Welcome to the Illinois Health Matters Blog

What health reform means for the people of Illinois

A blog by IllinoisHealthMatters.org

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