Older Americans Oppose Approval Process for Home Care Services

Eighty-three percent of seniors oppose a Medicare policy that requires a government contractor to approve claims for physician-prescribed home health care, according to a poll sponsored by Bring The Vote Home. The Centers for Medicare & Medicaid Services (CMS) recently implemented a pre-claim review demonstration that imposes documentation requirements on home health agencies and referring physicians. Doctors have to provide a broad array of eligibility-related documentation and clinical support for review by government contractors. Home health leaders warn that the new requirements could delay care and increase healthcare costs. Seniors say that requiring a government contractor to approve home heath care will have the following results:

  • 80% say it will delay care.
  • 77% say it will increase Medicare costs.
  • 75% say that will increase out-of- pocket costs.
  • 45% say it will decrease fraudulent home health claims.

For more information, visit bringthevotehome.org.

Employer Sponsored Insurance Rate Remains Stable

Since 2009, employer-sponsored insurance has been on the decline in California. A key question around the Affordable Care Act (ACA) was whether the reforms would further erode employer-sponsored insurance coverage. A recent survey by the California HealthCare Foundation finds that employer-sponsored insurance in the state has remained stable from 2013 to 2015. Worker eligibility for employer-sponsored insurance also remained stable, and even increased among some groups. However, the percentage of eligible workers who chose to enroll in employer-sponsored insurance declined from 86.4% in 2013 to 80.2% in 2015, bringing California closer to the national average take-up rate of 79%. This decline could be caused by the availability of alternative coverage options through Medi-Cal and Covered California.

Trump v. Clinton: How They Line Up On Health

The Philadelphia Inquirer offers an analysis on the Candidate’s Position on health care. The following is a summary the article:

Health insurance

  • Clinton: Wants to improve the Affordable Care Act. She wants to reduce the cost of health insurance purchased on exchanges and provide a tax credit of up to $5,000 a family to offset out-of-pocket costs and premiums above 5% of household income. She would expand tax credits and cap the cost of premiums at 8.5% of family income. She calls for fixing the “family glitch” so families can access coverage in the exchanges when their employer’s family plan is not affordable. She would allow undocumented immigrants to buy insurance through the exchanges. In what is seen as a nod to Bernie Sanders’ supporters, she is affirming support for a public option that would allow people as young as 55 to buy health insurance through Medicare.
  • Trump: Opposes requiring people to buy health insurance. He wants to repeal the Affordable Care Act. He proposes to make coverage more affordable by allowing sales of health insurance across state lines and permitting people to deduct health insurance premium payments from their taxes. He would emphasize tax-deductible health savings accounts (HSA) where funds could accumulate if they are not used. He wants to require price transparency by health-care providers so that people can shop around for the best prices. He also wants would-be immigrants to certify that they can pay for their own health care.

Prescription drugs

  • Clinton: Wants to eliminate tax breaks that pharmaceutical companies get for direct-to-consumer advertising, and require those that benefit from federal research spending to reinvest profits into research. She would ban legal settlements in which pharma companies pay competitors so they will hold off on introducing generics and would allow consumers to import cheaper drugs from countries such as Canada. She supports allowing Medicare to negotiate lower drug prices and would cap out-of-pocket costs for people with chronic health problems.
  • Trump: Calls for a free market for prescription drugs, including allowing consumers to import them from countries that regulate prices. This practice is now illegal, though the law is not firmly enforced.

Medicaid

  • Clinton: Supports president Obama’s proposal to let states that sign up for Medicaid expansion to get a 100% match for the first three years. She would expand access to Medicaid and children’s health insurance.
  • Trump: Wants states to get federal Medicaid funding through block grants, which could mean fewer dollars for many states, but would give local officials more authority over expenditures.

Medicare

  • Clinton: Has vowed to fight proposals to privatize or phase out Medicare, and would give Medicare the power to negotiate lower drug costs.
  • Trump: Is against abolishing Medicare.

Social Security

  • Clinton: Opposes privatizing Social Security, reducing annual cost-of-living adjustments, and raising the retirement age. Clinton would expand Social Security for some, such as widows and caregivers, and help to fund the benefit through a wealth tax.
  • Trump: Has voiced support for Social Security and called it “honoring a deal.” He has said that Republicans cannot win elections if they seek to change it substantially.

Veterans Administration

  • Clinton: Says she would ensure more timely benefits, block privatization efforts, and strengthen services for military families and employment programs for veterans.
  • Trump: Has vowed to reform the agency and make it more efficient in delivering service and employment assistance.

Abortion

  • Clinton: Wants to protect access to safe and legal abortion.
  • Trump: Back in 1999, he told Meet the Press that, despite his personal dislike of abortion, “I’m very pro-choice.” More recently, he announced, “I am pro-life.” This year, Trump he said on MSNBC that if abortion were banned, women who violated the law would have to be punished. Soon after, his campaign released a statement saying that providers, not patients, should be held liable. His running mate, Indiana Gov. Mike Pence, has backed some of the nation’s toughest abortion restrictions.

HIV/AIDS

  • Clinton: Her proposals include funding research to seek a cure; finding more affordable treatment, including capping prescription costs; urging all states to extend Medicaid coverage for people living with HIV; and increasing use of HIV prevention medication.
  • Trump: Has not issued a policy on HIV and AIDS, though some in the advocacy media say his goals of lowering prescription drug costs and increasing transparency about health care pricing could be beneficial.

Medical research funding

  • Clinton: Advocates increasing funding for Alzheimer’s research to $2 billion a year, paying for care-planning services through Medicare, and funding a federal program to help locate Alzheimer’s patients who wander.
  • Trump: Has called funding for Alzheimer’s research “a total top priority,” but he has not offered many specifics about policies he would pursue. He has alarmed the research community with scientifically unfounded statements about Ebola, autism, and climate change.

Autism

  • Clinton: Has called for a nationwide early-screening campaign. She wants to push all states to require health insurance coverage for autism services, help get adults on the autism spectrum connected to employment opportunities, and fund more research.
  • Trump: In tweets and during a presidential debate, Trump has linked autism to some vaccinations, a tie that has been widely debunked by international medical authorities and advocates, such as Autism Speaks, a group that Trump has supported.

Addiction and drugs

  • Clinton: Would increase funds for addiction treatment and prevention, and emphasize rehabilitation over prison for low-level and non-violent drug offenses. She wants more preventive services for adolescents, opioid antidotes for all first responders, and more training for drug prescribers.
  • Trump: In New Hampshire, Trump vowed to fight addiction on two fronts saying, “First, we have to support locally based and locally run clinics, and we have got to close the border. That’s where the drugs are coming from.”

Medical marijuana

  • Clinton: Supports the use of medical marijuana.
  • Trump:.Supports the use of medical marijuana.

Family and medical leave

  • Clinton: Advocates a paid family and medical leave of up to 12 weeks with at least a two-thirds wage replacement rate. She proposes paying for the plan with taxes on the wealthy.
  • Trump: He told Stuart Varney on Fox News last year, “Well, it’s something that’s being discussed. I think we have to keep our country very competitive, so you have to be careful of it.”

Federal funding of Planned Parenthood

Clinton: Supports federal funding of Planned Parenthood.
Trump: At a news conference on Super Tuesday, Trump said he would not give federal funds to Planned Parenthood because the organization performs abortions. But he praised the health care it provides, saying, “millions and millions of women – cervical cancer, breast cancer – are helped by Planned Parenthood.”

Moving Medi-Cal Forward

California is a national leader in extending Medicaid to low-income people. But the program has not kept pace with dramatic changes in the Medi-Cal population, according to a report by the California Health Care Foundation (CHCF). Medi-Cal is now the largest single source of health insurance in the state. But Medi-Cal has also become a complex patchwork due to the its relationship with the counties, how care is delivered and financed, marketplace developments, and multiple initiatives that have been adopted throughout the years. This patchwork has had mixed results in quality of care, access to care, care coordination, and patient satisfaction. California is looking to reforms to drive timely access to high quality, coordinated, and cost effective care. The Affordable Care Act (ACA) has triggered a shift toward value-based purchasing in the commercial marketplace as well as in Medicare and Medicaid. These reforms are challenging in any environment, but the structural underpinnings of California’s Medicaid program make such changes all the more difficult to address.

Medi-Cal has accomplished a great deal in a short time, including a significant expansion of coverage, and important delivery system innovations in communities throughout the state. With Medi-Cal’s expanded role and the new Medi-Cal 2020 waiver recently launched, there is an extraordinary opportunity to reform the delivery system. To do so, California needs a plan to deliver better care and promote better health. The California Health Care Foundation (CHCF) retained Manatt Health to consider the current state of the Medi-Cal program and delivery reform, focusing particularly on Medi-Cal managed care.

Many states are developing ways to reform their Medicaid care delivery systems. For example, Oregon established locally driven regional coordinated care organizations, which bear full risk and are considered managed care organizations under federal rules. They have flexibility in designing their systems of care and, to some degree, choosing the services they will provide while meeting statewide quality and cost metrics. Massachusetts and New York are moving to require health plans to contract with accountable-care organizations or adopt alternative payment methods with a large portion of their providers. Colorado does not rely on managed care plans, but contracts directly with accountable care organizations. To get the report, “Moving Medi-Cal Forward on the Path to Delivery System,” visit chcf.org.

A Profile of Uninsured Men

At the start of 2015, there were over 27 million uninsured non-elderly adults in the U.S. Over half were non-elderly men, according to a report by the Kaiser Family Foundation. Men are more likely to be uninsured than are women and less likely to have Medicaid or other public coverage. Many men were not eligible for Medicaid before the ACA since the program excluded non-disabled adults without dependent children. Seventy-six percent of non-elderly uninsured men live in a household with at least one full-time worker, but more than half are low-income. Thirty-two percent of non-elderly uninsured men said they were having trouble paying medical bills in 2014.

Forty-four percent of non-elderly uninsured men are eligible for financial assistance under the ACA. In Medicaid expansion states, 55% of men are eligible for assistance, including 35% who are eligible for Medicaid. In non-expansion states, 33% are eligible for assistance, including just 2% who are eligible for Medicaid while 20% fall into the coverage gap.

A man’s likelihood of being uninsured varies based on where he lives. The uninsured rate for men ranged from a high of 25% in Texas to a low of 6% in Massachusetts. The following factors raise the risk for men to be uninsured: they have family incomes below 100% of the federal poverty level; they have less than a high school education; they are Black, Hispanic, and/or non-citizen immigrants. The uninsured rate for White men was 11%.

Only 36% of non-elderly uninsured men have a usual source of care compared to 67% of those with Medicaid and 77% of those with private coverage. Non-elderly men with health coverage are more than two times as likely to get preventive care compared the uninsured. Non-elderly uninsured men are more likely (32%) than non-elderly men with Medicaid (15%) or non-elderly men with private coverage (10%) to have had trouble paying medical bills in 2014. Men without coverage are more likely to have serious financial strain due to medical bills. In 2014, 27% of non-elderly uninsured men said that medical bills caused them to use up all or most of their savings, have difficulties paying for basic necessities, borrow money, or be contacted by a collection agency. In contrast, only 9% of non-elderly men with Medicaid and 7% of non-elderly men with private coverage experienced this kind of financial strain due to medical bills.

Since many uninsured men are in working families, small businesses and job placement offices may be effective outreach sites for information on health coverage. Identifying trusted contacts will be key to increasing enrollment. For example, low-income fathers may be connected to father’s organizations that could connect them to health coverage options. Other community-based organizations and agencies that serve men may also be effective including workforce development programs, child support agencies, and justice-system agencies.

People learn about health coverage options through multiple avenues, including word-of-mouth, mass media, and healthcare providers. Broad-based messages are effective in educating people about coverage while targeted messages are important in enrolling hard-to-reach groups, including low-income men and fathers. Some messages have been found to be effective, including discussing the importance of coverage for maintaining good health, the value of getting screenings and preventive care; the affordability of coverage options, the availability of financial help, and the financial protections of having coverage; and how coverage helps them be an effective provider for the family. Messaging about free in-person enrollment assistance has also been particularly useful. Findings also suggest that talking with fathers about their children’s health and health care coverage can be an effective entry point for discussing their own health and health coverage

Low Income Consumers Give Their Take on Reducing Health Care Costs

The California Healthcare foundation (CHFC) asked consumers what are the most acceptable ways to reduce harmful and wasteful medical care. They interviewed lower- to middle-income health plan members from Covered California and CalPERS and people with Medi-Cal. Participants got background information about the overuse of three common medical services — antibiotics for adult bronchitis, c-sections for first-time normal deliveries, and MRIs for common low back pain. These are their reactions:

  • 57% support oversight of physicians. This approach would change physician behavior through external approval, internal monitoring, or stricter rules about when the intervention will be covered.
  • 21% support patient cost sharing. A minority say that the patients should pay a higher copayment or pay the extra cost of care if they insist on an ineffective medical intervention.
  • 13% support physician payments to encourage appropriate and cost-effective care. A much smaller percentage support penalties or nonpayment to physicians.
  • 9% support taking no action. Fewer than one in 10 agree with leaving the decision entirely to individual doctors and patients.

Merger Improves Health Net’s Financial Strength

A.M. Best has improved its outlook for Health Net, giving the company a financial strength rating of B++ (Good) This follows Centene’s acquisition of Health Net on March 24. Health Net is now a wholly owned subsidiary of Centene, and is no longer a publicly traded company. The combined company will be headquartered in St. Louis. The acquisition has created a leading diversified multi-national health care organization with more than 10 million members throughout the United States.

A.M. Best says that the combined company will have a strong presence in the California Medicaid program and will be one of the largest Medicaid managed organizations in the country. it also provides growth opportunities in government programs including TRICARE, the Dept. of Veterans Affairs, and exchange products in multiple states. Also, the new company may save a lot by integrating specialty services and improving capabilities in information technology and process management. Over the past eight months, Centene and Health Net teams have been developing an integration plan that uses the talents and expertise of companies.

Health Net’s 2015 fiscal year end operating showed increased revenue and earnings. Also, the company reported higher shareholder’s equity for the year. The growth trends have been supported primarily by higher membership in Medicaid programs. However, some of Health Net’s core subsidiaries have reported a significant decline in earnings due to the costs of participating in the exchange and other fees related to the Affordable Care Act. Also, during 2015, a number of capital infusions from the holding company were made to several of its insurance subsidiaries to maintain risk-adjusted capital levels. A.M. Best expects that the parent company to continue to provide capital support when needed. Health Net shareholders received 0.622 shares of Centene common stock and $28.25 in cash for each share of Health Net common stock held at closing, for a total transaction value of about $6 billion, including the assumption of debt.

Costs and Eligibility Are the Biggest Barriers for the Uninsured

Two-thirds of uninsured Californians were eligible for coverage in 2014, but most said they did not enroll because of the cost. The remaining third were ineligible for coverage under the Affordable Care Act due to their immigration status, according to a study by Berkeley’s Center for Labor Research and Education and the UCLA Center for Health Policy Research. The study finds uninsured Californians fall into four groups:

  1. Undocumented residents 32%: Residents who don’t qualify for health coverage under the Affordable Care Act are predominantly low-income, Latino, and have limited English proficiency.
  2. Those eligible for Medi-Cal 28%: Adult citizens and legal immigrants with incomes at or below 138% of the federal poverty level and children at 266% of the poverty level.
  3. Those eligible to buy health coverage through Covered California with a federal subsidy 31%: Citizens and legal immigrants with incomes from 139% to 400% of the poverty level.
  4. Those eligible to buy health coverage through Covered California without a federal subsidy 9%: Citizens and legal immigrants with incomes above 400% of the poverty level, which disqualifies them from federal subsidies.

The largest percentage of citizens and legal immigrants (46%) cited cost as the main reason for being uninsured. Miranda Dietz, a researcher at UC Berkeley said, “We’re a relatively high cost-of-living state. It’s no wonder that some Californians, who may be unaware they qualify for health subsidies and other programs, still find the cost of health insurance out of reach.”

California has more than 1 million undocumented immigrants who don’t benefit from the Affordable Care Act. Nadereh Pourat, director of research for the UCLA center said, “Hundreds of thousands of men, women and children, not to mention the workers who power California’s economy, are one health emergency away from potential financial ruin because they lack insurance. From an economic perspective, it’s bad business to rely on workers and then not offer them equal health protection. And from a humanitarian perspective, it’s just wrong.”

UCLA and UC Berkeley also collaborated on a related on Medi-Cal study. About one-third of those who were uninsured, but eligible for Medi-Cal thought they were ineligible or didn’t know if they were eligible. Another 20% said they were getting insurance, reflecting a major backlog during the first year of processing applications, which has largely been resolved since then. Both studies were funded by the Blue Shield of California Foundation. The study notes that many previously uninsured Californians have enrolled for coverage, but fully covering those still uninsured will require changes in policy to improve affordability and expand eligibility.

CBO updates ACA cost projections

Over the next 10 years, the Affordable Care Act will cost $1.34 trillion, according to the Congressional Budget Office, up 11% from projections a year ago, mostly because of higher-than-expected enrollment in Medicaid. The law gave 22 million people access to coverage they otherwise would not have had, the report found, and the cost of providing that coverage from 2016 to 2019 will be $465 billion, 25% less than projected when the law was passed. The New York Times (free-article access for SmartBrief readers) (3/24), San Francisco Chronicle (free content)/The Associated Press (3/24)

Health Costs for Older Singles vs. Couples

During a two-year period, single and couple households ages 65 and older spent an average of $2,500 per-person on out-of-pocket costs for recurring health care services. Recurring services include doctor visits, dentist visits, and prescription drugs, according to the study by the Employee Benefit Research Institute (EBRI). However, there are large differences in non-recurring health care spending between older singles and older couples. This includes overnight hospital stays, outpatient surgery, home health care, nursing home stays, and other services. Singles 85 and older spent and average of $13,355 on non-recurring health care while couples 85 and older spent and average of $8,530 during the two-year period. Some of the largest differences involve home health care and nursing home expenses.

Last Updated 09/12/2019

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