When Pennsylvania launches its Community HealthChoices (CHC) program for older adults and individuals with disabilities over the next few years, it will join a growing number of states shifting to managed care plans to provide long-term services and supports (MLTSS) to Medicaid beneficiaries. Up to 450,000 Pennsylvanians could eventually be enrolled in CHC. So far, Medicaid MLTSS has had mixed results around the country. If implemented well, MLTSS has the potential to provide better, more coordinated care. But there are also risks that its implementation could interrupt care, cut vital services and squeeze out community providers. Two things are certain though: there are many lessons to be learned from states that have already implemented MLTSS programs; and these programs can only be successful with meaningful input and feedback from the communities they serve.

The Center for Consumer Engagement in Health Innovation was honored to be invited by the Jewish Healthcare Foundation to travel to Pittsburgh last week to lead a day-long training for community and consumer groups aimed at helping them prepare for and engage in the launch of CHC in Southwest Pennsylvania. Over 50 people from a variety of organizations, most of whom work with and advocate for older adults and people with disabilities, attended the training.

We started off the day with an overview of best practices from around the country for consumer-centered MLTSS implementation using a Community Catalyst-designed tool. Then we moved into detailed discussions around four topics: successful beneficiary communications; smooth transitions of care; ensuring network adequacy; and building meaningful consumer engagement. We were joined by three dynamic guest speakers – Bill Henning from the Boston Center for Independent living (pictured with Alice Dembner of Community Catalyst), Larke Recchie from the Ohio Association of Area Agencies on Aging and Marisa Scala-Foley from the Administration for Community Living. During small group brainstorming sessions, participants shared their ideas on how to make consumer engagement in CHC as meaningful as possible, and what can be done to identify, recruit and support consumers who want to become involved.

There is much to do in preparation for CHC’s launch next summer. We are grateful to the staff of the Jewish Healthcare Foundation for their commitment to making sure CHC will be as successful as possible. We look forward to continuing to work with the foundation and advocates throughout Pennsylvania to support them in shaping this program.

 

 

After six-plus years of rhetoric and sixty-some repeal votes, the House Republican caucus finally produced a document they refer to as a plan to replace the Affordable Care Act. (To call the plan disappointing would be an understatement. Despite my low expectations, the document the Republican working group produced was even worse than I thought it would be.)

It is a paltry effort. Six of the document's 37 pages are essentially devoid of content. Much of the remainder is taken up with political bombast full of misleading and flat out untrue statements. The actual policy proposals it does contain, when it pauses for breath from excoriating the ACA, are a warmed over rehash of the same harmful, unworkable ideas various Republican lawmakers have been pushing for years with nearly all of the critical details missing. Although the lack of detail makes any precise comparison to the ACA impossible, it is safe to say that if adopted, the proposals released this week would cause millions of people to lose their health insurance, and increase health care costs for millions more.

It's not worth the time to read, let alone to write a correction of every misstatement and deconstruction of every bad idea, but here are some of the "highlights."

Undermines critical insurance reforms while shifting costs to lower-income people and benefits to the affluent

A few of the ACA insurance reforms would remain, such as allowing young adults to stay on their parents' plan and no lifetime benefit cap. However, most reforms would likely be swept away, such as access to preventive services with no cost sharing. There would be no guaranteed minimum benefit package, and tax credits would not adjust with income, so lower-income people would be less able to afford coverage. Many would drop out of the insurance pool since the individual mandate would also be repealed. Credits would not adjust to keep pace with the rising cost of insurance, so every year fewer and fewer people would be able to afford coverage.

The Republican "plan" would also make shopping for coverage much more difficult. There would be no plan standardization. Competing "private exchanges" would be allowed, each of which might have a different set of insurers and benefit designs. Making "apples – to - apples" comparisons would become almost impossible.

At the same time tax credits for low-income people are wiped out, Republican lawmakers would double down on high deductible health plans and Health Savings Accounts (HSAs) by increasing the amounts that could be contributed to HSAs. This change primarily benefits those in higher tax brackets who also have the spare cash to put into their accounts.

Would cause millions to lose Medicaid coverage and increase financial barriers for those that remain. Children, in particular, could lose vital protections.

Apparently, the drafters couldn't decide between a Medicaid block grant and a Medicaid per capita cap, so they included both ideas and would let states decide. Either way, beneficiaries would lose. Federal contributions would not keep up with health care costs, and states could for the first time create enrollment caps or waiting lists to exclude otherwise eligible beneficiaries from coverage. Financial protections would be scaled back allowing states to impose higher premiums on beneficiaries that would force many to drop coverage. Those who remain could also get fewer services and pay more in cost sharing. If states chose a block grant instead of a per capita cap, beneficiaries would fare even worse, especially children, who would lose nearly all of the current legal protections that ensure low-income children have a comprehensive benefit package with no cost sharing.

With more and more costs shifted onto states, and with states having more freedom to shift costs onto beneficiaries or exclude currently eligible people altogether, there is little doubt that millions would be harmed.

Erodes benefits and increases costs for Medicare beneficiaries

Repeal of the ACA would immediately increase prescription drug costs for Medicare beneficiaries by eliminating the expansion of the Medicare drug benefit. Most beneficiaries (those who didn't go to the hospital in a given year) would also see higher out-of-pocket costs through a new deductible structure that would increase the amount they would have to pay for most services before Medicare kicked in. The Republican work group also proposes increasing the Medicare eligibility age, an idea that CBO has determined does not save much money for the federal government but does increase costs for employers and individuals.

But wait, there's more. Starting in 2024 Medicare beneficiaries would lose guaranteed access to a defined benefit package. Instead, they would be given a set amount of money they could put toward a plan. While the details are lacking, one thing that is clear from the document is the size of this payment would shrink over time relative to the cost of health care, leaving seniors and people with disabilities with ever skimpier coverage.

And now for the good news (sort of)

The ideas contained in this grab bag of horribles are wildly unpopular, and an attempt to enact them would provoke a huge backlash. Even in the event of a Trump election this doesn't represent where actual health policy would go, since under any conceivable scenario Republicans would not have enough votes to pass a bill like this. Moreover, not all of these changes could be made via budget reconciliation. That said, and despite all the missing detail, this compendium of "greatest hits" creates a chilling picture of where health care could be heading depending on what happens this November.

On Monday, Vermont Governor Peter Shumlin signed a new law that will allow dental therapists to work in Vermont. It’s an exciting victory on a number of levels.

To start, this makes Vermont the fourth state to add dental therapists to the dental team and the most recent victory in the movement to transform our dental delivery system so that people who need care the most can get it.

Currently, tens of thousands of Vermont residents go without needed dental care each year, including almost 40 percent of children on Medicaid coverage, because they can’t afford dental care or find a dentist that accepts their insurance. This action will allow Vermonters to have greater access to critically-needed routine and preventive care and will improve health in the state.

Our congratulations go out to the Oral Health Care for All coalition, led by Voices for Vermont’s Children, for their hard work to garner community support for this bill. More than forty organizations including consumer groups, dental hygienists, individual dentists and thousands of community members worked for five years, generating over 200 personal stories, 1,500 petition signatures and countless phone calls, letters and meetings in support of this proven provider.

But the coalition and their supporters didn’t do it alone. Policymakers and government officials looked at the facts and took action to reduce costs in the health system and increase access to dental care for the people who they represent instead of responding to the special interests of the dental lobby. We applaud Vermont’s state legislators for standing up for affordable, high-quality dental care for the people in their state.

Over the past year, close to a dozen state and tribal governments have pursued establishing these health care professionals as a way to solve deep oral health disparities and severe unmet dental needs. Dental therapists have been working as part of the dental team in Minnesota for five years and in Alaska for more than a decade. The Swinomish Indian Tribal Community in Washington State is employing their first dental therapist and soon the providers will be working in Oregon under a statewide pilot program. 

The victory in Vermont is another clear sign that momentum is on our side. In the last few weeks alone health care leader Dr. Don Berwick stated oral health is a human right in his endorsement of dental therapists; the Boston Globe identified dental therapy as must pass legislation; the New York Times featured the benefits the Swinomish Tribe is seeing from employing their first dental therapist; and the Federal Trade Commission released a statement that all communities should benefit from this proven and effective provider. 

Dental therapists are coming. They will be working on dental teams in every state and in tribal communities across the country. The results will be greater access to care and a more cost-effective health care system. Similar to how physician’s assistants were opposed by doctors in the beginning, dental therapists have been opposed by the dental lobby. However, dentists working with the provider see the quality of their work and how the dental therapists can grow their practice by increasing access to care. Week by week, dentists are changing their minds.

As more communities nationwide move to include dental therapists as part of their dental team, the evidence surrounding dental therapists’ efficacy is beginning to outweigh the misinformation spread by the special interest lobby. Kansas and Michigan recently introduced strong, evidence-based legislation that keeps dental therapy education in the hands of dental educators and the same dental accrediting body that oversees dentists. In addition, the Indian Health Service recently announced its plan to expand Alaska’s successful Community Health Aide Program (CHAP), which includes dental therapists, to tribal communities across United States.  

Momentum is on or side but is it is still up to us—consumers, health advocacy groups, public health dentists, primary care doctors, educators, hygienists and you—to help take this message to lawmakers and government officials. Authorizing dental therapists is not a panacea. But it is a smart, evidence-based part of the solution to updating our dental delivery system and getting critically needed oral health care to those who need it most.

To stay current on the Dental Access Project, sign up for our newsletter and project updates by clicking Oral Health on our E-updates page.

Last June, following the mass murder in Charleston, South Carolina, Anton Gunn, a South Carolinian and Community Catalyst board member, commented on Governor Nikki Haley’s (R-SC) change of heart about taking down the Confederate flag from the grounds of the South Carolina State House. Gunn asked at that time a vital question: “If you take the flag down tomorrow, what is going to substantively change in the lives of black people and people affected by inequality in South Carolina?” 

A similar question can be asked of Governor Rick Scott (R-FL) following the mass murder at a gay nightclub in Orlando, Florida -- the deadliest mass shooting by a single gunman in the United States. Scott laid flowers at a memorial in Orlando to the victims, who were predominantly Latino and members of the city’s LGBTQ community. While we can appreciate his gesture of sympathy, we need to ask him a similar question: What are you doing to substantively change the lives of lesbian, gay, bisexual and transgender people in Florida? What are you doing to substantively change the lives of Latino people in Florida? Despite the fact both these groups are at disproportionate risk of being uninsured, Scott – like Haley – opposes closing the coverage gap. As a result, nearly a million people are uninsured in Florida and many among them are LGBTQ and/or Latino. It is likely that some among the men and women seriously injured in the Orlando attack, and facing a long and difficult road of recovery and healing, are doing so without the benefit of insurance coverage that could have been available to them through enlightened state action.

Governor Scott is also a strong opponent of gay marriage and sensible legislative proposals to strengthen background checks and reduce the availability of assault weapons.

Given the long and painful history of discrimination against marginalized communities in our nation, the laying of flowers – like the lowering of an offensive flag – is not sufficient to satisfy the needs of people. For justice’s sake, we need to demand more. And that will require people to stand up to Haley and Scott and demand substantive change.

(Last year, the Robert Wood Johnson Foundation launched a joint initiative with Community Catalyst called the Value Advocacy Project (VAP). The project is supporting consumer health advocacy organizations in six states in their non-lobbying advocacy efforts to pursue local and state policy and health system changes that increase the value of health care by improving health outcomes and lowering health care costs, especially for populations that have disproportionately poor outcomes. Building on the Center for Consumer Engagement in Health Innovation’s recently released Consumer Policy Platform for Health System Transformation, we will be highlighting our state partners working on issues outlined in the policy platform and encouraging them to share how their work can translate to advocates across the country.)

Ohio is one of the nation’s unhealthiest states, ranking 40th in overall population health, yet we spend more per person than all but 15 states. Additionally, the state ranks last in racial disparities of infant mortality, speaking to the need for a more robust approach to health equity.

In 2009, Governor John Kasich created the Office of Health Transformation to change the way we pay for and deliver health care, to move from volume to value. Leveraging the influence of large self-insured employers, the administration brought together the four largest insurers, public payers and providers to develop a payment/delivery reform plan (described below), leading to the award of a federal State Innovation Model (SIM) Implementation Grant.

But what about the role of consumers? That’s where we come in.

In the next five years, Ohio plans to move 80 percent of Ohioans into two new payment models: Patient-Centered Medical Homes (PCMH) and episode-based payments. Episode-based payments refer to paying providers for treating a whole “episode of care,” such as joint replacement, rather than the individual services. This incentivizes providers to get the care right (they get paid the same even if the patient gets a bad infection requiring multiple hospitalizations), creates more price transparency and narrows the wide variation in charges among providers for the same treatment.

The SIM application talks about patient engagement, but we need to identify the strategies for building in robust and meaningful patient engagement. Furthermore, strategies for addressing population health also need to be identified. Thus our coalition, Ohio Consumers for Health Coverage, is focusing its Value Advocacy Project campaign on shaping the PCMH model of care as an instrument to improve population health driven by a robust, institutionalized consumer voice at all levels of Ohio’s health transformation efforts.

Regional PCMH collaboratives in Ohio demonstrate both the potential and challenges of relying on primary care transformation to make strides in population health. On the one hand, we’ve seen PCMH practices virtually eliminate racial disparities in delivery of diabetes care in Cleveland (check out Better Health Partnership). On the other hand, The Southwest Ohio Comprehensive Primary Care Initiative (which is one of seven sites in the federal CPCI initiative), has Medicaid covering only 5 percent of patients, due to federal restrictions. And CPCI’s patient population does not reflect the racial and ethnic diversity of Ohio. Yet, the Kasich administration is calling it the model for Ohio’s PCMH model.

On the plus side, a handful of PCMH practices in the southwest Ohio demonstration are using Patient-Family Advisory Councils (PFACs) to involve their patients in improving care quality – a best practice for patient engagement that we plan to promote as a state benchmark.

Where do we begin?

We’re working in three areas:

  1. Advocating that the Ohio PCMH model include standards and metrics to measure and improve consumers’ experience – including their participation in their care – and promote population health by connecting consumers to resources like patient self-management programs, housing and food assistance that improve their health and overcome non-health barriers;
  2. Building the voice of consumers at several levels: at the individual level by promoting expanded use of PFACs in PCMHs and recruiting consumers for them, at the systems level by getting consumers and advocates more vocal, at the regional collaborative levels in our three largest metropolitan areas and the policy level where we recently won four seats on the PCMH model design workgroup; and
  3. Ensuring that Ohio’s PCMH initiative promotes health equity, including institutionalizing effective use of community health workers to reduce health disparities and engaging the Ohio Statewide Health Disparities Collaborative in developing a health equity action agenda for this initiative.

Perhaps our greatest challenge is figuring out how to energize consumers in the three biggest metropolitan regions (and beyond) to get involved as advocates for better primary care that supports efforts to lead healthier lives. We hope to draw in people newly enrolled by community-based assisters, especially ones we trained and placed primarily in communities of color, as part of our enrollment follow-up activities to promote better health literacy and patient engagement. And we’ll turn to our activated enrollees in our integrated care (“dual eligibles”) demonstration, some of whom we are training for managed care plan consumer advisory committees.

Most of all, we plan to borrow promising practices from consumer advocates in other states who have been infinitely creative in causing a stir. Ohio needs a lot of creativity!

Author: Cathy Levine, Former Executive Director, UHCAN Ohio