Last week the health care justice community lost one of our visionaries and strongest leaders, Andy Hyman.Andy Hyman, talks with other attendees at Community Catalyst's anniversary dinner.

Andy was an idealist and realist rolled into one. He believed in nothing less than quality, affordable health care for all. Perhaps more than anyone, Andy knew what it would take for us to reach our collective goal. He knew it would require a broad base of support and a strategy that linked policy, communications and organizing.

Andy deeply understood the importance of having consumers at decision-making tables. He knew the input of those affected the most would make a profound difference in the outcomes. It was with this in mind that Andy helped create the Robert Wood Johnson Foundation’s (RWJF) Consumer Voices for Coverage Program. He helped not only lead RWJF’s efforts to support consumer health advocacy but also often spoke to the larger philanthropy community and opinion leaders about the value and importance of supporting the consumer voice.

Andy was also a true partner in our work in every sense of the word. He helped build bridges to connect organizations and stakeholders. He pushed us to be better. He challenged our assumptions. He was honest and forthright. He was someone you could always trust to do what he thought was right.

Our community of consumer advocates is stronger today because of Andy. His legacy is a respected and vibrant state consumer advocacy community. 

Andy was not only a partner in our work for health care justice, he was also a friend. We will miss him deeply. But he will live on in our memories, in the lives of the people he helped, and in our work for high quality, affordable health care for all. 

It seems like a distant memory when states had to choose their Essential Health Benefit (EHB) benchmark plans, the benefit baseline that all new individual and small group plans, including Qualified Health Plans (QHPs), have to cover. However, according to recently released regulations, this process will repeat itself, as states have the option to pick new benchmark plans for the 2017 plan year based on a 2014 health plan.

For many consumers, the EHB benchmark plans have fallen short. We applaud the federal response to address some of these shortfalls through proposed regulation, including a re-examination of prescription drug inclusion in the EHB. However, gaps remain. With one year of EHB coverage behind us, we know that consumers have struggled to access critical care addressing substance use disorders, pediatric services related to hearing, vision, and behavioral health, and habilitative services. The inadequacy in EHBs forces many families to forgo needed services or pay out of pocket for a loved one’s medical care. A robust benchmark plan selection will break down these barriers and allow consumers to access the services they need to keep themselves and their families healthy.

During the previous EHB benchmark selection process, who or what entity selected the benchmark plan varied from state to state, ranging from governors to legislatures to departments of insurance (check out this page to get more of a sense of the process in your state). On the other hand, 26 states either did not engage in the selection process or were unable to select a plan, and defaulted instead to the smallest group plan. Although some states might use a similar mechanism as last time to make the decision for 2017, shifting dynamics in many states will mean that there is not yet a definitive way the decision will or will not be made. 

Advocating for the selection of a robust benchmark plan remains complicated. Consumer advocates last time around had varying roles in the process, ranging from sitting on workgroup tables and directly informing EHB benchmark selection, to providing input during public comment periods, and sometimes having no role at all. Many may remember the large “listening sessions” from the first round of EHB selection, which often felt overwhelming, lacked focus, and turned into a laundry list session of needed health services. Going forward, advocates will need to look back at what did or did not work last time and what strategies will work in the next round.

The timeline for a new EHB decision remains unclear. For the 2014 plan year, states selected their benchmark by September 2012 and the QHP certification process began in April 2013. The timeline for QHP certification remains similar in recent Center Medicare and Medicaid Services (CMS) regulations.

If we assume a similar federal approach to EHB selection and supplementing of benchmark plans, most states will need to make the decision for 2017 in the latter half of 2015 in anticipation of QHP certification beginning in the first half of 2016. While 2017 may seem far off, the opportunity to influence the decision and ensure meaningful consumer input is upon us.

The most pressing advocacy opportunity arises in states where the legislature makes the final benchmark call and where legislative sessions are short. Utah, Washington, New Hampshire, and California are four states where the legislature played a role previously, and their sessions end in March, April, June, and September respectively. To take advantage of the opportunity for states to revisit the benchmark plan selection, legislators will need to know that doing so is important to consumers in their state.

Advocates in all states must 1) press the responsible entity to revisit the benchmark plan in the first place, rather than simply deferring to the default plan, and 2) provide input about the selection of a plan that comprehensively meets the needs of consumers. This is not an issue to wait to react to – it is an issue that is our responsibility to bring to the forefront. One of the first steps in accomplishing this is to build the narrative around EHBs by identifying areas where current benchmark plans fall short and highlighting how it affects real families. EHBs will have a significant impact on the quality of care your friends, family and neighbors receive and it’s time to start the conversation about the EHB benchmark plan in your state. 

Here at Community Catalyst, we have always been proponents of closing the coverage gap, knowing that access to coverage is good for consumers, communities and state budgets. However, 22 states are still leaving just under 4 million people without access to health care. Fortunately, good news from Kentucky provides compelling evidence that closing the gap is the right decision, and we hope other states take note. In addition to covering 310,000 previously uninsured Kentuckians (and that’s just counting through June of 2014), closing the coverage gap produced a domino effect of benefits to the state’s economy and helped the state’s uninsured rate drop to 12 percent from 20 percent. The state recently released a detailed report that elevated these important economic impacts which include:

  1. Closing the coverage gap added 12,000 jobs in 2014. This number will rise to 40,000 jobs by 2021, with an average salary of $41,000. The combination of federal Medicaid dollars coming into Kentucky and newly paying patients will boost health care jobs and services, and spending in other sectors. Together, these added jobs will raise more than $1 billion in state income and sales taxes from now until 2021.
  2. Closing the coverage gap boosted Kentucky’s state budget by $50 million by June 2014. Federal funds took a greater share of several state departments’ budgets and more state tax revenue was brought in from job creation (Table 22 of the report). Over the next eight years, Kentucky’s state budget will benefit from an $819.6 million net gain.
  3. Closing the coverage gap brought down the costs of treating uninsured patients. As more consumers gained coverage and became paying patients, uncompensated care fell by more than $1 billion dollars, or 60 percent, from 2013 to 2014. Reducing uncompensated care is a boon for state and local budgets, which bear a 32 percent share of uncompensated care costs. A companion Medicaid Hospital report revealed that Medicaid expansion revenues significantly exceeded federal funding (DSH payments) for uncompensated care (Tables 8 and 9 in the report, respectively). Thus, when DSH cuts go into effect in 2017, federal dollars from closing the coverage gap will ensure that hospital doors stay open to care for its patients.

Broadening access to health care coverage, adding jobs, generating revenue to the state economy and reducing uncompensated care is good news for Kentucky, and a proof point for every state still considering whether to close the gap. These initial results are especially illuminating in the South, where the opportunity to make a difference for consumers in the gap and state economies is high. Luckily for us all, this good news is attainable, but only if states legislators and governors decide to close the coverage gap.

Medicaid and the Children’s Health Insurance Program (CHIP) are the most comprehensive and affordable forms of coverage available for the children they serve. These programs were designed with children specifically in mind, with the intent of making high-quality pediatric coverage available to families that would otherwise struggle to pay for it. In particular, we know that without CHIP, 1.1 million children who are currently enrolled in the program would become uninsured. Disrupting Medicaid and CHIP to any degree would move us backward on coverage for kids.

Two weeks ago, on February 12, Senate Finance Committee Ranking Member Wyden (D-OR) and Senators Brown (D-OH), Casey (D-PA), and Stabenow (D-MI) introduced the Protecting and Retaining Our Children’s Health Insurance Program (PRO-CHIP) Act in the Senate. The same day, Representative Green (D-TX), the ranking member of the Health Subcommittee of the House Energy and Commerce (E&C) Committee, also introduced a CHIP funding bill in the House. These bills both take steps to sustain coverage for millions of children, as well as continue important initiatives to improve pediatric quality of care.

Yesterday, Senate Finance Committee Chairman Hatch (R-UT), House E&C Chairman Upton (R-MI), and Representative Pitts (R-PA) released a discussion draft that outlines their vision for the future of CHIP. We are pleased that they are engaging on this issue and are committed to extending coverage for low-income children. Notably, we are glad that this draft includes an extension of the current formula for determining how much federal CHIP funding states receive—which governors generally reported to be successful—as well as the qualifying state option, which fairly compensates states that proactively increased children’s Medicaid eligibility levels. That said, we have serious concerns about some aspects of this proposal that would make children worse off by reducing access to an effective source of coverage:

  • Longer waiting periods: The authors assert that states need the option of imposing waiting periods up to a year to prevent crowd-out, enrolling children who could be covered through employer-sponsored coverage in public insurance. First of all, we know that 33 states have eliminated waiting periods, suggesting that their usefulness is limited. However, in states that choose to use such flexibility, this proposal would have the practical effect of forcing CHIP-eligible children to endure up to a year without insurance. While this time in limbo would be hard for any child, we are deeply concerned about the implications for children and youth with special health care needs. Moreover, this policy is in direct opposition to regulations issued in 2013 limiting waiting periods to a maximum of 90 days, as well as the spirit of both CHIP and the Affordable Care Act (ACA).
  • Reducing matching funds for states: This draft reduces federal financial participation in states’ coverage of children over 250 percent of the federal poverty level (FPL) and ends federal support for CHIP coverage of children over 300 percent FPL. Pulling back federal matching for CHIP coverage at a time when many states are facing difficult budget situations would likely mean that states stop offering coverage at these levels. For these children, reduced eligibility could mean they become uninsured, particularly if they are subject to the family glitch, and the accompanying financial risk could prevent some families from exploring economic opportunities such as entrepreneurship.
  • State flexibility on Medicaid and CHIP eligibility: This draft includes the suggestion that states not be held to the Maintenance of Effort (MOE) requirement of the ACA, which prevents states from rolling back Medicaid and CHIP eligibility for children until 2019. As we have seen from recent experiences in Arizona, when states are allowed to roll back coverage, the detrimental effects for children and families are significant. Moreover, the authors of this draft assert that states should be able to move stairstep kids  from Medicaid back to CHIP, even though we know that in states where Medicaid and CHIP are not identical, Medicaid is the more comprehensive option as it includes Early Periodic Screening, Diagnostic, and Treatment services, the gold standard of children’s coverage.

So where do we go from here? Because this is a discussion draft, Chairmen Hatch and Upton will be accepting comments on the content of this proposal. We are hopeful that subsequent drafts and the ensuing negotiations will do more to protect children’s coverage as well as recommend refunding pediatric quality improvement programs, which have been integral to our efforts to make children’s health care more effective, efficient and patient-centered. We look forward to a conversation about the best ways to move forward. We encourage our partners to comment to the Chairmen about this proposal and continue advocating for high quality, affordable coverage that is accessible for all children. 

Overdose deaths from opioids – a type of drug that includes prescription pain relievers and heroin – continue to rise in the U.S. and show few signs of slowing down. This has grabbed the attention of many federal and state lawmakers who are crafting laws and regulations to address the epidemic. The President’s Fiscal Year 2016 budget released earlier this month makes a commitment to reducing drug use and its consequences. It is highly unlikely that the President’s budget will be enacted in the current political environment, but it still gives us a roadmap for how key federal agencies plan to tackle the nation’s drug problems. 

It’s encouraging to see the public attention and the resources directed at these problems, but we may be missing the mark when it comes to prevention. For example, the National Drug Control Budget includes drug monitoring, law enforcement, evidence-based addiction treatment, and reducing overdose deaths, but only five percent of the total budget is allocated to prevention. Similarly, states across the country are implementing laws and regulations to help first responders and bystanders prevent overdose deaths. 

These measures play a crucial role in saving lives and mitigating the consequences of substance misuse, but what are we doing to prevent addiction before it starts?  

Parents, teachers and health care providers should be asking young people early and often about their substance use. Drug screening by trusted adults is an important and effective first step for the prevention of drug and alcohol problems. In fact, simply asking about drugs and alcohol can lead young people to reduce substance use. From state and federal policies to local community-based solutions, we need a greater emphasis on screening as a prevention tactic for a few simple reasons:  

Young people want to talk about it. As it turns out, young people are willing to talk to adults about their drug and alcohol use. One study found that more than 6 out of 10 adolescents said they wanted to talk about substance use with their primary care doctor. The biggest reason they didn’t talk about it? Nobody asked them.

Young people are truthful when asked. Some providers are skeptical about whether young people will tell the truth about their substance use, which can make adults reluctant to ask. Let’s set the record straight: Young people are overwhelmingly truthful in their self-reports of substance use.

Screening is cost-effective. A recent report coming out of Massachusetts confirms the low cost of screening. Research on the cost of a new Massachusetts’s law requiring insurers to reimburse providers for drug and alcohol screening, shows the cost burden on policy holders would be less than a penny per member per month. While the Massachusetts study was on commercial insurance, it supports other findings about the relatively low cost of screening.

Screening tools can guide the conversation: Numerous tools have been studied and established as powerful indicators of current and future problematic drug or alcohol use. This includes the CRAFFT (see below) or AUDIT, which are designed for youth. These short and effective tools can guide providers and other adults in their conversations with young people about substance use.

From the first time a young person misuses alcohol or drugs, they become susceptible to addiction and its long-term consequences. We need to scale up screening efforts nationwide to reach youth in a variety of health care and community settings. One model doing just that is called SBIRT (screening, brief intervention, and referral to treatment). SBIRT involves asking young people a few questions about their drug and alcohol use and providing guidance or referring to treatment, if a problem exists.

SBIRT has been gaining traction across the country with federal support from the Substance Abuse and Mental Health Services Administration (SAMHSA) since 2003. SAMSHA has issued 75 SBIRT training and implementation grants and included $30 million in the FY2016 budget to continue this work. The Conrad N. Hilton Foundation is also a driving force moving SBIRT forward with an expansive nationwide initiative to bring SBIRT to youth and young adults.

Community Catalyst is among the numerous organizations supported by The Conrad N. Hilton Foundation to expand the use of screening and early intervention to young people. Community Catalyst is currently working with consumer advocates in five states – Georgia, Massachusetts, New Jersey, Ohio and Wisconsin – to educate the public and policymakers about the need to improve health insurance coverage for SBIRT and increase the number and types of locations where it is conducted.

Additional federal and state support is needed for SBIRT and other initiatives that promote screening and brief intervention. We need to talk to young people about their drug and alcohol use more frequently, and in a broad array of settings where youth interact regularly with trusted adults. These conversations are the cornerstone of prevention.




Image Credit: Georgians for a Healthy Future