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Obamacare Shopping Is Trickier Than Ever. Here’s A Cheat Sheet.

Kaiser Health News:HealthReform - November 10, 2017

Health care is complicated. Shopping for an individual health plan just got even more so, with President Donald Trump’s decision last month to block $7 billion in Affordable Care Act subsidies.

Known as cost-sharing reduction payments (CSRs), these federal funds had helped insurers offset the costs of the discounts they are required to offer to some lower-earning customers to help them pay for deductibles and copays.

We’ll spare you the details. But because of how state regulators responded to the chaos and how insurers are trying to recover the money through higher premiums, common-sense rules of shopping may no longer apply.

This KHN story also ran on NBC. It can be republished for free (details).

A high-coverage “gold” plan in many states might now be cheaper than a medium-coverage “silver” plan. The reported 15 or 20 percent premium spikes resulting from Trump’s move might nail you right in the wallet. Or, weirdly, it could save you hundreds of dollars next year if you play your cards right.

Experts’ advice, in brief, is: SHOP AROUND. Play with different options on or state marketplaces. Don’t just renew this year’s plan. More than ever, for 2018 that might not be the best deal.

Find your situation here:

Household income is between $12,060 and $30,150 for an individual, $16,240 and $40,600 for a couple and $24,600 and $61,500 for a family of four.

By law, insurers still must pass along the cost-sharing reductions, even though Trump cut off the reimbursement. And you are probably eligible for them.

But to qualify for the cost-sharing reductions, which lower deductibles and copays when you seek care, you must purchase a silver plan on the marketplace. People buying the other metal levels — the more comprehensive gold or platinum plans or less generous “bronze” plan — cannot get this benefit. So unless you hardly ever see a doctor, get a silver plan.

However, if you’re healthy and at the lower end of these income ranges, a bronze plan might make the most sense.

That’s because of the other Obamacare subsidy, which reduces premiums.

These subsidies are paid directly to qualifying consumers in the form of tax credits. The premium subsidy is so generous for 2018 (we explain why, below) that, for many people, they could cover the entire cost of bronze plans.

Cost-sharing reductions help only if you expect to pay out-of-pocket costs for docs and hospitals. If you don’t — and if you feel like gambling that you won’t need expensive care — a free or super-cheap bronze plan might be better.

At the lower ranges of this income group, you might be eligible instead for Medicaid — in states that expanded that program under the ACA. This online subsidy calculator can help you figure it out.

Household income is between $30,150 and $48,240 for individuals, $40,600 and $64,960 for a couple and $61,500 and $98,400 for a family of four.

You’re eligible for subsidies to reduce premiums but not the cost-sharing reductions. Even so, Trump’s decision to cut them may affect you — in a good way.

To recover the missing $7 billion, most insurers are jacking premiums for silver plans — an estimated 20 percent extra.

The good news is that higher premiums don’t hurt most marketplace consumers. Obamacare caps how much eligible consumers are expected to pay for health insurance — even if premiums go to the moon. The federal premium subsidies cover the difference.

But that’s not all. Trump’s move makes the premium subsidy more generous. Here’s how.

The level of premium subsidy you receive is based not just on your income but also on silver-plan prices, and now silver premiums are going up a lot. The higher the silver premiums, the more generous the subsidies. But that subsidy is not limited to use on a silver plan.

Anybody eligible can take those subsidies and shop for any kind of plan on the marketplace. That’s why in Texas, Pennsylvania, Michigan and other states a high-benefit gold plan might be less expensive next year or not much more than a silver plan. It’s why many consumers could see their premium bills fall in 2018 — in some cases, to zero.

To repeat: Shop around. Shop early. The plan you have now probably won’t be cheapest next year.

Household income is more than $48,240 for individuals, $64,960 for a couple and $98,400 for a family of four.

More than 7 million of these folks buy individual health insurance plans through or outside the ACA’s online marketplaces.

If this is you, you’re ineligible for any Obamacare subsidies. That means your chances of getting slammed by premium increases for 2018 are high. Silver-plan premiums are soaring by 35 percent or more because of high claims and Trump’s decision to stop cost-sharing reimbursement to insurers.

But there are ways to limit the pain. Generally avoid silver plans and look at bronze and gold. Those premiums are probably rising less.

However, California and about a dozen other states allowed insurers to sell a separate class of silver plans without the cost-sharing money built into premiums. These may be available only outside the official, online ACA marketplaces, so to find them you have to ask a broker or check websites of insurers or online brokers such as eHealth or GetInsured.

Household income is less than $16,643 for an individual, $22,411 for a couple and $33,948 for a family of four.

You may qualify for Medicaid, the federal and state health program for low-income people. However, 19 states, mostly in the South, did not expand the program under the health law.

Medicaid eligibility in those places is much narrower, especially for adults, than in the rest of the country. That accounts for many of the 28 million uninsured Americans.

The subsidy calculator shows whether your income makes you eligible for Medicaid and whether your state has expanded Medicaid.

Maine Voters Greenlight Medicaid Expansion, But Governor Says Whoa

Kaiser Health News:HealthReform - November 09, 2017

Just hours after Maine voters became the first in the nation to use the ballot box to expand Medicaid under the Affordable Care Act, Republican Gov. Paul LePage said he wouldn’t implement it unless the Legislature funds the state’s share of an expansion.

“Give me the money and I will enforce the referendum,” LePage said. Unless the Legislature fully funds the expansion — without raising taxes or using the state’s rainy day fund — he said he wouldn’t implement it.

LePage has long been a staunch opponent of Medicaid expansion. The Maine Legislature has passed bills to expand the insurance program five times since 2013, but the governor vetoed each one.

That track record prompted Robyn Merrill, co-chair of the coalition Mainers for Health Care, to take the matter directly to voters Tuesday.

The strategy worked. Medicaid expansion, or Question 2, passed handily, with 59 percent of voters in favor and 41 percent against.

This story is part of a partnership that includes Maine Public, NPR and Kaiser Health News. It can be republished for free. (details)

“Maine is sending a strong and weighty message to politicians in Augusta, and across the country,” Merrill said. “We need more affordable health care, not less.”

Medicaid expansion would bring health coverage to about 70,000 people in Maine.

As a battle now brews over implementation in Maine, other states will likely be watching: groups in Idaho and Utah are trying to put Medicaid expansion on their state ballots next year.

With passage of the ballot measure, Maine is poised to join the 31 states and the District of Columbia that have already expanded Medicaid to cover adults with incomes up to 138 percent of the federal poverty level. That’s about $16,000 dollars for an individual, and about $34,000 for a family of four.

Currently, people in Maine who make too much for traditional Medicaid and who aren’t eligible for subsidized health insurance on the federal marketplace fall into a coverage gap. It was created when the Supreme Court made Medicaid expansion under the Affordable Care Act optional.

That’s the situation Kathleen Phelps finds herself in. She’s a hairdresser from Waterville who has emphysema and chronic obstructive pulmonary disease. She said she has had to forgo her medications and oxygen because she can’t afford them. “Finally, finally, maybe people now people like myself can get the health care we need,” she said.

Medicaid expansion would also be a win for hospitals. More than half of those in Maine are operating in the red. Across the state, hospitals provide more than $100 million a year in charity care, according to the Maine Hospital Association. Expanding Medicaid coverage will bolster their fiscal health and give doctors and nurses more options to treat their formerly uninsured patients, said Jeff Austin, a spokesman with the association.

“There are just avenues of care that open up when you see a patient from recommending a prescription drug or seeing a counselor,” he said. “Doors that were closed previously will now be open.”

But voter approval may not be enough. Though a legislative budget analysis office estimates Medicaid expansion would bring about $500 million in federal funding to Maine each year, it would also cost the state about $50 million a year.

The fate of the Medicaid expansion will now be in the hands of the Legislature, where lawmakers can change it like any other bill. Four ballot initiatives passed by Maine voters last year have been delayed, altered or overturned.

But state Democratic leaders pledge to implement the measure. “Any attempts to illegally delay or subvert the law … will be fought with every recourse at our disposal,” Speaker of the House Sara Gideon said. “Mainers demanded affordable access to health care yesterday, and that is exactly what we intend to deliver.”

This story is part of a partnership that includes Maine PublicNPR and Kaiser Health News.

Grass-Roots Network Of Doctors Delivers Supplies To Puerto Rico

Kaiser Health News:Marketplace - November 09, 2017

After Hurricane Harvey flooded her city of Houston in August, Dr. Jennifer McQuade planned to donate socks to those affected. Instead, surprised by the lack of medical care at a nearby shelter, McQuade, an oncologist, became the unofficial leader of a group of physicians and mothers providing emergency aid at the George R. Brown Convention Center in Houston. She triaged patients, solicited donations and recruited more doctors to join.

Their efforts were so successful that McQuade and the other volunteers still had 2,500 pounds of medical supplies when federal authorities took over the Houston shelter after about a week. So, when Hurricane Maria devastated Puerto Rico on Sept. 20, leaving hospitals without power and short of supplies and drugs, the challenge was finding a plane to deliver the precious cargo to the island.

“Asking for planes, it’s a crazy ask,” said Dr. Ashley Saucier, a pediatric emergency physician in Baton Rouge, La., who was working with McQuade on the effort in Houston. But that didn’t stop her.

This KHN story also ran on It can be republished for free (details).

Across the United States mainland, an agile, jury-rigged network of doctors has scrambled to deliver aid to their counterparts in Puerto Rico, often reaching clinics before federal assistance arrived. They draw on a sense of solidarity in the medical community, connections formed through the hurricanes in Houston and Florida — and the use of private jets belonging to corporations, sports teams and individual donors.

By mid-October, doctors in the states estimate, they delivered 40 tons of supplies.

Saucier, working through a Facebook introduction, got in touch with the Cajun Airlift, a loosely organized group of Louisiana pilots who had volunteered their planes for Texas flood victims. They moved some of the supplies.

Rick Shadyac, the CEO of St. Jude’s Hospital in Memphis, Tenn., put Saucier in touch with FedEx, which is also headquartered in Memphis, to pick up more surplus supplies from McQuade in Houston and then fly them to Puerto Rico.

And through another doctor, McQuade was introduced to Hilda and Greg Curran, a couple who have family in Puerto Rico and a jet they planned to use.

Five days after Maria made landfall, the Currans delivered 1,000 pounds of medical supplies — additional donations supplied by the Texas Children’s Hospital or purchased through funds raised by Saucier — to the University of Puerto Rico Comprehensive Cancer Center in San Juan.

Hospitals on Puerto Rico remain without electricity, forced to rely on generators. Clinics were left in shambles in many parts of the island, desperate for supplies and drugs, including tetanus and influenza vaccines, antibiotics, insulin and anti-inflammatory drugs.

Many of the physicians organizing the donation drive have family in Puerto Rico, while others — including Saucier and McQuade — had no previous connections to the U.S. territory.

Saucier’s experience with front-line disaster relief dates to August 2016, when southern Louisiana was hit with deadly floods. Shortly after, she formed a small nonprofit called Baton Rouge Emergency Aid Coalition, which raised funds and organized physicians who were ready to spring into action. When Puerto Rico was devastated by Hurricane Maria, that small network joined something much bigger, which grew organically and by word-of-mouth as the scope of the medical disaster on the island unfolded.

The grass-roots network tends to skew younger and female. “It’s 90 to 95 percent women I’m working with, both here and in Puerto Rico,” said Rafael Enrique Guerrero-Preston, a cancer researcher and geneticist in Baltimore, who was born in Puerto Rico. He “met” McQuade and Saucier online on the recommendation of another physician.

“We don’t know each other personally,” he said.

Dr. Dalian Caraballo, a family physician in Miami, was organizing a separate donation campaign and Facebook page for Puerto Rican doctors when one contact introduced her to the volunteers in Texas and Louisiana. Because she lives in a city that is a convenient pit stop for pilots to fuel up, Caraballo has taken charge of collecting supplies and loading them onto jets before they travel to Puerto Rico.

The planes typically fit 1,000 pounds at most, so only supplies that a doctor in Puerto Rico specifically requests will go onboard. Every box is weighed, labeled and accompanied by a “manifesto,” or instructions of who it goes to next. “Even if [the shipment] is small, you know it’s getting to the right doctors,” Caraballo said.

Doctors help for personal reasons and in ways that tie in to their specialties. Dr. Amarilis Sanchez-Valle, a physician in Tampa, studies metabolic genetic conditions that require a specialized formula for infants to avoid brain damage and other health effects.

Initially, her concern was for her family. “I have a sister in Puerto Rico with multiple sclerosis [who] has only two doses left of her medicine,” she wrote in emails to the American Red Cross and the National MS Society on Sept. 25, five days after Maria made landfall. “Is there a way to get medicine to Puerto Rico in the next few days?”

Representatives from both groups apologized, saying they couldn’t help because all the official channels for delivery had been disrupted.

Sanchez-Valle contacted neurologists in Tampa to get a few samples of the medicine. “The problem was, how to get it there? The airport was closed. FedEx was closed.”

A friend put her in touch with a person who works for American Airlines. The airline employee agreed to put the medication in the cargo hold of a relief flight. Sanchez-Valle said her sister is “lucky she’s got me. But what about all the other patients out there? What about my [infant] patient population?” she asked.

Sanchez-Valle contacted former colleagues in Puerto Rico and the formula suppliers she works with. Several companies agreed to donate a few hundred pounds of formula.

The formula reached the island thanks to Dr. Elimarys Perez-Colon and her colleague Dr. Asa Oxner, two internal medicine specialists in Tampa. The women took a commercial flight to San Juan in the beginning of October, each carrying five suitcases with 800 pounds of supplies, everything from syringes to water filters to donations they received from manufacturers and doctors like Sanchez-Valle. When they arrived in San Juan, the airport appeared to be almost fully functional. And the capital and other coastal towns seemed to be receiving adequate help from the Federal Emergency Management Agency and the military, the women say.

Dr. Asa Oxner, an internal medicine physician in Tampa, Fla., uses a headlamp to count pills while working in an area of Puerto Rico without power. (Courtesy of Dr. Asa Oxner)

But as they traveled to inland towns like Villalba, where they delivered supplies, they found incredible needs.

The hospitals and clinics they reached were running on diesel generators. Asthma medication was in short supply, Perez-Colon noted. People in small towns were drinking untreated water, a major risk for infection. “Clean water is one of the biggest issues,” she said.

For some residents who already had health problems, their conditions worsened in the heat, with no power and limited access to water. Some reported being visited by FEMA once; others, not at all.

“The help is not getting to the small towns. It’s not getting to the middle of the island,” Perez-Colon said.

HHS Names Patient Matching Algorithm Challenge Winners

HHS Gov News - November 08, 2017

The U.S. Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) today announced the winners of the Patient Matching Algorithm Challenge.

ONC selected the winning submissions from over 140 competing teams and almost 7,000 submissions using an ONC-provided dataset.  “Patient matching” in health IT describes the techniques used to identify and match the data about patients held by one healthcare provider with the data about the same patients held either within the same system or by another system (or many other systems). The inability to successfully match patients to any and all of their data records can impeded interoperability resulting in patient safety risks and decreased provider efficiency.

“Many experts across the healthcare system have long identified the ability to match patients efficiently, accurately, and to scale as a critical interoperability need for the nation’s growing health IT infrastructure.  This challenge was an important step towards better understanding the current landscape,” said Don Rucker, M.D., national coordinator for health information technology.  

Winners include:

Best “F-score” (a measure of accuracy that factors in both precision and recall):

  • First Place ($25,000): Vynca
  • Second Place ($20,000): PICSURE
  • Third Place ($15,000): Information Softworks

Best First Run ($5,000): Information Softworks

Best Recall ($5,000): PICSURE

Best Precision ($5,000): PICSURE

Each winner employed widely different methods. PICSURE used an algorithm based on the Fellegi-Sunter (1969) method for probabilistic record matching and performed a significant amount of manual review. Vynca used a stacked model that combined the predictions of eight different models. They reported that they manually reviewed less than .01 percent of the records. Although Information Softworks also used a Fellegi-Sunter-based enterprise master patient index (EMPI) system with some additional tuning, they also reported extremely limited manual review.

The dataset and scoring platform used in the challenge will remain available for students, researchers, or anyone else interested in additional analysis and algorithm development, and can be accessed via the Patient Matching Algorithm Challenge website.

Election Night Surprise: Health Care Galvanizes Voters

Kaiser Health News:HealthReform - November 08, 2017

Health care appears to have played an unexpectedly robust role in Tuesday’s off-year elections, as Democrats swept statewide races in Virginia and New Jersey and voters told pollsters it was a top concern.

The health headline of the night came in Maine, where voters by a large margin rebuked Republican Gov. Paul LePage and approved a referendum  expanding Medicaid under the Affordable Care Act. Maine is one of 19 states that has not expanded the program to people with incomes up to 138 percent of the federal poverty line, or about $16,600 for an individual. An estimated 70,000 to 90,000 Mainers could gain insurance under the expansion.

The Legislature has passed similar bills five times, but LePage vetoed each one. And despite Tuesday’s outcome, he held firm in his opposition. The governor announced Wednesday that he would not implement the expansion, which he said would be “ruinous” for the state’s budget, unless it is fully funded by the Legislature.

Use Our ContentThis KHN story can be republished for free (details).

Medicaid expansion might also be back in play in Virginia. Voters there not only elevated Democratic Lt. Gov. Ralph Northam to the governorship, they may have steered Democrats to a takeover of the state House of Delegates, which has been the primary source of opposition to Gov. Terry McAuliffe’s efforts to expand Medicaid. As of Wednesday morning, Democrats had picked up 15 of the 17 seats they would need to take over the majority with several races too close to call or requiring a recount.

And while it was not a headline issue in the governor’s race, health care proved decisive to Virginia voters, according to exit polls funded by a pool of media organizations.

Health care was by far the top issue for voters, according to the poll, which asked voters which of five issues mattered most to them. Nearly 4 in 10 said health care was the issue most important to their vote, followed by gun policy at 17 percent, taxes at 15 percent, immigration at 12 percent and abortion at 8 percent. Among those voters who cited health care, 77 percent voted for Democrat Northam, making it his strongest issue by a wide margin.

Pollsters were quick to add, however, that at least some of health care’s prominence in the poll was due to the fact that voters were not given the chance to choose issues that are typically more popular, such as the economy or education.

The fallout will depend on who holds which views, said Rodney Whitlock, a former GOP Senate staffer. If health care is a top concern for Democrats, “that doesn’t have a lot of meaning for Republicans,” he said. But if independents are the ones who see health as a salient voting issue, “that means much more.”

But Robert Blendon, a professor of health policy and political analysis at Harvard University, said the election results suggest that health care has again become a positive for Democrats. “You don’t have to say you love the ACA, but that you don’t want to drop millions of people” from coverage, he explained.

In New Jersey, voters said they were more concerned with state issues, with property taxes and corruption topping the list of topics they told exit pollsters drove their votes. But health care was third.

Still, the election results likely hinged on a host of concerns, warned Drew Altman, president and CEO of the Kaiser Family Foundation. Health issues are still strongly viewed through partisan lenses, he said, and the voting probably was more of a referendum on President Donald Trump than on health care. But the results in the Maine referendum could have repercussions beyond that state, showing that Medicaid expansion is “far more popular” than Republicans have acknowledged. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

In Ohio, voters defeated what some called a confusing ballot measure aimed at limiting prescription drug prices to no more than the amount paid by the Department of Veterans Affairs. A similar measure was voted down in California last year.

Update: This story was updated on Nov. 8 to add more detail about the exit polling.

Estados podrían imponer el requisito de estar trabajando para tener Medicaid

Kaiser Health News:HealthReform - November 07, 2017

La administración Trump señaló el martes 7 de noviembre que permitiría a los estados imponer requisitos de trabajo a algunos adultos inscriptos en el Medicaid, una meta que los conservadores desearon por largo tiempo, y a la que se oponen demócratas y defensores de los más pobres.

Esta decisión marcaría un giro importante en la política federal. La administración del presidente Barack Obama dictaminó en repetidas ocasiones que los requisitos de trabajo eran inconsistentes con la misión del Medicaid de proporcionar asistencia médica a personas de bajos ingresos.

El anunció lo realizó Seema Verma, directora de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), quien se dirigió a través de un video a los directores estatales del Medicaid durante una reunión. En un comunicado de prensa lanzado antes del discurso, se explicó que esta decisión es parte de un plan para que los estados tengan más flexibilidad para modificar sus programas locales del Medicaid.

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La idea de que un programa diseñado para nuestros ciudadanos más vulnerables deba usarse como un vehículo para servir a los adultos sanos en edad de trabajar no tiene sentido, pero la administración anterior luchó contra las reformas impulsadas por los estados que habrían permitido que el Medicaid evolucionara”, dijo Verma en una copia de sus comentarios publicados momentos antes de que hablara.

“Para las personas que viven con discapacidades, los CMS siempre han creído que un trabajo acorde es esencial para su autosuficiencia económica, la autoestima, el bienestar y la mejora de su salud”, dijo. “¿Por qué no creer lo mismo para los beneficiarios del Medicaid en edad de trabajar y sanos?”

Ocho estados -Arizona, Arkansas, Indiana, Kentucky, New Hampshire, Maine, Utah y Wisconsin- han enviado solicitudes a los CMS para que se les permita exigir a las personas bajo Medicaid que trabajen o presten servicios a la comunidad.

El comunicado no indicó cuándo Verma se pronunciaría sobre las solicitudes pendientes, pero un funcionario de los CMS dijo que probablemente sería antes de fin de año.

Sin embargo, estudios demuestran que la gran mayoría de las personas que reciben Medicaid ya están trabajando, buscando empleo, yendo a la escuela o cuidando a un familiar.

Alrededor del 59% de los adultos sin discapacidades en el Medicaid, que son menores de 65 años, tienen trabajo, según un análisis de la Kaiser Family Foundation. (Kaiser Health News es un programa editorialmente independiente de la fundación).

Verma enfatizó el compromiso de la agencia de considerar propuestas que darían a los estados más flexibilidad para poner a prueba los esfuerzos para sacar a los beneficiarios de la pobreza.

“Todos los estadounidenses merecen la dignidad y el respeto de tener altas expectativas, y como funcionarios públicos debemos ofrecer programas que despierten la esperanza y le digan a cada beneficiario que creemos en su potencial”, dijo Verma.

Los estados y el gobierno federal se dividen los costos del programa Medicaid, que suman $575 mil millones, para cubrir a 74 millones de personas. Los estados pueden establecer beneficios y reglas de elegibilidad dentro de amplias pautas federales.

Desde la década de 1990, el gobierno federal ha permitido cada vez más a los estados que renuncien temporalmente a las reglas que rigen el Medicaid para que puedan experimentar cómo administran el programa. Los estados han usado esas opciones para esfuerzos tales como agregar primas mensuales o personalizar su expansión del Medicaid según la Ley de Cuidado de Salud Asequible (ACA) de 2010.

Dos requisitos a largo plazo de estas exenciones son que no aumenten los costos federales y que se mejore la cobertura de salud de los más pobres.

Los CMS dijeron el martes que ampliar el acceso ya no es un objetivo clave de las exenciones federales del Medicaid. Esta declaración representa un cambio filosófico en el programa que abriría la puerta para aprobar requisitos de trabajo que, reconocen los mismos estados, reduciría el número de personas inscriptas.

“Esto me indica que la agencia se está preparando para negar un objetivo central de la ley federal y, en cambio, tratar de lograr exactamente lo que la ley no permite, es decir, una reducción en el nivel de asistencia disponible para los estadounidenses más pobres y médicamente más vulnerables”, opinó Sara Rosenbaum, profesora de derecho y políticas de salud en la Universidad George Washington, en Washington, DC

Ya se esperaba este anuncio de Verma. Antes de ser nombrada como titular de los CMS, fue consultora de atención médica y ayudó a los programas del Medicaid de Indiana y Kentucky a redactar sus solicitudes de exención, incluidos los requisitos de trabajo. Para evitar un conflicto, los CMS aclararon que Verma no participará en las decisiones sobre esos dos estados.

La decisión de apoyar los requisitos laborales probablemente terminará en una batalla judicial, dijo Jane Perkins, directora legal del Programa Nacional de Ley de Salud, un grupo de defensa. Perkins dijo que los CMS tienen poder para permitir que los estados experimenten con el programa del Medicaid, pero no restringiendo la elegibilidad.

“Esto es realmente un cambio, con los CMS diciéndoles a los estados: ‘vengan a decirnos lo que quieren hacer y si quieren recortar el programa, les daremos el visto bueno'”, dijo Perkins. “Eso es inconsistente con la intención del Congreso sobre las exenciones del Medicaid”.

El video de Verma dirigido a la Asociación Nacional de Directores del Medicaid marca una de sus pocas apariciones públicas desde que asumió el cargo. A pesar de supervisar tanto al Medicaid como al Medicare, programas que impactan a más de 120 millones de estadounidenses, ha concedido pocas entrevistas o discursos públicos.

Los gobernadores republicanos defienden los requisitos de trabajo, diciendo que tal mandato proporcionará “dignidad” a los afiliados y los estimulará a no contar con el programa de derechos del gobierno.

“Este programa ofrece oportunidades para que las personas tomen el control de sus vidas”, dijo el gobernador de Kentucky el republicano Matt Bevin, al revisar su propuesta de requisitos de trabajo en julio.

Quienes se oponen a los requisitos de trabajo afirman que muchos inscriptos en el Medicaid ya trabajan y que un mandato es contraproducente. Negar a las personas el acceso a la atención médica podría evitar que se mantengan saludables y que puedan conseguir empleo, argumentan.

El discurso de Verma ocurrió después que los CMS anunciaran el lunes que agilizarían el proceso, a menudo arduo, para obtener exenciones al Medicaid. Ofreció acelerar algunas solicitudes y dijo que permitiría a los estados obtener exenciones de hasta 10 años, cinco años más de lo que actualmente se permite.

Verma también dijo que el gobierno federal dará a conocer información que muestran los resultados del Medicaid, pero no dio detalles sobre qué medidas se evaluarían.

La mayoría de los inscritos en el Medicaid se encuentran en planes privados de atención administrada, que son evaluados cada año por los estados, analizando todo: desde las tasas de vacunación para niños hasta las tasas de detección del cáncer para adultos.

Más de 16 millones de personas se han sumado al Medicaid desde 2013, principalmente porque 31 estados ampliaron la elegibilidad para el programa, siguiendo la línea del Obamacare.

Medicaid Chief Says Feds Are Willing To Approve Work Requirements

Kaiser Health News:HealthReform - November 07, 2017


The Trump administration signaled Tuesday that it would allow states to impose work requirements on some adult Medicaid enrollees, a long-sought goal for conservatives that is strongly opposed by Democrats and advocates for the poor.

“Let me be clear to everyone in this room: We will approve proposals that promote” employment or volunteer work, Seema Verma, the head of the Centers of Medicare & Medicaid Services (CMS) said in a speech to the nation’s state Medicaid directors.

Such a decision would be a major departure from federal policy, and critics said it would lead to a court fight. President Barack Obama’s administration ruled repeatedly that work requirements were inconsistent with Medicaid’s mission of providing medical assistance to low-income people.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve the working-age, able-bodied adults does not make sense, but the prior administration fought state-led reforms that would’ve allowed the Medicaid program to evolve,” Verma said.

Use Our ContentThis KHN story can be republished for free (details).

“For people living with disabilities, CMS has long believed that meaningful work is essential to their economic self-sufficiency, self-esteem, well-being and improving their health,” she added. “Why would we not believe that the same is true for working-age, able-bodied Medicaid enrollees?”

Verma also blasted the Affordable Care Act, saying the health law’s efforts to give coverage to so-called able-bodied adults was a mistake because it resulted in “stretching the safety net for some of our most fragile populations,” such as children, pregnant women and people with disabilities. It also has added to the problems for Medicaid enrollees getting access to care, she said.

The speech got a cool reception from the state directors. None of her comments brought immediate clapping from the nearly 1,000-person audience, but there was polite applause at the end.

Eight states — Arizona, Arkansas, Indiana, Kentucky, Maine, New Hampshire, Utah and Wisconsin — have submitted requests to CMS seeking to require nondisabled Medicaid enrollees to either work or provide community service.

The proposed work requirement rules vary by state. Arizona calls for enrollees to be working, seeking work or attending school or job training for at least 20 hours a week.

New Hampshire would require enrollees to work, engage in job training or acquire education for more hours the longer they are in Medicaid. For example, they would put in 20 hours a week the first year they were enrolled, 25 hours the second year and at least 30 hours in their third year.

Verma did not say when she would rule on the pending applications, but one CMS official said it would likely be before the end of the year.

The Medicaid chief said she wants to give states more flexibility as CMS officials “reset the federal-state relationship, and restore the partnership,” so that Medicaid “is sound and solvent and helps all beneficiaries reach their highest potential.”

Kentucky expects to get a green light from CMS and plans to implement the mandate by July, said Stephen Miller, the state’s Medicaid director. “We were in sync with what she had to say” about work requirements, he said.

He said that even though the state’s Medicaid rolls have soared to cover 33 percent of residents, Kentucky still has high rates of cancer, smoking and obesity. “We have to try something else,” he said. “We need to do more than just help people access health care.” The move would also help the state save money, he added.

Allison Taylor, Indiana’s Medicaid director, said a work requirement would help the state find the nearly 1 million workers it is estimated to need by 2025.

Studies show the vast majority of Medicaid enrollees are already working, looking for work, going to school or caring for a relative.

About 59 percent of nondisabled adults on Medicaid who are under 65 do have jobs, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Verma said the Obama administration was wrong when it denied states’ requests to implement work requirements, also known as community engagement mandates. “Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” she said. “Those days are over.”

New York Medicaid Director Jason Helgerson said the speech created an “us vs. them” scenario. “To suggest that the work we do is some form of bigotry is disgusting,” he said.

While he welcomed more flexibility from CMS toward states, Helgerson said the ACA has been a boon to New York and there is no evidence of people having longer waits for care since the expansion.

Verma decried the Obama administration’s emphasis on Medicaid enrollment. “While many responded to this expansion with celebration, we shouldn’t just celebrate an increase in the rolls, or more Medicaid cards handed out,” she said. “For this population, for able-bodied adults, we should celebrate helping people move up, move on and move out.”

Several Medicaid directors said they were upset that Verma suggested they care only about adding people to Medicaid rolls. “We do so much more than that,” said one Medicaid director, who refused to be named because of concerns about working with CMS.

More than 16 million people have been added to Medicaid since 2013, mostly as a result of 31 states and the District of Columbia expanding eligibility under the federal health law.

States and the federal government split the costs of the $576 billion Medicaid program, which covers 74 million people. States are allowed to set benefits and eligibility rules within broad federal guidelines.

Since the 1990s, the federal government has increasingly allowed states to temporarily waive Medicaid rules to give states the ability to experiment with how they administer the program. States have used those options for efforts such as adding monthly premiums or customizing their expansion of Medicaid under the 2010 Affordable Care Act.

Two long-term requirements of such waivers are that they do not increase federal costs and they improve health coverage of the poor.

CMS said Tuesday that expanding access is no longer a key purpose of federal Medicaid waivers. That would be a philosophical change in the program that would open the door to approve work requirements, which states acknowledge would reduce the number of people enrolled.

“It tells me that the agency is preparing to disavow a central objective of federal law and instead will attempt to accomplish exactly what the law does not countenance, namely, a reduction in the level of assistance available to the poorest and most medically vulnerable Americans,” said Sara Rosenbaum, a health policy and law professor at George Washington University in Washington, D.C.

Verma’s decision had been widely expected. Before being appointed to CMS, she was a health care consultant, and she helped the Indiana and Kentucky Medicaid programs draw up their waiver requests, including work requirements. To avoid a conflict, CMS said Verma will not be involved in decisions on those two states.

A decision to support work requirements would likely end up in a court battle, said Jane Perkins, legal director of the National Health Law Program, an advocacy group. Perkins said CMS has power to allow states to experiment with the Medicaid program but not by curtailing eligibility.

“This is really a change in the complexion of the Medicaid program, where CMS is saying to states, ‘Come tell us what you want to do and if you want to cut back the program, we will give you the go ahead,’” Perkins said. “That is inconsistent with congressional intent” of Medicaid waivers.

Verma’s address to the National Association of Medicaid Directors meeting in Arlington, Va., marks one of her few public appearances since taking office. Despite overseeing both Medicaid and Medicare — programs that affect more than 120 million Americans — she has given few interviews or public speeches.

She has frequently been mentioned as a possible replacement for Health and Human Services Secretary Tom Price, who resigned in September following allegations of wasteful travel spending.

Verma’s speech came after an announcement by CMS on Monday that it would streamline the often-arduous process to get Medicaid waivers. It offered to fast-track some requests and said it would allow states to get waivers for up to 10 years — five more years than currently allowed.

Verma also said the federal government would release scorecards showing Medicaid outcomes, but she gave no details on what measures would be evaluated. Some state officials fear CMS will use the new grading measure to lower their federal funding.

Most Medicaid enrollees are in private managed care plans, which get evaluated each year by states, looking at everything from vaccination rates for children to cancer screening rates for adults.