Why Maine’s Medicaid expansion proposition could be big news for other states

This Tuesday, Maine voters will be deciding whether the state that has continued to vote for Medicaid expansion in their legislature will take the unusual avenue of approving Medicaid expansion through a proposition. The referenda would make Maine the first state to expand Medicaid not through the governor or state legislature’s authority.

The legislation is currently polling well with the last publicly released poll putting the referendum at 69 percent. Although it’s important to note that referendum, especially propositions that involve state spending, as this one would, tend to lose support closer to Election Day. Further, because this is an off year election with few major statewide races on the ballot, turnout is likely to be lower than Presidential or Congressional years. Typically, the voter base in low turnout elections favors conservatives.

Governor Paul LaPage who helped form a group in opposition to the measure heavily opposes this particular ballot measure. However, currently the spending by those in favor of the proposition exceeds those opposed to the ballot measure. Additionally, the groups in support of the ballot measure have instituted grassroots measures of knocking doors and passing out voting literature in and around the Portland region.

Several states have already initiated signature gathering process to include Medicaid expansion on the ballot in future elections. Utahans and Idahoans are are currently collecting signatures to include Medicaid expansion on the 2018 statewide ballot.

In 2014 Wisconsin 19 of the 72 counties included a resolution to expand Medicaid and the proposal won by large majorities across the state, even in counties that went heavily for Republican Governor Scott Walker. The referendum overall received 74 percent statewide. The legislature and the governor uniformly rejected the non-binding ballot initiative and no further action has been taken on Medicaid expansion in the state.

There is concern that the same can be said about the Maine initiative. Unlike in many Western states where propositions are written into the state constitutions, in Maine the governor has the ability to declare that there is not enough funding available and the initiative must go back to the legislature for approval within 45 days of the start of the session. This ballot question requires that the state submit a plan to the US Department of Health and Human Services within 90 days of the initiative taking effect. However, Maine has a history of slow walking initiatives in the state and failing to implement them all together. This particular case may be different because the legislature has voted and approved expansion about six times only to be blocked by the governor’s veto. At the same time, the legislature and Presidential administration has changed since these votes and the legislature never had the votes to override a veto. Taken together, the process of Maine expanding Medicaid could take a significant amount of time if the Governor and state legislature so decides.

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Puerto Rico Medicaid funding in House CHIP Bill

The House released and voted on an amended version of their CHIP reauthorization bill this week. This bill primarily changed the way that the CHIP program is paid for by the federal government by increasing the premiums for high income earning Medicare beneficiaries. The bill has come under criticism for including a large number of partisan proposals that primarily focused on repealing various provisions of the Affordable Care Act. One provision of this bill that has largely escaped critique is the additional funding for Puerto Rico following the hurricanes that have devastated the island.

As I have discussed previously in this blog, Puerto Rico’s Medicaid program is block granted, meaning that they are limited in the amount of federal funds they receive. This makes events such as the hurricanes especially difficult. More people rely on the Medicaid program during an emergency or time of economic distress. The program is counter cyclical in that it acts as a safety net to ensure that people who are facing financial downfall do not experience greater distress under periods of larger financial distress. It blunts the pain.

The plan passed by the House GOP provides $1 billion toward the Medicaid program in Puerto Rico and the Virgin Islands. The two islands’ programs have been financially strained under the weight of more people requiring health services and more people losing their insurance coverage and qualifying for Medicaid. The finances would not provide sustained funding but would act as a band-aide. One requirement of the funding is that they would only be able to access a portion of the funds if they meet certain anti-fraud measures. This is interesting because such provisions were not included in similar funding bills made available to Florida and Texas following their hurricanes. Additionally, the provision only applies to the Medicaid program when there is likely significant fraud in both the private insurance market and the Medicare Managed Care program in the territory. Yet only the Medicaid program is called out for reduction in fraud. True that Medicare and the fraud control for the program is run at the federal level and the bill is related to Medicaid funding. Both of these points are good reasons why fraud prevention programs and targets would not be included in this bill. However, the purpose of this bill is to give the territory disaster relief, not to continue the basic functions of the Medicaid program in the territory. Therefore, an equal argument can be made that the purpose of the bill is not to enact fraud control thus requiring Puerto Rico to do so also violates the germaneness of the bill.

This bill unlike other forms of previous legislation funds the Medicaid programs for both Puerto Rico and the Virgin Islands. The Virgin Islands’ Medicaid increase is pegged to Puerto Rico’s spending on a per capita basis. Therefore, if Puerto Rico spends $100 per a person in Puerto Rico the Virgin Islands will also receive $100 per person. This does not take into account the health needs of the Virgin Islands or the difference between the income or other population differences of the two territories. The Virgin Islands also experienced the brunt of the hurricanes and the island is in need of disaster relief, however this shouldn’t necessarily be tied to Puerto Rico’s spending, it should be additive in a manner that makes the most sense for both of the islands.

Additionally, Reuters wrote about the latest request from the territory for a greater infusion of funds for the Medicaid program over the next 5 years. Definitely worth a read to better understand the dire situation on the island.

Medicaid in Puerto Rico

Following the devastation of hurricane Maria in Puerto Rico, attention has been paid to helping the territory recover. One of the facts that has largely been under reported is the island’s Medicaid program. Nearly half (46 percent) of all Puerto Ricans are covered by the territory’s Medicaid program. This week, the Hill reported that if funding issues aren’t resolved for the Medicaid program approximately 900,000 residents will be cut from the program.

Puerto Rico uses essentially a block grant from the federal government to fund its Medicaid program. This means that the federal government provides a certain fixed amount and the territory will pay for the remaining funds. Under normal circumstances the territory would reduce benefits or eligibility in order to meet their program costs. As is obvious, residents were devastated and many people are in need of health care services following the major hurricane that hit Puerto Rico. This means many more will likely qualify for Medicaid because of an increase in poverty in the state and many more will need services because of the health effects of the hurricane. Vikki Wachino and Tim Gronniger explain why block grants in Medicaid have hurt the island in their recent Health Affairs blog.

Rather than providing an aide package to Puerto Rico alone, a $1 billion increase in Medicaid funding was added to the CHIP reauthorization package. The House has stalled their passage of the CHIP reauthorization because their bill included many pay fors that were partisan and had more to do with the repeal of various provisions of the Affordable Care Act than the reauthorization of the CHIP program. The Senate did not include pay fors in their version of the bill. Congress passed a disaster relief bill in recent days that did not include additional funding for the Medicaid program. As of now that is still tied to the CHIP reauthorization.

It appears that the CHIP reauthorization is becoming the main vehicle for health related legislation. Keeping the Puerto Rican Medicaid program available to residents while the island works to recover from the hurricane now looks tied to funding for the health insurance for 9 million kids.

The IMD Exclusion’s Days Look Numbered

The National Association of Attorneys General recently released a letter from 39 Attorneys General that advocates for the removal of the prohibition on reimbursement for Institutions for Mental Disease (IMDs). This letter was signed by some of the most progressive Attorneys General such as Maura Healey of Massachusetts as well as some of the most conservative Mike Hunter of Oklahoma, who recently replaced Scott Pruitt who joined the Trump Administration to head the EPA.

The policy that they are advocating for make sense on the face of it but whether it is effective in the end is less known. IMDs help provide treatment for people with drug addiction. Medicaid cannot pay for these services out of an artifact of history. States had historically paid for these programs and a main concern of the architects of the Medicaid program was to not replace existing state programs. Had we started out with a health care system that had Medicaid as the primary state medical service from the beginning these services would likely have been included.

However they do not provide the counseling and community supports that are shown to be effective in rehabilitation and maintenance of a life without addiction. One concern with putting addiction recovery in the hands of the health care system and away from the community is that funds directed to community engagement projects will be eliminated. Medical systems have not historically shown good results with tracking patients through their recovery outside of the hospital.

Secondly, it’s unknown how much this policy change would impact care. The Obama Administration changed the requirements for managed care plans to allow certain reimbursement for IMD facilities through managed care programs. Since managed care is now the primary way Medicaid provides health care services for beneficiaries, for 77 percent of beneficiaries, these services are already reimbursed. Further, the populations that don’t receive managed care are primarily the elderly and disabled. It’s important here to note that the IMD exclusion only applies to those under the age of 64. This means that few people are subject to the IMD exclusion as compared to 5 years ago.

Further, in 2015 the Centers for Medicare & Medicaid Services (CMS) released a letter to states outlining ways that states could use Section 1115 waiver authority to expand coverage for IMD services through their Medicaid programs to individuals that would be subject to the restrictions.

Essentially, every state already has the authority to give their Medicaid beneficiaries access to IMD services either through a waiver or through their managed care entities. While receiving coverage in an institution may be the correct method of treatment for some individuals, it is not a silver bullet to provide care for all people needing treatment for opioid dependency. In fact, the original reason for instituting the ban on payment for these services must be remembered. Addiction is not a disease that we can cure with medicine and institutionalize treatment alone. While the services provided in IMDs are important, so are community based counseling and even more so addressing the underlying causes of addiction. These more than a single policy change could help us stem the opioid crisis.

Medicaid-for-All receives boost from gubernatorial candidate

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Local Coloradans thinking about Medicaid-for-All undoubtedly

Colorado’s crowded Democratic governor’s race has seen one candidate distinguish herself from her competitors based on her health care policy. Cary Kennedy, the former state treasurer, came out in support of a Medicaid-for-All platform.

The plan would essentially allow Colorado residents to purchase Medicaid coverage. Since Medicaid costs significantly less than private and other public insurers, Kennedy argues this will keep cost down. The way Medicaid keeps costs down primarily is by reimbursing providers at lower rates. However, the program is also largely run by managed care plans that place limits on excessive utilization and narrow networks. Colorado has several counties with a limited number of plans available in the Exchange market. This plan would provide an additional plan offering for these consumers.

This plan follows the Nevada “Sprinklecare” proposal released earlier this year and the proposal by Senator Schatz earlier this summer. While Medicaid-for-All hasn’t seen such publicity before, d it was briefly discussed as a potential option for a public plan in 2009/2010. The thought that likely ended that conversation was that it didn’t have the public backing that Medicare had. It’s clear the idea is gaining momentum now, in part due to the strong show of public support resulting from the repeal debate this year.

ABLE Accounts

The ABLE Act was passed in 2014 and allows states to start a program that would allow certain people with disabilities to open tax-exempt savings accounts. Last week, CMS released guidance on how this law interacts with state Medicaid programs.

The law is designed to allow certain people with disabilities to save money and use their savings on services and expenses to maintain their quality of life, maintain health, independence and quality of life. The program is not meant to supplant existing programs and notably missing is language that calls for improvements in people’s lives. One key part of this account is that these funds cannot be counted as resources or assets for determining a person’s Medicaid eligibility. The earnings and interest gained on these accounts would not be counted for income purposes. States can use the funds to account for estate recovery after the beneficiary has died. This could potentially reduce the problems associated with transfer of assets and selling of houses by disabled beneficiaries in an effort to protect assets from estate recovery policies. The benefit is only available to people who have had a diagnosed disability and eligible for SSDI prior to the age of 26 and living in a state with an ABLE program. This is a limited group of beneficiaries and exempts many different types of working disabled adults.

Medicaid and SSDI benefits exist to assist people who need the safety net of assistance. In these safety nets we should provide a pathway to improve their quality of life and assist them to be able to receive better health and independence. This program improves the existing reality for many disabled adults, however there is more to be done to ensure that more people are able to live at their highest quality of life with independence. Medicaid is a pathway to improving lives for many but there are many barriers to prevent people from reaching opportunities they could achieve.

Medicaid is already flexible: part 2538925729

In the continuing series on this blog we will examine how Medicaid already contains significant flexibilities that allow states to tailor their programs to the needs of the state and respond to emerging issues.

This time- responding to the opioid epidemic. In January 2016, CMS released a letter to states outlining the existing flexibilities and new flexibilities states could use to provide benefits to Medicaid eligible residents in their states. Anna Gorman at Kaiser Health News has a nice piece out about what California’s project looks like and how it’s impacting people. Virginia, Massachusetts, and Maryland have expanded treatment using these flexibilities and West Virginia and Michigan are pursuing waivers from the federal government.

These flexibilities and waivers were executed using existing Medicaid flexibilities and CMS encouraged states to apply using the specific flexibilities. This will hopefully bring more care to people with opioid addiction and help turn the tide of our crisis in America.