Posts About Health System Transformation

“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

– Winston Churchill, 1942

On the heels of the 7th anniversary of the signing of the Affordable Care Act (ACA), House Republican leadership abruptly withdrew the American Health Care Act – their plan for repealing and replacing the ACA – from a long-promised floor vote. Many of us breathed a (brief) sigh of relief, particularly for the 24 million Americans who could have lost their health care coverage if this bill had been enacted.

But even as we celebrate the integral role consumers – including many older adults and people with disabilities – played in defeating the bill, the work to improve health care is as urgent and pressing as ever. Now that we’ve reached what we hope is the “end of the beginning,” here are three things we’re doing here at the Center to create a more person-centered health care system:

Identify and disseminate innovative models of care.

There has been tremendous progress in the development and rollout of innovative models of care that improve health and outcomes, often while saving money at the same time. For example, Massachusetts’ Community Support Program for People Experiencing Chronic Homelessness (CSPECH) provides supportive services to help people obtain and stay in housing. The benefits in quality of life and improved health have resulted in annual per-person net savings of up to $7,013. This year, the Center will highlight innovations that are person-centered, responsive to the needs of the community and built with consumer input in a series of publications we’re calling, “What Works.”

Build a network of consumers who can drive health care innovation.

Consumers have a unique and critical role to play in ensuring that health innovation efforts result in care that is oriented around the needs of the people served. As such, the Center recently awarded a series of grants, with more on the way, to help state consumer advocacy organizations build out a base of consumers – particularly older adults, people with disabilities and those from communities of color – who can drive person-centered care innovation in their states. Over the next year and supported by one-on-one technical assistance provided by the Center, our grantees plan to reach out to 22,000 consumers, sign up roughly 2,000 consumers to engage with our partners and develop 90-100 new consumer leaders who can advance health care innovation.

Stand up for person-centered care.

Despite the AHCA’s late March collapse in the House, I expect that there will continue to be threats to comprehensive, person-centered care. For one thing, there may be more attempts at “repeal and replace”. But even short of repeal, threats might come in the form of policies that limit eligibility for and/or complicate enrollment into coverage, increase financial barriers for accessing care, take away support for innovative care models, or reduce services (for example, non-emergency medical transportation) that we know are critical for health and which are cost-effective, too. As new proposals come forward, we will assess them through the lens of whether they will improve health, particularly for people with complex health and social needs, and we will continue to sound the alarm about programs that co-opt the language of person-centeredness to instead impose policies that hurt the most vulnerable.

While March 24, 2017 perhaps marked the end of one chapter in the history of health care policy in the United States, it is certainly not the end of the journey to improve health care. We have much work ahead and I look forward to sharing this journey and its inspirations, challenges and, hopefully, celebrations as we move forward.

What’s the one thing you’d change about the health system tomorrow to make it more patient-centered? Tweet us @ccehi and share your thoughts!

I recently had the privilege of joining partner advocates at the Rhode Island Organizing Project (RIOP) at a “house meeting” in the Providence community. RIOP staff have long used house meetings as a powerful organizing tool, gathering consumers in comfortable settings in or near their homes to engage in meaningful conversations on important issues that affect their health and well-being. The gatherings have a particular focus on vulnerable and historically disempowered populations such as low-income older adults and people with disabilities, including those in minority communities.

This meeting was at a low-income senior housing residential building. There were 12 attendees and eight were Spanish speakers with limited proficiency in English. I was so happy to be there and have the opportunity to hear from the Latino community while serving as a translator for the RIOP organizer. The major issues attendees talked about were their difficulty in getting access to home-based care and needed dental, vision and hearing coverage. Several older adults also spoke about their isolation, which was very compelling.

This was the first time that RIOP organizers were reaching out at the residential level to the Latino population in Providence. They were able to provide vital information about help with the new 50-cent fare on the city bus system for people with disabilities and adults over age 65. Previously, those two groups rode Rhode Island Public Transit Authority (RIPTA) buses free. RIOP and other advocates fought hard against this new fare over the past years, but it went into effect in February of this year. Now that it’s here, the one option to soften the blow is a RIPTA card that provides 10 free trips monthly. This is not much, but it is vital assistance to low-income people struggling to balance all their needs each month on very limited funds. RIPTA had posted the application for this program online in several languages, including Spanish, but finding it requires access to and familiarity with computer use. So, for many of these Spanish speaking folks, this was the first time they were learning about this benefit’s existence. After the meeting, they went directly to City Hall to obtain their 10-ride bus passes. 

They also learned about the new INTEGRITY Plan, the state’s recently launched dual eligible demonstration project at Neighborhood Health Plan of Rhode Island for older adults that coordinates all Medicare and Medicaid benefits and services. Some of those eligible had received letters in Spanish about this new plan but still needed more information and clarification. They were confused as to why their existing insurance plan was asking them to consider this new plan, and worried about making any changes that might interrupt their current care. The RIOP advocates were able to provide them with the contact number of the ombudsman program for the Integrity plan, which offers information in Spanish. 

These were two practical and empowering things these consumers learned about at the meeting.

What this experience reinforced for me is how much people long to be heard and understood. I learned that there is a pressing need for health care information for the Latino population. It is not enough to simply know about their issues and fight for what we think will benefit them, but that we need to be able to meet and engage personally with people across a diverse range of communities. That is what the advocates in Rhode Island are doing by revealing their presence to this community. They are building meaningful new relationships; they are building bridges. RIOP advocates understand that all people have the right to be informed of decisions that affect them, to be involved in the process and to participate actively in their own health care. By attending these meetings, sharing their stories and partnering with local advocates, consumers from diverse language communities can in turn play a major role in working for just, consumer-centered health care policies. 

On top of the uncertainty surrounding Medicaid expansion and Medicaid funding stemming from GOP Affordable Care Act (ACA) repeal efforts, HHS Secretary Tom Price and CMS Chief Seema Verma’s recent letter to governors adds another layer of change and uneasiness. This letter affirms the new administration’s intent to use Section 1115 Medicaid waivers to cut key consumer protections that have made Medicaid a vital, comprehensive source of health and financial security to millions of low-income Americans.

Concerning Waiver Directions

Strong evidence demonstrates that Medicaid is efficient and cost-effective – and that the ACA’s coverage expansion has had a positive effect on state budgets and enrollees’ health. Nevertheless, the Price-Verma letter gives states the green light to move towards Medicaid policy provisions that could lead to loss of coverage and access to care, and potentially hurt state budgets, such as:

  • Cost-sharing requirements. Studies show Medicaid beneficiaries lose coverage and experience barriers to care when states impose premiums and copayments. An evaluation of Indiana’s most recent waiver suggests beneficiaries who are subject to copayments likely have higher use of the emergency department (ED) as a result. Collecting premiums and copayments has shown to be inefficient and costly.
  • Eliminating non-emergency medical transportation (NEMT). Medicaid beneficiaries are more likely than those privately insured to have health care access barriers and NEMT helps bridge that gap. NEMT helps Medicaid expansion enrollees access critical care and treatment including behavioral health services, preventive health services and substance use treatment.
  • Copayments for non-emergent use of the ED. Copayments do not reduce unnecessary use of the ED, financially burden Medicaid consumers and fail to address larger systemic health care access issues.
  • Waiving presumptive eligibility and retroactive coverage. These provisions facilitate access to care and important protections for both enrollees and the providers that serve them, especially when there are delays in the application and enrollment process.
  • Support for work requirements. The letter stops short of explicitly saying it will approve work requirements, but includes language that strongly encourages states to impose training or work programs. Work requirements would be onerous on beneficiaries (most of whom are already in working families) and costly for states to administer.

We are troubled by a few other aspects of the letter. First, HHS’ intention to expedite waiver approvals and extensions may roll back important public input and evaluation requirements that have supported a fair and transparent waiver approval process. Second, a willingness to approve state waiver requests that replicate approvals in other states is troubling, since 1115 waivers are meant to be temporary demonstrations to test different approaches to providing Medicaid services. HHS should assess the impact of a waiver provision on access to care for beneficiaries in a single state, before approving it across the board.

Finally, the letter expresses an incorrect view that childless adults are not “vulnerable” and do not fit in with the mission of the Medicaid program. In fact, these low-income adults have experienced a historic lack of access to affordable health care, fluctuating income and language and cultural barriers, and thus, are appropriately served by Medicaid. Covering more adults under Medicaid has benefitted state budgets, consumer health and hospitals. Rolling back these gains would be detrimental.

Trump HHS Commits to Combatting Opioid Epidemic, But There’s a Catch

Medicaid is a critical source of coverage for adults with substance use disorders (SUD). For instance, almost 500,000 individuals (most who were previously uninsured) in Ohio have received  treatment for mental illness or substance misuse under the state’s expansion of Medicaid. HHS’ letter commits to continuing the important work begun in the Obama administration to enhance Medicaid services for SUD and improve access to comprehensive substance abuse treatment. For instance, HHS plans to continue the Medicaid Innovation Accelerator Program that provides technical assistance to states in enhancing SUD services. We hope that HHS continues the previous administration’s explicit support of waivers that contained a specific set of evidence-based measures including Screening, Brief Intervention and Referral to Treatment (SBIRT), integration with primary care, recovery support services, and medication-assisted treatment. Of course, the proof of HHS’ commitment will be in what state proposals they eventually support.

However, HHS Secretary Price’s support of ACA repeal and cutting federal Medicaid payments is at odds with the letter’s promise to address opioid addiction. The latest ACA repeal bill would jeopardize an estimated 1.3 million Americans with substance use disorders or mental illness who have received treatment through Medicaid expansion.

Allowing States to Assess Their Own Compliance on Home and Community-Based Services

The letter also says the administration will give states more time and say in implementing regulations ensuring that long-term services and supports are appropriately provided to people in their homes or communities. Allowing individual states to assess their own compliance could open the door to services that are less responsive to consumer needs and preferences.

Keeping an Eye on Medicaid

The upside to this letter is that none of the harmful waiver provisions listed can take place unless the states themselves choose to pursue such avenues. However, we do anticipate that this is just the first of many regulations and guidances HHS will produce that could undermine consumer protections in Medicaid. We intend to track these developments and provide more resources that equip advocates to push back. Stay tuned!

Reviews are in on the House GOP health care plan, which has been enthusiastically embraced by President Trump, and they are pretty terrible. The plan has been panned by nurses, doctors, hospitals and insurers as well as organizations representing older adults, cancer patients and others. But don't take their word for it, most of the conservative health policy establishment also gives the bill a failing grade. Setting aside the far right ideologues (who also hate the bill, but for different reasons) ACA critics have, among other things, called the plan "worse than Obamacare itself" and say there is "little doubt it will price millions out of the health care market".

Our dystopian health care future under ACHA

Thanks to the ACA, the percentage of uninsured people in the U.S. has dropped to an all-time low. But that progress would be reversed under the GOP’s proposed plan. The Brookings Institute estimates that 15 million people would lose coverage. The combination of reduced tax credits, increased out-of-pocket costs and weak incentives to enroll would touch off an adverse selection spiral that would push premiums higher and cause even more people to drop coverage.

These changes are only the tip of the iceberg. Cuts to the Medicaid program would also force millions more to lose coverage. Cuts to Planned Parenthood would result in an increase in unplanned pregnancies and a significant decrease in health care access for millions of women and LGBTQ people. As the dominoes continue to fall, providers would begin to see revenue go down as uncompensated care costs rise, leading to service cutbacks, layoffs and in some cases, especially in rural communities, hospitals would be at a heightened risk of closure. Resources to combat the opioid crisis would be lost and states' capacity to finance long term care for older adults and people with disabilities would be undermined just as the need increases due to the aging of the baby-boom generation.

It would only get worse as it moves through the House (if it does). The bulk of the discussion in the House has been with the far-right Republican Study Committee and even farther right Freedom Caucus who are demanding more cuts to the Medicaid program. With only 22 votes to spare, it is likely that Speaker Ryan will accommodate their demands and Pres. Trump has already signaled that he is on board.

Why is the bill so bad?

Why have the Republicans produced such a bill so bad that even their own policy experts think it is a disaster? The answer is that the repeal and replace debate has always been a political exercise driven more than anything else by the needs of far-right House members in deep red districts. Their biggest fear is that what happened to Eric Cantor (a successful primary challenge from the right in case you forgot) will happen to them. Their goal is to vote on a bill that hews as closely as possible to the Heritage Action orthodoxy. Whether that bill actually offers a framework for workable health policy or even whether it ever becomes law are secondary concerns.

And while House districts are becoming less ideologically diverse, the bill that is emerging is very bad for a number of states with key Republican Senators.

Consider West Virginia; the state has seen one of the biggest drops in the percentage of uninsured in the country thanks to both Medicaid expansion and ACA tax credits. Additionally, there has been a huge expansion in access to treatment for substance use disorders. As a relatively rural state, both West Virginia’s hospitals and rural consumers would be big losers as coverage declines.

Or consider Alaska; no state in the country would feel a bigger impact from the rollback of health insurance tax credits. On average people in Alaska would receive $10,000 less than they do now.

Or take Arizona, a state with a lot of early retirees and a rapidly growing elderly population. Proposals to increase insurance costs for older adults and cut funding for Medicare could prove very unpopular. And a squeeze on Medicaid funding would undermine the state's successful Medicaid expansion as well as its ability to finance long term services and supports for its aging population.

Maine is in a similar situation even though it did not take up the Medicaid expansion. With the oldest median age population in the country as well as being a relatively low-income state, increases in insurance costs for older adults and decreased Medicaid funding would hit the state hard.

It's no wonder that senators from these states have expressed reservations about the emerging legislation. And it is still unclear that, given differing political dynamics between the House and the Senate, there is enough common ground between the two branches to get a bill through.

Sen. McConnell is a skillful and determined party leader, but success of a bill with consequences as disastrous as this one be might actually be worse for Republicans than failure. Pres. Trump has already put Plan B on the table -- let it (cause it) to fail and blame the Democrats. While they would never admit it openly, some Republican Party leaders may secretly prefer continuing to have a weakened ACA to kick around for a couple more years. If they succeed in passing a law, then they would own the consequences of Trumpcare and it ain't going to be pretty.

All this suggests that the debate over the direction of health policy is far from over regardless of the outcome of ACA repeal efforts over the next few weeks. If a bill passes, Republicans will feel a need to put lipstick on the pig (an effort that will probably be much better financed than defense of the ACA ever was). However, as coverage declines and the effects ripple through providers, state budgets and communities across the country, it will be hard for them to escape the blame. If the legislation fails, expect ongoing efforts to undermine the ACA through administrative action (and inaction) along with efforts to pin the blame for the resulting problems on the law itself. Either way expect the fight to carry right into the 2018 election.

On Monday, March 6, our Center team hosted a briefing at the National Press Club in Washington, D.C. that brought together the voices of leaders of innovative health systems. Titled “Too Much to Lose: Protecting Patients, Protecting Progress in Health Care,” and co-sponsored by The Commonwealth Fund, Missouri Foundation for Health and the Institute for Healthcare Improvement, the event highlighted how the coverage provided by the Affordable Care Act and Medicaid has enabled health systems to improve care for the people they serve in fundamentally new ways. We were honored to be joined by four health and hospital system leaders on the front lines of health care, as well as our two keynote speakers who framed the importance of the presentations in the current national health care environment:

  • Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI)
  • David Blumenthal, MD, president of The Commonwealth Fund
  • Glenn Crotty, Jr., MD, executive vice president & COO at the Charleston Area Medical Center Health System (Charleston, WV)

  • Timothy Ferris, MD, senior vice president for Population Health Management at Partners HealthCare (Boston, MA)

  • Steven M. Safyer, MD, president & CEO at Montefiore Medical Center (Bronx, NY)
  • Shelly Schlenker, vice president of Public Policy, Advocacy and Government Relations for Dignity Health (headquartered in San Francisco, CA)

Speakers at the event described programs that help pregnant mothers suffering from addiction to have healthy pregnancies and deliver babies who are substance free and that help to address patients’ needs for housing and food – all interventions made possible by the ACA and which are helping to improve health and thus lower health care costs. The leaders reflected on the ways that Medicaid coverage and the ACA have enabled progress at their institutions, from dramatically increasing the numbers of insured individuals (585,000 Medicaid patients at Dignity Health alone) to improving their financial ability to make investments in programs that connect parents with substance use disorders to behavioral health services.

In conjunction with the event, leaders of 24 health systems and organizations signed on to a statement affirming the importance of coverage as a foundation to health innovation and reading in part: “Nobody can have high quality care if they can't get care in the first place. The ACA’s expansion of coverage, including a Medicaid program with comprehensive benefits, is an essential component of those efforts.”

We were gratified to see so many prominent leaders step forward to share how their institutions have been working to improve care and health thanks to the coverage and innovation initiatives under the Affordable Care Act. With the introduction of the House Republicans’ ACA repeal bill , which also imposes sharp cuts on all Medicaid programs, we know we’ll need these voices of leadership more than ever in the fight to ensure that we protect progress, protect innovation and protect the patients that we all care for.

What are your concerns about the GOP repeal legislation? What innovation are you scared of losing? Tweet us @CCEHI with the hashtag #ProtectInnovation and let us know.

As a crossword puzzle enthusiast, I am always amazed at how many words have multiple meanings. And completely unrelated meanings, at that. Is the answer for “leaves” foliage or departs? Is the answer for “foil” to stymie or a food wrap?

Grammarians refer to a word of a given spelling that has two or more different meanings as a homograph. And in the sphere of consumer engagement, we are having a homograph problem. 

The very words that we have long used to talk about our goals for health care: consumer centeredness, consumer engagement, patient empowerment and consumer direction have taken on multiple meanings. While these multiple meanings are currently uneasily co-existing, the shifting political landscape promises to put them on a collision course.

For example, think about consumer or patient engagement, something we promote and implement in our work here at the Center. Our vision for consumer engagement regards patients as active partners in their care and aligns with definitions developed by the Institute of Medicine, reflected in the National Quality Strategy and incorporated in a number of innovative care models. A new National Academy of Medicine publication defines patient- and family-engaged care as care which is planned, delivered, managed and continuously improved in active partnership with patients and their families to ensure integration of their health and health care goals, preferences and values.

This vision of consumer engagement is important in value-based payment models, where providers have financial incentives to improve the cost and quality of care. Consumer engagement can help contribute to the success of this work, improving the health system in the process, and is an important component of person-centered care.

Yet, there is an alternative vision of consumer engagement driven by a different perspective on “value,” which emphasizes the patient’s role as a “shopper” for health care services. This vision typically emphasizes insurance arrangements in which patients must pay a higher share of the costs of services they use, such as through a high-deductible health plan or a health plan that has high point-of-care cost-sharing. The idea is to incentivize consumers – sometimes even very low-income consumers – to make cost-conscious decisions.

Speaker Paul Ryan’s health care proposal, “A Better Way,” describes the need to “empower Americans and put them in the driver’s seat of their health care decisions.” Rep. Tom Price’s health care proposal was titled the “Empowering Patients First Act.” Seema Verma, President Trump’s pick for administrator of the Centers for Medicare and Medicaid Services (CMS), described the development of the Healthy Indiana Plan, which charges $1 premiums even to very low-income individuals (making less than $500 per year), as “encourage[ing] members to stay engaged with their health plan, providers, and overall personal health.” Under this program, individuals who don’t pay premiums can be downgraded to  coverage that has fewer benefits and which requires paying more for each doctor’s visit, prescription and hospital admission, or they can be blocked from Medicaid coverage altogether.

So, here we have two very different visions employing an overlapping lexicon, one that includes the words “consumer-directed,” “consumer-centered,” “patient engagement” and “patient empowerment,” but with each term conveying wholly different meanings. While there are situations where the two ideas might not directly conflict, those of us who care for (and about) low-income patients with complex health and social needs should be concerned about this etymological appropriation.

This is because some of the program features currently being described as “patient empowerment” – such as requiring patient cost-sharing at the point of care or imposing “lockout” periods from coverage from patients who miss premium payments – make it harder for both patients and providers to establish a care partnership and for patients to obtain the care they need. In particular, research has shown that low-income consumers are more likely to forgo needed care and face worse health outcomes when faced with financial barriers to care.

More subtly, a fundamental premise of promoting shopping behavior – encouraging consumers to seek out the lowest-cost care – can be problematic for patients with complex needs, such as frail elders or people with multiple chronic illnesses, who might be better served by establishing an ongoing care relationship with a team of providers, rather than fragmenting care across many different providers or institutions.

What’s happening now is that established words and phrases with specific meanings are being appropriated to mean something very different. If used often enough in the new context, the new usage can delegitimize the original meaning, or at the least create enough confusion that the power of the terms may be devalued in all contexts. For the appropriators, that is a success in itself.

So what can we do?

I suggest that we, as a community dedicated to advancing consumer engagement as a partnership between patients and providers, be forceful and clear in what we are – and aren’t – talking about. We need to differentiate these two models by talking about “patients as partners,” in contrast to “penalties for patients.” We also need to speak up and call out when policies that are potentially harmful (particularly to low-income consumers) are being misleadingly promoted as patient-centered.

What do you think? Do you have other phrase suggestions or ideas on how to make sure the clarity of our syntax is preserved? Tweet us at @ccehi to share your thoughts!

This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Olivia's Story

In 2014, Community Catalyst shared Olivia Richard’s story in a video. Olivia is enrolled in the One Care program, the Massachusetts demonstration project which coordinates care for people with disabilities eligible for both Medicare and Medicaid (“dual eligibles”). Olivia uses a wheelchair and relies on personal care attendants (PCAs) to help her with activities of daily living. Before enrolling in the One Care program, she had not been receiving an adequate amount of PCA hours, nor other services she needed to achieve the quality of life and degree of independence she envisioned for herself. After enrolling in One Care, Olivia was able to live independently, with services that met her needs, preferences and goals, thanks to a coordinated plan developed together with her Independent Living-Long Term Services and Supports Coordinator. This was possible because of the Affordable Care Act (ACA), which enabled the creation of the dual eligible demonstration projects now ongoing in Massachusetts and 12 other states (formally termed the Financial Alignment Initiative.)

Fast forward to November 9, 2016: Individuals like Olivia now face the serious possibility that this much-improved coordination of their Medicare and Medicaid benefits may be significantly undermined by repeal of the ACA, impacting the delivery of critical services. Dual eligibles are a particularly vulnerable population – doubly in the line of fire – not only from the immediate attack on the ACA, but also from proposals circulating among the Republican-controlled Congress that threaten to seriously undermine each program in other ways in the future.

Beyond the unfolding rush to repeal the ACA, proposals in favor among Republican congressional leaders and the nominee for HHS Secretary, Rep. Tom Price, would permanently rework the structure and financing of Medicaid and could end the existing guarantee of coverage for all those who qualify for the program. In addition, House Speaker Paul Ryan has for years floated proposals to change Medicare from a defined benefit program to one in which adults over 65 get “premium support” to purchase private insurance, a plan slanted toward benefitting those older adults who are more affluent and in better health, leaving low-income elders in poorer health without the safety net that they have counted upon.

Who Are the Duals?

Dual eligible beneficiaries are entitled to Medicare either by virtue of age (being 65 or older) or by having a permanent disability and receiving Social Security Disability Insurance (SSDI). They are also eligible for Medicaid based on low-income eligibility guidelines. Currently, there are over 10 million dually eligible beneficiaries, with the majority (59 percent) aged 65 and older, and with most of them (73 percent) also eligible for full Medicaid benefits. Dually eligible beneficiaries comprise 14 percent of all Medicaid beneficiaries, but account for 33 percent of Medicaid spending; they also make up 20 percent of the Medicare population, but account for 35 percent of Medicare spending. In part, this disproportionate spending is because dual eligibles tend to have complex health needs, with higher rates of diabetes, mental illness and cognitive impairment. Another reason is that these beneficiaries have to navigate two complex systems, Medicare and Medicaid, which more often than not, has resulted in very fragmented and inefficient care. 

Altering Medicaid Will Have Serious Implications

The most significant implication of GOP proposals to restructure Medicaid – like changing to block grant or per capita cap funding methods – is the strong likelihood that eligibility will be limited and critical services will be cut, as the total federal dollar payments to states would be greatly reduced. Block grants or per capita caps would also limit states’ abilities to pursue innovative strategies that address issues beyond medical services such as access to long-term services and supports and the addressing of social determinants of health, which result in better integrated and more coordinated care. This is true for many low-income populations, but the dually eligible population is particularly at risk.

Medicaid, especially since the passage of the ACA, has served as fertile ground for innovative solutions to addressing health care cost, quality and access issues. Medicaid programs have been vital to improving care for dual eligibles, often serving as a catalyst for innovation. Fundamental changes to the Medicaid program could jeopardize such innovative programs as:

  • The Dual Eligible Demonstration Projects: as noted above, thirteen states are running demonstration programs – like the One Care program in Massachusetts helping Olivia – to better align the financing of the Medicare and Medicaid programs in order to better integrate services for dual eligible enrollees. These demonstration projects could not have been possible without the ACA creating the Center for Medicare and Medicaid Innovation (CMM) and the Medicare-Medicaid Coordination Office (MMCO) within CMS.
  • Medicaid Accountable Care Organizations (ACOs): ten states are actively running Medicaid ACO programs to improve care coordination and delivery of Medicaid benefits by holding providers accountable through quality improvements, increased financial risk and innovative information technology. Some states are using or are planning to use ACOs as a model of care for dual eligibles, such as Maryland and Oregon.
  • Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents - the MMCO and CMMI are spearheading an initiative to help improve the quality of care for people in long-term care (LTC) facilities by reducing potentially avoidable inpatient hospitalizations. The most recent evaluation report for this initiative shows a decline in all-cause hospitalizations and potentially avoidable hospitalizations in participating sites. The evaluation report also finds that there were reductions in overall Medicare expenditures relative to a comparison group.

Innovations such as these will be seriously impacted if the ACA is repealed and/or if Medicaid funding were to be radically undermined. Investments in delivery and payment reform in Medicaid are critical and must continue. The dual eligible population has complex medical and social needs and taking away needed services and shifting costs onto a group of consumers the least able to take on new financial stresses is bad policy. If innovative changes to our health care system can work better for the most vulnerable, they can work better for everyone. Stakeholders, including providers, plans, payors and advocates, need to come together now and raise their voices loudly to protect the ACA and the Medicaid program itself. This fight is nothing less than a fight for health care justice, period.

HIH Collage

This final 2016 edition of Health Innovation Highlights comes to you on the Winter Solstice. For those of us in the Northern Hemisphere, today we experience the inflection point from the days getting shorter, to the gift of a few more minutes of daylight each passing day through winter and spring. In other words, we enter a phase of “gathering light,” even as we prepare for our coldest months.

In these coldest months, we face threats to health coverage, access, innovation and quality. Along with our colleagues here at Community Catalyst and in coalition with health care and social and economic justice groups nationwide, we are fighting efforts to take away health care, particularly from those who are most vulnerable, like older adults, individuals with disabilities, and those with complex health and social needs.

As we prepare for the year ahead, I’d like to spend a few moments during this holiday season to reflect on the many things for which we are grateful. We’ve been blessed to have had the chance to celebrate many successes – not just of the Center, but our partners as well – in our mission to elevate the consumer voice as the key to health system innovation.

A few highlights from our first trip around the sun:

Launching the Center: At our January launch, Dr. Donald Berwick called on all of us to think about health beyond the traditional enclaves of the health care system and in the context of communities. He observed, “The new news is that to achieve health and justice, we have to reconsider and redesign the very fabric of what we call health care today.” His words, and the insights shared by panelists John Arnold, Amy Berman, Stuart Butler, Robert Crittenden and L. Toni Lewis, gave us our marching orders to create a health care system that better meets the needs of all.

Supporting Maryland’s Faith Community Health Network: In February, the Maryland Citizens’ Health Initiative, a longtime Community Catalyst partner, in collaboration with LifeBridge Health and faith leaders from throughout the state, launched the Maryland Faith Community Health Network with a training retreat for participating clergy and lay leaders. The concept is simple and effective – connect liaisons from participating congregations with congregants who are in the hospital to help them get the most out of their inpatient care and get the services and assistance they need once they are discharged.

Helping consumers prepare for Managed Long-Term Services and Supports in southwestern Pennsylvania: In June, we were welcomed to Pittsburgh by the Jewish Healthcare Foundation to lead a training for community and consumer groups. We were honored to play a role in helping these groups prepare for and engage in the launch of the Community HealthChoices program. We believe that the active engagement of consumers and community members will be critical to ensure that this program ultimately provides better, more coordinated care to Medicaid beneficiaries who need long-term services and supports.

Documenting best practices in consumer engagement in Medicaid ACOs: Medicaid accountable care organizations (ACOs) are an increasingly popular option for improving the quality of care and health outcomes while containing health care costs. But if Medicaid ACOs are to be successful, members and communities served by these programs must have a voice in their design, implementation and ongoing oversight. We dug into program documents and debriefed consumer advocates engaged in the design and rollout of these new programs to learn about what is working and what isn’t, and to identify ways that health care organizations can encourage meaningful consumer engagement.

Fighting to improve transportation services for low-income individuals: We have been hearing consumer horror stories from partners across the country about non-emergency medical transportation (NEMT). NEMT is a critical service that helps Medicaid beneficiaries without access to transportation get to doctors’ appointments, dialysis and cancer treatment. We have heard about children with compromised immune systems sharing transportation with sick individuals, patients with kidney failure who can’t get to their dialysis treatments and elderly people who are abandoned for hours at the doctor’s office. To address this issue, we are coordinating consumer organizations that are working to improve NEMT in their states. We also worked with our friends at Justice in Aging on a brief that highlights recommendations that policymakers and advocates can adopt to improve NEMT across the country.

Protecting care for people with disabilities in Massachusetts: In Massachusetts, advocates for people with disabilities scored a significant win when MassHealth, the state’s Medicaid program, backed off its proposed limits on personal care attendant hours. Disability advocates organized to raise awareness about how harmful the proposed limits could have been for the elderly and people with disabilities, who depend on personal care attendants to help them live with independence and dignity. While the fight is not over – the state loosened its restrictions but didn’t eliminate them entirely – the work of the advocates, on a very short timeline and in the midst of many other battles, was impressive indeed.

Bridging the gaps between health and housing: Every day, doctors and nurses care for people with serious illness who live in shelters, on the streets or in unsafe housing. And we know that unless we address these patients’ need for safe and secure housing, they will be back to the emergency room and hospital again and again with ever-worsening (and more expensive) conditions. In Pennsylvania, our partner Pennsylvania Health Access Network launched a collaborative Housing as Health campaign that brings together a statewide coalition of physical and behavioral health care providers, social services, housing-related entities, faith and community groups, advocates, and people enrolled in Medicaid to build a case for supportive housing services. Our state partners have been successful in elevating the issue of housing as a social determinant of health that should be prioritized by educating communities and policymakers, sharing the impact and savings of supportive housing services and sharing personal stories that illustrate the importance of their campaign.

Building the consumer voice in Rhode Island’s dual eligible demonstration project: In Rhode Island, advocates played a major role in the creation of a new Implementation Council to guide the state’s dual eligible demonstration project. Our state partners, Rhode Island Organizing Project (RIOP) and Senior Agenda Coalition, were instrumental  in everything from the drafting of the bylaws, to training of consumers as they take their places on the council. We hope that these strong consumer voices will help steer this demonstration toward truly person-centered care.

The “lights” that I’ve gathered here – and so many more that space doesn’t allow for – illustrate the dedication, passion and commitment of the consumers, consumer health advocates, providers, health care leaders, and others we at the Center have had the honor to encounter, learn from and collaborate with in our first year. Even as we confront the challenges ahead, I know that we will continue to gather light, on our journey to consumer-centered care.  In this holiday season, I wish you peace and light in the year to come.

The holidays are often a tough time for people struggling with drug and alcohol addiction or mental illness. But Congress has provided an early present that may ease some of these struggles in years to come:

  • Half a billion dollars in state grants to be awarded early in the new year to prevent and treat addiction to opioids, including heroin and pain pills, and a promise for another half a billion dollars in 2018
  • Authorization of a 5 year, $50 million demonstration project to train more health professionals to provide mental health and substance use disorders services in underserved community-based settings that integrate these services with primary care
  • Authorization of $25 million in grants to increase screening and treatment for post-partum depression, and separate support for early intervention and treatment of mental illness in children
  • Small steps to improve oversight and enforcement of the parity law preventing health insurers from discriminating against people with mental illness or substance use disorders
  • Allowing use of federal grants for programs that provide community-based services to divert people with substance use or mental illness from the criminal justice system prior to arrest or before they are “booked” for an alleged offense

These gifts come in a giant package called the 21 Century Cures Act that President Obama signed into law yesterday, and a separate law he signed on Saturday to fund the government through April. The Cures Act, approved in a rare bipartisan congressional vote, also includes many other provisions on cancer, research and other health issues. Unfortunately, the Cures package also includes a fair amount of coal:

  • It robs the Prevention and Public Health Fund of $3.5 billion that was authorized in the Affordable Care Act for prevention services across the health spectrum.
  • It weakens Food and Drug Administration rules designed to protect Americans from unsafe medicines.
  • While it authorizes more funding to the National Institutes of Health, the money is vulnerable to cuts because it has to be voted on annually.

Like many gifts being received this season, this present needs some assembly.

The federal government just released the application for the $500 million in opioid state grants, which can be used for prevention, treatment, and recovery support services. All states are eligible to apply. Advocates and their partners need to weigh in with state officials to make sure they apply and that this money is put to the best use. We need to remind state officials who oversee substance use services of the importance of prevention, including verbal screening and early intervention for youth, as part of a holistic approach to substance use disorders.

In 2017, federal advocacy is also needed to secure an appropriation for other $500 million authorized for opioid services in the Cures Act. Similar advocacy is needed to shake loose the money to treat maternal depression and to train more people to treatment mental illness and substance use disorders.

Meanwhile, the portions of the law designed to reduce inequities in treatment for substance use disorders and mental illness also require the federal government to issue new regulations and develop an action plan to coordinate federal and state enforcement. While President Trump has said the nation needs to address the opioid epidemic, he has been more outspoken about reducing regulation and government “overreach.” Advocates must speak up loudly and clearly for more enforcement of the law requiring parity in mental health and substance use disorders treatment vis-à-vis treatment for physical illnesses. 

New data last week highlights the continuing toll of the opioid epidemic: More than 33,000 deaths from overdoses last year. The new funding for state opioid grants and better enforcement of parity is critical to stopping this tremendous loss of life. But we also need to keep the expanded insurance coverage and access to services that 22 million people gained through the Affordable Care Act (ACA), or the death toll will only get worse. In addition to the opioid deaths last year, alcohol and non-opioid drugs contributed to more than 100,000 other deaths and untreated substance use costs the nation $400 billion annually in crime, health, and lost productivity.  

The best holiday gift we could imagine would be for the Trump administration and Congress planning to give up their plans to repeal the Affordable Care Act.

This is the second blog in a series to highlight the dangers of the repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

In 2015, Belhaven, North Carolina Mayor Adam O’Neal and supporters from 11 other states set out on foot for their second 300-plus mile trek from his rural town to our nation’s capital to draw attention to an important issue: rural communities in danger of their hospitals closing.

The walk idea was sparked when O’Neal’s local hospital, Vidant Pungo, closed its doors in July 2014. For many in that small town, not only were those hospital jobs lost, but the nearest hospital is now 30 miles away. Sadly, this is a scenario being replicated all across America. A major source of rural hospitals’ financial stress can be traced to their state decisions to turn down federal funding to cover more people through Medicaid. With some Republicans in Congress and the incoming Trump Administration bent on repealing the Affordable Care Act (ACA) with no plan to replace it, we seem to be moving further from finding a solution to this crisis.

For the 50 million Americans living in rural parts of the country, accessing health care has often meant facing a variety of barriers: difficulty making an appointment with a provider or specialist, traveling long distances to the nearest hospital, and a high rate of local hospitals closing their doors. People living in rural areas will have even more to lose if the incoming administration dismantles the gains we've made under the ACA.

Figure A. Rural Counties Across the U.S.

In the past six years, while millions of Americans have benefited from the ACA, Americans living in rural areas have made more progress under the ACA than the general population. People living in rural communities saw a 7.2 percentage point increase in coverage from 2013 to 2015, compared with a 6.3 percentage point increase for urban individuals. Of the nearly 2 million rural customers who bought health coverage through the ACA Marketplace in 2016, about 9 out of  10 rely on tax credits to make their coverage affordable. Also, because of the ACA, the share of rural Americans who cannot afford necessary care decreased by six percentage points. In real terms this means that families are able to have coverage regardless of their health status and are able to take advantage of financial assistance to make it possible.

But now these much-needed health care gains for rural communities are under threat. Congressional leaders and the incoming administration have indicated the first item on their agenda is repeal of the ACA without a replacement plan (including a repeal of Medicaid expansion). Rural Americans’ health coverage and livelihoods could be hit especially hard.

In addition to historical barriers to care, rural America’s struggles with health care are rooted in policy decisions that have left them worse off. For example, rural individuals are concentrated in states that have resisted reforms available to them under the ACA, like Medicaid expansion. These state decisions have had significant implications: more than a million rural individuals fall into the Medicaid coverage gap and many hospitals in rural areas are unable to draw in the benefits of a more insured patient mix. This is a large reason why more than 70 rural hospitals – most located in non-expansion states – have shut down since 2010. Many more hospitals are at-risk of closing because of financial pressure, in which Medicaid expansion would provide a lifeline. Hospitals are important employers and contributors to the local economy, so these hospital closures are happening to rural communities that can least afford to lose these economic benefits. Our rural communities know all too well the struggles of keeping their communities healthy and safe. Any reforms undertaken on a large national scale should improve health care, not put it in a state of uncertainty (Figure B). 

Figure B. Why the ACA is A Critical Lifeline for Rural Communities

Repealing the ACA without an adequate replacement would shut off any hope of saving these vulnerable communities from additional hospital closures. ACA repeal would also deny a pathway for individuals to gain affordable coverage and endanger gains made in rural communities in states that have embraced the health law.

One state with a lot at stake is Kentucky, which closed the coverage gap and set up its own state-based exchange under the ACA. Because of these decisions, the state’s uninsured rate dropped from 20 percent in 2013 to only 7.5 percent in 2015 – one of the biggest successes in the nation. Rural areas of Kentucky, which have been hard hit by poverty and poor health, disproportionately benefit from these gains in coverage. Ending the health law could be detrimental to in places with a high share of rural communities like Kentucky and Louisiana as well – which also closed their coverage gap in 2016 – where many have been able to obtain health insurance for the first time and use important preventive services that are shown to improve health and cut health costs over the long-term.

Communities are only as healthy as the people that comprise them. When people are healthy, they are able to raise thriving families and contribute to their local economies. This could not be truer in rural America, where the communities here would be in some of the greatest danger if the ACA is repealed without an appropriate replacement plan that protects and expands on the coverage gains of the last six years. 

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