Category Archives: Health Care

This is how America rations health care

Source: Sarah Kliff, Vox, February 11, 2016

….Harvoni (and its predecessor, a similar drug called Sovaldi) is among the most expensive drugs to hit the American market in recent memory. It’s not that these drugs contain some excessively expensive ingredient. Rather, drugmakers have found that hepatitis C patients are desperate enough for a cure to allow these types of prices. Insurers did the math. They knew that there are 3.2 million people in the United States living with hepatitis C — and the costs of buying Harvoni for all of them would cause premiums to skyrocket. Some began to ration access. Morton’s insurer, Group Health, decided to limit coverage to hepatitis C patients with more advanced liver disease. …. Patients are starting to fight back. Morton is part of a class-action lawsuit that argues these insurers must make good on their contractual promise to pay for “medically necessary” services. The complaint is unique — and the eventual ruling could have national consequences as more expensive new drugs come onto the market….

Federal Employees Health Benefits (FEHB) Program: An Overview

Source: Kirstin B. Blom, Ada S. Cornell, Congressional Research Service, CRS Report, R43922, February 3, 2016

The Federal Employees Health Benefits (FEHB) Program provides health insurance to federal employees, retirees, and their dependents. This report provides a general overview of FEHB. It describes the structure of FEHB , including eligibility for the program and coverage options available to enrollees, as well as premiums, benefits and cost sharing, and general financing of FEHB. The report also describes the role of the Office of Personnel Management (OPM) in administering the program. Eligible individuals include federal employees, retirees, an d their family members. As of calendar year 2014, Members of Congress and certain congressional staff are no longer eligible to enroll in plans offered under FEHB as employees but may be eligible to enroll in retirement. Coverage options available to eligible individuals include individual or family coverage in an approved health benefits plan. Beginning in calendar year 2016, individuals have a third coverage option: self plus one coverage for themselves and one eligible family member. Generally, available health benefits plans fall into two broad categories: fee-for-service (FFS) or health maintenance organizations (HMOs). FFS plans tend to be available nationwide, and HMOs tend to be locally available. Premiums are shared between the federal government and the employee or retiree. Benefits and cost sharing vary among FEHB plans, but all plans must cover basic services such as hospital and physician care and may require cost sharing in the form of deductibles, co-payments, or coinsurance. FEHB financing includes government contributions to premiums, contingency reserves in the U.S. Treasury to offset unexpected increases in costs, and administrative expenses incurred by OPM. The report also discusses how FEHB interacts with the United States Postal Service (USPS) and with Medicare as well as the impact of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) on FEHB….

Rich, Poor, Singles, and Couples. Who Receives Medicaid in Old Age and Why?

Source: Margherita Borella, Mariacristina De Nardi, Eric French, National Bureau of Economic Research (NBER), NBER Working Paper No. w21873, January 2016
(subscription required)

From the abstract:
We use the Health and Retirement Survey (HRS) data set to study who receives Medicaid in old age and why. First, we conduct a descriptive analysis of Medicaid recipiency along a number of important observables. This analysis shows that, while fewer people with high permanent income receive Medicaid, a significant fraction of high permanent income people receive Medicaid at very old ages. It also shows that more single people receive Medicaid than people in couples, that people who just lost their spouse rapidly become very similar in their Medicaid recipiency and other important observable characteristics to people who have been single for much longer, and that bad health commoves with Medicaid recipiency. Finally, this analysis shows even people having long-term care insurance end up on Medicaid, but that the fraction of people in this group that is on Medicaid is one-third that of the entire population of the elderly. Second, multivariate regression analysis allows us to disentangle the effects of many observables on Medicaid recipiency while conditioning for others and reveals several interesting patterns. First, permanent income and other variables capturing economic background have a major role in determining individuals’ Medicaid coverage and explain much of the observed differences in Medicaid recipiency among singles, couples, and people who recently lost their spouse. Second, impairments in the activities of daily living and residency in a nursing home have a large effect on the probability of being on Medicaid, with the effect of nursing home residency being relatively large for those in the middle and upper income groups. Lastly, having long-term care insurance has no independent effect on the probability of ending up on Medicaid.

Beyond the Affordable Care Act’s Premium Tax Credit: Ensuring Access to Safety Net Programs

Source: Mary L. Pareja, University of New Mexico School of Law, UNM School of Law Research Paper No. 2015-19, 2015

From the abstract:
The United States took a gigantic step toward universal health care with the passage of the Affordable Care Act (“ACA”). Under the ACA, nearly everyone is required to have coverage, and correspondingly, no one can be turned away. To ease the financial burden of the individual mandate, the ACA subsidizes coverage for lower-income people. The primary subsidy is a refundable tax credit called the Premium Tax Credit, first available in 2014.

To claim the credit, a person must file a tax return — but not just any return. The ACA requires married individuals to file jointly. For many, this is problematic if not downright dangerous. The tax code currently has some exceptions that allow married individuals to be treated as single, but those exceptions do not reach all people for whom filing jointly is dangerous or difficult. In recognition of this reality, the IRS published temporary regulations implementing an exception to the joint filing requirement for certain victims of domestic abuse or spousal abandonment.

This article urges the IRS to expand the exception to other categories of individuals who face serious hurdles to filing jointly, such as long-separated spouses. Couples in long-term separations tend to be low-income racial and ethnic minorities with children, exactly the target population for the Premium Tax Credit. This article makes concrete suggestions for reforms that would better protect vulnerable populations and lead to more equitable results.

Looking beyond the Premium Tax Credit, this article outlines other tax benefits that are lost when not filing jointly. The Premium Tax Credit is but one example of a more systemic problem. For example, the Earned Income Tax Credit, the single largest federal cash assistance program, is lost to a married taxpayer without a joint return. This article looks critically at why the tax code repeatedly requires joint filing to claim tax benefits and argues that the Premium Tax Credit exception should be extended to apply to other tax benefits. If we are truly concerned that a domestic violence victim cannot (or should not) file jointly with an abuser, then we should enable the victim to receive all the tax benefits that are so critical to our anti-poverty efforts.

Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply

Source: Robert Kaestner, A. Bowen Garrett, Anju Gangopadhyaya, Caitlyn Fleming, National Bureau of Economic Research (NBER), NBER Working Paper No. w21836, December 2015
(subscription required)

From the abstract:
We examined the effect of the expansion of Medicaid eligibility under the Affordable Care Act on health insurance coverage and labor supply of adults with a high school education or less. We found that the Medicaid expansions increased Medicaid coverage by approximately 4 percentage points, decreased the proportion uninsured by approximately 3 percentage points, and decreased private health insurance coverage by 1 percentage point. The Medicaid expansions had little effect on labor supply as measured by employment, usual hours worked per week and the probability of working 30 or more hours per week. Most estimates suggested that the expansions increased employment slightly, although not significantly.

Mental health care for prisoners could prevent rearrest, but prisons aren’t designed for rehabilitation

Source: The Conversation, January 19, 2016

Mental health conditions are more common among prisoners than in the general population. Estimates suggest that as many as 26 percent of state and federal prisoners suffer from at least one mental illness, compared with nine percent or less in the general population. And prisoners with untreated mental illness are more likely to be arrested again after they are released.

But prisoners’ access to health care, including mental health care, varies from prison to prison. This is partly because funding varies annually due to budget restrictions and changing policies requiring use of funds for other purposes. And public support for rehabilitation is constantly fluctuating. As you can imagine, many people consider mental health treatment among prisoners to be a low funding priority compared to other federal programs, such as college student financial aid….

Employee Wellness Programs Not So Voluntary Anymore

Source: Rebecca Greenfield, Bloomberg Businessweek, January 15, 2016

Take a blood test or lose your health coverage….

….Like many employers, Flambeau uses a wellness program to cut insurance costs by encouraging healthy employee habits. In the past, submitting to on-site tests of blood pressure, body-mass, and cholesterol meant saving a few hundred dollars. Now companies such as Flambeau have gone a step farther, denying healthcare entirely to those who don’t participate. People like Arnold must instead pay for more expensive coverage through the government’s COBRA program.

According to several federal courts—including one that ruled in favor of Flambeau—this is all perfectly legal.

In a case filed by the Equal Employment Opportunity Commission, the U.S. government argued that Flambeau’s wellness program didn’t comply with the Americans with Disabilities Act, which limits companies from requiring medical exams or personal health information from workers. Denying employer-sponsored coverage crosses the line from voluntary to coercive, the EEOC contended…..

Both The ‘Private Option’ And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults

Source: Benjamin D. Sommers, Robert J. Blendon and E. John Orav, Health Affairs, Vol. 35 no. 1, January 2016
(subscription required)

From the abstract:
Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the “private option”). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November–December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky’s traditional Medicaid expansion and Arkansas’s private option, which suggests that both approaches improved access among low-income adults.

Little Change Seen In Part-Time Employment As A Result Of The Affordable Care Act

Source: Asako S. Moriya, Thomas M. Selden and Kosali I. Simon, Health Affairs, Vol. 35 no. 1, January 2016
(subscription required)

From the abstract:
There has been speculation that the Affordable Care Act’s coverage provisions and employer mandate have led to an increase in part-time employment. Using the Current Population Survey for the period 2005–15, we examined data on weekly hours worked by firm size, reason for working part time, age, education, and health insurance. We found only limited evidence to support this speculation.

Toolkit: State Strategies to Enroll Justice-Involved Individuals in Health Coverage

Source: Sarabeth Zemel, Anita Cardwell and Chiara Corso, National Academy for State Health Policy, November 16, 2015

From the summary:
Under the Affordable Care Act (ACA), many individuals involved in the criminal justice system are now eligible for Medicaid, including many young, low-income males who did not previously qualify.

States confront considerable costs associated with addressing the complex health care needs of individuals involved in the criminal justice system—in fiscal year 2011, states spent $7.7 billion on correctional health care. Health insurance options available through the ACA offer new opportunities to enroll individuals involved in the criminal justice system into coverage and provide access to physical and behavioral health services critical to their successful reentry into the community. Additionally, states and localities have the potential to benefit from cost savings from enrolling this population in health coverage because of possible reductions in uncompensated care costs and the potential for reduced recidivism rates.

Of the approximately 10 million individuals released annually from prisons or jails, 70 to 90 percent are estimated to lack health insurance. Without health coverage, these individuals are much less likely to receive the services or treatment they need to improve and maintain their health and well-being. Lacking coverage and a regular source of care, these individuals may seek treatment in hospital emergency departments, which shifts health care costs to states and localities. Additionally, for individuals with mental illness or substance use disorders in particular, a lack of access to health care is correlated with increased recidivism rates.

Although individuals are not permitted to receive Medicaid benefits while incarcerated, Medicaid enrollment processes can begin prior to an individual’s release from incarceration. In some states, prisons and jails have taken steps to implement procedures to begin the Medicaid application process as individuals are nearing their incarceration release dates. NASHP conducted a series of interviews with state officials and found strategies states are using that have made these efforts successful:
– Identifying simple and streamlined ways to integrate Medicaid enrollment procedures with existing correctional institution processes, such as incorporating enrollment efforts into existing discharge planning activities or centralizing application processing functions
– Developing strong partnerships between state Medicaid agencies and correctional authorities to support enrollment efforts, characterized by effective communication and backing from organizational leadership
– Implementing flexible approaches that can be adapted and improved over time, such as moving from a paper Medicaid application for incarcerated individuals to an electronic process

Implementing processes to enroll justice-involved individuals in health coverage on a large scale is a new endeavor for states and their efforts are in the early stages. Given this, many states are currently working through various policy and operational challenges. For example, some state officials noted the challenge of identifying an individual’s specific release date, especially for the jail population. However state officials reported that overall they viewed these efforts as successful considering the large number of enrollments that have occurred.

For detailed information on selected states’ efforts to enroll justice-involved individuals in health coverage, click through the toolkit below.