’t think they’re going to get healthy people in the risk pool, they’re going to increase their rates further to protect themselves,” Jost said. “And as they raise their rates further to protect themselves, people … start to drop out.”

Thus, the president’s position on the mandate is leaving insurance carriers and commissioners “apprehensive,” noted Mike Kreidler, Washington state’s insurance commissioner.

A Bare Market

Skittishness on the part of insurers could lead them to drop out of some marketplaces, leaving consumers in some areas with few or no choices. Those “bare markets” are possible under even stable circumstances — and preventing them requires active federal involvement.

Under the Obama administration, high-level officials were “on the phone daily with insurance company executives … trying to get them to participate,” Corlette said. “It was very much an all-hands-on-deck, ‘we’re going to make it work for you guys’ kind of communication.”

And so far Trump’s Department of Health and Human Services doesn’t appear to be emphasizing this kind of essential outreach, both Corlette and Jost suggested. A few months ago, Kreidler agreed, HHS staffers appeared interested in helping states fill their bare counties — but that support has since dwindled.

“This may be sort of under the radar, but it can have real, lasting effects” for consumer choice, Corlette said.

All Quiet On The Enrollment Front

The administration could further undermine the marketplace by dropping outreach to consumers. It’s already a shorter enrollment period this year — spanning six weeks instead of three months, from Nov. 1 to Dec. 15 — though that change was already slated to eventually take effect.

That shorter period means people may miss the memo on signing up — or at least need an extra push, Corlette said. And that’s another way the administration could undermine the marketplaces: simply choosing not to advertise them.

Last sign-up season, HHS stopped open enrollment advertising in January, pulling ads a few days before the period ended. Enrollment dropped compared with previous years, Jost and Gaba noted, with young, healthy people being more likely not to buy coverage.

The administration also just stopped funding federal contractors that supported efforts by community groups and other organizations in some of the nation’s largest cities to sign up people.

Dropping advertising, shortening open enrollment or simply scaling back on technical maintenance for the marketplace website could all have significant impact, Corlette said. People who are sick and need insurance will likely seek it out, but those who are healthier — for whom health insurance is a less pressing priority — could miss the boat.

Again, Jost said, that affects insurer participation.

“Insurance is a product that need to be sold,” he said. “If the insurers believe they’re not going to get any help at all in marketing their product,” he added, fewer will want to enter the marketplace.

Word of (Bad) Mouth

HHS has taken an active role in criticizing the health law — pushing press releases and videos that argue it has hurt more than helped. That strategy could do a lot of harm, experts said. These actions are the focus of the GAO review.

If consumers keep hearing the law is failing, Jost noted, some will ultimately believe it, buying coverage only if they need it and thereby skewing the insurance risk pool.

Perceived hostility also has an effect on insurers, steering them away from marketplace participation.

“When you undermine confidence in the marketplace, you don’t need a Ph.D. in economics to know it’s not good long term,” Corlette said.

Categories: Insurance, Repeal And Replace Watch, The Health Law

Tags: Insurers, Obamacare Plans, Trump Administration

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