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What health reform means for the people of Illinois

A blog by IllinoisHealthMatters.org

Wednesday, December 19, 2012

Advanced Practice Nurses: Willing to Meet the Needs of the Medicaid Expansion


This guest post was written by Donna Petko, MSN(c), BSN, RN; Clinical Director; 1st Choice Home Health Providers, LLC

If Medicaid Eligibility Expansion (HB 6253) is approved in early January 2013, an estimated 342,000 low-income adults in Illinois will become eligible and enrolled in Medicaid over the next four years.  Once these individuals become insured, they are likely to seek out primary care providers.  However, as designated by the United States Department of Health and Human Services, 100 counties in Illinois have been identified as having State Physician and/or Federal Health Professional Shortage areas (Health & Medicine Policy Research Group [HMPRG], 2012).  Who will provide primary health care services to these newly enrolled Illinois residents?

Advanced practice nurses (APNs) are one solution to the growing shortage of primary care physicians (PEW, 1999).  APNs are registered nurses who have advanced knowledge and clinical training, a graduate degree, and hold national certification.  These professionals serve as health care providers in a broad range of primary care, acute care, and outpatient settings.  In Illinois, there are four categories of APNs: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner, (CNP) and certified registered nurse anesthetist (CRNA).  Currently, there are more than 7,500 advanced practice nurses in the state of Illinois (HMPRG, 2012).

What do advanced practice nurses do?  APNs diagnose illnesses, prescribe treatments and medications, and provide primary care services in a variety of settings which include hospitals, clinics, community health centers, nursing facilities, and schools (HMPRG, 2012).  According to the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health (2010), APNs increase patient safety, access, and continuity of care.  Data from studies on APNs show that these professionals deliver safe, high-quality primary care services (ANA, 2012). 

In order to meet the growing need for healthcare services within the state, APNs need to practice to the fullest extent of their education and training. How do we increase access to healthcare services for Illinois residents?  By changing the Nurse Practice Act and removing practice barriers: 

  • Eliminating the requirement for a written collaborative agreement between physicians and APNs 
  • Allowing APNs to participate in the insurance exchange as primary care providers
  • Providing APNs with full plenary authority to provide access to Illinois residents needing primary care services (HMPRG, 2012).

Besides providing safe, high-quality healthcare, APNs provide a considerable cost savings as well.  For example, the average cost of a nurse practitioner (NP) visit is between 20-35% less than the average cost of an office-based physician visit (Medical Expenditure Panel Survey, 2010).  Furthermore, malpractice rates of NPs are no higher in states with independent NP practice when compared to those states where collaboration is required for practice (HMPRG, 2012).

In addition to supporting HB 6253, which will allow Illinois to leverage over $5 billion in federal Medicaid funding to provide comprehensive health care coverage to over 342,000 low-income individuals (Becker, 2012), please support advanced practice nurses in their quest to provide better access to healthcare services for Illinois residents.  Because APNs are more likely to work in underserved areas caring for Medicaid beneficiaries than primary care physicians (Grumbach et al., 2003; Kaiser, 2011), the barriers to practice must be removed.

The Illinois General Assembly needs to pass HB 6253 by January 9, 2013, the end of the current legislative session, to ensure programs and systems are in place just 12 months from now, when one of the largest parts of health care reform begins (IHM, 2012).  Once this bill is passed, the only way to ensure better access to care for Illinois residents is by changing the Nurse Practice Act to allow APNs to practice to the fullest extent of their education and training. 

Please continue to support this common-sense, fiscally sound legislation in Illinois.  To find out who your legislators are, go to the Illinois State Board of Elections Search PagePlease share this message and urge your friends and family members to tell their legislators to support these efforts between now and January 9, 2013. For more info, read this fact sheet from Health & Medicine Policy Research Group. 

Tuesday, December 18, 2012

What Happens to the Pre-Existing Condition Plans on Jan. 1, 2014?

This post is the first in a series on the Illinois State Partnership Exchange Blueprint Application, which is pending approval by the Federal Government. 

For years, health insurance carriers refused to sell coverage to individuals with pre-existing medical conditions. The Affordable Care Act (ACA) created federally funded high risk pools across the country, including the Illinois Pre-Existing Condition Insurance Plan (IPXP) so that people denied for that reason would not have to go without health insurance. Starting on January 1, 2014, the ACA bans insurance companies from denying coverage based on pre-existing conditions. As a result, IPXP will no longer be needed, and coverage under the plan will be terminated.

So what happens to the enrollees of IPXP on January 1, 2014? 

The ACA dictates that anyone currently enrolled in IPXP will be transitioned into a private insurance plan via the state health insurance exchange. This transition process will happen at the end of 2013. According to the Illinois State Partnership Exchange Blueprint Application, the state has mechanisms in place to prevent lapses in health coverage, as follows:
  • Illinois will send at least three letters to IPXP enrollees containing information on the transition process;
  • The state will conduct proactive outreach to IPXP participants and update the IPXP website with relevant information; and
  • The Illinois health insurance exchange will have extra personnel at the call center specifically to assist with the IPXP transition.

IPXP will only extend coverage for health services until December 31, 2013, which means that all current IPXP enrollees will need to find an alternative health plan before January 1, 2014.  Claims dating from before December 31, 2013 will need to be filed in the close-out period, which will run until June 30, 2015. If deferral funding for the IPXP program has run out, however, even claims filed before that date will not be payable.

Open enrollment into the state health insurance exchange will begin on October 1, 2013, with insurance coverage beginning on January 1, 2014. If current IPXP enrollees purchase a plan during open enrollment, there should be no gaps in their health coverage. Since Illinois is still in the process of establishing its health insurance exchange, check back here for details on how and where to enroll in a health insurance exchange plan, as well as future updates on the IPXP transition process. If you have questions now, contact IPXP at (877) 210-9167, or e-mail your question directly to IPXPInquiry@healthalliance.org

Monday, December 17, 2012

Five Myths about the Medicaid Expansion

The Supreme Court's June 2012 Affordable Care Act ruling was decisive about the implications of the individual mandate; however, it was less decisive about the ACA's Medicaid expansion. The court gave flexibility to each state to decide whether to expand Medicaid to its low income uninsured (below 138% FPL) residents. This flexibility has caused some confusion (some legitimate and some purposeful) about the implications of the Supreme Court decision. Below we address some of the myths vs. realities of the Medicaid Expansion and what it means for Illinois residents:

Medicaid Myth #1: Few states will expand their Medicaid programs.
Reality:
As of 12/12/12, according to health care experts Avalere Health, 18 states have signaled that they will expand, 10 have said that they won't and 23 are undecided. Another health care expert, the Advisory Board Company, shows 14 states in the "not participating" or "leaning toward not participating" group while 18 states are in the participating or leaning toward participating group. Notably, this week, Nevada's Republican Governor and GOP leaders just signaled that they will opt in.

Medicaid Myth #2: Many low-income residents would be eligible for federal subsidies on the exchange if a state does not expand Medicaid. Expanding Medicaid takes away their opportunity to purchase private insurance.
Reality:
The reality is that people living under 100% FPL WILL NOT qualify for subsidies to buy health insurance on the Exchanges and will be the only ones (besides undocumented immigrants) left out in the cold if Illinois doesn't expand Medicaid. Without the new Medicaid eligibility category, these individuals are in a new “donut hole” and will likely be priced out of affordable health insurance through the Exchange because they won’t qualify for the federal financial help. The Urban Institute estimates that of the newly eligible population, approximately 431,000 Illinoisans with household incomes less than 100% FPL will be left in the cold if Illinois does not implement the new Medicaid eligibility category. They will have to continue to access safety-net providers and emergency rooms for care, driving up costs for these providers and showing up sicker. In addition, we all pay more when others are uninsured: according to a study conducted by Millman, Inc., an independent actuarial consulting firm, every family with health insurance pays an additional $1,000 per year to pay for care for the uninsured.

The only "low-income" residents that are either eligible for subsidies on the Exchange OR can participate in Medicaid if Illinois expands Medicaid are people living between 100% -138% FPL. This is a small number of people. Even among those small numbers who DO qualify for exchange subsidies and take up that coverage, the greater cost-sharing requirements for exchange coverage than in Medicaid means that these adults will experience greater financial burdens associated with meeting their health care needs.
 
Medicaid Myth #3: The state will pay for the Medicaid expansion but will not pay for federal insurance subsidies.
Reality
: Not true. The state will not pay for Medicaid Expansion from 2014 through 2016. The federal government pays 100% of the expansion. From 2017
through 2020, the state will slowly start picking up a very small percentage that will slowly increase from 5% to 10% by 2020. In 2020 and beyond, the state will only be responsible for 10% of the cost of the Expansion population.

Medicaid Myth #4: The federal government is already trying to shift more Medicaid expansion costs to the states as a major part of the fiscal year 2013 budget.
Reality:
We have no reason to believe that this will happen and the reality is that President Obama is committed to ensur
ing full implementation of the Medicaid Expansion by states. On December 10, the Obama administration backed away from roughly $100 billion in Medicaid savings it had proposed during deficit-reduction talks earlier this year. In its December 10, 2012 FAQ to states, CMS notes: "The Supreme Court decision has made the higher matching rates available in the Affordable Care Act for the new groups covered even more important to incentivize states to expand Medicaid coverage. The Administration is focused on implementing the Affordable Care Act and providing assistance to states in their efforts to expand Medicaid to these new groups." We have no reason to believe that the federal government will change its mind about the 90% match in the year 2020 and beyond for the Expansion population.

Medicaid Myth #5: Overloading a broken Medicaid program hurts the most vulnerable. Adding so many more people to the Medicaid program will only make these problems worse. 
Reality: The poor who are also uninsured right now still get sick and use health care services. They just don't receive care when they need in the appropriate setting because they end up waiting until their conditions worsens or becomes an emergency. The Medicaid Expansion will allow this group for the first time to have health insurance, and therefore greater access to care at the right time, in the right setting. In addition, in a report released by the GAO (Government Accountability Office) last month, the GAO found that "in calendar years 2008 and 2009, less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance." In fact, IL received a bonus payment of over $15 million last year for meeting quality and other standards in the CHIP program

The current Illinois Medicaid program is not broken; it is efficiently run. Nationally, the per enrollee cost growth in Medicaid (6.1%) is lower than the per enrollee cost growth in comparable coverage under Medicare (6.9%), private health insurance (10.6%), and monthly premiums for employer-sponsored coverage (12.6%). Illinois’ average annual growth in Medicaid spending for FY2007-FY2010 was 6.6%. While it is true that Medicaid in Illinois pays providers less than they typically receive from private insurance (and therefore fewer providers accept patients with Medicaid), to address this issue, beginning January 2013, the Affordable Care Act will be increasing Medicaid payments for primary care doctors.

These aren't the only myths about the Medicaid expansion; the opponents are so bereft of data that they have to result to myth-making. The reality is that the Medicaid expansion makes good fiscal sense and will make a huge difference in the lives of literally hundreds of thousands of Illinois residents. The reality is that the Medicaid expansion is an excellent deal for the state of Illinois.


Health & Disability Advocates
Heartland Alliance for Human Needs and Human Rights
Sargent Shriver National Center on Poverty Law

Friday, December 14, 2012

The Affordable Care Act and You: The New Consumer Benefits

The election is over, and the Affordable Care Act (ACA) is here to stay. The Shriver Center, along with numerous national and local advocacy organizations, has been active in getting the word out about what is in the ACA. Surveys show that many people are unaware of the benefits that are available to them because of the ACA and that most Americansapprove of the consumer benefits offered by the Act. And so, we are launching a biweekly blog series called “The Affordable Care Act and You” because it is time to get to know the ACA.

Let’s start with the basics. What is the Affordable Care Act? Signed on March 23, 2010, the Affordable Care Act sets forth provisions and regulations to reform our health care system in a way that offers more people access to health care. It is important to know that not all insurance plans are subject to the consumer protections rules of the ACA. Employer-sponsored health insurance plans that existed before March 23, 2010, are granted a “grandfather status,” which basically means that they have to abide only by some of the rules of the ACA. However, insurance plans created after that date must abide by all of the ACA’s regulations.

The ACA has decreased the number of uninsured individuals in the U.S., ensured that insurance companies spend at least 80% of your premium dollars on your medical needs, and has made it easier for small businesses to offer health insurance to their employees. These are just some of the existing reforms made by the ACA; in this first blog in the series we will talk about several more consumer benefits provided for in the Act.

1. The ACA makes preventive services free of cost-sharing.

Too many Americans refrain from getting needed preventive care because of the expenses they must pay out-of-pocket.Preventive care is crucial for the simple fact that it helps individuals to avoid costly and deadly illness by detecting health issues early. The ACA requires health plans, excluding grandfathered plans, to offer you preventive services at no additional cost. This means that your immunizations, screenings, and checkups are covered—no out-of-pocket expenses. And for women, well-woman visits, mammograms, contraceptives, and other services are also free of cost-sharing. You can find the full list of preventive services that are now free of cost-sharing here.

2. The ACA bans lifetime dollar limits.

Medical expenses are costly for a healthy individual; for millions of Americans living with a chronic medical condition, health care costs can lead to financial ruin and loss of health insurance. For years, it has been perfectly legal for insurance companies to impose a lifetime dollar limit on your health coverage. And once you reach that amount, they can stop paying for your health expenses. Now, because of the ACA, if you or someone you know has a medical condition, there is no longer a need to worry about losing insurance coverage because of lifetime dollar limit. Because of the ACA, insurance companies are banned from imposing a lifetime dollar limit on your coverage. In addition, the use ofannual dollar limits will be phased out over the next two years and banned entirely in 2014.

3. The ACA provides for dependent coverage for young adults up to the age of 26.

The ACA’s dependent coverage provision allows young adults up to the age of 26, to stay or be added to their parents’ health insurance. The young adult population, or so-called “young invincibles,” often struggle to afford health insurance, and many just go without. Since the dependent coverage provision went into effect in 2010, 13.7 million young adultswere able to remain or rejoin their parents’ health insurance. If you are under the age of 26, or a parent of a young adult under the under this age, check to see if your insurance plan offers dependent coverage up to the age of 26.

4. The ACA will assure that pre-existing conditions will no longer be a barrier to coverage.

Several common health conditions—asthma, high blood pressure, arthritis—can be considered pre-existing conditions. Insurance companies, if they choose to, can refuse to cover you because of a pre-existing condition. Since the passage of the ACA, children can no longer be denied health insurance because of a pre-existing condition. Adults, on the other hand, must wait until 2014 to receive the same benefit. Luckily, the federal government, under the ACA, provided funding to the states for temporary high-risk pools. This funding provides health insurance for adults with pre-existing conditions who are unable to find coverage because of their conditions. In Illinois, this program is called the Illinois Pre-existing Condition Plan (IPXP), and you can enroll by contacting the Department of Insurance.

5. The ACA will end gender rating.

In many states, women can be charged more for health insurance than men—as much $391 more annually! This surprisingly common practice—where insurance company charge more based on gender—is called gender rating. In states that do not already prohibit gender rating, 95% of the best-selling health insurance plans practice it. In Illinois, 100% of the best-selling health insurance plans practice gender rating. Starting in 2014, the ACA will ban gender rating in all states.

These five patient consumer benefits are only the tip of the iceberg. Once the ACA is fully implemented, Americans can expect health insurance to be more accessible, affordable, and comprehensive. Now you know some of the consumer benefits that may benefit you or your family and friends. So spread the word!

This post originally appeared on The Shriver Brief.
Coauthored by Viviane Clement and Andrea Kovach.

Friday, November 30, 2012

Illinois Takes Three Big Steps Forward in Health Reform Implementation

After the November election confirmed the permanent status of the Affordable Care Act (ACA), Illinois wasted no time getting the law’s reforms under way. In less than a month, three big changes have brought the state closer to ACA implementation:

1. On November 19, 2012, Cook County opened enrollment into “County Care,” the Medicaid expansion program for eligible county residents. Through a Section 1115 Waiver approved by the federal government, Cook County will pilot the ACA’s Medicaid expansion in 2013 – a full year before the rest of the state. The program will provide eligibility and access to care to approximately 250,000 low income adults in the County and will operate on a “medical home” model – which means the county’s patients would have a doctor, a nurse, a social worker, and a medical assistant assigned to manage their health care. Stay tuned for County Care progress reports.

2. Not to be out-done by Cook County, Illinois legislators filed a bill (HB 6253) earlier this week to expand Medicaid to all low income Illinoisans (earning up to 138% FPL or about $16,000/year). The Medicaid expansion is a cornerstone of the ACA’s success: it will provide comprehensive medical benefits to 600,000 individuals and is a fiscal boon to the state - bringing in an estimated $5.7 billion in Medicaid provider payments (through 2016) with no net state costs. It will also reduce hospital, Township and local government costs to cover the uninsured. To learn more, check out these fact sheets – one by Health & Disability Advocates and one by the Department of Health & Family Services.

3. The Illinois Department of Insurance was also busy this month, submitting on November 16, 2012, the state’s application to run a Partnership Health Insurance Exchange. In a partnership model, the state and federal government will share responsibilities for administering the online marketplace that will help over one million individuals and small businesses shop for quality health coverage. The state will need to decide soon how it will roll out its Navigator and in person consumer assistance programs. Once the blueprint becomes public, we will post it on Illinois Health Matters.

Finally, we'd be remiss if we didn't mention major policy activity on the federal level, too: right before Thanksgiving HHS published proposed rules governing the ACA's Essential Health Benefits provision, wellness programs and private insurance market reforms. Health Affairs has a great blog post summarizing these federal notices.

Illinois Health Matters will be following all of these federal and state developments closely. Check back for news and updates! Or feel free to ask us a question directly: email us at info@illinoishealthmatters.org.
 
Stephani Becker
Project Director, Illinois Health Matters

Friday, November 16, 2012

Update:Illinois’ Care Coordination and Managed Care System

In January 2011, the Illinois legislature passed a bill that requires 50% of the State’s Medicaid population to be covered in a risk-based care coordination program by 2015. Subsequently, in May 2012, the State Legislature passed the SMART Act, cutting Medicaid services and projecting cost savings through various care coordination initiatives.

The care coordination, or managed care, initiatives referenced through this bill are: the Integrated Care Program, the Dual Eligibles Capitation Demonstration and the Innovations Program. All three of these initiatives have a goal to better coordinate primary, acute, behavioral health and long-term supports and services thereby improving the delivery of health services and lowering health costs.

The move to better coordinate care across primary, acute, behavioral health and long-term supports and services is in alignment with the federal Affordable Care Act (ACA), passed in March 2010. In fact, Illinois has made an effort to take advantage of several of the ACA provisions to move towards a better coordinated and integrated health system.

One of the ACA provisions Illinois is interested in is called Medicaid health homes for individuals with chronic conditions. To date, Illinois has filed a draft Medicaid state plan amendment to create health homes. The other federal ACA inititiave relating to care coordination that Illinois interested in is the Medicare-Medicaid Alignment Initiative, or the Dual Eligibles Demonstration Project. Illinois has submitted a proposal for this demonstration project.

For more details about the various care coordination, or managed care, initiatives in Illinois, please reference the document “Illinois Health Reform 2012: Care Coordination, Managed Care and Long-Term Services and Supports” developed by Health & Medicine Policy Research Group.


Kristen Pavle
Associate Director, Center for Long-Term Care Reform
Health & Medicine Policy Research Group

Monday, November 12, 2012

After The Election: A Consumer's Guide To The Health Law


This post originally appeared on Kaiser Health News; bMary Agnes Carey and Jenny Gold

Now that President Barack Obama has won a second term, the Affordable Care Act is back on a fast track.
Some analysts argue that there could be modifications to reduce federal spending as part of a broader deficit deal; for now, this is just speculation. What is clear is that the law will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.
While some of the key features don't kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits.
Here's a primer on parts of the law already up and running, what's to come and ways that provisions could still be altered.
I don't have health insurance. Under the law, will I have to buy it and what happens if I don’t?
Today, you are not required to have health insurance. But beginning in 2014, most people will have to have it or pay a fine. For individuals, the penalty would start at $95 a year, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016.
For families the penalty would be $2,085 or 2.5 percent of household income, whichever is greater. The requirement to have coverage can be waived for several reasons, including financial hardship or religious beliefs.
Millions of additional people will qualify for Medicaid or federal subsidies to buy insurance under the law.
While some states, including most recently Alabama, Wyoming and Montana, have passed laws to block the requirement to carry health insurance, those provisions do not override federal law.
I get my health coverage at work and want to keep my current plan. Will I be able to do that? How will my plan be affected by the health law?
If you get insurance through your job, it is likely to stay that way. But, just as before the law was passed, your employer is not obligated to keep the current plan and may change premiums, deductibles, co-pays and network coverage.
You may have seen some law-related changes already. For example, most plans now ban lifetime coverage limits and include a guarantee that an adult child up to age 26 who can't get health insurance at a job can stay on her parents' health plan.
What other parts of the law are now in place?
You are likely to be eligible for preventive services with no out-of-pocket costs, such as breast cancer screenings and cholesterol tests.
Health plans can't cancel your coverage once you get sick – a practice known as "rescission" – unless you committed fraud when you applied for coverage.
Children with pre-existing conditions cannot be denied coverage. This will apply to adults in 2014.
Insurers will have to provide rebates to consumers if they spend less than 80 to 85 percent of premium dollars on medical care.
Some existing plans, if they haven't changed significantly since passage of the law, do not have to abide by certain parts of the law. For example, these "grandfathered" planscan still charge beneficiaries part of the cost of preventive services.
If you're currently in one of these plans, and your employer makes significant changes, such as raising your out-of-pocket costs, the plan would then have to abide by all aspects of the health law.
I want health insurance but I can’t afford it. What will I do?
Depending on your income, you might be eligible for Medicaid. Currently, in most states nonelderly adults without minor children don't qualify for Medicaid. But beginning in 2014, the federal government is offering to pay the cost of an expansion in the programs so that anyone with an income at or lower than 133 percent of the federal poverty level, (which based on current guidelines would be $14,856 for an individual or $30,656 for a family of four) will be eligible for Medicaid.
The Supreme Court, however, ruled in June that states cannot be forced to make that change. Republican governors in several states have said that they will refuse the expansion, though that may change now that Obama has been re-elected.
What if I make too much money for Medicaid but still can't afford to buy insurance?
You might be eligible for government subsidies to help you pay for private insurance sold in the state-based insurance marketplaces, called exchanges, slated to begin operation in 2014. Exchanges will sell insurance plans to individuals and small businesses.
These premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four (based on current guidelines).
Will it be easier for me to get coverage even if I have health problems?
Insurers will be barred from rejecting applicants based on health status once the exchanges are operating in 2014.
I own a small business. Will I have to buy health insurance for my workers?
No employer is required to provide insurance. But starting in 2014, businesses with 50 or more employees that don't provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchange will have to pay a fee of $2,000 per full-time employee. The firm's first 30 workers would be excluded from the fee.
However, firms with  50 or fewer people won't face any penalties.
In addition, if you own a small business, the health law offers a tax credit to help cover the cost. Employers with 25 or fewer full-time workers who earn an average yearly salary of $50,000 or less today can get tax credits of up 35 percent of the cost of premiums. The credit increases to 50 percent in 2014.
I'm over 65. How does the legislation affect seniors?
The law is narrowing a gap in the Medicare Part D prescription drug plan known as the "doughnut hole." That's when seniors who have paid a certain initial amount in prescription costs have to pay for all of their drug costs until they spend a total of $4,700 for the year. Then the plan coverage begins again.
That coverage gap will be closed entirely by 2020. Seniors will still be responsible for 25 percent of their prescription drug costs. So far, 5.6 million seniors have saved $4.8 billion on prescription drugs, according to the Department of Health and Human Services.
The law also expanded Medicare's coverage of preventive services, such as screenings for colon, prostate and breast cancer, which are now free to beneficiaries. Medicare will also pay for an annual wellness visit to the doctor. HHS reports that during the first nine months of 2012, more than 20.7 million Medicare beneficiaries have received preventive services at no cost.
The health law reduced the federal government's payments to Medicare Advantage plans, run by private insurers as an alternative to the traditional Medicare. Medicare Advantage costs more per beneficiary than traditional Medicare. Critics of those payment cuts say that could mean the private plans may not offer many extra benefits, such as free eyeglasses, hearing aids and gym memberships, that they now provide.
Will I have to pay more for my health care because of the law?
No one knows for sure. Even supporters of the law acknowledge its steps to control health costs, such as incentives to coordinate care better, may take a while to show significant savings. Opponents say the law’s additional coverage requirements will make health insurance more expensive for individuals and for the government.
That said, there are some new taxes and fees. For example, starting in 2013, individuals with earnings above $200,000 and married couples making more than $250,000 will paya Medicare payroll tax of 2.35 percent, up from the current 1.45 percent, on income over those thresholds. In addition, higher-income people will face a 3.8 percent tax on unearned income, such as dividends and interest.
Starting in 2018, the law also will impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year and $27,500 for families. The tax has been dubbed a "Cadillac" tax because it hits the most generous plans.
In addition, the law also imposes taxes and fees on several major health industries. Beginning in 2013, medical device manufacturers and importers must pay a 2.3 percent tax on the sale of any taxable medical device to raise $29 billion over 10 years. An annual fee for health insurers is expected to raise more than $100 billion over 10 years, while a fee for brand name drugs will bring in another $34 billion.
Those fees will likely be passed onto consumers in the form of higher premiums.
Has the law hit some bumps in the road?
Yes. For example, the law created high-risk insurance pools to help people purchase health insurance. But enrollment in the pools has been less than expected. As of Aug. 31, 86,072 people had signed up for the high-risk pools, but the program, which began in June 2010, was initially expected to enroll between 200,000 and  400,000 people. The cost and the requirements have been difficult for some to meet.
Applicants must be uninsured for six months because of a pre-existing medical condition before they can join a pool. And because participants are sicker than the general population, the premiums are higher.
Enrollment has increased since the summer, after the premiums were lowered in some states by as much as 40 percent and some states stepped up advertising.
A long-term care provision of the law is dead for now. The Community Living Assistance Services and Supports program (CLASS Act) was designed for people to buy federally guaranteed insurance that would have helped consumers eventually cover some long-term-care costs. But last fall, federal officials effectively suspended the program even before it was to begin, saying they could not find a way to make it work financially.
Are there more changes ahead for the law?
Some observers think there could be pressure in Congress to make some changes to the law as a larger package to reduce the deficit. Among those options is scaling back the subsidies that help low-income Americans buy health insurance coverage. The amount of the subsidies, and possibly the Medicaid expansion as well, could be reduced.  
It’s also possible that some of the taxes on the health care industry, which help pay for the new benefits in the health law, could be rolled back. For example, legislation to repeal the tax on medical device manufacturers passed the House with support from 37 Democrats (it is not expected to receive Senate consideration this year). Nine House Democrats are co-sponsoring legislation to repeal the law’s annual fee on health insurers.
Meanwhile, the Independent Payment Advisory Board (IPAB), one of the most contentious provisions of the health law, is also under continued attack by lawmakers. IPAB is a 15-member panel charged with making recommendations to reduce Medicare spending if the amount the government spends grows beyond a target rate. If Congress chooses not to accept the recommendations, lawmakers must pass alternative cuts of the same size.
Some Republicans argue that the board amounts to health care rationing and some Democrats have said that they think the panel would transfer power that belongs on Capitol Hill to the executive branch. In March, the House voted to repeal IPAB.

Friday, November 9, 2012

The Outlook for "Obamacare" in Two Maps

By Tracy Weber and Charles Ornstein; originally posted at ProPublica, Nov. 8, 2012, 10:30 a.m.

It wasn't just President Barack Obama who won Tuesday. His signature health care plan did as well. But while the Affordable Care Act remains alive, less clear is how its various mandates will proceed and who will participate.
To a large extent, the success of the health overhaul lies in how many of the nation's uninsured get coverage. And that is largely in the hands of the states, which have been all over the map in their willingness to cooperate.
We mean that literally. The maps here show the lack of consensus on two key parts of the act: Creating insurance exchanges and expanding Medicaid.
Here's why each map matters.

Map 1: Where Will We Buy Insurance?

Source: Kaiser Family Foundation, current as of Sept. 27, 2012.

The health care act requires all Americans who aren't already insured to buy coverage. But where? That's where insurance exchanges come in.
States have to decide whether to set up these online marketplaces, where individuals can choose among different insurance plans. Setting up an exchange allows states to customize the offerings to the needs of their residents.
States can also partner with the federal government on exchanges. But if they elect not to, the federal government will take over with its one-size-fits all exchange. States are supposed to decide which course to take by Nov. 16.
Along the West coast, legislatures have already voted to set up exchanges. Other states, including Texas, Maine and Alaska, have decided to punt.
But many states in the Midwest and South haven't committed either way. Some governors, such as New Jersey's Gov. Chris Christie, have held off setting up a state insurance exchange until after the election.
A health care consultant group predicted yesterday that 20 states will elect to operate exchanges.

Map 2: Will States Cover More Poor People?

Source: The Advisory Board Company
Obamacare hopes to expand coverage to 30 million of the country's 48 million uninsured residents. A big part of that would come though Medicaid.
States must also decide whether to expand Medicaid to all residents under 133 percent of the federal poverty line (about $14,893 for an individual and $30,657 for a family of four).  Medicaid currently covers poor children, pregnant women, seniors and some disabled adults. The federal government will pay the full cost for the expanded coverage for three years, and then gradually reduce its contribution to 90 percent over the next three years.
As passed in 2010, the Affordable Care Act required states to expand Medicaid or risk losing all federal matching funds for the program. But the U.S. Supreme Court ruled in June that it was coercive to force states to expand their program just to keep money they were already getting.
Now, states that don't opt in will keep their current funding, but residents who might have qualified under an expansion will likely remain uninsured. There isn't a deadline for the expansion, but the federal government says states will receive less federal help if they decide to expand later, according to The New York Times.
As with exchanges, the states are divided.
So far, a handful u2013 including California, Washington and Illinois u2013 have already embraced the expansion. Florida, South Carolina, Mississippi and Louisiana have opted out.
(The states marked with scales participated in litigation against the Act that culminated in June's U.S. Supreme Court decision.)

Too Murky to Map  
Not everything is left to states. Other issues remain murky about the law, perhaps because the deadlines are further in the future.
The requirement for individuals to either buy insurance or pay a fee to the IRS begins Jan. 14, 2014. But the federal government has not made clear how vigorously it plans to pursue those who don't comply.
Here's a flow chart showing who has to pay and who doesn't.
Also unclear is the impact on employers, who will be required to provide health insurance to full-time workers beginning in 2014. Some, according to The Wall Street Journal, are responding by moving employees to part-time positions.
Finally, the Act's opponents in Congress and on the grassroots level will likely do what they can to delay or dilute these requirements, which are among its most unpopular.
If you're interested in comparing the politics further, here's a link to the final presidential election results by state.
Help Us Investigate Patient Safety Have you or a loved one been harmed in a medical facility? Share your story with us. Are you a provider? Tell us your observations about patient harm.

Thursday, November 8, 2012

The Cook County Health & Hospitals System (CCHHS) 1115 Medicaid Waiver—What is CountyCare?

Blog Post by Margie Schaps, Executive Director, Health & Medicine Policy Research Group 

Last month the Cook County Health & Hospitals System received word from the Federal Centers for Medicaid and Medicare that their request for an 1115 Waiver to the Illinois Medicaid system had been conditionally approved, pending the State of Illinois officially accepting the “terms and conditions” of the Waiver. So, as of right now, the expectation is that the State will make this official within the next couple of weeks.

CountyCare, as the new Medicaid program will be known, has been provided for through the Affordable Care Act. CountyCare will allow the CCHHS to enroll tens of thousands of currently uninsured people into this Medicaid Program. People can begin applying on November 5th by phone 312-8648200 or toll free at 855-6718883. Coverage will start January 1, 2013.

This provides a great opportunity and enormous challenge for the health system to transform care by creating patient-centered medical homes rather than relying on expensive and inefficient use of emergency rooms. The focus of the program will be primary care centric with all specialty care, diagnostic and inpatient services coordinated through the medical home.

Eligible people include:
  • Live in Cook County 
  • Be 19-64 years old 
  • Have income at or below 133% FPL 
  • Not be eligible for “state Plan” Medicaid 
  • Not be eligible for Medicare 
  • Be a legal immigrant for 5 years of more or a US citizen 
  • Have a social security number of have applied for one 

Not all doctors within the CCHHS system will be part of the network, and there will be many community health centers that will be part of the network (this list has not officially been released yet)

The CCHHS website has a list of answers to Frequently Asked Questions: http://www.cookcountyhhs.org/patient-services/county-care/


Advocates, providers and patients still have unanswered questions, many of which have been submitted by us to the CCHHS leadership and consultants. We anticipate getting answers to these in the coming weeks and will provide updates to this blog post as we get the information.

Monday, November 5, 2012

Why Physician Groups Support the Affordable Care Act

Physician groups support the Affordable Care Act (ACA) because it will improve health care for our patients. Doctors care about patients, and we support laws that help us do our work for patients—laws that protect those to whom we’ve dedicated our careers. By helping us provide better care, the ACA will make your healthcare better.

Our organization–the National Physicians Alliance (NPA)–was formed in 2005 and is committed to advancing the core values of the medical profession: service, integrity, and advocacy. The organization has key guiding principles that focus on putting our patients health and wellness above all other concerns. NPA’s advocacy has emphasized the need to ensure patient protection and to repair the broken covenant that our nation’s healthcare system must benefit all Americans. Our commitment and our obligation to care for our patients is limited by many factors: insurance company policies that restrict the care we can provide, health disparities that persist despite individual efforts to address them, and a lack of insurance that limits access to health insurance and healthcare.

As a result of NPA’s determination to ensure equitable and affordable healthcare for all Americans, the organization has worked to secure the passage of the ACA and to advocate for its full implementation. In keeping with NPA’s guiding principles, our support of the ACA has been focused on the benefits the law provides to patients as well as its protection of the doctor-patient relationship we hold as a sacred responsibility as professionals.

How does the ACA protect patients?

The ACA provides important benefits for ALL Americans: The ACA provides multiple benefits for the middle class. Considering the major role that healthcare costs play in personal bankruptcies (PDF), it is clear that ensuring the affordability of healthcare provides a crucial protection for middle class Americans. Affordable insurance–made more so by government support to help lower income families and changes in insurance enrollment that are predicted to reduce the cost for all–will allow most Americans to see the health benefits of having health insurance (PDF). Adult children will now be able to stay on parents’ insurance policies until they are 26 years old, thereby enhancing their ability to access health insurance while in school and starting out in the workforce. Coupled with reforms that will remove limits on annual and lifetime coverage benefits for patients, Americans will be better protected as they look to move into the middle class and secure a better future for themselves and their families. In addition, preventive care services including vaccines, pap smears, colonoscopies, and other necessary services will be made available to Americans without requiring co-pays, making them more available than ever before.

The ACA promotes fairness and equality in medical care: The ACA reverses one of the most egregious facts of healthcare insurance in the US: the fact that a person’s gender was the basis for charging women more for health insurance than men. This difference exists only because a woman was a woman, and is not due to specific coverage (PDF) such as for pregnancy or maternity care. The ACA will also target national healthcare inequalities by strengthening the nation’s community health centers, increasing the number of physicians working in medically underserved areas by increasing National Health Service Corps scholarships. Finally, the ACA begins to address our national need for more primary care physicians and move towards a healthcare workforce that is accessible to all.

The ACA protects patients from insurance company abuses: Thanks to the ACA, insurance companies will have less control over patients’ healthcare. Insurers will be required to offer insurance to everyone regardless of whether or not they have a preexisting medical condition–a benefit that has already gone into effect for children and is planned to go into effect for adults in 2014. The ACA prevents insurance companies from setting arbitrary limits to patients’ lifetime health insurance benefits, and as of 2014 will eliminate annual limits to care. Insurance companies are required to spend 80-85% of members’ premiums on providing benefits to those members, as opposed to using that money for administrative costs or executive salaries. The ACA bans the practice of rescissions, in which insurance companies would seek reasons to retroactively cancel members’ insurance coverage once those members became ill and most needed the protection. The ACA provides greater governmental scrutiny of unreasonable insurance rate hikes, helping insure that Americans are not being harmed by insurers willfully increasing policy costs without reason or justification. Finally, by establishing health insurance marketplaces (or exchanges), the ACA will require all insurers to show the purchasers of their products–our patients–that the companies are effective and responsive to their customers’ needs or they will risk patients finding coverage elsewhere. This should increase transparency and provide greater benefits to patients who will be able to vote with their feet and leave ineffective companies to look for better options.

The NPA is not the only physician organization to support the ACA. The law is also supported by the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the Association of American Medical Colleges, the American Osteopathic Association, and the American Medical Student Association. This broad-based support has been given additional voice by nonprofit organizations such as NPA and Doctors for America.

The reasons all of these physician groups support the ACA is simple. As physicians, the law’s reforms allow us to provide better care for our patients–without being limited by insurance regulations or lack of access to health insurance. The ACA removes important barriers to care, and lets us get back to the core focus of our profession: the covenant to do whatever we can to improve our patients’ health and wellness.


This post, by Mark Ryan, MD, originally appeared here, on the National Physicians Alliance blog, on November 4, 2012

Monday, October 15, 2012

Healthcare by the Numbers

In the United States in 2012:
  • Annual health care costs: $2.7 trillion
  • Percent of healthcare costs linked to individual behaviors: 70%
  • Cost of tobacco, alcohol, soda, illicit drugs, unsafe sex, sedentary lifestyle, etc: $1.89 trillion.
The numbers tell a story—of how much money we can save on medical spending if as a society, we find ways to change individuals’ risky health behaviors.

Fee for service reimbursements to doctors:

  • 5 minute cardiac stent: $1500
  • 45 minute behavioral counseling: $15
Current reimbursements favor intervention, not prevention. We pay big bucks for sick care not health care.

Average annual salary:

  • Interventional cardiologist: $320K
  • Family physician: $168K
  • Nutritionist: $53K
  • Athletic trainer: $45K
We need to fairly reimburse the care that will keep people well. We need less high tech and more high touch interventions to empower people to change their lifestyles. We need more athletic trainers, yoga instructors, exercise physiologists, nutritionists, and dietitians, working together with the medical team to promote healthy behaviors. As a society, we need to make healthy choices easy choices.Simplify food labeling.Subsidize fruits and veggies instead of commodities like corn. Ensure the creation of bike trails and city parks.

“We don’t need to spend ourselves into poverty on health care,” cautioned a speaker in the documentary film Escape Fire. “We just need to do it differently.”


We need to reimburse health and wellness instead of more-more-more medical care. We need to pay fee for value instead of fee for service.

If health care inflation applied to the rest of the economy from the 1950s to today, food costs would be:

  • A dozen eggs: $55.
  • A gallon of milk: $48.
We can’t afford the status quo in the way we spend our healthcare dollars. We need to value health, and shift from desperate medical interventions to stave off death to gentle lifestyle changes to promote health. Together, we can pay for the powerful, simple, low tech low cost interventions that motivate patients to change their risky health behaviors, and stop the runaway inflation of our medical costs.

By Dr. Kohar Jones 
This post originally appeared on the Doctors for America blog

Tuesday, October 9, 2012

Affordable Care Act ("Obamacare"): Things Businesses Should Know

Either as an individual or the owner of a small business, you may be affected by the Affordable Care Act tax provisions. The Affordable Care Act (also known as Obamacare) was signed into law by President Obama on March 23, 2010, and recently survived a challenge in the United States Supreme Court. While the main focus of the Affordable Care Act is health reform legislation, there are several tax provisions that will take effect as different parts of the legislation are implemented. The following is an outline of some of the important tax-related consequences of the Affordable Care Act that have already been implemented and some information for what you can expect as the legislation is fully rolled out between now and 2014.

In addition to making sweeping changes to the U.S. health care system, the health care reform legislation added a number of new taxes and made various other revenue-increasing changes to the Code to help finance health care reform.

One of the provisions that were enacted in 2010 was the Small Business Health Insurance Tax Credit. For tax years from 2010 through 2013, the maximum credit is 35% of health insurance premiums paid by small business employers. A small employer is one that has fewer than 25 full-time equivalent employees, pays an average wage of less than $50,000 a year, and pays at least half of the employee’s health insurance premiums. The credit is scheduled to increase to 50% for small business employers after 2013. However, in tax years that begin after 2013, an employer must participate in an insurance exchange in order to claim the credit, and other modifications and restrictions on the credit apply.

In 2011, insurance companies were required to prove they spent at least 80% of the premium payments on medical services, rather than on things like advertising and executive salaries. Those that didn’t were required to provide rebates to policyholders. You may have seen letters, or even rebate checks, hitting your mailboxes recently stipulating to these facts. These rebates may be taxable income to you if you previously received a tax benefit from a deduction for the insurance premiums paid. Your tax advisor should be consulted.

In 2012, employers are required to disclose the aggregate cost of applicable employer-sponsored coverage on an employee’s annual Form W-2. Reporting is for informational purposes only. However, for 2012 Forms W-2 (and W-2s issued in later years, unless and until further guidance is issued), an employer is not subject to reporting for any calendar year if the employer was required to file fewer than 250 Forms W-2 for the preceding year.

Upcoming changes in 2013 include an increase in the deduction for medical expenses. Under prior law, medical expenses had to exceed 7.5% of adjusted gross income in order to be deductible for regular tax purposes, and 10% of adjusted gross income for Alternative Minimum Tax (AMT). The Affordable Care Act increases the regular tax limitation to 10% of adjusted gross income for those who are under the age of 65, bringing it in line with the AMT limitation.

The Medicare Surtax will also kick-in in 2013. For single taxpayers making more than $200,000 and married filing jointly taxpayers making more than $250,000, an additional 3.8% Medicare tax on dividends, capital gains, and rental and royalty income will apply. The KOS Bottom Line Bulletin September 2012 edition included an article titled “Get Ready for the Medicare Surtax in 2013.” To read this article, click here or go to the KOS website at www.koscpa.com/announcements.

If you contribute to a Flexible Savings Plan that your employer provides, beginning in 2013 the amount you may contribute annually to that plan will be limited to $2,500. This is down from the $5,000 prior limitation and will be adjusted annually for inflation.

In 2014, the state-run health exchanges will be set up and the penalties for individuals who do not purchase insurance will kick-in. The penalty will increase over the three year period from 2014 to 2017 as follows:

2014 – The greater of $95 or 1% of income.
2015 – $325 or 2% of income.
2016 – $695 or 2.5% of income

Businesses with 50 or more workers will be subject to a $2,000 per worker penalty if they don’t offer health insurance. Those that do receive a tax credit of 50% of the premium cost.

Nearly all businesses will have to make changes in order to comply with the Affordable Care Act. Do you have questions about how this act affects you? As an employer, are you aware of what changes you need to make? If so, you should attend our breakfast seminar on November 14 titled “What Does the Affordable Healthcare Act (AKA “Obamacare”) Mean for Employers?” This FREE program takes place from 8:30 until 10:30 a.m. at the KOS office at 1101 Lake Cook Road, Suite C in Deerfield, Illinois. To reserve a space, contact Kelly Wallaert at 847.580.4100 or kwallaert@koscpa.com.

Christie Butcher, CPA, MST
Manager, KOS Public Accountants

(This article was originally posted on the Kessler Orlean Silver website here)


Friday, October 5, 2012

The Seven Things We Learned From Escape Fire

 
We hope you make time to see the documentary, Escape Fire, which premiered tonight in cities across the US. Thank you to those of who joined us for the Chicago screening and lively discussion afterwards.

For those of you who haven’t seen it, the film tackles the American healthcare system, a subject that carries with it decades of debate and misinformation.

Recent media attention has focused on partisan politics, rather than what is broken in the system and how best to move forward. There is wide agreement that something has to be done, but until now there hasn’t been a unbiased lens to view the problem. Escape Fire finally provides that lens. The film “seeks to explore possibilities to create a sustainable system for the future and to dispel misinformation in order to create a clear and comprehensive look at healthcare in America."


Below are the seven things or “big ideas” about the American health care system captured by this film. Many of these things you may have already heard about or experienced yourself; however, seeing them packaged in 90 minutes of intense storytelling through the eyes of patients, providers, the military and business leaders makes the messages hit home loud and clear.


After you see the movie, tell us what you think. What did you learn about health and healthcare? What new questions came up for you as you watched? What changes in attitude or behavior are being sparked and inspired by the film? What can you do now or in the future to make a difference in your own health and healthcare as well as the health and healthcare of those around you? Drop us a line at info@illinoishealthmatters.org and let us know!

Barbara Otto, CEO

Health & Disability Advocates


Seven Things


1. PAYING MORE, GETTING LESS


The average per capita cost of healthcare in the developed world is $3,000. In the U.S., it’s around $8,000. As a country, we spend about $2.7 trillion on healthcare annually, and about one-third of healthcare costs, roughly $700 billion, do not improve health outcomes. In fact, for the first time in the history of our country, life expectancy is going down for many disadvantaged Americans. The high price of healthcare affects all of us, even if we’re already covered by health insurance. As costs spiral out of control, individuals are the ones who make up the difference, be it through higher premiums or taxes. The first step in changing the system is understanding that the current model is unsustainable.



2. TREATING THE WHOLE PERSON

Most doctors only have time for quick fixes, for putting Band-Aids on the problem. We need the healthcare system to provide incentives for leading healthier lifestyles, changing our diets, and being open to holistic methods of healing that can address the body and the mind — in other words, the whole person.


3. PREVENTING DISEASE

Roughly 75% of healthcare spending goes to treating preventable diseases. That’s a lot of unnecessary money and a lot of unnecessary illnesses. For too long, the American healthcare system has emphasized tests, screening, and awareness of disease. While these practices
might lead to earlier detection, they’re no match for true disease prevention. We don’t have to wait for disease to set in to live healthier lives. If we can make fresh food as cheap as processed food, and if we can live more active lives, we can curb disease before it ever has a chance to strike. But we need support: from our workplaces, from our communities, and from our healthcare system.


4. OVERMEDICATION

We spend $300 billion on pharmaceutical drugs. That’s almost as much as the rest of the world’s medicine spending combined. Prescription drugs play a vital role in helping patients who need them; however, too many drugs are being marketed to patients who don’t need them, leading to situations where the drug has the potential to do more harm than good. The military recognizes the problem, and they’re trying to wean soldiers off their drugs by putting more emphasis on alternative approaches: physical therapy, exercise, yoga, and meditation. They are preaching patient-centered care that better meets the needs of injured veterans.



5. OVERTREATMENT

For patients, “more” doesn’t necessarily mean “better.” When it comes to our health, recent studies show that “more” can actually mean “worse.” The reason? Any time we go into a hospital, we take on risk. Medical errors do happen. Harmful drug interactions do occur, especially when so many doctors and nurses are giving you care. A recent study showed that as many as 187,000 people a year
die from medical error or hospital-related illness. If that were an official cause of death, it would be the third largest killer in the U.S.


6. AN ENTRENCHED SYSTEM

Pharmaceutical companies, medical device manufacturers, hospitals, and insurance companies are profiting from our declining health. Some of the $2.7 trillion dollars we spend on healthcare every year goes to supporting lobbyists and politicians in Washington who maintain business as usual. To get back on track, we need to remember that healthcare is about more than just making money. It’s about making Americans healthier.


7. REIMBURSEMENT

“When you reward physicians for doing procedures instead of talking to patients, that’s what they’re going to do - procedures.”
- Dr. Leslie Cho, Cardiologist, Cleveland Clinic 


In general, the system rewards higher-tech, higher-cost procedures over low-cost, high-touch treatments. Primary care physicians aren’t paid to have long conversations about nutritional counseling or exercise regimens. Most alternative therapies aren’t covered. We need to shift payment to reward everyone in the system for providing the right kind of care rather than more of the wrong kind of care. If we can start reimbursing doctors and hospitals to keep patients healthy or, better yet, keep Americans from ever becoming patients, then we’ll see a rapid change in the way we give care.

[These "Seven Things" were adapted from the Escape Fire Screening & Discussion Guide. You can use this guide to hold your own screening - at your workplace, in your community, in your schools or at home.]