Posts tagged with Aca
Not much was known about the benefits of Medicaid relative to its cost until a kind of enrollment lottery in Oregon created an unusual opportunity for researchers.
In 2008, Oregon officials decided to pare down a Medicaid waiting list but they only had enough money to cover a fraction of the approximately 85,000 people wanting coverage. They decided a lottery was the fairest way to determine who got in and who didn’t.
The unique selection process resulted in two groups of people who shared similar characteristics but unequal access to the health care system. It didn’t take researchers long to realize they had a ready-made study group and a control group.
“It let us study the effects of insurance using a real, randomized control group,” said Kate Baicker, a professor of health economics at the Harvard School of Public Health. “That’s important because people who are on Medicaid look really different from the uninsured population.”
Baicker and her colleagues went to work.
They studied thousands of people — some who were selected in the Medicaid lottery and some who were not — to measure the extent to which Medicaid improved the lives and the health of those who received coverage.
The resulting studies have generated a wealth of information for policymakers about both the benefits of Medicaid and the factors that contribute to its escalating cost.
The study results are now front and center in the Medicaid expansion debate as governors and legislators across the country attempt to decide whether the benefits of covering millions more Americans outweigh the increased costs to taxpayers.
Baicker is scheduled to be in Topeka to speak about Medicaid expansion on Tuesday at a luncheon being organized by the Kansas Health Institute, the parent organization of the KHI News Service. A number of legislators and other health policymakers are expected at the event.
Kansas is one of 23 states that have chosen not to expand their Medicaid programs to include adults whose incomes are below 138 percent of the federal poverty line.
The decision means that approximately 85,000 uninsured Kansans may fall into in what is being called the “Medicaid gap.” They are ineligible for Medicaid but still too poor to qualify for federal subsidies that would all but cover the cost of private coverage purchased in the new marketplace created by the Affordable Care Act.
'Yes' to both questions
So, is Medicaid expansion a good thing that will benefit millions of people or a costly expansion of the safety net that could strain federal and state budgets? It’s both, Baicker said.
“I think we can eliminate both the unduly optimistic view of the program and the unduly pessimistic view of the program,” she said.
→ Continue reading at KHI.org/baicker
→ Tune in for free webstream of Baicker's presentation 12:30 p.m. Jan. 28 at KHI.org/baickerstream
Enrollment in health insurance via the Obamacare marketplace surged in December, with 1.8 million people nationwide selecting a plan last month versus just 400,000 in October and November combined.
In Kansas, according to federal officials:
- 14,242 people had selected a marketplace plan;
- 5,508 were steered to Medicaid by the marketplace;
- 27,763 have completed applications, that possibly would cover 45,228 lives; and
- 18,896 were determined to be eligible for financial aid.
The figures are part of new enrollment data released today by the U.S. Department of Health and Human Services.
Administration officials touted the numbers as proof of strong interest in the benefits of the health reform law.
"We're pleased to see such a strong response and heavy demand for the health insurance marketplace," said HHS Secretary Kathleen Sebelius in a teleconference with news reporters. "The numbers show that there is a very strong national demand for affordable health care made possible by the Affordable Care Act."
Of the 2.2 million people who have so far selected a private insurance plan via HealthCare.gov:
- 55 percent are ages 45 to 64
- 30 percent are ages 26 to 44
- 54 percent are female
- 79 percent will receive tax subsidies
- 60 percent selected a Silver plan
- 20 percent selected a Bronze plan
- 13 percent selected a Gold plan
- 7 percent selected a Platinum plan
- 1 percent selected catastrophic coverage
Michael Hash, Director of the Office of Health Reform, said enrollment so far mirrored the expectation that older people would enroll first, while younger people would wait until the deadline. Open enrollment for 2014 ends March 31.
"The trends so far, as we've released in this report, are suggestive of an appropriate mix in the marketplace. But we're only halfway through the open enrollment period and we expect an increase in the proportion of young adults," Hash said.
Sheldon Weisgrau — director of the Health Reform Resource Project, a foundation-funded initiative to educate Kansas consumers and businesses about the health reform law — said it would be difficult to draw many conclusions from the data released today.
"The key to appropriate risk balance in insurance pools is really healthy versus unhealthy. Because we no longer ask about health status on insurance applications, we usually use age as a proxy for health status. That’s appropriate for the most part, but is not the whole story. For example, an insurer would probably prefer a healthy, older enrollee to a sick, younger enrollee. But we don’t have these details," Weisgrau said.
"That said, the percentage of younger enrollees is lower than ideal given their representation in the population," he said, citing a recent study by the Kaiser Family Foundation that estimated that people ages 18 to 34 make up about 40 percent of the eligible population.
"So, the hope would be that they make up about 40 percent of enrollees," Weisgrau said. "But it’s much too early to draw conclusions. It was entirely predictable that the first people to sign up would be those most desperate for insurance coverage – people with pre-existing conditions who were previously denied coverage; people with very high premiums because of poor health status, etc."
Weisgrau said he expected enrollment figures would spike in March as the enrollment deadline comes.
Projections are that less than one-third of the uninsured population in Kansas would buy coverage via the insurance marketplace, Weisgrau said.
"So, assuming 360,000 uninsured in Kansas, at most 120,000 would be expected to purchase in the marketplace; 45,228 lives is about 38 percent of that number...that’s not bad," he said.
House Speaker Ray Merrick said it will be up to Gov. Sam Brownback to initiate discussions this year in the Legislature about possible Medicaid expansion.
"That’s the governor’s decision and I’ll wait for him to decide what he’s going to do with it," Merrick said in a pre-session press conference this afternoon. "He can request it and we can take it up."
Legislators last year passed a proviso stating that the program could not be expanded without "express approval" of the Legislature, so Merrick's comments indicate the GOP-dominated House is unlikely to give the issue much consideration without a push from the Governor's Office.
Merrick, a Stilwell Republican, said he didn't know yet how much interest fellow House members might have for reconsidering a broadening of the program, which currently is funded about 60 percent by the federal government and provides health coverage to about 380,000 poor Kansans, most of whom are disabled or elderly.
"This is a new year," Merrick said. "I really don't know" how many of the 125 House members might want to wade into the issue.
Between 58,000 and 85,000 Kansans could gain coverage, according to various estimates, if eligibility restrictions were relaxed in accordance with the federal Affordable Care Act, more commonly referred to as Obamacare. The federal law also calls for the feds to pay 100 percent of the cost of covering those newly eligible for Medicaid as a result of expansion. The federal match would drop to 90 percent after 2016.
Senate President Susan Wagle, a Wichita Republican, said earlier this week that she thought any sort of expansion would be difficult to get passed this year in light of the problems that accompanied the launch of the HealthCare.gov online insurance marketplace. But she said she thought the issue was worth debate and consideration.
She said she was interested in studying something like a plan proposed by Pennsylvania Gov. Tom Corbett, which would require program enrollees to be seeking work and also limit the number of doctor visits. The Pennsylvania plan, like some others being implemented or considered in Republican-dominated states, would use federal Medicaid dollars to buy enrollees coverage from private health plans.
In the past Brownback has said expansion would be up to the Legislature. But administration officials also recently have said that they continue to study the issue and what other states are doing about it.
Sara Belfry, a spokesperson for the governor, said this today when asked for comment on Medicaid expansion:
"Obamacare is fundamentally flawed and the disastrous rollout is just another indicator of the problems we will continue to see," she said. "Gov. Brownback's first priority is to extend KanCare (the state's name for Medicaid) to those who need it most: Kansans with disabilities on waiting lists for services."
The Kansas Hospital Association and a coalition of more than 50 social service and consumer advocacy groups are pushing policymakers to open up the Medicaid program to more people. Under the Affordable Care Act, hospitals stand to lose money they currently receive for treating the uninsured and without state approval of Medicaid expansion will not be able to offset those losses with additional Medicaid income.
Kathleen Christian is a remarkably healthy 63-year-old. She has no chronic conditions and rarely sees the doctor for anything other than preventive care.
Even so, she said she had been looking forward to getting health insurance under the Affordable Care Act, after having been without coverage since she was laid off in 2009.
But last month, Christian learned she would not be able to get coverage after all.
Because Kansas has not expanded Medicaid eligibility under the ACA, she is one of an estimated 85,000 Kansans who experts predict will fall into the so-called "Medicaid coverage gap."
Christian is not eligible for Medicaid (also known as KanCare in Kansas) because she earns too much to qualify for it but she is too poor to qualify for the ACA’s federal tax credits to buy private insurance.
Without the subsidies, there is simply no way she could afford $384 each month for the cheapest plan on HealthCare.gov, Christian said.
"Where am I supposed to get $384 every month? I budget and keep a spreadsheet. I know where every penny goes," Christian said.
Her 2012 adjusted gross income from part-time work was $5,008 and her monthly Social Security checks are about $800, she said.
"The last day of (November), I had $2.96 to my name. By the grace of God, every time I run out, usually the next day I have something to work with," she said. "I'm not alone. I know lots of people like me, lots of people who are struggling. There's just no way they can pay these premiums. It's just not realistic."
Christian said she lays equal blame on President Obama and Gov. Sam Brownback, who has opposed provisions of the ACA from the beginning.
"They're just a bunch of boys having an argument about who's better than who. It's all a political game for them. I don't think they're really seeing what they're doing to people," Christian said. "I guess people who have money just don't understand what being poor is. I'm not materialistically poor — I have a roof over my head, thank God, and we have enough food, although we could use a little bit more. We're not starving to death. But we're cash poor. That's just the way it is."
Christian said when she found out she'd be in the coverage gap, she wrote a letter to Brownback expressing her frustration:
She was laid off from her long-time job at a Lawrence home security company during the recession, she said.
Apart from a minimum wage job capped at 18 hours a week and the occasional temp job, she’s been out of work since.
"I'm in my sixties. It's not real easy to get a job," Christian said.
She has custody of her 13-year-old grandson and gets $115 per month in food stamps.
"It was $135, until they cut it back," she said.
When push came to shove, she filed for early retirement to get the Social Security payments, a move that means she gets lower monthly payments than if she had waited longer to take retirement.
"It was the only way I could support us. I didn't want to do early retirement, but I had no choice," she said.
Her grandson is covered by KanCare, which has less restrictive income requirements for children and pregnant women, but she has no health insurance. She pays for her dental cleanings every six months out of pocket.
"At this point, I'm just biding my time until I can get Medicare," she said.
Christian said she wrote to Brownback hoping a personal story might "get through to him."
“I told him that, as far as I'm concerned, the state of Kansas should be paying the premium credits for those people who do not qualify. I told him that maybe $384 is chump change to him and his people, but it's a lot of money for me,” she said.
Brownback spokesperson Sara Belfry acknowledged receipt of Christian’s letter.
“We did receive a letter from Kathleen (and), like all other correspondence we receive from constituents, we sent a response,” Belfry wrote in an email. “Beyond that, I have no further comment.”
Christian said that, as of this evening, she had yet to receive a response.
The head of the National Association of Insurance Commissioners and two members met today with President Obama to discuss the troubled rollout of the Affordable Care Act.
Kansas Insurance Commissioner Sandy Praeger, a moderate Republican who has generally supported the law, was invited but chose not to attend. NAIC President Jim Donelon, the Republican insurance commissioner from Louisiana, organized the meeting.
Praeger said she wasn’t trying to distance herself from the controversy surrounding the law’s problem-plagued rollout.
But she said the meeting was “premature” because the NAIC had not worked with its members to develop consensus on how to address remaining problems with the law’s implementation.
“It’s a huge honor to be invited to the White House,” Praeger told KHI News Service. “But I want to make sure that we use the president’s time wisely and that we are really able to have some constructive and meaningful dialogue.”
Praeger said the NAIC typically has been a “consensus organization.”
“As a past president of this organization, I think we have a real responsibility to communicate with the leadership and make sure that when we have a meeting that it’s not just representing a single point of view, but it's representing a consensus point of view that’s been arrived at through a vetting process,” she said.
In a joint email sent to their counterparts late Tuesday, Praeger and other commissioners who decided not to attend the meeting said they had “serious reservations about both the process and the policy issues surrounding such an important meeting.”
Adam Hamm, the Republican insurance commissioner from North Dakota, gave similar reasons for skipping the meeting in a statement to the New York Times.
“Because the topic for the meeting (Affordable Care Act) is so delicate and potentially divisive among the nation’s insurance commissioners, a meaningful discussion between all the commissioners needs to take place before a meeting with the president,” said Hamm, who like Praeger is a former president of NAIC. “Unfortunately, that did not happen so I had to respectfully decline to participate in today’s meeting.”
Bob Hanson, a spokesperson for the insurance department, said Praeger also wanted to remain in the state so that she could continue to work with Kansas insurers attempting to comply with President Obama’s recent request that the companies allow customers to temporarily keep policies that don’t meet the ACA’s minimum coverage requirements.
“The Commissioner and her department personnel are in the middle of conferring with companies on how the president's changes might be implemented,” Hanson said in an email. “Those business and regulatory discussions are keeping the commissioner here in Kansas to make sure any details are hammered out in the best interest of our citizens.”
Blue Cross Blue Shield of Kansas, the state’s largest health insurer, announced Tuesday that it would comply with the president’s request and work to reverse approximately 10,000 policy cancellations already in process, allowing policyholders to keep their nonconforming plans another year.
“This governmental change will allow many of our members to keep the benefit plan they already have and like, while still allowing them to consider new plans that they may be able to purchase with the help of a tax subsidy or small business tax credit,” the company said in a news release.
Praeger said reversing the cancellations likely would be costly to BCBS-KS and other insurers and could lead to premium increases. The main reason, she said, was that companies had based their rates on the assumption that many young, healthy people who had nonconforming policies would purchase more comprehensive plans thereby broadening the insurance pool. If significant numbers of those people decide to hang on to their current plans, the mix of policyholders enrolled in more comprehensive plans will be older and less healthy, Praeger said.
“If you’re going to let these healthier folks stay out of the mix for another year, there’s going to be a (cost) impact,” she said.
There are a lot claims circulating online and in the media about Obama's campaign pledge "If you've got a health care plan that you like, you can keep it" ... many of those claims miss the mark. So here's the lowdown:
If you bought your insurance plan before Obamacare was signed into law (March 23, 2010) your plan is grandfathered, and so long as you keep renewing it, you can keep it indefinitely.
Otherwise, your plan is not grandfathered. Some of those plans purchased after March 23, 2010 do not meet the law's requirement to cover "essential health benefits" (that includes covering childbirth and basic preventive care, for example). If you have one of those plans, you are one of the roughly 5% of Americans who received a letter saying you will have to update coverage to a plan offering the essential health benefits.
The state's largest insurer — Blue Cross Blue Shield of Kansas — has said that about 65% of people who purchase its individual plans (vs group or employer coverage) have grandfathered plans. Many of the remaining 35% already have plans that include most — if not all — of the essential health benefits and so their coverage and premiums will not change dramatically. Nevertheless, they may receive a letter notifying them of their options to update their coverage to comply with the law. Again, this only applies to people who enrolled in their current plan after March 23, 2010.
Of those people required to update their plans, some may see their total premiums go up.
However, many will now qualify for tax credits to buy updated insurance plans via the new marketplace — and so the amount they actually pay could be slashed dramatically. Those with incomes between 100% and 400% of the poverty level will qualify for tax credits. For example, a family of four earning between $23,050 and $92,200 will qualify for tax credits. Until HealthCare.gov is working properly, you can go to InsureKS.org to see how much tax-credit assistance you qualify for.
→ More coverage of Obamacare at khi.org/healthreform.
Perhaps it is a case of could-have-been.
Two years ago, Gov. Sam Brownback rejected a $31.5 million federal grant to set up a health insurance marketplace tailored for Kansas — defaulting instead to the federally run exchange that was launched Oct. 1 but which continues to be beset by problems.
Gary Schneider — the technology expert who was poised to lead Kansas' marketplace development until Brownback opted against it — left instead for Colorado, one of 16 states that chose to run their own marketplace. He now is the IT project manager for the Colorado Health Benefit Exchange.
In Colorado, so far, things are going smoothly, Schneider said.
More than 700 people have enrolled in insurance plans using Connect for Health Colorado, the state’s marketplace. And more than 30,000 people have created accounts on the website allowing them to compare plan options and see if they qualify for tax subsidies.
"We had some bumps in the road with our system when we first turned it on, but most of those have been resolved," Schneider said.
Like the federal marketplace, Colorado's website initially was overwhelmed with traffic.
"Until you turn a system like this on ‘live’ and experience a real load, you can't be sure how it's going to react," Schneider said. "That was the first couple days, but things got pretty stable pretty quick."
CGI, the contractor that built the Colorado marketplace, also built the federal exchange. But Schneider said the fact that so many states went the way of Kansas — opting to use the federal marketplace, HealthCare.gov — greatly complicated the task for the national government.
"If they had anticipated 35 or so states being in the federal marketplace, I'm sure they would have done some things differently,” he said. “But that just panned out in the last 18 months, where states made these decisions to opt out. I don't think they anticipated more than a handful of states to be in the federal marketplace.”
Schneider said he wasn't surprised that the federal marketplace is off to a rocky start “given the tight deadline and the fact that so many states opted to not have a state-based marketplace. That made their task extremely challenging...because there are business rules that apply to different states."
President Obama today held a press conference to reassure those frustrated with HealthCare.gov, saying that "nobody is more frustrated by (the glitches) than I am."
But, said Obama, "even with all the problems at HealthCare.gov, the website is still working for a lot of people, just not as quick or efficient or consistent as we want."
That complexity has been the federal marketplace’s undoing so far, said Timothy Jost, an expert on the health reform law and a professor at Washington and Lee University School of Law.
"The main culprit is just a very, very complex system that must be established to enroll millions of people in hundreds of different health plans," Jost said. "The fact that 36 states refused to participate I think was completely unexpected. And Congress has not appropriated funds — since the initial appropriation, that I know of — for the federal exchange," he said, referring to the federal marketplace.
"Instead Congress has held numerous hearings that have tied up key government officials and kept them from getting their job done. So I think Congress is probably more to blame than anybody else."
Jost also laid blame on "the states that have opposed implementation, including Kansas."
“The states' decisions to not run their own exchanges has had a very serious effect,” he said. “States that are running their exchanges are showing a lot of success.”
States including Hawaii, California and Colorado experienced problems in the opening days of their marketplaces, but according to most reports those have now been largely resolved.
Switching to a state-based marketplace
Should Kansas change direction and decide to run its own insurance marketplace — which for now seems unlikely given the opposition to Obamacare among the state’s Republican leaders — it could have the option of implementing proven software, such as that running Colorado's marketplace.
Schneider said he is in talks with several other states about using the system Colorado built, but Kansas isn't among them.
Kansans frustrated by their inability to shop for health insurance coverage on the federal marketplace website can now do much of the legwork on the state insurance department’s updated website, InsureKS.org.
Late Friday afternoon the department upgraded the site first launched in early September so that consumers in any county can access a list of the health plans available in the federal marketplace along with their prices.
“We’re pretty excited because if somebody goes on our website they can find out whether they qualify for a tax credit and they can take that information and look at the rates and plans and come pretty close to figuring out which plan they're interested in when they’re able to get on the (federal) marketplace. So, hopefully it will give them a little bit of a head start,” said Linda Sheppard, director of health care policy and analysis at the insurance department.
Consumers can do about everything on the insurance department website that they could do on the official federal site – if it were working – except finalize a purchase.
The marketplace website operated by the U.S. Department of Health and Human Services — HealthCare.gov — has been plagued by problems and has been mostly inoperable since its launch Oct. 1, though there were indications of progress Friday.
Officials with a consortium of nonprofit organizations training and deploying navigators to help consumers shop for plans said that, by day's end, five Kansans had managed to purchase coverage using the federal marketplace.
Sheppard said Kansas officials didn’t seek federal approval to add the work-around tools to the state site, which also includes a feature allowing users to locate navigators and marketplace-certified agents nearest them.
Kansas is one of 36 states that opted to have the federal government design and operate its marketplace rather than building its own.
Republican Gov. Sam Brownback returned a $31.5 million federal grant that Insurance Commissioner Sandy Praeger had obtained to build a state-based marketplace, sometimes called an "exchange."
Sheppard said Kansans she's talked to at meetings across the state haven’t been angry about their inability to use the marketplace, but they have been frustrated by their inability to get information about the coverage options available to them.
“They don’t seem angry about it, they just generally say something like, ‘Yeah, that’s what I expected,’” she said.
A new report finds some 78,000 Kansans are among those not poor enough for Medicaid but too poor to qualify for tax subsidies under the Affordable Care Act
About 78,000 Kansans are among 5.2 million poor, uninsured adults who will fall into the “coverage gap,” created by 26 states choosing not to expand Medicaid under the federal health reform law next year, according to a study released today by the Kaiser Family Foundation.
These people are projected to have incomes too high to qualify for their state’s existing Medicaid programs, but below the federal poverty level (nearly $11,500 for an individual) required to be eligible for tax subsidies to buy private coverage on the new insurance marketplaces set up by the Affordable Care Act, or ACA. Medicaid is the state-federal health insurance program for the poor.
“Millions of adults will remain outside the reach of the ACA and continue to have limited, if any, options for health coverage,” the study concludes.
The law provides full federal funding for three years to states that expand Medicaid to cover residents under 138 percent of the poverty level (or just under $15,900 for an individual).
But the Supreme Court made that requirement effectively optional for states, and most Republican led-states have opted against expanding the program.
There is no deadline by which states must opt to expand Medicaid, and a few states are still considering it.
Nearly half of the uninsured in the coverage gap live in Texas (1 million), Florida (763,980) and Georgia (409,350) — largely because those states have the most uninsured and limited Medicaid eligibility today.
Kansas among states with coverage gaps
In Kansas, about 78,000 adults will fall into the coverage gap, according to the report.
Alabama, Mississippi and Louisiana also will be especially hard hit, with more than a third of their uninsured adults falling into the coverage gap next year, the study shows.
In Kansas, 29 percent of uninsured adults fall into the coverage gap.
These states will feel the pinch because they have higher rates of poor uninsured adults and their existing Medicaid programs have some of the nation’s the tightest eligibility rules.
In Kansas, adults with children are eligible for Medicaid coverage if they earn less than $7,421 (for a family of three). Childless Kansans are not eligible regardless of income level.
Gov. Sam Brownback and the Legislature have shown no desire to expand Medicaid and seem unlikely to approve it this year.
Federal officials have said they have little ability to address the coverage gap, given the Supreme Court's ruling. The only way to fix that would be for Congress to modify the health reform law.
A new pilot program aimed at improving billing and collections at local health departments is beginning at a critical time — just as tens of thousands of Kansans are expected to get insurance coverage under the Affordable Care Act (ACA).
Currently, billing mistakes are costing many local health departments when it comes to collecting from private insurance companies and the Medicaid program. But that cost isn’t as significant as it could be because many of those now being served by departments are uninsured and so pay their bills directly.
The payer mix is expected to change as more Kansans obtain private coverage through the new online marketplace healthcare.gov, provided federal officials are able to solve technical problems that have plagued the website since its Oct. 1st launch.
A decision by Gov. Sam Brownback and the Republican-controlled legislature to expand eligibility for the state’s Medicaid program – known as KanCare – also would substantially increase the pressure on local health departments to improve their billing procedures. However, neither appear poised to authorize that expansion soon.
The pilot — spearheaded by the Kansas Foundation for Medical Care (KMFC), a Quality Improvement Organization — is beginning in this month in Douglas, Harper, Reno and Sumner counties.
Each of the four local health departments (LHDs) will receive up to $1,360 to train staff members on billing techniques that will maximize reimbursement for services provided to privately insured clients, said Stephanie Lambert-Barth, manager for KFMC's Immunization Billing Project.
“Training of LHD billing staff will streamline the billing processes and improve billing outcomes, resulting in a return on the training investment. Demonstrating this return on investment may help other Kansas LHDs make the case to fund training for their billing staff,” she said.
The Lawrence-Douglas County health department is one of the largest and best funded in the state. Nevertheless it only has one office assistant working two days a week on billing, said director Dan Partridge.
"For us billing has been a challenge because our capacity to dedicate and train staff has been limited," Partridge said.
Currently about 3/4 of his department's revenue comes from clients who pay their bills directly. The agency has an 85 percent collection rate among those clients. However, it collects only 57 percent of the amount it bills to Medicaid and only 20 percent of what it bills to clients covered by private insurance.
"Most of it is coding errors," Partridge said. "We feel confident our participation (in the pilot) will lead to improved collection rates. We also want to be prepared for whatever shift the ACA will create within our revenue streams as private insurance coverage increases."
KFMC’s Lambert-Barth said that, while the project is focused on improving reimbursement rates for immunization services, the plan is to evaluate all claims billed by the health department, including family planning services, for example.
"Our project's final product is a strategic plan report, which will include recommendations for how to move forward. It is not yet clear what those specific recommendations will be, but if the pilot goes well then expansion (of the pilot) would make sense,” she said.
The pilot project’s website contains links to billing resources, tools, project updates and other related information.
Will it come in with a big bang, dramatically and forever changing Americans’ health care? Or will it be something more like a whimper?
Tomorrow is the much-anticipated first day that millions of Americans without affordable health insurance will be able to turn to the new, online marketplace that is one of the central elements of the Affordable Care Act, commonly known as Obamacare.
Supporters of the health reform law have trumpeted the big moment for months and likewise there has been an onslaught of public relations campaigns from the law’s opponents, including a high-profile showdown in Congress over it that threatens to shut down much of the government.
But some of those most familiar with how the new system is expected to work here, particularly the insurance marketplace, are saying it wouldn’t hurt for Kansans simply to wait a bit before they try to sign up for coverage.
“Don't focus on Oct. 1,” said Sheldon Weisgrau of the Health Reform Resource Project. “The information will be available then, but whether you buy your policy Oct. 1, Nov. 1 or Dec. 1, won’t make a difference because the coverage won’t start until Jan. 1. I'm actually encouraging people to take a deep breath and wait because there might be a few bugs to work out.”
“Basically, when we've been out talking to the crowds in various locations, we’ve been encouraging them to wait maybe two or three weeks to let some of the potential bugs or glitches smooth out,” said Linda Sheppard, one of the top officials at the Kansas Insurance Department and one of the state’s leading experts on the Affordable Care Act.
Sheppard is suggesting people sit back until as long as Dec. 15 before choosing a plan.
People eligible to use the new marketplace will have until March 31 to sign up, so Oct. 1 is merely the first day of a six-month open enrollment period.
Slow start and limited awareness
Even if everything goes smoothly Day One with the marketplace enrollment system, it could be six months or longer before most Americans understand they can use the marketplaces.
A survey released today by the Commonwealth Fund showed that 76 percent of Americans between the ages of 19 and 64 know they are required by the Affordable Care Act to have health insurance next year.
But only two in five, or 39 percent, were aware of the new marketplaces or that they would be able to use them to apply for financial help with their premium costs.
Meanwhile, the so-called “navigators” certified to help people enroll in the marketplace plans remain in short supply with only about two dozen of the 250 planned for Kansas currently trained and ready to go, though that number is expected to quickly grow over the course of the next few weeks.
Because of the expected slow start to the new program, the Congressional Budget Office projects that only 7 million of the 48 million uninsured in America will enroll in plans through the marketplaces in 2014, though that number is expected to grow to a peak of 25 million a year by 2018.
About 52 percent of Kansans already have coverage through their employers, and another 29 percent already are enrolled in public health plans, which means a relatively small percentage of people here are expected to gain coverage through the new marketplace.
Of the state’s 365,000 uninsured, only about 188,000 — or roughly half — are expected to benefit from the marketplace, according to the Kansas Health Institute.
However, it is thought highly unlikely even that many will actually use it in 2014, given the historical “take-up” rates for government programs and the fact that many of the uninsured earn too little to face the new tax penalties for not having coverage.
And since Kansas is among the states where political leaders have chosen against expanding eligibility for the Medicaid program, there will be about 58,000 poor Kansans who fall into a coverage gap. Those Kansans — with earnings between about 32 percent and 100 percent of federal poverty guidelines — earn too much to be eligible for Medicaid but are too poor for subsidized health coverage through the new marketplace.
Tax subsidies to buy insurance
For those Kansans without access to affordable insurance through their employers, subsidies will be available on a sliding scale to those with incomes starting at 100 percent and up to 400 percent of federal poverty guidelines, which is $45,960 for an individual or $94,200 for a family of four.
Even with all the talk from Capitol Hill to Main Street about Obamacare, many people don't know what they have to do to comply with the law’s requirement that almost everyone have insurance beginning in 2014.
For those who are uninsured, the key to satisfying that requirement could be the new online health insurance marketplaces, which are set to open Oct. 1 for shopping. Policies will go into effect Jan. 1. Seven million Americans are expected to find coverage there.
More than 500,000 Kansans would have some reason to consider using the health insurance exchange to obtain coverage — such as those with a pre-existing condition — according to the Kansas Health Institute.
Here are 15 basic things you need to know about the marketplaces:
The insurance marketplaces are open to nearly everyone, but If you have insurance through work, Medicare or Medicaid, it’s likely you won’t need to shop for coverage there. They are really for people who are uninsured or folks who buy individual policies now.
Many people will qualify for subsidies to make coverage more affordable there. These subsidies — tax credits to help pay your premiums - will be available to people with incomes up to 400 percent of the federal poverty level. That's about $46,000 for one person or $94,000 for a family of four. And there are cost-sharing subsidies to reduce deductibles and copayments, depending on your income.
Immigrants who are in this country illegally are barred from buying on the exchanges.
You can enroll until March 31, 2014, though you'll generally need to sign up by Dec. 15 of this year, to be covered as of Jan. 1. You can find your state’s marketplace at healthcare.gov.
Through the marketplace, you can compare health plans in your area. The prices are based on where you live, your family size, the type of plan you select, your age and whether you smoke. All the plans have to comply with the Affordable Care Act’s requirement to have a basic benefits package, but the amount you have to pay in premiums, co-pays and deductibles will vary among plans.
When you apply for coverage on the exchange, you will find out if you’re eligible for subsidies to help pay for premiums. Or, if you have a low income, you can also learn if you are eligible for Medicaid coverage.
Your income — not your assets, such as your house, stocks or retirement accounts – will count toward determining whether you can get tax credits. When you buy your plan, you estimate your income for next year, and your tax credit is based on that estimate. The next year, your tax returns will be checked by the IRS and compared against your estimate.
If you qualify for a tax credit to pay your premiums, you can choose to either have the credit sent directly to the insurer or pay the whole premium up front and claim the credit on your taxes. If you qualify for cost-sharing subsidies, that subsidy will be sent directly to the insurer, and you won’t have to pay as much out of pocket.
If your income increases during the year, notify the exchange promptly so that you can avoid having to pay back the credits. On the other hand, if your income goes down, you could be eligible for a bigger subsidy. Either way it's important to notify the exchange if your income changes.
Each plan covers 10 “essential health benefits,” which include prescription drugs, emergency and hospital care, doctor visits, maternity and mental health services, rehabilitation and lab services, among others. In addition, recommended preventive services, such as mammograms, must be covered without any out-of-pocket costs to you.
You won’t have to pay more for insurance if you have a medical condition and that condition will be covered when your policy begins. But older people can be charged more than younger people and smokers could face a surcharge.
The prices for the marketplace plans are likely to be similar to those sold privately. If your broker offers you a plan that is also available on the exchange, you may be eligible for subsidies.
Your insurer generally can't drop you, as long as you keep up with your insurance premiums and don't lie on your application. Generally, people will be able to enroll in or change plans once a year during the annual open enrollment period. This first year, open enrollment on the exchanges will run for six months, from Oct. 1 through March of next year. But in subsequent years the time period will be shorter, running from October 15 to December 7.
There are certain circumstances when you would be able to change plans or add or drop someone from coverage outside the regular annual enrollment period. This could happen if you lose your job, for example, or get married, divorced or have a child.
The number of plans that you can choose from is likely to vary widely. In some states, only a couple of insurers have announced plans to offer policies though the marketplace, while in others there may be a dozen or more. Even within a state, there will be differences in the number of plans available in different areas. You can expect that insurers will offer a variety of types of plans, including familiar models like PPOs and HMOs.
State lawmakers' resistance to expanding Medicaid “just makes no sense,” Kansas Insurance Commissioner Sandy Praeger said Thursday, speaking at a meeting of safety-net clinic officials.
Many legislators, she said, “really don't understand” the consequences of not expanding Medicaid because there was “almost no discussion of the Affordable Care Act” during this year's legislative session.
Praeger, who has been hosting a series of informational forums on the health reform law for the past three weeks, said legislators will have a hard time not addressing Medicaid expansion in 2014.
“People are starting to understand what the lack of Medicaid expansion means,” she said. “And I think legislators are starting to hear from them.”
Currently in Kansas, non-disabled adults with children are eligible for Medicaid if their incomes fall below 32 percent of the federal poverty level, roughly $6,250 a year for a family of three.
“Let me put that in perspective for you,” said Health Reform Resource Project Director Sheldon Weisgrau, who also spoke at the annual conference of the Kansas Association for the Medically Underserved. “That means that a mother with two kids who works a minimum-wage job half-time makes too much money to be on Medicaid,” though the children would qualify.
Childless, non-disabled adults, are not eligible for Medicaid “under any circumstances,” he said.
Under the Affordable Care Act, commonly known as Obamacare, the federal government will cover all or most of the costs of expanding Medicaid to include adults whose incomes fall below 138 percent of the poverty level. However, expansion is optional and up to the political leaders in each state.
Low-income children and pregnant women already are covered under Medicaid.
In Kansas, Medicaid expansion would insure about 130,000 adults who are currently uninsured, according to various estimates.
Gov. Sam Brownback and the Republican majorities in both the House and Senate have shelved the Medicaid-expansion debate, saying they doubt the federal government will be able to keep its promise to cover most of the costs.
Cost of expansion
If adopted, Medicaid expansion would cost the state about $625 million over 10 years, according to a projection by the Brownback administration.
“To put that number into context, last year the State of Kansas spent $1.2 billion in state money on Medicaid,” Weisgrau said. “This increase of $625 million is over 10 years, but the Legislature decided we could not afford that.”
The administration's calculation, he said, did not include the offsetting costs to local programs — county health departments, safety-net clinics, hospitals — for covering the needs of the uninsured.
Some 27,000 people in Wyandotte County have no health insurance. Health officials are hoping Obamacare and the new insurance marketplace expected to be operating soon in Kansas can help change that.
“We assume quite a few (of the 27,000) are going to be able to qualify” for subsidies through the marketplace, said Joe Connor, director of the Unified Government of Wyandotte County Health Department.
The marketplace, which federal officials have pledged will be ready to launch on schedule Oct. 1, is aimed at making affordable health coverage available to thousands of Kansans who otherwise might not have it.
Nationally, the state marketplaces — also sometimes called insurance exchanges — are expected to serve millions of Americans and are a key component of the Affordable Care Act, which became law in 2010.
‘Misinformation and polarization’
Officials here have a task force that earlier this month began planning ways to get the word out about the exchange to some of the people considered most likely to benefit from it.
The panel is part of the Healthy Communities Wyandotte initiative and is chaired by former Kansas Medicaid Director Barb Langner. She now works at the University of Kansas Medical Center but is working on the initiative as a volunteer.
Langner said the group doesn’t want to duplicate public-awareness work that will be done by others, including the federal government and the Kansas Insurance Department, but that a local touch is needed if everyone in the county is to be reached.
“This is a county that's used to creating some local solutions,” Langner said. “I think the statewide (public outreach) effort will be all well and good, but there are some pockets of people you will not reach unless you have local involvement. A lot of people are not going to go to a public meeting about this. It has to be a little more user friendly.”
Langner said the task force hopes to provide easily understandable information about the exchange to people who already are trusted in the neighborhoods so they can disseminate it to likely exchange users.
“I think because of the misinformation and uncertainty and sort of the polarization on this topic, it’s going to take someone who is trusted to explain it. And you're going to be dealing people that most likely don't have a lot of familiarity with insurance products, so I think personal contact with someone they trust will be important,” Langner said.
“Our role is to get whatever information has been produced to the people who have the contacts in the community. The logical places are churches, perhaps daycares, schools, small businesses, salons. We’re still in the planning phase right now,” she said.
Little time left
Whatever the group does will need to happen soon, because Oct. 1 is looming. The coverage plans offered through the marketplace become effective starting Jan. 1, which isn’t too distant in time, either.
The big push by federal officials to get the word out in the next few months about the Affordable Care Act mostly will bypass Kansas, but even in this generally anti-Obama red state there are organizations and community groups gearing up to inform the public about the new health insurance exchange scheduled to launch on Oct. 1.
“I think that there's a lot of misunderstanding about what the Affordable Care Act is and how it works and there's so much noise from a political perspective that people can't really focus on what it is they need to know” about it, said Roberta Riportella, a professor of community health at the Kansas State University Extension. “What we're going to try to do is cut through that noise.”
Riportella has been on the job at K-State for about three months and for at least the next several will be spearheading an effort to use county extension agents and faculty members to inform the Kansas public about the federal health reform law, particularly the new insurance exchange through which millions of Americans and hundreds of thousands of Kansans are expected to purchase their health coverage.
The extension is a long-trusted K-State institution with agents working in all 105 counties. They do all sorts of things to help people, ranging from counseling on best farming practices to helping seniors enroll in Medicare Part D drug programs. They teach 4-H kids to make jelly and other skills, give parents tips on home economics, and are the state’s most persistent crusaders against musk thistle and other noxious pests.
Over the next several weeks, including as part of their annual training sessions in August in Manhattan at the K-State campus, the agents will be learning details of the Affordable Care Act and how to communicate its meaning to the people intended to benefit from it.
In at least one county, (Shawnee, home of Topeka), there will be as many as three extension agents working to get out the word.
They and their colleagues across the state will be trying to inform a public that still knows relatively little about the law three years after it was passed. A recent poll by the Kaiser Family Foundation showed that most Americans still don’t know much about the law commonly referred to as Obamacare.
“I think it will take a big educational effort and I don't expect everybody to get it by the deadline,” said Cindy Evans, a K-State extension agent who works in Shawnee County. “We'll just have to keep working at it and hopefully, if it turns out to be a good thing, people will tell their friends and family about it. It won't be just an agency like (extension) carrying the message. You’ll need community connections, churches and other groups letting people know.”
Each year for the past six, Evans said, she has worked one on one with seniors to help them enroll or re-enroll in the Medicare prescription drug program. But she said it would be impossible to work individually like that with people on the Affordable Care Act simply because of the thousands expected to use the insurance exchange.
'Keep politics out'
Sue Peterson has served for years as K-State liaison to the Kansas Legislature and she knows very well the revulsion the state’s elected conservative Republicans have for Obamacare. Gov. Sam Brownback campaigned for the job pledging to fight the law "every step of the way.”
“It was envisioned by the United States Congress when they passed the Hatch Act and Smith Lever acts, (that) research and extension would provide information to the public who needed or wanted information. The university, and research and extension provide unbiased scientific research findings or information to the public at large around the state,” Peterson told KHI New Service in an email when asked if she expected the university to face political repercussions at the Statehouse because of extension agents doing their jobs.
Evans said she didn’t want her efforts to be misconstrued as political.
“I think extension's role is going to be what it always been — education,” she said. “I don't want to be political at all on this. I just want to keep politics out. People have feelings on both sides on whether they think it will work or cost the system too much. It’s not my role in extension to be political. My role in health literacy and senior health counseling, is to just accurately help people understand the law as it is today.
“I’m not trying to take a stand whether it’s good or bad,” Evans said. “My major area is family finance and people spend a lot of money on insurance and health care and I want to help. My role in family finance is to help them make a good financial decision and not be political.”
Federal officials are preparing for a major public awareness campaign to be most evident in August and September that in some ways has already started. Today, for example, the U.S. Department of Health and Human Services announced a new website and a telephone call center in anticipation of the Oct. 1 exchange launch.
But the major focus of the marketing blitz by the feds and national health consumer groups is expected to be in states with high numbers of people without health coverage, including California and Texas.
Kansas is among the states where federal officials will run the new health insurance exchange but the state’s top insurance regulators said they hope to inject a local flavor.
Insurance Commissioner Sandy Praeger said her agency has been in discussion with the feds about having some of the more complex calls to the exchange’s toll-free helpline roll over to her department so that Kansas consumers come in touch quickly with local people more familiar with the Kansas insurance plans offered in the exchange and the governing regulations.
“We’re discussing how we can make a quick, relatively seamless transfer,” of appropriate calls to the Kansas Insurance Department, Praeger told KHI News Service.
“Our expectation is if you call the 800 number and if you have really simple questions like ‘I don't think I have the proper web address for the exchange or my password isn't working,’ a very operational question, they would handle it,” said Linda Sheppard, the insurance department’s director of health care policy and analysis. “But if it’s questions specifically related to anyone's benefits or coverage, those would be forwarded to us.”
The department already routinely fields calls from consumers with complaints about denials of insurance claims or delays in processing, so it only makes sense to carry that practice forward with implementation of the Affordable Care Act, Praeger said.
The exchange or marketplace is scheduled to be operational in each state by Oct. 1 with coverage purchased through the exchange effective Jan. 1.
'Hiccups along the way'
Some Republican officials have questioned whether the exchanges will be up and running by Oct. 1. Praeger, who has been generally supportive of the new law, is not among them. But she predicted it wouldn’t be a smooth start.
“Oh, I think they'll be up and running,” she said. “There will be some hiccups along the way. That's putting it mildly, especially if you look at how the Medicare prescription drug program rolled out in the Bush administration and this is much more complicated.”
→ Related story: Kansas insurers gearing up to market new plans on exchange
School administrators here say they are alarmed and confounded by the looming, new costs they face with the implementation of the Affordable Care Act.
“We've been talking about it (in anticipation) the last two years. I wish there was somebody smarter than me to find a solution,” said Chris Hipp, director of the North Central Kansas Special Education Cooperative Interlocal 636.
“We are not built to pay full health benefits for non-certified folks who work a little over 1,000 hours a year. I've spent hours and hours running every possible scenario. We can't pay for any of them, so it’s all kind of an academic effort really," he said.
As part of the federal health reform law, commonly referred to as Obamacare, larger employers across the country have a new set of insurance coverage obligations and fees they must pay. The new rules apply to commercial enterprises with 50 workers or more but also to public employers such as cities, school districts and the state of Kansas.
Kansas officials estimate the new fees alone will cost the State Employees’ Health Benefit Plan at least $4.7 million in 2014, or about $63 per worker. That’s without reckoning the added costs of the law’s new coverage requirements, much of which the plan already is absorbing.
For many businesses and larger governmental units, the new obligations are unwelcome but not unmanageable because they can be passed through either to customers or, at least partially, to health plan policyholders.
And for some governmental units, the expected costs represent a small percentage of overall spending. Lawrence officials, for example, estimate the new Obamacare fees will cost the city $137,200 in 2014, which could be considerably less than the potential costs of complying with a new conceal-carry firearm law passed earlier this year by state lawmakers.
Rural school districts
But the new health reform rules are particularly challenging for rural school districts and special education cooperatives, where officials say they have little or no place to turn for additional money, especially since state school aid has been held flat or reduced and more often than not the so-called “local option” school budget authority already has been maxed out.
“A lot of the districts and co-ops are looking at various options, including the option of getting out of offering health insurance and acknowledging that the most economical step for them is to pay the penalty and have their employees go to the exchange and get what's available through the marketplace. But a lot have not made that decision yet,” said David Shriver, assistant executive director for insurance services at the Kansas Association of School Boards.
The situation at the Phillipsburg special education cooperative offers a stark example of the complications many Kansas schools are facing, Shriver said.
The interlocal co-op is funded by 11 participating school districts that together cover an area of about 4,500 square miles spanning eight rural counties slightly west of the geographic center of the conterminous United States. It is square in the heart of the heartland. The districts collectively serve about 3,700 students, of which about 670 are in the special education program.
Hipp said NCKSEC Interlocal 636 has about 85 “certified” employees (mostly teachers) but also employs about twice that many people as “non-certified” teacher assistants or “paras” and other support staff.
Those workers, earning close to minimum wage, also are offered health benefits by the co-op. But about 100 of them don’t take it because it is too costly for them. The imbalance between their wages and their health insurance costs is so pronounced, Hipp said, that some of the para-educators who use the co-op’s health plan end up writing checks to the co-op two or three times a year just to cover their share of the benefits.
Under the health reform law, Hipp said, the interlocal must offer health coverage that meets the federal standard of affordability or pay a penalty for each employee that gets insurance through the subsidized federal exchange. The exchange — sometimes called a marketplace — is scheduled to be in operation by Oct. 1, with the coverage effective for policyholders beginning Jan. 1, 2014.
Here’s the dilemma for the co-op and similar organizations: On one hand, they can’t afford to pay their “non-certified” workers enough to make premium costs an affordable percentage of their incomes. But nor can the organizations afford to maintain a health plan and pay the annual penalties that must be paid by employers that have workers who opt for coverage through the insurance exchange.
Kansas insurance companies are preparing to sell a range of health plans on a new, online exchange being created by the federal government in an effort to make coverage more available to the thousands of people who have struggled to obtain it.
The Affordable Care Act, often called “Obamacare,” requires the new health insurance marketplaces to be up and running in every state by October, with the coverage sold through them effective on Jan. 1. But large numbers of Americans who stand to benefit most from the exchanges still know little to nothing about the law or how it will affect them, according to a recent poll by the Kaiser Family Foundation.
Anyone will be able to use the online marketplaces to purchase health coverage, but they are being created mostly to make private coverage more affordable for the uninsured and individual policies more widely available to those who don’t have access to group coverage through an employer.
“It’s going to create new opportunities for people who don’t have any insurance at all,” said Andy Corbin, chief executive of Blue Cross Blue Shield of Kansas, the state’s largest private health insurer. “And for those who don’t make much money, it may save them some dollars.”
Corbin said that plans offered on the exchange will “probably be more expensive” than the individual and small-group policies the company now sells. But he said in many cases the amount that consumers actually pay would be lower because of federal subsidies.
The exchange, or marketplace, also will give small businesses — those with fewer than 50 employees — new options. Rather than purchasing group insurance, they will be able to select a plan on the exchange and allow their workers to purchase individual policies. The businesses will have the option of helping their employees pay for the coverage, or not.
At least three insurance companies will sell multiple plans on the Kansas exchange, which will be operated by the federal government because Gov. Sam Brownback, a Republican opponent of the health reform law, declined to establish a state-run exchange. The companies are Blue Cross Blue Shield of Kansas, Coventry Health Care of Kansas and Blue Cross Blue Shield of Kansas City, which does business in two Kansas counties, Johnson and Wyandotte.
Subsidies to blunt higher premiums
Ron Rowe, a vice president for BCBS of Kansas City, predicted the cost of premiums for new, non-group policies would trend higher.
“Some people’s rates are going to go down and some are going to go up, but in aggregate it’s going to be about a 30 to 35 percent increase for that entire block of business,” he said.
But those increased costs could be mitigated for many. People who already have individual policies can keep them. And those who qualify for federal subsidies could end up paying less for more expensive and more complete coverage.
“Many people who are going to see big, high rate increases are going to qualify for a subsidy,” Rowe said. “And the amount that they’re going to pay out-of-pocket, net with the subsidy next year, will be less than they’re paying today even if the premium is significantly higher.”
For example, a person with annual earnings equal to 150 percent of the federal poverty level — $17,235 — would pay about $460 a year for a $5,000 policy, according to a cost-estimating tool developed by the Kansas Insurance Department. Federal tax credits paid directly to the insurance company would cover the remaining $4,540.
The credits, available only through the exchange, will be calculated on a sliding scale up to 400 percent of federal poverty guidelines, or annual earnings of $45,960 for an individual. But at that top level, the subsidy would amount to only about $630 leaving the consumer responsible for the remaining $4,370.
Despite the likelihood that many consumers purchasing through the exchange could pay less, both Corbin and Rowe said they anticipated a backlash from those forced to pay more.
“We’re trying to get out in front of the negative that’s going to come,” Corbin said.
To do that, he said, the company planned to do as much as it could to educate consumers about the exchange, the subsidies available and why some coverage would cost more.
Higher risks mean higher costs
Premiums are expected to rise because the reform law prohibits insurance companies from continuing practices they have historically used to reduce their risks. Those practices include denying or limiting coverage for high-cost individuals or capping their benefits. Going forward, the companies must sell policies to anyone regardless how sick they might be.
Kansas Insurance Commissioner Sandy Praeger, a Republican who has bucked the party line in supporting the law, said the old system often denied affordable coverage to people who needed it most.
“If you had any kind of pre-existing condition, you probably couldn’t buy (insurance) at all,” Praeger said. “You could be denied coverage because of allergies.”
Lawrence call center expected to add positions to handle insurance exchange calls.
Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Kansas is one of the four states.
Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A U.S. Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla. — all states with Republican leaders who oppose the law.
A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.
Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government. The other states are relying entirely on the federal government.
Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.
The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government.
The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.
States running their own marketplaces will have their own call centers.
The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.
Advocates pushing Kansas officials to expand Medicaid acknowledge it is unlikely they will achieve their goal this year.
But they said they remain hopeful they can convince Gov. Sam Brownback and legislators next year to make more Kansans eligible for the program.
“If it’s not going to happen the first year, we’ll continue to build grassroots support. We’re not giving up,” said Anna Lambertson, director of the Kansas Health Consumer Coalition, one of the groups pushing for expansion.
Medicaid, known in Kansas as KanCare, currently provides medical and long-term living assistance services for about 380,000 poor, disabled and elderly Kansans. Expansion could increase enrollment in the program by as many as 240,000, according to various projections.
The federal Affordable Care Act initially required states to expand Medicaid eligibility. However, the U.S. Supreme Court decision that upheld the law made expansion optional for states.
Expansion would have a bigger impact in Kansas than in many other states. That’s because the state’s current eligibility criteria exclude all but the poorest adults. Only those with children and incomes less than 32 percent of the federal poverty level — about $6,000 a year for a family of four — can qualify. Implementing expansion would mean that adults in that same family of four could make more than $31,000 a year and qualify.
The Brownback administration has estimated that expanding eligibility for the $3.2 billion program would cost the state an additional $600 million over 10 years.
Door still open
Whenever asked about expansion, Brownback says things that suggest he’s more likely to say “no” than “yes” to it. But advocates said they remain encouraged by the fact he hasn’t rejected the idea.
“If he’s really looking at the options with an open mind — as he himself has said he’s doing — then I see him taking his time (to decide) as beneficial,” Lambertson said. “I’d rather that he take his time than just say ‘no’.”
Last week, Brownback again expressed doubts that the federal government could afford to keep its promise to cover all the costs of expansion for the first three years and no less than 90 percent thereafter. Despite his misgivings, he said, he continues to have “active conversations” with expansion advocates and legislators on the topic.
“It’s in the legislative process,” Brownback said. “Expansion would have to be addressed by the Legislature. They would have to budget it.”
Brownback’s requirement that legislators budget for it before he would sign off on it has advocates convinced a decision won’t be made this year.
Members of the House-Senate conference committee negotiating a final version of the fiscal 2014-15 budgets are scheduled to return to the bargaining table early next month when the Legislature returns to Topeka for what leaders hope will be a brief wrap-up session.
With the filing deadline approaching, the nation’s largest tax preparation company is letting its customers know how they are likely to be affected by the Affordable Care Act.
“After the ACA was upheld by the Supreme Court in 2011, we did some focus groups and some surveys to try and measure the public’s understanding of what all is in the ACA,” said Meg Sutton, senior advisor for tax and health care services at H&R Block. “It became pretty clear that there needed to be a process for educating our clients.”
Sutton called the 2010 federal health reform law the “biggest tax-code change in the past 20 years.”
The company’s tax preparers, she said, have been calling their customers’ attention to the ACA’s penalties for not having health insurance and to the subsidies that will be available to low- and modest-income families.
The information also is available on an H&R Block website.
“Client reaction has been very positive,” Sutton said.
The company’s surveys, she said, had found that 77 percent of its clientele didn’t realize their 2013 tax returns would be used to determine their eligibility for health insurance subsidies and that 44 percent of those between ages 18 and 34 were unaware of the penalties for being uninsured.
Sutton said the company’s tax preparers do not tell their customers to buy - or not to buy – health insurance. Instead, she said, customers are “informed of their options” based on the information in their 2013 tax returns.
The ACA’s mandate that almost all Americans either have health insurance or pay a penalty takes effect Jan. 1, 2014.
Marvin Lawton has been a tax preparer at the H&R Block office in Topeka for the past eight years.
“I’ve found there to be quite a cross section in the way people react – all the way from being OK with it to being dismayed by it,” he said. “Some are OK with it because they already have insurance and won’t be affected by it, some are bewildered over how they’re going to afford it and some wonder why they have to pay a penalty if everybody in their family is healthy."
Most of his customers with little or no health insurance have seemed pleased to hear about the subsidies, he said.
“I’ve had a lot of people who used to have insurance through their job but ended up getting laid off in the past year,” he said. “They know how expensive health insurance is. So when I tell them about penalties, they say ‘But I can’t afford it.’ Then, when I tell them about the subsidies and how they’ll be able to buy it through the exchange and be part of a larger pool, they’re OK with it. They say they’re OK with it if it’s affordable. And I say that’s the intent, that’s why it’s called the Affordable Care Act.”
H&R Block customers have the option of signing up for email alerts on changes in the new health reform law.
Sutton said, H&R Block appears to be the only national tax preparation firm helping its customers predict the law’s effect on their 2014 taxes.
Surveys have shown that about 60 percent of the nation’s taxpayers use tax preparation companies. H&R Block accounts for almost 20 percent of the tax-preparation market.
Kansas Health Consumer Coalition Executive Director Anna Lambertson said she welcomed the company’s initiative.
“I think it’s great,” Lambertson said. “I give them high marks.”
The coalition, she said, has been looking for ways to launch a similar informational campaign in Kansas.
“We can’t do it alone,” she said. “And H&R Block can’t do it alone. It’s going to take everybody getting involved.”
Sheldon Weisgrau, a spokesman for the Health Reform Resource Project, also praised the company.
“I assume they’re hoping this will lead to more people coming to them to have their taxes done,” he said. “But that’s fine. Anytime you’ve got someone providing accurate information it’s a positive.
Weisgrau said federal officials have announced plans for launching a major outreach campaign in June.
“They don’t want to start too early, which makes sense,” he said. “The exchange won’t be up and running until October.”
Mary McBain, chief executive of the Kansas Society of Certified Public Accountants CEO said the H&R Block initiative had not gone unnoticed.
“The major accounting firms have definitely been ramping up for this,” she said. “Some of the bigger firms have hired people just to work on ACA – that’s all they do.”
MacBain said her organization was committed to providing its members with accurate information about the law.
“All of us, I think, need to take a deep breath and not get caught up in all the emotion that’s comes with health care reform,” she said. “We need to be informed because, frankly, there’s a lot of misinformation out there.”
→ Find more information on health insurance exchanges and other health reform topics at khi.org/healthreform.
After months of trying to dance around the politically charged issue, the administration of Gov. Sam Brownback has openly acknowledged that the $139 million Medicaid enrollment system that it is building will be interconnected with the online health insurance exchange required by the Affordable Care Act, and that the system will be ready to go by the Oct. 1 federal deadline.
“It's just a connectivity kind of a thing,” said Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, which is spearheading the project to overhaul the 26-year-old, paper-based system to a modern online one.
“I certainly appreciate the concerns that are tied to the political angst, but this program was well on its way when I came on board and my job is to make sure it gets completed successfully,” he said.
Entangled with the exchange
Overhauling the state’s antiquated Medicaid enrollment system has been in the works since at least 2009, when the project was called K-MED.
The project stalled briefly in August 2011, when Brownback returned a $31.5 million federal grant, most of which had been earmarked for developing the state’s new Medicaid enrollment system. Brownback said he was returning the grant because it was tied to the Affordable Care Act — which he he had pledged he would not implement prior to the U.S. Supreme Court ruling on the law, and later until after the 2012 federal elections.
Then that same month, administration officials announced a new contract with Accenture to develop the Kansas Eligibility and Enforcement System (KEES), using $118 million in federal funds to pay for the $139 million projected cost. K-MED became KEES.
A key condition of the federal funding was that the KEES system would have to be “interoperable” with the coming health insurance exchange — an online marketplace scheduled to launch Oct. 1 where consumers can compare and buy coverage that will begin Jan. 1, 2014.
In Kansas and the 25 other states that elected not to run their own health insurance exchanges, the federal government will build and operate them.
Moser said interoperability of KEES and the exchange means that — for consumers — there will be a single entry point for enrolling in private health insurance or in Medicaid, the state-federal health care program for low-income, elderly and disabled persons. Medicaid in Kansas is known as KanCare.
“You enter in some information, most of it is going to be yes/no. If you're eligible for Medicaid then it would pop up the KEES patient portal,” Moser said. “If it shows that your income level is such that you don't qualify for Medicaid…it's going to push your information over to the federal exchange. So those two systems literally will be handing back and forth inquiries.”
Moser said the fact KEES would interface with the insurance exchange was no different than integration with other federal computer systems, such as Homeland Security or the Internal Revenue Service.
“It doesn't really have that significant of an implication in my mind. But then again, I'm a physician and a little bit more patient-centered and look at the convenience factor. If that person is in a hospital setting and I think they need admitted, but they're worried about the cost because they don't have coverage, I'd like to be able to determine at that point in time 'Are they eligible for coverage' and use that as leverage to get them in to the hospital,” Moser said.
Is the whirl of hospital revolving doors slowing?
Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.
With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.
If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.
Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.
Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.
“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.
Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.
There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.
According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.
The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.
The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.
‘A community problem’
“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care.
A study released today by the Kansas Hospital Association says that expanding Medicaid eligibility to levels called for in the federal health reform law would pump more than $3 billion into the state’s economy and create 4,000 new jobs by 2020.
The study, done for the association by the Center for Health Policy Research at George Washington University and Regional Economic Models, Inc., also shows that expansion would save the state more than it would cost.
Tom Bell, the association’s chief executive, said the projected economic benefits were too significant to be ignored by Gov. Sam Brownback and legislative leaders as they consider whether or not to expand eligibility for the healthcare program that serves poor, elderly and disabled Kansans.
Brownback has been a vocal opponent of the Affordable Care Act but has not made a decision on Medicaid expansion, which was made optional for states as the result of last year’s U.S. Supreme Court decision upholding the law.
“I think from our perspective, it’s not unlike the state landing a huge federal contract,” Bell said.
The impact of the expansion on the Kansas economy could rival that of the National Bio and Agro-Defense Facility in Manhattan, Bell said.
“That’s the way we look at it, as an opportunity for our state,” he said.
Bigger impact in Kansas
Since Jan. 1 in Kansas, the Medicaid program has operated under the name of KanCare. Three health insurance companies are under contract with the state administer it.
The health reform law requires that the federal government cover state costs of expanding Medicaid for three years. After that, the federal share would recede gradually until it reaches 90 percent, where it would remain.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level (FPF) — currently $5,900 a year for a family of four.
Because those numbers are so low, expanding Medicaid would have a bigger impact in Kansas than in many other states by making all Kansans who earn up to 133 percent of FPL — $30,660 for a family of four — eligible for the program.
Various estimates suggest that expansion could add between 226,000 and 240,000 Kansans to the 380,000 now enrolled in Medicaid.
Net benefit to the state
A Kansas Department of Health and Environment report released last week estimated Medicaid costs would climb by $513 million over 10 years regardless of whether the state expanded eligibility for the program. That’s because heightened attention surrounding the expansion issue is expected to prompt many people who already are eligible but not enrolled to sign up.
Covering only those who are made eligible by the expansion would cost another $600 million over 10 years, the KDHE report said. Even so, the hospital association report said that expanding Medicaid would produce a net savings to the state of $82 million from 2014 to 2020.
“That’s front loaded into those first three years, but it’s still a substantial net benefit,” Bell said.
Brownback has not ruled out expansion but neither has his administration shown much, if any, enthusiasm for the idea. Reacting to the KDHE cost estimate, Sherriene Jones-Sontag, the governor’s chief spokesperson, said expanding Medicaid would affect the state’s ability to fund other “core responsibilities.” The impact would be even greater “if the federal government fails to keep its promise to pay for its part of the expansion,” she said.
Bell said administrators at the association’s 126 member hospitals understand Brownback’s concerns, which are shared by many legislators. But he said they believe the Medicaid expansion dollars are needed to offset the anticipated loss of other federal funds that hospitals have used to cover the cost of caring for the uninsured.
“From an economic perspective for our members — especially those that treat a higher number of uninsured — they think it makes great sense to take a serious look this and see if we can make it work,” Bell said.
Many Kansas hospital officials say they are worried that if state policymakers choose not to expand eligibility for the state’s Medicaid program, the hospitals will see a significant drop in the money they receive to help care for patients who can’t or won’t pay their medical bills.
Currently, 64 of the state’s 127 hospitals divide about $51.3 million a year in what are called Medicaid disproportionate share payments.
They use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured.
“It’s a significant amount of funding for us,” said Bruce Witt, director of governmental relations at Via Christi Health in Wichita.
In the current fiscal year, Via Christi Health is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state.
Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced, starting in October.
“We’re being told that ‘disproportionate share’ won’t be completely phased out, but that roughly 50 percent will be going away,” said Tom Bell, chief executive of the Kansas Hospital Association. “It may end up being somewhere between 50 and 75 percent. We don’t know at this point.”
Though Via Christi could expect to lose the most dollars, the smaller, rural hospitals likely would be the hardest hit proportionately based on an analysis done for the KHI News Service by its parent organization, the Kansas Health Institute. The analysis calculated the likely revenue hit on each Kansas hospital based on recent payment histories, bed counts and inpatient stays.
State option on Medicaid
The law’s design, Bell said, preceded the U.S. Supreme Court’s June 28, 2012 ruling that gives states the option of choosing to not expand their Medicaid coverage to include non-disabled, childless adults whose incomes fall below 133 percent of the federal poverty level.
Since the ruling, governors in at least 10 states – Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, South Carolina, South Dakota, Oklahoma, and Texas - have said they will not expand Medicaid eligibility.
“Our lieutenant governor is saying he’s not sure that DSH (disproportionate share) is going away because the (U.S.) Supreme Court has said the federal government can’t penalize states for not going along with the Medicaid expansion,” said Shawn Rossi, a vice president with the Mississippi Hospital Association.
“We don’t know if that’s a correct assumption,” Rossi said, “but we are for sure telling our legislators that if DSH goes away, we’re definitely going to need something to take its place. We see a very large number of people who are uninsured.”
Brownback looking it over
Kansas’ Gov. Sam Brownback has been an outspoken opponent of the Affordable Care Act, has not yet decided whether to implement the Medicaid expansion.
The Brownback administration has not ruled out implementing the Medicaid expansion called for in the federal health reform law.
But a spokesman today told members of the Legislature’s Joint Committee on Health Policy Oversight that prior to making a decision administration officials want to develop their own estimate of how many Kansans are likely to sign up for the health care program and how much the expansion would cost the state.
“We’re continuing to study the issue,” said Mark Dugan, chief of staff for Lt. Gov. Jeff Colyer. “We would like to come to you with our own numbers.”
Currently, there are several competing estimates of how the expansion would affect Medicaid enrollment and the cost of the program. The latest, released earlier this month by the Kansas Health Institute indicated that approximately 240,000 additional low-income, disabled and elderly Kansans would enroll in a program that currently serves about 380,000. According to the KHI analysis, expanding Medicaid would cost the state an additional $519 million between its implementation in 2014 and 2020.
The KHI projections are higher than those in a 2010 report prepared for the now defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis done in 2010 by the Kaiser Family Foundation. However, they considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act.
The KHI News Service is an editorially independent program of KHI.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level — $5,900 a year for a family of four.
The ACA expansion would have a bigger impact in Kansas than many states. It would raise the eligibility threshold for all Kansans to 133 percent of FPL — $30,660 for a family of four.
Two of the four legislators who braved inclement weather to attend Thursday’s meeting of the 12-member committee made it clear that they favored the expansion.
Rep. Don Hill, a moderate Republican from Emporia, said that virtually all legislators regardless of party and ideology agree that the current health care system is broken and in need of reform to lower costs and reduce the number of people who are either uninsured and under-insured.
He said while the ACA is far from perfect, “it has some redeeming elements.” One of those, he said, is the Medicaid expansion because of its potential to extend coverage to many of the state’s 365,000 uninsured.
Citing the federal government’s promise to shoulder the cost of serving all those made eligible by the expansion for the first three years, Sen. David Haley, a Kansas City Democrat, asked, “Why can’t we cover more Kansans and why shouldn’t we?”
“I think we’re going to take a good look at it,” Dugan answered.
But, Dugan said, a factor that must be considered is whether or not the cash-strapped federal government can be counted on to keep its funding promise. After paying all of the costs of the expansion for three years, the federal government would gradually reduce its commitment until it reached 90 percent, where it would be maintained.
“He (Gov. Brownback) doesn’t have a high degree of confidence in the federal government maintaining that 90 percent commitment over the long term,” Dugan said.
Dugan said the federal government missed an opportunity to negotiate a compromise with Republican governors skeptical of the expansion when it rejected the idea of allowing states to increase eligibility to only 100 percent of FPL.
“That was an opportunity for middle ground that was lost,” he said.
Like Kansas Gov. Sam Brownback, Bob Laszewski is a staunch opponent of the Affordable Care Act.
Despite that, the Washington, D.C. consultant said at a meeting here today that Brownback is making a mistake by refusing to partner with the federal government to run the Kansas health insurance purchasing exchange that the law requires to be operational by 2014.
“Do the partnership. That is a no-brainer,” Laszewski said to about 100 legislators, lobbyists and health care providers at a meeting sponsored by the Kansas Health Institute, the parent organization of the KHI News Service.
Laszewski, whose client list consists mostly of health insurance companies, said it’s time for opponents of the law to stop fighting it and start doing what they can to ensure that it is implemented in a way that does the least harm to the industry and consumers. One way to do that, he said, would be to implement exchanges – new online marketplaces – that encourage competition among insurance companies rather than rely on regulations to moderate increases in premiums.
“Putting the insurance exchange up doesn’t mean you support the thing (the reform law), it means you are trying to minimize the damage,” Laszewski said, predicting that premiums in the individual and small-group markets would go up no matter who runs the exchanges.
Brownback last year blocked Kansas Insurance Commissioner Sandy Praeger’s attempts to establish a state-operated exchange, returning a $31.5 million federal grant in the process. Last month, the governor told Praeger, who also is a Republican, that he would not support her efforts to partner with the federal government to operate and fund the Kansas exchange.
“Kansans feel Obamacare is an overreach by Washington and have rejected the state’s participation in this federal program," Brownback said, explaining his decision.
Praeger, who also spoke at the KHI meeting, said she would try once more before a Feb. 15 federal deadline to convince the governor and legislators that partnering on an exchange would be better than allowing the federal government to run it. Federal officials recently extended the deadline in an effort to accommodate states where governors had opposed or held out on state participation pending the outcome of the November national elections.
“There is still some opportunity for us to retain some control,” Praeger said. “Our department looks forward to working with the Legislature and the governor to see if that still is an option. The decision really rests with them.”
Praeger said partnering with the federal government would allow her department to retain authority to approve the plans marketed in the exchange and manage consumer protection efforts. She said it might also prevent federal officials from over-regulating the exchange.
The ACA calls on states to expand Medicaid eligibility to include adults earning up to 138 percent of the federal poverty level — $30,660 a year for a family of four. But the U.S. Supreme Court decision earlier this year that upheld the law also made the program expansion optional for states.
Implementing the expansion in Kansas would make more than 300,000 additional adults eligible for a program that today serves approximately 380,000 Kansans – mainly women, children, seniors in nursing homes and people with disabilities.
A KHI analysis handed out at the meeting estimated that about 240,000 additional Kansans would enroll in Medicaid if the expansion were implemented in 2014, including 122,185 adults and 117,886 children. According to the analysis, expanding Medicaid would cost the state an additional $519 million between 2014 and 2020.
The projected cost and enrollment figures in the KHI analysis are higher than those in a 2010 report prepared for the now-defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis prepared in 2010 by the Kaiser Family Foundation. But the costs projected in the KHI analysis were considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act and its implementation. The Kansas Policy Institute also projected the program’s cost through 2023.
Currently, the state’s Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and then only if they earn less than 32 percent of FPL – $5,900 a year for a family of four.
Brownback hasn’t said whether he plans to implement or recommend the expansion for Kansas. But he has said that he doubts the federal government would keep its promise to initially pay 100 percent of the cost of serving all those newly made eligible by the Medicaid expansion. Under current law, the federal commitment would be good for the first three years, drop to 95 percent in 2017 and then to 90 percent in 2020, where it would remain.
Laszewski said covering currently uninsured Kansans in Medicaid would be significantly cheaper for taxpayers than providing them with tax credits to purchase private coverage in the exchange. And he said by agreeing to the expansion, Brownback and other Republican governors might be able to get federal officials to agree to their long-standing request to convert the program to block grants to states with fewer restrictions on how the money is spent.
“Put up or shut up, that’s what I say to Republican governors,” Laszewski said. “It gives you leverage to get what you’ve always said you wanted — autonomy. Go to the Obama administration and say, ‘OK, we’ll expand Medicaid but we’re not going to do it your way.’”
About 100 people rallied outside the Kansas Statehouse Nov. 9, urging state officials to expand Medicaid eligiblity as provided for in the federal health reform law.
A Lawrence pastor cast the expansion as a Christian imperative during a call-and-response exercise with the crowd.
“If Jesus was up in the Capitol would he make a choice to keep 130,000 people without care?” said the Rev. Joshua Longbottom, associate pastor at Plymouth Congregational Church in Lawrence.
"No," the crowd shouted.
“If Jesus was up in the Capitol, would he tell families that they just need to get better jobs so that they could afford to take care of themselves?” Longbottom asked.
Again, the answer was "no."
“Did Jesus say, ‘I’m sorry you can’t get to the well, Mr. Leper, but you need to cultivate some self-reliance’?” Longbottom said.
“No,” the crowd yelled.
“So I ask the question, Gov. Brownback, ‘What would Jesus do?” Longbottom said. “I thought the mark of his ministry was caring for the ill, caring for the sick, caring for the dispossessed, caring for the marginalized, caring the first for the least.”
Longbottom said he hoped the governor wasn’t a “…politician who puts on his Christianity like it’s a cardigan (sweater), using it to gain access to a constituency.”
Brownback, a conservative Republican, has been outspoken about his Christianity and penned a spiritual autobiography titled "From Power to Purpose."
He's been a consistent political foe of the Affordable Care Act, also known as ObamaCare, first in the U.S. Senate and later as governor.
He has said repeatedly that the majority of Kansans are opposed to the reform law and cites the success of the law's opponents in recent state elections as the proof.
Expansion not ruled out
Last week, the governor announced that he would block the state’s participation in a state-federal insurance exchange, one of the hallmarks of the new law. But unlike some Republican governors, he hasn't ruled out the possibility he would support some sort of Medicaid expansion.
"The Medicaid expansion is a separate issue" from the insurance exchange, said chief Brownback spokesperson Sherriene Jones-Sontag in an email Friday to KHI News Service in response to a question asking if the governor would oppose opening up the program.
"We are continuing to discuss options and alternatives with like-minded states and with our legislative partners in Kansas," she said.
The U.S. Supreme Court has upheld the Affordable Care Act, but said the law couldn't oblige states to expand their Medicaid programs. The law gives states the option of expanding their Medicaid programs to include adults earning up to 133 percent of federal poverty guidelines.
Kansas Insurance Commissioner Sandy Praeger said today that she wants to meet this week with Gov. Sam Brownback about how to move forward with implementation of the federal health reform law.
Specifically, Praeger said she wants to talk to Brownback about the state partnering with the federal government on a health insurance purchasing exchange. Kansas no longer has the option of designing its own online insurance marketplace but it can still partner on one with federal officials, if it acts quickly, she said.
Praeger said partnering with the federal government on an exchange would allow the state to maintain its authority to review and license insurance plans.
Praeger, a moderate Republican who supports the reform law, said she must let federal officials know by Friday, Nov. 16 whether the state intends to partner on an exchange. But she said she needs the governor’s blessing on that and a grant application her department has prepared, which must be submitted by Thursday, Nov. 15.
“The governor needs to agree that he won’t oppose us applying for the grant,” Praeger said. “He doesn’t have to give tacit approval necessarily, but just indicate it’s OK if we want to move forward on this.”
Brownback, a conservative Republican, voted against the Affordable Care Act as a member of the U.S. Senate and as governor has tried to block its implementation pending the outcome of a U.S. Supreme Court ruling on the law and then later the outcome of the presidential race.
Brownback in August 2011 rejected a $31.5 million federal grant intended to help Kansas develop an exchange as part of a program to develop models for other states to use.
Praeger said President Obama’s re-election means that the reform law won’t be repealed. It also means that states that have been slow to act will have to play catch up to meet approaching implementation deadlines.
Under the law, each state is to have an exchange operational by Jan. 2014.
“It’s time to stop resisting,” Praeger said.
If policies proposed by GOP presidential candidate Mitt Romney and his running mate, Paul Ryan, were put in place, among the results would be deep cuts in federal Medicaid spending in Kansas and other states, according to a new report from the Kaiser Commission on Medicaid and the Uninsured.
Nationwide, federal Medicaid spending would drop $1.7 trillion between 2013 and 2022, according to the analysis. Of that, $932 billion would come from repealing the Affordable Care Act. The other $810 billion would come from reductions or savings realized by converting Medicaid to a block grant program for states, capping the amount of federal aid each state could receive.
Romney's Medicaid and budget proposals already have been approved twice in the Republican-dominated U.S. House but were not advanced due to opposition from the Democrats who control the U.S. Senate and the White House.
Romney once again voiced his support for Medicaid block grants and his vow to repeal Obamacare before a national audience during the third presidential debate on Monday night. Romney said the block grants had been successfully tried in Rhode Island and Arizona.
Kansas Gov. Sam Brownback, a Republican, also has championed Medicaid block grants and has asked federal officials to grant one to Kansas as part of a Medicaid waiver application his administration submitted with his plan to put virtually all Kansas Medicaid enrollees into managed care plans run by private insurance companies.
That request is still pending.
Supporters of the Romney Medicaid and budget proposals say they are needed to help cut the federal budget deficit. Critics say they would mean certain cuts in services to Medicaid patients and reduced payments to hospitals and other medical providers.
The Kaiser report, a more detailed reprise of one published in 2011, offered new information by breaking down the projected reductions in federal Medicaid spending in each state, should the Romney proposals be enacted.
Kansas would see a 36 percent reduction in federal Medicaid dollars over the 2013-2022 period, or about $12 billion, according to the report.
Kansas is expected to spend about $3.2 billion on Medicaid next year, with the federal government picking up about 57 percent of that cost.
The analysis drew on estimates prepared earlier by the Congressional Budget Office.
The projected reductions in spending from repealing Obamacare were based on an assumption that each state would expand the number of people eligible for Medicaid services under the law. The U.S. Supreme Court ruled earlier this year that states could not be obliged under the law to expand Medicaid eligibility.
Some Republican governors have signaled that their states would not add people to Medicaid, should the health reform law stay on the books.
Brownback has been a vocal opponent of the Affordable Care Act, but has not yet said whether he would propose expanding the program in Kansas. He has said he expects the reform law to be repealed.
State health officials are raising concerns about the future of a federally funded program that helps county health departments prevent infertility in women by testing for the sexually transmitted diseases of chlamydia and gonorrhea.
“There hasn’t been an official announcement, but it certainly appears that the funding will be going away after January of 2014,” said Jennifer VandeVelde, who runs the Kansas Infertility Prevention Project at the Kansas Department of Health and Environment. “The assumption is that with the Affordable Care Act everyone will have insurance so we won’t need the funding we have now.”
Combined, chlamydia and gonorrhea are the leading cause of infertility, according to the Centers for Disease Control and Prevention (CDC).
The mandatory coverage provisions in the federal health reform law are scheduled to take effect Jan. 1, 2014.
What’s unclear, VandeVelde said, is how county health departments would offset the costs of testing patients who, despite new law’s requirements, will remain uninsured.
“A lot of health departments today are dealing with people who won’t be eligible for health insurance under any circumstances – the undocumented folks, for example,” said Greg Stephenson, head of the clinical services division at the Wyandotte County Public Health Department.
Also, thousands of Kansas adults whose incomes fall below 133 percent of the federal poverty level and who are currently uninsured would remain uninsured if Gov. Sam Brownback decides to opt out of the Medicaid expansion provisions in the Affordable Care Act.
Brownback, an outspoken critic of the reform law, has said he will not announce his decision about the Medicaid expansion at least until after the November election. Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.
The leading cause of infertility
Last year, KDHE conducted more than 27,500 tests for chlamydia and gonorrhea. Of those, 19,200 involved women younger than 26 years old and 8,400 of the tests involved older women and men.
Almost 9 percent of the younger women, 4 percent of the older women and and 17 percent of the men tested positive for chlamydia.
Less than 1.5 percent of the women and less than 5 percent of the men tested positive for gonorrhea.
“Chlamydia and gonorrhea are the leading cause of infertility, both in Kansas and nationally,” VandeVelde said, noting that between 10 percent and 15 percent of women with untreated chlamydial infections develop infertility-related problems.
According to KDHE, the state’s health providers – a group that includes health departments as well as family physicians, OBGYNs, emergency rooms, student health centers and other walk-in health clinics - reported more than 10,600 confirmed cases of chlamydia and 2,200 cases of gonorrhea last year.
It’s not known how many tests were performed by private laboratories because providers aren’t required to report tests that do not come back positive.
“Chlamydia is so widespread that it hits every demographic you can think of,” VandeVelde said. “It’s very across-the-board, very non-discriminatory.”
Those who test positive, VandeVelde said, are treated and counseled about “behavior changes” to limit their exposure to sexually transmitted diseases. They’re also asked to identify their sexual partners so that the partners also can be treated.
“The idea is to treat (partners) preventatively so that they do not re-infect the person who tested positive and so that they don’t continue to pass it along to anybody else,” she said.
Finding a way to cover costs
Assuming though that the Affordable Care Act remains on the books and that the federal funds for testing for chlamydia and gonorrhea go away, county health departments would have to figure out a way to cover the costs of testing those who remain uninsured, Stephenson said.
For many, the term co-op evokes images of grain elevators, Depression-era workers stringing electric lines or maybe the more contemporary picture of a place where local-food devotees go to get a weekly helping of fresh produce.
But a group at work in Wichita has a different vision. They are working to develop a member-owned co-op that would provide thousands of Kansans with health insurance. And they want the coverage to be different from plans offered by traditional carriers.
Anne Nelson, associate director of the Central Plains Health Care Partnership in Wichita, an affiliate of the Medical Society of Sedgwick County, said the goal is to create a Kansas cooperative that offers individual and small business coverage that is both affordable and innovative in that it will emphasize patient-centered and preventive care.
“There will be a direct relationship with the people who are served by the products in the plan. If a product isn’t working based on consumer feedback, the consumer leaders (of the cooperative) can make changes,” Nelson said.
If the co-op does well financially, it would be required to use money not needed for claims or state solvency requirements to lower premiums or increase benefits.
Working with a small planning committee that includes health care providers, lawyers, actuaries, insurance experts and representatives of the business community, Nelson is preparing to apply for millions of dollars in federal loans to fund the launch of the nonprofit health insurance cooperative. She said she plans to submit the loan application this fall to the U.S. Department of Health and Human Services, which already has provided nearly $850 million in start-up and sustainability loans to health insurance cooperative in 10 states.
The loans approved earlier this year ranged from around $57 million to a cooperative in Oregon to nearly $175 million to the Freelancers Health Service Corporation, a union-affiliate co-op in New York. Midwest Members Health, which is planning to offer coverage to residents of Iowa and Nebraska, received $107 million.
“We don’t know yet what our application will be. But it’s a multimillion-dollar project,” Nelson said.
Money in health reform law
Creating more competition in the health insurance marketplace is one of the objectives of the controversial and still not-well-understood Affordable Care Act. The health reform law authorizes $3.4 billion in low-cost federal loans to start and help sustain at least one consumer-governed health plan in each state
In Pittsburg, the community health center so desperately needed more space that last year staff converted closets and a bathroom into offices.
But next year the number of patients the center sees is expected to grow 24 percent, said Krista Postai, chief executive of the Community Health Center of Southeast Kansas.
"And I have no place to put them," she said. "This building is totally and completely at capacity."
That should soon change.
By December 2014, using a $4.7 million federal grant, the center will nearly triple its space from 15,000 to 40,000 square feet.
The grant was announced today by the U.S. Department of Health and Human Services. It is part of more than $21.6 million awarded to five Kansas community health centers.
About 40,000 new patients will gain access to care thanks to the construction and renovation projects funded by the grants, according to HHS.
The funding stems from the Affordable Care Act, which authorized $9.5 billion to expand health services over five years and $1.5 billion for construction and renovation at community health centers.
“For many Americans, community health centers are the major source of care that ranges from prevention to treatment of chronic diseases," HHS Secretary Kathleen Sebelius said in a prepared statement. "This investment will expand our ability to provide high-quality care to millions of people while supporting good paying jobs in communities across the country.”
The grant amounts for the other Kansas health centers were:
■ $2.7 million for the Salina Family Healthcare Center in Salina.
■ $4.6 million for Hunter Health Clinic in Wichita.
■ $4.5 million for Konza Prairie Community Health Center in Junction City.
■ $5 million for PrairieStar Health Center in Hutchinson.
The grant funds were disbursed directly to the health centers, which are private, nonprofit organizations.
In Pittsburg, the new construction is set to begin in July and finish by December 2014, Postai said.
The center will then be able to expand most existing services as well as add optometry, physical therapy and speech therapy services. An estimated 8,200 additional patients will be able to access the center.
Plans are to add 42 positions at an average salary of $45,700 as a result of the expansion, center officials said.
The waiting room has been at capacity for years with more demand on it after one of the area's biggest employers was shuttered at the end of 2008. The wheel maker Superior closed as the auto industry crashed and the number of people near Pittsburg without insurance shot up from 12 percent in 2009 to nearly 18 percent in 2010.
"From the time we open, it is wall-to-wall people. We need space," Postai said. "You can only be open so many hours and you can only schedule so creatively. And our efficiency has been impacted by our lack of space."