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Updated: 23 hours 26 min ago

Senators Grill Top Indian Health Officials About Trump Budget

July 12, 2017

Leaders of the Indian Health Service struggled Wednesday at a Senate hearing to defend the Trump administration’s plans to slash funding to the agency, which is reeling from quality of care problems at several of its hospitals, a doctor shortage and facilities showing their age.

The lack of answers infuriated both Democrats and Republicans on the Appropriations subcommittee.

“I cannot believe what has transpired today. All I want is some damn answers, that’s it,” said Sen. Jon Tester (D-Mont.), as he admonished Rear Adm. Michael Weahkee, the Indian Health Service’s acting director since June.

When Weahkee refused to say how staffing levels would be affected under the Trump administration’s proposed 2018 budget, Tester became visibly shaken and yelled back: “I did not come in here with my hair on fire but I am leaving here with it. … It’s no wonder [the agency is] in crisis.”

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The administration officials could not answer some basic questions from senators, including how much money the agency has gained from the health law’s Medicaid expansion and whether President Donald Trump’s budget proposal would help the agency to hire more staff.

The Indian Health Service, which oversees care to 2.2 million American Indians and Alaska Natives, has been chronically underfunded, and several of its hospitals have lost accreditation or been put under special watch by Medicare because of conditions that harmed patients. It has a 30 percent vacancy rate for doctors, dentists and physician assistants.

In 2013, Indian Health Service spending for patient health services was $2,849 a person, compared with $7,717 for per capita health care spending nationally, according to a report from the National Congress of American Indians. Despite less funding, Native Americans typically have higher incidences of serious health problems than the general public, including higher rates of diabetes, liver disease and unintentional injuries.

Trump’s budget includes $4.7 billion for the agency. Sen. Lisa Murkowski (R-Alaska), who chairs the Subcommittee on Interior, Environment and Related Agencies, which held the hearing, said that would amount to a 6 percent cut from the current funds. She noted the trim was well below other Department of Health and Human Services agencies, where proposed funding is reduced by an average of 18 percent.

Yet she said she was stunned to hear IHS officials at the hearing say the Trump budget has enough money to improve care.

“You have not answered my question on whether we have provided you sufficient resources,” Murkowski told Weahkee. “I can’t stand down knowing our system is failing so many Native Americans around the country.”

Weahkee, a member of the Zuni tribe, was previously CEO of the IHS’ largest hospital in Phoenix. He said the proposed budget prioritizes funding on patient care, while it cuts funding to modernize and build facilities. He said the agency’s appropriations are augmented by payments from Medicare and Medicaid. Medicaid provided $880 million in funding in 2016 — more than any other third-party funding source, according to a report released Wednesday by Center on Budget and Policy Priorities.

Murkowski said she is worried about the effects on the Indian health care system if Congress were to accept a Republican health plan to replace the Affordable Care Act. The current version being advanced by Senate leaders would end the ACA’s Medicaid expansion and cap future Medicaid funding to states.

Alaska was one of 31 states to expand Medicaid under the Affordable Care Act, and Murkowski has said she has serious qualms about the current plan.

Senate GOP leadership delayed the bill when it failed to get enough support before the July Fourth recess. A new version of the legislation is expected to be released Thursday.

Operating in some of the nation’s poorest places, the Indian Health Service has failed to meet minimum federal standards for medical facilities, turned away gravely ill patients and caused unnecessary deaths, The Wall Street Journal reported last week, citing federal regulators, agency documents and interviews.

Murkowski said she was dismayed by the agency’s recent track record, particularly after she helped steer an extra $29 million in this year’s budget to address quality of care problems at three of its hospitals in the Midwest.

“I believe the agency is sincere in its desire to fix these problems,” she said, “but a year later­ these problems remain and appear to more serious than ever.”

Senate GOP Bill Aims To Add Psych Beds; Squeeze On Medicaid Signals Their Undoing

July 10, 2017

A little-discussed provision in the Senate health care bill is designed to boost the number of hospital beds for psychiatric care, providing a long-sought victory for mental health advocates.

The provision would amend an obscure Medicaid funding rule that has sharply limited the number of beds for those with schizophrenia, bipolar disorder or other mental illnesses.

Yet leading mental health groups say they see no reason to celebrate.

That’s because the Senate bill would also wring out $772 billion from Medicaid — the joint state-federal insurance program that is the single-largest provider of care for people with serious mental illness. The nonpartisan Congressional Budget Office has said that the Senate bill, drafted by Republicans as a replacement for the Affordable Care Act, would reduce overall Medicaid spending by 26 percent by 2026 and by 35 percent the following decade.

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The loss of those funds would devastate health care services for people with mental illness, who are some of the most vulnerable and disadvantaged people in the country, said Bethany Lilly, deputy director of policy and legal advocacy at the Bazelon Center for Mental Health Law, an advocacy group.

“Medicaid is the safety net for people with serious mental illness,” said Ronald Honberg, senior policy adviser at the National Alliance on Mental Illness.

Without decent mental health care and support services, people with psychotic disorders can quickly deteriorate, ending up in overcrowded emergency rooms, jail and prison cells or dangerous city streets, Honberg said. “This bill is a prescription for making all these problems worse.”

Republicans who crafted the Senate draft bill have noted that Medicaid spending will still increase under their plan but at a rate lower than currently projected. The Senate bill would make Medicaid spending more sustainable, said Julia Lawless, a spokeswoman for the Senate Finance Committee, one of the Senate committees that oversees health legislation.

“Even before Obamacare’s unprecedented Medicaid expansion, the program was plagued by quality issues, states were barred from using innovative solutions to improve patient care, and both federal and state Medicaid spending was growing at unprecedented, unsustainable levels,” Lawless said. “The Senate bill will reverse this course and slow the growth of Medicaid without cutting actual benefits.”

The Medicaid program has traditionally refused to pay for inpatient stays in large freestanding psychiatric hospitals, making exceptions for patients under age 21 and facilities with 16 beds or fewer. The rule, which has changed little since Medicaid was created five decades ago, was aimed to prevent the federal government from paying for long-term care in psychiatric institutions.

But the Medicaid rule also has contributed to a severe shortage of psychiatric beds for people in crisis, said John Snook, executive director of the Treatment Advocacy Center, a nonprofit that focuses on people with serious mental illness.

Last year, the Centers for Medicare & Medicaid Services eased the policy, paying for up to 15 days of inpatient hospital care for patients in Medicaid managed-care plans. But in a letter to the Medicaid program last year, the National Association of Medicaid Directors noted that some patients with mental illness or substance abuse disorders might need closer to a month of inpatient care.

The Senate bill, dubbed the Better Care Reconciliation Act, would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year.

The Medicaid change was included in the Republican bill because several senators were concerned that patients didn’t have enough access to hospital care for mental illness and addiction, according to a GOP Senate aide who was authorized to speak only on condition of anonymity. The senators involved included Orrin Hatch (R-Utah) and Rob Portman (R-Ohio).

While Honberg welcomes that change, he said that reducing overall Medicaid spending could devastate rural hospitals and ones that serve as “safety nets” — providing free care to people who are uninsured or poor — and force closures.

If these hospitals go out of business, the total number of hospital beds available to people with mental illness could shrink, not expand, Honberg said.

Medicaid pays for a wide variety of supportive services for people with schizophrenia and other serious mental illnesses, beyond doctor’s visits and medications, Honberg said. States can use Medicaid funds to pay for case managers; transportation to and from doctor’s appointments; supportive housing, which helps people with serious mental illness live independently; supported employment, which provides job training and other services; and teams of professionals who assist people who need intensive, comprehensive help navigating the health system and social services.

AARP: States Lag In Keeping Medicaid Enrollees Out Of Nursing Homes

June 14, 2017

States are making tepid progress helping millions of elderly and disabled people on Medicaid avoid costly nursing home care by arranging home or community services for them instead, according to an AARP report released Wednesday.

“Although most states have experienced modest improvements over time, the pace of change is not keeping up with demographic demands,” said the report, which compared states’ efforts to improve long-term care services over the past several years. AARP’s first two reports on the subject were in 2011 and 2014.

The organization ranked states’ performance on long-term care benchmarks such as supply of home health aides, nursing home costs, long nursing home stays, the employment rate of people with disabilities and support for working caregivers.

With 10,000 people a day turning 65 and the eldest baby boomers beginning to turn 80 in 2026, the demand for long-term care services is expected to soar in coming years.

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AARP officials said the House’s bill to repeal the Affordable Care Act would worsen the situation by capping annual federal revenue for states’ Medicaid programs. That bill is now before the Senate.

“The proposed cuts to Medicaid — the largest public payer of long-term assistance — would result in millions of older adults and people with disabilities losing lifesaving supports,” said Susan Reinhard, senior vice president and director of the AARP Public Policy Institute.

The report found strikingly wide variances in the share of state Medicaid spending for long-term care directed to home- and community-based services for elderly and disabled adults in 2014, the latest year for data covering all states. Minnesota, the top-ranked state, spent about 69 percent, but Alabama, ranked last, spent less than 14 percent.

Nationwide, the average edged up from 39 percent in 2011 to 41 percent in 2014.

Only nine states and the District of Columbia spent more on home- and community-based services than on nursing home care, according to the report. Such services include home health care, caregiver training and adult day care.

People turning 65 this year face about a 50-50 chance of needing long-term care services in their lifetime, AARP officials said.

Trish Riley, executive director of the National Academy for State Health Policy, said states face several obstacles to expand home- and community-based options. They include a strong nursing home lobby that does not want to give up its Medicaid dollars and a shortage of transportation and housing options, particularly in rural areas.

An Alabama Medicaid spokeswoman said the state is working on the issue highlighted by AARP but refused to comment on its report.

John Matson, a spokesman for the Alabama Nursing Home Association, rejected the notion that nursing homes are to blame. “We think it’s a shift that needs to happen in Alabama. … We can’t build enough nursing homes to meet [the needs of] everyone that is coming,” he said.

The state’s effort to shift Medicaid patients from long-term care into managed care organizations starting next year will help, because those entities will have a financial incentive to keep people at home for care when possible, Matson said.

Reinhard said many states have struggled to expand home- and community-based options for Medicaid enrollees needing long-term care because that is an optional benefit. Nursing homes are mandatory under federal law. While states focus on Medicaid coverage for children and families — as well as non-disabled adults covered by the Medicaid expansion under the Affordable Care Act — adults with disabilities have received less attention.

“Long-term care is a stepchild of the program and not a top focus for states,” she said.

To view the full report, go to www.longtermscorecard.org. The report was funded by the AARP Foundation, The Commonwealth Fund and The SCAN Foundation.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

‘You’ve Got Mail’: Emails And Robocalls Hit Home In Promoting Medicaid Enrollment

May 26, 2017

Postcards, robocalls and other low-tech outreach tools can be as effective as personalized enrollment assistance at encouraging eligible people to sign up for Medicaid, a new study found.

Researchers conducted two randomized, controlled trials in Oregon that evaluated the extent to which people who were potentially eligible for Medicaid signed up for coverage following different types of outreach in 2013.

Medicaid is the federal-state health insurance program for low-income people, and Oregon is one of 31 states and the District of Columbia that expanded Medicaid under the Affordable Care Act to cover adults with incomes up to 138 percent of the federal poverty level (about $16,000).

For one study group, researchers targeted people who were likely eligible for Medicaid coverage under the ACA because they were already enrolled in assistance programs with similar income standards, including the Supplemental Nutrition Assistance Program (often referred to as food stamps) or those whose kids were signed up with the state Medicaid program.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

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For the other study group, researchers identified people who had expressed interest in and won a lottery to enroll in Medicaid coverage under the state’s existing program for low-income nondisabled adults. After winning the lottery, they had 45 days to sign up for coverage.

Members of the lottery trial were randomly assigned to one of three groups. The control group received the state’s basic outreach materials, which included a notification letter and an application packet. In addition to the basic state outreach materials, the second group got other “low-intensity” nudges, including additional postcards and other mail, emails and automated phone calls to encourage them to sign up. The third, “high-intensity” group received all the other materials plus in-person enrollment help from trained assistants as well as personalized phone calls.

Twenty-seven percent of the people in the lottery control group signed up in the weeks after being notified. Enrollment was significantly higher — 41 percent — among those who received extra outreach efforts. There was no difference in enrollment between the people who received one-on-one help and those who were sent mass-outreach materials.

The low-intensity interventions cost an average $1.75 per person, while the high-intensity interventions cost $28 per person, on average, the study found.

“The extra personalization and individual-level contact that we layered on didn’t add much,” said Katherine Baicker, a professor of health economics in the Department of Health Policy and Management at Harvard University’s school of public health, who co-authored the study published in the May issue of Health Affairs. That’s good news for states, Baicker said, who can get more enrollment bang for the buck.

Since the high-intensity interventions had proven relatively ineffective, researchers tested only the low-intensity interventions against the control group in the second trial of people who were likely eligible under the ACA’s Medicaid expansion and looked at the effect on enrollment in the program over time.

The differences in enrollment were less pronounced in that trial. Thirty-eight percent of the control group were still enrolled a year after the intervention, compared with 41 percent of those who had received additional low-intensity encouragement to sign up.

The less dramatic difference in results for this study group makes sense, said Baicker.

In contrast to the lottery group, who had already expressed an interest in being included in the state’s Medicaid lottery, “this group didn’t proactively express any interest in being insured,” she said. However, once the outreach tools got through to them, people stayed insured. “Those people that we reached, there was a durable response,” Baicker said.

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Citing CBO Report, Critics Decry GOP Bill’s Potential Fallout In California

May 25, 2017

Though the budget analysis released Wednesday on the GOP health care bill didn’t address California specifically, both the state’s Medicaid program and its individual market could be seriously harmed if the legislation passes, according to legislators, consumer advocates and other critics.

“I feel like I am in a bad dream,” said Sen. Ed Hernandez, the West Covina Democrat who chairs the state Senate Health Committee.

The Congressional Budget Office confirmed what Hernandez expected — that large numbers of people would lose coverage and poorer, older Californians would pay significantly more for coverage under the American Health Care Act.

The Republican bill passed the House of Representatives earlier this month with no Democratic support and is now in the hands of the Senate, which is working on its own version.

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Hernandez said he’s especially concerned about the changes to the Medicaid program, known as Medi-Cal in California. “The state budget is not going to be able to absorb this,” he said. “We are going to have a real problem.”

All 14 members of California’s Republican delegation in the House voted for the GOP bill. Like their counterparts nationally, several have said that President Obama’s signature health law was failing and that the new legislation would offer consumers more choice and better care at better prices.

But critics said the law would roll back much of what California had achieved when it heartily embraced the Affordable Care Act, which brought the state’s uninsured rate to record lows.

Nationally, the $119 billion in savings projected by the CBO over a 10-year period doesn’t seem worth the anticipated cost of adding 23 million to the rolls of the uninsured, said John Baackes, CEO of LA Care Health Plan.

In California, Baackes said, the cuts to Medi-Cal “will create a huge gap that the state would have to fill.” And he said it could end the Medicaid expansion ushered in by the Affordable Care Act. Since the law took effect, about 5 million more people enrolled in Medi-Cal, including 3.7 million who became newly eligible under the expansion.

An earlier analysis of the House bill by the California Department of Health Care Services, which oversees the state’s Medicaid program, estimated that the state would lose more than $24 billion annually by 2027 compared to what it would have received under the ACA.

Covered California officials declined to comment on the budget analysis Wednesday but have said in the past that the GOP legislation would make coverage unaffordable for many Californians, especially those who have lower incomes and live in pricier areas.

If California does not keep the 10 essential benefits spelled out under the ACA and continue to prohibit higher premiums for those with preexisting conditions, the individual market in the state would be destabilized, said Laurel Lucia, a health care researcher at the University of California-Berkeley Labor Center.

For many people, the Republican proposal also would reduce premium subsidies for Covered California plans, which Lucia said would make coverage less affordable. And proposed caps on federal Medicaid spending would tightly squeeze the California program, she said.

“Overall there would be substantial loss of coverage for low- and middle-income Californians, especially older Californians,” Lucia said.

Jen Flory, a policy advocate at the Western Center on Law & Poverty in California, said the CBO report shows that “drastic cuts to Medicaid are largely offsetting tax cuts for wealthy Americans.”

Flory said she also feared that that optional Medi-Cal benefits under the law — such as prescription drugs and nursing home care — would be at risk. “The state would be faced with some really tough choices,” Flory said.

Carmela Castellano-Garcia, CEO of CaliforniaHealth+ Advocates, said the CBO score is “devastating.”

“It will impact millions in the state of California,” she said.

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

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