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

Federal Recognition of Same-Sex Marriage Could Mean Big Changes for Taxes and Health Care Reform

The Supreme Court issued two key rulings today on same-sex marriage, United States v. Windsor (regarding the federal Defense of Marriage Act or "DOMA") and Hollingsworth v. Perry (regarding California's Proposition 8). The Court struck down DOMA as unconstitutional and dismissed the appeal in the Proposition 8 case for lack of standing.

"These momentous decisions certainly have implications for taxes and the Affordable Care Act (ACA)," said Brian Haile, Senior Vice President for Health Care Policy, Jackson Hewitt Tax Service Inc. "Same-sex partners should understand some of the implications of marriage to their health insurance options under the ACA before they tie the knot. Simply put, getting hitched affects their health care."

Haile outlined the following:

1. Same-sex partners may now be able to file as "spouses." Under the federal income tax rules as currently written, taxfilers may be able to claim a same-sex partner as a dependent if they live together for the year, if the partner resides legally in the U.S., if the taxfiler provides at least 50 percent of the total support for the partner and the household, and if the partner has very limited income. This is a murky area – and the Court's decisions only partially clarify the law.

To the extent that the Court's rulings expand the federal definition of marriage, then many of these individuals in jurisdictions that recognize same-sex marriages may now be able to file as "spouses" rather than "dependents." Other same-sex individuals who did not meet the restrictive dependent test may now become part of the taxfiler's household as a spouse in those states that recognize same-sex marriage. (For reference, 12 states and the District of Columbia marry same sex couples.) However, the marital status vis-a-vis federal law of same-sex couples who live in states that do not recognize their marriage remains unclear.

2. Same-sex partners with similar incomes may lose out. For example, same-sex partners who each have an income of $40,000 may be eligible for the premium assistance tax credits under the ACA – but only if they remain single. If they marry (in those states that allow same-sex marriage), then they would lose eligibility because their income would be over the threshold for a household of two.

3. Same-sex partners with different incomes may gain. For example, two persons in a same-sex relationship who had incomes of $30,000 and $80,000, respectively, would not qualify for the tax credits if they were married in states that recognize same-sex marriage (because their combined income is above the limit for a couple). However, the individual making $30,000 would qualify for the tax credits if he or she remains unmarried (as that individual's income is below the threshold for a household of one). Of course, the couple may end up paying a lower marginal tax rate if they marry and exercise a new right to file jointly – so part of the decision about whether and when to marry in states that recognize same-sex marriage may involve a complicated trade-off between minimizing taxes and accessing insurance.

4. Same-sex couples who currently access domestic partner benefits may gain. Under the current federal income tax rules, the value of the benefits that employers provide to opposite-sex spouses is largely excluded from income; however, the opposite is true from same-sex partners – and they have to pay taxes on the full value of the employer's contribution for same-sex partner health insurance, etc. These taxfilers may no longer have to treat the value of the health insurance as imputed income if they get married in states that allow them to do so – meaning that their taxes may go down. The same is true for employers: they may pay lower payroll taxes if the couple marries and no longer has to treat the value of the employer's contribution as imputed income.

5. Same-sex couples who do not have or do not access domestic partner benefits may lose out. If the couple marries (assuming that they live in a state that recognizes same sex marriage) and one employer offers spouse or dependent coverage, then the same-sex spouse may lose eligibility for the ACA tax credits. The ACA limits the tax credits to spouses and dependents who do not have access to coverage. Even if the employer does not subsidize spouse or dependent health coverage, the fact that a spouse has access may disqualify him or her from the tax credit program.

6. Married same-sex couples receiving ACA tax credit will have to file jointly. If a same sex couple were to get married in a state that allows them to do so and claim the new tax credits under the ACA, then the ACA rules require them to file a joint return for the respective tax year (as is the case with opposite-sex married couples).

Even with the Court's decisions, HHS still faces several related policy questions. The final rules about the new insurance marketplaces clarify that the marketplaces and insurers must "…[n]ot discriminate based on race, color, national origin, disability, age, sex, gender identity or sexual orientation."* Consequently, many observers had a number of questions about how HHS would interpret these requirements in the context of the small group marketplace even before the Court's rulings. For example, must the small group marketplace require insurance companies to provide same-sex domestic partner coverage to participating employers and employees?

"To my knowledge," Haile added, "the agency's only requirement in this regard is that insurers in the federal marketplace self-attest that they do not discriminate on this basis."**

Surprisingly, many same-sex couples (particularly lower-income same-sex couples) may be better off if HHS answers "no" to such questions. The reason is simple but not intuitive: the final rule on premium tax credit eligibility states that individuals who have access to "affordable" employer-sponsored coverage are ineligible for premium tax credits. However, "affordability" of employer-sponsored insurance is determined only with regard to the employer contribution to the employee-only coverage. Consequently, a same-sex partner (and for that matter, any dependent) may be ineligible for tax credits if the employer offers same-sex coverage – even if the employer makes no contribution to toward the associated premium. However, if partner or other dependent coverage is unavailable, then a same-sex partner or other dependent may have some hope of qualifying for a tax credit.

The Internal Revenue Service and other federal agencies may issue interpretive guidance later this year to clarify some of the outstanding questions, but the implications of the Court's rulings today certainly complicate both the tax code and health care reform.

* 45 CFR Section 155.120(c)(2); 45 CFR Section 156.200(e).
** Letter to Issuers, April 5, 2013, available at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf.

Brian Haile 
Senior Vice President for Health Care Policy
Jackson Hewitt Tax Service Inc. 

For more information about the Affordable Care Act and its impact on taxpayers, please visit Jackson Hewitt's public website or Brian Haile's Twitter channel.

(This post originally appeared on PRNewswire here)

New Fact Sheet: How the Health Reform Law Helps People with HIV

Still wondering how the Affordable Care Act helps people living with HIV/AIDS? Well, there’s no need to wonder anymore!

The HSS Office of Health Reform has developed a new fact sheet about how the Affordable Care Act (ACA) is particularly important for people living with HIV/AIDS, as well as other people living with serious medical conditions. The law has made significant progress in addressing the concerns and advancing the rights of people with HIV consistent with the goals of the President’s National HIV/AIDS Strategy.

Among the ways the new health law is helping people with HIV are the following:

• Ensuring that AIDS Drug Assistance Program (ADAP) benefits are now considered as contributions toward a Medicare beneficiary’s true Out of Pocket Spending Limit for drug coverage.
• Improving access to coverage and protecting people with HIV/AIDS now by making available a Pre-Existing Condition Insurance Plan in every state and making important insurance reforms to protect people from insurance company abuses;
• Offering quality coverage and care to every person with HIV/AIDS in 2014 and beyond via Medicaid expansion, additional insurance reforms, and closing the “Donut Hole”, and
• Increasing opportunities for health, well-being, and cultural competency.

So, whether you are just learning about the Affordable Care Act or looking for updated information, this fact sheet gives you the tools you need to make informed choices about your health. Read more details in the fact sheet (PDF) about what the health care law does to help people with HIV/AIDS.

This post originally appeared on the HIVHealthReform.org Blog.

The Affordable Care Act & Nursing Home Abuse

A Look at Nursing Home Abuse  

Elder abuse in nursing homes is largely due to the inadequate staff levels. According to a 2001 Health and Human Services (HHS) study, 90 percent of nursing homes are understaffed. Lack of adequate staffing is known to lead to:

• An over-worked staff.
• An under-trained staff.
• High staff turnover.
• Mistakes in patient care.
• Inadequate time with patients. (Most nursing homes do not meet the federal government’s recommendation for 4 hours of patients care with every patient, daily.)
• Staff exhaustion, burn-out and stress
• Inadequate staff-to-patient ratios
• Inadequate staff background checks.

Before the Affordable Care Act, the federal government did not require nursing homes to complete staff background checks. According to an HHS report:

• 90 percent of nursing homes employ at least one staff member with a criminal background.
• Almost 50 percent employ 5 or more staff members with at least one conviction.
• 5 percent of nursing home staff members have at least one criminal conviction.

Ultimately, all of these are potential causes of abuse, and intentional and negligent neglect.

A Look at The Patient Protection and Affordable Care Act and Nursing Home Abuse

The Affordable Care Act (ACA) will affect nursing homes in a positive way and, if successful, curb the rate of abuse in these facilities. According to Families USA, the ACA will establish important programs, committees, and grants that will increase the effectiveness of the long-term care workforce and care. These numerous establishments aim to:

Improve the long-term facility workforce through:

• Increasing the size of the long-term care workforce to meet the needs of long-term care residents.
• Understanding and analyzing workforce supply and demand.
• Encouraging people to enter the long-term care workforce.
• Curbing the long-term care workforce’s staff turnover rate through retention efforts.
• Improve the quality of staff training by educating staff about demanding resident conditions, such as dementia; proper ethics; the importance of reporting staff abuses of residentsm identifying signs of elder abuse and identifying administrative abuse.

Improve elder care by:

• Increasing the at-home care and decreasing long-term care facility usage; at-home care is less expensive to state and federal governments
• Increasing the knowledge of caregivers by providing resources concerning finances, care, etc.
• Increasing consumer knowledge of nursing home facility deficiencies and staffing levels.
• Improving long-term facility environments.

Decrease elder abuse through:

• Increasing resources to increase how quickly elder abuse cases are investigated.
• Establishing quality staffs through mandatory nationwide staff background checks and education.

Amber Paley, Blogger/Writer
Nursing Home Abuse.net

Essential Health Benefits: What’s it mean for people with HIV?

On December 16, 2011, the U.S. Department of Health and Human Services (HHS) announced that states would decide what essential health benefits will be provided under health care reform.  Although we had urged HHS to adopt a uniform, national benefits floor that states could build on, the federal proposal offers important flexibility for states. (Check out our essential health benefits archive.)

So, what does the essential health benefits announcement mean for people with HIV?  The short answer is that we’re working on it.  Here are some of the hoops we’ll have to jump through just to figure out what the benefits might look like in a state.

Which plans are we talking about?  HHS gives states the choice of:

(1) the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;
(2) any of the largest three State employee health benefit plans by enrollment;
(3) any of the largest three national FEHBP [Federal Employee Health Benefit Plan] plan options by enrollment; or
(4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

Yeah, we weren’t sure where to start either.  There’s no centralized federal repository of health plan data, since states regulate health insurance.  Every state publishes plan information online differently, or not at all.  We’ll probably have to submit a special data request to each of the 50 state insurance departments.

What benefits does each plan offer?  Once advocates identify the largest plans, the next step is to determine exactly what benefits they offer.  You can bet that Blue Cross doesn’t publish on their website a description of each of their hundreds of plans offered in a state.  We’ll might have to ask companies directly for plan descriptions, or pour through regulatory filings at state insurance departments.

Once we have this information, we can start to figure out what the plans will look like for people with HIV.  Of course, we’ll partner with national and state advocates to gather and analyze information.  At the state level, it’s more essential than ever that advocates work together to figure out the benefit puzzle and don’t duplicate effort.

And here’s an idea:  Could advocates, employers and insurance companies collaborate to gather all this information?  Sure, old adversaries would have to sit at the same conference table to share opinions and information – but that might be just “what the doctor ordered” in the new world of health care.

Read the federal fact sheet
Read the HHS Essential Health Benefits Bulletin
Federal white paper on benefits in small group and state and federal plans
Federal fact sheet on individual market benefits

John Peller, VP of Policy
AIDS Foundation of Chicago
jpeller@aidschicago.org

Originally posted here on HIVHealthReform.org