President Scraps Marketplace CSRs- but the Sky Isn’t Falling

Late last week the President announced that HHS won’t make any more subsidy payments to insurance companies that offer plans on the Marketplace.

The subsidy payments (cost-sharing reductions or CSRs) are payments to insurers to reimburse them for discounts they give policyholders with incomes under 250% of the federal poverty line (about $30,000 in income a year) for an individual. The discounts shield lower-income customers (that buy insurance in the Marketplace) from out-of-pocket expenses, like deductibles or copays.

Cutting off these payments to insurers doesn’t mean the policyholders won’t get help. The ACA and insurance company contracts require those discounts be granted by Marketplace insurers.

The decision does mean that insurance companies on the Marketplace will have to figure out how to recover the money they were promised under the ACA.  The two Marketplace insurers in AZ (Blue Cross Blue Shield and Centene Corp’s Ambetter by HealthNet) announced that they’ll have stable premiums next year. They apparently had already assumed that the CSRs wouldn’t be paid because they don’t expect this decision to impact their 2018 rates.

Remember, the cost-sharing reductions are separate from the tax credit subsidies (called advance premium tax credits) that help millions of people pay their premiums.  The premium tax credit is a refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace.

People with income between 100-400% of the Federal Poverty Level still qualify for the tax credits, which are calculated depending on income, and help (and will continue to help) families pay their Marketplace health insurance premiums.

 

Integrated Health Plan for Children in AZ Foster Care?

AHCCCS & Mercer are conducting an analysis of an integrated health plan for children/youth involved in Arizona’s foster care system (e.g. a plan that would cover both acute care and behavioral health services).

Mercer is holding a series of stakeholder sessions – two with providers and two with family members (foster, adoptive, kinship and biological) and youth/young adults currently or previously involved with Arizona’s foster care system to solicit input about the concept. The goal is to gather feedback about the future of AZs health care system for kids in the foster care system

Tuesday, October 24

1 N. MacDonald, 3rd floor Mesa, AZ

Providers:                              10:00 a.m. – 11:30 a.m.

Family/Youth/ Young Adults:   3:30 p.m. – 5:00 p.m.

Wednesday, October 25

400 W. Congress Room 444, 4th floor Tucson, AZ

Providers:                              10:00 a.m. – 11:30 a.m.

Family/Youth/ Young Adults:   3:30 p.m. – 5:00 p.m.

To attend any session by phone, call 1-877-820-7831 and use guest code 679145.

 

200 Stories: Tucson Healthcare Forum Sunday, October 29

·        Are you concerned about the future of healthcare and health insurance?

·        What will the Affordable Care Act, Medicare and Medicaid look like in the future?

·        Have you had problems accessing affordable medical care, insurance, or medication?

Legislators from Legislative Districts 9 and 10 are hosting healthcare a forum in Tucson on Sunday, October 29.  Senators David Bradley & Steve Farley & Reps. Kirsten Engel, Randy Friese & Pamela Powers Hannley will be there to listen to your concerns and hear your stories about Medicare, Medicaid, the Affordable Care Act, insurance, medical care, drugs, cost and related topics.

Sunday, October 29, 2017 1:30 – 3:30 p.m. Unitarian Universalist Church of Tucson 4831 E. 22nd St.  Here’s the Eventbrite Link to sign up.

 

WV Medicaid Waiver Could Bode Well for AZ Opioid Treatment

CMS recently approved West Virginia’s proposal to expand Medicaid coverage for substance abuse treatment by lifting a restriction on Medicaid payments for inpatient treatment at large residential facilities. This waiver also allows the state Medicaid program to cover naloxone, peer support services, and methadone.

This approval could be important for Arizona because it signals that CMS is receptive to these kinds of waiver requests- and a similar recommendation was made in ADHS’ September 5 Opioid Action Plan.

 

2018 Public Health Law Conference

The Network for Public Health Law will be holding next year’s national Public Health Law Conference in Phoenix on October 4 – 6, 2018. They’re already accepting abstracts for panels and individual presentations.

They’re soliciting abstracts related to this year’s Conference theme,Health Justice: Empowering Public Health and Advancing Health Equity, as well as abstracts on other timely public health law topics. Deadline for abstract submission is December 15, 2017.  Here’s theSave-the-Date and Call for Abstracts.

 

Retail Marijuana & Opioid-Related Deaths in Colorado, 2000–2015

Researchers in Colorado did an interesting study recently that was published in the November American Journal of Public Health. They looked to see whether Colorado’s legalization of recreational cannabis had an impact on deaths from opioids in CO.

They used what’s called an interrupted time-series design (2000–2015) to compare monthly opioid-related deaths before and after Colorado stores began selling retail marijuana.  creational cannabis.

Interestingly, they found that opioid related deaths were reduced by 0.7 per month after retail sales of marijuana became legal. This is not a huge reduction by any means, but it was statistically significant.  Here’s what the authors described in the section labeled Public Health Implications:

“Although we found an apparent public health benefit in a reduction in opioid-related deaths following recreational cannabis legalization in Colorado, we note that expanded legalized cannabis use is also associated with significant potential harms. For policymakers to balance the potential beneficial and deleterious effects of these laws, researchers must continue to examine the full range of health effects in both clinic- and population-level research.”

There’s growing bipartisan support for a Health Center Funding Cliff Fix called the “CHIME Act” ( S. 1899 in the Senate and H.R. 3770 in the House). The Bill also addresses reauthorization of funding for the National Health Service Corps and Teaching Health Center Graduate Medical Education.

Community health centers rely on a combination of Medicaid payments and “330” grant revenues to keep their doors open. Because they also serve persons without any health insurance (on a sliding fee scale), they can’t rely solely on insurance claims to keep the doors open- which is why the 330 grant funding is so critical.

This new Bill (the CHIME Act) is better than the previously introduced called the CHAMPION Act– because the CHAMPION Act would have cut the Prevention & Public Health Fund by 57% (a cut of $6.35B over the next 10 years). 

You can express your opinion to your Representative and Senators by sending your Members of Congress a message

Contraception and family planning are among the most significant public health interventions of all time- and among the top of the list when it comes to return on investment.

Family planning and contraception are key to reducing teen pregnancies and inter-generational poverty.  It’s no secret that poverty is a key driver for a host of poor health outcomes.  Family planning is also a high return on investment intervention for improving preconception health because it allows women to make more deliberate decisions about the spacing of babies- which improves the health status of mom and baby.  Family planning is also good for businesses, because it allows employees to plan their families in a way that improves their work-life balance, improving attendance and retention.

The Affordable Care Act initially required that health insurance plans cover no-cost contraception services, a big win for public health. A couple of years ago the US Supreme Court ruled that family owned and other closely held companies can opt out of these ACA’s provisions.  The owners of the Hobby Lobby had objected on the grounds of religious freedom.

This week things slipped further, when Attorney General Sessions expanded the religious exemption for employers who object to providing insurance coverage for birth control because of their religious or moral beliefs.  His “religious liberty directive” instructs federal agencies to do as much as possible to accommodate those who claim their religious freedoms are being violated, effectively lifting a burden from religious objectors to prove that their beliefs about marriage or other topics that affect various actions are sincerely held.

Here’s the Attorney General’s guidance and his implementing memo. 

Each Fall state agencies turn in requests for changes in their funding to the Governor’s Office for consideration in his or her proposed budget.  These requests are then evaluated by the executive branch and synthesized into a final budget proposal from the Governor, which is usually released in mid-January.

Here’s an abbreviated snapshot of what ADHS, AHCCCS and ADES turned in this year:

AHCCCS

• AHCCCS is estimating an average Capitation Rate increase of 3.1% across all lines of business.  They turned in cap rate increases for special populations of 12% for Children’s Rehabilitative Services, 9.6% for behavioral health and a 3.5% decrease for the Comprehensive Medical and Dental Program (a state program for providing quality care for kids in the foster care system); 

• This request would add $72M from the state General Fund to cover costs for enrollment growth, capitation rate increases and state-federal match rate changes;

• Maintaining current state funds dedicated to the state’s behavioral health Crisis System ($14M) non-Title XIX services for persons with a serious mental illness ($78.8M) & $5.3M for Supported Housing; and

• They’re asking that behavioral health costs be blended into the acute care and ALTCS (long term care) line items.

Arizona Department of Health Services

• ADHS is requesting $500K to continue funding for response to public health emergencies;

• Seeking $750K to maintain minimum standards for health care licensure staff and responses to growing demand for services because of the growth and workload in licensing; and

• Requesting funds to respond to new responsibilities to oversee the AZ Radiation Regulatory Agency with a 1-time request for $500K for proper handling and disposal of radioactive materials.

Arizona Department of Economic Security

• Seeking $3.9M to respond to ongoing Adult Protective Services caseload growth;

• Adding $10M to accommodate a 2% capitation increase & accommodate a caseload increase of 4.9% for persons with Developmental Disabilities in the Arizona Long Term Care System (ALTCS);

• Addressing DDD structural shortfall by adding $6.4M to cover Long Term Care services for non-XIX services of room & board;

• Requesting $3.3M for targeted case management services for the state-only DDD clients; and

• Responding to mandates imposed by Prop 206 on the minimum wage by adding for DDD $11.6M to assure network sufficiency.

Family Planning Services Lose Traction

Contraception and family planning are among the most significant public health interventions of all time- and among the top of the list when it comes to return on investment.

Family planning and contraception are key to reducing teen pregnancies and inter-generational poverty.  It’s no secret that poverty is a key driver for a host of poor health outcomes.  Family planning is also a high return on investment intervention for improving preconception health because it allows women to make more deliberate decisions about the spacing of babies- which improves the health status of mom and baby.  Family planning is also good for businesses, because it allows employees to plan their families in a way that improves their work-life balance, improving attendance and retention.

The Affordable Care Act initially required that health insurance plans cover no-cost contraception services, a big win for public health. A couple of years ago the US Supreme Court ruled that family owned and other closely held companies can opt out of these ACA’s provisions.  The owners of the Hobby Lobby had objected on the grounds of religious freedom.

This week things slipped further, when Attorney General Sessions expanded the religious exemption for employers who object to providing insurance coverage for birth control because of their religious or moral beliefs.  His “religious liberty directive” instructs federal agencies to do as much as possible to accommodate those who claim their religious freedoms are being violated, effectively lifting a burden from religious objectors to prove that their beliefs about marriage or other topics that affect various actions are sincerely held.

Here’s the Attorney General’s guidance and his implementing memo. 

Just when we thought the Prevention and Public Health Fund (PPHF) was going to be OK because of the downfall of the ACA repeal efforts, along comes the “Champions Act” which would cut this important public health fund by 57%.

The “Community Health & Medical Professionals Improve Our Nation Act” of 2017, or CHAMPION Act, would do some good things like support “330” grant funding for Community Health Centers, continue to fund the National Health Service Corps and Teaching Health Center Graduate Medical Education. 

But, the legislation pays for the extension by cutting the Prevention & Public Health Fund by 57% (a cut of $6.35B over the next 10 years). 

The ACA established the Fund to establish a framework for prevention, wellness, and public health initiatives to reduce long-term health costs. It focuses on preventing expensive chronic medical conditions by providing expanded and sustained national investment in public health programs that improve health and restrain the rate of growth in health care costs.

This investment in public health infrastructure is evidence-based. Research suggests that funding for community-based public health has a 5.6 to 1 return on investment. In other words, every dollar invested in evidence-based prevention programs results in a $5.6 in savings in overall health care costs.

Arizona state and county public health programs have received more than $52.6M via the Fund since 2010. This $9.3 million annual investment is at work in Arizona, providing critical resources that support evidence-based, community prevention activities tailored to meet community health needs and preferences. Evidence-based investments in Arizona include:

• Building immunization services to prevent serious infectious disease outbreaks;

• Prescription painkiller (opioid) and heroin use prevention;

• Health security funds for bioterrorism, disease outbreaks, and disasters;

• Promoting better detection and response to disease threats;

• Lead poisoning prevention;

• Reducing tobacco use; and

• Reducing diabetes, heart disease, and obesity.

Here’s a report we wrote with the Vitalyst Health Foundation that details the public health programming that’s at risk again.

We’ll continue to track this bill and issue an Action Alert when the time is right.

Funding for KidsCare (CHIP) expired last week.  This program (run by AHCCCS) currently covers about 23,000 kids with a pretty good set of benefits and reasonable premiums.  It’s only available for kids in families that don’t qualify for regular Medicaid and who live in a family that makes under 200% of poverty.

Even though the program hasn’t been reauthorized by the October 1 deadline, most states have reserved enough funding for the next three months. AHCCCS apparently has funding to continue the for a few weeks past the October 1 expiration date.

There is light on the horizon. The Senate Finance Committee introduced a CHIP funding proposal (Hatch/ Wyden) that would extend funding to states through FY 2022 but gradually reduce federal contributions. 

Enough matching funds would remain for Arizona to keep the program as-is through FY 2019 but after that our KidsCare program could be at risk because the federal contribution will be less than what’s currently wired into state law for funding AZ’s share of the program. 

But, that’s something that could be changed in either the 2018 or 2019 AZ Legislative Sessions.

 

When Arizona expanded our Medicaid program (AHCCCS) to cover people up to 138% of poverty we used a provision in the ACA that allows states to expand coverage with the federal government absorbing all the cost at first.

But that meant we had to first cover all “childless adults” below the federal poverty level- a group that lost AHCCCS coverage during the recession.  We paid for covering the childless adults with an assessment (fee) on hospitals (right now it’s about $264M).

AHCCCS set the assessments using a formula that made sure each hospital chain would be OK with the assessment because their fee would be lower than what they stood to gain by the reduction in uncompensated care.

The bill that authorized the assessment and Medicaid expansion barely passed with just over 50% of the House and Senate.  Many of the lawmakers that voted “no” believe that the bill should have required a supermajority because of a voter approved initiative that requires tax increases to pass by 2/3 of each chamber.

The Executive Branch believes that the assessment is not a tax, but a fee set by an agency director.  That’s the crux of the Biggs v. Betlach suit that challenges our Medicaid expansion.

The Goldwater Institute filed new documents this week with the Arizona Supreme Court, who will ultimately decide if the assessment is a fee or a tax. 

If the Court ultimately agrees with the Plaintiffs, AHCCCS wouldn’t be able to collect $264M hospitals pay and there won’t be enough money to fund the childless adults or the expanded coverage.  Unless the legislature were to vote by a 2/3 majority to fund the program, the only path to keeping the coverage would be via a voter initiative- which just got a lot harder to do with the passage of HB 2404 (preventing signature gatherers from getting paid by the signature) and HB2244 (changing the citizen’s initiative compliance standard from “substantial compliance” to “strict compliance”).

There will be Oral Arguments on the Biggs v. Betlach case on Thursday, October 26 starting at 9 am at the Arizona Supreme Court (Case CV-17-0130-PR).

ADHS’ Bureau ofEmergency Medical Services and Trauma System has been awarded $3.1 million by the Substance Abuseand Mental Health Services Administration for development of a comprehensive first responder opioid/naloxone program in partnership with the University of Arizona and the Arizona Peace Officer Standards and Trainingboard. Naloxone is a medication that can counteract an opioid overdose.

This joint initiative will implement a statewide naloxone delivery system to provideaccess to naloxone for first responders, an acute opioid overdose recognitionand naloxone administration training program for first responders, and addressa targeted first responder opioid screening, brief intervention, and referralto treatment curriculum to instruct first responders how to recognize actual orpotential opioid-related substance abuse and to provide appropriateinterventions and referrals to care.

The budget approved by the Legislature last session provided the funding for AHCCCS to cover emergency dental services for all adult members (over 21) up to $1,000 per year beginning October 1. AHCCCS turned in a plan to the Centers for Medicare and Medicaid fortheir approval a few weeks ago.

The next public health question is “what is the definition of Emergency Dental Services” so folks can know what’s covered. 

AHCCCS posted proposed language that defines what will be covered awhile back (the comment period ended September 21).  In it, they proposed covering dental servicesfor: “…an acute disorder of oral healthresulting in severe pain and or infection as a result of pathology or trauma.”

The proposed language is posted at 310-D1 – Dental Services for Members21 Years of Age and Older and also clarifies what kinds of procedures meet the criteriafor treating an “acute disorder of oral health resulting in severe pain and orinfection as a result of pathology or trauma”. 

I couldn’t tell whether this is going to be the final definition and list ofprocedures or not that will shortly become covered.  I’ll keep my eye out for that.

Children up to age 21 enrolled in AHCCCS have had (and continue to have) access to comprehensive and even preventative oral health coverage under the program.