Welcome to the Illinois Health Matters Blog

What health reform means for the people of Illinois

A blog by IllinoisHealthMatters.org

Monday, April 30, 2012

The Affordable Care Act: Dollars Flowing into Illinois

There’s no debating that Illinois could use some healthcare help. The state is ranked the 29th healthiest state—not the absolute bottom, but nowhere near the top. A recent poll also listed Illinois as the 31st most obese state and 25th for diabetes—not exactly stellar statistics. The same source noted that ,while Illinoisans benefit from high usage of early prenatal care and a comparative availability of primary care doctors, the state faces severe challenges, including prevalent binge drinking, high pollution levels, and a high rate of preventable hospitalizations.

These problems are not insurmountable. However, we all know the state is in a budget crisis. Governor Quinn has announced a plan to drastically reduce spending and raise revenues for Medicaid. We understand the state budget crisis, but obviously, people in Illinois need medical services, and the state is currently struggling to provide them.

Luckily, the Affordable Care Act is there to throw a lifeline out to health service providers and state agencies and especially to the real people who need healthcare. Thanks to the ACA, the states will spend about $90 billion less on healthcare with the implementation of the law than they would have spent without it. Thousands of people will still be getting the increased services mandated by the Act, but much of the funding will be federal rather than state.

It’s important to note that these benefits are not in the distant future; Illinoisans from birth to retirement are already benefiting from the Affordable Care Act.

Assistance from the ACA starts when kids are young; the ACA has already provided:

  • $10.3 million for Maternal, Infant, and Early Childhood Home Visiting Programs. These programs bring health professionals into individual homes to connect families to the services they need to raise happy and healthy kids. These services include prenatal care, pediatric care, education, and parenting skills. 
  • $191,000 for Family-to-Family Health Information Centers, organizations run by and for families with children with special health care needs.
  • $4.9 million for expanding and improving school-based health centers. Illinois funds 38 school-based clinics that provide screenings, physicals, exams, and more to students.
  • $555,000 to support the Personal Responsibility Education Program, which educates youth on abstinence and contraception to prevent teen pregnancy and sexually transmitted infections, including HIV/AIDS.

The ACA is also spending money putting people to work at improving healthcare! Illinois has received:
  • $400,000 to support the National Health Service Corps, by assisting Illinois in repaying educational loans of health care professionals in return for their practice in health professional shortage areas. This program is designed to help medical, dental, and mental health providers who choose to work in needy communities to repay their student loans. This is a particularly critical program because these professionals provide medical and dental care that individuals desperately need; the program allows professionals to provide care to needy individuals without worrying about their reimbursement rates or their ability to pay back debt.
  • $5.1 million for health professions workforce demonstration projects. This program is designed to supplement the workforce in areas that are either already short-staffed or expected to be in the future. The Illinois Workforce Investment Board’s report noted shortages of both registered nurses and licensed practical nurses in Illinois. 

And the ACA helps elderly Illinoisans, too!

So far, Illinois has received $170.7 million in grants due to the Affordable Care Act. These grants are creating tangible improvements to the physical and fiscal health of our state. Thanks, Affordable Care Act!

This article, written by Caitlin Padula, was originally posted on The Sargent Shriver National Center on Poverty Law's blog, The Shriver Brief

Friday, April 27, 2012

New Report Shows Medicaid Cuts Will Hurt Illinois Economy

A new report from Families USA and the Campaign for Better Health Care shows that Governor Quinn’s proposed $2.7 billion one-year reduction in Medicaid spending would hurt “Illinois’ economy, its health care providers, and the Illinoisans who depend on Medicaid for health care.”

The report, released on April 25, emphasizes Medicaid cuts mean both lost jobs and lost business activity. For example, a 5 percent reduction in state Medicaid spending would jeopardize more than 7,000 jobs and cost the state about $923 million annually in business activity. A 10 percent reduction doubles those figures. Quinn’s proposed 18 percent cuts mean the potential loss of more than 25,000 jobs and more than $3.3 billion in lost business activity. Short-sighted cuts can have long-term negative effects on Illinois’ economy. 

“Just because Medicaid gets cut doesn’t mean that people will get any less sick or need any less medical care. With no source for preventive or primary care, patients will eventually end up in the emergency room with a more severe illness or complications,” notes Jim Duffett, Executive Director of the Campaign for Better Health Care. “Chronic conditions such as diabetes, high blood pressure and cardiac issues must be managed or the consequences can be fatal.” 

“Medicaid is not just a safety net. It helps strengthen families in tough times, and it provides security for the most vulnerable, such as our kids, who are the future. For those of us who have private insurance and think we are immune from drastic cuts and changes in the Medicaid Program, think again. Slashing eligibility and services will financially cost you and your family more than the political rhetoric of some who say gutting the program will save you money." Duffett explains, "The expanded cost to pay for uncompensated care is then passed on to consumers, employers, and businesses in the form of higher insurance premiums. It is estimated that, in 2008, family coverage cost $1,017 more because of higher premium charges (cost shifting) that resulted from passing along the costs of uncompensated care.” 

Illinois Hospital Association President & CEO Maryjane Wurth says that blunt cuts are devastating to patients and the entire health care system. “Drastic Medicaid cuts hurt everyone—not just the Medicaid patients. Hospitals will be forced to reduce jobs. Local businesses will be impacted. And hospitals will be forced to cut or eliminate medical services that everyone uses—there is not a separate set of staff, equipment and facilities just for Medicaid patients.” 

The cuts would be costly for the state as well, since Illinois receives slightly more than one dollar in federal matching funds for every dollar it spends on Medicaid. The federal match brings new money into the state that the state would not otherwise have. 

“We have workable solutions such as expanded coordinated care that will not compromise patient care,” says Wurth. “We have presented these multi-year proposals to members of the General Assembly and look forward to working with them to create a more effective Medicaid system. It’s important that Medicaid patients get the most efficient, high-quality care possible.” “The Governor’s proposed cut to Illinois’ Medicaid program is both cruelly insensitive and economically unsound,” said Ron Pollack, Executive Director of Families USA. “His proposal will deny the state more than a billion dollars in federal support, cost the state billions in economic activity, put tens of thousands of jobs at risk, and hurt the state’s most vulnerable families and senior citizens. For many reasons, this is the wrong direction for Illinois in these difficult economic times.” The report is available at www.cbhconline.org. 

 # # # 

About Families USA 
Families USA is the national organization for health care consumers. It is nonprofit and nonpartisan and advocates for high-quality, affordable health care for all Americans. For more information, · www.familiesusa.org 

About the Illinois Campaign for Better Health Care 
We believe that accessible, affordable, quality health care is a basic human right for all people. The Campaign for Better Health Care is the state’s largest coalition representing over 300 diverse organizations, organizing to help create and advocate for an accessible, quality health care system for all. For more information, visit www.cbhconline.org. 

About the Illinois Hospital Association 
The Illinois Hospital Association, with offices in Naperville, Springfield and Washington, D.C., is an advocate for 200 hospitals and health systems and the patients and communities they serve. For more information, visit www.ihatoday.org.

The Economic Toll of Health Disparities

April is National Minority Health Month, and we are commemorating it with this post on health disparities from the Heartland Alliance blog, Heartbeat. The Affordable Care Act's reforms will make a difference in some of these disparities, such as the focus on expansion of access to primary care, innovations in medical delivery models, increased access to health insurance and the Medicaid expansion

Health disparities among minority groups account for 30.6% of direct medical expenditures, reflecting the significant toll being African-American, Asian or Hispanic has on one's health and economic well-being.

A study by the Joint Center for Political and Economic Studies found that between 2003 and 2006 almost a third of health care costs for minorities were due to poorer care compared with whites. Minorities face greater barriers to preventive care, acute treatment and chronic disease management.

Eliminating those disparities would have reduced by $229.4 billion direct medical expenditures by minorities, according to the Joint Center's estimate. Minorities could have saved more than $1 trillion on indirect costs -- such as those associated with illness and premature death -- during the four years studied if disparities didn't exist.

The 2010 National Healthcare Disparities Report found that rates of potentially avoidable hospitalizations for blacks are double those of whites. Blacks and Hispanics have higher rates of potentially avoidable hospitalizations for chronic conditions compared with whites.

Differences in access to care, provider biases, poor provider-patient communication and poor health literacy contribute to health disparities, according to the report. It states:
"Unfortunately, Americans too often do not receive care that they need, or they receive care that causes harms. Care can be delivered too late or without full consideration of a patient's preferences or values. Many times, our system of health care distributes services inefficiently and unevenly across populations."

Quoted in an America's Wire article on health disparities, Jennifer Ng'andu of the National Council of La Raza said minority children are particularly impacted by a lack of access to care. Children "will experience developmental setbacks because they are sick or their parents are sick. It makes it harder for them to achieve in school and can have serious consequences on their future."

Financial strains on families due to health care can hinder children's academic success and, in turn, future earnings. At the same time, minority youth are increasingly affected by chronic diseases such as diabetes.

Hispanics in general have higher rates of high blood pressure and obesity than non-Hispanic whites. They are twice as likely to die from diabetes as non-Hispanic whites, according to the Centers for Disease Control and Prevention.

Caring for chronic disease over a lifetime is expensive. With minorities representing more than half of uninsured Americans, the effect on their health and finances can be great. We support efforts to expand access to care -- particularly for preventive services -- to minority communities to eliminate health disparities and the economic costs that come with those disparities.

This article was originally posted on the Heartland Alliance Heartbeat blog

Let's Be Clear: this Cut Will Backfire

Many of the impending Illinois Medicaid cuts are short-sighted and will result in an increase in expenditures. This is particularly true for Medicaid community-living waiver programs that offer services for older adults and younger persons with disabilities.

A 2009 article in The Gerontologist showed that 2006 budget cuts to Michigan's state Medicaid community-living waiver program "were associated with increases in adverse outcomes: ER visits, hospitalizations, and permanent [nursing facility] placement." The study suggests that when we cut Medicaid waiver programs for persons with disabilities, these individuals cannot continue to live at home and require greater use of health services.

The Illinois legislature proposes changing the eligibility criteria for Medicaid community-living waiver programs, much like in Michigan. Let's be clear: this cut will backfire. It will ultimately cost the state more money through increased rates of hospitalization, ER visits and permanent nursing facility placement.

And I haven't even mentioned that there's more than balancing the state's budget at stake: in Olmstead v. L.C., the U.S. Supreme Court mandated a community-living option for all persons with disabilities. With three landmark lawsuits in Illinois recently settled under Olmstead (for mental health, developmental disabilities and physical disabilities), is the state of Illinois seeking to add a fourth lawsuit to the docket?

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

(Originally posted in the Chicago Tribune "Local Voices" here)

Thursday, April 26, 2012

Choose Wisely, Illinois: Alternatives for Balancing the Medicaid Budget

On Thursday, April 19, 2012, the Governor released a proposal for the reduction of the current $2.7 billion Medicaid budget deficit. The proposal, developed with a group of legislators on the Medicaid Commission, includes $2 billion in cuts to eligibility levels, benefits, and payment rates to providers, and a $1 per pack increase in the cigarette tax. Some of the Governor’s most concerning proposals include eliminating the Illinois Cares Rx program, reducing eligibility for FamilyCare, eliminating the General Assistance Medical Program, eliminating the adult dental program, and requiring a co-pay from vulnerable populations utilizing federally qualified community health centers.

Many of these cuts will not be “fixed” by the implementation of the Affordable Care Act in 2014. For example, Illinois Cares Rx covers costs not covered under Medicare or the ACA such as premiums, deductibles, lower co-pays, and medications not covered in the Medicare formulary. The biggest misconception is that the ACA will fill the Medicare “donut hole.” It gradually reduces costs in the donut hole over the next 8 years but never completely eliminates that cost-sharing as Illinois Cares Rx does.

Other cuts may be “repaired” by the implementation of health care reform, such as coverage for low income parents, but at what cost? How much preventative care will be missed in the next 18 months which will cost the state more in expensive emergency or acute care after January 1, 2014?

Medicaid is a vital source of health care for many Illinoisans. Although the Medicaid program must become more efficient to safeguard taxpayer dollars, there are other alternatives to the proposed cuts. Solutions such as cutting prescription drug coverage, eligibility, or optional services are unacceptable and will drive up long-term state costs. The General Assembly and Governor have underfunded Medicaid for 20 years and the cuts do not need to all happen immediately; a multi-year solution is needed to balance the program budget. Furthermore, short term solutions, such as cutting prescription drug coverage, eligibility or optional services are unacceptable, and will only drive up long-term state costs. It is important for Illinois legislators to keep in mind that transformative Medicaid reforms currently being implemented and require time to work, and that The Medicaid budget cannot be balanced with Medicaid cuts alone. New revenue and savings from legislative changes in other budget areas must be applied to Medicaid.

Some of the proposed alternatives are:

Medicaid system Delivery reforms: Reforms such as the Care Coordination Innovations Project, Integrated Care Program, and other projects to better manage the care of some of the highest-need Medicaid patients need time to be implemented to see the full scope of savings and improved health outcomes.

Changes for Nursing Home and IMDs: Nursing homes and Institutions for Mental Disorders (IMDs) have excess capacity, resulting in thousands of empty beds across the state. Reducing the number of licensed beds could save Medicaid money. Refocusing efforts on community-based services, rather than institutional placement, would also reduce costs, and in some cases, qualify for more Federal funding. Also, Illinois could implement the nursing home bed tax, already approved by the federal government, which has not yet been implemented because the nursing home industry has not agreed on a formula to redistribute funds.

Stop paying for medically unnecessary, elective C-sections: C-sections are significantly more costly, require a longer recovery time for both the mother and often the infant, and can lead to complications due to premature birth. Nearly half of all C-sections in the U.S. are medically unnecessary, and it is estimated that Illinois’ Medicaid program spent between $54M and $76M on medically unnecessary C-sections in 2009.

For more information, see the Responsible Budget Coalition's fact sheet on alternatives to the cuts here.

Stephanie Altman
Program and Policy Director
Health & Disability Advocates

Whose Budget Problem is Worse than Illinois?

Illinois has a budget problem.   Ironically, our state leaders all agree that one of the ways to solve this problem is to pass it along to the household budgets of some of our most vulnerable seniors and people with disabilities. How?   Eliminate Illinois Cares Rx
State leaders, editorials, and other opinion leaders would lead you to believe Illinois Cares Rx is some “extra” program that we can no longer afford.    What they always fail to talk about is how this “extra” program helps real people.  And, they have no good answer for what these folks are supposed to do after Illinois Cares Rx is eliminated. 
The typical Illinois Cares Rx enrollee is the one who always has just a little too much income to qualify for our traditional needs-based poverty programs but not enough income to afford the cost of their healthcare and other necessities.  He or she typically has a chronic health condition such as Multiple Sclerosis, or heart disease or Alzheimer’s and lives on the edge financially…carefully saving their money, trying to stay within a budget that does not have a lot of “wiggle room,” and often having to do this with little to no help from their government or anybody else.   

Illinois Cares Rx steps in to help this group so that they don’t have to make choices to skip doses of specialized medication, cancel a doctor’s appointment, pay rent late, or receive shut off threats from the utility companies.      

Here is a budget problem more difficult than the one our state leaders are facing: 

A typical Illinois Cares Rx enrollee might have $1500 per month in income from Social Security.  After premiums, co-payments and deductibles, the enrollee might be left with about $1300 per month, if they are lucky.  Illinois Cares Rx provides about $100 in benefits to the average enrollee each month.  So, we will be reducing their available income another $100 to $1200 per month if Illinois Cares Rx goes away. Now, what do we cut to make up for this?  Food?   Utilities?   Rent?   A follow up visit to the doctor?   And state leaders thought they had a tough job with the Illinois budget…

Call the AARP Illinois Hotline which will connect you with your state legislator. Contact them now and tell them to protect this vital program while budget negotiations are still happening. Call 1-888-616-3322 and tell them to “Preserve Funding for Illinois Cares Rx.”

John Coburn
Senior Policy Attorney

Wednesday, April 18, 2012

Keep Illinois Medicaid Strong: Principles for Financial Stability

The Illinois Medicaid program provides life-saving health coverage to nearly 2.7 million
low-income children, parents, seniors, and people with disabilities and behavioral health
needs, including addiction and mental illness. However, the program faces a $2.7 billion deficit this year, and legislators are exploring a range of solutions. We all need to ask: How much does each of these “solutions” actually cost us in health and long-term care outcomes and state funds? Our organizations endorse the following principles for stabilizing the Illinois Medicaid program.

Solutions such as cutting prescription drug coverage, eligibility, or optional services are unacceptable and will drive up long-term state costs. The services people on Medicaid receive now reduce future state health spending by providing prevention services and early intervention. 

Transformative Medicaid reforms are being implemented but need time to work. To improve the health and lives of Medicaid recipients while reducing costs, Illinois is contracting with commercial managed care companies and networks of providers to implement robust care coordination models. However, these programs cannot be in place overnight.

The General Assembly and Governor have underfunded Medicaid for 20 years; a multi-year solution is needed to balance the program budget. Medicaid reforms enacted in 2011 already establish a decade-long glide path to pay old bills, and this plan should be followed.
The Medicaid budget cannot be balanced with Medicaid cuts alone. New revenue and savings from legislative changes in other budget areas must be applied to Medicaid. Medicaid cannot be firewalled from the rest of the state budget; it is an economic engine that supports families, creates jobs, and helps children learn.

Supporters of this Statement: AARP IllinoisAccess LivingAgeOptionsAIDS Foundation of Chicago
American Cancer Society (Illinois Division)Campaign for Better Health Care, Chicago ADAPT, Citizen Action IllinoisCJE SeniorLifeDoctors Council SEIUHaymarket CenterHealth and Disability AdvocatesHealth and Medicine Policy Research GroupHeartland Alliance for Human Needs & Human RightsIL Alcoholism and Drug Dependence AssociationIL Alliance for Retired AmericansIL Association of Public Health AdministratorsIL Association of Rehabilitation FacilitiesIL Chiropractic SocietyIL Coalition for Immigrant and Refugee RightsIL Iowa Center for Independent LivingIL Maternal and Child Health CoalitionIL Partners for Human ServiceIL Primary Health Care AssociationIL Public Health AssociationIL Society for Advanced Practice NursingIllinois Society for Public Health EducationIL Valley Center for Independent LivingIllinois Network of Centers for Independent LivingImpact CILLatino Policy ForumNational Organization of Nurses with DisabilitiesNew Age ServicesOunce of Prevention Fund

Tuesday, April 17, 2012

Care Providers on the Affordable Care Act

The nurse practitioner-in-training
Gerald Whitney Santangelo, 47, of Arlington Heights, Ill., quit his job at Hewlett-Packard (HPQ) this year. He’s studying to become a nurse practitioner.

For the last 16 years I’ve worked at Hewlett-Packard in several senior sales positions. I’ve recently made a decision to go back to school. It was an absolutely gut-wrenching decision. I’m giving up a salary of more than $150,000 a year. I’ll be lucky to make 50 percent of that. At the same time, I believe in universal health care. I wanted to find where I could serve the individual, not an organization.

We’re going to need nurse practitioners. It’s going to be a very long process, and it’s actually very daunting. I’ll be 54 or 55 at the end of my studies.

So now I find myself at the local community college taking prerequisites because you really have to take a lot of science just to apply to nursing programs. Certainly it is a little strange with looks I’m getting from kids—’Who’s this old dude? Why is he here; what’s wrong with him?’ Overall, I’m having the time of my life.

I’m not Don Quixote. I’m a practical person that wants to provide a solution. We used to say in business: ‘You can’t boil the ocean.’ You look at what you can impact and put a plan in place. What I can impact is helping a small community have basic health-care services.

I don’t expect everybody to quit and become a nurse. Everybody could participate in their own way—whether it’s supporting reform or putting out ideas of what positive change could be. But sitting back and just saying ‘no’ is not a solution.

The primary-care doctor
Dr. Kohar Jones, 34, is a family physician who works part-time at the Chicago Family Health Center, a community clinic on the South Side of the city.

I’m a National Health Service Corps scholar, which means the government paid for me to go to medical school, and in return I pay the American people back by serving an underserved community.

The ACA has been really positive so far. There’s been $11 billion allocated for community health centers and $6 million of those came to Chicago Family Health Center, enabling us to revamp a clinic in the Pullman neighborhood.

In many ways ACA is health insurance reform rather than health-care reform. There have been some important changes to protect patients from lack of coverage.

I see the need all the time. I see it with diabetics—they stop buying the medicines they need. One patient lost his job, lost his insurance, then lost sensation in his hands and feet because his sugar was so out of control. He stepped on a nail and didn’t notice it until he smelled it, and then he had to lose his foot. Insulin, when it’s not subsidized, costs $100 to $200 a month, but that costs so much less than disability and sickness, losing a limb.

We need a health-care system, and the ACA doesn’t give us a system. It gives us shifts and incentives within a health-care hodgepodge that has too many people falling through the cracks. The point of a system is to promote health and ultimately find a way to do that efficiently, effectively, and encompassing as much of the population as possible.

The business advocate
A former Republican governor of Michigan, John Engler, 63, is president of the Washington-based lobby group the Business Roundtable.

Businesses would like to have a significant say because the Roundtable companies are the health-care innovators. As the people who write the checks, our concern has been the rising cost.

The law is complex, it’s expensive, and I think increasingly difficult to implement.

There is a very strong belief among business health-care providers that the private marketplace is still very important and that transparency and accountability are two components that have been missing in some ways.

The taxes that are levied are of great concern. This is driving the cost up now. At this point, the benefits are de minimis compared to some of the costs.

To me, a much more consumer-directed, market-driven health system is highly desirable. Just because someone’s poor doesn’t mean they’re not fully capable and desirous of playing a bigger role in making health-care choices and decisions. We have to keep in mind that we spend dramatically more than anybody in the world on health insurance, and we do that despite not getting health care that’s dramatically better than everybody else.

The debate is not over. The obligation on the part of business and other groups is to actually bring forward ideas and alternatives that would deal with the fundamental problem, that we want people in the 21st century to be having access to health care when they need it.

— As told to Leslie Patton and Christopher Flavelle. 
This article originally appeared on Bloomberg Businessweek

Monday, April 16, 2012

Today is National Healthcare Decisions Day

April 16 has been designated National Healthcare Decisions Day, a day to raise awareness of and encourage advance care planning. National Healthcare Decisions Day is a collaborative effort of national, state, and community organizations to ensure that all adults with decision-making capacity are empowered to communicate and document their healthcare decisions.

Many people find it difficult to discuss end-of-life care, either their own or that of a loved one. Although most Americans have thought about their preferences regarding end-of-life care, less than one third has a living will. These conversations should not be put off; no one can predict just when he or she will be rendered unable to participate in their own healthcare decisions. The process of clarifying your own wishes, choosing a health care agent to speak for you when you’re no longer able to speak for yourself, sharing these decisions with loved ones and your doctor, and writing them down on Advance Directive forms will ensure that your treatment is carried out in the manner your desire and will make treatment decisions easier for your family and loved ones when the time comes.

End-of-life care decisions can be complicated. A discussion with a healthcare professional may help you begin thinking about the possibilities that may arise, can assist your understanding of your options, and help you clarify your values and preferences and the level of medical intervention you may want. Originally, CMS included advance care planning in the list of additional services that could be included in the Medicare annual wellness visit, provided for by the Affordable Care Act. However, last January CMS rescinded this element, citing a lack of opportunity to consider the wide range of views held on the subject. Nonetheless, patients can still turn to healthcare facilities for additional information and guidance in their advance care planning. The Federal Patient Self-Determination Act requires that all healthcare facilities participating in the Medicare program provide information to patients on Advance Directives and health care decision-making rights.

Some avoid engaging in advance care planning because they mistakenly believe that an attorney’s assistance is required to prepare the documents. Although an attorney can assist you, sample forms are available on the Illinois Department of Public Health website, which you may fill out yourself and which require just a few signatures, as specified by law. The site provides an overview of Illinois law and explains the signatures and number of witnesses required for each type of advance directive. Illinois allows for three types of advance directives: health care power of attorney, living will, and mental health treatment preference declaration. If you do not want to use the sample forms provided, you can also write your own health care power of attorney or living will, as long as the required signatures are still obtained.

Some Advance Care Decisions to think about:

  • Healthcare Power of Attorney: enables you to choose an “agent” who will make healthcare decisions for you if you become unable to do so yourself. As long as you remain able to make your own healthcare decisions, you will be able to continue to do so. Unless you specify a time limit, the power of attorney will remain effective until your death, but you are free to cancel it at any time
  • Living Will: informs your healthcare provider whether you want death-delaying procedures used if you have a terminal condition and are unable to make your own healthcare decisions. Unlike the healthcare power of attorney, a living will only is effective if you have a terminal condition. The living will may be cancelled at any time.
  • Mental Health Treatment Preference Declaration: enables you to say whether you can to receive electroconvulsive treatment (ECT), psychotropic medicine, or may be admitted to a mental health facility when you have a mental illness and cannot make healthcare decisions for yourself. You can also use the form to choose someone who will make your mental health treatment decisions for you (called an “attorney-in-fact”).
  • Do-Not-Resuscitate Order (DNR order): A medical treatment order that states that if your heart and/or breathing stops, CPR will not be attempted. Illinois has developed a Uniform DNR Advance Directive form which contains two parts: an advance directive that is consented to by the patient or his or her legal representative and witnessed by one adult, and a physician’s order, signed by the physician. All appropriate medical treatment other than CPR will still be rendered to you. Illinois’ Uniform DNR form is currently being updated to reflect the standards of the National Physician Orders for Life-Sustaining Treatment program.
After making any end-of-life treatment preference decisions and filling out any advance directive documentation, it is your responsibility to make sure that loved ones, doctors, attorneys, and/or any agents you appoint are aware of your wishes. You may want to give each a copy of your advance directive(s) as well. Although advance care planning can be an emotional and difficult process, taking the time now to have these discussions will make certain your loved ones and physician are aware of and understand your treatment preferences, and will ensure your wishes can be carried out when the time comes.

Amanda Swanson
LL.M. in Health Law Candidate
Loyola University Chicago School of Law

Friday, April 13, 2012

Moving Forward: Current Waivers for Coordinated Care Projects in Illinois

“Care Coordination,” along with related terms like “managed care” and “medical home” have become the buzz words of health care reform. The terms refer to new types of health care delivery models that many states and programs are turning to as the key to reforming the costly and arguably inefficient health care system.  Currently, the health care system mostly operates as a “fee-for-service” model, which critics argue incentivizes overutilization of medical services and shifts the focus away from effective preventative care, leading to excessive costs. Organizing groups of health care providers around patients, with a greater level of communication between doctors and a greater focus on care that keeps patients from getting ill could streamline health care delivery in a way that lowers costs and improving quality of care (for a more in-depth look at coordinated and managed care, go here or here).

In recent years, federal health programs, like CMS, have started to investigate the potential of care coordination via demonstration projects, grants and waivers for states or health care providers willing to participate. The Affordable Care Act also encourages exploration of these new care delivery models. In 2011, Illinois passed Public Act 096-1501, also known as Medicaid Reform, and began the Illinois Innovations project. As a part of that reform, the state is currently utilizing these waivers and grants:

The Integrated Care Program (ICP) is a 5-year pilot program that transfers all Medicaid (but not Medicare) eligible adults in Suburban Cook County to a Managed Care organization (MCOs). The 40,000 people included in the program, have two MCOs to choose from, one Aetna Better Health and IlliniCare Health Plan, Inc. The program is currently in Phase I, which focused on medical care. Phase II will focus on long-term care (set to begin September 2012), excluding long term care for those with developmental disabilities, which will be the focus of Phase III (no current implementation date).

Coordinated Care Entities (CCE) is a project intended to help Illinois enroll 50% of Medicaid clients into coordinated care projects (as called for by Public Act 096-1501). The CCEs are looking to cover at least 500 enrollees in a Health Home, FFS, Shared Savings or Bundled Payment model of care delivery. Illinois decided to release a request for proposals to medical care providers, in order to test the interest and capacity of community health organizations to offer coordinated care to patients, instead of simply enrolling Medicaid clients into Health Maintenance Organizations (HMOs). In January, Illinois released requests for proposals for Health Homes for chronically ill adults. Awards are expected to be announced by May 2012. HFS plans to release requests for proposals for CCEs to target children with complex medical needs by June 2012.

The proposed Cook County 1115 Waiver, currently pending with CMS, seeks to cover up to 200,000 uninsured patients who will become eligible for Medicaid once Affordable Care Act Medicaid Expansion takes place in 2014.

The Dual Eligibles program targets those who are eligible for both Medicaid and Medicare. The program would integrate the care that dual eligibles receive into one Managed Care Program. The proposal was open to a 30-day public comment period that closed in late March, and will be sent to CMS for approval.

Under the We Choose Health Community Transformations grant, the Center for Disease control has given the Illinois Department of Public Health $4,781,121 to serve the state of Illinois, excluding large counties. Work will focus on expanding efforts in tobacco-free living, active living and healthy eating, quality clinical and other preventive services, social and emotional wellness, and healthy and safe physical environments. This grant will dovetail with Illinois’ State Health Improvement Plan (SHIP), a prevention-focused, comprehensive approach to improving the health of Illinois residents.

The State has proposed changes and possible mergers of the Home and Community Based Waiver programs including the DORS Home Services Program and the Community Care Program. The major proposal affecting the HCBS waivers is a proposed change from a Determination of Need (DON) threshold of 29 to 37 in order to obtain services. DORS has also proposed reducing the Service Cost Maximums in the HSP program to the levels in the CCP program.

Wednesday, April 11, 2012

Do What’s Best for Illinois

The dispute in Washington, D.C. over health-care reform is stirring debate everywhere. Opinions on what aspects of reform matter to many puts us at risk of losing sight of what matters to all — quality, affordable health care. Regardless of what the Supreme Court decides, Illinois lawmakers should ensure that Illinoisans see lower costs, better quality and more stability in their health coverage.

They can start by creating a health insurance exchange program that allows individuals and small businesses to pool their buying power and negotiate for better prices for health-care coverage. Smart economic decisions are based on ample choice and price comparison. The more health-care options, the better the cost and access to primary care. An exchange program would provide consumers the opportunity to be in control of their own health coverage.

More than 8,000 of our patients are uninsured and do not qualify for Medicaid or Medicare. An insurance exchange program could secure affordable coverage for their primary health-care needs and keep them from seeking routine care in a hospital emergency room. As a Federally Qualified Health Center, we know the importance of primary care for not only promoting better health, but preventing diseases. Illinois should do what is best for its residents, not for big insurance companies.

Warren J. Brodine, CEO,

Originally published in the Chicago Sun Times on April 4, 2012

Tuesday, April 3, 2012

Supreme Court Wrap Up - A Law Student's Perspective

Last week the Supreme Court heard oral arguments on the Affordable Care Act (ACA), commonly known as health care reform. Hearings were held for more than six hours over three days -- more time than has been given to a case in over 50 years.  At least 170 briefs were filed -- more than any other case in history.  Efforts to overturn provisions of the history-making law are proving to make history themselves.

On the first day, the Court heard arguments on the impact of the Anti-Injunction Act (AIA) on the constitutional challenge to the ACA’s minimum coverage provision.  The AIA works to prevent federal courts from hearing cases in which taxpayers are seeking court orders to prevent the government from assessing or collecting a federal tax - the theory being that the proper time for a court’s involvement in such cases is after the tax in question has already been paid (which for the ACA could be not for a couple more years).  As a consequence, before the Supreme Court can consider whether the ACA is constitutional, it must determine whether the AIA takes away the authority of federal courts to hear the case, or whether it does not apply to this controversy.  Counsel for the states argued that even if the penalty is a tax, the controversy should still be heard by the Court because the respondents are not seeking to enjoin the assessment or collection of a tax, but instead the requirement that everyone purchase health insurance.  The Justices considered the use of the word “penalty” in the ACA, the relationship between the insurance mandate and the penalty, and the effect of both provisions (individually and together) on the public and the states.
On Tuesday, the Supreme Court heard arguments on the minimum coverage provision of the ACA, which requires that all Americans (with limited exceptions) maintain a minimum level of “essential health care coverage.”  The issues the Court must address are whether it is within Congress’s power under the Commerce Clause of the Constitution to mandate the purchase of health insurance coverage, and whether Congress has the authority to assess a penalty against those who refuse to do so.  Americans have already been subjected to a number of mandates before the ACA, such as filing income tax returns and serving on a jury, but challengers to the ACA argue that purchasing health insurance is not a duty of citizenship, as other mandates have been.

Under the Commerce Clause, Congress has the power to regulate an activity that has a substantial affect on interstate commerce.  The questioning on Tuesday centered mostly around which market was being regulated by the ACA: the insurance market, health services generally, or the portion of health services utilized by the uninsured.  The Justices also posed many questions with regard to the argument that everyone is in the healthcare market, noting that almost everyone is going to require some kind of healthcare during their lifetime, that having health insurance is often a requirement for people to access the healthcare they need, and that the government is able to mandate vaccinations when a public health emergency arises.

On the third day of oral arguments, the Court heard arguments on the severability of the individual mandate provision and state sovereignty in the Medicaid expansion.  The severability issue considers whether Congress would have intended the rest of the ACA to stand if the individual mandate provision was found to be unconstitutional.  Challengers to the ACA argue that the individual mandate is the essence of the ACA, and that Congress would not have intended the additional “miscellaneous” provisions of the ACA to stand without it.  The Court also heard arguments in support of leaving the rest of the ACA intact and letting Congress decide whether to enact further amendments if needed, and the government’s argument in favor of striking also only those additional provisions found closely linked to the individual mandate; the guaranteed-issue and community-rating provisions.

The hearings concluded with arguments on the Medicaid expansion.  Under the Medicaid program, the federal government provides funds to participating states, and in return the states agree to follow certain standards.  The ACA set new standards for the Medicaid program in expanding eligibility to individuals with incomes up to 133 percent of the poverty level, the increased costs of which will be paid for entirely by the federal government until 2016, and then decrease to 90 percent federal coverage by 2020.  As a result, states would be required to expand coverage of their state’s Medicaid programs, or lose all federal Medicaid funding (typically 50 to 83 percent of the state’s Medicaid program spending).  Arguments on this issue addressed the possible coercion created by the ACA, by offering states an offer that cannot be refused.  Whether coercion depends on how much the federal government threatens to take away or what it is offering and the relationship between both was also discussed.  At the end of the hearing, Justice Ginsburg sought clarification that the challengers to the ACA would be satisfied with providing states the opportunity to opt out of the Medicaid expansion, instead of striking the expansion from the bill entirely.
Finally, last Friday, the Supreme Court Justices cast their votes on the constitutionality of the ACA in a conference room with no one else present.  In the weeks to come, the Justices will draft opinions and dissents on the case, and one Justice may be assigned to write the majority opinion, or multiple will be assigned to each write about different issues.  While each Justice’s vote can certainly change over the course of the next several weeks as they draft their opinions, most often changes are from the minority to the majority after reading the opinion, although it is possible that a vote change will affect the outcome of the controversy.  It will be late June or early July before the decision is finalized and the opinion is made available to the public.  Until then, we can only speculate as to where the Justices will fall on the issue.

Amanda Swanson
LL.M. in Health Law Candidate

What’s Next for Health Care Policy in Illinois?

The past two weeks were a non-stop affair for health care policy—the ACA saw its 2nd anniversary right before the Supreme court heard oral arguments for the historic case against the law, and here at IHM we premiered our data visualization tool. However, health care reform news has not stopped. Here’s a brief overview of what the next few months have in store for health care in Illinois:

Health Insurance Exchange: State legislators made little progress towards votes on the establishment of a competitive health care marketplace, though negotiations on HB 4141 are underway. Legislators still have time to establish an exchange, but the Federal deadlines are looming closer, and to miss deadlines could cause Illinois to lose out on important Federal grant money. If the group waits to move forward with the exchange until the Supreme Court announces its decision on the ACA case -- a prospect that interests some legislators -- , there may not be enough time to set up a functioning exchange. Governor Quinn has said that he would establish the exchange via an executive order if necessary.

Potential Cuts to Medicaid: The Illinois Medicaid program faces a $2.7 billion deficit in the coming fiscal year. In order to deal with that budget, the Department of Healthcare and Family Services has proposed a list of possible cuts to Medicaid services in order to balance the budget. As legislators go into the upcoming spring sessions, many advocates are calling for other methods of fixing the Medicaid budget deficit that do not compromise important health care services that the program provides.

The Illinois General Assembly starts its April sessions on the 17th.. Follow the progress of these health policy issues with IHM!