Posts tagged with Brownback
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.
Finn Bullers is a 49-year-old Prairie Village man who suffers from Muscular Dystrophy. Earlier this winter, Bullers testified several times about proposed cuts to his Medicaid service level before legislators charged with oversight of the transition to KanCare, the state's new managed care program overseen by three private insurance companies.
In a Facebook post early on Christmas morning, Bullers wrote:
"...On Christmas Eve day, my UnitedHealthcare case manager came to our home to tell us that her firm had reinstated my full-time care.
The sun had never shined brighter.
We're a big organization where change moves slowly, my case manager told me just before Christmas when asked why United had reversed course.
This is all new to us. We've learned a lot this past year, she said. We've learned that each case is unique and health care is not one size fits all.
What a Grand Canyon sigh of relief..."
The head of the state agency that oversees programs for the developmentally disabled has outlined steps the state will take to assure payments aren't delayed to providers of DD services, if federal officials approve the state's request to include all DD services in KanCare starting next year.
But advocates for the developmentally disabled said the safeguards, described to them in private meetings earlier this week, failed to allay their concerns and instead signaled that administration officials anticipate significant billing problems similar to those experienced by other Medicaid providers after the first phase of KanCare was launched at the beginning of 2013.
"I do believe it's a sincere effort on the part of the state to understand why their contractors can't get their bills paid...but I guess it's part of an all-hands-on-deck strategy since this thing is not working the way they thought it would," said Tom Laing, executive director of Interhab, the association that represents most of the state's 27 Community Developmental Disability Organizations.
Interhab has fought the administration's effort to pull long-term residential services for the developmentally disabled into KanCare, one of the signature initiatives of Gov. Sam Brownback.
KanCare was launched Jan. 1 this year when virtually all the state's 380,000 Medicaid beneficiaries were assigned to managed care plans run by three commercial insurance companies.
Long-term services for the developmentally disabled were excluded from the program in its initial phase after protests from DD advocates and families, but standard medical services for the developmentally disabled have been in KanCare from the outset.
Brownback officials earlier this year submitted a request to federal officials seeking to add the long-term DD services to the program beginning Jan. 1, but federal officials still haven't ruled on the proposal. Public comment on the plan continues through Dec. 24 and no decision from the Centers for Medicare and Medicaid Services is expected before then, which means if approval comes it will only be days or less before the state's planned launch of its expansion.
Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services, also outlined the additional billing safeguards the state is preparing to use today during a public meeting of the KanCare Advisory Council, a reorganized group that last met in May.
Sullivan said the KanCare managed care companies were "putting billing edits in their systems to be ready for Jan. 1," and that the state was devising a monitoring system that would allow state officials to know quickly if payments by the KanCare contractors to some 400 DD service providers dipped significantly below sums historically paid the organizations.
"We are in the process of uploading each provider's average monthly payments from over the last couple of quarters," Sullivan said.
He said state officials could then work with the providers and the KanCare managed care companies to quickly determine the reasons for payment drop-offs should they occur.
Final documentation on the safeguard and flagging processes to be used should be completed within a couple of days, Sullivan said, once state officials have finalized the details with the managed care companies.
The state has been working the past few months with DD service providers in an effort to test the MCO billing systems prior to the tentatively planned Jan. 1 launch of the KanCare expansion.
But all involved with that pilot, or transition program, have acknowledged glitches or problems with the billing of the sort that have been a source of consternation for a wide variety of the service providers pulled into KanCare in its initial phase.
Pharmacists, hospitals, safety net clinics, nursing homes and others have all complained at some point over the past few months about stalled or delayed payments from the KanCare insurance companies. The delays fall particularly hard on smaller organizations that operate on thin margins and without large cash reserves.
Earlier this year, the managed care companies cut "emergency" checks to some of the state's safety net clinics after clinic officials complained to state officials that payment for services was lagging and jeopardizing their operations.
Laing said Sullivan had discussed the possibility of "pre-payments" to DD service providers as a way to assure they would continue to have enough operating cash, but he said it wasn't clear how or if that could be done.
"I can say he articulated several different things they will try to do to make sure the billing flows, which is a clear signal they anticipate the billing issues won't be resolved by January," Laing said.
ACCSES weighs in
Also today, ACCSES, a national association of disability service providers, filed comments with federal officials asking them to deny Kansas' request to include long-term DD services in KanCare.
"We oppose the carving of (the) services into KanCare because we believe that, as proposed, the changes threaten the ability of the LTSS (long-term service and support) system to maintain access to the services and programs for Kansans with intellectual and developmental disabilities," wrote Terry Farmer, the group's chief executive.
A new director has begun work at the statewide suicide hotline and counseling organization, Headquarters Counseling Center, but only on an interim basis.
Headquarters volunteer Steve Lopes took charge the Lawrence-based suicide prevention center Monday in the wake of the sudden departure of longtime director Marcia Epstein. After heading the agency since 1979, Epstein's last day was Nov. 20. Her departure was not explained by Epstein or by Headquarters.
Lopes said that he does not see himself as a replacement for Epstein.
"No one can replace Marcia. The responsibility for the business end, yes, I accept that. But no one could ever replace Marcia, and I would never agree to that. In fact, I am committed to building on her legacy,” Lopes said.
A statement on the Headquarters website refers to “the pain that Marcia is experiencing,” but offers no elaboration. The entire board of directors resigned 18 months ago, and Lopes said he's been told that the agency’s budget is now about half what it was two years ago. (The lion's share of a $480,000 federal grant recently awarded to Headquarters can't be used for day-to-day operations.)
But Lopes said he doesn’t know whether either of those problems had anything to do with the change of leadership. He said his goal for the next six months is to modernize operations — perhaps through the use of social media — to stabilize the agency’s finances, and to help select someone to lead Headquarters on a long-term basis.
The changes at the state's suicide prevention center come amid a dramatically rising suicide rate in Kansas. Suicides in Kansas increased 31.5 percent in 2012, totaling 505 deaths versus 384 in 2011.
Historically, the state's approach to suicide prevention focused on supporting community mental health centers. But the mental health centers’ initiatives, he said, have been squeezed by cuts in state and county spending.
As the percentage of Kansas children living in poverty continues to climb, the number receiving welfare assistance is falling, according to a new report.
In 2012, more than 23 percent of children lived in poverty — that's up from 21 percent the previous year, according to a report released today by the Topeka-based advocacy group Kansas Action for Children.
The report also indicated that the average monthly enrollment in Temporary Assistance for Needy Families (TANF) had dropped from nearly 26,000 in 2011 to about 21,600 in 2012.
In 2007, there were also about 21,000 Kansans receiving TANF, but in that year only 18 percent of children were living in poverty.
The poverty line for a family of four is about $23,000 a year.
“Many Kansas families haven’t yet rebounded from the recession. These are working parents who aren’t able to earn enough to make ends meet — they need these programs to help them feed their children and keep them healthy and safe,” Shannon Cotsoradis, chief executive of Kansas Action for Children, said in a prepared statement accompanying the report.
“And yet the Department of Children and Families (DCF) continues to make administrative changes without legislative oversight or consideration for the impact on families. It’s time to reverse course.
“The greatest threat to the well-being of children is a lack of economic security,” said Cotsoradis. “Making it more difficult to access safety-net programs only hurts our chances of reducing poverty.”
Among the administrative changes cited by Cotsoradis were:
- More work and job training requirements for TANF,
- Requiring new mothers to return to work after two months — instead of six months — to receive TANF aid,
- Reducing the lifetime limit on TANF benefits from 60 months to 48 months,
- Changing the way household income is calculated to qualify for foodstamps,
- Eliminating funding for programs that spread awareness of foodstamp availability,
- Separating the application processes to apply for TANF and for Medicaid.
The state has also instituted new drug screening for TANF and has stepped up fraud detection.
And last week, Gov. Sam Brownback proposed diverting about $18 million from TANF — which typically consists of cash payments to families — to help pay for a new reading initiative.
‘Helping adults achieve self-sufficiency’
Theresa Freed, spokeswoman for DCF, said the agency "is making every effort to reduce childhood poverty" by helping families find work.
"Previous efforts to reduce poverty by eliminating work requirements have proven ineffective in helping Kansas families. It is a top priority to help adults achieve self-sufficiency so that they can meet their own needs and those of their children," Freed said in an email.
"We understand that some jobs do not pay enough to make ends meet. That is why we have various assistance programs available and with job training through our state partners, families can achieve complete self-sufficiency," she said.
She said the reading program also would help reduce poverty by providing children the skills they need in the workforce.
"The Reading Roadmap programs that are supported by TANF funds are strictly for out-of school literacy efforts. This is again, to encourage the prevention of the cycle of poverty. By empowering young people with the tools they need to succeed later in life, we are supporting the objectives of the federal TANF program," Freed said.
Officials have said another goal of the reading program is to reduce teen pregnancies.
"A 2012 study by Dr. Ian Bennett at the University of Pennsylvania found that seventh grade girls with a less-than-average reading skill were 2.5 times more likely to have a child in their teen years compared with those with average reading skill," Freed said.
At least once a week, Kimberly Rowlands talks to someone contemplating suicide.
“It’s a big chunk of what I do,” she said.
Rowlands, 48, is what is called a mental health co-responder. When Olathe police respond to reports of someone threatening to kill himself or herself, she goes with them.
“I wouldn’t even guess how many times I’ve been called out,” she said. “I’m not on duty 24 hours a day, but when I’m working and a call comes in, I go out.”
Rowlands is on the front line of a problem that is growing nationally and in Kansas.
In the U.S., suicides have exceeded automobile deaths since 2009 to become the 10th leading cause of death. According to the Centers for Disease Control and Prevention, suicide accounted last year for more than 1.4 million years of life lost before age 85.
The number of Kansas suicides increased more than 31 percent between 2011 and 2012. According to the Kansas Department of Health and Environment’s recently released vital statistics report, coroner’s offices across the state reported a record-high 505 suicides last year.
There are significant regional differences in suicide rates. For the past decade or more, the rates typically have been highest in the states of the mountain west and lowest in the more heavily populated states of the northeast.
But with Kansas’ significant recent increase, it has moved into the rank of states with the highest rates. No one seems to know why, or whether the dramatic one-year increase was an aberration or the beginning of a disturbing trend.
Between 2011 and 2012, the state’s suicide rate went from 13.4 deaths per 100,000 population to 17.6 deaths per 100,000 population.
“The numbers are very troubling,” said Miranda Steele, spokesperson for the Kansas Department of Health and Environment. “We’ll be working with our partner agencies and with KDADS (Kansas Department for Aging and Disability Services) on seeing where we go next with our interventions.”
Funding an issue
Historically, much of the state’s response has been defined by its support for community mental health centers; the work of groups such as the Governor’s Mental Health Services Planning Council, and education campaigns.
“We’ve made a good start,” said Michael Garrett, chief executive at Horizons Mental Health Center in Hutchinson. “Every mental health center in the state puts on programs for educating the public about depression and how to recognize the signs that someone is contemplating suicide. We do training five or six times a year in Reno County.”
But the mental health centers’ initiatives, he said, have been squeezed by cuts in state spending.
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.
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.
Kansas Medicaid officials are preparing for a new phase of KanCare that will target services to the seriously mentally ill.
They will be using a “health home” model that appears to be producing good — though preliminary — results in other states and which will allow Kansas to draw additional federal aid dollars as part of the Affordable Care Act.
Among the goals of federal and state officials in using the model is to reduce emergency room visits and hospital readmissions among Medicaid enrollees.
The Kansas Medicaid program — which was rebranded as KanCare at the beginning of 2013 when virtually all 380,000 enrollees were moved into commercially run managed care plans — is scheduled to begin health home efforts on Jan. 1, 2014, and will direct them at about 36,000 of the state’s seriously mentally ill, though participation is voluntary.
A health home is not so much a place as it is a concept of care delivery built on close coordination among a patient’s various medical providers so that health crises can be prevented or minimized through better management of a person’s conditions.
The mentally ill are disproportionately likely to also suffer other chronic conditions.
“They (federal Medicaid officials) expect fewer emergency room visits, fewer readmissions to inpatient settings and, of course, they also want to see lower costs,” said Becky Ross, Medicaid initiatives director at the Kansas Department of Health and Environment, the state’s chief Medicaid agency. “There are some things they will require all states to measure and then we have some additional things we’ll be measuring.”
Kansas officials are in the process of developing a state Medicaid plan amendment, which Ross said they would formally submit to federal authorities in October after earlier submission of a draft document. And they plan to consult with federal mental health officials on the plan before Aug. 2, Ross said.
Work on the Kansas health home initiative began in April 2012, when a team of state officials began meeting about it. That quickly grew to include a “focus group” of about 70 people who work with the Medicaid program as providers or as association representatives.
And Tuesday, at least 200 people are expected for a forum in Topeka where Ross said state officials hope to collect additional information from potential health home providers so that finishing touches can be put to the state’s plan amendment. An earlier forum was held in April and Ross said Tuesday’s gathering would be the final one.
WICHITA — After opposing the move for nearly two years, many providers of long-term services for the developmentally disabled say they now are largely resigned to the state’s plan to fully include their system in KanCare. But that doesn’t mean all the questions and worries about the proposed changes have gone away.
Chief among them seems to be this: How will the whole thing work?
“There was that whole debate this past (legislative) session and last year’s session about whether it’s good for people with DD to be in this (KanCare), but that debate is behind us now,” said Jerry Michaud, president of Developmental Services of Northwest Kansas, Inc., (DSNWK) a nonprofit Community Developmental Disability Organization that serves about 500 developmentally disabled, or DD, people in the state’s 18 northwestern-most counties.
“And so now, it’s how do we set up a system that's going to work and not wait until the first day to realize there are some major hiccups,” Michaud said.
State officials this week are holding two public hearings on an application they plan to file with federal authorities, probably in mid or late August, seeking approval for the KanCare expansion and some other Medicaid program changes.
The second of the two public comment sessions is set for 10 a.m. Tuesday in the Madison Ballroom at the Downtown Ramada Inn in Topeka (map).
However, state officials said they believe they already have all the authority they need for the so-called “DD carve-in” as a result of the initial federal sign-off on KanCare in December 2012, just days before the KanCare initiative was launched on Jan. 1.
Kansas officials said federal officials have been urging states to broaden their Medicaid managed care programs so that various services can be better coordinated. And key spokespersons for the state's developmentally disabled service groups said they don’t expect the federal Centers for Medicare and Medicaid Services to block the expansion once they receive the state’s Medicaid waiver request.
But there are a number of key questions about how the changes scheduled to begin Jan. 1 will be accomplished and whether or not some of the problems experienced by KanCare providers in the past few months will have been smoothed out so that the new expansion is relatively easy or seamless for the developmentally disabled and those who assist them.
State officials have said for two years that they intend to leave the current, time-honored service delivery system in place. But the nature of the working relationship the providers will have with the state’s three KanCare contractors and their myriad subcontractors is still being sorted out.
“We are meeting two times a week with the MCOs (the KanCare managed care companies) and the different provider work groups to make sure we get this correct and to make sure we have this exactly correct the first time out,” said Aquila Jordan, director of Home and Community Based Services for the Kansas Department for Aging and Disability Services (KDADS), the agency that oversees the state’s Medicaid DD programs.
Gov. Sam Brownback’s Medicaid makeover has been putting a financial squeeze on small Kansas pharmacists and spokespersons for the hometown druggists are calling for the administration to enforce the terms of its contracts with the three KanCare managed care companies.
“I think the simple answer is for the State of Kansas to make sure the MCOs (KanCare managed care companies) are living by their signed contracts and that should have been ready to go Jan. 1 (when KanCare was launched),” said Mike Larkin, executive director of the Kansas Pharmacists Association.
“We understand there will be bumps and hiccups in the implementation of a new program, but I can't help but think that if the shoe was on the other foot and they (the MCOs) were losing money instead of making money, they would have been on this (problem) a lot quicker,” he said.
Pharmacists say the heart of the issue is that the KanCare companies — Amerigroup, UnitedHealthcare and Sunflower State Health Plan — often fail to reimburse the druggists for the costs they incur serving Medicaid enrollees.
“I guess the bottom line is that we were led to believe in the first year (of KanCare) that there would be no changes on reimbursement or anything,” said Ron Booth, owner of the Corner Pharmacy in Leavenworth. “But you see, these (KanCare MCOs) are for-profit companies. They are changing all the rules and no one in Topeka is holding them accountable. I'm speaking out of frustration as a small, locally owned pharmacy. I want to be treated fairly.”
The pharmacists, before and after KanCare, work from rate sheets that list the maximum they will be reimbursed by Medicaid for each of the long list of medications they dispense.
But here is what changed with KanCare, according to pharmacists and others familiar with the business: In the past, the state kept a single list or rate sheet of “maximum allowable costs” and when its reimbursement rates failed to cover a druggists’ costs, it was more or less routine for the pharmacist to appeal and have the rate revised upward. The druggists could then resubmit those claims to the state and be paid enough that they weren’t losing money on the transactions.
With KanCare, each of the state’s contractors — or rather their pharmacy subcontractors — keeps a separate rate sheet, the formulation of which is considered proprietary. Booth and others said getting prices adjusted by the MCOs, so that the pharmacists aren’t losing money on many of their Medicaid claims, has largely been an exercise in futility. And they also are frustrated that they can’t get access to the methods the MCOs use for calculating their reimbursement rates, something obliged of them in their contracts with the state.
Customers turned away
Booth’s pharmacy, which was established in 1871, still has a soda fountain and other small-town amenities of a largely bygone era. It is a hub of activity in the middle of Leavenworth’s historic downtown district and Booth is a proprietor clinging to and clearly relishing his role in the vanishing tradition of local merchant as “pillar of the community,” in daily contact with his customers and their concerns.
Booth said since KanCare started he has served hundreds of his customers at a loss and turned away more than that because he could no longer afford to fill their prescriptions. And he said he has not had a single appeal approved or adjusted upward by any of the KanCare companies since the program started six months ago. He gets form-letter denials, he said, and little or no understanding from the KanCare customer service reps when he calls to complain or ask for assistance.
“My problem is I'm dealing with real people in front of me at the counter,” he said. “They are my friends and neighbors. I actually care about them.”
Reviewing the appeals data
State officials said they were aware of the pharmacists’ concerns with reimbursements (outlined in a May letter from Larkin to KDHE) and were looking into them.
“KDHE has heard provider concerns that fewer MAC (maximum allowable cost) appeals are being approved in KanCare than in fee-for-service Medicaid,” said Kari Bruffett, director of KDHE’s Division of Health Care Finance. “KDHE is in the process of reviewing both KanCare MAC appeals data in aggregate and a sample of denied appeals to ensure compliance with our expectations.”
Meanwhile, Bruffett said, the state’s overall pharmacy spending was up from last year.
“Through the first five full months, overall pharmacy reimbursement is running about 8 percent ahead of the same time period in 2012,” she said in an email to KHI News Service.
“Someone probably is benefiting,” from KanCare, Booth said, but it hasn’t been him.
In fact, you probably shouldn’t get him talking about it unless you have some time to listen.
“At first, we were just absorbing the cost. But I decided I'm not going to do it anymore,” he said. “I'm going to be the squeaky wheel. Someone's got to stand up. I don’t want to subsidize these big MCOs that make millions each year. I work about 70 hours a week. I’m fighting for my life everyday. The big boys don’t need me. They don’t need Ron Booth who gets up in the middle of the night for his patients, sees them at Rotary, sees them at church, goes to the ballgames. I’m part of this community and unfortunately I have a conscience.”
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
Medicaid services for the disabled in Kansas have been undergoing dramatic changes in the past 18 months and in response many smaller providers of so-called “payroll agent” or “financial management services” for disabled persons who prefer to hire their own care attendants are either changing their business models or simply going out of business.
Some in the business predict major consolidations. Instead of dozens of small firms dotting the landscape, they foresee perhaps four or five large ones.
“There will just be less options for people. More consolidation. The bigger you are, the more likely you are to make a profit on FMS (financial management services),” said Scott Criqui, executive director of Trinity In-Home Care in Lawrence.
Trinity has been in business since 1976. But effective this month, it no longer will provide the administrative services it has offered clients who prefer to “self-direct” their personal care attendants.
Criqui said the nonprofit agency’s decision to stop providing the services was the result of state policy and reimbursement changes that began in November 2011.
“The reimbursement level for FMS is so low we're no longer going to be providing that service,” Criqui said.
For almost 20 years, disabled Kansans who rely on Medicaid for services that allow them to live at home and avoid having to move to a nursing home have had the choice of hiring their own attendants, which is called “self-directed care,” or using those provided by an agency – “agency-directed care.”
'Taken apart piece by piece'
Because personal care workers often provide a number of intimate needs such as helping with bathing, grooming and toileting, many disabled persons or their families have preferred the self-directed option instead of relying upon a person sent by an agency.
But to do that, they need the help of a “payroll agent” to process the timesheets and payments for the personal care attendant.
Now, it seems, many of the state’s 62 payroll agents are shutting their doors or concentrating on other types of services.
Doug Gerdel runs Life Patterns, a Topeka-based agency that serves about 400 self-direct customers in the eastern half of the state,
Historically, Gerdel said, Kansas had “always been way ahead of other states in terms of in-home supports and we were one of the very first states – back in the 1980s – to offer self-directed care.”
But that’s been changing as a result of the new policies.
“People can still self-direct,” he said. “But here in the last 18 months, you can see how that’s being taken apart, piece by piece.”
State officials said despite the changes they think there are enough payroll agent businesses to serve the state’s disabled.
“We currently have more than 60 FMS (Financial Management Service) providers in Kansas, and believe that represents an ample number of choices for consumers,” said Angela de Rocha of the Kansas Department for Aging and Disability Services. “The number of FMS providers fluctuates a bit every month. If there is an apparent consolidation, we are not seeing it yet. We would not be surprised to see some consolidation, but do not at this time anticipate anything too drastic. KDADS has no set optimal number of FMS providers.”
Some agencies, like Trinity in Lawrence, will continue to provide other services. But the agency has already notified more than 90 clients that it no longer will provide payroll agent services.
“It meant I had to quickly find a new payroll agent for my children,” said Shannon Graham, a Lawrence mother who adopted four significantly disabled children and relies on between eight and 10 personal care attendants and nurses to assist her with them. “I think it’s tough on everybody. The people who work and support my children in my home have to be rehired through a different agency.”
Graham said she would now rely on an agency in Olathe, Helpers Inc., for financial services.
KDADS officials said they had “seen no reports on the number of (Medicaid) waiver participants who are shifting agencies in order to continue to self-direct their services.”
'Change, change, change'
Anne Cousin is chief executive at Helpers Inc., which has more than 650 payroll-agent customers across the state. It is one of the larger operators.
“We intend to stay in business,” she said. “But we’re having to work harder than we’ve ever had to work just to stay on top of all the changes that are going on. Everything is change, change, change.”
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—Every day a small army of Kansans — officials estimate there are about 16,000 of them — are at work helping some of the state’s neediest cope with the demands of daily life so that they can remain in their own homes rather than nursing homes or state institutions.
The personal care attendants or PCAs, as they are called, do all sorts of things to help: They clean house, fix meals, line out doses of medications, change adult or infant diapers, scour feeding tubes, lift people on and off toilets and in and out of beds, bathtubs and wheelchairs. They advance the pieces on a board game so a child can play with a younger brother. They let the dog out. Sometimes they are small but tough women presented impromptu tasks that would intimidate others, such as calming a large, shouting man made erratic by a brain injury.
They are people like Cydney Bunner, a University of Kansas graduate student who helps a Lawrence family that has four significantly disabled children.
Or Sally Fronsman-Cecil, one of two personal care attendants for an 85-year-old Topeka woman who is diabetic, had a lung removed and is beginning to show signs of dementia but is still in her own home.
Or Fred Miller, a grown-up farm kid, who does the heavy lifting for a young woman robbed of self- locomotion by muscular dystrophy and a litany of accompanying ailments.
They usually are paid between $9 and $10 an hour, generally without benefits such as health insurance, vacation or paid time off to deal with their own illnesses or problems. Collectively, they care for about 20,000 Kansas Medicaid beneficiaries any given month.
Some are employed by agencies, others are hired directly by the people or families they help. Either way, it is Medicaid that pays for their labors.
“Without the personal care attendants and the nurses in my house, I would not be able to have the children that I have,” said Shannon Graham, a Lawrence woman who became a foster mother about 15 years ago and then ended up adopting five of the children in her care. Four of the five are seriously disabled. “It can be very intimate support that is provided. They become a part of your family at that level.”
‘Not even considered providers’
Graham said any given week she has between eight and 10 care attendants and nurses in her home helping with the children. She hires and trains most of them herself, she said, placing ads at the University of Kansas to be seen by prospective nursing students.
One of Graham’s sons, six-year-old Max, relies on a wheelchair. He is developmentally disabled and prone to serious epileptic seizures.
Max requires “a special diet because of his horrible epilepsy,” Graham said.
“He has a nurse with him all the time at school,” she said. “These people (the care attendants) have to be trained to learn to look at him and know when he might need oxygen. If he has a seizure, there's a protocol they need to follow and these people are getting paid 9 to 10 bucks an hour.”
Because they mostly help people in their homes, the work of the personal care attendant is largely unseen by the public and they often are overlooked by policymakers. Many, if not most, are exempt from wage-and-hour laws.
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 for the developmentally disabled held a Statehouse press conference today to praise Gov. Sam Brownback's plan to reduce by 600 the number of disabled Kansans awaiting home- and community-based Medicaid services.
"We think this is a great move by the governor," said Tim Wood, campaign manager for End the Wait, a group pushing for elimination of the waiting lists. "This is a good step in the right direction."
Wood and fellow advocates also urged the Legislature to consider developing a plan to fully eliminate the waiting lists, which have grown over the past decade to include more than 5,000 people with physical or developmental disabilities. About another 1,200 people with developmental disabilities are receiving some of the services but waiting for more.
The governor last week released a budget amendment asking the Legislature to spend an additional $18.5 million to reduce the waiting lists. The recommendation came after state budget forecasters concluded that state spending on Medicaid services would be about $98 million less than previously expected for the fiscal year that ends June 30, including about $37.6 million from the State General Fund.
The governor characterized the reduced costs as "dividends" from the enactment of KanCare, the initiative he launched Jan. 1 that expanded managed care in the state Medicaid system. State budget analysts attributed much of the foregone spending to fewer people receiving Medicaid services. When federal officials approved the administration's KanCare plan, one of the "special terms" of the agreement was that if money were saved, some of it would be used to reduce the waiting lists.
Wood said he and other advocates also would urge lawmakers to aim for equal reductions in the lists for the physically disabled and the developmentally disabled. The governor proposed that the money be split evenly between the two waiting lists but because the cost of caring for the developmentally disabled is higher on average, fewer people could be served.
Wood said ideally that 300 people would come off each the two lists rather than 400 off the physically disabled list and 200 off the developmental disability list.
"While we appreciate the need to bring all people off the waiting lists," he said, "we want the Legislatuare to consider a fair and equitable way to divvy up the dividends."
In related news, spokesmen for Interhab, a group that represents most of the state's Community Developmental Disability Organizations, said more than 1,000 people had signed up to attend a rally scheduled for Wednesday at the Statehouse to urge legislators to exclude long-term DD supports from inclusion in KanCare.
The following video was produced to present to Kansas legislators by the advocacy group End The Wait, which is funded by the Kansas Council on Developmental Disabilities.
People involved with Medicaid services for children say they are hopeful the state’s new KanCare program will someday lead to improved services and health outcomes.
But for now, they report dealing with some of the same problems and frustrations others in the program, which also serves the poor elderly and disabled, have experienced since its launch on Jan. 1: Billing problems, payment delays, concerns about patient access to care and increased administrative complexity.
“There are a lot of bumps in the road; we'll put it that way,” said Dr. Melinda Miner, a Hays Dentist who along with her husband, Dr. Daniel Miner, is one of the leading Medicaid dental providers in her part of the state.
Miner said her clinic just recently began receiving payments for services earlier this year from the KanCare managed care companies and that other dental providers she knows have had the same problem.
“We still have a lot of outstanding claims,” she said. “We never had problems like this when the state ran the program (using two managed care companies). That was the best thing about HealthWave, claims got paid in a timely manner. You didn’t have to worry about them. I think they have that under control now, or at least they’re working hard on it.”
Other Medicaid providers for children also described problems when interviewed by KHI News Service.
“From a provider perspective, it’s been kind of frustrating,” said Dr. Dennis Cooley, a Topeka pediatrician who sees a large number of Medicaid patients, “mostly from dealing with three, brand new MCOs (managed care companies) and each one has their own set of rules.”
'A lot of difficulties'
Cooley, like others dealing with the new system, said “we’ve had a lot of difficulties with prior authorizations,” which are the approvals for payment required from the state’s KanCare contractors before services can be delivered to a patient. “We’ve had difficulty, I think, in getting our patients some of the services, especially like with pharmacy and what meds (the MCOs) are covering. I know at least in our practice it’s been very frustrating and that’s what I’ve heard in talking with other providers, too.”
Cooley said his practice “had good rapport” working with the state’s prior HealthWave managed care companies and that “time would tell,” if the same sort of relationships would develop with the new KanCare contractors: Amerigroup, UnitedHealthcare and Sunflower State Health Plan a subsidiary of Centene.
And here’s an assessment of KanCare’s progress from Tribune, a small town near the Colorado border.
“It’s going OK, we’re just butting up against some billing issues,” said Bonnie Mote, who handles the billing for Greeley County Health Services, a rural health clinic once directed by Dr. Robert Moser, currently secretary of the Kansas Department of Health and Environment, the state’s lead Medicaid agency.
Mote said she thought services for patients had been unaffected by KanCare and that the claims and billing problems would soon be sorted out.
“Dr. Moser contacted us and said they (KDHE) would be contacting the MCOs,” she said.
KanCare moved virtually all the state’s 380,000 Medicaid enrollees into managed care plans run by for-profit insurance companies. But even before the program makeover, the large majority of beneficiaries — more than 280,000 — were children covered by what was then known as HealthWave.
Push is again coming to shove in the struggle over whether the long-term care and support services received by Kansans with developmental disabilities will become part of KanCare or remain outside the control of the private companies hired by the state to manage the Medicaid program.
Advocates pushing for a permanent “carve out” of developmental disability services have circled May 8 on their calendars. That’s the day that the Kansas Legislature is scheduled to return to Topeka to wrap up its 2013 session.
“When you show up in numbers, it makes a difference in the legislative process,” said advocate Tom Laing, speaking last week to approximately 175 parents and advocates at a meeting sponsored by Johnson County Developmental Services.
“A lot of times when politicians do the wrong thing it’s because they haven’t heard from the folks who are the most impacted. If they don’t hear from you, we can’t succeed,” said Laing, executive director of Interhab, an association that represents most of the state's Community Developmental Disability Organizations.
Laing and other advocates said they are hoping that thousands of Kansans with developmental disabilities would turn out with their parents and guardians for a rally on the south steps of the Statehouse and to meet individually with legislators to make their case.
“I’m not a guy who believes in pitch forks and torches. We need to be persuasive, not abrasive,” Laing said.
'Carve in' date approaching
Medical services for the developmentally disabled already are part of KanCare, the reform initiative launched on Jan. 1 by Gov. Sam Brownback. It moved virtually all of the state’s 380,000 Medicaid beneficiaries into managed care plans run by three insurance companies: Amerigroup, United Healthcare and Sunflower State Health Plan, a subsidiary of Centene.
But yielding to pressure from advocates and service providers, the governor and legislators agreed last year to delay the inclusion of long-term, DD support services for a year — until Jan. 1, 2014. With the “carve in” date approaching, advocates are pressing their case again.
“We have to keep these services out of the hands of the profiteers,” said Bridget Murphy, director of the Downs Syndrome Guild of Greater Kansas City.
'Misinformation' fueling concerns
Murphy’s concern that the for-profit managed care companies will disrupt services now generally provided by a network of community-based, non-profit organizations is shared by many parents and advocates.
That frustrates Shawn Sullivan, the secretary of the Kansas Department of Aging and Disability Services, who has spent more than a year meeting with stakeholders to convince them they have nothing to fear from the new managed-care system.
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.
The first 90 days of KanCare have passed, which means the transition period during which the state's 380,000 Medicaid beneficiaries could switch managed-care health plans this year is over.
That is important — for among other reasons — because many KanCare enrollees may find themselves in situations where the medical providers they are accustomed to using are not in the network of the KanCare plan to which they were assigned or chose themselves before the changeover period ended April 4.
And as the 90th day was marked last week, many Medicaid providers continued to report persistent problems with the program that was rolled out Jan. 1 by the administration of Gov. Sam Brownback.
'Number of issues'
"We still have a number of issues that pharmacists have to deal with," said Michael Larkin, executive secretary of the Kansas Pharmacists Association. "In the big picture, our number one concern is assuring that the managed care organizations adhere to the contracts signed (with the state) back in June."
Larkin said the contracts called for the KanCare companies to use a "transparent" process for determining the reimbursement rates for pharmacy services. In the association's view, he said, those contract provisions have been ignored by the KanCare companies "across the board."
"And also the managed care organizations when they do change their pricing are supposed to notify us, let it be known to everyone that the pricing has changed. I don't know that they're doing that either," Larkin said.
He said a meeting was held last month with KanCare company representatives to try to resolve the concerns but that the problems continue apparently because "the wrong people were in the room to discuss that."
Larkin said he was trying to set up another meeting that also would include state officials.
Association members also are reporting reduced or delayed payments from the KanCare companies for durable medical equipment.
"They're having trouble getting proper reimbursement and knowing, if in fact, they will be reimbursed before the equipment goes out the door," Larkin said.
Administration officials acknowledged some ongoing problems but said on whole they are pleased with the program's progress.
"It's been very workmanlike," Lt. Gov. Jeff Colyer said of the transition.
He also repeated what administration officials have said since the first month of KanCare: "There haven't been as many bumps in the road as we expected. Everybody's been very committed to working with people who are having issues."
Larkin said from the pharmacists' perspective the problems have been "something in between a bump in the road and grave concern."
"We're hopeful things will turn out for us. So far, it hasn't happened," Larkin said.
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.
The Senate has tentatively approved a bill that could lead to some school districts holding back first graders who fail a reading test.
The measure was based on Gov. Sam Brownback’s proposal for improving fourth grade reading scores by holding back third graders known to be having trouble reading.
“We need to be getting to these kids as early as we can,” said Sen. Laura Kelly, a Topeka Democrat, who proposed changing the focus of Senate Substitute for House Bill 2140 from third graders to first graders.
Kelly’s amendment was endorsed by Sen. Steve Abrams, an Arkansas City Republican and chair of the Senate Education Committee.
“It’s fairly well known that through the third grade children are learning to read,” he said. “After the third grade, they’re reading to learn.”
Abrams said he considered Kelly’s amendment to be “friendly.”
The Senate endorsed the bill on a voice vote shortly before 8 p.m. Tuesday. A formal final action vote is set for Wednesday morning.
Abrams said an earlier version of the bill had stalled in the education committee after several members argued that it constituted a mandate and was likely to do more harm than good.
Those concerns were resolved, he said, by adoption of a number of amendments in the committee and during the floor debate aimed at exempting students in special education or English-as-a-Second-Language classes, allowing students to take the test more than once, limiting the mandate to school districts with below-average reading scores, and giving parents the final say in whether their children were promoted.
“The concern that what was initially proposed did not include parental involvement ended up being resolved in this bill,” Kelly said.
The amended bill also would allow teachers to declare whether students who fail the test should be allowed to advance.
It wasn't immediately clear how many first graders might be affected by the bill or what the cost might be for school districts. Neither question was raised during the debate.
Child advocates had testified against the initial bill, arguing that state resources would be better spent on early childhood development programs, many of which have long waiting lists.
Shannon Cotsoradis, chief executive for the advocacy group Kansas Action for Children, welcomed the changes to the bill.
“Tonight’s floor debate in the Senate underscores the commitment to early intervention and to investments in early learning programs as a path to literacy,” she said. “The amendments will also provide the flexibility to act in the best interests of individual students rather than mandating a one-size-fits-all approach.”
The bill calls for spending $10 million — $5 million a year for two years — on a grant program aimed at helping children learn to read.
It also would set aside $1 million a year for two years to reward school districts with the most improved reading scores.
If the bill passes on final action, as expected, it would be sent to the House, where it’s likely to be referred to a conference committee.
Related stories on khi.org
→ Brownback reading initiative questioned by education experts
→ Governor's office restates support for reading initiative
Susan Wagle, already distinct in history as the first woman elected president of the Kansas Senate, said there are other things for which she would prefer to be remembered:
“A fiscal conservative, a social conservative, a mom, a businesswoman and a schoolteacher . . . that’s pretty diverse,” she said.
This is her 23rd year in the Legislature — 10 in the House, 13 in the Senate.
Her tenure has been punctuated by causes she took on when broader interest among legislators was not always apparent and which brought her statewide, sometimes national, attention.
“I’m a second-born of six children — two boys and four girls - and you know how second-borns are,” she said. “I was a challenge for my parents and I can be a challenge up here (at the Statehouse) if it’s an issue I care about.”
The 59-year-old Wichita resident was at the forefront of a conservative Republican takeover of the Senate in the November 2012 general elections.
She was elected the chamber’s leader in December and in January presided over a major rules change that barred any floor amendments that would add costs to spending bills. That so-called ‘pay-go’ provision, championed by conservative Republicans, was adopted 28-11, mimicking one already in force in the House.
‘Dancing not dating’
Despite that and other changes, she is regarded by some as “old school.”
“In many respects, I believe Susan is kind of old school in terms of her appreciation of the political process and the exchange of ideas,” said Senate Minority Leader Anthony Hensley, a Topeka Democrat.
ln 2002, he said, she worked with Democrats on a Senate redistricting map that was adopted despite opposition from Republican moderates, then the majority in the GOP caucus.
He also credited her with putting together a coalition of GOP conservatives and Democrats to break a 2007 budget deadlock.
“Just because she’s of a different political stripe doesn’t mean we can’t work with her,” Hensley said. “We’ve always had an understanding that we’re only dancing, we’re not dating.”
Health policy background
Wagle has had more experience with health policy issues than has been the norm for those who have risen to the Senate presidency.
From 2001 to 2007, she was chair of the chamber’s Health Care Strategies Committee. It was a period in which the Legislature was unusually active in its consideration of potentially far reaching state Medicaid and other health reforms.
She also had an unsuccessful run at statewide office before becoming president, which is a bit uncommon in that top legislative leaders often aren’t that well known to general voters outside their own districts.
In 2006, she ran for lieutenant governor on the ticket with GOP gubernatorial nominee Jim Barnett of Emporia, a physician and fellow senator who since has retired from politics. The pair was handily defeated in the general election by Democrat Kathleen Sebelius and her running mate Mark Parkinson.
In 2000, Wagle launched an investigation of how then- Kansas Attorney General Carla Stovall, a fellow Republican, had hired her former law firm to represent the state in the lawsuit that led to the master settlement agreement with the nation’s tobacco companies. Stovall’s former firm collected $27 million for its role. The state's ongoing share in the settlement has been earmarked mostly for children’s programs.
Three years later during debate on the Senate floor, Wagle accused a professor at the Kansas University School of Social Welfare of showing pornographic videos, condoning pedophilia, and using foul language in a popular class he taught on human sexuality. Her move to cut funding for the school was vetoed by Sebelius.
A subsequent university investigation and report on the allegations exonerated the professor.
In 2011, as chair of the Senate Commerce Committee, Wagle held several contentious hearings on allegations that the chief executive at the Kansas Bioscience Authority had mishandled or misrepresented the agency’s activities. The executive resigned and took a job out of state.
“You want her on your side,” said Tim Shallenburger, a former Kansas House speaker who now serves as Gov. Sam Brownback’s chief legislative liaison. “Not so much because she’s president of the Senate but because of the passion she brings to an issue. She’s very hard working.”
Wagle says her political energies are now focused on improving the economy.
“Clearly, the state of Kansas is in the midst of an economic downturn, followed by long-term stagnation that, I believe, has been caused by a lack of leadership at the federal level,” she said. “We’re at a turning point. If we don’t get control of federal spending, this country and this state will take a turn for the worse and the opportunities I had growing up will not be the same as those that my children will have.”
The best way to stimulate the state’s economy, she said, was “…through lower taxes, smaller government, and less regulation.”
She said she shares that view with Gov. Sam Brownback, a confidante for many years, and House Speaker Ray Merrick.
“We are unified on that goal, although we may have to take different paths to get there,” Wagle said.
Wagle, a former elementary school teacher, said her readiness to cut taxes dated to 1986 when a statewide reappraisal tripled the property taxes on some commercial property that she and her husband owned.
“Our taxes went from $5,000 a year to $15,000 a year,” she said. “I was shocked.”
Four years later, she ran for the House and won.
Wagle, who grew up in east Wichita, also is well known for her opposition to abortion.
“I didn’t start out pro-life,” she said. “I graduated from (Wichita) Southeast (High School) in 1972, which was about the time that Dr. (George) Tiller started his practice. I had friends — young girls — who saw the clinic as a form of birth control and who later suffered emotional consequences. But we were young and I didn’t think that much about it.”
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.
While acknowledging “bumps in the road,” state officials for several weeks have been saying that the launch of KanCare, the state’s new Medicaid program, has been going better than they expected.
But people who work at some of the clinics that specialize in treating poor and uninsured Kansans describe it differently. They say the transition, now entering its third month, has been an ordeal for them and that some of the problems are compromising patient care.
“I went through the tornado in Joplin (in May 2011) and survived,” said Lori Lowrey, chief revenue officer for the Community Health Clinic of Southeast Kansas. “I would equate the anxiety of KanCare with the anxiety I felt following that event. It’s just been an inferno everyday. When you walk through the door, you’re greeted by staff frustrated at every level...nurses, administrators, patients and then trying to communicate with the (KanCare companies) and their contractors, it’s just very taxing. I just don't feel like it’s been accurately portrayed by the people at the state level or the MCOS (managed care companies). It’s been a road full of potholes. It’s not been a few bumps.”
The clinic here serves about 29,000 people a year at its eight sites scattered across the corner of Kansas that generally ranks as the state’s poorest and least healthy. That makes is a key medical provider, particularly when it comes to primary care for the poor. About 35 percent of its patients are on Medicaid, according to clinic officials.
State and KanCare company officials acknowledge there have been problems at the safety net clinics and more so at some of the 16 that are designated as Federally Qualified Health Centers, which includes the Community Health Clinic of Southeast Kansas. The FQHCs together have more than 20 satellite clinics scattered across the state and collectively serve many thousands of the state’s poorer families.
A special meeting that included clinic directors, state officials and KanCare contractors was held privately two weeks ago in Topeka to discuss the situation.
An “issues log” of 86 problems submitted by the clinics to the Kansas Association for the Medically Underserved (KAMU), a group that represents the safety net clinics, was presented at the meeting.
Among the problems cited:
Delayed or stalled payments from the KanCare companies,
Poor communication and misinformation
Troubles getting clinic doctors and other providers included in the KanCare provider networks and patients properly assigned.
Difficulty getting treatments or medications approved for patients.
The list was similar to but longer than the problem tally submitted to state officials a week earlier by the Kansas Medical Society and the Kansas Medical Group Management Association along with a letter asking the state to extend the KanCare transition period to allow more time for smoothing things out.
Kari Bruffett, the director of the Division of Health Care Finance at the Kansas Department of Health and Environment, has been the point person for the administration of Gov. Sam Brownback on much of the KanCare implementation.
Bruffett said state officials determined from the meeting with clinic officials “that while there were some crosscutting issues, there were a lot of issues specific to the individual (clinics), so what we asked the managed care organizations to do with those (clinics) was to work with them individually and basically keep us posted.”
She said she had been assured that many of the problems raised at the meeting were being dealt with and that the chief executives of the KanCare companies have been responsive whenever concerns were brought to their attention.
One result of the meeting, according to some who attended, was an agreement by at least two of the KanCare companies to make “advance payments” to clinics that asked for them to help deal with their cash-flow problems.
“I know of at least one (KanCare MCO) that is in the process of sending out advance payments,” said Cathy Harding, executive director of KAMU, “and another said they would do the same thing.”
She said she expected the third company also would agree to advance or expedited payments.
But in a series of interviews late last week with the KHI News Service, clinic directors from across the state give KanCare what could at best be described as mixed reviews. And those unhappy with the way KanCare is rolling out said they had seen little or no improvement as a result of the meeting.
“In our opinion, it’s kind of going from bad to worse,” said Krista Postai, executive director of the Community Health Clinic of Southeast Kansas. “I have nurses now spending all day on the phone trying to get pre-approvals (for patient medications from the KanCare insurance companies or their subcontractors) and not getting them. A lot of my providers have been doing this for years and they never had anything this absurd on pre-authorizations. I understand that is meant to control costs…but this is costing us a fortune.”
One of the state’s largest assisted-living chains has curtailed its participation in the Kansas Medicaid program.
“Of our 18 facilities, 15 are no longer taking any new Medicaid clients,” said Denise German, senior vice president of Vintage Park, which is headquartered here.
The decision, German said, was driven by a 2012 reduction in Medicaid reimbursements and by concerns that payments would be cut more under KanCare. The three Vintage Park facilities that still accept Medicaid clients are in towns with no other facilities. The company’s local administrators there chose to continue so there would be local options for residents.
KanCare is the name for Gov. Sam Brownback’s Medicaid makeover initiative, which involved the hiring of three managed care companies to run day-to-day operations of the state’s $3.2 billion Medicaid program. The KanCare companies are Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene.
The companies took over Jan. 1.
Looking to cut costs
“These are for-profit companies. We know they’re going to be looking for ways to cut costs and since reimbursement is very minimal already, we’ve elected not to continue to participate in the program,” German said.
Vintage Park began changing its policy a few months after Brownback first announced his KanCare plan in November 2011. Its individual Kansas facilities began making the changes more or less at their own pace. The result has been a major reduction in the number of Medicaid residents. Before this year, German said, Vintage Park facilities in Kansas had been admitting about 100 Medicaid residents annually.
“A year ago, we probably had 250 Medicaid residents in 18 facilities,” she said. “Now, I’d say we’re down to about 120.”
The company, she said, has been doing “fine” without new Medicaid admissions.
Vintage Park won’t ask private-pay residents to leave if they deplete their life savings and end up on Medicaid, she said. But the 15 facilities no longer admit residents already on Medicaid.
Vintage Park is a for-profit company. Most of its facilities are in small and mid-size towns in the eastern third of the state. All 18 facilities passed state inspections the last two years with no deficiencies noted, which generally is taken as an indication of well-run operations.
Not identified as a problem
It’s not clear whether other companies are following Vintage Park’s lead. State officials said they were unaware of the company’s decision and hadn’t seen evidence of a problem.
“We have not heard that assisted living facilities are declining to admit residents who are on Medicaid,” said Angela de Rocha, a spokesperson for the Kansas Department for Aging and Disability Services.
“Assisted living facilities’ refusal to accept residents who are on Medicaid has not been identified as a problem at this point,” she said. “And it is in the financial interest of the (KanCare managed care companies) to keep their members in a community setting instead of admitting them to nursing homes.”
An assisted living facility is considered a community setting.
Others in the industry said they knew too well the pressures cited by Vintage Park officials.
“Our company continues to accept Medicaid,” said Steven Hatlestad, vice president of skilled nursing operations at Americare, another for-profit chain with operations in several states that has 11 nursing homes and six assisted living facilities in Kansas. “But I do not believe that what Vintage Park is doing makes it an outlier. I’m afraid we’ve reached a point where some companies — some really good companies — just can’t afford to do Medicaid anymore.”
Ray Vernon runs Wesley Towers, a large retirement community in Hutchinson that offers in-home care, independent living, congregate living, skilled nursing care, and assisted living. It is a subsidiary of the Kansas West Conference of the United Methodist Church.
Vernon said while reimbursement rates are an issue, his facility won’t refuse to accept residents because they are on Medicaid.
“That would go against our mission,” he said. “But I have to say there’s some validity to what Vintage Park is saying because, in reality, (Medicaid) reimbursement has been flat for quite some time and healthcare inflation runs about twice what it is for the economy at large.”
Jim Klausman, chief executive at Midwest Health, a for-profit operation active in four states and with 24 nursing homes and 11 assisted living facilities in Kansas, said the company shares Vintage Park’s concerns but has a different strategy.
“We understand — and we share — some of the frustrations being expressed by Vintage Park, but we think we have a better shot at changing the system from within rather than pulling out,” he said.
Midwest Health’s nursing homes have signed contracts with all three KanCare companies, he said. But Midwest chose to sign an assisted-living contract with only one: Sunflower State Health Plan.
“We’re still taking Medicaid,” for assisted living, he said, “but you’ll need to be on Sunflower.”
The decision to only sign with one KanCare plan, Klausman said, was meant to strengthen Midwest’s bargaining position.
“We’d rather negotiate with one company than three,” he said.
‘Uncertainty over reimbursement’
Debra Zehr, chief executive with LeadingAge Kansas, a trade group, keeps close tabs on the state’s nonprofit assisted living facilities.
“There’s a lot of uncertainty over reimbursement and the administrative costs that come with having to deal with three payers — the (KanCare) managed care companies — instead of one,” she said. “I don’t know of anybody who thinks they’re breaking even on Medicaid. It’s more of a community service than anything else. You do it because it’s the right thing to do.”
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.
After months of advisory committee haggling over what it should look like, state officials say they are ready to launch the pilot program that will pave the way for including long-term services for the developmentally disabled in the new KanCare program.
Now, all they need to start the pilot are participants.
A recruiting letter went out Friday, seeking organizations and individuals willing to volunteer, but representatives from the state’s developmental disability organizations said doubts remain strong among their members about the pilot in particular and KanCare in general. It seems that nobody, including administration officials, expects a throng of eager participants.
“The advisory committee talked about really wanting, hoping to have a broad representation of providers (in the pilot), including different types of providers,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “I don't know that it’s necessarily as important to have numbers as it is to have different types. I’m hoping to have five providers, at least.”
The administration of Gov. Sam Brownback originally sought to have long-term services for the developmentally disabled included in KanCare when the managed-care program was launched Jan. 1. But groups, including parents, that represent the developmentally disabled, persuaded legislators to postpone that for a year.
KanCare is the governor’s ongoing remake of the state Medicaid program. Since it was launched a few weeks ago, virtually all the state’s 380,000 Medicaid enrollees have been assigned to health plans run by three commercial insurance companies.
The same legislative proviso that delayed the administration’s push to roll long-term developmental disability services into KanCare also called for the pilot program. But disagreement between the administration and advocates for the disabled over what the pilot should try to gauge or accomplish went on for months after the 2012 Legislature adjourned and still hasn’t been fully resolved.
What kind of pilot?
Advocates for the developmentally disabled said they wanted a pilot that would test the administration’s still-unproven theory that the KanCare insurance companies could effectively manage long-term or “non-medical” developmental disability services, producing healthier customers while cutting government costs yet presumably earning profits.
That ambitious set of pledges is something that hasn’t been solidly demonstrated anywhere in the country and sounds “too good to be true,” as Maury Thompson, former director of Johnson County Developmental Supports.
Some experts at Kansas universities are questioning Gov. Sam Brownback’s plan to cut spending on established early childhood development programs in order to fund a proposed new initiative aimed at improving the reading scores of the state’s fourth-graders.
Though the governor hasn’t yet provided much detail on how the new Kansas Reads to Succeed program would work, he has said he favors requiring third graders to pass a reading test before being advanced to the fourth grade.
‘Irresponsible and cruel’
“Passing children up the grade ladder when we know they can’t read is irresponsible and cruel,” Brownback said in his State of the State speech to the Legislature last month.
But reading specialists at two Kansas universities said research has shown that holding children back a year often does more harm than good.
“Children who are retained, typically, are more likely to not graduate from high school,” said Suzanne DeWeese, a reading recovery specialist with the Jones Institute for Education Excellence at Emporia State University. The university trains many of the state’s K-12 teachers.
“Children who aren’t learning to read need better instruction, not a repeat of a curriculum that’s already failed them,” she said. “And the sooner they have access to that instruction, the better.”
Diane Nielsen, an associate professor of education at the University of Kansas, said waiting until students were in third or fourth grade to address reading deficiencies was shortsighted.
“To do what it appears the governor wants to do, it would need to be done in the grades below fourth, beginning with support in preschool,” said Nielsen, a specialist in reading instruction.
“The emphasis should not be on a single year’s test results,” she said. “It should be on early intervention because there are so many things that need to be in place before a child reaches the fourth grade. Reading is not the simple process that people tend to think it is. It can be very complicated.”
Brownback, who campaigned for governor promising to boost 4th grade reading skills, told KHI News Service that he has been disappointed by the proficiency ratings.
“They’ve been fairly level for a long time,” he said. “We need to do better.”
Sherriene Jones-Sontag, the governor’s chief spokesperson, said details of Brownback’s new initiative would be made public in a bill that would be introduced by a legislative committee probably sometime this week.
“We reviewed models for potential legislation from several other states, including Florida,” she said. “Some aspects will be similar, some will be different and some completely unique to what other states have done to help struggling readers.”
The governor’s plan has been endorsed by the Kansas Policy Institute, a conservative think tank based in Wichita.
“What we’ve seen in places like Florida, which has had practices like this in place for over a decade, is that when you set up the (reading) test in third grade, the (school) districts and teachers see the significance and start building in interventions early on,” said James Franko, the institute’s director of policy.
“So instead of waiting for students to reach the third grade, they’re taking a soup-to-nuts look at how they do reading for (kindergarten) through third grade, identifying those students who are struggling, and getting them the help they need so there isn’t this rude awakening when, all of a sudden, they get to the third grade and can’t read with their peers,” Franko said.
There have been plenty of problems and frustrations. No one denies it.
But as Gov. Sam Brownback’s Medicaid makeover entered its fourth week, administration officials, some legislators and a variety of others involved with KanCare said they thought the massive changes underway in the $3.2 billion program so far have gone smoother than many expected.
KanCare, which launched Jan. 1, moved virtually all the state’s 380,000 Medicaid enrollees into health plans run by three of the nation’s largest managed-care companies: United HealthCare, Amerigroup and Sunflower State Health Plan, a subsidiary of Centene.
“I think we’re in the growing-pains phase,” said Mike Larkin, executive director of the Kansas Pharmacists Association, which months ago began preparing its members for the changes. “Some of our members are getting different answers on things, depending on who they call.”
Because people tend to see their pharmacists more often than other medical providers, pharmacies were among the first to file claims and otherwise deal directly with the new system.
Larkin said he expected to be “inundated” with calls from members dealing with KanCare problems the first week of January.
“I was pleasantly surprised that I wasn’t,” he said. “I think we were more prepared than maybe some other folks for the things that are coming down. There are some stipulations of the contract that the state signed with the MCOs (managed care organizations) that we’re still waiting to see fruition on…but as far as the pharmacies go, there are some frustrations but for the most part, I suppose it could be worse.
“I’m looking at mid-February. I was talking with a legislator and we agreed that if Feb. 15 comes and some things haven’t settled down, then we’ve probably got a problem,” Larkin said.
State officials anticipated there would be difficulties during the transition and took some steps to ease them.
First 90 days
For the first 90 days of KanCare — and in some instances longer — the state is requiring the insurance companies to comply with previously established "plans of care" for Medicaid clients in order to minimize disruptions to the patient's usual or expected services.
Also for the first 90 days, the state is requiring the companies to reimburse Medicaid services given by any medical provider regardless whether the provider has signed a contract joining the companies' service networks.
As the program's launch date approached, state and MCO officials began holding daily 9 a.m. teleconferences with Medicaid providers and beneficiaries to help troubleshoot problems as they arose.
State and insurance company officials answer questions from callers, make note of problems and sometimes post them to their respective online “issues logs," though state officials concede many problems marked "resolved" on the the logs have simply been brought to the attention of someone to work on, rather than fixed.
The most frequent, single response to callers during the daily calls has been “can we get back to you on that?” or words to that affect. But many callers also seem to go away satisfied with the answers they get.
One of those who called in recently was Vicki DeStefano of Fairway. She telephoned on behalf of her 53-year-old brother, Mike, who receives Medicaid-funded assistance after suffering a serious brain injury in a 2006 motorcycle accident that left him mostly unable to move or speak and eating through a tube.
He needs attention around the clock, she told KHI News Service in a later telephone interview, and before November there were six people being paid, not including her, to help care for him at different times of the day or week.
Now there is only one person to help her with her brother. The others left because they stopped getting paid. DeStefano said she is paying the remaining person out of her own pocket because some things she simply cannot do by herself.
She said the agency that handled the payments to the workers told her they weren’t getting reimbursed by the managed care companies. But DeStefano said she was more upset with the intermediary Financial Management Services (FMS) agency (commonly referred to as a “payroll agent”) than she was with United HealthCare, because the company seemed to be trying harder to help her and her brother.
She said her prior experiences with state officials and a succession of its contracting payroll agents had left her exhausted, frustrated and ready for any kind of change in the system.
“We really needed a change,” she said. “Whenever you have the government doing something, it’s a mess. I think we need a change, I just don’t think they did the research to make it go right…The state just dumped it on to all these MCOs and didn’t do anything to help them.”
DeStefano said she was alarmed by how unprepared many of the MCO employees seemed to be, but she said she expected things would only get better. She said she was impressed that the day after she called in to complain about her problems, a United representative called on her to see about fixing them.
Her problems weren’t resolved yet, she said, “but even when they can’t resolve it right away, they’re trying.”
She said she never got quick responses from the state, so the new attention from the MCO was welcome.
Cathy Harding is executive director of the Kansas Association for the Medically Underserved, which represents the state’s safety-net clinics. She also said she was pleased by the responsiveness of the MCOs.
“I think most people expected it wouldn’t be possible to implement a huge program like this without bumps in the road,” Harding said. “The thing I was concerned with (going in) was how responsive would the MCOs be when we bring them problems. In that regard, we have been extremely pleased. All three MCOs, when we bring things to their attention they have literally jumped right on it.”
Harding said there were ongoing transitional problems but that she expected things could be running smoothly within three months.
“This is a guess on my part,” she said, “but given how things are working at this point in terms of addressing issues, I’d be a little surprised if we don’t have all these kinks worked out in three months. Three months for a program of this size is certainly not bad. We’ll see.”
Among the frequent complaints or questions from Medicaid providers during the state’s daily teleconferences have been those about claims rejections or delays in payment from the MCOs.
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.
A week into major changes of the Kansas Medicaid program questions persist about whether a new consumer advocate will have the freedom and the resources to do his job.
Lawrence attorney James Bart was recently hired as the ombudsman for the new KanCare program being implemented by Republican Gov. Sam Brownback. Officials say the Jan. 1 expansion of managed care to include virtually all the state’s Medicaid enrollees is intended to slow the growth in Medicaid costs and improve the care provided to the more than 380,000 low-income, elderly and disabled Kansans in the program.
But some legislators and consumer advocates are questioning whether housing the ombudsman’s office in one of the state agencies responsible for KanCare implementation will hinder Bart’s effectiveness. They also question whether he will have sufficient resources to handle what could initially be large numbers of consumer complaints with the new system.
Bart, the only full-time employee in his office at the Kansas Department for Aging and Disability Services, was asked directly about the adequacy of his resources today during a meeting of the KanCare Specialized Care and Network Issues Workgroup in Topeka.
Sheldon Weigrau, a workgroup member, said if only 1 percent of the state's Medicaid enrollees filed complaints with the ombudsman, that would mean at least 10 complaints or problems a day to handle. He questioned whether Bart would have the resources to deal with that many of them, "otherwise, you're going to be overwhelmed."
Bart said 10 issues landed on his desk during the first working week of KanCare, which ended Jan. 4, and all had been resolved. And he said he had assurances from KDADS Secretary Shawn Sullivan that he could draw on on more of the agency's resources if needed.
"I can't solve every issue," Bart said. "But I can be the grease in the wheels. If it gets to the point where I feel I can't deal with the issues with the resources I've got, then I'll go get more resources."
Question of independence
Sen. Laura Kelly, a Topeka Democrat, is among the legislators asking questions about the ombudsman's office.
“It’s just beyond me to see how someone who is housed in an agency and who is dependent on that agency for the resources they need to do their job can be truly considered to be independent,” Kelly said after the issue was raised at a recent meeting of the Legislature’s Joint Committee on Health Policy Oversight.
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.
A Lawrence man who serves on the Kansas Council on Developmental Disabilities has been hired by the state to be the ombudsman for KanCare enrollees.
James Bart, 50, started the job today. He will office at the Kansas Department for Aging and Disability Services headquarters at 503 S. Kansas Ave. in Topeka.
Bart said he has a law degree from Creighton University but had not practiced law since leaving Nebraska for Kansas about 17 years ago. He is married and the father of a 19-year-old son with developmental disabilities and three younger children.
"I'll make a serious commitment to consumers of Kansas Medicaid to help them in any way I can," Bart said.
Bart said he previously worked in the automotive and insurance industries but preferred to not discuss the details. According to the profile he posted on Linked-in, an online network for business professionals, his employment before this job was as an auto damage appraiser for Crystal Carstar.
Bart said his passion has been advocating for the disabled and that the ombudsman job will allow him to wed his professional experience with his desire to help others.
According to KDADS officials he has worked with ARC of Douglas County, an organization that helps disabled persons and their families in Douglas, Jefferson, Osage and Franklin counties. He completed training in "community-based outreach and graduate network development" with the Kansas Council of Developmental Disabilities and also graduated from a "Special Education Law Boot Camp," conducted by Wrightslaw. He has a bachelors degree in Industrial Relations and Human Resource Management from the University of Iowa.
KDADS officials said Bart would be responsible for assisting Medicaid enrollees with "unresolved access, service and benefit problems," particularly those who receive home- and community-based services or are in long-term care situations. His annual salary will be $62,500.
OLATHE — Workforce shortages prompted by the overhaul of the Kansas Medicaid program are hampering operations at some social service agencies in Johnson County and elsewhere in the state, according to executives at the organizations.
Human Services Director Debbie Collins said since September, her Johnson County agency had lost three of its nine case managers that assist frail elderly Medicaid clients through the Area Agency on Aging.
Collins said the workers all left for similar positions at UnitedHealthcare, one of the three insurance companies hired by the state as part of the new Medicaid program, which the state has dubbed KanCare. Virtually all the state’s 380,000 Medicaid recipients are scheduled transfer into the KanCare managed care plans effective Jan. 1.
The other two KanCare contractors are Amerigroup and Sunflower State Health Plan, a subsidiary of Centene. All three companies have been busy hiring workers for the past few months.
Collins and other agency administrators interviewed for this article said the bright side of losing the workers was knowing that the KanCare companies had hired qualified staff.
They said they didn’t blame their workers for taking the jobs because the employees told them they would get substantially higher pay at the managed care companies.
But the agency leaders said they weren’t sure how KanCare could save the state money, if the contractors will have significantly higher personnel costs.
“We are all befuddled about that,” Collins said.
Savings will come through a focus on patient education, preventive care, and by “ensuring members have access to the right care, at the right place and at the right time,” said Monica Stoneking, a spokeswoman for Sunflower State Health Plan.
Sunflower, she said, was paying “competitive wages in accordance with industry standards.”
Amerigroup spokesperson Maureen McDonnell declined to comment.
Alice Ferreira, a spokesperson for United Healthcare said the company was giving its new hires flexibility so that their former employers wouldn’t be left in the lurch.
“UnitedHealthcare has been working collaboratively with the agencies to provide case managers the work flexibility to ensure they are able to continue to work with the members as appropriate,” she said in an email. “We are committed to ensure members receive the care they need, and anticipate that this partnership will result in a smooth transition.”
She the company also was dedicated to “creating new jobs in Kansas.”
Officials at each of the KanCare contractors have said they would hire as many as 300 people as they prepare for the new program. Each company also has a Kansas headquarters office.
Officials in the administration of Gov. Sam Brownback estimate KanCare will save the state and federal governments $1 billion over the next five years.
Among the various social service and state agencies that have lost workers to the KanCare companies are the state’s Area Agencies on Aging, which, in any event, are seeing their roles change under KanCare.
Though the agencies are handing off case management for the frail elderly to the KanCare companies, they are expected to take on expanded roles in serving individuals with physical disabilities and traumatic brain injuries by assessing their needs for assistance and helping them choose the right KanCare plan, in the event the persons are not content with their state-assigned plans.
Collins said the changes have left her uncertain about what her staffing needs will be after the first of the year.
“We may very well have to expand,” she said. “We really don’t know what the workload will be.”
Other organizations experiencing KanCare-related personnel pinches include the Johnson County Mental Health Center and the Southeast Kansas Area Agency on Aging in Chanute.
Johnson County Mental Health has had 15 staff members take positions with the KanCare companies, according to agency officials, including a senior administrator and a number of clinicians and case managers.
In response, the center has pressed supervisors and everyone else with proper certification and training into service to coordinate care for clients, said Executive Director Maureen Womack.
The main problem, she said, was that clients had lost their connections to workers with whom they felt comfortable dealing.
“What is falling through the cracks,” she said, “is the therapeutic relationship.”
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.’”
After prodding from local consumer advocates and federal overseers, Kansas officials have made public more details about how they would implement KanCare and say they plan to release more information as quickly as it becomes available.
A federal decision on the state’s plan to remake its Medicaid program is expected any day and the new information is evidence of the back-and-forth in the discussion between the federal Centers for Medicare and Medicaid Services as the administration of Gov. Sam Brownback continues its push for a Jan. 1 launch of the new program.
Brownback officials so far have posted six section 1915c waiver amendments on the KanCare website and also within the last several days have posted six “implementation activities” reports that outline previously undisclosed details about how they expect KanCare to work.
"These are some very specific implementation reports we're submitting to CMS and making available to all of you simultaneously," said Kari Bruffett, director of the division of health care finance at the Kansas Department of Health and Environment, talking last week in a teleconference with Medicaid providers.
Among the things outlined in the reports:
• State officials intend to create an ombudsman position at the Kansas Department for Aging and Disability Services to field complaints and questions about KanCare from Medicaid enrollees and service providers. They began recruiting for the new position Nov. 12 and began interviews last week with the goal of having a person hired by Jan. 1.
• A timeline and plan for communicating the KanCare changes to Medicaid enrollees and providers.
• A plan for following up on “returned” mail, information sent to enrollees that fails to reach the intended recipient.
• Details of how eligibility and enrollment in KanCare will be verified.
• A plan for how the customer call centers will deal with the influx of expected queries from Medicaid enrollees. According to the report, 226 customer-service representatives are “ready to step in as needed.”
Some of the state’s recent actions seem to stem, at least in part, from CMS having heard concerns from some Kansas advocacy groups about the need for more information about KanCare and the creation of an ombudsman position.
Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said she and other advocates met with CMS officials and followed up with a Nov. 13 letter to them outlining their concerns about KanCare. CMS responded 10 days later.
Letter to CMS
“We asked for the state to be more transparent, posting more on line,” Lambertson said. “And we made some very specific requests of the state for an outreach education plan that meets the needs of the various populations and involves the stakeholders.”
Lambertson said she was still reviewing the documents posted subsequent to the group’s letter to CMS. But she said she already had seen enough of the ombudsman plan to know that it fell short of what the consumer groups were seeking.
“We feel very strongly there are certain things that really need to be in place in order for the state to be ready to kick off on Jan. 1, “ she said. “And I personally don’t feel those processes are in place.”
A child advocacy organization is criticizing Gov. Sam Brownback for restricting access to some programs that help low-income Kansans while more children and families are slipping into poverty.
Shannon Cotsoradis, chief executive of Kansas Action for Children, said recent changes made by the Brownback administration to tighten eligibility criteria for cash and child-care assistance programs are making it harder for some struggling families.
Cotsoradis cited data in 2012 KIDS COUNT report released on Thursday. It showed that the numbers of Kansas children enrolled in Medicaid and receiving food stamps had gone up significantly while the numbers receiving cash and child-care subsidies had gone down.
“You see this huge discrepancy in the data,” Cotsoradis said. “It just doesn’t make a lot of sense.”
Angela de Rocha, a spokesperson for the Kansas Department of Children and Families, defended the administration’s policy changes as efforts to encourage people to become more self-reliant.
“I think we should be praised, not criticized,” she said.
According to the new KIDS COUNT report, 21 percent of Kansas children are living in poverty, up from 18 percent in 2007. The average number of children enrolled in the Supplemental Nutritional Assistance (food stamp) Program rose to more than 136,000 in 2011 – an increase of nearly 40,000 since 2007.
Also, nearly half of all school-aged children in Kansas – 48.6 percent – qualified for free or federally subsidized lunches this year. That is an increase of almost 10 percentage points in four years.
Over the same period, the report shows that the number of families receiving cash-assistance through the Temporary Assistance for Needy Families program has been trending down. In 2011, there were 25,981 families that received assistance, down from 26,633 in 2007. Families receiving child-care assistance decreased to 19,735 in 2011 from 21,025 in 2007.
Officials at the Kansas Department of Children and Families anticipate that the TANF numbers will continue to drop. The official caseload estimate released earlier this month by the Kansas Legislative Research Department says the agency anticipates spending $2.4 million less from the state general fund to support the program in the 2014 budget year “due to the continuation of recent changes in policies.”
Cotsoradis said that explanation “confirms that they (administration officials) are creating barriers to those programs.”
But de Rocha said the declining numbers of families receiving cash and child-care assistance isn’t necessarily the result of the policy changes. She said it could mean that many have gotten full-time jobs because of the department’s insistence that they comply with job-search, training and part-time work requirements.
“It is either people who got a job or who don’t want to cooperate with the job-search and work requirements,” she said. “All we’re saying is ‘we’re happy to help you get back on your feet, but you need to find a job.’”
Cotsoradis said the changes to the assistance programs seemed at odds with Brownback’s campaign promise to make reducing childhood poverty one of his administration’s top priorities.
On Wednesday, the governor appointed a 12-member task force and charged its members to report back with “concrete ideas” on reducing childhood poverty.
“All too often in our state, children who are living in poverty today become tomorrow’s poor parents,” Brownback said. “Intergenerational poverty such as this affects our state’s long-term productivity and wellbeing. We need concrete ideas on how to change this pattern.”
The first task force meeting is scheduled for 10 a.m. Monday in the Kansas Board of Regents Conference Room on the 5th floor of the Curtis State Office Building in Topeka.
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.
Detailed spending proposals for the coming fiscal year prepared by officials at the state’s three top health agencies outline how Gov. Sam Brownback’s administration is planning to cap or cut spending on a broad range of health-related programs.
The governor’s formal budget recommendations for fiscal year 2014, which begins July 1, 2013, won’t be delivered to the Legislature until January when its new session begins. But agency chiefs were told as early as August by the governor to keep spending in check and to present alternatives for cutting 10 percent from each department’s upcoming state general fund budget.
The documents presented by the Kansas Department of Health and Environment, the Kansas Department for Children and Families, and the Kansas Department for Aging and Disability Services to the state budget office as part of the governor’s budget building process were obtained by KHI News Service and are made available here.
Administration officials declined to answer questions about their spending plans.
“We will not comment on the budget proposal at this time,” said Angela de Rocha, spokesperson for the Kansas Department for Aging and Disability Services and the Kansas Department for Children and Families.
Fading state aid
But there is abundant comment contained in the budget documents themselves and representatives of many, if not all, the organizations and programs that rely upon state health dollars have been advised informally within the past couple of weeks by administration officials of the planned spending limits and possible cuts. However, none of the representatives interviewed by KHI News Service had been given the full details laid out in the documents.
“We actually had a meeting with the secretary (Shawn Sullivan of the Kansas Department for Aging and Disability Services) but he didn’t give us any numbers,” said Cindy Luxem, chief executive of the Kansas Health Care Association, which represents for-profit nursing homes and some of the state’s providers of home and community-based services for the elderly.
“The providers at this stage of the game are not getting any kind of bump in the rates (for Medicaid services). The intention of the state is to keep the rates flat, essentially for the next two years, is what he told us,” she said.
Michelle Ponce, executive director of the Kansas Association of Local Health Departments, said she was alerted that the “reduced resources” budget proposed by the Kansas Department of Health and Environment could mean a cut in state aid to the local health agencies.
If adopted as outlined in the agency’s budget plan, 40 local health departments would see their state grants cut with the biggest decreases falling on the state’s largest local agencies.
“It’s maybe too early to tell you exactly what it would all mean,” Ponce said. “But it is unlikely all those agencies could absorb those cuts and maintain current services.”
Ponce said state support for local public health agencies hadn’t increased in years despite the added costs of inflation so any cuts would fall all the harder on the departments. She said association research had showed that since at least 1984, local governments have been stuck with absorbing the growing costs of health department programs as state aid has faded.
Health and Environment
Throughout the budget documents, officials note the need to hold down spending, though sometimes the notes are accompanied by caveats that seem to argue against some of the possible reductions.
At KDHE, officials said “that in recognition of the reality we find ourselves in as a state agency in the current budget environment, the (agency) will not be asking for budget enhancements” in fiscal 2014.
In fact, agency officials proposed total state general fund spending of about $1 million less than for fiscal 2013. About 80 percent of the agency’s $2.6 billion annual budget comes from fees, grants or federal aid as opposed to state tax dollars.
As part of the agency’s “reduced resources” options for cutting 10 percent from the state general fund portion of its budget, officials said they would trim administrative costs by almost 34 percent as a way to forestall more cuts to direct services.
A Kansas health consumer group is planning a post-election rally at the Statehouse in support of expanding the state’s Medicaid program.
Meanwhile, Lt. Gov. Jeff Colyer today headlined an event in Overland Park that was sponsored by a conservative think tank that opposes broadening the Medicaid program. Colyer, however, didn't make explicit what intentions, if any, the administration of Gov. Sam Brownback might have with respect to the issue.
Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said the group "wants to get the dialogue started," on the potential benefits for Kansans, if policymakers here decide they will open up eligibility to include adults earning up to 133 percent of federal poverty guidelines.
Currently, the state's Medicaid program is mostly restricted to poor children, pregnant women, the disabled and the elderly. A non-disabled adult rearing children is currently eligible for Medicaid, if his or her income is below 32 percent of the poverty level – about $5,200 a year for a young mother with two children.
Kansas’ eligibility threshold is among the lowest in the nation.
Affordable Care Act
Under the federal Affordable Care Act, commonly referred to as Obamacare, states would have the option of expanding their Medicaid programs to include adults with incomes at or below 133 percent of federal poverty guidelines or about $30,700 a year for a parent in a four-person household or about $14,900 a year for a childless adult.
Brownback, an outspoken critic of the health reform law, has said he won't consider any aspect of the health reform law's implementation, including a possible Medicaid expansion, until after the Nov. 6 election.
Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.
Governors in at least six states – Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas – have said they will reject the expansion, citing concerns that it would prove to be too expensive and would expand – rather than shrink – the role of government.
Governors in at least 13 states have said they will expand the program.
According to a preliminary estimate by analysts at the Kansas Health Institute, if the expansion is approved here it could add 130,000 people to Kansas Medicaid by 2019.
Colyer was the main speaker at a Kansas Policy Institute (KPI) meeting today in Overland Park that drew about 60 people. He confined his remarks to describing the administration's rationale and goals for its KanCare Medicaid reforms.
He didn't offer new information, but instead repeated points he and other administration officials have made in various venues since unveiling their plan about a year ago. He didn't touch on the question of Medicaid expansion and did not take queries from the audience before leaving for another engagement.
But earlier in the two-hour event, KPI President Dave Trabert said that expanding Medicaid in the state could increase the program's enrollment by 254,000 people by 2023 and increase state general fund spending on Medicaid by $4.7 billion within a decade.
Under the law, the federal government, starting Jan. 1, 2014, would finance 100 percent of the costs of covering the newly eligible Medicaid enrollees for three years: 2014, 2015, and 2016.
The federal match would drop to 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent in 2020 and beyond.
Currently, the federal government picks up about 57 percent of the state’s Medicaid cost. The state pays the remainder.
By the end of this week, officials in the administration of Gov. Sam Brownback are expected to decide if their KanCare Medicaid reforms will move forward on the original timeline of a Jan. 1 launch or whether the program will get pushed to a later, yet-to-be-decided date.
A few things are scheduled to happen over the course of the next five days that will shape that decision, according to Brownback officials. Among them:
Sometime this week, perhaps by Wednesday, completion of the last of the state’s “readiness reviews” of the three managed care companies is due.
Officials have said they will not proceed on schedule unless Amerigroup, United Healthcare and Sunflower State Health Plan, a Centene subsidiary, each has demonstrated it is ready. (The companies had an Oct. 12 deadline for demonstrating that their networks of hospitals, doctors and other service providers were “90 percent adequate,” but administration officials said they wouldn’t make public the status of the companies’ respective network capacities until the end of this week, so it isn’t yet clear how well each company fared with the deadline.)
On Thursday, the day before the administration’s go/no-go decision date, top Kansas health officials are set to meet in Baltimore, Md., with federal officials from the Centers for Medicare and Medicaid Services, the Office of Management and Budget and others.
Reviewing the waiver request
The purpose of the meeting is a review of the state’s so-called Section 1115 waiver application. Much, if not most, of the KanCare plan requires federal approval, either as part of the waiver application, the state’s ongoing Medicaid plan on file with federal officials, or the KanCare contracts and rates. The federal government gets a large say in keeping with the fact that it pays more than half the state’s annual Medicaid costs, which next year are expected to reach $3.2 billion.
Though administration officials have said the launch date for KanCare is contingent upon the various factors still in play as of this week, at the same time they’ve made clear to legislators and others that they have no major fallback plans in place in the event the program is delayed.
“With all those caveats and decision points along the way, we're marching forward for Jan. 1 and all our efforts are for implementation on Jan. 1,” Bruffett told members of the Joint Legislative Budget Committee last week during an update on the KanCare program.
For example, KanCare is expected to supersede HealthWave, the state’s program for providing government subsidized health coverage to children and pregnant women from low- and moderate-income homes. The state’s contracts with the current HealthWave managed care companies, Unicare and Children’s Mercy Family Health Partners (recently purchased by Coventry Health Care), are due to expire Dec. 31. There is no plan to extend those contracts in the event KanCare is delayed.
“We’ve not had any of those kinds of conversations,” Bruffett told KHI News Service.
If necessary, Kansas could continue HealthWave services with the more expensive alternative of paying fees for services instead of relying on managed care contractors, “but that isn’t a good option,” Bruffett said.
As much KanCare as possible
When asked by Sen. Laura Kelly, a Topeka Democrat who serves on the budget committee, what administration officials would do if federal officials do not approve the 1115 waiver on the Brownback timeline, Bruffett said the administration’s intention was to launch as much of KanCare as possible without federal approvals on Jan. 1.
“Everything we have authority to do in the KanCare model, we will do,” she said.
But at this point, it isn’t clear how much of the program could be initiated without the OK from the feds.
The Children's Cabinet should start planning to receive as little as $12 million in tobacco dollars — or $44 million less than current funding — for programs in fiscal 2014, said chair Amanda Adkins at a cabinet meeting today.
Adkins was relaying an estimate from Attorney General Derek Schmidt of "the absolute worst-case scenario" if an arbitration panel rules against Kansas and other states in a dispute with tobacco companies.
"We could have to pay back or be on the hook for as much as $42 million, which means in fiscal year 2014 our tobacco settlement dollars could be as low as ... $12 million. That is just the hard reality in which we find ourselves right now," Adkins said. "If we're really committed to the work that's being done by everybody in this room, we have to plan for the worst-case scenario."
The Children's Cabinet oversees the Children's Initiatives Fund, or CIF, which gets its money from tobacco settlement payments that Kansas and 45 other states negotiated in 1998 with four major tobacco companies. Among the 20 or so CIF programs are Early Head Start, child care and services that assist at-risk families, such as those with disabled children.
Kansas received $56 million in fiscal year 2013 and has received $761 million in total since 1999. However, tens of millions of those funds could be reclaimed out of future payments if an arbitration panel agrees with tobacco companies, which claim Kansas and 31 other states haven't upheld their end of the settlement. The panel is expected to issue its ruling in June.
Cabinet member Sen. Laura Kelly, D-Topeka, said she would like more information on how the attorney general's office arrived at its projection.
"I think it's important to be prepared for disaster, but I'm not convinced we have a disaster on the way," Kelly told KHI News Service, noting that that last year the attorney general projected $40 million in tobacco receipts and the state ultimately received $56 million.
When asked how officials arrived at the $12 million figure, a spokesman for the attorney general declined to comment.
"As this matter is in arbitration we decline comment," Jeff Wagaman wrote in an email today.
Preparing for the worst
Adkins said cabinet members should start planning for the worst-case scenario by seeking funding from additional sources, including businesses, charitable organizations and the state.