Medicaid Cut Puts Schools in a Jam, Children With Disabilities and Others Disadvantaged at Risk

June 6, 2017

Our Secretary of Education seems still confused (charitable word) about our equal opportunity in education laws.

She was asked again in a Congressional hearing whether her department would deny federal funds to private schools with students who have vouchers her budget would pay for if they discriminated. And she said again she thinks that’s a choice for states to make.

But the Individuals With Disabilities Education Act is one of three major federal laws prohibiting discrimination in federally-funded education programs. And it’s by far and away the most specific.

Schools must assess children with disabilities and develop plans for each that will meet their unique needs, enable them to learn as much as they possible can of what’s expected of their classmates and in the “least restrictive environment,” i.e., by including them in regular classrooms and other such settings, except in special child-specific circumstances, rather than routinely segregating them.

States get federal grants to help defray their school districts’ costs. But that’s not the only source of funds they use. They tap Medicaid to reimburse them for the costs of screening and providing appropriate health services to their low-income disabled students.

They may also use Medicaid funds for the early and periodic screening, diagnostic and treatment services that the law entitles all enrolled children to. Their parents may not even know their children can get them until the school informs them and perhaps helps them apply.

Needless to say, I hope, the House Republicans and Trump administration plans to convert Medicaid to a block grant or set a per beneficiary reimbursement limit have school officials very worried.

A recent member survey conducted by the American Association of School Administrators tells us why, both in summary form and numerous personal responses.

Once the federal government shifts costs to states by whichever means, they foresee a losing competition with other institutions that rely on Medicaid funds, e.g., hospitals, doctors, other providers like the Federally Qualified Health Centers I wrote about.

States will have the flexibility to choose who’s eligible for their programs, what services they can receive and, as we now learn, time limits perhaps, work requirements, premiums they’ll have to pay or get kicked out of the program.

States may, AASA says, decide that school districts can’t get any Medicaid funds at all. But schools will still have to comply with the IDEA requirements. Where will that money come from?

A top line answer is that schools would lay off health professional staff and others with expertise in educating children with disabilities. Alternatively — or perhaps in addition to — schools would cut back on services for all students in so far as they legally can.

AASA and some members quoted cite mental health services in particular. About one in five children show symptoms indicating needs each year.

Neglect them and children suffer not only anxiety, depression and other effects due to trauma or toxic stress. Their academic performance suffers, setting them on the path to drop out when they’re teens.

Their abilities to control their emotional impulses, plan and manage their activities productively and relate well to others suffer too.

These so-called social and emotional competencies obviously give those that have them advantages in both their personal lives while young and long thereafter — and advantages that make getting and keeping a job every so much more likely.

Seems like a lot I know to pack into a post on only one — and hardly the most consequential — impact of what Trump’s roughly estimated $1.3 trillion cut to Medicaid funding would do — or even the House Republicans’ $839 billion.

But the well-being and futures of school-age children ought to matter to all of us. And as I said, it’s not only children with disabilities those cuts would put at risk, but all their peers.

Most at risk are the other educationally disadvantaged students for whom Title VI of the Elementary and Secondary Education Act—now called the Every Child Succeeds Act—aims to make the equal educational opportunity guarantee in the Civil Rights Act a reality.

Trump’s budget would increase ESSA by $1 billion, but channel the extra only to districts that promote parental choice.

It would also siphon off money from high-poverty schools by shifting each student’s share to any publicly-funded school s/he transfers to. And we know that’s not going to be another high-poverty school.

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House Majority Denies Low-Income Seniors and People With Disabilies Choice of Living in Their Homes

May 12, 2017

Some followers may have noticed a long silence. I’ve just rejoined the networked world after another fall — this one, unlike the first, a complication of a complication of a condition only recently diagnosed.

As you might imagine, I’ve been dwelling on health care even more than I would have otherwise. So I was ready to launch a diatribe against major, widely-reported harms inflicted by the House repeal-replacement bill.

I’ll instead focus on another that a columnist for TalkPoverty.org ferreted out. It’s directly relevant to people in my condition, i.e., elderly and/or disabled, at least temporarily, but only those with incomes low enough for eligibility in their state’s Medicaid program.

The Affordable Care Act did more than aim to expand Medicaid eligibility nationwide. It also offered state incentives to expand Medicaid in-home services to the overlapping groups I cited above.

Among the most successful, says the TalkPoverty columnist is the Community First Choice program. It increases states’ usual federal match on their spending by 6% for services that will maximize recipients’ ability to continue living safely and as self-sufficiently as possible in their own homes.

They can receive not only help with so-called activities of daily living, e.g., bathing, eating, and health-related tasks like taking medications on schedule, but also training so they can master these tasks. They can also get equipment to assist them and training on how to use it.

Agencies may further support living at home by providing hands-on help with tasks like meal preparation, light housework and transportation.

Here’s a true win-win. We all, I suppose want to stay in our homes, assuming they’re safe and in relatively good repair.

We surely prefer living in our community to an institution where there’s no one we know and good care is far from assured. Perhaps also not one we know who cares enough and lives close enough to visit regularly.

Government agencies surely prefer this too. An in-depth AARP study found that Medicaid paid roughly three times as much for institutional care as for home-based services. The data are far from current, but there’s no reason to think the basic cost saving has significantly changed.

Another study — this one of a pilot project — found that Medicaid costs dropped by about $11,900 a year for every older adult transitioned from a nursing home back into his/her community.

The House bill would eliminate the CFC program in 2020, cutting an estimated $12 billion in federal Medicaid funding in the first six years.

It’s a minuscule fraction of the nearly the nearly $840 billion the bill would cut from Medicaid. But it would somewhat more than pay for the late-added funds states could use for high-risk insurance pools, if they opted to let insurance companies deny coverage because of pre-existing conditions.

You may have already read about this provision because it’s how the Republican leadership quelled colleagues’ well-grounded anxieties about eliminating the ACA’s guarantee against such discrimination.

People who’ve suffered injuries like mine would be vulnerable, of course. But we’re told that insurance companies have classified a wide range of conditions as pre-existing, including acne, transexuality, pregnancy and recovery from domestic violence or rape with help from therapy.

For this and other reasons, the high-risk pools probably won’t offer insurance that’s either sufficiently broad or affordable. We need only look to pools states established.

They surely won’t without a lot more money than the Medicaid shift, even if states also tap other, more broadly defined funding streams. Two conservative economists estimated the annual cost at $15-$20 billion — this back in 2010. The left-leaning Center for American Progress estimates at least $31 billion.

I’m inclined to think that some House Republicans who voted for the bill knew this, though, as we know for sure, House Speaker Ryan chose to rush it through, rather than wait for an official score from the Congressional Budget Office.

We can also, I think, be pretty sure that House Republicans know they passed a bad bill, from both the promised repeal and replace-with-something=better perspectives. They believe passing nothing would be worse, what with their valuing their re-election prospects more than their constituents’ well-being.

Happily, the Senate will start from scratch and clearly intends to take as much time as the drafters (all Republicans) feel they need.

So the story’s far from over. But broad-based research and advocacy organizations—and the rest of us interested parties—need be less focused on this one hot issue, when there are already many others.


Looming Threats to Health Centers and Their Low-Income Patients

April 10, 2017

I recently met someone who follows my blog — one of the benefits I treasure. She’d come to the District for a meeting of the National Association of Community Health Centers. I learned a lot about this important piece of our federally-subsidized healthcare system.

I could see right off ways that they and the low-income people they serve are threatened now. But Terri told me about another that’s more than a threat.

Federally Qualified Health Centers

Terri serves as the strategist and advocate for a Southern California network of Federally Qualified Heath Centers — outpatient clinics that have met a set of requirements and receive grants from a Health and Human Services Department agency.

The FQHCs must, among other things. provide specific healthcare services — primary, preventive and emergency, plus education so that patients with diabetes and chronic kidney disease can monitor and control their conditions.

They must serve an otherwise under-served area or under-served people elsewhere. And they must use income and family size as the basis for their fees. So people with no income can get care, even if not enrolled or eligible for Medicaid.

A number of clinics provide additional services, e.g., dental care, mental health and/or substance abuse treatment. The clinic where Terri is based does all this and more.

It has social workers, for example, who link patients to sources of help, according to their individual needs, including navigating them through online enrollment in Medicaid.

The clinic goes beyond its diabetes management requirement by giving its diabetic patients cellphones that read their blood sugar levels and relay them to the clinic.

Terri, her colleagues and counterparts across the country are worried about how they will continue to operate — and what will happen to the low-income they serve if they can’t.

Her network receives some donations. But like all FQHCs, it depends largely on the HHS grants and partial cost reimbursements for patients enrolled in Medicaid.

Raid on Medicaid Still a Threat

California jumped at the chance to expand its Medicaid program when the Affordable Care Act became effective. The clinic Terri works in experienced a large influx of newly-eligible people with untreated conditions, e.g., diabetes, high blood pressure, oral diseases, mental health problems.

Congressional Republicans haven’t block-granted Medicaid or the similarly cost-shifting per capita alternative.

But the Affordable Care Act assured states that the federal government would reimburse 90% of care costs for their newly-eligible enrollees from 2020 on forward — the last phase in the incentive pay scheme.

What with Trump now trying to cut a deal with far right-wing members of the House, one might reasonably expect the product to end this level of funding like the failed repeal-replace bill. All expansion states, including California would face some tough choices then.

Federal Grants in Two-Part Jeopardy

The legislation that authorizes the federal government to award the FQHC grants will expire at the end of September. Without the grants, the health centers will collectively lose about 70% of their federal funding.

So a must-do for Congress is a straightforward extension, like the one included in the same law that kept the Children’s Health Insurance Program alive. Given the lack of hearings, other preoccupations and usual long summer break, simply kicking the expiration deadline forward is the only way to avert a for-sure funding loss.

But that would only give HHS authority to spend as much money as Congress chooses — and the President agrees to. Trump’s budget plan would cut the HHS budget by 17.9% — $15.1 billion less than it’s getting now. We don’t know the details, but we shouldn’t, I think, rule out anything.

Even if Congress won’t go along with such radical spending cuts (a likely response), the Budget Control Act’s cap on spending for non-defense programs will kick in again, after the latest two-year halt.

What this means it that Congress will have to cut spending on these programs by $2.9 billion. So the size and/or number of the FQHC grants are at risk — unless Congress decides to again defer or altogether eliminate the caps.

Immigrant Roundups and Healthcare Needs

The clinic where Terri is based is in a community where many immigrants live, including some unknown number without the documents authorizing them to live and work in this country.

Even immigrants here legally generally can’t qualify for Medicaid for the first five years, though they can receive Medicaid-financed emergency services.

California, as well as some other states provides a few others, regardless of immigration status. But as the Los Angeles Times reports, the community health care centers “treat all comers.”

We all know how federal immigration enforcement authorities have aggressively ramped up raids aimed at deportation. They’re active in the clinic’s community, where local authorities have partnered with them.

The agents have started patrolling side roads, including one leading to the clinic. Staff have witnessed a large drop off in immigrants seeking care.

One day an agent showed up in the building, with a warrant for something (not somebody). He opened the door to the waiting room. Patients fled, dragging children by the hands. What’s going to happen to them and their kids now that fear will keep them away?

These aren’t the only threats to the health of low-income people. The unremitting efforts to defund Planned Parenthood clinics put them at high-risk too, notwithstanding the anti-choice Congress members’ and supporters claim that clinics like Terri’s can fill the gap.

May have more to say about this than I already have.


Republicans’ Healthcare Word Choices Can’t Alter Facts

March 27, 2017

Maybe it’s because my formal education trained me to be sensitive — even hypersensitive — to words. Whatever the reason, I’m impressed and riled up when I read how House Republican leaders and some top officials in Trump administration are styling the features of their Obamacare repeal-replace bill.

Both responses because their word choices artfully appeal to widely-shared values, while obscuring basic truths that anyone who reads even a summary of their plan can see.

And just because neither the Republican House leadership nor Trump could herd enough of their cats to pass their final bill, doesn’t mean we’ve seen the end of this. Some notable examples then.

Access to Coverage. A favorite word. House Speaker Paul Ryan says it’s the Republicans’ “job to have a system where people can get access to affordable coverage.”

A Republican House staffer, speaking anonymously and thus perhaps less focused on the selling the work-in progress, said, “We would like to get to a point where we have what we call universal access, where everybody is able to access coverage to some degree or another.”

Now, access isn’t the same thing as ability to buy. For example, I have access to a full-length mink coat. The coat’s in a store I can get to. I can walk right up to it. And it’s great coverage, especially when in cold weather.

So a poor person can review a health insurance policy, with ample coverage, a minimal deductible and small co-pays. Doesn’t mean s/he can pay for it.

Now that we’ve got credible estimates of the many millions of Americans who’d no longer have health insurance, Ryan harps again on access, coupled with another favorite word — and not only in the healthcare context.

Choice. For families, Ryan says, access means, among other things, “more choices.” Well, who doesn’t like having choices? Do we like being told we must do or have some specific thing — or can’t?

But the bill, as I’ve just said, doesn’t mean more choices for lower-income families, except the choice of going without health insurance — or buying one of those low-cost, high deductible plans.

Ryan touts the larger maximum people can contribute to a health savings account, avoiding the corollaries, i.e., that only people with high-deductible plans can have them and that those who live paycheck to paycheck don’t have money to stash away.

Only 6% of families with incomes less than $30,000 a year contribute anything to an HSA now. More than half the families that contribute have incomes of at least $100,000 — a tax saver for them, rather than a needed savings account.

Freedom. When Ryan was asked how many Americans would lose coverage if the Republican’s bill became law, he said he couldn’t answer. “People are going to do what they want with their lives because we believe in individual freedom.”

And indeed we do, but only up to a point. We don’t believe everyone should be able to do whatever they want, especially when what they would cause harm to others, directly or otherwise.

In the immediate case, people would be freer to go without health insurance, since the bill would eliminate the annually-growing penalty for that.

But they’d drive up premiums because most would have reasons to believe they’d remain healthy — at least for awhile. But if they then had a medical emergency, a hospital would have to eat the costs of treating them.

An immigrant from Finland cites several other instances of the Republicans’ using “freedom” as a selling point and, as her op-ed’s headline says, explains why it’s “fake,” in contrast to the freedom she had before.

Care. The Director of the Office of Management and Budget asserts that the Republicans’ goal isn’t health insurance coverage nor a plan people can afford.

It’s care they can afford. He cites his family’s high deductible when he was in the House of Representatives, earning considerably more than would qualify them for a tax credit to subsidize it, let alone one for a family eligible for the highest.

We earlier heard something, though more extreme from the Secretary of Health and Human Services — a former orthopedic surgeon and then Republican House member who proposed his own version of repeal-replace.

While in the House, he said that he “knew oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people.”

Seems fair to gather what he means from the reported views of a radically right-wing professional organization he belonged to — minimal, if any health insurance regulations or medical quality standards, e.g., that physicians be licensed to practice, no vaccination requirements and no Medicare at all.

Well, save me from care so free of intervention. But these views hardly reflect what the majority of doctors believe — even those represented by the traditionally conservative American Medical Association, which has decided that the repeal-replace is far worse than the “imperfect” law we have.

Rebuttal Story. The Washington Post recently published a column by a doctor at primary care clinic that expressly rebuts the interference with care claim — and, by example, the other negatives that the Republicans’ word choices imply.

The doctor tells the story of one of his patients. Mr. R. first came to him when he got health insurance, having had none before because he couldn’t afford it.

The Affordable Care Act changed that, enabling him to purchase a plan that cost him less than $50 a month, thanks to the subsidies low-income people receive. But that’s not all.

Mr. R can neither read nor write. So he could hardly use the online system to choose and actually apply for a plan. He had the help of a navigator — a trained, unbiased helper — whose role the ACA established.

So he’d gotten help with logging on and entering some basic information. The the system then determined he had somewhat too much income qualify for Medicaid. So it kicked him over to the health insurance exchange.

The navigator explained terms like “premium” and “out-of-pocket maximum” and helped him fill out the forms. In short, as the physician says, “the federal policies … worked synergistically.”

Mr. R had — and still has — access to coverage, freedom, choice and care from a caring doctor. What “some politicians … seem not understand,“ the doctor says, “is that without the ACA, I wouldn’t have a relationship with patients like Mr. R at all.”

They actually do, I think, just as they understand the weasely way they’re using terms like “access,” “choice” and the rest. But what’s the alternative? To acknowledge that their bill would cause nearly as many people to have no health insurance than before the ACA?


House GOP Defunds Planned Parenthood, Endangers Low-Income Women

March 13, 2017

Nicholas Kristof wrote a presciently timely column for the next-to-the last Sunday New York Times. He recounts a visit to a women’s health clinic in small town in Maine, including what he observed during a consultation.

A teenager had come to the clinic because she felt itchy in her vaginal area. The nurse practitioner takes swab, diagnoses a yeast infection, but has also tested for sexually transmitted diseases.

She then talks to the teenager about birth control methods, including a long-acting reversible contraception. The young woman likes that, learns it’s fully covered by her insurance.

The nurse practitioner also gives her some condoms and tells her to always insist that her prospective sexual partner use one to protect her from STDs.

In short, as Kristof says, this is health care at its best, preventing both unwanted pregnancies and diseases.

Indirectly, poverty also, since the poverty rate for single-mother families is consistently the highest of any household type the Census Bureau reports — 36.5% last year and even higher for families with color, except Asian-Americans.

The Maine clinic apparently receives federal funds — either through the state’s Medicaid program, a Title X family planning grant or both. So it — —and the women who depend on it — are in big trouble because it provides abortions.

No federal funds used for these because laws already prohibit that. But the clinic probably can’t survive on donations and what it receives from health insurance companies for serving patients who’ve got the coverage the House Republicans’ Affordable Care Act repeal-replace bill would provide.

The bill won’t let people use the tax credits they’ll get to help pay their insurance premiums for a policy that covers abortions, except in the same limited cases the Medicaid prohibition carves out,

And, as you’ve probably read, it denies federal funding to Planned Parenthood, though initially for only one year. This perhaps to evade a stumbling block to swiftly passing the bill with only a simple majority in the Senate, rather than the usual 60 votes.

In the meantime, knowing the bill won’t pass swiftly anyway — if at all in its current form — the House passed and the Senate’s expected to pass a measure that overturns an Obama administration rule which effectively prohibits states from denying Title X funds to family planning projects because they provide abortions.

Well, none of this will make much difference to well-off women who live in cities or major suburban areas. They’ll have ob-gyns or other clinics they can go to. If they need an abortion, they can readily get one from their ob-gyn or another competent physician — and pay for it out of their own pockets.

But low-income women — and perhaps many not-so-low who live in small, rural towns — will no longer have a nearby clinic for tests that detect cancer as well as other diseases, counsel on how to prevent them and on safe, reliable birth control. Nor the procedure to insert a LARC — and replace it when necessary.

Planned Parenthood operates the largest network of women’s health clinics in the country — nearly 650, serving every state and the District of Columbia. They provide services to about 2.5 million women and men a year. Nearly 80% were poor or near-poor two years ago.

A tiny fraction of the funds it disburses go for abortions — 3%, as measured by services. Roughly a third help prevent untended pregnancies. Most of the remainder test, provide treatment and/or help prevent diseases.

Notwithstanding what some Republicans have said, other community clinics can’t readily meet these needs if the freed-up funds were available to them. Nor new clinics spring up all over the country.

Planned Parenthood is 100 years old now. You don’t get the resources to build or expand facilities, find and hire specialized health professionals to fully staff them, ensure stocks of testing equipment and supplies, etc. in a couple of years.

All these attacks on Planned Parenthood — and now apparently a broader attack on women’s health clinics — are a sop to the active pro-life movement.

What a cleverly chosen name, I’ve often thought, since it casts Americans who believe women should have the freedom to choose when and if to become mothers as against life.

Well, let’s consider the life of a low-income woman who can’t get regular Pap, other cervical cancer or breast cancer exams, plus instructions on how to monitor for breast lumps herself.

Or the life of a woman who doesn’t find out she has HIV/AIDS until she contracts some life-threatening infection — and perhaps by then has passed the disease on to a partner or a baby she’s borne.

How about a woman who’s decided that she’s unready — financially, emotionally or otherwise — to become a mother? She perhaps plans to enroll in a college-level program that will prepare her for a fulfilling, well-paying career — or is already in one.

She may, in fact, still be in high school and with no family member to care for a baby — or the money or the transportation to put him/her in an infant daycare program or even one nearby that’s not fully booked. She’s likely to drop out of high school, as 90% of pregnant teens do.

Her life may turn out okay, but the prospects are significantly dimmer. As I already said, she’s at high risk of poverty. What kind of life will that child have? Many studies tell us that children born and raised in poverty are at high risk for a host of problems and likely to remain poor long after.

None of this is to say that the self-labeled pro-lifers are wrong to publicly opposing abortions. If I believed that people were legally murdering others, I would speak out too, join with others to protest, call for an end to it.

But when human life begins, the value of preserving fetuses likely to die at birth or survive severely damaged, the countervailing weight of harms to the expectant mother and the like are matters of personal belief, often based on sectarian religious teachings.

The Supreme Court acknowledged women’s Constitutional Right to abortion more than 44 years ago. The federal government has nevertheless long curbed that right by prohibiting uses of federal funds for abortions.

Now, even if the House Republican leadership can’t push through its bill and the efforts to fashion a more acceptable substitute drag on, we can expect more proposals to defund Planned Parenthood — if not in Congress (though likely), then by states, 10 of which have already moved to do so.

And we can’t, I think, trust the new administration to intervene in defense of equitable funding for organizations that can provide the services Medicaid covers, given Trump’s bifurcated view on the Planned Parenthood issue.

A call to action then in defense of low-income women by the majority of voters who believe that abortion should remain legal in all or most cases. Because what’s a legal right if you’re too poor to exercise it?


House Republicans Unveil Reverse Robin Hood Healthcare Plan

February 27, 2017

House Speaker Paul Ryan and his lead colleagues have generated even more news about the Republicans’ plans to repeal the Affordable Care Act.

Still no legislation. Still spare details. And still, it seems, no genuine consensus, though a large majority now understand that simply repealing the ACA would be a disaster politically, as well as for the 20 million or so Americans who’ve gained health insurance coverage since the law kicked in.

Ryan, however, has released a policy brief that purports to set out the major elements of the House Republicans’ repeal-replace plan.

Needless to say, it aims to radically cut federal spending on health care. Beyond that, a New York Times headline captures the major thrust: “Republican Health Care Proposal Would Redirect Money From Poor to Rich.”

Here briefly are the major changes and how they’d make the shift. Long post, but on one of the biggest immediate threats to the well-being of low and moderate-income people in this country and our common — though obviously not universal — concept of equity.

End of Medicaid As We Know It

Many concerned parties, including yours truly, have animadverted before about Ryan’s plans to convert Medicaid to a block grant.

Basically, states would no longer receive partial reimbursements for the costs they incur in providing health care to the poor and near-poor people they’ve enrolled. They’d instead receive a fixed sum of money, coupled with even fewer requirements and restrictions on what they can do.

We can predict from the fate of other block grants that the fixed sum will either remain the same, regardless of increases in the number of very low-income people in need — or grow somewhat, but not enough to not enough to benefit everyone eligible or who would have been had the block grant not been created.

Ryan’s new plan includes this option, but leans toward a variation — per capita grants. These too use a formula to set states’ funding, but it’s based on the regular federal match that each received in a base year for people in specific categories, e.g., children, people with disabilities.

The grants would increase, based on the inflation rate. But the rate, as commonly measured, reflects the prices of goods and services consumers commonly pay for, e.g., food, fuel, housing, with medical expenses merely folded in.

As we all know, health care costs rise more. And they’re projected to rise considerably higher, boosted by aging baby boomers, new, high-priced drugs and other drivers.

In short, same basic result, achieved by something with less tarnished name — and with a further, predicable cost-shift to all the states and the District of Columbia that have expanded their Medicaid programs.

Specifically, the plan would fold in repeal of the higher federal government match for newly-eligible people enrolled in Medicaid programs. States would continue to have the it for some unspecified time so as “not to pull the rug out from” them or beneficiaries.

The rug would, however, be immediately pulled out from under adults deemed able to work, regardless of whether they do, but at a very low wage — or have any reasonable prospects of landing a non-poverty wage job.

Redirected Tax Credits

Under the current law, people who buy health insurance on an exchange get a tax credit that serves as a subsidy if their annual income is less than 400% of the federal poverty line — currently $97,400 for a four-person family. The subsidy goes directly to the company that provides the insurance the beneficiary chooses.

It’s greatest for those in the lowest income bracket and diminishes till it reaches the highest. So it ensures that very low-income people can afford comprehensive health insurance, while not spending federal money on people in upper-income brackets.

The Ryan plan would instead award tax credits directly to people who have no employer-sponsored health insurance or coverage under a government program.

They’d would be based only on age, with larger (unspecified) credits to older people. As the Times column suggests, this would seem to make some sense, since older people tend to need more medical care.

But it means is that some very wealthy people would get a larger benefit than many of the very poor, who not only need more help in affording health insurance, but often have more health care problems.

Expanded Health Savings Accounts

Our current system already offers people opportunities to sock money away tax-free for specific medical and dental needs by putting it into a Health Savings Account.

As with the better-known Individual Retirement Accounts, you can save only up to a maximum in any given year, but the cap is based on age, when you become eligible and the type of insurance you have (see below), rather than age and taxable earnings.

You’re not required to withdraw any money during a given year. So what you’ve invested continues to grow, assuming it’s invested well and that administrative costs don’t offset real-dollar gains.

And you don’t have to pay income taxes when you withdraw, if you spend the money for approved healthcare purposes — another difference from an IRA.

The biggest difference, however, is that you have to expose yourself and your family to budget and/or health risks because you can’t have an HSA unless your insurance plan is a high deductible, i.e., covers only what are sometimes referred to as catastrophic costs.

Current federal rules, for example, allow insurance companies to require high-deductible customers to pay as much as $7,850 for an individual or $15,700 for a family before they start covering costs.

HSAs are thus obviously beneficial to some people who can afford what they and any dependent family members need and still have money left over because they’ll owe less at tax time. But only those who can stash enough to cover thousands of dollars of healthcare costs.

The Ryan plan would allow people to contribute their maximum out-of-pockets to their HSAs. Another provision would allow spouses to contribute all or part of so-called catch-up contributions, i.e. those made in a given year to compensate for lower than maximum contributions previously.

Conservatives, including lead Congressional Republicans have long argued that healthcare costs would drop if people had “more skin in the game,” i.e., more to save or lose depending on whether they choose to seek health care and, if so, what sort and from whom.

This, as I think everybody knows, is profoundly unrealistic. We’ve neither the knowledge nor, in many cases, the time to choose healthcare services the way we choose, for example, large-screen TVs.

It’s nevertheless the theory underpinning the HSA expansion, with its inherent push toward high-deductible plans. And again, it’s effectively spending more on well-off people — in this case, by forfeiting tax revenues.

Undermining the ACA Before Full Repeal

Long as this post is, I haven’t covered all parts of the plan — most notably, the full repeal part.

Sufficeth it to say that it would roil the insurance market — by immediately eliminating the penalty for having no insurance, for example, and the penalty imposed on larger employers that don’t cover most of their full-time workers.

So if Obamacare isn’t failing now — as the policy brief misleadingly says it is — it surely would during the transition period the brief promises.

NOTE: Last Friday, two insider news sources posted a leaked draft of the House Republicans’ legislation. It generally tracks the measures I’ve summarized.


Let’s Not Forget Affordable Dental Care

January 23, 2017

A comment posted some time ago raised an issue about Medicaid that seems even more timely now because it opens to the door to larger current and prospective issues.

Seems the commenter had to have some teeth pulled. Her dentist told she would have to wait for dentures until her mouth heals instead of getting a temporary set. She felt that she and others covered by Medicaid were “treated differently from other people,” who aren’t doomed to toothlessness. Would I look into this?

And I did, learning more in the process about not only the source of her problem, bur dental care in our health insurance system — today and prospectively. Results, as follows.

The commenter is actually quite fortunate. States don’t have to include dental services in their Medicaid programs, except when they administer the Children’s Health Insurance Program by expanding them.

For adults, dental care is an optional benefit, both for those whom states covered before the Affordable Care Act and those who became newly eligible when states opted for expansion. Those states must provide “essential health benefits” for the latter, but dental care isn’t one of them.

Virtually all states and the District of Columbia do cover some dental services, but only fifteen cover a comprehensive mix, the Kaiser Family Foundation reports.

Many cap per person spending or the number of services covered. And thirteen cover only emergency treatment. Even coverage doesn’t ensure affordability because beneficiaries may face high out-of-pocket costs.

Not all states that cover dental services cover dentures. And even fewer cover dentures for all beneficiaries as often as they might need them. They’re responding here to limits the federal government sets on reimbursements.

But low-income adults aren’t treated all that differently from their better-off peers. Traditional Medicare provides no coverage for dental services, except in certain limited cases when the beneficiary is in a hospital.

We who’ve had employer-sponsored health insurance also know that incomplete—or no—coverage for dental services is more common than the commenter apparently assumed.

But better-off people can shell out for dental care or supplementary insurance. Not so for low-income working age adults. Only 19% of those who were officially poor went to a dentist in 2013. And 44% had had untreated cavities in the prior two-year period.

Nearly a third of those with incomes low enough to qualify for an expanded Medicaid program reported an unmet need for dental care last year.

Without it, they may not only lose teeth and have to live with gaps in their mouths. Untreated oral diseases, including cavities can cause or worsen a range of other health problems.

Lack of sufficient coverage is obviously a major barrier, but it’s not the only one. In some places, e.g. rural areas, inner cities, there simply aren’t enough dentists. That’s partly due to an unwillingness on their part to treat low-income patients, especially those covered by Medicaid.

Dentists object to the paperwork and lost income because Medicaid patients—at least, by reputation—often don’t show up for appointments. But dentists also cite low reimbursement rates—sometimes so low as to not even cover costs.

Now, we know that states often cut provider reimbursement rates when economic downturns drive up their Medicaid costs because that’s more politically palatable than tightening up on eligibility or coverage.

And we know they’d face budget crunches—and not only during recessions—if Republicans in Congress convert Medicaid to a block grant and the President agrees.

Not much of an “if” here. The Trump’s campaign’s policy positions included a block grant. And Congressman Tom Price, his choice for Secretary of Health and Human Services, folded a block grant into the House budget plan when he chaired the responsible committee.

Looking at how states now use their flexibility to limit dental care coverage, we could reasonably expect them to make further cuts there.

They might instead (or also) cut dentists’ reimbursement rates. More than half the states did that in the aftermath of the Great Recession. So Medicaid beneficiaries who still had dental coverage may have had more problems finding someone to treat them, as certainly seems the case in Washington and in Florida.

Some states might instead join those that provide no coverage whatever.

The block grant is only one of the clear and present dangers to the health of poor and near-poor people, including the health of their teeth, gums and everything else in and around their mouths.

The impending repeal of the Affordable Care Act would immediately deny higher federal reimbursement rates to the 31 states and the District of Columbia that have expanded their Medicaid programs.

The repeal, in and of itself, would free them to shrink or eliminate dental health benefits for the newly-eligible children they enrolled because they’d no longer have to provide the essential health benefits the ACA specified.

This would also be true for most other insurance plans, unless state regulations required them because the same EHB requirements apply. And if, as predicted, premiums soar, one could expect plans to drop dental care or, at least, radically cut back coverage.

Some of you may recall the boy who died from a brain infection because his mother couldn’t find a dentist to treat him in time—this for wont of Medicaid. We might have more such cases, with or without it.

We’d almost surely have more low-income adults toothless (and not only temporarily) and more dead too because they couldn’t afford dental care—or related medications.

I know this seems a worst case scenario and perhaps an unwarranted leap from a singular problem to a vast array. But when we think about what will happen in the aftermath of health care “reforms,” we need get beyond the numbers, as important as they are.

Price objects to our government programs because they get between doctors and their patients. But, in fact, people who should be patients won’t be.

And when we think of them, we shouldn’t forgot those who need dental care because, as one dentist said, “the mouth and the head are connected to the rest of the body.”