Medicaid Buy-in has a New Face

I’ve been saying privately that Medicaid Buy-in needs a Congressional voice. It appears to have gotten that today with Sen. Brian Schatz (D-HI).

Politically, he’s been outspoken against many policies of the Trump administration and is often referred to as a rising star in the party. As this policy emerges, Schatz’s support could mirror that of Bernie Sanders and single payer plans. Younger Democrats don’t have the aversion to government sponsored programs that their Reagan-era pragmatic counterparts hold so the fit matches the epicenter of support for this plan. Whether this idea can capture the single payer support enjoyed by Sanders remains to be seen.

The Confusing Financing Policies that Could Hamper Medicaid Expansion Efforts Across the Country

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New Hampshire.

This weekend it was reported that New Hampshire received a letter from the Trump administration saying that the voluntary contributions from insurance companies may be out of compliance with federal policy. The letter reportedly goes on to ask the state to change the way New Hampshire pays for Medicaid expansion or else the state could risk federal funds being differed or disallowed. The state included a provision that would end the expansion of Medicaid if federal funding is reduced, putting the expansion at risk in future years if the policy is unchanged. New Hampshire has expanded Medicaid since 2014, insuring approximately 40,000 people.

The Trump Administration’s actions could have broad implications for Medicaid expansion in other states. As of 2016, Arkansas, Arizona, Colorado, Illinois, Indiana, Louisiana, New Hampshire and Ohio all use provider taxes or fees to fund the state’s share of the Medicaid expansion. While the exact structure of these payments varies by state and there may not be legal issues with many of these payments, there is concern that CMS’s investigation into New Hampshire’s payment methodology could put new scrutiny on these states as well. Further, using similar payment methodologies is often discussed in the 19 states that have yet to expand Medicaid.

The basis of this argument comes down to what are known as hold-harmless provisions of Medicaid. Medicaid Disproportionate Share Hospital (DSH) payments were established in the early 1980s to assist hospitals that provide services to uninsured and Medicaid patients. By the early 1990s it was clear that states were using creative accounting to game the system and get disproportionate share of the DSH payments by soliciting donations from hospitals to cover the cost of Medicaid. Since this wasn’t the original intent of the DSH program, Congress passed laws that restrict donations from entities that may benefit from that donation, known as hold-harmless. There are certain instances where limited donations are allowed, but these policies are discouraged.

The Administration has threatened disallowance or deferral of payment if New Hampshire does not correct the payment. These sorts of actions are not unheard of, yet it is more common when overpayments are made or the state is spending money inappropriately.

The Administration is not the only actor threatening to make paying for Medicaid more difficult for states. Provider taxes are complex. All states with the exception of Alaska currently have at least one provider tax to fund their Medicaid programs. There are limits that allow provider taxes and in recent months Congress has been working to reduce the limit, making it harder for states to finance Medicaid outside of general revenue. If the proposed reduction were to be passed by Congress, nearly 1/3 of the provider taxes would fall outside of the limit. This means that states would have to alter their revenue sources to fund their Medicaid program, relying more on limited state general revenue. This reliance on general revenue could lead to cuts to Medicaid or other state programs.

Medicaid and hearing aides, implications for work requirements

Screenshot 2017-08-09 16.55.00In this month’s Health Affairs Michelle Arnold, Kathryn Hyer, and Theresa Chisolm examined hearing aide coverage among states. They found that nearly half of states do not offer hearing aides for age-related hearing loss. This optional benefit is offered in 28 states and is not offered uniformly across states that do offer the benefit. For example, if you are unable to hear conversations at normal volume or in other states, you are unable to hear a vacuum cleaner may qualify you for hearing aides. In another state a more severe level of hearing loss is required, equivalent to not being able to hear a car horn. And in many states even this level of hearing loss does not allow the coverage of hearing aides.

According to the authors, age related hearing loss affects more than 26 million adults in the US. Loss of hearing is associated with other health impacts such as mental health problems, falls, and increased cognitive decline. Age related hearing loss can be caused by environmental factors such as loud noise or medications. The only treatment for hearing loss at this time is hearing aides or implants.

While this condition primarily affects older adults, one in three people by the age of 65 have the condition. This means that people approaching Medicare eligibility, or many people made newly eligible for Medicaid through the expansion, have high rates of age related hearing loss. With the increase in earbuds and other loud devices, the age at which people start to experience hearing loss is getting younger. It is becoming more common for children to experience age related hearing loss. Medicaid is a primary insurer of health insurance for children, although the EPSDT program will often cover hearing aides because of the mandate to treat eligible children. Therefore, only coverage for people over the age of 21 was examined for this study.

One major limitation to this study is that Medicaid managed care plans are not analyzed. Most Medicaid beneficiaries are covered by managed care plans and these plans may decide to cover hearing aides. However, if a state has not explicitly required this benefit for Medicaid enrollees, the coverage of hearing aides is at the discretion of the managed care plan.

With the recent 1115 waiver requests to require that Medicaid beneficiaries meet work requirements (currently pending approval or completed application from Arkansas, Arizona, Indiana, Maine, Kentucky, and Wisconsin) it is important to remember that hearing loss does not qualify as a disability. Therefore, states that begin to take up work requirements will begin requiring people who cannot hear to work in order to maintain their health care coverage. Yet, that health care coverage may not cover a device that would allow you to get to work and hold most jobs. In many parts of the country one needs to drive to get to a job and hearing is a key aspect of traffic safety.

Hearing loss is one of many conditions that are not considered disabilities that would inhibit people from working. Yet. this and other conditions such as chronic pain, severe diabetes, or heart conditions can impede a person’s ability to hold a job. While the coverage of hearing loss is not uniform across states, there are many parts of the country including all of the states proposing work requirements with the exception of Wisconsin and Indiana, where a low-income person would not be eligible for hearing assistance and then expected to work.