Posts Tagged ‘Medicaid’

« Older Entries

The Insider: The Cost of Compromise

Tuesday, August 10th, 2010

FMAP: Victory at a Price

SNAP Offset Graphic FinalThe Senate voted on Thursday to provide additional federal assistance to state Medicaid programs (and additional support for teachers to avoid layoffs) and the House followed suit today, but the price was high. After several attempts to pass an FMAP extension on an emergency basis (meaning no tax increase or spending cut to offset the new spending) were blocked by a united Republican Senate caucus, the leadership decided to pay for the financial assistance to states by rolling back a temporary increase in food stamps (SNAP). The SNAP increase, part of the American Reinvestment and Recovery Acct (ARRA), was originally projected to phase out in 2014, however, the slow growth in food prices would have extended the increase until 2018. The FMAP legislation means that the increase will indeed end in 2014, creating a cliff that at that time will cause a drop in SNAP benefits.

Senate leaders (supported by the administration) faced with the specter of failure on the fiscal relief legislation and the resulting layoffs of teachers and other state workers plus the scaling back of Medicaid benefits, decided that avoiding the harm now was the lesser of two evils. With luck there will be a chance to restore the SNAP benefit before the cut actually goes into effect in 2014.

The really sorry thing is what the FMAP/ SNAP trade says about the balance of power in the US Senate today. As much as we decry the use of SNAP as one of the funding sources, it is a sad fact that a more progressive source would have been unable to clear the Senate. Unfortunately, things are only likely to get worse in the short run. Republicans, aided by conservative Democrats, will continue to block important legislation (such as FMAP, or an extension of unemployment benefits or the energy bill) and then benefit from it electorally because the problem isn’t solved and people vent their bad mood on the party in power (see example here). With the electoral winds at their back – projections are for gains in the House, Senate and governorships – what’s the incentive for Republicans to change? The prototype for this behavior was health reform under Clinton which the Republicans were able to sabotage and then ride to victory in 1994. Running the same play in 2010 is likely to create new obstacles to ACA implementation in 2011. With a more closely divided Senate ahead, we can expect more replays of the FMAP dynamic until at least 2013.

What does the MO vote really mean? Not much, but VA decision more troubling

While ACA opponents are trumpeting the passage of Proposition C in Missouri, there really isn’t much ‘there’. The voter turnout was heavily weighted to GOP voters, making it more of a straw poll of Republican sentiment than a true test of public opinion. For example, in the Senate primary race 578,582 voted in the Republican primary while only 316,107 or 35 percent of the total voted in the Democratic primary – not too different from the 70-30 split on Prop C.

Further complicating the interpretation of Proposition C was the confusing wording of the multi-part question which addressed the mandate, the right to pay for health services and the ability to make changes to the rules for liquidating certain insurance companies. As a result, Proposition C is a much less accurate barometer of public opinion than the polling which is showing that public support for the ACA is growing (albeit slowly), opposition is declining and the “intensity gap is almost inside the margin of error.” However, the Missouri vote is likely to encourage continued ACA nullification efforts, which got something of a bigger boost from the Virginia court decision last week.

Essentially, the judge hearing the case ruled that, notwithstanding the supremacy clause of the Constitution, a state can pass a law that conflicts with federal statute and then sue to enforce it. To be sure, this is just a procedural decision and a number of legal experts believe the judge has erred and that the case will ultimately be resolved in favor of the ACA, but reading the judge’s reasoning can’t give supporters of the ACA great comfort; nor does the possibility of sending a case all the way to the current Supreme Court.

Be careful what you wish for

If ACA saboteurs really got their way, what would it mean?  Two new reports shed light on that question. A new analysis from economist Jonathan Gruber estimates that implementing the ACA without the Individual Mandate would increase premiums by 27 percent while Medicare Trustees say that total repeal would shift the Medicare trust fund into a deficit a dozen years earlier than current predictions (2017 vs. 2029). But then again, if your goal is to destroy Medicare and you don’t care about expanding coverage, maybe that doesn’t matter.

Is Howard Dean right about the Individual Mandate?

Criticism of the Individual Mandate does not only come from the right. Howard Dean recently was quoted as saying not only that the mandate would be repealed but that it wasn’t necessary. As evidence he cites his own state’s experience with providing near-universal coverage to children without a mandate. Actually Vermont, while offering good coverage for kids, is not unique. The state ranks 14 in the country with respect to the rate of children’s coverage according to Kaiser State Health facts, but even the state that ranks best – Massachusetts – lacks a mandate on kids coverage. The Massachusetts mandate applies only to adults. Does this prove Dean right? Not really.

Hypothetically a similar coverage result could be achieved without the Individual Mandate if Congress could be persuaded to make insurance subsidies sufficiently robust and accept a large migration of moderate-income workers from private to public coverage. However, the outcome of the Congressional debate over the ACA, when there were 60 Democratic Senators and a large majority in the House does not auger well for a large increase in publicly financed health insurance subsidies in the near future. Gruber’s analysis shows that only about 7 million people would gain coverage at current ACA subsidy rates without the Individual Mandate, as opposed to 32 million with the mandate.

The other alternative to the Individual Mandate often mentioned – late enrollment penalties – could work from the insurance industry’s point of view. Late enrollment penalties would protect against adverse selection by charging higher premiums to people who did not obtain coverage when it was available. It’s the method used to guard against adverse selection in Medicare Part D, but it is more likely to create insurmountable barriers to coverage for low-wage workers than it is to produce something approaching universal coverage.

– Michael Miller, policy director

Tags: , , , , ,
Posted in Health Reform Insider, national health reform | No Comments »

Cross-Catalyst Post: New generics: A shot in the arm for state Medicaid programs?

Thursday, July 15th, 2010

On our PostScript blog today, we posted about a Harvard study published in this month’s Health Affairs that looked at generic drugs and the potential benefit they can provide in savings to cash-strapped Medicaid programs. The researchers conclude that if pharmacists are allowed to switch patients from a brand name drug to a generic, savings abound for tight Medicaid budgets. While generics are completely safe and chemically equivalent to the brand name drugs, pharmaceutical marketing often has patients convinced that brand name equals better. Not so. Here’s an excerpt:

“While all states have adopted generic substitution laws, the extent to which pharmacists or patients can influence the medications they choose differs from state to state.  The Harvard researchers found that states that did not require patient consent to switch prescriptions from Zocor to the clinically equivalent, less costly simvastatin saved $15.35 per prescription on these medications in the first quarter after patent expiration.  If all states had adopted such policies, Medicaid programs could have saved $19.8 million nationwide on the introduction of simvastatin.

“While patients should be empowered to participate in their own health decisions, this study demonstrates that requiring patient consent for generic substitution impedes patients from initially choosing generics even when they will eventually prefer them to the brand name.”

Read the rest of the post on how generic prescriptions can save money with out sacrificing quality on PostScript.

– Joy Lee, policy intern

Tags: , , ,
Posted in prescription drugs | No Comments »

Case study shows community health workers improve primary care and enrollment

Friday, July 9th, 2010

Policy changes in two states to expand and strengthen the workforce of community health workers provide a model for other states as they implement the Affordable Care Act, says a new case study, “Community Health Workers: Part of the Solution,” in the July Issue of Health Affairs (free abstract—subscription required). Coauthored by Community Catalyst’s Director of Health Equity Lisa Renee Holderby, who previously headed the Massachusetts Association of Community Health Workers, the paper looks at how Minnesota and Massachusetts turned to community health workers to address shortages in the health care workforce and improve enrollment and primary care.

The case studies found that policy changes that supported the use of community health workers (CHWs), who provide patients peer-to-peer assistance managing their health and navigating the health care system, helped increase enrollment and quality of care in their communities. The Institute of Medicine has recommended that CHWs be included in care teams to help improve the health of underserved communities.

“As members of the community,” the authors write, “these front-line workers are valued for their cultural competence and mediate between providers and other members of diverse communities. Evidence is accumulating that including community health workers in determining the appropriate use of services has a sizable positive return on investment.”

So what policy changes do the authors want to see in other states? First, sustainable funding for CHWs to participate in the system – including reimbursement by public programs like Medicaid, Medicare and CHIP. And they suggest states establish workforce education programs and occupational standards to train and credential CHWs like other health care workers. The authors also propose that states establish some uniform guidelines they can use to chart and evaluate CHWs and their participation in the health care workforce – something that is going to be happening in many corners of the health care system as part of the Affordable Care Act.

“Community health workers can be vital to efforts to restructure the delivery of primary health care. The patient-centered medical home has been described as providing ‘accessible, comprehensive, family-centered, coordinated, compassionate and culturally effective care.’ Although the workforce required for the medical home model has not been fully defined, close ties to the community and cultural competence are essential. Additionally, a successful medical home will require continuity of communication between provider and patient.

“Community health workers are uniquely qualified to meet these responsibilities and to complement other members of the health care delivery team. These workers’ valuable capacity to increase patient engagement will be important to consider in evaluations of quality improvement.”

“Community Health Workers: Part of the Solution” is part of a special issue of Health Affairs on the implementation on health care reform, and the whole thing’s worth a read (caveat: subscription required.)

–Kate Petersen, Health Policy Hub

Tags: , , , , ,
Posted in care coordination/quality | No Comments »

Websites like wine: healthcare.gov good now, getting better

Friday, July 2nd, 2010

HealthCare.gov: Take health care into your own hands Learn MoreThe web portal Healthcare.gov (@healthcaregov for all you twitterheads out there) went live, launching ahead of its July 1 deadline by hours Wednesday night. HHS deserves props for this site: not only was it delivered ahead of schedule, but it’s spiffy-looking, easy to use, and full of important info to help people get covered.

The website is what it says – a door through which consumers can check out what private insurance plans are available to them, depending on their age, state, current coverage, and health conditions.  There’s also information about public programs, like Medicaid, and how reforms in the new law affect people soon – such as the small business tax credit, high-risk pools for people with pre-existing conditions, and the ability of young people to join or stay on their parents’ plan till age 26.

If you haven’t checked it out yet, you should. We did a walk-through ourselves yesterday and were impressed by the clear, appealing design, the plain-language navigation to help consumers find out what their options are and, oh yeah, all that information.

In October, a more in-depth version will launch, and will include rates, coverage exclusions and other pricing information—a level of detail we think is critical for consumers looking for insurance options. To our mind, the more information, the better. And we’d like to see the portal move toward standard benefit descriptions that help people make “apples-to-apples” comparisons.

Other things we’d like to see on Healthcare.gov?  We think the website should include all private insurance products, such Medicare Advantage and Medigap plans. Right now, it doesn’t.

And it would be great instead of just describing and giving contact info or redirects to public programs, like state Medicaid agencies, if someone visiting the website could determine whether they were eligible and if so, enroll online.  Downloading an application, printing it out, finding out where to submit it, and getting there is often too many steps in a process that could be moved online. A report by the Urban Institute in January showed that there are 9.8 million uninsured individuals who are eligible for but not enrolled in Medicaid, and a one-stop online enrollment platform on the portal makes a lot of sense to help those people get health care coverage.

We’re glad to see that patient protections in the new law – what the administration’s calling the “patient bill of rights” – are prominent and spelled out clearly on the site.  In the future, we’d like healthcare.gov to point to consumer assistance programs, too, especially non-profit ones, which have a great track record of helping people navigate the system, determine eligibility, and enroll.

And for consumers with medical bills, we also want to make sure that the portal makes hospital financial assistance policies available, prominent, and easily searchable on healthcare.gov. We’re encouraged that there seems to be placeholder language about free and reduced care where more specific policy information will go in the future

Certainly there is room to refine and build. But this is day two. And improvements are already underway. In fact, a banner stretched across the top of every page says “Health care is getting better. So is HealthCare.gov. Help us improve by adding your comments”—this thing is a work in progress. But it’s also a work of progress, one we’ve proudly bookmarked.

–Kate Petersen, Health Policy Hub

Tags: , , , , ,
Posted in Hospital Accountability/Charity Care, national health reform, private insurance | No Comments »

The Insider: All this could be yours someday

Monday, June 14th, 2010

Fuzzy logic
As the “tax extenders” bill makes its way through the Senate, a provision to extend COBRA premium subsidies for the unemployed is in jeopardy. Opponents in the Senate and the Blue Dogs in the House who stripped the provision from legislation two weeks ago argue that it’s unfair to help people who are unemployed when other, equally needy people are getting no assistance.

Just stop and think about that for a minute: It’s not like they’re identifying an alternative beneficiary for assistance, or arguing to accelerate implementation of the Affordable Care Act. They are basically saying, “Because we can’t help everybody, we won’t help anybody.” If you apply that reasoning more broadly it leads you to advocate the repeal, or at least the suspension, of Medicare and Medicaid until 2014, when financial assistance to obtain coverage becomes more generally available–a move few Congressmembers would dare consider, even in a non-election year.

With unemployment remaining high, the COBRA premium subsidies in limbo are badly needed. They are good for the economy, the health care system, and mostly for the thousands of struggling families who will be able to retain their coverage. Find out more at Community Catalyst’s implementation headquarters.

Faulkner on health care
When William Faulkner wrote, “The past is never dead. It’s not even past,” he could have been talking about the politics of health care more than a half-century into the future. Congressional Republicans’ challenge of the White House public education campaign on Medicare changes as misuse of government funds for partisan advantage hearkens back to Democrats’ attacks on the Bush administration over the original Medicare Part D roll-out.

And Senators who opposed PPACA seem intent on re-debating the legislation at every opportunity: first, in the context of Don Berwick’s nomination to head CMS, and now in the debate over the Medicare physician payment fix. Republicans have offered an alternative that does more for the physicians but partially pays for it by eliminating desperately-needed financial assistance for state Medicaid programs—while slipping in a “poison pill” that would roll back the individual responsibility provisions in PPACA. Such a move could appeal to many on the left who are concerned that the affordability provisions don’t go far enough.

Someday, all this could be yours
As the “repeal and replace” drumbeat goes on, a third ‘r’ should be added to the sequence: Recycle. Congressional Republicans are recycling ideas from the debate that were shown to fail to reduce the number of uninsured or eliminate insurance discrimination.

But as several states move forward with anti-Affordable Care Act ballot measures, new research from Massachusetts shows just how wrongheaded such opposition is. Until the coverage provisions of the Affordable Care Act kick in in 2014, Massachusetts provides the closest thing we have to a “beta site” for what the health care system of tomorrow will look like. While critics focus on the continuing cost challenges (problems that pre-dated health reform in Massachusetts  and were not really addressed in the landmark law in 2006) new reports published by the Urban Institute and the National Bureau of Economic Research underscore just what other states can gain as they move forward with implementing the law.

Urban’s latest report shows that the coverage gap between racial and ethnic minorities and non-Hispanic whites has been closed—the only place in the country where this is true. Additional findings show:

  • –high rates of coverage in Massachusetts persist despite continued high unemployment
  • –economic barriers to obtaining care remain low and have declined further for some populations since the inception of the law
  • –four years into implementation, there is still no evidence of ‘crowd-out’ of private coverage, and public support for the Massachusetts system remains high.

Get the details here (pdf).

The NBER paper found that since reform in Massachusetts, there have been fewer preventable hospitalizations and emergency room-generated admissions, and length of hospital stays has been reduced, most likely due to improvements in access to ambulatory care.

Sure makes implementation look like a lot better idea than repeal.

–Michael Miller, director of strategic policy

Tags: , , , , , , , , ,
Posted in Health Reform Insider, Health disparities, Repeal Watch, affordability, national health reform, state reform | No Comments »

Senate should restore COBRA and Medicaid subsidies

Friday, June 4th, 2010

As we said Tuesday, the House removed provisions for federal Medicaid and COBRA subsidies from H.R. 4213, and the Senate departed for Memorial Day recess without taking action. The subsidies are critical to help hurting states that are struggling with budget cuts and families who have lost jobs during the worst economic time since the Depression.

The Senate will take up the bill when it returns from recess, and is likely to make changes. It is critical that the FMAP and COBRA extensions are put back into the baseline bill that is brought to the Senate floor, since it’s difficult to add the provisions back in through a floor amendment.

States are relying heavily on the FMAP extensions in their state budgets. It is very possible that this will be the last chance to secure those funds. Please contact your Senators before Tuesday and ask them to support the inclusion of the FMAP and COBRA extensions in the “tax extenders” bill (Also known as H.R. 4213, “The American Jobs, Closing Tax Loopholes and Preventing Outsourcing Act.”) to be considered by the Senate.  You can use Families USA’s toll-free number to connect to Capitol Hill, 1-866-922-4970.

For talking points, see the Community Catalyst implementation page.


Tags: , ,
Posted in affordability, national health reform, state reform | No Comments »

Implementation for Kids

Wednesday, June 2nd, 2010

Have you been wondering how health reform implementation will affect children’s health care programs?

Are you looking for information on when changes to CHIP and Medicaid go into effect?

Do you want to learn more about the new provision allowing young adults to stay on their parents’ plans through age 26?

We’ll, look no further than the New England Alliance for Children’s Health Implementation Website. The site has health reform summaries, timelines, and fact sheets – with a particular focus on how the new law impacts children and families.

Still can’t get enough implementation? Community Catalyst’s “Making national health care reform a reality” page is frequently updated with the latest fact sheets, alerts, and need-to-knows about, well, making health care reform a reality.

Also check out our Utah partners’ awesome “Implementation Station” for myth-busters, cheat sheets, and ways to get involved in the implementation process!

–Maia Fedyszyn, New England Alliance for Children’s Health

Tags: , ,
Posted in children's health, national health reform | No Comments »

The Insider: Last minute collapse on doc payments, Medicaid and COBRA subsidies a bad omen?

Tuesday, June 1st, 2010

In the lead-up to passing the health reform law, Congress debated what to do about the Medicare physician payment problem.  Under current law, the formula for setting Medicare physician payment rates, known as the Sustainable Growth Rate, or SGR, will impose large and escalating annual cuts on physician reimbursement.  The SGR issue was ultimately separated out from health care reform, and doctors were assured that the issue would be addressed before the scheduled payment cut June 1.  Physicians pressed for a permanent solution to the problem but because of the price tag, Congress scaled back, first to a 5-year patch and then to a 19-month fix.  The scaled-back SGR patch passed the House just before the Memorial Day recess, but without enough time for the Senate to act.  Theoretically that means that a Medicare payment cut of over 20 percent kicks in today, but CMS is holding onto claims for a couple of weeks assuming that when the Senate comes back they will enact a retroactive payment increase.

While the physician payment fix is likely to get sorted out, two other critical provisions face a more uncertain future.  With unemployment still high and state budgets still in trouble, House and Senate leaders attempted to extend enhanced federal Medicaid payments to states through the end of state fiscal year 2011 (the enhanced payments are currently scheduled to end halfway through the year) and to continue the subsidy of COBRA premiums created by ARRA last year.  But in what’s being described as victory for House fiscal conservatives, both of these measures were struck from the House legislation late last week, and whether the Senate will restore them remains uncertain.  Roughly 20 states are already counting on the extra Medicaid help in their state budgets.

However, that victory may prove short-lived. Both the COBRA and Medicaid provisions themselves are popular with core Democratic constituencies, and it’s entirely possible that the Democratic Blue Dogs who have drawn a line in the sand in the name of controlling federal spending will be punished at the polls, not rewarded, if the Medicaid and COBRA funding is not restored. They could lose support from the Democratic base without picking up any offsetting support from more conservative voters.

If funding is not restored there are several implications that go beyond politics.  The first is harm these cuts do to low- and moderate-income families who will lose coverage or services as a result. Second, the loss of COBRA subsidies is a blow to the drive to provide health security for all, while the loss of Medicaid funding will certainly turn up the heat on the already charged debate over the role of Medicaid in reform.  Finally, if there is a more conservative Congress in 2011 as anticipated, future debates over federal health care funding and implementation could become similarly difficult, with Congress unable to agree on funding for provisions in PPACA that are authorized but lack an appropriation.

The immediate implication for health care reform advocates is that we need to redouble our efforts to persuade the Senate to revive the COBRA and Medicaid funding.  It’s time to step in to keep reform on the right track.

More on Living in Chicken Little Land

You know it’s Chicken Little time when people can (and do) go on about how awful health reform is without any regard to the available facts.

Exhibit A:  Public opinion. The most recent Kaiser tracking poll (pdf) shows that the top concerns opponents have about health care reform is that it will increase health care spending and is not paid for.

Both the Congressional Budget Office and the CMS Office of the Actuary have refuted these claims in the past.  CBO has found that health reform will reduce the deficit (pdf) while the CMS actuary projects that reform will provide coverage to over 30 million people with a negligible increase in costs.  Recently, a Commonwealth Fund/Center American Progress analysis has suggested that both CBO and CMS are being too conservative in their projections.  Essentially both agencies assume no savings at all from efficiency gains, quality improvements and delivery system changes–sources that could, by moderate estimates, generate a potential $600 billion savings over 10 years.

Exhibit B: state government.  Numerous states have vociferously complained about the burden the Medicaid expansion, a core component of health reform, will impose on them; many going so far as to file a lawsuit to block the expansion.

The facts? A new paper released by the Kaiser Commission and the Urban Institute tells a different story (pdf).  The study shows that on average health reform will add only 1.4 percent to state Medicaid spending between now and 2019.  This is very similar to the 1.25 percent estimate developed by the Center on Budget and Policy Priorities.  And neither of these forecasts take into account savings to states from changes in the delivery system or from reductions in spending on services that are now 100 percent state funded but will be covered by Medicaid in the future.  Although state by state estimates vary, in no state does the federal government contribute less than 94 percent of the cost of the expansion.

Unfortunately, it isn’t much use telling the truth to people whose minds are already made up. Facts don’t matter to Chicken Little, who gets all his information from the Fox (news).  As we noted in the last post, the only thing that will persuade these folks is when the sky doesn’t fall in 2014 and, at least for some, they start receiving benefits under the law.  Then they’ll probably join the “keep government out of my Medicare” crowd.

DoJ presents its case
The Department of Justice has, in several legal briefs, laid out its basic arguments against the lawsuits seeking to undermine health reform.  Here’s a CliffsNotes version of the arguments:

•    States have no standing relative to the individual coverage requirement, which applies to individuals, not states (duh).
•    There is no need to block the law from going forward now since there is no possible injury until April 2015, when penalties for failure to purchase coverage would be due.
•    Individuals who now claim the law would require them to purchase coverage can’t know their circumstances in 2014, so the “injury” is purely speculative.
•    State residents cannot vote to exempt themselves from federal law they don’t happen to like.
•    The minimum coverage requirement is a reasonable part of the regulatory scheme that governs economic activity related to health care and health insurance, and thus falls within the Commerce Clause,
•    Tax penalties associated with the requirement to purchase coverage fall within Congress’ power to tax and spend for the general welfare.

Call it what it is—then change course

When responding to repeal proponents it’s important to:
a) Call the attacks what they are: an attempt to preserve an unsustainable status quo that leaves millions without coverage and millions more who have coverage at risk of financial ruin.

b) Turn to the benefits of the law—reform will:
•    Provide security to millions of working Americans
•    Guarantee people access to the same plans as members of Congress
•    Help women, children and people with serious medical conditions get more affordable and more secure coverage
•    Strengthen oversight of insurance premiums and help people get better value for their premium dollar

–Michael Miller, director of strategic policy

Tags: , , , , , , , ,
Posted in Health Reform Insider, Repeal Watch, national health reform | No Comments »

The Insider: Repeal Watch

Tuesday, April 27th, 2010

With Enemies Like This, Who Needs Friends?

As they tried to regain their footing after the surprise Senate election of Scott Brown, reformers received an unexpected boost from for-profit insurer Wellpoint. In February, the insurance giant announced it was planning to raise rates by 39 percent in California, and similarly large increases were reported elsewhere. Coming off a $2.5 billion profit in the last quarter of 2009, this didn’t sit so well with much of anyone but insurers, and became a major rallying point in the White House, Congress and advocates’ final push for reform. Some conservative commentators went so far as to blame Wellpoint for reform’s subsequent passage.

Now Wellpoint is at it again.  Recent headlines suggesting that the company routinely targets women with breast cancer for rescission boost the case that, if anything, the tougher insurance oversight that is part of the Patient Protection and Affordable Care Act doesn’t go far enough.   Since it seems the folks at Wellpoint can’t help themselves, it’s up to advocates and regulators to stop them before they kill again (no joke).

Repeal Watch 1: Public opinion
This latest Wellpoint scandal makes it crystal clear: The repeal chorus is defending the indefensible.  And yet, with 45 percent of conservatives getting most of their information from cable news, it’s unclear that the indefensible is making it on air. The latest Kaiser tracking poll (pdf) has some moderately good news for reformers: a plurality of the country supports reform, but many are confused (or misinformed) about what reform actually does.

This lack of understanding underscores both the need and opportunity for an aggressive public education effort using all available means—everything from paid and earned (and social!) media to one to one conversations at the community level.

More bad news for repealers (and good news for us): there is strong cross-partisan public support—among Democrats, Republicans and Independents—for the early provisions of reform like small business tax credits, $250 rebate for seniors with high drug costs and coverage for children with pre-existing conditions.

But people over 65 continue to hold a more negative view of reform than younger adults do—and that’s worrisome, especially in light of their disproportionately big turn out at the mid-term polls, which we’ve talked about here before.

Even so, repeal may not be the ticket to ride that some conservative activists hoped for. A recent poll of Florida voters showed that a majority think that the state Attorney General McCollum’s decision to sue the federal government was a bad idea and that McCollum, the front runner in the Florida governor’s race, was losing ground.

Repeal Watch, Part 2:  Breaking down the repeal arguments

Voters have good reason to be skeptical of the repeal efforts, which have overwhelmingly been advanced by candidates seeking higher office or as part of a larger right-wing electoral strategy. A growing number of state legislatures hold a similarly skeptical view—so far more than 12 have rejected repeal measures.

And they are right to, since the main repeal arguments are so far-fetched.  Basically, they amount to:

  • The law is illegal because the Medicaid expansion imposes new costs on states. By the same reasoning, other provisions of Medicaid law, such as the requirement to cover certain children or people with disabilities, would also be illegal, and Medicaid would become nothing more than a blank check written to the states. And what of those new costs? A recent CBPP report shows that new state costs through 2019 add up to only 1.25 percent of projected state spending, and that’s before factoring in possible offsetting savings to states.
  • States have the ability to selectively decide which federal laws they will obey. This argument essentially parallels the case made by segregationists almost 50 years ago and has been decisively rejected by the courts.
  • The individual mandate falls outside of Congress’ authority to regulate interstate commerce because it regulates “inactivity” and/or it is an impermissible tax.

But from a legal standpoint, the “mandate” falls squarely within Congress’ authority to raise taxes. Semantics aside, the individual mandate is not really a mandate, but a financial incentive to purchase coverage.  From an economic standpoint, it is no different than the existing tax subsidy that goes to employer-sponsored coverage; lowering the cost of doing something or raising the cost of not doing it are functionally the same (more at the New England Journal of Medicine–subscription required).

In sum, both the legal and political campaigns for repeal (if indeed the two are distinguishable) rest on shaky ground—and more and more voters and political leaders are beginning to figure that out.

–Michael Miller, director of strategic policy

Tags: , , , , , , , ,
Posted in Health Reform Insider, Repeal Watch, national health reform | No Comments »

Health Reform Insider Goes to the Toast and Polls

Tuesday, March 30th, 2010

President Obama signed the final piece of the health reform package today. So before we do anything else and get caught up in the next round of debate, here’s a toast to all those who have worked so hard over the past year to get us this far.

And what goes better with toast than a bill summary?

(We couldn’t think of anything, either.)

So now what?
Congress’s work on health reform is complete (at least for now) but with barely a pause for breath, the hissy fit against reform has continued, merely shifting venue to the states and the upcoming fall elections. Public outreach is still needed, both because a number of provisions take effect very quickly (here they are), and the ongoing smear campaign against reform.

Thirty something
As we mentioned last week, legislators in over 30 states have filed legislative proposals or constitutional amendments regarding health reform. Although there are a few variations on the theme, the main claim is that Congress does not have the authority to impose a tax penalty on people who do not have qualifying health insurance.

And a dozen or so Attorneys General have filed suit against the federal government, claiming, among other things, that it does not have the authority to condition federal Medicaid matching funds on states meeting federal eligibility criteria, because to do so would impose costs on the states. (This is a strange argument, since the federal government has been doing exactly that since the beginning of the Medicaid program.)

Analysts have concluded that the proposed challenges lack legal merit. See:

But merits shmerits. Remember, the goal here isn’t to build sound legal cases but to gin up fervor to elect anti-reform members to Congress (or in the case of the AGs often to get themselves elected to higher office) and create a screen of apparent public opposition to reform for state officials intent on foot-dragging to hide behind.

They may also be trying to force the administration to make a potentially damaging public admission that the individual mandate constitutes a tax—thus violating an Obama campaign pledge.

A dead end strategy?
Given some truly awful recent Supreme Court decisions, no one can afford to laugh at the prospects of litigation, even though most nonpartisan analysts have concluded that they are without merit.

Still, challenges aside, there is reason to be optimistic about the future of reform.

First, the status quo is unsustainable—and more and more civic leaders are recognizing that. Reform opponents have no meaningful alternative that will address the rising costs and rising numbers of uninsured that are undermining the system.

Second, reform does a number of popular things (insurance reforms and subsidies, say) that will be not only be difficult to undo, but also difficult to separate from some of the less-popular aspects.

Third, reform creates more winners than losers among interest groups. There are not that many stakeholders who have a vested interest in repealing (not to be mistaken for amending) key parts of reform. Hospitals, doctors and drug companies can all find provisions they do not like but on balance, the extension of coverage to more than 30 million people will be good for the health care industry. States have concerns about the cost of the Medicaid expansion, but the expansion is 100 percent federally-financed in the short run, and provisions like increasing the Medicaid drug rebate rate will reduce state costs.

What about businesses? Although some may have concerns about the “free rider” provisions, only a very small percentage of employers will actually be subject to any penalties (The Congressional Research Service estimates only about 5 percent).

So too with the individual mandate. Most people already have private or public insurance or would voluntarily purchase coverage once a subsidy is available. The mandate is a tool to ensure the broadest possible risk pool and to prevent people from churning off and on health insurance on an as-I-need-it basis.

But if Massachusetts is any guide, the mandate will (notwithstanding the political furor of the moment) be, in practice, fairly acceptable to the general public.

Even the insurance industry, which spent millions to defeat reform, may think twice before getting behind a repeal effort. Especially since if the effort is only partly successful, it could be left with new requirements to cover high-risk and high-cost individuals without the guarantee of a bigger and on average healthier subscriber base.

And it looks, early on anyways, that public opinion is swinging toward reform.

This may be the case in part because broadstroke polling has always overstated the opposition—polls and stories before reform passed often failed to break out the anti-reformers from those who were unhappy with the current bills because they wanted reform to go further.

But new post-reform polls (check out this Five-Thirty-Eight post) that have gone deeper show an upward trend of support for reform.

Those, for instance, who say the law is a step in the right direction are unlikely to see repeal as anything but two steps back.

The question becomes: How much of the public can be made to believe things that are not true about health care reform—and for how long—now that it is law?

And here, there’s some cause for concern that goes beyond the persistent misunderstandings of what is in the law. A recent Harris poll shows 23 percent of adults in the US (41 percent of Republicans) think that President Obama wants to use an economic collapse or terrorist attack to assume dictatorial powers, and 24 percent of Republicans think President Obama may be the anti-Christ. We may surmise that these folks are unlikely to be persuaded on health care no matter what advocates (or anyone else) says or does.

On the other hand, as Nate Silver noted in the above link, public support seems to be going toward reform, though it is too soon to say whether this is a long-term trend.

The best thing advocates can do is go out and explain what reform really does (and what it doesn’t do). The more public understands reform, the less support there will be for a rejectionist agenda. Reaching out to constituencies that will benefit from early improvements (again, check out our Quick Win fact sheet)—including seniors, small businesses and children and adults with pre-existing conditions—are a good place to begin.

Seniors have generally been more opposed to reform than most age groups, and opponents have consistently claimed that reform is bad for Medicare. The first changes that seniors will see is the beginning of a phase out of the doughnut hole and new preventive care benefits in Medicare.

Many small businesses are probably unaware that they are exempt from “free rider penalties” or that the new law includes an immediate tax credit for small, low-wage businesses that offer health insurance.

For children and adults with major or chronic conditions, the bill has provisions to, immediately eliminate pre-existing conditions for children (pending HHS regulation), allow young adults to remain on their parents’ plan, eliminate lifetime benefit caps and create (or enhance) a high risk pool, and will provide immediate benefits for children and young adults with special health care needs.

Implementation: a three-piece puzzle

Going forward the keys to successful implementation include:

-An aggressive effort to build public support for reform

-Engagement at the state and federal level around the state laws and state and federal regulations that will govern the details of implementation

-Maintaining and strengthening the Medicaid program during the interim period when the states’ fiscal crisis is still squeezing the program and new federal coverage rules have not yet kicked in.

We’ll look at the way these three interlocking pieces fit together and developments in the weeks ahead.

–Michael Miller, director of strategic policy

Tags: , , , , , ,
Posted in Health Reform Insider, national health reform | No Comments »

« Older Entries