Tagged Medicaid

Podcast: KHN’s ‘What The Health?’ Live from Aspen!

With President Donald Trump and Republicans in Congress stymied in their efforts to change the nation’s health care system, individual states are wrangling with public ire over price and coverage.

Two guests this week, Democratic Govs. John Hickenlooper of Colorado and Steve Bullock of Montana, have made health a priority in their states and are among the governors who have signed on to bipartisan efforts to shore up parts of the Affordable Care Act that are not working. Both governors are also among the long list of Democrats mentioned as possible presidential candidates in 2020.

Meanwhile, actions in Washington, including this week’s regulation expanding the availability of association health plans, often leave states scrambling to figure out what it will mean for their own health insurance markets.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Both governors said they think health care will be a dominant voting issue in 2018 and 2020. They say governors are among the few who are able to work on the issue on a bipartisan basis.
  • The conservative health plan unveiled this week as a replacement for the Affordable Care Act would give states more flexibility. It also would likely pose an enormous challenge because, over time, it would reduce the amount of federal health care dollars and wouldn’t give states much time to implement their programs.
  • If a federal court in Washington, D.C., opts to throw out Kentucky’s Medicaid work requirement for nondisabled adults, expansion plans in a number of states could be thrown into disarray. Some of them, like Kentucky, say they will not keep the expansion without the work requirement.
  • Montana offered a somewhat different path to work for people who are covered under the Medicaid expansion. Eighty percent of them are working already. Instead of being punitive, Bullock said, the state made a number of support services and employment training options available and, in turn, that raised the number of those working by 9 percent.
  • Hickenlooper said that in Colorado, because the unemployment rate is below 3 percent, most of the nondisabled adults who were covered under Medicaid expansion and not working are instead caring for their children or elder family members.

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Postcard From D.C. Courthouse: Medicaid Work Requirements And Manafort

It’s probably safe to say that the scrum of reporters — noses and lenses pressed up to the glass doors of the E. Barrett Prettyman Federal Courthouse in Washington, D.C., — were not there to cover a hearing regarding Kentucky’s work requirements for some Medicaid recipients.

No, the news satellite trucks parked outside and long queue of spectators stacked up against the building where there to catch a glimpse of Paul Manafort, President Donald Trump’s former campaign chairman, who was appearing that same morning before another judge in another federal courtroom.

But while the hearing for the Stewart v. Azar case might not have generated as much buzz as Manafort’s, it has the potential to impact many more people. Kentucky itself says as many as 95,000 enrollees would likely lose coverage.

Judge James E. Boasberg acknowledged that he wasn’t presiding over the flashiest case in the courthouse.

“I guess the Paul Manafort overflow room was full so you decided to come in here,” he said.

Even so, Boasberg’s courtroom was packed, with about 65 people inside and a few others waiting outside.

People started to line up for entry more than 90 minutes before the hearing’s 11 a.m. start. They huddled in the cream-colored hallway near its marble pillars to discuss health policy — and the Manafort scene. By 10:30 a.m., a security guard arrived on the scene to shush the assembled crowd, complaining that she could hear their chatter from “every level” of the courthouse.

Who knew Medicaid wonks were such a rowdy bunch?

There was a lot at stake, though. The case’s outcome could reverberate across the country and help determine how much authority the Trump administration has to unilaterally change Medicaid.

Medicaid is the federal-state health insurance program for low-income and disabled people. Kentucky expanded Medicaid under the Affordable Care Act, but got approval from the Trump administration this year to require healthy adults who gained that coverage to prove that they are working, volunteering or taking care of family members for at least 80 hours each month.

Three advocacy organizations sued the federal government on behalf of 15 Kentucky Medicaid recipients who said they would lose their coverage if the work requirements, and some other aspects of Kentucky’s plan, were implemented.

The crux of the argument boiled down to this: What is the purpose of Medicaid?

Ian Heath Gershengorn, the attorney arguing on behalf of the Medicaid recipients, said the Kentucky plan went too far. Instead of tweaking some things to make Medicaid better or allow it to serve more people, he argued that Kentucky was fundamentally turning it away from a program designed to improve medical access.

The main goal of the Medicaid statute, according to Boasberg, was to furnish “medical assistance” to people. How then could stripping coverage from 95,000 individuals fit that definition, he asked.

Justice Department attorney Ethan Davis said people who lost their coverage because of the work requirement would find it in the private or employer-sponsored market. Plus, the secretary of Health and Human Services had interpreted Kentucky’s plan to be consistent with Medicaid’s, he added.

Davis also said if Kentucky’s work requirements were struck down, it would discourage other states from expanding their Medicaid programs.

Boasberg said he would try to have a decision by the end of June. Kentucky’s work requirements are scheduled to go into effect July 1.

As Medicaid Costs Soar, States Try A New Approach

MINNEAPOLIS — Sandy Dowland has been to the emergency room 10 times in the past year and was hospitalized during four of those visits. She has had a toe amputated and suffers from uncontrolled diabetes, high blood pressure, major depression, obesity and back pain.

But her health is not high on the 41-year-old woman’s priority list.

“I have a lot going on,” said the unemployed mother of five who lives in a homeless shelter. She said it’s a struggle just to get herself and children through each day.

Her health bills are covered by Medicaid, the state-federal health insurance program for the poor. That’s a relief for her, she said. But state officials say Medicaid is busting Minnesota’s budget, particularly with patients like Dowland and its system of paying hospitals for each admission, ER visit and outpatient test.

To ease that financial strain, Minnesota is at the forefront of a growing number of states testing a Medicaid payment system. It rewards hospitals and physician groups holding down costs by keeping enrollees healthy.

Under this arrangement, those health care providers are asked to do more than just treat medical issues such as diabetes and heart disease. They are called on to address the underlying social issues — such as homelessness, lack of transportation and poor nutrition — that can cause and exacerbate health problems.

It’s why North Memorial arranged for a community health worker and paramedic to meet Dowland on a recent weekday at a day care center for homeless families. They advised her on how to take her insulin, prodded her to use a patch to quit smoking and helped her apply for Social Security disability payments and food stamps.

“This is nice to have someone who I can talk to about everything in my life and give me access to the community resources I need,” said Dowland, who added that she puts off her own health needs in order to care for her children and look for housing and a job. “I appreciate the help because, at the clinic, the doctor doesn’t have time for this.”

North Memorial is among 21 health systems in Minnesota participating in this new model of care, called accountable care organizations. ACOs get to share in money they save Medicaid by keeping spending under a budget and by reaching quality targets, such as averting hospital-acquired infections and controlling patients’ blood pressure and asthma.

The shift toward ACOs is occurring with Medicare and employer-sponsored insurance, too. But for Medicaid programs, it presents unique challenges. Medicaid enrollees, by definition, are low-income. Many have little experience navigating health systems and large numbers are homeless or dealing with mental health problems, conditions that can lead to difficulties in encouraging healthy behaviors.

“The goal [of ACOs] is really exciting to make health systems more responsive to what people need to be healthy,” said Ann Hwang, director of the center for consumer engagement and health innovation at Community Catalyst, a Boston-based consumer advocacy group. “But the jury is still out as to whether they are really moving the needle in addressing social services such as transportation, housing and food insecurity — the things we know affect people’s ability to be healthy.”

Nationwide, a dozen states are experimenting with Medicaid ACOs and 10 more are making plans for them.

About half of Minnesota’s 1 million Medicaid recipients are in ACOs, which officials said saved the state $213 million since 2013. Hospitals and doctors received $70 million of that.

In addition to North Memorial, other participating health systems include the Mayo Clinic and Hennepin Healthcare, the state’s largest safety-net provider based in Minneapolis.

‘Going To Where The Patient Is’

For giant health systems that for years have competed by adding the latest technology or building sleek facilities, the ACOs are a huge shift. In effect, the ACOs push hospitals to address patients’ problems before they end up in the ER or operating rooms.

“We are learning to have to do a better job of going to where the patient is … as we now realize we are responsible for the patient when they are engaged with us and when they are not here,” said Robert Stroebel, who helps leads the ACO effort at Mayo Clinic.

So far, the model isn’t proving to be a panacea.

In six states using ACOs, a March federal study in found, Medicaid enrollees received more primary care services — such as doctor visits — but the program did not reduce hospital visits in most states or lower costs.

“Changing provider and beneficiary behavior may take more time than the few years this report covers,” concluded the study.

Minnesota’s experience demonstrates the challenges of changing to a new Medicaid payment system. In 2016, the latest year for which data are available, only six of the 16 ACOs were eligible to share in cost savings.

But Marie Zimmerman, Minnesota’s Medicaid director, noted the state’s program has seen a 7 percent cut in ER visits and a 14 percent reduction in hospital stays in areas where health providers participate in an ACO.

“Medicaid is 20 percent of Minnesota’s population, and we have to care about getting the best deal and the long-term fiscal ability of the program and not cutting eligibility and provider rates and benefits to show sustainability,” she said.

At Hennepin Healthcare in Minneapolis, Dr. Allison Wert examines Medicaid enrollee Rachel Rowell, who participates in the ACO.(Phil Galewitz/KHN)

Struggle To Change Behaviors

The switch to ACOs accelerated efforts by hospitals and physician groups to attack so-called social determinants of health, such as the lack of stable housing and poor nutrition. But providers still struggle to change patients’ behaviors, particularly helping those with addiction and mental health problems, according to interviews with officials at several ACOs.

Doctors, nurses and social workers at Hennepin dealt with that head-on during a recent routine review of their patients. When they came to a 58-year old man suffering from alcoholism, anxiety and heart problems and living in a homeless shelter, they noted how they couldn’t get him into a primary care clinic and saw him only during frequent hospital admissions.

“Best we can hope for him is if we can facilitate a safe ending,” said Dr. Rachel Silva, a Hennepin internist, acknowledging that despite their best intentions, health providers likely would not be able to prevent his early death.

Even with teams of nurses, social workers and community health workers, Hennepin officials say they struggle to keep up with many Medicaid enrollees who have addiction problems, and many patients still go to the ER out of habit or convenience rather than the organization’s primary care clinics, which are as close as across the street.

Yet, there are success stories, too. The Mayo Clinic has started a community health worker program to help at-risk patients connect to social services such as housing and transportation.

Nancy Zein, 47, a Medicaid recipient who uses the Mayo Clinic, said having weekly meetings with community health worker Tara Nelson has been life-changing for her and her mother, who is also on Medicaid.

“She’s been a godsend,” said Zein, who noted how Nelson helped her get Social Security disability payments and her mom find affordable housing for disabled adults, as well as get both enrolled for food stamps.

“It’s made such an impact on our health,” Zein said. “My mom has depression issues, and with Tara helping us with housing, it helped her depression.”

With the opportunity to share in financial savings, North Memorial has hired additional community paramedics to visit high-risk patients. Mayo Clinic has added community health workers to help patients find housing and transportation and nurses to make home visits to patients after leaving the hospital. Hennepin set up special clinics for the most challenging Medicaid patients and sends doctors to care for patients in homeless centers, jails and the county’s mental health center — to reach people who may need help even before they are likely to end up in their ER and on Medicaid.

Nearly 20 percent of Hennepin’s adult Medicaid ACO members are homeless. In the past four years, social workers and other staff have helped more than 500 of their Medicaid patients — including in the ACO — get into public housing.

Cuts For Managed-Care Companies

The ACO model has raised concerns among managed-care companies that Minnesota and other states have used for decades to control Medicaid spending. Those companies get a monthly fee from Medicaid for each enrollee and often require those patients to seek care with doctors and hospitals that have contracts with the managed-care firm. The companies profit if they spend less on care than they receive in the state allotment.

“We are aligned with the goals … to explore innovation and provide better delivery of care,” said Scott Keefer, vice president of Minnesota Blue Cross and Blue Shield of Minnesota, which has 300,000 Medicaid members. But, he added, much of the ACO savings cited by state officials are dollars taken from managed-care company profits.

His health plan lost more than $200 million from Medicaid operations during the past two years, partly because it had to pay part of its state funding to ACOs.

“We are not magically saving money. … We are moving the financial deck chairs around,” he said.

Most Texans Want State To Expand Medicaid And Help Poor Get Health Care

Texans think the Legislature should expand Medicaid to more low-income people and make health care more affordable, according to a survey released Thursday.

Researchers surveyed 1,367 Texans between March and May of this year about topics ranging from Medicaid, the Affordable Care Act, maternal mortality and the role of government in tackling health care issues.

Here are some takeaways from the survey by the Kaiser Family Foundation and the Episcopal Health Foundation. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

1) Almost All Texans See A Role For The Texas Legislature

Texans overwhelmingly agree that the state should have a role in making health systems work. According to the survey, 67 percent of those surveyed said the state should have a “major role” and 28 percent said a “minor role” in health care. Only 5 percent of Texans said the state should have no role.

“A majority of Texans say that the state has an important role to play in health care,” said Elena Marks, the president and chief executive officer of the Episcopal Health Foundation. “The state is not doing enough and the state should spend more. And people also believe that the state has a role to play in increasing access to insurance.”

2) Texans Are Concerned About Maternal Deaths

When asked what the state Legislature should make a top health care priority, 59 percent of Texans said “reducing the number of women who die from causes related to pregnancy and childbirth.”

That response came in a close second to “lowering the amount individuals pay for health care” (61 percent).

Marks says she thinks a lot of this concern is probably related to media coverage around maternal mortality and that the question itself is really a “no-brainer.”

“‘You mean people are dying from pregnancy and childbirth?’” she said. “I think people may just look at that and go, ‘Well, of course you should be doing something about that.’”

3) Medicaid Expansion Is Popular

About two-thirds of Texans (64 percent) said they think Texas should expand Medicaid to cover more low-income people. Texas is 1 of the 17 states that have not expanded Medicaid under the Affordable Care Act.

Even though feelings in the state are still mixed on the ACA, the survey found that Medicaid is quite popular.

“Roughly 4 million people are covered by Medicaid in Texas, nearly three-quarters of whom are children,” according to the survey’s authors. When asked, 6 in 10 Texans said Medicaid is important to their families.

Marks said she thinks the conversation about Medicaid expansion in Texas is limiting for people seeking more insurance coverage here. She says the state should have a conversation about coming up with its own way to expand access to affordable coverage, which is a popular idea across the political spectrum.

“Let’s stop talking about Medicaid expansion and let’s start talking about expanding access to affordable health insurance coverage,” Marks said.

4) Texans Say We Aren’t Helping The Poor Enough

Roughly two-thirds of Texans also say the state is not doing enough to make sure low-income people get the health care they need.

Respondents also think lawmakers could do more to help children (45 percent) and immigrants (41 percent) get coverage. Broken down by party, Republicans were less likely to say that the state is not doing enough to help vulnerable populations get health care services.

5) A Lot Of Texans Don’t Know Basic Facts About Health Care Here

One of the standouts in this survey is how little people know about the state’s health care system. Consistently, however, Republican respondents were more likely to be misinformed.

For example, groups asked Texans whether the state’s uninsured rate is higher compared to other states. According to the survey, 3 in 10 Texans (31 percent) correctly answer that it is higher. Broken down by party, only 24 percent of Republicans knew Texas has a larger than average share of uninsured people, while 38 percent of Democrats did.

Marks says that could explain why Republicans are less likely to say they think there are problems with the state’s health care system.

“If you think we have about the same or lower uninsured rates, then you don’t think there’s a problem unique to us that we need to solve,” she said.

Texans were also asked whether Medicaid had been expanded in the state; 51 percent of those surveyed correctly said the state had not expanded it.

According to the study’s authors, “Democrats are somewhat more likely than Republicans and independents to know that Texas has not expanded its Medicaid program” (62 percent, 43 percent, and 52 percent, respectively).

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.


KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

5 Things To Know About Medicaid Work Requirements

The Trump administration’s decision in January to give states the power to impose work requirements on Medicaid enrollees faces a federal court hearing Friday.

The lawsuit before the U.S. District Court in Washington, D.C., will determine whether tens of thousands of low-income adults in Kentucky will have to find jobs or volunteer in order to retain their health coverage.

But the ruling could have far-reaching implications affecting millions of enrollees nationwide and determining how far the Trump administration can go in changing Medicaid without congressional action.

Kentucky was the first of four states, so far, to win federal approval to advance a work requirement. Indiana, Arkansas and New Hampshire are the others. Each is now in the early stages of implementation.

Arkansas, for instance, in June began having Medicaid enrollees inform the state about their work status. In September, the state could begin disenrolling members who fail to report or meet the work rules.

Seven more states — Arizona, Kansas, Maine, Mississippi, Ohio, Utah and Wisconsin — have applications pending and several others are poised to join them.

Kentucky’s legal challenge encapsulates a debate about two competing views of the role of Medicaid, the nation’s largest health program that covers nearly 75 million low-income Americans.

The Trump administration and many conservatives see it as a welfare program that should provide only temporary help and should prepare enrollees to gain employment and negotiate private health insurance.

Democrats, advocates for the poor and most legal experts see Medicaid as a health program meant to help the nation’s poorest citizens access health coverage. They say the administration’s approach of requiring enrollees to work to get health coverage is backward because enrollees need health coverage so they are healthy enough to work.

“There is zero evidence to suggest that depriving people of Medicaid will lead to greater levels of employer insurance,” 40 health policy scholars wrote in an amicus brief supporting the lawsuit filed on behalf of several Kentucky Medicaid enrollees.

“The CMS work ‘demonstration’ destroys, not improves, Kentucky’s substantial health care achievements and defeats, rather than promotes, Medicaid’s purpose as a safety net insurer,” according to the brief.

The 2010 Affordable Care Act spurred 33 states to expand Medicaid to nondisabled adults without children. Before that, the program mainly served children, pregnant women and people with disabilities.

That expansion, which provided billions in new federal funding to states, triggered an unprecedented drop in uninsured rates nationwide and tempted some Republican governors to pursue the additional health care dollars. But some of these GOP-controlled states also sought to add the new work requirement, in part to show conservative voters they weren’t simply providing a government handout to poor adults.

States that didn’t expand Medicaid and have some of the strictest eligibility limits in the country —including Kansas and Mississippi — also applied for work requirement waivers.

Here are five things to know as this court case unfolds:

1. Why do the Trump administration and states want to add the new work requirement?

Top Trump officials say the work requirement is meant to help enrollees find jobs. They say people who work or do volunteer service are healthier. Seema Verma, administrator of the U.S. Centers for Medicare & Medicaid Services, said Medicaid should be a “hand up” not a handout.

According to CMS, while the work requirement is a change in policy, it still fits within the agency’s long-standing missions of promoting health and improving health outcomes.

2. How does the work requirement work?

Kentucky’s program would require nondisabled adults each month to participate in 80 hours of work, job training, education or other qualified “community engagement.”

Those who are exempt include children and former foster care kids; pregnant women; seniors; people who are the primary caretakers for a child or a disabled adult; those who are deemed medically frail or diagnosed with an acute medical condition that would prevent them from working; and full-time students.

Adults in northern Kentucky would have to begin registering their work hours this summer, and the rest of the state would follow by the end of 2018.

State officials acknowledge the new requirement could be complicated for many enrollees. “We need to be careful and thoughtful how we roll out the ‘community engagement,’ recognizing this is a huge change,” said Kristi Putnam, deputy secretary for Kentucky’s Cabinet for Health and Family Services.

States have set up different rules on how many hours a month Medicaid enrollees must work or volunteer and who is exempt.

In Arkansas, everyone enrolled in Medicaid has to document their work hours through an online portal created by the state — with no option to submit information in person, over the phone or by mail. Critics of the work requirement fear that will be a barrier, considering the state has the second-lowest rate of home internet access in the nation.

3. What are the main objections to the work requirement from a legal and practical standpoint?

Critics say the requirement would lead many low-income people to lose their health coverage and, therefore, hinder their ability to get medical care. They note Kentucky’s own projections show that 95,000 Medicaid enrollees would lose coverage within five years.

The work-requirement approvals were based on the Health and Human Services secretary’s authority to test new ways of providing Medicaid coverage. The critics also argue, though, that the Trump administration is overstepping its statutory boundaries because the requirement would reduce eligibility rather than expand it.

Lastly, work requirement opponents note most people on Medicaid already work — or go to school, have a disability or care for relatives.

A June 12 Kaiser Family Foundation study concluded that only 6 percent of able-bodied adults on Medicaid who are targeted by states’ work requirements are not already working and unlikely to qualify for an exemption. In addition, 6 in 10 nondisabled adults on Medicaid work at least part time, although they often aren’t offered health benefits through those jobs or can’t afford them. (Kaiser Health News is an editorially independent program of the foundation.)

Surveys show that many Medicaid enrollees who don’t work are in job training, go to school or are taking care of a child or an elderly relative, conditions that would make them exempt from the new mandate.

4. When is the court expected to rule, and could this issue go to the Supreme Court?

Both sides expect a quick decision, likely by late June. But an appeal is likely no matter who wins.

If the Trump administration wins, it’s uncertain if plaintiffs will be able to get a stay on the work requirement taking effect while an appeal is in process.

5. While the work requirement is getting most of the attention, what else is at stake in the court case Friday?

The lawsuit filed by advocates on behalf of Medicaid enrollees seeks to overturn the entire Kentucky Medicaid waiver approved by the Trump administration in January.

Kentucky’s waiver also sets precedent because it would become the first state to charge Medicaid premiums of up to 4 percent of an individual’s income. The current limit has been 2 percent. Moreover, Kentucky would become the first state to lock out Medicaid enrollees from coverage for up to six months for failure to timely renew their coverage or failure to alert the state if their income or family circumstances have changed.