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Reaching Beyond Delivery System Walls To Improve Colorectal Cancer Screening

Fri, 24 Mar 2017 14:53:02 +0000

Payers are increasingly using value-based payment to push delivery systems to redefine their product and place. Much has been written about what the new “product” should be, from a hospital stay plus 30 days post-admission, to all the care required by an enrolled or attributed population for a year. Less has been written about the changing place of health care delivery. Delivery systems are designed to care for people who walk through their doors. However, many value-based payment arrangements hold delivery systems accountable for achieving population health goals, such as cancer screening. These goals can best be met by engaging people who may never enter a medical office. For most delivery systems, engaging people before they become patients involves a new skill set. In this post, we describe how one large delivery system—Kaiser Permanente—learned to reach beyond its walls to engage healthy members in colorectal cancer (CRC) screening. The organization shifted from an opportunistic screening program that depended on patients entering its physical premises to a proactive program that leveraged opportunities to communicate with and screen members in their homes. These efforts have dramatically improved CRC screening rates, resulting in reduced incidence of colorectal cancer. This experience is relevant for other delivery systems under value-based payment arrangements, which provide financial flexibility to focus on care that happens outside of the traditional “place” of service delivery. Why Is Colorectal Cancer Screening So Important And Effective? In the United States, colorectal cancer (CRC) is the third-most common cancer and second leading cause of cancer-related death. More than 49,000 people died of the disease in 2016. Although CRC is highly treatable if caught early, only about two-thirds of Americans aged 50-75 receive the recommended screening. Screening rates among certain populations, particularly Latinos and low-income individuals, are even lower. The National Colorectal Cancer Roundtable set a goal of increasing CRC screening rates in the U.S. to 80 percent by 2018. Such an improvement would prevent 277,000 new cancers and 203,000 CRC deaths by 2030. There is clear evidence that three types of CRC screening—colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT)—reduce cancer incidence and mortality. These screenings are highly effective because the cancer is slow-growing, and the tests are designed to find both early cancer and pre-cancerous growths called polyps. Polyps can be removed before they turn into cancers. The most commonly used CRC screening test in the U.S. is colonoscopy, with FOBT a distant second, and flexible sigmoidoscopy third. Colonoscopy and flexible sigmoidoscopy can be burdensome for patients because they are invasive, unpleasant, and require an in-office procedure that interrupts normal activities. These tests also require specialized equipment, dedicated space in a health care facility, and significant health care manpower. In contrast, FOBT is a noninvasive test that patients can perform in their own homes and can be easily processed by health care systems. Though doctors—particularly gastroenterologists—may be more likely to offer colonoscopy than other types of tests, research suggests higher uptake of testing when patients are offered either FOBT or a choice among methods. In 2002, Medicare began covering colonoscopy for CRC screening, and in 2010, the Affordable Care Act required private health plans to cover CRC screening tests with no patient cost-sharing. With financial barriers removed, it is up to health systems and insurers to encourage patients to get tested. However, most health systems are not set up to do this, as they rely on opportunistic screening, offering tests to patients who are already in the office for a routine visit or when sick. Colorectal Cancer Screening At Kaiser Permanente: Meeting Patients Where They Are Kaiser Permanente, headquartered in Oakland, California, is the nation’s larges[...]

House Republicans Tweak AHCA Again; CBO Scores Earlier Changes

Fri, 24 Mar 2017 05:23:58 +0000

Editor’s note: This post has been edited to reflect continuing developments and emerging understanding of proposed legislative language. It is now reported that the full House will vote on the American Health Care Act on Friday, March 24, 2017. Late on March 23, a further manager’s amendment was offered (summary here), apparently to pick up extra Republican votes. The amendment would first delay the repeal of the Affordable Care Act’s additional Medicare tax on the wages of taxpayers exceeding $250,000 a year ($200,000 for single filers) from 2016 to 2023, and repeal a transition rule applying to the withholding of this tax by employers for 2017. This measure would raise about $63 billion in revenue. Second, the amendment would make a number of changes to the AHCA’s Patient and State Stability Fund. Under the amendment, states would be able to use the fund for reducing the cost of insurance coverage in the individual and small group market for individuals who have high health insurance costs due to the low population density of states where they reside. The fund would also be available for maternity and newborn care and for prevention, treatment, or recovery support services for people with mental illness or substance abuse disorders. The mental health and substance use disorder funds could be focused on inpatient or outpatient clinical care and/or on early identification and intervention of children and young adults with serious mental illness. The amendment also appropriates $15 billion for 2020 for the Patient and State Stability Fund for maternity, mental health, and substance abuse purposes. Changes Regarding Essential Health Benefits Finally, the amendment revises the section of the ACA defining essential health benefits (EHB). First, it strikes from the definition of “essential health benefits package,” the current provision that the EHB package is to include EHB as defined, “by the Secretary” (of Health and Human Services). The EHB package, however, includes the EHB “under subsection (b).” The amendment changes the “subsection b” definition of EHB—which currently reads “Subject to paragraph (2), the Secretary shall define the essential health benefits” to cover the ten ACA EHB categories—to say “subject to paragraph (2) and (6), the Secretary shall define the essential health benefits,” to include the ten mandatory categories.  Paragraph 2 provides that EHB must be equivalent in scope to a typical employer plan. The amendment next adds a new paragraph 6, stating: (6) ESSENTIAL HEALTH BENEFITS FOR PLAN AND TAXABLE YEARS BEGINNING ON OR AFTER JANUARY 1, 2018.—For plan years and taxable years beginning on or after January 1, 2018, each State shall define the essential health benefits with respect to health plans offered in such State, for the purposes of section 36B of the Internal Revenue Code of 1986 All plans in the individual and small group markets that are not grandfathered (or grandmothered) must cover the EHB package. The ACA also prohibits applying annual and lifetime limits to EHB and caps out-of-pocket spending for EHB. Under the amendment, HHS would apparently continue to define the EHB for these purposes, and EHB as defined by HHS must continue to cover the ten required services and be equivalent to the typical employer plan. For the limited purpose, however, of determining premium tax credits, states would be required to define EHB. Literally, the amendment seems to say that the state would only define EHB for purposes of determining what benefits covered by health plans can be paid for by premium tax credits, although it is also possible to read the amendment to say that states must define the EHB that must be covered by plans when the plans themselves are paid for by premium tax credits.  How the states would do so (by legislation, regulation, or guidance), and whether they would be capable of doing so by January of 2018, is an open question. (Insurers must file their 2018 plans by late June of 2017). Also, EHB ar[...]

Prescription Drug Regulation, Promotion, And Advocacy Has Gotten More Vexing In 2017

Thu, 23 Mar 2017 17:12:28 +0000

Editor’s note: This post is part of a series stemming from the Fifth Annual Health Law Year in P/Review event held at Harvard Law School on Monday, January 23, 2017. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. Early 2017 has been one of the most interesting and challenging times for anyone concerned with medication regulation and evidence-based prescribing — as well as for the patients and health care professionals who will be so heavily impacted recent policy changes. The 21st Century Cures Act In December 2016, Congress passed and then-President Obama signed the “21st Century Cures Act.” Its numerous sections relating to drug regulation offered a flawed solution to a problem that doesn’t really exist — the idea that the U.S. Food and Drug Administration is very slow in making its drug approval decisions, and has unreasonably high standards for approval. As a result of these failings, the reasoning goes, Americans are being denied timely access to needed drugs, and have to pay more for them once they are approved. Fortunately for all of us, that isn’t even close to the truth. The FDA’s evaluation times are among the fastest on earth, and the agency can turn around an approval decision within as little as six months. Further, its rate of approval is very high, and for years the agency has supported the idea that drug-induced changes measured solely by a laboratory test can be sufficient grounds for approving a new medication, rather than requiring that the new drug demonstrate an improvement in patients’ clinical outcomes. Nonetheless, in response to the pharmaceutical industry lobby and many patient groups, Congress passed the law encouraging FDA to widen its reliance on improvements in laboratory tests, imaging studies, or other “surrogate measures” as a sufficient basis to speed the approval of new medications, instead of demanding clinical trial evidence of the drug’s impact on study subjects’ health. If embraced fully by the agency, this could well result in its approving drugs simply on the basis that they have modest effects on such biomarkers, while benefitting patients minimally or not at all. Marketing Claims, Right-To-Try, And Other Challenges To Look Out For In 2017 Meanwhile, FDA’s authority over what statements drug companies can make in promoting their products is being eroded in the courts, through First Amendment challenges arguing that marketing claims by drug manufacturers constitute a kind of “commercial free speech” that the government must not limit. These cases, making their way through the federal court system for several years, supported by the drug industry and libertarian “action tanks,” had developed serious momentum even before the November election.  A new FDA Commissioner will soon be dropped into this swirling mix of counter-regulatory fervor and the new administration’s overall anti-government animus. Fittingly, the current nominee, Scott Gottlieb, once argued in an op-ed for The Wall Street Journal that the agency is a key barrier keeping much-needed drugs and medical devices from Americans. Meanwhile, in state legislatures throughout the nation, advocacy groups have been attacking FDA’s legitimacy at the local level by demanding the adoption of “right-to-try” laws, which would enable severely ill patients to use medications that have not been approved (or even fully evaluated) by the FDA. As it turns out, the government is not usually the main barrier to accessing such untested drugs. FDA is almost always open to approving these requests; it’s usually the manufacturers themselves who are reluctant to make such products available.  There is some good news dotting this otherwise depressing landscape. To combat the erosion of drug approval standards and the likely lifting of limits on pharmaceutical companies’ promotional statements, there is growing interest in programs that p[...]

Essential Health Benefits: What Could Their Elimination Mean?

Thu, 23 Mar 2017 15:08:41 +0000

At almost midnight on March 22, 2017, the House Rules Committee adjourned for the night. It had been expected to adopt House leadership amendments to the American Health Care Act and then pass the entire AHCA on to the House for a floor vote on March 23, the seventh anniversary of the adoption of the ACA. Instead the Rules Committee ended the evening by adopting a “martial law,” or same day rule, allowing it to amend and send to the floor the AHCA on March 23 (or anytime thereafter up until Monday, March 27) and the House to vote on the bill the same day as the Rules Committee vote. Approval of the bill was delayed because the Republican leadership does not have the Republican votes to pass it and no Democratic support is expected. Reportedly, President Trump is negotiating with conservatives to get enough votes to pass it. Some conservatives are apparently insisting that all of the ACA’s Title I insurance reforms be repealed before they will vote for the bill. These would include not just the provisions already amended or repealed in the AHCA—the individual and employer mandate (repealed immediately); the ACA’s premium tax credits, cost-sharing reduction payments, and small business tax credits (repealed as of the end of 2019): the actuarial value metal level requirements (repealed as of the end of 2019), and the 3 to 1 age ratio rating requirement (amended to 5 to 1). Additional provisions of Title I that could potentially be repealed include: The requirement that insurers sell coverage to all applicants, The guaranteed renewal requirement, The preexisting condition exclusion ban, The ban on health status underwriting, The single risk pool requirement for the individual and small group market Limits on the rating factors insurers may consider in the individual and small group market to age, tobacco use, geographic location, and family unit, The prohibition against annual and lifetime limits, The out-of-pocket limit requirement, The requirement that health plans provide an understandable and comparable summary of benefits and coverage, The medical loss ratio reporting and rebate requirements, The requirement that health plans provide access to pediatricians, obstetricians and gynecologists, and emergency care, and cover the routine costs of clinical trials, The requirement health insurers justify unreasonable rate increases, The requirement that insurers cover adult children up to age 26 on their parents policies, The requirement that insurers cover preventive services without cost sharing, The prohibition on rescissions except for fraud or material misrepresentation, Health plan quality rating and quality payment system requirements, Internal and external appeal requirements, The 90-day limit on group health plan waiting periods before eligible employees get coverage, The prohibition against discrimination against providers based on licensure status, The prohibition against discrimination on the basis of age, sex, national origin, race, or disability in federally funded health care programs, The exchanges or marketplaces; and The ACA’s risk adjustment program. This comprehensive a repeal of the ACA would have far-ranging consequences for our health care system that can scarcely be described, much less understood, in the hours that remain before a vote on the bill. Repeal of Title I would also expressly contradict President Trump’s promises that he would preserve at least the pre-existing condition ban and the coverage of adult children requirement. The pre-existing condition ban could be carved out of the repeal, but without the guaranteed availability requirement and health status underwriting prohibition, a preexisting condition exclusion ban is meaningless—insurers would simply refuse to sell coverage to an applicant with a preexisting condition. The full effect of the repeal of Title I or any of its protections would depend on what would happen to prior law and on interactions with state law. The Health Insurance Por[...]

The New Line On The HHS Blog; Suit For Federal Money Owed CO-OP Dismissed

Wed, 22 Mar 2017 17:14:10 +0000

For the past nearly seven years, the HHS blog has regularly highlighted the achievements of the Affordable Care Act. With the change in administrations, the change in the HHS blog has been dramatic. On March 14, 2017 it carried a post praising the proposed Republican American Health Care Act (AHCA). On the same day it carried a statement from Secretary Price challenging the Congressional Budget Office (CBO) report questioning the effects of the AHCA. On March 20, 2017, the about-face continued, with a post carrying an announcement of a new website highlighting HHS actions to roll back Affordable Care Act requirements. Transitional Plans The website, titled “Providing Relief Right Now for Patients,” lists three current HHS initiatives. The first of these, “Helping Patients Keep Their Plan,” highlights the administration’s decision to extend access to transitional plans for another year. It asserts, “This decision will help ensure lower premiums and real choices for millions of Americans, especially entrepreneurs, early retirees, and employees of small businesses.” Transitional coverage does potentially offer lower premiums to those who qualify for it. Not noted on the website, however, is that such coverage is only available to people who have had continuous coverage since 2013, can impose annual and lifetime limits and preexisting condition exclusions, and is not required to cover the ACA’s essential health benefits or limit out-of-pocket expenditures. More Time For Insurers The second entry, titled, “More Calendar Flexibility = More Options for Patients,” notes the decision of HHS to extend the time allowed to insurers to file qualified health plans and rates for 2018. Given all of the uncertainty surrounding health care reform at this moment, this extension of time is certainly necessary. Market Stabilization The third entry, “Stabilizing the Market for Patients,” praises the administration’s proposed changes to various ACA market rules. Given the fact that these are proposed rules, on which the administration is currently reviewing public comments, the forcefulness with which the administration endorses the proposals is somewhat surprising. Under the heading “Plans that Fit Your Budget,” HHS praises its proposal to allow plans with lower actuarial values by increasing allowed “de minimis” variation in actuarial value. The entry states that this change would permit plans with lower premium so that “more Americans would be able to find plans that work for their budget.” These plans, however, would have higher cost sharing and would result in lower premium tax credits, increasing the cost for premium tax credit recipients. Under the heading “Plans that Work for Patients,” the entry notes that HHS has proposed “lifting and streamlining one-size-fits-all requirements about what kind of access insurers have to offer,” lowering regulatory costs, and providing “broader options for Americans who want affordable insurance.” The proposal would end federal oversight of network adequacy requirements and leave to the states or accreditation agencies the task of determining when provider networks are too skimpy to provide basic health coverage. Finally, under the heading “No More Gaming the System,” the website recognizes the need for sick people to have access to health insurance, but claims that under current rules people are buying coverage while sick but dropping coverage while healthy. It makes the (disputed) statement, “The gaming of the system is pretty common.” It then describes several provisions of the proposed rule intended to discourage this “gaming.” The first of these is shortening the open enrollment period for 2018 to 45 days, which HHS states will discourage healthy people from putting off purchasing coverage to the last moment.  As younger people have tended to sign up late in the open enrollment period in the past, however, shortening the open [...]

What Can US Policymakers Learn About Essential Health Benefits From Israel?

Wed, 22 Mar 2017 16:56:31 +0000

In a February 14, 2017 article for Health Affairs Blog, Ian Spatz and Michael Kolber argue that the Affordable Care Act’s (ACA’s) essential health benefit (EHB) provisions “go to the heart of what it means to have health insurance and what health care we, as a society, want to ensure people can access.” To be sure, they recognize that states play the primary role in regulating health insurance. But the ACA’s essential health benefits place a floor nationwide on the parameters of coverage in the two markets—individual and small group coverage—that historically have been the most vulnerable to policies containing huge gaps in covered benefits and services. At the same time, the ACA’s essential health benefit guarantee, which by regulation (45 C.F.R. §156.100 et seq) is linked to states’ own baseline insurance laws is broad; indeed, the standard assumes that states will continue to adopt coverage standards that reflect the desires of their populations. One of the ironies of the election of Donald Trump and the consequent focus on repealing and replacing the ACA is that it focuses the policy mind, and perhaps even public debate, on this key element of health insurance reform. And regardless of whether the concept of a nationwide floor on coverage in the most vulnerable health insurance markets survives, states will continue to bear the lions’ share of responsibility for making this coverage meaningful. Inspired by Spatz and Kolber’s article, we outline here five key points that we believe policymakers should consider when approaching the law’s essential health benefit provision: Standardizing benefits for qualified health plans is both desirable and viable Plans should be allowed to vary actuarial exposure of beneficiaries while holding benefits constant Policymakers should establish a true budget for basic health coverage and then adjust the actual terms of coverage to reflect budgetary realities Any reference plan should incorporate these basic coverage concepts, coupled with a mechanism for periodically updating the model as technology, population health needs, and local circumstances warrant; and, States should continue to assume the primary role in determining coverage Lessons From Israel US policymakers confronting these complex questions could benefit from a close look at how other health systems approach them. In particular, it may surprise readers to know that Israel has a system very much in line with many US policymakers’ goals of fostering a competitive private insurance market. The Israeli system rests on the concept of competing private health plans selling care in a market of empowered consumers. But one crucial difference is how Israel approaches the question of what it means to be covered. In this respect, we believe that US policymakers have much to learn — especially those states willing to use their regulatory powers over health insurance markets to guarantee relatively robust coverage as a basic population health protection. The Israeli system, which guarantees its population a “basic basket of health services” that is defined and updated over time may hold lessons for states and the federal government. In establishing its national health system in 1995, the Israeli government in great part followed the core elements we outlined above. Israel is of course a small state, though its population of 8 million exceeds that of 42 US states. At the same time, Israel’s health care system, like that of any nation, needed the stability and structure produced by a comprehensive health reform strategy aimed at ensuring universal coverage while containing costs and building incentives to provide care that is both appropriate and efficient. Of course, as in any nation, there are robust debates about how generous the system should be, but to a remarkable degree, Israel has succeeded in achieving these goals. As of 1995 every Israeli citi[...]

The AHCA Gets It Wrong: Health Care Is Different

Wed, 22 Mar 2017 15:22:26 +0000

Congressman Ryan has now produced his fundamental health care reformation to support a “consumer-directed” vision in which services would be bought and sold like other goods and service in the economy. Indeed, responding to the Congressional Budget Office’s assessment that 24 million Americans would lose their health insurance if the House legislation becomes enacted, Ryan was rather nonchalant about that outcome, reasserting the conservative vision that, “People are going to do what they want to do with their lives because we believe in individual freedom in this country,” just as they do across all sectors of the economy. In many ways, the House’s American Health Care Act’s reliance on consumers to fend for themselves in buying health care services represents a fundamental rejection of the prevailing policy viewpoint, brilliantly formulated by Nobel laureate, economist Kenneth Arrow, in his 1963 article, “Uncertainty and the Welfare Economics of Medical Care.” Coincidentally, Arrow died on February 21, as the Republican proposal was taking shape. In a recent Health Affairs Blog post, Victor Fuchs paid tribute to Arrow’s seminal work. As testament to its impact, in 2002, the Journal of Health Policy Politics and Law devoted an entire issue to reprinting the paper along with 22 essays by a “who’s who” of health policy experts across a broad ideological spectrum, each one reviewing a particular aspect of the 33-page paper — it was that packed with novel insights. Kenneth Arrow on Health Care Markets To oversimplify this remarkable work, Arrow articulates the unique aspects of what were then called medical care markets, including uncertainty about diagnosis and prognosis, and, therefore, also about insurance risk; substantial asymmetry of information between the buyer—the patient—and seller—the physician providing medical care services; the mutual benefits of a trust-based relationship between the patient and physician, who has a professional duty to act in the patient’s best interests. Layered over these unique aspects of the physician-patient relationship, the broad desire for and reliance on insurance to protect against the uncertain need for medical care, inevitably produces “moral hazard” — an overuse of services and indifference to prices, as patients are insulated from the actual costs of the care they receive. Some conservative policy experts forthrightly have acknowledged that their advocacy of consumer-directed health care markets runs up against Arrow’s argument that health care markets are fundamentally different. Avik Roy, in particular, takes on Arrow directly in “The Gospel According to Ken Arrow.” Working his way through the core tenets of Arrow’s paper, he argues that what Arrow proffered as unique aspects of health care markets now are actually quite common in many sectors and that, nevertheless, market-based solutions have been found, without the need to resort to government “interference.” So, extended warranties, traveler’s insurance, and a range of other instruments have developed to protect again the unpredictability of life. Similarly, Roy argues that consumers, having to confront increasingly technical information in many parts of their lives, now have ready access to expert intermediaries to address information asymmetry, for example, financial advisors on investments. Some argue—while others dispute—that the internet has reduced information asymmetry, suggesting that individuals can, in essence, act as their own physicians for routine care, as they are expected to do under high-deductible plans. Roy also takes on Arrow’s unique role of trust in physician-patient relationships, arguing that trust is important not only in medicine but in many other commercial transactions, citing the trust consumers have that airline pilots and airline mechanics are[...]

The House Manager’s Medicaid Amendments: The State Block Grant Option

Tue, 21 Mar 2017 19:33:51 +0000

The 1995 Medicaid block grant provisions contained in the Balanced Budget Act of 1995 that was sent to (and vetoed by) President Clinton consumed 100 pages of dense legislative drafting. The block grant provisions of the American Health Care Act (AHCA)—which faces an imminent vote on the House floor—are much more efficient, taking up about eight pages in the House Manager’s Amendment (Policy Changes). Read in some detail—although there is not much detail to read—the block grant option can be read as an astonishing expression of legislative policy, and even more so perhaps, a statement of child health policy. The lax nature of the amendment can be seen in the lack of federal integrity controls over hundreds of billions of dollars in federal spending. And the public health implications of the amendment can be seen in the degree to which the provision would—as a statement of general federal policy—move the role of government away from ensuring access to adequate health care for its very poorest residents, who, under the amendment’s terms, disproportionately are infants and children. Titled “Flexible Block Grant Option for States,” the amendment adds a coda of sorts to the bill’s new Medicaid per capita cap payment system. Under the amendment, states would have an option to receive a certain portion of their federal Medicaid funding in the form of a block grant. A state would opt for the block grant model on a 10-year basis and would qualify for block grant funds simply by filing a state 10-year plan with the HHS Secretary; the state’s plan would be deemed approved if the agency fails to stop the clock within a 30-day window because the proposed plan is either “incomplete” or “actuarially unsound.” Because there are virtually no requirements, it won’t be too difficult for states to write such a plan. A state’s plan must indicate which block grant eligibility categories the state wishes to include in its option. For the populations included in these categories, the plan must provide “block grant health care.” (More on what this might actually mean below.) In terms of the categories of individuals to be incorporated into the block grant, states will have two choices. Under the first choice, beginning as early as October 1, 2017, a state could choose a block grant that includes all poverty-level children for whom coverage is mandatory, newborns deemed automatically enrolled in the program, and working-age adults who are neither disabled nor part of the optional ACA adult expansion population. These adults would consist of pregnant women and very poor parents and caretakers who meet Medicaid’s traditional financial eligibility rules — that is, they make less than half the federal poverty level. States taking this “children and caretaker/parents” block grant option would have to cover only children and pregnant women and therefore could entirely cut out the very poorest parents and caretakers for whom coverage is now mandatory. Under the second choice, a state could simply block grant its traditional working-age adults, leaving children out of the mix. States that choose the second option would be obligated to cover pregnant women, but the obligation would end there. As in the first option, all other adults apparently could be eliminated, and since the funding is block granted, either option would allow states to keep the surplus. Disappearing Coverage Standards What kind of health care would states operating block grants need to finance for block-granted eligibility groups? The amendment virtually eliminates any coverage obligations. (Block grant states would have to undergo audits to ensure that they were spending their block grants on block grant health care. The audit would be conducted by the state and “made available” to the Secretary. Children and adults w[...]

Redesigning New Jersey’s Medicaid Program: Philanthropy Steps Up

Tue, 21 Mar 2017 17:39:00 +0000

In early March 2017, the New Jersey Health Care Quality Institute (NJHCQI), a nonprofit quality improvement group, released Medicaid 2.0: Blueprint for the Future, a landmark plan to redesign and modernize New Jersey’s Medicaid program. A year in the making, the Blueprint resulted from a carefully designed process that brought together a wide variety of stakeholders from across New Jersey, including health care providers, health plan executives, hospital leaders, government officials, union representatives, academics, advocacy groups, and patients. The report—released against a backdrop of political uncertainty about the future of federal Medicaid funding, and in 2017, an election year in New Jersey—lays out a set of twenty-four recommendations to improve the quality, and reduce the cost, of the program. The Nicholson Foundation conceived of and funded the Blueprint as part of a larger project to promote the efficient delivery of high-quality health services for Medicaid recipients in New Jersey. This aligns with our mission to address the complex needs of vulnerable populations in New Jersey’s urban and other underserved communities. Central to that mission is strengthening Medicaid, the health care financing and delivery system that serves the state’s safety-net population. The process we used to develop the Blueprint shows that when state governments do not take the lead in fundamentally transforming their Medicaid programs, foundations can step up to support Medicaid modernization. Medicaid’s Role In New Jersey Medicaid now provides health insurance to nearly 1.8 million, or nearly one in five, New Jersey residents. It costs the state about $15 billion annually; the state’s share of Medicaid represents 20 percent of New Jersey’s total budget. Despite this investment, it is clear that the Medicaid program in New Jersey—as in many other states—often does not meet the needs of its recipients. Obstacles to access persist, care is fragmented, and capacity for treating the whole person (that is, for concurrently addressing physical, behavioral, and health-related social needs) is limited. Barring substantial change, the costs of the program will continue to grow without demonstrable improvements in health outcomes. The Nicholson Foundation understood the need for change long before the 2016 election altered the political landscape and ushered in increased scrutiny of Medicaid in Washington, D.C., and in state capitals. Nearly seven years ago, we began looking at the quality and cost of medical services delivered to safety-net populations in New Jersey to understand how they could be improved. The subsequent work of our grantees on service delivery reform, payment reform, and data and decision making, made important steps forward but considered only isolated pieces of the Medicaid puzzle. We realized that to achieve truly transformative systems reform, we would have to supplement our “piece of the puzzle” approach with a more comprehensive strategy. We decided it was time to examine the entire puzzle. The Medicaid 2.0 Project Many states have launched Medicaid modernization efforts in recent years, as chronicled in Health Affairs (journal, Blog). Typically, governors have conceived, led, and funded these efforts because the growing cost of Medicaid tends to crowd out the rest of their policy agendas. Although New Jersey’s Medicaid program faces problems similar to those of other states, New Jersey did not initiate a comprehensive reform process. With the administration of the incumbent governor (Republican Chris Christie) winding down, The Nicholson Foundation saw an opening to provide the next administration with a ready-to-roll, nonpartisan plan for a Medicaid overhaul. First, we had to find the right partner to lead this effort. We chose the NJHCQI because it is respected by stake[...]

What’s In The Manager’s Amendment To AHCA?

Tue, 21 Mar 2017 16:19:43 +0000

On March 20, 2017, the Republican House leadership released a manager’s amendment to the American Health Care Act. This amendment is intended to respond to critics of the original AHCA from the right and from the middle. It is less clear that it responds to concerns raised by the Congressional Budget Office report on the original AHCA, as will be discussed later. The original AHCA, as it passed the House Budget Committee, (Budget Committee Report) contained provisions that would: Phase out the ACA’s Medicaid expansion; Impose a per capita cap on Medicaid going forward; Eliminate the ACA’s Prevention and Public Health Fund; Defund Planned Parenthood; Repeal the ACA’s cost sharing reduction payments; Create a $100 billion Patient and State Stability Fund for states to use for reinsurance and other purposes; Repeal the ACA’s individual and employer mandate penalties; Create a penalty for individuals who try to enroll in coverage who have not had continuous coverage; Repeal the ACA’s actuarial value metal level requirements; Change the ACA’s age rating ratios from three-to-one to five-to-one; Amend the ACA’s current premium tax credits to allow them to be used for off-marketplace plans and to change the tax credit formula to make it more favorable to younger enrollees; Create new fixed-dollar, age adjusted tax credits for after 2020; and, Liberalize some requirements pertaining to health savings accounts. The manager’s amendment leaves most of these provisions in place. It consists of two sets of amendments, labeled technical changes, (summary) and policy changes (summary). In fact, however, some of the policy amendments (which deal primarily with the Medicaid program and tax repeals) are quite technical, while a few of the technical amendments (which deal primarily with changes in the tax credit program as well as Medicaid) make significant policy changes. Speaker Ryan states that the technical changes were necessary for the House bill to comply with Senate reconciliation rules, although it is not easy to discern how they do this. Medicaid The manager’s amendment would end the ACA’s mandatory expansion for childless, nondisabled, non-pregnant adults up to 133 percent of the poverty level and sunset the ability of states to decide to cover adults above 133 percent of poverty with an enhanced Medicaid match as of the end of 2017. States could cover the ACA expansion population, however, as an optional category with their normal Medicaid match after that date. Medicaid expansion enrollees enrolled prior to the end of 2019 would retain the enhanced match after 2019 (90 percent in 2020), but only so long as they remained continuously enrolled and only in states that had expanded Medicaid by March 1, 2017. The manager’s amendment would allow states to impose a work requirement on nondisabled, nonelderly, non-pregnant adults as a condition of Medicaid coverage. The requirement is modeled after requirements and exemptions in the TANF program. States could include as countable work activities subsidized private or public sector employment, on-the-job training, job search or readiness activities, community service programs, various educational programs, or providing childcare to an individual participating in a community service program. In fact, most Medicaid expansion adults who are capable of working are currently employed, usually at low-wage jobs that do not offer health insurance. Indeed, expansion population adults have a better record of workforce participation than the general population. Nevertheless, getting Medicaid beneficiaries to work was a key demand of conservatives and thus an optional work requirement is in the amendments, along with a 5 percent administrative cost bump for states that impose work participation programs, recognizing the considerabl[...]