Could Medicaid Buy-In Push Aside Medicare for All?

Officials in ten states are giving consideration, in one form or another, to permitting uninsured low-income residents to buy into their Medicaid programs.

So while Washington considers the possibility of Medicare for all, the ten states – Nevada, New Mexico, California, Delaware, Oregon, Washington, Connecticut, Illinois, Minnesota, and Wisconsin – are tackling the many issues they must address if they intend to pursue such a ground-breaking option.  Among them:

  • Who would be eligible to participate?
  • What benefits would be offered?
  • Would health plans be available on Affordable Care Act health exchanges, and if so, would ACA subsidies be available to potential purchasers?
  • How would cost-sharing, such as premiums, co-pays, and deductibles, be addressed?
  • In the absence of federal matching funds, how would the states pay for their share of Medicaid benefits purchased by those not eligible for Medicaid?
  • Would such as effort be approved by the federal government?

To the extent that Medicaid buy-in would turn uninsured patients into insured patients, Medicaid buy-in would be beneficial for private safety-net hospitals.

Learn more about what the states are considering and the potential obstacles they face in the Stateline article “Medicaid ‘Buy-In’ Could Be a New Health Care Option for the Uninsured.”

 

CMS Introduces New Waivers

The Centers for Medicare & Medicaid Services has introduced four new “state relief and empowerment waivers” that are widely viewed as new vehicles for states to circumvent Affordable Care Act requirements to implement their own new approaches to health care.

  • Through “account-based subsidies” waivers, states may direct public subsidies into defined-contribution, consumer-directed accounts that individuals use to pay for health insurance premiums or other health care expenses.
  • “State-specific premium assistance” waivers enable states to create their own subsidy programs.
  • “Adjusted plan options” authorizes states to provide financial assistance for different types of health insurance plans, including short-term and other health insurance policies that do not meet Affordable Care Act benefits and coverage requirements.
  • “Risk stabilization strategies” waivers give states greater flexibility to implement reinsurance programs or high-risk pools.

These waiver options have been introduced not through regulations but through guidance published in the Federal Register.  States must apply for these waivers, which must meet section 1332 federal standards for  comprehensiveness, affordability, coverage, and federal deficit neutrality.

Learn more about state relief and empowerment waivers in this CMS fact sheet and this guidance that was published in the Federal Register.

Hospital Government Payment Losses Could Reach $218 Billion by 2028

A recent study concluded that hospitals can expect to lose about $218 billion in federal Medicare and Medicaid payments between 2010, when the latest round of major cuts began, and 2028.

Among those cuts cited in the study, which was commissioned by the American Hospital Association and the Federation of American Hospitals, are:

  • $79 billion for DRG documentation and coding adjustments
  • $73 billion for Medicare sequestration
  • $26 billion for Medicaid disproportionate share payments (Medicaid DSH)
  • $11 billion in cuts associated with the American Taxpayer Relief Act of 2012

Other cuts came, or will be coming, through regulatory changes, the introduction of value-based payment programs, and other means.

Learn more about these cuts and their potential implications in this Healthcare Dive story.

 

NAUH Urges Senators to Oppose Graham-Cassidy Bill

NAUH has declared its opposition to the Graham-Cassidy proposal to partially repeal and replace the Affordable Care Act.

In a message to senators, NAUH stated that its opposition is based on the millions of people the bill would leave uninsured, its lack of federal protection for individuals with pre-existing medical conditions, its failure to repeal massive Affordable Care Act cuts in Medicare and Medicaid payments, and its proposal to reduce the limit the ability of states to levy provider taxes to finance some of their share of their Medicaid costs.

NAUH’s message to senators explained that the association

…welcomes proposals that would enhance access to care in an affordable and responsible manner but we do not believe this legislation offers such potential.

See the full text of NAUH’s message to senators here.

ACOs, APMs Proliferate

The number of accountable care organizations and alternative payment models is growing, as is the number of people served by such programs.

According to a new study published on the Health Affairs Blog, there are more than 900 ACOs across the country – a 10 percent increase over a year ago.

32 million Americans are served by ACOs today – 2.2 million more than a year ago.  Among them, 59 percent are served through commercial contracts, 29 percent by Medicare contracts, and 12 percent under Medicaid contracts.  ACO growth is greatest in metropolitan areas, the states with the greatest ACO penetration are Rhode Island and Maine, and the states with the least ACO penetration are Wyoming and West Virginia.

Among alternative payment models, growth is greatest among shared-savings and shared-risk ACOs, include episode-based models and partially- and fully-capitated payments for patient populations.  Today, APMs account for more than 30 percent of Medicare payments, with the greatest number, by far, participating in Medicare’s Comprehensive Primary Care Plus Model, followed by Medicare’s Comprehensive Care for Joint Replacement and Shared Savings Program models.

Learn more about the growth of ACOs and APMs, the current policy environment for such approaches, and possible future changes in these approaches in this Health Affairs Blog article.

Medical Homes and High-Need Patients

With five percent of patients accounting for 50 percent of health care costs, such high-need patients are the subject of increasing attention as health care providers search for better ways to serve them at less cost.  Such patients are especially challenging when they lack the financial resources and personal support systems needed to address their considerable medical needs.

One of those ways is through the concept of the medical home:  an approach to primary care, also often referred to as a patient-centered medical home, that is a team-based approach to delivering patient-specific, coordinated, accessible care that focuses on quality and safety and that features as one of its defining characteristics closer contact between patients and their caregivers.

Private safety-net hospitals typically care for large numbers of such high-need patients.

In a new report, the Commonwealth Fund tells how one such program, Chicago’s Medical Home Network, is attempting to make a difference in the lives of its low-income, high-need patients.  See that report here.

NAUH Expresses Views on Health Reform Proposal

NAUH does not support the American Health Care Act in its current form, the organization told members of the House of Representatives in a letter it sent yesterday.

In its letter, NAUH noted that the recently proposed AHCA would result in millions of Americans, many of them Medicaid beneficiaries and low-income individuals and families, losing their health insurance over the next ten years.  Private safety-net hospitals serve especially large numbers of these patients.

In addition, the bill inadequately indexes future growth in federal Medicaid spending; proposed two years of reduced Medicaid disproportionate share (Medicaid DSH) payments in some states; and calls for reduced federal funding for the Affordable Care Act’s Medicaid expansion population in a manner that NAUH believes could lead to some combination of tightened Medicaid eligibility requirements, reduced benefits, and reduced provider payments.

For these reasons, NAUH does not support the AHCA in its current form.

In its letter, NAUH also expresses hope that Congress will consider addressing these issues when it refines and improves the bill.

The ACHA proposal would repeal and replace the Affordable Care Act.

See NAUH’s letter to Congress here.

New Series Examines Serving High-Need, High-Cost Patients

The Commonwealth Fund is launching a new series of case studies describing “innovative programs designed to address the needs of the nation’s high-need, high-cost patients, a group that accounts for a disproportionate share of health care spending.”

commonwealth fundAmong the types of programs it will profile are:

  • home-based primary care
  • enhanced primary care
  • programs of all-inclusive care (PACE)
  • accountable care for Medicaid populations
  • guided care

For a closer look at the new series and the programs it will profile go here, to the web site of the Commonwealth Fund.

Congressional Task Force Considers Medicaid Reforms

A House Energy and Commerce Committee group is looking at potential Medicaid reforms for 2017.

The task force, consisting entirely of Republican members, was created late last year to “… strengthen and sustain the critical program for the nation’s most vulnerable citizens.”

energy and commerceAt a recent event at George Mason University, task force chairman Brett Guthrie (R-KY), cited continued high Medicaid spending as a reason to consider reform and noted that the degree to which the task force could tackle Medicaid in 2017 would depend on which party occupies the White House and controls Congress. He suggested that the task force would look for ways to prevent people from needing to choose between getting jobs and keeping health insurance. Among the potential legislative vehicles for reform, Guthrie said, are reauthorization of the Children’s Health Insurance Program and Medicare extenders.

Because they serve so many Medicaid and low-income patients, the task force’s deliberations will be of particular interest to private safety-net hospitals.

Learn more about the House Energy and Commerce Committee’s Medicaid Task Force here and about Rep. Guthrie’s remarks at the George Mason University forum here.

Affordability a Challenge for Many Newly Insured

Many Americans who have obtained private health insurance through the Affordable Care Act continue to have problems affording health care.

According to a Kaiser Family Foundation report based on focus groups six states, low-income individuals with new private insurance report continued problems with:

  • kaisermedical debt
  • affording care that is not covered by their insurance plans
  • handling out-of-pocket expenses, including deductibles
  • unexpected bills for treatment they thought was covered

Such patients pose a challenge for many private safety-net hospitals because of their inability to afford their co-pays and deductibles, leaving these hospitals with unexpected uncompensated care and bad debt. Because they care for more low-income patients than the average hospital, this is a bigger problem for private safety-net hospitals.

For a closer look at how the study and focus groups were conducted and what they found, go here for the Kaiser Family Foundation report Is ACA Coverage Affordable for Low-Income People? Perspectives from Individuals in Six Cities.