Tag: Health Brief

How Two States Reveal a Deeper Divide on Insuring Kids’ Health

Arizona and Florida lawmakers saw trouble ahead for children in 2023, with states slated — as the covid-19 pandemic waned — to resume disenrolling ineligible people from Medicaid.

So, legislators in both states voted to expand a safety net known as the Children’s Health Insurance Program, or CHIP, which covers those 18 and younger in families that earn too much for Medicaid.

Florida Gov. Ron DeSantis (R) and Arizona Gov. Katie Hobbs (D) signed the bills into law last year, giving their state Medicaid agencies the green light to apply to federal regulators to raise the family income limit for CHIP eligibility.

But while Arizona’s plan hewed to Biden administration policies, such as keeping eligible children enrolled in CHIP even with unpaid premiums, Florida’s proposal ignored those coverage protections; the state has removed at least 22,000 children from CHIP for unpaid premiums since the rule banning such disenrollments took effect Jan. 1.

Clearly, there is a divide, said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured. “It simply may be between the policies of the Trump administration and the Biden administration.”

These differences are also evident in the context of the 2024 presidential election. Former president Donald Trump has suggested he is open to cutting federal assistance programs if elected to a second term, while the Biden administration has taken steps to make it easier for low-income Americans to keep their health coverage.

The flexibility for states to design different CHIP programs is a big reason Republicans and Democrats have supported the federal initiative since 1997, when it was signed into law, Tolbert said.

But how Arizona and Florida have handled CHIP premiums underscores key ideological differences on the government’s role in subsidizing health insurance for children.

The Sunshine State ultimately sued the Biden administration over its unpaid premium policy, but U.S. District Judge William Jung dismissed the case May 31, saying the matter was up to federal regulators to decide.

Sara Lonardo, a spokesperson for the federal Department of Health and Human Services, said in an email that the Biden administration says the law requires states to give children in CHIP the same coverage protection as kids in Medicaid — continuous enrollment for 12 months, even if the premium is not paid.

“No eligible child should face barriers to enrolling in CHIP or be at risk of losing the coverage they rely on to stay healthy,” Lonardo said.

However, Florida officials have said on social media and in legal filings that the state’s CHIP plan is “a bridge from Medicaid to private insurance,” intended to get families used to premiums, cost sharing and the risk of losing coverage when they miss a payment.

Research shows the cost of premiums can block many families from obtaining and maintaining CHIP coverage even when the cost is low.

“Premiums are more about an ideological belief that families need to have skin in the game, rather than any practical means of paying money to support the program,” said Matt Jewett, director of health policy for the Children’s Action Alliance of Arizona, a nonprofit that promotes health insurance coverage for kids.

DeSantis’s office, Florida’s Medicaid agency and Florida Attorney General Ashley Moody’s office did not respond to questions about CHIP — or if Florida will appeal the court decision.


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Presidential Politics, Polka and Wisconsin

Wisconsin, the land of fried cheese curds and the Green Bay Packers, is one of a half-dozen key battleground states where President Biden is trying to make health care a key issue in his expected November matchup with former president Donald Trump.

Biden narrowly won Wisconsin in 2020, after it went for Trump in 2016. And while recent polling indicates that Trump now holds a slight edge, many people here still can’t figure out whom to vote for, or whether to vote at all. Across the state, the rising cost of health care is high on their list of concerns.

A Wisconsinite to my core, I wanted to gauge what is motivating voters. Among the best places to understand the state’s mood are the many summertime polka festivals that draw voters of all political stripes.

This past weekend, for instance, I met Bob Prelipp, 79, at the Birnamwood Polka Days in Birnamwood, population about 700.

A Republican who served in Vietnam during his stint in the Navy, Prelipp voted for Trump in 2016, then switched to Biden in 2020. Prelipp said Trump angered him with his comments disparaging military veterans.

After Trump supporters stormed the U.S. Capitol on Jan. 6, 2021, “I knew I couldn’t vote for him again,” Prelipp said. “I can’t believe we can’t find a better Republican candidate. I’m still trying to decide what to do.”

His veteran health care has improved remarkably under Biden, yet he still can’t stomach voting for him. “I’m not happy with Biden,” he said. “Everything is getting so unaffordable, even health care.”

Birnamwood is in a rural part of the state that’s ruby red — Trump hats pepper the crowd and Trump flags dot the landscape. Biden supporters are more visible in liberal, heavily populated cities like Madison and Milwaukee.

Greg Laabs, a tuba player in a local polka band, proudly displays a Trump sticker on his instrument.

“There are thousands of people coming across the border,” Laabs said, expressing concern over a Democratic president providing immigrants lacking legal residency access to health care — an idea he recalled Vice President Harris supporting in 2019 and that California has passed. “We cannot support the whole world.”

Meanwhile, Biden and members of his administration are trying to win over voters by touting major Obamacare expansions while promising to do more to expand access to care, especially in rural communities.

“Nine million more people have health care because of fights this administration has taken,” Neera Tanden, Biden’s domestic policy adviser, said last week in the city of Rothschild, announcing an $11 million federal investment in the health-care workforce. “There’s a clear choice.”

But Wisconsin voters at the Rothschild town hall-style event told Tanden and Health and Human Services Secretary Xavier Becerra that the state losing hospitals and clinics has upended access.

“We had a hospital that’s been serving our community for over 100 years close very suddenly,” said Michael Golat, an independent voter who lives in the town of Altoona and believes Biden would prioritize health care, yet says the president must do more to expand access to health care and mental health treatment. “It’s really a crisis here.”


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Like Doctors, More Nurse Practitioners Are Heading Into Specialty Care

If your doctor can’t see you now, maybe the nurse practitioner can.

Nurse practitioners have long been a reliable backstop for the primary-care-physician shortfall, which is estimated at nearly 21,000 doctors this year and projected to get worse.

But easy access to NPs could be tested in coming years. Even though nearly 90 percent of nurse practitioners are certified to work in primary care, only about a third choose the field, according to a recent study.

Health-care workforce experts worry that NPs are being lured toward work in specialty practices for the same reason that some doctors steer clear of primary care: money.

“We get what we pay for,” said Candice Chen, an associate professor of health policy and management at George Washington University.

Physicians must do a residency and usually a fellowship, and pass muster with a national certifying body to practice in a specialty such as oncology or endocrinology. But NPs generally don’t need to be endorsed by a standard-setting group before transitioning to specialty care.

There are advanced programs in specialties such as endocrinology or dermatology that they can enroll in if they wish, but it’s not required.

There’s not much data on salary differences among NPs, but according to AMN Healthcare Physician Solutions, a staffing firm, specialist NPs and physician assistants make about $6,000 more annually on average than those in general practice.

In Yankton, S.D., nurse practitioner Raina Hoebelheinrich is studying for a certificate in endocrinology from a local university to boost her knowledge and increase treatment options for patients with diabetes who otherwise may have to drive hundreds of miles to see a specialist.

“I’ve experienced firsthand with family members the difficulty getting in to receive this type of care,” she said.

She said she’s not sure how she’ll use her new skills. But they’ll surely expand her employment options, even in rural America.

There’s not a lot of data, but some evidence points to nurse practitioners moving away from primary care. The Milbank Memorial Fund’s 2024 primary care scorecard found that between 32 and 34 percent of NPs worked in primary-care practices from 2016 to 2021.

Meanwhile, “nurse practitioner” is one of the fastest-growing occupations, according to the federal Bureau of Labor Statistics, projected to grow 45 percent and add 123,600 jobs by 2032. The staffing firm AMN says NPs have been the most requested position search from their clients for three years running.

Atul Grover, executive director of the Research and Action Institute at the Association of American Medical Colleges, said the numbers indicate there are probably ample NPs, physician assistants and physicians to meet primary-care demand in the future. At the same time, “expect more NPs and PAs to also flow out into other specialties,” he said.


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California Dabbles With Reining in Health Spending

California is now among the states trying to keep health-care costs down by setting spending caps — a task that pits public officials against a deeply entrenched and heavily lawyered set of players.

It’s uncertain whether the state can get insurers, hospitals and medical groups to collaborate on containing costs even as they jockey for their slice of California’s $400 billion-plus health-care pie.

The verdict could take years.

In late April, the state’s new Office of Health Care Affordability set a five-year target for spending growth that starts at 3.5 percent for 2025 and drops to 3 percent by 2029. The goal of the embryonic agency is to make care more affordable and accessible while improving health outcomes and reducing inequity.

To do so, California’s affordability office must confront high prices, unnecessary medical treatments, overuse of high-cost care like emergency rooms, and administrative waste. Not to mention state policies that favor greater investment in health care, which means more revenue for the industry.

This year, when the office was considering an annual per capita spending growth target of 3 percent, the California Hospital Association said the figure did not account for the state’s aging population, new investments in its Medicaid program and other cost pressures. Instead, the hospitals proposed a 5.3 percent average annual target over the five-year period.

The California Medical Association, which represents the state’s doctors, has expressed similar concerns.

For health-care organizations that miss the target, a long and messy process begins that could end with fines of as much as 100 percent of the overspending. But that probably wouldn’t happen until 2030 or beyond, if ever.

In 2013, Massachusetts was the first state to set annual spending targets. Connecticut, Delaware, Nevada, New Jersey, Oregon, Rhode Island and Washington are among other states that have set targets.

The results in Massachusetts have been mixed: The state beat its target in three of the first five years, falling below the average national spending increase.

But more recently, its health spending has increased. In 2022, it exceeded the target by nearly double, and the state’s Health Policy Commission, which oversees spending control efforts, warned of “many alarming trends.”

Proponents of California’s affordability agency hope that open dialogue — coupled with plans to make more detailed spending data public, including for specific health-care organizations — will foster greater industry accountability.

Rhode Island, despite a preexisting policy of limiting hospital price increases, exceeded its overall health-care spending growth target in 2019, the year it took effect. In 2020 and 2021, spending was largely skewed by the coronavirus pandemic. But in 2022, the spending increase came in at half the state’s target rate.


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End of Internet Subsidy Leaves Millions Facing Telehealth Disconnect

When the clock struck midnight on May 31, more than 23 million low-income households were dropped from a federal internet subsidy program that for years had helped them get connected.

The Affordable Connectivity Program was created in 2021, in the midst of the covid-19 pandemic, to help people plug into jobs, schools and health care by reducing their internet costs by up to $75 a month.

Helping connect households was particularly important in rural America, where telehealth services are often leaned on to fill health care gaps and address provider shortages.

But that aid evaporated last month when Congress didn’t move to keep it funded.

“Internet bills for millions of Americans are increasing because Congressional Republicans failed to act,” White House spokesperson Robyn Patterson emailed me.

Some lawmakers have argued that too much of the subsidy money went to people who don’t need it. Last month, Republicans and Democrats introduced proposals to address those concerns. The ACP debate continues, with a funding measure expected to be part of the Spectrum and National Security Act of 2024, under consideration Wednesday by the Senate’s Commerce, Science and Transportation Committee.

The day before the subsidies expired, White House officials offered a consolation prize, announcing they had worked out a deal with 15 internet providers that agreed to keep offering low-cost plans. The announcement isn’t really new, though, nor as robust as a previous deal.

In 2022, the Biden administration announced that 20 companies would offer plans for $30 a month or less. AT&TVerizon and Comcast are among the players continuing to sell low-cost plans the administration says will benefit an estimated 10 million households.

Of course, low-cost plans still come with bills consumers must pay. And without the connectivity program’s monthly assistance, 77 percent of households that benefited from it will have to change plans or drop their internet connections, Jessica Rosenworcel, chair of the Federal Communications Commission, wrote in a letter to lawmakers.

“A consistent theme is that many ACP recipients are seniors on fixed incomes struggling to pay competing bills and make ends meet,” she wrote.

Those affected are people like Myrna Broncho, 69, a Shoshone-Bannock tribal member who talked with me at the Fort Hall Reservation in southeastern Idaho. She had qualified for a $75 subsidy, enough to eliminate her internet bill after she signed on last year.

Without the subsidy, she’ll have to “go back on my tight budget.” Retired and ranching, Broncho said she uses the internet for shopping, paying bills and keeping track of her health care.

Rosenworcel’s letter arguing for renewed funding for the ACP was sent to a handful of lawmakers, including Sens. Maria Cantwell (D-Wash.), who chairs the commerce committee, and Ted Cruz (R-Tex.), who has proposed greatly narrowing eligibility for the program.


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