By Erin Mershon, CQ Roll Call

September 23, 2016 -- The health care policy proposals of Hillary Clinton and Donald Trump would have dramatically different impacts on the uninsured rate in the United States and on out-of-pocket health care costs. But they share one trait: Both would add to the federal deficit, according to a study released Friday.

Trump's plan, which centers on repealing and replacing the Affordable Care Act, would increase the number of uninsured Americans by somewhere between 16 million and 25.1 million people, depending on which parts were enacted, and drive up out-of-pocket costs for enrollees currently benefiting from the health law. Clinton's proposals, on the other hand, would reduce the number of uninsured by between 400,000 and 9.6 million people. Her most ambitious reforms would decrease health spending for low-income consumers by as much as 33 percent.

The numbers highlight the extremes of the potential policy changes and come from The Commonwealth Fund, which supports the health law. The group relied on a RAND simulation to assess the individual impact of each presidential candidate's health care proposals.

The analysis underscores the broad range of policy proposals that have been offered ahead of the November election. 

Trump's plan could cost anywhere between $0.5 billion to $41 billion, relative to current law. Clinton's on the other hand, could range between $0.7 billion and $90 billion, depending on which policies are implemented. 

While both Clinton and Trump laid out ambitious agendas for their respective presidencies, political realities will almost certainly limit what they can accomplish.

"It's clear that there are two widely disparate approaches to ensuring Americans' health care coverage, access to the care they need, and protection from burdensome health care costs," said Commonwealth Fund President David Blumenthal.

Commonwealth found that the controversial public option, which would add a government-run insurance program to the exchanges, might increase the insured population by just 400,000 people—the smallest impact on the uninsured rate of any of the proposals the group examined. That option also would not dramatically affect most people's out-of-pocket spending, the researchers said.

The group examined three other Clinton proposals, all of which centered on making health insurance on the exchanges more affordable. They examined her proposals to add a cost-sharing tax credit of between $2,500 and $5,000 per family, to reduce the maximum contributions families must make toward their health insurance premiums to qualify for existing tax credits, and to eliminate the so-called "family glitch."

Clinton's tax credit proposal would have the biggest impact on both the uninsured rate and the deficit. Commonwealth found that about 9.6 million more people would gain insurance. Eliminating the family glitch and reducing the maximum premium contribution would increase the number of insured Americans by a combined total of about 2.8 million.

All four proposals would reduce out-of-pocket costs for at least some groups, though the cost-sharing tax credit would have the biggest impact on those costs. That option, however, also came with the largest price tag: $90.4 billion.

The group examined each of the proposals separately, in part because Clinton has offered a number of other health care policy ideas on issues such as drug price negotiation, Alzheimer's research, and a Medicare buy-in for younger individuals.

In their examination of Trump's proposals, the group was careful to describe their limitations. The researchers said their analysis lacked key details and noted that they had not considered some Republican proposals to replace the 2010 health law with, for example, advance refundable tax credits, none of which Trump has specifically endorsed.

Instead, the researchers modeled his proposals to fully repeal the 2010 health law, allow individuals to deduct health insurance premiums from their tax returns, convert the Medicaid and Children's Health Insurance Programs to block grants, and promote the sale of health insurance across state lines.

"Modeling health reform proposals that have not yet been turned into legislation can be challenging because of lack of specificity," they wrote in their brief. "Further, Trump would implement several other proposals that could interact with the health policies, such as changes in tax rates."

By Kerry Young, CQ Roll Call

September 21, 2016 -- The ranking Democrat on the Senate Finance Committee recently unveiled a bill that would take several steps to ease the financial hit of Medicare for senior citizens and people with disabilities. These include caps on out-of-pocket spending and a limit on what's now a lifetime penalty for people who enroll late.

The measure from Sen. Ron Wyden, D-Ore., also would end the two-year waiting period that those with disabilities face to join the giant federal health program.

"Today, the promise of Medicare falls short for too many who find their health costs becoming more and more unaffordable," said Wyden in a statement.

A longtime advocate for senior citizens, Wyden is poised to regain the gavel of Senate Finance if the Democrats gain control of the chamber through the November election. His bill, titled the Medicare Affordability and Enrollment Act, serves as a preview of issues he likely would pursue in the next session of Congress. No major revisions to Medicare are expected in the remaining months of this year.

Among Wyden's priorities is streamlining the Medicare enrollment process and reducing penalties for those who delay signing up for the program. Wyden called the current enrollment process "outdated and confusing," with delays triggering higher premium costs for a lifetime. Monthly premiums for Part B outpatient care may go up 10 percent for each full 12-month period that an eligible person delayed signing up for the program, according to Medicare information. Wyden is calling for limiting the Part B late enrollment penalty to 10 percent per month for twice as long as the time that an eligible person waited to enroll. The bill would allow for special enrollment periods for Medicare due to exceptional circumstances, such as a natural disaster. 

Wyden's bill also would set a maximum out-of-pocket cap for medical services under traditional Medicare, which exists today for Medicare Advantage and most commercial insurance plans. The bill calls for setting the total amount of out-of-pocket costs, including deductibles and copays, for Medicare Part A and B programs at $5,500 for 2018. It would then be increased or decreased in subsequent years by a percent change pegged to the Consumer Price Index. The cap would apply only to covered services, according to a summary of the bill.

Among the groups that endorsed his bill, according to his office, are:  American Federation of State, County and Municipal Employees; The Arc; Center for Medicare Advocacy' Dialysis Patient Citizens; Families USA; Justice in Aging; Medicare Rights Center; National Coalition on Aging; and the National Committee to Preserve Social Security and Medicare.

Rep. Frank Pallone Jr. of New Jersey, the ranking Democrat on the House Energy and Commerce Committee, and Rep. Sander M. Levin of Michigan, the ranking Democrat on the House Ways and Means Committee, will lead the introduction of a counterpart in their chamber, Wyden's office said. In the Senate, cosponsors of Wyden's bill are Democrats  Debbie Stabenow of Michigan, Michael Bennet of Colorado, Bill Nelson of Florida, and Sherrod Brown of Ohio.

By Kerry Young, CQ Roll Call

September 22, 2016 -- Medicare officials on Thursday said the average monthly premiums will slip by $1.19, or about 4 percent, next year for customers of the insurer-run Advantage plans.

The average premium may drop to $31.40 from $32.59 for this year, the Centers for Medicare and Medicaid Services (CMS) said in a statement. About two-third of people in the program, or 67 percent, will see premiums remain stable or drop, according to CMS. 

Enrollment in the Medicare Advantage program has grown rapidly in recent years. The insurer-run plans often offer benefits that traditional Medicare does not, such as dental, vision and hearing benefits. The number of people in Advantage plans may rise to 18.5 million next year, a 60 percent increase from 2010. Almost a third, or 32 percent, of all the people enrolled in Medicare will then be in an insurer-run plan, up from 24 percent in 2010.

By Kerry Young, CQ Roll Call

September 23, 2016 --House Ways and Means Chairman Kevin Brady plans to put forward within months major revisions to his proposal for revamping how Medicare pays for services provided to people recovering after strokes and serious illnesses and injuries.  

The Texas Republican told CQ HealthBeat in a Thursday evening interview that he is taking a close look at responses to his legislation (HR 3298), which seeks to move post-hospital care more toward value-based purchasing. Groups responded strongly to his call for feedback on the measure, which would set performance standards and scores to rank providers and then peg payments to them. Trade associations last week said they couldn't support the bill in its current version, citing concerns about its penalties and the timing of proposed changes.

Brady said he is developing a revised version of the measure. He's hoping to finish it this year. Still, this work could take until early next year, meaning that he would introduce a new bill in the 115th session of Congress.

"It all depends on when we can find common ground," Brady said of the timeline. "The feedback we are getting is really helping us shape this."

Brady said he's looking at complaints raised about proposed quality measurements, timing and penalties in his bill.

Brady sees his bill as part of the continuing efforts to change how Medicare spends its money. Congress over the years has placed demands on doctors and hospitals to better coordinate care of the senior citizens and people with disabilities enrolled in Medicare. Lawmakers now want to do the same for what's called post-acute care, which includes home health services and treatments provided in skilled nursing centers and rehabilitation facilities. This field represents about 10 percent of Medicare's annual budget. 

"These reforms are very important to saving Medicare for the long term because it is moving toward real incentives for quality in the post-acute setting, just as we have redesigned reimbursement for doctors and hospitals to reward quality as well," Brady said.

By Marissa Evans, CQ Roll Call

September 22, 2016 -- Children's mental health directors nationwide are having difficulties convincing policymakers to prioritize and fund such care, according to a new Journal of Behavioral Health Services and Research study.

New survey results released Thursday found that funding, departmental organization and work shortages were some of the biggest challenges children's mental health directors face. Authors conducted a survey of 48 directors from 46 states, the District of Columbia, and one U.S. territory. The study was published by the National Council for Behavioral Health.

Lead author Mario Hernandez, chair of the Department of Child and Family Studies for the University of South Florida's Louis de la Parte Florida Mental Health Institute, said in an interview that the most telling part of the survey was that many states did not designate one person to focus on children's mental health. The lack of focus could decrease awareness about the issue.

"If there's nobody paying attention to this then it can really continue to be diminished," Hernandez said. "These are important roles and people in states and they need to be empowered."

Hernandez said the group plans to replicate the study again to allow comparisons in the future. "We hope to do another one and look at it over time," he said.

One of the problems children's mental health directors report is that they are often unable to make their priorities clear to people outside their departments such as legislators, according to the authors. More than 80 percent of directors reported that "a lack of attention, accountability, and funding given to children's mental health services compared to adult services."

Funding for children's mental health is also a problem. Directors complained that they didn't control all of the funds for mental health and said funding should be increased.

Children's mental health directors may have the title but their levels of authoritative powers on their budgets varied, according to the report. The lack of time and resources available for data collection has also been a concern for respondents since without data, "children's mental health agencies will struggle to advocate for continued support and funding."

Besides funding and organizational woes, children's mental health directors are also concerned about the mental health workforce shortage. The report found that directors were concerned about the few state-supported training and technical assistance programs for mental health professionals and the lack of licensed clinicians and child psychiatrists available.

The shortages were also part of problems with access to service that the directors noted in their survey. While the states may have licensed mental health professionals who can work with children, directors in the report pointed out that some of them were unwilling to work with Medicaid and uninsured children.

The group surveyed directors by using the roster for the Children, Youth and Families Division of the National Association of State Mental Health Program Directors.  

By Kerry Young, CQ Roll Call

September 21, 2016 -- A senator's daughter who leads a blue-chip drug company has become the face of public outrage over rising drug prices.

Emerging details about Mylan N.V.'s marketing of the widely used EpiPen allergy shot appear likely to keep drug costs on the congressional agenda through the end of the year. The focus on drug prices began gaining traction a year ago, when Martin Shkreli gained notoriety as the then-leader of Turing Pharmaceuticals by increasing the price of a different generic drug to treat a rare infection from $13.50 to $750 a pill. 

The House Oversight and Government Reform Committee on Wednesday held a hearing with Mylan Chief Executive Heather Bresch, the daughter of Sen. Joe Manchin III, D-W. Va. Jason Chaffetz, R-Utah, the panel's chairman, questioned why there are not competitors to drive down the cost of EpiPen, which now has a list price of roughly $600 for a two-injection pack.

"The market forces aren't at work," Chaffetz said. 

EpiPen's sales could reach $1.1 billion this year, said Rep. Elijah Cummings of Maryland, the ranking Democrat on the House Oversight and Government Reform Committee, citing documents obtained by the panel. In 2008, just after Mylan's acquisition of the product, sales were about $184 million.

News stories also have focused on Bresch's payouts from Mylan. Mylan reported that her total compensation was $25.9 million for 2014 and $13 million last year, plus an additional almost $6 million of her taxes that the company paid, according to a regulatory filing. Mylan also requires Bresch to use its corporate aircraft for business and personal purposes, according to a regulatory filing.

Lawmakers have seized on the rewards given to Bresch and other Mylan executives since their best-known product, the EpiPen, put a dent in many family budgets. Cummings said Mylan executives grew "filthy rich" at the cost of American consumers. 

The widely used EpiPen has moved to center stage of the debate around drug prices. A top Food and Drug Administration (FDA) regulator, who oversees most drug approvals, touched on this product in her opening statement for a Senate Agriculture Appropriations Subcommittee hearing, also Wednesday, on generic drugs.

Generic drugmaker Teva stumbled earlier this year in its efforts to win FDA approval of a copycat version.

"At FDA, we are aware of the recent spike in the price of the EpiPen," said Janet Woodcock, the director of the FDA's Center for Drug Evaluation and Research, at the Senate hearing. "While there are currently no FDA-approved generic epinephrine auto-injectors, we stand ready to quickly review additional applications that come to us from both generic and innovator drug companies."

Separately, Rep. Lloyd Doggett, D-Texas, a senior member of the House Ways and Means Committee, requested that the Federal Trade Commission investigate reports that Mylan prohibited schools from purchasing competitors' products as a condition of receiving discounted EpiPens, and to determine whether these agreements violated federal antitrust laws.

The Senate Judiciary Committee also has taken a strong interest in questions about Mylan's business strategies and the lack of competition for its EpiPen.

The product is a shot of the generic drug epinephrine delivered in what's meant to be an easily used "pen" injection device. The convenience of this administration is a draw for parents and others who may need to help someone facing life-threatening anaphylaxsis without much training or preparation.

At the House hearing, Cummings urged his fellow lawmakers to look beyond the outrage surrounding EpiPen and the rise in price for a generic drug by Shkreli's former firm Turing Pharmaceuticals and look broadly at costs.

"We need solutions. It's time for Congress to act. We will hold today's hearing, just like we held our previous hearings," Cummings said in a statement prepared for the hearing. "But it's time to start legislating. It's time to start doing our job and passing laws to rein in these out-of-control drug companies."

Doggett and Rep. Peter Welch, D-Vt., had arranged a Wednesday briefing for their fellow House Democrats with advocates on another drug funding issue—an Obama administration effort to control Medicare spending on cancer drugs and other treatments administered in doctors' offices. The so-called Part B drug model is a test of Medicare payments that the administration proposed in March. Opposed by many Republicans and some Democrats, the plan is the Obama administration's jab at the industry's rising prices but is likely to be scaled back from the proposed version.

Family Ties

Manchin's wife, who is Bresch's mother, helped foster use of EpiPen in her role as an education advocate, according to a CQ Roll Call article Tuesday that followed a USA Today report that day. Gayle Manchin served as president of the National Association for State Boards of Education in 2012, the group said. Kristen Amundson, executive director of NASBE, said in a statement Tuesday that the group stands by "the validity and usefulness of the work NASBE has done around epinephrine." 

"Following passage of federal legislation encouraging states to require schools to stock epinephrine, legislatures in over a dozen states passed laws in 2012-13 governing epinephrine and anaphylaxis response," Amundson said. "NASBE recognized the important role state boards of education would play and stepped in to help them set policies that would ensure students' health and safety."

Manchin in a separate statement recapped his wife's education credentials, including her time spent as a teacher. "She served with distinction and has received universal praise for her commitment to education and the children of West Virginia," Manchin said. "She is held in the highest regard for her compassion, honesty and devotion by me and all who know her."

Manchin's connection to Mylan through his daughter drew scrutiny in 2014 when he introduced a bill to ban the painkiller Zohydro. The drug was considered a rival to fentanyl, a product sold by Mylan. A Manchin spokesman told CQ Roll Call at the time that the senator's "office focuses on what is best for the people of West Virginia and nothing else." Manchin, whose state was hard hit by the opioid crisis, has been active on other measures intended to address narcotic abuse.