Tammy Boudreaux (right) and her girlfriend Laura Perez at home in Missouri City. Boudreaux is uninsured because Laura's job doesn’t offer same-sex benefits (Photo courtesy Tammy Boudreaux).
Boudreaux, 43, lives just outside of Houston and works as a psychiatric social worker on a freelance basis, with no benefits.
This year Boudreaux estimates she spent about $1,500 on medical care, including a trip to the ER for a cut finger. She also takes a few prescription medications and occasionally sees a psychiatrist and a nutritionist.
She can’t get insurance through her partner, because her partner’s employer doesn’t offer benefits to same-sex couples.
And, Boudreaux has been skipping mammograms and other check-ups for a few years. "It's worrisome," she says. "It's like gambling. Gambling with my health, and it is very frustrating."
Boudreaux was hoping to find a better deal on healthcare.gov. Boudreaux has logged on, looked at the plans, and so far, remains largely unimpressed.
She likes the monthly premiums that she sees but balks at the annual deductibles.
"Let's say if I paid the $178 a month, my deductible would be $5,000," she says. "I would have to pay up to $5,000 before I received any kind of payment from my insurance company."
As a comparison, the average deductible for single coverage in employer sponsored insurance is about $1,135, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
Boudreaux could get a lower deductible if she paid a higher premium, but about $200 a month is all she feels she can afford. She doesn't qualify for subsidies to help pay for a policy, either.
"I don’t smoke, I'm relatively healthy, so I was pretty insulted when I saw this [price]," she says. "I was extremely angry actually. I felt hoodwinked by the insurance companies: 'Oh here's this wonderful insurance plan but by the way you need to come up with $6,000 out-of-pocket first before we pay for anything.'"
That reaction is typical, says Caroline Pearson, an analyst and expert on the new health insurance marketplaces for the consulting firm Avalere Health.
"A lot of people aren't ever going to get out of that deductible," says Pearson. "Only if you have a catastrophic health event or you're really chronically ill will you ever hit your out-of-pocket cap. People are left, I think, feeling like 'I spent a lot of money this year on premium and I didn't get any meaningful coverage from my insurance.'"
But Pearson says people forget two things if they just focus on the high deductible. One is that the new plans must offer some free preventive services, like mammograms and yearly physicals. The other is that having a plan protects you from medical bankruptcy if you get in an accident or face something like a cancer diagnosis.
That's because Affordable Care Act requires that health plans have a yearly limit on out-of-pocket expenses. If something did happen to Boudreaux, she wouldn’t pay more than $6,350 in the year.
Not As Generous As Workplace Coverage
Nevertheless, Pearson points out that the plans sold on the exchange are not as generous as employer-sponsored insurance. The plans have a range of deductibles, depending on which level -- bronze, silver, gold or platinum – the consumer picks.
"We think most people are going to be enrolled either in silver or bronze plans, which will cover 60 to 70 percent of a person’s health care costs, and a typical employer plan covers 80," Peason says. "So when the law was passed, by definition we knew these plans would be less generous than employer coverage. And that has definitely played out."
Boudreaux has been managing her health needs without insurance for several years. For her depression, her doctor prescribes her double doses of her psychiatric medicines, which she then cuts in half, and because the meds are generic they only cost her about $40 per year.
But Boudreaux has considered the possibility that something catastrophic can happen.
"That is a huge fear. What if …" she says.
If nothing unexpected happens, she thinks she'd pay less just continuing to go along on her own. And she could put the $200 that would go to the monthly premium into a savings account.
In any case, Boudreaux doesn't feel any urgency to sign up right away. She's been uninsured for a few years, so what’s a month or two more?
With the holidays coming up, this is one difficult and confusing decision she’d rather just avoid for now.
"Whoa, shut the computer. Find something else to do. There's something much better I could be doing with my time than trying to figure out this rigmarole of insurance policies and deductibles and what's covered and what’s preventative and what’s included and blah blah blah," she says. "It's not very well explained."
If Boudreaux does not enroll in a plan by the end of March, her tax penalty would probably be a few hundred dollars – for the first year. The penalty starts out at $95 or 1 percent of income in 2014 and rises in later years.
This story is part of a collaboration that includes KUHF, NPR and Kaiser Health News.
In Efforts To Implement The Health Law, Delays Stack Up
Aug 14, 2013
Recent news coverage has focused on a delay until 2015 for the overhaul's provision that limits out-of-pocket costs for some patients.
Bloomberg: Consumer Cost Protection In Obama Health Plan Is Delayed Federal regulators have delayed a consumer protection in President Barack Obama's signature health law that limits the out-of-pocket costs of people with insurance. The one-year postponement of the annual limit on costs that patients must pay above what their insurance covers is another setback for a health care law that has met resistance from Republicans and faced delays in enforcement of other key provisions (Dorning, 8/13).
NPR: Obama Delays Implementing Another Part Of Affordable Care Act The Obama administration has delayed implementation of another part of Affordable Care Act -- this time, it's the rules aimed at limiting out-of-pocket costs for patients (Varney, 8/14). This story was done in partnership with Kaiser Health News. In addition, KHN's Julie Appleby was featured on WBUR's Here and Now to discuss the delay (8/13).
Los Angeles Times: Federal Officials Delay Another Health-Law Provision For Employers In another delay for the federal health care law, some employers will have until 2015 to comply with new limits on out-of-pocket medical spending for consumers. Federal regulators notified group health plans earlier this year that some would have an extra year to meet the new rules instead of January 2014 as originally proposed (Terhune, 8/13).
The Wall Street Journal: Health Law Delays Starting To Pile Up Republicans opposed to the health care overhaul have had scant luck in overturning or delaying the law, but corporate America has succeeded in persuading the Obama administration to temporarily postpone a growing number of its provisions. In February, the administration delayed part of a requirement that some employer health-insurance plans cap employees' out-of-pocket costs (Schatz, 8/13).
The Washington Post's Wonk Blog: Four Ways To Understand The Latest Obamacare Delay There's a rule in Obamacare that limits out-of-pocket costs -- including deductibles and co-payments -- to $6,350 for individuals and $12,700 for families. Sounds simple enough. But when the Obama administration went to implement the rule, it found it wasn't going to be that easy. Some insurers and employers lack the capacity to keep track of an individual's out-of-pocket health costs. They often use different companies to administer medical benefits and pharmaceutical benefits -- and those companies' computer systems don't speak to each other. Implementing the rule would require upgrading those systems -- and that takes time (Klein, 8/13).
CBS: Key Consumer Protection In Obamacare Delayed The Obama administration has quietly delayed another key element of the Affordable Care Act, the New York Times reported Tuesday, exempting some insurers for a year from the new limit on out-of-pocket expenses. The Affordable Care Act, signed into law in 2010, explicitly set annual limits -- $6,350 for individuals and $12,700 for a family -- on out-of-pocket expenses. Mr. Obama touted the reform as one of the many consumer protections his sweeping health care law would include to make insurance more affordable (Condon, 8/13).
CQ HealthBeat: Out-Of-Pocket Health Spending Caps Start In 2014 With Limited Exceptions, Administration Says The Obama administration emphasized Tuesday that a wide swath of American consumers will benefit in 2014 from first-ever federal limits on how much health insurers can require their policyholders to pay out of pocket for medical expenses, as the White House attempted to fend off a new flurry of Republican attacks on its implementation of the health law (Reichard, 8/13).
Uncle Sam wants your doctor to go digital. And the federal government is backing up that goal by offering money to practices if they start using digital records systems.
Nearly half of all physicians in America still rely on paper records for most patient care, and time is running out to take advantage of the government incentive payments. So practices like Colorado Springs Internal Medicine are scrambling to get with the program.
Dr. James Kinsman stands in the practice's records room, surrounded by patients files that date back only two years (Photo by Barry Gutierrez/For KHN).
Nearly 200 patients will cycle through the office on any given day. Doctors and staff pop in and out of exam rooms and offices constantly, carrying big stacks of manila folders holding patient charts.
Just behind the front desk, Dr. Jay Kinsman stands at the practice's information nerve center.
"There’ll be probably 500 pieces of paper come in on the fax, two times, three times a day," he chuckles. "If that goes down we might as well close."
He is only half-joking. They have a back-up fax machine just in case.
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About a year ago the practice decided it’s time to switch to an electronic health record system, or EHR, and Kinsman took charge of shopping for the right one. He quickly felt overwhelmed.
"Do we really need 250 different EHRs, and 30 fairly widely used ones and 15 really big ones?" he asks. "Could we get by with one? Would we do better with just one product?"
Actually, there’s closer to a thousand products out there. The market exploded when the federal government started offering doctors incentive payments to buy them. The government also said that those who don’t go digital will face payment penalties in the future.
So, all across the country, doctors like Kinsman are taking sales calls. His decision will directly impact not only his and his partners’ days, but also everyone’s incomes.
Heather Garris, a custodian of medical records, organizes patients files at the Colorado Springs Internal Medicine in Colorado Springs, Colo. (Photo by Barry Gutierrez/For KHN).
He explains, "When we were starting to think about this, we were hearing dollar figures on the order of $40,000 per physician to purchase an EHR and install it, and then lost revenue in the first two or three or four months. Basically we’re planning on seeing only half as many patients a day for the first two to four weeks."
There are also decisions about computer hardware -- laptops or tablets in the exam room? Host the system on their own server, or in the cloud? Hire an IT specialist, or outsource it?
Vexing as all that is, the practice’s business manager, Vicky Bonato, says it’s probably not even their biggest challenge.
Dr. Michael Spangler, who has been practicing medicine for 40 years, is happy using paper records. He isn't convinced that going digital will be an improvement (Photo by Barry Gutierrez/For KHN).
"Having everybody have a positive attitude to do it. If we could all keep positive and just get through it and learn it, I think we’ll be OK," she says.
Not every doctor in the practice is equally enthusiastic about switching to electronic records. Dr. Mike Spangler has been practicing medicine for 40 years. He’s not convinced that going digital is going to improve things.
"It's going to take a lot of time, it's going to decrease productivity," he says. "And it's going to be very expensive. So, it means kind of three strikes against it and not as many strikes for it."
"Especially when people are finding that they bought a product and now are not happy with it. It wouldn't surprise me if there would be two or three times a replacement process before things settle down for any given practice," she says.
The message from the federal government is much more upbeat. It says American medicine is making great progress towards reaping the benefits of the digital age. The White House says more than half of U.S. doctors are now using electronic records in a meaningful way, and the Obama administration’s head of health information technology says digital records will transform the practice of medicine.
Auditors: Medicare Could Save Millions By Limiting Advance Payments to Insurers
By Julie Appleby
April 16th, 2013, 6:00 AM
Medicare could earn up to $111 million annually if it limited insurers’ ability to retain investment earnings on the billions they are paid through the prescription drug program, according to a government report out today.
That’s because Medicare prepays the private insurers approximately 20 days before the insurers pay their pharmacy bills and does not require them to return any of the interest they earn while holding that money, says the report by the Office of the Inspector General for the Department of Health and Human Services.
That contrasts with how the government treats insurers in the Federal Employees Benefit Program, which provides health coverage for federal workers, the report said
The report is advisory and was given to the Centers for Medicare & Medicaid Services (CMS) and to members of Congress.
The auditors recommend that CMS pursue legislation to change the timing of payments so insurers pocket the money only briefly before they pay their bills. If the government had such a rule in effect in 2009 – the year the auditors studied – the Medicare Part D trust fund would have earned $111.2 million in interest.
The report said the agency could also consider regulations requiring private insurers to reduce their bid proposals to reflect expected interest earnings.
CMS disagreed with the auditors, saying those options would lead most insurers to raise their prices to the government to recoup the investment loss.
Tight Medicaid Eligibility Leads to More Adults Delaying Care
By Ankita Rao, Kaiser Health News
March 27th, 2013
Illustration by New England Journal of Medicine
Hidalgo is a county in southern Texas just across the Rio Grande from Mexico. It’s also home to the highest prevalence of U.S. adults – about 40 percent of the population– delaying necessary medical care because of cost, according to data in the March 28 New England Journal of Medicine.
The research letter in the March 28 issue of the journal found this number to vary significantly across the country and to be lower in places with less restrictive eligibility criteria for Medicaid, the federal-state insurance program for low-income citizens.
Authors found that people with incomes between 67 percent and 127 percent of the federal poverty line, which is $23,550 for a family of four, had up to a 16 percent chance of delaying care. The odds went up to 42 percent for those with lower incomes.
The findings come at a time when states are deciding whether to pursue the Affordable Care Act’s Medicaid expansion, which would extend eligibility to adults with incomes at or below 133 percent of the poverty level.
Norfolk, Mass., with a 6.5 percent prevalence of adults delaying care, was at the opposite end of the spectrum from Hidalgo, researchers said. Massachusetts’ adoption of state health reforms since 1990, including Medicaid expansions, and the state’s history of investing in health care were likely reasons, said one of the authors, Dr. Cheryl Clarke from Brigham and Women’s Hospital in Boston.
“We were surprised by the depth of variation between states,” she said. “It’s important these trends continue to be monitored.”
The study’s authors looked at county-level data of about 289,000 adults to determine the relationship between Medicaid eligibility and adults delaying care. They also took into account the sociodemographic and clinical characteristics at hand.
Researchers found that the counties with residents most vulnerable to delaying care were also likely to have more Hispanic residents and high rates of chronic diseases commonly associated with low-income communities. Texas and Florida were among the states with the highest prevalence.
But Clarke said the study shows that it is possible to develop health infrastructure – through Medicaid, community clinics and more primary care doctors – to combat an issue that might be taking a toll on the country’s health. And she said federal investments are moving in that direction.
“This seems to be a strategy that is feasible,” she said. “We’ll see how that plays out over time.”
“This was a very, very good business for a short time, with people buying long-term care insurance like it was candy in a candy store,’’ said Michael Perry, a vice president at the Opus Advisory Group, a strategic financial planning firm in Purchase, N.Y.
No more. Mr. Perry has sold only one long-term care policy in the last six months and is “backing off from marketing’’ them as he watches this corner of the insurance business contract, raise premiums, tighten eligibility requirements and reduce key benefits. Long-term care insurance is a comparatively new product, launched in the late ’80s, and only now, as claims begin to pour in, have the actual costs to insurers become apparent.
Companies like MetLife, Prudential Financial, Allianz and Berkshire Financial (a subsidiary of Guardian) have stopped selling new policies and are hiking premiums for the ones already in place — up 37 percent, by one estimate, in 2011. Insurers are increasing elimination periods — the period during which a beneficiary must cover his or her own costs — and reducing inflation protection to 3 percent from 5 percent, once customary. They are requiring home visits instead of phone interviews from new applicants, as well as blood tests and a thorough examination of their medical records.
But the change that has generated the most public attention is so-called gender-distinct pricing, a new strategy that will raise rates for single women by as much as 40 percent beginning in April. Genworth Financial, the nation’s largest long-term care insurance provider with more than a million policy holders, is the first to win approval by state insurance commissions to raise rates for single women purchasing new policies. Women, most of them single by the time they reach advanced age, cost the company $2 of every $3 in benefits paid so far, according to Steve Zabel, Genworth’s senior vice president for long-term care insurance.
The company also will introduce what Mr. Zabel called “enhanced underwriting,” or more stringent qualifying standards, including blood testing to check for nicotine, drugs and markers of cardiovascular disease for all new applicants, regardless of gender or marital status.
Now permitted in all states except Montana and Colorado, gender-distinct pricing will not affect Genworth’s current policyholders, only new applicants. But all other carriers are likely to follow, according to Jesse Slome, executive director of the American Association for Long-Term Insurance, a trade group in Westlake Village, Calif. With the entire industry headed toward higher rates, Mr. Slome recently warned women that “the window is closing” and that now is the time to grab a policy while the price is still manageable.
Women have always paid less than men for life insurance. But because they live longer, women are the disproportionate beneficiaries of long-term care insurance, which paid out $6.6 billion in benefits in 2011. Mr. Slome expects that number to top $7 billion in 2012.
The reasons are well known:
* On average, women outlive men by five years. Among those born in 1960, the average man will live to age 67 and the average woman to age 73. And women who reach age 65 can expect to live an average of 20 more years.
* By age 75, 7 in 10 women are widowed, divorced or have never been married. Some 40 percent of them live alone, compared to 22 percent of men. Two-thirds of those past the age of 85 are women, as are 80 percent of centenarians.
* Women who live to age 65 experience on average two years of disability requiring assistance before death. Those who reach age 80 will require three years of assistance.
* In nursing homes, the most expensive form of long-term care, 7 in 10 residents are women. They represent 76 percent of the residents in assisted living facilities and two-thirds of the recipients of home care. Virtually none of this is paid for by Medicare, the government’s health plan for those 65-and-over. In nursing homes, Medicaid, a poverty program, kicks in for residents who run out of money.
“Woman live longer than men,” said Suzanna de Baca, a vice president of wealth strategies at Ameriprise Financial. “This may mean we experience a longer period of decline. Unfortunately, we are often less likely to have a partner around to help take care of us than our male counterparts.’’
Long-term care, Mr. Slome said, “is truly a women’s issue.”
While acknowledging the extra expense of caring for women, Mr. Slome said that in his view insurance carriers are being disingenuous in blaming the new policies on long-apparent gender differences. Rather he said, the culprit in the changing requirements is interest rates. “Blame the Federal Reserve,’’ he said.
Insurance carriers invest premiums and need to earn enough on that investment to pay benefits. When interest rates were higher, it was not all that difficult. Now the numbers don’t pencil out, and stockholders are fuming. But it is illegal to file for premium increases with the state insurance commissions based on changes in the financial market, Mr. Slome said.
This position does not endear Mr. Slome to his membership, at least one of whom disputes the claim. Asked if the new rate policies were related to interest rates, Mr. Zabel of Genworth, in an e-mail, replied with a succinct “no.”
Insurers say they were not able to judge the costs of care until the payouts began in earnest.
So what is a woman trying to prepare for old age supposed to do, especially after the elimination of the Class Act, a modest attempt to include long-term care in the Affordable Care Act?
Ms. da Baca suggests “careful and thorough budgeting,” “focusing on wellness,” and “proactive steps” to research suitable places to live when home is no longer an option. Ms. da Baca also advises women to make home modifications — incrementally, as one’s budget permits — to increase the chances that you’ll be able to stay there longer.
Mr. Perry, of the Opus Advisory Group, suggests an intriguing option: life insurance with a chronic care rider, which permits the policy-holder to spend money for such needs while alive, although doing so will reduce the tax-free death benefit. Still, not all buyers — or their survivors — are willing to sacrifice those benefits.
“The need is still there, no question about it,’’ Mr. Perry said. But long-term care insurance is likely to become much harder for everyone to find and afford, especially women.
For years, Medicare recipients with chronic conditions have had difficulty qualifying for home health services administered by nurses and therapists.
Now, a legal settlement between consumer advocates and the federal government has paved the way for patients with chronic conditions to receive such services both at home and in skilled-nursing and outpatient facilities.
The settlement, which covers those enrolled in both original fee-for-service Medicare and private Medicare Advantage plans, requires Medicare to end a long-standing practice of denying coverage for skilled-nursing services and physical, speech and occupational therapy to patients whose conditions are unlikely to improve.
"You can no longer be denied simply because you aren't going to improve," says Judith Stein, founder of the nonprofit Center for Medicare Advocacy, which represented the plaintiffs. She estimates that the settlement will help "tens of thousands" of Medicare recipients with chronic conditions qualify for such services.
To receive this coverage, patients must meet specific requirements. First, a doctor must prescribe care from a nurse or therapist. Patients in skilled-nursing facilities also must demonstrate a need for daily services from a nurse or therapy five times a week, says William Dombi, vice president for law at the National Association for Home Care and Hospice.
To secure coverage for home health care, Medicare requires a patient to be homebound, which typically means the individual needs help moving about from a device (like a wheelchair) or a person. A doctor must approve a "plan of care" every 60 days that includes the services of a nurse or physical or speech therapist. In addition, the patient must contract with a home health agency certified by Medicare.
Medicare recipients with chronic conditions don't have to wait for a federal judge to approve the settlement before filing claims, says Ms. Stein, who expects Vermont Chief Judge Christina Reiss to sign off on the settlement some time after a hearing to be held on Jan. 24, 2013. (The lead plaintiff in the case lives in Vermont.)
But patients with chronic conditions may still encounter claims denials, in part because the federal Centers for Medicare & Medicaid Services has yet to update its manuals to correct "suggestions that Medicare coverage is dependent on a beneficiary 'improving,' " warns the Center for Medicare Advocacy.
For instructions on how to appeal a denied claim, see the "Self Help Packet for Home Health Denials" at medicareadvocacy.org. To bolster your case, ask your doctor to explain why you need the services and submit a copy of the settlement agreement, available on the site as well, says Ms. Stein.
Under the settlement, anyone who filed a claim that was denied on or after Jan. 18, 2011, on the grounds of having a condition that's unlikely to improve, is entitled to an additional "special" appeal, says Ms. Stein.
Kaiser Health News Video
Medicare Changes Loom As 'Fiscal Cliff' Negotiations Pick Up KHN's Mary Agnes Carey talks with Jackie Judd about Republican and Democratic proposals and possible cuts in federal health care spending.
Hospitals, Home Health Care Services Lobby Against Cuts in Deficit Deal
As lawmakers and President Barack Obama discuss possible changes to federal entitlement programs as part of a larger deal to avoid the fiscal cliff, expect provider groups to make their case loud and clear: Don’t cut us.
Photo by Karl Eisenhower/KHN
The American Hospital Association is circulating a list of alternatives that are well-known and included in other deficit-reduction plans, such as raising Medicare’s eligibility age, “modernizing” cost-sharing for Medicare and Medicaid and taxing junk foods and sugary drinks.
“Providers already face billions of dollars in Medicare and Medicaid payment cuts” and additional reductions could jeopardize beneficiaries’ access to care, according to the document. “True entitlement reform and approaches to change the health care delivery system are needed – not provider cuts,” it states.
The Partnership for Quality Home Healthcare is also weighing in with a report to remind lawmakers that home health services save Medicare money because beneficiaries are cheaper to care for at home. Requiring cost-sharing for home health services would add to the financial burden seniors already face for housing, food, health care and other costs, and may mean that seniors skip physician-prescribed home health care, the group says. “Some could end up in more expensive institutional settings,” the report states.
Former House Energy and Commerce Committee Chairman Billy Tauzin, R-La., a senior counsel to the home care group, said seniors already have “big skin in the game” when it comes to paying for their Medicare. “Just ask them. They’ll tell you.”
While hospitals, home health agencies and other Medicare providers don’t like the idea they’ll face further cuts as part of the deficit reduction plan, other groups are recommending just that as part of their plans to cut the deficit.
On Wednesday, the Center for American Progress, a left-leaning think tank, released a plan that calls for hospitals, drug companies, home health providers and others to lose billions in Medicare funding over the next decade.
Candidates Clash over health law, Medicare and Medicaid proposals
Published on October 5, 2012 at 5:20 AM·
Although only a portion of Wednesday night's debate was supposed to focus on health issues, the presidential candidates sparred on Medicare, Medicaid and specific provisions of the health law throughout the entire 90-minute event.
The Associated Press/Washington Post: Romney, Obama Tangle Over Health Care Reform Law In First Presidential Debate Republican Mitt Romney is vowing to repeal President Barack Obama's health care law, saying it adds costs to the health system and has led to Medicare cuts. Romney says in the first presidential debate that Obama spent his energy pushing through a massive health care law rather than trying to fix the struggling economy. … Obama says his administration worked on the health care law at the same time he was working to create jobs. He says the law has helped people with pre-existing conditions and those who have children under age 26. The president counters that he based the law on Romney's own plan when he was governor (10/3).
Reuters: Obama, Romney Debate Sheds Little Light On Healthcare Issues President Barack Obama and his Republican challenger Mitt Romney agree that the $2.8 trillion U.S. healthcare system is broken, but neither candidate on Wednesday presented voters with a clear idea of how to fix it. Their comments about Medicare, Medicaid and healthcare in general dominated more than one-quarter of a presidential debate and gave both candidates a chance to articulate their policies for an estimated 50 million viewers (Morgan, 10/4).
National Journal: One Bright Spot For Obama In Debate: Medicare In a tough debate for President Obama, Medicare may have been the high point. Obama made a strong case that the Medicare reform proposal offered by Mitt Romney could shift costs to seniors and potentially undermine the traditional government insurance program, even if the plan includes it as an option. Romney never fought back on Obama's central assertion, that his plan amounted to a "voucher," even after moderator Jim Lehrer asked him if he supported "a voucher system" (Sanger-Katz, 10/3).
Medscape: Romney, Obama Hammer Each Other On Medicare In Debate President Barack Obama and Republican challenger Mitt Romney hammered each other on the high-stakes issue of Medicare Wednesday night in the first of 3 presidential debates, with each candidate hitting his favorite hot buttons on the subject more than once. For Romney, one hot button was the figure of $716 billion -; the amount of savings that the Affordable Care Act (ACA) extracts from Medicare over 10 years by cutting payment to Medicare Advantage plans, hospitals, and other providers. That spells trouble for patient access, he said. "Some 15% of hospitals and nursing homes say they won't take any more Medicare patients under that scenario," said Romney. "We also have 50% of doctors say they won't take any more patients" (Lowes, 10/3).
Roll Call: Mitt Romney Tweaks Plans, Lands Punches Against Barack Obama Romney repeatedly sought to find the middle ground on health care, regulations and the like. He contended that his national health care plan to replace Obamacare would cover people with pre-existing conditions - but he hasn't detailed how beyond what current law allows. He defended his Massachusetts health care overhaul that Obama used as the template for his health care law, but he said that should be a model for states on a state level and not imposed at the federal level. ... The president said his policies would make sure insurance companies can't "jerk you around" and would give millions of people with pre-existing conditions access to affordable health insurance. And he said the Medicare plan proposed by Romney running mate Rep. Paul Ryan (R-Wis.) would ultimately hurt existing seniors as well (Dennis and Livingston, 10/3).
Politico Pro: Obama, Romney Clash Over Medicaid The first health care clash between President Barack Obama and Mitt Romney during Wednesday's debate was not over Medicare or "Obamacare." Rather, it was over Medicaid. Obama argued that Romney's plan to let the states run Medicaid programs would result in a 30 percent cut to the program, meaning less care for seniors in nursing homes and children with disabilities. "That's not a right strategy to move forward," he said. Romney retorted that his proposal to give states more control over their Medicaid programs had bipartisan support from Republican and Democratic governors. He said his plan would provide states the same level of funding they currently get and link it to inflation plus 1 percent (Cheney, 10/3).
Kaiser Health News: How Will The Election Change Medicaid? The future of Medicaid -- the state-federal workhorse of the nation's health system that provides health coverage to the poorest and sickest Americans -- hangs in the balance on Election Day. President Barack Obama and Republican nominee Mitt Romney have vastly different approaches to the program (Galewitz, 10/3).
Medpage Today: Health Care Takes Stage In First Debate President Obama and Mitt Romney traded sharp jabs on healthcare in the first presidential debate Wednesday night, with each attacking the other's plans on health reform and Medicare. The first mention of the night for healthcare came in the first half-hour, when Romney said he'd cut "Obamacare" because it wasn't worth the cost. After Romney apologized for using the term Obamacare, the president said, "I like it." The former Massachusetts governor, unlike his earlier reticence on the subject, didn't shy away from his work to achieve universal coverage in his state. Instead, he said that work wasn't meant to serve as a model for the entire country, although it did seem to do that for the Affordable Care Act (Pittman, 10/3).
The Medicare NewsGroup: Medicare Takes Center Stage In First Presidential Debate Misstatements about Medicare abounded during the first of the 2012 presidential debates, which aired Wednesday, October 3. President Barack Obama and GOP candidate Mitt Romney sparred repeatedly on Medicare, resurrecting sound bites that have featured prominently and consistently in their campaigns to date. Romney repeatedly accused Obama of cutting $716 billion from Medicare through the Affordable Care Act and vowed to repeal the act on day one of his presidency. Obama defended his signature legislative achievement, saying it will drive innovative changes in Medicare and health care more broadly that will result in better care and lower costs (Szot, 10/3).
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
Tele-Medicine Helps Stroke Patients, With Medications, Rehabilitation
Article Date: 09 Aug 2012 - 1:00 PDT
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Tele-Medicine Helps Stroke Patients With Medications, Rehabilitation
When a stroke patient is discharged from the hospital, they often must cope with a new disability or lack of function, so changes in their medications or a new dosing prescription can be particularly confusing. This can lead the patient to overmedicate, take the wrong medication or skip medications entirely and can result in being readmitted to the hospital.
But a pilot study that is looking at a new discharge strategy and being led by researchers at Wake Forest Baptist Medical Center, indicates that phone calls and conversations with a "stroke coach" seem to keep a patient on the road to recovery.
Cheryl D. Bushnell, M.D., associate professor of neurology and director of Wake Forest Baptist's Primary Stroke Center, saw firsthand the need for a better hospital-to-home transition. "Many patients are not only overwhelmed with the new diagnosis of stroke, but also the risk factors that might be uncovered during the stroke hospital stay. This means new medications or adjustments to the old ones. Most important, all of the stroke education we give to people in the hospital before going home may be forgotten with everything else that happens during the hospital stay, so getting some additional teaching after getting home could help this transition."
Bushnell, Wake Forest Baptist neurology colleague Elizabeth Sides, MEd., and colleagues from Duke University School of Medicine, followed stroke patients who were discharged from the hospital with two or more changes in their medications between admission and discharge. Their findings were recently published online in the journal BMC Public Health.*
The study followed 30 stroke patients who had a change of at least two medications between admission and discharge. The first 20 patients were selected for coach calls and the remaining patients served as a control group and did not receive coaching.
Prior to discharge, the coach reviewed a packet of information with each patient and their caregiver. The information included: specifics about when to call 911 or their physician and/or pharmacist; lifestyle suggestions to prevent stroke; a checklist of the individual patient's risk factors with additional information about each; and a list of their current medications, what they treat and the dosage.
Within two weeks of discharge, each of the 20 study participants received a call from the medication coach who provided general information about stroke and the importance of preventing another stroke, how to mitigate their individual stroke risk factors and the importance of taking their prescribed medications. The medication coach assessed each participant's understanding of their discharge orders by reviewing each stroke prevention medication on the participant's discharge list, asking whether each was still taking the medication, and if not, why. The coach also determined whether the participant understood the purpose of each medication, asking how to take it, refill it, and to identify its side effects. In closing the call, the coach asked participants if they had any specific questions about their medications or stroke recovery.
Following each call, the coach forwarded medication-related questions to a pharmacist and stroke-related questions to a stroke nurse, compiled their responses and called the participant back with the information. These responses were also summarized and sent to the participant's primary care provider. Finally, the coach summarized any lengthy answers, writing at a 7th grade level, and sent them to each participant in a follow-up letter.
At the end of three months, an interviewer contacted all study subjects to hear how participants had fared. Overall, researchers found very little difference between the coaching and control group when it came to knowledge of medications and stroke. However, more participants in the coaching group (93.8 percent) knew what to do if problems or symptoms worsened than the control group (77.8 percent) and a significantly larger number of coaching participants (93.8 percent) had seen their primary care provider since discharge than those in the control group (60 percent). In addition, there were trends toward lower depression severity scores in the intervention group, higher reported health status scores and lesser disability among those in the control group.
While recognizing the limitations of a small study, Wake Forest Baptist researchers believe the overwhelmingly positive feedback from participants about the post-discharge coaching, the feasibility of adding this element to discharge plans, and the early influence on keeping follow-up appointments with their primary care providers show the promise of this type of program.
(* http://www.biomedcentral.com/1471-2458/12/549 Co-authors include Eric D. Peterson, M.D., Louise O. Zimmer, MPH, Leslie Wilson, B.S., and Wenqin Pan, Ph.D., all of Duke Clinical Research Institute, Duke University School of Medicine, and DaiWai M. Olson, Ph.D., Department of Medicine, Division of Neurology, Duke University Medical Center. Competing Interests: Dr. Bushnell receives research salary support from NIH/NINDS K02 NS058760, but this funded research is not related in any way to the study presented in this manuscript. Dr. Peterson received salary support from the Agency for Health Care Research Quality, the funding source for this study. None of the other coauthors have any competing interests to disclose. Acknowledgements: This project was supported by grant number U18HS016964 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors would like to thank Patricia Frazier, MA for enrolling participants, Judith A Stafford, MS for statistical programming, Charlie Stoner, PharmD, BSN, for triaging pharmacy questions and Bob Sanderford for data entry. Wake Forest Baptist Medical Center
n.p. "Tele-Medicine Helps Stroke Patients With Medications, Rehabilitation."Medical News Today. MediLexicon, Intl., 9 Aug. 2012. Web. 9 Aug. 2012. )
Analysis of Affordable Care Act Decision, National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al., No. 11-393
By: Akin Gump Strauss Hauer & Feld LLP
June 28th, the Supreme Court upheld the constitutionality of the Affordable Care Act’s minimum coverage provision and partially upheld the constitutionality of the Medicaid expansion. With respect to the latter, the Court held that, while the expansion itself is constitutional, the Secretary lacks the authority to cut off all Medicaid funding for States that choose not to expand their coverage. States thus now have the choice of either expanding Medicaid coverage and accepting funding under the Act, or declining the expansion and continuing with pre-Act Medicaid.
The effect of those two rulings is that the Court rendered the two most controversial aspects of the law essentially optional: (1) with respect to the mandate, there is no mandate; instead, individuals have the choice of either buying insurance or paying a tax on their non-insured status; and (2) with respect to Medicaid, States may either accept federal funds and cover more individuals under an expanded Medicaid program, or opt out of that expansion and forgo the extra funding. The effect of the law on the number of individuals who opt to forgo coverage and the number of States who opt to forgo additional federal funds under an expanded Medicaid program remains to be seen. It is conceivable that these changes could result in a smaller number of uninsured individuals obtaining coverage than was previously expected as a result of the expanded coverage provisions of the Affordable Care Act.
The Constitutionality of the Minimum Coverage Provision a/k/a the Individual Mandate
By a vote of 5 to 4, the Court voted to uphold the constitutionality of the individual mandate, but not in the way that most observers predicted, or on the theory that the government most forcefully put forth. The government in briefs and at oral argument argued strongly that the minimum coverage provision should be upheld as proper exercises of Congress’s power under the Commerce Clause and the Necessary and Proper Clause. The taxing power was advanced as a back-up authority. Five Justices (the Chief Justice, and Justices Scalia, Kennedy, Thomas and Alito) rejected the argument that the minimum coverage provision falls within Congress’s Commerce or Necessary and Proper Clause power, which they construed as not empowering Congress “to order people to buy health insurance.” Op. 44.
But a different majority, Chief Justice Roberts, and Justices Ginsburg, Breyer, Sotomayor, and Kagan, ruled that the minimum coverage provision is nevertheless constitutional as a valid exercise of Congress’s power to “lay and collect Taxes.” U.S. Const., Art. I, § 8, cl. 1. Explicitly relying on the principle that “every reasonable construction must be resorted to, in order to save a statute from unconstitutionality,” the Court held ”[t]he Federal Government does have the power to impose a tax on those without health insurance,” and that the minimum coverage provision can be upheld as a “tax,” notwithstanding that Congress labeled it a “penalty.” Op. 32. As a consequence, “[t]hose subject to the individual mandate may lawfully forgo health insurance and pay higher taxes, or buy health insurance and pay lower taxes. The only thing they may not lawfully do is not buy health insurance and not pay the resulting tax.” Op. 44. 11 At the outset of its opinion, the Court held that the federal Anti-Injunction Act did not bar its decision in this case. The Act provides that “no suit for the purpose of restraining the assessment or collection of any tax shall be maintained in any court by any person.” 26 U.S.C. § 7421(a). In plain English, that means, if you are challenging the lawfulness of a tax, you must pay first and sue later for a refund. The Court explained that, because the Affordable Care Act labeled the shared-responsibility payment a “penalty,” Congress did not intend for the Anti-Injunction Act to apply. Such questions of statutory construction are fully within Congress’s power to direct. When it comes to questions of constitutional law, however, the Court explained that substance, not labels, controls, and the substance of the minimum coverage provision is sufficiently akin to a tax to be sustained under Congress’s constitutional taxing power. The Constitutionality of the Medicaid Expansion
By a vote of 7 to 2, and for the first time in its history, the Supreme Court ruled that Congress’s exercise of its power under the Spending Clause, Art. I, § 8, cl. 1, unconstitutionally coerced the States. In particular, the Court concluded that the provision of the Medicaid Act providing that, if a State’s Medicaid plan does not comply with the Act’s requirements, the Secretary of Health and Human Services can cut off all Medicaid funding—both the expansion and pre-Act Medicaid funds—violates the Spending Clause. That all-or-nothing proposition, the Court ruled, unconstitutionally coerced States by forcing them to choose between a dramatic expansion of Medicaid coverage or losing $3.3 trillion in federal funding for the Medicaid program States have been operating for decades. This, according to Chief Justice Roberts, is not “mild encouragement” but rather “a gun to the head.” Id.
For many years, Congress has, under this spending power, provided federal grants to states to assist them in providing care to specified categories of needy individuals under the Medicaid program. Acceptance of the money by the States was optional but, if taken, the States were obliged to comply with federal requirements governing coverage and care. The practice of making conditional federal grants has generally been considered a constitutional one, although the Supreme Court has occasionally suggested that some federal grants may be unconstitutionally coercive.
The Affordable Care Act proposed to expand Medicaid to cover all adults earning less than 133% of the federal poverty line, albeit with most of the new individuals covered with significant (never less than 90% to 100%) federal funds. The particular constitutional problem with this expansion—and the ground upon which the majority concluded that it was unconstitutionally coercive—was that a State that failed to comply with the Affordable Care Act’s expansion of coverage was threatened with losing all Medicaid funding, not just the funding for the newly covered individuals. The Court said that was too much. While Congress could condition new money on new coverage, it could not imperil ongoing Medicaid funds as well.
It is important to note that no specific opinion on the Medicaid expansion garnered five votes; instead, the Court’s holding results from counting the votes in the various opinions issued. Ultimately, the vote tally was seven to two to hold the expansion unconstitutionally coercive, but five to four to remedy the violation by allowing the States to simply opt out of the Medicaid expansion and continue with old Medicaid instead. Under this latter choice, States are free to decline the substantially increased coverage (and also the billions of dollars of federal funding that come with the Medicaid expansion) while nevertheless maintaining pre-expansion Medicaid coverage and funding.
Process Moving Forward
The practical implication of this decision for the Texas Association for Home Care & Hospice is that none of the major provisions of the Affordable Care Act that have a direct impact have significantly changed (i.e., payment adjustments, rebasing). However, it is noteworthy that the Court came close to throwing out the entire law, including these provisions. Specifically, all four of the dissenting judges voted to invalidate the entire law.
As you know, the Affordable Care Act required that states set up Insurance Exchanges, which are intended to create “one-stop shopping” for health insurance coverage. States are required to submit blueprints for their Exchanges to HHS by November 16, 2012. Exchanges are required to be certified by HHS by January 1, 2013. Prior to the Supreme Court’s decision, many Republican governors had stated that they would delay decisions about implementing Exchanges in their States until the Court had issued its decision. In the aftermath of the Court’s decision, some of these governors indicated that they would continue to wait until the outcome of the November election to determine whether or not to implement Insurance Exchanges. Given that the election falls on November 6 and the Exchange blueprint deadline is November 16, the window for implementation in these States would be very narrow. If a State fails to meet the deadline, the federal government will step in and establish an Exchange in that State. Texas Association for Home Care & Hospice June 29, 2012. The Medicaid expansion ruling may turn out to be significant. Some observers have questioned whether a State could politically or economically decline the large federal matching dollars that are associated with the Medicaid expansion provision. However, it is estimated that changes related to the Medicaid expansion could increase costs for States by $21 billion for the 2014 to 2019 period. For some States, those costs may be substantial enough to weigh against embracing the Medicaid expansion, notwithstanding the hefty federal match provided under the law for the expansion.
Although the Affordable Care Act has cleared the Supreme Court, the law still faces ongoing challenges, particularly depending upon the outcome of the Presidential and Congressional elections in November. Early reactions to the Court’s opinion suggest that the decision may energize the Republican base in November. Depending upon the makeup of Congress and who is elected President, the Affordable Care Act could still face tremendous challenges.
Health Reform Explained
The Road We Have Taken
Texas Looks to Fund Medicaid Women's
Health Program Without Federal Funds
AUSTIN, Texas -- Texas Republican Gov. Rick Perry on Thursday directed state officials to begin looking for money to keep the Medicaid Women's Health Program, even if the Obama administration revokes federal funding amid a fight over clinics affiliated with abortion providers.
"We'll find the money. The state is committed to this program," Perry told reporters, shortly before he issued a letter directing Thomas Suehs, head of the Texas Health and Human Services Commission, to work with legislative leaders and identify money to keep the program going if federal funds are halted.
But pulling that off will be no mean feat: The program costs about $40 million and the federal government currently covers 90 percent of that.
The health program provides care to about 130,000 low-income women statewide. It had been expected to close next week, when Texas begins enforcing a law passed last summer that bars state funding from clinics affiliated with abortion providers. The Obama administration has said it will stop funding the program because federal law requires women to be able to choose any qualified clinic.
Perry spokeswoman Catherine Frazier countered that Texas has the right under federal law to determine qualified providers in the program.
The law is part of a long-running campaign by conservatives in the Republican-dominated Texas Legislature to shut down abortion providers by imposing strenuous regulations and cutting off state and federal funds for their non-abortion services. Perry and Republican state lawmakers specifically don't want Planned Parenthood clinics, which treat 40 percent of the program's patients, to get any state funding, even when that money is not spent on abortions.
That has created a legal standoff, with federal and state officials accusing each other of political extremism while poor women will be left without necessary health care. The Women's Health Program serves women ages 18-44 earning less than $20,000 a year or less than $41,000 for a family of four.
Perry did not specify where the funding for the Women's Health Program might be found. "We've got a multibillion-dollar budget, so we've got the ability to be flexible on where the money comes from," he said after an event at Texas Republican Party headquarters.
His letter to Suehs noted officials have been discussing the possibility of making up lost federal funding in the Women's Health Program for weeks.
The state Legislature is out of session and does not meet again until next year, but Frazier said the governor has the authority to redistribute available funds as he sees fit – and would not need to convene a special session.
Perry said he's anxious to save the program after the Legislature last year cut funding for 160,000 women enrolled in it. In total, lawmakers slashed $83 million in funding for women's health programs. It was not immediately clear what other areas would have to be scaled back to make funds available for the governor to keep his promise.
The Texas Democratic Party blasted Perry for removing funding from other parts of the state budget to save the program.
"Instead of diverting resources from already strained state services Perry should own up to his mistake," party spokeswoman Rebecca Acuna said in a statement.
State law already forbids taxpayer money from going to organizations that provide abortions, so groups such as Planned Parenthood have established legally distinct corporations to separate family planning and women's health providers from clinics that perform abortions.
The law about to be enacted goes a step further to make any affiliation between a clinic and an abortion provider grounds for cutting off funding. That can mean sharing a name, employee or board member, even if the two clinics are legally and financially separate. Lawmakers last year said their goal was to cut off all state funding for Planned Parenthood, not to leave poor women without health care.
"Those people that are out there trying to say, `Oh they're going to kill this program' are just dead wrong," Perry said of the Women's Health Program on Thursday. He said the Obama administration is "trying to support an organization that supports them. ... But Texans don't want Planned Parenthood, a known abortion provider, to be involved in this."
In a letter to President Barack Obama, Perry accused the administration of trying to violate states' rights "by mandating which health providers the State of Texas must use."
"I will not allow these services to be denied by your administration's political agenda and opposition to enacted Texas law that prohibits abortion providers and their affiliates from receiving taxpayer dollars," the letter said.
Associated Press writers Chris Tomlinson in Austin and Angela K. Brown in Fort Worth contributed to this story.
Calvert Gives Support to Local Volunteer Fire Department
Calvert Home Health Care will be supporting the local Volunteer Fire Departments this Christmas by making a donation to one of local departments. Calvert will announce which of the local departments will receive the donation at our Christmas Luncheon on the 15th of December. If you would also like to support please contact us at (806) 747-8972.
Medicare's annual enrollment period will begin on october 15th and continue through December 7th. As Medicare Advantage (MA) and Medicare Prescription Drug Plans (PDPs) begin marketing their products for the 2012 calendar year, we will be working to make sure that the agents and brokers working on behalf of these plans act appropriately and in accordance with Medicare's laws and guidelines. Medicare has a comprehensive surveillance and enforcement strategy in place and the power to take action against plans. Texas Department of Insurance has the power to take enforcement action against agents or brokers that engage in inappropriate activity.
Calvert Administrator Becomes President of TAHC
Calvert owner and administrator, Dana Madison, was recently inducted as the President of the Texas Association of Home Care and Hospice. You can see her induction speech on youtube at the following link:
The mission of the Texas Association for Home Care & Hospice (TAHC&H) as a non-profit association is to promote quality and economic viability of licensed providers of home and community support services in Texas.
TAHC&H is over 1,200 members strong and speaks with a strong, unified voice for the interests of home care throughout the state of Texas. Its mission joins together home care member organizations and individuals in a shared commitment to every citizen in need of quality, affordable home care services.
As a nonprofit association, TAHC&H has championed the collective interests of Texas home care agencies, organizations, service and supply companies, and individual professionals since its founding in 1969. TAHC&H headquarters, located in Austin, Texas, gives home care providers a strategic pathway to key state lawmakers and health care regulators.
By organizing the energies of its Board of Directors, committees, members, and staff, TAHC&H channels its efforts into these major areas of activity: advocacy and representation, communications, education, and public information.