From Health Care

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First Edition: January 17, 2020

Medi-Cal’s Very Big Decade

Medi-Cal had a big decade.

The number of Californians enrolled in the state’s health insurance program for low-income residents swelled by 5.5 million from 2010 to 2019. It now covers 1 in 3 Californians and 40% of children.

The program’s annual budget — a combination of state and federal money — tops $100 billion, more than the entire state budget of Florida.

“Medi-Cal is the largest Medicaid program among all of the states,” said Dr. Andrew Bindman, a professor of medicine at the University of California-San Francisco who helped implement the Affordable Care Act as part of the Obama administration.

It’s most likely going to get bigger. On Friday, California Gov. Gavin Newsom released his 2020-21 state budget blueprint, which would boost Medi-Cal’s annual budget to more than $107 billion and expand coverage to even more people.

Medi-Cal, California’s version of the federal Medicaid program, was transformed in the past decade by federal and state laws — especially the federal Affordable Care Act — and by the ups and downs in California’s economy.

In early 2010, Medi-Cal covered 7.2 million people. Enrollment peaked at 13.7 million in March 2016, and slowly but steadily decreased to 12.8 million people in August 2019, according to the most recent enrollment data from the state Department of Health Care Services. About 4.9 million of them were under age 19.

In 2018, half of enrollees identified as Hispanic, 18% as white, 10% as Asian or Pacific Islander and 8% as black, according to the department. Thirteen percent of enrollees did not report their race/ethnicity.

The federal Affordable Care Act spurred the most significant changes to Medi-Cal since 2010, largely because it allowed states to broaden eligibility for their Medicaid programs to low-income people who had not previously qualified. Thirty-six states plus Washington, D.C., have adopted Medicaid expansions.

In California, Medi-Cal enrollment grew 78% from January 2010 to August 2019, primarily due to the expansion, which began in 2014.

“California went all-in on that,” Bindman said, and reduced its uninsured rate from 18.5% in 2010 to 7.2% in 2018.

Before the change, adults usually didn’t qualify unless they were parents with dependent children, pregnant or had certain conditions or disabilities.

Under the expansion, any adult who met the income guidelines could enroll, which represented a “radical shift” in the way the program operates, said Jen Flory, a policy advocate at the Western Center on Law & Poverty.

It transformed Medi-Cal “to more general low-income coverage,” she said.

The number of adults enrolled through the expansion has hovered around 3.7 million since mid-2016, while the rest of the Medi-Cal population dropped from 10 million to 9 million during the same period. Flory credited a strong economy and low unemployment in part, as more people got jobs that offered employer-based insurance and others surpassed the income limits to qualify.

But Flory and Bindman said other factors might be contributing.

They pointed to fears within immigrant communities over increased immigration enforcement, and policies such as the Trump administration’s “public charge” rule. The rule would allow immigration officials to more easily deny permanent residency status to those who depend on certain public benefits such as Medicaid.

Federal judges temporarily blocked the rule from taking effect in mid-October, but the Trump administration on Monday asked the U.S. Supreme Court to allow it to implement the rule while the legal battles continue.

As a result of such policies and proposals, they said, some immigrants may not be enrolling in Medicaid and other government programs, even if they are eligible.

In the past decade, Medi-Cal has also changed how it delivers care. In January 2010, roughly half of Medi-Cal enrollees participated in the traditional “fee-for-service” model, in which patients can see any doctor who accepts them, and providers are reimbursed for each medical service or visit.

The other half received care from managed-care plans. Under managed care, the state contracts with health plans to deliver benefits to enrollees and pays them a fixed monthly rate to cover the expense of doing so — a payment system known as “capitation.”

The percentage of enrollees served by managed care climbed to 82% by July 2019 as California, like many other states, looked to that model to save money.

The Trump administration and Republicans in Congress have weakened Obamacare and called for limits on federal spending on Medicaid. Such proposals may accelerate if Republicans retain the White House and regain control of the U.S. House of Representatives this year.

While the federal government moves to restrict funding and enrollment, California lawmakers continue to expand eligibility for Medi-Cal.

Starting this year, low-income young adults up to age 26 became eligible for full Medi-Cal benefits regardless of their immigration status, joining unauthorized immigrant children, who became eligible in 2016.

On Friday, Newsom proposed expanding full Medi-Cal benefits to eligible undocumented immigrant adults ages 65 and over as part of his state budget proposal.

California’s policies offer “a striking contrast to the policies of the current federal administration,” Bindman said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Employers’ Dream Of Controlling Health Costs Turns To Workers’ Sleep

Charlie Blakey had a sense he was sleeping poorly since he often would wake up tired and hear from his wife how loudly he breathed during the night.

So he jumped at the chance when his employer, Southern Co., an Atlanta-based electric utility, offered to test him in 2018 for sleep apnea, a potentially serious disorder in which people repeatedly stop breathing while asleep.

After he tested positive, the utility arranged for him to have a machine that provides continuous airflow through a mask while he sleeps — at no cost to him. Within weeks, Blakey, of Augusta, Georgia, noticed a difference.

“Without a doubt, it’s helped me feel more refreshed when I get up,” said Blakey, 38, a safety and health specialist at the company.

About 4,000 of Southern’s 30,000 employees have been screened for sleep apnea in the past three years, and 1,500 are being treated. Southern officials said the program is saving money on health costs — $1.2 million in 2018 alone — because it reduces medical services for dangerous conditions such as heart disease that are complicated by sleep apnea.

Sleep is the latest in an ever-growing list of wellness issues — such as weight loss, exercise and nutrition — that firms are targeting to improve workers’ health and lower medical costs.

Whether all these sleep programs deliver on their promises is not yet clear. A study published last year in the Journal of the American Medical Association followed nearly 33,000 employees of BJ’s Wholesale Club for 18 months and found the wellness program did not lead to significant reductions in health spending.

Harry Liu, a researcher at the Rand Corp. who studies job-based wellness initiatives, said that while studies show “improving sleeping habits can reduce absenteeism and improve productivity,” it’s uncertain if employers’ efforts will have long-term effects for individual workers.

A study published by researchers at the University of Minnesota, Harvard Medical School and other institutions in October found that 1,200 commercial truck drivers who participated in an employer sleep apnea screening and treatment program saved an average of $441 per month in health costs compared with drivers who were not treated. An earlier study of members of a health plan serving Union Pacific employees also found overall health savings among workers who were diagnosed with sleep apnea and got treatment.

About 1 in 4 large employers offer programs to help workers get better sleep and more than half plan to implement such efforts by 2021, according to a 2019 survey by benefits firm Willis Towers Watson. Most businesses hire contractors to manage the programs.

Benefits officials say promoting a good night’s sleep for employees is as important as making sure their blood sugar and cholesterol are under control.

Despite the public’s concerns about privacy, employers say workers have been eager to reveal information about how they sleep to company vendors. To protect employees’ medical privacy, the data on individual workers does not go to their bosses; companies receive only aggregated data to measure program spending and effectiveness.

Katie Kirkland, director of benefits at Southern, said a lack of sleep may promote an unhealthy lifestyle of not exercising or eating a poor diet.

In addition to reducing medical costs, the company was motivated to offer its program because state transportation department rules require that some employees who operate heavy equipment and have certain health conditions be tested for sleep apnea and get treated if diagnosed.

With a diagnosis of apnea, a patient is typically prescribed a continuous positive airway pressure (CPAP) machine. But Kirkland said many workers needed help sustaining treatment because of difficulties in learning to sleep with a mask.

“With sleep apnea, there is a high drop-off rate, where you pay a lot for the equipment and then it doesn’t get used,” she said. “We found it’s a much better experience with the personal coaching.”

When the company took on the issue, it made sense to offer the help to its entire labor force, Kirkland added.

Beyond sleep apnea, some employers also help workers with insomnia.

The Hartford Financial Services Group, based in Hartford, Connecticut, contracts with London-based Sleepio to offer employees a sleep questionnaire and online tutorial to deal with specific sleep issues.

Sandra Trisdale, a sales consultant with the company in San Diego, said she’s sleeping better after finishing a six-week online course on how to fall asleep faster.

Tips Trisdale used include room-darkening window shades and getting a noise machine to drown out other noises. She also learned the importance of trying to go to sleep and wake up at the same time each day. The program had her keep a diary to track how the changes she made affected her sleep.

“It was tremendously helpful,” Trisdale said, “and I got to see how making some small changes led to some big results.”

According to the Hartford, the 2,000 workers who completed its six-week education program have gained an average of seven hours of sleep per week.

Judy Gordon, wellness director at the company, said a preliminary analysis suggests the sleep program is saving the company money through fewer medical claims.

The company began looking into sleep issues after it found employees with an insomnia diagnosis have more than double the average health costs of those without one. In addition, she said, employees who sleep better are likely to be more productive at work.

“There is a business reason to look at insomnia,” Gordon said.

Remedying sleep issues can also alleviate some anxiety and depression, she said.

Case Western Reserve University in Cleveland also recently began working with its employees on sleep. About 185 workers took part in a voluntary four-week program last year that provided sleeping tips and asked employees to keep a record of how they slept each night. Claude “Bud” Morris, a maintenance worker, said the program helped by nudging him to turn off electronics an hour before bedtime.

Officials at the Washington Suburban Sanitary Commission, a government agency that provides drinking water for parts of Maryland near the District of Columbia, feared sleep problems were plaguing many of their employees who often work late nights or early mornings. When they looked over workers’ medical and pharmacy claims, they found 226 of 1,600 employees had been diagnosed with sleep apnea and most of them had at least one chronic disease such as asthma or diabetes.

“It wasn’t rocket science to tell sleep was an issue,” said Lee McDonough, the commission’s wellness program manager.

Many of the employees with sleep apnea who had started on a CPAP machine quit using it regularly because of difficulty wearing the mask.

“They would take it and throw it in a corner and not get better,” McDonough said.

The commission contracted with FusionHealth of Suwanee, Georgia, which tests employees for sleep apnea and provides doctors and respiratory therapists to counsel individuals on how to wear the mask. The company also monitors employees remotely and follows up with regular phone calls and emails.

After 16 months using the service, the commission found the extra level of personal support helped many employees sleep better.

“The human touch combined with the technology has helped employees stick with it and given them a fighting chance to get better,” McDonough said.

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With Fate Of Roe V. Wade Unsure, Abortion Fight Shifts To New Territory

Jan. 22 marks the 47th anniversary of Roe v. Wade, the landmark case that legalized abortion nationwide. Those on both sides of the furious debate say this could be the year when everything changes.

In March, the Supreme Court will hear its first abortion case since Justice Brett Kavanaugh replaced Anthony Kennedy, who had been the swing vote on abortion cases. A decision is expected by summer.

The case, June Medical Services v. Gee, challenges a Louisiana law that requires doctors who perform abortions to have admitting privileges at a nearby hospital. It’s a reprise of a case decided in 2016, when a five-vote majority (including Kennedy’s) struck down a substantially similar Texas law in Whole Women’s Health v. Hellerstedt.

On Jan. 2, more than 200 Republican members of the House and Senate filed a brief in the Gee case urging the justices to use it to overturn Roe once and for all. “Forty-six years after Roe was decided, it remains a radically unsettled precedent,” the brief said. And the 1992 case that reiterated a curtailed right to abortion, Planned Parenthood of Southeastern Pennsylvania v. Casey, did not help, the members argued. “Casey clearly did not settle the abortion issue, and it is time for the Court to take it up again.”

The court is far more likely to rule narrowly in the case than to use it to overturn Roe and/or Casey because that’s what the Supreme Court tends to do.

Even if the court does not overturn Roe, it might do something that could hasten Roe’s demise: uphold the Louisiana law by ruling that abortion providers cannot sue on behalf of their patients, something the state of Louisiana is urging it to do. That would make it much more difficult to challenge state abortion restrictions because only women seeking abortions would be able to challenge those laws in court. Many pregnant women seeking abortions don’t want to go to the additional trouble of becoming part of a lawsuit that could take years.

“That would be a bigger deal” than finding some legal justification to uphold Louisiana’s law, said Mary Ziegler, a law professor at Florida State University who has written several books on abortion and abortion law.

It’s part and parcel of an anti-abortion strategy: make abortion more difficult to obtain even where it is technically legal. “A right is certainly important, but if you cannot access abortion care, that right is meaningless,” said Elisabeth Smith of the Center for Reproductive Rights, an abortion-rights law firm.

Since 2004, that center has periodically looked at what would happen to abortion laws in the states if the Supreme Court were to reverse its conclusion that abortion, at least in some cases, is a right guaranteed by the U.S. Constitution. In its original report, titled “What If Roe Fell,” and again in 2007 and 2017, the center assessed the likely legal status of abortion in the states, because in the absence of Roe, abortion’s legality would be determined by state lawmakers or state constitutions.

But in its 2019 version of “What If Roe Fell,” the group took a slightly different tack. This latest iteration looks at likely legality, but also at the relative availability of the procedure. The report concludes that if the Supreme Court eliminates federal protections for abortion, the procedure is likely to be immediately prohibited in 24 states, and remain legal and generally available in 21. The five other states and the District of Columbia have not established a right to abortion.

Smith said that, even with Roe still standing, some states, such as Mississippi and Missouri, are already abortion “deserts,” where the procedure is all but unavailable. But “the situation would be much worse if the federal right is limited or overturned,” she said. In fact, some states are “havens” that have made abortions easier to obtain. For now, “abortion is still legal. Every state has at least one abortion clinic,” Smith added.

This is far from the first time it appeared Roe was teetering on the brink. In 1992, after Justice Clarence Thomas replaced Thurgood Marshall, one of the original seven justices in the majority in Roe, the country braced for an overturn. It did not happen. In 2005, when abortion swing vote Justice Sandra Day O’Connor retired and was replaced by Justice Samuel Alito, the alarms were raised again. And again, it did not happen. Then in 2018, when O’Connor’s successor as the abortion swing vote, Kennedy, retired and was replaced by Kavanaugh, the bells rang once more.

The Louisiana case is the first chance for what would appear to be a clear five-vote anti-abortion majority to rule.

Ziegler, the Florida State law professor, warns that overturning Roe would not end the fight. “If this goes back to the states, it’s going to continue indefinitely,” she said. “The endpoint for people who oppose abortion is not just allowing states to decide.”

In other words, if you think the abortion issue is inflammatory now, just wait until Roe is gone.

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Listen: How High-Deductible Plans Hurt Rural America

KHN senior correspondent Markian Hawryluk joined Colorado Public Radio’s Avery Lill on “Colorado Matters” to discuss his recent story on how high-deductible health plans are especially hurting rural America. (His segment begins at 11 minutes and 40 seconds in, after you click on the link for the full show.)

Such insurance plans are more prevalent in rural areas, where incomes tend to be lower, compared with urban areas, leaving patients with hefty bills they cannot afford when a health care crisis occurs.

These plans also pinch rural hospitals: When a patient arrives at a rural hospital needing critical care, the person is often stabilized and transferred to a larger facility. But bills from the first site of care generally get applied to the patient’s deductible. When patients can’t afford their deductible, the smaller hospital winds up eating the costs.

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KHN’s ‘What The Health?’: Trump Takes Credit Where It Isn’t Due

Can’t see the audio player? Click here to listen on SoundCloud.

The final debate for Democratic presidential candidates before the Feb. 3 Iowa caucuses did not delve as deeply into health care as some earlier debates. But it did include discussion of several health issues that have received relatively little attention, including prescription drug prices and long-term care.

Meanwhile, President Donald Trump is claiming credit for having “saved” federal protections for preexisting health conditions, perhaps the most popular piece of the Affordable Care Act, even as his own administration is in court trying to have the entire health law declared unconstitutional.

And Kansas may soon become the latest state to expand the Medicaid program under the ACA, as the Democratic governor and GOP Senate majority leader strike a deal.

This week’s panelists are Julie Rovner from Kaiser Health News, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Shefali Luthra of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Some advocates have complained that the Democratic presidential candidates are not discussing threats to abortion rights during the debates. But, generally, candidates look to talk about issues that differentiate them from their primary opponents, and all of the Democrats on stage are supportive of a woman’s right to an abortion.
  • Trump’s claim this week that he was protecting the right of consumers with medical problems to get health coverage was widely derided by ACA supporters. But his contention goes to the heart of the administration’s effort to buttress its health care initiatives ahead of the campaign.
  • At the same time, the Trump administration has set a requirement for plans sold on Obamacare marketplaces to bill consumers separately for the portion of the plan that covers abortion, generally a minuscule amount. That could confuse customers and create billing headaches for insurers and prompt some to discontinue the coverage.
  • Recent action by the Supreme Court may signal some changes coming in its view of abortion rights, now that the court has a stronger conservative majority. The justices refused to take an appeals court decision upholding a Kentucky law that requires doctors to show women seeking an abortion an ultrasound image of the fetus and describe the procedure to them.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Deductible’s “Seven for the Twenties: A Futurist Looks at the Next Decade,” by Jeff Goldsmith

Alice Miranda Ollstein: The Wall Street Journal’s “Plan to Revamp Medicaid-Eligibility Checks Draws Criticism,” by Stephanie Armour

Tami Luhby:’s “Everybody Covered,” by Dylan Scott, Ezra Klein and Tara Golshan

Shefali Luthra: Kaiser Health News’ “High-Deductible Plans Jeopardize Financial Health Of Patients And Rural Hospitals,” by Markian Hawryluk

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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