Posts Tagged ‘Affordable Care Act’

« Older Entries

Medicaid and the Children’s Health Insurance Program Buffer the Impact of the Recession on Children

Wednesday, November 30th, 2011

In most respects, children have not been exempt from the impacts of the current economic downturn. The number of children living in poverty in the United States rose to 15.7 million in 2010—a 19 percent increase from 2008. Despite this bleak picture, a new report shows that the rate of uninsured children actually dropped by 14 percent during this same time. What accounts for these counterintuitive findings?

The new report from our partners at the Georgetown University Health Policy Institute’s Center for Children and Families (CCF) (click here for the executive summary) provides strong evidence that the uninsured rate for children decreased in the midst of the worst recession in decades because Medicaid and the Children’s Health Insurance Program (CHIP) were in place to prevent children from failing through the cracks.

CCF found that private insurance coverage of children eroded during this period—dropping by 4.5 percent. This is no surprise, since the recession cost millions of families their jobs and their employer-sponsored insurance (ESI). But public insurance coverage of children increased by 5.8 percent during this same time, filling the gap left by declining ESI. This is simple, hard evidence that public coverage programs are irreplaceable sources of coverage that protect children’s access to care when the economy falters.

Ironically—maybe only in the Alanis Morissette meaning of the word—it’s during these hard economic times, when Medicaid and CHIP are most needed as a safety net, that their funding is most at risk. As policy makers scramble to fill state budget gaps, they too often turn to harmful Medicaid and CHIP cuts such as reductions in provider payments, restrictions on covered services, and increased premiums and co-payments. The findings in the report emphasize why it’s essential that policy makers turn instead to the dozens of delivery and payment system reform options that can achieve savings in Medicaid and CHIP without undermining—and often by actually strengthening—these programs. (See our Medicaid Report Card for ideas on how your state can save money in Medicaid.)

The report also highlights the importance of the maintenance of effort requirement in the Affordable Care Act, which prohibits state policymakers from cutting eligibility for children on Medicaid and CHIP until 2019. The heartening findings in the CCF report would simply not have been possible had states been permitted to slash eligibility in these programs.

The full report includes state-specific data on children’s insurance rates, so check it out and see how your state did (only one state, Minnesota, had a statistically significant increase in uninsured children). With our economic woes likely to continue for some time, this report should renew our commitment to protecting Medicaid and CHIP. The health of our children depends on it.

—Katherine Howitt, Senior Policy Analyst
and Patrick M. Tigue, Senior Policy Analyst

Tags: , ,
Posted in Affordable Care Act implementation, children's health, Medicaid, Uncategorized | No Comments »

IOM releases its long awaited EHB Guidance: Tough Medicine

Tuesday, October 11th, 2011

As the Institute of Medicine (IOM) unveiled its report on Essential Health Benefits (EHB) on Friday, there were few surprises.  The panel delivered a high level outline for selecting benefits with a strong recommendation that cost consciousness be its guiding principle.

Learn more about EHB process here and strategy here.

The IOM panel was tasked with outlining what criteria should be used to determine a minimum set of benefits for new health plans in the individual and small group market starting in 2014; these benefits serve as the benchmark for new Medicaid plans. The 300-plus page report recommends a framework for Health and Human Services (HHS) to use as they build the EHB package. The headline from this report is: cost before benefits. 

This is a disappointment for advocates. Shifting the focus from robustness to predefined cost parameters could leave many Americans underinsured. In recognition of the difficult task presented to the panel, cost is an important factor in determining health benefits. As correctly noted in the report, “the more expansive the benefit package was, the more it was likely to cost and the less affordable it would be. How to balance the competing goals of comprehensiveness of coverage and affordability was “key.” However, making cost the guiding decision point rather than a factor of many alters the conversation from what is a good package for consumers to how much does that benefit cost?

Affordability doesn’t just mean lowest cost. Rather, getting people what they need at a price that they can afford is paramount. Too much emphasis on costs risks achieving the lowest premium possible without regard to the health needs of consumers. 

The report guides HHS through five areas: 1) defining the EHB and developing a target premium; 2) public deliberation; 3) monitoring the EHB; 4) allowance for state variation; and 5) updating the EHB.

Consumer advocates will play an important role in each of these areas – particularly in defining priorities through public input. The IOM recommends that HHS hold public hearings or small group discussions throughout the country in order to aid in priority development. This is an opportunity for consumer advocates to voice their concerns and offer recommendations to HHS about services to include in the EHB package. 

The panel also recommends that the package be released for comment to HHS by late spring 2012.  For consumer advocates, this means a short time frame of influence.

A second priority for consumer advocates that is next in the development of the EHB package is how states will respond to it. By encouraging state-tailored options, the IOM suggests that there can be some state variation in the package. This may alleviate some stress regarding the many state mandates that exist in states – ranging from 13 in Idaho and 69 in Rhode Island – yet raises other concerns about exclusion of benefits.

Many challenges lie ahead for consumer advocates, including coordinating state- based consumer health care coalitions to respond to EHB. These coalitions can play a pivotal role in protecting consumers: a voice at public forums, a watch dog of EHB implementation from 2014 and beyond, and a feedback loop for HHS. The EHB will continue to change over time and advocates can play a key role in influencing EHB development.

IOM suggested timeline:

May 2012:  HHS has developed an EHB package with a national premium target based on typical small and individual market plans

January 2013:  HHS should develop a framework for data collection and analysis for purposes of monitoring implementation and updating the EHB package.

January 2016: The Secretary should update the EHB to make it increasingly more specific, and update annually.

-Eva Marie Stahl, Policy Analyst

Tags: , , ,
Posted in Affordable Care Act implementation, care coordination/quality, Uncategorized | No Comments »

New Steps in the Fight Against Childhood Obesity

Tuesday, October 11th, 2011

In the United States, childhood obesity is an epidemic. Data from the Centers for Disease Control and Prevention (CDC) indicate that 17 percent of children between ages 2 to 19 are obese. CDC data also show that since 1980 the prevalence of obesity among children and adolescents has nearly tripled. Childhood obesity is linked to a number of debilitating and expensive diseases including cardiovascular disease, diabetes, hypertension, several kinds of cancer, and other chronic conditions. Clearly, childhood obesity is one of the most pressing health issues facing children across the nation.

And that’s why here at the New England Alliance for Children’s Health, a program of Community Catalyst, we were excited to see that the CDC recently announced a new initiative aimed at addressing childhood obesity. The Childhood Obesity Demonstration Project was created by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and funded through the Affordable Care Act (ACA). It will provide $25 million over a four year period to comprehensively identify effective health care and community approaches to reduce childhood obesity in the areas of supporting healthy dietary choices and promoting active living. Children aged two to twelve who are enrolled in CHIP are the target population for the project.

CDC chose only four grantees to participate in the project. Three grantees will serve as research facilities (the University of Texas Health Science Center at Houston, San Diego State University, and the Massachusetts Department of Public Health) that will identify strategies that are effective means to reduce childhood obesity and one grantee (the University of Houston) will serve as the evaluation center for the project and share lessons learned across identified strategies. The project will conclude in September 2015 at which time CDC will widely share the findings from the initiative and make recommendations about effective strategies to prevent childhood obesity among undeserved children.

What we learn from this project needs to inform policy choices at the federal, state and local level if we are going to make much needed progress on the childhood obesity epidemic. And thanks to CHIPRA and the ACA, we now have an even better chance of doing so.

—Patrick M. Tigue, Senior Policy Analyst

Tags: , ,
Posted in Affordable Care Act implementation, children's health, Uncategorized | No Comments »

Following the Leaders: How Some Hospitals Use Community Benefit Programs to Address Health Equity

Monday, September 26th, 2011

We’ve used this space to talk at some length about the shortcomings that follow from our “patchwork quilt” of state and federal standards for community benefit. Today, we’re taking a detour to talk about what’s right with community benefit—specifically, steps some hospitals are taking to address disparities in health through community benefit programs.

Naming the Problem
The face and voice of America is changing. Racial and ethnic minorities currently comprise one-third of the U.S. population; nearly 47 million people—18 percent of the population—speak a language other than English at home. With this change in demography, the health of the United States as a whole is becoming increasingly dependent on the health of minority populations. Yet disparities in health are widespread, well-documented, and present in every factor that impacts how long and how well people live: from healthy behaviors to clinical care access and quality, and from social and economic factors (like income, housing, and education) to physical factors such as environmental quality. Each year, an estimated 83,000 deaths are attributable to racial and ethnic health disparities.

Fortunately, some hospitals are responding to factors contributing to disparities in health by creating community benefit programs that address all of the factors impacting health in their communities, including access.

Creating Solutions through Community Benefit
Last week, hospital community benefit officers and consumer advocates shared their experiences with partnering to address health disparities.

First, we shared Community Catalyst’s vision for “community benefit” as goods, services and resources provided without reimbursement (or with partial reimbursement) to address community-identified needs and concerns, particularly those of groups who are underserved. Community benefit implies a partnership—a social contract, of sorts—between hospitals and their communities. This vision sees an active role for community partners in identifying community needs and assets and shaping the priorities hospitals choose to address. These programs can focus on a variety of issues impacting health equity—health care access through financial assistance or funding for free clinics, for example, or programs to increase access to healthy foods.

Then, hospital community benefit officers shared how hospitals are addressing health disparities:

• Vondie Woodbury of Trinity Health System, Mercy Health Partners and the Muskegon Community Health Project in Michigan shared how initial community efforts to increase access to care for the uninsured led to the creation of the Access Health Program, a community-based, non-profit cooperative that now partners with Mercy Health to provide access to a full range of services for small business employees who were previously priced out of the commercial insurance market. The program focuses significantly on educating members about healthy living and prevention. “First and foremost, we learned we had to democratize the [community benefit] system so that all of the voices in the community have a chance to shape what is happening. That’s been key to our success,” she said. Trinity hospitals also use a common enrollment form that asks questions to determine if patients are presumptively eligible for financial assistance, prescription drug help, food stamps, and a free vision program offered by a community partner. Trinity also sends outreach workers to visit patients who are behind on their bills and enroll them in financials assistance or Medicaid, rather than allowing their accounts to proceed to collections erroneously.

• In Sonoma County, California, the community benefit arm of Saint Joseph Health System takes a broad, comprehensive approach to address the social determinants of health, according to Dory Magasis Escobar. It deploys health promoters from the communities it serves to educate their friends and neighbors about healthy behaviors and available services, as well as sponsoring free services through community clinics. But it also teaches community members how to relate to systems of power in order to effect change. For example, the health system trains community leaders to respond to neighborhood concerns; participates in community coalitions; and engages in advocacy at the local, state, and federal level on issues that impact vulnerable members of its community.

While these hospitals are stellar examples, advocates can still make progress when local hospitals aren’t as inclined to partner with the community. “Be persistent,” said Claudia Lennhoff of Champaign County Health Care Consumers, an Illinois organization that first approached hospitals about improving financial assistance and debt collection policies. “We started out as adversaries because they wouldn’t meet with us. We were able to move that to a very different place and recently worked together to increase dental access in our community.”

Good News Is (Potentially) on the Way
While hospital leadership plays a major role in determining community benefit programs, the Affordable Care Act also includes some new requirements that can help public health and community advocates raise their concerns. Starting in 2012, all tax-exempt hospitals will have to engage in a “community health needs assessment” and plan implementation strategies that take input from public health experts and community representatives. And while the final rules are still being written, the most recent document put out for comment by the IRS includes a substantial role for grassroots leaders and community members. (Community Catalyst submitted comments on this document.)

While it pays to understand the issues policymakers will be wrestling with in the coming months, community benefit planning processes should be underway in most hospitals. Health equity advocates should ask for a seat at the table, no matter where their hospitals are in the planning process. After all, we share a common vision for communities that promote the health of everyone.

- Jessica Curtis, Project Director, Hospital Accountability Project

Tags: ,
Posted in Affordable Care Act implementation, Health disparities, Hospital Accountability/Charity Care | 1 Comment »

ACA Opponents Grab a (Partial) 11th Circuit Win

Tuesday, August 16th, 2011

In a 2-1 decision this past Friday, the 11th Circuit U.S. Court of Appeals in Atlanta handed ACA opponents a partial victory and dealt a partial blow to the Obama Administration and ACA supporters. While the ruling is frustrating to those working tirelessly on ACA implementation, the good news is that the entire law wasn’t ruled unconstitutional. The individual mandate provision – or the requirement that everyone who can afford insurance must obtain it – was struck down, raising doubts about the long-term sustainability of the ACA. However, let us grab the bits of good news that are sprinkled (lightly) throughout this ruling.

Medicaid is no bully.

 Medicaid expansion is at the heart of expanding coverage to millions of uninsured Americans in the coming decade. The appeals panel confirmed that the Medicaid program is a legitimate federal mechanism to expand coverage to the uninsured. It is not a coercive tool, as charged by the plaintiffs; rather, Medicaid is a longstanding federal-state partnership to address the uninsured in states. The panel writes “If states bear little of the cost of expansion, the idea that states are being coerced into spending money in an ever-growing program seems to us to be ‘more rhetoric than fact.’”

The individual mandate is one provision of many…

It is worth noting that the panel declined to uphold Judge Vinson’s lower court ruling that the entire law be thrown out. Therefore, it raises the possibility that the individual mandate could be severed from the ACA, leaving the law intact. This does raise concerns for ACA supporters and insurers alike because the mandate is a way to include everyone – healthy and sick – and is used as a tool for calibrating risk.

Politics aside…or front and center?

Pam Bondi, the Florida AG leading the 26 state lawsuit against the ACA, commented that due to the bipartisan nature of the 11th Circuit ruling, “politics are out of this now.” (Judge Hull of the majority opinion is a Clinton appointee; however, she is also cited as a compromise candidate during a fierce partisan nomination battle for judges during the mid-nineties). Did Bondi really say that? If that were the case, the 6th Circuit ruling where Republican appointed Judge Sutton upheld the individual mandate would have marked the beginning of the end of ‘politics.’ Saying ‘this is the end of politics’ surrounding these ACA legal challenges is merely politics. Yes, it is confusing. What is clear, however, is that the individual mandate provision of the ACA is bound for the Supreme Court. All pundits agree that the Justices cannot avoid taking an ACA case– as to when the Justices take the case may depend on, well, politics.

Therefore, perhaps you feel a tinge of pity for the Supreme Court as everyone waits to see what ruling they will choose to hear. Will it be the 4th Circuit where we are still awaiting an appeals decision? Will it be the 6th Circuit that has already petitioned the Supremes? Or will it be the 11th Circuit where we are awaiting the Administration’s decision as to whether or not to appeal (they have 90 days)? You can hear the chorus now – “Pick me! Pick me!” Most believe the Obama Administration will win this leg of the race (rare to turn down an Administration petition). Who will reach the finish line first? Well, that is the topic of another blog.

- Eva Stahl, Policy Analyst

Tags: , ,
Posted in Affordable Care Act implementation, Uncategorized | No Comments »

Setting the Record Straight on Medicaid

Friday, July 8th, 2011

Earlier today, Community Catalyst joined 118 groups representing consumers, people of faith, and health care providers in 34 states to raise our collective voices in support of Medicaid.

Together, we sent a response to the letter that Senator Hatch and Congressman Upton wrote to Governors last month. Their letter attacked Medicaid, falsely claiming that it provides poor quality care, lamenting its enrollment growth over the past decade, and blaming it for federal and state budget crises. Our letter sets the record straight:

• Medicaid provides high-quality care that is uniquely suited to meet the needs of the vulnerable Americans it serves. Medicaid is certainly not perfect, and there is always room to improve care. But studies consistently show that Medicaid beneficiaries get care that is equal to – and sometimes better than – the care they would get in private coverage. Just yesterday a new study was released documenting the positive impact Medicaid has on its vulnerable beneficiaries’ health and financial security.

• Medicaid plays an essential role in reducing the number of uninsured. Of the 46 million low-income children and parents that rely on Medicaid, the majority are in working families without access to private coverage. Policies that scale back on Medicaid eligibility for this population – like those promoted by Senator Hatch – would drive up the ranks of the uninsured, leaving vulnerable Americans without access to the health care they need.

• Medicaid is markedly more cost-effective than private coverage. If the low-income children and parents on Medicaid were insured instead on the private market, national health care expenditures would be significantly higher.

We felt particularly compelled to respond because Hatch and Upton’s letter perpetuates a larger anti-Medicaid narrative that would:

• Reduce the deficit on the backs of those with least political clout. Responding to their mandate from the tea-party, Republican Congressional leaders are insisting on trillions of dollars in spending cuts in exchange for their votes to lift the debt-ceiling (a vote Congress must take in early August to avoid going into default on our nation’s debt). It’s nearly impossible to achieve that level of savings without making devastating cuts in the “big three” entitlements that take up 40 percent of the federal budget: Social Security, Medicare, and Medicaid. But Social Security and Medicare are fiercely guarded by a well-organized political constituency – seniors – which makes cuts in those programs politically unpalatable. That leaves Medicaid, which serves a much more vulnerable and less politically empowered population, as the sacrificial lamb.

• Undermine the Affordable Care Act. The attacks against Medicaid also play into a second tea-party-driven agenda to repeal the Affordable Care Act (ACA.) Since Congressional Republicans don’t have the votes for repeal, they’re trying the next-best approach: weakening the law’s foundations. Medicaid accounts for nearly half of the coverage gains expected under national health reform, so inflicting dramatic cuts on the program would jeopardize the ACA before its even been implemented.

But Medicaid is not a political chit. It’s a lifeline for millions. It provides long-term care to our nations’ seniors, enables people with disabilities to get the care they need to live independently and helps low-income children see the doctor when they’re sick.

The 118 consumer, faith-based and provider organizations from across the country who signed onto our letter know the value of Medicaid in their communities and why it’s worth protecting. And polls show that the overwhelming majority of the American public does too. Is Congress listening?

-Katherine Howitt, Policy Analyst

Tags: , ,
Posted in Medicaid, Uncategorized | No Comments »

Protecting Prevention Funding Is Key to Controlling Health Costs

Thursday, April 14th, 2011

As House Republicans hammered away this week at federal spending, they took another whack at the Prevention and Public Health Fund. But if their goal is really saving money, they just hit their thumb instead of the proverbial nail.

The Affordable Care Act established the Prevention Fund and allocated $15 billion over the next decade to help shift the focus of our health system from treating diseases to preventing illness. The ultimate goal is improving the health of Americans and reducing long-term health costs. Already, the Fund is supporting state and local initiatives to reduce obesity, cut tobacco use, prevent HIV/AIDS and train more public health workers.

This year, it will also fund the Community Transformation Grants, an innovative program to support local efforts to reduce chronic disease and health disparities. Expanding prevention initiatives is one third of the package needed to control health care spending, along with reducing waste and occasional bad care in Medicaid and Medicare, and cutting prices and high administrative costs in the private sector.

But Republicans in Congress have repeatedly targeted the fund for repeal, or attempted to take its funding for other purposes. Yesterday, amid claims that the money provides a “slush fund” for Health and Human Services Secretary Kathleen Sebelius, the Republican-controlled House voted 236 to 183 to repeal the fund and rescind all money not already spent. This struck a political blow against the Affordable Care Act, but if the repeal were to pass the Senate and get signed by the president, it would leave the country sicker – from both diseases and rising health costs.

Fortunately, President Obama and Senate Democratic leaders understand that prevention can both save lives and save money.  Senate President Harry Reid and Senator Tom Harkin, chairman of the Senate Health, Education, Labor and Pensions Committee and the father of the fund, are not likely to bring the repeal bill to the Senate floor for a vote. Also yesterday, the White House issued a statement  indicating that the President would likely veto any attempt to eliminate the Fund.  The “statement of administrative policy” said repeal “could worsen the nation’s health and increase system costs.” Indeed. The prevention funding is also key to expanding jobs and improving the health and productivity of America’s workers.

There continues to be some risk that money from the Fund will be used to pay for existing prevention efforts, rather than the new initiatives envisioned by Harkin and others. The Fund escaped a direct cut in the compromise plan to fund the federal government for the rest of this fiscal year, despite $38 billion taken from other programs. However, there remains the unfortunate possibility that the Obama administration may tap the Fund to replace some of the $730 million cut from the Centers for Disease Control and Prevention.

The bottom line: It remains important to educate all members of Congress about the long-term savings that result from reducing chronic diseases, and the important role the Prevention Fund plays in our nation’s long-term financial health. 

- Alice Dembner, Deputy Policy Director

Tags: , ,
Posted in Affordable Care Act implementation, Health disparities, Uncategorized | 1 Comment »

Less pain, more gain: defining an alternative to harmful Medicaid cuts

Monday, February 28th, 2011

(please note most links below are pdfs)

On Friday, Community Catalyst sent a letter to Secretary Sebelius, outlining eight policies states could implement to cut Medicaid costs. We were inspired to weigh in by a series of letters between the Secretary and Republican Governors that contrasted two very different approaches to reducing Medicaid expenditures.

Cutting Coverage vs. Cutting Waste
Republican Governors wrote a letter to Congress and the Administration in January, asking them to lift the Maintenance of Effort (MOE) requirement – the provision in the Affordable Care Act (ACA) that prevents most states from reducing Medicaid eligibility between now and 2014. The basic premise of their letter was that states need to cut low-income children, parents, seniors, and/or people with disabilities off coverage in order to “responsibly manage [their] state budgets.” We anticipate Republican Governors will reiterate this argument at the Energy and Commerce hearing Tuesday about the impact of the ACA on Medicaid.

Secretary Sebelius responded with a letter explaining why that basic premise simply isn’t true (see our blog and summary of her letter.) She outlined dozens of ways states can trim costs in their Medicaid programs without eliminating coverage for vulnerable families. By tackling the inefficiencies in our fragmented health care delivery system, many of the policies she suggested not only cut costs but they also have the potential to improve care for beneficiaries in the process. Sebelius also made it clear that her department remains open to suggestions of additional policies states can pursue to accomplish those dual goals.

When Secretary Sebelius Calls, We Answer
We took the Secretary up on that challenge. Our letter to the Secretary highlights eight additional policies states can pursue to lower Medicaid costs and maintain or improve care. More details about these options can be found in the text of our letter, but here are the highlights:

  • Recalibrate provider payment rates, shifting dollars from inpatient care to outpatient care, to give providers an incentive to treat patients in the lowest-cost settings.
  • Rebalance long-term care dollars away from institutions and towards home- and community-based settings by taking advantage of more funding opportunities created by the ACA to help states front the cost of this readjustment.
  • Better integrate care for those who are eligible for both Medicaid and Medicare by expanding existing programs such as the Program for All-Inclusive Care for the Elderly (PACE) and fully-integrated Special Needs Plans (SNPs) that provide a comprehensive and patient-centered model of care.
  • Reduce preventable hospital readmissions and complications by tying hospitals’ payment levels to their preventable complication and readmission rates.
  • Increase the use of generic drugs by making it easier for pharmacists to substitute equivalent generics when the patient was prescribed a brand name drug.
  • Improve evidence-based drug selection and purchasing by expanding utilization management and the use of state Preferred Drug Lists (PDLs) created by an evidence-based evaluation of available therapies. It’s important to include measures to protect access and quality, especially when applied to classes of drugs or medical conditions that have traditionally been excluded from PDLs (such as mental health, HIV/AIDS and cancer).
  • Improve prescriber education by creating an “academic detailing” program that provides prescribers with up-to-date information about the effectiveness of different medications and alternative treatments, serving as an unbiased alternative to pharmaceutical industry promotion.
  • Combat off-label drug promotion and inappropriate prescribing by requiring that physicians inform their Medicaid beneficiary patients whenever the physician prescribes a drug for an unapproved use, and that the patient consents to the treatment.

A Better Path to Savings
These policies — coupled with the consumer-friendly options offered in Sebelius’ letter — offer a clear alternative to cutting low-income children, parents, seniors and people with disabilities off Medicaid; they illustrate why Congress does not need to lift the Maintenance of Effort requirement for states to make their Medicaid programs more efficient.

They also offer clear alternatives to some of the more harmful cost-cutting tools that states already have at their disposal: imposing higher cost-sharing and eliminating or restricting “optional” benefits such as prescription drugs. Those tools just shift costs onto vulnerable beneficiaries, and risk harming their health. And research suggests they result in fewer savings than states might assume: when patients delay or forgo certain services because of cost-sharing or benefit restrictions, their illnesses can worsen and eventually require more expensive care, canceling out some of the state’s savings.

Our letter lays out a better path — one that not only saves money but also can improve the lives of vulnerable Americans. If Governors are serious about fiscal responsibility, they should jump at these opportunities to cut waste and improve the sustainability of the Medicaid program.

-Katherine Howitt, Policy Analyst

Tags: , , , , , , ,
Posted in Affordable Care Act implementation, care coordination/quality, Medicaid | No Comments »

The Insider: Health Reform and the Elections, part I

Monday, November 8th, 2010

What happened…
By now, no one needs a detailed recap of the election itself. Although Senate Democrats may have done a little better than expected, the U.S. House of Representatives made a major swing to the right, as did statehouses across the country. This week’s Insider looks at the cause of that shift and tries to untangle the spin on the role of health insurance reform in the outcome. A second installment will look at ahead to the implications for implementation.

…and what the ACA has to do with it
Although Republican leaders are already busy claiming that their electoral victory equals a voter mandate to repeal the ACA, the facts tell a different story.

Only 19 percent of voters said that health care was their main concern—and the majority of those voters voted for Democrats.  Furthermore, voters are split nearly between those who want to repeal the ACA, and those who want it to remain in place or go even farther. Taking this in, it’s hard to claim the election outcome was a call to repeal ACA.

It’s the Economy, Stupid

If health care wasn’t the driver, what was? Simply and clearly, the economy. Sixty-two percent of voters reported in exit polls that the economy was their number one issue and the majority of these voters (52 percent) cast their ballots for Republicans.

Despite the fact that the recession is officially over and the stock market has recovered the value it lost then, votes probably reflected the persistently bleak jobs picture.  The unemployment statistics since President Obama took office in January 2009 show that not only did the jobs numbers not get better; they got worse.

The “U6” rate calculated by the Bureau of Labor Statistics includes not only active job seekers (the number most commonly cited in unemployment data) but also counts discouraged workers and those who have a marginal attachment to the workforce and are looking for more work hours. The U6 now stands at 17 percent: that’s three percentage points higher than when President Obama took office and only one-tenth of a point off its high-water mark in 2010.

So the numbers suggest jobs was the biggest election factor, not views on health reform.

It’s also important to note that while the wave of GOP victories was widespread, it was far from evenly distributed.  Nearly 90 percent of House Democrats up for reelection this year who represented districts President Obama carried in 2008 were reelected.  The corresponding percentage for those in districts carried by Senator McCain was only 24 percent.  In other words, most of the Republican gains in the House came in districts that tended to vote Republican.  In a weak economy, Democratic House members in Republican-leaning districts were extremely vulnerable, regardless of their stand on health care.

Nonetheless, it would be a mistake to say that popular views of the ACA played no role in the outcome.  Without attributing causality, it’s noteworthy that Democrats in Obama-carried districts who voted against the ACA did worse than their counterparts who voted yes, while the hearty few who followed their conscience and voted yes on ACA while representing a McCain-carried district were almost all defeated.

Popular views of the ACA may also have played a role in the turnout and voting preferences of older adults.  Starting with the big lie about death panels in August 2009, there has been a deliberate, relentless and largely successful misinformation campaign aimed at older adults to turn them against the ACA.  Older voters are the age segment least supportive of the ACA.  They represented a larger share of the electorate this year than in 2010, and the majority voted for Republican candidates.  It’s not much of a stretch to suggest that their concerns about the ACA—however unfounded—helped bring them to the polls and affected their ballot choices.

And Democrats did not use the ACA to help motivate their core voters, even as they lost ground among older Americans.  Democratic messaging on the ACA focused heavily on the elimination of pre-existing condition exclusions—an issue that resonates particularly well with swing voters (who nonetheless trended Republican)—and pretty much ignored the importance of expanding coverage to more than 30 million Americans; an issue that plays better with core Democratic voters and particularly with younger voters, and racial and ethnic minorities, whose participation in the 2010 election fell sharply from 2008.

One notable (and perhaps too-late) exception? President Obama’s appearance on the Daily Show with Jon Stewart the week before the election, where he highlighted the coverage expansion as a key part of the ACA and made it part of his overall appeal to core Democratic voters.

The ACA, Medicare Advantage and the fall of Troy
It’s more than a little ironic that senior voters turned away from the party most closely associated with the creation of Medicare (and Social Security) in favor of the party whose leadership has been very public about their intention to radically reshape, if not dismantle, the program.  Medicare beneficiaries made themselves willing, if unintentional, accomplices in undermining the program, and the Trojan Horse that made it all possible was the Medicare Advantage program.

The designers of Medicare Part D built in a formula that overpaid Medicare Advantage plans, thereby accomplishing two things at once.

First, the extra payments to the managed care plans enabled the plans to offer benefits that were richer than the statutory Medicare program.  The goal was to encourage beneficiaries to abandon traditional Medicare so that it would, in Newt Gingrich’s infamous phrase, “wither on the vine,” and make it easier to move from a guaranteed set of benefits to a voucher program.

Second, since the program increased Medicare costs overall, Medicare Part D would help precipitate a financing crisis that could be used as further ammunition for those who call for its restructuring.

The fortuitous (and surely unintended) twist on this strategy is the success ACA opponents have had in casting the elimination of those overpayments as a Medicare cut, cynically turning seniors against both the ACA and the party that has traditionally defended Medicare, and putting themselves in prime position to dismantle it–a long-held GOP goal.

So now what?
With the election behind us, the next Insider will discuss what the new political landscape means for ACA implementation, and point to some silver linings among the clouds.

–Michael Miller, policy director

Tags: , , , , ,
Posted in Affordable Care Act implementation, Health Reform Insider | 1 Comment »

Cross Post: Insurance Commissioners Respond to Consumer Concerns

Friday, October 22nd, 2010

This blog was originally posted on Say Ahhh! A Children’s Health Policy Blog

By now many of you have probably heard about the big news coming out of the NAIC meeting this week in Orlando. After seven months of intense debate and negotiation, the NAIC voted in favor of a regulation defining the ACA’s required “medical loss ratio” (MLR). They rejected several amendments that were heavily pushed by insurance companies and brokers, scoring a big win for consumers who deserve better value for their health care dollar.

What hasn’t been reported so widely is all the other work NAIC did this past week, from advancing model state laws on major consumer protections required by the ACA, developing a model law on state insurance exchanges, and defining how an insurer must justify an “unreasonable” rate increase. Here are a few highlights:

– A key NAIC task force adopted model state laws implementing three market reform provisions of the ACA: rescissions, young adult coverage up to age 26, and choice of health professional. These now will be reported up to the NAIC’s “B” Committee, which is the umbrella committee for health issues. The same task force is also developing model laws on: lifetime/annual limits, elimination of pre-existing condition exclusions for children under 19, access to preventive benefits, and grievances and appeals, all of which are ACA provisions that went into effect on September 23, 2010.

– Consumer representatives are urging changes to the model law on the kids’ “pre-ex” provision to encourage states to prevent “child only” health plans from withdrawing from the marketplace. We also made formal presentations applauding Commissioner Sevingy from New Hampshire and Commissioner Kreidler from Washington for their leadership and toughness in requiring their states’ insurers to offer coverage to kids.

The consumer reps also pushed for better notice requirements for health plans that have received a waiver from the ACA’s restrictions on annual benefit limits, so that consumers know that the plan doesn’t provide the full range of consumer protections promised under the health reform law. The NAIC’s working group on state insurance exchanges also met in Orlando. They’ve received a whopping 200+ pages of comments on their first draft of a model state law and sometime within the next two weeks they’ll schedule a conference call to receive oral comments. A few issues were raised in the meeting that are worth watching:

– Coordination with Medicaid. My impression is that the model law will probably not delve into the tricky issues of how the exchanges will coordinate with state Medicaid agencies. When one of the Commissioners asked about this, the chair of the work group, Commissioner McRaith from Illinois, said that they have not been working with Medicaid Directors, and emphasized that it would be a “NAIC Model” and therefore would focus on insurance-related issues.

– Dual regulation. The members of the work group were very concerned about exchanges potentially usurping their traditional role regulating health insurance through rate review, market conduct exams and grievances. They’ll probably add new language to the model that will have a more clear delineation of regulatory roles between state insurance departments and the exchange.

– Pediatric dental. The current draft model doesn’t have any language reflecting the ACA’s provision allowing the inclusion of stand-alone dental plans that offer pediatric dental benefits in the exchange. A representative from Delta Dental pointed that out to the group and Commissioner McRaith asked him to submit legislative language. The consumer reps will keep an eye on this issue as it develops.

– Another key NAIC task force has been working for many months to develop the form that insurance companies will have to fill out if they are proposing an “unreasonable” rate increase. This form will provide unprecedented transparency on rate increases, and will include essential information for consumers and employers to better understand the factors driving proposed increases. The task force finalized the form this week and reported it to the “B” Committee, in spite of last-minute opposition from America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association. Even in the face of many hours of open and inclusive conference calls and meetings, both trade associations claimed that the form had been developed without sufficient industry input.

– Last but not least, the NAIC has created a new working group to tackle the issue of limited benefit plans, or “mini-meds.” A joint effort of the “B” Committee and an anti-fraud committee, the group will investigate whether plans are making misrepresentations about their products and whether they are being sold by unlicensed brokers. Because many of these plans provide little or no real coverage if someone actually gets sick, the group will also be looking into the “utility” of these products for consumers.

– Sabrina Corlette, Georgetown Health Policy Institute

Tags: , , ,
Posted in Affordable Care Act implementation, private insurance | No Comments »

« Older Entries