Thankful I Live in DC

November 25, 2015

Like many of you, I suppose, I try to take some time before Thanksgiving Day to focus on what I have to be thankful for. In my case, a lot, even on this Thanksgiving, when I’ll have no one ministering to the turkey — my late husband Jesse’s traditional (and favorite) holiday task.

One thing I’m thankful for and recur to often as I browse policies that affect low-income people is the fact that I live in the District of Columbia.

As followers know, I gripe about policy choices our mayors and the DC Council make. Sometimes more than gripe.

I’m constantly reminded, however, of how relatively progressive the major choices generally are — and of how even current debates occur within a relatively progressive framework. A few examples.

Jobless Workers

The Council seems poised to increase unemployment insurance benefits for at least some jobless workers, as well as to enable some to get them for longer

A bill cosponsored by a majority of members would, among other things, increase the maximum weekly benefit — long stuck at $359 — to $430 and then adjust it annually so that it didn’t again lose purchasing power.

It would also enable recipients to work part time without losing as much of their benefits as they do now — another increase of sorts.

Meanwhile, nine states have cut UI benefits by reducing the maximum time jobless workers can receive them to fewer than the customary 26 weeks. Two states will now cut the lifeline at 12 weeks when their unemployment rates drop to 5-5.5%.

And five states have chosen not to ask for waivers of the highly-restrictive SNAP (food stamp program) eligibility maximum for able-bodied workers without dependents. One of them — Kansas — is among the states that cut eligibility weeks for UI benefits.

So ABAWDs who are jobless for as little as 16 weeks will have neither cash income nor a cash equivalent to feed themselves — unless they can get into a job training program.

Unlikely, since states don’t have to provide any training slots for them. And most don’t, as the Center on Budget and Policy Priorities has again reported.

The District has not only preserved the waiver it’s entitled to. It’s done other things to extend SNAP benefits to as many residents as possible — and to make them as sufficient as seems possible, even to the extent of committing local funds to boost the minimal minimum.

Affordable Health Care

The District swiftly embraced the opportunities in the Affordable Care Act — both to expand its Medicaid program and to establish an online marketplace so that residents with incomes above the new maximum could purchase health insurance, in many cases subsidized.

And it promoted enrollment in a variety of ways — through advertising, partnerships with the local soccer team and largest drug store chain and funding for 35 divers organizations to support trained “assisters,” who help residents understand the ACA and navigate their way to a sign-up.

At the same time, it retained the locally-funded Healthcare Alliance so that low-income residents barred from Medicaid and the exchange — mainly undocumented immigrants — could get affordable health care too.

As a result, the District’s already low uninsured rate dropped to 5.3% last year — bested only by Massachusetts, which provided the model for the ACA.

Meanwhile, 20 states still refused to expand their Medicaid programs. And 13 of them passed laws to hobble the federally-funded navigators — one of the two types of “assisters” the District provides.

We see the results in the same Census health insurance report I linked to above. Highest uninsured rates in the non-expansion states — led by Texas, with a rate well over three times the District’s.

Not surprisingly, when Texas, among others, excludes all childless adults from its Medicaid program and covers only parents with incomes no greater than 15% of the federal poverty line — about $3,013 for a parent with two kids.

Family Planning Rights

The District would — if it could — use its own tax revenues to ensure that low-income women who live here can choose to end a pregnancy when they believe that’s best, a right they supposedly have under the Constitution.

The District can’t because Congress exercised its prerogative to meddle in the local budget in ways it can’t — and wouldn’t dare to — if the District were a state like any other.

Meanwhile, 24 states have cleverly (they think) found a way around the Supreme Court’s ruling in Roe v. Wade, which made the Constitutional right operative.

They’re using their taxpayer dollars to defend laws that effectively deny the right by requiring clinics that provide abortions to meet wholly unnecessary standards — all very costly and at least two sometimes absolutely impossible to comply with.

Texas will defend its unusually expansive rules before the Supreme Court, using tax dollars women have perforce contributed. The governor makes no bones about the intent of the rules.

“The ideal world, ” he says, “is one without abortion. Until then, we will continue to pass laws to ensure that they are as rare as possible.” So much for the alleged concern for women’s health and safety.

Well-off women will, of course, still have abortions. They’ll travel to communities with clinics that have managed to meet the standards — or to states that haven’t enacted targeted regulations of abortion providers, so-called to produce the appropriate acronym, i.e., TRAP.

They’ll perhaps have abortions in hospitals, as well-off women with compassionate doctors sometimes did before Roe.

Meanwhile, hundreds of desperate women have already tried to-it-yourself abortions — at genuine risk to their health and safety. Who knows how many more have borne children they didn’t want and can’t care for? How many have instead done away with themselves?

Got my juices flowing here, when I should be thinking about turkey juices. But I am truly thankful that I’ve settled in the District. And I’m thankful for Jesse, without whom I probably wouldn’t have. But that’s another story.


Glitch in Law Leaves Former Foster Care Youth Without Health Insurance

November 5, 2015

Kaiser Health News leads off an article with the story of a young woman who’d aged out of foster care and moved to another state, where she soon came down with a bad ear infection. She went to a hospital and discovered she was no longer covered by Medicaid.

So this young adult, now on her own, had to clean out her bank account and borrow to pay for the antibiotics she needed. And all because of another drafting glitch in the Affordable Care Act — a wrong word buried deep in the 974-page text.

Limited Parity for Former Foster Care Youth

As you probably know, the ACA allows young adults to remain covered under their family’s health insurance plan until they’re twenty-six. This has protected some 5.7 million of them from the risks of insufficient health care and/or catastrophic bills.

But it’s of no help to young adults whom a state assumed responsibility for because it decided that their parents couldn’t or wouldn’t fulfill their responsibilities. The ACA tries to extend protection to these youth.

It requires states and the District of Columbia to cover them up to twenty-six under their Medicaid program if the youth had been in their foster care program when they reached the age of “emancipation” from the child welfare system.

But it doesn’t require states or the District to cover these youth if they move to another state. Nor to transfer them to their Medicaid programs when the youth move in.

This, at any rate, is how the federal agency responsible for Medicaid interprets the wording, though the drafters clearly intended to provide parity for all young adults.

No Continuous Coverage … or Perhaps Any

Former foster care youth can secure Medicaid coverage, if they’re eligible according to their new home state’s standards. But they have to go through the whole enrollment process just like any other adults.

In the best of cases, they’ll have no health insurance for awhile — perhaps longer than most because the state may insist on checking information that could be hard to verify, e.g., income, residency.

In the worst of cases, no health insurance period. That’s most likely in the 19 states that won’t expand their Medicaid programs to cover everyone (except some immigrants) with an income no higher than 133% of the federal poverty line — actually, 138% because of a technicality in the ACA.

If our former foster care youth have incomes at or above 100% of the FPL — and the savvy or assistance needed — they can purchase subsidized health insurance on the exchange for eligible residents in their new state. That too could leave them without coverage for awhile.

But some will fall between the cracks. Fifteen states exclude all childless adults from their Medicaid programs, including those too poor to buy on an exchange. An additional seven cover only those who meet criteria set by approved pilot projects.

The Letter of the Law, Not the Spirit in DC

We can generally look to the District for enlightened healthcare policies. But unlike thirteen states, it’s decided not to recognize the Medicaid eligibility of former foster care youth who become residents.

The Department of Health Care Finance says it can’t readily verify their eligibility because there’s no national database. True enough. But couldn’t the agency ask the youth’s former home states to verify? That doesn’t seem to me so “administratively burdensome” as it claims.

Couldn’t it at least develop some agreement with Maryland, where I’m told many of the District’s aged-out foster care youth move? (No agreement with Virginia would be needed because it’s one of the thirteen that’s exercised its flexibility to provide continuous Medicaid coverage.)

Health Care Finance needn’t assume any burden, however. At least one state just takes a youth’s word for his/her former foster care status and Medicaid enrollment — an option the federal administrative agency expressly allows.

A Nationwide Fix

Bills in both the House and Senate would correct the drafting error so that all former foster care youth have the protection Congress intended.

All they’d do — because all that’s needed — is change “or” to “and” in one paragraph “the” to “a” in two other paragraphs of the Social Security Act that the ACA amended.

Are the bills going to go anywhere in this Congress, with Republican majorities intent on dismantling the ACA? A rhetorical question, of course.

So at least for the time being, former foster care youth must depend on state and District officials for the affordable health insurance they need. Seems to me the District should be out in front here, instead of doing the least it legally can.

Do Nothing Congress Gets Something Pretty Good Done

October 30, 2015

So Congress did indeed pass a big package to deal with pressing, undone business. It’s entitled the Bipartisan Budget Act. And one could call it that, though it would have died in the House if still-Speaker Boehner hadn’t relied on Democrats to get it through.

No one, so far as I know, likes everything in it. But it’s a whole lot better than no bill at all — and not only because the federal government was mere days before defaulting on the debt.

I can’t possibly cover every jot and tittle. Here instead is what I’ve learned about several major issues I’ve blogged on.

Spending Caps

The bill doesn’t eliminate the spending caps that the Budget Control Act imposed. It does, however, lift them for this fiscal year and the next. For non-defense programs that depend on annual appropriations, this will mean an extra $40 billion — the same as the extra for defense.

Most of the extra non-defense money applies to the budget for this fiscal year, which Congress still hasn’t produced. Only another half billion or so will be left for the following year. Then the caps kick in again, forcing cuts unless the next Congress and President agree to prevent them.

On the upside, the non-defense programs will have $34 billion more this year than they would have had with no budget deal. On the downside, they’ll have 12% less in real dollars than they had the year before the BCA first cut and then capped spending.

What this means, in practical terms, is that we can’t hope for significantly larger investments in the safety net programs funded as much (or little) as Congress chooses each year — WIC, for example, housing assistance and homeless services.

Nor for significantly larger investments in a wide range of programs that offer low-income people opportunities to fare well without “welfare,” e.g., education, job training, affordable, high-quality child care.

In short, as CLASP says, the cap relief is “a welcome down payment,” but only that.

Disability Insurance Benefits

The bill shores up the trust fund that helps pay for Social Security Disability Insurance benefits. As I’ve written before, the trustees projected total depletion next year. That would have forced across-the-board benefits cuts of about 20%.

The bill preserves full benefits, with no changes in eligibility standards by shifting money from the retirement benefits trust fund, as many experts have recommended ever since insolvency loomed on the horizon.

This should avert a shortfall for seven years. And, no, it doesn’t “rob Social Security,” as the Heritage Foundation (and other right-wingers) claim.

Some funds to offset the costs of the package as a whole will come from the DI program. These include savings expected from beefed-up investigations to identify fraud, plus revenues from steeper penalties.

The bill also eliminates a long-standing pilot program that enabled staff responsible for processing SSDI claims in 20 states to determine eligibility without an independent medical opinion.

All applicants will henceforth have to have two written evaluations from medical experts, either their own doctors or doctors the DI office refers them to.

The fact that the bill anticipates savings from this indicates that the scorekeepers expect it to result in more denials and/or longer delays in approvals. But the projected savings are very small — about 0.3% of benefits paid.

A small price to pay for fending off cost-reduction measures some Congressional Republicans have pushed for, e.g., denying SSDI benefits to recipients who returned to the workforce and then received unemployment benefits because they were laid off.

The bill also requires the Social Security Administration to test an alternative way of encouraging SSDI recipients to try working again.

Seems like a good idea, but probably won’t reduce the DI rolls by much, since most former workers who make it through the screening process are far too disabled to ever “engage in substantial gainful activity” again.

Medicare Premiums

That Medicare Part B premium spike I blogged on earlier this week won’t occur. Well-off seniors will, as always, have to pay more for the outpatient care and other health-related costs Part B covers.

The rest of the 16.5 million or so who were going to get hit hard will have to pay only the same amount more as they would have if all Part B beneficiaries paid a share of the expected spending increase, just as they do virtually every year when Social Security benefits are adjusted to reflect estimated living cost increases.

The unprotected will now have to pay about $15 a month more, plus an additional $3 over a longer period of time so as to restore general tax revenues tapped to cover the costs of the remedy. Rolling the two together, I figure premiums will increase, on average, by about half as much as they would have without the fix.

Not the End of the Story

So Congress packed up for the weekend, having done what seemed impossible. If no one’s altogether happy — and no one ever is with bipartisan deals — reasonable people on both the left and right seem pretty satisfied.

Need I add relieved that we won’t find out how much damage to our economy and economies around the world an unprecedented default on the federal debt would cause?

Now comes the budget or some equivalent to prevent a government shutdown before mid-December. So no one with an interest in any of the multifarious issues can rest easy. But advocates for programs and services that benefit low-income people should feel good about how much they’ve achieved.


Medicare Premium Spike Will Hit Some Low-Income People … and All States

October 26, 2015

I’m sure you’re aware that the seemingly endless Presidential campaign season has set off another round of debate on so-called entitlement reform — that, plus the need to somehow stave off a government shutdown.

Much of what we hear is what we’ve heard for a long time. Republicans want changes that will reduce the amount the federal government pays for Social Security retirement and Medicare benefits.

Democrats will have none of this. But turns out a goodly number now want reform too. Or so one gathers from their leaders in Congress and the still-leading candidate for the nomination.

For them, the issue isn’t how much the federal government pays. It’s how much about 16.5 million people — mostly seniors — may have to pay for Medicare Part B, the part that covers outpatient care, plus some other health-related costs.

They face significant increases due to our low inflation rate. This has led the Social Security Administration to conclude that a cost-of-living adjustment is unwarranted, since because the consumer price index it uses for COLAs has actually dipped down a bit.

But Part B spending almost surely won’t. It’s been rising steadily for a number of reasons, e.g., new technologies, increasing charges for services and “medically necessary” equipment for personal use, more services and supplies needed as those received prolong lives.

The Social Security Act shields about 70% of Medicare beneficiaries from premium hikes next year because it says that increases can’t exceed increases in their retirement benefits.

What this means is that the other 30% will get hit with higher increases because total premiums paid are supposed to cover a fourth of projected spending on seniors.

Medicare trustees have predicted that premiums could therefore rise to about $159 a month — or by 34%, on average, according to my calculator. But The New York Times reports that premiums for some could increase by about 50%.

So who are these unprotected beneficiaries? Some have relatively high incomes and thus already pay higher premiums than most — more than three times as much if they’re in the top income bracket.

Some, however, may have little or no income except their Social Security benefits. And those can be very small because they’re based on annual wages, including years when they totaled zero.

And some don’t receive any Social Security benefits. They include most seniors who didn’t work steadily for at least 10 years or had a spouse who did. Others are former recipients of Social Security Disability Insurance benefits who still qualify for Medicare.

Still others are elderly government employees who are covered under an old, separate retirement plan — more than 800,000 of them former federal workers.

Now, some of the low-income Medicare beneficiaries are only technically unprotected from the impending increases. They’re the so-called dual eligibles — seniors covered by both Medicare and Medicaid. State Medicaid programs pay their premiums.

This is also true for some other poor and near-poor seniors — those with incomes no greater than 100-135% of the federal poverty line, plus $20.

For individuals, that’s now a maximum of $16,140 a year and, for couples, about $21,755. Not all have protection, however. Only those with very limited assets they can draw on for emergencies or the deductibles and co-pays charged for Part B medical services and supplies.

Other seniors whom many analysts classify as near-poor will have to pay a share of the projected Part B cost increase. That’s because they’ve just become Medicare beneficiaries and thus haven’t paid premiums before.

No increase for them, in other words. Just a substantial deduction from their monthly Social Security checks.

Some Congressional Democrats have pushed for a fix to protected all Medicare beneficiaries from a premium hike. The Obama administration has joined them, though it reportedly would find something less than a total freeze acceptable.

This is not a strict party-line issue. The bipartisan National Governors Association, for example, has urged Congress to find a solution — understandably, since Medicaid programs will otherwise have to pick up extra premium costs.

The National Association of Medicaid Directors has also written Congress — again, not necessarily to protect Medicare beneficiaries, but states. Costs to them, it estimates, will total more than $2.3 billion.

Republicans in Congress may not be averse to a solution. House Speaker John Boehner had huddled with Minority Leader Nancy Pelosi before the kerfuffle over a new speaker made action on anything except (one hopes) the looming debt crisis and soon-to-be-looming government shutdown doubtful.

But both he and Senator Orrin Hatch, who chairs the committee responsible for Medicare, apparently won’t accept a proposal to stave off the premium increase unless the cost is fully offset by savings elsewhere.

An estimated $7.5-$10 billion would do it — chump change for a budget that would total about $3.8 trillion in the Republicans’ plan.

But Republicans already have to come up with savings — or some budget gimmick — to offset the costs of replenishing the Highway Trust Fund, since they won’t raise the gas tax.

And their leaders almost surely can’t get a budget for this fiscal year through both the House and Senate unless they and their Democratic counterparts agree to eliminate — or at least, suspend — the cap on non-defense spending.

That too will send everyone scurrying for an offset. So as we lurch from crisis to crisis, averting the Part B premium hike could become another of those things that ought to get done, but doesn’t.

Or it might get rolled into some massive, last-minute package. Hard to predict. But we know that some low-income seniors and younger people with disabilities will have a harder time making ends meet if Congress doesn’t protect them PDQ.



House Republicans Set to Promote Single Motherhood

August 3, 2015

Seems the House will vote next month on budgets for the agencies lumped together as Labor, Health and Human Services and Education. Some increases, many cuts. Two of the latter would deny low-income women safe, reliable, affordable contraception.

There’s something extremely perverse about limiting women’s opportunities to postpone childbearing until they feel ready to fulfill — alone or with a spouse or partner — the heavy-duty responsibilities of motherhood.

Especially perverse, given all the expressed concern about single mothers, their dependency on welfare, how they’re breeding criminals, etc.

Labor-HHS-Education Overview

The House bill would cut total spending for the programs it includes by $3.7 billion. On top of cuts made since 2010, they’d have $29 billion (16%) less in real dollars, the Center on Budget and Policy Priorities reports.

Republicans claim they’ve got no choice because the Budget Control Act caps spending on domestic programs subject to annual appropriations.

They could, of course, have adjusted the cap — or done away with it altogether — by adopting a more balanced approach to deficit reduction, as the President’s proposed budget would and Senate Democrats seem ready to insist on.

Cap aside, it’s still the case that the Appropriations Committee foisted the largest dollar cut — and the second largest percent cut — on Labor-HHS-Education.

Predictable Defunding of Health Care Reform

HHS would take a $216 million hit, as compared to its current budget. By far and away the largest part reflects a near-total block on spending related to the Affordable Care Act — a significant source of expanded health insurance coverage for birth control, as well as other preventive services.

Were the budget to become law, which it won’t, HHS could no longer operate health insurance exchanges in the 34 states that haven’t created their own — or in three others that use its infrastructure.

Hard to see how this wouldn’t mean loss of the subsidies that make health insurance affordable for low and moderate-income people — or the related measures that limit out-of-pocket costs for health care.

Low-income individuals and families could also wind up without affordable health care, including no-cost family planning services, because the Republicans’ bill effectively bars HHS from covering most of the costs of newly-eligible people in states that have expanded their Medicaid programs.

Hammering another nail into the coffin, the House bill would prohibit HHS from enforcing certain consumer protections.

These are intended to prevent insurance companies from denying coverage or charging higher premiums, based on health conditions or gender. They also require most companies to cover birth control, as well as numerous other preventive services at no extra charge.

Renewed Direct Attack on Family Planning Services

The Labor-HHS-Education bill would zero out funding for Title X of the Public Health Service Act — the source of grants to nonprofits and public agencies that provide free or low-cost family planning and certain other preventive services, e.g., screenings for sexually-transmitted diseases and for cervical and breast cancer.

They can’t use the funds for abortions. But earlier zero-funding efforts leave no doubt that House Republicans intend to cripple Planned Parenthood, which, as we all know, does perform abortions, using privately-donated funds and, in some limited cases, funds it can claim from Medicaid.

Now, I’m hardly the first to observe that if you object to abortions, then you should want women to have the option of effective, affordable birth control.

For women (and men) with incomes below the poverty line, Title X-funded services, including contraception, must, in most cases, be free. Somewhat over 70% of Title X family planning clients qualified in 2013, the latest year we’ve got official figures for.

Folding in the near-poor, we see that defunding Title X would jeopardize family planning and other reproductive health services for more than 4 million people, mostly women.

Roughly 3.5 million of them either began or continued using some form of contraception as a result of their last visit to a Title X center. Some who didn’t were pregnant or wanted to be.

Anti-Anti-Poverty Choice

Brookings Institution economist Isabel Sawhill has persuasively argued that encouraging and enabling women to deliberately choose motherhood, rather than just “drifting” into it is a more realistic poverty prevention strategy than the patently unsuccessful efforts to promote marriage.

The end result would be fewer poor single mothers — thus fewer children growing up in poverty, with all the disadvantages that entails. Fewer women forced to compromise education and career goals too. Fewer at risk of depression and perhaps abuse.

Yet LARCs (long-acting, reversible contraceptives) — the surest protections against unplanned pregnancies — can reportedly cost as much as $1,000, counting only one followup visit after the initial insertion procedure.

That’s a formidable barrier for low-income women — or rather, would be without effectively enforced ACA requirements, expanded Medicaid coverage and family planning services covered by Title X.

What Next?

It’s doubtful that the final budget for the upcoming year will deny all funds to Title X. The Senate’s Labor-HHS-Education bill — still in an earlier stage than the House bill — would allocate $257.8 million to the program.

This, however, would represent a cut of roughly $27.8 million. Even level funding would almost surely mean less available for services because program costs rise, much as our own living costs do.

What next year’s budget will look like is anybody’s guess, especially because the President has said he’ll veto any spending bill that reflects the caps.

Meanwhile, Senate Republicans — not quite all, however — have decided to make a cheap political gesture, before the pseudo-scandal stales, by denying federal funds of any sort to Planned Parenthood — the largest of our nonprofit family planning providers.

“[H]ard to see other clinics stepping in to fill the gap,” Vox health care blogger Sarah Kliff remarks. Indeed. We probably won’t see that sort of gap, however — at least, not right away.

But we won’t see enough funding for affordable family planning and other preventive healthcare services either.

UPDATE: I’ve learned that the Senate Labor-HHS-Education bill has cleared the full Appropriations Committee. So it is as far along as the House bill.



Big Sigh of Relief As Supreme Court Majority Upholds Affordable Health Insurance Nationwide

June 25, 2015

This is a post I’ve been hoping to write. And now I can because, as you’ve undoubtedly read, the Supreme Court majority has preserved the subsidies low and moderate- income people have been getting to help them afford health insurance purchased on the federally-operated exchange.

You may also have read some of the dire warnings of what would happen if the Court had ruled otherwise. Perhaps not as many as I’ve ferreted out, however. So I’ll begin with them. Then I’ll briefly highlight a less publicized warning of yet further harm, presumably averted.

Nearly Three-Quarters of Subsidies Saved

As you probably know, plaintiffs contended that the federal government couldn’t subsidize the costs of health insurance purchased on the exchange it created for people in the 34 states that wouldn’t — or in some cases, decided they couldn’t — create their own exchanges.

Say five instead of three Supreme Court members had agreed.

About 6.4 million people would have lost the tax credits that serve as subsidies, according to the latest enrollment figures. That’s roughly 74% of all those who receive them.

Their subsidies average $272 a month. So if premiums stayed the same, they’d have had to come up with an additional $3,264 a year. But premiums wouldn’t have stayed anywhere near the same. They’d have increased by an average of 35% next year, according to Urban Institute analyses.

Basic market forces would have driven a so-called death spiral. First, relatively young, healthy people would have decided to forgo health insurance rather than pay what their subsidies had covered. Insurance companies then would have faced higher per-customer healthcare costs. So they’d have jacked up their premiums to compensate.

Which, of course, would have led to more younger, healthier dropouts. Which would have led to … Well, you see where this is going. Premiums would ultimately have increased by 47%, the RAND Corporation concluded — unless states belatedly set up their own exchanges.

Some might have given it a shot. But few, if any could have gotten their own exchanges up and running by next year.

Some surely wouldn’t have tried. We’ve still got 18 states that refuse to expand their Medicaid programs, even though the federal government would initially cover all the healthcare costs of newly-eligible beneficiaries — and virtually all so long as that part of the ACA remains intact.

Most of these states, as well as others were in a wait-and-see mode. Some clearly looked to Congress to let them do whatever they fancied. And indeed, the House Republicans’ latest block grant plan would have. Not a happy prospect, for various reasons.

Greatest Reprieve for Poor and Near-Poor

An adverse ruling wouldn’t have affected the very poorest Americans. They never had a chance to buy subsidized health insurance on an exchange because their household incomes put them below the federal poverty line.

Some are eligible for Medicaid, even in the recalcitrant states. Texas, for example, will cover parents in three-person families with annual incomes at or below 19% of the FPL — currently $3,817. No Medicaid for even the poorest childless adults — nor in any other non-expansion state except Wisconsin.

But the near-poor apparently took advantage of the exchange option. We see, for example, that 94.5% of Mississippi residents enrolled benefit from subsidies averaging $351 a month.

More generally, individuals and families hovering just above the FPL would obviously have been the least able to pay for unsubsidized premiums — and full out-of-pocket costs like copays too. For those Mississippi folks, the average premium hike alone would have been 650%.

Hospitals Saved From Large Losses

Meanwhile, hospitals would have faced bigger cost crunches because they’d have been obliged to provide more emergency care for uninsured people. Through their major associations, they agreed to a lower compensation rate for the uninsured on the assumption there’d be fewer.

A ruling for plaintiffs would have blown another hole in the assumption. (The earlier ruling that made Medicaid expansion optional was the first.)

But hospitals are — and would still have been — stuck with the compensation rate. Their losses due to newly-uninsured patients would have totaled $3.8 billion next year, the Urban Institute estimates.

Next Step in Gutting the Affordable Care Act Short-Circuited

A victory for plaintiffs could well have prompted another round of litigation to dismantle the ACA — or, as one of the strategists put it, to kill “the bastard … as a matter of political hygiene.”

In this scenario, the anti-ACA funders and their allies would probably have called on the courts to invalidate federal funding for Medicaid and the Children’s Health Insurance Program in those same 34 states where residents lost their subsidies.

A  bit of background to understand how they’d go at it. The case before the Supreme Court hinged on what the ACA means when it refers to “an exchange established by the state” — or alternatively, whether the use of that term was a drafting glitch, clearly at odds with the intent of the law and other provisions in it.

Well, two wholly separate provisions use the same term, as Modern Healthcare reports. The more consequential conditions federal Medicaid/CHIP funding on states’ ensuring coordination between these programs and “an exchange established by the state.”

A ruling for plaintiffs in the case just decided wouldn’t automatically have denied Medicaid/CHIP funding to the 34 states without their own exchanges. But would it have given ACA opponents a good shot at another challenge affordable health insurance for poor and near-poor Americans? You betcha.

More Ways Public Programs Could Improve Life for Low-Income Seniors

June 4, 2015

Here, as promised, are the remaining three steps that Kevin Prindiville, the Executive Director of Justice in Aging advocates to fight senior poverty — and though he doesn’t say so, the hardships of those who’ll remain poor or nearly so.

Increase Assistance With Healthcare Costs

Rising healthcare costs are “one of the drivers of seniors’ economic vulnerability,” Prindiville says. We can go a step further.

Medical out-of-pocket costs are the main reason the senior poverty rate rises when the Census Bureau uses its Supplemental Poverty Measure, instead of the official measure. Factoring them out would produce a 6.3% drop in the SPM senior poverty rate — about 2.8 million fewer poor seniors.

Prindiville advocates reducing or altogether eliminating medical out-of-pockets for low-income seniors. He also urges unspecified expansions of programs designed to help poor and near-poor seniors afford health care — Medicaid, Medicare Savings Programs and the low-income subsidy for Medicare Part D.

Basically, the savings programs help low-income individuals and married couples pay for Medicare premiums — both Part A (hospital costs) and Part B (out-patient costs) for the lowest-income group. The program for these Qualified Medicare Beneficiaries also helps them pay those out-of-pockets.

The subsidy program pays for either the full or partial costs of the optional Part D insurance program, which generally covers some share of prescription drug costs. Here too, how much help beneficiaries get depends on their income level.

Prindiville again stresses the need to protect these programs from cost-shifting proposals. I earlier suggested that he was referring to Republicans’ premium support, a.k.a voucher, programs for Medicare.

But a recent Part D reform needs protection as well, since Republicans seem set on repealing the Affordable Care Act. That would reopen the so-called donut hole, which the ACA has shrunk and will ultimately close.

More seniors would again have to pay the full costs of prescription drugs that exceed a fairly low maximum — just $2,830 in 2010, when the ACA was passed.

And they’d have to continue paying those costs till they reach another maximum — more than $6,000 by 2020, according to Families USA, which optimistically forecast, in 2012, that the ACA will stay in place.

Provide Federal Support for the Long-Term Care Safety Net

Seniors, as well as younger people with severe disabilities can face formidable costs for in-home help with daily activities, e.g., bathing, dressing, housework, and for community-based services like transportation.

Medicaid covers some long-term care costs for some beneficiaries — for whom and how sufficient depends on their state’s policies. A patchwork then — and no safety net at all for seniors with more than minimal incomes and assets.

We’re often advised to take out long-term care insurance, which will partially defray the costs of services in our homes and communities or, when they won’t suffice, residence in a nursing home or assisted living facility.

I have long-term care insurance. Let me tell you, it’s not cheap, especially if you don’t buy in while you’re young and spry. My annual premium is well over twice the average monthly Social Security benefit for retirees.

The ACA attempted to address this problem and the related low-coverage problem by creating a voluntary long-term care insurance program structured somewhat like Social Security. But the U.S. Department of Health and Human Services concluded that the program couldn’t, as intended, pay for itself.

So HHS suspended it. And Congress subsequently repealed it. We’re thus back to square one — a long-term care safety net for some seniors, inordinate costs and/or burdens on younger family members for the rest.

Prindiville launches a preemptive strike against what might surface next. Proposals that would instead rely on seniors, including the poor and potentially poor, to save more for their long-term care needs are “simply unrealistic,” he says.

So he advocates strengthening and expanding public programs to meet long-term care needs, especially through services that enable seniors to age in place — or at the very least, in their communities. Specifics yet to come, I suppose. But we see glimmers in the last of his five steps.

Reauthorize the Older Americans Act

OAA is one of those programs that provides state and local agencies with grants they can use for a wide range of services — all for seniors, of course, but not necessarily only those in poverty.

We’re perhaps most familiar with Meals on Wheels, but it’s also a source of funding for transportation, legal services, benefits counseling, divers health-related services and more.

Poor seniors rely on OAA-funded services heavily, Prindiville says. For seniors more generally, they’re often the difference between aging in place, as most of us want to do, and living out the rest of our days in a nursing home.

In this respect, one could view them as part of the long-term care safety net — and a cost-effective one too. A semi-private room in a nursing home costs, on average, more than $80,00 a year.

Medicaid picks up all or most of the costs for about 70% of elderly nursing home residents. So there’s a compelling fiscal case, if needed, for the OAA-funded services that complement the in-home and community services that Medicaid funds.

OAA is also one of those programs that Congress should have reauthorized some years ago. A pending bipartisan bill in the Senate would do that. Here’s one step that might actually get taken.

Getting the program adequately funded to meet the needs of our graying population is a whole other matter.

Prindiville’s steps — both protecting what we have and gaining what we don’t — all hinge on persuading our federal policymakers that we view the well-being of seniors as a high priority. Justice in Aging has a petition we can sign. And it does it need more signatures!



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