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Daily Archives: February 2, 2018

Indiana Gets Federal Approval For Medicaid Plan That Could Slice Enrollment

Indiana on Friday became the second state to win federal approval to add a work requirement for adult Medicaid recipients who gained coverage under the Affordable Care Act, but a less debated “lockout” provision in its new plan could lead to tens of thousands of enrollees losing coverage.

The federal approval was announced by Health and Human Services Secretary Alex Azar in Indianapolis.

Medicaid participants who fail to submit in a timely manner their paperwork showing they still qualify for the program will be blocked from enrollment for three months, according to the updated rules.

Since November 2015, more than 91,000 enrollees in Indiana were kicked off Medicaid for failing to complete the eligibility redetermination process, according to state records. The process requires applicants to show proof of income and family size, among other things, to see if they still qualify for the coverage. Until now, these enrollees could simply re-apply anytime. Although many of those people likely were no longer eligible, state officials estimate about half of those who failed to comply with its re-enrollment rules were still qualified.

Indiana’s Medicaid expansion began in February 2015, providing coverage to 240,000 people who were previously uninsured, helping drop the state’s uninsured rate from 14 percent in 2013 to 8 percent last year. The HHS approval extends the program, which was expiring this month, through 2020.

The new lockout builds on one already in place in the state for people who failed to pay monthly premiums and had annual incomes above the federal poverty level, or about $12,200 for an individual. They are barred for six months from coverage. During the first two years of the experiment, about 10,000 Indiana Medicaid enrollees were subject to the lockout for failing to pay the premium for two months in a row, according to state data.

In addition, more than 25,000 enrollees were dropped from the program after they failed to make the payments, although half of them found another source of coverage — usually through their jobs.

Another 46,000 were blocked from coverage because they failed to make the initial payment.

“The ‘lockout” is one of the worst policies to hit Medicaid in a long time,” said Joan Alker, executive director of the Georgetown University Center for Children and Families. “Forcing people to remain uninsured for months because they missed a paperwork deadline or missed a premium payment is too high a price to pay. From a health policy perspective it makes no sense because during that six-month period, chronic health conditions such as hypertension or diabetes are just likely to worsen.”

Indiana’s Medicaid expansion is being closely watched in part because it was spearheaded by then-Gov. Mike Pence, who is now vice president, and his top health consultant, Seema Verma, who now heads the federal Centers for Medicare & Medicaid Services.

The expansion, known as Healthy Indiana, enabled non-disabled adults access to Medicaid. It has elicited criticism from patient advocates for complex and onerous rules that require these poor adults  to make payments ranging from $1 to $27per month into health savings accounts or risk losing their vision and dental benefits or even all their coverage, depending on their income level.

Indiana Medicaid officials said they added the newest lockout provision in an effort to prompt enrollees to get their paperwork submitted in time. The state initially requested a six-month lockout.

“Enforcement may encourage better compliance,” the state officials wrote in their waiver application to CMS in July.

The new rule will lead to a 1 percent cut in Medicaid enrollment in the first year, state officials said. It will also lead to a $15 million reduction in Medicaid costs in 2018 and about $32 million in savings in 2019, the state estimated.

The number of Medicaid enrollees losing coverage for failing to comply with redetermining their eligibility has varied dramatically each quarter from a peak of 19,197 from February 2016 to April 2017 to 1,165 from November 2015 to January 2016, state reports show. In the latest state report, 12,470 enrollees lost coverage from August to October 2017.

The Kentucky Medicaid waiver approved by the Trump administration in January included a similar lockout provision for both failing to pay the monthly premiums or providing paperwork on time. Penalties there are six months for both measures. But the provision was overshadowed because of the attention to the first federal approval for a Medicaid work requirement.

Like Kentucky, Indiana’s Medicaid waiver’s work requirements, which mandate adult enrollees to work an average of 20 hours a month, go into effect in 2019. But Indiana’s waiver is more lenient. It exempts people age 60 and over and its work-hour requirements are gradually phased in over 18 months. For example, enrollees need to work only five hours per week until their 10th month on the program.

Most Medicaid adult enrollees do work or go to school or are too sick to work, studies show.

Indiana also has a long list of exemptions and alternatives to employment. This includes attending school or job training, volunteering or caring for a dependent child or disabled parent. Nurses, doctors and physician assistants can give enrollees an exemption due to illness or injury.

Three patient advocacy groups have filed suit in federal court seeking to block the work requirements.

Robin Rudowitz, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured, said it’s difficult to gauge whether work requirements or renewal lockouts will have more of an impact on coverage.  She noted both provisions apply to most demonstration beneficiaries. (KHN is an editorially independent program of the foundation).

“Any documentation requirement could lead to increased complexity in terms of states administering the requirements and individuals complying,” she said, adding that it could result “in potentially eligible people falling off of coverage.”

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Stalled Health Programs Await A Green Light On The Hill

With the clock ticking on the current stop-gap bill that funds the federal government through Feb. 8, Congress is steeling itself to consider another must-pass budget bill. And, once again, health care could be caught in the crosshairs.

During previous debates over government funding, it was the high-profile Childrens Health Insurance Program that went months without reauthorization and became a bargaining chip in January. That program has since been extended for six years.

But the future of a host of other programs remains unsettled. Among them, funding for the nation™sŁ,400 community health centers and a delay on capping Medicare coverage of physical and outpatient therapy.

The specific provisions behind these initiatives expired last fall. Advocates now are pressing lawmakers to keep them operational by including language in the broader spending bill that must pass next week to prevent another government shutdown.

Some of the items in this eclectic legislative mix are often left to the last minute to catch a ride on another bill — known as “extenders” by Washington insiders, because they extend funding that is set to expire or delay funding cuts that would otherwise take effect.

On the surface, these efforts may sound like wonky, inside-the-Beltway machinations, but program advocates say they have real-life implications for many of the nation’s neediest patients. For them, the congressional delay is causing concern. Here are some things you should know:

The provisions are important and wide-ranging.

Renewing federal funding for community health centers is the biggest ticket item — the clinics cost $3.6 billion per year, and provide basic health care for about 27 million low-income people. Also at stake is the Maternal, Infant and Early Childhood Home Visiting Program, through which trained home visitors teach poorer, at-risk mothers healthy parenting strategies to new mothers who are deemed at-risk and have low incomes.

Another provision forestalls planned reductions put in place by the Affordable Care Act — in federal funds given to particularly vulnerable hospitals that serve a particularly high rate of low-income patients, known as Disproportionate Share Hospitals.

And yet another would prevent limits, put in place by earlier budget bills, from being applied to Medicare’s coverage of physical therapy, outpatient therapy and speech-language pathology treatment. Without action, coverage would be cut off after $2,010 of occupational therapy is provided and another $2,010 for the combination of physical therapy and speech-language pathology. Each limit would translate into Medicare reimbursement for fewer than 20 visits.

OK, so why hasn’t Congress acted on these yet?

These are generally smaller programs that, in the past, were authorized or extended via provisions attached to larger, must-pass bills. One of the favorite vehicles was the “doc fix,â which regularly moved through Congress to make adjustments in how Medicare paid doctors. That is, until a landmark 2015 law — the Medicare Access and CHIP Reauthorization Act, or MACRA — permanently addressed physician payment.

CHIP finally got funding in the Jan. 22 federal spending deal, but the other items were left on the table. One issue, many said: They’re simply not as sexy, and the impact is harder to spot immediately.

“The problem is too much of the focus was on just one egg in the basket, and that egg got done. Now the rest of the eggs are saying, ‘What about me?’” said Rodney Whitlock, a health policy consultant and former Republican Senate staffer. “The real-world impact of not addressing those is slowly becoming problematic.”

Most of the programs aren’t politically controversial.

These programs usually pass with bipartisan support. For lobbyists and policy analysts on both sides of the aisle, that makes the funding lapse especially disorienting.

“Even things that should be easy and bipartisan are taking much, much longer and encountering much more difficulty than I think any of us would have expected,” said Eliot Fishman, senior director of health policy at the liberal advocacy group Families USA and a former member of the Obama administration. “It’s clearly a matter of political gamesmanship.”

There is some room to debate how to pay for these initiatives. But even that is limited, suggested Thomas Miller, a resident fellow at the conservative American Enterprise Institute.

“If it’s your economic interest at stake this is an end-all and be-all. But these are not gigantic items — the consequences for the larger fiscal picture are not immense,” Miller said.

Take the therapy caps. They were first put in place as part of the 1997 Balanced Budget Act, as part of an effort to curb Medicare outpatient spending.

But in 1999, right when the caps were scheduled to kick in, pushback from physicians and patient advocates led Congress to delay their effective date. Since then, Congress, has except for a brief lapse — kept them at bay.

This delay in funding has consequences for patients.

Stephanie Weyrauch, a Minnesota-based physical therapist concerned about the therapy caps, said she and her colleagues are already starting to ration care.

She described, for instance, a 69-year-old man who is recovering from a stroke and about halfway through his allotted therapy. He will require several more sessions later this year just for that condition, which would bring him up to the cap. If his other ailments â shoulder problems and poor blood flow – worsen, Medicare wouldn’t cover treatment.

“We have to make sure we’re doing what’s best for our patients. Sometimes that means we stop therapy early to prepare for a potential next episode,” she said.

A fix from Congress could come next week. 

Congress already provided some short-term funding for community health centers, which is “keeping the lights on,” Fishman said. But it lasts only until the end of March.

And the Maternal, Infant and Early Childhood Home Visiting Program is operating on previously allocated dollars.

In the meantime, the affected programs are struggling to plan for the future, Fishman noted. They are trying to come up with budgets and make staffing decisions without a sense of what their income will actually be.

But some people expressed optimism about what will be included in the funding bill likely to take shape in Congress next week.

“I continue to believe that when a spending deal gets worked out this train will ride along. … It is an election year,” Whitlock said. “No matter what, this is one of those where it’s got to get worked out.”

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Perspectives: 5 Questions for Trump About The Opioid Crisis; Pros And Cons Of Amazon’s Health Care Plan

Editorial pages highlight these important health care issues.

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Research Roundup: Microcephaly; Insurance Coverage; And Child Mortality

Each week, KHN compiles a selection of recently released health policy studies and briefs.

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State Highlights: Calif. Struggles To Expand Care For Mentally Ill Inmates; New Ore. State Hospital Chief Pledges To Raise Level Of Care

Media outlets report on news from California, Oregon, Colorado, Pennsylvania, Washington, Illinois, Texas, Maryland and Florida.

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Texas Lawmakers Aim To Reduce Maternity Mortality; Nurse Practitioner Bill Makes Headway In Va.

State legislatures also focus on telemedicine practices and medical marijuana.

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‘It’s Just So Scary’: Brett Favre Cringes Over Physical Toll Football Takes On Little Kids

The veteran NFL star says that with all the new information out about brain damage and concussions that can result from the sport, it’s hard to watch kids play it. In other public health news: gut microbes, seizures, tainted baby formula, Alzheimer’s and heart failure.

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Judge Overseeing 200 Suits Against Painkiller Makers Holds Summit To Get To Root Of Crisis

Taking Purdue Pharma’s most powerful pill off the market was one suggestion at the gathering held by U.S. District Judge Dan Polster. Meanwhile, those on the front lines of the epidemic are struggling to deal with the crisis without extra funding from the federal government.

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Effectiveness Of Flu Vaccine Looks Like It Will Be Even Lower Than CDC Experts Expected

Canadian researchers offer the first study on the vaccination’s effectiveness in North America this year. Their midseason estimate suggested that the H3N2 component of the vaccine is 17 percent effective at preventing infection.

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Bickering In Congress Created Vacuum That Tech Billionaires Decided To Fill With Health Initiative

The idea of businesses stepping in where they see government failing is nothing new. But will the initiative from Amazon, Berkshkire Hathaway and JPMorgan actually succeed with the odds stacked against it?

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