The American Health Care Act Hurts

The American Health Care Act (2017) is a radical step back from progress made to provide health insurance for all Americans.  It breaks the federal government’s fundamental compact, where the federal government promised to pay its fair share in providing health coverage to the nation’s most vulnerable people. That includes the working poor, people with disabilities, older adults, and children.

The AHCA makes it harder to access health insurance

The Affordable Care Act provides support, through tax credits and subsidies, for millions of the working poor, Americans who earned too much for Medicaid but who cannot afford the premiums for individual insurance. The AHCA shatters that reality by promoting a system where financial assistance is slashed and fewer people will be able to afford coverage.

The AHCA moves financial assistance from the poor to the rich
The AHCA will punish the working poor. The current system of tax credits and subsidies will change radically. Tax credits based on income, and other factors, would become a flat amount based only on a person’s age. The Congressional Budget Office report details how a 21 year old living at 175% of the federal poverty level would see her current tax credit drop from $3,400 to $2,450. Cost-sharing subsidies to help pay out of pocket costs would  be eliminated, placing further burden on her and the millions living near the poverty line who need these critical supports to pay for health insurance.

The AHCA makes coverage more expensive for older adults

The AHCA is particularly hard on older Americans.  It allows insurance companies to charge seniors 67% more for their insurance premiums than what they would be charged today. The AHCA does this by giving insurance companies the right to charge seniors 5 times more for their coverage than they would for someone in their 20s. Even though the Republicans have proposed age rated tax credits to help seniors pay for their insurance, it won’t be nearly enough to help cover these increased costs.

Adding to these financial burdens, the AHCA also makes insurance more expensive if you have a gap in coverage. No matter how you look at it, the AHCA adds burdens to the working poor and older Americans instead of providing the support so many need.

The AHCA breaks the promise to provide care to the most vulnerable
The American Health Care Act breaks the federal government’s 50 year compact with the states in assisting in the cost of providing health coverage to low-income people, including children, pregnant women, people with disabilities and adults. Medicaid is the underpinning of the nation’s health care system; it is the safety net for 68 million Americans and financing the program has always been a shared responsibility between the federal government and states.

The AHCA siphons billions in federal dollars out of the Medicaid program, leaving states to pay up and make cuts

The CBO estimates that the AHCA would cut the federal government’s support for Medicaid by $880 billion, forcing states to accept a fixed funding formula for the Medicaid program.  This will leave states responsible for a larger percentage of their Medicaid costs. Since states must balance their budgets annually, reductions in federal funding will lead to state cuts in eligibility, benefits or payment rates.

The AHCA also allow doesn’t grow this set amount at a rate equal to Medicaid growth rates, which means states will have less money each year as expenses increase and funding doesn’t keep up.

The AHCA is a bad deal for Illinois, where Medicaid dollars are already stretched

Medicaid finance reform is happening at a time when Medicaid covers 1 of every 5 births, and 1 in 4 lives in Illinois. Medicaid spends nearly 30% of its total expenditures on services and supports that help people live independently in their communities. Illinois has been seeking a waiver from the federal government to bring in more dollars for much needed behavioral health services and supports. Illinois already has some of the lowest payment rates in the country.

Changing the Medicaid funding formula would dramatically impact Illinois’ ability to maintain current Medicaid funded services and supports which the state has already deemed inadequately funded. Further cuts to federal funding for the state would devastate an already ailing health delivery system.

Illinois can’t afford the AHCA

The AHCA hinders access to health insurance, curtails financial assistance to the most vulnerable, raises costs for older adults, and leaves our state in an even worse fiscal situation. Illinois residents can’t afford it. Our state can’t afford it.

We urge the Illinois Congressional delegation, and Governor Rauner to aggressively push back on the AHCA.

Related reading

• Analysis from Sen. Durbin's office: TrumpCare: Less for More
• Vox: The Republican plan to slash Medicaid, explained
• Washington Post: Sleeper issue of Medicaid’s future could prove health-care plans’ stumbling block
• Congressional Budget Office: report
• House Ways & Means Committee: Section by section summary
• Commerce & Energy Committee: Section by section summary

Key Lessons from Health & Medicine’s Budget Forum

On January 15, 2016, Health & Medicine hosted a meeting of The Chicago Forum for Justice in forum proceedings notes as a reference guide for the forum’s content.

Our notes are written as a summary and while they can’t fully capture the presentations, videos of each of the five mini panels are available on the event webpage, as are slides from speakers who used them in their presentations. We thank CAN TV for recording, editing, and sharing videos of the forum, extending the potential impact of our panelists’ presentations.

We hope these notes will be useful for advocates and policymakers seeking to understand issues related to the budget, think about potential revenue solutions, and consider strategies, framing, and narratives likely to advance progress.  Health & Medicine will be convening a small group soon to review the forum proceedings and discuss next steps for our work on this critical area, which we’ll share on our website.

While the budget problems and solutions are more complex than this, here are some main points that have emerged for me from conversations and from the presentations and discussion at the conference:

• Illinois lacks sufficient revenue, which represents a structural budget problem, priming the State to have recurring budget shortages and hampering our ability to provide Illinoisans with the public services they need and want, thus harming the health of the public, and disproportionately harming vulnerable communities.
• The structural budget problems have several potential revenue solutions, including a progressive income tax structure and efforts to ensure corporations pay their fair share, both of which are more equitable than our current system and would better grow revenue in proportion to the size of Illinois’ economy.
• State elected officials are collectively responsible for passing a budget and using a selection of revenue solutions that will help preserve and improve the vital health, social, and education programs and services that support people’s health and Illinois’ economy.  Inaction on the structural revenue shortages that Illinois faces is an unacceptable abdication of the governing duties our public officials share.

Of course, these salient points are based on a range of facts and history about Illinois’ taxes and budgets, beyond the scope of this post.  A significant amount of such relevant detail is covered in the forum proceedings notes, as well as the slides and videos on the event webpage (linked to above).

Also, related to this subject, Health & Medicine’s Executive Director, Margie Schaps, had two letters focused on Illinois’ budget published in the last couple of weeks:

• Consider the long-term consequences Regarding the recent layoffs at Lutheran Social Services of Illinois published in Crain’s Chicago Business
• Illinois needs a budget. Governor Rauner, let’s get it done.  A response to Governor Rauner’s State of the State Address in the Chicago Tribune

Wesley Epplin
Director of Health Equity
Health & Medicine Policy Research Group

Medicaid: The Long-Term Costs of Short-Term Savings

The Rauner Administration’s decision to cut $1.5 billion in Medicaid spending to balance the state budget is like the proverbial cutting off the nose to spite the face. Central to the Rauner “plan” is to tighten eligibility for people with disabilities and older adults to access long-term care services and supports (LTSS). The Administration is proposing to increase the minimum eligible level of something called the “Determination of Need” score. The DON eligibility process determines how many hours of assistance an older adult or person with a disability can get in order to stay in their own home.

While the Administration views this as an appropriate cost-cutting measure, in reality such a move will ultimately reduce needed community-based services for people with significant disabilities, and will spread those costs to other parts of the healthcare delivery system.

Where the costs go

What happens to those costs? They get passed on to hospitals and urgent care providers, taxpayers (in the form of other social programs), and family members who are either under-employed or unemployed in order to help a loved one.

Persons who are aging or living with a disability require access to long-term care to live independently, and do not have other options to find support for their medical needs. Reducing access to home and community-based services means individuals who are at risk of living in more costly nursing facilities become desperate to find any help with activities of daily living, through friends or family members who may be able to assist with financial or personal healthcare needs.

This is easier said than done, however, as family members or friends who can volunteer to assist are often being forced to choose between their own employment and assisting their family member or a loved one. Creating a further burden is Rauner’s proposed elimination of funding for developmental disabilities respite care, a program that provides assistance for people who care for persons with disabilities,

Medicaid is not only the payer of last resort, but the program of last resort, for persons with significant medical needs – paying for as much as 49% of the country’s long-term care services.

How to save the state money

Keeping people out of emergency rooms and nursing homes ultimately saves the state money. Progress Center for Independent Living released data showing that home services remove pressure from Medicaid spending on nursing homes, saving the state more than $17,500 per person, per year in the Home Services Program for people with disabilities.

The cost savings for seniors in the Community Care Program are even greater, at more than $24,150 per person, per year. Consider the fact that the Home Services Program serves 30,000 people with disabilities, and the Community Care Program serves more than 80,000 people year round (based on the FY 2014 Public Accounting Report for both HSP and CCP from the Illinois Office of the Comptroller), and you have staggering numbers for cost savings. According to the Service Employees International Union, more than a third of people with disabilities now in the Home Service Program – some 10,000 people – will lose access to care in their homes, thereby creating a dependence on hospitals and institutions to address their long-term care needs. The Community Care Program will be losing more than 38,700 seniors.

Debate surrounding the state budget should be aimed at taking concrete strategic actions, rather than cutting low-cost and money-saving programs. Governor Rauner appears bent on forging ahead despite opposition from the Illinois house and senate.

The facts are clear. The cuts to the Medicaid budget are not cost-effective, and they isolate vulnerable populations. The notion that diminishing social safety nets is a good way to control state budget deficit is at best misguided, and we need to move on from this policy.

Related reading:

• Community-Based Long-Term Services & Supports at Medicaid.gov
• Gov. Rauner's Health Benefits for Workers with Disabilities site
• Kansas to break new ground in demeaning the poor? column by Michael Hiltzik in the LA Times
• ACA, Medicaid and Unintended Consequences for People with Disabilities post at the IHM blog
• Disability Rights Advocates Deliver Coffin To Rauner, Decry 'Deadly' Human Services Cuts in Progress Illinois

Rauner's Budget is Bad Medicine for State's Health Services

The following post originally appeared on Crain's Chicago Business.

The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:

• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding

It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:

• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.

As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:

• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).

We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.

Barbara A. Otto
CEO
Health & Disability Advocates

Safety Net Hospitals Spared, But Not Much Else in Medicaid Bills

Although Medicaid is a state & federal program, the City of Chicago got involved in the raging debate in Springfield. On Tuesday, May 22, 2012, Alderman George Cardenas (12th Ward) called a meeting of the Chicago City Council Committee on Health and Environmental Protection to discuss the way Governor Quinn’s proposed Medicaid cuts would affect medical care providers, specifically Safety Net Hospitals. Those hospitals have a client base that is primarily those without insurance, or those insured via Medicaid, which puts the hospitals in a position to be disproportionately affected by any Medicaid cuts.

Hospital CEOs, including those representing St. Anthony's, Mercy Hospital and Norwegian American Hospital and others, and community leaders including Metropolitan Chicago Healthcare Council, Health & Disability Advocates, Catalyst Schools, Lawndale Christian Development Center and the National Latino Education Institute, testified in front of the committee. Each person spoke about the impact of the cuts to their constituencies. The cuts would not only mean a loss of accessible healthcare in Chicago communities but also a steep decline in jobs, as many of the hospitals fuel the economic engine in the communities they serve.

Turns out some of the voices were heard: SB 2840, the final Medicaid budget bill (Named the "Save Medicaid Access and Resources Together (SMART) Act"), softens the original blow—sparing safety net hospitals from proposed provider reimbursement cuts, and lowering cuts overall from $240 million a year instead of $675 million. Passed by both houses on May 24, 2012, it will go to the Governor's desk for signature and will most likely be signed.

Unfortunately, many other health care programs for low income people and those with disabilities in Illinois were not spared in the bill. A full list can be found here, but the cuts include:

• Elimination of Illinois Cares Rx
• Family Care Eligibility reduction to 133% FPL (from 185%-400% FPL)
• Elimination of General Assistance Medical
• Adult Dental Eliminated (except in emergencies)
• 4 Prescription per month limit

These cuts will be devastating to many vulnerable populations and advocates are gearing up for the anxious phone calls from clients and providers.

The one silver lining in yesterday's legislative action is that the Cook County 1115 waiver (HB 5007) passed both houses which will allow Cook County Health and Hospital System to expand access to care for about 250,000 low income adults (below 138% FPL) in the area. Under the Affordable Care Act, their health insurance will be covered by the federal government so this will save the State $36 million per year. Of course, this is dependent on the Supreme Court upholding the ACA. Assuming it does, this early expansion of Medicaid is a huge kickstart toward ACA implementation in Illinois.

One baby step forward, two giant steps back:

So, while we mourn the Medicaid losses in SB 2840, we need to celebrate the gains in HB 5007. Nevertheless, it's important to keep talking about the life-threatening and costly implications of the stunning loss of access to affordable, quality health care that will be triggered by the signing of this "SMART" law. We also need to share clear information about the potential benefits of implementation of the Affordable Care Act, even though the ACA will not completely undo the economic cost and harm set forth in yesterday's decision.

Stephani Becker
Health & Disability Advocates, project director of Illinois Health Matters

Medicaid plan would shake up the way hospitals are paid

A draft copy of Medicaid reform legislation closely resembles a proposal that Gov. Pat Quinn made last month. However, it appears that it would reform the way some medical providers are paid and potentially avoid immediate cuts to their rates.

The plan would transition hospitals to a payment plan known as an All Patient Refined Diagnosis Related Groups (APR-DRG) system, according to a draft version of the amendment obtained by Illinois Issues. The legislation covers more than 400 pages.

Quinn’s office did not respond to questions about the draft amendment.

APR-DRGs were created by 3M Health Information Systems for the Center for Medicaid and Medicare Services. “The design and development of the [Diagnosis Related Groups (DRGs)] began in the late '60s at Yale University,” said an overview of DRGs from 3M. “The initial motivation for developing the DRGs was to create an effective framework for monitoring the quality of care and the utilization of services in a hospital setting. The first large-scale application of the DRGs was in the late '70s in the state of New Jersey. The New Jersey State Department of Health used DRGs as the basis of a prospective payment system in which hospitals were reimbursed a fixed DRG specific amount for each patient treated.” The system takes into consideration the complexity of the health issues facing patients that hospitals are treating.

Starting in October 2012,The Department of Health and Family Services would determine the reimbursement rates for inpatient services at hospitals under the APR-DRG payment plan, but Hospitals would still get paid current rates. DHFS would work with the Illinois Hospital Association and a "hospital technical advisory group" on a path to transitioning to the APR-DRG rates by the end of Fiscal Year 2014.

Danny Chun, vice president of corporate communications and marketing for the Illinois Hospital Association, would not comment on specifics of the amendment but said rate cuts to medical providers should be a “last resort.” “There are other options and alternatives that we have been talking to everybody about over the past weeks and months that we think can generate substantial savings and revenues,” Chun said.

Quinn’s original plan would have cut provider reimbursement rates by $675 million. Quinn also proposed a $1-a-pack cigarette tax increase to protect the program and providers from deeper cuts. Such a tax increase would likely be moved in separate legislation.

The draft amendment calls for savings in areas that Quinn outlined in his original proposal. Under the plan:

• The Department of Healthcare and Family Services would no longer be required to provide adult dental care or eyeglasses. This does not mean that it would necessarily eliminate eyeglasses. It could also offer to scale back the program by offering replacements less often.

• Illinois Cares RX, a program that provides prescription drug health to seniors, would be eliminated.

• All patients would be limited to four prescriptions a month. Three of them could be brand name drugs. Patients would pay a $2 copay for generic drugs. They currently have no copay for generics.

• Coverage for group therapy in nursing homes, adult chiropractic care and in patient detox programs would be eliminated.

• Repairs to or replacement of medical equipment, such as wheelchairs and prosthetic devices, would require prior approval from DHFS. The proposal also contains provisions targeting fraud and calls for the state to contract with a vendor to help DHFS verify the eligibility of Medicaid patients.

Sen. Dale Righter, a member of a legislative working group charged with finding Medicaid savings, said he had not seen the amendment. He said he expects Quinn to file his plan by the end of the week. Righter said the rates paid to Medicaid providers have been a pivotal part of negotiations. “I know there is still a lot of talk going on about [provider reimbursements], and I think we’re going to learn a lot more in the next couple of days,” he said.

That's not to say, however, that provider rate cuts would not be a part of the final legislation. Another possibility being considered would spare so-called safety net hospitals — which take a high rate of Medicaid patients and are often in underserved communities — from rate cuts while other hospitals would have to bite the bullet on reductions. Those close to negotiations say the overall plan is still a work in progress and that Quinn’s final proposal would likely see changes from the amendment that is currently circulating.

Righter, a Republican from Mattoon, said it is unlikely that the working group will present competing legislation. “I don’t think it will shake out that way. There will be competing ideas out there, but I don’t think you’re going to see a governor’s bill and a working group’s bill, I don’t think it will break out like that.” 

By Jamey Dunn and Ashley Griffin
Illinois Issues Blog - The official blog of Illinois Issues magazine, published by the Center for State Policy and Leadership at the University of Illinois Springfield

(Originally posted here on 5/16/12)

5 Ways Health Care Reform Will Benefit Illinois Small Businesses

Illinois has strong, vibrant neighborhoods and small businesses play a vital part in those communities. However, while small businesses are working to meet their bottom line, it can be challenging for them to afford to provide health insurance for their employees. According to the Small Business Majority, an average of 86% of small businesses owners who don't offer health coverage to their employees say they can't afford to provide it. The Affordable Care Act (ACA) has put into place reforms – some right now and some rolling out later – that will make it easier for the owners of small businesses to buy affordable insurance. Below we list five ways that health care reform will benefit Illinois small businesses and their employees.


At Ruby's Restaurant, Health Care May Be On The Table - Images by Jay Dunn

1. RIGHT NOW: Since March 2010, tax credits are being offered to small businesses owners with 25 or fewer full time equivalent employees in order to help them offset the costs of providing health insurance. Until 2014, small businesses who pay for at least half of their employees’ health care premiums will receive a tax credit to offset 35% of those premium costs. Starting in 2014, the tax credit will increase: for those small businesses who buy insurance through the insurance exchange (see #5 below), the tax credit increases to 50%. September 15th is an important deadline for filing so check out the tax credit calculator here to see if you are eligible.

2. RIGHT NOW: Small businesses often struggle with unpredictable and often steep health insurance premium increases from year to year. One of the priorities of the Affordable Care Act is to implement consumer protections so that insurance companies are more transparent and accountable with things like premium increases. As of September 1, 2011, health insurers seeking to increase their premium rates by 10 percent or more must submit their request to state or federal reviewers to determine whether they are reasonable or not. This rate review program will bring more predictability to health insurance costs and in many cases will lower costs for small business owners.

3. RIGHT NOW: Many small business owners cannot purchase affordable insurance, because they have a pre-existing condition. A pre-existing condition is a physical or mental health condition, disability or illness that you have before you enrolled in a health plan. If you or your employees are uninsured and have a pre-existing condition, you may be eligible for the Illinois Pre Existing Condition Insurance Plan, which is an insurance plan that was established by the Affordable Care Act. Questions? Call the Toll Free Number: (877) 210-9167, or email your question directly to IPXPInquiry@healthalliance.org.

4. LATER: Under the Affordable Care Act, denying health coverage or excluding benefits due to a pre-existing condition will no longer be allowed. As a result, if you have a pre-existing condition that has prevented you from buying affordable insurance for yourself and your employees, on January 1, 2014, it will not make you uninsurable any longer. This change is already in place for children under age 19.

5. LATER: The new health reform law establishes a competitive healthcare marketplace, commonly known as an “insurance exchange” run by each state or the Federal government. Slated to be up and running by the beginning of 2014 in Illinois, the Exchange will make purchasing insurance easier for individuals and small businesses by giving them the power to compare health care plans in one digital hub. The Exchange will also ensure that quality health insurance options are available – and that subsidies are also available to those who need them. These online marketplaces will create competition among insurance companies that will help to drive down the costs of insurance. More information about Illinois’ progress toward establishing an Exchange, can be found here.

If you have questions about the new health care law and how it affects you or your small business, submit your questions here and we will write you back.

An employee and customer at Ruby’s. The owners of the restaurant currently can’t afford to pay for health insurance for their employees, but that could change with the Affordable Care Act reforms