February 14

The Health 202: Medicaid plans: We’re not ‘hyperventilating’ about work requirements

Guess who’s not fretting over making low-income Americans work or volunteer in return for government health benefits? The Medicaid insurers covering them.

“I think some of the heavy breathing about how terrible work requirements are going to be is over the top,” Jeff Myers, president of Medicaid Health Plans of America, the country’s largest association of Medicaid plans, told me last week.

There has lately been a frenzy of pushback from Democrats and progressives against the Trump administration’s unprecedented move to allow states to enact work requirements as a condition of receiving benefits. Some red states are imposing such requirements for the first time in the program’s five decades, following the failure of the GOP Congress to repeal and replace Obamacare — which expanded Medicaid in many states.

Last month, the Centers for Medicare and Medicaid Services issued guidance saying states may require non-disabled Medicaid recipients to work, volunteer or undergo job training to participate in the program. Out of a dozen states that have applied for work requirements, CMS granted Kentucky’s request last month and on Friday gave the go-ahead to Indiana, my colleague Amy Goldstein reports.

Because this is a pioneering move for CMS — the Obama administration rejected work requirements, saying they were inconsistent with Medicaid’s objectives — it has incited spirited applause from the political right but loud groans from the left. House Minority Leader Nancy Pelosi (D-Calif.) called work requirements a “shameful violation of the letter and spirit of Medicaid” when the guidance was initially issued.

“This mean-spirited decision will have a particularly damaging impact on women, including women currently taking care of seriously ill family members and those who have chronic health conditions of their own,” Pelosi said.

Last week, Frederick Isasi, executive director of the liberal consumer health lobby, Families USA, called Indiana’s waiver “a profound and deeply saddening departure from our nation’s commitment to the health of our families.”

Yet given the small number of enrollees likely to be affected by the work requirements, the uproar may be premature. Myers says he’s watching states closely to see exactly how they implement work requirements. But he feels that if done the right way, such requirements could give some recipients — but only a small number of them — a needed boost toward employment.

“Most people probably won’t be covered by this work requirement,” Myers said.

Members of MHPA contract with states to cover the 74 million Americans who rely on Medicaid, the federal government’s primary health insurance program for low-income individuals. It’s their plans that stand to lose customers if work requirements prompt a reduction in Medicaid enrollment, as many critics predict. Myers acknowledges that’s a likely effect — after all, enrollment dropped when work requirements were introduced to welfare in the 1990s — but he’s expecting only a minimal effect.

“We’re not hyperventilating that millions of people will get thrown off the rolls,” Meyers told me. “We just want to make sure as states do this, they understand there is a cost involved.”

Why might the effect be limited? For one thing, the majority of Medicaid recipients work or cite some valid reason they don’t, such as a disability or illness, acting as caregivers or attending school. Forty-two percent of Medicaid recipients work full time and 18 percent work part time, according to population survey data analyzed by the Kaiser Family Foundation.

That’s a top argument among critics for why they don’t think work requirements are needed. But it’s also a reason the requirement probably won’t have a massive wave effect on the program — most recipients either work or have some other life circumstance that prevents them, exempting them from the new requirements.

In addition, CMS is giving wider latitude than many were expecting to ensure states provide plenty of exemptions from a work requirement, moving to broadly define what constitutes “work.” For example, the agency in its guidance said those caring for children or undergoing substance abuse treatment could be exempted from working. So could be the 10 million people on Medicaid who have a disability.

And work doesn’t have to mean a paying job, according to the administration. States could also count job training, job searching, volunteer work or education as satisfying the requirement.

It’s still true that imposing more rules on government benefits increase the likelihood that even eligible people won’t be able to sign up because of higher barriers. Kentucky officials have predicted between 90,000 and 95,000 fewer people will be on Medicaid by the end of the state’s five-year waiver period — although that’s only a fraction of the more than 2 million Kentucky residents enrolled in the program.

Tom Miller, a health-care fellow at the conservative American Enterprise Institute, estimates work requirements might affect 20 to 30 percent of the Medicaid population at most.

“The reality is these are marginal things,” Miller said. “You can do this for a smaller fraction of the entire Medicaid population — you’re not going to nudge a large number of folks into full-scale work.”

Critics view diminished Medicaid rolls as a negative, but remember that conservative proponents view it as a victory. The idea, they’ve emphasized, is to make Medicaid a temporary safety-net program with incentives to propel people up the economic ladder.

“True compassion is lifting Americans most in need out of difficult circumstances,” CMS Administrator Seema Verma wrote in an op-ed published in The Post on Sunday.

Myers’s major concerns around these new requirements are logistical in nature. He wants to make sure states don’t impose new burdens of oversight on plans as it’s the states that have traditionally handled enrollment qualification. And he wants safeguards to minimize churn in the program so Medicaid recipients don’t find their care disrupted.

To Myers, the devil is in the details. Back in the 1990s, when work requirements were first added to welfare, enrollment in the Temporary Assistance for Needy Families program declined while job participation increased, especially among low-income single mothers (although the 2001 recession stalled much of that progress), said Ron Haskins, a senior fellow for economic studies at the Brookings Institution.

But Haskins and Myers, too, stress that success varied widely among states, depending on how good they were at helping TANF participants find work. With the new Medicaid rules, states face a lot of decisions about how to implement the requirements, how to enforce them, how broad their scope should be and how to help people fulfill them. The Trump administration is expected to respond to waiver requests from perhaps as many as 10 more states to implement work requirements.

“This is what I think the people talking about work requirements are missing,” Myers said. “There are all kinds of granular decisions to be made at the state level before this can even be implemented.”

AHH: Enrollment in religious health-care sharing ministries has skyrocketed, especially in states whose Affordable Care Act marketplaces have been plagued by spiraling premiums and reduced competition, Politico’s Paul Demko and Renuka Rayasam report. Only about 150,000 individuals were enrolled in such faith-based plans when the ACA was passed eight years ago, but the nonprofit groups that offer these plans say they now have more than 1.1 million members.

“What was once a fringe idea, limited to devout Evangelicals and small Mennonite churches in more rural parts of the country, has found acceptance with a segment of the population for whom the government safety net is unavailable and the free market options are unaffordable,” Paul and Renuka write. “As more people look for cheaper alternatives to health insurance, they are stumbling on ministry plans to escape Obamacare’s requirements and state oversight, but still satisfy the law’s individual mandate which, despite its repeal in the recent tax overhaul, remains in effect until 2019.”

OOF: There’s no clear evidence that radiation from cellphones causes cancer in humans. That’s after a $25 million National Institutes of Health study that found while exposure to cellphone radio-frequency radiation led to a higher risk of tumors, DNA or tissue damage and lower body weight in some groups of rodents, there are no clear implications for human health, our colleague Ariana Eunjung Cha reports. The study of 3,000 test animals is believed to be the most comprehensive assessment of the health effects of such radiation on rates and mice.

“The strongest finding in the new study involved male rats…that developed tumors in the nerves surrounding their hearts,” Ariana writes. “The experiment involved placing rats and mice into special chambers and exposing them to levels of radiation that mimic 2G and 3G phones, which were standard when the study was launched, for nine hours a day.” Even the lowest levels of radiation used in the study were much higher than the maximum exposure a frequent cellphone user would get.

John Bucher, a senior scientist at the National Toxicology Program, said “at this point we don’t feel that we understand enough about the results to place a huge degree of confidence in the findings.” The Food and Drug Administration issued a statement saying “evidence that whole body radio-frequency energy exposures given to rats or mice in the study actually caused cancer in these animals” is mostly “equivocal or ambiguous.”

Asked if he had changed his cellphone use as a result of the study, Bucher said: “no.”

OUCH: The Department of Health and Human Services appears to have blacklisted a reporter from the trade publication Modern Healthcare for refusing to delete three sentences from a story that Seema Verma, administrator for the Centers for Medicare and Medicaid Services, didn’t like, according to an account from the Association of Health Care Journalists.

Reporter Virgil Dickson got pushback from CMS after publishing a story a few weeks ago about the abrupt resignation of former Medicaid official Brian Neale, reporting that his departure was prompted by a disagreement with Verma. Dickson says he was told by an agency spokesman he’d no longer be allowed on CMS press calls unless he changed the story.

“Dickson believed the agency was making good on its threat on Thursday when, he said, his phone went mute during a CMS press call and a woman’s voice told him he was not allowed to participate,” AHCJ vice president Felice Freyer writes. “An editor later confirmed with CMS officials that he had been banned from press calls, Dickson said….But after AHCJ sent CMS several questions about the incident, an agency spokesman on Saturday evening emailed a one-sentence reply: ‘No reporters have been banned by CMS.'”

The incident underscores rising tension between HHS and some mainstream media outlets, which, as I noted in Friday’s Health 202, have been recently left out of press calls announcing major initiatives, including Medicaid work requirements.

— Sen. Marco Rubio (R-Fla.) is teaming up with Ivanka Trump to marshal Republicans behind an issue Democrats have typically supported: paid family leave. Politico’s Seung Min Kim reports Rubio is floating allowing people to draw Social Security benefits for family leave and then delaying their checks when they hit retirement age. Under this approach, a person who would begin receiving full benefits when he or she turns 67 years old but wants to take six weeks of paid leave would have to wait an extra six weeks after his or her 67th birthday to start getting Social Security checks.

“Capitalizing on President Donald Trump’s endorsement of the idea in his State of the Union address, Rubio is trying to marshal Republicans behind a plan that would neither impose a mandate on employers nor raise taxes to pay for it — two hurdles that have long halted the GOP from embracing paid family leave,” Seung Min writes. Rubio is still in the early stages of crafting a specific plan, but he and Ivanka have recently exchanged emails about it, and Sen. Mike Lee (R-Utah) has also pitched the idea to the president’s daughter, Seung Min reports.

“That’s a new idea for Republicans who still identify it as something that comes out of the left,” Rubio said. “Forcing companies to provide it is perhaps an idea that finds its genesis on the left, but the notion that pregnancy should not be a bankruptcy-eliciting event is one that I think all Americans should be supportive.”

February 14

NAELA Warns House on Vote to Undermine Civil Rights of People with Disabilities

Washington, DC — Under the guise of “drive-by lawsuits,” proponents of the Americans with Disabilities Act (ADA) Education and Reform Act of 2017 (H.R. 620) seek to subvert the rights of people with disabilities to access public places like stores, hotels, and even doctors’ offices.

“I lived through the indignities of life before the ADA. Enforcement under the current law is critical. The proposed bill strips our civil right to access public accommodations and places undue burdens on the individual,” said Michael J. Amoruso, Fellow, CAP, President-Elect of the National Academy of Elder Law Attorneys who is blind, has significant bi-lateral hearing loss and relies on his Seeing Eye Dog and hearing aids for mobility.

Under the ADA, individuals with disabilities can go to court to enforce their rights and to press for timely removal of the barrier that impedes access. H.R. 620 upends that system and puts the onus on the individual with a disability.

“The ADA has been law for more than a quarter century; businesses are already on notice of its requirements,” said Amoruso.

NAELA urges Congress to maintain the integrity of the ADA and vote NO on H.R. 620, the ADA Education and Reform Act of 2017.

Members of the National Academy of Elder Law Attorneys (NAELA) are attorneys who are experienced and trained in working with the legal problems of aging Americans and individuals of all ages with disabilities. Upon joining, NAELA member attorneys agree to adhere to the NAELA Aspirational Standards. Established in 1987, NAELA is a non-profit association that assists lawyers, bar organizations, and others. The mission of the National Academy of Elder Law Attorneys is educate, inspire, serve, and provide community to attorneys with practices in elder and special needs law. NAELA currently has members across the United States, Canada, Australia, and the United Kingdom. For more information, visit NAELA.org.

February 14

11,000 disabled student veterans left without rent and expense money due to computer glitch

Monthly government stipends for 11,000 disabled student veterans are delayed this month, potentially causing the former troops to be late paying rent and other pressing bills.

The subsistence allowance payments are made through the Department of Veterans Affairs as part of its Vocational Rehabilitation and Employment program. The money should have been disbursed Jan. 31 but will be delayed until Feb. 6 because of a “computer glitch,” according to an internal VA memo obtained by The Washington Post.

The memo instructs VA operators to apologize to veterans and tell them their payments are on the way.

The program is popular because it connects disabled veterans with job counseling and pays for them to earn a college degrees or learn technical skills. They are offered internships and help with contacts and résumés.

Army veteran Rick Collin, 30, of Portland, Ore., is one of the veterans who didn’t receive his stipend. As a result, he had to put off paying bills and will now have to pay late fees. Collin, who served in Afghanistan, suffers from severe memory loss and post-traumatic stress, along with chronic back and shoulder pain. He was involved in a car accident on his way to psychiatric therapy at Fort Riley in Kansas.

“This was going to be my first month with money left over after bills, and now that will all go to late fees,” said Collin, who has four children, ages 9, 7, 2 and 9 months.. He is studying photography at Portland Community College.

He said he’s in his fifth week of the term, has yet to receive a computer he was promised and only last week received his camera.

The troubled VA has been under scrutiny for a range of issues, including long wait times for appointments and medical malpractice.

“Any large bureaucracy has their glitches, but anytime veterans are not getting their benefits on time, especially when on a program like this, it’s a real hardship,” said Garry J. Augustine, executive director of 1.3 million-member Disabled American Veterans.

The glitch “has been fixed and it won’t occur again the future,” VA spokesman Curt Cashour said in response to an inquiry from The Post.

“We apologize to the veterans affected by this inconvenience,” he added.

February 7

U.S. government proposes 1.84 percent hike in 2019 payments to Medicare insurers

By Caroline Humer via Reuters.com

The U.S. government on Thursday proposed an increase of 1.84 percent on average in its 2019 payments to the health insurers that manage Medicare Advantage insurance plans for more than 20 million elderly or disabled people.

The proposed rate, which affects how much insurers charge for monthly healthcare premiums, plan benefits and ultimately, how much they profit, was near analyst expectations, and insurer shares were largely unchanged in after-hours trading.

UnitedHealth Group Inc, Humana Inc, Aetna Inc and WellCare Health Plans Inc are the largest sellers of Medicare Advantage health insurance. Under the program, they are paid a set rate by the government to cover member healthcare costs.

The 2019 payment proposal also expands the benefits that insurers can offer in the plans to include items like wheelchair ramps and devices to diminish the impact of health conditions, a positive for insurers competing with traditional Medicare for members.

Kim Monk, managing director of company and investing research group Capital Alpha Partners, said she had expected an increase of 1 percent to 2 percent on average. Payments rates will vary based on geography and on factors like the health of members and the quality ratings of the insurer.

January enrollment data showed that Medicare Advantage 2018 enrollment was 20.9 million and had grown to account for 35 percent of overall Medicare enrollment, BMO Capital Markets analyst Matt Borsch said in a recent research note.

Medicare Advantage competes with the traditional Medicare fee-for-service program. Both have grown as the so-called “Baby Boomer” generation ages into Medicare and together cover more than 55 million people.

Insurers have bet on future growth of Medicare Advantage as the Trump Administration turns to private insurers to control healthcare costs.

The Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Resources, releases the proposed rate early each year and then opens a public comment period. The final rate released in April could be higher or lower than the proposed one.

In December, CMS provided a forecast for medical services cost growth of more than 4 percent, one of the key components of the total payment rate, which also includes other factors. For instance, the law requires the government to pay similar amounts in the Medicare Advantage plans and the fee-for-service Medicare program, which typically results in a payment cut to insurers.

February 6

People with Medicare Largely Forgotten in Spending Bill Debate

Center for Medicare Advocacy – Matt Shepard: 860-456-7790, shepard@MedicareAdvocacy.org
Medicare Rights Center – Deane Beebe: 212-204-6248, dbeebe@medicarerights.org

Statement from
The Center for Medicare Advocacy and The Medicare Rights Center

— People with Medicare Largely Forgotten in Spending Bill Debate —

Washington, DC – We are relieved that Congress has reached an agreement to fund the federal government through February 8, as any lapse in federal funding can have serious consequences for people with Medicare and their families. We are also relieved that as part of this deal, Congress reauthorized the Children’s Health Insurance Program (CHIP), which provides affordable health coverage for over 9 million children in working families — many of which include people with Medicare.

However, we are concerned that key, bipartisan health policies were not addressed in this legislation. As Congress seeks to resolve outstanding spending and policy debates in the coming weeks, we urge lawmakers not to forget older adults and people with disabilities by overlooking the need to fund and extend these initiatives. The health and financial well-being of people with Medicare is at stake.

Without delay, we urge Congress to fully repeal the harmful Medicare therapy caps. These arbitrary caps create a barrier to accessing necessary therapy services, particularly for individuals with long-term, chronic conditions. The absence of such therapy can lead to avoidable health declines and permanent deterioration. To prevent these outcomes, the cap should be repealed or, at the very least, the process that has allowed individuals to seek an exception to the cap must be reinstated. A permanent fix is urgent to ensure that care is delivered to vulnerable patients, protects beneficiaries from high out-of-pocket costs, and safeguards the long-term viability of the Medicare program.

We also urge Congress to extend funding for community-based organizations to provide outreach and enrollment to low-income Medicare beneficiaries. Previous allocations for these critical activities have led to important, proven results, such as helping 2.5 million beneficiaries in need pay out-of-pocket health care costs they could not otherwise afford. Half of all people with Medicare—nearly 29 million older adults and people with disabilities—live on annual incomes of $26,200 or less, and one quarter live on $15,250 or less. Most people with Medicare simply cannot afford to pay more for health care, and without this assistance, many would be forced to go without care.

These policies have a long history of bicameral, bipartisan support and must be extended immediately. If not addressed soon, people with Medicare will face increased costs, reduced access to care, and decreased health and economic security. Congress must act now to protect and strengthen Medicare by funding and enacting permanent solutions for these vital health care extenders policies.