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Updated: 13 hours 35 min ago

As Puerto Rico Struggles To Rebuild Health System, Changes In Medicaid Loom

May 31, 2018

Kaiser Health News reporter Carmen Heredia Rodriguez joined Tanzina Vega, the host of WNYC’s “The Takeaway,” and Omaya Sosa Pascual, co-director of Puerto Rico’s Center for Investigative Journalism, to discuss changes in Puerto Rico’s Medicaid program and health care issues there.

Listen: Virginia Reverses Course On Medicaid Expansion

May 31, 2018

Virginia lawmakers Wednesday voted to expand the state’s Medicaid program, ending several years of bitter fights with Democratic governors and providing coverage for an estimated 400,000 people. Julie Rovner, Kaiser Health News’ chief Washington correspondent, discusses the development with WAMU anchor Matt McCleskey. She says that since the state has one of the least generous Medicaid programs in the country, adding coverage for such a large number of people is likely to strengthen the state’s health care system, especially hospitals.

Under Trump Proposal, Lawful Immigrants Might Be Inclined To Shun Health Benefits

May 11, 2018

The Trump administration is considering a policy change that might discourage immigrants who are seeking permanent residency from using government-supported health care, a scenario that is alarming some doctors, hospitals and patient advocates.

Under the proposed plan, a lawful immigrant holding a visa could be passed over for getting permanent residency — a green card — if they use Medicaid, a subsidized Obamacare plan, food stamps, tax credits or a list of other non-cash government benefits, according to a draft of the plan published by The Washington Post. Even the use of such benefits by a child who is a U.S. citizen could jeopardize a parent’s chances of attaining lawful residency, according to the document.

Health advocates say such a policy could frighten a far broader group of immigrants who will avoid government-supported health coverage, creating public health problems that could prove dire. About 3 million people received green cards from 2014 through 2016, government records show. Immigrants with visas or those who may have no legal status but plan to seek citizenship based on a close family relationship would be affected.

“We are very concerned that this rule, if finalized, would have a significant impact on health in this country,” said Erin O’Malley, senior director of policy for America’s Essential Hospitals, which discussed the plan with Trump administration officials in mid-April.

O’Malley said she fears that some visa holders and their families would steer clear of getting routine treatment and resort to going to emergency rooms for medical care. Such a change would “undermine the stability of our hospitals by creating uncompensated care costs and creating sicker patients,” O’Malley said.

Wendy Parmet (Courtesy of Northeastern University)

The policy change could force a mother to weigh the need for hospital inpatient care for an ailing newborn against losing her legal immigration status, said Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University.

“The administration, in the draft, talks about self-sufficiency,” she said. “But we don’t expect that of [babies]” who are U.S. citizens because they were born in this country. “It’s extremely hardhearted.”

Pushback has begun even though the proposal is in the earliest stages of the rulemaking process.

Washington state Gov. Jay Inslee, a Democrat, is sending staff in mid-May to meet with the White House Office of Management and Budget, which is vetting the proposed rule. Inslee sent a letter on April 24 urging OMB Director Mick Mulvaney to consider the impact on tax-paying, lawful immigrants.

Gov. Jay Inslee (D-Wash.) (Courtesy of the Washington Office of the Governor)

“This will undoubtedly lead to people across the U.S. going hungry, not accessing needed medical care, losing economic self-sufficiency, and even becoming homeless,” Inslee wrote.

The leaked draft said immigration officials would count the use of one or more non-cash benefits by the applicant within three years as a “heavily weighed negative factor” in deciding whether to grant permanent residency.

On March 29, the Department of Homeland Security sent a version of the proposal to OMB, which reviews it for conflicts with existing law. Next, it will be published as a proposed rule that the public can comment on before it’s finalized.

Marilu Cabrera, public affairs officer with the U.S. Citizenship and Immigration Services, declined to comment on whether the draft published by the Post mirrors what the OMB is reviewing.

Dr. Julie Linton (Courtesy of Wake Forest Baptist Medical Center)

Fear in immigrant communities already weighs on physicians. Dr. Julie Linton, a spokeswoman for the American Academy of Pediatrics, treats many Latino immigrant families at an outpatient clinic in Winston-Salem, N.C. She said one woman from Mexico, who had a newborn baby and three other children, told Linton she was afraid to keep her family enrolled in the nutrition program for Women, Infants, and Children (WIC). “Is it safe to use WIC?” the woman asked her.

Linton said questions like that put pediatricians in a tough position. She said evidence shows enrolling in WIC leads to better health outcomes for kids. But what if it also puts the family at risk of being split apart?

“It feels very frightening to have a family in front of me, and have a child with so much potential … and be uncertain how to advise them” on whether to accept public benefits, Linton said.

Maria Gomez, president of Mary’s Center, which runs health clinics in Washington, D.C., and Maryland, said she’s seeing three to four people a week who are not applying for WIC and are canceling their appointments to re-enroll in Medicaid.

Maria Gomez (Courtesy of Mary’s Center)

The leaked draft of the proposal zeroes in on who is considered a “public charge.” The concept emerged in immigration law in 1882, when Congress sought to bar immigrants who were “idiots, lunatics” or those likely to become a burden on the government.

The notion of a “public charge” last surfaced in 1999, when the immigration service clarified the concept. Then and now, an immigrant considered a “public charge” is inadmissible to the U.S. if the person is likely to rely on the government for income, or lives in a government-funded long-term institution.

Yet the guideline published in 1999 clarified that legal residents were free to access non-cash benefits like Medicaid, food stamps and assistance for heating bills. “These benefits are often provided to low-income working families to sustain and improve their ability to remain self-sufficient,” the guideline says.

The proposal, as drafted, would upend that.

Under such a policy, anyone who had recent or ongoing use of a non-cash government benefit in the previous 36 months would likely be deemed a “public charge,” and therefore inadmissible to the U.S. The use of such benefits by a spouse, dependent parent or child would also be taken into account.

Applicants who have “expensive health conditions” such as cancer, heart disease or “mental disorders” and had used a subsidized program would also get a “heavily weighed” negative mark on their application, the draft says.

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Marnobia Juarez, 48, battled cancer successfully and is hoping her husband’s green card application is approved; she also dreams of one day getting her own. She said she never wanted to apply for public benefits until she was diagnosed with breast cancer in 2014. Since then, she has been treated at no cost under a program run by the state of Maryland.

“I’m alive thanks to this program,” said Juarez, who is a health volunteer with an immigrant advocacy group. “You don’t play with life, and they are playing with life.”

The draft says immigrants could post a minimum $10,000 bond to help overcome a determination that they are likely to be a “public charge.”

Such changes would affect people sponsored by a U.S. citizen family member, most employment-based immigrants, diversity visa immigrants and “certain non-immigrants,” the draft says. In 2016, 1.2 million people got their lawful permanent residence status, or a green card. Of the total, 566,000 were immediate relatives or spouses of U.S. citizens and 238,000 more were family-sponsored, Department of Homeland Security data show.

Some immigrants, such as refugees and asylees, would not be affected. Nor would the proposed changes apply to undocumented immigrants.

“We’re talking about middle-class and working families,” said Madison Hardee, senior policy attorney with the Center for Law and Social Policy, which has organized a coalition to fight the proposal. “This could really put parents in an impossible situation between seeking health assistance for their children and obtaining a permanent legal status in the U.S.”

The list of benefits includes the Children’s Health Insurance Program, known as CHIP; non-emergency Medicaid; the Supplemental Nutrition Assistance Program, or food stamps; WIC; and short-term institutionalization at government expense and others. The leaked draft notes that foreign-born and native-born Americans use such programs at similar rates.

The draft says the proposal is meant to ensure that people seeking to “change their nonimmigrant status are self-sufficient.” It notes “relevant congressional policy statements,” including one that says “the availability of public benefits [should] not constitute an incentive for immigration to the United States.”

KHN correspondent Emmarie Huetteman contributed to this report.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Hoping To See Your Doctor Via Telemedicine? Here’s A Quick Guide.

May 09, 2018

Tucked into the federal budget law Congress passed in February was a provision that significantly expands the use of telemedicine — long a hyped health care reform, and now poised to go mainstream within five to 10 years.

“There’s much broader recognition of the benefits,” said Mei Wa Kwong, executive director of the Center for Connected Health Policy, a research group that promotes telemedicine in Sacramento, Calif. “The law is the latest to make telemedicine more accessible. But we still have a ways to go before most consumers are aware of the option.”

The new law allows Medicare to cover telemedicine services for people who have had a stroke and those who get kidney dialysis, either at home or at a dialysis facility. It also permits Medicare Advantage Plans — private plans that enroll a third of Medicare beneficiaries — to offer telemedicine as a covered benefit.

Separately, as of Jan. 1, Medicare began allowing doctors to bill the government for monitoring certain patients remotely using telemedicine tools — for example, tracking heartbeat and rhythm, blood pressure and blood glucose levels.

Telemedicine, also referred to as telehealth, uses computers — and their display monitors, software and capacity for data analysis — to deliver virtual health services.

In the easiest-to-understand example, a patient is in one location and has an e-visit with the doctor in another location. They are connected via a secure video link. Proponents say that more sophisticated monitoring is on the horizon and that virtual encounters will become more commonplace.

As acceptance and adoption of telemedicine expands, so does coverage. All private health plans, Medicare, state Medicaid programs and the Department of Veterans Affairs now cover some e-visits — albeit with restrictions. More health centers and hospitals are launching virtual health centers. And websites offering virtual “doctor-on-demand” services are proliferating.

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Concerns exist, however. Doctors worry that they may get paid less if insurance reimbursement is lower for e-visits than in-person appointments, or that e-visits could undermine the doctor-patient relationship by reducing valuable face time. They point out that for some ailments, like strep throat, it’s best if doctors or other health providers see the patient.

Health economists, meanwhile, are concerned that e-visits could add to costs rather than constrain them — if, for example, doctors and patients abuse e-visits by scheduling them unnecessarily because they are quick and easy. Also, insurers may be motivated to push doctors to do more e-visits instead of in-person visits to save money. And for some people, access to proper equipment or internet access can be difficult.

“The potential for abuse is there,” says Dr. Robert Berenson, a Medicare expert at the Urban Institute. “We will need to prevent gaming and misuse of the system. But, generally, helping people avoid unnecessary doctor’s office and hospital visits is a good thing, if we do it right.”

Here’s a briefing on telemedicine basics:

Q: Are e-visits available from most hospitals and doctors?

Not yet. But access is increasing. Ask your doctor, clinic or hospital.

In some cities, medical centers are setting up telehealth “hubs” to handle patients. For example, Penn Medicine in Philadelphia launched its Connected Care center in February with 50 full-time employees, 24/7 access to care and a program to treat chronically ill patients at home. Some of the center’s e-visit services are open only to Penn Medicine employees, but other services are available to anyone, with a focus on residents of Pennsylvania, New Jersey, Delaware and Maryland, said Bill Hanson, vice president and chief medical information officer at Penn Medicine.

Similarly, Mercy Virtual in Chesterfield, Mo., a St. Louis suburb, serves patients throughout the Midwest, and those treated at Mercy Health’s network of 44 hospitals in five states. Launched in 2015, Mercy Virtual provided care to 750,000 people in 2017 with a team of 700 doctors, nurses and support staff.

Other medical centers with virtual health programs include Avera Health based in South Dakota; Cleveland Clinic in Ohio; Dignity Health in San Francisco; Intermountain Healthcare in Utah; and Kaiser Permanente, a managed-care health system in California and elsewhere.

Kaiser Permanente reported last year that 21 percent of its 110 million patient interactions in 2015 were e-visits. Officials there predict that by 2020 e-visits will exceed in-person visits. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

Q: What restrictions do health plans, Medicare and Medicaid put on e-visits?

Health plan coverage varies, but most private insurers cover e-visits, and 34 states and the District of Columbia require that they do. A few states still require that a patient relationship be established with an in-person visit before the provider can bill for an e-visit. Check with your insurer about its policies.

Medicare’s coverage of e-visits is more restrictive. First, e-visits must take the place of an in-person visit. Second, with exceptions allowed under February’s budget law, Medicare largely restricts e-visits to those that occur in rural areas that have a shortage of doctors and/or hospitals. And third, most e-visits can’t occur when the patient is at home. They can be done from a variety of other locations, such as a rural health clinic, a dialysis center or skilled nursing facility. A bill in Congress would loosen that restriction.

In contrast, almost all state Medicaid programs cover e-visits in the home. But restrictions still apply. For example, only 22 states cover remote patient monitoring for Medicaid enrollees.

The Telehealth Resource Centers, a federally funded organization promoting telemedicine and providing consumer information, has detailed explanations of e-visit restrictions and limitations.

Q: Do I need special computer equipment?

No. E-visits and other forms of telemedicine are done over commonly available computers, laptops, tablets and smartphones — and are typically encrypted to protect privacy. Specialized equipment is usually needed for remote monitoring, such as blood pressure or heart rate. One vexing barrier: broadband availability in rural areas. Also, millions of low-income and older Americans still lack Wi-Fi in their homes.

Q: What services can I get through telemedicine?

Most e-visits are for primary care or follow-up services, such as assessing symptoms or checking on people who have had a medical procedure. But a growing number — no one keeps national statistics — cater to people with chronic conditions who are being monitored at home, said Kwong.

Dermatology e-visits are becoming especially common. You can send a close-up photo of a skin rash, mole or other problem for an immediate assessment. Psychotherapy by e-visit is also expanding.

Sometimes an e-visit may provide an initial medical assessment for an injury, wound or illness that is clearly not life-threatening. Some cities are testing ambulance services that use telemedicine to triage whether people need a trip to the hospital.

Q: Will I save money if I do an e-visit instead of going into the doctor’s office?

E-visits are generally less expensive than a trip to the doctor, but you may not see the difference if your insurance covers both with only a small copay or no copay. If you have a large deductible, however, an e-visit may mean you pay less out-of-pocket for that encounter.

Some states require insurers to make equal reimbursements for in-office and telemedicine consultations on simple matters.

Q: Are there downsides or risks with telemedicine and e-visits?

There’s no evidence so far that your risk of being diagnosed wrongly or treated inappropriately is any greater with an e-visit compared to an in-person visit.