Posts Tagged ‘Medicare’

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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

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

The Insider: Putting Things in Perspective

Tuesday, February 1st, 2011

Putting the Florida Legal Ruling in Perspective
The media is full of stories this morning about the ruling yesterday of Judge Vinson, not only that the Individual Responsibility Requirement (IRR) of the ACA is unconstitutional, but also that the entire law must fall as a result. While this sounds dramatic, there is rather less than meets the eye.

Essentially the ruling has no immediate practical significance other than providing fresh ammunition for the attack dogs who were quick to seize on it. It doesn’t really change the calculus with regard to implementation. Federal regulators will certainly move ahead and the situation is not much different in the states. Since all or most of the ACA that pertains to states is likely to survive the legal challenges, the consequences of inaction are too significant for state government to sit back and do nothing while the court cases play out. For example, state administrations politically opposed to the ACA who want to use this ruling as an excuse for inaction risk turning over the operation of the Exchange (and the keys to Medicaid eligibility) in their state to the federal government.

The main concern about the ruling is that it opens up new ground on the far right, moving the Virginia ruling — which struck the IRR while upholding the rest of the law — into the center. This could create cover for the Supreme Court to follow suit in dumping the IRR while upholding the rest of the law.

If it comes, a Supreme Court ruling along the lines of the Virginia decision would create a major challenge for ACA backers. If the law, minus the IRR, remains intact, there could be significant adverse selection in private insurance pools. Technically, there are a number of alternatives that could be put in place to allow ACA implementation to move forward without major disruption.

The challenge is political. Bipartisan cooperation would be needed to enact an alternative. Republican opponents of the ACA could demand other major changes in return for an agreement to enact an alternative mechanism to prevent adverse selection.

During the debate on expiring tax cuts, Congressional Republicans showed themselves willing and able to avail themselves of this type of “hostage taking” opportunity to preserve tax breaks for the wealthy. They seem likely to attempt a similar strategy both with regard to completing the work on the FY’11 budget and the upcoming vote to raise the federal debt ceiling (see below). During the tax debate, neither the Obama administration nor Democrats in Congress were willing to play hardball. It remains to be seen whether the same dynamic plays out with respect to health care.

Stay tuned for more detail on the Vinson ruling.

The Next Dragon in the Road
The much-hyped House vote on ACA repeal is already fading into the rearview mirror. While Senators Reid and McConnell jockey over scheduling a similarly symbolic Senate vote, far more significant threats loom ahead that advocates must be prepared to meet. One critical fight that is rapidly approaching is a likely vote on whether to amend or repeal the Medicaid Maintenance of Effort (MoE) requirement contained in the ACA.

The ACA prohibits states from reducing Medicaid eligibility or putting in place new administrative enrollment barriers for most adults prior to 2014 and for kids until 2019. Recently, Republican Governors sent a letter to President Obama and Congressional leaders calling for repeal of the MoE. Even more recently, the National Governors Association (which includes all of the nation’s governors — Democrats as well as Republicans) sent another letter that, while less explicit in calling for repeal, also took a stance in opposition to the MoE requirement.

Medicaid is the foundation on which the ACA rests. The repeal attempt on the MoE is the opening move in what will be a sustained effort to undermine both the ACA coverage expansion and the entitlement nature of Medicaid itself, which is why we can be sure that Congressional opponents of the ACA will push it.

MoE repeal would not only lead to an increase in the number of uninsured, it would also create new barriers to full expansion in 2014. States that rolled back coverage would have to reinstate that coverage at their regular Medicaid match rate, making the 2014 expansion more difficult. Politically, moderate Senate Democrats, especially those up for reelection in 2012, may be reluctant to hold the line on eligibility given the poor fiscal condition of states and the looming expiration of enhanced federal Medicaid matching dollars. MoE is an especially hard vote for ACA supporters because, unlike total repeal, MoE repeal, will be scored by CBO as a budget saver, making it attractive to Senators eager to burnish their credentials as deficit cutters or for use as a “pay for” for another priority that has a price tag attached.

They just can’t help themselves
Although posing as defenders of Medicare helped Republican candidates rack up positive vote margins with older voters, some members of the House GOP caucus seem eager to cough up those gains. Republican House leaders are considering a measure to convert the Medicare program into a voucher system as part of the House budget proposal, which could take shape within a month. The proposal being considered would convert Medicare into a voucher by 2021 and would also raise the eligibility age for Medicare to 69 (a change that would add substantially to employer health costs). The same idea is likely to be advanced during the debate over an increase in the debt ceiling expected to occur this spring.

Eyes of the Beholder
Did CMS Actuary Richard Foster validate the supporters or opponents of the ACA (or some of both)? Both Democrats and Republicans claim that Foster’s testimony before the House Budget Committee bolstered their views of the ACA. Democrats say that Foster agreed that the ACA would reduce the budget deficit. Republicans point to his statements relating to overall health costs and whether people could stay on their current plans as support for their criticism of the ACA. Let’s take a closer look at these two latter statements.

First, Foster said the claim “if you like what you have, you can keep it” is not true in all cases. Given the way he qualified his statement, on this point, he seems obviously correct. Although Foster may have had changes to Medicare Advantage in mind, conceding that the ACA will force junk insurance off the market isn’t anything that ACA supporters should apologize for. Sooner or later (and generally speaking the sooner, the better) plans that take subscribers money without offering them either reasonable value or adequate financial protection in the event of a serious illness will be forced off the market. People who have them now and like them only like them because they are cheap, and will only like them as long as they don’t get really sick. Just because it’s cheaper to have cars without working brakes or airbags does not mean they should be allowed on the streets.

The more serious contention is that the ACA will not contain health care costs. The statement rests on the Office of the Actuary’s (OACT) projection of total health spending under the ACA and whether the Medicare cost containment provisions will actually be implemented.

The OACT is quite pessimistic about the cost containment potential of the ACA relative to other analysts like the CBO or Council of Economic Advisors. This is a general tendency of the office, not unique to the ACA. For example, the OACT overestimated the cost of Medicare Part D by 25 percent. Nonetheless, their analysis concludes that the ACA will expand coverage to over 30 million uninsured people with virtually no net increase in health spending. Since uninsured people get only about half the care of the insured, this large coverage expansion with a negligible increase in cost is actually an endorsement, rather than a rejection of the ACA’s cost containment effect.

Most importantly, Foster is making a political rather than analytic judgment that the Medicare cost containment provisions won’t be sustained. The endless replay of the drama around how to prevent the cuts in physician fees mandated by the Medicare Sustainable Growth Rate would seem to bolster his view, but, as Paul Van de Water of CBPP points out, the SGR is the exception rather than the rule when it comes to Medicare cost containment efforts. Notwithstanding the routine fee increases approved by Congress, savings from reductions in Medicare physician fees still exceed the levels projected at the time of SGR passage.

Don’t hold your breath
While the repeal and harass parts of the repeal, replace and harass strategy seem well underway, replace seems to be lagging and the likelihood of a coherent replace strategy emerging is much lower. The problem is that most of the ideas previously advanced by House Republicans don’t actually work—having at most a modest effect on health spending and even less on coverage, while failing to adequately protect those with preexisting condition exclusions. Even McCain advisor Douglas Holtz-Eakin, a vociferous critic of the ACA says, “If it’s all they do, it’s not a serious effort.”

Nonetheless the old Boehner bill constitutes too much government intervention for some in the incoming class of freshman Republicans. As a result, coming up with an alternative to the ACA is likely to prove much harder than trying to unravel it by picking at the less popular provisions. In addition, an alternative acceptable to the House majority may not be very popular with the American people who like most of the provisions of the ACA.

In their own little corner
The health care debate in the rest of the country may be focused on repeal, replace, defund and harass or on the fiscal challenges facing state budgets, but a different story is unfolding in Vermont. Newly elected Governor Shumlin campaigned on single payer, and he is taking the issue seriously. Shumlin contracted with William Hsiao, who, among other things, helped design the national health system in Taiwan, and Jonathan Gruber, who modeled coverage expansion costs in Massachusetts and for Congress during the ACA debate, to help design a single payer plan for Vermont. Their report, released a week ago, showed that a single payer system would significantly lower health care costs and create jobs while covering more people with coverage at least as good as offered by the ACA. (They also modeled the ACA and found that it too would create jobs and lower health care costs relative to the status quo, but not as much.)

Even with a supportive governor and a Democratic legislature, there are still many legal, operational and political challenges ahead. How the plan is received by the provider community, whether there would be a role for the state’s Blue Cross plan (which now has a 75 percent market share), and the distribution and reaction of winners and losers among employers in the proposed shift from premiums to payroll taxes, are all likely to play a large role in the ultimate fate of the effort. To date, the national news media have paid relatively little attention to the Vermont effort, but if the state succeeds in establishing a single payer plan, VT could become the mouse that roared in health policy terms.

– Michael Miller, Policy Director

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

A Health Advocate’s Guide to the Debate on Deficit and Debt Reduction

Monday, December 13th, 2010

Recently, a blizzard of deficit and federal debt reduction plans has emerged from across the political spectrum. Many of them—especially those coming from the center/right—propose major changes in the benefits and/or financing of Medicare and Medicaid in the name of getting the nation’s “fiscal house in order” and restoring economic growth.

For different reasons and in different contexts, these public insurance programs already have been getting some rough treatment in public debate.

For Medicare, the recent context has included continuing debate over cost containment provisions in the Affordable Care Act—a debate that includes allegations of death panels, rationing, and the forcing of seniors onto “government-controlled” health care. (Note: It doesn’t have to make sense; it’s just a sound bite.)

For Medicaid, the challenge has rested mainly at the state level. Cash-strapped states have struggled to keep up with increased demand for Medicaid amidst falling revenue streams and other realities arising from the recession. Many states have filed suits to block the ACA-mandated expansion of Medicaid eligibility. Some have gone so far as to threaten withdrawal from the Medicaid program.

However, as a new political alignment prepares to take the reins in Washington, new federal level threats are aimed against Medicare and Medicaid, which form the foundation of our nation’s health care safety net, particularly for older adults, people with disabilities and children. The deliberations of the official Deficit Reduction Commission (DRC) appointed by President Obama, along with related policy proposals, such as the one released by the Bipartisan Policy Center (an organization financed by Peter G. Peterson – a long-term proponent of reduced federal spending on entitlement programs), bring these threats into focus.

Putting the Deficit Debate into Context
As Henry Aaron of the Brookings Institution observed in the New York Times, the various official and unofficial “commission” reports aim at three distinct problems: the short-term increase in the national debt, a projected shortfall in Social Security funds, and a projected long-term rise in the national debt. Let’s look at the short- and long-term issues in turn.

It’s the economy, stupid (and the wars and the Bush tax cuts)
Most economists agree that the current short-term increase in public debt is attributable almost entirely to the wars in Afghanistan and Iraq, the Bush tax cuts (mainly benefiting the wealthy) and the recession. Also, lingering effects of the recession, not health spending or the debt, pose the most immediate and serious threat to our health security and general well-being. Persistent high unemployment rates reduce the proportion of people who have employer-sponsored health insurance, and also reduce the revenue to fund Medicare, Medicaid and Social Security while driving Medicaid enrollment up. With enhanced federal support for Medicaid slated to expire in June even while states face continued significant revenue shortfalls, pressures on Medicaid will be greater than ever.

Meanwhile, the actions and words of President Obama’s financial advisors make it clear that they do not regard the possibility of a “double dip” recession as being out of the question, especially without additional fiscal stimulus. By spurring job growth, additional stimulus would support the economic recovery and restore growth, creating the conditions necessary to bring down the short-term debt. Reducing unnecessary military spending and restoring more progressivity to the tax code also would help. However, the type of stimulus that would include additional federal funds for state Medicaid programs appears to be off the table.

Medicare and Medicaid in the crosshairs
Finally, and most significantly for health care advocates, the various commission reports all addressed the issue of long-term projected increases in Medicare and Medicaid spending. The CBO has projected that the growth of federal debt long-term is attributable almost entirely to the growth of health care spending, particularly Medicare and Medicaid. Based on this, various debt-buster report recommendations to reduce health care spending in Medicare and Medicaid vary from the benign (increasing funds for fiscal oversight, reducing fraud and payment errors, and collecting the Medicaid drug rebate for all dual-eligibles) to the alarming (increasing Medicare cost-sharing, setting a global cap on federal health spending equal to GDP growth plus one percent, turning Medicare into a voucher program, and eliminating the federal commitment to matching state Medicaid spending on no less than a dollar for dollar basis).

Beware of GIGO (Garbage In Garbage Out)
Before entertaining any drastic action to cut Medicare and Medicaid, policymakers should subject the assumptions underlying the Deficit Reduction Commission and similar reports to careful scrutiny. First, although you would never know it from any of these reports, there is actually very little evidence to support any particular debt-to-GNP ratio as a target that we must adhere to or risk financial disaster. (See this and this for discussions that call into question the basic premises of the deficit commission. An opposing view is here.)

Policymakers also should closely examine underlying assumptions in the CBO forecast. Projections of explosive debt growth are very sensitive, both to assumptions and to policy change. (See, for example, the difference between the 2009 and 2010 CBO forecasts.) James Galbraith and others have pointed out that the CBO baseline assumes an unlikely combination of circumstances that includes low inflation (except in health care) and, notwithstanding that low inflation rate, significantly higher interest rates. CBO also assumes that there are no long-term cost savings effects from the ACA. While it may be prudent not to assume a continuing cost-containment effect from the ACA, it also would be prudent to give the law a chance to work before performing radical surgery on the core of our health care safety net.

Finally, neither the assumed need for debt reduction nor the use of arbitrary caps to reduce the percentage of our economy devoted to Medicare and Medicaid are helpful lenses through which to consider the question of health care cost containment. On the one hand, reduction of the debt is taken as a primary good, with benefits assumed but not demonstrated. On the other hand, discussion of the impact of proposed cuts on health programs serving older adults and others served by Medicare and Medicaid is nowhere in evidence. It is impossible to judge the reasonableness of proffered recommendations without looking at their costs, as well as any alleged benefits.

A few facts are important to keep in mind:

– Medicare already offers coverage benefits that are less generous than those typically available through employer-sponsored insurance.
– Older adults already devote a substantial share of their income to health care –well above what younger groups spend.
– Medicaid beneficiaries are both the poorest and sickest members of society. A retrenchment in Medicaid is therefore likely to create substantial hardship both for the low-income frail seniors and younger adults and children with chronic illnesses and disabilities on whom most Medicaid dollars are spent.
– The same proposals that envision reducing the value of Medicare also envision reducing Social Security benefits, creating a double whammy for all who do not participate fully in the labor force because of old age, disability or other categorical dependency.

The cost of public programs providing health coverage and services is tied to the overall growth in health care costs. Focusing only on public spending in this equation obscures this link and leads toward draconian solutions that harm vulnerable populations rather than smarter, more system-wide approaches. Arbitrary cuts in public spending for health care would be a cure worse than the disease. What we need is not an arbitrary cap on health spending, but long-term integrated approaches to reducing the rate of growth in health care costs that also improve quality and value. The Affordable Care Act plants the seeds of such a program. More could be done, but that will require less demagoguery and ideological rigidity than was on display during the debate on passage.

Is the threat real?
For now, the debt reduction juggernaut may be temporarily stalled. Even Congress might blush before recommending major cuts to popular programs immediately after voting to increase the deficit by $900 billion, as they are now considering doing. But it is not dead. When the debate turns again to debt reduction, it is critically important for advocates of quality affordable health care for all to block a stampede caused by debt-phobia that would undermine health security for millions of Americans.

– Michael Miller, Policy Director

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Posted in Health Reform Insider | 1 Comment »

Doc-Fix Dips Into Affordable Care Act Funding: The First Step on a Slippery Slope?

Thursday, December 9th, 2010

Earlier today, Congress passed a law to avert a scheduled 25 percent cut in Medicare reimbursement rates for doctors. While preventing those cuts is critical to ensuring access to needed care for America’s seniors, the way Congress paid for the “doc-fix” weakens the Affordable Care Act and imposes financial hardship on low- and moderate-income families.

How did Congress pay for the doc-fix?
Starting in 2014, the Affordable Care Act provides sliding-scale tax credits to help lower the costs of premiums and cost-sharing for people earning up to 400 percent of the Federal Poverty Level (around $73,000 for a family of three.) The law allows the federal government to pay these tax credits directly to your insurer each month, so you’ll only be billed for the amount of the premium you owe in excess of your tax credit. Congress paid for the “doc-fix” by increasing the amount you will have to repay if it turns out, when you file taxes at the end of the year, your income was higher than expected and as a result you got a larger tax credit throughout the year.

As the Affordable Care Act was originally passed: if your income was above 400 percent FPL, then you would have to pay back the entire amount of the tax credit you received. But if your income was below 400 percent FPL, you would only have to pay back up to $250 for an individual or $400 for a family. Essentially, the law protected low- and moderate-income people from facing too harsh a penalty for having found a better job or gotten a raise.

As the Affordable Care Act was amended to pay for the “doc-fix”: the repayment caps are higher, and on a sliding-scale. If your income is below 200 percent FPL, you will have to pay back up to $300 as an individual or $600 as a family. The caps rise quickly as your income goes up, so that at 400 percent FPL you could have to pay back up to $1,500 as an individual or $3,000 as a family. The amendment also extends the caps up to 499 percent FPL, where families would have to repay up to $3,500 and individuals up to $1,750.

What’s the bottom line?
Preventing the 25 percent payment cut for Medicare doctors is critically important. However, the way Congress paid for that “doc-fix” is harmful because it:

– Imposes a financial hardship on thousands of low- and moderate-income families, and threatens to undermine support for the Affordable Care Act. For a moderate-income family, suddenly discovering that they owe $3,000 could be financially devastating. Stories of families experiencing this type of financial harm could lead to further decline in public support for the Affordable Care Act.

– Risks reducing the number of people who will enroll in the advanced tax credits, since they will fear this type of unexpected financial penalty. This means fewer people will get the coverage they need.

– Sets a bad precedent that the Affordable Care Act can be raided to pay for other Congressional priorities. Supporters of the Affordable Care Act have already had to fight back attempts to gut the law’s $15 billion Prevention and Public Health Fund to pay for a provision to reduce paperwork burdens on small businesses. No doubt, policymakers will continue turning to cuts in the Affordable Care Act to finance other priorities. By paying for the “doc-fix” by weakening the Affordable Care Act’s protections for low- and moderate-income families, Congress took the first step down a dangerous path.

– Katherine Howitt, policy analyst

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Posted in Affordable Care Act implementation | 2 Comments »

Stuck in the Middle with You

Tuesday, November 16th, 2010

A few weeks ago, Time magazine included a short essay that caught the eye of several of us here at Community Catalyst. In “The Coping Conundrum,” author Nancy Gibbs gently, but insistently, spotlights the unique issues faced by Americans in the sandwich generation — those among us who are simultaneously raising kids even as they are pulled deeper into caring for our aging parents.

“As they age, our parents need constraints, but the context shifts,” writes Gibbs. “Just as with teenagers, we put limits on their freedoms: No, you can’t wear those heels, drive at night, explore that city alone. But this involves taking away freedoms they’ve had, not preparing them for new ones. […]If you are a wife, mother and daughter or son, father and husband and all those ties are pulled taut, you are no longer a net. You are a sieve, and the first thing to slip through is peace of mind.”

Gibbs points to statistics from just one illness — Alzheimer’s — to illustrate the impact care giving has on family members’ lifestyles, relationships, and even career opportunities. Citing the Shriver Report, she states that one in every three caregivers reports being “responsible [for providing care] around the clock — and four in ten say they had no choice about taking on the role.” Over a third of family caregivers struggle with depression, and 40 percent say care giving strains their marriage.

This is troubling, and it speaks volumes about the way our current health care system works — or doesn’t — for the frail elderly, many of whom have one or more chronic illnesses, and the people who love them. Ironically, incentives in many states actually work against keeping people in their homes and communities, pushing them into institutions like nursing homes. Not that nursing home care is an easy solution. As Gibbs notes, Medicare doesn’t cover long-term care services, and “you have to burn through your savings to qualify for Medicaid [which may cover long-term care].” In addition, many providers don’t routinely coordinate patient care with one another. That burden falls to patients and family caregivers, who may get conflicting diagnoses and treatment plans without the benefit of a point person to help them make sense of it all.

All of this makes for a system that’s disjointed, confusing, and frustratingly complex. None of it makes for easy care giving.

That’s not to say there are no bright lights shining. Tomorrow, November 17 marks the launch of the “Year of the Family Caregiver” — a year-long celebration that will recognize family caregivers for all that they give, and all that we ask of them. (It’s also the 10th anniversary of the National Family Caregiver Support Program, created by the Older Americans Act to support family caregivers.) And, the Affordable Care Act (ACA) includes a number of provisions intended to improve the way patients — and their family caregivers — experience care.

Despite politicians’ midterm posturing on the ACA, there’s no question that we need to take advantage of the opportunities it presents to address what’s not working well for patients and family caregivers. Red state, blue state, purple, green — no matter what the political landscape looks like, focusing on what’s not working for our ever-aging population and the people who care for them is one issue that should cross party lines. To quote Nancy Gibbs, “If anything should be a postpartisan issue, this is it. Liberal or conservative, we all get old; we all care about the people we love; and in the years ahead, the support needs to come without being summoned if our families are going to stay strong.”

After all, we’ll all be there, someday.

– Jessica Curtis, Integrated Care Advocacy Project and the Campaign for Better Care

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Six months in: The new health law gives us the key to better care

Thursday, September 23rd, 2010

Our fourth post celebrating the six month anniversary of the Affordable Care Act.

Six months ago today, the Affordable Care Act was signed into law. Since then, the new health law has offered some concrete advances, including some that go into effect today and it’s laying the groundwork for even more.

By 2030, it is estimated that 72.1 million people in the United States will be age 65 or older, more than twice the number of older adults in 2000. As our population ages, it is vital that we improve how the system cares for and engages with patients who have multiple chronic conditions so they get care that’s tailored to their individual needs, receive clear information from their doctors, don’t have to repeat tests, and get the supports and services they need to stay in their homes and out of the hospital.

So far, the Affordable Care Act has helped to close the donut hole for Medicare beneficiaries, created new patient protections, made it possible for people to get better information and compare health insurance plans online. But we know much more is needed to provide quality, coordinated care for millions of vulnerable patients and their family caregivers — the people who need help the most. And there is more to come.

Starting next year, preventive services and annual check-ups will be free for Medicare beneficiaries, hospitals will receive more funding to help provide a smoother transition from hospital to home, and primary care providers in Medicare and Medicaid will receive increased payment — to make sure that everyone has access to primary care.

Perhaps most importantly, the ACA offers unprecedented opportunities to improve the poor coordination that plagues our health care system — one of the core issues we and our partners at the Campaign for Better Care are working to address. These include:

– A new Center at CMS designed to promote innovative ways of providing care, such as using team-based primary care
– A new option for states to create medical homes
– Incentives for hospitals to reduce preventable infections and readmissions

These and other ACA reforms give us the tools to create sustainable, effective coordinated care programs that can provide patients and their families with better care and better outcomes. The ACA can bring the improvements we urgently need — but only if it is implemented with patients and their family caregivers as the focal point. Making that happen is the mission of the Campaign for Better Care.

Community Catalyst has been working toward this mission since it helped create the Commonwealth Care Alliance, and we are proud to bring the lessons from CCA and others to the work of the national Campaign and to the six state Campaigns in Maine, Massachusetts, North Carolina, Ohio, Pennsylvania and Wisconsin. In each of these states, advocates are at the table where decisions are being made to implement key ACA delivery system reforms. We applaud this critical work and urge Hub readers to join existing Campaign efforts or to learn how to get involved in their own states.

Happy Half-Birthday, ACA!

– Renée Markus Hodin, Director Integrated Care Advocacy Project

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The Future of Health Care

Friday, September 17th, 2010

How are we going to change the cost curve in health care and provide the highest quality of care? Dr. Bob Master – one of the country’s leading health care visionaries – has a great answer.

Six years ago, Bob came to Community Catalyst as a fellow of the Institute of Medicine as a Profession. Our idea was that he would use the fellowship to incubate a care delivery system that would serve Massachusetts’ most vulnerable people, including frail older adults with chronic conditions, people with significant physical disabilities and people who are dually eligible for Medicaid and Medicare. By focusing on primary care and prevention, this system would deliver high quality care and reduce costs.

After two years at Community Catalyst, Bob launched the Commonwealth Care Alliance (CCA) upstairs from our offices on 30 Winter Street. We wanted to ground CCA closely to consumers, so Health Care For All and the Boston Independent Living Center became CCA’s corporate members and I became president of the board.

Six years later, Bob and his committed staff at CCA have created a comprehensive system of care that not only improves their members’ health, but also has been proven to lower costs by keeping people out of the hospital and out of nursing homes. Last year, NCQA, widely viewed as a national leader in driving healthcare improvement and quality, honored Bob for his efforts to successfully reform health care delivery by improving quality and reducing cost for Medicare and Medicaid Patients.

Recently, WBUR’s (Boston’s National Public Radio affiliate) CommonHealth blog ran a nice piece on Bob and CCA. So what does CCA’S care model look like? Here’s how the WBUR bloggers describe it:

The organization is essentially a full-service provider of medical care and social support for chronically sick, elderly and sometimes disabled people on Medicare, Medicaid, or both. From the moment a patient signs on, he or she has access — 24 hours a day, 7 days a week — to a nurse practitioner who is armed with up-to-date electronic medical records and has the authority to call in other specialists as needed. Patients can choose from 25 primary care sites around the state, and for the homebound, house calls are also part of the plan. For those who need to get to the hospital, Commonwealth Care contracts with 8 hospitals in the state, but will only use providers who agree to Medicare reimbursement rates.

Continuity of care is essential. So the program offers non-traditional assistance to patients at no extra cost, including transportation to medical appointments and help with daily chores and activities. Commonwealth Care tries to rescue patients from the kind of fragmented, procedure-driven care that can leave them feeling like “an anonymous piece of baggage on a never ending airport conveyor belt, always tagged for the wrong destination,” as one senior put it.

This is precisely the kind of care that Community Catalyst and our partners at the Campaign for Better Care are pursuing as the Campaign works to implement the delivery and payment reform provisions of the new health law in ways that benefit older adults and their families.

Community Catalyst is proud to be able to highlight the good work at CCA, and we encourage Hub readers to get to know them better. To paraphrase an old saying, “We’ve seen the future of health care, and it is CCA.”

– Robert Restuccia, Executive Director

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Posted in affordability, care coordination/quality | 1 Comment »

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

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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

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

A big f#*@*!* deal

Wednesday, March 24th, 2010

4458527284_21d7409410_mPresident Obama’s signing of the national health reform bill yesterday marks an historic achievement in American history on par with the passage of Social Security and Medicare.  The Patient Protection and Affordable Care Act (summary here) establishes a framework to provide health security for all, and takes immediate steps in that direction.  Of course, there are flaws and omissions in the law as there were (and still are) with those earlier milestones, but PPACA gives us a strong foundation on which to build. How strong? Our fact sheet tells you.

This victory could not have happened without the commitment of the President and legislative leaders, the tireless dedication of staff, and the amazing work of advocates for the health and economic security of all Americans.

Ugly and Ducking

While we can and should celebrate this victory, it has certainly been sad and sobering to witness the opposition’s extremist acts.  Members of the Congressional Black and Hispanic caucuses, as well as openly gay Congressman Barney Frank, were verbally assaulted and spat on.

Someone threw a brick through the window of Rules Committee Chairwoman Louise Slaughter’s office, and Republican Congressman Neugebauer shouted an epithet at Rep. Bart Stupak from the House floor (Rep. Neugebauer later apologized, saying he was talking about the bill).

Many of the protests have called up the worst mob-like vitriol we saw on the 2008 Presidential campaign. House Republicans have generally declined to distance themselves from these events and instead offered embarrassingly weak rationales.

Apocalypse Now?  No?  Well how about now?

Those watching the House floor debate wouldn’t be blamed for feeling like they’d heard the GOP’s world-ending predictions somewhere before.

It seems through a warp in the space-time continuum (perhaps brought about by health reform’s passage) Congressional Republicans are using the same speechwriters as Alf Landon, the 1936 Republican candidate for president, and as the Medicare opponents who wrote this for then pitchman-for-hire Ronald Reagan.

In one sense, however, those who claim this health reform law marks the end of America as we know it are right.  In America as we know it, thousands of people die every year because they don’t have health insurance, and thousands more face bankruptcy from health care bills they can’t afford.

As of yesterday, that America is on its way to being history—the kind of history we learn from, and move beyond. As REM sang, “It’s the end of the world as we know it and I feel fine.”

The Senate Process—the end of the beginning

Democrats scored a key victory late Monday when the Senate parliamentarian ruled against an effort by Republicans to strike on technical grounds an amendment to the excise tax on high-cost health plans.  Yesterday the Senate voted to take up the amendments and started the clock on the 20 hours of debate allowed under the rules of reconciliation.

During the debate we are seeing Republicans do everything they can to delay passage, but their chance of derailing the bill is minimal. This is political theater, but it’s not responsible governing.

The bill now on the floor of the Senate makes mainly popular fixes to the now-law  reform by closing the Medicare prescription drug “doughnut hole,” increasing Medicaid funding for states, striking special deals, and reducing the excise tax on high-cost health plans.

Everything right is wrong again

With the law signed, opponents’ goal is no longer to stop these things from becoming law on the Senate floor (an almost certainly vain effort), but to offer amendments that will make good fodder and embarrassing ads for the November election.

Amendments are being offered on all kinds of subjects, many of them unrelated to the bill, for the express purpose of forcing Democrats to take hard votes. Although it’s possible that some changes will be made in the Senate, which would necessitate a conference committee or one more vote in the House, there is little doubt as to the final outcome.

While passage of the amendments to PPACA will mark a welcome end to a lengthy and often acrimonious debate, there is little time to pause to enjoy the achievement.

With the ink barely dry, the action is already moving in new directions. State and federal officials must begin the task of implementing the bill, some provisions that take effect almost immediately, while opponents are already launching legal and political challenges.

Not in My Backyard

Seven minutes after President Obama signed health reform into law yesterday, 13 state AGs filed a lawsuit claiming the individual mandate in unconstitutional. More than 30 states have threatened to bring bills and ballot questions to repeal health care reform, or elements of it.

Most legal scholars say such challenges are legally specious and will have little purchase on implementing reform. But rolling back reform isn’t the primary aim of such repeal threats anyway–it’s to drive reform opponents (plus the angry and misinformed) to the polls in November.

But already doubts are growing about this strategy. Some Republican leaders are suggesting that they’d like to repeal some parts of the law, but leave others alone (no one wants to be the guy who re-allows insurers to deny coverage to kids with pre-existing conditions).

And a Gallup poll yesterday suggests public support for health reform has already jumped. As more and more people understand what reform is (and what it’s not) those numbers are likely to improve even more.

And that’s the key to making this thing go—the more real people understand the real help that comes from this bill, the harder it will be for state politicos with dreams of the Governor’s mansion to make the case for taking it away.

So the work goes on. Advocates and others who helped this bill become a law now must step up to the challenge of keeping it strong.

–Michael Miller, director of strategic policy

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