Yesterday, we alerted our partners to the great news that the Senate had passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In addition to permanently repealing the Sustainable Growth Rate, the flawed formula used to determine Medicare physician payment rates, we are pleased that MACRA refunds the Children’s Health Insurance Program (CHIP) for two years with all its current provisions intact. It also provides funds for community health centers, the Maternal Infant Early Childhood Home Visiting program, and family-to-family information centers and continues the Transitional Medical Assistance program which supports families as they transition out of Medicaid eligibility.

In reflecting on this huge win for children and families, we want to thank our partners for their tireless advocacy for CHIP. These advocates encouraged their governors to submit comments about the importance of CHIP in their state, educated their Congressional delegations about the harm that would come from losing CHIP funding, and activated their grassroots to ensure policymakers heard the message loud and clear. Their engagement on the issue of CHIP funding has been unflagging, and we are deeply appreciative of their work—we hope they will take a moment out of their busy schedules to take a victory lap!

So what’s next for children’s health? We still have plenty of work to do, ensuring that kids who enroll in Marketplace plans—now or in the future—have access to comprehensive benefits and provider networks via policies that are affordable for their families. We need to continue exploring policies that will support continuity of coverage and reduce churn, so kids can stay connected to the care they need. And we are excited to think about health system transformation with an eye toward children’s health, building on our existing work on children’s health care quality. We are looking forward to engaging with our partners on all these topics and more. 

Imagine you have diabetes and your insurer won’t pay for insulin. Instead, you have to pay out of pocket or face blindness, or even death? Now imagine you learn that people like you with diabetes were twice as likely to be denied treatment compared to people with other medical problems. Sound unfair to you?

For millions of people who need treatment for drug and alcohol problems or mental illness, inequity is a reality.

Behavioral health discrimination in health insurance is once again in the spotlight. Health insurance denials for substance use and mental health care in private insurance plans were nearly twice those for other medical care in the last year, according to a report released last week by the National Alliance on Mental Illness (NAMI). NAMI is one of our partners advocating for more fair treatment for people living with chronic behavioral health problems.

For years, people with behavioral health issues, their loved ones and advocates have pushed for a more equitable system, one in which substance use and mental health treatment is covered equally, or at parity with, other forms of medical treatment under health insurance plans. This work resulted in the 2008 passage of the Mental Health Parity and Addiction Equity Act, a federal law requiring many health insurance plans to follow parity rules, meaning that if they offer mental health and substance use disorders benefits, they must cover them equally to other medical benefits. The Affordable Care Act (ACA) has extended these protections to more health plans. New federal regulations were issued in late 2013 for private plans and proposed regulations came out last week for Medicaid.

NAMI surveyed nearly 3,000 behavioral health consumers (thanks to those of you who participated!) and analyzed 84 insurance plans in 15 states. The takeaway? While more consumers than ever should have access to health plans that require behavioral health parity as a result of the ACA and the federal parity law, consumers are often left without the treatment they so desperately need.

In addition to the high rate of substance use and mental health coverage denials, the survey’s highlight other common problems with parity implementation:

  • Many insurance networks have far too few substance use and mental health providers
  • Discriminatory drug tiering, when insurance companies make medication for certain conditions more costly for the consumer, creates barriers to needed for substance use and mental health disorders
  • Consumers do not have enough information about behavioral health coverage to compare health plans and choose a health plan that meets their needs

What can we do?

If you’re looking for even more ideas, you’re in luck! Keep your eye out for new Community Catalyst resources on behavioral health parity enforcement in the coming months. It’s time to leverage the letter of the law to make behavioral health equity a reality in our health system. Together we can make change – let’s work to keep the spotlight on parity.  

We know we’re starting to sound like a broken record, but we couldn’t help but share that yet another report boasts how closing the gap is good for state budgets. It’s no surprise—similar to the outcomes we highlighted in previous posts, this most recent study from the Robert Wood Johnson Foundation and Manatt Health Solutions finds that closing the gap will deliver more than $1.8 billion in savings and new revenues for eight states by the end of 2015.

These savings and revenues come from three key sources:

  • Savings from enhanced federal matching. States that have closed the gap receive 100 percent federal funding for providing full Medicaid coverage to beneficiaries who previously had limited Medicaid benefits. These folks include “medically needy” individuals, pregnant women and individuals with disabilities. Seven out of the eight states in this study projected savings in this category.
  • Reduced state spending on programs for the uninsured. Now that certain groups of people are no longer in the coverage gap and are able to secure full Medicaid benefits, every expansion state will spend much less on state-funded health care for prisoners, mental and behavioral health programs, public health programs and uncompensated care funding to hospitals.
  • Increased revenue from insurer taxes. Four states in the report were able to capture increased revenue because more people are covered – although all states with these taxes will get in on this action. For example, Arkansas brought in $4.7 million in 2014 and will bring in almost $30 million in 2015 as a result of having closed the coverage gap.

The results are clear – drawing down federal funds to cover more people is good for state budgets. It’s also exciting that both Arkansas and Kentucky were able to calculate that their savings and revenue will more than pay for expansion through 2021. We only hope that policymakers in states with a remaining coverage gap hear this good news loud and clear!

Last week, the Edward M. Kennedy Institute for the United States Senate opened here in Boston. The institute features a to-scale replica of the Senate chamber and will be used as a tool to teach civic engagement, negotiation and debate. The dedication of the institute was a moving tribute to Senator Kennedy and to the legislative body in which he served for 47 years.

It is also a fitting acknowledgement of the  man who worked tirelessly toward health care coverage and access for all Americans that, next week, the Senate will return from recess and resume its consideration of a H.R. 2, a legislative package that would extend the Children’s Health Insurance Program (CHIP). Senator Kennedy and Senator Orrin Hatch (R-UT) worked with colleagues from both sides of the aisle to launch CHIP in 1997, and more than 17 years later, this program is still vital to the health and well-being of millions of children across the country.

The Senate must act quickly next week to extend CHIP and protect the coverage of 8 million children. Advocates and governors across the country have asked Congress to continue CHIP. We are hopeful that the Senate will move swiftly to answer them. 

With April being National Minority Health Month and May Older Americans Month, the time is now to stand against the barriers that create the social, health and economic disparities experienced by the older adult population – a population that demographic data clearly tells us is becoming more and more diverse. That’s why we were struck by the most recent issue of Generations, the quarterly journal of the American Society on Aging, which is entirely devoted to these timely and critical issues.

First Let's Talk About the Landscape

African Americans, Latinos and Native Americans in the U.S. receive lower quality health care and experience disproportionately high rates of mortality and health status disparities compared to other high-income countries, say Alberto Palloni and James Yonker. And as author Steven P. Wallace states in his article, “Health inequities are the result of avoidable differences between populations that affect less powerful groups in society. They stem from a pattern of health determinants, outcomes and resources associated with broader social inequities.”

Several other authors in Generations argue that we need public policies and institutions that create healthy environments for older adults with diverse backgrounds, that make the “healthy choice the easy choice.” Determinants such as economic status, safety and adequate housing, are important as these facilitate healthy behaviors.

Valuing caregivers can also help address disparities, author Nancy R. Hooyman argues. Most caregivers and care recipients are women. Hooyman's article points out that gender inequities experienced by women are inextricably linked to the widespread undervaluing of caregiving, saying, “These disparities are reinforced by social institutions of the family and the labor market.” The solution lies in viewing caregiving as a “public value” rather than a private duty, as is often the attitude in the U.S.

Taking a Closer Look: LGBT Older Adults

Generations features a number of articles focused on particular populations, including one about lesbian, gay, bisexual or transgender (LGBT) older adults. According to Karen I. Fredriksen-Goldsen, there are 2.4 million adults 50 and older in the U.S. who identify as LGBT, accounting for 2.4 percent of the population in that age range. She goes on to say that “LGBT adults who are middle-age and older experience significant health disparities, defined as variations in health attributable to systemic environmental, economic and social barriers that place individuals at a disadvantage in the larger society.”

It is critical to ensure comprehensive support services for mid-life and older LGBT adults. Adequate resources will ensure that this population does not experience social isolation and poor health outcomes. The Affordable Care Act (ACA) provides important steps forward in advancing policies that address the needs of LGBT older adults, such as establishing the non-discrimination protections in health care services based on sexual orientation or gender identity. 

Taking Advocacy to the Next Level

So, which strategies and advocacy approaches can take this movement to the next level? Generations authors highlight initiatives underway through the Administration on Aging (AOA), including the Administration for Community Living and the Older Americans Act. For example, authors Boutaugh et al, suggest that these initiatives offer lessons that can help address the issues of access for racial and ethnic minorities. One such initiative the AOA has supported bolsters evidence based health and prevention programs such as the Chronic Disease Self-Management Program. Other initiatives, made possible through the ACA, can also advance health equity for vulnerable, diverse older adult populations, such as the demonstrations to integrate care for those dually eligible for Medicare and Medicaid.

The Bottom Line

The latest Generations issue* keenly reminds us that the transformation of our health care system must fully recognize the diversity of America’s aging population and tackle, head on, the social and health disparities it experiences. Fortunately, the ACA offers myriad opportunities to take on this challenge and, critically, to make older adults’ voices central to the decisions being made about their health. 

*This issue is available to ASA members or for single-issue purchase here.