Health Reform's Best-Kept Secret

The Basic Health Program could bring more affordable, more reliable coverage to millions of adults--and improve access to care for children, too.

For all the attention devoted to the Affordable Care Act, scant consideration has been paid to a little-known part of it called the Basic Health Program. It's an option for states that could, if implemented nationwide, make health care coverage more affordable and accessible for more than 5 million adults and bring health coverage to more than 600,000 who would not otherwise have it.  Because many of these adults are likely parents of Medicaid- and CHIP-eligible children, the Basic Health Program could improve coverage and access to care for low-income children as well.

Most Say Ahhh! readers likely know how it works, but here's a quick recap of the Basic Health Program: under health reform, low-income people without health coverage will receive federal subsidies starting in 2014 to buy health insurance through Exchanges. States that implement the Basic Health Program in addition to an Exchange would contract with health plans or networks of doctors and hospitals to provide health care to people with incomes up to twice the Federal poverty line--just under $22,000 for a single adult--who don't qualify for publicly-financed programs such as Medicare or Medicaid. The Basic Health Program would replace subsidized coverage through Exchanges for this lower-income population. Washington would pitch in by providing states with 95 percent of the tax credits and subsidies that would have otherwise been provided through health reform.

According to an Urban Institute paper commissioned by our organization, the Association for Community Affiliated Plans, costs for subsidized health coverage through the Exchange are projected to cost low-income individuals more than $1,650 per year in premiums, copays and deductibles. For most people, that's a terrific deal. But for someone making $22,000 a year, $1,650 is nearly a month's pay. Many could well forgo coverage through the Exchange, pay a tax penalty of up to $700 and apply the difference to food, rent, or electricity. While health reform goes a long way towards making coverage more affordable through Exchanges and subsidies, health coverage may remain out of reach for some people with low incomes.

But if states were to implement the Basic Health Program to provide coverage modeled on Medicaid and CHIP, the Urban Institute estimates that annual premiums and out-of-pocket costs for adults would drop from a combined $1,650 to just under $200. At that level of affordability, paying the tax penalty makes no sense. The Urban Institute estimates that 600,000 people who would otherwise not purchase insurance would do so if all states ran a Basic Health Program. That's reason for cheer on its own.

Better still, the Basic Health Program could help more children access coverage and care in two ways. First, covering more adults will help children. While the Basic Health program would primarily cover adults in 2014 (Medicaid and CHIP handle low-income children), the lower premiums and reduced cost-sharing that could happen under BHP for adults would help children, as research has suggested a link between parents' insurance status and their children's access to care.

It could also serve as a backstop: should Congress not authorize new funding for CHIP in 2015, the Basic Health Program could serve as a bridge program for children, providing them with CHIP-like coverage rather than coverage through an Exchange. Finally, children who are prohibited from receiving Medicaid or CHIP coverage because of the 'five year bar' could be covered by the Basic Health Program. CHIPRA in 2009 gave states the option of covering these kids, but only six states had done so as of January 2011.

The Basic Health Program remains a work in progress, and there's work yet to be done: the Department of Health and Human Services must provide states guidance on several issues that will affect how states tailor their Basic Health Programs--notably, clarification of the mechanisms for calculating and delivering Federal funds. States must ensure that reimbursement levels for health plans and providers are high enough to attract an adequate number of participating physicians to meet demand for services generated by the program. While some analysts have questioned whether the Basic Health Program could adversely impact Exchanges, policy solutions could be found to address these impacts if they do occur.

The Basic Health Program represents the best health reform has to offer: more affordable and accessible care for millions of Americans, including parents and their children, and up to 600,000 fewer uninsured.

Given the financial pressures felt in statehouses across the country--and the professed desire by leaders on both sides of the aisle for affordable health options--the Basic Health Program deserves a long, close look. Governors, Medicaid directors and state legislatures across the country owe it to the people they serve to give Basic Health Program serious consideration.

Because this program is simply too promising to be kept a secret.

By Meg Murray and Jenny Babcock,Association for Community Affiliated Plans

This post originally appeared in Say Ahhh! A Children’s Health Policy Blog.

The Essential Health Benefits--Comments from Health and Disability Advocates

On December 16^th 2011, the Department of Health and Human Services released a much-anticipated bulletin on the Essential Health Benefits (EHB) package. Instead of containing information on what the package would contain, the bulletin deferred the task of defining EHB to each state. Supplementary information designed to clarify the approach taken in the bulletin was released on January 25, 2012.

Health & Disability Advocates, the organization which powers Illinois Health Matters, submitted their comments on these bulletins to HHS on January 31, 2012, reflecting specific concerns:

The role of the EHB package was to create a standard of health care covered by insurers for all Americans purchasing insurance through the state exchanges. This would mean a standard of adequate care for all, without discrimination due to age, gender, disability, chronic illness or geographical location.  It is the vehicle that would bring the goal of health care reform, that is, high-quality, comprehensive care, to many citizens.

The proposed plan gives states a vague benchmark system, with no federal oversight currently put in place, to use in defining the EHB. Although it is understandable for states to want flexibility in defining their EHB package, the degree of flexibility HHs is allowing could permit states the freedom to eliminate important benefits or the protection the EHB provides against insurance discrimination. Furthermore, to hand off all of the important decisions regarding the EHB package to the states goes against Congress’s intentions in the ACA of a federal standard, defined by HHS, for minimum coverage. As HDA states in their comments, “Simply said, the HHS EHB Bulletin is inadequate at best, and at worst, is an impediment to effective implementation” of health care reform.

HDA urges HHS to protect the potential of EHB plans by establishing an official, federal oversight process that involves a diverse range of perspectives, including those of people with disabilities and chronic illness. The HDA comments outline specific suggestions for the development of an EHB plan going forward that would safeguard the potential benefit of the EHB package, including the following:

•  Reflects an appropriate balance among the categories describes in such subsection, so that benefits are not unduly weighted toward any category
• Does not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.
• Takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups
• Ensures that health benefits established as essential are not subject to denial to individuals on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree or medical dependency, or quality of life.

To read the full list of HDA’s specific concerns, read the full comments here.

Barbara A. Otto

Chief Executive Officer

Health & Disability Advocates

ACOs: Health Care’s Big Project

Medicare beneficiaries who are patients of 32 groups of health care providers have started to receive letters informing them that they are now patients of an Accountable Care Organization, or ACO.

ACOs are the focus of a new Medicare demonstration project that is testing out a new model for health care delivery and payment. The ACO demonstration is one of many demonstrations that the Affordable Care Act has planned.

The ACO project relies on a coordinated care system: organization and communication between doctors, hospitals, and other care providers to better coordinate care for patients. The improvements in care come from the potential that lies within sharing information about a patient between medical offices, avoiding unnecessary repeated procedures, and other improvements in the efficiency of medical care providers. The efficiency, along with the improved care being given to patients, is said to lead to savings for the medical care providers. Better care means healthier patients, which ultimately means that patients will be less likely to need some of the more expensive medical care, such as visits to the emergency room. 

The demonstration is led by Center for Medicare and Medicaid Services (CMS). The ACO demonstration is the third of its type that CMS has undertaken; following a demonstration that began in 2000, and a second in 2005, that investigated the efforts of care groups that were already coordinated to a certain degree, and the benefits that lay within that coordination. For this demonstration, health care provider groups will be measured on 33 points of quality and efficiency in treating Medicare patients, while receiving in return one of two different types of bundled payments from Medicare. The first package allows for less risk, in that CMS will act as a financial buffer if the ACO model is not successful, but a small percentage of the savings, while the second offers the reverse situation to provider groups.

32 groups signed up to participate in this demonstration, including many programs in the Midwest, such as the OSF Healthcare System in Central Illinois. Each of the participants represents one ACO, that is, a coordinated group of physicians, many of which were not coordinated prior to this demonstration. Each participating group must meet specific ACO criteria, such as having established an adequate organizational structure that accounts for not only medical care, but also the necessary administrative and legal processes that go along with coordinated care. Furthermore, all participating ACOs must have 5,000 or more Medicare participants participating, and must have defined the ways in which they will be working to improve the care for those patients, as well as the metrics they will use to measure that quality. If the demonstration goes as planned, the ACO groups will be able to improve the health of their patients in such a way that cuts down on costs, saving the ACO and Medicare money.
              

 If successful, the ACO demonstration could mean bigger changes down the line for health care reform.  In essence, the program uproots the current fee-for-service health care model, in which medical care providers are paid for each service they provide for patients, for a new one. As Ezra Klein phrased it in a blog post: “The hope is to do nothing less than change the basic business model of American medicine from making money by getting patients to spend more money to making money by saving patients money.”

Responses

Although the responses to the ACO demonstration all seem to emphasize that changes to the current health care system must be made, the demonstration has stirred up criticism from those in the medical sector:

•     Some see the project as too risky for medical provider groups—particularly if that group is middle range or smaller, meaning that to establish a care coordination model is a substantially greater undertaking, and thus, a greater risk as well.
•      Others are wary because of a past failed attempt at revamping the health care system, namely Health Management Organizations, or HMOs. An HMO is an insurance plan that only allows beneficiaries to see the doctors and providers who have agreed to participate in the HMO plan. The original intent of HMO systems was that by organizing a managed care group of providers for each patient, the costs would be reduced for insurance providers, and thus, for the patients—similar to the way ACOs are predicted to cut costs through provider organization. However, costs were not ultimately lowered for insurance companies, and patients were asked to sacrifice flexibility in choosing providers without paying less in the long run. Some critics of the ACO plan say that it will be doomed to the same fate.
• One big factor in the success of ACOs are the patients themselves. Since the majority of the expected savings will come from keeping patients out of the hospital or from requiring expensive visits with specialist doctors, a lot is riding on the patients’ ability to remain healthy. Suppose a group’s patients are unable or unwilling to make lifestyle changes prescribed by their doctors that could be the key point in the success of their preventative care, and they all end up in the emergency room, despite their doctors’ best attempts? Or, suppose a physicians’ group is just unlucky, and for the first few years of participating in the ACO program, they have a high number of patients who end up in the hospital for unforeseeable circumstances? In these cases, the hospitals or physicians’ groups would most certainly lose money in the ACO model. These concerns are exacerbated when one considers the fact that patients will not join the ACOs willingly, but will be assigned, may not understand what the ACO or their role in it entails, and, currently, receive no extra incentives or benefits from active participation. In contrast to concerns over the role of patients, some are saying that if ACO models do save Medicare money, the result could be lower premiums or co-pays for Medicare beneficiaries. Furthermore, there could be savings for private insurance companies, as well, which could translate to lower premiums and co-pays for private insurance customers down the line.
•  Others are concerned that the costs of establishing a coordinated care system are just too high, and will not be offset by the predicted savings. Estimates for this cost range from $10$30 million dollars in consultants’ fees, IT staff, systems and equipment, systems care management, extra trainings, etc. Even if the ACO program does return substantial savings to a group, the savings may not cover those costs for years. Furthermore, the start-up costs may be too great for all but the largest hospitals or physicians’ groups.
• Some are citing the two previous demonstrations that are the model for this ACO Medicare demonstration were not successful enough to guarantee any type of success with ACOs.  Since those demonstrations worked with groups that were already coordinated care organizations to some extent, to expect to see similar results with as of yet uncoordinated groups may be setting the bar at an unrealistic height.
• Others are worried that the structure of the ACO demonstration and the lack of a safe middle ground between cutting costs and losing money will have coordinated care groups shifting the focus too heavily on saving money, instead of on finding innovative ways to provide patients with the quality care they require.

The CMS has been listening to these concerns, and although a successful outcome is still far from guaranteed, they have made some alterations to the original ACO proposal, with things like advanced payments to provider groups to help offset coordination start-up costs, increasing financial incentives while reducing financial risk, and allowing for a broader variety of governance structures within the organizations.  However, the outcomes, both positive and negative, remain to be seen. 

IHM and CAN-TV

Illinois Health Matters' Neighborhood Stories will be broadcasting on Chicago television station CAN-TV! We are excited to share these stories of how health care reform will impact real people and organizations in Chicago with a whole new audience. Please tune in at any of the times listed below to see one of the great Neighborhood Story videos:

Neighborhood Story	Upcoming Air Date/Time on CAN TV
Waiting for Health Care Reform	2/11 -  5:52 am - Channel 36 2/11 - 11:51 am - Channel 19 2/12 - 1:17 pm - Channel 36
Health Insurance May be on the Table	2/08 -   6:50 pm - Channel 36 2/10 -  9:05 am - Channel 19 2/11 -  3:47 pm - Channel 36 2/12 -  8:50 pm - Channel 36
Policy to the People	2/08 - 7:26 pm - Channel 19 2/11 - 2:55 pm - Channel 36 2/11 - 4:54 pm - Channel 19 2/12 - 4:50 pm - Channel 36
Wellness on the Westside	2/09 -  9:25 pm - Channel 36 2/11 - 8:17 pm - Channel 36 2/12-  12:56 am - Channel 36 2/12 -  8:22 am - Channel 36

For more info on the IHM Neighborhood Stories, and to read the articles that accompany each video, click here. 

Cutting Illinois Cares Rx Would be Penny-Wise & Pound Foolish

The Chicago Tribune recent editorial, "Time to move on medicaid spending," correctly points out that Illinois must look at its Medicaid spending and implement innovative ways to cut costs while preserving care to its very poor and sick participants.

However, the suggestion to cut the small but extremely crucial program, Illinois Cares Rx, to assist in this important endeavor would be penny-wise and pound foolish. Illinois Cares Rx plays an important role in our medical safety net system. By assisting Illinois Cares Rx participants with deductibles and co-payments for their Medicare Part D plan, the cost of which are otherwise out of reach for them, we don’t force them to cut corners on taking their medicines or skip filling prescriptions altogether. This, in turn, keeps our Medicare beneficiaries healthier and out of hospitals and nursing homes, where Medicare beneficiaries quickly become Medicaid recipients. By investing in prescription access now, we avoid greater costs later.

Just because the federal government does not foot the bill does not mean it is not a good idea.

John V. Coburn
Senior Policy Attorney
Health & Disability Advocates

The Affordable Care Act: Preventing Chronic Diseases

Did you know that switching the focus from treating chronic illnesses to preventing the diseases will not only improve the health of individuals and families all over the country, but will also rein in health care costs and strengthen the economy?

The Affordable Care Act (ACA) is applying this logic in its fight to lower the rate of preventable chronic illnesses, produce real savings in the health care sector, and recover lost economic activity at the local, state, and national levels. And it’s doing it in the name of prevention through effective public health initiatives.

The prevalence of chronic health conditions in the United States is taking a huge toll on our citizens, our nation’s health care spending, and our workforce. More than half of the people living in the United States have at least one chronic health condition, such as heart disease, stroke, diabetes, obesity, and cancer. Chronic health conditions account for 7 out of 10 deaths in Americaand rack up 75% of our nation’s health care spending. The cost for treating people with type 2 diabetes, heart disease, hypertension, and stroke, alone, amounts to $238 billion each year. In 2010, the United States spent almost $2.6 trillion on health care, meaning we spent around $1.9 trillion just last year on treating and managing chronic illnesses, most of which are largely preventable. Here in Illinois, more than 6.7 million people have reported being diagnosed with a chronic health condition, costing the state $12.5 billion in annual health care expenses.

What’s more is that the cost of chronic health conditions goes beyond the money spent on health care services. The toll these illnesses take on our workforce productivity is telling. According to the Gallup Poll, 7 out of 8, or 83 percent of American workers either have a chronic health condition or are obese. The poll estimates that this prevalence of chronic illness and obesity in our workers could be costing our economy $153 billion a year in lost productivity due to increased sick days. Other reports that take into account other chronic conditions and factors like lost productivity from workers who show up on the job while sick estimate that chronic health conditions are costing the United States more than $1 trillion each year in lost economic activity. To bring these statistics home, chronic disease plaguing Illinois’s workforce cost the state $14.3 billion in lost productivity. And the commonality of chronic disease is rapidly increasing. It is estimated that the number of Americans living with a chronic health condition will increase by 36%, or 46 million people by the year 2030, and that we could be spending $685 billion a year on medical treatment for chronic disease by 2020. Other sources estimate the total economic toll of chronic health conditions to reach $6 trillion a year by the middle of the century.

But it doesn’t have to be this way. As the CDC states, “Access to high-quality and affordable prevention measures (including screening and appropriate follow-up) are essential steps in saving lives, reducing disability and lowering costs for medical care.” And research has proven that for every dollar invested in effective prevention and public health initiatives, $5.60 is saved. The same study reveals that, if we invest $10 per person every year in effective community-based public health programs, we could save the United States more than $16 billion in just five years. 

Fortunately, the Affordable Care Act recognizes the benefits to be had from investing in smart and effective preventive and public health efforts. The ACA established the National Prevention, Health Promotion and Public Health Council within the Department of Health and Human Services (HHS), made up of secretaries from various federal departments and chaired by the Surgeon General. The Council is responsible for developing our first ever National Prevention and Health Promotion Strategy, which was released in June of 2011 and identifies four strategic directions for preventing disease and improving health nationwide. The four strategic directions are: creating healthy and safe community environments; expanding access to quality clinical and community preventive health service; empowering people to make healthy choices; and eliminating health disparities. The Council is charged with providing leadership moving forward with the National Prevention and Health Promotion Strategy.

The ACA also established a Prevention and Public Health Fund, which is administered by the Secretary of HHS, Kathleen Sebelius, and provides financial support for state and community-wide efforts to prevent disease and promote healthy lifestyles. The Fund is a 10-year, $15 billion commitment to support prevention and public health programs across the country, like theCommunity Transformation Grants, which fund community-level programs geared towards reducing the prevalence of chronic disease and promoting healthy lifestyles.   Already, $103 million in grant money has been issued to 61 different state and community programs across the country, reaching 120 million people.

So what does all of this mean for chronic disease in Illinois? Already, the State of Illinois has received $17.14 million out of the Prevention and Public Health Fund to support community- and state-level wellness and prevention programs aimed at preventing chronic disease and raising awareness about healthy living. For a breakdown of what programs received funding and for how much, visit HealthCare.gov online.

The Secretary of HHS will continue to issue funds for prevention and public health programs across the country to reverse the trend of chronic disease, so stay tuned as health reform continues to make a positive impact in our communities. To find out what other kinds of initiatives the Affordable Care Act has taken to increase access to preventive health measures and decrease illness in America, visit the Shriver Brief online.

This post was originally posted on The Shriver Brief by Caitlin Padula. It is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Happy 1st Birthday, Illinois Health Matters!

A year ago today, Health & Disability Advocates, along with a collaboration of Chicago-based health policy and advocacy groups, with the generous support of The Chicago Community Trust, launched Illinois Health Matters. The stated goal of the website is "to provide up-to-date information on health care reform and its impact—now and in the future—for Illinois consumers, small businesses, the media and policymakers, and community-based organizations."

So - after we blow out our candle and have some birthday cake - we need to assess: are we meeting our goal?  

First, a look at the numbers, which help give some insights into our ablity to reach people with our health care reform messages: 

• 151,937 news feed impressions of our press releases
• 106,460 post views on Facebook 
  
• 18,707 page views  on the website - the most popular being this Blog and our Neighborhod Stories series
• 1663 tweets to 675 Twitter followers. 
• 660 Views of our YouTube videos
• 413 Connections on Linkedin
• 76 Blog Posts with over 9500 page views.

So to sum up, Illinois Health Matters has provided unbiased, health reform implementation information to over 300,000 "eyes" over the past year. We've passed along and translated information about Affordable Care Act milestones [and setbacks] and Illinois' progress meeting those milestones. We've tried to reach audiences in a variety of ways knowing that different people have different appetites for information: - short bites (through Twitter), larger ones (Facebook) and then more indepth analysis through blog posts, email newsletter and our resource pages.

Sounds good, right? But what does that really mean? Who have we really connected with over the past year to help inform them about the Affordable Care Act changes?

First let's start with consumers. Take Henry Edwards, the subject of one of our Neighborhood Stories. Henry is a Chicago resident in his early 20's who suffers from asthma and could not afford health insurance. He was unable to get regular treatment and medication for his asthma due to the cost. Then, his wife gave birth to their first child, making their whole family eligible for insurance under the Illinois FamilyCare program. If Henry's or his wife's income were to grow and place them out of eligibility for Family Care, Henry would be faced with the high costs of insurance, and even if he could afford to buy coverage, insurance companies could refuse to cover him due to his pre-existing condition, asthma. However, starting January 1, 2014, because of the Affordable Care Act, insurance companies will no longer be able to deny coverage due to a pre-existing condition. Furthermore, Henry will be able to shop for coverage in the competitive health care marketplace, and possibly take advantage of tax credits that will help those of low income to afford insurance.

Another story, Shana, a 19-year-old student with ulcerative colitis who was ineligible for Medicaid and had been unable to get private insurance in order to cover important surgeries due to her pre-exisiting condition. She posed this dilemma to us in the Q&A section of IHM, and got a response about the IPXP, the state-run, federally funded insurance plan under the Affordable Care Act for those with a pre-exisiting condition. She has since enrolled in the program and gotten coverage!

In addition to individuals and families who we've talked to about their own health care needs, we have connected with small business owners to inform them about how the ACA can impact their employees. For example, we talked with Henry Henderson, owner of Ruby's Restaurant in Garfield Park, who can't afford to purchase health insurance for his employees yet although he'd love to do so. And then there is Mike Quinlan, executive director of the Near West Side Chamber of Commerce who said in response to our conversation with him: “It’s got me thinking this is something we should bring up. . . In terms of health care reform, it would help to identify expert speakers who can present the message at chamber meetings to our members.”  

Over the past year, we have also made new connections to local and national media who have helped us amplify our health reform message, including all of the Chicago Smart Community Portals, Community Media Workshop, Chicago Reporter, Progress Illinois, and Politico--a more impressive roster of partners than we could have imagined being able to claim at this point one year ago!

Last but not least, we have strengthened existing community partnerships and made new connections with policymakers, community organizations and service providers -- which will be especially invaluable as 2014 draws closer and over 1 million people will have new opportunities for affordable coverage in Illinois. As these health reform provisions roll out and previously uninsured Illinoisans are looking for guidance in how to navigate the system, we've already established connections with clinics, doctors, pharmacies, navigator groups and others who will help pave the way for a new way of getting care and staying healthy.

So, Happy Birthday to us! We have a lot to show for our first year -- and we have a lot more work to do.