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Updated: 44 min 20 sec ago

‘An Arm and a Leg’: When Insurance Won’t Pay, Abortion Assistance Funds Step In

November 23, 2022

Can’t see the audio player? Click here to listen.

Click here for a transcript of the episode.

As Americans choose their insurance plans for next year, some might wonder: How does the recent rise in state abortion restrictions affect insurance plans?

There’s no single answer, but for a lot of people, insurance has rarely helped pay for abortions. Most pay cash, and many can’t afford it.

That’s where abortion funds come in. These organizations have been providing financial and logistical assistance to people seeking abortion care for decades.

The “An Arm and a Leg” podcast spoke with Oriaku Njoku, executive director of the National Network of Abortion Funds, and Tyler Barbarin, a board member with the New Orleans Abortion Fund, to understand the history behind these services and how they’re operating in a post-Roe v. Wade environment.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, StitcherPocket Casts, or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Path Cleared for Georgia to Launch Work Requirements for Medicaid

November 18, 2022

Georgia is set to become the only state to have work requirements for Medicaid coverage.

Republican Gov. Brian Kemp’s reelection — and a surprising Biden administration decision not to appeal a federal court ruling — have freed the state to introduce its plan that would allow for a limited increase in the pool of low-income residents eligible for Medicaid.

Questions remain about the rollout of Kemp’s plan. But it would set up Georgia as a test case for a work provision that has been proposed by several states and struck down in federal courts and by the Biden administration.

Meanwhile, advocacy groups are concerned about barriers to obtaining and maintaining the coverage. They also point out that the Kemp plan would be more expensive per enrollee and cover a fraction of the people who would get Medicaid under a full expansion. The new Georgia eligibility program would require a minimum of 80 hours of work or volunteering a month.

“The best-case scenario is that some uninsured Georgians would get coverage for some amount of time,’’ said Laura Colbert, executive director of the consumer advocacy group Georgians for a Healthy Future. “It’s going to be a big headache for the state and for people who enroll or try to enroll.”

The Trump administration approved Medicaid work requirements for Georgia and 12 other states. Georgia got approval under a “waiver,” or a federal permission that lets states run programs that differ from standard rules on Medicaid, the government insurance that covers the poor and the disabled.

But the Biden White House rejected the Georgia plan.

In August, though, a federal judge in Georgia ruled the Biden administration overstepped its authority, clearing the way for the Kemp plan to proceed. The federal government allowed the 60-day appeal window to lapse without making a move.

The rationale behind the White House decision not to appeal the court decision remains murky. A Centers for Medicare & Medicaid Services spokesperson, Bruce Alexander, said “as a matter of policy, CMS does not comment on matters of litigation.”

CMS’ reluctance to appeal may be connected to where the case would head next, said Leonardo Cuello, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families. If appealed, the case would go to a conservative federal court that may be favorable to the lower-court decision — and establish it as a stronger precedent. 

“The decision not to appeal may have been based on fear that the result would get confirmed on appeal, since most of the appellate judges in the 11th Circuit are Republican-appointed,’’ he said.

Biden administration officials could also be waiting for the plan to play out before they step in, said Catherine McKee, a senior attorney with the National Health Law Program, a nonprofit advocacy program. Federal health officials “could let the state go forward and monitor it, and take action in the future,’’ she said.

Kemp’s office did not respond to KHN’s requests for comment on the status of the plan, but the governor celebrated the federal court’s August ruling in a series of tweets.

“Despite the Left’s efforts to claw back good policy for partisan politics, this week the judiciary … Ruled the Biden Admin erred in striking down our innovative healthcare waiver which would better serve Georgians than a one-size-fits all Medicaid expansion,” the tweets said.

The Georgia Department of Community Health, which oversees the Medicaid program in the state, declined an interview to answer questions about the work requirement plan.

But the agency recently posted on its website two pages related to the “Georgia Pathways” program: one with information on how to sign up, the other with details on the plan’s requirements. Both pages were taken down after KHN asked the agency about them.

“Pathways is not yet going live so the links were disabled to avoid confusion,” said Fiona Roberts, an agency spokesperson.

Work requirements for Medicaid have a short history of implementation nationally.

The only state to run a full-fledged work requirement program was Arkansas, which launched the rule in 2018. It led to about 18,000 people losing Medicaid coverage. A federal court suspended the requirement the next year.

Kemp’s victory over Democrat Stacey Abrams in this month’s midterm election also stymied — at least for now — Georgia Democrats’ long-standing push for full Medicaid expansion, projected to cover an estimated 450,000, versus about 50,000 under the Kemp plan. On Nov. 8, South Dakota voters approved a ballot measure for full expansion, which would cover more than 40,000 additional people in that state.

Georgia’s per-enrollee cost for the work requirement program is expected to be at least three times higher than it would be under a regular Medicaid expansion, said Colbert.

The federal government would have paid for at least 90% of the costs of insuring hundreds of thousands of Georgians under a full expansion. That compares with the expected 67% matching rate from the feds under the slimmer Kemp plan. And that difference doesn’t account for a Biden administration incentive for expansion that would net Georgia $710 million, according to a KFF estimate.

The administrative barriers to the Kemp work plan would be significant, consumer advocates say. Full-time caregivers, people with mental health conditions or substance use disorders, and people unable to work but who have not yet qualified for disability coverage would find it hard to qualify, Colbert said.

Other challenges could include a lack of transportation that makes it hard for enrollees to get to work and, for potential enrollees, limited access to computers to sign up.

Besides volunteering, other qualifying activities for coverage in the Kemp plan include education and job training.

Many people struggling with homelessness in Georgia would likely not meet the work or volunteer thresholds, said Kathryn Lawler, CEO of Saint Joseph’s Health System, an Atlanta-based nonprofit. Sixty percent of patients at its Mercy Care community health centers are homeless, she said. Coverage through Medicaid expansion would let patients afford health care, address chronic conditions, and relieve the stress of medical bills, she said.

People who need medical care often are too sick to go to work, Lawler said, adding that a single mother with three small children could be deemed ineligible. Full Medicaid expansion, through increased payments to providers, would ultimately allow Mercy Care to serve more people in need, she said.

The decision by CMS not to appeal “was a little surprising,’’ Colbert said, but she added that another unfavorable court ruling could pose a risk to other states’ Medicaid programs, by clearing the way for other work requirements.

The CMS inaction could inspire similar bids for work requirements in other GOP-led states, McKee said.

The Georgia plan, meanwhile, would probably not start until the end of the covid-19 public health emergency, which has provided continuous coverage for many Medicaid enrollees during the pandemic, and looks set to continue into early next year.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Cómo el optimismo puede cerrar la brecha de cobertura de Medicaid

November 16, 2022

Más de 2 millones de personas de bajos ingresos, la mitad de ellos en Florida y Texas, no tienen seguro porque están atrapados en una brecha de cobertura. Ganan demasiado para tener derecho a Medicaid, pero debido a una peculiaridad de la Ley de Cuidado de Salud a Bajo Precio (ACA), ganan demasiado poco para tener derecho a un plan subvencionado del mercado de la Ley.

El problema afecta a las personas en 11 estados donde no han ampliado Medicaid.

Algunos de estos consumidores, sin embargo, podrían obtener ayuda financiera para comprar un plan de salud del mercado. Todo lo que tienen que hacer es estimar de buena fe que en 2023 ganarán al menos el nivel de pobreza federal (FPL), o $13,590 para un individuo. Ese es el ingreso mínimo requerido para poder optar a los subsidios que ayudan a pagar las primas de los planes del mercado.

Si sus ingresos en 2023 resultan ser inferiores a esa estimación, no se enfrentarán a una multa financiera ni tendrán que devolver el dinero al gobierno siempre que la predicción no se haya hecho “con una negligencia intencionada o imprudente de los hechos”, dijo Eric Smith, un portavoz del IRS.

Ninguno de los entrevistados por KHN aconseja a las personas atrapadas en esta “brecha de cobertura” que mientan en sus solicitudes del mercado (lo cual es un delito). Pero determinar si una estimación de ingresos es optimista o fraudulenta es un área gris. Predecir los ingresos con exactitud es a menudo imposible, sobre todo para las personas que trabajan a tiempo parcial o tienen pequeños negocios.

“Las personas tienen que ser honestas a la hora de predecir sus ingresos del próximo año, pero ¿qué significa ser honesto cuando no tienes ni idea de cuáles van a ser tus ingresos?”, preguntó el investigador del Urban Institute Jason Levitis, que trabajó en el Departamento del Tesoro hasta 2017 y ayudó a implementar la ley de salud.

La inscripción abierta en el mercado federal comenzó este mes y se extiende hasta el 15 de enero.

Muchas personas no se dan cuenta de que la obtención de subsidios del mercado depende de su previsión de ingresos del próximo año, no de los ingresos del año actual o del anterior, explicaron los agentes de seguros y los navegadores de ACA, que ayudan a los consumidores a inscribirse en los planes del mercado. En cambio, la elegibilidad para Medicaid y la mayoría de los otros programas de asistencia del gobierno se basan en los ingresos actuales, y algunos estados se niegan a inscribir a cualquier adulto sin hijos, incluso si tienen ingresos extremadamente bajos.

Varios navegadores de ACA y agentes de seguros entrevistados por KHN pensaron erróneamente que los clientes tendrían que devolver dinero al gobierno si estimaban que sus ingresos superarían el nivel de pobreza, aunque luego no ocurriera. También creían que el gobierno pediría a los solicitantes la documentación que verificara sus ingresos si su estimación no coincidía con otros datos del gobierno.

Pero esa suposición también es incorrecta.

“El mercado ya no requiere documentación adicional sobre los ingresos si los datos disponibles de años anteriores muestran ingresos por debajo del 100% del FPL, pero la declaración para el año en curso está por encima del 100% del FPL”, señaló Ellen Montz, administradora adjunta y directora del Centro de Información al Consumidor y Supervisión de Seguros de los Centros de Servicios de Medicare y Medicaid.

Anteriormente, se requería documentación cuando los solicitantes proyectaban que sus ingresos estarían por encima del nivel de pobreza y los datos federales mostraban que los ingresos actuales estaban por debajo. Pero en marzo de 2021, un tribunal federal anuló esa disposición. Y no alcanzar el nivel de pobreza no afecta a la elegibilidad de un individuo para solicitar subsidios en los próximos años, añadió Montz.

ACA exigía a los estados que utilizaran miles de millones de dólares federales para ampliar la elegibilidad de Medicaid, el programa de salud federal-estatal para personas de bajos ingresos, a todas las personas con ingresos de hasta el 138% del nivel de pobreza, actualmente $18,755 para un individuo. Pero en 2012, el Tribunal Supremo dictaminó que la expansión era opcional para los estados.

Actualmente, 11 estados tienen un vacío de cobertura porque no ampliaron Medicaid. Además de Florida y Texas, esos estados son: Alabama, Georgia, Kansas, Mississippi, Carolina del Norte, Carolina del Sur, Dakota del Sur, Tennessee y Wyoming. Los votantes de Dakota del Sur aprobaron este mes una enmienda constitucional para ampliar la elegibilidad a partir de julio de 2023. Wisconsin tampoco amplió Medicaid, pero cubre a los adultos que ganan hasta el 100% del nivel de pobreza.

Sarah Christian, coordinadora de navegadores de la Asociación de Atención Primaria de Salud de Carolina del Sur, dijo que desconocía que no existiera una penalización para las personas que ganan menos del nivel de pobreza y sobreestiman sus ingresos para tener derecho a los subsidios. Indicó que su organización había aconsejado a los consumidores basándose en la creencia de que “el gobierno identificará” las previsiones que superen los ingresos actuales y pedirá pruebas.

Alison Holmes, de 58 años, de Longwood, Florida, pensó que estaría atrapada en la brecha de cobertura de Medicaid por décimo año consecutivo en 2023 porque los ingresos de su familia este año eran de $16,000, muy por debajo de los $27,750 que una familia de cuatro personas debe ganar para obtener los subsidios del mercado. Pero después de que le ofrecieran recientemente un trabajo a tiempo parcial como redactora de subvenciones, cree que sus ingresos en 2023 harán que la familia supere el nivel de pobreza. Por ello, tiene previsto inscribirse en el seguro.

Por primera vez en una década, Holmes dijo sentirse esperanzada de que el seguro médico pueda estar a su alcance. “Aunque fuera por un año”, afirmó, “poder hacerme todas las pruebas, qué peso me quitaría de encima”.

Los hijos de Holmes están cubiertos por Medicaid, y su marido tiene cobertura a través del Departamento de Asuntos de Veteranos.

Aunque se ha reunido con navegadores de ACA, Holmes dijo que no sabía que el IRS no podía exigirle que devolviera el dinero si los ingresos de su familia finalmente no llegaban al nivel de pobreza. Sin cobertura sanitaria, le preocupa no poder mantenerse sana para cuidar de su hijo, que tiene una discapacidad.

Kelly Fristoe, presidente de la Asociación Nacional de Aseguradores de Salud y agente de seguros en Wichita Falls, Texas, contó que les pide a los clientes que no tienen derecho a Medicaid, pero cuyos ingresos son inferiores al nivel de pobreza, que piensen en cómo pueden ganar más dinero. “Cuando me dicen que solo ganan $10,000 o $12,000 al año, les digo: ‘Pero ¿hay algo más que puedas hacer para ganar dinero, como cortar el césped o limpiar un garaje, para llegar a la marca de $13,500?”, dijo Fristoe. “‘Y si haces eso, puedes tener tu seguro médico sin costo alguno'”.

Esto se debe a que las personas con los ingresos más bajos tienen derecho a los subsidios más altos, lo que generalmente les permite elegir un plan de salud sin prima mensual y con pocos o ningún gasto de bolsillo. Fristoe afirmó que ayuda a inscribirse a quienes están seguras de que ganarán lo suficiente para superar el nivel de pobreza federal. Pero “algunos dicen que no, que no hay manera de que puedan hacerlo, y yo tengo que decirles: ‘Entonces no hay manera de que pueda ayudarte'”.

Cynthia Cox, vicepresidenta de KFF, señaló que los solicitantes del mercado suelen esperar ganar más dinero al año siguiente y pueden ser razonablemente optimistas.

Añadió que los salarios de las personas con bajos ingresos suelen fluctuar, en parte porque el número de horas que trabajan puede cambiar durante el año. Los consumidores pueden dar una estimación de buena fe para el próximo año que sea superior a lo que ganaron en el año en curso.

“¿Cómo distinguir el fraude del optimismo?”, preguntó.

Aunque las personas con ingresos por debajo del nivel de pobreza no tienen que devolver nada por sobrestimar los ingresos del año siguiente y recibir los subsidios del mercado de ACA, se espera que las personas con ingresos más altos devuelvan dinero al gobierno si subestiman sus ingresos y obtienen un subsidio mayor del que les corresponde, hasta ciertas cantidades. Por ejemplo, una persona soltera cuyos ingresos se sitúen entre el 100% y el 200% del nivel de pobreza deberá devolver un máximo de $350 si sus ingresos en 2023 son superiores a los previstos, según el IRS.

José Ibarra, que supervisa a los navegadores de ACA en CentroMed, un centro de salud comunitario de San Antonio, aseguró que alrededor de un tercio de las personas que acuden en busca de ayuda tienen ingresos por debajo del nivel de pobreza y están en la brecha de cobertura.

“Es desgarrador conocer personas justo en la burbuja”, dijo. “Les preguntamos a los solicitantes si creen que podrán conseguir algunas horas más de trabajo porque están muy cerca del umbral. Queremos que se haga la mejor proyección para el próximo año, y les tomamos la palabra”.

Islara Souto, directora del programa de navegación para la organización sin fines de lucro Alianza de Epilepsia de Florida, explicó que, en el pasado, el sistema de verificación de ingresos del gobierno para las personas con ingresos por debajo del nivel de pobreza hizo que no se inscribieran, por lo que muchos consumidores dejaron de buscar ayuda y los navegadores dejaron de ayudarles a aplicar.

“Nos falta la costumbre. Somos un estado sin expansión de Medicaid”, afirmó Souto. “Si caes bajo el límite de ingresos, no vas a recibir subsidios”.

Pero después de aprender de un reportero KHN sobre la flexibilización de los requisitos, Souto dijo que iba a trabajar con los navegadores para llegar a los consumidores a los que se les había negado el subsidio en el pasado. “Volveremos atrás y encontraremos a los consumidores que estaban en esa situación y los volveremos a visitar y tal vez les digamos: ‘Vamos a probar esto'”, concluyó.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

How Optimism Can Close the Medicaid Coverage Gap

November 16, 2022

More than 2 million low-income people — half of them in Florida and Texas — are uninsured because they are stuck in a coverage gap: They earn too much to qualify for Medicaid, but because of a quirk of the Affordable Care Act, they earn too little to qualify for a subsidized ACA marketplace plan.

The problem affects people in 11 states that haven’t expanded Medicaid.

Some of these consumers, however, likely could get financial help to purchase a marketplace health plan. All they have to do is estimate in good faith that in 2023 they will earn at least as much as the federal poverty level, or $13,590 for an individual. That is the minimum income required to qualify for subsidies that help pay the premiums for marketplace plans.

If their 2023 income turns out to fall short of that estimate, they won’t face a financial penalty or have to pay back money to the government as long as the prediction was not made “with an intentional or reckless disregard for the facts,” said Eric Smith, a spokesperson for the IRS.

No one KHN interviewed is advising people stuck in this “coverage gap” to lie on their marketplace applications (which is a crime). But determining whether an income estimate is optimistic or fraudulent is a gray area. Forecasting income exactly is often impossible, particularly for people working part time or running small businesses.

“People need to be honest in predicting their next year’s income, but what does it mean to be honest when you have no idea what your income is going to be?” said Urban Institute senior fellow Jason Levitis, who worked at the Treasury Department until 2017 and helped implement the health law.

Open enrollment in the federal marketplace began this month and runs through Jan. 15.

Many people don’t realize that whether they get marketplace subsidies depends on their forecast of next year’s income, not the current or previous year’s income, said insurance agents and ACA navigators, who help consumers enroll in marketplace plans. In contrast, eligibility for Medicaid and most other government assistance programs is based on current income, and some states refuse to enroll any adults without children even if they have extremely low incomes.

Several ACA navigators and insurance agents interviewed by KHN mistakenly thought clients would have to pay money back to the government if they estimated their incomes would exceed the poverty level but then didn’t. They also believed the government would ask applicants for documentation that verifies their income if their estimate didn’t match up with other government data.

But that assumption is also untrue.

“The marketplace no longer requires additional income documentation if available data from previous years shows income below 100% FPL but the attestation for the current year is above 100% FPL,” said Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services.

Previously, documentation was required when applicants projected that their income would be above the poverty level and federal data showed current earnings below. But in March 2021, a federal court overturned that provision. And falling short of the poverty level doesn’t affect an individual’s eligibility to apply for subsidies in future years, Montz said.

The Affordable Care Act required states to use billions in federal dollars to expand eligibility for Medicaid, the federal-state health program for low-income people, to everyone with incomes up to 138% of the poverty level, currently $18,755 for an individual. But in 2012, the Supreme Court ruled that the expansion was optional for states.

Today, 11 states have a coverage gap because they did not expand Medicaid. In addition to Florida and Texas, those states are: Alabama, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, and Wyoming. South Dakota voters this month approved a constitutional amendment to widen eligibility starting in July 2023. Wisconsin also did not expand Medicaid, but it covers adults earning up to 100% of the poverty level.

Sarah Christian, navigator coordinator with the South Carolina Primary Health Care Association, said she was unaware that there was no penalty for people who earn less than the poverty level and overestimate their income to qualify for subsidies. She said her organization had advised consumers based on the belief that “the government will flag” predictions that exceed current income and ask for proof.

Alison Holmes, 58, of Longwood, Florida, thought she would be stuck in the Medicaid coverage gap for a 10th consecutive year in 2023 because her family’s income this year was $16,000 — well short of the $27,750 that a family of four must earn to get marketplace subsidies. But after recently being offered a part-time job as a grant writer, she believes that her 2023 earnings will push the family’s income over the poverty level. As a result, she plans to sign up for coverage.

For the first time in a decade, Holmes said, she felt hopeful that health insurance might be within her reach. “Even if it was for one year,” she said, “to be able to get all the tests, what a weight it would be off my shoulders.”

Holmes’ children are covered by Medicaid, and her husband has coverage through the Department of Veterans Affairs.

Even though she has met with ACA navigators, Holmes said, she did not know the IRS couldn’t require her to pay back money if her family’s income ultimately fell short of the poverty level. Without health coverage, she worries she won’t be able to stay healthy to care for her son who has a disability.

Kelly Fristoe, president of the National Association of Health Underwriters and an insurance agent in Wichita Falls, Texas, said he asks clients who aren’t eligible for Medicaid but whose incomes are less than the poverty level to think about ways they can make more money. “When I hear people say they only make $10,000 or $12,000 a year, I say, ‘C’mon, man, is there anything else you can do to make money, such as mowing grass or cleaning out a garage, just to get you to the $13,500 mark?’” he said. “‘And if you do that, you can get your health insurance at no cost.’”

That’s because people with the lowest incomes qualify for the highest subsidies, which generally allows them to choose a health plan with no monthly premium and little or no out-of-pocket costs. Fristoe said he helps enroll people who are confident they will earn enough to put them over the top of the federal poverty level. But “some say, no, there’s no way they can do that, and I have to say, ‘There’s no way I can help you,’” he said.

Cynthia Cox, vice president of KFF, said marketplace applicants often expect to make more money the following year and can be reasonably optimistic.

She noted that the earnings of low-income people often fluctuate, partly because the number of hours they work and their pay can change during the year. Consumers may want to give a good-faith estimate for next year that is higher than what they earned in the current year.

“How do you distinguish fraud from optimism?” she said.

Although people with incomes below the poverty level don’t have to pay anything back for overestimating the following year’s income and receiving ACA marketplace subsidies, people with higher incomes are expected to pay money back to the government if they underestimate their earnings and get a larger subsidy than they are entitled to — up to certain amounts. For example, an unmarried person whose income is 100% to 200% of the poverty level would pay back a maximum of $350 if the person’s 2023 income was higher than predicted, according to the IRS.

José Ibarra, who oversees ACA navigators at CentroMed, a community health center in San Antonio, said that about a third of the people coming in for help have incomes below the poverty level and are in the coverage gap.

“It’s the most heartbreaking situation when we run into people right on the bubble,” he said. “We coach people to ask applicants if they think they can expect to pick up a few more hours of work because they are so close to the threshold. We want people to make the best honest projection for the next year, and we take them at their word.”

Islara Souto, navigation program director for the nonprofit Epilepsy Alliance Florida, said the government’s past income verification system for people with incomes under the poverty level deterred people from signing up, so many consumers stopped seeking help and navigators stopped trying to persuade them to apply.

“We’re so under the habit. We’re a Medicaid non-expansion state,” she said. “You fall under the income limit, and you’re not going to get subsidies.”

But after learning from a KHN reporter about the easing of requirements, Souto said she would work with navigators to reach out to consumers who had been denied in the past. “We’ll go back a few years and find consumers we know had that situation and revisit them and maybe reach out and say, ‘Let’s try this,’” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

Medicare Plan Finder Likely Won’t Note New $35 Cap on Out-of-Pocket Insulin Costs

November 15, 2022

A big cut in prescription drug prices for some Medicare beneficiaries kicks in next year, but finding those savings isn’t easy.

Congress approved in August a $35 cap on what seniors will pay for insulin as part of the Inflation Reduction Act, along with free vaccines and other Medicare improvements. But the change came too late to add to the Medicare plan finder, the online tool that helps beneficiaries sort through dozens of drug and medical plans for the best bargain.

Officials say the problem affects only 2023 plans.

To fix anticipated enrollment mistakes, Medicare officials will give beneficiaries who use insulin a chance to switch plans next year. They can make one change after Dec. 8 and throughout 2023 through a special enrollment period for “exceptional circumstances.” Typically, people are locked in for an entire year.

The Centers for Medicare & Medicaid Services provided initial details of the opportunity in a document distributed to the State Health Insurance Assistance Program, or SHIP, which assists Medicare enrollees in every state. Although Medicare did not publicize the document, beneficiaries can get more information by contacting their local SHIP office. CMS officials would not answer questions about whether the ability to change plans will be granted automatically.

“We are pleased that CMS is offering the special enrollment period that will allow insulin users to change plans in 2023,” said Chris Reeg, director of the Ohio Senior Health Insurance Information Program.

In some cases, a special enrollment period can be avoided, said Janet Stellmon, director of the Montana State Health Insurance Assistance Program. If the plan charges more than a $35 copayment for a member’s insulin, a SHIP counselor can ask the plan to correct the mistake. “Plans usually try to make it right quickly,” said Stellmon, who helped one beneficiary save $565 a month on insulin.

Medicare patients spent $1 billion in 2020 on insulin products — four times the amount in 2007, with some paying as much as $116 a month out-of-pocket, KFF has found. Americans paid an average of five to 10 times as much for insulin in 2018 than in other countries, according to a recent study. About 3.3 million people with Medicare rely on one or more insulin products to control blood sugar levels.

The $35 copay for injectable insulin products takes effect Jan. 1, and July 1 for patients who use an insulin pump.

When beneficiaries who use insulin now check the plan finder, the price could show up as thousands of dollars a year instead of the maximum $420 stipulated by law. An inaccurate price could also distort the costs of other drugs, which depend on what coverage phase patients reach. For example, once both the plan and the patient spend a total of $4,660 for all drugs next year, the member pays no more than 25% of the cost for non-insulin drugs.

It’s extremely difficult for consumers to evaluate policy options without the plan finder. One plan might have the lowest price for one drug but not another. Or a plan might have the lowest premium but higher drug prices. Or a preferred pharmacy in one plan may be excluded in another.

Medicare officials caution consumers about the problem. “This new $35 cap may not be reflected when you compare plans,” according to a warning that pops up during a plan finder search. “You should talk to someone for help comparing plans,” it says, pointing readers to the Medicare help line — 800-633-4227 — or a counselor with SHIP. It doesn’t mention the option of changing plans after the Dec. 7 enrollment deadline.

But both SHIP counselors and representatives answering the Medicare help line rely on the same flawed plan finder.

Georgia Gerdes at AgeOptions in Oak Park, Illinois, trains people across the state to assist Medicare beneficiaries. She said she searches for policies without adding insulin to a client’s medication list and separately searches plans that cover the type of insulin the client takes. Then she reviews those lists to see which ones on the insulin list are also on the list of non-insulin drugs and manually adds the $35 monthly insulin cost before making recommendations.

Medicare beneficiaries filled prescriptions for at least 114 kinds of insulin in 2020, and those who did not get low-income subsidies paid on average $572 out-of-pocket, according to the KFF study.

But drug plans do not have to cover all injectable insulins, said Tatiana Fassieux, an education and training specialist at California Health Advocates. “It’s all about the formulary,” she added, referring to the plans’ covered drugs.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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California acumula multas de residentes sin seguro en lugar de reducir los costos de la atención

November 14, 2022

SACRAMENTO — Casi tres años después de que California comenzara a multar a los residentes que no tienen seguro médico, KHN supo que el estado no ha distribuido ninguno de los ingresos que ha recaudado, un dinero que estaba destinado a ayudar a los californianos que luchan por pagar la cobertura.

Y, hasta ahora, la mayoría de los californianos que pagan la multa fiscal por no tener seguro son personas de ingresos bajos y medios, según funcionarios fiscales estatales, justamente a los que se pretendía ayudar con ese dinero.

“Es preocupante”, dijo Diana Douglas, cabildera de Health Access California, quien abogó por el mandato. “La idea general era si íbamos a recaudar dinero de las personas que no pueden pagar la cobertura, para usar esos ingresos para ayudar a las personas a pagarla y a realmente obtener atención. Pero no es justo para las personas que no pueden pagarla”.

Los funcionarios de finanzas estatales han estimado que los ingresos recaudados a través de la multa en sus primeros tres años, desde 2020 hasta 2022, sumarán alrededor de $1.3 mil millones. El gobernador Gavin Newsom argumenta que el estado debería retener el dinero en caso de que los californianos necesiten ayuda para pagar el seguro médico en el futuro.

Newsom y los legisladores demócratas adoptaron el requisito de seguro médico estatal en 2019, casi dos años después de que el Congreso controlado por los republicanos eliminara la multa federal por no tener seguro médico que se había establecido en virtud de la Ley de Cuidado de Salud a Bajo Precio (ACA). El entonces presidente Donald Trump presionó para eliminarla, argumentando que la disposición de Obamacare era “muy injusta”.

Sin embargo, Newsom argumentó que el llamado “mandato individual” ayudaría a California a lograr una cobertura universal al exigir que todos tengan un seguro médico, y dijo que el dinero de la multa se usaría para ayudar a los residentes a comprar planes a través de Covered California, el mercado de seguros estatal de ACA.

Se suponía que los ingresos por estas multas ayudarían a financiar los subsidios estatales para los californianos de ingresos medios y bajos que compran cobertura a través de Covered California que Newsom y los legisladores estatales aprobaron el mismo año. Los subsidios estatales complementarían la asistencia financiera federal existente que se ofrece bajo el Obamacare.

Pero covid-19 cambió las reglas.

Para evitar que las personas perdieran el seguro durante la pandemia, la administración Biden y el Congreso controlado por los demócratas aumentaron los subsidios federales para los estadounidenses que compran un seguro médico a través de los mercados del Obamacare, y que se ampliaron recientemente bajo el Inflation Reduction Act.

La administración Newsom argumentó que la asistencia federal adicional era suficiente para ayudar a los residentes a pagar la cobertura, y California dejó de proporcionar los subsidios estatales en mayo de 2021. Estuvieron vigentes menos de dos años y fueron financiados con alrededor de $328 millones en dinero inicial de un fondo general del estado.

Pero el estado continuó imponiendo la multa fiscal, y la administración de Newsom está acumulando parte del dinero dadas las proyecciones fiscales que muestran que California enfrenta una perspectiva económica incierta, según H.D. Palmer, vocero del Departamento de Finanzas del estado.

Los ingresos fiscales de este año están miles de millones por debajo de las proyecciones, dijo, y el dinero de la multa podría ser necesario cuando expire la asistencia financiera federal adicional a fines de 2025, si no se extiende antes de esa fecha, o si los republicanos toman el control del Congreso o de la Casa Blanca, y luego desechar los subsidios mejorados.

“La reciente caída en los ingresos fiscales estatales destaca la importancia de reservar esos fondos”, dijo Alex Stack, vocero de Newsom.

En 2021, Newsom y los legisladores estatales transfirieron $333,4 millones del dinero de las multas a un fondo especial “para uso futuro para programas de asequibilidad de la salud” en Covered California, aunque ese fue un movimiento único y el dinero no se gastará pronto, dijo Palmer.

California se encuentra entre varios estados que adoptaron requisitos de seguro médico después de que se eliminara la multa federal. California impone su multa a los residentes sin seguro cuando presentan sus impuestos estatales.

Para el año fiscal 2020, el primer año en que estuvo vigente el mandato, California recaudó alrededor de $403 millones de personas sin seguro, con una multa promedio por persona de $1,196, según la Junta de Impuestos de Franquicias del estado.

De los aproximadamente 337,000 californianos penalizados ese año, unos 225,400 tenían ingresos iguales o inferiores al 400% del nivel federal de pobreza, o $49,960 para una sola persona y $85,320 para una familia de tres. Algunas personas con ingresos más bajos están exentas de pagar esta multa.

La administración Newsom proyectó que los ingresos por esta penalidad fiscal aumentarían tanto en 2021 como en 2022, incluso a $435 millones este año.

Debido a que la recaudación de impuestos tarda en procesarse, el total exacto recaudado hasta la fecha no está claro. Pero la administración estima que el estado recaudará alrededor de $1.3 mil millones durante los primeros tres años del mandato.

La mayor parte de ese dinero se depositará en el fondo general del estado y se puede gastar en cualquier cosa que el gobernador y los legisladores decidan. No existe ningún requisito de que el dinero de la multa se use para atención médica o asistencia financiera, confirmó Palmer.

Mientras tanto, las primas están aumentando para muchos consumidores que compran cobertura a través de Covered California, con un alza promedio del 5,6 % para 2023, según James Scullary, vocero del mercado.

Los deducibles y otros gastos de bolsillo también están aumentando para algunas personas, y los defensores de los consumidores temen que sin una mayor asistencia financiera, más californianos optarán por no comprar cobertura o renunciarán a la atención por completo.

Por ejemplo, un plan médico de Covered California de nivel medio para una persona tendrá un deducible de $4,750 y un desembolso máximo anual de $8,750 en 2023, frente a $3,700 y $8,200, respectivamente, este año.

“Ya teníamos preocupaciones sobre la reinstauración de la penalización para las personas sin seguro porque afecta más a las personas pobres, y ahora vemos que las personas de bajos ingresos toman decisiones difíciles sobre el pago de la atención médica u otras necesidades básicas como la gasolina, los alimentos y el alquiler”, dijo Linda Nguy, cabildera del Western Center on Law and Poverty. “Gastemos el dinero que estamos recaudando para ayudar a que sea más asequible o eliminemos el mandato si no lo estamos gastando”.

Algunos legisladores demócratas, respaldados por Heath Access y una amplia coalición de defensores de la salud, aseguradoras y pequeñas empresas, están presionando a Newsom para que use los ingresos de la multa para ayudar a los californianos sin seguro y de bajos ingresos. Argumentan que incluso con la asistencia federal adicional, las personas aún necesitan ayuda para reducir sus gastos de bolsillo.

“Las pequeñas empresas y sus empleados están luchando para pagar la atención médica”, dijo Bianca Blomquist, directora de políticas de California del grupo de cabildeo Small Business Majority. “Cuando se estableció el mandato individual, se entendió que, aunque el dinero se destinaría al fondo general, se gastaría en asistencia económica en Covered California. Esa es una gran razón por la que lo apoyamos”.

Este año, un proyecto de ley del senador estatal Richard Pan (demócrata de Sacramento), quien deja el cargo debido a los límites de mandato, buscó canalizar el dinero de las multas estatales a Covered California para reducir los costos de desembolso de algunos consumidores, incluida la eliminación de sus deducibles. Pero Newsom vetó el proyecto de ley, argumentando que el dinero podría ser necesario en los próximos años para restablecer los subsidios estatales.

Los defensores prometen continuar presionando el próximo año.

“Tener un seguro no significa nada si no puedes pagar el deducible, y esa es una gran barrera para las personas con enfermedades crónicas que tienen costos de atención médica muy altos”, dijo Pan. “La gente todavía no puede permitirse ir al médico”.

Los republicanos se unieron a los legisladores demócratas para expresar su frustración. El ex senador estatal Jeff Stone, quien fue un acérrimo opositor del mandato estatal y desde entonces se mudó a Nevada, criticó la multa como un “Robin Hood a la inversa”: quitarle a los pobres y dárselo a los ricos.

“Las personas empobrecidas se ven obligadas a pagar esa multa, y se coloca directamente en el fondo general para cualquier propósito”, dijo. “Si el estado no lo gasta como dijo el gobernador, debe devolverlo a los contribuyentes”.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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California Stockpiles Penalties From Uninsured Residents Instead of Lowering Care Costs

November 14, 2022

SACRAMENTO, Calif. — Nearly three years after California started fining residents who don’t have health insurance, the state has not distributed any of the revenue it has collected, KHN has learned — money that was intended to help Californians struggling to pay for coverage.

And so far, the majority of Californians paying the tax penalty for not having insurance are low- and middle-income earners, according to state tax officials — just the people the money was intended to help.

“It’s concerning,” said Diana Douglas, a lobbyist with Health Access California, which advocated for the mandate. “The whole idea was if we’re going to collect money from people who can’t afford coverage, to use that revenue to help people afford it and actually get care. It’s not fair to people who can’t afford it.”

State finance officials have estimated that the revenue collected via the penalty in its first three years, from 2020 through 2022, will total about $1.3 billion. Gov. Gavin Newsom argues the state should hold on to the money in case Californians need help paying for health insurance in the future.

Newsom and Democratic lawmakers adopted the state health insurance requirement in 2019, nearly two years after the Republican-controlled Congress eliminated the federal penalty for not having health insurance that had been instituted under the Affordable Care Act. Then-President Donald Trump pushed to scrap it, arguing that the Obamacare provision was “very unfair.

Newsom argued, however, that a so-called individual mandate would help California achieve universal coverage by requiring everyone to have health insurance, and said the penalty money would be used to help residents purchase plans via Covered California, the state’s Affordable Care Act insurance marketplace.

The penalty revenue was supposed to help fund state-based subsidies for low- and middle-income Californians who purchase coverage through Covered California that Newsom and state lawmakers approved the same year. The state subsidies would supplement the existing federal financial assistance offered under Obamacare.

But covid-19 changed the equation.

To prevent people from losing insurance during the pandemic, the Biden administration and the Democratic-controlled Congress boosted federal subsidies for Americans who buy health insurance through Obamacare exchanges — and which were recently extended under the federal Inflation Reduction Act.

The Newsom administration argued the additional federal assistance was enough to help residents afford coverage, and California stopped providing the state subsidies in May 2021. They had been in place less than two years and had been financed by about $328 million in startup money from the state’s general fund.

But the state continued levying the tax penalty, and the Newsom administration is stockpiling some of the money given fiscal projections that show California is facing an uncertain economic outlook, according to H.D. Palmer, the spokesperson for the state Department of Finance. Tax revenues this year are billions below projections, he said, and the penalty money could be needed when the additional federal financial assistance expires at the end of 2025 — if it’s not extended in the meantime — or if Republicans take control of Congress or the White House and then scrap the enhanced subsidies.

“The recent downturn in state tax revenues highlights the importance of having those funds set aside,” Newsom spokesperson Alex Stack said.

In 2021, Newsom and state legislators transferred $333.4 million of the penalty money into a special fund “for future use for health affordability programs” in Covered California, though that was a one-time move and the money will not be spent anytime soon, Palmer said.

California is among several states that adopted health insurance requirements after the federal penalty was gutted. California assesses its penalty on uninsured residents when they file their annual state income taxes.

For the 2020 tax year, the first year the mandate was in place, California collected about $403 million from uninsured people, with the average per-person penalty amounting to $1,196, according to the state Franchise Tax Board.

Of the roughly 337,000 Californians penalized that year, about 225,400 had incomes at or below 400% of the federal poverty level, or $49,960 for a single person and $85,320 for a family of three. Some lowest-income earners are exempt from the penalty.

The Newsom administration projected that the revenue from the tax penalty would increase in both 2021 and 2022, including to $435 million this year.

Because tax collections take time to process, the exact total raised to date is unclear. But the administration estimates the state will collect about $1.3 billion over the first three years of the mandate. Most of that money will be deposited into the state general fund and can be used for anything the governor and lawmakers choose to spend it on. There is no requirement that any penalty money be spent on health care or financial assistance, Palmer confirmed.

Meanwhile, premiums are rising for many consumers purchasing coverage through Covered California, with an average increase of 5.6% for 2023, according to James Scullary, a spokesperson for the marketplace.

Deductibles and other out-of-pocket costs are also going up for some people, and consumer advocates fear that without greater financial assistance, more Californians will opt out of purchasing coverage — or forgo care altogether.

For instance, a mid-tier Covered California insurance plan for an individual will have a $4,750 medical deductible and an annual out-of-pocket maximum of $8,750 in 2023 — up from $3,700 and $8,200, respectively, this year.

“We already had concerns about reinstating the penalty on the uninsured because it hits poor people the hardest, and now we’re seeing lower-income people making tough choices about paying for health care or other basic necessities like gas, food, and rent,” said Linda Nguy, a lobbyist with the Western Center on Law and Poverty. “Let’s spend the money we’re collecting to help make it more affordable or eliminate the mandate if we’re not spending it.”

Some Democratic lawmakers, backed by Heath Access and a broad coalition of health advocates, insurers, and small businesses, are pushing Newsom to use the penalty revenue to help uninsured and low-income Californians. They argue that even with the additional federal assistance, people still need help to lower their out-of-pocket costs.

“Small businesses and their employees are struggling to afford health care,” said Bianca Blomquist, California policy director for the Small Business Majority lobbying group. “When the individual mandate was established, the understanding was that even though the money is going to the general fund, it would be spent on affordability assistance in Covered California. That’s a big reason we supported it.”

A bill this year by state Sen. Richard Pan (D-Sacramento), who is leaving office because of term limits, sought to funnel state penalty money into Covered California to reduce out-of-pocket costs for some consumers, including scrapping their deductibles. But Newsom vetoed the bill, arguing that the money could be needed in future years to reinstate the state-based subsidies.

Advocates vow to continue pushing next year.

“Having insurance doesn’t mean anything if you can’t afford the deductible, and that’s a huge barrier for people with chronic diseases who have very high health care costs,” Pan said. “People still can’t afford to go to the doctor.”

Republicans joined Democratic lawmakers in expressing frustration. Former state Sen. Jeff Stone, who was a staunch opponent of the state mandate and has since relocated to Nevada, blasted the penalty as “reverse Robin Hood” — taking from the poor and giving to the wealthy.

“Impoverished people are being forced to pay that penalty, and it’s being put right into the general fund for any purpose,” he said. “If the state isn’t spending it like the governor said it would, return it to taxpayers.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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‘An Arm and a Leg’: No Money, No Job, No Health Care? Not Always.

November 11, 2022

Can’t see the audio player? Click here to listen.

Click here for a transcript of the episode.

If you don’t have money and you don’t have a job, what are your best options for getting health care? 

It’s 2023 open enrollment season, and a lot of Americans are shopping for health insurance plans. And some are weighing the risks of skipping health insurance altogether.

One listener wrote to “An Arm and a Leg” about his son, a student with no income who has aged out of the family’s health insurance. He asked: If his son buys a plan, would he be signing away the possibility of getting charity care (financial assistance) at his local hospital? 

To answer this question, podcast host Dan Weissmann relied on expert help from Karen Pollitz, a senior fellow at KFF, and Jared Walker, founder of Dollar For and an expert on charity care.

If you want to go deeper:

  • “An Arm and a Leg” did a three-part series on picking health insurance in its First Aid Kit newsletter. Start here
  • An episode from last year explored other do’s and don’ts for picking health insurance.
  • In a 2018 episode, Weissmann talked with another listener — a “financial therapist” — who had her own deep questions about health insurance. 

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, StitcherPocket Casts, or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Journalists Tackle the Midterms and Open Enrollment

November 11, 2022

KHN chief Washington correspondent Julie Rovner discussed how politicians plan to take on health care costs and how health issues are playing into the midterm elections on WNYC’s “The Brian Lehrer Show” on Nov. 4.

KHN senior correspondent Julie Appleby discussed open enrollment and Affordable Care Act health plans on the “America’s Heroes Group” podcast on Nov. 5.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Por qué algunos estados quieren garantizar Medicaid para los niños desde que nacen hasta los 6 años

November 10, 2022

Antes de que comenzara la emergencia de salud pública por covid-19 en 2020, millones de niños entraban y salían de Medicaid cada año, un indicio de que muchos perdían la cobertura por problemas administrativos, y no porque sus familias ganaran más y ya no fueran elegibles.

Ahora, varios estados del oeste del país, como California, buscan cambiar esta situación con nuevas políticas de inscripción continua para los miembros más jóvenes de Medicaid. La posibilidad de cambiar estas normas, vigentes por décadas, surge cuando los estados valoran los cambios causados por la pandemia.

Los legisladores de California han aprobado una propuesta —pendiente de la autorización federal— para que los niños que cumplan los requisitos para recibir Medicaid se inscriban al nacer y permanezcan inscritos hasta los 5 años, a partir de 2025.

Oregon ya ha conseguido la aprobación de una política similar. En 2023, cuando se espera que termine la emergencia de salud pública, Oregon se convertirá en el primer estado en permitir que los niños elegibles para recibir Medicaid se inscriban al nacer y permanezcan en el programa hasta que cumplan 6 años, independientemente de los cambios en los ingresos familiares y sin tener que volver a solicitarlo.

“Se trata de una medida obvia en términos de apoyo a los niños”, dijo Jenifer Wagley, directora ejecutiva de la organización Our Children Oregon. Según Wagley, mantener a los niños con cobertura —sobre todo temprano en su desarrollo— garantizará que no pierdan importantes chequeos y cuidados debido a las brechas en la cobertura.

En julio, el estado de Washington pidió permiso al gobierno de Biden para ofrecer cobertura continua a los niños hasta los 6 años, y se aguarda una decisión en las próximas semanas. Por su parte, Nuevo México ha solicitado comentarios públicos sobre un plan para mantener a los niños inscritos hasta los 6 años y se espera que solicite el consentimiento federal a finales de este año.

La inscripción en Medicaid ha alcanzado niveles récord después que el gobierno federal prohibiera a los estados dar de baja a sus miembros durante la emergencia de salud pública, a menos que murieran o se trasladaran fuera del estado. Esta norma ha contribuido a que la tasa de no asegurados del país alcance un mínimo histórico.

De las casi 90 millones de personas que reciben Medicaid y el Programa de Seguro de Salud Infantil (CHIP), unos 41 millones son niños. CHIP es un programa federal-estatal que cubre a los niños de hogares con ingresos superiores a los que se pueden acoger a Medicaid.

Joan Alker, directora ejecutiva del Centro para la Infancia y la Familia de la Universidad de Georgetown, calificó el hecho de que los estados pasen a tener períodos más largos de cobertura continua para los menores como “una consecuencia positiva de la pandemia”.

Señaló que desde el cuarto trimestre de 2020 hasta el primero de 2022, la proporción de niños sin seguro en Estados Unidos se redujo del 6,7% al 3,7%, en gran parte debido a la norma de emergencia que ha impedido a los estados dejar sin cobertura a los inscritos en Medicaid.

“Los estados tendrán que hacer mucha divulgación sobre esta nueva política para que todos los bebés salgan del hospital con seguro médico y los padres no tengan que preocuparse por la cobertura hasta que el niño vaya al jardín”, señaló Alker.

Si la emergencia de salud pública finaliza el año que viene, casi 5,3 millones de niños podrían perder la cobertura de Medicaid, según un análisis federal publicado en agosto. De ellos, alrededor de 1,4 millones saldrían de las listas porque ya no cumplen los requisitos, pero casi 4 millones de niños que reúnen los requisitos perderían la cobertura por motivos administrativos, como no haber presentado la documentación a tiempo.

Dado que los umbrales de ingresos familiares de Medicaid suelen ser más altos para los niños que para los adultos, es menos probable que los niños pierdan la cobertura por pequeños cambios en los ingresos. Pero pueden perder su derecho a la cobertura si los padres no la renuevan cada año, o no responden cuando el estado busca información para confirmar que los ingresos de la familia se han mantenido lo suficientemente bajos pra mantener la elegibilidad.

Por lo general, los inscritos en Medicaid deben informar de cualquier cambio en los ingresos de la familia u otros criterios que puedan afectar a su elegibilidad durante el año, y los estados deben actuar sobre estos cambios.

Esto supone un reto para los beneficiarios de Medicaid y las agencias estatales, ya que los ingresos de las personas suelen fluctuar. Como resultado, los inscritos pueden perder la cobertura, verse obligados a cambiar entre Medicaid y la cobertura subvencionada del mercado de seguros de la Ley de Cuidado de Salud a Bajo Precio (ACA), o experimentar brechas de cobertura si el papeleo resulta difícil de completar.

Para solucionar este problema, casi la mitad de los estados dan a los niños un año de elegibilidad continua de Medicaid, independientemente de los cambios en los ingresos familiares. Ese grupo incluye estados controlados tanto por republicanos como por demócratas, y estados como Alabama y Mississippi, que no han ampliado Medicaid bajo ACA.

Antes de pasar a la cobertura continua para los niños hasta los 6 años, Oregon les ofrecía 12 meses de elegibilidad continua. Sin embargo, los funcionarios estatales de Medicaid estiman que en 2019, antes del comienzo de la pandemia, más de 70,000 menores de 6 años —un tercio de los inscritos— entraron y salieron de Medicaid. Alrededor de 29,000 de esos niños tuvieron lagunas de cobertura que superaron los seis meses, según dijeron funcionarios estatales a KHN.

Los funcionarios de Oregon estiman que, tras cuatro años de aplicación, la nueva política de inscripción beneficiará a más de 51,000 niños en 2027, a un costo de $177 millones.

“La emergencia de salud pública ha demostrado claramente el valor de tener un seguro de salud continuo, particularmente para las poblaciones que experimentan disparidades de salud y han tenido barreras históricas para el acceso a la atención médica”, afirmó Elizabeth Gharst, vocera de la Autoridad de Salud de Oregon, que supervisa el programa estatal de Medicaid.

La garantía de seis años también reducirá los costos administrativos de Oregon, ya que no tendrá que tramitar algunas solicitudes cada año. Y los funcionarios esperan que reduzca los gastos médicos del programa, ya que los niños que permanezcan en Medicaid tendrán acceso a servicios de atención primaria y preventiva que pueden reducir la necesidad de tratamientos relacionados con los atrasos en la búsqueda de atención.

Oregon ofrece cobertura de Medicaid y CHIP a los niños de familias con ingresos de hasta el 300% del nivel federal de pobreza, que es de $83,250 para una familia de cuatro miembros.

Lori Coyner, asesora principal de políticas de Medicaid en Oregon, dijo que el cambio reducirá las desigualdades en materia de salud porque ayudará a los niños de color a conservar la cobertura y el acceso a la atención médica.

Además de mantener a los niños en Medicaid durante más tiempo, Oregon obtuvo la aprobación federal en octubre para convertirse en el primer estado en dar a los niños de 6 años o más y a los adultos dos años de elegibilidad continua, independientemente de los cambios en los ingresos de su hogar.

A nivel nacional, KFF estima que alrededor del 11% de los niños inscritos en Medicaid perdieron su cobertura durante al menos un día en 2019. El estado de Washington también reporta un 11%.

En California, funcionarios de Medicaid estiman que unos 64,000 —el 6%— de los inscritos menores de 5 años fueron retirados de las listas y luego volvieron a inscribirse en el mismo año.

Mike Odeh, director de salud del grupo Children Now de California, espera que el estado se sume pronto. “Preferiríamos que el estado pagara para que los niños recibieran atención en lugar de pagar por el papeleo”, señaló, y añadió que tener que volver a inscribirse cada año puede ser un obstáculo para las familias de bajos ingresos. “Queremos que estén sanos y preparados para la escuela”, afirmó Odeh.

El Departamento de Servicios de Atención Sanitaria de California, que supervisa Medi-Cal, calcula que el cambio de política costaría $39,1 millones en 2025, suponiendo que se aplique en enero, y $68 millones para el año fiscal 2025-26. El estado todavía está sopesando cuándo buscar la aprobación federal.

Los funcionarios de Medicaid en el estado de Washington aseguraron que hace tiempo que consideran la posibilidad de dar a los niños elegibilidad continua durante varios años. “Las familias de Medicaid están muy ocupadas, y lo último en lo que pueden pensar es en renovar su cobertura, por lo que esto queda relegado al final de su lista de prioridades”, explicó Amy Dobbins, directora de sección en la Oficina de Elegibilidad y Política de Medicaid.

Dobbins señaló que la emergencia de salud pública por covid, durante la cual más niños han tenido cobertura y han recibido servicios de salud, fortaleció la idea de la elegibilidad continua.

Dianne Hasselman, directora ejecutiva interina de la Asociación Nacional de Directores de Medicaid, piensa que algunos estados serían cautelosos a la hora de seguir el ejemplo de Oregon. “A los legisladores estatales también les podría preocupar el aumento de las inscripciones en el programa Medicaid, especialmente en un momento en el que las inscripciones ya han crecido significativamente”, expresó.

Además, los legisladores no verían con buenos ojos ampliar la cobertura a personas con otras opciones de seguro, como el del lugar de trabajo de los padres, agregó Hasselman.

Aunque se alegra de que algunos estados mantengan a los niños en Medicaid hasta los 6 años, Alker, de Georgetown, subrayó que la nueva política de Oregon entrará en vigor —al final de la emergencia sanitaria— justo cuando millones de niños pierdan la cobertura.

“Los estados que no presten atención a las necesidades de los niños cuando termine la emergencia de salud pública probablemente verán un aumento masivo de niños sin seguro”, señaló Alker. “Así que se avecinan situaciones muy diferentes”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Stopping the Churn: Why Some States Want to Guarantee Medicaid Coverage From Birth to Age 6

November 10, 2022

Before the covid-19 public health emergency began in 2020, millions of children churned on and off Medicaid each year — an indication that many were losing coverage because of administrative problems, rather than because their family’s income had increased and made them ineligible.

Spurred by pandemic-era lessons, several states are rethinking their enrollment policies for the youngest Medicaid members. Oregon is leading the way after getting federal approval to implement a new continuous-enrollment policy.

In 2023, when the public health emergency is expected to end, Oregon will become the first state to allow children who qualify for Medicaid to enroll at birth and stay enrolled until they turn 6, regardless of changes in their household’s income and without having to reapply.

“This is really a no-brainer in terms of supporting kids,” said Jenifer Wagley, executive director of Our Children Oregon, an advocacy group. She said that keeping kids insured — particularly at the youngest ages, when their bodies and minds are still developing — will ensure they don’t miss important checkups and care because of gaps in coverage.

Three other states are moving to implement similar policies for their Medicaid plans, which provide health coverage to people with low incomes and are funded by states and the federal government. Washington state in July asked the Biden administration for permission to provide continuous coverage to kids until age 6, and a decision is likely in the next few weeks. California lawmakers have approved a proposal for kids to stay covered until age 5, starting in 2025, pending federal approval. And New Mexico has sought public comments on a plan to keep kids enrolled until age 6 and is expected to seek federal consent later this year.

Medicaid enrollment nationally is at a record high after the federal government prohibited states from dropping members during the public health emergency unless they died or moved out of state. That rule has helped push the country’s uninsured rate to a record low.

Of the nearly 90 million people on Medicaid and the Children’s Health Insurance Program — a federal-state program that covers children in households with incomes above Medicaid eligibility — about 41 million are children.

Joan Alker, executive director of Georgetown University’s Center for Children and Families, called states’ moving to longer periods of continuous coverage for children “a silver lining of the pandemic for children.”

She noted that from the fourth quarter of 2020 through the first quarter of 2022, the share of uninsured children in the U.S. fell from 6.7% to 3.7%, largely because of the emergency rule that has blocked states from dropping Medicaid enrollees.

“States will have to do a lot of outreach about this new policy so that every baby leaves the hospital with health insurance and the parents don’t have to worry about coverage until the child goes to kindergarten,” she said.

If the public health emergency ends next year, nearly 5.3 million children could lose Medicaid coverage, according to a federal analysis that was released in August. About 1.4 million of them would be moved off the rolls because they no longer qualify, but nearly 4 million eligible kids would lose coverage for administrative reasons, such as failing to submit paperwork on time.

Because Medicaid’s household income eligibility thresholds are typically higher for children than adults, kids are less likely to lose coverage because of small changes in income. But children can lose their eligibility if parents fail to renew the coverage each year or don’t respond when a state seeks information to confirm that a family’s income has remained low enough to qualify.

Medicaid enrollees generally must report any changes to household income or other criteria that may affect their eligibility during the year, and states must act on these changes. That’s challenging for Medicaid beneficiaries and state agencies because people’s incomes often fluctuate. As a result, enrollees may lose coverage, be forced to switch between Medicaid and subsidized marketplace coverage on the Affordable Care Act insurance exchanges, or experience coverage gaps if the paperwork proves difficult to complete.

To address that problem, about half of states give children one year of continuous Medicaid eligibility regardless of changes in their household’s income. That group includes both Republican- and Democrat-controlled states, including some states — such as Alabama and Mississippi — that have not expanded Medicaid under the ACA.

Before moving toward continuous coverage for kids up to age 6, Oregon offered 12 months of continuous eligibility for children. Nonetheless, state Medicaid officials estimate that in 2019, prior to the pandemic’s start, more than 70,000 children younger than 6 — one-third of those enrolled — churned in and out of Medicaid. About 29,000 of those kids had coverage gaps that exceeded six months, state officials told KHN.

Oregon officials estimate that after four years in place, the new enrollment policy will benefit more than 51,000 children in 2027, at a cost of $177 million.

“The public health emergency has clearly demonstrated the value of having continuous health insurance, particularly for populations that experience health disparities and have had historical barriers to health care access,” said Elizabeth Gharst, a spokesperson for the Oregon Health Authority, which oversees the state’s Medicaid program.

The six-year guarantee will also reduce administrative costs for the state, since it won’t have to process some applications each year. And officials hope it will reduce the program’s medical costs, as children who stay on Medicaid will have access to preventive and primary care services that can reduce the need for treatments related to delays in seeking care.

Oregon provides Medicaid and CHIP coverage to children from families with incomes of up to 300% of the federal poverty level, which is $83,250 for a family of four.

Lori Coyner, Oregon’s senior Medicaid policy adviser, said the change will reduce health inequities because it will help children of color retain coverage and access to care.

In addition to keeping children on Medicaid longer, Oregon won federal approval in October to become the first state to give children 6 years and older and adults two years of continuous eligibility regardless of changes in their household’s income.

Nationally, KFF estimates that about 11% of children enrolled in Medicaid lost their coverage for at least one day in 2019 before having it restored. Washington state also reports 11%.

In California, where a continuous-coverage policy is being considered, Medicaid officials estimate that of the nearly 1.2 million children younger than 5 who are covered, about 64,000 — or 6% — were dropped from the rolls and then reenrolled in the same year

Mike Odeh, senior director of health for the California advocacy group Children Now, believes the state’s churning estimate is too low. He thinks 89,000 children a year are affected. The California legislature included the continuous eligibility provision in the budget approved in June. California would cover children in Medicaid from birth until age 5 starting in 2025 as long as the state can afford it.

The California Medicaid agency estimates the policy change would cost $39 million in 2025, assuming a January implementation, and $68 million for the 2025-26 fiscal year. The state is still weighing when to seek federal approval.

Odeh hopes the state moves ahead soon. “We would rather see the state pay for kids getting care than paying for paperwork,” he said. Having to reenroll every year, he added, can be a barrier for low-income families. “We want them healthy and ready for school,” Odeh said.

Medicaid officials in Washington state said that they have long considered giving children continuous eligibility for multiple years. “Families on Medicaid are really busy, and the last thing they can think about is renewing their coverage — and so this gets dropped to the bottom of their priority list,” said Amy Dobbins, section manager of the Office of Medicaid Eligibility and Policy.

She said the covid public health emergency, during which more children have had coverage and received health services, only strengthened the case for continuous eligibility.

Dianne Hasselman, interim executive director of the National Association of Medicaid Directors, predicts that some states may be cautious about following Oregon’s lead. “State legislators might also be concerned about increasing Medicaid program enrollment, particularly during a time when enrollment has already grown significantly,” she said. In addition, lawmakers could be leery of extending coverage to people with other insurance options, such as from a parent’s workplace, she said.

While pleased to see some states keeping children on Medicaid until age 6, Georgetown’s Alker emphasized that Oregon’s new policy will go into effect — at the public health emergency’s end — just as millions of children lose coverage.

“States that are inattentive to the needs of children when the public health emergency ends will likely see a massive increase in uninsured children,” Alker said. “So very different outcomes lie ahead.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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South Dakota Voters Approved Medicaid Expansion, but Implementation May Not Be Easy

November 10, 2022

RAPID CITY, S.D. — South Dakotans voted Tuesday to expand the state’s Medicaid program to cover thousands of additional low-income residents, becoming the seventh state to approve expansion via the ballot box.

But as other conservative states have shown, voter approval doesn’t always mean politicians and administrators will rush to implement the change.

In Missouri, for example, experts said subpar publicity efforts and an outdated application system led to a glacial pace of enrollment after voters there approved Medicaid expansion in 2020.

A similarly slow rollout could occur in South Dakota, said Tricia Brooks, a Georgetown University research professor who studies Medicaid.

South Dakota’s Medicaid computer system “has a long way to evolve,” Brooks said. “Unless they’re going to really boost their eligibility [processing] capacity, then I think we’re in for a rough or rocky start to expansion.”

That could leave some South Dakotans temporarily uninsured even after they become eligible for Medicaid coverage.

Brooks said state administrators could face additional complications if the federal government ends the covid-19 public health emergency while South Dakota is enrolling newly eligible people into Medicaid. During the health emergency, states have been barred from dropping people who are no longer eligible for Medicaid, but they will resume doing so once the emergency ends.

Officials with the South Dakota Department of Social Services acknowledged Wednesday that they need to prepare. “We anticipate needing a significant number of additional staff and technology resources for implementation,” Laurie Gill, the department secretary, said in a statement. She said the department created a leadership team to oversee necessary policy and system changes.

Missouri and most other states where voters approved Medicaid expansion faced politicians who tried to hamstring implementation.

But the pro-expansion group South Dakotans Decide Healthcare is confident that the change will be implemented as required by the constitutional amendment that voters approved Tuesday, campaign manager Zach Marcus said.

Marcus pointed to deadlines included in the amendment, and he noted that Gov. Kristi Noem — a Republican who opposed expansion — promised during a debate to implement the change if voters approved it.

South Dakota became the 39th state to approve Medicaid expansion, after 56% of voters supported the measure. The Department of Social Services expects about 52,000 newly eligible residents ages 18 through 64 will enroll in Medicaid.

Medicaid is the nation’s leading public health insurance program for people with disabilities and low incomes. It is funded and administered by the federal government and states.

The 2010 Affordable Care Act initially required states to expand their programs so more low-income adults could gain coverage, with the federal government paying 90% of the costs. But a U.S. Supreme Court ruling struck down that mandate.

Most states adopted Medicaid expansion through governors’ orders or legislature-approved bills. But voters in Maine, Idaho, Nebraska, Utah, Missouri, Oklahoma, and South Dakota overrode resistance from lawmakers and governors by approving expansion through ballot measures. Every time Medicaid expansion has been on the ballot, it has passed.

Expansion proponents in South Dakota sought a constitutional amendment, which can’t be easily repealed or revised. The amendment includes implementation deadlines and bars the state from creating extra rules, such as work requirements, for people who newly qualify for Medicaid.

In the past, South Dakota politicians have filed lawsuits that successfully argued that voter-approved measures violated the state constitution.

Last year, for example, Noem spearheaded a lawsuit that overturned a voter-approved amendment to legalize recreational marijuana. But she recently said the Medicaid expansion amendment “appears to be written constitutionally.”

States can face hurdles in rolling out Medicaid expansion even after implementation begins. Education, enrollment, and processing policies play a role.

For example, in 2021, Missouri hit roadblocks when lawmakers refused to fund the program, and the state implemented the change only after a judge ordered the state to begin accepting applications. Experts said Missouri officials put little effort into outreach and required people to navigate a bureaucratic application process. Data shows the state also failed to process applications on time.

Oklahoma, where voters approved expansion the same year, had the opposite experience. Lawmakers there agreed to fund the program, and the state spread the word about expansion through social media campaigns, TV interviews, and outreach events. The state also evaluated whether people who had applied to other benefit programs might be newly eligible for Medicaid.

By December 2021, Oklahoma had enrolled more than 210,000 people through Medicaid expansion, while Missouri had enrolled fewer than 20,000.

Shelly Ten Napel, CEO of Community HealthCare Association of the Dakotas, said officials can take steps to ensure a positive experience in South Dakota. Creating a “simple administrative process” means less work for applicants and state workers, said Ten Napel, who advocates for clinics that serve low-income and uninsured patients.

Brooks, the Georgetown expert on Medicaid administration, said South Dakota’s Medicaid practices aren’t as strong as other states’. “South Dakota is not advanced in their use of technology,” Brooks said. “I worry if it’s too manually driven that the state will be overwhelmed. And that will slow down the processing and you could potentially see what we’ve seen in Missouri.”

Brooks’ concerns are supported by studies and data.

South Dakota uses multiple applications and processing systems for Medicaid and other benefit programs when it could use just one, according to a March report by KFF and Georgetown’s Center for Children and Families.

The report also says South Dakota is one of three states without an online account system. That means South Dakotans can’t monitor their applications or upload documents to renew their coverage.

The Department of Social Services must submit its Medicaid expansion plan to the federal government by March 1 and begin providing benefits to newly eligible people by July 1.

Gill said the department is developing a system that is cellphone friendly and will allow people to create online accounts.

But she said those changes won’t be ready until fall 2023. That’s months after the department is expected to see a flood of new, post-expansion applications.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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