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Ascension’s decision to cut back services stirs debate among Milwaukee officials
Milwaukee officials are urging Ascension Wisconsin to postpone its controversial scale back of services at Milwaukee-based Wheaton Franciscan-St. Joseph Hospital, which primarily serves a low-income neighborhood, according to Wisconsin Public Radio.
St. Joseph Hospital, which primarily serves patients covered by Medicare and Medicaid, plans to shutter its surgical and medical units, slowly sifting out inpatient care by July 1. Roughly 51 percent of the hospital’s patients are covered by Medicaid, 5 percent are uninsured and about 20 percent are covered by commercial health plans.
The closure of the surgical and medical units would leave no general acute care hospital north of downtown Milwaukee, an area plagued with widespread health disparities. Ascension, however, emphasized it is not leaving the city. Another Ascension hospital, Milwaukee-based Columbia St. Mary’s, is located 5.6 miles southeast of St. Joseph’s.
“We aren’t abandoning where low-income [patients] live, we are actually strengthening our ability to serve the people that live in the city of Milwaukee by combining the efforts of Columbia St. Mary’s and St. Joe’s,” Bernie Sherry, senior vice president who oversees the Wisconsin market of St. Louis-based Ascension Health, told Becker’s Hospital Review.
Since Ascension disclosed it would stop providing surgical and inpatient care at St. Joseph Hospital April 5, the health system has received criticism from multiple city officials and residents.
“We have an economic model now where if you have money, you’re going to get the best healthcare in the world, but if you’re poor, guess what? Get on a bus, hopefully you can get to a hospital five miles away and maybe you’ll get healthcare,” Milwaukee Alderman Michael Murphy told WPR. Mr. Murphy also emphasized that the implications of reducing services at St. Joseph go beyond the individual hospital.
Milwaukee Alderman Bob Donovan is asking Ascension to delay the closure of these units by one year to collect community feedback and find ways to mitigate the loss of services prior to phasing them out.
“If this request is rejected, I have already contacted the Office of the City Attorney and have asked them to watch carefully the process followed by Ascension to ensure that at a minimum, the corporation is in full and exact compliance with applicable state and federal laws and regulations,” said Mr. Donovan, according to WPR.
St. Joseph is part of Milwaukee-based Wheaton Franciscan Healthcare, which merged with St. Louis-based Ascension in 2016.
Indiana University Health prepares for $1B transformation
Indianapolis-based Indiana University Health is preparing for a major consolidation project, which is expected to cost $1 billion, according to the Indianapolis Business Journal.
The project will include a major overhaul and expansion at IU Health’s 589-bed Methodist Hospital and Riley Hospital for Children, both located in Indianapolis. In addition, the project calls for closing University Hospital, which is located about 2 miles from Methodist, and consolidating clinical operations into the two expanded facilities.
Currently, health system officials are looking at which buildings on the Methodist campus should be renovated and which should be demolished. According to the report, the Methodist campus consists of a hodgepodge of buildings that were constructed decades apart. Some of these facilities even have mismatched plates and uneven ceilings.
While hospital officials have yet to publicize which buildings will be saved, the ages of the various buildings provide some clues. For example, the newest buildings, including a 10-story patient tower constructed in the 1990s, are likely to remain because they are in good shape mechanically and architecturally.
“It’s very complicated to renovate an old hospital, and often not worth the effort,” Timothy Frank, a partner at Artekna, an Indianapolis-based design and architecture firm specializing in healthcare, told the Indianapolis Business Journal. “Just fighting with the infrastructure is always a challenge. Trying to accommodate new technology, new equipment, new code requirements into a building of any significant age is tough. You’re trying to shoehorn operations and utilities. … It becomes a spaghetti bowl.”
IU officials expect to fully unveil its plan for the transformation project by the end of 2018.
Mainers voted to expand Medicaid last year. Could these states be next?
Republicans in Congress may have relented on their attempts to repeal the entire Affordable Care Act, but the battle has shifted to states. Citizens in Idaho, Utah, Missouri and Nebraska have taken Medicaid expansion under the Affordable Care Act into their own hands via ballot initiative campaigns, hoping to force statewide votes to either adopt or reject expansion this coming November.
Medicaid provides health coverage for more than 68 million Americans with low incomes or disabilities through federal and state programs. The far-reaching 2010 Affordable Care Act law, which expanded Medicaid coverage, was lambasted by conservatives as federal overreach. A 2012 Supreme Court ruling said that rather than being forced, states had to opt into Medicaid expansion.
Since then, 32 states have done so. But 18 states have not.
It’s been politically challenging for governors and legislators “who spent years railing against the federal overreach or the assaults on individual liberty in the ACA” to now back Medicaid expansion, said Matt Salo, executive director of the National Association of Medicaid Directors.
But for many states “expanding Medicaid makes a lot of sense” since more people get coverage and the federal government pays nearly the full cost, said Ben Ippolito, a research fellow at the American Enterprise Institute who focuses on health economics.
The campaigns to expand Medicaid via ballot have varied in scope and success. After Maine voters petitioned for and passed a first-of-its-kind expansion last November, campaigns in Idaho and Utah have gained momentum to expand Medicaid coverage. In Missouri, there was a longshot effort to gather 100,000 signatures to put expansion on the state ballot. The head of the campaign, Gary Peterson, couldn’t get the state Democratic party on board, only mustering support from local church groups. He told the PBS NewsHour that he suspended his campaign in February. And in Nebraska, residents launched a petition drive to appeal to voters this November after six consecutive years of failed legislation.
Where is the fight over Medicaid expansion now, and where will it go next? Here’s what we know.
Who exactly does Medicaid affect?
In 24 states, at least 50 percent of births are financed by Medicaid, according to data compiled by the Kaiser Family Foundation. Medicaid also covers costs for about 62 percent of seniors living in nursing homes.
The ACA’s Medicaid expansion raised the income limit on the program, allowing more people to qualify, and also allowed adults without children to enroll.
In a 2016 study, the Urban Institute reported that expanding Medicaid in the 19 states who had not yet done so would make more than 13 million people newly eligible. (Maine didn’t expand until 2017.)
Maine
The issue: In November, Medicaid expansion made the ballot in Maine — the first time this had occurred in any state since Congress passed the ACA in 2010. Fifty-nine percent of Mainers who voted supported expanding Medicaid, rebuking Republican Gov. Paul LePage, who had previously vetoed five expansion bills.
On July 2, people will become eligible under the law.
What’s happening now: LePage, who called expansion “fiscally irresponsible,” had to submit by April 3 a state plan to the federal government on how it would fund the expansion. In December, LePage sent a letter to the Maine Legislature outlining demands for how to fund the expansion, stating, for example, that raising taxes or drawing money from Maine’s Budget Stabilization (or, rainy day) Fund was “not an option.”
When asked whether the administration submitted the state plan by the deadline, LePage spokeswoman Julie Rabinowitz said that “we should not make a down payment without a plan to pay for the ongoing cost” and that LePage “laid out four simple principles to guide how to pay for expansion without jeopardizing the state’s long-term fiscal health,” referring to the December letter.
What’s next: In an interview, Maine’s Democratic Speaker of the House Sara Gideon called LePage’s December correspondence “his imaginary if-I-were-king letter,” and said that it was “not really going to impact what we’re doing here.”
If the administration shirks funding duties, Gideon said the state’s existing Medicaid funds “are enough to start getting people [from the expansion] online” until January.
Idaho and the “Medicaid mobile”
The campaign: In summer 2017, Luke Mayville drove his forest green 1977 Dodge Tioga RV, dubbed the “Medicaid mobile,” across Idaho to campaign for expanded health care access.
His RV had been the rolling trademark of Reclaim Idaho, the organization coordinating the Medicaid expansion ballot initiative. The “Medicaid for Idaho” campaign began as “an awareness raising tour” with the founders touring the Medicaid mobile across Idaho to gauge and build support, Mayville said.
An estimated 78,000 Idahoans fall into the Medicaid coverage gap — people with incomes too high to qualify for Medicaid, but too low to be eligible for the ACA subsidies that help buy coverage.
By the end of the summer, the RV “was covered with signatures.”
What’s happening now: For Medicaid expansion to reach the ballot, the campaign must gather signatures from a total of 56,192 voters (six percent of the state’s 936,529 registered voters in the 2016 general election). They must also meet separate signature thresholds in just more than half of the state’s 35 legislative districts by May 1.
What lawmakers say: Most of the state’s registered voters are Republican and the GOP-led Legislature stalled on expansion in the past. Republican Gov. Butch Otter presented his own plan, but it was pulled from the House floor in February.
What’s next: So far, the campaign has accumulated about 40,000 signatures, leaving about three weeks to gather the remaining 16,000. Mayville said he believes Medicaid is a nonpartisan issue that people on either side of the aisle can sympathize with. “It really cuts across party lines,” he said.
Utah
The campaign: Advocates have been pushing for Medicaid expansion in Utah for years. In 2016, drawn-out battles in the Legislature and governor’s office led to a limited expansion. But advocates like Utah Democratic Sen. Jim Dabakis called it “less than crumbs,” according to The Salt Lake Tribune.
RyLee Curtis, campaign manager of Utah Decides Healthcare, the organization coordinating Utah’s Medicaid expansion ballot initiative, said early efforts she was involved with attracted the attention of The Fairness Project, a nonprofit organization that supports ballot initiatives on issues such as raising the minimum wage and expanding Medicaid. The organization has provided more than 90 percent of Utah Decides’ roughly $900,000 in contributions, much of which has been spent on signature gathering, according to public records.
What’s happening now: Paid canvassers and volunteers have racked up more than 130,000 signatures to date.
What lawmakers say: At the same time, the state Legislature passed a new partial expansion last month that is estimated to cover about 70,000 low-income Utahns in the Medicaid gap, The Salt Lake Tribune reported. For states that undergo full ACA Medicaid expansion, the federal government funds 90 percent of its costs while the state finances the rest. But this partial expansion, which includes a work requirement, must get federal approval for that same 90 percent federal funding.
Matt Salo, executive director of the National Association of Medicaid Directors, said that the Trump administration did not approve a similar request from Arkansas and says it’s unclear whether the administration will approve Utah’s request. Still, it could be “an attractive political compromise.”
What’s next: The campaign for a ballot initiative has exceeded the required 113,143 signatures statewide, but still has to get at least 10 percent of voters from the time of the 2016 election in 26 of the state’s 29 senate districts by April 15. All considered, Curtis said, “we are confident that we can get there.”
Nebraska
The campaign: Proposals have been introduced into the Nebraska Legislature for six consecutive years — all have failed. So one state senator and a group of Nebraskans are trying different approaches.
A petition drive kicked off last month to put Medicaid expansion on the ballot.
Insure the Good Life, the organization leading the charge, and local media outlets have said that expanding Medicaid would provide coverage for about 90,000 additional Nebraskans.
What’s happening now: Amanda Gershon, a sponsor of the petition, told Live Well Nebraska that “the governor and the legislature haven’t solved this problem, so it’s now time for the people to decide.”
Gershon, 35, has been battling chronic health problems since college and around that time lost her health coverage. She said she “went so long without [health] care” that she became gravely ill, but was eventually able to get Medicaid through disability. Even after being approved for disability it took another nine months of paperwork to qualify for Medicaid, Gershon said.
“I really don’t want to see anybody else have to go down that same road to get the health care they need,” Gershon added.
What lawmakers say: Nebraska’s governors have staunchly opposed Medicaid expansion. Republican Gov. Pete Ricketts has a slew of lengthy statements outlining his objections to Medicaid expansion and decrying attempts by the Legislature to expand coverage.
But 32-year-old state Sen. Adam Morfeld, a Democrat, proposed a state constitutional amendment that would also put expansion on the ballot. “Every year that we have tried on Medicaid expansion in this state, the people that are opposed to it have never come up with alternative solutions — the governor included,” Morfeld told the NewsHour.
“[F]or thousands of people in my district who are low-income, working-class folks, it’s [current Nebraska health care] not only making them go bankrupt, they’re starting to die,” Morfeld said. His bill was referred to a committee.
What’s next: Organizers will have until July 5 to collect about 85,000 valid signatures and meet thresholds in 38 of 93 Nebraska counties.
https://www.pbs.org/newshour/health/why-maine-voted-to-expand-medicaid-and-whats-next
Trump administration issues rule further watering down Obamacare
The Trump administration took additional steps to weaken Obamacare on Monday, allowing U.S. states to relax the rules on what insurers must cover and giving states more power to regulate their individual insurance markets.
The Centers for Medicare and Medicaid Services issued a final rule that allows states to select essential health benefits that must be covered by individual insurance plans sold under former President Barack Obama’s healthcare law. The 2010 Affordable Care Act requires coverage of 10 benefits, including maternity and newborn care and prescription drugs. Under the new rule, states can select from a much larger list which benefits insurers must cover.
That could lead to less generous coverage in some states, according to Avalere Health, a research and consulting firm.
President Donald Trump’s administration has used its regulatory power to undermine Obamacare after the Republican-controlled Congress last year failed to repeal and replace the law. About 20 million people have received health insurance coverage through the program.
The new CMS rule also allows states the possibility of modifying the medical loss ratio (MLR) formula, the amount an insurer spends on medical claims compared with income from premiums that is also a key performance metric. A state can request “reasonable adjustments” to the medical loss ratio standard if it shows that it could help stabilize its individual market.
Insurers could also have an easier time raising their rates under the new rule. Obamacare mandated that premium rate increases of 10 percent or more in the individual market be scrutinized by state regulators to ensure that they are necessary and reasonable. The new CMS rule raises that threshold to 15 percent.
1115 Medicaid Waivers: From Care Delivery Innovations to Work Requirements
After months of debate, the Medicaid program emerged from efforts to repeal and replace the Affordable Care Act (ACA) without major legislative changes. Now, however, the Trump administration is encouraging states to apply for waivers that place new conditions on Medicaid eligibility as well as additional costs on beneficiaries in the form of premiums and copayments at the point of service.
To better understand the continuing controversy over Medicaid, let’s take a look at the waiver program’s objectives and how states have used waivers in the past. Are recently proposed state waivers consistent with Medicaid’s underlying mission? And are federal and state authorities appropriately evaluating them for their impact on Medicaid populations?
What is a Medicaid Section 1115 waiver?
Medicaid grants states autonomy in how they run their programs. Under a provision of the Social Security Act, Section 1115, the U.S. Secretary of Health and Human Services (HHS) can waive federal guidelines on Medicaid to allow states to pilot and evaluate innovative approaches to serving beneficiaries. Most waivers are granted for a limited period and can be withdrawn once they expire.
States seek 1115 waivers to test the effects of changes both in coverage and in how care is delivered to patients. The Centers for Medicare and Medicaid Services (CMS), a government agency, reviews each waiver application to ensure not only that it furthers the core objective of Medicaid — to meet the health needs of low-income and vulnerable populations — but also that the proposed demonstration does not require the federal government to spend more on the state’s Medicaid program than it otherwise would.
However, a recent General Accountability Office (GAO) review found that, because of significant limitations, evaluations of 1115 demonstrations often do not provide enough information for policymakers to understand the waivers’ full impact.1 The GAO recommended that CMS establish procedures to ensure that all states submit final evaluation reports at the end of each demonstration cycle, issue criteria for when it will allow limited evaluations of demonstrations, and establish a policy for publicly releasing findings from federal evaluations.
How have 1115 waivers been used in the past?
States have been granted waivers throughout the 53-year history of Medicaid. Most waivers were small in scope until the 1990s, when states started to use them for a wide range of purposes, including to: expand eligibility, simplify the enrollment and renewal process, reform care delivery, implement managed care, provide long-term services and supports, and alter benefits and cost-sharing. Some states have used 1115 waivers to change the way care is delivered to Medicaid patients, like encouraging investments in social interventions. Oregon, for example, used its waiver to establish Coordinated Care Organizations — partnerships between managed care plans and community providers to manage medical, behavioral health, and oral health services for a group of Medicaid beneficiaries.
With the ACA’s enactment, a new category of low-income adults became eligible for Medicaid. After the Supreme Court ruled in 2012 that this eligibility expansion was optional for states, eight states applied for 1115 demonstration waivers from the Obama administration to test different approaches to expanding eligibility, including the introduction of premiums and copayments that exceeded federal guidelines. One of those states, Arkansas, has used Medicaid funds to purchase private health insurance for marketplace enrollees.
How are 1115 waivers changing?
With encouragement from the Trump administration, many states are applying for waivers to make employment, volunteer work, or the performance of some other service a requirement for Medicaid eligibility. The administration has also encouraged waivers to impose premiums and increases in cost-sharing.
States can take different approaches to work or service requirements. Some might require them only for the Medicaid-expansion population (working-age adults with incomes up to 138 percent of the federal poverty level), while other states might also require employment of the traditional Medicaid population.
As of early April 2018, three states — Kentucky, Indiana, and Arkansas — have received approval for work- or service-requirement waivers. Seven others have pending waivers for new applications, amendments to existing waivers, or requests for renewals or extensions.
In Kentucky — the first state to have its work-requirement waiver approved — affected beneficiaries must complete 80 hours per month of community-engagement activities, such as employment, education, job skills training, or community service. Documentation of meeting this requirement is required to remain eligible for coverage. Exemptions are granted to pregnant women, people considered medically frail, older adults, and full-time students. Indiana and Arkansas have received approval for similar waivers.
Shortly after Kentucky’s waiver was approved, attorneys representing 15 Medicaid beneficiaries sued the HHS secretary in federal court (Stewart v. Azar), arguing that the objective of promoting work is not consistent with Medicaid’s core purpose of “providing medical assistance (to people) whose income and resources are insufficient to meet the cost of necessary medical services.”2 The lawsuit’s outcome will affect whether some of the state demonstrations will be able to proceed.
What’s the bottom line?
The 1115 demonstration waiver program is intended to fulfill the primary purpose of Medicaid: to provide health care protection to poor and disabled Americans. The new waivers seeking to impose work or service requirements, as well as others that would impose lifetime coverage limits or premiums, should be fully and carefully evaluated to determine whether they meet this goal. In addition to state and federal evaluations, independent assessments of state demonstrations will be important to informing policymakers and the public about the waivers’ full impact.
HENRY KOTULA 