The Affordable Care Act Will Not Replace Illinois Cares Rx

Illinois Cares Rx is one of the many health programs on the chopping block in Governor Quinn's Medicaid budget plan. This will affect 160,000 low income seniors and people with disabilities who receive Illinois Cares Rx to help them pay for life-saving medications, typically for chronic health conditions such as Multiple Sclerosis, heart disease or Alzheimer’s.

There are no "good" choices when it comes to budget cuts in health & human services in Illinois - but it's critical for state legislators to separate the myths from the facts when decision time arrives. One of the myths being spread around is that Illinois Cares Rx can be cut because the Affordable Care Act will replace it in 2014.

Simply put, that is not true:

• Illinois Cares Rx pays for Medicare Part D premiums; the Affordable Care Act will not.
• Illinois Cares Rx covers Medicare Part D deductibles; the Affordable Care Act will not.
• Illinois Cares Rx reduces the cost of medications when seniors and people with disabilities hit the "donut hole;" while the Affordable Care Act has begun to close the donut hole it will not completely close it until 2020.

See a full comparison chart here that shows what Illinois Cares Rx currently provides for low income seniors and people with disabilities and how it intersects with the Affordable Care Act. You can see that the overlap is minimal.

Please call your legislators and make sure that they have the facts about Illinois Cares Rx cuts which affects all districts in Illinois. Call 1-888-616-3322 which will connect you directly to your legislators and tell them to “Preserve Funding for Illinois Cares Rx.”


John Coburn
Senior Policy Attorney
Health & Disability Advocates

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)

Schools: The Missing Link in Promoting Healthy Children

On May 9^th, 2012, Healthy Schools Campaign and Trust for America’s Health, along with a group of partner organizations (including Health & Disability Advocates), released policy recommendations to Secretary of Education Arne Duncan and Secretary of Health and Human Services Kathleen Sebelius. The recommendations called on the departments to “further support the critical connection between health and learning, and build this priority into the Department’s infrastructure and leadership.”

A strong connection exists between children’s health and education. A child who is healthy is more likely to attend school and engage in learning. However, many schools lack things necessary to promoting health, such as access to clean air and water, nutritious food and school nurses; and do not provide an opportunity for students to be active throughout the day.  

School’s lack of emphasis on health comes at a time when promoting health is of the utmost importance. Rates of chronic diseases, such as asthma, diabetes or obesity, have doubled among kids in the last several decades. Students with a chronic condition often need extra care to manage their condition, and school—a place where many kids spend most of their time—could play an important role in their health.

Our nation faces a growing achievement gap in our nation’s students—which recent studies have shown to be linked to health issues. Low-income minority students are more likely to suffer from health issues, as well as more likely to attend a school without a healthy environment.

Healthy Schools Campaign, Trust for America’s Health and their partner organizations crafted their recommendations with these strong connections between health and learning in mind. The recommendations focus on actions that are within the government’s role to make and can have an immediate impact on the health of students and the achievement gap:

Recommendations to the Department of Education:

1. Expanding the mandate of the Office of Safe and Healthy Students (OSHS) and appointing a Deputy Assistant Secretary to the office in order to build up the office’s capacity for leadership.
2. Support pre-service and professional development programs for teachers and principals by making health a priority in grants and other training programs.
3. Make health an important factor of the standard of excellence for the Blue Ribbon Program.
4. Developing and disseminating best practices for colleges and universities to support teachers’ and school leaders’ abilities to address student health needs
5. Support the development of resources for schools to effectively engage parents around school health and wellness issues.
6. Support the development of educational data systems and school accountability programs that incorporate student health.

Recommendation to the Department of Health and Human Services:

1. Reduce barriers schools face in providing health care to students: Currently, restrictive regulations limit the reimbursements schools can receive from Medicaid. Removing these restrictions, which HHS itself deemed “unenforceable,” would allow schools to expand the health care schools can afford to provide to students.
2.   Include Schools in the National Prevention Strategy: The strategy emphasized the importance of making good health a priority in all areas of life, not just within a health care setting. It is important for HHS to acknowledge how important schools are to an effective prevention strategy, and to fully investigate the role schools may be able to play in promoting health.

At the event, Secretary of Health and Human Services Kathleen Sebelius announced a $75 million investment in the establishment of school health centers, as a part of the School-Based Health Center Capital (SBHCC) Program, created by the Affordable Care Act. These health centers offer disease prevention and health screenings to students. This announcement marks one of many necessary steps in the right direction towards the integration of health and education.

Stephanie Altman

Health & Disability Advocates; Program and Policy Director

Check back with Illinois Health Matters for more info on how the Department of Education and the Department of Health and Human Services integrate health into the nation’s schools. 

Essential Health Benefits in Illinois - What's Next?

In December 2011, the Department of Health and Human Services released long-awaited regulations on the Essential Health Benefits (EHB). A major piece of the Affordable Care Act, EHB will define the minimum level of coverage that must be offered in plans sold to individuals and small businesses both inside and outside the new health benefits exchanges. Although the hope was that the EHB regulations would create a minimum level of coverage that would ensure equal coverage for all who purchase health insurance, the Federal government handed off the responsibility of defining the EHBs to the states.

The December 16, 2011 bulletin that handed off that responsibility also provided some guidelines for how to go about doing that. The ACA determined that the EHB plan must cover benefits from 10 categories:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management, and
10. Pediatric services, including oral and vision care

Each state must select a health insurance plan currently operating within the state to act as the “benchmark” of services offered under the EHB. The state can choose from four types of existing health insurance plans:

• One of the three largest small group plans in the state; 
• One of the three largest state employee health plans; 
• One of the three largest federal employee health plan options; or 
• The largest HMO plan offered in the state’s commercial market.

If a state fails to establish a set of benefits that meets the criteria by the September 2012 deadline, the largest small group plan in that state will automatically become the benchmark.

The federal guidelines offer states a great deal of flexibility in defining their EHB plans. The plan that a state chooses will be supplemented to meet Federal standards before it is certified as the EHB plan. If, for instance, the selected benchmark plan is lacking coverage of the maternity category, the state would supplement by using the coverage of that category from another insurance plan currently available in that state. However, HHS offered no guidance as to which category certain benefits should be categorized under, leaving the content of categories a mystery.

Insurance companies, as well, have some flexibility in how they implement EHBs. Insurance plans must offer coverage that is “substantially equal” to the coverage offered in the benchmark plan. Also, insurance plans can modify the coverage they offer within a category, and potentially between categories, as long as the federal government does not see the modification as a reduction in value of coverage.


How Will Illinois Define its Essential Health Benefits?

It is not yet clear what the Illinois EHB or benchmark plan will look like. Illinois’ listing in the report of each states’ three largest small business plans, released by HHS for the purposes of selecting a benchmark, is constituted by three plans offered by Blue Cross Blue Shield of Illinois: BlueAdvantage Entrpreneur PPO, BlueEdge HSA, and BluePrint PPO. However the federal government has not yet approved the pool of eligible benchmark plans for the state of Illinois. In some states, comparison of potentially eligible plans has revealed that most of these plans offer comparable coverage, but it is still unclear if that holds true for Illinois. Also, it is not clear if Illinois plans to define the state’s EHB and benchmark plans itself, or to default to the federal government.

Advocates in Illinois have begun the conversation around the issue of the state’s EHB plan. The American Cancer Society, with assistance from other advocacy groups, has called for the Illinois Department of Insurance to clarify the levels of coverage offered in the plans that will constitute the pool of possible plans: They have specifically asked for information on any non-monetary coverage limits that may exist in those possible plans, and have developed a survey tool that highlights 31 areas of coverage, in an attempt to what the Illinois benchmark plan could look like, and to better develop advocacy efforts in favor of a more comprehensive set of EHBs.

Check back here for additional news on Essential Health Benefits in Illinois...decisions have to be made by states by September 2012!

New Study Shows Higher Tobacco Taxes Greatly Reduce Youth Smoking

Health advocates today urged Illinois leaders to increase the cigarette tax by $1/pack following a new national study that confirms higher tobacco taxes are very effective at reducing smoking and other tobacco use, especially among kids.

The new study, conducted by researchers at the University of Illinois at Chicago, found that the large federal tobacco tax increase implemented on April 1, 2009, reduced the number of youth smokers by at least 220,000 and the number of youth smokeless tobacco users by at least 135,000 in the first two months alone.

The researchers emphasized that the study measured only the immediate impact of the tax increase through May 2009, and the number of youth prevented from smoking and using smokeless tobacco would be much larger over time.

The study showed that a large tobacco tax increase “can influence youth tobacco use prevalence within a very short time period,” the researchers wrote. “Adolescents not only respond to tax policy changes, but the speed of their response is fast. The prevalence of smoking and use of smokeless tobacco… dropped immediately following the tax increase in this study, and statistically significant and meaningful changes could be measured and detected within 30 days of the tax increase.”

In Illinois, health advocates are working to increase the cigarette tax by $1/pack to reduce further cuts to the Medicaid program.

“This study shows exactly why Illinois should increase the tobacco tax – because it will keep kids from smoking, encourage smokers to quit and save lives,” said Kathy Drea, Vice President, Advocacy for the American Lung Association in Illinois. “The tobacco companies are fighting the tobacco tax for the same reason – because they know it works and will reduce smoking. Illinois legislators should side with kids over Big Tobacco and increase the cigarette tax by $1 per pack.”

Health advocates say a higher tobacco tax is a win-win-win for Illinois – a health win that reduces smoking and save lives, a financial win that reliably raises revenue and a political win that polls show is popular with voters.

More Information on New Study

A 2009 law approved by Congress, the Children’s Health Insurance Program Reauthorization Act , increased the federal tax rate on cigarettes by 61.66 cents per pack (from 39 cents to $1.0066 per pack) and on moist snuff, the most common form of smokeless tobacco, by 92.5 cents per pound (from 58.5 cents to $1.51 per pound). Taxes were also increased on other forms of smokeless tobacco.

The new study investigated the changes in youth smoking and smokeless tobacco use rates following the April 2009 federal tobacco tax increases, using data from the Monitoring the Future survey, an annual national survey of 8th, 10th and 12th grade students. Because the survey is conducted from February through May each year, it coincided with the April 1 tobacco tax increase and provided an effective means to measure the immediate impact.

The study found that the tobacco tax increase had a substantial and immediate impact.

The percentage of students who reported smoking in the past 30 days dropped between 9.7 percent and 13.3 percent immediately following the tax increase, while the percentage who reported using smokeless tobacco dropped between 16 percent and 24 percent (because the survey asked about behavior in the past 30 days, the study used three different models, with different cutoff dates, to fully assess the impact of the tax increase).

Because of the tax increase, there were between 220,000 and 287,000 fewer current smokers and between 135,000 and 203,000 fewer smokeless tobacco users among middle and high school students in May 2009, the study estimated.

The study controlled for other factors that influence youth tobacco use, including individual, family and school characteristics as well as state tobacco control measures, including state cigarette taxes, smoke-free air polices and tobacco control funding.

The study also found that, even as youth tobacco use declined, federal tobacco tax revenues increased by 147 percent in the 12 months following the increase – from $7.1 billion in the 12 months before to $17.5 billion in the 12 months after.

The new study adds to the already overwhelming evidence, confirmed by the recently released Surgeon General’s report on tobacco, that higher tobacco taxes are one of the most effective ways to reduce smoking, especially among kids.

Tobacco use is the leading preventable cause of death in the United States, killing more than 400,000 people and costing the nation $96 billion in health care bills each year. In Illinois, tobacco use claims more than 16,600 lives each year and costs the state $4.1 billion annually in health care bills, including $1.8 billion in Medicaid payments alone.

Support for the study was provided by the Robert Wood Johnson Foundation and the National Cancer Institute. The study was published online by the National Bureau of Economic Research.

Kathy Drea, Vice President, Advocacy

American Lung Association in Illinois

A Helping Hand for Small Businesses: Health Insurance Tax Credits

The Affordable Care Act (ACA) established a tax credit to help small businesses provide health insurance for their employees. According to a new study released today from Families USA and the Small Business Majority, 3.2 million small businesses, employing 19.3 million Americans, will benefit from these tax credits. Out of the 198,910 small businesses in Illinois, 137,900 will be eligible for a small business tax credit—that’s 69.3%.

The cost of health insurance is often the prohibitive factor when it comes to coverage for small business employees. Whereas almost all businesses—99 percent—with 200 or more employees offer coverage for their workers, small business have a much lower rate: 71% of businesses with 10-24 workers, and 48% of businesses with fewer than 10 workers offered employee health coverage.

The small business tax credit is an integral part of the ACA – created in order to help small businesses provide coverage for their employees. The credit is designed to provide assistance to the smallest businesses that face the highest premiums. In order to qualify, all businesses must cover at least 50% of each employee’s health insurance.

• Businesses with up to 25 FTEs and average wages of less than $50,000 will receive credits on a sliding scale. To see if your business qualifies, go to the Small Business Majority Tax Calculator here. 

• Businesses with 10 or fewer employees and average wages of less than $25,000 are eligible for the maximum 35% tax credit.. 

• Non-profit businesses are eligible for a 25% refund. In 2014, when health care reform is in full-force, the tax credits will cover up to 50% of small businesses’ health coverage plans, and non-profits will receive a refund up to 35%. 

Unlike individuals, whom the ACA mandates to have coverage, small businesses are not mandated to provide coverage to their employees. However, if a business of 50 or more workers has an employee who receives an individual subsidy to cover the purchase of individual plan insurance, that business will be levied a fee.

What does the small business tax credit mean for Illinois small businesses and their employees? 

1,206,000 Illinoisans are employed at small businesses. Out of that number, 757,300 (62.8%) are employed at businesses that are eligible for a tax credit, making it easier for their employers to provide health coverage for them. Overall, the state will receive $634,615,800 in tax credits, or about $838 per employee, on average.

54,130 (39.3%) of Illinois small businesses will be eligible for the Maximum (35%) credit. 220,400 people will benefit from the maximum credits, or 29.1% of those employed by a small business.

The country suffers from large ethnic and racial disparities in health care, and coverage is no different in small businesses, where a disproportionate number of African American and Latino small business employees are without insurance, as compared to white, non-Latino employees. Many of these workers could benefit from the small business tax credit. In Illinois, 188,090 Latino workers are employed by small businesses. 74.5% (140,040) of those workers will benefit from small business tax credits. 118,310 African American, non-Latino workers are employed at small businesses, of which 78,170 (66.1%) will benefit from tax credits.

As with many other aspects of the Affordable Care Act, the small business tax credit is still underused and unknown. We found in our Neighborhood Stories series last year that many small business owners and chambers of commerce in the South and West Sides of Chicago had not heard of the small business tax credit. The Families USA and Small Business Majority Report released today will help to continue to publicize the availability of the credit.

A First for Illinois - Health Information Exchange Advocacy Day

On May 2, 2012, Illinois will hold its first Health Information Exchange Advocacy Day in Springfield; a day to educate healthcare professionals, providers, and patients on the opportunities for health information technology (HIT) to improve healthcare in Illinois.

What is HIT?
HIT utilizes computer networks to store, manage, and exchange health information, and provides a great opportunity to improve health care in Illinois and nationally. When providers have access to a patient’s complete health information, treatment decisions can be made more quickly and accurately, and duplicate tests can be avoided. These goals can only be realized if the available technologies are adopted and used by the health care industry, a barrier that has been addressed through education, outreach, and funding opportunities.

The importance of HIT to the future of health care in America has gained broad recognition and support, and has even bridged the political divide surrounding broader health reform and the Patient Protection and Affordable Care Act (ACA). Before enacting the ACA, President Obama took one of his first steps to reform the American health care system when he signed the Health Information Technology for Clinical Health Act (HITECH Act) into law in early 2009, as part of the stimulus bill, the American Recovery and Reinvestment Act. The HITECH Act aimed to increase the effectiveness and efficiency of health care, reduce costs, and increase overall access to health care by encouraging the use of HIT through the provision of financial incentives for the adoption and utilization of HIT, particularly electronic health records (EHR). The idea of employing HIT to improve the health care system was carried through in several provisions of the ACA which rely on a strong IT foundation, such as those related to accountable care organizations, health insurance exchanges, and government transparency.

What will you learn if you attend the HIE advocacy day?
The goals of this advocacy day are to:

• Explain the roles of the Illinois HIE and the Illinois Office of Health Information Technology (OHIT) and how the use of HIT will benefit healthcare providers and patients alike;
• Discuss the current HIE initiatives and legislative efforts; and 
• Provide resources and answer any questions about HIE.

Kimberly Baldwin-Stried Reich, President-Elect of Illinois Health Information Management Association (ILHIMA), explains further: "ILHIMA and GCCHIMSS, two Illinois professional health information management organizations, are partnering to bring you an outstanding educational session on the Illinois Health Information Exchange (HIE). Whether you are a patient, provider, consumer or health care professional, this event is especially for you! Join us to learn how the Illinois HIE will assist health care providers in Illinois to utilize technology to share health information with the goal of lowering health care costs, increasing patient safety and quality and improving care coordination and population health."

OHIT has already worked extensively in promoting the development of HIT in Illinois, and is integrally involved in the creation of the HIE with the Illinois Health Information Exchange Authority.

"We are very pleased to participate in Illinois' first Health Information Exchange Advocacy Day,” says Laura Zaremba, Director of OHIT. “This event will highlight the tremendous progress that Illinois is making in implementing health information technology to improve health care for patients and help build awareness of this vital work. The health information management professionals who comprise the membership of ILHIMA and GCC-HIMSS have been among the most active participants in Illinois' efforts to transform health care through technology and continue to demonstrate leadership in their sponsorship of HIE Advocacy Day."

The Illinois’ HIE will act as a centralized “hub,” facilitating the exchange of information from different health care facilities, state offices, insurance companies, labs, and pharmacies across the state. The goal is to pull a unique patient’s information from a number of sources and bring it all together to populate a single electronic health record (EHR) for the patient; a complete record of the patient’s health information that is accessible at any HIE participating facility. Illinois is making great strides in integrating HIT into its health care system. HIT has already improved the quality of care in rural Illinois; to read about this please see this month’s Illinois HIE Newsletter for Patients and Consumers, available in English and Spanish.

One lesson that you are sure to learn from the advocacy day tomorrow: HIT is transforming health care, and it is here to stay.

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