By JoNel Aleccia via khn.org

California voters passed a law two years ago that allows terminally ill people to take lethal drugs to end their lives, but controversy is growing over a newer rule that effectively bans that option in the state’s eight veterans homes.

Proponents of medical aid-in-dying and residents of the Veterans Home of California-Yountville — the largest in the nation — are protesting a regulation passed last year by the California Department of Veterans Affairs, or CalVet, that requires that anyone living in the facilities must be discharged if they intend to use the law.

That’s a position shared by most — but not all — states where aid-in-dying is allowed. As more U.S. jurisdictions consider whether to legalize the practice, the status of terminally ill veterans living in state-run homes will loom large.

“It would be a terrible hardship, because I have no place to go,” said Bob Sloan, 73, who suffers from congestive heart failure and other serious cardiac problems. He said he intends to seek medical aid-in-dying if doctors certify he has six months or less to live.

“I’m not going to be a vegetable,” said Sloan, a Vietnam War-era veteran who moved into the Yountville center five years ago. “I’m not going to end up living in so much pain it’s unbearable.”

A CalVet official said the agency adopted the rule to avoid violating a federal statute that prohibits using U.S. government resources for physician-assisted death. Otherwise, the agency would jeopardize nearly $68 million in federal funds that helps run the facilities, said June Iljana, CalVet’s deputy secretary of communications.

California is not alone. Three other states where aid-in-dying is legal — Oregon, Colorado and Vermont — all prohibit use of lethal medications in state-run veterans homes.

In Montana, where aid-in-dying is allowed under a state Supreme Court ruling, officials didn’t respond to multiple requests about whether veterans would be able to use the law in the residences. However, Dr. Eric Kress, a Missoula physician who prescribes the lethal medication, says he has transferred patients to hospice, to relatives’ homes, even to extended-stay hotels to avoid conflict.

In Washington, D.C., where an aid-in-dying law took effect last summer, the Armed Forces Retirement Home won’t assist patients in any way. Those who wish to use the law would be referred to an ethics committee for individual consideration, spokesman Christopher Kelly said in an email.

Only Washington state has a policy that allows veterans to remain in government-run residences if they intend to ingest lethal medications.. At least one veteran has died in a state-run home using that law, said Heidi Audette, a spokeswoman for the state’s Department of Veterans Affairs.

Paul Sherbo, a spokesman for the U.S. Department of Veterans Affairs, said the choice is up to the states.

“VA does not mandate how states comply with federal law,” Sherbo said in an email. “There are a number of ways individual states can choose to handle such situations and still be in compliance.”

To date, none of the 2,400 residents of California’s veterans homes has formally requested medical aid-in-dying, said Iljana. That includes the more than 900 residents of the Yountville center, located about 60 miles north of San Francisco.

“We would respectfully and compassionately assist them in transferring to a hospice, family home or other location,” Iljana said in an email. “We will readmit them immediately if they change their minds.”

But Kathryn Tucker, executive director of the End of Life Liberty Project, an advocacy group that supports aid-in-dying, said that CalVet is interpreting the federal regulations too broadly and denying terminally ill veterans the right to choose a “peaceful death” through medical assistance.

“Nothing exists in the federal statute’s language that would prohibit a resident from receiving aid-in-dying services at state homes, so long as they are not provided using federal funds or employees,” she said.

Ed Warren, head of the Allied Council, a group representing veterans at the Yountville site, co-signed a letter to CalVet officials protesting the ruling.

“My point of view is that it is inhumane to expect people in the last stages of dying to go through the hullabaloo of leaving their homes,” he said.

In Washington state, a 60-year-old man diagnosed with terminal chronic obstructive pulmonary disease, or COPD, died in June 2015 after ingesting lethal drugs at the Washington Soldiers Home in Orting, where he lived.

“It was all done very much in the open,” said Chris Fruitrich, a volunteer with the group End of Life Washington, which assisted the man.

There has been no indication that the policy jeopardizes the nearly $47 million the agency receives each year in federal funds, said Audette, the state VA spokeswoman.

In California, additional protests have centered on allegations that CalVet suppressed information about the aid-in-dying law.

Critics at the Yountville home contend that CalVet passed the discharge rule quietly, with little public input. Then the agency refused to broadcast a public meeting about medical aid-in-dying on KVET, the center’s state-run, closed-circuit television station.

Iljana said the broadcast of the Aug. 21 meeting, led by Tucker and Dr. Robert Brody, also a supporter of aid-in-dying, violated state rules that prohibit using public resources to promote political causes.

“Free speech is great and criticizing the government is great, but not using the government’s own resources and paid staff to advocate for a change in the law,” Iljana wrote in an email to prohibit the broadcast.

That decision, however, prompted Jac Warren, 81, who has been KVET’s station manager for eight years, to resign last month in protest, citing censorship.

“What is at issue is whether a state may completely suppress the dissemination of concededly truthful information about entirely lawful activity,” Warren wrote in an email to CalVet.

The hour-long meeting, attended by about 50 people, was not propaganda, Tucker said, but “an educational event with information provided by an attorney and a physician who both specialize in their respective fields in end-of-life care.”

Bob Sloan, who works as an engineer at KVET for a $400 monthly stipend, disagreed with the decision not to broadcast the meeting on the system that serves residents of the Yountville home.

Sloan said he knows other residents who would like to be able to use California’s aid-in-dying law if their illnesses progress.

“The only other option that people have in this state is committing suicide,” he said. “If I can’t find some way of doing it legally, I’ll do it illegally.”

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

[Update: An earlier version of this story said an Aug. 21 meeting held regarding aid-in-dying violated state rules. In fact, officials said that broadcasting the meeting using state resources would have resulted in a violation.]

By Nathaniel Weixel – via TheHill.com

The Trump administration is facing a crucial test of how much flexibility they are willing to give states to remake their Medicaid programs.

Federal officials have already given the green light to two states to impose work requirements on Medicaid recipients, and at least eight other states are hoping to follow.

But a handful of other states want to go even further by putting a lifetime cap on how long people can be enrolled in the Medicaid program.

No state has ever put a limit on how long a person can receive Medicaid benefits. But given that the Trump administration has already shown a willingness to approve conservative policies like work requirements, premiums and lockout periods for Medicaid, many experts and advocates think lifetime limits could also win approval.

Critics of lifetime limits say they would fundamentally shift Medicaid from a health care safety net program for the poor and sick to a welfare program.

“It’s clear that [the administration] view[s] Medicaid not as a health insurance program. They are hopeful to get as many people off the program and off public assistance as possible,” said Jessica Schubel, a senior policy analyst at the Center on Budget and Policy Priorities.

The Trump administration has made state innovation a priority and has promised to fast-track Medicaid waivers, especially those that will impose work requirements on beneficiaries.

To date, five states — Maine, Arizona, Utah, Wisconsin and Kansas — have applied for waivers from the Department of Health and Human Services to put a cap on how long Medicaid beneficiaries can receive health benefits.

The waivers vary, but the proposals are generally tied to work requirements. Utah and Arizona both seek a maximum of five years eligibility. In Arizona, the five-year window would only apply when a beneficiary doesn’t meet the work requirement.

Utah’s request makes a deliberate link between benefit limits and welfare.

“This limit frames public healthcare coverage for adults as temporary assistance (similar to Temporary Assistance for Needy Families (TANF)), with the expectation that they do everything they can to help themselves before they lose coverage,” the application says.

The lifetime cap proposals reflect the administration’s view that only the “able-bodied” will be impacted. In all the requests, children, pregnant women and people with disabilities would be exempt from coverage limits.

The Department of Health and Human Services doesn’t comment on outstanding waiver requests, but Seema Verma, administrator of the Centers for Medicare and Medicaid Services, has made clear her view that Medicaid should only be for the most vulnerable citizens.

“True compassion is lifting Americans most in need out of difficult circumstances,” Verma said in a recent Washington Post column.

“This administration stands for a policy that makes Medicaid a path out of poverty by empowering states to tailor programs that meet the unique needs of their citizens,” she wrote.

Conservatives have long argued that spending on entitlement programs like Medicare, Medicaid and Social Security needs to be curtailed before the costs overwhelm the federal budget.

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Trump officials face decision on lifetime limits for Medicaid
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The Trump administration is facing a crucial test of how much flexibility they are willing to give states to remake their Medicaid programs.

Federal officials have already given the green light to two states to impose work requirements on Medicaid recipients, and at least eight other states are hoping to follow.

But a handful of other states want to go even further by putting a lifetime cap on how long people can be enrolled in the Medicaid program.

No state has ever put a limit on how long a person can receive Medicaid benefits. But given that the Trump administration has already shown a willingness to approve conservative policies like work requirements, premiums and lockout periods for Medicaid, many experts and advocates think lifetime limits could also win approval.

Critics of lifetime limits say they would fundamentally shift Medicaid from a health care safety net program for the poor and sick to a welfare program.

“It’s clear that [the administration] view[s] Medicaid not as a health insurance program. They are hopeful to get as many people off the program and off public assistance as possible,” said Jessica Schubel, a senior policy analyst at the Center on Budget and Policy Priorities.

The Trump administration has made state innovation a priority and has promised to fast-track Medicaid waivers, especially those that will impose work requirements on beneficiaries.

To date, five states — Maine, Arizona, Utah, Wisconsin and Kansas — have applied for waivers from the Department of Health and Human Services to put a cap on how long Medicaid beneficiaries can receive health benefits.

The waivers vary, but the proposals are generally tied to work requirements. Utah and Arizona both seek a maximum of five years eligibility. In Arizona, the five-year window would only apply when a beneficiary doesn’t meet the work requirement.

Utah’s request makes a deliberate link between benefit limits and welfare.

“This limit frames public healthcare coverage for adults as temporary assistance (similar to Temporary Assistance for Needy Families (TANF)), with the expectation that they do everything they can to help themselves before they lose coverage,” the application says.

The lifetime cap proposals reflect the administration’s view that only the “able-bodied” will be impacted. In all the requests, children, pregnant women and people with disabilities would be exempt from coverage limits.

The Department of Health and Human Services doesn’t comment on outstanding waiver requests, but Seema Verma, administrator of the Centers for Medicare and Medicaid Services, has made clear her view that Medicaid should only be for the most vulnerable citizens.

“True compassion is lifting Americans most in need out of difficult circumstances,” Verma said in a recent Washington Post column.

“This administration stands for a policy that makes Medicaid a path out of poverty by empowering states to tailor programs that meet the unique needs of their citizens,” she wrote.

Conservatives have long argued that spending on entitlement programs like Medicare, Medicaid and Social Security needs to be curtailed before the costs overwhelm the federal budget.
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“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working age, able-bodied adults … does not make sense,” Verma said in a speech late last year.

Advocates promise a legal fight, and say lifetime limits go against the entire purpose of Medicaid.

“This strikes me as lawsuit bait. I suspect this could be a bridge too far,” said Jocelyn Guyer, a consultant with Manatt Health. “Work requirements are also a sweeping change, and this is a step beyond. This seems like it would be asking for more litigation and controversy and trouble.”

Advocates for Medicaid also argue that coverage limits would be a huge administrative burden, and that there’s no evidence they even work.

Lifetime limits “won’t take away the need for care,” said Jerry Vitti, CEO of Healthcare Financial, a health care advocacy company. “You’re not lifting someone up by lowering their health status.”

Advocates also argue that the administration is encouraging states to break the law. ObamaCare allowed states to expand Medicaid to anyone making up to 138 percent of the federal poverty level — about $16,600 this year.

Republicans believe the expansion discourages “able bodied” people from working because it provides free health care. Legislation that congressional Republicans pursued unsuccessfully last year would have repealed ObamaCare and rolled back the Medicaid expansion.

“This is clearly an attack on the [Medicaid expansion] population. What could not be done legislatively is being done administratively,” Vitti said.

Some Medicare beneficiaries would pay more for their prescription drugs under President Donald Trump’s budget even as the sickest patients save thousands of dollars, a complex trade-off that may make it harder to sell Congress on the plan in an election year.

In budget documents, the administration said its proposals strike a balance between improving the popular “Part D” prescription benefit for the 42 million seniors enrolled, while correcting design flaws that increase program costs for taxpayers. Health and Human Services Secretary Alex Azar is expected to testify on the proposal later this week in Congress.

Trump has made bringing down drug costs a top priority, but his administration’s plan would create winners and losers. The high cost of medicines is the leading health care concern among consumers.

Independent experts said the administration’s plan will help beneficiaries with the highest prescription drug costs, an estimated 1 million of the sickest patients, those whose individual bills reach a total of more than $8,418 apiece.

But about 4.5 million seniors in the group just behind them could end up spending more of their own money. That’s because the budget proposes a change in how Medicare accounts for manufacturer discounts received by patients whose total bills range between $3,750 and $8,418. They could wind up paying about $1,000 more.

A senior Senate Democrat said the Trump plan missed the mark.

“Instead of picking winners and losers and leaving big pharma unscathed, the president should follow through on his promise to lower high drug prices by getting Republicans in Congress to work with Democrats on behalf of Americans who are getting clobbered at the pharmacy counter,” Sen. Ron Wyden, D-Ore., said in a statement. Wyden is the ranking Democrat on the Finance Committee, which oversees Medicare.

“The package reduces costs for some but increases costs for others, and the effect on premiums is not clear,” said Tricia Neuman, a Medicare expert with the nonpartisan Kaiser Family Foundation. Also unclear is how the Trump plan interacts with changes to the Medicare prescription plan enacted by Congress just last week.

Medicare’s prescription drug benefit is delivered through private insurance plans. Here’s more detail on the trade-off for beneficiaries:

— The budget eliminates cost sharing for Medicare beneficiaries who reach the program’s “catastrophic” coverage threshold, currently $8,418 in total costs. Instead of paying 5 percent of the cost of their medications, the sickest patients would pay nothing. They’d be the winners.

— A second group just behind the sickest patients would lose ground financially. Currently Medicare counts manufacturer discounts received by patients in this group to calculate total spending that determines when they qualify for catastrophic coverage. That practice would stop, meaning beneficiaries would have to spend more of their own money to reach the threshold for the richer catastrophic coverage.

“It’s complicated,” said Joe Baker of the Medicare Rights Center. “The winners in this proposal are people with very high drug spending. The people who are the losers here are the people who are stuck in the middle.”

In other Medicare drug changes, the budget calls for requiring insurers to share manufacturer rebates with patients, and it expands coverage for medications to treat substance abuse.

By Angela Antonelli via Marketwatch.com

As a bullish 2017 stock market continued its steady rise to record breaking levels, President Trump and others took the opportunity to highlight these gains for retirement savers and their 401(k)s. But that record-breaking streak came to end in early February as the stock market finally tumbled, reminding us that what goes up usually comes down.

The lesson from this: highlighting short-term gains to retirement portfolios can do more harm than good to long-term retirement savings and can weaken the financial well-being of today’s workers.

Behavioral economists tell us that people don’t often act in their best interests because we often suffer from inertia and a short-term vision when it comes to making important financial decisions. We are seeing this now as a rising stock market increased the size of retirement portfolios. A recent Washington Post article reported that some investment managers are seeing clients cash in on that euphoria by pulling dollars out of retirement funds for vacations, college and home improvement. This can be a costly mistake in the long run by jeopardizing retirement readiness.

If a 40-year-old couple decides to withdraw $20,000 from their retirement fund to pay for a luxury dream cruise, they would pay a 10% penalty, or additional $2,000, on the withdrawal. If they kept that same $20,000 invested in their 401(k) for 25 more years until they reach age 65 and, assuming a 4% annual return, they would have an additional $53,000 in their retirement portfolio. Is that luxury cruise worth the extra $33,000 or more over your lifetime if you take that money out of your retirement fund now to pay for it?

John Wasik, in a Forbes column published just after the market tumble, offers sage advice regarding how to view the stock market when it comes to retirement savings. “No matter which mix you choose, stay the course and hew to your savings goals. By knowing how much to save for retirement and keeping on the road to get there, you’ll surprise yourself at how much money compounds over time. Compounding is the one thing you don’t have to work for, and it’s effective for everyone.”

Now more than ever, employers and plan providers can make a difference by improving and investing in workplace-based retirement savings plans and offering financial literacy education to help workers make informed and better decisions about saving. Even the simple step of making available free online calculators so workers can see how much they need to save to achieve their goals or how much that dream vacation will cost them now versus 25 years from now can lead to better outcomes.

But the greater tragedy of only focusing on the gains in 401(k) or other retirement plans is that it creates a false sense of progress in the overall retirement readiness of American workers. A 2016 U.S. Government Accountability Office report found that the median defined contribution savings among working households aged 25-64 was $41,900 in 2013 and an estimated one-third of working households had no defined benefit or defined contribution retirement savings from a current or former job. And a rising tide can’t lift all boats if one-half of those boats aren’t even in the water. More than half today’s private sector workers – an estimated 55 million Americans – do not have access to an employer-sponsored retirement savings program.

Wall Street might be getting the message. During the recent World Economic Forum in Davos, Switzerland, BlackRock Chief Executive Larry Fink spoke about access and inclusion. “I think the question isn’t the financial system but the inclusiveness of the financial system, and we don’t talk about that at all,” he said during a panel about Remaking the Future of Global Finance.

Fink highlights that the equity market has nearly tripled in the last 10 years, which only benefits those who own stocks. “We are not addressing the issue of inclusion, of more participation in the marketplace,” Fink said on CNBC. And that “has to come from working with the majority of the population on financial literacy, and improving that financial literacy so they don’t feel frightened of moving their money into long term instruments.”

Providing greater access to retirement savings programs is important to improving financial well-being. Even families with modest incomes can find a way to save if they have good information, access to payroll deduction and advice about how to balance competing financial concerns, and budget and save for a range of different needs, such as short-term emergencies. Planning and discipline can help families avoid short-term decisions that could cost them dearly in retirement.

Policy makers understand the importance of developing innovative ways to expand access to the millions of workers who currently do not have an employer-sponsored retirement plan at work. Workers are 15 times more likely to save if they are offered a plan through their employer. In states like California, Connecticut, Illinois, Maryland, Oregon, Vermont and Washington, policy makers are partnering with the private sector to expand access to retirement savings options. They are offering simple, low-cost, easy ways for employers – especially small businesses who most often do not provide such plans – to provide their employees with access to individual retirement accounts (IRAs) or 401(k)s. These policy leaders are at the forefront of including so-called behavioral nudges, such as auto-enrollment, in program design to help millions of Americans begin to save for their retirement.

The best time to save is when things are looking good. The recent volatility of the stock market represents an important teachable moment about investing and saving for retirement. Saving for retirement is a long-term game. When times are good, and more people have more to save, policy makers, educators, employers and Wall Street should be doing even more to provide workers and families with the best information, financial literacy and savings options possible to help them make well-informed financial decisions to weather the economic storms and generate benefits to last a lifetime.

Angela Antonelli is a research professor and the executive director of the Georgetown University Center for Retirement Initiatives (CRI) at the McCourt School of Public Policy.

By Elizabeth O’Brien February 12, 2018

Not loving your Medicare Advantage plan? You have until Feb. 14 to ditch it under the annual Medicare Advantage Disenrollment Period, which ends on Valentine’s Day.

Note that this isn’t a continuation of open enrollment, the annual period from Oct. 15 through Dec. 7 when you can make any number of changes to your Medicare coverage. Only one move is permitted during the winter disenrollment period: switching from Medicare Advantage to original Medicare, which is Parts A and B. You can also buy a Part D drug plan and a Medigap supplement plan. Unless you have special circumstances, you’ll have to wait until October to make any other changes to your coverage for a Jan. 1, 2019 start date.

Medicare Advantage, also known as Part C, is insurance offered by private carriers that are contracted with the government to provide Part A hospital coverage and Part B outpatient coverage. Since 2004, the number of beneficiaries enrolled in these private plans has more than tripled from 5.3 million, or 13% of all beneficiaries, to 19 million, or one-third of beneficiaries, according to the Kaiser Family Foundation. The average monthly premium for enrollees of Medicare Advantage plans with drug coverage is $36 per month in 2017, although some plans have $0 premium.

One reason Medicare Advantage plans are popular is because many pay for services and treatments that original Medicare doesn’t, such as eyeglasses, hearing aids and dental work. What’s more, many Medicare Advantage plans offer prescription drug coverage with no deductible, compared with a deductible of up to $405 under the Part D drug plans that are sold to beneficiaries on original Medicare.

The trade-off is that the majority of Medicare Advantage plans are HMOs with relatively narrow networks, so your doctor and hospital choices are more limited. In 2015, more than one-third of Medicare Advantage enrollees were in plans with narrow doctor networks, according to the Kaiser Family Foundation.

By contrast, under original Medicare, beneficiaries can see any doctors around the country who accept Medicare. That’s a big reason why you might want to go back to original Medicare.

There’s a big caveat, though: if your plan is to have original Medicare and a Medigap supplement plan, keep in mind that these supplemental plans are medically underwritten. That means, you may be charged more for coverage or rejected altogether based on your health status. While it’s too late to complete the underwriting process before the deadline, a consultation with a broker should give you a good idea whether you’re a candidate for the supplemental plans available in your region, says Joe DeLuca, director of sales at eHealthMedicare.com, a broker that helps consumers select private Medicare plans.

“The key is to call before the 14th,” he says. Each carrier has different selection criteria, and an experienced broker should be able to steer you to one that will accept you.

Don’t drop your Medicare Advantage plan until you’ve gotten assurances that you can buy a Medigap supplement plan at a price you can afford, DeLuca cautions.