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Medicaid paid $5.5 million to cover health care services for dead Texans

But the state did not have adequate policies and procedures to identify when beneficiaries had died, the OIG report stated. For example, there were 77 individuals who did not have a date of death noted at all, and whose status could not be verified despite $850,587 in payments.

The inspector general’s  audit, which aims to identify waste, mismanagement and abuse of federal health services, ran from October 2016 through June 2017. The findings were presented to the state this fall, along with recommendations to prevent future issues.

A Medicaid challenge: Poor health, but a drive to improve – ABC News

It’s one of Medicaid’s challenges.

While low-income people are more likely to struggle with health problems such as smoking and depression, new research shows many are motivated to improve.

Thursday’s study from the Gallup-Sharecare Well-Being Index found that 40 percent of people on Medicaid say they’re in fair or poor health, compared with 11 percent of those with workplace coverage.

The analysis for The Associated Press also showed that Medicaid recipients are invested in their health, with 4 out of 5 saying they have a personal doctor, 3 out of 5 saying they eat healthy, and nearly half saying they exercise frequently.

Medicaid could gain by putting more emphasis on prevention, and stressing better coordination of care, experts say. Such strategies are already employed by many workplace health plans and by Medicare.

Medicaid is a federal-state program originally envisioned as a safety net for poor families and severely disabled people. Today, it covers about 1 in 5 Americans, at a total cost of about $600 billion annually. In states that expanded Medicaid under former President Barack Obama’s health law, it’s become the insurer for many low-income working adults. The Trump administration tried to unravel Obama’s expansion, but officials also say they want to better the health of Medicaid beneficiaries, not just pay medical bills.

“We now have emerging evidence in Medicare and commercial insurance of how care coordination and prevention can help patients with chronic conditions avoid costly hospitalizations and ER visits,” said Kavita Patel, a policy expert at the Brookings Institution who’s also a practicing physician. “This really should become the standard across Medicaid programs.”

In Stuttgart, Arkansas, Vickie Rose says Medicaid is helping her try to quit smoking for good, which would entail shutting down a decades-long habit that once reached three packs a day.

“I’m not going to be able to stay out of hospitals if I don’t take matters into my own hands,” said Rose, who’s in her early 60s and has worked jobs from factory supervisor, to retail, to staffing an animal shelter. Sometimes she travels 20 miles to the Mid-Delta community health center in neighboring Clarendon for smoking cessation meetings.

“Instead of waiting on everyone else, this time I’m going to do it for myself,” said Rose.

Thirty-six percent of Medicaid recipients said they smoked in the Gallup-Sharecare study, compared to 13 percent of those with employer or union health insurance, and 16 percent of Medicare beneficiaries.

The Gallup-Sharecare survey interviews about 500 people a day on health care issues, yielding a trove of data. The new analysis for AP compared health indicators among people with different types of coverage.

In other findings:

—25 percent of Medicaid beneficiaries said they are currently suffering from depression, compared with 7 percent of those with employer coverage.

—36 percent of people with Medicaid said they are obese, compared with 28 percent of people in employer plans, and 30 percent of those with Medicare.

Still, survey director Dan Witters said that’s only half the story.

“Just because they smoke more, doesn’t mean that they don’t have an interest in their health,” Witters said of those with Medicaid. “Their interest in their health is generally just as high as it is for other groups … although I think they are swimming upstream.”

Having a low income has long been associated with poor health, but Witters said on questions such as exercise frequency, eating healthy, and eating fruits and vegetables, the answers from Medicaid recipients generally tracked those of people with workplace coverage.

In one counterintuitive finding, 81 percent of Medicaid recipients said they had a personal doctor, about the same as 83 percent of those on employer plans. Because Medicaid pays less than private insurance or Medicare, a longstanding criticism is that beneficiaries might not be able to find a doctor who’ll see them. But most states now contract with private insurers to administer their programs, and those insurers must provide a physician network.

In theory the networks used by Medicaid insurers could also serve to promote prevention and care coordination, but Matt Salo, head of the National Association of Medicaid Directors, cautioned against a cut-and-paste approach to adapt strategies used by employers.

“The Medicaid population is not just an employer population with less income,” said Salo. “It is people who have health conditions.”

Salo said he was struck by the high rates of depression in the survey. “Depression is inextricably linked to physical health and the ability to engage effectively in the workforce,” he said.

Some states are trying to get ahead of the health challenges of their Medicaid beneficiaries. In Michigan, for example, people covered by expanded Medicaid complete an annual health assessment, somewhat similar to workplace wellness programs.

The Gallup-Sharecare results are based on telephone interviews conducted Jan. 2-Nov. 5, with a random sample of 147,465 adults, aged 18 and older, living in all 50 U.S. states and Washington. D.C.

For the total sample of national adults, the margin of sampling error is plus or minus 1 percentage point. For Medicaid recipients, the margin of sampling error is plus or minus 1.6 percentage points.

———

Online:

Gallup-Sharecare – https://tinyurl.com/yahmpox5

Poor Health, High Expectations for Medicaid, Analysis Finds

People on Medicaid are more prone to smoke, struggle with depression and obesity, or rate their own health as fair or poor. But that’s not the whole story.

A new study suggests that low-income Medicaid recipients are also invested in their health, with 4 out of 5 saying they have a personal doctor, 3 out of 5 saying they eat healthy, and nearly half saying they exercise frequently.

Experts say the analysis for The Associated Press by the Gallup-Sharecare Well-Being Index indicates that Medicaid could gain by putting more emphasis on prevention, and stressing better coordination of care. Such strategies are already employed by many workplace health plans and by Medicare.

Call it Medicaid’s health care challenge.

Trump: Order ‘Very Big Step’ to Dismantling ‘Obamacare’

President Donald Trump talked about his intent to dismantle former President Barack Obama’s health care law “step by step,” starting with an executive order he signed Oct. 12 to offer lower premiums and an upcoming one halting payment to insurers working under “Obamacare” policies.

(Published Friday, Oct. 13, 2017)

A federal-state program originally envisioned as a safety net for poor families and severely disabled people, Medicaid has grown to cover about 1 in 5 Americans, at a total cost of about $600 billion annually. In states that expanded Medicaid under former President Barack Obama’s health law, it’s become the insurer for many low-income working adults. The Trump administration tried to unravel Obama’s expansion, but top officials have also said they want to work to better the health of Medicaid beneficiaries, not just pay medical bills.

“We now have emerging evidence in Medicare and commercial insurance of how care coordination and prevention can help patients with chronic conditions avoid costly hospitalizations and ER visits,” said Kavita Patel, a policy expert at the Brookings Institution who’s also a practicing physician. “This really should become the standard across Medicaid programs.”

In small town Stuttgart, Ark., Vickie Rose says Medicaid coverage is helping her try to quit smoking for good, which would entail shutting down a decades-long habit that once reached three packs a day.

“I’m not going to be able to stay out of hospitals if I don’t take matters into my own hands,” said Rose, who’s in her early 60s and has worked jobs from factory supervisor, to retail, to staffing an animal shelter. Sometimes she travels 20 miles to the Mid-Delta community health center in neighboring Clarendon for smoking cessation meetings.

“Instead of waiting on everyone else, this time I’m going to do it for myself,” said Rose.

Thirty-six percent of Medicaid recipients said they smoked in the Gallup-Sharecare study, compared to 13 percent of those with employer or union health insurance, and 16 percent of Medicare beneficiaries.

Trump Announces Sweeping Tax Reform Plan

President Trump traveled to Indianapolis Wednesday to pitch his new tax reform plan.

“Under our framework, the vast majority of families will be able to file their taxes on a single sheet of paper,” the president said.

(Published Wednesday, Sept. 27, 2017)

The Gallup-Sharecare survey interviews about 500 people a day on health care issues, yielding a trove of data. The new analysis for AP compared health indicators among people with different types of coverage.

In other findings:

— Twenty-five percent of Medicaid beneficiaries said they are currently suffering from depression, compared with 7 percent of those with employer coverage.

— Forty percent of people with Medicaid said they were in fair or poor health, compared with 11 percent of those in employer plans and 31 percent of those on Medicare.

— Thirty-six percent of Medicaid beneficiaries said they are obese, compared with 28 percent of people in employer plans, and 30 percent of those with Medicare.

Still, survey director Dan Witters said that’s only half the story.

School Shooting Leaves 3 Dead in New Mexico

A shooting at Aztec High School in New Mexico has left three dead.

(Published 6 hours ago)

“Just because they smoke more, doesn’t mean that they don’t have an interest in their health,” Witters said of those with Medicaid. “Their interest in their health is generally just as high as it is for other groups…although I think they are swimming upstream.”

Having a low income has long been associated with poor health, but Witters said on questions such as exercise frequency, eating healthy, and eating fruits and vegetables, the answers from Medicaid recipients generally tracked those of people with workplace coverage.

In one counter-intuitive finding, 81 percent of Medicaid recipients said they had a personal doctor, about the same as 83 percent of those on employer plans. Because Medicaid pays less than private insurance or Medicare, a longstanding criticism is that beneficiaries might not be able to find a doctor who’ll see them. But most states now contract with private insurers to administer their programs, and those insurers must provide a physician network.

In theory the networks used by Medicaid insurers could also serve to promote prevention and care coordination, but Matt Salo, head of the National Association of Medicaid Directors, cautioned against a cut-and-paste approach that grafts on strategies used by employers.

“The Medicaid population is not just an employer population with less income,” said Salo. “It is people who have health conditions.”

Salo said he was struck by the high rates of depression in the survey. “Depression is inextricably linked to physical health and the ability to engage effectively in the work force,” he said.

Top News: Pearl Harbor Anniversary Commemorated

Some states are trying to get ahead of the health challenges of their Medicaid beneficiaries. In Michigan, for example, people covered by expanded Medicaid complete an annual health assessment, somewhat similar to workplace wellness programs.

“We’ve got some figuring out to do,” Salo said.

The Gallup-Sharecare results are based on telephone interviews conducted Jan. 2-Nov. 5, with a random sample of 147,465 adults, aged 18 and older, living in all 50 U.S. states and Washington. D.C.

For the total sample of national adults, the margin of sampling error is plus or minus 1 percentage point. For Medicaid recipients, the margin of sampling error is plus or minus 1.6 percentage points.

A Medicaid challenge: Poor health, but a drive to improve

It’s one of Medicaid’s challenges.

While low-income people are more likely to struggle with health problems such as smoking and depression, new research shows many are motivated to improve.

Thursday’s study from the Gallup-Sharecare Well-Being Index found that 40 percent of people on Medicaid say they’re in fair or poor health, compared with 11 percent of those with workplace coverage.

The analysis for The Associated Press also showed that Medicaid recipients are invested in their health, with 4 out of 5 saying they have a personal doctor, 3 out of 5 saying they eat healthy, and nearly half saying they exercise frequently.

Medicaid could gain by putting more emphasis on prevention, and stressing better coordination of care, experts say. Such strategies are already employed by many workplace health plans and by Medicare.

Medicaid is a federal-state program originally envisioned as a safety net for poor families and severely disabled people. Today, it covers about 1 in 5 Americans, at a total cost of about $600 billion annually. In states that expanded Medicaid under former President Barack Obama’s health law, it’s become the insurer for many low-income working adults. The Trump administration tried to unravel Obama’s expansion, but officials also say they want to better the health of Medicaid beneficiaries, not just pay medical bills.

“We now have emerging evidence in Medicare and commercial insurance of how care coordination and prevention can help patients with chronic conditions avoid costly hospitalizations and ER visits,” said Kavita Patel, a policy expert at the Brookings Institution who’s also a practicing physician. “This really should become the standard across Medicaid programs.”

In Stuttgart, Arkansas, Vickie Rose says Medicaid is helping her try to quit smoking for good, which would entail shutting down a decades-long habit that once reached three packs a day.

“I’m not going to be able to stay out of hospitals if I don’t take matters into my own hands,” said Rose, who’s in her early 60s and has worked jobs from factory supervisor, to retail, to staffing an animal shelter. Sometimes she travels 20 miles to the Mid-Delta community health center in neighboring Clarendon for smoking cessation meetings.

“Instead of waiting on everyone else, this time I’m going to do it for myself,” said Rose.

Thirty-six percent of Medicaid recipients said they smoked in the Gallup-Sharecare study, compared to 13 percent of those with employer or union health insurance, and 16 percent of Medicare beneficiaries.

The Gallup-Sharecare survey interviews about 500 people a day on health care issues, yielding a trove of data. The new analysis for AP compared health indicators among people with different types of coverage.

In other findings:

—25 percent of Medicaid beneficiaries said they are currently suffering from depression, compared with 7 percent of those with employer coverage.

—36 percent of people with Medicaid said they are obese, compared with 28 percent of people in employer plans, and 30 percent of those with Medicare.

Still, survey director Dan Witters said that’s only half the story.

“Just because they smoke more, doesn’t mean that they don’t have an interest in their health,” Witters said of those with Medicaid. “Their interest in their health is generally just as high as it is for other groups … although I think they are swimming upstream.”

Having a low income has long been associated with poor health, but Witters said on questions such as exercise frequency, eating healthy, and eating fruits and vegetables, the answers from Medicaid recipients generally tracked those of people with workplace coverage.

In one counterintuitive finding, 81 percent of Medicaid recipients said they had a personal doctor, about the same as 83 percent of those on employer plans. Because Medicaid pays less than private insurance or Medicare, a longstanding criticism is that beneficiaries might not be able to find a doctor who’ll see them. But most states now contract with private insurers to administer their programs, and those insurers must provide a physician network.

In theory the networks used by Medicaid insurers could also serve to promote prevention and care coordination, but Matt Salo, head of the National Association of Medicaid Directors, cautioned against a cut-and-paste approach to adapt strategies used by employers.

“The Medicaid population is not just an employer population with less income,” said Salo. “It is people who have health conditions.”

Salo said he was struck by the high rates of depression in the survey. “Depression is inextricably linked to physical health and the ability to engage effectively in the workforce,” he said.

Some states are trying to get ahead of the health challenges of their Medicaid beneficiaries. In Michigan, for example, people covered by expanded Medicaid complete an annual health assessment, somewhat similar to workplace wellness programs.

The Gallup-Sharecare results are based on telephone interviews conducted Jan. 2-Nov. 5, with a random sample of 147,465 adults, aged 18 and older, living in all 50 U.S. states and Washington. D.C.

For the total sample of national adults, the margin of sampling error is plus or minus 1 percentage point. For Medicaid recipients, the margin of sampling error is plus or minus 1.6 percentage points.

———

Online:

Gallup-Sharecare – https://tinyurl.com/yahmpox5

AP Exclusive: Poor health and high expectations for Medicaid

People on Medicaid are more prone to smoke, struggle with depression and obesity, or rate their own health as fair or poor. But that’s not the whole story.

A new study suggests that low-income Medicaid recipients are also invested in their health, with 4 out of 5 saying they have a personal doctor, 3 out of 5 saying they eat healthy, and nearly half saying they exercise frequently.

Experts say the analysis for The Associated Press by the Gallup-Sharecare Well-Being Index indicates that Medicaid could gain by putting more emphasis on prevention, and stressing better coordination of care. Such strategies are already employed by many workplace health plans and by Medicare.

Call it Medicaid’s health care challenge.

A federal-state program originally envisioned as a safety net for poor families and severely disabled people, Medicaid has grown to cover about 1 in 5 Americans, at a total cost of about $600 billion annually. In states that expanded Medicaid under former President Barack Obama’s health law, it’s become the insurer for many low-income working adults. The Trump administration tried to unravel Obama’s expansion, but top officials have also said they want to work to better the health of Medicaid beneficiaries, not just pay medical bills.

“We now have emerging evidence in Medicare and commercial insurance of how care coordination and prevention can help patients with chronic conditions avoid costly hospitalizations and ER visits,” said Kavita Patel, a policy expert at the Brookings Institution who’s also a practicing physician. “This really should become the standard across Medicaid programs.”

In small town Stuttgart, Ark., Vickie Rose says Medicaid coverage is helping her try to quit smoking for good, which would entail shutting down a decades-long habit that once reached three packs a day.

“I’m not going to be able to stay out of hospitals if I don’t take matters into my own hands,” said Rose, who’s in her early 60s and has worked jobs from factory supervisor, to retail, to staffing an animal shelter. Sometimes she travels 20 miles to the Mid-Delta community health center in neighboring Clarendon for smoking cessation meetings.

“Instead of waiting on everyone else, this time I’m going to do it for myself,” said Rose.

Thirty-six percent of Medicaid recipients said they smoked in the Gallup-Sharecare study, compared to 13 percent of those with employer or union health insurance, and 16 percent of Medicare beneficiaries.

The Gallup-Sharecare survey interviews about 500 people a day on health care issues, yielding a trove of data. The new analysis for AP compared health indicators among people with different types of coverage.

In other findings:

— Twenty-five percent of Medicaid beneficiaries said they are currently suffering from depression, compared with 7 percent of those with employer coverage.

— Forty percent of people with Medicaid said they were in fair or poor health, compared with 11 percent of those in employer plans and 31 percent of those on Medicare.

— Thirty-six percent of Medicaid beneficiaries said they are obese, compared with 28 percent of people in employer plans, and 30 percent of those with Medicare.

Still, survey director Dan Witters said that’s only half the story.

“Just because they smoke more, doesn’t mean that they don’t have an interest in their health,” Witters said of those with Medicaid. “Their interest in their health is generally just as high as it is for other groups…although I think they are swimming upstream.”

Having a low income has long been associated with poor health, but Witters said on questions such as exercise frequency, eating healthy, and eating fruits and vegetables, the answers from Medicaid recipients generally tracked those of people with workplace coverage.

In one counter-intuitive finding, 81 percent of Medicaid recipients said they had a personal doctor, about the same as 83 percent of those on employer plans. Because Medicaid pays less than private insurance or Medicare, a longstanding criticism is that beneficiaries might not be able to find a doctor who’ll see them. But most states now contract with private insurers to administer their programs, and those insurers must provide a physician network.

In theory the networks used by Medicaid insurers could also serve to promote prevention and care coordination, but Matt Salo, head of the National Association of Medicaid Directors, cautioned against a cut-and-paste approach that grafts on strategies used by employers.

“The Medicaid population is not just an employer population with less income,” said Salo. “It is people who have health conditions.”

Salo said he was struck by the high rates of depression in the survey. “Depression is inextricably linked to physical health and the ability to engage effectively in the work force,” he said.

Some states are trying to get ahead of the health challenges of their Medicaid beneficiaries. In Michigan, for example, people covered by expanded Medicaid complete an annual health assessment, somewhat similar to workplace wellness programs.

“We’ve got some figuring out to do,” Salo said.

The Gallup-Sharecare results are based on telephone interviews conducted Jan. 2-Nov. 5, with a random sample of 147,465 adults, aged 18 and older, living in all 50 U.S. states and Washington. D.C.

For the total sample of national adults, the margin of sampling error is plus or minus 1 percentage point. For Medicaid recipients, the margin of sampling error is plus or minus 1.6 percentage points.

Priority Health’s money-saving move will be hard on some Medicaid patients

GRAND RAPIDS, MI — Rebecca Joehlin is a frequent face at her neighborhood pharmacy, Maple Valley.

Her husband, Aaron, 26, has a host of serious health issues including seizures and fibromyalgia. He is on disability and Joehlin, also 26, cares for him full time.

Money is tight for this Barry County couple. She plots out trips to the pharmacy, grocery store and other necessities to make sure she has enough gas in the tank. Maple Valley Pharmacy is close enough to her Nashville home that she can walk in a pinch.

“We are on a fixed income,” Joehlin said. “Every appointment is budgeted. If there is an emergency with his medicine, that can be hard.”

Beginning this month, she drives 40 minutes round trip to pick up some of his prescriptions at a pharmacy in Hastings. She’ll still be able to pick up some medications that are covered directly by Medicaid from Maple Valley.

A change by her family’s health insurance carrier resulted in the need for the couple to find a pharmacy outside the small village in Barry County.

Joehlin worries that bouncing between two pharmacies will complicate managing her husband’s 10 medications, which can change if doctors determine a medication is losing its effectiveness in treating Aaron’s symptoms.

Maple Valley is one of at least 15 pharmacies that have been cut out of Priority Health’s new pharmacy network for Medicaid patients.

Escalating Costs

The new pharmacy rules are part of the Grand Rapids-based healthcare insurer’s efforts to respond to limited Medicaid funding. Pharmacy costs are a major contributor to the overall cost of health care, said Amy Miller, Priority Health spokeswoman.

Drug costs went up just over 11 percent last year, and are on pace to climb even higher in 2017.

Miller said she couldn’t say how much Priority Health is saving with its new network.

“We are challenged as a Medicaid provider to be good stewards of those funds and with pharmacy costs continuing to escalate at significant rates, this is one area we can proactively address health care costs,” Miller said.

To lower its costs, Priority Health has contracted with an outside entity, Express Scripts, one of the two largest pharmacy benefit managers in the country, which processes prescriptions claims for patients.

Medicaid patients account for about 10 percent of Priority Health’s membership — or about 12,500 people.

Only 5 percent of the Priority Health’s Medicaid patients — about 325 people  — won’t have access to a pharmacy within 5 miles of their home, Miller says. She adds that the network still includes locally owned pharmacies but declined to share the list of pharmacists.

Priority Health has a contract with the state to provide insurance to nearly 125,000 Medicaid patients across 20 counties in west and southwest Michigan.  

Owned by the Grand Rapids-based Spectrum Health System, Priority Health is the state’s second largest health insurance company. The nonprofit is one of Michigan’s biggest providers of Medicaid coverage, according to Dominick Pallone, executive director of the Michigan Association of Health Plans.

With medication accounting for 20 percent of premiums, more insurers are looking for ways to reduce pharmacy costs.

“The growth has been dramatic over the last decade,” said Pallone. “Some of that increase is because of the development of new life-saving drugs. Unfortunately, those drugs come at a high cost.”

Insurers, especially those providing Medicaid coverage, can’t restrict enrollees access to these expensive new drugs, he said. So they have to look for other ways to reduce costs.

The Lansing organization represents 13 health-care insurers that provide Medicaid, Medicare and professional coverage in the Michigan. Together, those members have more than an 80 percent market share for the state’s Medicaid patients.

‘Bizarre deal’

Medicaid patients who want to stay with their current pharmacy have to drop Priority Health and pick up a different HMO. There are six health-care options in Barry County and the other 12 counties that make up Region 4.

Shane McNeil’s Maple Valley Pharmacy, at 219 Main St., is the only pharmacist in the rural community of less 2,000 people. McNeil, a pharmacist and a former assistant Barry County prosecutor, says he is outraged with Priority Health’s treatment of his poorest customers.

In a letter to about 100 Medicaid patients, he urged them to stand up to the bureaucracy that is going to turn their lives upside down by changing HMOs.

“Make yourself heard. This coverage is paid by taxpayer dollars, for your welfare and care — not their bank accounts,” read part of his letter.

As of Dec. 1, his pharmacy no longer had access to fill many prescriptions for his Priority Health Medicaid patients.

“If they have new scripts or valid refills still remaining at our store, we can fill and comp enough meds so they avoid some health crisis, but we cannot feasibly do this on the meds that cost $5-$10+/tablet,” he said in an email. 

Cherry Health, which operates a clinic near Hastings for low-income residents, says some of its patients are impacted by Priority Health’s pharmacy network change.

The organization is stepping in to help patients with the transition, said Dr. Leslie Pelkey, Cherry Health’s sssociate chief medical officer.

Don Eichholz, pharmacist and owner of Hasting Pharmacy, says some of his patients were in tears when they received letters announcing they could no longer fill prescriptions at his pharmacy.

“We do extra things that other places aren’t going to do,” said Eichholz, referring to packaging of medicines, extra time explaining and free delivery.

He estimates he’ll lose about 100 patients, which is less than 5 percent of his customer base.

The change was made without giving pharmacists a chance to bid on a contract.

“It’s a bizarre deal and we are all truly confused,” said Eichholz. “They are telling our patients that we didn’t sign a contract. We weren’t offered one.”

His pharmacy, at 400 W. State St., is right across the street from Walgreens, which is one of Priority Health’s designated pharmacies.

Biggest impact on rural communities

Usually, pharmacists are paid the cost of medication and a dispensing fee. But in some cases, the prices set by the benefit manager are less than the cost of the medicine. A retailer like Walgreens has deeper pockets for loss leaders.

Walgreens is a good fit for the Priority Health pharmacy program because of the chain’s nationwide locations which means customers can refill prescriptions anywhere they travel in Michigan and across the country, said Jim W. Graham, a spokesman for the Illinois-based pharmacy chain. 

“We offer many locations that are open 24 hours a day and our pharmacies offer benefits such as drive-through service and private consultation rooms,” Graham said in email. “Increasingly our customers find it invaluable to access our services through an excellent personalized online experience and through an our easy to use mobile app.”

The change comes as Priority Health is switching to a pharmacy manager with a “very closed network,” according to Larry Wagenknecht, chief executive officer of the Michigan Pharmacists Association.

The Lansing organization counts locally owned, chain and hospital pharmacies among its members. So far, the MPA has heard from about 15 pharmacies with Priority Health patients who aren’t in Priority Health’s new Medicaid pharmacy network. Many are rural.

The new rules don’t affect Medicare, coverage provided to those 65 years or older. But they restrict Medicaid patients, who qualify for the coverage because their income is below the federal poverty line.

“The issue that we are most concerned about is the disruption to patients in their care,” said Wagenknecht. “Today, many Medicaid patients frequently have transportation issues. They picked their pharmacy because they can walk to it.”

Michigan requires Medicaid contractors to consider distance, travel time and access to transportation when selecting providers for enrollees, but doesn’t have any specific requirements.

“This is the first time we’ve seen this,” Wagenknecht said of the Priority Health change. “There is a fear that this may spread out.”

East Mental Health overbilled Medicaid, court papers allege


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Health plans line up to snare Medicaid contracts

TALLAHASSEE — More than 20 managed-care organizations are seeking state Medicaid contracts that could be worth up to $90 billion over a five-year period.

A review of state records shows that a total of 21 managed-care organizations are seeking to be part of Florida’s Medicaid program, which provides health coverage for the poor.

Southeast Florida, specifically Broward, Miami-Dade and Monroe counties, attracted the most interest, with 17 managed-care organizations submitting bids to the state Agency for Health Care Administration by a Nov. 1 deadline.

Conversely, a largely rural area of North Florida drew the least amount of interest from managed care plans, with 10 responding to the state’s invitation to negotiate.

Agency for Health Care Administration officials did not respond to a request for comment on the number of health plans seeking the contracts.

Trying to hold down costs and improve the quality of care, the Legislature in 2011 passed a sweeping rewrite of the state’s Medicaid program, requiring nearly all beneficiaries, from the cradle to the grave, to enroll in managed-care plans.

The state issued the latest invitation to negotiate, the second under the Medicaid managed-care program, this summer and expects to announce the winning bids in April 2018. It will transition from the current health plans under contract to new plans at the end of 2018, according to state documents.

Currently, 11 managed-care organizations participate in the Medicaid program. All of those plans submitted bids for the second invitation to negotiate, commonly known as an ITN.

Amerigroup, which is part of the Anthem group of health plans, responded to the ITN but not under that moniker. Company officials said they responded to the ITN under the Simply Healthcare brand and, if chosen, will participate in the program under that name, not Amerigroup.

The state has more than 4 million Medicaid beneficiaries, and 85 percent of them are enrolled in the state’s managed-care program, according to Medicaid Deputy Secretary Beth Kidder.

More than 3.1 million are enrolled in what’s considered the “managed medical assistance” portion of the system, and another 98,420 Medicaid beneficiaries — including many seniors — are enrolled in the “long term care” portion.

Florida’s Medicaid program is the fourth largest in the nation in terms of number of people. Expenditures in the program for fiscal year 2017-2018 are nearly $27 billion, according to Kidder.

For contracting purposes, the state is divided into 11 regions. State law establishes a minimum and maximum number of plans that can operate in each of the 11 regions.

Regions 1 and 2, which encompass the western Panhandle, must have at least two managed-care plans. Miami-Dade County, on the other hand, is authorized to have a minimum of five managed-care plans and as many as 10.

Moreover, the law makes clear that if a “provider sponsored network” is competing and submits a responsive bid, the state, must choose it as one of the plans. PSNs are provider owned and operated and don’t require an HMO license from the Florida Office of Insurance Regulation.

Of the health-care organizations that submitted responses to the ITN, 10 want to participate statewide.

The Northwest part of the state has traditionally struggled to attract managed-care plans. But 12 plans responded to the ITN in Region 1, which includes the far western Panhandle, and 12 plans responded in Region 2, which includes other parts of the Panhandle and the Big Bend area.

 

 

Iowa mental health providers concerned with Medicaid instability

DAVENPORT, Iowa — As the clock winds down, thousands of Iowans who rely on Medicaid are scrambling to find a back-up plan.

AmeriHealth Caritas, one of the three companies managing Iowa’s Medicaid system, is ending its services on November 30, 2017.

“It feels like a crisis right now, trying to get this resolved quickly, because as of December 1st, which is Friday, thousands of Iowans will not have coverage,” said Chris McCormick Pries, clinical director at Vera French Community Mental Health Center.

On Wednesday, mental health professionals at Vera French shared their concerns with Iowa lawmakers, explaining that mental health patients will be especially vulnerable.

“Medicaid is such a big part of their life, and it’s what covers their mental services to a large degree,” said Richard Whitaker, CEO of Vera French.

Whitaker called on legislators to bring stability to the state’s Medicaid system.

“Number one, they can solve this MCO (managed care organization) issue. We’ve got to get to where Medicaid funding is more stable, like it used to be,” said Whitaker.

The State has agreed temporarily oversee benefits for some Iowa Medicaid patients who were dropped by AmeriHealth. The State plans to manage about 10,000 people who tried to switch to one of the other providers, Amerigroup.

Those patients will remain under state management until Amerigroup can build up enough capacity to take over the additional cases.

However, the uncertainly surrounding the system has caused frustration for both patients and healthcare workers.

“Is that going to leave a number of Iowans uninsured? And that’s not just for mental health. What if they fall and break their leg? What if they have heart disease?” said McCormick Pries. “This is going to impact people immediately, and that becomes very problematic.”

It’s still unclear how long affected patients will receive coverage through the state’s fee-for-service model.

The state used the reimbursement payment system before it privatized in 2016.

Medicaid Expansion Takes A Bite Out Of Medical Debt

As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state Legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

Since graduating from college more than 20 years ago, Wilson has mostly had to pay out-of-pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson said.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with a deeply discounted rate from a nearby hospital, she couldn’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson said. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as an illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past-due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th-highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golberstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7-percentage-point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points from 2012 to 2015.

Medicaid, as opposed to private insurance, is the key, said the Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, they aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell said.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the administrator for the Centers for Medicare Medicaid Services, she and Tom Price, then head of the Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma said that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what we’re seeing in our paper,” Caswell said. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she said, she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she said.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson said. “It’s hard losing your dreams.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

Several States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor

81141_tightrope-1-7e9f9c532fce90b4f6aa372b44327e6230d378d4-s1100-c15 Several States Roll Back 'Retroactive Medicaid,' A Buffer For The Poor

If you’re poor, uninsured and have a bad car wreck or fall seriously ill, there’s a chance in most states to enroll for Medicaid after the fact. If you qualify for Medicaid, the program will pay your medical bills going back three months.

This “retroactive eligibility” provides financial protection as patients await approval of their Medicaid applications. It protects hospitals, too, from having to absorb the costs of caring for these patients.

But a growing number of states are rescinding this benefit. On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed.

Each state had to secure approval by the federal government to make the change.

Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.

All four states — New Hampshire, Indiana and Arkansas, in addition to Iowa — have expanded Medicaid under the federal health law, which allowed states to include in their Medicaid program adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person.

81141_tightrope-1-7e9f9c532fce90b4f6aa372b44327e6230d378d4-s1100-c15 Several States Roll Back 'Retroactive Medicaid,' A Buffer For The Poor

In theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.

The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.

State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll.

It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and mean hospitals will be picking up the cost of more uncompensated care when patients can’t pay.

Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children who are younger than a year old. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.

“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child Family Policy Center in Des Moines, whose organization opposed the change.

Patients who are undergoing treatment for severe health conditions may neglect to apply immediately for Medicaid; that could leave them financially responsible for days or months of care they received before they submitted their application, even though they may have been eligible for Medicaid all along.

That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassessed every year.

“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.

In addition, complications can arise for people who might need Medicaid coverage for long-term care services.

81141_tightrope-1-7e9f9c532fce90b4f6aa372b44327e6230d378d4-s1100-c15 Several States Roll Back 'Retroactive Medicaid,' A Buffer For The Poor

Others argue that a 90-day retroactive eligibility guarantee is counterproductive. “We’re trying to get people to behave more responsibly, not less responsibly,” says Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky says.

In contrast to the Iowa waiver, the ones in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)

Kentucky has a request pending that, like Iowa’s, would eliminate retroactive Medicaid eligibility except for pregnant women and infants younger than age 1.

Under federal law, officials are permitted to waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years.

Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, says Bonnyman.

“There was no reason for anybody to be uninsured except undocumented immigrants,” says Bonnyman. “It didn’t seem to have the potential for harm.”

But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.

Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah.

Bonnyman says his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family,” he says, “one or two days in the hospital is enough to ruin you financially.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter @mandrews110.

California health insurers make billions through Medicaid

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Medicaid is rarely associated with getting rich. The patients are poor, the budgets tight and payments to doctors often paltry.

But some insurance companies are reaping spectacular profits off the taxpayer-funded program in California, even when the state finds their patient care is subpar.

Health Net, a unit of Centene Corp., the largest Medicaid insurer nationwide, raked in $1.1 billion in profits from 2014 to 2016, according to state data obtained by Kaiser Health News. Anthem, another industry giant, turned a profit of $549 million from California’s Medicaid program, known as Medi-Cal, in the same period.

Overall, Medicaid insurers in the Golden State made $5.4 billion in profits from 2014 to 2016, in part because the state paid higher rates during the inaugural years of the nation’s Medicaid expansion under the Affordable Care Act. Last year, they made more money than all Medicaid insurers combined in 34 other states with managed care plans.

“Those profits are gigantic — wow,” said Glenn Melnick, a health economist and professor at the University of Southern California.

Jennifer Kent, California’s Medicaid director, said that health plan profits were higher than anticipated during the ACA expansion. But she said the state expects to recoup a significant amount of money within the next year, once audits are complete and retroactive rate adjustments are made.

“We’re going to be taking a lot of money back. We’re talking billions of dollars,” Kent said in an interview this month. No one should think “these plans just made off like bandits, and we’re not going to see them again. … We are very mindful we use taxpayer money.”

Health insurers that profited substantially from Medi-Cal defend their good fortune. They say these surpluses follow losses in earlier years, and they always run the risk of red ink if medical costs spike.

“The expansion may have been a little rich in the beginning,” said Jeff Myers, chief executive of the Medicaid Health Plans of America, an industry trade group. But “you are starting to see margins come back down.”

More than 1 in 3 Californians, or 13.5 million people, is covered by Medi-Cal — more than the entire population of Pennsylvania. About 80 percent of those in California’s program are enrolled in a managed-care plan, in which insurers receive a fixed rate per person to handle their medical care. The goal is to control costs and better coordinate care.

In anticipation of the Affordable Care Act rollout, officials in California and elsewhere boosted their payments to managed care companies because they expected Medicaid costs to increase as newly insured patients rushed to the doctor or emergency room after going years without coverage. But those sharply higher costs didn’t materialize — and insurers pocketed more money as a result.

Moreover, California’s payments keep flowing steadily even when patients fare poorly. Two of the most profitable insurers in California — Centene and Anthem — run some of the worst-performing Medicaid plans, according to medical quality scores and complaints in government records.

California officials acknowledge they need to do a better job of connecting money and quality.

“We are looking at alternative payment methods and those types of things that we can do to help improve and to tie quality to payment,” said Lindy Harrington, a deputy director at the California Department of Health Care Services, which runs Medi-Cal. “But as you can imagine, it’s a difficult ship to turn.”

Before the ACA expansion, Medi-Cal plans collectively were barely in the black, with $226 million of net income for 2012 and 2013 combined. Traditionally, these insurance contracts have yielded slim profit margins of 2 to 3 percent. California said it aims for 2 percent when setting rates, based on prior claims experience and projected costs.

But in the years since the health law took effect, many health insurers have posted margins two or three times that benchmark.

Centene’s Health Net unit in California enjoyed a profit margin of 7.2 percent from 2014 to 2016. Centene acquired Health Net for $6.3 billion in March 2016. Anthem’s profit margin in the Medi-Cal program was 8.1 percent for 2014 to 2016.

Health Net said that its profit margins are comparable to other Medi-Cal health plans and that the company has made major investments to improve Californians’ health and access to care.

Anthem declined to comment on its financial results. The company said that it has worked with the state to meet the needs of Medi-Cal patients by extending clinic hours and helping with transportation to appointments. The company said it’s committed to providing “high quality care to our Medi-Cal members.”

Overall, Centene has 7 million Medicaid enrollees across the country, with about 2 million in California. Anthem is close behind with 6.4 million Medicaid members, about 1.3 million in the state.

The federal government footed the entire bill for Medicaid expansion during the first three years, instead of taking the usual approach of splitting the costs with states. Now, states have more incentive to rein in spending, as their share of the costs grows to 10 percent by 2020.

Sen. Ron Johnson, R-Wis., has demanded that California and seven other states account for how they spent federal Medicaid expansion dollars. Johnson, chairman of the Senate Homeland Security and Governmental Affairs Committee, asked California officials in a letter Sept. 27 whether they have conducted audits and requested information on insurance company payouts.

In her Oct. 11 response, Kent said the state spent $6,181 per expansion enrollee in 2015, below the national average of $6,365. She also said the state’s rates paid to insurers for enrollees in the expanded program have decreased significantly since 2014.

Kent wrote that “California is a cost-efficient Medicaid program.”

Chad Terhune and Anna Gorman are senior correspondents for Kaiser Health News, an editorially independent service of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Email: cterhune@kff.org, agorman@kff.org Twitter: @chadterhune, @annagorman

Provision In Health Care Bill Passed By Mass. Senate Would Allow A ‘Medicaid Buy-In’

There’s a provision tucked into a sweeping health care bill approved by the Mass. Senate that would let anyone, no matter how much you earn, buy insurance through the state’s Medicaid program.

Medicaid, which is free insurance for low and moderate income residents, typically has lower costs than private plans and can be better coverage for some services, like mental health. No states currently sell insurance through Medicaid, but this year, a handful of states are or have considered it.

Michael Sparer, who teaches health policy and management at Columbia University’s Mailman School of Public Health, has published a number of articles in support of a so-called Medicaid buy-in, a movement he calls “Medicaid for More.” Sparer joined WBUR’s Deborah Becker to discuss the provision passed by the Senate.

Interview Highlights

On the benefits of a Medicaid buy-in

At this point the question that Democrats and others are engaged with is how do we reach the remaining uninsured.  They cannot afford private insurance. They’re either deterred from buying on the Exchange [called the Health Connector in Massachusetts] or they’ve decided not to buy on the Exchange, and I think a Medicaid buy-in provides a reasonable option for them.

On criticisms of the provision

There’s no question that Medicaid does not pay physicians and hospitals as much as commercial insurance or as much as Medicare for that matter. Hospitals and community health centers and clinics treat a lot of Medicaid patients and they survive on that Medicaid reimbursement. Obviously the rates are a bit lower. And obviously doctors are going to complain about that but I don’t think it’s necessary to raise rates although I think that’s an important issue that a proposal like this needs to grapple with.

On the political viability of “Medicaid for More”

I don’t think it’s a backdoor route to single payer coverage. We have a private insurance industry and an employer sponsored insurance payment system that’s going to stay here in the United States. The question, what do we do about the remaining 25 to 30 million uninsured, and I think Medicaid provides a perfectly reasonable vehicle to take care of those additional individuals.

On ensuring quality of care

I think the evidence shows that Medicaid beneficiaries received perfectly reasonable access and quality to care. There’s a talking point among conservatives that Medicaid is a substandard program and I think that might have been true in the 60s and 70s. But Medicaid has evolved significantly as a program. Medicaid today serves over 75 million Americans. The quality is fine in the Medicaid program and the popularity of the program is evidence of that.

There are a lot of folks looking at Medicaid.  In Maine voters just approved an expansion of their Medicaid program. But the top Trump administration official said Medicaid has already expanded beyond the people it was created to help. And now you have some states saying let’s take a new look at Medicaid and maybe make it an even bigger option. Can Medicaid withstand all of those competing pressures?

There is a really interesting and important national debate underway today about the future of the Medicaid program. Over the last 30 years, Medicaid has continued to grow despite a tax on it from conservative leaders. My own view is that Medicaid is quite a politically resilient program and it’s going to survive the challenges.

The Health 202: Medicaid won bigly in Tuesday’s elections

THE PROGNOSIS

b3c6d_imrs The Health 202: Medicaid won bigly in Tuesday's elections

Supporters of Medicaid expansion celebrate their victory, Tuesday, Nov. 7, 2017, in Portland, Maine. (AP Photo/Robert F. Bukaty)

Here’s the health-care takeaway from Tuesday’s elections: Voters across two states resoundingly sided with Medicaid expansion, sending a clear rebuke to Republicans who spent the past year trying to whittle down spending on the program.

Up in Maine, voters said “heck, yeah,” to growing the low-income health insurance program, making their state the first in the nation to embrace via the ballot box Obamacare’s vision of Medicaid coverage for Americans earning slightly above the federal poverty line.

And across the river in Virginia — a state where the GOP-led House of Delegates had for years blocked Medicaid expansion despite efforts by Gov. Terry McAuliffe (D) — voters overwhelmingly sided with a whole slate of Democratic candidates who pressed for finally adopting that part of the Affordable Care Act.

“All the folks who fought me on Medicaid expansion, they all got blown out,” McAuliffe said at the election-night party for Gov.-elect Ralph Northam, who promised throughout his campaign to lead the state in expanding the program.

Maine Gov. Paul LePage (R) has vowed to throw roadblocks in the way as much as he’s able, and there’s still a chance Republicans will be able to stymie Democrats if they retain a slim majority in the Virginia House. According to the most recent vote counts, there are 51 Republican seats and 49 Democratic seats in that body; that could shift toward Democrats as several close races are recounted over the next few days.

Paul Goldman, a longtime Virginia Democratic strategist, told me he thinks Medicaid expansion is a “done deal” in Virginia, even if Republicans retain their slim majority.

“All you need is a couple of Republicans, and the question is who is going to stand up and block it,” Goldman said. “It’s inconceivable to me that Medicaid expansion won’t happen.”

Regardless, the Maine and Virginia outcomes signal a trajectory toward an even broader embracing of the ACA by states, even as congressional Republicans cling to dimming hopes they will one day be able to dismantle President Barack Obama’s 2010 health-care law.

House Budget Democrats did some gloating:

Center on Budget and Policy Priorities’ Jacob Leibenluft previewed the takeaways in a tweet last month:

The Post’s Greg Sargent:

Rep. Gene Green (D-Tex.):

Rep. Jim Cooper (D-Tenn.):

With the addition of Maine and Virginia, the number of states offering their low-income residents expanded Medicaid would reach 34. Activists who organized the Maine vote are trying to pull together similar efforts in Utah and Idaho.

“I would think the Republicans would take a sober second look after these election results,” said Tim Jost, a health law professor at Washington and Lee University and a member of the Virginia Organizing Project’s health-care committee.

Here’s something else that should give Republicans pause. Health care was the top concern by far for Virginia voters even though it didn’t get a lot of airtime during the campaign. Thirty-nine percent said a candidate’s position on health policy was the top factor in deciding how they’d vote, according to exit polls. Gun policy was the next-biggest issue, but only 17 percent of voters picked that as their biggest concern.

Connecticut Sen. Chris Murphy (D), a fierce gun-control advocate from the state where the Newtown school shooting occurred:

And don’t forget that marketplace premiums are through the roof in Virginia. Even with that situation, a majority of voters sided with Northam, who embraced the ACA, over his opponent Ed Gillespie, who had talked about trying to reduce premiums and out-of-pocket expenses.

These are “health-care voters,” writes actor Blake Cooper Griffin, who urged Americans in a HuffPost op-ed to make health care their No. 1 issue in next year’s midterm elections.

“After everything Trump and congressional Republicans have thrown at us, and as we saw in last night’s election results, we have taken on a new role — health-care voters,” Griffin wrote.

The Healthcare.gov website. (AP Photo/Alex Brandon)

–We’re into Week 2 of the ACA’s open enrollment period. In this section, we’re featuring letters from readers who have been enrolling in marketplace coverage. Here’s today’s:

“I was born with Cerebral Palsy, but was able to work for over 26 years…Since my state didn’t expand Medicaid, I applied on the Healthcare.gov exchange and have been using the ACA for insurance ever since. Since I am low income, I receive a subsidy. I became depressed and suicidal when Donald Trump won the election, because I knew eliminating the ACA was at the top of his agenda. After many months of anxiety, and after my 2017 health insurance company left the market this year, I have another plan for 2018 and pay only $50.34 a month on premiums and have a $100 deductible. My heart goes out to those who do not get the subsidy. I know the uncertainty and the elimination of the [cost sharing reduction payments] have made premiums and deductibles much higher. My premium went from $612 last year to $1,243 this year. The subsidies need to be expanded to everyone until the cost of healthcare and insurance goes down. I will be eligible for Medicare in October of 2018 but the ACA has been a life saver.”        –Patricia Cox, Nebraska

b3c6d_imrs The Health 202: Medicaid won bigly in Tuesday's elections

(John Moore/Getty Images)

AHH: The drug naltrexone might be highly effective at helping people break their heroin addictions — even more so than the mainstay drugs buprenorphine and methadone used to treat addiction by substituting for heroin in the brain. Use of naltrexone — which instead halts opioids from binding the opioid receptor, thus making drug use less rewarding — gave somewhat better results for opioid-addicted patients in a study at the Norwegian Center for Addiction Research, The Post’s Keith Humphreys reports.

Researchers observed patients suffering from opioid addiction who were either treated with a daily dose of buprenorphine or monthly injections of the extended-release naltrexone. After three months, most patients receiving either type of treatment had stopped using opioids, but the rate of abstinence was statistically higher for patients on extended-release naltrexone, Keith reports.

The findings are depicted in the chart below:

b3c6d_imrs The Health 202: Medicaid won bigly in Tuesday's elections

Additionally, patients using naltrexone were also more satisfied with their care and more likely to recommend treatment as the drug “made them feel protected against relapse and overdose,” Keith writes. 

Signage is displayed outside the Humana Inc. office building in Louisville, Ky. (Luke Sharrett/Bloomberg)

OOF: Humana plans to slash about 2,700 jobs in a cost-cutting measure that comes as many insurers continue to grapple with uncertainty over the future of the health-care industry.  The Louisville-based company’s CFO Brian Kane said yesterday on a third-quarter earnings call that the move would save “hundreds of millions of dollars,” The Courier Journal reported. 

Humana is working on a turnaround after steep losses from selling individual policies under Obamacare and a scrapped plan to merge with industry rival Aetna, although CEO Bruce Broussard said the cuts were part predated the failed merger. 

b3c6d_imrs The Health 202: Medicaid won bigly in Tuesday's elections

(Photo by Joe Raedle/Getty Images)

OUCH: Repealing Obamacare’s individual mandate to buy coverage would save less money than previously estimated by the Congressional Budget Office — now just $338 billion over a decade instead of the agency’s previous estimate of $416 billion. That’s because the CBO now considers the mandate less effective at convincing people to buy coverage than it had previously estimated. 

The agency says 13 million fewer people would be uninsured without the mandate, down from 15 million people under previous projections. Fewer people getting coverage means fewer people accessing government subsidies to help cover the costs. And that translates to less government spending. 

This creates an uncomfortable situation for Republicans, who had previously blasted CBO for overestimating the mandate’s effects. But now, just when they’re considering using repeal to help fund a tax overhaul, the CBO is responding to their concerns and thus scoring rolling back the measure accordingly. If you want to read more about how all this works, check out Tuesday’s The Health 202, where I previewed the CBO’s shift.

Sen. Rand Paul (R-Ky.) said he has six broken rids after he was attacked over the weekend. (Photo by Chip Somodevilla/Getty Images)

— The story around the attack on Sen. Rand Paul over the weekend gets curiouser and curiouser (as Winnie the Pooh would say, per my toddler). The Kentucky Republican tweeted yesterday that he’s recovering from six broken ribs (not five, as initially reported) and fluid has built up around his lungs:

 

Initially, the New York Times and others pointed to landscaping as the root cause of the altercation between Paul and his next-door-neighbor, Rene Boucher. Boucher tackled Paul at his home last Friday, leaving him with his injuries. The Times cited three Kentucky Republicans who said the attack was the result of a landscaping dispute, although a friend who visited Paul on Saturday also told the Times that Paul was “still unsure why he was attacked.”

Then, yesterday, Paul’s chief strategist, Doug Stafford, appeared to call the landscaping theory into question, tweeting a link to a Breitbart story that casts doubt on it:

Boucher’s motive is still unclear, even though he has basically admitted to the attack, my colleague Aaron Blake writes. Aaron lays out a number of puzzling questions that neither Paul nor Boucher nor their attorneys have answered. Like what the dispute Boucher’s attorney described as “trivial” was really about — and why they couldn’t explain whether it really is trivial. Stafford sure didn’t seem to describe it as trivial. “It is a pending, serious criminal matter involving state and federal authorities,” Stafford said. “We won’t have any further comments at this time.”

“The wording there — ‘involving state and federal authorities’ — is also somewhat intriguing,” Aaron writes. “Why are the federal authorities going to be involved? We only know so far of the arrest warrant in Kentucky. Is it just because Paul is a U.S. senator and they are inherently involved? Federal law, for what it’s worth, makes attacking federal officials like members of Congress punishable by up to 10 years in prison if ‘personal injury results’…There are a lot more questions than answers right now. And the whole thing seems to be getting more opaque rather than less.”

—Boucher is due to appear in court today to face charges, my colleague Ed O’Keefe reports. He was charged with fourth-degree assault and released last Saturday on $7,500 bond. Kentucky State Police said Monday that Boucher may face more serious charges given the extent of Paul’s injuries.

Read the Breitbart piece as well as one in The Washington Examiner, which posits a political theory of the case.

— Do Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) feel like broken records yet? Maybe, but they’re continuing to petition Congress to pass legislation funding the extra Obamacare payments to insurers to cover their cost-sharing discounts for the next two years — payments the Trump administration has ceased making. Alexander took to the Senate floor yesterday to again make his case, pointing to skyrocketing marketplace premiums in his home state of Tennessee. Congress should pass the bipartisan measure before President Trump returns from his stint in Asia, he urged.

“I hope that when the president returns from Asia, he will go to his desk and find a nice package there with a bow on it, presented by Senator Murray and me, 24 of us in the United States Senate, Republicans, Democrats, that does exactly what the American people I think want us to do — lower premiums, avoid chaos, work together, take a step in the right direction, and let’s see if we can help the American people in that way,” Alexander said.

b3c6d_imrs The Health 202: Medicaid won bigly in Tuesday's elections

Rep. Diane Black, (R-Tenn.). (AP Photo/J. Scott Applewhite).

—Yesterday, a group of abortion-opposing lawmakers and activists pressured leaders in Congress to include language in a year-end spending package allowing health-care providers to sue if they’re pressured to perform an abortion over their personal objections. Existing law already prohibits discrimination against any health-care providers who won’t participate in abortions, but the Conscience Protection Act would enable providers to also take legal action if they feel coerced or face discrimination for not participating in the procedure, The Hill reports.

Rep. Diane Black (R-Tenn.), chair of the House Budget Committee, urged swift action on her legislation. “It is time for this comprehensive, reasonable and modest bill to be voted on so we can allow millions of Americans who believe as I do in the sanctity of life to abide by those beliefs without having them trampled on by their own government,” she said.

March for Life President Jeanne Mancini said this: “It is un-American for someone to be forced to go against what they know in their conscience is wrong. I can’t think of anything more un-American than forcing a person – especially a health care professional who is responding to a life saving mission —to take part in the destruction of life.”

A few more select reads from The Post and beyond:

Today

  • The Washington Post hosts Secretary of Veterans Affairs David Shulkin for a discussion that will include his department’s efforts to curb the veterans’ suicide rate, address post-traumatic stress disorder and other health concerns.

Coming Up

  • The American Enterprise Institute holds an event on the opioid crisis with Rep. Greg Walden (R-Ore.) on Nov. 13.

  • STAT holds an event on the FDA on Nov. 13.

What if Hillary Clinton had won? From The Post’s Depatment of Satire:

Watch Rep. Steve Scalise (R-La.) challenge Rep. Sam Johnson (R-Tex.) to a scooter race:

Former President Bill Clinton chats with Conan O’Brien:

 

Watch the official trailer for Steven Spielberg’s movie about The Post:

State to pay down employee health insurance, Medicaid bills – The State Journal

Billions of dollars in old state employee health insurance bills and Medicaid bills will be paid off in the next few days with money from bonds issued to cut into the state’s nearly $17 billion bill backlog, Comptroller Susana Mendoza said Wednesday.

Combined with federal matching funds available for some of the bills, a total of nearly $9 billion can be used to pay down medical-related bills, many of which are subject to late payment penalties.

“Important to all of the providers, many of them, who have been waiting far too long to get paid, will begin to see immediate relief,” Mendoza said at a Statehouse news conference. “Tonight, the first round of major payments on paying down the bill backlog will be taking effect.”

As part of the budget deal in July, lawmakers authorized the state to issue up to $6 billion in bonds to pay down old bills accumulated before July 1. Mendoza said that because the state got a very good interest rate on the bonds, there effectively is $6.4 billion to apply to old bills.

Mendoza said $2 billion was going out Wednesday toward old state employee group health insurance bills. Another $2.5 billion was being applied to Medicaid bills.

On Monday, another $1.9 billion will be used to pay down group health insurance bills.

By the time it’s done, Mendoza said, about two-thirds of the backlogged group health insurance bills will be paid. Her office said between $1.3 and $1.5 billion will remain in the hopper.

“We’re still going to owe group health,” Mendoza said. “It’s not enough money to cover, even remotely, all of our bills, even when we’re done paying this $6.4 billion total.”

Medicaid bills, which are mostly subject to late payment penalties and also qualify for federal matching funds, that were accumulated prior to July 1 will be paid off.

None of the bond money is being earmarked to pay bills owed to human service agencies and other vendors owed money by the state. Mendoza said she is sympathetic to those entities, but said bills owed to human services agencies generally don’t qualify for late payment penalties. She said the fiscally prudent thing to do is pay off old bills that qualify for late payment penalties. The state owes about $900 million in late payment penalties.

Mendoza also said that her office has given priority to human services payments as much as possible during the state’s budget crisis.

Mendoza said it is difficult to say exactly what the bill backlog will look like in another week after the payments are made because bills continue to arrive in her office, some of them that the office didn’t know existed. That could change under legislation approved in the Senate Wednesday.

The Senate voted 52-3 to override Gov. Bruce Rauner’s veto of the Debt Transparency Act, legislation pushed by Mendoza to give her a clearer picture of state finances. The bill requires state agencies to report monthly on bills being held in the agencies awaiting payment. Currently, those bills only have to be reported once a year. Mendoza noted that the Rauner administration disclosed $2.8 billion in spending no one knew existed when the state marketed the bill payment bonds.

She said a clear picture of state bills is vital to deal with the state’s financial issues.

“We, the legislature and my office, can’t do the job we’ve been elected to do without this full transparency,” Mendoza said.

Rauner vetoed the bill because he said it was an attempt by Mendoza to micromanage his agencies and he said the agencies themselves didn’t have the capability to report bills on a monthly basis.

Mendoza didn’t buy it.

“The numbers are available, they know what they are and they should report them,” Mendoza said. There’s no excuse for it.”

Contact Doug Finke: doug.finke@sj-r.com, 788-1527, twitter.com/dougfinkesjr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Health 202: Work requirements are on their way for Medicaid

THE PROGNOSIS

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, gave a sweeping speech yesterday outlining her approach to the Medicaid program. (Photo by Jabin Botsford/The Washington Post)

Seema Verma declared to a roomful of state Medicaid officials yesterday that they can — for the first time — impose work requirements on recipients of the health program for low-income Americans. But guess who the director of the Centers for Medicare and Medicaid Services will really have to convince of this shift? The courts.

Over the next few months, watch for CMS to approve requests from a half-dozen GOP-run states that want to mandate work or community volunteering for those enrolled in Medicaid. Verma essentially promised to give the go-ahead in a sweeping speech yesterday at the National Association of Medicaid Directors in which she laid out several ways the Trump administration wants to put its mark on the program – most dramatically through requiring Medicaid beneficiaries to get a job. It’s a 180-degree swing from the approach taken by the Obama administration, which had slammed the brakes on states attempting to go that direction.

If CMS gives the go-ahead — probably most immediately to Kentucky and then perhaps Indiana — there will almost certainly be lawsuits challenging the federal government’s ability to allow states to create these kinds of mandates for a program that is supposed to make medical care accessible to people who can’t afford it.

The central question will be: Do work requirements go against the original purpose of the Medicaid program when Congress created it in 1965?

At the time, President Lyndon B. Johnson said the aim of approving an insurance program for the poor “is not only to relieve the symptoms of poverty, but to cure it and, above all, to prevent it.” Verma recited that very quote during her speech Tuesday — indicating that she and other CMS officials probably have thought about how they’d argue for work requirements before a judge.

“If we are going to live up to the promise of Medicaid, we need to do more than simply pay for health-care services,” Verma said. “It’s why we believe community engagement requirements are actually in the spirit of Johnson’s idea.”

Verma and other advocates for employment requirements say that enrollees should be incentivized to find employment, as jobs obviously improve peoples’ lives. They point to studies showing that adding work requirements to Temporary Assistance for Needy Families (TANF), the federal welfare program, increased labor force participation for single mothers and lowered their poverty rates.

Verma even used the term “soft bigotry” to describe those who oppose more requirements for enrollees.

“Believing that community engagement requirements do not support the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” she said. “Those days are over.”

Kentucky Gov. Matt Bevin (R) speaks at the NRA convention. Kentucky could be the first state to get permission from the feds to attach a community involvement requirement to Medicaid enrollment. (Photo by Scott Olson/Getty Images)

Kentucky Medicaid Commissioner Stephen Miller, who is expecting CMS to approve his state’s waiver request soon, told me that requiring people to be more involved in their communities (Kentucky is requesting permission to require certain “employment activities” for Medicaid enrollees) has a direct connection to better health outcomes.

“If you look at different pyramids about what impacts health status, you’re looking at access to care, you’re looking at genetics, you’re looking at social determinates,” he said. “Social determinates are the biggest one by far — the personal choices people make. We’re trying to put them in a position where they can make better choices.”

It’s hard to argue that employment doesn’t have a big effect on well-being. Studies show that being unemployed is closely linked to higher rates of depression. Work provides not only financial stability, but emotional stability, too, as people feel they have a purpose in life.

But whether low-income Americans should be required to find a job to get Medicaid coverage is another question, and one that the Trump administration could find challenging to defend before a judge.

For one thing, a majority of Medicaid recipients already have jobs, opponents of work requirements say. About three-quarters of Medicaid recipients live in a family with at least one part-time or full-time worker, according to the Center on Budget and Policy Priorities.

Rather than prompting unemployed Medicaid recipients to find jobs, work requirements could have the opposite effect of causing them to drop health insurance entirely. Indeed, Kentucky has projected that 95,000 fewer people would be enrolled in its program at the end of five years (although some of that could be from people finding jobs that provide health coverage).

And while Congress enacted work requirements for TANF, it has not done so for Medicaid. The Medicaid statute says nothing about requiring enrollees to have a job. Nor does the Affordable Care Act, which allows states to expand Medicaid, mention anything about beneficiaries working.

As Verma laid out her case yesterday, she pointed to a troubling statistic — that labor force participation among men ages 25 to 54 has declined dramatically over the past 60 years.

But is it Medicaid’s job to try to fix that? The jury’s still out.

The Healthcare.gov website. (AP Photo/Andrew Harnik, File)

–Healthcare.gov has been up and running for a full week, and we’re expecting an enrollment snapshot from the Department of Health and Human Services soon. Stay tuned, because initial reports of sign-up figures indicted they’re surprisingly robust, even given the reduced marketing and outreach efforts.

It’s unclear exactly what is driving the interest, although it could be partly due to the increased role that outside brokers are able to play this year due to an HHS rule change. My colleagues Juliet Eilperin and Colby Itkowitz checked in with the handful of states running their own marketplaces to get a sense of how the first few days of enrollment went for them.

Here are some highlights:

–Washington Health Benefit Exchange: Chief marketing officer Michael Marchand said the mixed messages and doomsday forecasts leading up to Nov. 1 may have actually helped increase marketplace visitation — which is up 20 percent — because it forced people to ask themselves how the changes will affect them personally.

–Covered California: Executive Director Peter Lee said people who tend to sign up for coverage as enrollment starts tend to need insurance the most, and the critical question is how many young, healthy Americans will enroll some weeks from now. While federal enrollment this year lasts just 45 days, several states are allowing residents to sign up for ACA plans into January. Roughly 5,900 Californians selected plans last Wednesday, a 25 percent increase over last year.

–New York: Department of Health spokeswoman Erin Silk said more than 140,000 people visited the state’s website and 73,000 placed calls to its customer service line the first three days.

–HealthSource R.I.: Director Zach Sherman said enrollment this year is five times higher in the first week than it was last year. An early outreach campaign by the state seems to have paid off with more than 500 people enrolling, compared to 109 people in the first week last year.

–D.C. Health Link: The District’s marketplace has seen the highest volume of first-week activity since the first year of enrollment. On just the first day last week, nearly 9,300 people visited the DC Health Link website to shop for plans, compared to 6,727 last year and just over 2,000 in years two and three.

–Yesterday, I invited readers of The Health 202 to send me stories about their experiences with Healthcare.gov and the other state-run marketplaces — and you responded! Over the next five weeks of open enrollment, I’ll feature one or two of your letters every day. Please keep ’em coming — the good, the bad and the ugly. (I also accept mild sedatives for my 3-year-old and awesome cocktail recipes.)

Today’s letter:

“I am so grateful someone is finally noticing the families like us who make “too much” to qualify for a subsidy under Obamacare. We make just slightly over the limit to qualify, and here in Northern Colorado, the least expensive plan for our family of four is a Kaiser Bronze plan with a $13,000 family deductible and 50% co-insurance.  The premium is $1,574, which sounds reasonable until you consider we are paying 50% of all costs after the $13,000 deductible.

“What is most frustrating for us is why we need Obamacare: My husband, an engineer, lost two jobs to outsourcing in the last 10 years. Now all he can find is ‘contract work’ that doesn’t offer benefits. My company was acquired by a Canadian hedge fund, and I was ‘downsized’ too. Our COBRA runs out in mid-December. I’m still looking for a permanent position that will offer enough hours to qualify for health insurance. Many companies offer part-time work, contract work, or hours that are just below the limit to get health benefits. Let’s face it, companies do not want to offer employees health insurance anymore. It’s expensive for them too. Between the outsourcing, downsizing and insurance costs, we feel like we are falling further and further behind every year.”  –Denise DeVore, Loveland, Colorado

bbc77_imrs The Health 202: Work requirements are on their way for Medicaid

United Medical Center, D.C.’s public hospital. (Photo by Salwan Georges/The Washington Post)

AHH: Yesterday, the D.C. Council narrowly voted 7-6 not to extend a multimillion-dollar contract for the company running the District’s only public hospital, United Medical Center, after a string of stories by The Post’s Peter Jamison exposing recent incidents raising questions about patient safety. 

“The vote came after an intense flurry of last-minute lobbying by the Bowser administration on behalf of the firm, whose leaders were political donors to the mayor in 2014,” Peter writes. “Veritas, a company that has been in business less than three years, was awarded a no-bid contract to run United Medical Center — at a fee of $300,000 per month — in the spring of 2016.”

Scrutiny of the hospital grew in August, when the city’s health regulators abruptly shut down the hospital’s nursery and delivery rooms without disclosing a reason. The Post obtained, and published, a letter from D.C. Department of Health Director LaQuandra Nesbitt showing that regulators had uncovered dangerous medical errors in the treatment of pregnant women and newborns.

The following month, The Post reported that at the time of its most recent contract review, Veritas was falling short in 41 percent of its performance metrics and had generated just $1.07 million of the $9 million in revenue the firm anticipated by altering hospital operations.

Then in October, Peter reported on the case of Warren Webb, a 47-year-old resident of UMC’s on-site nursing home who died of a heart attack after calling out for help and being left on the floor by his nurse. The hospital also did not report key details of that incident to regulators.

bbc77_imrs The Health 202: Work requirements are on their way for Medicaid

Devin Kelley, the suspect in the shooting at the First Baptist Church in Sutherland Springs, Texas, on Sunday. (Texas Department of Public Safety via AP)

OOF: The 26-year-old alleged gunman who opened fire on a Texas church over the weekend escaped from a mental health facility in 2012 while he was in the Air Force, our colleagues Eli Rosenberg, Mark Berman and Wesley Lowery report. That was just one of the warning signs in the life of Devin Kelley, who’d also been convicted for beating his then-wife and stepson, charged with animal cruelty and investigated for domestic assault and threats against his family members.

“Interviews and police and military documents depict Kelley as a distressed — and at-times, violent — man in the years before authorities said he walked into the First Baptist Church in Sutherland Springs, Tex., and fired round after round into the congregation gathered for Sunday morning services,” Eli, Mark and Wesley write.

“Police in El Paso reported that five years before the church massacre, officers were dispatched to a bus terminal after Kelley escaped from a nearby behavioral facility,” they continue. “Officers wrote they were told Kelley, who was serving in the Air Force, ‘was a danger to himself and others’ at the time and ‘was also facing military criminal charges.’ While it is unclear why Kelley was at the behavioral facility and whether he ever faced military discipline for the threats, he was court-martialed that same year and convicted of abusing his wife and stepson.”

–The report about Kelley’s stint at a mental health facility follows President Trump’s comments Monday on the shooting where he insisted that “mental health is our problem here,” not access to guns. But some experts have been warning against always assuming that mental health is directly tied to violence. “It really hurts a lot because one of the things we always have said in the aftermath of these kinds of tragedies is, you cannot equate mental illness with violence,” Paul Gionfriddo, the CEO of Mental Health America told Axios.

–And The New York Times studied the links between various factors and mass shootings and found that the highest correlation by far is the amount of guns in the a certain country. The United States has more guns — 270 million — that any other nation in the world, and the highest number of mass shooters from 1996 to 2012. 

OUCH: Trump’s nominee for a top health post at the Pentagon yesterday called it “insane” that a civilian is able to purchase a semi-automatic weapon, even as he acknowledged his comments might get him in trouble with Republicans.

“I’d also like to — and I may get in trouble with other members of the committee — just say, you know, how insane it is that in the United States of America a civilian can go out and buy … a semi-automatic assault rifle like an AR-15, which apparently was the weapon that was used,” Dean Winslow, a physician and nominee to be the assistant secretary of defense for health affairs, said during his Senate Armed Services confirmation hearing, per Politico. “I think that’s an issue not as much for this committee, but elsewhere.”

Texas officials have described the weapon used by the gunman as a Ruger AR-556, an assault-style rifle that is a variant of the AR-15 and similar to what is used by the military.

Winslow, a retired Air Force colonel, was answering a question by Sen. Jeanne Shaheen (D-N.H.) about whether he believed the Texas gunman should have received a “dishonorable discharge” instead of the less severe “bad conduct” discharge. After his remarks, Sen. John McCain (R-Ariz.) warned: “Dr. Winslow, I don’t think that’s in your area of responsibility of expertise.”

bbc77_imrs The Health 202: Work requirements are on their way for Medicaid

Supporters of Medicaid expansion celebrate their victory, Tuesday, Nov. 7 in Portland, Maine. (AP Photo/Robert F. Bukaty)

–Man, Maine. Yesterday, the state became the first in the nation to accept the Affordable Care Act’s Medicaid expansion through a ballot question. Voters — by a nearly 20-percentage point margin — said they want to expand the program, in a pretty clear rebuke to their Republican Gov. Paul LePage, who had five times vetoed legislation to do so.

“What happened in Maine could provide momentum for progressives to get voters in other states to expand Medicaid, such as Alaska and Idaho, where groups have already started similar Medicaid expansion ballot initiatives next year,” The Post’s Amber Phillips reports.

“This will send a clear signal to where the rest of the country is on health care,” Jonathan Schleifer, executive director of the Fairness Project which helped put together the ballot initiative, told Amber. Schleifer said his group had spent the past year in Maine — and some $2 million — laying the groundwork.

“Looking at what progressives were able to accomplish by ballot initiatives in 2016, we asked ourselves what do we do for biggest challenge out there, which is the threat to Affordable Care Act,” Schleifer said. “We asked ourselves: What can we do to not just hold the line but to advance things?”

From Politico’s Dan Diamond:

Organizing for Action communications director Jesse Lehrich:

Think Progress’s Judd Legum:

bbc77_imrs The Health 202: Work requirements are on their way for Medicaid

Sen. Susan Collins (R-Maine) speaks at a news conference. (AP Photo/Robert F. Bukaty, File)

–The Medicaid vote just about guarantees the state’s Republican senator, Susan Collins, will never vote for a bill repealing and replacing the ACA if it rolls back Medicaid expansion. Collins had already been highly skeptical of all the GOP health-care bills; now Maine’s decision to join the ranks of Medicaid expansion states could make it impossible for her Senate colleagues to ever sway her.

Matt Viser, Washington bureau chief for the Boston Globe:

–Medicaid expansion may soon become more likely in Virginia, with major victories by Democrats yesterday. Democrat Ralph Shearer Northam, a pediatrician, incidentally, won a hard-fought race to become Virginia’s 73rd governor, beating Republican Ed Gillespie 54 to 45 percent. Democrats also seized the lieutenant governor and attorney general offices and made significant gains in the House of Delegates, perhaps even winning the majority depending on the outcome of several ongoing recounts.

Voters said health care was what they most cared about, according to an NBC News poll, despite the fact it wasn’t a top issue for the candidates. Thirty-seven percent of respondents cited health care as the most important issue to their vote, followed by gun policy (17 percent), immigration (14 percent) and taxes (14 percent) and abortion (9 percent). 

A few other good reads from The Post and beyond:

POST PROGRAMMING: The Washington Post hosts Secretary of Veterans Affairs David Shulkin for a discussion that will include his department’s efforts to curb the veterans’ suicide rate, address post-traumatic stress disorder and other health concerns on Thursday.

Today

  • Kaiser Health News holds an event on advance care planning.
  • Axios hosts an event on a new era in cancer innovation with former Vice President Joe Biden and former first lady Jill Biden.

  • The House Education and the Workforce Subcommittees on Early Childhood, Elementary, and Secondary Education and Higher Education and Workforce Development hold a joint hearing on opioids.

  • The House Energy and Commerce Subcommittee on Health holds a hearing on MACRA and alternative payment models.
  • Rep. Chris Smith (R-N.J.) will host a press conference on the Conscience Protection Act of 2017 this morning with several other lawmakers.

Coming Up

  • The American Enterprise Institute holds an event on the opioid crisis with Rep. Greg Walden (R-Ore.) on Nov. 13.

  • STAT holds an event on the FDA on Nov. 13.

Republicans are trying humor to promote their tax plan:

House Speaker Paul Ryan says “enforcing the laws we got on the books” on guns is the solution:

Here’s what happened in Virginia’s 2017 election:

Stephen Colbert said Ed Gillespie would lose in Virginia thanks to Donald Trump Jr.: 

Overnight Health Care: Trump officials to allow work requirements for Medicaid

The Trump administration will encourage states to pursue work requirements for certain Medicaid beneficiaries, a top official said Tuesday.

The remarks by Centers for Medicare and Medicaid Services (CMS) administrator Seema Verma would signal a significant departure from the Obama administration’s approach to such requests.

Several states have already proposed work requirements, and Verma’s comments indicate a willingness to fast-track those approvals.

The Obama administration repeatedly said work requirements were inconsistent with Medicaid’s mission of providing health care to low-income people.

According to Verma, allowing states to impose work requirements is an essential part of granting them more flexibility. Making Medicaid beneficiaries work will ensure they bring themselves out of poverty.

“Let me be clear to everyone in this room, we will approve proposals that promote community engagement activities,” Verma said. She defined “community engagement activities” as working, receiving job training, going to school or volunteering.

The speech was Verma’s most detailed explanation of the direction she wants to take the program. She also sharply criticized the Obama administration’s opposition to work requirements.

“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Verma said, according to prepared remarks of a speech to the National Association of Medicaid Directors.

“Those days are over.”

Read more here.

 

FDA chief: Keep defense medical approvals in our sphere 

Food and Drug Administration (FDA) Commissioner Scott Gottlieb said the agency should retain control over medical device and drug approvals after a provision in the defense policy bill would give this power to the Defense Department for soldiers.

Gottlieb pointed to an alternative proposal he supports that, he said, would accelerate drug and device approvals at the FDA for the battlefield.

“That’s important because we think we provide a level of oversight that helps ensure the safety of products, helps follow-up to make sure that if there are adverse events we’re monitoring them, we’re collecting that information,” Gottlieb said at The Hill event Tuesday on opioid prevention sponsored by the Pharmaceutical Care Management Association, a trade group for pharmacy benefit managers. “So we think keeping it within the FDA context is the right thing.”

At issue is a provision of the Senate’s National Defense Authorization Act now going through conference committee. The measure would allow the Pentagon to sign off on unapproved medical devices and drugs to be used on military personnel for emergency use, which Politico first reported Monday. Approving drugs and devices is currently the FDA’s responsibility.

Gottlieb said alternative language has been shared with both chambers’ Armed Service Committees and that he is willing to make modifications to this language.

Read more here.

 

GOP unlikely to repeal ObamaCare mandate in tax measure 

The House is unlikely to repeal the mandate to buy insurance under ObamaCare as part of its tax-reform bill, GOP sources say, though the issue could return down the road.

President Trump and conservative lawmakers are pushing for the individual mandate to be repealed in the bill, but House Ways and Means Committee Chairman Kevin BradyKevin Patrick BradyUS wins trade case over ‘dolphin safe’ tuna labeling Overnight Finance: House adopts Senate budget, taking step to tax reform | GOP worries Trump feuds will endanger tax plan | Trump talks NAFTA withdrawal with senators | Treasury calls for looser oversight of insurers The Hill’s 12:30 Report MORE (R-Texas) has expressed worry that the controversial measure would jeopardize the broader tax-reform bill, given the Senate’s failure on health care earlier this year.

“It hasn’t ever been in the [House] bill,” said one Republican on the Ways and Means Committee who has been taking part in the negotiations. “I expect that it will be added somewhere down the sausage-making venture.”

Read more here.

 

 

GOP senator says CBO moving the goalposts on ObamaCare mandate

Sen. Mike LeeMichael (Mike) Shumway LeeDallas Morning News: Cornyn ‘betrays’ GOP by backing Roy Moore GOP senators ask Trump for meeting on biofuels mandate Jeff Flake knows the GOP is in trouble, and so does the base MORE (R-Utah) on Tuesday sharply criticized the Congressional Budget Office (CBO) for shifting its estimates of the effect of ObamaCare’s individual mandate as GOP lawmakers consider new ways of repealing the rule.

Lee’s comments come after Sen. Bill CassidyWilliam (Bill) Morgan CassidyAdvocates pan Trump effort on opioid crisis Conservatives scoff at bipartisan health bill Week ahead: Senators push to win support for ObamaCare deal MORE (R-La.) told The Hill earlier on Tuesday that he has been informed the CBO is now projecting that repealing the mandate will provide significantly less savings than it previously projected.

Some Republicans are pushing to repeal the mandate in their tax reform bill to help pay for cuts, so a projection of less savings would make mandate repeal less useful.

“Just a few months ago the CBO had us playing by one set of rules for debating health care policy and now we are being told those rules have been completely changed for tax policy,” Lee said in a statement.

Lee has a bill that would require the CBO to publish information on how it comes up with its analyses.

Read more here.

 

Notre Dame reverses decision to end no-cost contraceptive coverage 

The University of Notre Dame has reversed its decision to end free contraceptive coverage for employees.

The insurance company used by employees at Notre Dame will keep a plan with contraceptive coverage with no co-pay, US News World Report reported Tuesday.

“The University of Notre Dame, as a Catholic Institution, follows Catholic teaching about the use of contraceptives and engaged in the recent lawsuit to protect its freedom to act in accord with its principles,” the university said in an email Tuesday.

Read more here.

  

Op-eds in The Hill 

Faulty assumptions linking mental illness to violence is the wrong approach

The ACA won’t work without the individual mandate. We must keep it.

 

What we’re reading

Pain relievers worked as well as opioids in ER patients (Associated Press)

Six ways Amazon could up-end the pharmacy business (Bloomberg)

With online medical marijuana, it’s buyer beware (Reuters)

 

State by state 

Nevada gets low marks for inmate health spending (Las Vegas Review-Journal)

Wisconsin: Employer, health care groups clash over workers’ compensation (lacrossetribune.com)

This election day, Ohio is a bellwether in the national fight over drug costs (statnews.com)

Maine Voters Will Decide If They Want More Access To Medicaid

c47ab_maine-1-67c99202283b28571c8c523c51bbde948f18a9a5-s1100-c15 Maine Voters Will Decide If They Want More Access To Medicaid

Kathleen Phelps, who lacks health insurance, speaks in favor of expanding Medicaid at a news conference in Portland, Maine on Oct. 13, 2016.

Patty Wight/Maine Public Radio


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Patty Wight/Maine Public Radio

Kathleen Phelps, who lacks health insurance, speaks in favor of expanding Medicaid at a news conference in Portland, Maine on Oct. 13, 2016.

Patty Wight/Maine Public Radio

Maine is one of 19 states that rejected Medicaid expansion through the Affordable Care Act. But on Tuesday, it could be the first to approve it at the ballot box.

Question 2 asks Maine voters if they want to provide roughly 70,000 Mainers with health care coverage by expanding eligibility of Medicaid, known as MaineCare. It provides health coverage for people living at or near the poverty line.

The national battle over Medicaid expansion began with a 2012 U.S. Supreme Court decision that conservatives originally hoped would hobble the Affordable Care Act, President Obama’s signature legislative achievement.

But instead of repealing the law’s individual mandate requiring that most Americans obtain health insurance, the court upheld it. The court then struck down a provision requiring all states to expand eligibility of Medicaid.

That surprise 2012 court ruling shifted the political battle. While the GOP-led House of Representatives would go on to take over 50 symbolic ACA repeal votes, progressive and conservative activists descended on state legislatures to fight over Medicaid expansion.

The intensity of those battles illustrated the importance of Medicaid expansion as a component of the ACA. The program not only lowered the number of people without health insurance it, also has arguably made repealing the health care law harder.

Medicaid funding cuts included in Senate bills to repeal ACA were the primary reason that Sen. Susan Collins, R-Maine, broke ranks with most of the GOP to oppose the bills.

“First, both proposals make sweeping changes and cuts in the Medicaid program. Expert projections show that more than $1 trillion would be taken out of the Medicaid program between the years 2020 and 2036,” she said in September. “This would have a devastating impact to a program that has been on the books for 50 years and provides health care to our most vulnerable citizens, including disabled children and low-income seniors.”

Collins has also cited the impact on Maine’s rural hospitals, which are heavily dependent on Medicaid reimbursement payments.

Effects On The Uninsured

Architects of the federal health care law sought to lower the number of people without health insurance by requiring most Americans to have coverage. The law also lets states expand access to Medicaid, a federal program run by the states and funded with a mix of state and federal money.

In 2013, Maine’s legislature voted to expand the state’s program, and Republican Gov. Paul LePage vetoed the bill. It was the first of a half dozen vetoes.

About 9 percent of Maine residents lacked insurance in 2016, comparable to 8.6 percent in the 31 states and the District of Columbia that expanded Medicaid. That could be because the state had expanded its program in 2002 and 2003.

The number of people enrolled in Medicaid has been dropping, as the LePage administration moved aggressively to restrict eligibility

In 2012, there were 345,000 Mainers receiving Medicaid. There were 268,000 through June of this year, according the Department of Health and Human Services. The state spends $2.6 billion on the program, with two-thirds of that coming from the feds.

Meanwhile, roughly 70,000 Mainers have fallen into what’s known as the ACA coverage gap. The gap occurs in the 19 states that did not expand Medicaid.

The ACA originally conceived Medicaid expansion as a bridge between low-income adults already eligible for Medicaid coverage and those who could qualify for subsidies to purchase their own individual plans.

But without expansion, thousands of Mainers neither qualify for subsidies nor Medicaid.

Most of the 70,000 people who would gain coverage if Question 2 passes earn up to 138 percent of the federal poverty level — about $16,000 a year for an individual and $34,000 for a family of four.

For And Against

Conservative and progressive activists have engaged in a long, pitched fight over Medicaid expansion. The arguments for and against expansion haven’t changed much, and neither have the methods of persuasion.

Conservatives repeatedly note that Maine was an early expander of Medicaid in 2002-2003. They claim that the state’s uninsured rate was unaffected by increasing eligibility and that the program became a budget buster, creating deficits when state revenues declined during the economic downturn.

Progressives counter that early expansion helped keep Maine’s uninsured rate steady while other states saw a surge. Additionally, they argue that the higher federal reimbursement rate offered through the ACA protects the state.

If expansion passes, the federal government will initially cover 94 percent of the cost. That ratchets down to 90 percent by 2020 and stays at that level, as long as Congress doesn’t cut reimbursements.

But Brent Littlefield with the anti-expansion Welfare to Work PAC says there’s still a cost to Maine taxpayers.

“The current plan would have state taxpayers paying between $50 million to $100 million per year,” he says.

The expansion debate has been marked by its heated rhetoric. Opponents have repeatedly called would-be recipients “able bodied,” while calling the proposal “welfare expansion” — descriptions designed to tap sharply divided public perceptions of people receiving public assistance.

Proponents, meanwhile, have been stressing the human impact, focusing on personal stories of those who would benefit from the program.

High Stakes

Question 2 has been billed by some as a final resolution, but it could also be a litmus test for public sentiment about the Affordable Care Act. GOP repeal efforts have not polled well. While the ACA has not been a centerpiece of the proponents’ arguments for expansion, an affirmative expansion vote on Nov. 7 could be spun as a tacit public endorsement for the health care law, because Medicaid is such a key component.

Locally, the political stakes are high. LePage has been a leading critic of expansion, and he’s taking an active role in opposing Question 2. Defeating Question 2 could validate the governor’s stance. Conversely, an affirmative vote could deal a blow to the governor’s full-court press against the law.

But a victory for supporters of Question 2 could be fleeting. The state legislature changed, delayed or attempted to repeal all four of the ballot initiatives that voters approved last year.

Steve Mistler is chief political correspondent for Maine Public Radio.

Enriched by the poor: California health insurers make billions through Medicaid

By Chad Terhune and Anna Gorman, California Healthline

Medicaid is rarely associated with getting rich. The patients are poor, the budgets tight and payments to doctors often paltry.

But some insurance companies are reaping spectacular profits off the taxpayer-funded program in California, even when the state finds their patient care is subpar.

A unit of Centene Corp., the largest Medicaid insurer nationwide, raked in $1.1 billion in profits from 2014 to 2016, according to state data obtained and analyzed by Kaiser Health News. Anthem, another industry giant, turned a profit of $549 million from California’s Medicaid program in the same period.

Overall, Medicaid insurers in the Golden State made $5.4 billion in profits from 2014 to 2016, in part because the state paid higher rates during the inaugural years of the nation’s Medicaid expansion under the Affordable Care Act. Last year, they made more money than all Medicaid insurers combined in 34 other states with managed care plans.

19fca_1107_nws_ldn-l-medi-cal-gfx3 Enriched by the poor: California health insurers make billions through Medicaid
Kaiser Health News graphic

“Those profits are gigantic — wow,” said Glenn Melnick, a health economist and professor at the University of Southern California.

Alan Sager, a health-policy professor at Boston University, was surprised — and dismayed.

“California is being wildly open handed and excessively generous with insurers,” he said.

Jennifer Kent, California’s Medicaid director, said that health plan profits were higher than anticipated during the ACA expansion. But she said the state expects to recoup a significant amount of money within the next year, once audits are complete and retroactive rate adjustments are made.

“We’re going to be taking a lot of money back. We’re talking billions of dollars,” Kent said in an interview last week. No one should think “these plans just made off like bandits and we’re not going to see them again … We are very mindful we use taxpayer money.”

Health insurers who profited substantially from Medicaid, known as Medi-Cal in California, defend their good fortune. They say these surpluses follow losses in earlier years, and they always run the risk of red ink if medical costs jump.

“The expansion may have been a little rich in the beginning,” said Jeff Myers, chief executive of the Medicaid Health Plans of America, an industry trade group. But “you are starting to see margins come back down.”

More than 1 in 3 Californians, or 13.5 million people, are covered by Medicaid — more than the entire population of Pennsylvania. About 80 percent of those in California’s program are enrolled in a managed-care plan, in which insurers receive a fixed rate per person to handle their medical care. The goal is to control costs and better coordinate care.

In anticipation of the Obamacare rollout, officials in California and elsewhere boosted their payments to managed-care companies because they expected Medicaid costs to increase as newly insured patients rushed to the doctor or emergency room after going years without coverage. But those sharply higher costs didn’t materialize — and insurers pocketed more money as a result.

Moreover, California’s payments keep flowing steadily even when patients fare poorly. Two of the most profitable insurers in California — Centene and Anthem — run some of the worst-performing Medicaid plans, according to medical quality scores and complaints in government records.

“If there is that much extra money sloshing around in California, then it’s worth asking whether you could expect more in terms of performance,” said Andy Schneider, a research professor with Georgetown University’s Center for Children and Families.

California officials acknowledge they need to do a better job of connecting money and quality.

“We are looking at alternative payment methods and those types of things that we can do to help improve and to tie quality to payment,” said Lindy Harrington, a deputy director at the California Department of Health Care Services, which runs Medi-Cal. “But as you can imagine, it’s a difficult ship to turn.”

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Kaiser Health News graphic

Medi-Cal Suddenly A Cash Cow

Before the ACA expansion, California’s Medicaid plans collectively were barely in the black, with $226 million of net income for 2012 and 2013 combined. Traditionally, these insurance contracts have yielded slim profit margins of 2 percent to 3 percent. California said it aims for 2 percent when setting rates, based on prior claims experience and projected costs.

But in the years since the health law took effect, many health insurers have posted margins two or three times that benchmark.

Centene’s Health Net unit in California enjoyed a profit margin of 7.2 percent from 2014 to 2016. Centene acquired Health Net for $6.3 billion in March 2016. Anthem’s profit margin in California’s Medicaid program was 8.1 percent for 2014 to 2016.

Investors have cheered those results. Shares in Anthem have more than doubled since January 2014, when the Medicaid expansion began. Centene shares are up 50 percent since the company purchased Health Net last year.

“We have proven our ability to provide high-quality, cost-effective healthcare to state beneficiaries while saving states money and delivering strong returns to our shareholders,” Michael Neidorff, Centene’s chairman and chief executive, told investors in February.

In a statement, Health Net said its profit margins are comparable to other Medi-Cal health plans and the company has made major investments to improve Californians’ health and access to care.

Anthem declined to comment on its financial results. The company said in a statement that it has worked with the state to meet the needs of Medicaid patients by extending clinic hours and helping with transportation to appointments. The company said it’s committed to providing “high quality care to our Medi-Cal members.”

Charles Bacchi, chief executive of the California Association of Health Plans, said they deserve some credit for making the Medicaid expansion work.

“The expansion was an incredible lift and we can’t do it for nothing,” he said. “It would be a shame to look at one snapshot in time and ignore the success of California’s expansion that has helped millions of people.”

Overall, Centene has 7 million Medicaid enrollees across the country, with about 2 million in California. Anthem is close behind with 6.4 million Medicaid members, about 1.3 million in the state.

With so many people’s healthcare at stake, state officials say they did not want to risk having health plans come up short during the expansion.

As it turned out, they need not have worried.

A nationwide study published in September found that average monthly spending on newly eligible Medicaid enrollees was 21 percent less than the amount spent on those who were already eligible. It helped that many of the new enrollees appeared to use fewer medical services than those already on the program, researchers said.

In 34 states and the District of Columbia, Medicaid managed-care profits more than tripled to $3.9 billion in 2015 from $1.1 billion in 2013, according to consulting firm Health Management Associates’ analysis of insurance filings. Those figures don’t include California.

By 2016, profits dropped as some states reduced Medicaid rates to insurers to reflect the lower costs incurred during expansion. Kent, the California Medicaid director, said the state’s rates paid to insurers for enrollees in the expanded program have decreased by 38.5 percent since January 2014.

The federal government footed the entire bill for Medicaid expansion during the first three years, instead of taking the usual approach of splitting the costs with states. Now, states have more incentive to rein in spending, as their share of the costs grows to 10 percent by 2020.

19fca_1107_nws_ldn-l-medi-cal-gfx3 Enriched by the poor: California health insurers make billions through Medicaid
Kaiser Health News graphic

Quality Not In The Equation

In the meantime, however, some evidence suggests that in California, richer plans provided care of poorer quality.

The state scores Medi-Cal insurers from zero to 100 percent on how they perform on dozens of measures, such as diabetes testing, cancer screenings and checkups for children. Statewide, the average score was 63 percent for 2016.

For Centene and its Health Net unit, seven of its 10 regional health plans in Medi-Cal scored below average on quality. The company’s San Joaquin health plan ranked last statewide at 31 percent. State officials have ordered the company to improve in areas such as ensuring women get postpartum care and providing routine eye exams and other tests for diabetics.

Among patients, a chief complaint is how hard it is to find a specialized doctor. In a March audit, Medi-Cal said Health Net “did not maintain an adequate number of specialists within its network.” The state found that “member grievances on referral for services and availability of appointments with specialists were among the highest complaints.”

Five months later, after reviewing the company’s corrective actions, the state said Health Net was back in compliance.

Chandra Marshall, a Medicaid patient in Modesto, said she has suffered from limited access to specialty care.

She said her primary-care doctor in her Health Net plan recently recommended she visit a dermatologist for a biopsy. But she said the only available dermatologist on her plan was 90 miles away in San Francisco.

Worried she might have skin cancer, Marshall agreed to go but still hasn’t heard back about an appointment.

“Why can’t Health Net afford more specialists in the area?” said Marshall, who also suffers from kidney disease. “If Health Net doesn’t provide access to dermatologists and other specialists, people may just risk [not going].”

Her Health Net plan in Stanislaus County scored below 50 percent on quality care measures.

In a statement, Health Net said it is “committed to helping improve the quality and availability of healthcare services for our members that produce enhanced health outcomes. We work diligently with our contracting medical groups to help ensure our members get care that is easy to access.”

In the case of Anthem, eight of its 12 regional Medi-Cal plans scored below average on patient care. The state has told Anthem to do better at providing prenatal care, controlling patients’ high blood pressure and monitoring medications for asthma patients, among other issues.

In a written response to questions, Anthem said its scores have improved over time and two of its plans, in San Francisco and Tulare counties, are among the top 10 statewide.

While not tied directly to payments, California officials said they do reward insurers with higher quality scores by assigning more Medicaid enrollees to those plans.

Profits A Political Hot Button

The profits of managed care plans feed into Republican criticism of the ACA’s costs and its expanded Medicaid rolls. President Donald Trump has called for the law’s repeal, in part, because it enriches health insurers.

“They have made a fortune,” Trump tweeted on Oct. 13.

Sen. Ron Johnson (R-Wis.) has demanded that California and seven other states account for how they spent federal Medicaid expansion dollars. Johnson, chairman of the Senate Homeland Security and Governmental Affairs Committee, asked California officials in a letter Sept. 27 whether they have conducted audits and requested information on insurance company payouts.

In an Oct. 11 response, Kent said the state spent $6,181 per expansion enrollee in 2015, below the national average of $6,365.

“California is a cost efficient Medicaid program,” she wrote.

By one standard measure, the state’s oversight has been less than efficient.

Starting in 2014, the federal government required that 85 percent of Medicaid expansion funding be spent on care and quality improvement efforts, rather than administrative overhead and profits. But three years in, California officials acknowledged they have just started audits to determine whether companies might have to return excess money.

What’s clear is that insurers’ spending on both expansion and traditional Medicaid enrollees often falls short. Eight of California’s 22 Medicaid insurers failed to hit 85 percent in medical spending for the year ending June 30, 2016, according to state data obtained by Kaiser Health News. Anthem ranked lowest at 77 percent; Health Net spent 81 percent of Medicaid premiums on medical care, state records show.

Each percentage point below the threshold can amount to tens of millions of dollars that should have been spent on behalf of patients.

In July, a federal rule went into effect establishing 85 percent as a national benchmark for all Medicaid managed care. Three months later, California Gov. Jerry Brown signed a law mandating that same percentage. But the state requirement doesn’t kick in fully until 2023.

Michael McCue, a professor at Virginia Commonwealth University who studies Medicaid managed care, said the profit margins in California “raise a lot of red flags.” He said government officials owe it to taxpayers and patients to do more to hold insurers accountable.

“You have to make sure you’re getting a bang for your buck,” McCue said. “Right now, [for insurers] California’s Medicaid program is the golden nugget.”

California Healthline is a service of the California Health Care Foundation produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Will New York’s school health centers survive Medicaid change?

  • 8597b_920x920 Will New York's school health centers survive Medicaid change?

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ALBANY — The number of New York public schools with on-site health centers has nearly doubled in the past two decades, with data showing benefits to both student health and academics.

But a looming change in the way these centers are reimbursed for Medicaid patients could cause them to scale back services or close altogether, officials warned Tuesday in a news conference in the Legislative Office Building.


State legislators and health and education leaders called on the governor to sign legislation that would halt the change, by granting school-based health centers a permanent “carve-out,” or exemption, from the state’s Medicaid Managed Care program.

“Forcing school-based health centers into Medicaid managed care plans will wreck a model that works,” said Assembly Health Chair Richard Gottfried, who co-sponsored the legislation with Sen. James Seward.

The centers have received a carve-out for years on the grounds that shifting to managed care plans is too great an administrative burden. The exemption is set to expire on July 1, 2018.

Under the current system, school-based health centers receive Medicaid reimbursement directly from the state Health Department on a fee-for-service basis. Starting in July, however, they will be required to negotiate the terms and conditions for reimbursement with the students’ health plans directly. That could put 252 centers serving more than 200,000 children around the state at risk of reduced payments and increased administrative costs, including three centers in Albany, two in Schenectady, two in Middleburgh and one in Lake Luzerne, advocates say.

“If it ain’t broke, we probably don’t need to fix it,”said David Shippee, president and CEO of Whitney M. Young Jr. Health Services, which oversees centers at Giffen Memorial Elementary School, Philip Schuyler Achievement Academy and Sheridan Preparatory Academy in Albany.

The centers differ from an average school nurse’s office in that they provide a wide range of services from flu shots, annual physicals and immunizations to dentistry, mental health counseling and chronic illness management, and they are typically run by hospitals or medical practices.

They’ve become increasingly popular as a method of boosting school attendance. Students who receive their health care right in school are less likely to miss school and show up late, and more likely to seek out help for mental health issues.

A study by Johns Hopkins University found reduced hospitalization and inappropriate emergency room use among regular users of school-based health centers. A study by Emory University found the centers were responsible for a reduction in Medicaid expenditures related to inpatient, drug and emergency department use.

The legislation to grant a permanent Medicaid carve-out passed both the Senate and Assembly this June, and is awaiting a signature from the governor, whose office did not respond Tuesday to a request for comment.

It is supported by the New York School-Based Health Alliance, Greater New York Hospital Association, New York State United Teachers, the United Federation of Teachers and the New York State School Boards Association.