Tagged Medicaid

Medicaid Officials Target Home Health Aides’ Union Dues

Medicaid home care aides — hourly workers who help the elderly and disabled with daily tasks like eating, getting dressed and bathing — are emerging as the latest target in the ongoing power struggle between conservatives and organized labor.

About half a million of these workers belong to the Service Employees International Union, a public-sector union that represents almost 1.9 million workers in the United States and Canada. The union is an influential donor to liberal politicians and boasted strong ties to the Obama administration.

A proposed rule from the federal Centers for Medicare & Medicaid Services would prohibit home health aides paid directly by Medicaid from having their union dues automatically deducted from their paychecks, though it doesn’t name the fees explicitly.

Blocking these direct Medicaid payments means the workers — especially those who don’t work in a single, centralized office, or don’t have a credit card or a bank account — are far less likely to pay dues, diminishing the union’s potential influence.

CMS’ language affects only “individual providers” — that is, those who aren’t employed by the private, for-profit agencies that dominate this industry. Individual providers, who are technically state employees, are far more likely to be unionized.

The directive, which would overturn an Obama administration policy put in place to ease the collection of union dues and pay for other fees, such as health benefits, could take effect by the end of this year. A month-long comment period, ending Monday, has attracted more than 3,300 responses.

“This is just another way to make life more difficult for public-sector unions,” said Jake Rosenfeld, an associate professor of sociology at Washington University in St. Louis, who studies unions and their influence.

The proposed rule comes on the heels of June’s landmark Supreme Court ruling, in which a 5-4 majority held that public-sector workers don’t have to pay unions for the cost of collective bargaining, calling it a violation of their free speech.

That decision expanded on the Supreme Court’s 2014 ruling in Harris v. Quinn, in which the high court found that home care workers must explicitly state their desire to be in a union before the organization can collect dues. But because these workers are not attached to a single office or meeting point, organizing them into a collective unit poses a distinct challenge; collecting membership dues, even more so.

As union membership has waned in other sectors, organized labor has doubled down on home care, lobbying liberal governors to declare thousands of workers as state employees, rendering them eligible to organize and engage in collective bargaining.

The median annual salary for home health aides in 2017 was $23,100, with about 67 percent turnover in 2017. The federal Bureau for Labor Statistics projects that demand for home care will increase by as much as 41 percent from 2016 to 2026, as more Americans age.

Both SEIU and the National Employment Law Project, an advocacy group, said that, if the rule takes effect, they expect to file a lawsuit seeking to reverse the decision. And a spokesperson for California Attorney General Xavier Becerra, who has frequently clashed with the White House, said the state will “take any action necessary” to blunt its impact.

In states where home care workers are unionized, the group can have the state withhold membership fees from their paycheck and transfer them directly to the union. Workers must actively choose to join the union.

In California, where most home care workers don’t work for private agencies, about 250,000 belong to the state SEIU chapter.

“They’ll effectively lose their voice on the job and their ability to advocate,” said Laphonza Butler, president of SEIU Local 2015, the California branch of the union.

Beyond California, home care aides have unionized in states including Connecticut, Massachusetts, Minnesota, Illinois, Oregon, Vermont and Washington.

The government is arguing that federal law does not allow states to divert Medicaid dollars to pay for a home care worker’s other benefits, such as health care or job training.

“The law provides that Medicaid providers must be paid directly and cannot have part of their payments diverted to third parties outside of a few very specific exceptions,” said Tim Hill, acting director for CMS’ Center for Medicaid and CHIP Services, in a statement.

Supporters of the rule, such as the National Federation of Independent Businesses, argue it stops powerful unions from using taxpayer dollars to pad their lobbying budget.

But it’s a controversial take. Critics said CMS’ argument inappropriately casts workers’ paychecks as government property, instead of as their own money. And they said it leaves vulnerable workers — arguably, the backbone of elderly care — unable to fend for themselves.

“When a state pays a worker, and the worker pays the union, it’s the worker’s money going into the union,” said Benjamin Sachs, a professor at Harvard Law School who studies labor law. “CMS doesn’t have the authority to decide.”

Some conservatives suggested that limiting union membership is less about home care policy and more about curtailing a powerful liberal lobbying force.

“There have been steps taken in underlying law and practice to provide extra favors to public sector unions. They are as much political bodies as they are representatives,” argued Thomas Miller, a resident fellow at the conservative American Enterprise Institute.

But labor advocates warned the consequences could be steep, and not just for home care workers.

Surveys from the National Employment Law Project suggest that unionized home care workers stay in their jobs longer when represented by unions, partially because they can negotiate better pay and benefits. Higher pay also makes the job more appealing, especially as need grows.

That, many experts argued, means patients also benefit.

“We can be putting more money into making these good quality jobs. The shortages and turnover we are facing —it is not rocket science what is causing that,” said Caitlin Connolly, who runs the National Employment Law Project’s campaign to increase home care wages. “If we made these quality jobs, we would be able to ensure that people had access to quality care.”

Must-Reads Of The Week From Brianna Labuskes

The next time I even hint that we’re drifting into a slow news period, feel free to remind me not to jinx things: This week was bursting with industry moves, health law attacks, midterm strategizing, and, oh yeah — an indictment.

A quick programming note before we dive into all that: The Breeze is going on hiatus as I breeze out of town for a bit. But I’ll be back Aug. 31, just as we really start heading into midterm season, so look for me again then.

Now for the news you may have missed:

This week’s swipe at the health law focused on accountable care organizations (shorthand explanation: a program that took a carrot-and-stick approach to getting hospitals, doctors and other providers to coordinate, with the end result of higher-quality, more efficient care). They were supposed to save the government billions of dollars, but data show they’ve failed to measure up to the promise, so the program is being overhauled.

The Washington Post: Trump Administration Proposes Further Dismantling of Affordable Care Act Through Medicare

Rep. Chris Collins (R-N.Y.) was charged with fraud in connection to alleged insider trading after an investigation into his ties with Innate Immunotherapeutics, an Australian biotech firm.

Politico: GOP Rep. Chris Collins Charged With Securities Fraud

If that all sounded vaguely familiar, it’s because back when then-HHS secretary nominee Tom Price was being vetted for any possible ethics violations, his connection to both Innate and Collins was put in the spotlight. And just a small plug: KHN did deep reporting on this, and you can read the stories here.

Medicare Advantage got some leverage to curb drug costs this week by way of “step therapy” (or, as it’s known to critics, “fail first”). Essentially, the private plans will be able to require that patients try cheaper versions of drugs before moving on to more expensive ones. To be clear: This is a pretty distant cry from campaign promises to let Medicare negotiate drug prices, and there’s no guarantee patients will actually see any savings from this move.

Stat: Private Medicare Plans Will Be Able to Use a New Tool to Lower Drug Costs

Would a Netflix model work for drugs? That’s what Louisiana wants to find out. Under the proposal, the state would pay a subscription-type fee to be able to cover all of its Medicaid patients who need hepatitis C treatment. Beyond the click-baity notion, though, experts warn that because drug prices are such a moving target (with some costs coming down quickly) the state may not actually save money.

Stat: Louisiana Explores a ‘Netflix’ Subscription Model for Buying Hepatitis C Drugs

For even some moderate Democrats, “Medicare-for-all” is a pipe dream involving all sorts of politically unpopular complications like trillions of dollars in government spending (the current point of contention). But on the trail, it’s a rallying cry. Gubernatorial candidates, especially, are embracing it, suggesting their states become early testing grounds for universal coverage plans that have been more rhetoric than action so far.

The Washington Post: Tossing Aside Skepticism, Democratic Candidates for Governor Push for State-Based Universal Health Care

The Hill: Ocasio-Cortez: ‘Medicare for All’ Is ‘Not a Pipe Dream’

Apart from “Medicare-for-all,” Democrats could have a winning health issue with drug prices. The problem? They can’t really coalesce behind a plan, all these “concessions” as of late are making it harder to attack the administration, and, uh, there may be a lack of interest in cutting off campaign cash this close to the elections.

Stat: Drug Prices Could Be a Winning Issue for Democrats — If Only They Had a Plan

The idea to penalize legal immigrants’ use of Medicaid has been rumbling around for a bit now, but it picked up some speed in recent days. Though it could be a winning issue for Republicans on the trail, the argument isn’t really backed up by the data. It turns out that legal immigrants are likely subsidizing native-born Americans’ health care.

The New York Times: Plan to Punish Immigrants for Using Welfare Could Boost G.O.P. Candidates

The Hill: Study: Immigrants Have Lower Health-Care Costs Than People Born in US

Buckle up, there were industry moves galore this week. I’ll try to keep it quick:  Billionaire Carl Icahn came out against Cigna’s attempts to acquire Express Scripts, saying it is (in my favorite vocab usage of the week) a “$60 billion folly”;  Rite Aid called off its (unpopular) merger with Albertsons; the American Medical Association came out against CVS’ deal with Aetna; and GM signed an exclusive deal with a health system to provide care for its workers.

The Wall Street Journal: Carl Icahn Publicly Opposes $54 Billion Cigna-Express Scripts Deal

The Wall Street Journal: Rite Aid, Albertsons Call Off Merger Amid Investor Opposition

Reuters: American Medical Association Opposes Merger of CVS and Aetna

The Wall Street Journal: GM Cuts Different Type of Health-Care Deal

If that wasn’t enough news for you, here’s my miscellaneous file: A billionaire and his PTSD clinics have become entangled in the fierce debate over VA privatization; a look at how Zika babies are faring as they grow up is sobering in the breadth of damage the virus has done; an app can warn those recovering from addiction when they’re in neighborhoods or with acquaintances that could trigger a relapse; and a medical examiner is writing to doctors personally each time one of their patients dies from an overdose — and it’s working.

ProPublica: Steve Cohen Is Spending Millions to Help Veterans. Why Are People Angry?

The Washington Post: 1 In 7 Babies Exposed to Zika in U.S. Territories Have Birth Defects, Nervous System Problems

Stat: Can An App’s Warnings to Avoid Triggers Prevent Opioid Addiction Relapses?

Los Angeles Times: Coroner Sent Letters to Doctors Whose Patients Died of Opioid Overdoses. Doctors’ Habits Quickly Changed

 —

And don’t miss one of my favorite long reads of the week (which I got sucked into while on deadline, thank you very much) about an Appalachian odyssey and a hunt for ALS genes.

Stat: Appalachian Odyssey: Hunting for ALS Genes Along a Sprawling Family Tree

Have a great weekend, all!

Medicaid Expansion Making Diabetes Meds More Accessible To Poor, Study Shows

Low-income people with diabetes are better able to afford their medications and manage their disease in states that expanded Medicaid under the Affordable Care Act, a new study suggests.

The Health Affairs study, released Monday afternoon, found a roughly 40 percent increase in the number of prescriptions filled for diabetes drugs in Medicaid programs of the 30 states (including Washington, D.C.) that expanded eligibility in 2014 and 2015, compared with prior years.

By contrast, states that didn’t embrace the Medicaid expansion saw no notable increase.

“Gaining Medicaid insurance would have significantly reduced out-of-pocket spending for insulin for previously uninsured patients, thereby facilitating uptake of the medication,” the Health Affairs study said.

Diabetes, characterized by abnormally high blood sugar, is a chronic disease thfat requires expensive and ongoing medical care.

In the long run, preventing diabetic complications not only saves lives, but it improves public health and saves public money,” said Dr. Michael Bush, an endocrinologist in Beverly Hills, Calif., and president of the California chapter of the American Association of Clinical Endocrinologists.

Bush and other experts said the Health Affairs study shows that the Medicaid expansion can help patients manage their health and also limit unnecessary spending. An analysis by the Centers for Disease Control and Prevention cited by the study shows that each diabetic patient who is treated for the condition can lead to a $6,394 reduction in health care costs (in 2017 dollars) because of fewer hospital admissions.

In California, roughly 3.9 million people gained coverage when the state expanded eligibility for Medi-Cal, the state’s version of the federal Medicaid program. In all, about 13.5 million people — more than one-third of Californians — are enrolled in Medi-Cal.

By 2016, about 12 million people had enrolled in Medicaid nationwide as a result of the expansion, according to the Kaiser Family Foundation. The foundation estimates that more than 2 million people who live in non-participating states would have qualified for Medicaid had their states chosen to expand. (Kaiser Health News is an editorially independent program of the foundation.)

“It’s not particularly surprising that extending Medicaid opened up this door for lots of other people to be able to fill prescriptions and be able to take advantage of managing a chronic disease like diabetes,” said Flojaune Cofer, director of state policy and research at Public Health Advocates, a nonprofit organization based in Davis, Calif., that seeks to eliminate health inequalities in California.

But Michael Cannon, director of health policy studies at the libertarian Cato Institute, said the Medicaid expansion may not mean good news for everyone.

Medicaid pays a fraction of a drug’s list price, so pharmaceutical companies may hike prices for everyone if they don’t feel they’re being compensated fairly, he said. That, in turn, could drive up everyone’s premium costs or lead those with private insurance to pay more out-of-pocket.

“You have to look at not just the immediate effects of a policy, but all of the effects of a policy,” Cannon said. “As prices rise, fewer people will be able to afford diabetic medications.”

Last year, nearly 900,000 Californians with Medi-Cal were known to have diabetes, according to state figures.

One of them is James Warden, 62, a retired rancher near Fresno, Calif., who said he was forced to stop working because of a back injury several years ago.

Warden enrolled in Medi-Cal in 2016 and was diagnosed with diabetes last year after a urinary condition landed him in the hospital, he said. Without the coverage, he said, he wouldn’t have the insulin his body needs.

“Medi-Cal saved me,” he said. “I wouldn’t have the money to be able to pay, or go to the doctor or anything.”

The researchers found that people in groups with a higher prevalence of diabetes before the ACA became law, such as those ages 55–59, showed larger increases in filling their diabetes prescriptions after the Medicaid expansions.

The price of insulin, a staple medication for many diabetes patients, rose almost 200 percent from 2002 to 2013, according to the study.

And nearly 40 percent of insulin users who responded to the American Diabetes Association’s 2018 insulin affordability survey reported that they had faced a price increase in the past year. As a result of the price hikes, many said, they took less of the medication, missed doses or switched to a cheaper drug.

In states that didn’t expand Medicaid after 2014, such as Texas and Florida, the number of diabetes prescriptions filled remained relatively flat, the study found. In these states, low-income and uninsured diabetics must rely on a “patchwork of options” to get insulin and other medications to treat their disease, according to the American Diabetes Association. Patients may need to seek help through drug company patient assistance programs or charities, the group said.

The study also showed a surge in filled prescriptions for newer, pricier diabetes drugs that have fewer side effects and control diabetes more effectively. And there was an increase in prescriptions for metformin, a generic drug that is often used as a first line of treatment for new Type 2 diabetes patients.

The rise in metformin prescriptions suggests the federal health law also led to more people being diagnosed with the disease, the authors said.

The study, conducted by University of Southern California pharmaceutical and health economists, was based on an analysis of filled prescriptions before and after the state Medicaid expansions began in 2014. The number of states that expanded Medicaid has since grown to 33 states and Washington, D.C.

The prescriptions analyzed cover the period from 2008 to 2015. About 15 percent of retail pharmacies did not share their information, and the data did not include prescriptions filled by health clinics or via mail-order, which could have led to underestimates of the total effect, the authors said.

Bush, the Beverly Hills endocrinologist, acknowledged that providing diabetes drugs to Medicaid patients is costly to taxpayers. But he said it’s money well spent.

“This is clearly a disease where if you take care of it now, you can prevent complications that occur later,” he said.


KHN’s coverage of these topics is supported by
California Health Care Foundation
and
Laura and John Arnold Foundation

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

In Weary Post-Storm Puerto Rico, Medicaid Cutbacks Bode New Ills

SAN JUAN, Puerto Rico — Blue tarps still dot rooftops, homes lack electricity needed to refrigerate medicines, and clinics chip away at debts incurred from running generators. Yet despite the residual effects from last year’s devastating hurricanes, Puerto Rico is moving ahead with major cuts to its health care safety net that will affect more than a million of its poorest residents.

The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory’s agreement with the federal government as the island claws its way back from fiscal oblivion.

Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory’s historically astronomical Medicaid expenses — on an island where the average household earns $20,000 and diabetes and hypertension are widespread.

But physicians, health insurers and former government officials say the drastic cuts demanded defy actuarial science and provide too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks will give private health insurance companies the incentive to shuttle around patients with costly chronic diseases or mental illness, critics warn. And they do nothing to address the underlying fiscal imbalance at the root of Puerto Rico’s health care woes, which stem from the fact that the federal government contributes a tiny fraction of the island’s Medicaid budget, compared to what it contributes to the 50 U.S. states.

“We are rearranging the chairs on the Titanic,” said Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.

Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.

“These people who have been under our service for the last four or five years, all of a sudden I have to abandon them,” said Dr. José Joaquín Vargas, chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

Health Crippled By Debt

If Puerto Rico were a state, the federal government would pay 83 percent of Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according to a formula that takes a state’s economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent, as a fixed annual payment — a so-called block grant.

In February, Congress approved $4.8 billion in additional funds to help pay the island’s Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory’s fiscal oversight board. That’s a federal control board established by Congress in 2016 to oversee Puerto Rico’s budget, negotiate with its creditors and help restructure at least some of the island’s debt.

Gov. Ricardo Rosselló’s administration aims to reduce Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló’s plan, the companies will be forced to offer island-wide insurance plans and compete for customers.

“We do not have the luxury” of continuing to spend inefficiently, said Ángela Ávila Marrero, executive director of Puerto Rico’s Health Insurance Administration.

If Rosselló’s overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Some 1.1 million Puerto Rican residents on Medicaidout of 1.6 million enrollees — are at risk of losing coverage next fall, their health held hostage to the island’s need to pay back its crippling debt.

Puerto Rico’s government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession, a corporate tax break that ended in 2006 and reckless spending by a bloated government.

But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico’s staggering Medicaid burden.

Poverty is so pervasive here that nearly 1 in 2 people qualify for public health insurance; Medicaid expenses in 2016 totaled $2.4 billion. Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.

Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island’s fiscal health, health economists say.

Researchers of health care say that, putting aside interest on Puerto Rico’s debt, the territory’s primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.

“The main issue is that we are not yet a state,” said Rep. Jenniffer González-Colón, the commonwealth’s nonvoting member of Congress. The island must pay for Medicaid, she added, “with local funds that we don’t have.”

Battered Even Before The Storm

Puerto Rico’s health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act and 900,000 Puerto Rican residents would lose coverage.

Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology and fueled the exodus of thousands of physicians to the mainland in search of better incomes.

Today, Medicaid patients face long waits to see doctors on the island.

“If your kid needs a neurologist, for example, the waiting period is around six to 12 months,” said Dr. Jorge Rosado, a pediatrician in San Juan. “For a genetics specialty, it’s two to three years.”

The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.

Little Time To Waste

Barring the unlikely passage of bills that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out next fall. González-Colón also authored a bill calling for statehood, which would eliminate the federal government’s unequal treatment toward the island’s Medicaid program.

The fiscal control board established by Congress openly acknowledges the impending disaster. In an April 19 report, the board projects monthly costs per Medicaid patient will rise nearly 40 percent over the next six years, barring any changes, and that Puerto Rico “will hit a ‘Medicaid cliff.’”

Beginning this fall, Medicaid patients will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.

Puerto Rico has long capped monthly payments insurers receive for Medicaid patients regardless of how many medical services they use, a form of managed care. But the government here believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.

The island’s government has vowed to pay private insurers extra money to care for those with expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.

“I support the government on what they’re trying to do, but they didn’t price it properly,” said Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.

He added, “The oversight board is fixated on cuts, but we’re never going to improve health care unless more money is put into the system.”

Government health officials argue Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But the island’s clinics and hospitals fear they will be squeezed by insurers seeking to lower costs, just as they are still reeling from hurricane-related expenses.

Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.

Many experts are skeptical that managed-care companies will hire the army of social workers and nurses like Calderón needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty. Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.

Many people displaced by the storm haven’t yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.

“The managed-care companies need to produce revenue,” said Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. “That’s a setup for concern.”

Bottom line? The economic overhaul doesn’t rectify Puerto Rico’s fundamental problem — it can’t sustain its Medicaid program so long as Congress treats the territory differently than it treats states.

“Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens,” said Torres. But, he added, “it’s time the local government started thinking about a Plan B.”