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!

 


CHIP Renewal: Will the Perfect Be the Enemy of the Good?

April 2, 2015

Last week, the House passed a bipartisan (yes, really) bill that would, among other things, extend the Children’s Health Insurance Program for two years, with the higher matching rate that was part of the Affordable Care Act. The Senate will vote on the shortly after members return from their two-week break.

The bill is far from perfect. CHIP supporters and others of progressive leanings will have to decide whether — and at what point — to say it’s good enough.

A Lot at Stake and the Outcome Uncertain

Some Senate Democrats, urged on by lead children’s advocates, have insisted on a four-year CHIP extension. That would, of course, tend to avert another go round in 2017, when we could have a Republican President. And it would enable states to plan for the longer term.

But withholding support for the package could kill it, especially because it’s under fire for reasons that have nothing to do with CHIP, e.g., an offset that would raise Medicare premiums for better-off beneficiaries, the usual ban on using federal funds for abortions, except in certain limited cases. And, of course, some of those self-identified deficit hawks object because the costs aren’t fully offset.

Defeat of the bill would leave not only CHIP imperiled, but also other programs that benefit low-income children, including the Maternal, Infant and Early Childhood Visitation program, the Transitional Medical Assistance program and a provision in the ACA that funds community health centers.

Why the Bipartisan Deal Now?

As I’ve written before, CHIP will receive no more federal funding after September unless Congress extends it. That, however, is not why we’ve got votes on an extension now. There’s an urgent need, as there is virtually every year, to prevent the Sustainable Growth Rate from taking effect.

Congress enacted the SGR nearly 20 years ago in an effort to control Medicare costs. It provided a formula to curb spending on physicians’ services to Medicare beneficiaries.

But physicians claimed — perhaps, in some cases, rightly — that the reimbursements wouldn’t even cover their costs of providing care. So Congress temporarily suspended the SGR, but left the provision otherwise intact.

And it’s done the same ever since, allowing instead very small — or in some years, no — rate increases. The so-called doc fix has become increasingly necessary because, without it, all the annual rate reductions would take effect. Doctors are thus hypothetically facing a rate cut of 21% — hypothetically because, of course, Congress won’t let that happen.

The package now pending in the Senate would, at long last, repeal the SGR, but not the intent because it establishes a new reimbursement rate scheme.

Risks for CHIP

We’ll, of course, have another doc fix if the final package doesn’t pass. But we can’t count on full funding for CHIP — let alone, at the higher matching rate. For one thing, a bill brewing in the Senate would not only repeal that rate, but cut program funding in several other ways.

For another, we’ve now got a House budget plan that would fold CHIP into the same block grant as Medicaid. States would thus have to cope with an ever-greater funding squeeze. And they’d have the “flexibility” to eliminate benefits and/or beneficiaries.

Fund Cut-Off for Home Visiting Programs

Meanwhile, funding for MIECV would remain in limbo. And it expires at the end of this month. The pending bill would extend it until October 2018, at the same funding level it has now.

The program is quite small. It has nevertheless helped agencies establish and expand programs that offer poor and other at-risk pregnant women and parents of young children the opportunity to have trained professionals come to their homes, assess their family’s needs and then provide and/or refer them to a variety of services.

These include, but are by no means limited to health-related services, e.g., advice on infant care and child nutrition, screenings for developmental disabilities.

States reported serving about 115,000 families last year — surely a small fraction of those that could benefit. Hard to believe that as many would be served if Congress lets funding for the home visiting program dry up.

Other Health-Related Programs

The bill would convert two time-limited healthcare law programs that benefit low-income people into permanent law.

One — Transitional Medical Assistance — enables families to temporarily remain in Medicaid after they’ve moved from welfare to work. That move can happen when they’re by no means earning enough to afford other health insurance because state income eligibility thresholds for welfare, i.e., Temporary Assistance for Needy Families, are so low.

TMA doesn’t altogether take care of the problem, especially in states that have refused to expand their Medicaid programs. But it gives parents some additional time to increase their income — or find an employer that offers health insurance they can afford.

The other program provides states with funds to pay for the Medicare Part B premiums of qualifying individuals. Since I’m focusing here on support for children’s health and wellbeing, I’ll refer those interested to a short, clear summary by the Center on Budget and Policy Priorities.

Lastly, the bill would extend the funding for community health centers initiated by the ACA. It’s helped support preventive care and treatment for 21.7 million people, according to the latest (somewhat outdated) figures from the U.S. Department of Health and Human Services. Nearly a third of those people were children.

A Difficult Balancing Act

What all this means, I think, is that advocates for children — and for appropriate, affordable health care generally — have to balance priorities and prospects. They understandably want CHIP funded at the higher matching rate for the full four years the ACA envisions. Backing off now could doom efforts to get that in the Senate.

On the other hand, once Congress has taken care of the SGR problem — permanently or just for another year or two — chances it will renew CHIP at the higher matching rate don’t look good. What will happen to the other programs that benefit low-income children is a question mark.

Recall that both House and Senate Republicans seem set on drastically reducing federal spending (except for defense, of course). Not a good time to leave some many healthcare programs for vulnerable people wide open.

 

 

 

 


Be Careful What You Wish For

March 5, 2015

So here I was elaborating on reasons Congress should renew funding for the Children’s Health Insurance Program. No sooner had I finished the post than the Center on Budget and Policy Priorities published a damning brief on a draft bill that would — sort of.

The draft is especially worrisome because it’s the product of the chairmen of the committees that have primary responsibility for CHIP — Senator Orrin Hatch, who heads the Senate Finance Committee, and Congressman Fred Upton, head of the House Energy and Commerce Committee.

The Hatch-Upton bill would significantly reduce federal funding for CHIP in several different ways. It would, among other things:

  • Altogether deny a federal match for the healthcare costs of children in families with incomes above 300% of the federal poverty line — currently $60,270 for a single parent with two children. Eighteen states and the District of Columbia currently cover children at this income level.
  • Use the regular Medicaid matching rate, rather than the higher CHIP rate for children whose family incomes are between 250% of the FPL and the 300% cut-off. If the law were in effect now, 27 states and the District would lose, on average, 13% of their match.
  • Repeal the higher CHIP matching rate that the Affordable Care Act established for 2016 through 2019, when CHIP would officially expire, unless renewed. So all CHIP programs would take a hit, even those that cover only lower-income children.

States and the District would have have to pick up more of the costs of covering children whose family incomes aren’t low enough to qualify them for Medicaid — and more of some of those who are because the ACA provided the higher CHIP match for children states had to shift into Medicaid.

Or rather, they would if they decided to keep their CHIP programs as they are. States could, if they chose, shift children back from Medicaid to separate CHIP programs. This, CBPP says, would probably mean less comprehensive coverage and higher out-of-pocket costs.

More generally, states could change their laws to make fewer children eligible for CHIP because the Hatch-Upton bill repeals a so-called maintenance of effort provision in the ACA that prohibits them from doing this before the end of the 2019 budget year.

States could also impose long waiting periods — up to a year — before enrolling children in CHIP. They could do this for virtually all families who’d had — or “declined an offer of” — group health insurance.

States can now require waiting periods of up to 90 days, but not for all children. They must waive the waiting period for “good cause,” e.g., if the child loses health insurance because a parent dies or can no longer get coverage through an employer-sponsored plan. Children with special healthcare needs must also be able to get CHIP coverage immediately.

Only 14 states have opted for a 90-day waiting period. Thirty-three and the District have no waiting period at all. But who knows what they’d do if faced with the funding crunch the draft bill would create?

The MOE repeal and the extended waiting period option are, of course, other, though less direct ways the Hatch-Upton bill would cut federal spending for CHIP.

Still another is by omission, rather than commission. The bill would fail to renew Express Lane Eligibility — an expiring tool that allows states to use information they’ve already collected, e.g., from SNAP (food stamp) applications, to determine eligibility for Medicaid and CHIP.

This can not only reduce administrative costs, but boost enrollment — and get children the health insurance they need quicker, according to an evaluation for the U.S. Department of Health and Human Services.

Lest we should miss the intent, the bill also repeals a provision in the current CHIP law that offers states a higher match rate for interpretation and translation services so that language barriers don’t become barriers to enrollment.

In short, as the Executive Director of Georgetown University’s Center for Children and Families says, the “proposal comes with fine print that could reverse our nation’s progress in covering kids.”

Not only covering them, but as I earlier wrote, ensuring that they can receive the full range of healthcare services they need at affordable rates. By this measure, as well as others, the draft bill is hardly what we should wish for.


Children’s Health At Risk Without CHIP Funding, Even If They’re Insured

March 2, 2015

I came belatedly to an enlightening article on the potential end of funding for the Children’s Health Insurance Program. Learned more than I knew when I blogged about it last October.

Professor of Pediatrics Aaron Carroll, who wrote the piece, notes the concern about children who may have no health insurance whatever — about 2.2 million, according to one count. But he focuses mainly on concerns for those who will have coverage because their parents have an affordable family plan purchased on a health insurance exchange.

Or we surely hope so. As you’ve probably read, the Supreme Court has been asked to rule that the federal government can’t subsidize plans purchased on the exchange it established for people who live in states that didn’t create their own.

Many trustworthy experts think the Court won’t. But if it does, as many as five million children could wind up with no affordable health insurance, according to a friend-of-the-court brief filed by the American Academy of Pediatrics and seven other organizations engaged in healthcare services and advocacy for children.

Carroll doesn’t allude to this doomsday scenario. He instead makes several points in favor of renewing CHIP funding, even with the subsidies intact.

The first is that CHIP covers a larger portion of children’s healthcare costs — more than 90%, as compared to 70% in the mid-level silver benchmark plans the Affordable Care Act provides for.

A troublesome difference. Some parents, however, might opt for plans with rock-bottom monthly premiums, but even higher deductibles and other out-of-pockets. This could cause them to forgo needed care — for themselves and perhaps their children.

Cost aside, Carroll raises several concerns about the health care children could receive through plans available on the exchanges. They’re rooted in the fact that the plans, unlike CHIP, aren’t tailored to children’s healthcare needs.

The problem begins with the ACA itself. The law establishes essential benefits that all plans must cover, both those offered directly to individuals and those small employers can purchase. They include pediatric services, with vision and dental care specified.

For reasons known best to the U.S. Department of Health and Human Services, the rules are silent on all but the two named services. And they allow for a separate, optional dental care plan — at an additional, unsubsidized cost — rather than requiring coverage in the overall plan.

I don’t suppose I need to elaborate the potential consequences for low-income children.

More generally, the failure to specify essential pediatric services has allowed states to choose as the basis for their minimum requirements plans that exclude a variety of healthcare services for children.

Carroll cites, among others, services for children with learning disabilities and autism. He also notes gaps in services expressly required, e.g., care of congenital defects, hearing aids and implants for children whom hearing aids can’t help.

Another related variation applies to plans families may purchase. Some, Carroll says, have very narrow networks, i.e., hospitals and physicians whose services the insurance company will pay for.

They’re narrow for providers of pediatric care than care for adults — and especially narrow for providers of specialty care, he adds. The narrow-network plans tend to be cheaper. And we’ve some evidence that many purchasers don’t understand the trade-off.

So parents may learn, when it’s too late, that there’s no in-network children’s hospital or other source of affordable services from doctors trained to treat children with complex, chronic conditions.

What’s rather strange about CHIP is that the ACA extends it through Fiscal Year 2019 — and sets a higher federal match rate for states’ costs beginning in Fiscal Year 2016. Yet it gives the federal government authority to spend money on the program only through this fiscal year.

States may have some leftover funding, but it’s unlikely to last through the year. There’d still be a match for low-income children who’ve been served through Medicaid, rather than separate CHIP programs, but it could be lower. It would definitely be lower for the children states shifted into Medicaid, as the ACA required.

For the rest, there’s no assurance state exchanges would have insurance plans with benefits and cost-sharing comparable to CHIP. Carroll’s analysis suggests that many don’t now. They could, but wouldn’t have to if CHIP funding dries up.

Surely it would be irresponsible to let CHIP funding lapse and see what happens. If children’s health problems aren’t promptly and expertly diagnosed and/or don’t get appropriate treatment, no one can remedy the harms by restoring CHIP or refining the ACA later.

 


What Good Is Health Insurance If You Can’t See a Doctor?

January 22, 2015

I’ve already said my piece (for now) about why everyone needs comprehensive, affordable health insurance. But that’s not the end of the story for the more than 68.5 million low-income people now enrolled in Medicaid. They’ve got to find doctors who will treat them.

This may become even more difficult than it’s been in the past — and for the same reason it’s been difficult. Medicaid doesn’t pay enough. Or at least, that’s what doctors say.

As The New York Times has reported, Congress didn’t renew a now-expired provision in the Affordable Care Act that requires state Medicaid programs to pay qualifying physicians at the same rate Medicare does when they provide primary care.

Like the now-optional Medicaid expansion provision, the Medicaid parity provision has been wholly paid for by the federal government. In other words, federal funds have made up the difference between what state Medicaid programs were paying and what they had to pay because of the ACA.

The two provisions are closely related because having more low-income people enrolled in Medicaid could otherwise make it more difficult for them to get preventive and various other outpatient services when they need them — or indeed, at all.

Before the parity provision because effective, in 2013, only two states reimbursed for the covered services at the Medicare rate or higher. The shortfall in all but 11 of the rest was at least 25%, but so much higher in many that the study I’m linking to estimated the nationwide average fee boost at 73%.

As of last October, only 15 states had said they’d use their own funds to preserve, at least partially, the so-called fee bump. Twenty-two and the District of Columbia said they definitely wouldn’t, in response to a Kaiser Family Foundation survey. Only one of them — North Dakota — had previously paid more than the fee bump required.

The Center for Health Care Strategies reports, based on we don’t know what, that six states and the District “have taken it upon themselves to extend the [parity] policy on their own.” If accurate, a far larger number of Medicaid beneficiaries could wind up with health insurance that means little or nothing if they need primary care. And who doesn’t?

We don’t for sure what will happen if Congress continues to sit on its hands. We do, however, have some indications.

A survey conducted in 2011 found that nearly a third of doctors didn’t intend to accept any new Medicaid patients. Higher percents would accept new patients with private insurance or Medicare. So it wasn’t that they were all fully booked.

A deeper dive discovered that higher percents of doctors would accept new Medicaid patients in states that paid higher reimbursement rates — and conversely. Which looks like bad news for Medicaid enrollees who don’t already have — or need to change — primary care providers in a lot of states that will revert to their prior rates.

A 10-state audit conducted during the months immediately before and after the fee bump officially kicked in found that only about 58% of Medicaid patients could get an appointment with a primary care physician, though 84.7% of privately-insured patients could.

On the other hand, an Urban Institute analysis of other survey results found that only a small fraction of working-age adults who’d had Medicaid for at least a year couldn’t get an appointment — or get one soon enough.

So, as Martha Heberlein at The Children’s Health Blog observes, the access problems seem pretty well limited to new enrollees — some of them probably folks who’d gained coverage because their states expanded Medicaid.

Some doctors have said they began accepting Medicaid patients — or accepting more — because of the fee bump. A recent Urban Institute report tells us that we don’t yet have good data on whether many have done any such thing.

By the time we do, the horse may be out of the barn. And as the law stands now, it’s unclear whether either primary care physicians or Medicaid beneficiaries who can’t get needed treatment because states won’t pay enough can even get a hearing in a federal court. The U.S. Department of Justice has argued that the former can’t.

Meanwhile, a ruling that will almost surely provoke an appeal held Florida accountable for failing to ensure that children in Medicaid receive the medical and dental care they’re entitled to. Low reimbursement rates are “by far the most important factor,” the court said.

I personally find it hard to believe that rate cuts averaging nearly 43% — and over 50% in four states, including populous California and New York — will have no effect on whether Medicaid beneficiaries can get primary care when they need it.

And they’ll have suffered harms that can’t be undone — even if, as seems doubtful, the Supreme Court ultimately results in their favor.

 

 

 


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