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Coffee CAHC policy round-up: January 19, 2018

Coffee CAHC is a twice-weekly newsletter where we round up and comment on the latest health coverage policy developments both nationally and here in Maine. We hope you find these updates helpful!

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Coffee CAHC

115th Congress, 2nd session

128th Maine Legislature, 2nd regular session


Friday, January 19th, 2018

I feel like I’m facing down the cold/flu that’s flying around up here right now, stubbornly refusing to submit before I head out on a trip next week. Meanwhile, my world is a sea of sniffles. Bring on the OJ!


National level

The federal government today seems to be hovering in a state that I guess I’d call “Schrödinger’s Shutdown”: it seems as though it currently is, and is not, shut down.

The House passed a short-term continuing resolution (CR) yesterday that is now sitting in the Senate, where its prospects look, at best, murky. You need 60 votes to open debate (meaning, you need some Democrats), and then 51 votes to pass the bill. Even if the Democrats voted to allow debate to proceed (which they apparently are not interested in doing), it seems that Republicans are three-ish votes shy of 51.

That means that, while the federal government is currently open, and will be until at least midnight tonight, it seems impossible that a resolution to the impasse will emerge before midnight. Hence, the federal government both is, and is not, open.

One curious historic footnote: I read that this would be the first and only time that the government has shut down while under single-party control.

The slightly odd thing for us in the health world is that the short term CR does fund 6 years of CHIP, but is silent on other critical issues (such as funding for health centers, and – the crux of the current standoff – an immigration package to address the “dreamers” that I wrote a little bit about in Wednesday’s Coffee CAHC).

This has led to what may, at face value, seem like a slightly paradoxical situation of advocating against a bill (the CR) that accomplishes a vital priority (extending CHIP). But, let’s remember that the bill would only renew CHIP for six years, and does so by trying to play politics in pitting kids against immigrants against health centers. That’s a bad deal for everybody. I’m especially afraid that, with CHIP being used as a political hostage, extending the program for only six years will put us right back in that same position six years from now. Couldn’t it just happen again in a decade? Maybe, but at least we’d have ten years of funding before getting to this point again.

At the same time that Washington is flailing its way into a government shutdown, the Trump Administration is presiding this week over news that the uninsurance rate went up in President Trump’s first year in office, by about a percent and a half. Particularly hard hit in the coverage losses last year were, as the linked article notes, “young adults, blacks, Latinos and households making less than $36,000 a year”. This is something that the Administration should frankly be ashamed of. There’s absolutely no credible way to paint big coverage losses as a good thing.

State level

As the federal government lumbers toward shutdown, it’s natural to ask how that impacts anything here in Maine. Well, I’ve spent a good part of my day chasing down the answer(s) to that question for you.

And the answer is…probably not much, maybe, at least right away?

There are a lot of functions in state government, and a ton of positions in state government, that are at least partially funded by federal dollars. That means that, if the federal government shuts down tonight, then we should expect state workers to continue being able to do their jobs. The state share of the cost of that work will continue uninterrupted, and once the shutdown ends, everything should get reconciled.

In our world, that means, for instance, that people who apply for MaineCare will still be able to count on having eligibility specialists on the job at DHHS to receive, process, and determine those applications.

There are a few programs and positions that are purely federal funding, and of those, the only ones that I’m aware of that might impact folks focused on health policy are a team of specialists who make disability determinations for SSI eligibility. But I haven’t heard for sure, one way or the other, if they actually will be impacted – just that they might be.

As for legislative business, well, as I predicted, it’s heating up quick! The halls are bustling at the State House.

Yesterday, we weighed in on LD 1032, a bill that would clarify the definition of a “clinical peer” when insurance companies are reviewing requests for authorization for procedures and services. Allow me to explain why this is a big deal.

Imagine a consumer, let’s call her Carol Danvers, experienced an unusual accident and has been experiencing some unfortunate side effects. Carol’s doctor, Dr. Banner, is an expert radiologist and recommends a particular gamma ray treatment for her. Dr. Banner goes to Carol’s insurance company and requests authorization for the treatment.

Carol’s insurance company assigns an internal staff medical reviewer – say, a family practitioner – to review the request and decide whether or not to approve or deny the claim based on their medical knowledge. Let’s say they deny it.

Here’s where things get tricky.

Under current law, there’s an appeals process that Carol and Dr. Banner could engage to try and get the insurer to change their mind. But before getting to that point, Dr. Banner could request what’s called a “peer-to-peer”, where he presents his informed opinion (along with any supporting medical evidence or documentation) to the insurer’s medical reviewer to see if the insurance company will reverse the decision and authorize the treatment.

The problem, and we see this quite a bit through our HelpLine here at CAHC, is that these peer-to-peers often feel a little mismatched. What frequently happens is that somebody with one type of training or expertise is making a judgment call on the medical necessity of a service or procedure from a very different specialty. You might have a pediatrician denying a geriatric cancer treatment, or a podiatrist denying brain surgery, or a brain surgeon denying an obstetrical procedure.

Understand, we are not trying to pit doctors against each other. I am in no way trying to say that “specialty X” is better or smarter than “specialty Y”. What we are saying is that complex medical decisions should be reviewed by somebody with the correct training to recognize what they’re looking at. We’ve worked cases where the consumer’s specialist had to explain basic facts about the condition to the reviewer before the reviewer could even begin to grasp what the case was about.

LD 1032 would do that. It would say “hey, a peer has to be an actual peer”. We think that would save a lot of time, money, and – most importantly – stress and agony for consumers who end up being thrown into an appeals process that can take weeks or even months to resolve, delaying treatment for their underlying condition. This takes a huge toll on people who are paying their premiums and deserve better from their insurers. To say nothing of the fact that not every consumer has the time, energy, or even knowledge to get through the appeals process.

And by the way, we think it might save insurance companies money, too. Based on statistics that were presented at the hearing yesterday, it seems that a lot of cases that go to appeal end up decided in the consumer’s favor anyway. That could be because the appeals process puts the cases in front of medical reviewers who are exactly the kind of specialist-to-specialist peers that are at the heart of this debate.

Rather than wasting everybody’s time and money on a length appeals process, why not let the real experts make the decision in an earlier step? That way we can avoid unnecessary appeals and make sure consumers are getting the treatments they need, while still giving insurance companies a chance to have medical experts review claims to make sure that the services being requested are necessary and cost-effective, and avoid unnecessary or experimental requests.

That’s 1032 in a nutshell. It will have another work session in the Insurance and Financial Services committee soon (I think I heard, this coming Tuesday, 1/23). The ombudsman bill that I mentioned in Wednesday’s Coffee CAHC is scheduled for a work session this coming Thursday, 1/25.

This coming Monday, the 22nd, the Health Care Task Force is meeting again. CAHC has been invited to present some information this time. I’ll be sure and recap how that goes for you in next week’s Coffee CAHC.

Finally, a quick word on next week’s Coffee CAHCs. I will be in Washington, DC for the Families USA Health Action conference from Tuesday evening through Saturday. So, while I will still be busting out Coffee CAHC for you, be warned that they may be a little shorter and more bullet-point-y than the norm.


Would you like to know more?

Kaiser Family Foundation has a new issue brief out yesterday exploring the gains in coverage for LGBTQ Americans as a result of the ACA. This is a population that has benefited enormously from Medicaid expansion and the ACA overall. Very important data to highlight.

…and is particularly sobering in light of the Trump Administration’s decision to create a unit within HHS that will work to shield providers who refuse to perform certain services or treat certain individuals “on moral grounds” from reprisal. Ugh.


Until next time, friends, I remain,


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