Article Courtesy of PBS.org

WASHINGTON — As part of its effort to expand private health care, the Department of Veterans Affairs is exploring the possibility of merging its health system with the Pentagon’s, a cost-saving measure that veterans groups say could threaten the viability of VA hospitals and clinics.

VA spokesman Curt Cashour called the plan a potential “game-changer” that would “provide better care for veterans at a lower cost to taxpayers,” but he provided no specific details.

Griffin Anderson, a spokesman for the Democrats on the House Veterans Affairs Committee, said the proposal — developed without input from Congress — would amount to a merger of the VA’s Choice and the military’s TRICARE private health care programs. Committee Democrats independently confirmed the discussions involved TRICARE.

News of the plan stirred alarm from veterans groups, who said they had not been consulted, even as VA urges a long-term legislative fix for Choice by year’s end.

Health care experts also expressed surprise that VA would consider a TRICARE merger to provide private care for millions of active-duty troops, military retirees and veterans. The two departments generally serve very different patient groups —older, sicker veterans treated by VA and generally healthier service members, retirees and their families covered by TRICARE.

TRICARE is insurance that is paid by the government, but uses private doctors and hospitals. The VA provides most of its care via medical centers and clinics owned and run by the federal government, though veterans can also see private doctors through VA’s Choice program with referrals by VA if appointments aren’t readily available.

“My overarching concern is these are very dramatic changes in the way health care is delivered to veterans,” said Carrie Farmer, a senior policy researcher on military care at Rand Corp., who has conducted wide-ranging research for VA. “There haven’t been studies on what the consequences are in terms of both costs and quality of care.”

Navy Commander Sarah Higgins, a Pentagon spokeswoman, confirmed it was exploring with VA “many possible opportunities to strengthen and streamline the health of our service members and veterans.” She declined to comment on specifics “unless and until there is something to announce.”

In its statement to The Associated Press, Cashour explained that VA Secretary David Shulkin was working with the White House and the Pentagon to explore “the general concept” of integrating VA and Pentagon health care, building upon an already planned merger of electronic health care records between VA and the Pentagon. Because Shulkin has said an overhaul of VA’s electronic medical records won’t be completed for another seven to eight years, an effort such as a TRICARE merger couldn’t likely happen before then.

“This is part of the president’s efforts to transform how government works and is precisely the type of businesslike, commonsense approach that rarely exists in Washington,” Cashour said.

At least four of the nation’s largest veterans’ organizations — The American Legion, Veterans of Foreign Wars, AMVETS and Disabled American Veterans — called a TRICARE merger a likely “non-starter” if it sought to transform VA care into an insurance plan.

“VA is a health care provider and the VFW would oppose any effort to erode the system specifically created to serve the health care needs of our nation’s veterans by reducing VA’s role to a payer of care for veterans,” said Bob Wallace, executive director of VFW’s Washington office.

Louis Celli, director of veterans’ affairs and rehabilitation for The American Legion, said any attempts to outsource services away from VA medical centers and clinics would be financially unsustainable and likely shift costs unfairly onto veterans with service-connected disabilities.

He noted something similar occurred with TRICARE — military retirees were promised free care from military base hospitals. But then TRICARE began offering insurance to use private-sector care and TRICARE beneficiary co-pays are now rising. “The precedent the TRICARE model sets is not something we would accept on the VA side,” Celli said.

During the 2016 campaign, President Donald Trump pledged to fix VA by expanding access to private doctors. In July, he promised to triple the number of veterans “seeing the doctor of their choice.” More than 30 percent of VA appointments are made in the private sector.

Some groups have drawn political battle lines, with the left-leaning VoteVets and the American Federation of Government Employees warning of privatization and Concerned Veterans for America, backed by the billionaire conservative Koch brothers, pledging a well-funded campaign to give veterans wide freedom to see private doctors.

Rep. Tim Walz of Minnesota, the top Democrat on the House Veterans Affairs Committee, said the quiet discussions to integrate TRICARE with VA’s Choice were evidence “the White House was taking steps to force unprecedented numbers of veterans into the private sector for their care.”

“The fact that the Trump administration has been having these secret conversations behind the backs of Congress and our nation’s veterans is absolutely unacceptable,” said Walz, the highest-ranking enlisted service member to serve in Congress. He called for an immediate public explanation “without delay.”

A spokeswoman for Rep. Phil Roe of Tennessee, the Republican chairman of the House committee, said he planned to continue proceeding with his bipartisan legislative plan to fix Choice without integrating TRICARE.

By Joan Lunden, Next Avenue Contributor

When my mom’s dementia no longer made it possible for her to live alone, I began searching for an assisted living community. After I started working with an adviser from A Place for Mom — the senior-living referral service where I’m now a spokeswoman — I learned that my mother was eligible to receive Veterans Administration (VA) benefits that would help offset the costs of her care.

My mother had remarried a man who was a World War II veteran (my dad died in a tragic plane crash when I was 13). I had no idea that as the widow of a veteran there was this kind of financial assistance.

The Veterans Aid & Attendance Pensions Benefit

By the time I learned about the Veterans Aid & Attendance Pensions Benefit, my mom had already spent years in assisted living. She and I had no idea that the federal government guarantees veterans and their spouses some long-term care assistance.

When I finally found out about this program, I got to work immediately. I pulled together the necessary paperwork and sent in her application. But as life would have it, by the time my mom was accepted by the program, it was too late. She passed away just before her 95th birthday.

A Well-Earned Long-Term Care Benefit

In going through this process, I learned that, shockingly, only 5 percent of these assistance funds are even applied for, because people simply do not know about the program. And for that reason, as Veterans Day approaches, I want to spread the word to those Americans who could really use this well-earned long-term care benefit.

The Veterans Aid & Attendance Pension Benefit, or “A&A benefit,” provides up to $1,794 per month to a veteran, $1,153 to a surviving spouse or $2,127 to a couple. The money, which is tax-free, can be used for in-home care, board and care, an assisted living community or a private-pay nursing home.

This is helpful for many vets and their families because neither Medicare nor Medicaid pays for assisted living care. It’s kind of like a private nursing home insurance policy you haven’t had to pay into.

But like private insurance, there are certain qualifications you’ll have to meet before you can apply. (One of the best resources explaining the A&A benefit is VeteranAid.org, which provides a brief questionnaire to help you determine if you or your loved one can benefit from this program

How to Qualify

To qualify for the benefit, a veteran or spouse must meet requirements including:

Wartime service The veteran had to have served at least 90 days of active duty with at least one day during one of the specified wars. He or she must have had an honorary discharge.

Financial need This means assets of under $80,000 (excluding a home and a car). The VA takes into consideration “countable income” as part of assets, the veteran’s or spouse’s monthly income — including Social Security, pensions and IRAs — minus the costs of assisted living or in-home care.

Medical needs The veteran or spouse must need assistance with eating, bathing or dressing.

Experts say it takes six to eight months, on average to get approved; some applicants wait more than a year. But once the application is approved, it’s applied retroactively to the date of application.

On Veterans Day, it is my hope that all wartime veterans and their spouses can find a senior community where they can feel safe and happy in their later years and can get the financial assistance that they deserve from the Veterans Aid & Attendance Pensions Benefit program. And I would like to thank all veterans and their families for their service to our country.

By Lynnley Browning and Laura Davison

Vice President Mike Pence said Republicans would repeal the estate tax — a step that the Senate GOP tax plan doesn’t currently plan to take.

“Death should no longer be a taxable event,” Pence said Thursday night during the annual dinner of the Tax Foundation, a conservative-leaning Washington policy group. He promised that the tax-overhaul plans now under consideration in Congress would eliminate the levy — a long-sought Republican goal.

Pence also promised his audience that Congress would repeal the Affordable Care Act’s requirement that individuals buy health insurance — a provision that Senate tax writers have added to their plan but the House hasn’t included.

“We will repeal the death tax once and for all and cut taxes on working Americans when we repeal the Obamacare individual mandate in this bill,” Pence said.

He also called for creating a new 25 percent tax rate on partnerships, limited liability companies and other so-called “pass-through” businesses. That’s in the House bill, but not the Senate plan, which would use a different approach.

The vice president’s mix-and-match promises contradicted White House Press Secretary Sarah Huckabee Sanders’s earlier response to a question about differences in the two chambers’ plans. Sanders told reporters Thursday afternoon that President Donald Trump likes both the Senate and the House plan, and doesn’t prefer one over the other.

The two chambers will have to compromise on a final bill before it could reach Trump’s desk.

The House on Thursday passed an ambitious tax overhaul that would include a provision to repeal the estate tax in 2025. But the Senate plan, which remained under discussion by the Senate Finance Committee Thursday night, would leave the tax in place.
Tax Thresholds

Under current law, the estate tax applies a 40 percent levy to estates worth more than $5.49 million for single individuals and $10.98 million for couples. The bill approved by the House would double the exemption thresholds for the tax, and then repeal it. The Senate measure would also double thresholds, but that change would be temporary, and end in 2026.

The Senate Finance panel is also considering the repeal of the individual mandate that was part of the 2010 health care law known as Obamacare. Abolishing the mandate beginning in 2019 would save the federal government $318 billion over 10 years that would help pay for the deep tax rate cuts that Republicans want to enact. But it would also leave 13 million Americans uninsured by 2027, according to an estimate by the Congressional Budget Office.

The chambers are also divided on how to cut taxes for closely held businesses that are organized as pass-throughs. Such businesses don’t pay tax themselves, but pass their earnings to their owners, who then pay tax at their individual tax rates.

The House legislation would tax some such businesses at 25 percent — and provide additional breaks for smaller businesses. The Senate plan would take a different approach, granting pass-through owners a 17.4 percent deduction — up to a certain threshold — before taxing the income at their individual rates.
Different Plans

Senate leaders have said they plan to hold a floor vote on their bill during the week of Nov. 27. But several Senators have already expressed concerns about aspects of the proposal –including pass-through tax treatment, the inclusion of the individual mandate repeal, and the impact the entire plan could have on federal budget deficits.

Pence said the ultimate tax bill would be the “biggest tax cut in American history” and pass before the end of the year. But recent studies suggest that the tax plans — both of which would reduce federal revenue by $1.4 trillion or so before accounting for any larger economic effects — would be shallower than than those enacted in 1981 under then-President Ronald Reagan.

The Centers for Medicare and Medicaid Services (CMS) has announced that the 2018 premium for Part B of Medicare will remain at $134 a month. But even with no change, millions of Social Security recipients will pay sharply higher Part B premiums that will eat up all or most of next year’s 2 percent cost of living adjustment (COLA) for Social Security.

To explain why, let’s back up and explain some basic facts of Medicare. Part B covers insured expenses for doctors, outpatient services and durable medical equipment. (The other component of basic Medicare is Part A, which covers hospital and nursing home expenses.)

Increases in Medicare premiums can’t cause a person’s Social Security benefits to decline from one year to the next, according to Social Security’s “hold harmless” rule. About 30 percent of Medicare beneficiaries are not held harmless each year. This group includes people who have not yet begun receiving Social Security benefits, new enrollees in 2018, low-income people whose Medicare premiums are paid by state Medicaid agencies, and people who pay Medicare’s high-income premium surcharges.

Recent COLAs have been very small – zero in 2016 and 0.3 percent this year – so increases in Part B premiums were either eliminated or reduced for most of the 70 percent of Medicare enrollees who have Part B premiums automatically deducted from their monthly Social Security payments.

Those hold-harmless reductions will disappear next year for most people, with some or all of their 2 percent COLA increases eaten up by increases in their Part B premiums. The numbers here can be confusing, so please bear with me.

According to CMS, 60 percent of those who will be held harmless in 2018 (equal to 42 percent of all Part B enrollees) will pay the full Part B premium. In other words, the 2 percent COLA will generate enough increased benefits for them to pay $134 without reducing their net Social Security benefits.

For the other 40 percent of those held harmless (28 percent of all Part B enrollees), their Social Security COLA increase will not be sufficient to cover the entire Part B premium. They will pay a range of smaller Part B premiums, based on their 2018 COLAs.

To figure out how this will affect you, subtract your current Part B premium from $134. Then multiply your current monthly Social Security benefit by 2 percent. Your 2018 Part B premium change should be the smaller of these two numbers. Add this figure to your 2017 premium to determine what you will pay next year. Like I said, it’s confusing.

One thing is clear: Many Social Security recipients will receive little if any boost in their benefits next year. And while most of these folks have been shielded by the hold-harmless rule from paying the full Part B premiums in recent years, I don’t expect any of them to send thanks for this to the folks at Social Security and Medicare who came up with this system for determining Medicare premiums.

Here are other important 2018 benchmark numbers announced by CMS:

The Part B annual deductible will be unchanged at $183.

The Part A annual deductible will rise by $24 to $1,340 from $1,316. There is a separate deductible for each hospital stay, usually defined as being separated by at least 60 days during a calendar year.

The Part A coinsurance charge for hospitalizations lasting from 61 to 90 days will rise by $6 to $335 a day in a benefit period; for lifetime reserve days linked to longer stays, it will rise $12 to $670 a day. The coinsurance charge for skilled nursing facility stays lasting from 21 to 100 days in a benefit period will increase by $3 to $167.50.

People who have worked at least 40 quarters in jobs where they paid Social Security payroll taxes qualify for premium-free Part A. The Part A premiums for people with 30 to 40 hours of coverage will rise by $5 to $232 a month. For those with fewer than 30 hours, it will increase $9 to $422 a month.

There will be no changes next year in Medicare’s high-income Part B premium surcharges, while the Part D surcharges will decline slightly. Details on both sets of surcharges may be found here.

By — Philip Moeller

A U.S. district court holds that a Medicaid applicant’s § 1983 case against the state for imposing a penalty on the transfer of her home to her caregiver son is barred by the Eleventh Amendment because she seeks retroactive relief from the transfer penalty. Williams v. Connolly (U.S. Dist. Ct., D.N.J., No. 17-1631 (RBK/AMD), Nov. 15, 2017).

John Davis brought his mother, Elizabeth Williams, to live with him in 2012 when she was diagnosed with Alzheimer’s disease. Mr. Davis sold his mother his home and cared for her in the home for three years. In 2014, Ms. Williams deeded the home back to Mr. Davis for $1 and entered a nursing home. In 2015, Ms. Williams applied for Medicaid benefits. The state imposed a penalty period because Ms. Williams had transferred the home to Mr. Davis.

Ms. Williams appealed, arguing that the caregiver exemption applied to the transfer. The state determined that the transfer did not fall within the caregiver exemption because Ms. Williams paid for additional caregivers in addition to her son. Ms. Williams sued the state in federal court under § 1983. The state filed a motion to dismiss.

The United States District Court, District of New Jersey, grants the state’s motion to dismiss, holding that because the claim seeks retroactive relief from the transfer penalty, it is barred by Eleventh Amendment immunity. According to the court, it “cannot require the State of New Jersey to pay benefits it previously determined it would not pay.”