Millions Eligible for Health Insurance Remain Uninsured

More than 15 million Americans who are currently entitled to free or subsidized health insurance are currently uninsured.

Among them are 11 million who are eligible for Medicaid but have not applied for benefits and 4.2 million who could afford insurance with the help of federal premium subsidies and either have decided not to take advantage of those subsidies or are unaware of the availability of such subsidies.

In addition, another two million people would be eligible for Medicaid if their states expanded their Medicaid program as authorized by the Affordable Care Act.

In light of such figures, it is not entirely surprising that the uninsured rate, according to the census bureau, rose last year for the first time since implementation of the Affordable Care Act.  That uninsured rate, 15 percent at the time the law was adopted in 2010, fell to 7.9 percent in 2017 but rose to 8.5 percent in 2018.  The uninsured rate has especially risen among Hispanics and the foreign born.

Another possible reason for the rise in the number of uninsured Americans:  the federal government has greatly reduced its outreach effort to inform people about the various options they have for obtaining insurance.

Learn more about who is uninsured and why the uninsured rate has risen in the Washington Post story “Millions of Americans aren’t getting health insurance, even though they’re eligible for free or affordable plans.”

 

ACA Has Reduced Insurance Disparities

The Affordable Care Act is responsible for a major reduction in the disparity of insurance status among racial and ethnic minorities.

According to a new Commonwealth Fund analysis,

All U.S. racial and ethnic groups saw comparable, proportionate declines in uninsured rates…  However, because uninsured rates started off much higher among Hispanic and black non-Hispanic adults than among white non-Hispanic adults, the coverage gap between blacks and whites declined from 11.0 percentage points in 2013 to 5.3 percentage points in 2017. Likewise, the coverage gap between Hispanics and non-Hispanic whites dropped from 25.4 points to 16.6 points.

Learn more about specific differences among racial and ethnic groups, differences based on residence in Medicaid expansion states and non-expansion states, and differences in securing public or private health insurance in the Commonwealth Fund study “Did the Affordable Care Act Reduce Racial and Ethnic Disparities in Health Insurance Coverage?”

Uninsured Rate Rose in 2017

The rate of uninsured Americans rose in 2017, the first such increase since implementation of the Affordable Care Act.

According to a new Urban Institute study,

The increasing uninsurance rate between 2016 and 2017 was driven by losses of private nongroup coverage, such as that purchased in the health insurance marketplaces, and decreases in Medicaid and Children’s Health Insurance Program (CHIP) coverage (-0.4 percentage points each).

In addition,

Overall, coverage losses were concentrated in the 19 states that did not expand Medicaid eligibility under the Affordable Care Act by July 1, 2017…Between 2016 and 2017, uninsurance held stable in Medicaid expansion states but increased by 0.5 percentage points in nonexpansion states.

The study also noted that these declines occurred at a time when the economy was considered strong, incomes were rising, and more employers were sponsoring insurance coverage.

Learn more about where and why the number of uninsured people rose in 2017 in the Urban Institute report “Health Insurance Coverage Declined for Nonelderly Americans Between 2016 and 2017, Primarily in States That Did Not Expand Medicaid.”

CMS Introduces New Medicaid Opioid Management Guidelines

States must do more to monitor the prescription and use of opioids within their Medicaid programs, the Centers for Medicare & Medicaid Services told them this week.

In a formal guidance letter to state Medicaid programs issued as part of implementation of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018, CMS called on states to update their drug utilization programs, revise relevant portions of their state Medicaid plan, and introduce stronger practices for setting limits on the prescription of opioids and monitoring the use of opioids among patients for whom such drugs are prescribed.  These changes must include both prospective and retrospective drug utilization review.

The new requirements apply both to Medicaid fee for service and managed care programs and all of these steps must be completed by the end of calendar year 2019.

Learn more from the CMS guidance letter “State Guidance for Implementation of Medicaid Drug Utilization Review (DUR) provisions included in Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act.”

ACA’s Medicaid Pay Bump Helped But Benefits Now Lost, Study Says

Health status and access to care improved for Medicaid patients when the Affordable Care Act mandated a temporary rate increase for physicians serving newly insured patients covered through that law’s Medicaid expansion.

But when the mandate for increased physician payments ended and state Medicaid programs reverted to their previous, lower payments, many of those benefits were lost.

Or so reports a new study from the National Bureau of Economic Research.

According to the study, even a $10 rate increase improved access to care enough to reduce by 13 percent Medicaid recipients’ complaints about not being about to find a doctor.  Utilization also increased.  The temporary Medicaid pay increase has even been credited with improving school attendance and reducing chronic absenteeism.

Despite the benefits of the temporary increase in Medicaid payments to physicians, most states returned to lower payments when the mandated ended, most of the gains resulting from the better pay for treating Medicaid patients disappeared, and the disparities between privately insured individuals and Medicaid patients returned to their pre-Affordable Care Act levels.

Researchers estimate that increasing Medicaid payments to physicians by an average of $26 a visit would eliminate disparities in access to care.

These findings are especially relevant to private safety-net hospitals because the communities they serve have so many more Medicaid patients than the typical American community.

Learn more from the National Bureau of Economic Resarch study “The Impacts of Physician Payments on Patient Access, Use, and Health” and from the Healthcare Dive report “Even $10 increase in Medicaid payments helps erase disparities in care access, study says.”

Groups Seek to Block Medicaid Block Grants

Do not permit states to adopt block grants for their Medicaid programs, more than two dozen groups have asked the Centers for Medicare & Medicaid Services.

A letter signed by the American Diabetes Association, American Heart Association, COPD Foundation, March of Dimes, United Way, and others states that

Simply put, block grants and per capita caps will reduce access to quality and affordable healthcare for patients with serious chronic health conditions and are therefore unacceptable to our organizations.

The letter explains that

Per capita caps and block grants are designed to reduce federal funding for Medicaid, forcing states to either make up the difference with their own funds or make cuts to their programs that would reduce access to care for the patients we represent…  States under a block grant or per capita cap would struggle to respond to changes in standards of care, such as the development of ground-breaking but expensive treatment, and would have a greater incentive to impose additional barriers for treatments to manage their overall costs…  Additionally, per capita caps and block grants would cut Medicaid most deeply when the need is greatest, as these financing structures do not protect either states or patients from financial risk as the result of an economic downturn or other expected event.

NASH has long been skeptical about the use of block grants in state Medicaid programs.  The organization’s advocacy agenda for 2019 explains that

Block grants, whether based on individual states’ Medicaid enrollment or on their past Medicaid spending, could impose unreasonable limits on Medicaid spending that could potentially leave private safety-net hospitals unreimbursed for care they provide to legitimately eligible individuals. NASH will work to ensure that any new approach that involves Medicaid block grant continues to give states the ability to pay safety-net hospitals adequately for the essential services they provide to the low-income residents of the communities in which those hospitals are located.

Learn more about the groups that signed this letter and their objections to Medicaid block grants and per capita caps by reading their letter to CMS.

CMS Proposes Easing Medicaid Access Protections

States would have to do less to ensure access to Medicaid-covered services for their Medicaid population under a new regulation proposed by the Centers for Medicare & Medicaid Services.

In 2015, CMS required states to track their Medicaid fee-for-service payments and submit them to the federal government as part of a process to ensure that Medicaid payments were sufficient to ensure access to care for eligible individuals.  Now, CMS proposes rescinding this requirement, writing in a news release that

This proposed rule is designed to help streamline federal oversight of access to care requirements that protect Medicaid beneficiaries.  CMS anticipates that the proposed rule would, if finalized, result in overall cost savings for State partners that could be redirected to better serve the needs of their beneficiaries.

The proposed regulation itself explains that

While we believe the process described in the current regulatory text is a valuable tool for states to use to demonstrate the sufficiency of provider payment rates, we believe mandating states to collect the specific information as described excessively constrains state freedom to administer the program in the manner that is best for the state and Medicaid beneficiaries in the state.

CMS also notes that the current requirement applies only to Medicaid fee-for-service payments even though most Medicaid beneficiaries now receive care through managed care plans, the payments for which are not subject to the same process.

The agency adds that it intends to

…replace the ongoing access reviews required by current regulations with a more comprehensive and outcomes-driven approach to monitoring access across delivery systems, developed through workgroups and technical expert panels that include key State and federal stakeholders.

Because they care for so many Medicaid patients, the adequacy of the rates states pay for Medicaid services is especially important to private safety-net hospitals.

Learn more about CMS’s proposal in its news release on the subject or see the proposed regulation itself.  Learn about the process CMS intends to employ to replace its current approach to monitoring access to Medicaid services in this CMS informational bulletin.

 

The Role of Medicaid in Addressing Social Determinants of Health

Medicaid can play a major role in addressing the social determinants of health.

Or so argues a recent post on the Health Affairs Blog.

According to the post, social determinants of health – income, education, decent housing, access to food, and more – significantly influence the health and well-being of individuals – including low-income individuals who have adequate access to quality health care.  Medicaid, the post maintains, can play a major role in addressing social determinants of health.

The post outlines the role state Medicaid programs can play in addressing social determinants of health; describes tools for such action such as section 1115 Medicaid demonstration waivers; offers examples of efforts currently under way in some states; and presents suggestions for steps the federal government can take to facilitate such efforts.

Addressing social determinants of health is an especially important issue for private safety-net hospitals because they care for so many more Medicaid-covered low-income patients than the typical American hospital.

Learn more from the Health Affairs Blog post “For An Option To Address Social Determinants Of Health, Look To Medicaid.”

 

Study Finds Surprise in Sources of Medicaid, CHIP Growth

While enrollment in Medicaid and CHIP has been greatest among low-income families working full-time for small businesses, growth in Medicaid and CHIP enrollment among low-income families employed full-time by big businesses has been rising faster in recent years.

According to a new study published in the journal Health Affairs, Medicaid and CHIP enrollment among low-income families employed full-time by large companies rose from 45 percent to 69 percent between 2008 and 2016.  The driving force behind this growing reliance on public insurance appears to be the shift of health insurance costs from companies to employees:  employee share of health insurance premiums rose 57 percent during that same period, leaving many families unable to afford even employer-subsidized health insurance.

Learn more about the growing Medicaid and CHIP participation rates among different economic groups in the Health Affairs report “Growth Of Public Coverage Among Working Families In The Private Sector.”

CMS Outlines New Medicaid Program Integrity Activities

The federal government will introduce a number of initiatives to combat Medicaid waste, fraud, and abuse in the coming months.

In an article on the Centers for Medicare & Medicaid Services’ blog, CMS administrator Seema Verma outlined her agency’s major Medicaid program integrity efforts of the past year, including:

  • Oversight of state Medicaid claiming and program integrity
  • Disallowing unallowable claims of federal funding
  • Increased audits and oversight
  • Data sharing and partnerships
  • Education, technical assistance, and collaboration
  • Reducing improper payments

Initiatives to be introduced in the coming months include (as described in the blog post):

  • A proposed comprehensive update to Medicaid’s fiscal accountability regulations, to increase states’ accountability for supplemental payments. The update includes additional state reporting, clearer financial definitions, and stronger federal guidance to ensure that states use supplemental payments properly.
  • A proposed regulation to further strengthen the integrity of the Medicaid eligibility determination process, including enhanced requirements around verification, monitoring changes in beneficiary circumstances, and eligibility redetermination.
  • Additional guidance on the Medicaid Managed Care Final Rule from 2016 to further state implementation and compliance with program integrity safeguards, such as reporting overpayments and possible fraud.
  • Release of improvements to the Medicaid and CHIP Scorecard—a dashboard of program measures that increases public transparency about the programs’ administration and outcomes. The improvements include two program integrity measures to enhance transparency and continue to provide states with performance measures related to their Medicaid programs. Examples of such program integrity measures may include measures based on state initiation of collaborative investigations with their UPIC, state participation in the HFPP at any level, and performance data derived from improper payment drivers.
  • Conduct provider screening on behalf of states for Medicaid-only providers to improve efficiency and coordination across Medicare and Medicaid, reduce state and provider burden, and address one of the biggest sources of error as measured by PERM.
  • Medicaid provider education through Targeted Probe and Educate—which identifies providers who have high error rates and educates them on billing requirements—to reduce aberrant billing, as well as education provided through Comparative Billing Reports—which show providers their billing patterns compared to their peers.
  • Audit state claiming of federal matching dollars to address areas that have been identified as high-risk by GAO and OIG, as well as other behavior previously found detrimental to the Medicaid program.

Learn more in the CMS blog article “Medicaid Program Integrity: A Shared and Urgent Responsibility.”