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Denials and delays in getting on transplant list costing former federal worker precious time
The asbestos fibers filling Fred Rorabaugh’s lungs are killing him. A transplant could buy him some extra time. But he can’t get past the bureaucracy to get on the list.
Though UC San Diego Health’s transplant team declared him a good transplant candidate in October, the 67-year-old former federal worker still hasn’t seen his name added to the transplant list because he still has not received formal approval from the U.S. Office of Workers’ Compensation Programs (OWCP).
Despite months of letters, phone calls and out-and-out pleading, the university and the government agency have not completed the array of tests necessary for his case to move forward, and experts say his experience is emblematic of problems that have become all too common for federal workers injured while working for the federal government.
Meanwhile, the Oceanside resident’s condition continues to worsen.
Last week, doctors admitted him to UC San Diego Jacobs Medical Center in La Jolla because his lung condition had deteriorated significantly. Now that he’s in the hospital, tests that were supposed to have been performed in late 2018 are moving forward more quickly, but Rorabaugh knows he has lost valuable time.
He’s quick to make it clear that his frustration has nothing to do with the health care delivery side of the house.
“The medical part of it has been good,” Rorabaugh said. “These people clearly know exactly what they’re doing. But the approval part of it has been crazy, and I know I’m not the only one who has gone through this.”
He and his family say they understand that getting on the transplant list is no guarantee. It can take months for a set of donor lungs to become available. Going month after month without even making the list, he said, drains a man’s family of that first burst of hope that arrives when doctors say that transplant is a possibility.
“Nobody wants to tell their daughter who just had a baby that grandpa’s not going to be around to hug that baby. That part is painful, truly painful,” Rorabaugh said.
A tide of finger-pointing has brought the former heavy equipment operator and workplace safety educator to this point.
In December, UC San Diego’s lung transplant program notified Rorabaugh that it would not be moving forward with the myriad tests necessary to become a transplant candidate due to “insurance issues.” That was particularly surprising because the federal government approved his claim for asbestos-related lung damage years ago. He is also covered by Medicare and supplemental health insurance.
But the university indicated that it never received approval from the federal government for the testing that he required.
A letter written on Feb. 14 that Rorabaugh received from the workers’ compensation program said just the opposite, stating that they “authorized a number of tests requested by UCSD to facilitate the workup needed to assess (Rorabaugh) for a lung transplant.”
That was news to Dr. Kamyar Afshar, director of the UC San Diego Advanced Lung Disease Program.
“I was told we were not able to obtain any of the financial aspects to get authorization for testing,” Afshar said Friday.
He said the work could have been completed “within maybe a few weeks” after his initial workup in October had the back-and-forth approval process not occurred.
The two sides started talking again after repeated questions about the stalled approval process by The San Diego Union-Tribune. UC San Diego met with a workers’ compensation nurse newly assigned to Rorabaugh’s case and re-accepted him into the program on March 7. The plan at the time was to get his remaining tests completed quickly.
But plenty of diagnostic work remains to be done, and Afshar said he was not sure why things hadn’t moved more quickly once there was a fresh meeting of the minds in late February and early March. Now that the patient is hospitalized, he said, the plan is to move forward at high speed.
“Our goal is to try to get everything expedited as quickly as possible for all of our patients,” Afshar said.
Reluctance
The whole process has been particularly confusing for Rorabaugh because, at first, the transplant programs assured him that he would have no problem getting his transplant covered. His overall good health and the ready assistance of his wife, Diane, meant that he had a good chance of approval.
When UC San Diego initially told him he had been declined for insurance reasons in December, he thought UCLA, which he had also been in contact with, would accept him.
“They stopped returning my calls as soon as I mentioned that it was a federal workers’ comp case,” Rorabaugh said.
It was a similar situation with another transplant program in Arizona. They were willing to take his information, but conversations, he said, made it clear that he couldn’t afford to stay in another city for months after the transplant as is required for acceptance. At various centers, he said, some just leveled with him that no one wants to do federal workers’ compensation cases.
That’s not at all surprising to Daniel Goodkin, a Los Angeles employee rights attorney who specializes in federal employee rights cases. He said the paralegals in his firm spend their days trying to find doctors who will see patients with federal workers’ compensation claims, because most won’t go anywhere near them.
“There are entire cities out there where you can’t find a single doctor who will touch a federal workers’ compensation case,” Goodkin said.
Doctors, he said, usually cite two main reasons why they don’t want to get involved. First, he said, many complain that the workers’ compensation program requires much more paperwork and is much more prone to second-guessing than is commonly required for approval from the average health insurance company or Medicare.
“The doctors tell us that the OWCP wants it explained like you’re explaining it to a 10-year-old, and doctors don’t want to do that. They’re busy seeing hundreds of patients, and they’re not in the business of writing endless reports,” Goodkin said.
Speed of payment once treatment is rendered is the other major factor, Goodkin added.
“They say they just don’t have the time to spend to decipher exactly what it is that the Department of Labor wants in order to receive payment, so they just say, ‘I’m not taking any more federal workers’ comp cases,’ ” Goodkin said.
Reached Friday afternoon, a UC San Diego spokeswoman said that the university health system has no prohibition against treating patients with workers’ compensation claims. But a search of one university database handled by the university’s contracting department turned up no such cases performed in the past 10 years.
Federal workers’ compensation representatives were not available Friday afternoon to discuss Goodkin’s claims.
However, a Department of Labor spokesperson said several weeks ago that transplant is a very rare occurrence among workers’ compensation patients, with just “16 claims created within approximately the last 10 years” involving “conditions related to transplants.”
Stolen breath, stolen life
With the clock ticking on his remaining lung capacity, some might wonder: Why not just get the transplant covered under Medicare?
If only it were that easy.
As noted in Who Pays First? (PDF download), a guide published by the U.S. Centers for Medicare and Medicaid Services, Medicare won’t pay for care that is already covered by a valid workers’ compensation claim.
“Once it’s workers’ comp that’s involved, it’s end of story,” Rorabaugh said.
The experience of losing his lungs, he said, has been bad enough without the insurance insurgency.
Four years ago, no activity, from horse camping to late-night dancing with Diane, seemed out of reach for this tall, trim man prone to wearing casual shirts with collars and slightly mischievous smiles.
Today, just taking out the trash is a struggle.
When he was first diagnosed in 2015, he said, an inhaler was enough for him to continue living an active life. But today he never disconnects from his portable oxygen machine, not even to take a shower.
Receiving that denial letter in December, the Rorabaughs said, was particularly devastating because Fred had just signed a formal contract in November to enter the transplant program.
Everything looked so promising, then it just fell apart.
“There was hope and then, just like that, it’s just gone,” Diane said, trying but failing to hold back her tears.
“We have nine grandchildren and six children between the two of us,” Fred Rorabaugh added. “When you have to tell them you can’t go forward with a lung transplant, not only does it take the hope away from me, it takes the hope away from my whole family.”
Rorabaugh has been relentless in his quest to find a solution. His tenacity, he said, is borne of a career working in workplace safety, eventually teaching others how to follow the myriad rules and regulations mandated on federal job sites.
Many simply give up when they’re unable to find a doctor willing to provide the care that their claim entitles them to receive, said Daniel Goodkin, the federal workers’ compensation attorney.
Rorabaugh’s tenacity, he said, is impressive.
“I’m impressed that he was able to do that, and that reflects a lot of ability that the average federal employee just doesn’t have,” Goodkin said.
Don’t worry
Asbestos entered his lungs during an 18-year stint as a heavy-equipment and crane operator at the now-defunct Mare Island naval base in Northern California.
When the decision was made to close the base in the early 1990s, Rorabaugh said, the order came down to join a demolition crew and start collapsing old buildings, many which contained pipe insulation, ceiling and floor tiles and other materials that used asbestos as a fire retardant.
Despite questions about the clouds of dust that started filling the air when those buildings started to fall, Rorabaugh said the orders were clear.
“We were told, ‘Don’t worry about it, everything’s fine, just keep that water hose going to keep that dust down,’ ” Rorabaugh said. “We said, ‘Don’t you think we should have some masks or something?’ and they go, ‘nah, you’re fine, just keep loading this stuff out.’ ”
According to the Organ Procurement Transplant Network, the median wait for a lung transplant was 137 days from 2011 to 2014 for patients with Rorabaugh’s blood type. But the nation’s organ allocation procedures have changed since those numbers were compiled. In late 2017, a new policy started giving donated lungs to the sickest patients living within a 250 nautical mile radius of a donor’s residence. Previously, donations stayed within the “donor specific area” where they were harvested.
The upshot is that, while he would have likely received a donation only from a San Diego County donor in the past, he now qualifies to receive organs from throughout Southern California.
But statistics also make it clear that waiting too long can be deadly.
This year, due to a long-running organ shortage, 17 people nationwide have died on the transplant list; 213 died waiting for lung transplants in 2018.
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At a time when there aren’t enough livers for ailing Americans, wealthy foreigners fly here for transplants.
Earlier this fall, a leader of the busiest hospital for organ transplants in New York state — where livers are particularly scarce — pleaded for fairer treatment for ailing New Yorkers.
“Patients in equal need of a liver transplant should not have to wait and suffer differently because of the U.S. state where they reside,” wrote Dr. Herbert Pardes, former chief executive and now executive vice president of the board at New York Presbyterian Hospital.
But Pardes left out his hospital’s own contribution to the shortage: From 2013 to 2016, it gave 20 livers to foreign nationals who came to the United States solely for a transplant — essentially exporting the organs and removing them from the pool available to New Yorkers.
That represented 5.2 percent of the hospital’s liver transplants during that time, one of the highest ratios in the country.
Little known to the public, or to sick patients and their families, organs donated domestically are sometimes given to patients flying in from other countries, who often pay a premium. Some hospitals even seek out foreign patients in need of a transplant. A Saudi Arabian company, Ansaq Medical Co., whose stated aim is to “facilitate the procedures and mechanisms of ‘medical tourism,’” said it signed an agreement with Ochsner Medical Center in New Orleans in 2015.
The practice is legal, and foreign nationals must wait their turn for an organ in the same way as domestic patients. Transplant centers justify it on medical and humanitarian grounds. But at a time when President Donald Trump is espousing an “America First” policy and seeking to ban visitors and refugees from certain countries, allocating domestic organs to foreigners may run counter to the national mood.
Even beyond the realm of health care, some are questioning whether foreigners should be able to access limited spots that might otherwise be available to U.S. citizens. For instance, public colleges compensate for reductions in state funding by accepting more foreign students paying higher tuition, and critics say in-state students are being denied opportunities as a result.
Dr. Sander Florman, director of the transplant institute at the Mount Sinai Hospital in New York, said he struggles with “in essence, selling the organs we do have to foreign nationals with bushels of money.”
Mount Sinai has not performed any transplants on patients who came to this country specifically for that purpose, but it has done so for international patients here for other reasons.
Between 2013 and 2016, 252 foreigners came to the U.S. purely to receive livers at American hospitals. In 2016, the most recent year for which data is available, the majority of foreign recipients were from countries in the Middle East, including Saudi Arabia, Kuwait, Israel and United Arab Emirates. Another 100 foreigners staying in the U.S. as non-residents also received livers.
All the while, more than 14,000 people, nearly all of them American citizens, are waiting for liver transplants, a figure that has remained stubbornly high for decades. By comparison, fewer than 8,000 liver transplants were performed last year in the United States — and that was an all-time high. The national median wait time for a liver is more than 14 months, and in states like New York, the wait is far longer. (The wait for livers varies from one state to the next, depending on such factors as the number of organ donors, and the resourcefulness of organ procurement agencies.)
Many patients die before reaching the front of the line. In 2016, more than 2,600 patients were removed from waiting lists nationally because they either died or were too sick to receive a liver transplant.
Most transplant centers only serve American citizens or residents, either by happenstance or by design. Foreign transplants are concentrated among a handful of centers, including New York Presbyterian, Memorial Hermann -Texas Medical Center in Houston (31 such transplants from 2013 to 2016), Ochsner (30), and Cleveland Clinic in Ohio (21).
“When you take people from other parts of the world and provide an organ transplant to them rather than someone who’s here, there’s a real cost, there’s a real life that’s lost,” said Jane Hartsock, a visiting assistant professor of medical humanities and health studies at the Indiana University School of Liberal Arts. Hartsock and her colleagues wrote a journal article published last year saying foreigners should be last in line for a transplant.
New York Presbyterian said it does not advertise its transplant program to foreign patients and that the majority of the transplants it performed on foreign nationals traveling to New York for that reason — 11 of the 20 — were on children under 18.
In a statement, the hospital and its academic partner Columbia University said they follow federal guidelines. “We strongly support efforts that aim to address the critical issue of equitable distribution of livers for transplant and are working closely with a wide range of stakeholders to help increase the number of organ donor registrations in New York State.”
A spokeswoman for the Cleveland Clinic, Eileen Sheil, said her hospital does not actively seek out foreign national business and has a “thoughtful and ethical approach that is well within the rules and aligned with our overall mission for taking care of patients.” Ochsner similarly said, “patients seek out Ochsner’s expertise because of our relentless commitment to provide the highest-quality, complex care.” Memorial Hermann did not respond to requests for comment.
To be sure, the proportion of available livers that go to foreigners is tiny — slightly less than 1 percent of liver transplants nationwide from 2013 to 16. The figure appears to be dropping further in 2017. Even if all recipients were Americans, wait times would still be substantial. Moreover, foreigners queue up on the waitlist like everybody else — although it may be easier for them, since they aren’t rooted in any particular state, to choose a hospital in an area with a shorter wait, such as Ochsner. And some Americans discouraged by the lengthy wait in this country have gone abroad for transplants.
The transplant figures in this article do not include transplants involving living donors, meaning a relative or friend who donates part of his or her liver to a patient. No one interviewed for this story said it is inappropriate for a foreign national to come to the U.S. for a procedure with a living donor.
There’s also an important distinction between giving an organ to a foreigner who happens to be in the U.S. — someone on a student visa or even an undocumented immigrant — and giving one to someone flying over just for surgery. Someone in the first group would be eligible to donate an organ if something happened to them in this country; someone in the latter group would not because livers must be transplanted quickly and there wouldn’t be enough time to ship them.
“If you live in the United States, no matter what your [citizenship] status is, you could potentially be an organ donor if you get hit by a car or something happens to you,” said Dr. Gabriel M. Danovitch, medical director of the kidney and pancreas transplant program at Ronald Reagan UCLA Medical Center, who previously led the UNOS international relations committee. “But if your home is somewhere else, a long way away, there’s no way that you can be a donor or your family or your friends could be donors.
“And in some respects, when you then come to the United States, you are using up a valuable resource that is in great shortage here.”
Foreign patients generally are not entitled to the same discounts as those with private insurance or Medicare, the federal insurance program for seniors and the disabled. In 2015, for instance, the average sticker price for a liver transplant at New York Presbyterian was $371,203, but the average payment for patients in Medicare was less than one-third of that, $112,469, according to data from the Centers for Medicare and Medicaid Services, which runs Medicare. In the case of Saudi Arabia, its embassy in Washington often guarantees payment for patients.
The topic is emerging now because the nation’s transplant leaders will meet next month to consider rewriting the rules governing how livers are distributed, giving programs in New York City, Los Angeles, Chicago and other areas greater access to organs from people who die in nearby regions. The proposal by a committee of the United Network for Organ Sharing, the federal contractor that runs the national transplant system, faces opposition from programs and regions that stand to lose organs. Pardes’ comments were posted in an online comment forum devoted to the proposal, which does not address the issue of transplants for foreigners.
UNOS said it has worked to get better data on foreigners that receive transplants in this country but ultimately, federal law doesn’t prohibit these transplants.
“This is an individual medical decision that the individual transplant hospital makes,” spokesman Joel Newman said. “If we addressed citizenship or residency as a particular reason for whether to accept a patient or not, then that would open up the door to lots of other non-medical criteria — religion, race, political preference, any number of things that as a community we have decided from an ethical standpoint not to consider.”
UNOS has the authority to ask questions of transplant centers about surgeries on foreign nationals, but Newman said UNOS committees are still trying to figure out what information they would want, and, in any event, the transplant centers don’t have to answer the questions.
The federal rules governing the transplant system, written more than three decades ago, say organ allocation decisions must be based on medical criteria, which would exclude consideration of a person’s nationality or citizenship. While centers can perform as many transplants on foreigners as they want, many programs have tried to keep them below 5 percent of all transplants for each organ type. Until several years ago, 5 percent was the threshold above which UNOS could audit a program. No programs were ever formally audited, and the cutoff was eventually eliminated.
It’s time to revisit the rules, some lawmakers say.
“As a general rule, you’ve got to take care of Americans first as long as you have more demand than supply,” said Sen. John Kennedy (R-La) whose state is home to Ochsner, a leader in transplants for foreign nationals. Kennedy said he would favor curbing transplants for foreigners, while creating a national board that could make exceptions. “But what you don’t want to get into, it seems to me, is subjective areas like well, ‘If this person could live an extra few years, what could they contribute to society?’”
There have been scandals in the past about foreigners and organ transplants. In 2005, a liver transplant center in Los Angeles shut its doors after disclosing that its team had taken a liver that should have gone to a patient at another hospital and instead had implanted it in a Saudi national. The hospital said its staff members falsified documents to cover up the incident.
The University of California, Los Angeles, came under fire in 2008 for performing liver transplants on a powerful Japanese gang boss and other men linked to Japanese gangs, and then receiving donations afterward from at least two of the men. The hospital and its surgeon said they do not make moral judgments about patients.
Further complicating matters is a 2008 document endorsed by transplant organizations around the world, called the Declaration of Istanbul, which seeks to eliminate organ trafficking and reduce transplant tourism internationally. One concern was that patients went to China and received transplants using organs from prisoners. (China said it was stopping the practice in 2015, but experts question whether that has happened.) Another concern was that if a country’s wealthiest or most powerful residents could get transplants overseas, its leaders may not have an incentive to set up a system of their own.
The non-binding declaration also says that there should be a ban on “soliciting, or brokering for the purpose of transplant commercialism, organ trafficking, or transplant tourism.” It was endorsed by UNOS and other national transplant groups.
Former Ochsner employees say they recall Saudi nationals coming for transplants, some wealthy and some not. A New Orleans bar posted a photo on Facebook in 2015 of a young man who brought his mom from Saudi Arabia for a transplant.
Ochsner said in a statement that it was proud of its liver transplant program, which is the nation’s largest. It said that it is willing to accept donated organs that other centers turn down for medical reasons, expanding its ability to help patients while keeping its survival rate high. And it noted that the median waiting time for its patients is only 2.1 months, far below the national median.
“UNOS does not have any restrictions preventing transplant for international patients and they are subject to the same guidelines as domestic patients,” the statement said.
Still, many American candidates for livers don’t make Ochsner’s waiting list. It refused to put Brian “Bubba” Greenlee Jr. on its list right after Christmas in 2015, because of his “poor insight into his drinking and lack of proper social support,” his medical records show. He had cirrhosis and died weeks later at age 45.
His sister, Theresa Greenlee-Jeffers, said Ochsner led her brother to believe that he would get a new liver. Her brother had stopped drinking and she had volunteered to take care of him after a transplant, but then the hospital suddenly reversed course.
“His last Christmas, he was given false hope that he was going to get a transplant. That’s not OK. You don’t play with somebody’s emotions like that,” Greenlee-Jeffers said.
Ocshner did not answer questions about Greenlee’s care but said in its statement, “Not every patient is a candidate for transplant.” It said its criteria are similar to those of other liver transplant centers.
“At Ochsner, we are caregivers, dedicated to providing our patients with high-quality care, improved outcomes and the gift of a second chance at life,” its statement said.
Greenlee-Jeffers wonders if Ochsner excluded her brother and other Americans to make room for foreigners willing to pay more. “It’s not OK,” she said. “We need to take care of our people here at home first. We don’t have enough of this to go around.”
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Democratic Sen. Chuck Schumer tweeted that premiums would be 300 percent higher under the Senate Republican health care bill for a 64-year-old earning $56,800 in 2026, compared with current law. Republican Sen. John Barrasso said the bill “lowers the rates for insurance 30 percent a couple years from now.” Both cited the Congressional Budget Office. Who's right? They both are.
On premiums, there's something for both parties in the nonpartisan CBO's analysis of the GOP's Better Care Reconciliation Act.
That bill — just like the Affordable Care Act, and the House Republicans' bill — would affect premiums on the individual market in different ways, depending on individual circumstances. Let's go through the details.
It's all about the individual market. We've said this time and time again: These claims about premiums concern a relatively small segment of the insurance market where those without employer plans or coverage through a program like Medicaid buy their own insurance. About 7 percent of Americans buy individual, or nongroup, market plans, while 49 percent get coverage through employers. But politicians often leave out that important detail, perhaps giving the impression that all premiums would be significantly affected.
It's compared with current law — the Affordable Care Act. The price of insurance isn't something that typically goes down. The figures that Schumer, Barrasso (who made his comment at a press conference on June 27) and the CBO use are compared with current law. So, a 30 percent decrease in a few years may still be an increase from what premiums are right now.
What does happen in the next few years? “The legislation would increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to projections under current law,” the report by the CBO and Joint Committee on Taxation says. The report considers premiums for benchmark plans — currently the second-lowest cost silver plan — which are used to calculate the amount of tax credits.
In 2018, average benchmark premiums for single individuals “would be about 20 percent higher” than under current law, the CBO said, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” The following year, average premiums would be about 10 percent higher than under current law, but by 2020, the average premiums “would be about 30 percent lower than under current law.”
Why the drop? The Senate bill would use a less expensive benchmark plan starting in 2020. That year, benchmark plans would pay a smaller percentage of benefits than under current law. Plus, CBO said, funding in the bill to directly reduce premiums would do exactly that.
The current benchmark plans have an actuarial value of 70 percent, which means they pay, on average, 70 percent of the cost of benefits that are covered. The Senate plan would lower the actuarial value to 58 percent. So those benchmark plans pay out a lower percentage of covered benefit costs, on average, but that means the premiums are lower. It also means, CBO said, that the deductibles for those benchmark plans would be higher than the deductibles for benchmark plans under current law.
In about a decade — in 2026 — average benchmark plan premiums in “most of the country” would be about 20 percent below what we'd see under current law, CBO said. It notes that the averages for 2020 and 2026 include a wide range of impacts in different parts of the country, partly because of waivers some states would get to change required benefits or other aspects of the individual market.
Why would some 64-year-olds see a big increase? The Senate bill, as does the House GOP bill, allows insurers to charge older Americans five times as much as younger Americans for premiums (starting in 2019). The ratio under the ACA, or current law, is 3:1. This means premium costs for older individuals will be higher under the legislation than under current law.
For example, CBO estimates that a premium for a bronze-level plan for a 64-year-old in 2026 — not including any tax credits — would be $12,900 for the year under current law and $16,000 under the Senate bill. The difference is greater for a silver plan — $15,300 under the ACA and $20,500 under the Senate bill. A 21-year-old, however, would see lower premiums under the Senate plan ($3,200 for a bronze plan versus $4,300 under current law).
Schumer's tweet was about a 64-year-old earning $56,800. That's 375 percent of the federal poverty level in 2026, making that person eligible for tax credits under the ACA but not under the Senate bill, which cuts off subsidies after income of 350 percent of the poverty level. When it comes to how the bill could affect net premium costs, the change in subsidies adds another layer of complexity.
What about subsidies and out-of-pocket costs? Many buying plans on the individual market don't pay the full premiums, because they get tax credits that reduce the cost. The Affordable Care Act provides tax credits to those earning between 100 percent and 400 percent of the federal poverty level. The Senate bill would make them available to those earning between 0 percent and 350 percent of the poverty level. And it would adjust those credits based on age for those earning above 150 percent, so that younger individuals pay less toward their premiums.
That, coupled with the 5:1 pricing variation based on age, is bad news for a 64-year-old earning $56,800 in 2026, an income level above the tax-credit cut-off. Schumer's tweet included a graphic that said: “According to CBO, Congress' Non-Partisan Budget Office: In 2026, if you're 64 years old with an income of $56,800, under current law, you pay a $6,800 premium for a silver plan. Under the Senate GOP bill, you'll pay a $20,500 premium for that plan. That's a premium increase of 300%.” That's an accurate summary of the CBO report (see Table 5).
A 40-year-old, single person earning that much or more wouldn't see much of a difference in premium costs. And a 21-year-old earning $56,800 or more would pay about $1,000 less under the Senate bill for a yearly premium compared with current law, whether it's a bronze- or silver-level plan, according to CBO's projections. If that 21-year-old earned only $26,500 (175 percent of the poverty level in 2026), the situation is reversed: That person would pay less under current law.
CBO doesn't provide estimates on family premiums.
And then there are out-of-pocket costs to consider. One reason benchmark premiums are lower on average under the Senate bill is because those plans cover a lower percentage of benefit costs. Some people — say, the young and healthy — would rather have the lower premium and a higher deductible or copay; others wouldn't. CBO said: “Some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care even though benchmark premiums would decline, on average, in 2020 and later years.”
Also, in 2020, the Senate bill eliminates cost-sharing subsidies that lower out-of-pocket costs for those earning between 100 percent and 250 percent of the poverty level.
Determining the individual impact. Changes to the individual market made by the ACA, and the proposed changes under the Senate Republican bill, would affect people differently, depending on a variety of circumstances — age, income and health spending, among them. To get an idea of how the Senate bill could change premiums for you personally, use the nonpartisan Kaiser Family Foundation's interactive map.
CBO's Table 5 also gives scenarios for three different ages and four different income levels. In general, be wary of politicians' claims about premiums going up or down. They may be referring to specific situations, and even averages don't tell the whole story. As the CBO report shows, there's great variation on how premiums would change under the Senate bill, depending on the individual person.
These lethal policies would never pass through an accountable, participatory public process.
A secretive Senate working group is closing in on a bill to overhaul the U.S. healthcare system by gutting Medicaid and the Affordable Care Act (ACA). With Republican leaders tight-lipped, the details of what’s in the bill remain a matter of speculation. [updated, been released]
The closed-door deliberations by this all-male cabal of Republican senators are antidemocratic to the point of parody, but the stakes are dangerously high. Healthcare is not just one sixth of the U.S. economy: It is critical to people’s wellbeing and very survival.
These draconian policies would never pass through an accountable, participatory public process. By fast-tracking this bill with no transparency or public hearings, and perhaps as little as a handful of days for any public response, they are threatening tens of thousands of people’s lives.
How many lives could be at stake? If the Senate bill cuts 23 million people off of Medicaid and ACA insurance plans as the Congressional Budget Office calculated the House healthcare bill would, estimates suggest that somewhere between 17,000 and 44,000 people would die every year.
Skeptics may quibble that these estimates lean high, but does the precise figure matter? How many lives would it be acceptable for Republicans’ healthcare cuts to take?
Widespread suffering borne unevenly
Death by a thousand Republican cuts would hit people of every race and every gender in every state. Even people with comfortable incomes and comprehensive employer-sponsored insurance are just one illness, divorce or job loss away from danger. Yet the harm of the Senate bill would overwhelmingly fall on poor people, sick people, older people, women and people of color.
Senate Republicans’ plans would do incredible harm to poor and working-class people by slashing Medicaid and ACA subsidies in order to fund an enormous redistribution of resources up the income ladder. These funding cuts, along with deregulation of private insurance, would exacerbate the existing failures of the insurance market by raising people’s premiums and out-of-pocket costs, limiting coverage and leaving many uninsured entirely. All this would especially hurt the very people who most need care; people with serious illnesses and chronic conditions, as well as older people.
Women and people of color are disproportionately poor and thus more likely to be hurt by cuts to Medicaid and ACA subsidies. Women are impoverished by wage inequality, part-time jobs that don’t provide health benefits and lack of payment for domestic work. They would also be hurt by Republican plans to defund Planned Parenthood. Black and Brown communities are kept poor by racial inequities in public health, criminalization, education, hiring, housing, banking, and other arenas, and would thus be especially hard hit. At the same time, because more white people rely on Medicaid and ACA subsidies than people of any other racial or ethnic group, huge numbers of poor and working-class white people would be hard-hit too.
Illnesses and deaths ripple out too, taking an emotional and financial toll on entire families. The communities that Senate Republicans are targeting have the least resources to cope with the loss of a wage earner, caregiver or loved one.
Death by unnatural causes
Preventable deaths are not a natural disaster. They are produced by policy choices and are, by definition, totally avoidable.
The root of the problem is the way the U.S. healthcare system prices and pays for healthcare. Other wealthy countries guarantee healthcare to everyone as a fundamental human right by controlling healthcare prices and levying taxes to pay for healthcare as a public good. But in the U.S. healthcare system, insurance, hospital and drug corporations are allowed to set healthcare prices virtually without limit, and the private insurance system allocates healthcare not to those who need it, but to those who can afford to pay.
This pay-for-access healthcare market puts up cost barriers that force an enormous number of people to forego needed care. According to a survey by The Commonwealth Fund, even after the coverage gains of the Affordable Care Act, 63 million people (one in three adults under 65) skip doctors’ visits, prescriptions and other needed care because they can’t afford the costs. All these people suffer, and a portion die. The Senate bill would force this needless misery on millions more.
It’s not hard to see why costs create a barrier to care. In some cases, the ACA allows insurance companies to charge deductibles of over $14,000. Out-of-pocket costs that high prevent even middle-class people from going to the doctor and filling prescriptions. And if Senate Republicans have their way, deductibles could rise much higher.
For poor people, the cost barriers are even worse. Working a low-wage job and struggling to pay for rent, transportation, food, utilities and other necessities means that even a $20 copay can be prohibitively expensive.
Market-based healthcare pricing is especially cruel to poor people, but it hurts us all. People in the United States pay far more for healthcare than any other nation. We have the worst health performance in the industrialized world. And by dividing us into categories and forcing us into isolated struggles for survival rather than uniting us around our shared needs and values, the health insurance market frays our democracy.
Ultimately the only way to remove cost barriers and to stop forcing people to die tragically preventable deaths is by moving from private, for-profit insurance to a universal, publicly financed, single-payer insurance system. In the meantime, Senate Republicans must be stopped. Our lives depend on it.
The closely guarded [secret] Senate health care bill written entirely behind closed doors finally became public [bill text] Thursday in a do-or-die moment for the Republican Party's winding efforts to repeal Obamacare.
The unveiling of the legislation marks the first time that the majority of the Senate GOP conference gets a comprehensive look at the health care proposal. With Majority Leader Mitch McConnell pressing ahead for a vote next week, senators only a handful of days to decide whether to support or vote against the bill.
The bill is very similar to the version of the House bill that passed last month but with some key changes. The text released Thursday showed the Senate legislation would still make major changes to the nation's health care system, repealing Obamacare's individual mandate, drastically cutting back federal support of Medicaid, eliminating Obamacare's taxes on the wealthy, insurers and others. The Senate plan however would keep Obamacare's subsidies to help people pay for individual coverage.
McConnell's decision to keep the details tightly under wraps until Thursday was intentional and aimed at winning over his colleagues out of the public spotlight, but the secretive process has infuriated Democrats -- and aggravated plenty of Republicans, too.
"I need the information to justify a 'yes' vote. I have a hard time believing that we would have that in such a short period of time," Sen. Ron Johnson, R-Wisconsin, told CNN on Wednesday.
South Carolina Sen. Lindsey Graham joked: "We'll know if it's a boy or girl tomorrow."
McConnell has very little room for error -- he can only lose two Republican votes and still pass the bill.
President Donald Trump said Wednesday night he hopes to "surprise" with a plan that has "heart."
"I hope we are going to surprise with a really good plan," Trump said at a campaign rally in Cedar Rapids, Iowa. "You know I've been talking about a plan with heart. I said add some money to it. A plan with heart, but Obamacare is dead."
The House passed its version of health care reform last month, but while Republicans celebrated that bill with Trump at the White House, the President has since called it "mean."
A senior administration official said Senate leaders sounded "optimistic" about the fate of the health care bill in the Senate during their briefing for White House officials Wednesday night.
Can McConnell get the votes?
Senior GOP senators were still putting final touches on the draft legislation on Wednesday, and it is still likely to change before any vote as members express their preferences.
Much like in the House, where moderate and conservative lawmakers were deeply divided on health care policy leading up to a vote in May, Senate Republicans also have clashing ideological views and priorities.
Some of the key issues that lawmakers are most concerned about include Medicaid reform, regulatory waivers, the state stability fund and tax credits. McConnell has a tough needle to thread: making significant concessions to conservatives risks losing moderate votes, and vice versa.
What will CBO say?
The legislation will also have to undergo parliamentary scrutiny to ensure that it meets the strict requirements on what can or can't be included in a bill under the budget reconciliation process.
One report that will inform Senate Republicans as they decide whether to support the bill will be a score from the Congressional Budget Office, expected to come out in the coming days.
The CBO analysis will shed light on how much money the bill would cost and how many people would be covered. Senate Republicans hope to see better headlines from this CBO report than the one that the House GOP legislation received. CBO said the House bill would result in 23 million fewer people insured in 2026 than under Obamacare.
What's in the bill and differences with the House
While the Senate bill is largely similar to the House passed-bill, there are some key differences.
Medicaid has been one of the central sticking points in the debate. The bill would continue the enhanced Medicaid expansion funding from Obamacare until 2021 and then [still] phase it out over three years. This is a concession to moderates, who weren't pleased that the House version would end the enhanced support for new enrollees in 2020.
However, conservatives also get some of what they want when it comes to overhauling the entire Medicaid program. The Senate bill would keep the House plan to send a fixed amount of money to states each year based on enrollment or as a lump sum block grant. But it would shrink the program even more over time by pegging the annual growth rate of those funds to standard inflation, rather than the more generous medical inflation, starting in 2025. This would likely force states to cut enrollment, benefits or provider payments.
The Senate bill would also largely maintain Obamacare's premium subsidies structure, but tighten the eligibility criteria starting in 2020. Fewer middle class folks would get help because only those earning up to 350% of the poverty level would qualify, rather than the 400% threshold contained in Obamacare. But it would also open up the subsidies to enrollees below the poverty level so those living in states that didn't expand Medicaid could get some assistance.
Senators opted to keep Obamacare's subsidies to prevent the funds from being used for abortions. The House bill called for creating tax credits based largely on age, but adding abortion restrictions to these credits could have run afoul of Senate rules governing the bill. Still, the similarities to Obamacare will likely infuriate conservatives such as Kentucky Senator Rand Paul, who decried the House version as "Obamacare Lite."
Also, as in the House bill, it would defund Planned Parenthood for one year.
The Senate also backs away from some last minute House concessions to conservatives that would have allowed states to opt out of several protections for those with pre-existing conditions, but insurers would not be allowed to charge higher premiums to those with pre-existing conditions.
The bill would also aim to shore up the existing Obamacare market by allocating funds for the cost-sharing subsidies until 2019. This will placate insurers, who were distraught by Trump's refusal to commit to continue making these payments, leading many carriers to hike rates or drop out of the exchanges for 2018.
SUMMARY: In the debate over health care reform, President Trump must now decide whether he will continue to make payments to insurance companies in order to cover out-of-pocket costs and deductibles for low-income consumers. Judy Woodruff speaks with Robert Laszewski, president of Healthcare Policy and Marketplace Review, about the ramifications of cutting off those subsidy payments.
SUMMARY: President Trump's tax reform blueprint calls for eliminating the alternative minimum tax and the estate tax, cutting all itemized deductions except for mortgage interest and charitable giving, and getting rid of taxes on the first $24,000 if a couple's earnings. How does that affect tax revenue? William Brangham gets reaction from Jared Bernstein of the Center on Budget and Policy Priorities.
SUMMARY: Why are American health care costs by far the highest in the world? Journalist and former practicing physician Elisabeth Rosenthal chronicles how we got here in her new book, "An American Sickness." Economics correspondent Paul Solman talks with Rosenthal about the forces driving high prices and what could be done to bring costs down.
Capitol Hill is still embroiled in a debate about the cost of health care, who should pay for it and how. And Americans across the country have been having that debate — who gets covered, which physician they can see and how much they should pay — almost every day for years now, since Congress passed President Barack Obama’s signature health care law in 2010.
Last week, the House Republican plan to repeal and replace the Affordable Care Act failed to earn enough support for lawmakers to vote on the law, the American Health Care Act.
“Obamacare is the law of the land,” House Speaker Paul Ryan said after the latest reform effort failed. “It’s going to remain the law of the land until it’s replaced. We did not have quite the votes to replace this law. And so, yes, we’re going to be living with Obamacare for the foreseeable future.”
More than half of U.S. adults approve of the Affordable Care Act, according to a national survey from Pew Research Center, but those opinions quickly split along political party lines.
The PBS NewsHour asked people if they were concerned or encouraged by possible, future changes to the Affordable Care Act. More than 1,000 people responded from across the country — from Maine to Missouri and California.
These are a few of those stories.
JENNIFER CARTWRIGHT
AGE: 41
LOCATION: Wichita Falls, Texas
OCCUPATION: Car and house insurance agent
Jennifer Cartwright knew something was wrong when her 2-year-old son’s stomach swelled up like a balloon. Doctors later removed a fast-growing, softball-sized cancerous tumor — a rhabdomyosarcoma. The Affordable Care Act went into effect just as her son, Zach, entered a year of treatment, including radiation “that just fried his insides” below his lungs and above his knees. He was left scarred and could only eat through a tube, but he survived. Today, he loves to play video games, especially Mario Brothers and Lego Dimensions, and will celebrate his 10th birthday this June.
Annually, his medical bills for hospital visits and a dozen medications add up to as much as $100,000, which — in a good year — equals Cartwright’s entire full-time income selling car and house insurance. But Zach’s parents haven’t worried about him hitting a lifetime cap on insurance coverage because Obamacare abolished that practice, Cartwright said. To defray costs, she enrolled Zach into Medicaid, but she said Texas tightened access to Medicaid services and has rejected care Zach receives since November: “They just made everything harder. Everything needs pre-authorization.”
A lifelong Republican, Cartwright sees both sides of the health care debate that has embroiled the nation. She said she agrees the nation overspends on health care and must cut costs, “but where?” she asked. State policymakers and insurers don’t want to make life harder for pediatric cancer patients and their parents, she said, but “they don’t realize how delicate a balance it is, and now it’s out of whack.”
“I’m in this catch-22. I understand insurance. I understand it’s a business. It’s for-profit,” she said. “But I also see it from the personal side. Here I am in the middle of it all.”
TIMOTHY TRIBBETT
AGE: 50
LOCATION: Greensboro, North Carolina
OCCUPATION: Veterinarian
When Timothy Tribbett first became a veterinarian two decades ago, he said his health insurance was “super affordable” at $125 each month. But now, that price has quadrupled, and Tribbett grows angry when he talks about how he must pay more than his mortgage payment to stay insured.
After the Affordable Care Act passed, Tribbett said the small veterinary practice where he and 17 other people work announced they would no longer cover employee health insurance, and none of them qualified for subsidies to ease the burden. Tribbett, 50, said he blames Obamacare for driving all but one insurance company out of his community. Most North Carolina residents who buy marketplace insurance have only one option this year, NPR reported. Tribbett would rather see high-risk pools set up for the uninsured (“don’t take money out of my pocket”) and plans offered across state lines to encourage “some competition.” The latter is something not included in the current version of the American Health Care Act, but it’s been discussed as something that could be part of future phases of Republican health care reform.
“If you work for a small company, and you have to get it on your own, you are absolutely screwed,” he said. “I can’t chance going without it right now, but if it keeps going up, I just can’t afford it.”
In the past, Tribbett has taken medication for OCD and chronic neck pain, but he avoids going to the doctor to get prescription refills because his deductible for each visit is too high, he said.
While his premiums climb, Tribbett said he’s also trying to save some of his $75,000 annual income for retirement. He hopes to move back to his family’s 100-acre farm, nestled in the Blue Ridge Mountains near Roanoke, Virginia. But at this rate, Tribbett thinks he’ll be 70 before he can afford to stop working.
“I’m not looking forward to working another 20 years,” he said.
Tribbett thinks the Republican health care plan moving through Congress is a “step in the right direction.” He supports proposed tax credits “for middle class people like me that have to buy their own insurance without subsidies,” and while conservative groups have criticized parts of the House Speaker Paul Ryan’s plan, Tribbett said “hopefully, those concerns will be addressed.”
JULIA RAYE
AGE: 50
LOCATION: Shreveport, Louisiana
OCCUPATION: Currently unemployed auditor
Medicaid patient to GOP: ‘You’re signing my death sentence’
More than 11 million adults — like Julia Raye of Louisiana — gained health insurance through the Affordable Care Act’s expansion of the Medicaid program. But under the Republican plan to replace the ACA, Raye, an unemployed diabetic who will be starting a new job in the coming weeks, may be barred from reentering a much more restrictive Medicaid program in the future if she once again falls on hard times. Going without insurance and appropriate medications would be disastrous for her health, she says. “If you don’t think that Medicaid is important, then you’re signing my death sentence,” Raye said to the congressional leaders deciding the fate of the ACA. “If you’re comfortable with that, then go right ahead.”
MINA SCHULTZ
AGE: 31
LOCATION: Fairmont, West Virginia
OCCUPATION: Health insurance counselor for West Virginia Medicaid
Mina Schultz’s life was ready for launch. She had just earned her master’s degree in French from the University of Missouri in 2011 and wanted to join the Peace Corps. At age 25, she planned to go without insurance for a few months, but Schultz’s father took advantage of a then-new Obamacare provision that allowed him to add her to his insurance. Then her right knee began to ache and swell. She iced it for six weeks, and doctors suggested the avid runner give her hobby a break to let her condition improve, but her knee only got worse. She went for an MRI scan, covered by insurance.
“I joked with the technicians, ‘Did you see anything good in there?’ They said, ‘Yeah, you’ll be glad you came in.’ I thought, 'Ok, I must have torn something'”
Schultz had osteosarcoma, a rare bone cancer normally found in children. She still chokes up when she remembers the moment she learned she had cancer. A year later, doctors replaced her knee (half of her right leg is titanium), and she entered an Affordable Care Act health exchange for insurance while in remission. After purchasing an ACA plan, Schultz joined the effort to sign up more enrollees. In October 2014, she found a job at a community health center near her mother’s home in Fairmont, West Virginia, enrolling hundreds of West Virginians in the health insurance marketplace and onto Medicaid.
In December, Schultz said new enrollees streamed into her office, but after President Donald Trump’s inauguration, they’d scoff at the prices for coverage. She said they told her: "‘Trump is going to fix this. I only need this for a few months and then this will go away and it’ll be cheaper.’"
“People want the health insurance, they just don’t want huge deductibles and huge premiums,” she said.
With Obamacare, Schultz said her family avoided bankruptcy and she “can afford care despite a preexisting condition.” She said she’s terrified the exchanges may go away. Insurance companies decide in May which marketplaces they will commit to in 2018 and how much they will charge, but Schultz worried insurers may balk over uncertainty about Obamacare’s fate, raising insurance prices even more.
“They already went up too much this year,” she said. “I worry that people are going to drop out because they can’t afford it.”
KOURTNAYE STURGEON
AGE: 54
LOCATION: Indianapolis, Indiana
OCCUPATION: Marketing
When Kourtnaye Sturgeon cooks dinner, her thoughts drift to her older son, his hard-fought battle against his heroin addiction and how close he came to death.
The summer after her son Ryan graduated high school, Sturgeon learned about his drug use. When she confronted him (“with love, not anger”), Sturgeon said, “he broke down.”
Her son went in and out of treatment, including detox, counseling and taking suboxone, but his addiction’s hold was strong. He dropped out of college in summer 2010 and lost his job at a pasta restaurant. He not only stole from her, Sturgeon said, but also shoplifted meat from grocery delis and resold it to buy drugs and further fuel his addiction.
Finally, Sturgeon added him to her insurance in January 2011 under Obamacare. Her son ended up in a 90-day inpatient treatment with 60-day intensive outpatient care and counseling, all covered by Sturgeon’s insurance. He has since entered recovery, and this July, now 25 years old, he looks forward to celebrating three years of sobriety, Sturgeon said.
“I know my son would not have survived his illness. I feel very blessed, but I also carry a bit of guilt,” she said. “I’ve met so many parents who have lost their children to overdose.”
Sturgeon said she knows he is in continuous recovery and that “with this chronic disease, relapse is likely,” she said. “But he has learned so much along the way from the benefit of really high quality treatment to help carry him through the relapse back health recovery.”
The Trump administration unveiled its proposed budget earlier this month. It’s unclear which agency will take the lead on a national strategy to combat opioids, a job the White House Office on National Drug Control Policy has held for three decades. The Trump budget eliminates that office altogether.
Sturgeon’s son is not alone, Sturgeon said, and neither is she. At a time when an estimated 20 million Americans live with substance addiction, Sturgeon said it is important to make treatment accessible to combat this “complex disease.”
There is more.
SUMMARY: The Affordable Care Act withstood a Republican effort to "repeal and replace," but there are problems with the current law that lawmakers acknowledge need to be addressed. We meet a few Americans who have concerns about Obamacare. Then Mary Agnes Carey of Kaiser Health News joins Lisa Desjardins to discuss why affordability is an issue for some.
SUMMARY: The Congressional Budget Office numbers are out on the Republican health bill. What's the political impact? Judy Woodruff talks with Amy Walter of The Cook Political Report and Tamara Keith of NPR about the difficulties of selling the American Health Care Act, plus the lack of evidence to back up President Trump's tweet allegation of being wiretapped by President Obama.
SUMMARY: The Congressional Budget Office predicts that more people than who got health care under Obamacare will lose coverage under the repeal bill proposed by Republicans. But the bill also shows cuts in federal spending and a smaller deficit. John Yang gets reaction to the proposed law from Dr. Ezekiel Emanuel of the University of Pennsylvania and Lanhee Chen of the Hoover Institution.
SUMMARY: From both sides of Pennsylvania Avenue came talk of amending the GOP health care bill on Tuesday. New estimates released Monday from the nonpartisan Congressional Budget Office bolstered opposition from Democrats and had some Republicans warning that the bill needs work. Judy Woodruff speaks with Rep. Ted Yoho, R-Fla., a member of the House Freedom Caucus, about his reservations.
SUMMARY: Although leading Republicans are pushing to pass their Obamacare replacement bill next week, its impact on millions of Americans remains a point of worry. Some prominent interest groups directly involved in health care are expressing opposition to the plan. Jeffrey Brown talks to Dr. Andrew Gurman, president of the American Medical Association, about the group's concerns.
Amy Schnelle died a little less than a month ago due to an epileptic seizure she suffered at her home in Knoxville, Tennessee. The 31-year-old former factory worker had suffered from severe seizures and was on disability. Her government subsidized disability paid for her very strong anti-seizure medication. That was until September.
On disability for several years, Amy Schnelle was receiving powerful anti-seizure drugs and had been seizure free since 2015. Then the United States Social Security Administration threw her a curve ball in September 2016 when they informed her she was no longer sick.
Schnelle appealed this decision and in January of this year, the Social Security Administration put her back on disability. However, according to her mother, the time spent off of the drugs had a terrible effect on Amy Schnelle's health.
“She had a whole lot of seizures because one of the medicines didn't come through,” said Sylvia Schnelle. “Once you stop your medicine so abruptly you go into a tailspin of seizures and you don't come out of it.”
Writing to Congressman Jimmy Duncan, Amy Schnelle was able to convince the government to resume her benefits. That happened in January 2017, but in February 2017, from her apartment, she texted her mother she had a “bad” seizure and asked her to “please” come. Her mother rushed to Knoxville from her home in Dandridge.
Part of the Republican concept of healthcare is that you die or to go to the emergency room, and hopefully get lucky and don't die. What happened to Amy Schnelle can and will continue to happen to many more people now that tax breaks for the rich are the main focus of our government's healthcare plan.
SUMMARY: Republican lawmakers released their bill to repeal and replace the Affordable Care Act on Monday evening. Proposed changes include ending direct government subsidies in favor of tax credits, ending penalties of the individual mandate and phasing out the expansion of Medicaid in 2020. Lisa Desjardins talks with John Yang from Capitol Hill.
SUMMARY: The House bill that Republicans plan to pass to replace the Affordable Care Act keeps some of the most popular provisions of the law, but it does not mandate coverage and shifts how the government would provide financial help. John Yang looks at key aspects of the plan with Sabrina Corlette of the Health Policy Institute and Lanhee Chen of the Hoover Institution.
SUMMARY: On day one of the push to sell a long-awaited replacement for the Affordable Care Act, Republican leaders mounted an all-out offensive with help from both the president and vice president. Dubbed the American Health Care Act, the plan changes aspects of its predecessor, including contentious matters of Medicaid and tax credits. Lisa Desjardins reports from Capitol Hill.
SUMMARY: The Republican bill to replace the Affordable Care Act officially began its journey through Congress, as two committees started drafting details. Pushed by GOP leaders and the White House, the bill faces opposition from Democrats, conservative critics and powerful interest groups, while multiple analysts concluded that millions more will be left without coverage. Lisa Desjardins reports.
SUMMARY: Under the new Republican plan to repeal and replace the Affordable Care Act, tax credits would assist uninsured people to buy coverage. But the criteria that determine eligibility is shifting, with age becoming a greater factor than income. Judy Woodruff talks to Julie Rovner of Kaiser Health News about the impact if the plan becomes law.
SUMMARY: Under the new Republican health care plan to replace the Affordable Care Act, there are major changes to Medicaid funding for states. Judy Woodruff talks to Julie Rovner of Kaiser Health News about why those changes are causing concerns for some states.
