The end of Congressional détente?

Things have been relatively quiet in Congress lately and there has even been some bipartisan work getting done, but that could change relatively soon and I am not even talking about the continued parade of ACA repeal votes that are coming down the pike in the Highway bill or via budget reconciliation. Those efforts are getting shrugged off and consigned to the realm of symbolism.  I’m talking about a series of must-do measures that could bring us back to the world of hostage-taking, and government shut-down brinksmanship. Here are three leading flashpoints:

Appropriations: It is now clear that the appropriations process will not be completed on time. That means Congress will have to pass a continuing resolution (CR) in order to avoid a government shut-down. A CR would be easy to pass except that parts of the Republican caucus seem intent on using it to make policy changes, notably to strip all federal funding from Planned Parenthood.

Social Security disability insurance: The SSA Trustees report shows that unless Congress acts, millions of people with disabilities will receive a 19 percent cut in their already meager benefits. Again, an easy fix is available for Congress—they can vote to transfer funding to the SSDI account from the larger retirement trust fund (as Congress has done several times in the past with little fanfare).  However, congressional Republicans are seeking changes in the program as the price for extending its life, setting up what is sure to be a tense negotiation.

Debt limit: Although the timing is uncertain, analysts expect the Treasury Department’s measures for making payments on government debt will be exhausted before the end of the year. As always, Congress can simply vote to raise the debt ceiling to honor the obligations that they themselves have voted to incur. Beyond that, the debt ceiling could be scrapped altogether, an approach recommended in a recent GAO report. That would remove the recurrent threat of US government default, a threat which the GAO found harms the economy. Will Congress act rationally or will we be treated to another game of chicken regarding the nation’s economic health?

The dilemma for Republican Congressional leaders in all of these cases is that a significant part of their base both in and out of Congress wants to use these must-pass bills as “hostage-taking” opportunities to extract policy changes. However, both the policy changes themselves and the repeated threats of shut-down and default tend to be unpopular with the larger voting public.

The health care tie-in?  In some of cases—e.g. limiting access to family planning services by defunding PPFA—the connection is very direct. In other cases, the impact comes more from the economic harm that could be done to vulnerable populations, via benefit cuts or government shutdown and also because each “hostage-taking” incident represents a threat to vital health and social-welfare programs. In either event, health care advocates will need to keep a close eye on these developments and be prepared to pressure Congress to do the right thing.

A funny thing happened on the way to budget reconciliation

Following the victory in King v. Burwell it seemed that the appetite for another symbolic attempt to repeal the ACA was waning, but now it appears to be back in full force. What happened? Senators went home and talked to their base voters. Although ACA repeal continues to lose steam with the general public, it still commands a majority within the Republican Party. Hence the fruitless repeal votes will continue.

More victories for CTG but some states still don’t get the message

Following on the votes in the Montana legislature to close the coverage gap by accepting federal funds to provide insurance to low income adults, two more states in the West seem poised to follow suit. Governor Bill Walker of Alaska announced that he would move ahead with closing the coverage gap and negotiators in Utah announced a breakthrough in their talks will also likely lead to expansion. That would make three states in the western part of the country moving forward this year. As the number of states refusing the overwhelming logic in favor of coverage declines it becomes harder and harder, given the geography and demography of states and people in the coverage gap, to ignore the continuing role of race in shaping our politics. While symbolic actions, such as removing the confederate battle flag in South Carolina are a step forward, more concrete actions to close disparities in health and economic wellbeing are necessary. There is no better place to start than closing the coverage gap. 

Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

On Medicaid’s 50th anniversary, it’s worth a look back at how the biggest expansion in the program’s history has helped Coloradans.

In Colorado, we place a lot of value on common-sense solutions that make our residents healthier while being fiscally responsible. That’s why we accepted federal funds to cover more Coloradans with bipartisan support in the state legislature and with a broad coalition of consumers, businesses, and the health care industry.

It turns out, that sort of collaboration pays off.

Since the state closed the coverage gap and expanded the Medicaid program in January 2014, more than 400,000 Coloradans got covered through Medicaid, meaning they can now get the low cost care they need to stay healthy.

A new report from the State Health Reform Assistance Network shows, perhaps surprisingly, that expanding coverage to so many people has actually saved the state money. In 2014, alone, we saved $147 million, and we are on track to save an additional $160 million this year. Those savings are right in line with projections from a 2013 report by the Colorado Health Foundation issued during the debate in Colorado.

Accepting the federal funds was a good deal for Colorado because federal dollars cover 100 percent of the cost of new enrollees, as well as some current enrollees, for the first few years. It has also reduced Colorado’s tab on non-Medicaid costs, such as hospitalizations for prison inmates, to the tune of $10 million per year. Of course, spending fewer state dollars on health care also frees up needed cash for other priorities, and these realized savings can be channeled to other critical investments like education and transportation.

According to the head of the state’s Medicaid department, average costs per enrollee have declined 9 percent in recent years. The data show we’re getting a better bang for our buck in Colorado. That’s due in part to innovative approaches like care coordination to achieve better quality care. It’s also due to the fact so many newly enrolled consumers are younger folks who tend to use less medical care. In 2015, 25 percent of new Medicaid enrollees are kids under 18, and another 35 percent are young adults between the ages of 18 – 34.

Since 2013, we’ve gone from approximately 700,000 Coloradans covered to more than 1.1 million. These Coloradans can finally access care they haven’t received for years, and they can have the peace of mind they need to focus on the many other competing priorities in life – paying rent, finishing college, getting the kids off to school and helping with their homework, performing well at work, and all the rest.

Impact to the State’s Economy

This is all great news for the Coloradans who now have coverage. It’s good for our budget and taxpayers. And it’s also good news for the Colorado economy.

The 2013 report by The Colorado Health Foundation estimated that Medicaid expansion would add 14,357 jobs, primarily in health care, and $2.04 billion to Colorado’s GDP by June 2015. While the direct impact of Medicaid expansion in Colorado has not yet been analyzed, we have seen over 89,000 jobs created in the state since access to Medicaid coverage increased in January 2014. Some 21,000 of those jobs were in the education and health services sector, leading the state in job growth.

As we reflect on Medicaid’s 50th anniversary, we should be proud of the progress we’ve made together. After all, hardworking Coloradans deserve health care they can count on.

Ryan Biehle
Policy & Legislative Associate
Colorado Consumer Health Initiative

Medicaid provides health and financial security for millions of low-income, working Americans. Despite the fact that Medicaid is as efficient as (or even more efficient than) private insurance, it is often a target of state budget cuts. As we look to the future of Medicaid, advocates will need to play a vocal role in Medicaid budget discussions, both to defend Medicaid from harmful cuts, and to direct the discussion toward meaningful reform. Rhode Island and Ohio are two tales that illustrate how persistent advocate engagement in Medicaid reform is beneficial and critically important for consumers and state budgets.

Rhode Island: A Tale of Reform

Concerns about costs resulted in calls to dramatically reduce Rhode Island’s Medicaid budget. Luckily, consumer-friendly leaders like Governor Gina Raimondo (D) and other key officials set a positive tone for the state’s Medicaid reform efforts. Earlier this year, Governor Raimondo created the ‘Working Group to Reinvent Medicaid,’ with a goal to reform the Medicaid system over the long term while cutting $90 million from the Medicaid budget in 2015. 

With policymakers, advocates and industry representatives invited to the table, the Working Group proposed initial recommendations for FY15-16 budget savings that are a win-win for the state and consumers. These recommendations implement programs advocates have long been calling for. Below are a few highlights from the Working Group’s report, in which Rhode Island’s Medicaid program will:

  • Aim to reduce unnecessary hospital utilization
  • Improve quality and develop new payment arrangements that award value over volume
  • Temporarily decrease hospital payment rates and increase provider assessments
  • Pilot a hospital-based Accountable Care Organization (ACO) model that focuses on patients with long-term and complex needs

A final report with recommendations for long term reforms was published  and presented to Governor Raimondo earlier this month.

Ohio: A Tale of Advocate Intervention

In Ohio, Governor John Kasich (R) proposed dramatic rollbacks in coverage for certain Medicaid benefits. Unlike in Rhode Island, consumer health advocates were not invited to the table to help design savings initiatives. As a result, the state advanced harmful proposals that would make coverage harder to access.

Although they were not part of the initial policy discussion, advocates immediately jumped into action.

  • They challenged the harmful assumptions that the cuts would save money and that beneficiaries could get care through other means by using data and policy analysis.
  • Advocates organized call-in days, sign-on letters, and sent action alerts to their lists.
  • Advocates also found a legislative champion in the Republican Party (Republicans the state Senate and House) to introduce an amendment to these proposals.
  • They then called on strategic stakeholders and partners to carry the message. For instance, advocates worked with the Ohio chapter of the American Cancer Society to lobby against cuts to breast and cervical cancer screening coverage.

Advocates’ efforts paid off. They prevented rollbacks in eligibility for pregnant people and coverage for cervical and breast cancer screening. Unfortunately, the state still cut coverage for family planning services and health savings accounts, increased cost-sharing for some, and blocked the expansion of an innovative coordinated care model.

The Moral of the Stories

What lessons do the tales of these states teach us?

  1. Start early. It’s never too early to meet with your coalition and start planning to defend and/or reform Medicaid. Medicaid is chronically on the chopping block during state budget deliberations, so working with your coalition partners to proactively develop a Medicaid reform agenda will prepare you for this eventuality. It can also serve as a guide and reference for educating the public and lawmakers about the importance of this program. In addition to Rhode Island’s Reinventing Medicaid reports, check out Arkansas Advocates for Children and Families’ Top Ten Principles for Health Reform.
  2. Educate policymakers about the importance and benefits of Medicaid. Work with legislators to develop smart, consumer-friendly reforms to the Medicaid system, and cultivate them into champions for these reforms. Leverage your coalition partners and grassroots organizers to amplify the message through legislative meetings, lobby days, in-district events, and the media.
  3. Be creative. While planning your Medicaid defense/reform agenda, consider how Medicaid funds social services outside of the traditional health care system, such as supportive housing and housing infrastructure, early childhood development, and mental health and substance use disorder services. Explore how you can integrate the message of Medicaid system reform into these spaces, as well as pull unlikely partners into your Medicaid campaign.
  4. Collect data and stories. Press your state Marketplace and Medicaid office for data on who is falling through the gaps and who is churning off of Medicaid due to cuts. Boost this data with stories of real consumers who are falling through new coverage gaps. Refer to the Families USA story-banking toolkit for more resources to help you collect stories.
  5. Grow your lists and mobilize your grassroots. Lift up the voices of consumers who are falling through the gaps by helping consumers understand how to connect with their legislators. Advocates can also organize activities for consumers to engage in throughout the year so that legislators understand what their constituencies want before they need to start budget negotiations.

We know that this is not an easy battle, nor a new one. But we encourage you to get creative, strengthen old partnerships and engage new ones. Let’s work together to shift the conversation away from harmful cuts, and toward “Reinventing Medicaid.” 

Post King politics

Now that the Supreme Court has removed the (next to last) existential threat to the ACA, how is the health care world reacting? We turn first to politics where we find the appetite for using reconciliation for ACA repeal is waning.

Republicans have always been united in their opposition to the ACA but divided over what, if anything, should replace it. With the prospect of millions losing their tax credits and insurance premiums spiking in the wake of a decision in favor of King, House and Senate leaders were under substantial pressure to figure out a way to bridge those divisions. While prospects of actually enacting something in the wake of a King decision were never good, failure to come up with at least a plausible alternative would have been a political disaster.

In that context, the ability to move legislation through the Senate with only a simple majority would have been a big asset. With King decided in favor of keeping tax credits for all, the cost-benefit of using budget reconciliation looks different. With the tax credits upheld, there is no pressure on the White House to compromise. Republican Congressional leaders would have to do a lot of persuading to unite their caucus behind a replacement bill, and simple repeal could run into procedural difficulties since it would be scored as increasing the budget deficit. In addition to being hard to write and even harder to build consensus around, a replacement bill would itself become a political target. And since it would certainly be vetoed (and sustained) there would be nothing to show at the end of the day for all of the work and the opportunity to use reconciliation to actually make policy would be gone for the year. Small wonder then, that the leadership's enthusiasm for using reconciliation on ACA repeal has diminished.

Meanwhile back on Wall Street…

If the King decision left Congressional leaders feeling somewhat depressed, it has certainly energized insurance markets as the nation’s big insurance companies seek to adjust to a changing health care landscape by acquiring each other. Two factors are driving merger mania. First, companies are looking to strengthen their position in the growth markets in insurance. As a result of the ACA, enrollment in non-group insurance and Medicaid Managed Care is expanding and companies are looking to expand their footprint there. Growth in a third market segment—Medicare Advantage—is spurred less by the ACA and more by demographics, but in both cases the imperative is the same for insurers—to get in better position to take advantage of enrollment growth. The second factor is that the push to create integrated delivery systems is enhancing the market clout of providers relative to insurers and insurers are trying to respond by getting bigger themselves.

What does this mean for consumers? Typically, market consolidation leads to higher prices and there is some evidence that Exchanges with less competition among carriers have higher premiums. However, too many insurers can also be a problem for consumers. There are certain overhead costs in running an insurance company and increasing the number of carriers increases those costs—there are economies of scale in insurance. The other factor is that when provider markets are concentrated, if each insurer only has a small market share, their ability to negotiate favorable prices is diminished. Strong providers and (relatively) weak insurers are a recipe for higher prices. The question is really whether the regulatory mechanisms in the ACA—mainly the medical loss ratio requirements and rate review provisions—are strong enough to keep a monopolistic insurance industry from price gouging. There is a risk that where both provider and insurance markets are concentrated, insurers will find it easier to simply agree to pass higher rates on to rate payers than to negotiate for lower prices.

One curious feature of merger mania is that the political world seems almost entirely resistant to the obvious conclusion that the growing market concentration of both providers and insurers is going to require a stronger regulatory role. The explanation for that obliviousness can probably be found in the words of Upton Sinclair.

Zombie death panels

Horror film sequels are a summer movie staple and it seems that the same is true in health policy. The spectacle of ACA opponents who should have (and did) know better, feeding the public frenzy on “death panels” in the ACA, was perhaps the nadir of the political debate over ACA passage (and that’s going pretty low). Five years and a couple of false starts later, the idea that your doctor can get reimbursed by Medicare for the time spent discussing your end-of-life wishes is making a quiet comeback in a proposed Medicare rule, but this time with very little fanfare. Just goes to show you that sequels seldom draw as well as the original.

Do the right thing

It’s good to see South Carolina moving forward with removing the Confederate battle flag from the State House grounds, but, as South Carolina Congressman Jim Clyburn said (and we blogged last week), a more meaningful tribute to the memory of Senator Pinckney would be to close the Medicaid coverage gap in his state. Senator Pinckney was a fighter for health care justice. His Senate district included parts of six counties in which  more than 100,000 uninsured people live. There could be no better way to honor his memory that to extend health coverage to the thousands of people in his district and in his state who lack it today.

Final word: A shout out to CVS

The pharmacy chain took an industry leading position in withdrawing tobacco products from their shelves. Now, in light of recent revelations that the U.S. Chamber of Commerce played a leading role in promoting tobacco use in other countries, CVS has maintained the coverage of their convictions by resigning from the Chamber. We can only hope that other health care companies will follow suit.

The Dual Agenda, the bi-weekly newsletter of our Voices for Better Health project, periodically features “Eldercare Voices” guest columns, sharing contributions from providers or researchers directly involved in improving care delivery to older adults. This week’s column, Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults, is from Robyn I. Stone, Ph.D., Executive Director of the LeadingAge Center for Applied Research and Senior Vice President of Research at LeadingAge. Dr. Stone shares exciting progress being made in forging partnerships between senior housing facilities and health organizations, with significant implications for health system transformation efforts. We know that where one lives plays a large role in health, both in access to services and in a variety of upstream social determinants of health. The cutting edge work described in this piece highlights the opportunities to deliver coordinated care and services, with a meaningful role played by service coordinators in affordable senior housing facilities, helping foster good health while promoting health equity through culturally competent relationships with residents.

Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults

Guest contributor Robyn I. Stone, Ph.D.   
Executive Director, LeadingAge Center for Applied Research

An estimated two million older adults currently live in publicly subsidized housing properties located in urban, suburban and rural communities nationwide. Findings from a recent federally-funded study of affordable senior housing properties in 12 jurisdictions across the country, conducted by researchers at the LeadingAge Center for Applied Research (CFAR) and the Lewin Group, indicate that elderly residents of low-income housing properties have more chronic conditions, take more medications, are more functionally disabled and have higher emergency department (ED) and hospital visits than their peers living in the community. Approximately 70 percent of these elderly residents are dually eligible Medicare and Medicaid beneficiaries, underscoring their high-risk status and suggesting that publicly subsidized housing may serve as a locus for better management and coordination of services for vulnerable older adults.

Multiple efforts are underway at the federal and state levels, and in the private sector, to reform our health and long-term care delivery systems to better address the country’s care needs, particularly among vulnerable populations. These efforts focus on lowering Medicare and Medicaid expenditures by providing timely preventive care; improving care coordination and service integration; reducing over-utilization; and providing overall population health management at the community level.

The current reform climate, focused on transformation of our health care system, provides a unique opportunity for senior housing/health care organization partnerships to achieve common goals. Since residents of affordable senior housing communities are an ideal demographic for implementing population-based health reforms, they present especially conducive opportunities for the forging of such partnerships.

Continue reading this edition of Elder Care Voices here.