Per Capita Caps in Medicaid — Lessons from the Past

http://www.nejm.org/doi/full/10.1056/NEJMp1615696?query=featured_home&

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Medicaid’s introduction also generated large benefits. Medicaid reduced mortality among infants and children, provided financial protection for their families, and led to better health, higher employment, and lower use of public benefits when they grew up. Moreover, by increasing tax revenue and reducing cash transfers, Medicaid currently saves federal and state governments $21 billion per year.5

How do these historical policies compare with today’s Medicaid-reform proposals? Ryan’s proposed caps apply only to Medicaid spending and recipients, since Medicaid was long ago decoupled from cash welfare. The cap amounts would initially equal average 2016 Medicaid spending by eligibility category and by state, rather than a single statutorily defined amount. Yet the caps would be “set to grow more slowly than under current law,” so over time they cease being related to actual Medicaid costs, thereby limiting the ability of states to adjust to rapid advances in technology, epidemics, or other unforeseen events. Nevertheless, as in the 1950s, discouraging Medicaid recipients from receiving costly care or keeping the highest-cost patients out of the program would be the clearest ways to limit state outlays. Toward that end, the Ryan plan would allow states to impose work requirements, charge premiums, offer a limited benefit package, shift beneficiaries into the individual insurance market, and create enrollment caps or waiting lists.

Medicaid creates a divisive relationship between the federal and state governments. Federal mandates and open-ended federal cost sharing are meant to provide incentives for state spending, but states often balk at the large costs. Both state and federal budgets would benefit if each Medicaid recipient cost less. Unfortunately, a per capita cap on federal Medicaid spending is unlikely to achieve this aim. Rather than “modernize” Medicaid, the historical experience in the United States suggests per capita caps would simply shrink the program.

 

In This Next Phase Of Health Reform, We Cannot Overlook Long Term Care

http://healthaffairs.org/blog/2017/03/16/in-this-next-phase-of-health-reform-we-cannot-overlook-long-term-care/

It is becoming apparent that President Trump and the 115th Congress cannot start over with health care reform. Whether you love, begrudgingly support, or fervently hate the Affordable Care Act (ACA), a clean slate is not possible. First, ACA implementation is well underway and has benefited many patients and providers alike. Second, it is unlikely that Republicans in Congress can fully repeal the ACA without a 60 vote, filibuster proof super majority in the Senate. Starting over entirely with health reform is just not feasible.

Trying to address every problem facing the health care system at once is a tall—if not impossible—order. History has taught us that U.S. health reform is an incremental process. With the focus of Congress once again turning to health reform, we have an opportunity to fix the problems with the ACA, and find solutions to health care challenges that the ACA failed to address.

A Growing Need

Long-term care for America’s growing elderly population is a critically important issue for Congress to address in health reform proposals currently taking shape. While the ACA’s insurance expansion focused on providing coverage for the uninsured, the law’s progress on long-term care has been minimal. The ACA tried to address long-term care (LTC) by creating a voluntary system of LTC insurance, but the ill-fated CLASS Act was ultimately determined to be financially unviable and abandoned.

Although policy solutions have been elusive, the need for long-term care is constantly growing. According to current estimates, over two-thirds of elderly Americans will need LTC assistance at some point in their lives. Between 2014 and 2040, the portion of Americans over age 65 is expected to increase from 14.5 to 21.7 percent. At upwards of $60,000 annually, long-term care costs can quickly exhaust personal savings.

As policymakers throughout our history have debated health reform, these efforts have almost entirely centered on questions of medical coverage. They ask which benefits to cover, how much the coverage should cost, and how we can ensure people are not locked out of coverage because of their health status. We must take the same approach to LTC, examining the availability and affordability of services. LTC services include nursing home care and in-home care, as well as what is often referred to as “long-term services and supports” (LTSS). LTSS include assistance with daily activities, such as eating, bathing, dressing, doing laundry, paying bills, and taking medications.

Current Republican health reform proposals appear to do little to push the ball forward on long-term care. As Congress considers proposals to reduce federal spending on Medicaid, they should carefully consider the role of Medicaid in financing LTC.

 

What Does The House Health Care Bill Mean For California?

http://californiahealthline.org/news/what-does-the-house-health-care-bill-mean-for-california/?utm_campaign=CHL%3A%20Daily%20Edition&utm_source=hs_email&utm_medium=email&utm_content=45683230&_hsenc=p2ANqtz-8hQ_w4Pw5zHW51oLQoG_Xu0Ms93jCK5wrfNop7LshVTnlXB2FBzI2QEr6vrjLhLuv48jwJS8sMDL_9vbf-OT9Z2EdBlg&_hsmi=45683230

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As the most populous state with the largest economy in the country, California stands to be dramatically affected by changes to the nation’s health law.

About 1.5 million people buy health insurance through the state’s exchange, Covered California, and most get federal subsidies. About 4 million receive Medicaid (called Medi-Cal here) through the program’s expansion under the Affordable Care Act. Altogether, Medi-Cal covers 14 million people in the state, roughly a third of its population.

The current House bill proposes to significantly change how — and how much — the federal government pays for these programs.

A Congressional Budget Office analysis released Monday found that, if passed, the bill could leave 24 million people uninsured by 2026, while saving the federal government $337 billion. Some Republican leaders contested those estimates, although House Speaker Paul Ryan said he was encouraged by the potential drop in costs.

That likely would translate into millions of people in California losing coverage or seeing their costs rise. Medi-Cal might have to cut programs and eligibility.

On Tuesday, California health care reporter Stephanie O’Neill discussed the potential effects of the bill on California residents with NPR “Morning Edition” host Rachel Martin.

California Employer Health Benefits: Prices Up, Coverage Down

http://www.chcf.org/publications/2017/03/employer-health-benefits

Since 2000, the percentage of employers offering health benefits has declined in California and nationwide, although coverage rates among offering firms have remained stable. Only 55% of firms reported providing health insurance to employees in 2016, down from 69% in 2000. These findings underscore the important role that Medi-Cal and Covered California play in providing insurance to working Californians — coverage that could be negatively impacted by the Republicans’ repeal and replacement of the Affordable Care Act.

Nineteen percent of California firms reported that they increased cost sharing in the past year, and 27% of firms reported that they were very or somewhat likely to increase employees’ premium contribution in the next year. The prevalence of plans with large deductibles also continues to increase.

California Employer Health Benefits: Prices Up, Coverage Down presents data compiled from the 2016 California Employer Health Benefits Survey.

Other key findings include:

  • Health insurance premiums for family coverage grew by 5.6%. Family coverage premiums have seen a cumulative 234% increase since 2002, compared to a 40% increase in the overall inflation rate.
  • The average monthly health insurance premium, including the employer contribution, was $597 for single coverage and $1,634 for family coverage in California, and was significantly higher than the national average.
  • 41% of workers in small firms faced an annual deductible of at least $1,000 for single coverage, compared to 17% of workers in larger firms. The prevalence of these higher deductibles in small firms has increased substantially in the past five years.
  • Only one in four firms with many low-wage workers (those earning $23,000 or less) offered health coverage to employees in 2016.
  • In the past year, 24% of large firms extended eligibility for health benefits to workers not previously eligible.

The complete Almanac report, as well as past editions, is available under Document Downloads.

Medicaid Is About Grandma

http://www.huffingtonpost.com/entry/medicaid-is-about-grandma_us_58c823d8e4b022817b29178d?utm_campaign=KHN%3A%20Daily%20Health%20Policy%20Report&utm_source=hs_email&utm_medium=email&utm_content=45675040&_hsenc=p2ANqtz-8LGIyTmn6nhDk89cZo6cUrufFATTTJ0UEOLkEAL40dVGaTTKG-_3pnWLxOkvp2OhsqJnaKQT0UF6ciBSrrzUF_dRYROg&_hsmi=45675040

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Why don’t Democrats more often make the point Sen. Chuck Schumer made this week about the consequences of GOP efforts to scuttle Medicaid:

Medicaid is for poor people, but also 60 percent goes to people in nursing homes. And that affects not only them, but their kids. You’re a kid 45 or 50, your Mom or Dad is in a nursing home. They could be kicked out after this bill passes. What would you do? You have to take them at home, stop working to take care of them. Or you have to shell out thousands of dollars out of your pocket. — Schumer press conference (3/13)

Bill Clinton routinely made this point when Medicaid was debated during his presidency. Inexplicably he is among a surprisingly few Democrats who stress the program’s service to elder Americans in dire need of long term care. But the GOP continues to get away with feeding the illusion that it mostly serves malingerers who’d rather take a federal handout than get a job.

Baby boomers everywhere are facing the painful needs of parents who need nursing home care. Many are finding that Medicaid is their only choice. That’s the political pitch that can save Medicaid.

Repealing the Affordable Care Act

https://www.brookings.edu/blog/unpacked/2017/03/08/repealing-the-affordable-care-act/?utm_campaign=Economic%20Studies&utm_source=hs_email&utm_medium=email&utm_content=45259936

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THE ISSUE: If Congress rejects the new House Republican-backed replacement for the Affordable Care Act (ACA), the full repeal long advocated for by many Republicans could be their next option.

A straight ACA repeal would leave an estimated 20+ million people without health coverage.

THE THINGS YOU NEED TO KNOW

  • Republicans have long advocated for repealing the ACA and if their new replacement isn’t approved, that plan could soon be put into motion.
  • The ACA provides coverage, and subsidies towards coverage, to people who previously couldn’t get health insurance through the individual market.
  • A straight ACA repeal would leave an estimated 20+ million people without health coverage.
  • If the ACA is repealed, many lower-income Americans (earning a maximum family income of about $33,000) participating in Medicaid, which was expanded under the ACA, would lose health coverage.
  • Many individuals with pre-existing medical conditions, previously unable to get health insurance, would also lose coverage.
  • The ACA also benefits health insurance industry by stabilizing coverage, and provides assurance to state hospitals that patients have coverage of some kind.
  • It is incumbent upon Republicans to provide a clear plan and implement it quickly in order to stabilize the markets and assure Americans that whatever replaces the ACA will be at least as good and at least as affordable as their current plans.
  • Polling on repeal shows that people are unhappy with the ACA, but not with their coverage. They most frequently criticizes the cost and the availability of coverage.
  • Republicans are faced with a challenge: Americans don’t just want repeal, they want a replacement that is comprehensive and affordable.

CBO: Republican healthcare bill would cover millions fewer than ACA but reduce federal deficit

http://www.fiercehealthcare.com/aca/cbo-republican-healthcare-bill-would-cover-millions-fewer-than-aca-but-reduce-federal-deficit?mkt_tok=eyJpIjoiTW1OaFl6TXlZVFF6WldKayIsInQiOiI3eHNMN1ZraGpJWHJ0eUFFRmdzaDRjVFVsOXBpV0VKVzdtWlU1UmxTbVZWRkpnMDhEN0Rrb3cyZlwvM0NmZnFJMXZTOG1KYXlLRHc0YWNUQzA3MmhpOVNQRFN4WmNsNUZVQmNQTGdPWE5UNUczUGppRUFGZ2dwelltaldGXC9IM3pWIn0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

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The Congressional Budget Office on Monday released its highly anticipated score of House Republicans’ healthcare bill, finding that it would increase the number of uninsured individuals by millions, but also lower individual market premiums in the long run and decrease the federal deficit.

Congress uses the CBO’s cost estimates to evaluate the effects of any major legislation, and policymakers were particularly eager to get its estimate for the American Health Care Act given the high political stakes associated with the bill.

Here’s a brief rundown of the CBO’s estimates (PDF):

  • In 2018, 14 million more people would be uninsured under the GOP bill than under the Affordable Care Act—mostly due to the repeal of the individual mandate penalties. By 2026, that number would swell to 24 million because of changes to subsidies in the individual market and in the Medicaid program.
  • Relative to projections for the ACA, the Republicans’ bill would lead to higher average premiums in the individual market before 2020—15% in 2018 and 20% in 2019—and lower average premiums after that. The CBO notes, though, that premium changes under the new proposal would differ “significantly” for people of different ages, given the bill’s provision that allows insurers to charge older customers up to five times more for coverage.
  • Enacting the legislation would reduce federal deficits by $337 billion from 2017 to 2026, with the largest savings coming from reductions in Medicaid spending and eliminating the ACA’s subsidies for individual market customers. The largest costs, on the other hand, would come from the bill’s elimination of many of the ACA’s taxes and its creation of a new tax credit for health insurance.
  • The CBO estimates that the individual market would probably be stable in most areas under either the ACA or the AHCA. While tax credits under the newly proposed bill would be less generous than the ACA’s subsidies, other changes such as grants to states from the Patient and State Stability Fund would lower average premiums enough “to attract a sufficient number of relatively healthy people to stabilize the market,” the agency said.

Before the score emerged, the Trump administration had already cast doubt on the merits of the CBO’s projections. White House Press Secretary Sean Spicer pointed out during a press briefing Monday that the agency had originally projected 24 million people would be enrolled through the Affordable Care Act exchanges as of 2016, but the number ended up being only about 10.4 million.

“The CBO was off by more than half last time,” he said.

Later, he acknowledged that some senators are likely to look at the CBO’s score when evaluating the American Health Care Act, and it’s important to remind them of the agency’s past track record.

Previously, The Commonwealth Fund issued an analysis that sought to dispel such criticism of the agency’s estimates about the ACA. It concluded that while the CBO overestimated marketplace enrollment and costs and underestimated Medicaid enrollment, overall its projections were “reasonably accurate,” and closer to realized experience than the estimates of many other prominent forecasters.

 

CBO report predicts 24 million would lose coverage by 2026 under American Health Care Act

http://www.healthcarefinancenews.com/news/cbo-report-predicts-24-million-would-lose-coverage-2026-under-american-health-care-act

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An estimated 14 million people would lose coverage under the American Health Care Act, a number that would rise to 24 million by 2026, according to a Congressional Budget Officer report released Monday afternoon.

Most of the initial loss would be due to repeal of the federal mandate for individuals to buy coverage, due to lack of a financial penalty and higher premiums.

Uninsured numbers would rise due to the bill’s repeal of Medicaid expansion. Some states would discontinue the expansion. Also per beneficiary spending caps would affect coverage, the CBO said.

Due to a lack of subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative would rise to 21 million in 2020 and then to 24 million in 2026, the CBO said.

“In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law,” the CBO said.

Premiums are expected to rise 15 to 20 percent in 2018 and 2019.

Older Americans would pay five times the amount on their premiums as compared to younger enrollees.

 

Federalism and the End of American Healthcare Act

http://www.yalelawjournal.org/forum/federalism-and-the-end-of-obamacare

Federalism and the American Health Care Act

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Republicans may talk the talk of devolving health care policy to the states, but that’s not what the American Health Care Act does. Instead, it starves health reform of the funding upon which it depends.

Most significantly, Republicans intend to phase out the Medicaid expansion and to impose a hard cap on federal contributions. If a recession forces a state to exceed its cap in a given year, any overruns will come out of its Medicaid payments the following year. With that kind of shortfall, the states will have to make savage Medicaid cuts to make ends meet.

Republicans also want to slash the subsidies that make insurance affordable in the private market. Under the ACA, no one making less than four times the poverty level has to devote more than 10 percent of her income toward private coverage; most pay much less. The American Health Care Act would erase that affordability guarantee and, instead, extend age-based subsidies that would be much too meager for most people to afford coverage.

If federal money is withdrawn, states will be stuck. Because of the countercyclical trap and ERISA, they won’t be able to enact and sustain coverage expansions on their own. The end result will not be the diversity that federalism celebrates. It will be a uniformly crappy system that leaves millions of the sick and poor without coverage.

It doesn’t have to be this way. A group of Republican senators led by Bill Cassidy (R-LA) and Susan Collins (R-ME) has floated an alternative, the Patient Freedom Act of 2017, that retains the ACA’s funding streams while giving the states more room to choose how to use that money. That’s a model that deserves serious attention from both Republicans and Democrats. It might enable partisans on both sides move past the rancorous debate over the ACA.

For now, however, the Republicans seem intent on dismantling coverage gains across the entire United States. Their proposals trade on the rhetoric of states’ rights, but they would have the perverse effect of inhibiting state power. That’s bad for federalism — and bad for the country.

 

Traditional Medicare is cheaper

http://www.academyhealth.org/blog/2017-03/traditional-medicare-cheaper

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OK, you knew that already. But what are the implications for access to care?

t probably won’t come as a surprise to you that traditional Medicare (TM) pays lower health care prices than commercial market insurers. We’ve known this for quite some time. A significant issue, however, is whether lower TM rates lead (or could lead) to reduced access to care for Medicare beneficiaries.

Jacob Wallace and Zirui Song took up the issue in a Health Affairs paper published last year. They examined health care price and utilization of outpatient imaging and outpatient surgical procedures across the 65-year divide — when most people become eligible for Medicare. Their data included just over 200,000 individuals captured in Truven Health Analytics’ 2007–2013 Medicare and Commercial Claims and Encounters database with broad-network, commercial market insurance before age 65 and TM from age 65 onward.

As shown in the chart just below, unadjusted, per beneficiary, quarterly spending trends for outpatient imaging and procedures are about the same before and after Medicare eligibility, but there is a large discontinuity when Medicare eligibility begins. In the last quarter before age 65, spending for a privately insured patient is about $119. At age 65, on Medicare, that drops 25% to about $89. After adjusting for age, quarter, year, and individual fixed effects, the relative change upon Medicare eligibility is even larger: 32%.