obamacare – R&R – Reachout and Rebuild

How We Got Here

David Posnett — Fri, 24 Apr 2020 20:36:44 +0000

How We Got Here

The media has accurately reported how President Trump’s mismanagement of COVID-19 has exacerbated this global health crisis. But Trump’s damage to our public health goes back to the beginning of his administration — and for Congressman Lee Zeldin and the rest of the Republican Party, their culpability starts much earlier.

It begins with the universal Republican vow to eliminate the Affordable Care Act and is compounded by their ideological orthodoxy to starve every federal agency of funding, including those agencies that are charged with public health. Like every Republican, this was the platform Zeldin ran on in 2014, and this is how he has voted as a member of Congress.

But these dual GOP missions — repeal the ACA and reduce the size of government — have directly contributed to the disastrous federal response to this crisis.

The ACA, while primarily concerned with health insurance access and patient protections, also focused on public health issues through the Centers for Disease Control and Prevention. In 2010, the ACA established the Prevention and Public Health Fund (PPHF) at the CDC. It supported a public health mission that included the “early detection of and response to health threats.”

The GOP could not repeal the ACA while Obama was president, but once they took over the House after the 2010 election, largely on the strength of campaigning against the ACA, they worked hard to consistently weaken it, including weakening the PPHF. Then, in 2017, with the inauguration of Trump and complete control of the federal government, they went full-steam ahead to repeal the ACA and reduce the size of all federal agencies. The CDC and the PPHF were no exception.

In early 2018, Trump signed the budget bill that cut the PPHF by $1 billion over 10 years. Later, in 2018, Trump eliminated the global health security office within the National Security Council and made further cuts to public health programs by diverting money from the CDC and the National Institutes of Health for his policy to detain migrant children. Public health experts at the time warned that such drastic moves would harm the country’s ability to respond to and contain outbreaks of disease.

Trump and Zeldin are now working overtime to bury this history. To deflect blame, Trump insists that his name be stamped on the stimulus checks being mailed to desperate Americans. In a similar vein, Zeldin recently announced how he alone got much-needed medical equipment rushed to Suffolk County.

They would like you to forget how we got here.

Barbara Weber-Floyd

Westhampton Beach

Trump’s Sabotage of Healthcare

David Posnett — Wed, 19 Feb 2020 16:44:17 +0000

In spite of Trump’s SOTU lies, healthcare disinformation (with Lee Zeldin’s complicity), here is where we are on health care:

A recent poll shows Americans disapprove of President Trump’s handling of the Affordable Care Act by 56 to 35 percent and prescription drug prices by 54 to 30 percent.

Dismantling Pre-Existing Condition Protections – While President Trump lies to the American people that he supports protections for people with pre-existing conditions, he is in federal courts waging a campaign to eliminate these lifesaving protections and destroy every other protection and benefit of the Affordable Care Act. At every opportunity, President Trump has tried to undermine protections for people with pre-existing conditions. An excellent recent review demonstrates how Trump’s efforts to sabotage Obamacare are going:

1. Individual mandate eliminated 2. States allowed to add “work requirements” to Medicaid 3. Cost-sharing reduction subsidies to insurers have ended 4. Access to short-term “skinny” plans has been expanded 5. Funds to facilitate HealthCare.gov sign-ups slashed

Caving to Big Pharma on Drug Price Negotiation – After promising to negotiate drug prices “like crazy” before he was elected, President Trump caved to Big Pharma and has abandoned his pledge to support the drug price negotiation that House Democrats delivered in the Lower Drug Costs Now Act. Again and again, President Trump has pulled his punch on Big Pharma, making vague and unworkable announcements that have left seniors and hard-working Americans on the hook for sky-rocketing drug prices.

President Trump’s latest assault on health care: his new illegal Medicaid block-grant scheme.

The Administration’s plan for states to cap and slash Medicaid would push Medicaid recipients off lifesaving medicines, impose unaffordable premiums to maintain coverage and leave more vulnerable families exposed to catastrophic medical bills – with ruinous consequences for rural hospitals, for families seeking opioid addiction treatment for their loved ones and for middle-class seniors with long-term care need.

House Proudly Passed Lower Drug Costs Now

During this difficult time, the House will continue our strong legislative agenda For The People: lower health care costs by lowering prescription drug prices, bigger paychecks by building the physical and human infrastructure of America, and promoting cleaner government.

American seniors and families should not have to pay more for their medicines than what the drug companies charge people in other countries for the same drugs. That’s why Democrats proudly passed H.R. 3, the Lower Drug Costs Now Act, in December! This legislation finally levels the playing field for American patients and taxpayers:

Gives Medicare the power to negotiate directly with the drug companies, and creates powerful new tools to force drug companies to the table to agree to real price reductions, while ensuring seniors never lose access to the prescriptions they need.
Makes the lower drug prices negotiated by Medicare available to Americans with private insurance, not just Medicare beneficiaries.
Stops drug companies ripping off Americans while charging other countries less for the same drugs, limiting the maximum price for any negotiated drug to be in line with the average price in countries like ours, where drug companies charge less for the same drugs – and admit they still make a profit.
Creates a new, $2,000 out-of-pocket limit on prescription drug costs for Medicare beneficiaries, and reverses years of unfair price hikes above inflation across thousands of drugs in Medicare.
Reinvests in most transformational improvement to Medicare since its creation – delivering vision, dental and hearing benefits – and turbocharging the search for new cures.

The Democratic House has sent Senator McConnell more than 275 bipartisan bills – yet, calling himself the “Grim Reaper,” he still refuses to take them up! The American people deserve and demand action. In this New Year, we will continue to turn up the heat!

Another good article on the topic:

‘Trump is trying to kill Obamacare again and Democrats couldn’t be happier”

Published Sat, Mar 30 2019, 9:55 AM EDT. Updated Sun, Mar 31 201911:11 AM EDT

Medical Debt Collectors Decide Who Gets Arrested

David Posnett — Thu, 24 Oct 2019 01:54:45 +0000

From ProPublica comes a shocking story. While things aren’t quite as bad where I live, I think the story is telling about what to expect in the future unless we somehow reform our healthcare system. (D. Posnett)

Ambulance > Judge > Jail

Welcome to Coffeyville, Kansas, where the judge has no law degree, debt collectors get a cut of the bail and Americans are watching their lives — and liberty — disappear in the pursuit of medical debt collection.

On the last Tuesday of July, Tres Biggs stepped into the courthouse in Coffeyville, Kansas, for medical debt collection day, a monthly ritual in this quiet city of 9,000, just over the Oklahoma border. He was one of 90 people who had been summoned, sued by the local hospital, or doctors, or an ambulance service over unpaid bills. Some wore eye patches and bandages; others limped to their seats by the wood-paneled walls. Biggs, who is 41, had to take a day off from work to be there. He knew from experience that if he didn’t show up, he could be put in jail.

…

Biggs, who is tall and broad-shouldered, with sun-scorched skin and bright hazel eyes, looked up as defendants talked, but he was embarrassed to say much. His court dates had begun after his son developed leukemia, and they’d picked up when his wife started having seizures. He, too, had been arrested because of medical debt. It had happened more than once.

Judge David Casement entered the courtroom, a black robe swaying over his cowboy boots and silversmithed belt buckle. He is a cattle rancher who was appointed a magistrate judge, though he’d never taken a course in law. Judges don’t need a law degree in Kansas, or many other states, to preside over cases like these. Casement asked the defendants to take an oath and confirmed that the newcomers confessed to their debt. A key purpose of the hearing, though, was for patients to face debt collectors. “They want to talk to you about trying to set up a payment plan, and after you talk with them, you are free to go,” he told the debtors. Then, he left the room.

The first collector of the day was also the most notorious: Michael Hassenplug, a private attorney representing doctors and ambulance services. Every three months, Hassenplug called the same nonpaying defendants to court to list what they earned and what they owned — to testify, quite often, to their poverty. It gave him a sense of his options: to set up a payment plan, to garnish wages or bank accounts, to put a lien on a property. It was called a “debtor’s exam.”

If a debtor missed an exam, the judge typically issued a citation of contempt, a charge for disobeying an order of the court, which in this case was to appear. If the debtor missed a hearing on contempt, Hassenplug would ask the judge for a bench warrant. As long as the defendant had been properly served, the judge’s answer was always yes. In practice, this system has made Hassenplug and other collectors the real arbiters of who gets arrested and who is shown mercy. If debtors can post bail, the judge almost always applies the money to the debt. Hassenplug, like any collector working on commission, gets a cut of the cash he brings in.

Across the country, thousands of people are jailed each year for failing to appear in court for unpaid bills, in arrangements set up much like this one. The practice spread in the wake of the recession as collectors found judges willing to use their broad powers of contempt to wield the threat of arrest. Judges have issued warrants for people who owe money to landlords and payday lenders, who never paid off furniture, or day care fees, or federal student loans. Some debtors who have been arrested owed as little as $28.

More than half of the debt in collections stems from medical care, which, unlike most other debt, is often taken on without a choice or an understanding of the costs. Since the Affordable Care Act of 2010, prices for medical services have ballooned; insurers have nearly tripled deductibles — the amount a person pays before their coverage kicks in — and raised premiums and copays, as well. As a result, tens of millions of people without adequate coverage are expected to pay larger portions of their rising bills.

The sickest patients are often the most indebted, and they’re not exempt from arrest. In Indiana, a cancer patient was hauled away from home in her pajamas in front of her three children; too weak to climb the stairs to the women’s area of the jail, she spent the night in a men’s mental health unit where an inmate smeared feces on the wall. In Utah, a man who had ignored orders to appear over an unpaid ambulance bill told friends he would rather die than go to jail; the day he was arrested, he snuck poison into the cell and ended his life.

In jurisdictions with lax laws and willing judges, jail is the logical endpoint of a system that has automated the steps from high bills to debt to court, and that has given collectors power that is often unchecked. I spent several weeks this summer in Coffeyville, reviewing court files, talking to dozens of patients and interviewing those who had sued them. Though the district does not track how many of these cases end in arrest, I found more than 30 warrants issued against medical debt defendants. At least 11 people were jailed in the past year alone.

With hardly any oversight, even by the presiding judge, collection attorneys have turned this courtroom into a government-sanctioned shakedown of the uninsured and underinsured, where the leverage is the debtors’ liberty.

Seated at the front of the courtroom, Hassenplug zipped open his leather binder and uncapped his fountain pen. He is stout, with a pinkish nose and a helmet of salt and pepper hair. His opening case this Tuesday involved 28-year-old Kenneth Maggard, who owed more than $2,000, including interest and court fees, for a 40-mile ambulance ride last year. Maggard had downed most of a bottle of Purple Power Industrial Strength Cleaner, along with some 3M Super Duty Rubbing Compound, “to end it all.” His sister had called 911.

Maggard took his seat. He had cropped red hair, pouchy cheeks and mud-caked sneakers. “The welfare patients are the most demanding, difficult patients on God’s earth,” Hassenplug told me, with Maggard listening, before launching into his interrogation: Are you working? No. Are you on disability? He was diagnosed with schizoaffective disorder, bipolar type, and anxiety. Do you have a car? No. Anyone owe you money you can collect? I wish.

They had been here before, and they both knew Maggard’s disability checks were protected from collections. Hassenplug set down his pen. “Between you and me,” he asked, “you’re never going to pay this bill, are you?”

“No, never,” Maggard said. “If I had the money, I’d pay it.”

Hassenplug replied, “Well, this will end when one of us dies.”

Though debt collection filings are soaring in parts of America, Hassenplug speaks with pride about how he discovered their full potential in Coffeyville long before. A transplant from Kansas City, he was a self-dubbed “four-star fuck-up” who worked his way through law school. He moved to Coffeyville to practice in 1980 and soon earned a reputation as a hard ass. He saw that his firm, Becker, Hildreth, Eastman & Gossard, hadn’t capitalized on its collections cases. The lawyers didn’t demand sufficient payments, and they rarely followed up on litigation, he said. Where other attorneys saw petty work, Hassenplug saw opportunity.

Hassenplug started collecting for doctors, dentists and veterinarians, but also banks and lumber yards and cities. He recognized that medical providers weren’t being compensated for their services, and he was maddened by a “welfare mentality,” as he called it, that allowed patients to dodge bills. “Their attitude a lot of times is, ‘I’m a single mom and … I’m disabled and,’ and the ‘and’ means ‘the rules don’t apply to me.’ I think the rules apply to everybody,” he told me.

He logged his cases in a computer to track them. First with the firm and later in his own practice, he took debtors to court, and he won nearly every time; in about 90% of cases nationally, collectors automatically win when defendants don’t appear or contest the case. Hassenplug didn’t need to accept $10 monthly payments; he could ask for more, or, in some cases, even garnish a quarter of a debtor’s wages. His fee was, and often still is, one-third of what he collects. He asked the court to summon defendants, over and over again. It was the judge’s contempt authority that backed him, he said. “It’s the only way you can get them into court.”

The power of contempt was originally the power of kings. Under early English rule, monarchs were considered vicars of God, and disobeying them was equivalent to committing a sin. Over time, that contempt authority spread to English courts, and ultimately to American courts, which use it to encourage compliance with the judicial system. There is no law requiring that a court use civil contempt when an order isn’t followed, but judges in the U.S. can choose to, whether it’s to force a defendant to pay child support, for example, or show up at a hearing. A person jailed for defying a court order is generally released when they comply.

When Casement took the bench in 1987, after passing a self-study exam, he didn’t know much legalese — he had never been in a courtroom. But attorneys taught him early on that the power of contempt was available to him to punish people who ignored his orders. At first, Casement could see himself in the defendants. “I was a much more pro-debtor aligned judge, much more sympathetic, much less inclined to do anything that I thought would burden them,” he told me. “And over the years, I’ve gradually moved to the other side of the fulcrum. I still consider myself very much in the middle, and I don’t know if I am or not.”

Once a bustling industrial hub, Coffeyville has a poverty rate that is double the national average, and its county ranks among the least healthy in Kansas. Its red-bricked downtown is lined with empty storefronts — former department stores, restaurants and shops. Its signature hotel is now used for low-income housing. “The two growth industries in Coffeyville,” Hassenplug likes to say, “are health care and funerals.”

Coffeyville Regional Medical Center is the only hospital within a 40-mile radius, and it reported $1.5 million in uncollectible patient debt in 2017. A nonprofit run in a city-owned building, the hospital accounts for the vast majority of medical debt lawsuits in the county — about 2,000 in the past five years. It also accounts for the majority of related warrants. Account Recovery Specialists Inc. handles its collections, and it does so for hospitals in most Kansas counties. Though the hospitals can direct ARSI and its contracted attorneys to tell judges not to issue warrants, hardly any have. The Coffeyville hospital’s attorney, Doug Bell, said that its only motivation is to continue to serve the area, and that Kansas’ decision to not expand Medicaid under the Affordable Care Act has had a “dramatic effect on the economic liability of small rural hospitals.”

Three nearby hospitals in this rural region have closed in the past several years, meaning ambulances make more trips. A half-hour from Coffeyville, Independence runs its ambulance service at about a $300,000 annual loss. Its bills were at the root of four arrests this year alone. Derek Dustman, who is 36 and works odd jobs, had been driving a four-wheeler when he was hit by a car and rushed to the hospital. Though he was sued for not paying his $818 ambulance bill, he didn’t have a license to drive to the courthouse. This spring, he spent two nights in jail. “I never in a million years thought that this would end with jail time,” he told me.

For years, Hassenplug has requested that the judge issue warrants on the ambulance service’s behalf. When I asked Lacey Lies, the city’s director of finance, if she ever considered telling him not to resort to bench warrants, she was puzzled. “You’re saying an attorney with no teeth?”

The first time Tres Biggs was arrested, in 2008, he was dove hunting in a grove outside Coffeyville. It had been just a year since his 6-year-old son Lane was diagnosed with leukemia, and Biggs watched him breathe in the fresh air, seated on a haybale under an orange sky. When a game warden came through to check hunting permits, Biggs’ friends scattered and hid. He wasn’t the running type, and he took Lane by the hand. The warden ran Biggs’ license. There was a warrant out for his arrest. Biggs asked a friend to take Lane home and crouched into the warden’s truck, scouring his memory for some misstep.

The last few years had been a blur. His wife, Heather, had quit her job as a babysitter to care for their son. Then, she got sick. Some days, she passed out or felt so dizzy she couldn’t leave her bed. Her doctors didn’t know if the attacks were linked to her heart condition, in which blood flowed backward through a valve. To provide for his wife, son and two other kids, Biggs worked two jobs, at a lumber yard and on construction sites. He didn’t know when he would have had time to commit a crime. He’d never been to jail. As he stared out the window at the rolling hills, his face began to sweat. He felt his skin tighten around him and wondered if he would be sick.

The warrant, he learned at the jailhouse, was for failure to appear in court for an unpaid hospital bill. Coffeyville Regional Medical Center had sued him in 2006 for $2,146, after one of Heather’s emergency visits; neither of his jobs offered health insurance. In the shuffle of 70-hour workweeks and Lane’s chemotherapy, he had missed two consecutive court dates. He was fingerprinted, photographed, made to strip and told to brace himself for a tub of delousing liquid. His bail was set at $500 cash; he had about $50 to his name.

His friend bailed him out the next morning, but at the bond hearing, the judge granted the $500, minus court fees, to the hospital. Biggs compensated his friend with a motorboat that a client had given him in exchange for a hunting dog. But it wasn’t long before the family received a new summons. In 2009, a radiologist represented by Hassenplug sued them for $380.

Some court hearings fell on days when Lane had treatment, at a hospital in Tulsa, an hour south. Heather refused to postpone his care. Lane’s condition was improving — in a year, he would be cancer-free — and his dirty blond hair was sprouting again. Her health, though, had taken a turn. She began having weekly seizures, waking up on the floor, confused about where their Christmas tree had gone or why a red Catahoula puppy was skidding around their ranch house. Her doctors concluded she had Lyme disease, which was affecting her nervous system and wiping her short-term memory. Each time she woke up, she repeated: “Don’t take me to the hospital.”

Biggs was still on the hook for the bill that had landed him in jail; bail had covered only part of it, and the rest was growing with 12% annual interest. The hospital had garnished his wages, and the radiologist had garnished his bank account, seizing contributions that his family had raised for Lane’s care. Living on $25,000 a year, Biggs couldn’t afford to buy insurance. His family was on food stamps but didn’t qualify for Medicaid, a federal insurance program for people in poverty. Other states were about to expand it to cover the working poor, but not Kansas, which limited it, for families of his size, to those who earned under $12,000. Like millions of others across America, he and Heather fell into a coverage gap.

By 2012, the Biggs family had accrued more than $70,000 in medical debt, which it owed to Coffeyville Regional Medical Center and other hospitals, pediatricians and neurologists. Some forgave it; others set up lenient payment plans. Coffeyville’s was the only hospital that sued. The doctors who took them to court were represented by Hassenplug.

Biggs began to panic around police, haunted by the fear that at any moment, he might be locked up. That spring, outside the Woodshed gas station, he spotted a sheriff’s deputy who was also an old friend. To shake off his dread, he asked the friend to run his license. The deputy found another warrant, signed by Casement, involving the $380 radiologist’s bill. “You’re not really going to take me in, right?” Biggs remembers asking. The deputy said he had no choice. Bail, as usual, was set at $500.

The family filed for bankruptcy, a short-term fix that erased their debt but burdened them with legal fees. They lost their home and started renting. Biggs ultimately got a job that offered insurance, as a rancher, covered by Blue Cross Blue Shield. But it required Biggs to pay the first $5,000 before it covered medical expenses. When chest pain hit him as he worked cattle in the heat, and he began vomiting, the only nearby hospital was Coffeyville’s. In 2017, the hospital sued again. It was the family’s sixth lawsuit for medical debt.

Sitting in Casement’s courtroom this July, Biggs calculated that he was losing about $120 by taking time off from work to attend this hearing. “I haven’t received a bill,” he told me, slouched over his turquoise shorts. “The only thing I received was this summons.” Around noon, he finally sat down with an ARSI representative, who explained that the underlying bill had been garnished from his wages, but he still owed $328 in interest and court fees. He had another couple thousand dollars in collections for separate bills he hadn’t paid, for which he hadn’t yet been sued. He said the most he could afford to pay, every two weeks, was $12.50.

Before the end of the Tuesday docket, Casement returned to the courtroom to read off the names of the hospital’s defendants. Five had failed to show up for contempt citations, to give their reasons for missing their debtor’s exams. Casement saw that two of the no-shows hadn’t been properly notified of the hearing, so attorneys would need to try to reach them again. The judge read the names of the other three defendants and told the hospital’s collections lawyer, “That would be a bench warrant if you want it.”

The following morning, I was reading court files in the clerks’ office when Christa Strickland arrived at 10:20 in flip-flops and black leggings, her caramel hair wrapped in a bun atop her head. She ran her finger down a docket on the bulletin board and asked why her case wasn’t listed. When the clerk pulled up her file, she told Strickland that her contempt hearing had been on Tuesday and she was one day late. “You need to call the law office of Amber Brehm,” the clerk insisted, referring to ARSI’s contracted lawyer, who represents the hospital. She handed over the phone number.

Strickland sat on a hard bench and took out her cellphone. She had saved the hearing in the wrong day on her calendar, but she had taken the day off from work and wanted to clear up the misunderstanding. “I had a court date,” she said when a man answered at the law office. “I thought it was today but apparently it was yesterday. I’m just needing to see if I can set something up?”

“By not appearing at that, the court would be in the process of issuing a bench warrant,” he said.

“What does that mean?” Strickland asked, shaking her head.

“You don’t know what a bench warrant means?” he asked. “That means you will be arrested and taken to jail and ordered to post bond.”

“Oh my God.” Strickland squeezed her eyes shut, wetness smudging her mascara. She poked at her cheek with her index finger. Her father was a preacher. She’d never been in trouble with the law. She had made a mistake, she tried to explain. She wanted to make an arrangement to pay.

The man on the phone told her that it might take a couple weeks before the court processed her warrant paperwork, which the law office had not yet submitted. Once the judge issued the warrant, she could turn herself in. Strickland wanted to scream, I’ll pay the bill, don’t make me go to jail! but she didn’t have the money. Instead, she looked at the ceiling and asked: “Turn myself into the court? The police station?”

“The Sheriff’s Department,” he responded.

“They’re here in the same building,” she said. “I won’t leave here until I get this figured out. Thank you!”

She hung up. Prick, she muttered to herself. You’re going to talk to me like I’m a freaking idiot? That’s not okay. Educate me. The court has to process it? Her mind kept moving in circles. She herself worked in debt collection, for an auto title lending company. She understood that everyone was doing their job. Still, she couldn’t grasp how this bill had gotten this far.

Before she had taken this position, during her second pregnancy, her right breast had developed a chronic infection. In 2008, she was uninsured, needed surgery to remove the swollen abscess and ran up a $2,514 bill. More than a decade later, she was still chipping away at a balance that, because of interest and court fees, had more than doubled to $5,736. She had fallen behind on her monthly payment plan and now worried that her booking photo would be on Mugshot Monday, a Facebook album run by the Police Department. She imagined what she would tell her boss: I went to jail … because I missed a court date … for medical bills. It sounded absurd.

She spotted a sheriff’s deputy in a bulletproof vest with a name tag that said Bishop and a pistol on his hip. “Hey!” she called out, explaining her phone call and how the man said something about a warrant and turning herself in. Bishop radioed into dispatch and smiled with an update: “There’s no warrant in the system yet,” he told her.

“Yet!” Strickland replied, deflating his look of reassurance. “That’s what I’m worrying about.”

“You better give Amber a call back,” Bishop said.

When I asked ARSI about how attorneys decide to request warrants, Joshua Shea, who is general counsel, told me that they don’t. The judge can choose to issue one if court orders are not followed, he said. But Casement said the opposite, telling me that he gave the choice to the attorneys. “I’m not ordering a bench warrant. My decision is to give them that option,” Casement told me. “Whether they exercise it is up to them, but they have my blessing if that’s what they want to do.”

Shea sent me an eight-page email to make clear, in large part, that ARSI, as a collection agency, has no involvement in the courts, and that Brehm is a lawyer whom the agency contractually employs and who represents the hospital directly. Her email address, though, has an ARSI domain, and her resume lists her as ARSI’s director of legal. Brehm said that court hearings aren’t the only option for debtors, who can call her instead and answer questions under oath. Shea said nobody — not the hospital, ARSI, Brehm or the court — uses the threat of jail to “extract payment.”

Strickland reached Brehm after several days, and the attorney agreed to a new hearing. On Aug. 13, when they met in court, Brehm sat at the front of the room.

“We’re giving you a second chance on that citation; just to try to take care of this without there having to be any sort of bench warrant,” the lawyer said. “I want to make sure that we’re all on the same page about the consequences of not coming into court when the order has been issued.”

Strickland nodded.

“Again, if you set a payment plan and keep it,” Brehm said, “we won’t have to worry about that.”

In some courthouses, like Coffeyville’s, collection attorneys are not only invited to decide when warrants are issued, but they can also shape how law is applied. Recently, Hassenplug came to believe that debtors were only attending every other hearing in a scheme to avoid jail, and he raised his concern with the judge. He suggested that the judge could fix this by charging extra legal fees; Casement wrote a new policy explaining that anyone who missed two debtor’s exam hearings without a good reason would be ordered to pay an extra $50 to cover the plaintiff’s attorney fees. If they didn’t pay, they would be given a two-day jail sentence; for each additional hearing that they missed, they would be charged a higher attorney fee and get a longer sentence.

Most states don’t allow contempt charges to be used for nonpayment, and some, like Indiana and Florida, have concluded that it is unconstitutional. Michael Crowell, a retired law professor at the University of North Carolina and an expert in judicial authority, reviewed Casement’s policy. “You can’t lock people up for contempt for failing to pay unless you have gone to the trouble to determine that they really have the ability to pay,” he said. Casement told me he hadn’t made findings on ability to pay before ordering defendants to foot attorney’s fees, “but I know that’s something the court should consider,” he said. He also made plain why he wrote the policy: “Mr. Hassenplug and Brehm’s outfit have asked me to.” (Brehm denied she requested this.)

Casement has not done everything the debt collection lawyers have suggested. At first, he agreed to their requests to set bail at the amount of the debt, but he eventually settled on $500. “Most people can come up with $500,” he said. “It may not be their money, but they know someone who will pay.” He made sure no one was arrested unless they’d been reached by personal service or certified mail.

Kansas law allows courts to order debtors in “from time to time,” leaving discretion to judges. Casement limited the frequency of Hassenplug’s debtor’s exams to once every three months. He came to the decision by his own logic around what seemed like a reasonable burden for defendants, and it remains his personal policy today. The law also states that anyone found to be disabled and unable to pay can only be ordered to appear once a year. Without an attorney, debtors like Kenneth Maggard don’t know to assert this right.

Allowing bail money to count toward collections raises some of the most critical legal questions. Hassenplug told me that he thinks it’s great that cash bail is applied to the debt. “A lot of times, that’s the only time we get paid, is if they go to jail,” he said. Peter Holland, the former director of the Consumer Protection Clinic at the University of Maryland Law School, explained that this practice reveals that the jailing is not about contempt, but about collection. “Most judges will tell you, ‘I’m working for the rule of law, and if you don’t show up and you were summoned, there have to be consequences,’” he explained. “But the proof is in the pudding: If the judge is upholding the rule of law, he would give the bail money back to you when you appear in court. Instead, he is using his power to take money from you and hand it to the debt collector. It raises constitutional questions.”

Congress has not acted on advocates’ calls to amend the Fair Debt Collection Practices Act to prohibit collectors from requesting warrants. There are also no current efforts to bar nonprofit hospitals or medical providers that receive funds through Medicare or Medicaid from seeking warrants. Some states have reformed their laws, to make sure defendants are properly served or to prohibit wage garnishments for debt. But legal experts on collections say that more remains to be done, like taking jail out of the equation and instead requiring debtors to sign a financial affidavit or a promise to appear.

Shea, from ARSI, said that using the legal process is time-consuming and costly — a last resort; arrests are “the least desirable stage for any case to reach for all involved.” Even after lawsuits are filed, they try to connect eligible debtors with the Coffeyville hospital to apply for financial assistance, he said. Last year, the hospital wrote off $1.7 million in charity care, said Bell, the hospital lawyer. “That is evidence of a hospital that cares.”

Casement said he did not consider the legality of his policies a problem. He placed some blame on the health care system. “What we have isn’t working,” he said. “As a lifelong Republican, I would probably be hung, but I think we need health care for everybody with some limits on what it’s going to cost us.”

The way he saw it, he had wide latitude to enforce compliance with a court order, though he acknowledged that creditors used bail money to their advantage. “I don’t know whether the Legislature intended it to be used that way or not,” he told me. “I have not had enough pushback from the defendants’ side to give me the impression that I’m really abusing this badly.”

Before I left Coffeyville, I sat down with Hassenplug in the low-ceilinged courtroom. I asked him whether he thought that the system in Coffeyville was effectively imprisonment for debt, in a country that has outlawed debtors’ prisons. “The only thing they’re in jail for is not appearing,” he replied. “I do my job, I follow the law. You just have to show up in court.”

Debt collection is an $11 billion industry, involving nearly 8,000 firms across the country. Medical debt makes up almost half of what’s collected each year. Today, millions of debt collection suits are overwhelming state courts. The practice is considered a “race of the diligent,” where every creditor is rushing to the courthouse, hustling to get the first judgment, in order to be the first to collect on a debtor’s assets. In Hassenplug’s view, though, this work is not the rich taking from the poor. He laughed at how locals spread rumors, saying that he seized wheelchairs or Christmas trees. Once, he confessed, he took a man’s Rolex, only to find out it was a fake. Some months, he said, even his law office could not make ends meet.

After a couple of hours, a clerk poked her head into the courtroom and told us it was time to leave. Hassenplug and I began to walk out, and on the terrazzo steps, he asked if I wanted to see his buildings. He owned five of them on a shuttered stretch of town. He wondered out loud if he was making a mistake by inviting me, but he was pleased when I accepted. “There ain’t any place on earth quieter than downtown Coffeyville,” he said, leading me into the silent streets.

He walked me through the alleys under a cloudless sky, and when he arrived at one of his buildings, he tapped a code to his garage. The door lifted, and inside, five perfectly maintained motorcycles, Yamahas and Suzukis, were propped in a line. To their left, nine pristine, candy-colored cars were arranged – a Camaro SS with orange stripes, a Pontiac Trans Am, a vintage Silverado pickup with velvet seats. He toured me around the show cars, peering into their windows, and mused about what his hard work had gotten him.

By Lizzie Presser, Photography by Edmund D. Fountain October 16, 2019. Doris Burke contributed research.

Correction, Oct. 16, 2019: This story originally misstated the type of cancer Tres Biggs’ son, Lane, had. It was leukemia, not lymphoma.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

The emphases are mine (D. Posnett)

ACA in Reverse!

David Posnett — Thu, 03 May 2018 16:40:24 +0000

About 4 million working-age people have lost insurance coverage since 2016
The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

Check out the story here!

This is also interesting: Survey shows reversal in ACA coverage gains.

Gains in health insurance coverage made under the Affordable Care Act are beginning to reverse, according to the seventh iteration of The Commonwealth Fund’s ACA Tracking Survey.
According to the survey, the rate of uninsured people between ages 19 to 64 has increased to 15.5% from 12.7% in 2016, with higher rates in states that have not expanded Medicaid. Uninsured rates are higher in southern states.
Commonwealth attributes its findings to the repeal of the individual mandate, the rise of non-ACA-compliant insurance policies and support for Medicaid work requirements.

Continued drops are expected. Commonwealth estimates that 5% of currently-insured adults plan on dropping their insurance coverage because of the individual mandate penalty repeal.
The Trump administration is promoting expanding short-term health plans and association health plans, which supporters say will allow more affordable options for currently uninsured Americans. Several industry organizations and associations have criticized the move, arguing the expansion of short-term plans would undermine consumer protections, lead to higher premiums in the ACA-compliant individual market and jeopardize market stability.
Additionally, the Trump administration’s plans for short-term expansion would primarily impact the middle class, as lower-income people are protected from premium increases through the use of federal subsidies, according to a recent Kaiser Family Foundation report.
Gallup found that the uninsured rate increased in all demographic groups last year except for senior citizens, who are eligible for Medicare.

If you are worried about your healthcare, it is time to vote and boot out Lee Zeldin in Nov. 2018

Why are Drug Prices Going Through the Roof?

David Posnett — Fri, 01 Dec 2017 01:51:41 +0000

By Francesca Rheannon, Journalist

Writer’s Voice with Francesca Rheannon, Producer and Host

Twitter Accounts: @WritersVoice

On Facebook & LinkedIn

http://www.writersvoice.net/2017/11/wendell-potter-gerald-friedman/

Why are drug prices going through the roof? We talk with Wendell Potter about Big Pharma and what his new investigative journalism site, Tarbell, is finding out about it.

Critics say single payer health insurance would be too expensive. We talk with economist Gerald Friedman, who developed Bernie Sanders’ Medicare for All plan. He answers his critics point by point.

Wendell Potter

Are Americans getting swindled at the pharmacy? We pay an average of 300% more for medications than people in other major countries. And the costs just keep going up.

And of course, it’s not just drugs. We pay far more for all aspects of health care — insurance, doctors and hospital fees, tests and drugs — than other nations. But we aren’t getting our money’s worth.

Wendell Potter is a former health insurance industry executive turned whistleblower. We spoke with him several years ago about his book DEADLY SPIN, about how the health insurance industry skews the playing field in its favor, making sure to kill efforts at reform while getting laws passed that fatten its bottom line. His book NATION ON THE TAKE showed how corporate America in general does the same thing.

Now Potter has started a nonprofit investigative journalism site, Tarbell, to expose the inner workings of the healthcare industry. Tarbell went online in November with a series of investigative articles by different journalists about the influence of Big Pharma over our political process. We called up Wendell Potter to learn about the results of those investigations and to find out more about Tarbell itself.

How Big Pharma Keeps Drug Prices High

Gerald Friedman

During the presidential primary season last spring, we spoke with University of Massachusetts economist Gerald Friedman about Bernie Sanders’ Medicare for All plan. Friedman was the architect of that plan.

At the time, some mainstream economists published an op-ed in the New York Times saying the plan was too expensive. Then the Urban Institute came out with a study claiming that the Sanders’ plan would cost an extra $32 trillion. And candidate Hillary Clinton declared that single payer health care would “never, ever happen.”

Since then, Sanders has come out with a Medicare for All Senate bill that has actually garnered the support of sixteen Democratic senators, including some potential presidential hopefuls. Among them are Elizabeth Warren and Cory Booker.

With the GOP continuing its assault on health insurance coverage — the latest being the so-called Tax Reform bill that would collapse Obamacare and take billions out of Medicare — a push for single payer by an outraged electorate might actually gain steam.

So, would single payer really break the bank? We called up Gerald Friedman to ask him to address criticisms of his plan so we could make up our own minds. To listen to the interview on a podcast click on this link http://www.writersvoice.net/2017/11/wendell-potter-gerald-friedman/ and then click on the player to hear both interviews.

Trump Undercuts ACA with New Plan Options

David Posnett — Thu, 19 Oct 2017 18:12:36 +0000

Author Shannon Muchmore @stmuchmore

Published Oct. 12, 2017

Dive Brief:

President Donald Trump signed an executive order Thursday that rolls back a number of Affordable Care Act (ACA) provisions that set minimum requirements for health plans.
The order will allow small businesses and groups of people to band together and buy insurance as an association. The association health plans (AHP) available to them do not have to meet the requirements of the ACA, such as protection for people with pre-existing conditions and essential health benefits.
In addition, the order expands the use of short-term plans that also have looser requirements and allows plans to be sold across state lines.

Dive Insight:

Broadly, the executive order loosens the requirements health plans must meet and shifts regulation away from federal levels. This could lower out-of-pocket costs for people who don’t use much care, but would likely result in major cost increases for people with pre-existing conditions.

The biggest concern with offering these plans is that it would lead payers to cherry pick young, healthy people who are less expensive for payers. But separating them from people who will need services creates an unbalanced risk pool. That can quickly lead to prohibitive out-of-pocket costs for people who have a pre-existing condition or who unexpectedly need high-cost care.

There are still several steps to be taken before the order could have a real impact. HHS and the Department of Labor have been instructed to write new regulations which will go through the regular notice and comment process. The specifics of those regulations will be important to how the order ultimately plays out. Also, the order will almost certainly see a legal challenge. Still, it signals that Trump’s White House is ready to find ways of undercutting the ACA despite the high-profile legislative failures earlier this year.

It’s far from the first sign, though. HHS has drastically cut back efforts to promote this year’s open enrollment period, which begins Nov. 1. The ACA’s overall advertising budget was slashed by 90%, community groups that receive federal funding to help people enroll have been devastated by cuts and HHS recently barred regional directors from participating in enrollment events.

Short-term plans are inexpensive for people who are healthy, but they can exclude people with pre-existing conditions. They have previously been allowed for a limited stretch, such as three months, but extending that time and allowing these plans to count toward the individual mandate will mean an unstable risk pool.

Allowing plans to be sold across state lines is a staple of conservative health policy, but there is little reason to believe it would actually lower costs. There are also many unanswered questions about how these plans would be relegated.

Americans Don’t Want Senate’s Health Care Plan, But It’s Unclear What They Do Want

David Posnett — Thu, 13 Jul 2017 08:27:32 +0000

It’s Time For Politics To Take A Back Seat To Those They Serve. Let’s Have a Bi-Partisan HealthCare Solution: This Could Be A Start

David Posnett — Fri, 07 Jul 2017 20:30:53 +0000

A liberal think tank just released its own proposal to fix Obamacare

Posted on Vox.com

Jeff Stein Jun 29, 2017, 11:30am EDT

Sen. Tammy Baldwin (D-WI) and dozens of other Senate Democrats hold photos of patients on the Capitol steps. A new proposal from a liberal think-tank could form the basis of Democrats’ response to Obamacare’s problems (Vox/Jeff Stein)

The most influential center-left think tank in DC has a new plan to fix Obamacare — and, perhaps surprisingly, it includes some of the same provisions as the Republican health bill in the Senate.

On Thursday, the Center for American Progress released new legislative text that proposes repairing Obamacare’s exchanges through a mixture of new subsidies to help insurance companies cover their most expensive patients, and lower taxes to encourage insurers to set up shop in under-served markets.

The plan is almost certainly dead on arrival with a Republican caucus that has been bent on dismantling Obamacare for years. But CAP is casting it as a bipartisan solution that could give Republicans a lifeline should Majority Leader Mitch McConnell fail to find the 51 votes to pass his bill — and require Democratic support.

“We are at an inflection point where there’s an opportunity for senators to choose a different path,” said Topher Spiro, one of the report’s authors, in an interview. “But it’s a very small window.”

CAP’s plan to stabilize Obamacare, explained

The CAP plan has three main components — two of which are already included in Senate Republicans’ Better Care Reconciliation Act. (All three components have been floating around health policy circles for a number of years.)

The first involves guaranteeing Obamacare’s cost-sharing reductions, which help make copays and deductibles cheaper for lower-income people who get insurance through Obamacare. Trump threatened to stop making Obamacare’s CSR payments — a move that “destabilized” the markets by making it unclear to insurers if they could count on the payments being there. Both Senate Republicans’ BCRA and the CAP plan would guarantee the CSRs.

The second component is a $15 billion “reinsurance” fund. It calls for giving states federal money to give insurers funding for their most expensive, high-cost enrollees — which Spiro says would in turn reduce premium payments for everyone else on the exchanges. (Spiro also notes that Maine and Alaska — two states with moderate Republican senators — have already adopted similar approaches in their states that have shown signs of success.) Because the reinsurance fund would reduce premium costs, and thus the amount of tax credits the government would have to pay out, Blue Cross Blue Shield Association says the $15 billion fund would only cost the federal government $4 billion.

“It’s pretty well known that a very small percentage of patients drive the vast majority of health care costs. That’s the reasoning behind this solution: If you subsidize those high costs, it will bring premiums down for everyone,” Spiro said.

“And it’s plucked straight from the Senate Republican bill.”

These Republican ideas were put into BCRA in order to ease the blow created by the GOP plan to eliminate the individual mandate, which would cause instability in the Obamacare exchanges. CAP is proposing that Democrats and Republicans can agree on these proposals — without the tax cuts for the rich and gutting of Medicaid also envisioned by McConnell’s team.

The third proposal in the CAP plan isn’t in the GOP plan. It involves giving tax incentives to insurance companies who agree to cover patients in parts of the country where there is only one insurer (or fewer). One idea is to encourage insurers by eliminating the health insurance tax for plans that enter these markets, though Spiro said he’s open to other suggestions and tweaks. The plan also says that CAP would support a public option to make sure that everyone is covered.

Should the left be only calling for a public option or single-payer solution instead?

It goes without saying that the biggest difference between the CAP plan and Senate Majority Leader Mitch McConnell’s is that CAP would not call for, well, the rest of BCRA. It scraps BCRA’s massive tax cuts for billionaires, the steep cuts to Medicaid, the deep wound to Obamacare’s subsidies, and essentially only uses the ideas for guaranteeing Obamacare’s Cost Sharing Reductions and the reinsurance fund.

But it’s also a marked break from what some on the progressive left want to see: unified Democratic calls for a public option, or Medicare-for-all single-payer bill. (CAP also supports a public option, and lists it as one possible way to bring down the number of uninsured Americans in the report.)

Earlier this week, the Progressive Change Campaign Committee released a statement preemptively attacking any move on the left to embrace a fix for Obamacare that didn’t include these much more far-reaching fixes to Obamacare.

“Any bipartisan health care solution must, at a minimum, include a robust public option for all or a Medicare buy in for all — and if it doesn’t, it is dead on arrival with the progressive base and most Americans,” PCCC’s Adam Green said.

There is robust support in the Democratic caucus for these ideas. More than half of House Democrats have agreed to cosign Rep. John Conyers’s (D-MI) single-payer proposal — the most support it’s gotten in the party’s history.

Spiro says he’s not bothered by concerns that the left should instead be focused on demanding a public option or Medicare-for-all. Like many in the Senate Democratic caucus, he said the priority has to be on improving Obamacare for patients in the short term — and, above all, stopping Republicans’ dangerous bill.

“You’ve talked to some of these patients: They feel they’re at risk right now and that their care may be impacted next year or the year after. Our immediate focus has to be on stabilizing the markets and removing this threat and this uncertainty,” Spiro told me. “My number one priority, above all else, is to help and protect those people.”

Obamacare Inspires Unlikely Political Action In California’s Red Region

David Posnett — Thu, 06 Jul 2017 18:08:29 +0000

KAISER HEALTH NEWS/CALIFORNIA HEALTHLINE — REPEAL & REPLACE WATCH

By April Dembosky, KQED July 6, 2017

Greta Elliott talks to her staff at the Canby Family Practice Clinic in Modoc County. (April Dembosky/KQED)

Modoc County, in the northeastern corner of California, is roughly the size of Connecticut. It’s so sparsely populated, the entire county has just one stoplight. The nearest Walmart is more than an hour’s drive, across the Oregon border. Same with hospitals that deliver babies.

Greta Elliott runs a tiny health clinic in Canby, on the edge of the national forest. “Rural” doesn’t begin to describe the area, she says. This is “the frontier.”“There are more cows in Modoc than there are people,” Elliott said.

There’s a frontier mentality, too. People take care of each other, and they take care of themselves. They don’t like being told what to do. Being forced to buy insurance made “Obamacare” a dirty word.

Even clinic administrator Elliott, who doesn’t have job-based coverage, decided against buying it for herself.

“It’s too expensive,” she said. “I choose to put my money back into paying the bills of the whole family.”

But now a coalition of clinics from across the northeastern corner of the state is lobbying local officials to take an unpopular position in this conservative land: Defend Obamacare.

And the right-leaning Shasta County Board of Supervisors took them up on it.

“We thought, ‘Whoa! That is really bold,’” said Dean Germano, CEO of the Shasta Community Health Center. “I was surprised.”

Overall, the Affordable Care Act — known informally as Obamacare — helped 25,000 people in far Northern California buy plans through the state marketplace, Covered California. But the law helped three times as many people – 75,000 – enroll in Medi-Cal, the state’s Medicaid program that provides free health coverage for low-income residents.

“The data shows it’s the rural communities that have greatly benefited from the Medicaid expansion. That’s the irony,” Germano said. “These are places that voted much more heavily for Donald Trump.”

In Modoc and Lassen counties, 70 percent of people voted for Trump in the November election. In neighboring Shasta County, Trump won 64 percent of the vote.

Given the stakes, however, the Shasta County Board of Supervisors sent a letter in the spring to the local Republican congressman, Rep. Doug LaMalfa, asking him to vote against the initial GOP repeal and replace bill, because it would hurt local people.

“We have an obligation to say something,” said Supervisor David Kehoe. “And if it may be mildly offensive from a political standpoint for some, well, we’re not going to be intimidated by politics.”

LaMalfa still voted in favor of dismantling Obamacare.

He didn’t return calls and emails for this story, but, in May, LaMalfa told KQED that skyrocketing premiums were the main driver behind his vote.

“Unfortunately, the reality is that too many young and healthy individuals are deciding they’d rather pay the penalty than sign up for care, citing financial barriers and lack of choice,” he said in a statement. “A 28-year-old making $45,000 a year with no major health concerns is not going to pay upwards of $400 a month for a plan that does not even work for them.”

When clinic representatives met with LaMalfa’s staffers, they were told the congressman’s office was flooded with calls from middle-income consumers like this.

But poor folks on Medi-Cal didn’t call to say how much they appreciate the program. In fact, clinics struggled getting people to sign up for Medi-Cal, at first.

“They feel like it’s a handout and they’re too proud, they don’t want to,” said Carol Morris, an enrollment counselor for the Mountain Valleys health clinics in Shasta County.

One way clinic workers get around the stigma is to avoid calling it Medi-Cal. Instead, they promote the name of the insurer that manages the Medi-Cal contract in that region. People get a card for “Partnership Health Plan” and may not realize they’re actually covered by a government program.

“It feels like it’s more of an insurance,” Morris said. “It’s like a laminated, wallet-sized card that’s got your numbers on it. It just looks exactly like an insurance card.”

One patient at the Mountain Valleys clinic in Beiber, Kay Roope, 64, knew she had Medi-Cal, and she liked it.

“It did me good,” she said.

Now she has a subsidized commercial plan through Covered California, with modest premiums and copays, and she likes that, too.

“It’s OK. ‘Cause I’m at the doctor’s at least once a month,” she said.

But when asked what she thinks of Obamacare overall, she says she doesn’t like it.

“Because of Obama himself,” she said with a laugh. “I rest my case.”

The confusion and the contradictions are common among patients, explained Morris, the enrollment counselor.

“People just don’t understand the different names,” she said. “But, of course, it’s the same thing.”

Morris has seen the difference Obamacare has made for people in the region. She’s seen patients get treatment for diabetes and breast cancer, or get knee surgery that they otherwise wouldn’t have gotten.

Those patients won’t fight for Obamacare, Morris said, so that’s why the clinics have to.

This story is part of a partnership that includes KQED, NPR and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Promises Made To Protect Preexisting Conditions Prove Hollow

David Posnett — Fri, 23 Jun 2017 19:40:40 +0000

KAISER HEALTH NEWS — REPEAL & REPLACE WATCH

By Jay Hancock and Rachel Bluth June 23, 2017

Congressional Democrats joined activists on May 4 for a rally to urge not to replace the Affordable Care Act. (Alex Wong/Getty Images)

Senate Republicans praised the Affordable Care Act replacement bill they presented Thursday as preserving coverage for people with cancer, mental illness and other chronic illness.

But the legislation may do no such thing, according to health law experts who have read it closely.

Built into the bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.

Depending on what states and governors do, plans sold to individuals might exclude coverage for prescription drugs, mental health, addiction and other expensive benefits, lawyers said. Maternity coverage might also be dropped.

Somebody with cancer might be able to buy insurance but find it doesn’t cover expensive chemotherapy. A plan might pay for opioids to control pain but not recovery if a patient became addicted. People planning families might find it hard to get childbirth coverage.

“The protection your insurance provides could depend a lot on where you live,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. In some states, “over time, [patients with chronic illness] might find it increasingly difficult to find insurance companies that will offer plans that cover their needs.”

The Senate provisions aren’t expected to affect job-based health plans or Medicare for seniors. They would mainly affect the kind of insurance sold to individuals through the Affordable Care Act’s online exchanges, which cover about 10 million people.

Obamacare overhauls in both the House and Senate would also limit spending on Medicaid for low-income people, which analysts say would cause coverage losses for millions.

The Senate legislation, expected to be voted on next week, follows a widely criticized House bill that would also overhaul the Affordable Care Act, in its case giving states the option of denying coverage or raising premiums for those with preexisting illness.

On Thursday Republican Senators touted their bill as avoiding those features.

“I feel comfortable that no one is going to be denied coverage because they’ve been sick before,” said Sen. Lindsey Graham (R-S.C.) The bill “doesn’t change [protections for] preexisting illnesses, which is good,” he said.

Not explicitly. But it still gives insurers a potential way to shrink coverage for the chronically ill, albeit less obviously, said health law scholars.

“There’s nothing in the Senate bill that specifically would allow withdrawal of coverage for a person with a preexisting condition,” said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform. “What it does do is allow states to get waivers” allowing exceptions to rules requiring comprehensive coverage, he said.

The Affordable Care Act required carriers to offer “essential health benefits” covering a wide range of services including hospitalization, maternity, prescription drugs and mental health.

Both the Republican House bill and the Senate bill would let states change that rule. Under those measures, states could set their own standards that might not be as generous, allowing insurers to exclude benefits for those with preexisting illness.

“The Senate bill guarantees people with preexisting conditions access to insurance at the same rate as healthy people, but there is not a guarantee that the benefits they need will be covered by insurance,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Obamacare, too, allows states to make exceptions for essential health benefits — but with strict limits. Coverage must be at least as comprehensive as the federal standard, for one thing. The Senate bill contains no such safeguard.

“As long as they can show that it’s budget neutral, states would have a lot of latitude” to cut essential benefits, said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner.

Insurance plans for individuals might again start to look as they did in the days before Obamacare, when they typically excluded coverage for maternity, mental health and substance abuse, health policy experts said.

That’s especially true because the Senate bill would allow governors to lower coverage standards by executive certification — without approval from legislatures, Corlette said. The measure would also permit governors to raise or eliminate Obamacare’s caps on what patients pay annually out of pocket before insurance kicks in. That could make care for preexisting conditions unaffordable even if it’s covered by the plan.

For their part, insurers may heavily pressure states to make such changes, analysts said.

Unlike the Affordable Care Act and the House bill, the Senate bill contains no incentives or inducements for healthy people to maintain medical coverage. That could result in a disproportionately sick group of people buying individual insurance, driving up carriers’ costs and prompting them to seek ways to trim coverage and cut claims.

“If the only people motivated to buy insurance are going to be the ones who really need it, insurers are really going to have a strong incentive to use their benefit design to deter enrollment for the sickest people,” said Corlette.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.