Here at Community Catalyst, we have always been proponents of closing the coverage gap, knowing that access to coverage is good for consumers, communities and state budgets. However, 22 states are still leaving just under 4 million people without access to health care. Fortunately, good news from Kentucky provides compelling evidence that closing the gap is the right decision, and we hope other states take note. In addition to covering 310,000 previously uninsured Kentuckians (and that’s just counting through June of 2014), closing the coverage gap produced a domino effect of benefits to the state’s economy and helped the state’s uninsured rate drop to 12 percent from 20 percent. The state recently released a detailed report that elevated these important economic impacts which include:

1. Closing the coverage gap added 12,000 jobs in 2014. This number will rise to 40,000 jobs by 2021, with an average salary of $41,000. The combination of federal Medicaid dollars coming into Kentucky and newly paying patients will boost health care jobs and services, and spending in other sectors. Together, these added jobs will raise more than $1 billion in state income and sales taxes from now until 2021.
    
2. Closing the coverage gap boosted Kentucky’s state budget by $50 million by June 2014. Federal funds took a greater share of several state departments’ budgets and more state tax revenue was brought in from job creation (Table 22 of the report). Over the next eight years, Kentucky’s state budget will benefit from an $819.6 million net gain.
    
3. Closing the coverage gap brought down the costs of treating uninsured patients. As more consumers gained coverage and became paying patients, uncompensated care fell by more than $1 billion dollars, or 60 percent, from 2013 to 2014. Reducing uncompensated care is a boon for state and local budgets, which bear a 32 percent share of uncompensated care costs. A companion Medicaid Hospital report revealed that Medicaid expansion revenues significantly exceeded federal funding (DSH payments) for uncompensated care (Tables 8 and 9 in the report, respectively). Thus, when DSH cuts go into effect in 2017, federal dollars from closing the coverage gap will ensure that hospital doors stay open to care for its patients.

Broadening access to health care coverage, adding jobs, generating revenue to the state economy and reducing uncompensated care is good news for Kentucky, and a proof point for every state still considering whether to close the gap. These initial results are especially illuminating in the South, where the opportunity to make a difference for consumers in the gap and state economies is high. Luckily for us all, this good news is attainable, but only if states legislators and governors decide to close the coverage gap.

Medicaid and the Children’s Health Insurance Program (CHIP) are the most comprehensive and affordable forms of coverage available for the children they serve. These programs were designed with children specifically in mind, with the intent of making high-quality pediatric coverage available to families that would otherwise struggle to pay for it. In particular, we know that without CHIP, 1.1 million children who are currently enrolled in the program would become uninsured. Disrupting Medicaid and CHIP to any degree would move us backward on coverage for kids.

Two weeks ago, on February 12, Senate Finance Committee Ranking Member Wyden (D-OR) and Senators Brown (D-OH), Casey (D-PA), and Stabenow (D-MI) introduced the Protecting and Retaining Our Children’s Health Insurance Program (PRO-CHIP) Act in the Senate. The same day, Representative Green (D-TX), the ranking member of the Health Subcommittee of the House Energy and Commerce (E&C) Committee, also introduced a CHIP funding bill in the House. These bills both take steps to sustain coverage for millions of children, as well as continue important initiatives to improve pediatric quality of care.

Yesterday, Senate Finance Committee Chairman Hatch (R-UT), House E&C Chairman Upton (R-MI), and Representative Pitts (R-PA) released a discussion draft that outlines their vision for the future of CHIP. We are pleased that they are engaging on this issue and are committed to extending coverage for low-income children. Notably, we are glad that this draft includes an extension of the current formula for determining how much federal CHIP funding states receive—which governors generally reported to be successful—as well as the qualifying state option, which fairly compensates states that proactively increased children’s Medicaid eligibility levels. That said, we have serious concerns about some aspects of this proposal that would make children worse off by reducing access to an effective source of coverage:

• Longer waiting periods: The authors assert that states need the option of imposing waiting periods up to a year to prevent crowd-out, enrolling children who could be covered through employer-sponsored coverage in public insurance. First of all, we know that 33 states have eliminated waiting periods, suggesting that their usefulness is limited. However, in states that choose to use such flexibility, this proposal would have the practical effect of forcing CHIP-eligible children to endure up to a year without insurance. While this time in limbo would be hard for any child, we are deeply concerned about the implications for children and youth with special health care needs. Moreover, this policy is in direct opposition to regulations issued in 2013 limiting waiting periods to a maximum of 90 days, as well as the spirit of both CHIP and the Affordable Care Act (ACA).
• Reducing matching funds for states: This draft reduces federal financial participation in states’ coverage of children over 250 percent of the federal poverty level (FPL) and ends federal support for CHIP coverage of children over 300 percent FPL. Pulling back federal matching for CHIP coverage at a time when many states are facing difficult budget situations would likely mean that states stop offering coverage at these levels. For these children, reduced eligibility could mean they become uninsured, particularly if they are subject to the family glitch, and the accompanying financial risk could prevent some families from exploring economic opportunities such as entrepreneurship.
• State flexibility on Medicaid and CHIP eligibility: This draft includes the suggestion that states not be held to the Maintenance of Effort (MOE) requirement of the ACA, which prevents states from rolling back Medicaid and CHIP eligibility for children until 2019. As we have seen from recent experiences in Arizona, when states are allowed to roll back coverage, the detrimental effects for children and families are significant. Moreover, the authors of this draft assert that states should be able to move stairstep kids  from Medicaid back to CHIP, even though we know that in states where Medicaid and CHIP are not identical, Medicaid is the more comprehensive option as it includes Early Periodic Screening, Diagnostic, and Treatment services, the gold standard of children’s coverage.

So where do we go from here? Because this is a discussion draft, Chairmen Hatch and Upton will be accepting comments on the content of this proposal. We are hopeful that subsequent drafts and the ensuing negotiations will do more to protect children’s coverage as well as recommend refunding pediatric quality improvement programs, which have been integral to our efforts to make children’s health care more effective, efficient and patient-centered. We look forward to a conversation about the best ways to move forward. We encourage our partners to comment to the Chairmen about this proposal and continue advocating for high quality, affordable coverage that is accessible for all children. 

Overdose deaths from opioids – a type of drug that includes prescription pain relievers and heroin – continue to rise in the U.S. and show few signs of slowing down. This has grabbed the attention of many federal and state lawmakers who are crafting laws and regulations to address the epidemic. The President’s Fiscal Year 2016 budget released earlier this month makes a commitment to reducing drug use and its consequences. It is highly unlikely that the President’s budget will be enacted in the current political environment, but it still gives us a roadmap for how key federal agencies plan to tackle the nation’s drug problems. 

It’s encouraging to see the public attention and the resources directed at these problems, but we may be missing the mark when it comes to prevention. For example, the National Drug Control Budget includes drug monitoring, law enforcement, evidence-based addiction treatment, and reducing overdose deaths, but only five percent of the total budget is allocated to prevention. Similarly, states across the country are implementing laws and regulations to help first responders and bystanders prevent overdose deaths. 

These measures play a crucial role in saving lives and mitigating the consequences of substance misuse, but what are we doing to prevent addiction before it starts?  

Parents, teachers and health care providers should be asking young people early and often about their substance use. Drug screening by trusted adults is an important and effective first step for the prevention of drug and alcohol problems. In fact, simply asking about drugs and alcohol can lead young people to reduce substance use. From state and federal policies to local community-based solutions, we need a greater emphasis on screening as a prevention tactic for a few simple reasons:  

Young people want to talk about it. As it turns out, young people are willing to talk to adults about their drug and alcohol use. One study found that more than 6 out of 10 adolescents said they wanted to talk about substance use with their primary care doctor. The biggest reason they didn’t talk about it? Nobody asked them.

Young people are truthful when asked. Some providers are skeptical about whether young people will tell the truth about their substance use, which can make adults reluctant to ask. Let’s set the record straight: Young people are overwhelmingly truthful in their self-reports of substance use.

Screening is cost-effective. A recent report coming out of Massachusetts confirms the low cost of screening. Research on the cost of a new Massachusetts’s law requiring insurers to reimburse providers for drug and alcohol screening, shows the cost burden on policy holders would be less than a penny per member per month. While the Massachusetts study was on commercial insurance, it supports other findings about the relatively low cost of screening.

Screening tools can guide the conversation: Numerous tools have been studied and established as powerful indicators of current and future problematic drug or alcohol use. This includes the CRAFFT (see below) or AUDIT, which are designed for youth. These short and effective tools can guide providers and other adults in their conversations with young people about substance use.

From the first time a young person misuses alcohol or drugs, they become susceptible to addiction and its long-term consequences. We need to scale up screening efforts nationwide to reach youth in a variety of health care and community settings. One model doing just that is called SBIRT (screening, brief intervention, and referral to treatment). SBIRT involves asking young people a few questions about their drug and alcohol use and providing guidance or referring to treatment, if a problem exists.

SBIRT has been gaining traction across the country with federal support from the Substance Abuse and Mental Health Services Administration (SAMHSA) since 2003. SAMSHA has issued 75 SBIRT training and implementation grants and included $30 million in the FY2016 budget to continue this work. The Conrad N. Hilton Foundation is also a driving force moving SBIRT forward with an expansive nationwide initiative to bring SBIRT to youth and young adults.

Community Catalyst is among the numerous organizations supported by The Conrad N. Hilton Foundation to expand the use of screening and early intervention to young people. Community Catalyst is currently working with consumer advocates in five states – Georgia, Massachusetts, New Jersey, Ohio and Wisconsin – to educate the public and policymakers about the need to improve health insurance coverage for SBIRT and increase the number and types of locations where it is conducted.

Additional federal and state support is needed for SBIRT and other initiatives that promote screening and brief intervention. We need to talk to young people about their drug and alcohol use more frequently, and in a broad array of settings where youth interact regularly with trusted adults. These conversations are the cornerstone of prevention.

Image Credit: Georgians for a Healthy Future

On February 6 in a conference room at the American Dental Association’s headquarters in Chicago, the Commission on Dental Accreditation (CODA) voted overwhelmingly to adopt national training standards for dental therapy education programs.

The 22-6 vote (with two abstentions) signaled that organized dentistry’s accrediting body thought it was in the best interest of the dental profession and the public to develop national standards for the program. More importantly, the vote was recognition that dental therapy as a profession is here to stay.

Acknowledging the need for national standards and establishing them is another important step in dentistry’s path toward adopting team based providers. A step the medical community took decades ago when it expanded the medical team to include physician assistants and nurse practitioners.

The process to establish these new dental therapy standards has been more than five years in the making. Catalyzed by a 2009 request from the Dean of the University of Minnesota Dental School, CODA formed a task force to explore developing standards for dental therapy. CODA has put forth multiple draft versions of standards.

Thanks to the CODA’s policy to allow for public commentary, more than 200 of our partners including community organizations, tribal organizations, dentists, community colleges, dental hygienists, and former government leaders – signed onto or submitted comments to CODA. The comments ranged from former Secretary of Health and Human Services Louis Sullivan making the case for standards that would produce culturally competent providers to Community Catalyst arguing that providers are needed to meet unmet needs, to the National Congress of American Indians highlighting how this provider can benefit American Indian Populations to the American Association of Community Colleges asking for standards to help guide programs at their schools. 

As a result, CODA adopted standards that:

• Ensure training institutions will have national and streamlined standards to shape their training programs.
• Give students from underserved communities the ability to enter accredited programs, be eligible for financial aid, and graduate equipped to meet the unmet needs of their community.
• Provide a pathway for dental hygienists.

There is still work for be done, CODA needs additional information to vote to implement standards, but the hardest part is behind us. Thanks to last Friday’s vote, the profession is finally on track to add much needed team members to enhance their capacity to deliver patient centered care to people who need it most, in the communities where they live.

Having dental therapists helping dentists improve access to care can’t come soon enough for the millions of people suffering because they cannot find affordable care in their community. And now, not only is implementation of standards inevitable, the practice of dental therapists is imminent.

Last year, Maine added dental therapists to the team. Over a dozen states are exploring how to utilize dental therapists. 

And, now we have national standards. Thank you, CODA. 

Note: This blog was updated to reflect new information from the Centers for Meidcare and Medicaid Services (CMS).

More than 11 million people have signed up for 2015 coverage during the second open enrollment period. This enrollment success is in large part thanks to all of the assisters and advocates who used highly effective outreach strategies to enroll people across the country. You are all deserving of a much-needed break, but, as usual, there is more work to be done! While you are still helping consumers enroll and learn how to use their 2015 coverage, insurers are putting together applications for 2016 qualified health plan (QHP) certification.

A tight timeline

According to CMS’ letter to insurers, insurers participating in Federally Facilitated Marketplaces (FFMs) must submit a completed QHP application for all plans they intend to offer on an FFM by May 15. These applications will include a package of plans and benefits, rates data and provider networks. The review and revision phase will last through September 14. In general, state departments of insurance will play a significant role in reviewing these plans for compliance with market-wide requirements. However, for certain areas, such as network adequacy, CMS will keep a close watch on insurers’ compliance. If a QHP application is approved, insurers will receive the certification notices and sign the contract agreement to get ready for the third open enrollment period. These key dates are for insurers participating in FFMs, but State Based Marketplaces (SBMs) are advised to follow the same timeline.

Now is the time to affect requirements for 2016 plans

Community Catalyst developed a one-pager outlining the timeline and some action steps to assist you in your work as you advocate to strengthen consumer protections and work to ensure a positive consumer experience in shopping for coverage, accessing care and improving health outcomes. To get you started, we recommend three buckets of work for the next few months:

1. Network adequacy that enables consumers to access needed care for covered benefits in a timely manner
2. Rate review that guarantees opportunities for consumer engagement
3. Benefit design that includes the selection of essential and non-discriminatory health benefits

The specific issues within each bucket will depend heavily on your state environment and resources. However, you can start your work by capturing consumer stories to highlight successes or identify areas of improvements, barriers to care and emerging coverage issues at the state and federal level. These consumer stories will help you make the case for strengthened consumer protections with policymakers and stakeholders. Of course these three buckets of work are just the tip of the iceberg! If you or any of your state partners would like to share your strategies on the issue areas identified above, or others, please leave a message in the comment box.