The head of the National Association of Insurance Commissioners and two members met today with President Obama to discuss the troubled rollout of the Affordable Care Act.
Kansas Insurance Commissioner Sandy Praeger, a moderate Republican who has generally supported the law, was invited but chose not to attend. NAIC President Jim Donelon, the Republican insurance commissioner from Louisiana, organized the meeting.
Praeger said she wasn’t trying to distance herself from the controversy surrounding the law’s problem-plagued rollout.
But she said the meeting was “premature” because the NAIC had not worked with its members to develop consensus on how to address remaining problems with the law’s implementation.
“It’s a huge honor to be invited to the White House,” Praeger told KHI News Service. “But I want to make sure that we use the president’s time wisely and that we are really able to have some constructive and meaningful dialogue.”
Praeger said the NAIC typically has been a “consensus organization.”
“As a past president of this organization, I think we have a real responsibility to communicate with the leadership and make sure that when we have a meeting that it’s not just representing a single point of view, but it's representing a consensus point of view that’s been arrived at through a vetting process,” she said.
In a joint email sent to their counterparts late Tuesday, Praeger and other commissioners who decided not to attend the meeting said they had “serious reservations about both the process and the policy issues surrounding such an important meeting.”
Adam Hamm, the Republican insurance commissioner from North Dakota, gave similar reasons for skipping the meeting in a statement to the New York Times.
“Because the topic for the meeting (Affordable Care Act) is so delicate and potentially divisive among the nation’s insurance commissioners, a meaningful discussion between all the commissioners needs to take place before a meeting with the president,” said Hamm, who like Praeger is a former president of NAIC. “Unfortunately, that did not happen so I had to respectfully decline to participate in today’s meeting.”
Bob Hanson, a spokesperson for the insurance department, said Praeger also wanted to remain in the state so that she could continue to work with Kansas insurers attempting to comply with President Obama’s recent request that the companies allow customers to temporarily keep policies that don’t meet the ACA’s minimum coverage requirements.
“The Commissioner and her department personnel are in the middle of conferring with companies on how the president's changes might be implemented,” Hanson said in an email. “Those business and regulatory discussions are keeping the commissioner here in Kansas to make sure any details are hammered out in the best interest of our citizens.”
Blue Cross Blue Shield of Kansas, the state’s largest health insurer, announced Tuesday that it would comply with the president’s request and work to reverse approximately 10,000 policy cancellations already in process, allowing policyholders to keep their nonconforming plans another year.
“This governmental change will allow many of our members to keep the benefit plan they already have and like, while still allowing them to consider new plans that they may be able to purchase with the help of a tax subsidy or small business tax credit,” the company said in a news release.
Praeger said reversing the cancellations likely would be costly to BCBS-KS and other insurers and could lead to premium increases. The main reason, she said, was that companies had based their rates on the assumption that many young, healthy people who had nonconforming policies would purchase more comprehensive plans thereby broadening the insurance pool. If significant numbers of those people decide to hang on to their current plans, the mix of policyholders enrolled in more comprehensive plans will be older and less healthy, Praeger said.
“If you’re going to let these healthier folks stay out of the mix for another year, there’s going to be a (cost) impact,” she said.
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.
The Kansas Medicaid program seems to be catching up with the rest of the nation when it comes to dental care for children.
In the past dozen years the state has doubled the number of Medicaid children receiving dental services, said Kamyar Nasseh, an economist from the American Dental Association. Nasseh spoke at the Oral Health Kansas conference held here last week.
Nasseh said about 20 percent of Kansas children on Medicaid logged a dental visit in 2000. But in 2012, that figure was up to 40 percent, he said, citing statistics from the federal Centers for Medicare and Medicaid Services.
One explanation for the greater percentage of Kansas Medicaid children seeing a dentist could be the state’s school-based screening and sealant program, said Jennifer Ferguson, manager of the Kansas Children’s Oral Health Program. The program targets low-income students.
The program screened approximately 154,000 students during the 2012-2013 school year, more than double the number served just three years prior, according to a presentation by Ferguson.
But despite the improvements, the Kansas percentage remains slightly below the national average, Nasseh said.
Yesterday, KHI News Service reported that Kansas’ Medicaid-reform program, known as KanCare, had effectively shut down a grant-funded initiative that provided Medicaid dental services to children in Head Start programs.
Nasseh gave the keynote speech at the two-day conference, which drew about 160 people. It was held at Johnson County Community College.
Nasseh cited other Kansas figures:
Approximately 49 percent of low-income adults saw a dentist in 2010, down from about 53 percent in 2002. There was a similar decline in the national percentage.
Assuming full implementation of the federal health-reform law, approximately 545,000 Kansas children would have dental benefits by 2018, a roughly 16 percent increase over 2010. A key requirement of the law is that private health insurance plans must include pediatric dental and vision benefits starting next year.
The Medicaid reimbursement rate for dental services is less than half (46.9 percent) the commercial payment rate, which is about in line with the national average of 50.3 percent.
And he described a national survey by the dental association that found that more than a third of dentists reported they were not busy enough and could accept more patients.
Conference presentations are available online, along with the first-ever county-by-county oral health snapshot of the state, which was produced by Oral Health Kansas and released at the conference.
90 percent of counties short on dental providers
Tanya Dorf Brunner, executive director of Oral Health Kansas, said she was surprised to hear that given that 95 of Kansas’ 105 counties do not have enough dental providers.
Members of an oral health task force established by the Kansas Board of Regents recommended last year that the state open a dental school to help address the shortage.
The disconnect between the findings in the dental association survey and the Kansas statistics could boil down to differences among safety-net providers and private-practice dentists.
If state-run Medicaid had its problems, one part that was working well in Kansas was providing oral health care to kids through programs such as Kansas Cavity Free Kids, Head Start officials say.
By the fifth year of the pilot program, which began in 2007, more than 7,000 children in 41 rural counties had received regular cleanings, fluoride varnishes and sealants from dental hygienists in Head Start classrooms.
It worked so well that program officials planned to expand it to other areas of the state where access to dental care is chronically limited.
But the program was effectively shut down after the launch of KanCare on Jan. 1, when day-to-day management of the state's Medicaid program was turned over to three for-profit managed care companies.
UnitedHealthcare, one of the state’s three KanCare contractors, chose to not authorize payment for teeth cleanings performed at Head Start, a decision that effectively put the entire program on ice.
"United does not recognize (a hygienist's) services if she's working under Head Start for doing cleanings for kids or for pregnant women," said Kathy Hunt, the Head Start official who coordinated Kansas Cavity Free Kids.
The other two KanCare companies — Amerigroup and Sunflower State Health Plan, a Centene subsidiary — continued the previous state policy of allowing dental care performed at Head Start facilities to be billed under Medicaid.
But Hunt said the program could not continue serving children covered by those companies while turning away others covered by United.
"Quite frankly, we have not provided services since" KanCare began, Hunt said. "We can't say 'I'm going to provide services for this child and not for this child.'"
Hunt also serves on the board of directors for Oral Health Kansas. She testified about the problem last month at the first meeting of the Legislature’s KanCare oversight committee.
A month later, she hadn’t had any response from legislators, state officials or representatives of UnitedHealthcare.
There are a lot claims circulating online and in the media about Obama's campaign pledge "If you've got a health care plan that you like, you can keep it" ... many of those claims miss the mark. So here's the lowdown:
If you bought your insurance plan before Obamacare was signed into law (March 23, 2010) your plan is grandfathered, and so long as you keep renewing it, you can keep it indefinitely.
Otherwise, your plan is not grandfathered. Some of those plans purchased after March 23, 2010 do not meet the law's requirement to cover "essential health benefits" (that includes covering childbirth and basic preventive care, for example). If you have one of those plans, you are one of the roughly 5% of Americans who received a letter saying you will have to update coverage to a plan offering the essential health benefits.
The state's largest insurer — Blue Cross Blue Shield of Kansas — has said that about 65% of people who purchase its individual plans (vs group or employer coverage) have grandfathered plans. Many of the remaining 35% already have plans that include most — if not all — of the essential health benefits and so their coverage and premiums will not change dramatically. Nevertheless, they may receive a letter notifying them of their options to update their coverage to comply with the law. Again, this only applies to people who enrolled in their current plan after March 23, 2010.
Of those people required to update their plans, some may see their total premiums go up.
However, many will now qualify for tax credits to buy updated insurance plans via the new marketplace — and so the amount they actually pay could be slashed dramatically. Those with incomes between 100% and 400% of the poverty level will qualify for tax credits. For example, a family of four earning between $23,050 and $92,200 will qualify for tax credits. Until HealthCare.gov is working properly, you can go to InsureKS.org to see how much tax-credit assistance you qualify for.
→ More coverage of Obamacare at khi.org/healthreform.
The Health Care Foundation of Greater Kansas City has rolled out a new website designed to be a comprehensive source of health information for a six-county region in Missouri and Kansas.
The website KCHealthMatters.org has about 150 data indicators, and it allows users to analyze information down to the census tract.
“And it’s more than just numbers,” said Sarah Hurd, an analyst with the Kansas Health Institute, which helped develop the site. “There is a focus on action.” (The institute is the parent organization of the KHI News Service.)
In a presentation Wednesday, Hurd pointed to the “promising practices” portion of the site, which includes reports from local, national, and international sources. Users can submit their own promising practices.
The site covers the Health Care Foundation service area: Cass, Jackson and Lafayette counties in Missouri, and Johnson, Wyandotte and Allen counties in Kansas.
Officials involved with development of the site said they hope it can help the social service community in applying for grants. But, they said, it’s also meant to be a resource for a variety of users, including providers, government officials and the general public.
The website should prove to be a “wonderful tool” for the community, said Gretchen Kunkel, president of KC Healthy Kids, a nonprofit dedicated to reducing childhood obesity.
She said nonprofit officials are always looking for data.
“Data to help us tell a story of what (is) happening in the community, data that help us understand how we can apply limited resources, and data to help us create understanding and collaboration to bring those resources together so that we can realize a healthier community,” she said.
The site is similar to KansasHealthMatters.org, sponsored by the Kansas Partnership for Improving Community Health, a collaboration that includes nonprofit, government and university partners.
Perhaps it is a case of could-have-been.
Two years ago, Gov. Sam Brownback rejected a $31.5 million federal grant to set up a health insurance marketplace tailored for Kansas — defaulting instead to the federally run exchange that was launched Oct. 1 but which continues to be beset by problems.
Gary Schneider — the technology expert who was poised to lead Kansas' marketplace development until Brownback opted against it — left instead for Colorado, one of 16 states that chose to run their own marketplace. He now is the IT project manager for the Colorado Health Benefit Exchange.
In Colorado, so far, things are going smoothly, Schneider said.
More than 700 people have enrolled in insurance plans using Connect for Health Colorado, the state’s marketplace. And more than 30,000 people have created accounts on the website allowing them to compare plan options and see if they qualify for tax subsidies.
"We had some bumps in the road with our system when we first turned it on, but most of those have been resolved," Schneider said.
Like the federal marketplace, Colorado's website initially was overwhelmed with traffic.
"Until you turn a system like this on ‘live’ and experience a real load, you can't be sure how it's going to react," Schneider said. "That was the first couple days, but things got pretty stable pretty quick."
CGI, the contractor that built the Colorado marketplace, also built the federal exchange. But Schneider said the fact that so many states went the way of Kansas — opting to use the federal marketplace, HealthCare.gov — greatly complicated the task for the national government.
"If they had anticipated 35 or so states being in the federal marketplace, I'm sure they would have done some things differently,” he said. “But that just panned out in the last 18 months, where states made these decisions to opt out. I don't think they anticipated more than a handful of states to be in the federal marketplace.”
Schneider said he wasn't surprised that the federal marketplace is off to a rocky start “given the tight deadline and the fact that so many states opted to not have a state-based marketplace. That made their task extremely challenging...because there are business rules that apply to different states."
President Obama today held a press conference to reassure those frustrated with HealthCare.gov, saying that "nobody is more frustrated by (the glitches) than I am."
But, said Obama, "even with all the problems at HealthCare.gov, the website is still working for a lot of people, just not as quick or efficient or consistent as we want."
That complexity has been the federal marketplace’s undoing so far, said Timothy Jost, an expert on the health reform law and a professor at Washington and Lee University School of Law.
"The main culprit is just a very, very complex system that must be established to enroll millions of people in hundreds of different health plans," Jost said. "The fact that 36 states refused to participate I think was completely unexpected. And Congress has not appropriated funds — since the initial appropriation, that I know of — for the federal exchange," he said, referring to the federal marketplace.
"Instead Congress has held numerous hearings that have tied up key government officials and kept them from getting their job done. So I think Congress is probably more to blame than anybody else."
Jost also laid blame on "the states that have opposed implementation, including Kansas."
“The states' decisions to not run their own exchanges has had a very serious effect,” he said. “States that are running their exchanges are showing a lot of success.”
States including Hawaii, California and Colorado experienced problems in the opening days of their marketplaces, but according to most reports those have now been largely resolved.
Switching to a state-based marketplace
Should Kansas change direction and decide to run its own insurance marketplace — which for now seems unlikely given the opposition to Obamacare among the state’s Republican leaders — it could have the option of implementing proven software, such as that running Colorado's marketplace.
Schneider said he is in talks with several other states about using the system Colorado built, but Kansas isn't among them.
Kansans frustrated by their inability to shop for health insurance coverage on the federal marketplace website can now do much of the legwork on the state insurance department’s updated website, InsureKS.org.
Late Friday afternoon the department upgraded the site first launched in early September so that consumers in any county can access a list of the health plans available in the federal marketplace along with their prices.
“We’re pretty excited because if somebody goes on our website they can find out whether they qualify for a tax credit and they can take that information and look at the rates and plans and come pretty close to figuring out which plan they're interested in when they’re able to get on the (federal) marketplace. So, hopefully it will give them a little bit of a head start,” said Linda Sheppard, director of health care policy and analysis at the insurance department.
Consumers can do about everything on the insurance department website that they could do on the official federal site – if it were working – except finalize a purchase.
The marketplace website operated by the U.S. Department of Health and Human Services — HealthCare.gov — has been plagued by problems and has been mostly inoperable since its launch Oct. 1, though there were indications of progress Friday.
Officials with a consortium of nonprofit organizations training and deploying navigators to help consumers shop for plans said that, by day's end, five Kansans had managed to purchase coverage using the federal marketplace.
Sheppard said Kansas officials didn’t seek federal approval to add the work-around tools to the state site, which also includes a feature allowing users to locate navigators and marketplace-certified agents nearest them.
Kansas is one of 36 states that opted to have the federal government design and operate its marketplace rather than building its own.
Republican Gov. Sam Brownback returned a $31.5 million federal grant that Insurance Commissioner Sandy Praeger had obtained to build a state-based marketplace, sometimes called an "exchange."
Sheppard said Kansans she's talked to at meetings across the state haven’t been angry about their inability to use the marketplace, but they have been frustrated by their inability to get information about the coverage options available to them.
“They don’t seem angry about it, they just generally say something like, ‘Yeah, that’s what I expected,’” she said.
A new report finds some 78,000 Kansans are among those not poor enough for Medicaid but too poor to qualify for tax subsidies under the Affordable Care Act
About 78,000 Kansans are among 5.2 million poor, uninsured adults who will fall into the “coverage gap,” created by 26 states choosing not to expand Medicaid under the federal health reform law next year, according to a study released today by the Kaiser Family Foundation.
These people are projected to have incomes too high to qualify for their state’s existing Medicaid programs, but below the federal poverty level (nearly $11,500 for an individual) required to be eligible for tax subsidies to buy private coverage on the new insurance marketplaces set up by the Affordable Care Act, or ACA. Medicaid is the state-federal health insurance program for the poor.
“Millions of adults will remain outside the reach of the ACA and continue to have limited, if any, options for health coverage,” the study concludes.
The law provides full federal funding for three years to states that expand Medicaid to cover residents under 138 percent of the poverty level (or just under $15,900 for an individual).
But the Supreme Court made that requirement effectively optional for states, and most Republican led-states have opted against expanding the program.
There is no deadline by which states must opt to expand Medicaid, and a few states are still considering it.
Nearly half of the uninsured in the coverage gap live in Texas (1 million), Florida (763,980) and Georgia (409,350) — largely because those states have the most uninsured and limited Medicaid eligibility today.
Kansas among states with coverage gaps
In Kansas, about 78,000 adults will fall into the coverage gap, according to the report.
Alabama, Mississippi and Louisiana also will be especially hard hit, with more than a third of their uninsured adults falling into the coverage gap next year, the study shows.
In Kansas, 29 percent of uninsured adults fall into the coverage gap.
These states will feel the pinch because they have higher rates of poor uninsured adults and their existing Medicaid programs have some of the nation’s the tightest eligibility rules.
In Kansas, adults with children are eligible for Medicaid coverage if they earn less than $7,421 (for a family of three). Childless Kansans are not eligible regardless of income level.
Gov. Sam Brownback and the Legislature have shown no desire to expand Medicaid and seem unlikely to approve it this year.
Federal officials have said they have little ability to address the coverage gap, given the Supreme Court's ruling. The only way to fix that would be for Congress to modify the health reform law.
A new pilot program aimed at improving billing and collections at local health departments is beginning at a critical time — just as tens of thousands of Kansans are expected to get insurance coverage under the Affordable Care Act (ACA).
Currently, billing mistakes are costing many local health departments when it comes to collecting from private insurance companies and the Medicaid program. But that cost isn’t as significant as it could be because many of those now being served by departments are uninsured and so pay their bills directly.
The payer mix is expected to change as more Kansans obtain private coverage through the new online marketplace healthcare.gov, provided federal officials are able to solve technical problems that have plagued the website since its Oct. 1st launch.
A decision by Gov. Sam Brownback and the Republican-controlled legislature to expand eligibility for the state’s Medicaid program – known as KanCare – also would substantially increase the pressure on local health departments to improve their billing procedures. However, neither appear poised to authorize that expansion soon.
The pilot — spearheaded by the Kansas Foundation for Medical Care (KMFC), a Quality Improvement Organization — is beginning in this month in Douglas, Harper, Reno and Sumner counties.
Each of the four local health departments (LHDs) will receive up to $1,360 to train staff members on billing techniques that will maximize reimbursement for services provided to privately insured clients, said Stephanie Lambert-Barth, manager for KFMC's Immunization Billing Project.
“Training of LHD billing staff will streamline the billing processes and improve billing outcomes, resulting in a return on the training investment. Demonstrating this return on investment may help other Kansas LHDs make the case to fund training for their billing staff,” she said.
The Lawrence-Douglas County health department is one of the largest and best funded in the state. Nevertheless it only has one office assistant working two days a week on billing, said director Dan Partridge.
"For us billing has been a challenge because our capacity to dedicate and train staff has been limited," Partridge said.
Currently about 3/4 of his department's revenue comes from clients who pay their bills directly. The agency has an 85 percent collection rate among those clients. However, it collects only 57 percent of the amount it bills to Medicaid and only 20 percent of what it bills to clients covered by private insurance.
"Most of it is coding errors," Partridge said. "We feel confident our participation (in the pilot) will lead to improved collection rates. We also want to be prepared for whatever shift the ACA will create within our revenue streams as private insurance coverage increases."
KFMC’s Lambert-Barth said that, while the project is focused on improving reimbursement rates for immunization services, the plan is to evaluate all claims billed by the health department, including family planning services, for example.
"Our project's final product is a strategic plan report, which will include recommendations for how to move forward. It is not yet clear what those specific recommendations will be, but if the pilot goes well then expansion (of the pilot) would make sense,” she said.
The pilot project’s website contains links to billing resources, tools, project updates and other related information.
Will it come in with a big bang, dramatically and forever changing Americans’ health care? Or will it be something more like a whimper?
Tomorrow is the much-anticipated first day that millions of Americans without affordable health insurance will be able to turn to the new, online marketplace that is one of the central elements of the Affordable Care Act, commonly known as Obamacare.
Supporters of the health reform law have trumpeted the big moment for months and likewise there has been an onslaught of public relations campaigns from the law’s opponents, including a high-profile showdown in Congress over it that threatens to shut down much of the government.
But some of those most familiar with how the new system is expected to work here, particularly the insurance marketplace, are saying it wouldn’t hurt for Kansans simply to wait a bit before they try to sign up for coverage.
“Don't focus on Oct. 1,” said Sheldon Weisgrau of the Health Reform Resource Project. “The information will be available then, but whether you buy your policy Oct. 1, Nov. 1 or Dec. 1, won’t make a difference because the coverage won’t start until Jan. 1. I'm actually encouraging people to take a deep breath and wait because there might be a few bugs to work out.”
“Basically, when we've been out talking to the crowds in various locations, we’ve been encouraging them to wait maybe two or three weeks to let some of the potential bugs or glitches smooth out,” said Linda Sheppard, one of the top officials at the Kansas Insurance Department and one of the state’s leading experts on the Affordable Care Act.
Sheppard is suggesting people sit back until as long as Dec. 15 before choosing a plan.
People eligible to use the new marketplace will have until March 31 to sign up, so Oct. 1 is merely the first day of a six-month open enrollment period.
Slow start and limited awareness
Even if everything goes smoothly Day One with the marketplace enrollment system, it could be six months or longer before most Americans understand they can use the marketplaces.
A survey released today by the Commonwealth Fund showed that 76 percent of Americans between the ages of 19 and 64 know they are required by the Affordable Care Act to have health insurance next year.
But only two in five, or 39 percent, were aware of the new marketplaces or that they would be able to use them to apply for financial help with their premium costs.
Meanwhile, the so-called “navigators” certified to help people enroll in the marketplace plans remain in short supply with only about two dozen of the 250 planned for Kansas currently trained and ready to go, though that number is expected to quickly grow over the course of the next few weeks.
Because of the expected slow start to the new program, the Congressional Budget Office projects that only 7 million of the 48 million uninsured in America will enroll in plans through the marketplaces in 2014, though that number is expected to grow to a peak of 25 million a year by 2018.
About 52 percent of Kansans already have coverage through their employers, and another 29 percent already are enrolled in public health plans, which means a relatively small percentage of people here are expected to gain coverage through the new marketplace.
Of the state’s 365,000 uninsured, only about 188,000 — or roughly half — are expected to benefit from the marketplace, according to the Kansas Health Institute.
However, it is thought highly unlikely even that many will actually use it in 2014, given the historical “take-up” rates for government programs and the fact that many of the uninsured earn too little to face the new tax penalties for not having coverage.
And since Kansas is among the states where political leaders have chosen against expanding eligibility for the Medicaid program, there will be about 58,000 poor Kansans who fall into a coverage gap. Those Kansans — with earnings between about 32 percent and 100 percent of federal poverty guidelines — earn too much to be eligible for Medicaid but are too poor for subsidized health coverage through the new marketplace.
Tax subsidies to buy insurance
For those Kansans without access to affordable insurance through their employers, subsidies will be available on a sliding scale to those with incomes starting at 100 percent and up to 400 percent of federal poverty guidelines, which is $45,960 for an individual or $94,200 for a family of four.
Even with all the talk from Capitol Hill to Main Street about Obamacare, many people don't know what they have to do to comply with the law’s requirement that almost everyone have insurance beginning in 2014.
For those who are uninsured, the key to satisfying that requirement could be the new online health insurance marketplaces, which are set to open Oct. 1 for shopping. Policies will go into effect Jan. 1. Seven million Americans are expected to find coverage there.
More than 500,000 Kansans would have some reason to consider using the health insurance exchange to obtain coverage — such as those with a pre-existing condition — according to the Kansas Health Institute.
Here are 15 basic things you need to know about the marketplaces:
The insurance marketplaces are open to nearly everyone, but If you have insurance through work, Medicare or Medicaid, it’s likely you won’t need to shop for coverage there. They are really for people who are uninsured or folks who buy individual policies now.
Many people will qualify for subsidies to make coverage more affordable there. These subsidies — tax credits to help pay your premiums - will be available to people with incomes up to 400 percent of the federal poverty level. That's about $46,000 for one person or $94,000 for a family of four. And there are cost-sharing subsidies to reduce deductibles and copayments, depending on your income.
Immigrants who are in this country illegally are barred from buying on the exchanges.
You can enroll until March 31, 2014, though you'll generally need to sign up by Dec. 15 of this year, to be covered as of Jan. 1. You can find your state’s marketplace at healthcare.gov.
Through the marketplace, you can compare health plans in your area. The prices are based on where you live, your family size, the type of plan you select, your age and whether you smoke. All the plans have to comply with the Affordable Care Act’s requirement to have a basic benefits package, but the amount you have to pay in premiums, co-pays and deductibles will vary among plans.
When you apply for coverage on the exchange, you will find out if you’re eligible for subsidies to help pay for premiums. Or, if you have a low income, you can also learn if you are eligible for Medicaid coverage.
Your income — not your assets, such as your house, stocks or retirement accounts – will count toward determining whether you can get tax credits. When you buy your plan, you estimate your income for next year, and your tax credit is based on that estimate. The next year, your tax returns will be checked by the IRS and compared against your estimate.
If you qualify for a tax credit to pay your premiums, you can choose to either have the credit sent directly to the insurer or pay the whole premium up front and claim the credit on your taxes. If you qualify for cost-sharing subsidies, that subsidy will be sent directly to the insurer, and you won’t have to pay as much out of pocket.
If your income increases during the year, notify the exchange promptly so that you can avoid having to pay back the credits. On the other hand, if your income goes down, you could be eligible for a bigger subsidy. Either way it's important to notify the exchange if your income changes.
Each plan covers 10 “essential health benefits,” which include prescription drugs, emergency and hospital care, doctor visits, maternity and mental health services, rehabilitation and lab services, among others. In addition, recommended preventive services, such as mammograms, must be covered without any out-of-pocket costs to you.
You won’t have to pay more for insurance if you have a medical condition and that condition will be covered when your policy begins. But older people can be charged more than younger people and smokers could face a surcharge.
The prices for the marketplace plans are likely to be similar to those sold privately. If your broker offers you a plan that is also available on the exchange, you may be eligible for subsidies.
Your insurer generally can't drop you, as long as you keep up with your insurance premiums and don't lie on your application. Generally, people will be able to enroll in or change plans once a year during the annual open enrollment period. This first year, open enrollment on the exchanges will run for six months, from Oct. 1 through March of next year. But in subsequent years the time period will be shorter, running from October 15 to December 7.
There are certain circumstances when you would be able to change plans or add or drop someone from coverage outside the regular annual enrollment period. This could happen if you lose your job, for example, or get married, divorced or have a child.
The number of plans that you can choose from is likely to vary widely. In some states, only a couple of insurers have announced plans to offer policies though the marketplace, while in others there may be a dozen or more. Even within a state, there will be differences in the number of plans available in different areas. You can expect that insurers will offer a variety of types of plans, including familiar models like PPOs and HMOs.
State lawmakers' resistance to expanding Medicaid “just makes no sense,” Kansas Insurance Commissioner Sandy Praeger said Thursday, speaking at a meeting of safety-net clinic officials.
Many legislators, she said, “really don't understand” the consequences of not expanding Medicaid because there was “almost no discussion of the Affordable Care Act” during this year's legislative session.
Praeger, who has been hosting a series of informational forums on the health reform law for the past three weeks, said legislators will have a hard time not addressing Medicaid expansion in 2014.
“People are starting to understand what the lack of Medicaid expansion means,” she said. “And I think legislators are starting to hear from them.”
Currently in Kansas, non-disabled adults with children are eligible for Medicaid if their incomes fall below 32 percent of the federal poverty level, roughly $6,250 a year for a family of three.
“Let me put that in perspective for you,” said Health Reform Resource Project Director Sheldon Weisgrau, who also spoke at the annual conference of the Kansas Association for the Medically Underserved. “That means that a mother with two kids who works a minimum-wage job half-time makes too much money to be on Medicaid,” though the children would qualify.
Childless, non-disabled adults, are not eligible for Medicaid “under any circumstances,” he said.
Under the Affordable Care Act, commonly known as Obamacare, the federal government will cover all or most of the costs of expanding Medicaid to include adults whose incomes fall below 138 percent of the poverty level. However, expansion is optional and up to the political leaders in each state.
Low-income children and pregnant women already are covered under Medicaid.
In Kansas, Medicaid expansion would insure about 130,000 adults who are currently uninsured, according to various estimates.
Gov. Sam Brownback and the Republican majorities in both the House and Senate have shelved the Medicaid-expansion debate, saying they doubt the federal government will be able to keep its promise to cover most of the costs.
Cost of expansion
If adopted, Medicaid expansion would cost the state about $625 million over 10 years, according to a projection by the Brownback administration.
“To put that number into context, last year the State of Kansas spent $1.2 billion in state money on Medicaid,” Weisgrau said. “This increase of $625 million is over 10 years, but the Legislature decided we could not afford that.”
The administration's calculation, he said, did not include the offsetting costs to local programs — county health departments, safety-net clinics, hospitals — for covering the needs of the uninsured.
Some 27,000 people in Wyandotte County have no health insurance. Health officials are hoping Obamacare and the new insurance marketplace expected to be operating soon in Kansas can help change that.
“We assume quite a few (of the 27,000) are going to be able to qualify” for subsidies through the marketplace, said Joe Connor, director of the Unified Government of Wyandotte County Health Department.
The marketplace, which federal officials have pledged will be ready to launch on schedule Oct. 1, is aimed at making affordable health coverage available to thousands of Kansans who otherwise might not have it.
Nationally, the state marketplaces — also sometimes called insurance exchanges — are expected to serve millions of Americans and are a key component of the Affordable Care Act, which became law in 2010.
‘Misinformation and polarization’
Officials here have a task force that earlier this month began planning ways to get the word out about the exchange to some of the people considered most likely to benefit from it.
The panel is part of the Healthy Communities Wyandotte initiative and is chaired by former Kansas Medicaid Director Barb Langner. She now works at the University of Kansas Medical Center but is working on the initiative as a volunteer.
Langner said the group doesn’t want to duplicate public-awareness work that will be done by others, including the federal government and the Kansas Insurance Department, but that a local touch is needed if everyone in the county is to be reached.
“This is a county that's used to creating some local solutions,” Langner said. “I think the statewide (public outreach) effort will be all well and good, but there are some pockets of people you will not reach unless you have local involvement. A lot of people are not going to go to a public meeting about this. It has to be a little more user friendly.”
Langner said the task force hopes to provide easily understandable information about the exchange to people who already are trusted in the neighborhoods so they can disseminate it to likely exchange users.
“I think because of the misinformation and uncertainty and sort of the polarization on this topic, it’s going to take someone who is trusted to explain it. And you're going to be dealing people that most likely don't have a lot of familiarity with insurance products, so I think personal contact with someone they trust will be important,” Langner said.
“Our role is to get whatever information has been produced to the people who have the contacts in the community. The logical places are churches, perhaps daycares, schools, small businesses, salons. We’re still in the planning phase right now,” she said.
Little time left
Whatever the group does will need to happen soon, because Oct. 1 is looming. The coverage plans offered through the marketplace become effective starting Jan. 1, which isn’t too distant in time, either.
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.
Ben Alexander grew up in Shawnee, but you wouldn’t always find him there.
More likely, he’d be exploring in Kansas City, Mo., checking out the rural parts of the area, or heading to the Kansas River.
“I would ride my junky little bike all over the place,” he said, “and it got me in shape, kept me out of trouble and got me around the city.”
Alexander went on to graduate from Shawnee Mission Northwest High School in 2006, and four years later he emerged from the University of Kansas with undergraduate degrees in environmental studies, geography, international studies and Spanish.
Now, at age 25, he’s working to help underprivileged children learn and grow through biking like he did as a kid.
Alexander is founder and executive director of a nonprofit called FreeWheels for Kids, which is based in a spare bedroom of the house he and his wife own in the Strawberry Hill neighborhood here.
FreeWheels for Kids teaches bike safety to children as young as age 8.
Through the FreeWheels Earn a Bike program, middle school- and high-school can learn bicycle repair skills as they refurbish donated two-wheelers for themselves and other children. Alexander also tries to teach the students the benefits of mastering new skills and taking on big jobs.
It’s about having the confidence to look at a broken down bike, Alexander said, and being able to say, “Yeah, I can take this on. I’m going to make this happen.”
Alexander started the program in the fall of 2011 while working as a part-time paraprofessional in a Kansas City, Mo. charter school. He officially incorporated the enterprise as a nonprofit corporation early last year.
Within the last couple of years, he said, participants had refurbished approximately 450 bicycles.
The nonprofit received a grant earlier this month from the Health Care Foundation of Greater Kansas City. Alexander said that funding would go toward establishing bike clubs in conjunction with the Earn a Bike program.
In addition, the Bethel Neighborhood Center, located along Seventh Street near Central Avenue here, has earmarked about one fifth of a $50,000 grant it received to expand FreeWheels for Kids programming there. That grant was part of funding announced last month from the Unified Government of Wyandotte County/Kansas City, Kan.
The two grants, Alexander said, were a big reason why the nonprofit has a cash budget of about $60,000 this year. Last year’s cash budget was only about $5,000.
Alexander said the nonprofit was on track to serve about 900 children this year.
On Wednesday, Alexander was assisting Earn a Bike participants in the basement of the Bethel center.
On one side of the room, 12-year-olds Reyna Espino and Jaquelin Arambula worked to get the back tire off a pink Barbie bike propped upside down on its seat. Their workstation was a ping-pong table.
Eduardo Cruz, 12, sat nearby on a metal folding chair dealing with a tire issue of his own.
Reyna said the bike-repair skills she had learned could come in handy.
“If anything went wrong with my bike now,” she said, “I would know what to do with it besides putting it in the trash.”
Both girls said that working on bikes had taught them the benefit of patience. They also said it felt good to repair bikes that someone else could use.
Eduardo said what he had learned through FreeWheels made him feel safer riding his bike around the neighborhood, which he said he liked to do “because it is exciting and gets us in shape.”
The Rev. Mang Sonna, executive director at the Bethel center, said he wanted to work more with Alexander because he liked Alexander’s rapport with the children.
Evidence of that, he said, was seeing the Bethel center children riding around the neighborhood on the bikes they had fixed up in class.
It’s especially important to stress physical fitness for kids at the center, said Rakmi Shaiza, program director and volunteer coordinator, since most of them come from families with no health insurance.
Parents also realize the benefits of the program, she said. A lot of them work, she said, making it difficult for them to come to the center to register their children for things.
But “with this program, almost all of them immediately came to sign up,” Shaiza said.
→ Find ongoing coverage of issues that affect the health of Kansans at khi.org.
The big push by federal officials to get the word out in the next few months about the Affordable Care Act mostly will bypass Kansas, but even in this generally anti-Obama red state there are organizations and community groups gearing up to inform the public about the new health insurance exchange scheduled to launch on Oct. 1.
“I think that there's a lot of misunderstanding about what the Affordable Care Act is and how it works and there's so much noise from a political perspective that people can't really focus on what it is they need to know” about it, said Roberta Riportella, a professor of community health at the Kansas State University Extension. “What we're going to try to do is cut through that noise.”
Riportella has been on the job at K-State for about three months and for at least the next several will be spearheading an effort to use county extension agents and faculty members to inform the Kansas public about the federal health reform law, particularly the new insurance exchange through which millions of Americans and hundreds of thousands of Kansans are expected to purchase their health coverage.
The extension is a long-trusted K-State institution with agents working in all 105 counties. They do all sorts of things to help people, ranging from counseling on best farming practices to helping seniors enroll in Medicare Part D drug programs. They teach 4-H kids to make jelly and other skills, give parents tips on home economics, and are the state’s most persistent crusaders against musk thistle and other noxious pests.
Over the next several weeks, including as part of their annual training sessions in August in Manhattan at the K-State campus, the agents will be learning details of the Affordable Care Act and how to communicate its meaning to the people intended to benefit from it.
In at least one county, (Shawnee, home of Topeka), there will be as many as three extension agents working to get out the word.
They and their colleagues across the state will be trying to inform a public that still knows relatively little about the law three years after it was passed. A recent poll by the Kaiser Family Foundation showed that most Americans still don’t know much about the law commonly referred to as Obamacare.
“I think it will take a big educational effort and I don't expect everybody to get it by the deadline,” said Cindy Evans, a K-State extension agent who works in Shawnee County. “We'll just have to keep working at it and hopefully, if it turns out to be a good thing, people will tell their friends and family about it. It won't be just an agency like (extension) carrying the message. You’ll need community connections, churches and other groups letting people know.”
Each year for the past six, Evans said, she has worked one on one with seniors to help them enroll or re-enroll in the Medicare prescription drug program. But she said it would be impossible to work individually like that with people on the Affordable Care Act simply because of the thousands expected to use the insurance exchange.
'Keep politics out'
Sue Peterson has served for years as K-State liaison to the Kansas Legislature and she knows very well the revulsion the state’s elected conservative Republicans have for Obamacare. Gov. Sam Brownback campaigned for the job pledging to fight the law "every step of the way.”
“It was envisioned by the United States Congress when they passed the Hatch Act and Smith Lever acts, (that) research and extension would provide information to the public who needed or wanted information. The university, and research and extension provide unbiased scientific research findings or information to the public at large around the state,” Peterson told KHI New Service in an email when asked if she expected the university to face political repercussions at the Statehouse because of extension agents doing their jobs.
Evans said she didn’t want her efforts to be misconstrued as political.
“I think extension's role is going to be what it always been — education,” she said. “I don't want to be political at all on this. I just want to keep politics out. People have feelings on both sides on whether they think it will work or cost the system too much. It’s not my role in extension to be political. My role in health literacy and senior health counseling, is to just accurately help people understand the law as it is today.
“I’m not trying to take a stand whether it’s good or bad,” Evans said. “My major area is family finance and people spend a lot of money on insurance and health care and I want to help. My role in family finance is to help them make a good financial decision and not be political.”
Federal officials are preparing for a major public awareness campaign to be most evident in August and September that in some ways has already started. Today, for example, the U.S. Department of Health and Human Services announced a new website and a telephone call center in anticipation of the Oct. 1 exchange launch.
But the major focus of the marketing blitz by the feds and national health consumer groups is expected to be in states with high numbers of people without health coverage, including California and Texas.
Kansas is among the states where federal officials will run the new health insurance exchange but the state’s top insurance regulators said they hope to inject a local flavor.
Insurance Commissioner Sandy Praeger said her agency has been in discussion with the feds about having some of the more complex calls to the exchange’s toll-free helpline roll over to her department so that Kansas consumers come in touch quickly with local people more familiar with the Kansas insurance plans offered in the exchange and the governing regulations.
“We’re discussing how we can make a quick, relatively seamless transfer,” of appropriate calls to the Kansas Insurance Department, Praeger told KHI News Service.
“Our expectation is if you call the 800 number and if you have really simple questions like ‘I don't think I have the proper web address for the exchange or my password isn't working,’ a very operational question, they would handle it,” said Linda Sheppard, the insurance department’s director of health care policy and analysis. “But if it’s questions specifically related to anyone's benefits or coverage, those would be forwarded to us.”
The department already routinely fields calls from consumers with complaints about denials of insurance claims or delays in processing, so it only makes sense to carry that practice forward with implementation of the Affordable Care Act, Praeger said.
The exchange or marketplace is scheduled to be operational in each state by Oct. 1 with coverage purchased through the exchange effective Jan. 1.
'Hiccups along the way'
Some Republican officials have questioned whether the exchanges will be up and running by Oct. 1. Praeger, who has been generally supportive of the new law, is not among them. But she predicted it wouldn’t be a smooth start.
“Oh, I think they'll be up and running,” she said. “There will be some hiccups along the way. That's putting it mildly, especially if you look at how the Medicare prescription drug program rolled out in the Bush administration and this is much more complicated.”
→ Related story: Kansas insurers gearing up to market new plans on exchange
School administrators here say they are alarmed and confounded by the looming, new costs they face with the implementation of the Affordable Care Act.
“We've been talking about it (in anticipation) the last two years. I wish there was somebody smarter than me to find a solution,” said Chris Hipp, director of the North Central Kansas Special Education Cooperative Interlocal 636.
“We are not built to pay full health benefits for non-certified folks who work a little over 1,000 hours a year. I've spent hours and hours running every possible scenario. We can't pay for any of them, so it’s all kind of an academic effort really," he said.
As part of the federal health reform law, commonly referred to as Obamacare, larger employers across the country have a new set of insurance coverage obligations and fees they must pay. The new rules apply to commercial enterprises with 50 workers or more but also to public employers such as cities, school districts and the state of Kansas.
Kansas officials estimate the new fees alone will cost the State Employees’ Health Benefit Plan at least $4.7 million in 2014, or about $63 per worker. That’s without reckoning the added costs of the law’s new coverage requirements, much of which the plan already is absorbing.
For many businesses and larger governmental units, the new obligations are unwelcome but not unmanageable because they can be passed through either to customers or, at least partially, to health plan policyholders.
And for some governmental units, the expected costs represent a small percentage of overall spending. Lawrence officials, for example, estimate the new Obamacare fees will cost the city $137,200 in 2014, which could be considerably less than the potential costs of complying with a new conceal-carry firearm law passed earlier this year by state lawmakers.
Rural school districts
But the new health reform rules are particularly challenging for rural school districts and special education cooperatives, where officials say they have little or no place to turn for additional money, especially since state school aid has been held flat or reduced and more often than not the so-called “local option” school budget authority already has been maxed out.
“A lot of the districts and co-ops are looking at various options, including the option of getting out of offering health insurance and acknowledging that the most economical step for them is to pay the penalty and have their employees go to the exchange and get what's available through the marketplace. But a lot have not made that decision yet,” said David Shriver, assistant executive director for insurance services at the Kansas Association of School Boards.
The situation at the Phillipsburg special education cooperative offers a stark example of the complications many Kansas schools are facing, Shriver said.
The interlocal co-op is funded by 11 participating school districts that together cover an area of about 4,500 square miles spanning eight rural counties slightly west of the geographic center of the conterminous United States. It is square in the heart of the heartland. The districts collectively serve about 3,700 students, of which about 670 are in the special education program.
Hipp said NCKSEC Interlocal 636 has about 85 “certified” employees (mostly teachers) but also employs about twice that many people as “non-certified” teacher assistants or “paras” and other support staff.
Those workers, earning close to minimum wage, also are offered health benefits by the co-op. But about 100 of them don’t take it because it is too costly for them. The imbalance between their wages and their health insurance costs is so pronounced, Hipp said, that some of the para-educators who use the co-op’s health plan end up writing checks to the co-op two or three times a year just to cover their share of the benefits.
Under the health reform law, Hipp said, the interlocal must offer health coverage that meets the federal standard of affordability or pay a penalty for each employee that gets insurance through the subsidized federal exchange. The exchange — sometimes called a marketplace — is scheduled to be in operation by Oct. 1, with the coverage effective for policyholders beginning Jan. 1, 2014.
Here’s the dilemma for the co-op and similar organizations: On one hand, they can’t afford to pay their “non-certified” workers enough to make premium costs an affordable percentage of their incomes. But nor can the organizations afford to maintain a health plan and pay the annual penalties that must be paid by employers that have workers who opt for coverage through the insurance exchange.
Kansas insurance companies are preparing to sell a range of health plans on a new, online exchange being created by the federal government in an effort to make coverage more available to the thousands of people who have struggled to obtain it.
The Affordable Care Act, often called “Obamacare,” requires the new health insurance marketplaces to be up and running in every state by October, with the coverage sold through them effective on Jan. 1. But large numbers of Americans who stand to benefit most from the exchanges still know little to nothing about the law or how it will affect them, according to a recent poll by the Kaiser Family Foundation.
Anyone will be able to use the online marketplaces to purchase health coverage, but they are being created mostly to make private coverage more affordable for the uninsured and individual policies more widely available to those who don’t have access to group coverage through an employer.
“It’s going to create new opportunities for people who don’t have any insurance at all,” said Andy Corbin, chief executive of Blue Cross Blue Shield of Kansas, the state’s largest private health insurer. “And for those who don’t make much money, it may save them some dollars.”
Corbin said that plans offered on the exchange will “probably be more expensive” than the individual and small-group policies the company now sells. But he said in many cases the amount that consumers actually pay would be lower because of federal subsidies.
The exchange, or marketplace, also will give small businesses — those with fewer than 50 employees — new options. Rather than purchasing group insurance, they will be able to select a plan on the exchange and allow their workers to purchase individual policies. The businesses will have the option of helping their employees pay for the coverage, or not.
At least three insurance companies will sell multiple plans on the Kansas exchange, which will be operated by the federal government because Gov. Sam Brownback, a Republican opponent of the health reform law, declined to establish a state-run exchange. The companies are Blue Cross Blue Shield of Kansas, Coventry Health Care of Kansas and Blue Cross Blue Shield of Kansas City, which does business in two Kansas counties, Johnson and Wyandotte.
Subsidies to blunt higher premiums
Ron Rowe, a vice president for BCBS of Kansas City, predicted the cost of premiums for new, non-group policies would trend higher.
“Some people’s rates are going to go down and some are going to go up, but in aggregate it’s going to be about a 30 to 35 percent increase for that entire block of business,” he said.
But those increased costs could be mitigated for many. People who already have individual policies can keep them. And those who qualify for federal subsidies could end up paying less for more expensive and more complete coverage.
“Many people who are going to see big, high rate increases are going to qualify for a subsidy,” Rowe said. “And the amount that they’re going to pay out-of-pocket, net with the subsidy next year, will be less than they’re paying today even if the premium is significantly higher.”
For example, a person with annual earnings equal to 150 percent of the federal poverty level — $17,235 — would pay about $460 a year for a $5,000 policy, according to a cost-estimating tool developed by the Kansas Insurance Department. Federal tax credits paid directly to the insurance company would cover the remaining $4,540.
The credits, available only through the exchange, will be calculated on a sliding scale up to 400 percent of federal poverty guidelines, or annual earnings of $45,960 for an individual. But at that top level, the subsidy would amount to only about $630 leaving the consumer responsible for the remaining $4,370.
Despite the likelihood that many consumers purchasing through the exchange could pay less, both Corbin and Rowe said they anticipated a backlash from those forced to pay more.
“We’re trying to get out in front of the negative that’s going to come,” Corbin said.
To do that, he said, the company planned to do as much as it could to educate consumers about the exchange, the subsidies available and why some coverage would cost more.
Higher risks mean higher costs
Premiums are expected to rise because the reform law prohibits insurance companies from continuing practices they have historically used to reduce their risks. Those practices include denying or limiting coverage for high-cost individuals or capping their benefits. Going forward, the companies must sell policies to anyone regardless how sick they might be.
Kansas Insurance Commissioner Sandy Praeger, a Republican who has bucked the party line in supporting the law, said the old system often denied affordable coverage to people who needed it most.
“If you had any kind of pre-existing condition, you probably couldn’t buy (insurance) at all,” Praeger said. “You could be denied coverage because of allergies.”
Lawrence call center expected to add positions to handle insurance exchange calls.
Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Kansas is one of the four states.
Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A U.S. Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla. — all states with Republican leaders who oppose the law.
A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.
Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government. The other states are relying entirely on the federal government.
Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.
The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government.
The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.
States running their own marketplaces will have their own call centers.
The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.
With the filing deadline approaching, the nation’s largest tax preparation company is letting its customers know how they are likely to be affected by the Affordable Care Act.
“After the ACA was upheld by the Supreme Court in 2011, we did some focus groups and some surveys to try and measure the public’s understanding of what all is in the ACA,” said Meg Sutton, senior advisor for tax and health care services at H&R Block. “It became pretty clear that there needed to be a process for educating our clients.”
Sutton called the 2010 federal health reform law the “biggest tax-code change in the past 20 years.”
The company’s tax preparers, she said, have been calling their customers’ attention to the ACA’s penalties for not having health insurance and to the subsidies that will be available to low- and modest-income families.
The information also is available on an H&R Block website.
“Client reaction has been very positive,” Sutton said.
The company’s surveys, she said, had found that 77 percent of its clientele didn’t realize their 2013 tax returns would be used to determine their eligibility for health insurance subsidies and that 44 percent of those between ages 18 and 34 were unaware of the penalties for being uninsured.
Sutton said the company’s tax preparers do not tell their customers to buy - or not to buy – health insurance. Instead, she said, customers are “informed of their options” based on the information in their 2013 tax returns.
The ACA’s mandate that almost all Americans either have health insurance or pay a penalty takes effect Jan. 1, 2014.
Marvin Lawton has been a tax preparer at the H&R Block office in Topeka for the past eight years.
“I’ve found there to be quite a cross section in the way people react – all the way from being OK with it to being dismayed by it,” he said. “Some are OK with it because they already have insurance and won’t be affected by it, some are bewildered over how they’re going to afford it and some wonder why they have to pay a penalty if everybody in their family is healthy."
Most of his customers with little or no health insurance have seemed pleased to hear about the subsidies, he said.
“I’ve had a lot of people who used to have insurance through their job but ended up getting laid off in the past year,” he said. “They know how expensive health insurance is. So when I tell them about penalties, they say ‘But I can’t afford it.’ Then, when I tell them about the subsidies and how they’ll be able to buy it through the exchange and be part of a larger pool, they’re OK with it. They say they’re OK with it if it’s affordable. And I say that’s the intent, that’s why it’s called the Affordable Care Act.”
H&R Block customers have the option of signing up for email alerts on changes in the new health reform law.
Sutton said, H&R Block appears to be the only national tax preparation firm helping its customers predict the law’s effect on their 2014 taxes.
Surveys have shown that about 60 percent of the nation’s taxpayers use tax preparation companies. H&R Block accounts for almost 20 percent of the tax-preparation market.
Kansas Health Consumer Coalition Executive Director Anna Lambertson said she welcomed the company’s initiative.
“I think it’s great,” Lambertson said. “I give them high marks.”
The coalition, she said, has been looking for ways to launch a similar informational campaign in Kansas.
“We can’t do it alone,” she said. “And H&R Block can’t do it alone. It’s going to take everybody getting involved.”
Sheldon Weisgrau, a spokesman for the Health Reform Resource Project, also praised the company.
“I assume they’re hoping this will lead to more people coming to them to have their taxes done,” he said. “But that’s fine. Anytime you’ve got someone providing accurate information it’s a positive.
Weisgrau said federal officials have announced plans for launching a major outreach campaign in June.
“They don’t want to start too early, which makes sense,” he said. “The exchange won’t be up and running until October.”
Mary McBain, chief executive of the Kansas Society of Certified Public Accountants CEO said the H&R Block initiative had not gone unnoticed.
“The major accounting firms have definitely been ramping up for this,” she said. “Some of the bigger firms have hired people just to work on ACA – that’s all they do.”
MacBain said her organization was committed to providing its members with accurate information about the law.
“All of us, I think, need to take a deep breath and not get caught up in all the emotion that’s comes with health care reform,” she said. “We need to be informed because, frankly, there’s a lot of misinformation out there.”
→ Find more information on health insurance exchanges and other health reform topics at khi.org/healthreform.
After months of trying to dance around the politically charged issue, the administration of Gov. Sam Brownback has openly acknowledged that the $139 million Medicaid enrollment system that it is building will be interconnected with the online health insurance exchange required by the Affordable Care Act, and that the system will be ready to go by the Oct. 1 federal deadline.
“It's just a connectivity kind of a thing,” said Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, which is spearheading the project to overhaul the 26-year-old, paper-based system to a modern online one.
“I certainly appreciate the concerns that are tied to the political angst, but this program was well on its way when I came on board and my job is to make sure it gets completed successfully,” he said.
Entangled with the exchange
Overhauling the state’s antiquated Medicaid enrollment system has been in the works since at least 2009, when the project was called K-MED.
The project stalled briefly in August 2011, when Brownback returned a $31.5 million federal grant, most of which had been earmarked for developing the state’s new Medicaid enrollment system. Brownback said he was returning the grant because it was tied to the Affordable Care Act — which he he had pledged he would not implement prior to the U.S. Supreme Court ruling on the law, and later until after the 2012 federal elections.
Then that same month, administration officials announced a new contract with Accenture to develop the Kansas Eligibility and Enforcement System (KEES), using $118 million in federal funds to pay for the $139 million projected cost. K-MED became KEES.
A key condition of the federal funding was that the KEES system would have to be “interoperable” with the coming health insurance exchange — an online marketplace scheduled to launch Oct. 1 where consumers can compare and buy coverage that will begin Jan. 1, 2014.
In Kansas and the 25 other states that elected not to run their own health insurance exchanges, the federal government will build and operate them.
Moser said interoperability of KEES and the exchange means that — for consumers — there will be a single entry point for enrolling in private health insurance or in Medicaid, the state-federal health care program for low-income, elderly and disabled persons. Medicaid in Kansas is known as KanCare.
“You enter in some information, most of it is going to be yes/no. If you're eligible for Medicaid then it would pop up the KEES patient portal,” Moser said. “If it shows that your income level is such that you don't qualify for Medicaid…it's going to push your information over to the federal exchange. So those two systems literally will be handing back and forth inquiries.”
Moser said the fact KEES would interface with the insurance exchange was no different than integration with other federal computer systems, such as Homeland Security or the Internal Revenue Service.
“It doesn't really have that significant of an implication in my mind. But then again, I'm a physician and a little bit more patient-centered and look at the convenience factor. If that person is in a hospital setting and I think they need admitted, but they're worried about the cost because they don't have coverage, I'd like to be able to determine at that point in time 'Are they eligible for coverage' and use that as leverage to get them in to the hospital,” Moser said.
Is the whirl of hospital revolving doors slowing?
Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.
With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.
If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.
Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.
Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.
“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.
Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.
There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.
According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.
The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.
The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.
‘A community problem’
“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care.
A bill that would roll back a requirement that Kansas utility companies increase their use of renewable energy has been saved from the legislative bell.
The House failed last week to pass the bill — HB 2241 — as lawmakers worked to meet a mid-session deadline for moving legislation from one house to another. Instead, members voted 63-59 to send the measure back to committee.
Ordinarily, that would have ended consideration of the bill. However, House leaders quickly revived it by sending it to the Committee on Appropriations, where bills may remain alive until the end of the session.
The fact that the House leadership re-routed the bill indicated supporters were gearing up for another attempt to pass it.
Current law requires Kansas utilities to obtain 20 percent of their peak-demand power from renewable sources like wind and solar by 2020. The House bill would roll back that requirement to 15 percent, a benchmark state utilities have already all but met.
Opponents of the bill say passing it could send a negative signal to the wind energy industry strong enough to end a building boom that has created 13,000 jobs and pumped more than $7 billion into the Kansas economy since 2001.
“Why would we want to do that,” asked Rep. John Doll of Garden City. “It’s like stopping at the end of the race so to speak.”
Doll is one of several Republicans questioning the wisdom of rolling back regulations that supporters say have benefited the state economically while having no apparent impact on electric rates.
Opponents of the regulation point to studies by conservative think tanks that show renewable standards have contributed to rate increases in other states. But the fact they haven’t substantially increased rates in Kansas has weakened the case for the bill.
“It seems like that message isn’t true,” said Rep. Ronald Ryckman, Sr., a Republican from Meade.
The Kansas Corporation Commission tracks the impact of renewable standards on rates. In 2012, wind energy accounted for 0.72 cents of the average retail electric rate of 9.2 cents per kilowatt hour, according to the commission’s most recent report.
Despite that, influential national conservative organizations are pushing for passage of the roll-back bill. They include the American Legislative Exchange Council (ALEC) and American’s for Tax Reform, the organization headed by Grover Norquist.
In a letter sent last week to Kansas legislators, Norquist called renewable energy standards a “command and control policy” that forces utilities to utilize “more costly and less reliable” energy. He said while the roll-back bill was a good start, “Ultimately, it is imperative that lawmakers repeal the mandate all together.”
Kimi Narita, an energy fellow with the National Resources Defense Council, devoted her latest blog to the renewable battle in Kansas. In it, she cited “giant forces” behind the Kansas effort, which she calls “a nation-wide attack” on renewable standards that are on the books in 29 states and the District of Columbia.
“Kansas is one of the priority states on their list, and repealing the Kansas RPS represented a critical first step in their momentum building strategy,” Narta wrote.
More often than not, many of the groups pushing for a roll-back of the renewable standards are aligned with Republican Gov. Sam Brownback on issues. The renewable standards are an exception. Several legislators and lobbyists said the governor’s quietly stated concerns about weakening the standards led to the defeat last week of a Senate bill that would have given utilities more time to meet them. The bill — SB 82 — was defeated 27-13.
The Lawrence-Douglas County Health Department announced today that it has partnered with the University of Kansas to form the state's first "Academic Health Department."
Among other things, the research skills of the KU Work Group on Community Health and Development will be utilized to better gauge effectiveness of services and strategies deployed by the health department.
Dan Partridge, the health department's director, said the Academic Health Department would play a pivotal role in helping his agency evaluate and document the successes and failures of policies and systems that aim to improve community health.
“A major focus will be to answer the question: How well are community-based efforts working to improve health,” said Partridge. “We hope the answers will help inform future decisions promoting the health and vitality of Douglas County.”
The Academic Health Department will also function like a teaching hospital for KU students in applied behavioral psychology, the academic home of the KU Work Group, said Vicki Collie-Akers, who leads the group's research efforts.
“We hope to ultimately create a shared research agenda with the health department...to merge our goals with theirs,” said Collie-Akers, who will have an office at the health department.
The health agency and the KU work group already have a history of working together — most recently in facilitating a Comprehensive Community Health Assessment as part of the agency's work toward accreditation.
Among the short-term goals of the Academic Health Department will be implementation and evaluation of the county's first Community Health Plan, another component of the health department's work toward accreditation.
It's difficult to gauge how many Academic Health Departments there are in the U.S., said Kathleen Amos, who leads the AHD Learning Community for the Public Health Foundation in Washington, D.C. There are at least 36, from a list she's informally compiled, but she said that is likely far fewer than there actually are.
She pointed to the most recent National Profile of Local Health Departments (pages 71 and 72), which indicates that about 20 percent of health departments nationwide have worked with a four-year academic institution on program evaluation, and about 35 percent have some sort of written agreement with a university.
A Wichita lawmaker has introduced a bill that would require cities that fluoridate the water to notify users "that the latest science confirms that ingested fluoride lowers the I.Q. in children."
House Bill 2372 was offered by Rep. Steve Brunk, a Republican, who said he introduced the bill on behalf of Mark Gietzen, a conservative GOP activist and anti-abortion lobbyist also of Wichita.
But Brunk said he did not expect the bill to advance and that he had no interest in it himself.
"That was a constituent request," Brunk said. "As a courtesy, I gave him a bill introduction and told him that was as far as it goes. I'm not his champion of the cause," he said.
"I'm not aware of any interest in this bill at all (among fellow legislators). I'd be surprised if the (committee) chairman gives him a hearing."
Fluoridation has long been accepted by public health experts in the U.S. and elsewhere as an effective means to combat tooth decay, especially in children. Its use has been widespread among public water suppliers in the U.S. since the 1960s. According to the federal Centers for Disease Control and Prevention about 74 percent of the nation relies on fluoridated water supplies. The CDC has linked public fluoridation with an increase in the incidence of dental fluorisis, a condition that can cause tooth enamel to appear streaked but is not generally considered harmful to health.
Most research on the subject has shown municipal water fluoridation to be a safe and and effective practice. There are a few scientists who say their studies suggest otherwise, and that their findings have been marginalized by the broader scientific community.
Gietzen told KHI News Service he hoped to take advantage of the recent publicity surrounding Wichita's citywide vote on whether to fluoridate its public drinking water. Voters there rejected fluoridation, just as they did previously in 1978 and 1964. Wichita is among the few larger American cities that do not fluoridate public water supplies. The cities of Topeka, Lawrence, Manhattan and dozens of others in Kansas do add the CDC-recommended amount of fluoride to driking water. Many rural water districts also provide fluoridated water to their customers.
"The momentum of the Wichita fluoride debate (is) something we want to capitalize on," Gietzen said. "With everything — asbestos, lead, thalidomide, the drug we once thought was so good — when more modern science shows you that what you thought in the past was good and now you know it's not good, you need to put the brakes on it and stop harming people."
Gietzen cited a a 2012 study co-authored by a researcher at the Harvard School of Public Health that showed children in areas with high naturally occurring fluoride have significantly lower I.Q. scores than children in low-fluoride areas. He said it was that study that convinced him to vote against fluoridating Wichita's water.
"Eight months ago I didn't know how I was going to vote on the Wichita fluoride debate. I couldn't even spell fluoride, truth be known," Gietzen said. "If something opened your eyes and you realized you have knowledge of something other people are being harmed by and they didn't even know it, wouldn't you feel the obligation to at least let them know?"
The study by the Harvard researcher, however, mostly considered the effects of high levels of fluoride on brain development among children in China because that's where there are significant numbers of people exposed to high levels of fluoride, often from well water and not as the result of municipal fluoridation. The study's authors noted that it was difficult to find study subjects in other industrialized countries because children there aren't exposed to high fluoride levels in the water "even when fluoride is added to water supplies as a public health measure to reduce tooth decay."
Officials at the Kansas Health Foundation announced Friday they will issue grants this year to support the formation and work of Food Policy Councils across the state.
According to a foundation request for proposal, it will accept applicantions for “capacity building” grants of $10,000 and policy implementation grants of $40,000 that will be available through 2016.
Only local, county or state government agencies are eligible to apply for the grants, which the foundation said are designed to increase access to and consumption of healthy foods.
Grant recipients would be expected to contribute staffing or some other support to the effort.
The RFP lists several activities as examples of objectives the foundation would like to see Food Policy Councils pursue. Those include working with school districts to restrict student access to unhealthy foods and collaborating with local officials to increase public transportation options for people who have limited access to supermarkets or farmers markets. Helping local governments establish policies that promote locally grown foods and lead to the establishment of community gardens were among the other sample objectives listed in the RFP.
Additional information on the Food Policy Council grants and an online application are available at the foundation’s website, kansashealth.org.
The Kansas Health Foundation established the Kansas Health Institute with a multi-year grant and continues to provide most of the institute’s funding.
Weeks before the flu season typically peaks, nearly half of Kansas' county health departments report depleted or low supplies of influenza vaccines.
The Kansas Association of Local Health Departments surveyed its 99 members this week, asking which had depleted or nearly depleted their supply of flu vaccine. Among the 43 that replied:
• 21 are completely out,
• 17 are "low on supply," and
• Five were able to restock after running out once or more.
Officials at the Lawrence-Douglas County Health Department reported having adequate vaccine supply.
Michelle Ponce, the association's executive director, said in many rural communities, county health departments are the primary place people get flu shots because other health care providers and pharmacies tend to be fewer and far between.
"In many rural areas, you're not going to have a Walgreens (pharmacy) in town that you can go to (for a flu shot). Many private providers do give flu shots, but all health departments do."
The Sedgwick County health department was the sole exception. It didn't provide the vaccine this year, "based on the abundance of other providers offering them in the community," Ponce said.
Early vaccine shortage
In the survey, many health department officials indicated two factors were involved in the shortage: Fewer doses were ordered this year after many went unused last year and this season there was higher early demand.
"We were out by December 31st," wrote Kandy Dowell of Elk County. "Last year I ordered the usual amount and had to waste 120 doses, so I didn’t order as much this year."
"Pawnee County Health Department has given over 1,500 doses already. This is about 550 more doses than last year," Mary Beth Herrmann, the administrator, wrote, indicating she was low on all but one type of flu vaccine.
Marcia Hansen, Republic County administrator, wrote: "We have reordered numerous times and have given nearly twice the amount (of shots) we have in previous years...We have had a number of people come from neighboring counties during the past weeks."
In Wabaunsee County, administrator Janet Wertzberger wrote: "We ran out of flu vaccine about the 15th of December and did not try to order more because we did not want vaccine going to waste again this year... We did not have requests for vaccines until the national media started talking about the flu as an epidemic."
More severe flu season so far
This year's flu season so far has been more severe than in 2012, said Charlie Hunt, state epidemiologist at the Kansas Department of Health and Environment. But that doesn't necessarily indicate how the rest of the year will go, he said.
"Last year's levels were nowhere near what we've seen so far this year," Hunt said. "We don't know yet what the peak is going to be for this season...February is pretty typical over the last 10 years. We've seen a peak in October during the pandemic of 2009 and 2010, but having it start to increase in December is a little odd."
Hunt said the number of cases could go up or down.
"It will depend on how many people are vaccinated, and how many people are listening to messages about staying home when they're sick, covering their coughs and sneezes, washing hands," he said. "All those are factors."
The state health department earlier this month stopped analyzing HIV tests for many of the state's medium and small counties and also stopped providing rapid or oral test kits, which is creating a new burden for cash-strapped health departments and creating some uncertainty whether they can continue testing for the disease in some rural locations around Kansas.
Compounding the problem, some local department heads said, was the short notice they received that the services previously provided free to them by the state were being terminated.
Notification letters from the Kansas Department of Health and Environment went out in late November, they said, giving them only about five weeks, including the holidays, to make alternate arrangements in time for Jan. 1, when the new policy kicked in.
"It's another nail," said Julia Hulsey, director of the Reno County Health Department in Hutchinson.
Kansas routinely ranks low nationally in its support for public health agencies.
New cost for patients
Hulsey said her department was able to contract with a laboratory in Wichita that agreed to provide the testing supplies for free (though it will charge for the lab work) and so her agency plans to continue the tests but will start charging patients for them probably by Feb. 1, once she has a clear picture of her agency's new, added costs.
"I don't have that whole cost figured out yet," Hulsey said, "but, of course, it will be more than KDHE because they didn't charge for it."
She said her goal would be to price the tests as low as possible to not discourage people from getting them. She said the department historically has performed about 220 tests a year.
Dan Partridge, director of the Lawrence-Douglas County Health Department, said Lawrence Memorial Hospital agreed to help with the testing after KDHE withdrew the services, so it will only cost his agency about $9,000 a year to continue the testing instead of about $18,000. But he said the new obligation signals another state retreat from support for local health departments.
Urged to continue
State officials, in their November letter, urged the local departments to try to continue the services on their own.
KDHE "would like to encourage your agency to continue to provide HIV testing to clients requesting an HIV test, especially those reporting high-risk behaviors," the letter stated. "However, any test conducted at your agency beginning January 1, 2013, and continuing thereafter will need to be paid for by either your agency or by the client through insurance, public assistance programs, or out-of-pocket."
But a spokesperson for the state's local health departments said it would be difficult or impossible for some smaller departments to pay for the tests on their own.
"I suspect there will be some health departments in some areas that won't be able to find a workaround like Douglas County," said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. "I couldn't give you a firm number, but in some of those rural areas they may not have another option for testing."
The state’s letter also included some cost-comparison information to help the local departments shop for testing materials, lab work and other necessities of the program.
Hulsey in Reno County said she ended up considering four or five outside laboratories between the time she got the letter and Jan. 1 when the state assistance stopped.
"We got very short notice on this," she said. "And then having to go negotiate for ourselves...you never know if you're getting the best price."
State officials said they had to reduce the services because of cutbacks in a federal testing program administered by the Centers for Disease Control and Prevention that has been reconfigured to focus on areas where the incidence of HIV/AIDS is greatest.
In the past, according to state officials, 40 local health departments received the free services. That number has been trimmed to 10, according to Ralph Wilmoth, director of the HIV/AIDS program at KDHE. The 10 county health departments that will continue to get the aid include Johnson, Sedgwick, Wyandotte and Shawnee, the state’s most heavily populated, and also Crawford, Pratt, Riley, Saline, Thomas and Trego counties.
The state also will provide the testing services to various organizations other than health departments in about a dozen counties. For example, in Douglas County the services will be continued for the Douglas County Aids Project, a non-profit group. In Reno County, the services will continue for the state prison in Hutchinson.
Wilmoth said the CDC made the program changes in anticipation of the full-scale implementation of the Affordable Care Act, which begins Jan. 1, 2014. Millions of Americans are expected to become newly eligible for Medicaid then and HIV testing is among the health services covered by Medicaid.
Linked to Medicaid expansion
But when the U.S. Supreme Court ruled on the health reform law, it concluded that each state had the option to not expand its Medicaid eligibility and Gov. Sam Brownback nor the Kansas Legislature have yet determined whether Kansas will broaden access to its program, which is known as KanCare.
A recent survey has found that half of Kansas adults gamble about once a month and that almost one in 12 admits to having bet more than they could afford to lose.
“It’s a real problem,” said Joyce Markham, an addiction counselor and president of the Kansas Coalition on Problem Gambling. “This affects not only the gambler, it also affects family members, our friends, and our co-workers through bankruptcies, crime, domestic violence and health care costs.”
Markham said she knew of several families that had lost their farms, homes, and life savings due a father or mother’s addiction to gambling.
The survey, commissioned by the Kansas Department for Aging and Disability Services, also found that while a large majority of state’s gamblers said they did not have a gambling problem, 13 percent of the respondents said they had “been affected” by someone - spouses, family members, friends and co-workers - who did.
Conducted in October and November, the poll involved telephone calls to 1,600 randomly selected adults. Each respondent was asked 96 questions.
Buying a lottery ticket was considered a form of gambling.
“There is so much information here, it’s a bit overwhelming,” said Doug Ballou, a managing partner with Whitworth Ballou, a Kansas City marketing firm that assembled the questionnaire and oversaw the interviews.
Ballou presented an overview of the findings during a Wednesday morning meeting of the Kansas Coalition on Problem Gambling.
KDADS officials said they would use the survey to put together a policy on how best to spend the state’s problem gambling fund, which is expected to reach $8 million in the fiscal year that begins July 1.
Kansas law stipulates that 2 percent of the net revenue generated by the three state-owned casinos – Kansas Star Casino in Mulvane, Boot Hill Casino in Dodge City, Hollywood Casino in Kansas City – be spent on programs and services for people with addictive behaviors: alcoholism, drug abuse and problem gambling.
Net revenue is defined as the slot-machine and table-game income minus payouts.
In an email sent to members of the Kansas Association of Addiction Professionals last month, a KDADS official said there likely would be less money for prevention and treatment services in the proposed budget for fiscal 2014, which begins July 1, 2013. The amount of the reduction, if any, remains unclear.
Gov. Sam Brownback is expected to release his proposed budget on Jan. 16, the day after his state of the state address. The Legislature is then free to add or subtract from the the governor's spending plan.
In the current fiscal year, the 2 percent set-aside is expected to generate about $7 million, most of which is used to underwrite Medicaid-funded drug and alcohol abuse programs. KDADS treatment and prevention efforts receive about $750,000.
Several coalition members said expected the governor to propose eliminating state-funded support for prevention and treatment services.
The state’s toll-free hotline for problem gamblers (1-800-522-4700) fielded 691 calls last month.
The Brownback administration has not ruled out implementing the Medicaid expansion called for in the federal health reform law.
But a spokesman today told members of the Legislature’s Joint Committee on Health Policy Oversight that prior to making a decision administration officials want to develop their own estimate of how many Kansans are likely to sign up for the health care program and how much the expansion would cost the state.
“We’re continuing to study the issue,” said Mark Dugan, chief of staff for Lt. Gov. Jeff Colyer. “We would like to come to you with our own numbers.”
Currently, there are several competing estimates of how the expansion would affect Medicaid enrollment and the cost of the program. The latest, released earlier this month by the Kansas Health Institute indicated that approximately 240,000 additional low-income, disabled and elderly Kansans would enroll in a program that currently serves about 380,000. According to the KHI analysis, expanding Medicaid would cost the state an additional $519 million between its implementation in 2014 and 2020.
The KHI projections are higher than those in a 2010 report prepared for the now defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis done in 2010 by the Kaiser Family Foundation. However, they considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act.
The KHI News Service is an editorially independent program of KHI.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level — $5,900 a year for a family of four.
The ACA expansion would have a bigger impact in Kansas than many states. It would raise the eligibility threshold for all Kansans to 133 percent of FPL — $30,660 for a family of four.
Two of the four legislators who braved inclement weather to attend Thursday’s meeting of the 12-member committee made it clear that they favored the expansion.
Rep. Don Hill, a moderate Republican from Emporia, said that virtually all legislators regardless of party and ideology agree that the current health care system is broken and in need of reform to lower costs and reduce the number of people who are either uninsured and under-insured.
He said while the ACA is far from perfect, “it has some redeeming elements.” One of those, he said, is the Medicaid expansion because of its potential to extend coverage to many of the state’s 365,000 uninsured.
Citing the federal government’s promise to shoulder the cost of serving all those made eligible by the expansion for the first three years, Sen. David Haley, a Kansas City Democrat, asked, “Why can’t we cover more Kansans and why shouldn’t we?”
“I think we’re going to take a good look at it,” Dugan answered.
But, Dugan said, a factor that must be considered is whether or not the cash-strapped federal government can be counted on to keep its funding promise. After paying all of the costs of the expansion for three years, the federal government would gradually reduce its commitment until it reached 90 percent, where it would be maintained.
“He (Gov. Brownback) doesn’t have a high degree of confidence in the federal government maintaining that 90 percent commitment over the long term,” Dugan said.
Dugan said the federal government missed an opportunity to negotiate a compromise with Republican governors skeptical of the expansion when it rejected the idea of allowing states to increase eligibility to only 100 percent of FPL.
“That was an opportunity for middle ground that was lost,” he said.
Like many Kansans, Rick Cagan spent much of last weekend reading and listening to news reports about the gunman who killed 20 children and six adults at an elementary school in Newtown, Conn.
Cagan had a professional reason for learning what he could about the tragedy. He runs the National Alliance on Mental Illness-Kansas Chapter office in Topeka.
“It’s devastating,” he said. “It’s heartbreaking.”
According to initial news reports, the gunman, 20-year-old Adam Lanza, may have suffered from a personality disorder or had been diagnosed with Asperger’s, a form of autism. However, there is no indication that he had the kind of severe mental illness suffered by others responsible for mass shootings.
Jared Loughner, the man convicted of shooting former Arizona Congresswoman Gabrielle Giffords and killing six others, for instance, suffered from schizophrenia, a mental illness that causes disordered thinking and delusions.
And James Holmes, the man accused of shooting 12 people to death and wounding 58 others last summer at a movie theater in a Denver sought mental health treatment before the attack, according to multiple news reports.
Mass shootings nearly always rekindle debates about gun control and the adequacy of the nation’s mental health system. Commenting on the later, Cagan said many Kansans with mental illness are not getting the early treatment they need to avoid crises.
“More than 60 percent of the adults who have a serious mental illness are untreated,” he said, noting that in Kansas half the admissions to the state hospitals for the mentally ill involve people who’ve had no previous contact with their community’s mental health center.
In Kansas, state-hospital admissions are reserved for adults who are seriously mentally ill and have been deemed a danger to themselves or others.
“NAMI is always reluctant to jump in with some sort of comment when these kinds of incidents occur because there’s so much that we don’t know,” Cagan said, referring to the shootings. “But, still, blaming the individual only goes so far. At some point, we have to look at the overall well-being of our mental health system.”
Budget cuts in the mental health system
Kansas’ system, he said, hasn’t fared well in recent years.
“I don’t like saying this,” Cagan said, “but we’re just lucky this didn’t happen in Kansas.”
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.’”
The Lawrence-Douglas County Health Department will be closed for two days this week in order to finish implementation of an electronic health record system.
The clinic and staff offices will be closed from 8:30 a.m. to 1 p.m. on Dec. 4 and 5, as well as Dec. 26 while it trains staff on the new system.
Douglas County is now the fifth in the state to have its health department transition from paper health records to an electronic system. The others are Johnson, Wyandotte, Shawnee and Lyon counties, according to the Kansas Association of Local Health Departments.
Since 2009, use of electronic health records (EHRs) has been surging among hospitals and doctors, thanks to federal incentives to make the costly transition.
But of Kansas' 100 health departments, only Shawnee and Lyon qualified for the incentives because they are also Federally Qualified Health Centers.
In Lawrence, it made sense to implement an EHR even without the incentives, said Jennie Henault, director of Administrative Services. She said the new EHR system also will include new staff scheduling and reporting systems, both of which will greatly improve efficiency.
She said scheduling had been done in Excel, software made for spreadsheets. Consequently it was cumbersome to schedule a single appointment that spanned two program areas, such as immunizations and family planning. It also was not uncommon for staff members to double book or delete appointments scheduled by others.
"It was just very very easy to make mistakes or overwrite each other," Henault said.
Likewise, she said the reporting system will save staff members countless hours of manually compiling reports due to limitations of the current system.
"That was one of the biggest things we thought about, even after we found out we wouldn't be eligible for the incentives," Henault said. "Especially for time-sensitive information. For some grant funding and some mandated reporting, you have to be able to get that information quickly. And our health board wants more information, our director wants more information. It just doesn't make sense to keep wasting time manually counting things and going through pages and pages of reports."
An added benefit, she said, would be the capability of connecting to the statewide Kansas Health Information Exchange, which began exchanging patient data this summer. The exchange allows connected health care providers to use a private, secure network connection to quickly transfer digital health records instead of relying on fax machines or patients to deliver paper records.
When the health department would connect to the exchange, Henault couldn't predict — but when it does it will primarily be useful for immunization records and family planning records, such as Pap test results or medications lists, she said.
It makes sense for the state's largest health departments to implement EHR systems, said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. But it doesn't for most smaller health departments because of their lower client volume and limited budgets.
Kansas has become the first state in the country to connect to the national disease outbreak surveillance system via a digital health information exchange.
Officials at BioSense — the syndromic surveillance system at the Centers for Disease Control and Prevention (CDC) — said that the Kansas Health Information Network on Friday became the first HIE to begin contributing data. Various individual hospitals nationwide already are linked to the system.
Previously just one Kansas hospital — St. Luke’s South in Kansas City, Kan. — was connected to the CDC system, which keeps constant tabs on 89 syndrome categories as mandated by the Public Health Security and Bioterrorism Preparedness Response Act of 2002.
More hospitals contributing
With KHIN joining the system, 10 more Kansas hospitals are now submitting surveillance data to BioSense. And as more Kansas hospitals connect to KHIN, outbreak surveillance in the state will expand, a state health official said.
Kansas state epidemiologist Charlie Hunt said that his office at the Kansas Department of Health and Environment connected to BioSense this spring, but — with just one hospital contributing data — its usefulness for detecting an outbreak in Kansas was limited.
"The highway was built but there was only one car on it. Now there are a lot more cars traveling the highway and we'll be able to utilize the information better. As more facilities begin submitting data to BioSense through KHIN obviously the scope, the breadth and depth of information will be better for us," Hunt said. "This has a lot of potential for us to get information that we have not really had access to before, or information that we've collected in a manual process."
For example, during the H1N1 flu outbreak starting in 2009, KDHE asked hospitals to manually report influenza symptoms observed using a system made for reporting bed availability.
"That was a very labor-intensive process for them to go through their electronic health record system, manually pull out the number of patients (with flu-like symptoms) and then enter it into a separate system," Hunt said. "Once we get high enough participation in BioSense, we'll be able to query the system for influenza-like symptoms rather than have to have the hospitals report to us separately."
Among the 89 reporting categories are a wide variety of symptoms that — when aggregated across larger geographic areas — can reveal any number of possible outbreaks tied to a common diagnosis, including: asthma, abdominal pain, nausea and vomiting, hemorrhages, rashes and even spates of vehicle crashes.
Eliminating the routine use of antibiotics in livestock would be the single most effective way to improve public health by changing the way meat is produced in the U.S., said the keynote speaker at a conference here today.
The second most effective approach would be to aggressively enforce existing anti-trust laws and thereby increase competition in the livestock industry and foster more small-scale production, said Bob Martin, a senior policy advisor for Johns Hopkins School of Public Health in Baltimore.
"If we were only going to do two things, I think those would be the most transformative things we could do," Martin told about 75 attendees of “Healthy Farms, Healthy People: Agriculture and Health Summit."
The summit was organized by the Kansas Rural Center in partnership with the Kansas Farmers Union and the Kansas Health Institute. It was funded in part by the Centers for Disease Control and Prevention through a grant provided to the National Network of Public Health Institutes.
The policies that Martin listed as priorities were among 24 recommendations made in 2008 by the National Commission on Industrial Farm Animal Production, for which he was executive director.
"We looked at antibiotic overuse as the No. 1 public health concern because it adds significantly to the development of antibiotic-resistant bacteria that find its way into the community through a number of pathways," he said. "We're creating resistant bacteria, stronger bacteria that can infect human populations. And then we're seriously inhibiting our ability to fight those infections...I don't think it's alarmist to say we're on the verge of that point where we won't have effective antibiotics."
Overuse of antibiotics goes hand-in-hand with large-scale operations, Martin said.
"The type of operation that is most likely to misuse antibiotics are the large-scale operations where the animals are overcrowded and waste management is a problem. They stand over their own waste and it's flushed out from the barn a couple times a day. Those environments are really good breeding grounds for bacteria. So to suppress the infection rate, low levels of antibiotics are administered on a routine basis," Martin said.
"It's really true in this setting, the old adage 'what doesn't kill them makes them stronger.'"
The Kansas Livestock Association raised concerns about Martin’s views prior to the summit but no one from the organization attended or could be reached for comment afterwards.
However, the Kansas Farm Bureau, the state’s largest agriculture organization was represented. Meagan Cramer, KFB communications director, said her members welcomed discussions about the health impacts of modern, industrialized agriculture on consumers’ health. But she said some typical Kansas farmers should have been included in the line-up of presenters at the summit.
“That voice was maybe left out a little bit,” Cramer said. But she quickly added, “I think these types of discussions are good and they are becoming more mainstream.”
Consolidation big issue
Paul Johnson grows produce and lobbies for the Kansas Rural Center. He attributed much of the consolidation in the agriculture industry to the farm bill, the primary driver of federal agriculture and food policy. Among other things, it outlines agriculture subsidies and farm credits, conservation policy, and food and nutrition programs. It is the source of intense debate when the bill is renewed every five years or so.
"Concentration and consolidation have built off the farm bill politics. Eighty-five percent of all our farm payments from 1985 to 2009 went to 20 percent of farms. A third of our farms got no help at all from USDA payments," Johnson said.
As a result, Kansas has lost 90 percent of its hog farms since 1978. Today, he said, 319 farms account for 95 percent of hog sales in the state.
Over the same period, the number of Kansas dairies has dropped from 5,600 to 420, Johnson said. "Twenty of those have 65 percent of the cows," he said.
In beef production, "One percent of the cattle farms do half the sales in our state. About 10 percent do 75 percent of the sales," Johnson said.
Johnson said Kansas could create its own farm and food plan to counter consolidation forces and encourage smaller-scale agriculture.
"We have many resources to draw from in the state," he said, citing the beginning farm loan program out of Kansas Development Finance Authority, the Kansas State University Research and Extension, the marketing division in the Kansas Department of Agriculture. "People need to be players at this point," he said.
Support for local producers
The connection between the industrialization of agriculture and the nutritional value of the food Americans eat was what Emily Hampton and Ashley Craff came to hear about and discuss. The women work for Farmers and Educators United, a Lawrence-based program that facilitates getting locally produced food into childcare centers.
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.
How methods used to produce food affect the health of those who eat it will be examined at a conference here Friday.
The “Healthy Farms, Healthy People: Agriculture and Health Summit" is scheduled from 9 a.m. to 4 p.m. Nov. 16 at Topeka’s Ramada Inn (register here). About 120 people are expected to attend, said organizer Julie Mettenburg, executive director of the Kansas Rural Center.
"The point of the day is to start a wide-ranging discussion about a variety of health issues in our communities that intersect with agriculture," Mettenburg said. "For example, the issues surrounding consolidation in the farm industry. We are concerned about antibiotic use, chemical use, and pollution of our water, air and soil. But we don't advocate a certain agenda that anyone will be pushing that day. We work with farmers to find alternative practices."
Among the scheduled speakers is Bob Martin, a senior policy advisor for John Hopkins School of Public Health in Baltimore. Mettenburg said he was invited to speak, in part, because of his experience as executive director of the National Commission on Industrial Farm Animal Production. Among other things, the commission recommended fostering more competition in the livestock market and banning non-therapeutic use of antibiotics in animal husbandry.
Officials at the Kansas Livestock Association recently raised concerns about Martin’s appearance because of his support for the "Meatless Mondays" campaign.
That initiative was briefly proposed this summer by officials at the U.S. Department of Agriculture as a way of encouraging agency staff to cut meat from their diets for a day. Protests from the beef industry caused the department to abandon the campaign.
Todd Domer, communications director for the livestock association, said he could not specify what Martin's tie was to Meatless Mondays other than "he's a supporter."
"We didn't ask to keep him off the program, but we did express some concern over what message he might deliver," Domer said.
"Obviously, we would oppose Meatless Monday for a variety of reasons," he said. "It's pretty apparent that animal agriculture is vitally important to our state. Our members are really proud to continue producing a safe, great-tasting, nutritious product in the most sustainable way we know how and we try to get better at doing that every day."
At least one representative of the association is planning to attend the conference, Domer said.
Mettenburg, a beef producer, said she doesn’t know whether Martin plans to mention the Meatless Monday campaign. But she acknowledged some topics at the summit could be controversial.
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.
Sixty officials from a variety of disciplines and from around the state gathered here today to grade Kansas' public health system by collectively answering a battery of 600 questions as part of the National Public Health Performance Standards Program.
Kansas is one of 23 states to conduct the evaluation and first did so in 2008, a year after the program was started by the federal Centers for Disease Control and Prevention. Four years ago, however, only officials from the Kansas Department of Health and Environment participated, said Brenda Nickel, director of KDHE's Center for Performance Management.
"The intent at the time was to also conduct it with our external partners statewide. But in 2008, the recession was going on and that opportunity was never fully realized," she said. "What's going on here today with our external stateholders, I think is going to provide a richer report because we actually have those individuals with boots on the ground in communities, as well as state-level partners, who are helping answer these questions."
Participants split into three groups to each grade the state's public health system on 200 questions, such as:
• Does the state public health system commit financial resources to workforce development efforts?
• Does the system utilize the leadership of the state public health agency in planning and policy development?
• Does the system have the professional expertise to carry out effective health communications?
The quantity of questions to be answered in a single day left little time for discussion of each question before the group voted on a grade.
The pace of the evaluation helped keep the group focused and moving along, said participant Michelle Ponce, director of the Kansas Association of Local Health Departments.
"We don't have time to get caught up in the weeds or thinking through every single in and out — we have to limit ourselves to the big picture and stay focused on the larger system. It doesn't give you time to get mired down into who does what and who's responsibility exactly is it. We're focused on the system — what is everybody's responsibility, what do we do well, and what are the gaps," Ponce said.
The annual report of births, deaths and other vital statistics by the state health department is now available. The new data shows a decline in the Kansas birth rate to the lowest level since the record keeping began in 1912.
The abortion rate also continued to decline and reached the lowest level since 1971, which is when abortion reporting began.
The birth rate in 2011, according to the report, was 13.8 live births per 1,000 population.
There were 39,628 live births recorded, about 2 percent fewer than reported for 2010. The rate was slightly lower than the previous low of 13.9 births per 1,000 population in 1973.
Births to young mothers, those under age 20, were down 8.6 percent.
Among the other report findings:
• Cancer again topped heart disease as the leading cause of death.
• Injuries from accidents and pneumonia/influenza each rose one level in the ranking of top 10 causes of death, coming in at fourth and eighth respectively.
• There were 247 infant deaths in 2011, a decrease of 2.4 percent from the 253 deaths in 2010. Pregnancy associated maternal deaths increased to 24 in 2011 from 19 in 2010.
• The number of reported abortions fell from 8,373 in 2010 to 7,885 in 2011. The ratio was 99.6 abortions per 1,000 live births.
→ More Kansas vital stats from 2011 in the full report, available on khi.org.
Amid national concerns that the seriously mentally ill are dying from preventable diseases, a leading Kansas healthcare philanthropy is about to make a down payment on a multi-year initiative aimed at integrating physical and mental health services for safety-net patients.
Within the next couple weeks, the Sunflower Foundation expects to open a competitive grant program that Chief Executive Billie Hall said likely would provide more than $1 million in funds to selected health providers focusing on integrated patient care. Foundation officials expect to award the grants by March.
“When we made the decision to get into this particular area,” Hall said, “we knew it would be a long horizon. We know we are in for five, maybe 10 years, depending on how things go in our state.”
The foundation’s board chose the initiative as a major priority about 18 months ago.
To date, Hall said, the foundation has spent about $50,000 sending some providers from different Kansas clinics to visit Cherokee Health Systems in Tennessee, which has 43 clinical sites in that state and a history of melding medical and mental health services.
Integration can mean having mental health and primary medical care agencies housed in the same building, said Melody Martin, a program officer with the foundation. But that is not the only way to do it, she said.
For instance, community health centers in Lawrence and Newton now have social workers or behavioral health specialists who work alongside the clinics’ medical teams.
At Heartland Community Health Center in Lawrence, behavioral health specialist Karin Denes-Collar technically is employed by Bert Nash Community Mental Health Center, which is located several blocks to the west of the clinic. But her office is at Heartland, where she consults daily with the medical staff about the conditions of various patients.
For example, she said, a patient with diabetes might also suffer depression in ways that could hinder the treatments for the underlying medical conditions. A homeless man with a chronic physical malady likely also struggles with a range of other problems that compound the illness. Assistance with those problems might best come from a social worker.
Reconnecting kinds of care
Area providers and national experts alike say that better coordination of care is essential to proper treatment for the mentally ill.
In an April 2009 paper, the National Council for Community Behavioral Healthcare said that persons with serious mental illness were dying 25 years earlier than the rest of the population largely because treatable conditions — such as diabetes and cardiovascular disease — had gone unmanaged.
“The bottom line is that the mind and body are connected,” said Tim DeWeese, director of clinical services at the Johnson County Mental Health Center in Mission. “And so the more physically healthy you are, the more mentally healthy you are going to be and vice versa. I think it’s really just reconnecting the two things. I don’t know where we got off base.”
The Sunflower Foundation is building upon a pilot project started two years ago by a subsidiary of the Association of Community Mental Health Centers of Kansas in collaboration with the Kansas Association for the Medically Underserved (KAMU)
Providers from nearly a dozen communities, including Heartland in Lawrence, were part of the pilot, said Connie Hubbell, director of governmental affairs at KAMU. The participants collected data for about a year starting in early 2011.
Undertaken with little funding, Hubbell said the pilot yielded results that were encouraging nonetheless. For instance, data compiled on 81 patients indicated an 8 percent reduction in monthly expenses per patient.
“So we know it’s out there,” she said. “We know it can happen. The integrated model is cost effective, it does save money, and it’s much more appropriate for the patient.”
Integration in action
One of the biggest challenges, Hubbell said, is successfully melding the consultative atmosphere of mental health with the often-frenetic pace that goes with providing primary care in a safety-net clinic.
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.
Kansas has done a good job the past couple of years covering more children with health insurance.
In 2009, 8.2 per cent of children in Kansas were uninsured, according to a new report from the Georgetown Center on Children and Families. Two years later, the figure was down to 6.4 percent.
That 1.8 percentage point change was the seventh best improvement among states over the period, according to the report. Oregon and Texas improved the most, at 3.1 percentage points each. Missouri — which improved coverage by .2 percentage points — was among the bottom 10 states in reducing the percentage of its uninsured children.
Much of Kansas' increase in coverage for children is attributable to the state's Healthwave program — which insures children whose families earn a little too much to qualify for Medicaid — said Suzanne Wikle, director of policy and research for the non-profit advocacy group, Kansas Action for Children.
“In 2010, the eligibility level for our Healthwave program was increased to account for the fastest-growing group of uninsured children, who were just above the eligibility line at that point. So we made the program available to many more uninsured children in the state. That’s had a very big impact,” Wikle said.
Wikle said the state has also done a better job of marketing the Healthwave program. She's worried, though, that when Healthwave is incorporated into KanCare the name change may confuse some families and cause them to miss out on coverage they’re eligible for.
KanCare is Gov. Sam Brownback's plan to move most of the state's 380,000 Medicaid enrollees into managed care plans operated by three insurance companies.
Currently, large managed care companies only provide services to children and pregnant women from low-income families through HealthWave.
The authors of the Georgetown report say full implementation of the Affordable Care Act is the next opportunity to make substantial progress on insuring children.
Members of the governance committee for the Kansas Board of Regents have agreed that the full board should hear the pros and cons of a proposal to train mid-level dental practitioners.
Regents' officials said this week that discussion among board members likely would happen before the Legislature convenes in January, perhaps when the board that oversees state universities, junior colleges and technical schools next meets in November.
Bills authorizing the licensing of "registered dental practitioners" as a way of improving access to dental care for Kansans in rural and other underserved areas were considered by lawmakers in each of the past two sessions of the Legislature but were not advanced because of stiff opposition from the Kansas Dental Association, which represents about 75 percent of the state's dentists, of which there are fewer than 1,500.
Had the proposals become law, the mid-level practitioners would have been allowed to perform about 30 routine services and procedures — such as extracting loose baby teeth, taking X-rays and administering local anesthetic — that currently are limited to dentists. The practitioners, similar to a nurse practitioner, would be required to work under a dentist's "general" supervision, though the dentist would not be required at the technician's side.
Spokespersons for the dental association have argued that routine procedures quickly can turn dangerous and that allowing lesser-trained practitioners to do what dentists now do could put patients at risk.
But supporters of the measure, including a coalition that includes the state's safety-net clinics, argue that some people in Kansas, including children, have died due to lack of dental care and that putting more oral health workers into the field is essential for meeting the state's needs. They also cite studies from countries and states where the practitioners are licensed showing they provide good quality, cost-effective care.
Not enough dentists
According to the Kansas Department of Health and Environment the state's dental workforce is below the national average and shrinking. More than a dozen of the state's 105 counties have no dentist and many more than that have too few.
A proposal to create the new class of dental technician is expected to be before the Legislature again in the 2013 session, which begins in January.
Author and economist John Goodman is scheduled to talk about his ideas for reforming the U.S. health care system at an appearance next week at the University of Kansas Dole Institute of Politics.
Goodman sometimes is called "the father of health savings accounts," and has a new book: "Priceless: Curing the Healthcare Crisis." He co-wrote the 1992 book "Patient Power: Solving America's Healthcare Crisis."
He also developed the Health Care Contract with America, a five-point plan for reforming health care, which has been cited by the Congressional Health Care Caucus, a study group for Republican congresspersons and members of their staffs.
In his new book, among other things, Goodman calls for abolishing Medicaid and moving the program's beneficiaries into private insurance plans. Medicaid enrollees, under his plan, would instead get a $2,000 per person tax credit or refund that they could apply toward the purchase of private health insurance.
He also recommends replacing much of Medicaid outpatient spending for those who are not elderly or disabled with a "health stamp" system modeled on the food stamp program. Beneficiaries would be given the stamps and allowed to spend them as they saw fit for medical care. He also favors abolishing the Children's Health Insurance Program.
The main point of his book is that the current health system has neutered the function of pricing in the health care market, thereby driving up costs. Consumers, he argues, don't pay the real costs of medicine and largely are unaware of them. Providers aren't reimbursed for their true costs but instead take whatever the insurance companies and government are willing to pay.
"So, the overall conclusion of the book is that when we take prices out of the system we create perverse incentives," which have led to higher costs and inefficiencies, Goodman said in an interview with KHI News Service.