On Health Care, Conservatives Protest Too Much

Lately conservatives have been feeling like losers in health care and complaining loudly about it. They don’t like Obamacare or the increase in the government’s role in health care or the federal spending it brings with it, even if those things result in coverage for more than 30 million uninsured…

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The News Media and “Entitlement Reform”

In the coming debate about the deficit, policymakers will struggle to craft a package of spending reductions and new revenues that both Democrats and Republicans can agree on, totaling as much as four trillion dollars over ten years.  Medicare, Medicaid and potentially the Affordable Care Act will have their turn…

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Pulling it Together: How the ACA Can Help The Homeless

Estimates are that there are approximately 630,000 people who are homeless on any given night in the U.S. — about two-thirds in shelters and one-third on the street or without real shelter. Several million people are estimated to experience homelessness over the course of a year. About two-thirds are individuals and the…

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Pulling it Together: Reflections on This Year’s Four Percent Premium Increase

Our 2012 Employer Health Benefits Survey found a 4% increase in premiums this year, continuing the recent trend of moderation in health costs and spending reported in several studies. Double digit increases in premiums were once a common occurrence, but we have not seen any since a 10% increase in…

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Pulling it Together: As The International AIDS Conference Convenes, Some Positive News About Public Opinion and HIV

The American people are busy trying to make ends meet and take care of their families and they are constantly bombarded by messaging and spin. They rarely have a full understanding of policy issues and debates. Often it is their strongly held beliefs, whether based on accurate or inaccurate perceptions,…

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Pulling it Together: Duals: The National Health Reform Experiment We Should Be talking More About

The Center for Medicare & Medicaid Services (CMS) and 26 states are moving to launch a large scale managed care demonstration project potentially involving millions of the poorest, sickest, most expensive Medicare and Medicaid beneficiaries, the so-called dual eligibles. The experiment is getting more and more attention from policy experts,…

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                    [post_content] => Lately conservatives have been feeling like losers in health care and complaining loudly about it. They don't like Obamacare or the increase in the government's role in health care or the federal spending it brings with it, even if those things result in coverage for more than 30 million uninsured Americans and new protections from the worst abuses in the health insurance industry.

Actually, conservatives are winning at least as much as they are losing in health care, even if they don't know it or won't say it, because out in the real world of health insurance, beneath the politicized debate about Obamacare, the vision of health insurance they have always championed -- high deductible plans that give consumers lots of "skin in the game" -- is steadily prevailing in the marketplace. Moreover, the conservative vision of "skin in the game" insurance could actually get a boost from the health reform law.

Half of all workers in small firms now pay deductibles of $1,000 or more a year, and the percentage of workers in all firms paying big deductibles has tripled in the last six years. In the last five years the average deductible for single coverage has gone from $616 to $1,097 in all firms that have deductibles, and from $852 to $1,596 in small firms. Estimates are that in the basic plan offered in the health insurance exchanges under the Affordable Care Act, deductibles could be over $4,000 for individual policies and over $8,000 for family policies. These are big deductibles by any standard. Yes, the minimum coverage people will have to buy under Obamacare will be just the kind of "skin in the game" insurance that conservatives have always favored.

But from start to finish, the health care reform debate has not been about facts but about ideology and partisanship. Conservatives are certainly not happy that the Affordable Care Act has survived a Supreme Court challenge and an election and will now be implemented and will not be repealed. But even as they continue to vilify the law, they must take solace in the fact that many states are still balking at implementing major provisions that conservatives do not like, such as the law's insurance exchanges or its Medicaid expansion, which the Supreme Court made optional. Only 18 states and D.C. have chosen to implement their own insurance exchanges, and only seven are planning exchanges that are active purchasers, the more aggressive kind of exchange that liberals and consumer advocates would like because they weed out plans with high premiums.

The success of the Affordable Care Act now hinges on implementation, and more than any other single factor, the fate of the law will depend on what states do and how well they do it. The federal government will step in and operate exchanges in states that choose not to do so, but there is no federal fallback on Medicaid; if a state like Texas or Florida does not opt to expand coverage under the ACA, it will not happen.

It will behoove the Obama administration and advocates of the law to actively nurture pacesetting states so that they have tangible success stories to point to in 2014 and models that other states can learn from and emulate. If even a relatively small number of states can show that uninsured people are being covered in large numbers, that federal funding is flowing as promised to the states and to individuals who qualify for insurance subsidies, that the new health insurance reforms are working as planned and that coverage is affordable and, as in Massachusetts, the public is accepting the individual mandate, then other states will take notice, whatever the ideological predispositions of their governors or legislators. It is already clear that the test in 2014 will not be whether the law is working perfectly everywhere (there isn't time for that to happen, and it won't be) but whether it can work as intended. If a handful of states can demonstrate that, then the others will want to follow.
                    [post_title] => On Health Care, Conservatives Protest Too Much
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                    [post_content] => In the coming debate about the deficit, policymakers will struggle to craft a package of spending reductions and new revenues that both Democrats and Republicans can agree on, totaling as much as four trillion dollars over ten years.  Medicare, Medicaid and potentially the Affordable Care Act will have their turn on the operating table as policymakers look for savings.  It is unclear what reductions in Medicare and Medicaid spending policymakers will be able to agree on but whatever they do they will call it “entitlement reform”.   Like calling a new tax a revenue enhancement, calling spending cuts and program changes “reforms”, and even better “entitlement reforms”, makes them sound more palatable and forward thinking.  News organizations should resist mimicking labels like “entitlement reform” although understandably, policymakers and advocates will use them.

The dictionary defines reform as “to improve, remove faults or abuses, habilitate, reclaim or redeem”. You can see why there would be disagreement about applying that term in the current budget debate.

I was very involved in the welfare reform movement. Surely that was “reform”. Well, maybe. The essential purpose of welfare reform was to transform the welfare system from an emphasis on cash assistance to work.  Whether you were for or against welfare reform there was no question that it fundamentally changed the welfare system.  Most observers agree welfare reform has been a success and has moved welfare policy in a much better direction.  But not everyone shares that view and welfare reform has more than its share of critics.  They don’t think it is reform at all.  They see it as punitive, leading too often to low-paying jobs.  Welfare “overhaul” would have been a much more neutral description but I admit that when I was selling my welfare reform program in New Jersey and helping promote national legislation, I was more than happy to have the media call it reform.

What about “health reform”? It is clear that the law makes fundamental changes to the health insurance and health care systems and will do a great deal of good, but there is obvious and sharply partisan disagreement about whether the law overall is a good thing or a bad thing.  For this reason it is the policy at NPR to avoid using the “health reform” label (and along with it the more pejorative Obamacare).  This is the practice at our Kaiser Health News as well.

What then about “entitlement reform” in the context of the current budget debate?  There will be a long list of reductions in Medicare and Medicaid spending considered as this debate unfolds, from straightforward cuts such as reducing payments to hospitals and nursing homes, to changes in the rules of these two big entitlement programs such as rolling back the age of eligibility for Medicare, income relating Medicare premiums, or converting the Medicaid program to a per capita cap.  Each of these will have advocates and opponents and many of these proposals will be hotly debated.  All can appropriately be called “entitlement cuts”, or “spending reductions”, or “changes to entitlement programs”.  Some proposals - premium support for Medicare, a Medicaid block grant or per capita cap - will rise to the level of an “entitlement overhaul” or “restructuring”.  But whether a change is “reform” or good or bad will be in the eye of the beholder.  Is premium support a badly needed reform that will introduce fiscal discipline and market competition to the Medicare program as conservatives believe, or a backhanded way to cap federal spending, reduce the role of the federal government and end the Medicare entitlement, which is how many liberals view it?  Is a Medicaid block grant a way to give states more flexibility they have long wanted, or to sharply reduce federal funding to the states and eliminate the Medicaid entitlement under the guise of giving states greater flexibility?  Is raising the age of Medicare eligibility a reform whose time has come or a way to shift costs from Medicare to seniors and employers?  As we begin this new budget debate there is substantial agreement on the need to reduce spending but no agreement on what constitutes “reform” or on which “reforms” are the right ones to make.

Taking an insider debate with mind numbing numbers and complex policy options and making it understandable for the American people is always a huge challenge for the news media.  That challenge will take on new importance in the upcoming budget debate.  It is understandable that policymakers and advocates would frame what they believe in or have concluded is the best budget tradeoff to make in the most positive light, but calling every spending reduction a “reform” can obfuscate the hard choices that need to be made. Let’s hope the news media will avoid loaded labels and help the public understand the consequences of different approaches to deficit reduction.
                    [post_title] => The News Media and “Entitlement Reform”
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                    [post_content] => Estimates are that there are approximately 630,000 people who are homeless on any given night in the U.S. -- about two-thirds in shelters and one-third on the street or without real shelter. Several million people are estimated to experience homelessness over the course of a year. About two-thirds are individuals and the balance are in families.

These numbers are virtually identical to national estimates we used when I worked intensively on the issue of homelessness in the 1980s in state government in New Jersey and at the Robert Wood Johnson Foundation.

Back in the 1980s homeless families were the face of the homeless problem. Today, after two wars, it is the homeless vet.

Then, homelessness was often featured on the front covers of major national news magazines and on national TV news shows. Today it has largely slipped from the national consciousness and remains a prominent but local issue mainly in some urban areas where the homeless are on the streets in significant numbers.

There may be many reasons for this. The problems of the homeless may seem less urgent to the country when the middle class are struggling in a weak economy, and there may be less national emotional space to think about deep poverty, chronic mental illness, substance abuse, and the challenging combination of all three of these we often see in chronic homeless populations. The problems of urban America and low-income housing have also become less prominent, even as there seems to be more discussion of income inequality. At the same time, with cutbacks in state and federal funding, the budgets of cities and counties and community organizations who deliver services to the homeless could not be tighter.

When I worked on this problem previously, I focused mostly on establishing health and other outreach services for the homeless across the country through a national program operating in 19 cities I developed at the Robert Wood Johnson Foundation in partnership with the Pew Charitable Trusts and the U.S. Conference of Mayors. Later I worked on developing affordable housing options for homeless families as Commissioner of Human Services in New Jersey, trying to get homeless families out of “welfare hotels” and off of emergency homeless assistance and into more permanent arrangements. The overriding lesson I learned in all of this work was the importance of effective outreach to connect homeless people to services (and the difference housing, income support, and health care services could make if the connection was effectively made and sustained). Much of the debate about the homeless focuses on the chronically homeless population so visible in big cities and there is no doubt that this population can be very challenging. But several cities have shown good results with programs that aim to get even the hard core homeless off the streets and into better life situations, as chronicled in Malcolm Gladwell’s nice 2006 New Yorker piece, “Million Dollar Murray.” The fact that several million people move in and out of homelessness each year also suggests that for most who experience homelessness, it is not a long term situation; more can be done to address the larger problem of people living on the margin in our country – the sometimes homeless.

Another lesson I learned working on these programs was the effectiveness of peer outreach, especially in programs for homeless and runaway youth. This was a lesson we adopted at Kaiser in working on the loveLife HIV prevention program in South Africa, which deploys about 1,500 young people each year called Groundbreakers, who work in villages and urban neighborhoods across the country as the vanguard of the HIV prevention effort for youth and young adults. The Groundbreakers, all well trained young leaders, do absolutely stunning work in their distinctive purple and black loveLife t-shirts operating out of a network of youth-friendly clinics and youth centers established by the program. This kind of outreach, whether here or in South Africa, is work that can only be done at the grassroots level by exactly the front line service workers who are endangered by today’s tough budgetary environment at the state and local level. I remember talking with a homeless teenager in South Jersey, probing about whether this service or that would be more useful in health clinics we wanted to set up. His response: “Commissioner you don’t understand. What I need is not this or that service. What I need is someone I can trust.” His remark and many others like it caused us to develop intervention models that heavily emphasized social and mental health services in our “health care” clinics.

8355_cover_PITI go through this background now because there is a new opportunity to connect homeless people to services through the Affordable Care Act (ACA), which many people may not be aware of. That is because many homeless people are both poor and uninsured and will qualify for Medicaid coverage under the ACA in states that opt to expand Medicaid with mostly federal money. The ACA will provide coverage, in most states for the first time, for low-income, childless adults, which is who the majority of the homeless are. The vast majority of people who are homeless will be eligible for Medicaid under the ACA expansion since they generally have little income (except undocumented immigrants who are ineligible). We have just published a new report co-authored by Samantha Artiga and Rachel Arguello of our staff and Barbara DiPietro and Sarah Knopf of the National Health Care for the Homeless Council, which discusses in very practical terms what it will take to connect homeless people to an expanded Medicaid program under the ACA and get them the broad range of health care services they need. Many homeless families may also already be eligible for Medicaid under their state’s current rules, and other homeless adults qualify for Supplemental Security Income (SSI) but are not enrolled. Better outreach facilitated by the ACA could assist them as well.

Providing better health coverage can help connect the homeless to needed health services. That is important not only to relieve suffering, but because untreated medical and mental health problems are significant contributing factors to unemployment and homelessness. Increased Medicaid coverage can also relieve burdens on safety net clinics and hospitals who serve the uninsured homeless now. But the biggest payoff will come if the availability of health coverage under the ACA also provides a new outreach opportunity that serves as a gateway to housing, employment, and other services state and local agencies and community organizations use to help the homeless get back on their feet. Just as importantly, this new effort could bring renewed attention at the state and local level to the problem of homelessness itself.
                    [post_title] => Pulling it Together: How the ACA Can Help The Homeless
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                    [post_content] => Our 2012 Employer Health Benefits Survey found a 4% increase in premiums this year, continuing the recent trend of moderation in health costs and spending reported in several studies. Double digit increases in premiums were once a common occurrence, but we have not seen any since a 10% increase in 2004 and 13% growth in 2003. Rates of increase in total health spending have been holding at 4-6% per year recently, and per capita spending -- which is most analogous to premiums -- has been rising about a percentage point below that. These are strikingly low numbers to those of us who have been studying health costs for a long time. A 4% increase in health premiums is good news, although good news is seldom “news.” But will it last?

No one has yet been able to disentangle the causes of the slowdown persuasively. Health care use and the economy have always been closely tied, and my sense is that the recession and slow recovery are responsible for much of the recent health spending and premium trends. Increases in recent years in cost sharing through high deductible plans have probably played a supporting role. In tough times, when wages are flat, people avoid using the health care system if they can. We also know that higher out-of-pocket costs deter utilization, so it’s reasonable to assume that the growth of high-deductible plans and other forms of cost sharing has had an impact on health care use, magnifying the effect of the economy.

There is no perfect database that will enable us to spot a new wave of utilization building back up just over the horizon. Insurers can often spot trends in their claims and the publicly held companies sometimes give clues as to what’s going on in their quarterly earnings statements. Recent reports suggest that utilization may be starting to pick up modestly, at least for outpatient services.

Using data from our employer survey, Exhibit 1 shows cumulative premium increases for the years before and after the recession, suggesting (but not proving) the influence of economy on premium trends.
PIT-premiumchange_02_1.gif

Some observers think the cumulative effects of delivery and payment reform efforts across the country may also be playing a role in holding down costs. Employers, insurers, and providers have been organizing a range of efforts to reduce costs and improve quality. These efforts are promising, but they also tend to be locally based and small scale. Some focus on one employee group, or disease group, or on the efforts of one insurance plan in a state. The largest effort to encourage payment and delivery reform, the Medicare payment and delivery experiments funded under the Affordable Care Act, are only just beginning. Our colleagues at the Commonwealth Fund recently estimated that there are today about 2.4 million Medicare beneficiaries being served by providers participating in Accountable Care Organizations, far too few to impact costs nationally. The Congressional Budget Office has thus far been unwilling to score savings for delivery reform, at least as it has been embodied in legislative form. Whatever the promise of these efforts to reduce costs, experience to date is mostly small scale. Previous efforts produced mixed results according to the most rigorous evaluations we have, and we don’t have much new evidence yet.

Then there are chronic disease management programs. And wellness programs. And tighter managed care. It is possible that it is not any one thing but somehow the combined effect of all of these things that is holding back cost increases. Like other theories, the “all of the above” theory is not provable, at least not yet. Many claims are being made about current efforts to hold down costs – some in the interest of understanding what is happening in a complex health care system, others not entirely disinterested. The truth is that what we don’t know about the causes of the slowdown and the efficacy of current efforts exceeds what we do know by a wide margin. Our colleague, the health economist Gail Wilensky, said essentially the same thing in The New York Times not too long ago: “If there’s something else going on, we don’t know what it is yet. The most honest thing to say is that, one, the reduction in use is greater than the recession predicts; two, we don’t understand why yet; and, three, you’d be foolhardy to say that we can understand it.” My sense, from watching these trends for many years, is that explanations that focus on the recession and the economy, and secondarily on the recent growth in cost sharing and high deductible plans, are the most plausible. In the small group market where fewer firms are self-insured, it is also possible that recent medical loss ratio and rate review regulations are having some effect.

With the economy only slowly recovering and wage stagnation depressing utilization, there is no reason to expect a return to double digit increases in health insurance premiums anytime soon, if at all. Other new variables could also change the cost picture moving forward, including the implementation of the Affordable Care Act and reductions in Medicare or Medicaid spending that might arise out of budget talks. At the same time, there has been no obvious change in the fundamental underlying drivers of medical costs or in the delivery of, or payment for, medical services that should lead us to think that the recent historically low increases in health costs represents a “new normal.” There is no bigger or more challenging problem in health care than controlling costs, and the recent good news about premium increases is no reason to assume the problem is solved or to back off of new efforts to address it.

[post_title] => Pulling it Together: Reflections on This Year's Four Percent Premium Increase [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pulling-it-together-reflections-on-this-years [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:37 [post_modified_gmt] => 2014-03-04 16:14:37 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/quiz/pulling-it-together-reflections-on-this-years/ [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 22753 [post_author] => 25629999 [post_date] => 2012-07-19 13:37:34 [post_date_gmt] => 2012-07-19 17:37:34 [post_content] => The American people are busy trying to make ends meet and take care of their families and they are constantly bombarded by messaging and spin. They rarely have a full understanding of policy issues and debates. Often it is their strongly held beliefs, whether based on accurate or inaccurate perceptions, which color what they think about issues.  The classic case is the public’s perception of foreign aid, something they don’t like and that they believe consumes a far larger share of the federal budget than it actually does. (If people are given a specific and more popular purpose for aid, such as funding for global health or to alleviate hunger and poverty, their views flip and they are much more positive.) So it is something of a surprise, and more than a little bit heartening, to see in our new Kaiser Family Foundation-The Washington Post survey published in the paper this week that the American people get most of the essentials about the HIV epidemic right (but not necessarily all of the details). On the eve of the first International AIDS Conference in the U.S. since 1990 (the year we started the modern day Kaiser Family Foundation and made HIV one of our core priorities), there is a lot that is positive about public opinion on HIV. The state of public opinion on HIV, once an issue marked by great fear and misperception, contrasts sharply with the much more toxic environment on many other health issues we poll on, such as health reform, where we see much higher levels of confusion, misperception and division in public opinion.
  • Half of Americans (51%) see progress in combating the domestic epidemic, with 18% saying we are losing ground. Blacks (41%) are less likely than whites (52%) to believe progress is being made, which, of course, reflects the reality in the black community which has been much harder hit by HIV/AIDS.  The public has it right; there has been great progress, although there is still a long way to go.
  • Most Americans (58%) think the world is making progress on HIV/AIDS, with 18% saying we are losing ground.  Again, right on target.
  • People from communities who are most affected by the epidemic are the most likely to say they are worried about it.  For example, blacks are five times as likely as whites to worry about a family member getting HIV.
  • People know where the epidemic is now hitting hardest.  For example, over half the public (54%) – and even a larger share of blacks (63%) – recognize that the epidemic has had a greater impact on blacks than whites in the U.S.
  • Most people know that providing access to treatment is a problem in developing countries, with 87% percent of the public saying most people in developing countries don’t have access to HIV medications. This has been a theme in media coverage of the global epidemic. New data just out from UNAIDS finds recent gains have been made, although still almost half of people in low and middle income countries who need HIV medications are not getting them.
  • A majority (56%) says that more spending on HIV treatment will lead to meaningful progress in slowing the epidemic here at home, something experts would certainly assert.  (About a third – 34% – say it won’t make much difference.)
  • Recent research has shown the important benefits of treatment as prevention – that those with HIV on treatment can reduce the chances of spreading the virus to sexual partners by as much as 96%.  Half of Americans (49%) are aware of this link between treatment and prevention, a surprisingly high number for a fairly recent research finding that will not affect most of the public.
Still, there are misconceptions about HIV that stubbornly persist.  About a third of the American people still harbor some misunderstanding about a basic fact related to HIV such as thinking you can transmit the virus by sharing a drinking glass with an HIV positive person.  Thirty percent think Magic Johnson has been cured or are unsure.  Only 17% of the public knows that HIV drugs can lower the risk of people who are HIV negative but at high risk of contracting HIV (our poll was conducted just before the high profile FDA approval of the first drug for this purpose). This will be critical information to get to high risk groups. So why does the public grasp at least the essential contours of the epidemic?  One factor may be the cumulative effect over many years of media coverage, because the news media is by far the public’s top source of information on HIV.  But that cannot be the only explanation.  News coverage of HIV has been falling off for years, and this year only 14% of the public say they have seen, heard, or read “a lot” about HIV in the U.S. (22% say the same about HIV in Africa). That’s down from 34% and 51% respectively in our 2004 survey. Another factor, I suspect, is that people have learned about the epidemic because, sadly, many know someone with HIV.  Forty-five percent of the American people now say they have a family member or close friend (22%) or know someone else (another 23%) who has HIV.  People are likely to learn more about the epidemic when they have personal contact with it.  Still another factor is that significant shares of people are talking to doctors about HIV.  For non-elderly whites the percentage talking to doctors is up to 40%; for blacks it is now 64%.  No doubt the tireless efforts of HIV advocacy groups and advocacy campaigns have also played a significant, if hard to measure, role in the public’s general grasp of the epidemic. It is likely a combination of all of these factors and others that are responsible for the American people grasping the essentials of the epidemic.  While some share of the public will always get basic facts and details wrong, it is most important now to make sure people understand the significance of recent scientific advances, particularly for high risk groups, who can act on what has been learned about the benefits of early detection and treatment to protect themselves and others. Even so, knowledge of basic facts – like whether HIV can be transmitted from toilet seats or drinking glasses –  can be beneficial because it helps to reduce the persistent stigma directed towards those who are HIV positive, which contributes to the spread of the epidemic when people delay testing and treatment because of worries about how they will be viewed.  In fact, while the percentage of people who say they would be very comfortable working with someone with HIV has been rising, from 32% in 1997 to 48% this year, and the share of parents saying they would be comfortable if their kids had an HIV positive teacher is up, until attitudes like these are more universal, stigma will persist. The public’s grasp of the essentials (if not all the details) is important for future efforts to halt the HIV epidemic.  Despite progress and new breakthroughs in research on the role of treatment as a prevention tool, there is a long way to go in the effort to end the epidemic here and abroad.  There is still stigma and discrimination and new funding is exceedingly hard to come by in today’s weak domestic and global economies.  But there is a foundation of basic public knowledge and support which will serve the HIV effort well in years ahead. [post_title] => Pulling it Together: As The International AIDS Conference Convenes, Some Positive News About Public Opinion and HIV [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pulling-it-together-as-the-international-aids [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:38 [post_modified_gmt] => 2014-03-04 16:14:38 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/quiz/pulling-it-together-as-the-international-aids/ [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 26035 [post_author] => 25629999 [post_date] => 2012-06-01 15:16:51 [post_date_gmt] => 2012-06-01 19:16:51 [post_content] => The Center for Medicare & Medicaid Services (CMS) and 26 states are moving to launch a large scale managed care demonstration project potentially involving millions of the poorest, sickest, most expensive Medicare and Medicaid beneficiaries, the so-called dual eligibles. The experiment is getting more and more attention from policy experts, but with controversial issues like the survival of the Affordable Care Act and converting Medicare to a premium support program grabbing the limelight, it has otherwise flown under the radar screen. The 9.1 million dual eligible beneficiaries represent just a small share of the 97 million beneficiaries served by either Medicare or Medicaid but account for about 35 percent of all dollars spent by the two big programs. As a group they are sicker than other Medicare beneficiaries -- half have three or more chronic conditions and six in ten have cognitive limitations, leading to increased use of health and long-term care services. While most are over age 65, four in ten are younger with permanent disabilities. Two of three are women. A striking 56 percent have incomes of less than $10,000 per year. (Kaiser.EDU, Medicare/Medicaid Dual Eligibles.) Of the 26 proposed state demonstrations, most are planning capitated managed care models, but some propose using a managed fee-for-service approach. For the capitated model, states and the federal government will enter a three-way contract with private managed care companies to manage the care of the enrolled population. Medicare, which mainly pays for acute care, and Medicaid, which mainly pays for long-term care, will blend payments into one rate, with savings taken off the top for both Medicare and Medicaid. The demonstration is moving quickly; half of the 26 states are looking to implement either the capitation or fee-for-service model in 2013 and others in 2014. Both the challenges and the potential of this health reform experiment are enormous. (Dx For A Careful Approach To Moving Dual Eligible Beneficiaries Into Managed Care Plans, Health Affairs, June 2012.)

PIT-PIT0604n.gif

Analysis by researchers on our staff and at the Urban Institute shows that while the duals as a group are higher utilizers than other Medicare beneficiaries, a smaller subset of duals are very high utilizers: 2 million of 9 million duals in 2007 (the last year for which merged Medicare and Medicaid data were available) were responsible for 60 percent of Medicare and Medicaid spending; the remaining 7 million duals accounted for 40 percent of spending (The Diversity of Dual Eligible Beneficiaries). Some states will pursue broad demonstrations while others may pursue more targeted approaches, focusing on groups with recurring high expenses, such as nursing home residents. If states and health plans could target their efforts and more effectively coordinate the care of the very high utilizers, the benefits to both beneficiaries and the programs could be quite large. In the capitated model, managed care companies will strike deals providing front-end savings to Medicare and Medicaid to manage the care of this population. The real challenge will be to assemble the delivery networks at the local level to effectively manage the broad range of services duals use, including behavioral health, pharmacy, community-based and institutional long-term care services, and a full range of acute care services. Managing care for a population that includes some who are very reliant on long term care, in particular, will require developing new networks of services for many managed care companies. So will managing care for a population with a high incidence of cognitive and mental health problems. Very few health plans now have the necessary experience to manage the care of this complex population and it will take time to develop new arrangements for appropriate services. Medicaid is a federal-state program administered by the states and Medicare is a federal program, both with different populations and benefits (Medicare’s Role for Dual Eligible Beneficiaries; Medicaid’s Role for Dual Eligible Beneficiaries). It is predictable that there will be federal-state control issues to work through as a demonstration program involving a merger of both programs with private plans evolves. None of these challenges are reasons not to undertake the demonstration, only to recognize that implementation will take careful planning and time because the details of delivering care and services will matter. I learned first-hand about the challenges of developing new service networks in the early days of Medicaid managed care in the 1980's, as Human Services Commissioner in New Jersey. We established the first state-run, federally-qualified HMO for Medicaid. It achieved front-end savings and some ability to reallocate more of the Medicaid dollar to primary care. But we never were able to build the network of providers to more effectively manage care to improve outcomes or lower costs, for a population far less complex than the dual eligibles are. Across the country Medicaid managed care slowly replaced fee for service for children and their parents but it never became the huge cost saver it was originally expected to be. Thirty years after it began to gain momentum Medicaid managed care is now moving to higher cost populations where the potential for savings are thought to be larger but the risks to sick patients are also greater. With the spotlight on the ACA and Medicare and Medicaid budget challenges, this experiment involving millions of some of the highest cost, sickest people served by public programs has so far been under-reported. Eventually, covering this story will require getting inside delivery systems and interviewing policymakers, providers, and especially patients and their families, just the kind of journalism news organizations are hard pressed to do with their frayed budgets. This is not a breaking story a reporter can cover in one day. It will never have the drama of the highly politicized ACA and Medicare wars. But it deserves attention beyond our world of health policy. Success in the dual eligibles demonstration could help reduce federal and state health spending in both big health care entitlement programs and improve the health of a very needy population. But the pressure to save money always cautions prudence, patience, and in this case careful targeting and customization of services, when large numbers of low-income people with disabilities and serious illnesses are involved. [post_title] => Pulling it Together: Duals: The National Health Reform Experiment We Should Be talking More About [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pulling-it-together-duals-the-national-health [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:39 [post_modified_gmt] => 2014-03-04 16:14:39 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/quiz/pulling-it-together-duals-the-national-health/ [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 71223 [post_author] => 36621681 [post_date] => 2013-01-21 09:34:54 [post_date_gmt] => 2013-01-21 14:34:54 [post_content] => Lately conservatives have been feeling like losers in health care and complaining loudly about it. They don't like Obamacare or the increase in the government's role in health care or the federal spending it brings with it, even if those things result in coverage for more than 30 million uninsured Americans and new protections from the worst abuses in the health insurance industry. Actually, conservatives are winning at least as much as they are losing in health care, even if they don't know it or won't say it, because out in the real world of health insurance, beneath the politicized debate about Obamacare, the vision of health insurance they have always championed -- high deductible plans that give consumers lots of "skin in the game" -- is steadily prevailing in the marketplace. Moreover, the conservative vision of "skin in the game" insurance could actually get a boost from the health reform law. Half of all workers in small firms now pay deductibles of $1,000 or more a year, and the percentage of workers in all firms paying big deductibles has tripled in the last six years. In the last five years the average deductible for single coverage has gone from $616 to $1,097 in all firms that have deductibles, and from $852 to $1,596 in small firms. Estimates are that in the basic plan offered in the health insurance exchanges under the Affordable Care Act, deductibles could be over $4,000 for individual policies and over $8,000 for family policies. These are big deductibles by any standard. Yes, the minimum coverage people will have to buy under Obamacare will be just the kind of "skin in the game" insurance that conservatives have always favored. But from start to finish, the health care reform debate has not been about facts but about ideology and partisanship. Conservatives are certainly not happy that the Affordable Care Act has survived a Supreme Court challenge and an election and will now be implemented and will not be repealed. But even as they continue to vilify the law, they must take solace in the fact that many states are still balking at implementing major provisions that conservatives do not like, such as the law's insurance exchanges or its Medicaid expansion, which the Supreme Court made optional. Only 18 states and D.C. have chosen to implement their own insurance exchanges, and only seven are planning exchanges that are active purchasers, the more aggressive kind of exchange that liberals and consumer advocates would like because they weed out plans with high premiums. The success of the Affordable Care Act now hinges on implementation, and more than any other single factor, the fate of the law will depend on what states do and how well they do it. The federal government will step in and operate exchanges in states that choose not to do so, but there is no federal fallback on Medicaid; if a state like Texas or Florida does not opt to expand coverage under the ACA, it will not happen. It will behoove the Obama administration and advocates of the law to actively nurture pacesetting states so that they have tangible success stories to point to in 2014 and models that other states can learn from and emulate. If even a relatively small number of states can show that uninsured people are being covered in large numbers, that federal funding is flowing as promised to the states and to individuals who qualify for insurance subsidies, that the new health insurance reforms are working as planned and that coverage is affordable and, as in Massachusetts, the public is accepting the individual mandate, then other states will take notice, whatever the ideological predispositions of their governors or legislators. It is already clear that the test in 2014 will not be whether the law is working perfectly everywhere (there isn't time for that to happen, and it won't be) but whether it can work as intended. If a handful of states can demonstrate that, then the others will want to follow. 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