JustCare

Category: Medicaid

  • Medicare and Medicaid at 50: Their roles in our health care system

    Medicare and Medicaid at 50: Their roles in our health care system

    A 2015 article in Health Affairs by Drew Altman and Bill Frist speaks to Medicare and Medicaid at 50, looking at the numbers, their roles in our health care system, the challenges they face and emerging issues. Medicare, a federal social insurance program, helps ensure older adults and people with disabilities have affordable access to the care they need. Medicaid, a joint state and federal program, covers older adults, people with disabilities and people with low incomes.

    The Medicare and Medicaid numbers:

    • Collectively, they serve 111 million people, one in three Americans
    • By 2025, they will serve 139 million people
    • Ten million people have Medicare and Medicaid
    • They are responsible for $1 trillion in annual health spending, 39 percent of national health spending and 23 percent of the federal budget
    • They generate 43 percent of hospital revenues
    • Median income for people with Medicare is $23,500 and with Medicaid is $15,000

    The emerging issues:

    • Will Medicare and Medicaid continue to be “open-ended” programs, with guaranteed benefits and no spending cap?
    • Will they become increasingly privatized? Today, less than a third of people with Medicare are in private Medicare Advantage plans, but the number could increase. And, more than half of people with Medicaid are in private managed care plans.
    • Will they shift more costs onto the people they serve?
    • Will they continue to play a role in reshaping delivery of care and reform of our health care system?

    To date:

    • Expansion of Medicare and Medicaid eligibility and benefits; Medicare now covers people with disabilities and people with ALS and ESRD; Medicaid now covers people with incomes up to 138 percent of the federal poverty level in most states.
    • Stronger financial incentives to improve quality and efficiency
    • Polling data show both Medicare and Medicaid remain very popular. 72 percent of Americans have a favorable view of Medicare and 90 percent of adults 65 and older.

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  • John Oliver: Republicans are blocking access to health insurance in 20 states

    John Oliver: Republicans are blocking access to health insurance in 20 states

    In this video segment, John Oliver explains how the Supreme Court hurt millions of Americans by not upholding the Affordable Care Act in its entirety, why elections matter, and how Republicans in 20 states are turning away millions of dollars from the federal government. The government money is intended to cover 90 percent of the cost of health insurance for people with low incomes.

    By rejecting these funds designed to pay for an expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level ($27,724 for a family of three), the states deprive more than three million of their residents 0f health care coverage. The median Medicaid eligibility income in the states that have not expanded Medicaid is 44 percent of the federal poverty level ($8, 840 for a family of three) and childless adults are not eligible even at that income level. And, unfortunately, the ACA did not contemplate that the Supreme Court would allow states to reject Medicaid expansion, so it does not offer subsidies to people with incomes up to 138 percent of the federal poverty level.

    There are few options for people caught in this health insurance coverage gap, other than moving to a state that has expanded Medicaid or taking on more work. For a primer on Medicaid and why it’s important to all of us, click here.

     

  • Cutting edge small nursing homes: Green Houses

    Cutting edge small nursing homes: Green Houses

    If you’re looking into nursing homes for yourself or someone you love, consider a Green House.  Green Houses, conceived by Dr. William Thomas, are non-traditional nursing homes that transform long-term care, focusing on person-centered care.  They are small nursing homes that are designed to look and feel like a real home. And they promote caregiver relationships based on mutual respect and empowerment to make the lives of their residents meaningful.

    Green Houses are for older adults with or without disabilities. Studies show that they improve quality of life for residents, with higher resident satisfaction and as good health outcomes.  

    Green Houses are designed for between 10-12 residents.  Each resident has his or her own bedroom and bathroom, and there is a shared living room, dining room and kitchen.  The residents design their own daily routines.  

    Caregivers, nurse assistants, and social workers work together as a team to provide personalized care for residents. They provide four times more personal and social contact with residents than a traditional skilled nursing home. Staff are happier with their work than traditional nursing home staff.  

    Studies show that the costs to Medicare and Medicaid are as much as $2300 less than a traditional nursing home.  And, data show fewer hospitalizations for residents relative to people in traditional nursing homes.  

    Green Houses can be established as part of a traditional nursing home or independently. They began operating in 2003.  Today, there are 175 Green Houses, with about 1700 beds, in 27 states.  More than half the residents have Medicaid.  There are 16,000 nursing homes in the U.S., with about 1.5 million beds.

    Click here to learn why community matters in later life.

  • Half a million people with low incomes unable to get mental health care in states that have not expanded Medicaid

    Half a million people with low incomes unable to get mental health care in states that have not expanded Medicaid

    In 1996, the Mental Health Parity Act was signed into law to guarantee that insurers did not restrict access to mental health care but rather imposed the same or higher annual or lifetime dollar caps on mental health benefits as on medical benefits. Unfortunately, a new study reveals that the 24 states that have not expanded Medicaid eligibility have left hundreds of thousands of people unable to get mental health care. More than half a million Americans with low incomes diagnosed with a serious mental condition struggled to get the mental health care they needed in 2014.

    • People with Medicaid. Medicaid covers a wide range of mental health care services. And, in the 26 states that expanded Medicaid eligibility as a result of the Affordable Care Act, an additional 350,000 people received mental health care.
    • People with Medicare: Medicare covers a wide range of mental health care services. If you’re enrolled in traditional Medicare, Medicare covers 80 percent of the cost of your care from a medical doctor or from another Medicare-certified mental health provider.
    • People with incomes under 138 percent of the federal poverty level ineligible for Medicaid. Today, 24 states have not expanded Medicaid eligibility to people with incomes up to $15,521, even though the federal government pays the full cost of their Medicaid coverage for the first three years. As a result, 569,000 Americans were unable to get mental health services. They were ineligible for Medicaid in their states and lacked the money to pay privately for care. Many of these people end up in jail or homeless at a significant cost to states and local taxpayers.
  • Vast majority of Americans want to expand Medicare and Social Security or keep spending as is

    Vast majority of Americans want to expand Medicare and Social Security or keep spending as is

    A new Kaiser Family Foundation survey of Americans reveals that the public views Medicare and Social Security as the two most important federal programs, slightly more important than federal aid to public schools and the military. Eighty-three percent of the public see Social Security as very important, and 77 percent see Medicare as very important.

    In fact, 41 percent of people want to increase funding for Medicare (48 percent would keep spending where it is) and 50 percent of people want to increase spending for Social Security (43 percent would keep spending where it is). Check out this video to watch Robert Reich make the case for expanding Medicare.

    Overall, seven of ten Republicans and independents and nine of ten Democrats see Medicare as very important. People over 65 value Medicare especially highly, regardless of party affiliation—85 percent of Republicans, 89 percent if independents and 92 percent of Democrats see Medicare as very important. Not surprisingly, people over 65 are more satisfied with their Medicare health insurance than people under 65 with their commercial insurance.

    Support for Medicaid, a program for people with low incomes, differs more significantly based on party affiliation. Fewer than half of Republicans (47 percent) see Medicaid as very important, while 62 percent of independents and 78 percent of Democrats feel Medicaid is very important.

    Read more here about Medicare coverage and the key differences between traditional Medicare and a private Medicare Advantage plan.

  • At 50, Medicare and Medicaid Face the Challenge of Pricey Drugs

    At 50, Medicare and Medicaid Face the Challenge of Pricey Drugs

    Medicare and Medicaid turned 50 last week. Middle age. It’s fair to say both programs are feeling the years, even as they remain basically healthy. Together, the programs insure one in three Americans. Medicare was recently pronounced solvent until 2030. And Medicaid is poised to grow significantly in coming years as more states expand their programs under provisions of the Affordable Care Act, or as it’s often called, Obamacare.

    The challenges to both programs are not going to let up, however. They are forecast to consume ever-larger chunks of the federal budget and state budgets—which of course means taxpayers are on the hook as baby boomers flood into Medicare over the next 10 years, and Medicaid expands.

    Many conservative politicians don’t like the sounds of that and are again proposing reforms to both programs that would weaken the guarantee and scope of coverage and likely shift costs to the elderly (Medicare) and low-income people (Medicaid).

    I suggest they instead support efforts to constrain health care spending overall, which is the root of the problem. There are hundreds of such efforts underway, with a push from Obamacare but also from innovations in every nook and cranny of the healthcare industry. And make no mistake, it’s an industry, very much driven by the profit motive in this country.

    To wit, one emerging challenge deserves special attention: the increasing number of very expensive specialty drugs. For a detailed discussion, see this piece I wrote last month.

    The gist is this:

    • Specialty drugs accounted for 30% ($112 billion) of the $374 billion spent on prescription drugs in 2014, and they drove the bulk of the 13% increase in drug spending that year over 2013, according to IMS Institute for Healthcare Informatics. That leap in drug spending contrasted with low single digit increases for the previous few years.
    • Specialty drugs range in price from $2,000 to $10,000 a month. One source pegs the average at around $36,000 a year. Most are made through bioengineering. They are often referred to as biologics. When there were just a few, it wasn’t a big deal. But now there are a couple dozen. Some treat rare diseases that afflict a small number of people, but an increasing number target cancer, multiple sclerosis, rheumatoid arthritis, immune system disorders, and even heart disease. Some 900 biologics are now in the research pipeline, according to a 2013 industry report. By some estimates, specialty drugs could comprise over 50 percent of all drug spending by 2020.
    • Medicare (via Part D, Part B and Medicare Advantage) pays 25% to 30% of the nation’s prescription drug tab each year. Consistent with IMS’s finding for drug expenditure overall, Medicare drug spending leapt 12.6% from 2013 to 2014, the fastest rise in years. Almost all that increase stems from specialty drugs.
    • One drug alone–Sovaldi for hepatitis C, at $84,000 for a 12-week course of treatment—cost Medicare $4.5 billion in 2014, becoming the single most expensive drug Medicare enrollees received.
    • In a brief commentary this month in the journal Mayo Clinic Proceedings, 118 cancer doctors from leading cancer treatment centers called for immediate steps to lower the price of cancer drugs, the average price of which has increased to over $100,000 a year in 2012.
      • They wrote: “Drug companies keep challenging the market with even higher prices. This raises the question of whether current pricing of cancer drugs is based on reasonable expectation of return on investment or whether it is based on what prices the market can bear.”   They also noted that the structure of both private insurance benefits and Medicare means some cancer patients needing a $120,000 drug can be saddled with out-of-pocket costs as high as $30,000.

    It goes without saying that for lower and middle-income families, that’s simply untenable.

    Are these pricey medicines worth the cost? Do they yield good value? Are they fairly priced? Or are drug companies profiteering, as the cancer doctors imply. And, if specialty drugs are going to remain very expensive, how are we possibly going to afford them?

    The answers to these questions aren’t yet clear. There’s emerging evidence that Sovaldi may be worth it, because it essentially cures hepatitis C.   The same cannot be said of many cancer drugs. There’s not the space to discuss this at length here. It’s a complex issue that involves tough ethical issues, clinical judgments, patient preferences, and contradictory evidence. Suffice it to say that evidence grows steadily that too many new cancer drugs priced at $50,000 to $150,000 a year are buying most patients only a few extra months of life, on average, and those may not be months with good quality of life.

    Solutions? See the cancer doctor’s recommendations. I concur with them.

    Slightly elaborated here are my top 3:

    1. Permit Medicare to negotiate prices directly with drug companies, now explicitly barred by the 2003 Medicare Prescription Drug, Improvement, and Modernization Act.   As Medicare moves swiftly to pay providers based on the quality and value of their care, the same should hold for prescription drugs.
    2. Authorize the Patient-Centered Outcomes Research Institute (PCORI) to evaluate the benefits and value of new drug treatments, and include price in their assessments. That’s now blocked by a provision in the Affordable Care Act, which gave birth to PCORI. Industry and their political allies insisted on the provision. It’s time to repeal it.
    3. Allow people to import prescription drugs for personal use and give FDA the power to monitor the program and certify channels of purchase. An unenforced federal law blocks importation now. (I’d make this a pilot program for five years to immediately give consumers the option.)

    The politics of such measures is difficult, to say the least. I’m hoping it emerges as an issue in the 2016 elections. A Kaiser Family Foundation poll of 1,200 adults released last month found that three-quarters of Americans think prescription drug costs are unreasonable, and they blame the drug companies.

  • The rationale for an all-payer system for doctors and hospitals

    The rationale for an all-payer system for doctors and hospitals

    Unlike other developed countries, which negotiate or set uniform rates with doctors and hospitals regardless of who is paying the bill, an “all-payer system,” the United States takes a hands-off policy with regard to provider rates for private insurers and the uninsured. The result—except in the two states with an all-payer system for hospital services–is wildly varying rates that can be exorbitant, as Gerard Anderson and Ge Bai recently showed in their analysis of hospital prices. Health economist Uwe Reinhardt argues that if the U.S. had an all-payer payment system, we could more effectively control costs and help ensure that charges to patients were fair.

    Looking at steep hospital price increases in California and Oregon during the Great Recession, 2005-2009, Reinhardt shows that even in a weakened economy insurers were not able to control costs. He does not buy the argument that these increases were necessary to offset payments from Medicare and Medicaid. There is every reason to believe that hospitals and doctors negotiate for the largest rates they can get from insurers, regardless of their government payment rates.

    Put differently, private insurers are not forced to pay hospitals and doctors rates that are high to compensate for lower Medicare and Medicaid rates. That’s a myth. Hospitals and doctors are charging private insurers high rates because they can, because the health care market is broken.

    Moreover, if insurers lack the leverage to rein in costs for whatever reason, they should not be responsible for controlling costs. And, if provider rates are in any sense rational, how do you explain the huge differences in rates for the same services even within small geographic areas?

    According to Reinhardt, an all-payer system eliminates price discrimination in the health care marketplace. It prevents people from being charged wildly different amounts for the same service depending upon their insurer or their lack of insurance. It also simplifies the system for everyone and reduces administrative costs considerably.

    Our current system of giving insurers responsibility for negotiating provider rates adds no value to the system. They generally can’t control them effectively. Moreover, it incents providers to keep pushing prices higher.

    At a minimum, we should give everyone the option of enrolling in Medicare, as Robert Reich explains in this video.  It’s far more effective at controlling costs than private insurers.

     

  • Long-term care is unaffordable for middle-income families

    Long-term care is unaffordable for middle-income families

    Where you live matters, for all kinds of reasons, including because it affects the long-term services and supports that may be available to you and the people you love. The big headline, though, is that long-term care is too often unaffordable for middle-income families no matter what state you live in.

    As more and more boomers begin to need long-term services and supports, new policy solutions become critical. Today, Medicaid provides the only real safety net for older adults, people with disabilities and caregivers.  But, the adequacy of Medicaid supports varies considerably among the states.  And, long-term care insurance is not meeting people’s needs.

    If you’re interested to know how your state ranks in providing long-term services and supports, AARP has developed a scorecard.  The scorecard looks at how states fare in five areas (1) cost and access, (2) care providers and settings, (3) quality of life and quality of care, (4) support for family caregivers, and (5) effective transitions.

    Based on the scorecard, when it comes to long-term services and supports, Minnesota and Washington are the two best states to live in, and Alabama and Kentucky are the two worst states. South Dakota, New York and Montana rank 24, 25 and 26th respectively.

    For simple tips on how to plan for long-term care, click here.

  • Access to care a serious problem in Medicaid managed care plans

    Access to care a serious problem in Medicaid managed care plans

    A recent report by the HHS Office of the Inspector General reveals that private companies offering Medicaid managed care are failing to ensure adequate access to care to their enrollees. Each state has its own law regarding standards for access to care in managed care plans—both appointment availability and wait times for appointments—and different ways of determining compliance with standards.

    Given that the federal government is paying the full cost or a significant part of the cost of these plans, the report makes a strong case for the federal government to step in and create a baseline standard with enforcement mechanisms for managed care plans in every state.

    Disturbingly, the OIG found that appointments were not available from more than half of providers (51 percent) surveyed. More than one-third of providers (35 percent) surveyed were not even at the office listed by the plan. Another 8 percent were not in the plan’s network.  And yet another 8 percent were simply not taking new patients.

    Of the providers with whom appointments were available, the median wait time was two weeks and more than 25 percent of them required enrollees to wait more than a month for an appointment.The OIG surveyed 1,800 providers of care, both primary care physicians and specialists.

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  • Almost one in five people uninsured in states that have not expanded Medicaid coverage 

    Almost one in five people uninsured in states that have not expanded Medicaid coverage 

    Almost one in five people are uninsured in states that have not expanded Medicaid coverage. A recent report from the Urban Institute shows that states which have opted to expand Medicaid coverage show higher rates of insured residents than states that have opted not to expand coverage.  The Affordable Care Act gave states this right and substantial funding for this expansion.At the end of June 2014, states that had expanded Medicaid coverage had a 10.1 percent uninsurance rate.  States that had not expanded Medicaid coverage had an 18.3 percent uninsurance rate.  Overall, 13.9 percent of adults are uninsured.

    As of the end of November 2014, twenty-eight states are expanding Medicaid coverage, including the District of Columbia.  California, Illinois, New York, Pennsylvania and Ohio are all expanding coverage. Florida, Texas, Nebraska and Georgia are among the states that have not expanded Medicaid coverage to date.

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