Even with health care coverage, Medicaid beneficiaries still find themselves facing numerous barriers to accessing the care they need and achieving better health outcomes. One barrier that continues to cause serious access problems is transportation. There are an estimated 3.6 million people in the United States who miss or delay medical care because they don’t have access to transportation.

NEMT 3 Million PeopleIn early August, the Center for Consumer Engagement in Health Innovation (the Center) submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) regarding Iowa’s request to extend its waiver of Non-Emergency Medical Transportation (NEMT) benefits from its state Medicaid demonstrations (Iowa Wellness Plan and Marketplace Choice Plan). The waiver excludes coverage for NEMT services, a benefit that is standard in non-waiver Medicaid programs.

NEMT provides access to and from medical appointments for consumers who do not have other means of transportation. Reimbursed services can include shared van programs, taxis or public transit. Many in need of NEMT are lower-income beneficiaries, often older adults or people with disabilities. A high proportion of these individuals live with multiple chronic conditions such as end-stage renal disease, cancer or chronic obstructive pulmonary disease. Monitoring and treatment for these conditions require frequent medical appointments and limited transportation options may prevent access to timely, life-sustaining care.

Transportation barriers can have a “domino effect” on health outcomes and cost of care. Missed or delayed appointments can worsen health conditions and end up necessitating expensive ambulance services and costly emergency department visits. This is why NEMT has proven to be highly cost-effective.

For individuals in need of behavioral health services, NEMT is particularly critical. One study found that the largest proportion of adult beneficiaries who use NEMT do so to access mental and behavioral health services. More than 40 percent of NEMT trips in New Jersey and 30 percent of trips in Nevada were used to access mental health or substance use treatment appointments.  

The Center is concerned that several states have sought to exclude NEMT for some of their Medicaid beneficiaries. These actions reveal the need for consumer advocates to ensure that other states do not follow suit. 

This is why the Center submitted comments on Iowa’s waiver request and why we plan to also submit comments opposing Indiana’s similar proposal. We encourage others to do the same. The comment period for Indiana’s NEMT waiver request is open from August 12 - September 11, 2016. 

Submitted by Andrew Jopson, Summer Intern. Andrew is a graduate student at the University of Washington, Seattle.

Louisiana is the leading the way when it comes to being innovative to improve the lives of its citizens.

Our new Governor John Bel Edwards boldly campaigned that he would expand Medicaid in a deeply red state. He appointed a leader who thinks out of the box in Dr. Rebekah Gee, Secretary of the State Department of Health and Hospitals, and kept his promise. 

You may have read that Louisiana is the first state to utilize food stamp data to fast-track Medicaid enrollment. Through a state plan amendment, we were able auto-enroll about 105,000 eligible residents based on their participation in SNAP. Along with linking databases of participants in the Greater New Orleans Community Health Connections Program (which offered limited Primary Care in the four Parishes around New Orleans) and Take Charge Plus (which offered family planning benefits), there were already 233,794 enrollees in the first 30 days of the enrollment period. 

With such great early successes you may be wondering like me, what can they possibly do next? But, this innovative team just keeps on thinking. Their vision of having a healthier more equitable state is just beginning.

Health Care Innovation LouisianaThe Special Projects team is now engaging with the Department of Corrections (DOC) to set up pre–release enrollment for justice-involved individuals into Medicaid. This will allow those men and women released from prison or jail to not only be linked to an insurance plan that can cover their provider visits and medications, but also to receive much-needed care coordination upon release.

Prior to expansion, Medicaid was only available to cover the cost of hospital stays of eligible justice-involved individuals, which was typically limited to persons with disabilities. With Medicaid expansion, the cost of hospital stays for almost all justice involved individuals will now be paid for by Medicaid since eligibility will be based income rather than disability. This is expected to relieve a great financial hardship for the corrections system.  Additionally, for those offenders that DOC indicates have high-need medical issues, the Louisiana Department of Health and its contracted insurance plans are working to ensure those individuals have focused case management prior to their release. This ensures linkages to care and other needs in order to create the best opportunity for successful reentry and to prevent recidivism.

Due to the complexity involved in enrolling and stabilizing this population, the state is taking the project one phase at a time and starting with offenders at the state level in the nine state-run facilities first (approximately 3,500 releases each year). The next phase of the project will involve enrolling state offenders housed within 104 local jails (approximately 15,000 releases each year).  A stakeholder process will be initiated as the state approached phase 2 in order to engage local jails, providers and advocates to make enrollment successful.

We know that many of the individuals who are currently incarcerated have high rates of mental illness and substance use. This population in Louisiana is also disproportionate­ly male, minority and poor. Recidivism can be correlated to the lack of treatment of these behavioral health issues. The leadership Louisiana is providing in the pre – release enrollment project for Medicaid of the incarcerated population is an example of how innovation and creativity can not only decrease costs to systems but save lives.

As a proud Louisiana resident, I look forward to what ground breaking strategies this team will come up with next to ensure we have a healthier more prosperous state. Geaux Louisiana!!!  

Joia Crear Perry, M.D. is CEO of the National Birth Equity Collaborative and a member of Community Catalyst’s Board of Directors.

This month, the first wave of locally-transmitted Zika virus infections in the continental United States in Florida could signal the escalation of a public health crisis with lasting consequences. Early action by the Obama administration improved access to Zika preventives, such as mosquito repellant, for Medicaid beneficiaries. Yet Medicaid’s effectiveness to fight against Zika is hobbled by the refusal of many state governments to close the Medicaid coverage gap. Tens of thousands of those most at risk for Zika in states like Florida, Texas, and Georgia are uninsured because they’re stuck in that gap.

State health advocates have keenly noted the hypocrisy: at the same time that state officials are calling on the federal government to address Zika with emergency aid, these same states cite opposition to federal support as a key reason to resist closing the Medicaid coverage gap—which would make health care accessible for hundreds of thousands of people in need. The result is billions of federal dollars left on the table in non-expansion states – money that would ensure a more comprehensive approach to fighting Zika than relying solely on emergency funds after the situation worsens.

Florida health advocates bristled at the governor’s suggestion that women thinking of becoming pregnant should consult their health care providers about the risk of Zika. Florida CHAIN released a statement  emphasizing the absurdity of this advice for the more than 280,000 uninsured Florida women caught in the coverage gap. The Florida Health Alliance created a Zika fact sheet and this week called on members to contact their legislators about Zika.

Puerto Ricans migrating to the mainland United States are also highly at risk. Puerto Rico recently declared a state of emergency on the island due to Zika. The lack of health care in migrant and immigrant communities has concerning implications for health equity in Florida. This disturbing disparity could be alleviated if Governor Scott and other Florida policymakers took swift action to close the coverage gap this year.

As Texas braces itself to be the next state with local transmissions of Zika, advocates are already calling on state policymakers to close the coverage gap as part of the equation to address Zika. They believe waiting until Zika becomes an emergency to take action is the wrong choice for the roughly 800,000 uninsured Texans in the coverage gap. Increased access to Medicaid among low-income individuals is critical to efforts to detect and prevent the spread of Zika and associated health problems such as microcephaly, which will have long-term effects. Although pregnant women typically have more generous eligibility for Medicaid, women who might not know they are pregnant yet, and the partners of pregnant women – who can spread Zika through sexual transmission – often fall into the coverage gap.

Meanwhile, Louisiana’s newly expanded Medicaid program, Healthy Louisiana, took swift action to prevent Zika by covering mosquito repellant and other preventive services. Louisiana’s decision to close the coverage gap effective July 1, 2016 means that 375,000 Louisianans are newly eligible for Medicaid coverage as Zika heats up in the region. What a contrast!

Without a doubt the biggest health policy/politics story of last week was Aetna’s announced pullout from a large number of ACA markets. Predictably, the announcement was greeted with pronouncements of doom for the ACA. You might think that people who have been predicting disaster since 2010 and have been wrong every time would be a little more circumspect by now. Silly you.

Let's separate the reality from the political spin. A number of factors are contributing to the related phenomena of premium rate increases and carrier market exit. First, the marketplace risk pool is smaller, older and sicker than many analysts anticipated – not always for bad reasons. For example, fewer employers are dropping coverage than CBO expected, making the universe of people eligible for marketplace plans smaller. Other factors driving utilization in the marketplace plans include pent-up demand from the previously uninsured, the extension of certain non ACA-compliant plans that has kept what is likely to be a healthier population out of the ACA marketplace, and the gradual phase-in of the individual mandate, which has probably led some people to decide that going uninsured is still a better deal economically. Congressional efforts to undermine the ACA's risk stabilization programs have not helped either. And two of those programs are expiring in the next year, leading to a one-time premium bump.

In the case of Aetna, there are carrier-specific factors at work, as well. In particular, there seems to be a link between the prospects for Aetna's merger with Humana and its decision to pull out of the marketplaces. In a July letter to the Department of Justice (DOJ), Aetna warned if the merger was blocked, it would pull back on its marketplace participation. The announcement of the pullback came shortly after DOJ sued to block the merger. If you are a complete cynic, you would see this move as either retribution or, at best, a negotiating ploy. It's probably closer to the truth to say the company expected to make a lot of money from the merger and needed some regulatory goodwill to pull it off. In the absence of that goodwill, and with the merger now in doubt, they became less willing to sustain losses in the ACA market.

An understanding of the underlying dynamics leads to the conclusion that some of the factors that are causing the current turbulence will simply abate over time, even if no action is taken. The noncompliant "grandmothered" plans will fade away after 2017, the individual mandate will increase and the pent-up demand will decline. Coupled with stepped up efforts to enroll more young adults, we can expect the ACA market risk pool to improve. Meanwhile, carriers that have gotten out of the game and shed their unfavorable risk are likely to come back in with more competitively priced plans.

At same time, ACA supporters should not be looking at recent developments through rose-colored glasses. At a minimum, plan pullouts and 2017 rate increases coming on the heels of co-op failures create a negative profile for the ACA at a politically sensitive moment. More importantly, these events underscore a structural weakness in the law. The marketplaces were designed to operate with a public option in order to guarantee both the universal availability of coverage and to create a cost-effective benchmark plan with a broad provider network against which private insurers would have to compete. While a great deal of energy was spent during the fight for passage debating the merits of the public option, not enough attention was paid to how to make sure the marketplaces worked properly in its absence. The co-ops were one half-hearted attempt, but they were always a weak reed that has now pretty much broken.

States still have a number of levers they could pull, including creating a state-based public option or requiring carriers to service the ACA market if they wanted to sell to other segments. However, that presumes the state government in question wants to make the ACA succeed – not at all a safe presumption. In fact, the very states that are probably going to have the hardest time with the recent market shifts are the ones least committed to the ACA’s success. Fixes at the federal level are technically pretty straight forward, but remain politically challenging with a Congress committed to repeal.

What this means is that in many places, the gradual stabilization of the ACA market will just have to play out over time. In the short run, unless the current or a subsequent administration can identify some fixes that lie within their current scope of regulatory authority, ACA performance will remain something of a self-fulfilling prophecy at the state level – succeeding where state administrations want it to succeed and struggling somewhat where they don't.

It's been a surprising electoral campaign in many respects, but from a health policy standpoint, what isn't happening is perhaps as surprising as what is happening. For the first election cycle since passage, the anti-ACA dog is barely barking. And while it is far too soon to take anything for granted, Secretary Clinton has opened up a substantial lead in the polls at a point in the campaign when polls begin to matter.

If Clinton does prevail in November, will it create an opening in Washington to build on the ACA and correct some its shortcomings? And will the opposition finally learn to love the ACA? Probably not (very probably not). First of all, there are very limited points of agreement between the two parties with respect to the ACA. Aside from agreement on repealing the "Cadillac tax" and bipartisan bills to reduce cost-sharing for people with chronic conditions, the two parties want to move health policy in very different directions, at least with respect to coverage. But even these limited points of agreement face headwinds in the form of disagreements about how to offset their cost to the treasury.

Secondly, bear in mind the GOP platform and the House Republican health care blueprint call for major cuts to Medicare and Medicaid that would reduce coverage and increase costs for millions of beneficiaries. If these 50-year-old programs are still in the crosshairs, why would the ACA to be any different? Finally, consider that the basic forces driving political polarization have not abated. So, while the "hot war" may subside a bit (fewer repeal votes), we can expect a health policy "Cold War" to continue until the basic political dynamics change or until one party or the other receives a new electoral mandate.


States to the Rescue?

While political gridlock continue to stymie progress on health policy in Washington, the same is not necessarily true in the states. It seems every week more evidence piles up on the benefits states reap from closing the Medicaid coverage gap. Last week was no exception. Recent studies highlight how closing the gap reduces uncompensated care, provides economic and fiscal benefits to states and improves the health and economic well-being of enrollees. At the same time, new evidence shows closing the gap does not lead to a spike in emergency room utilization, a concern often raised by opponents

And the political winds may also be shifting in favor of closing the gap, as both voters and local government officials lose patience with state inaction. With President Obama exiting the political arena, a Clinton win could set the stage for progress among the 19 holdouts that have not yet expanded coverage.

But state progress will not necessarily be limited to closing the gap. Other issues are also likely to get a fair share of attention. One big issue gaining ground in states is addressing surprise out-of-network bills. With the rise of narrow network plans both on and off ACA marketplaces, more and more people are finding themselves paying unexpected medical bills even when they try to stay within their health plan network. California's legislation addressing surprise out-of-network billing has a good chance of passing this year. But the issue has legs not only in blue states but in red states, too. Texas is considering steps to protect consumers from surprise bills. Progress in the two biggest states – with wildly disparate political environments – could prompt similar action across the country.

Two other state initiatives to watch are ballot measures in California and Colorado. The California proposal would reduce the amount some state programs have to pay for prescription drugs, while the more far-reaching Colorado measure would create a single-payer system in that state. Both measures face a tough road. Opponents are heavily outspending proponents, and the Colorado measure recently suffered a setback when a fiscal analysis found the revenue sources for the proposal were not adequate to cover the costs. But as long as lawmakers in Washington remain stuck in the political mud, we can expect states to keep pushing the boundaries in searching for solutions to our nation's pressing health care problems.