DC Makes Right Choices on Health Care Reform

July 19, 2012

Reading about how states are responding to the Affordable Care Act, I feel proud to live in the District of Columbia.

Only 10 states have decided to expand their Medicaid programs by the 2014 deadline. The District has charged ahead.

It’s already lifted its income eligibility ceiling to 133% of the federal poverty line, as the ACA required — until the Supreme Court in effect said it couldn’t. The District has also requested — and received — a waiver to lift the ceiling to 200% of the FPL.

This is so fiscally smart.

Under a separate program called the DC Healthcare Alliance, the District had been paying the full costs of health coverage for people with incomes below 200% of the FPL who couldn’t qualify for Medicaid.

Now it’s shifted a majority of them from the Alliance into Medicaid. The federal government pays its regular 70% share of the costs. And as of 2014, it will pay 100% of the costs for the newly-eligible at or below 133% of the FPL.

Another cause for pride is the DC Council’s decision to preserve enough funding for the Alliance so that it can still cover hospital-based services for adults who can’t be shifted — mostly undocumented immigrants, we’re told.

Consider that some states are doing their best to drive these people out — most of them among the states that won’t admit even more poor U.S. citizens into their Medicaid programs.

And since I’m beating the drum here, I’ll add that the District has moved ahead to establish an exchange for health care insurance purchases, as the ACA envisions.

Only 14 states have even established the necessary legal framework. Mayor Gray signed the District’s law in January — after what seems to have been a good bit of work by an interagency task force, including efforts to get public input.

Virtually all states have gotten grants to plan exchanges, as has the District. But 17 of them decided to stop or slow down planning until the Supreme Court ruled on the ACA. Another six hadn’t really gotten started.

Now these states are behind the eight ball. If they don’t have a “blueprint” ready by November, the federal government may decide to run an exchange for them — just the kind of “takeover” conservative ACA opponents deplore.

Rhetoric aside, the laggard states may, for various reasons, wind up with a health care system that’s less satisfactory than what they’d otherwise have.

Six states have nevertheless decided not to even try to establish exchanges. Seems we’ve got a new legal strategy for making the health reform plan crash. Or maybe two.

Some ACA opponents, including a bunch of Congressional Republicans, now claim that the ACA doesn’t allow the federal government to impose penalties on employers who won’t provide adequate, affordable health insurance except in states that operate their own exchanges.

Others argue that the federal government can’t provide subsidies to households who purchase health insurance on exchanges that state inaction constrains it to create.

So we can look forward to more brawling in Congress — and perhaps another round of lawsuits.

But, as things stand now, these attacks on the ACA won’t affect District residents because our policymakers have viewed the law as an opportunity to “ensure  … access to quality, affordable health care” for all of us.

You’d think this would be a no-brainer. It’s a testimony to our times that it’s worth a shout-out.


Medicaid Block Grant Not The Only Threat To Health Care For Low-Income People

July 7, 2011

Economist Jared Bernstein reminds us that cost shifting is not cost saving — this in connection with Congressman Paul Ryan’s plan to convert Medicare to a voucher system.

I wonder whether the President and his White House advisors have their minds around this obvious fact — or frankly, how much they care.

What’s got me wondering is a new brief from the Center on Budget and Policy Priorities that takes us through the complexities of a proposal for Medicaid savings that the White House has offered up as part of its deficit reduction plan.

It’s called a blended rate because what it would do is create a single rate for the federal match that each state gets to help cover the costs of insuring low-income adults and children under Medicaid and CHIP (the Children’s Health Insurance Program).

Basically, the federal government now pays a fixed percentage of states’ regular Medicaid costs and a higher percentage for their costs of insuring children enrolled in CHIP.

Under the Affordable Care Act, it will initially pick up the full costs of ensuring people who become newly eligible in 2014, when the minimum federal income cut-off rises in 2014 and childless adults gain a right to coverage. It will then cover somewhat lower percentages, bottoming out at 90% in 2020.

States that expanded Medicaid coverage to childless adults before the ACA was passed will still get a match for them, even though they’re not newly eligible. This match phases in, reaching 100% in 2020.

In short, we’ve got a mix of matching rates — some higher than others. The blended rate would replace them with a single match. Which may sound okay until we learn that states would get significantly less than they would under current law.

Back in April, the White House issued its overall framework for deficit reduction. Savings from Medicaid totaled $100 billion over the first 10 years. CBPP President Robert Greenstein says that as much as $65 billion would have to come from the blended rate.

States would apparently realize some modest savings in administrative costs. But they’d be stuck with the rest of the loss from the replacement of their current and prospective matching rates.

This doesn’t mean they’d make up the difference out of their own revenues. Anyone who wonders what they’d do need only look at what they’ve already done to reduce their Medicaid costs.

They’d cut payments to health care providers, though current reimbursement rates are already so low that many physicians, particularly specialists won’t treat Medicaid participants.

They’d scale back benefits they don’t have to provide to get federal funds, e.g., dental care, eyeglasses and hearing aids, home health services, organ transplants (!).

The President apparently opposes the House Republicans’ Medicaid block grant proposal. “Not on the table” in the deficit reduction talks, says his top Medicare-Medicaid administrator.

But the impacts of the blended rate could be much the same, though probably less drastic.

The federal government would spend less, but not by reducing the costs of providing the health care that low-income people need. It would save by dumping a bigger portion of the rising costs on the states.

The states would then try to minimize the shifted costs. They too would probably rely more on cuts than on genuine cost-reduction strategies, e.g., better quality control, coordination and preventive care.

Ultimately low-income people, including children, would pay — with their health, in some cases their lives — to reduce the federal deficit.

This, I trust, is not what the President had in mind when he embraced “shared responsibility and shared sacrifice.”

NOTE: This posting and my recent cross-posting from Laura’s Life are part of  a Medicaid blog-a-thon organized by MomsRising — a virtual grassroots community that acts on issues that affect mothers and families.

UPDATE: MomsRising now has an online listing of all the blog-a-thon postings, with links. You can find it here. More member Medicaid stories are available in a story map.

How Congressman Ryan’s Radical Health Care Proposals Would Impact DC

April 12, 2011

Now the answer to a question I’ve been asking myself ever since I looked at Congressman Paul Ryan’s proposals for federal health care programs. What would they mean for the District of Columbia and its residents?

Families USA has just issued a report with state-by-state impact figures for each of the major health care parts of Ryan’s Fiscal Year 2012 budget resolution — his so-called Pathway to Prosperity.

Here’s what we learn.

Medicaid Block Grant. As you may recall, the Ryan plan would convert Medicaid to a block grant. Grants would be adjusted according to a formula that reflected neither rising health care costs nor the aging of the population. The latter is important because state Medicaid programs spend more for low-income seniors than for most other covered groups.

Under the block grant, the District’s existing program would lose $4.4 million next year. Losses would grow exponentially every year thereafter. For the entire first 10-year period, 2012-2021, they would total more than $3.4 billion.

Funding for Medicaid Expansion. Under the health care reform act, states must expand their Medicaid programs to include all people with incomes at or below 133% of the federal poverty line. The federal government will pay all the costs of the expansion for the first three years and most of the costs thereafter.

The Ryan plan would repeal both the expansion requirement and the related funding. Losses to the District by 2021 would reportedly total well over $1.2 billion.

“Reportedly” because Families USA assumed that the District would undertake the expansion in 2014, as the law requires. I understand it’s decided to move at least some eligible residents into Medicaid earlier. This might affect the estimate.

Tax Credits for Insurance Premiums. The health care reform act includes tax credits to help moderate-income families purchase health insurance in the exchanges that will be created. Credits will be available to families up to 400% of the federal poverty line.

The Ryan plan would repeal this provision also. District residents eligible for the tax credits would lose $37.4 million in 2014, the year they’d become available under the current law.

Here again, losses would dramatically escalate. During the 2012-21 period, they’d total close to $1.3 billion.

The health care reform act also provides tax credits for small businesses and some other incentives to encourage employers to provide health insurance. These too would be repealed under the Ryan plan.

Loss of all the tax credits, plus the loss of federal funding for expansion of Medicaid would mean that at least 46,600 District residents would have no health insurance 10 years from now.

Medicare Privatization. Under the Ryan plan, people now under 55 would be subject to an altogether different health insurance scheme when they reached Medicare eligibility age or became severely disabled before that.

Instead of enrolling in the fairly comprehensive, low-cost insurance plan we know as Medicare, they’d get the equivalent of a voucher to purchase health insurance in the private market. As I noted earlier, the value of the voucher would increase at a much lower rate than health care costs.

Families USA doesn’t provide state-by-state figures for the budget crunch that seniors and people too disabled to work would face. The Congressional Budget Office, however, did some preliminary national estimates.

According to these, typical 65 year olds enrolled in a private insurance plan similar to the current Medicare would pay 68% of their health insurance premiums and out-of-pocket costs in 2030. This is 43% more than what they’d pay under Medicare as it exists today.

And the total costs would be much greater because Medicare delivers more health care bang for the buck than private insurance plans.

Bottom Line. If the Ryan proposals for Medicaid, Medicare and health insurance tax credits were all adopted, the District and its residents would lose more than $6 billion in the first 10 years alone.

And for what? So that $4.2 trillion could be used to finance extended and expanded tax breaks that would make the wealthiest even wealthier.

Is Health Care Reform Dead?

January 23, 2010

It’s hard to keep up hope. Harder still to muster the fighting spirit that’s needed to keep health care reform alive. But it’s not dead yet. And it won’t be if enough members of Congress hear from enough of us.

That’s what I heard yesterday from seasoned advocates at Families USA and other partners in the Coalition on Human Needs. They’ve been working on health care reform since before it was a twinkle in Obama’s eye. And I figure if they’ve still got the hope and heart to advocate, then we should too.

We’ve come to this pretty pass for a couple of reasons. The most important, I think, is that we’ve lost sight of the forest for the trees. Understandably so, given the surfeit of blow-by-blow media reports, propaganda and detailed analyses of flaws and compromises.

I own a share of responsibility for this. So here’s my list of big good things the pending legislation would do:

  • Expand health insurance coverage to about 31 million more people–an even greater number if certain provisions in the House bill prevail.
  • Make health insurance–and health care–affordable for millions more who have insurance but are over-burdened by the premiums and out-of-pocket costs.
  • Enable more small businesses to offer health care benefits.
  • Ensure that we’ll have health care coverage even if we lose our jobs or our employers drop it.
  • Prevent insurance companies from denying coverage or charging exorbitant rates because of pre-existing health conditions, gender or age.
  • Keep Medicare affordable and narrow the gap in prescription coverage (the infamous doughnut hole).
  • Curb the soaring costs of health care, which jeopardize the coverage we have and our economy as a whole.

Some members of Congress–and perhaps the White House too–view the upset in Massachusetts and some recent polls as signals to step back. We hear talk of paring the package back to a few, relatively uncontroversial elements. Republican leaders say Congress should start all over again, with a bipartisan approach, a.k.a. their proposal.

History tells us there won’t be another chance to pass comprehensive health care reform for many years. Recall that the last serious effort died 15 years ago. But if the imperfect bill we’ve got now does pass, there will always be chances to improve it.

New York Times columnist Paul Krugman puts it well. “Whereas flawed social insurance programs have tended to get better over time, the story of health reform suggests that rejecting an imperfect deal in the hope of eventually getting something better is a recipe for getting nothing at all.”

I think our elected leaders know this. But they think that most of us don’t want comprehensive health care reform. We’ve got a small window of opportunity to convince them otherwise.

Families USA has an open letter to members of Congress urging them to move forward on meaningful health care reform now. So pass the news along if you belong to an organization that would endorse it or a listserv that would spread the word.

The rest of us can use the letter for personal messages to our elected representatives in Congress. Contact information and e-mail forms are on the House and the Senate websites.

I think it’s also worth writing the key decision-makers–President Obama, House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid. Just a line or two will do what’s needed.

UPDATE: Families USA has set up a toll-free hotline for us to call our Congressional representatives. It’s 800-828-0498. This number will take you to the Capitol Hill switchboard. So ask the person who answers to put you through to the appropriate office. Those of you who’ve got Senators will need to make three calls to cover all bases.

The link above will take you to a page that includes suggested talking points. But I think the link itself contains the germ of a great message: “Can’t back down.” Our representatives don’t have to be told all the reasons we need comprehensive health care reform. They need to know that we want them to pass it now.

Right To Choose Becomes a Middle-Class Privilege Again

December 20, 2009

I’m old enough to remember when abortions were illegal. I also remember how panicked I was when, as a college sophomore, I thought I was pregnant. I had hopes for a professional career. The college I went to didn’t even allow pregnant students to attend–let alone support them with the scholarship aid I depended on.

But my panic didn’t have to do with the prospects of becoming an unwed mother at nineteen. It was more the prospect of discovery–and of having to tell my mother what she already suspected I’d been up to.

Because I knew that middle-class girls like me could–and did–get abortions. Clean, safe procedures performed in doctors’ offices or hospitals. All you had to do was ask around to find a sympathetic ob-gyn–and come up with the money.

I’m writing this because we seem to be headed back to those bad old days. They’re already a reality for poor women who depend on Medicaid. The same is true for federal employees, since health insurance plans available to them don’t cover abortions except in cases of rape, incest or where necessary to save the woman’s life. For women serving overseas in the military, only risk to life triggers coverage.

Now Senator Ben Nelson (D-NE) has been placated by an amendment to the Senate health care bill that would allow states to prohibit abortion coverage under any insurance plan in the exchanges they will administer. Presumably at least some of the 17 states that already cover the costs of abortions for poor women will take a pass. But what about the rest?

Granted, the Nelson “compromise” isn’t as punitive as the House bill, which would establish the same prohibition nationwide. But the administrative complexities it establishes, e.g., separate accounts for prospective abortion services, seem likely to deter insurers from offering coverage, even where permissible. Whether they do or not, it appears that women with subsidized coverage would have to pay the full cost.

So once again, women who can afford to pay for abortions performed by qualified doctors in safe, sanitary conditions will get them if they choose. The rest … Well, just read what one ob-gyn remembers from the bad old days we’re reverting to.

We’re told that we shouldn’t let the perfect be the enemy of the good, that we won’t get a better health care bill if we ditch this one, that there will be opportunities to improve the new system over time.

I can’t argue with that. But when Congress passes this give-with-one-hand, take-away-with-the-other thing it’s created, you won’t see me dancing in the streets.

Let’s Make Health Care Reform Work For Low-Income Children

December 11, 2009

As I wrote awhile ago, the current health care reform bills could leave many low-income children worse off than they are now. The children at risk are some portion of those who are currently enrolled–and others others who should be enrolled–in the State Children’s Health Insurance Program.

Those whose families are poor enough will have a broad range of very low-cost benefits through Medicaid. Not-quite-so-poor children now enrolled in SCHIP will be shifted to the health insurance exchange–immediately under the bill the House passed and in 2013 under the bill the Senate is debating. And that’s where the problems lie.

Plans purchsed through the exchange will have considerably higher premiums and out-of-pocket costs. And neither the House nor the Senate bill requires them to cover all the health services children need.

Moreover, just because the Senate bill would temporarily extend SCHIP doesn’t mean that all eligible children would be covered. According to a Kaiser Family Foundation brief, most of the 8.9 million children without insurance now are eligible for a public health care program. The Congressional Budget Office estimates that SCHIP and Medicaid combined will cover only 5.6 million more children in 2013.

Nor does the current Senate bill mean that children in SCHIP will get adequate health care. The Children’s Defense Fund has called the current system “an unjust lottery of geography”–in part because some states operate SCHIP programs that offer less than the comprehensive screening, prevention, diagnosis and treatment services available under Medicaid.

Senator Bob Casey (D-PA) has introduced an amendment (#2790) that would address these problems. As his summary indicates, it would:

  • Continue federal funding for SCHIP through 2019.
  • Require the U.S. Department of Health and Human Services to report on differences between coverage under subsidized plans in the exchange and coverage under SCHIP, thus giving Congress a basis for deciding whether to preserve SCHIP beyond 2019.
  • Require states to offer the same range of services to children in SCHIP as they cover under Medicaid.
  • Provide federal matching funds for all covered services SCHIP children receive instead of giving states a predetermined grant for each year.
  • Prohibit states from reducing income eligibility standards for SCHIP and require them to cover all children up to 250% of the federal poverty line, beginning in 2014.
  • Ensure that SCHIP remains affordable by prohibiting states from increasing charges, except to reflect increases in the median income for low-income families.
  • Provide grants and a significant financial incentive for states to increase outreach and streamline their  enrollment process.

Voices for America’s Children has a customizable e-mail that those who have Senators can use to support this worthy amendment. We who live in Washington, D.C. can call or e-mail Senate Majority Leader Harry Reid, since he will reportedly will incorporate changes he likes into a final manager’s amendment.

The leadership is pushing to get something passed before Christmas. So time is of the essence here.

Senate Health Care Bill Puts Cost Burdens On Low-Income People

December 5, 2009

Bear with me for a moment. There’s been such an over-plus of proposals, polls, pontificating and  propaganda that I’ve half-forgotten why we decided to plunge into health care reform to begin with. And it seems I’m not the only one.

As I recall, the idea was to make good health insurance affordable for everyone because most people can’t get the health care they need without it. Bringing down health care costs was a means to this end, though it’s taken on a life of its own.

I’ve gone back to the basics because I think they’re a lens for looking at what the bill the House passed and the bill the Senate’s debating will do to ensure that low-income people can get sufficient, affordable health care.

I’ve already put in my two cents on the employer responsibility provisions. So what about affordable health insurance for those who won’t be able to get it through their jobs?

On this score, the House bill does more for poor and near-poor people. It would extend Medicaid, which offers good coverage at very low cost, to individuals and families up to 150% of the federal poverty line. The Senate bill would cut off Medicaid eligibility at 133% of the FPL.

Above these thresholds come a range of actuarial values, i.e., levels of subsidized coverage provided by insurance purchased through the exchange. These decrease as income brackets go higher. Put them together with the Medicaid cut-offs and you’ve got significant cost differences.

The Center on Budget and Policy Priorities has updated its comparative table. As it shows, the Senate bill would keep costs lower for individuals and families at higher income levels by shifting the costs to those who have less.

  • Individuals and families who would be covered by Medicaid under only the House bill would pay nearly two-thirds more under the Senate bill–$613 more for families and $362 more for individuals.
  • Those at 150% of the FPL would pay somewhat over a third more under the Senate bill–$462 more for families and $252 more for individuals.
  • The situation reverses at 300% of the FPL, with families paying $100 less and individuals $65 less under the Senate bill.
  • By 400% of the FPL, the point spread has increased to $1,611 less for families and $953 less for individuals.

Similarly, the House bill would provide cost-sharing assistance to families up to 350% of the FPL, while the Senate bill would cut it off at 200% of the FPL. At the same time, actuarial values are lower under the Senate bill at all levels except for 400% of the FPL.

This means that low-income households would have to pay larger deductibles and co-pays than under the House bill. And again, the differences would be greatest for those in the lowest income brackets.

CPBB estimates that a family of three at 175% of the FPL would be responsible for $3,867 in deductibles and co-pays if the Senate plan were in effect now. That would be more than 10% of its annual income. And it would already have paid $2,307–6.3% of its income–for the premium.

Yes, the family would have insurance. But would it be able to afford the health care services it needs. I rather doubt it. And there goes one of the bill’s two main objectives–“to provide affordable, quality health care for all Americans.”

And if the family can’t afford the out-of-pockets, its members are likely, as now, to wind up in emergency rooms–a very costly alternative to preventive and maintenance care. Or it may decide simply to pay the relatively modest penalty for not having health insurance. One way or the other, there goes the bill’s other main objective–“to reduce the growth of health care spending.”

Will the bill that comes out of the Senate come closer to these objectives? More likely getting those precious 60 votes will mean even more compromises at the expense of those who need health care reform most.