SC Alliance of Health Plans News

Trey Walker to Lead SC Alliance of Health Plans

Addie Thompson — Mon, 16 Mar 2026 16:35:41 GMT

Columbia, SC – The South Carolina Alliance of Health Plans announced today that Trey Walker, former longtime chief of staff to Governor Henry McMaster, has been named the new Executive Director of the organization.

Walker, who also previously served as senior government affairs advisor for BlueCross BlueShield of South Carolina, brings to the organization over thirty five years of state and national experience in government relations, political consulting, agency management and crisis communications.

This announcement follows last year’s retirement announcement by longtime Executive Director Jim Ritchie. While stepping away from the position, the former state senator will assist with the leadership transition.

“We are excited about Trey Walker joining our team and look forward to the energy and experience he will bring to the Alliance, said board president Stephen Moore, the chief financial officer for Absolute Total Care. And we are very appreciative of the service and stewardship that Jim Ritchie provided to the organization.”

The South Carolina Alliance of Health Plans represents the state’s commercial health plans and Medicaid managed care organizations by providing policy analysis, direct advocacy and trade association services for its members. The organization’s health plan members serve over 90% of all South Carolinians.

Health Care Costs 101: What’s Driving Premiums Higher and How to Make Coverage More Affordable

Wed, 21 Jan 2026 16:27:20 GMT

Families across the country are struggling with health care costs that continue to rise far faster than wages. A new report by the Centers for Medicare and Medicaid Services (CMS) shows that health care spending nationwide grew by 7.2% in 2024, reaching a record $5.3 trillion. The costs Americans paid “for hospital care, physician and clinical services, and retail prescription drugs all contributed more to overall growth in 2024 than during the 2014–19 period,” the report finds.

As policymakers discuss ways to address the affordability crisis affecting millions of Americans, research and data provide important clarity regarding the root causes of rising health care costs.

Health insurance premiums directly reflect the cost of medical care, with nearly 85 percent of Americans’ premium dollars directly going to cover the cost of hospital-based services, prescription drugs, physician fees and other medical services. When prices for these treatments and services go up, the premium consumers pay for their coverage must rise to keep pace.

For example, as one prominent lawmaker noted in POLITICO, “‘Insurance companies are dependent on what hospitals charge…I used to run the largest hospital company so I can tell you, insurance can’t charge a whole bunch less if the hospitals charge more.’”

So why do the prices set by drugmakers, hospital systems and physician groups continue to rise? Here are a few reasons:

Hospital consolidation: Decades of research underscores the impact of hospital consolidation on rising costs for Americans. Hospital markets are increasingly dominated by a few large systems, with three-fourths of U.S. metro areas classified as highly or very highly concentrated. Consolidation increases hospital systems’ market power, allowing them to demand higher prices from health plans and employers that in turn contribute directly to higher premiums. Total hospitals costs, including inpatient, outpatient and emergency department care, now account for 40% of every health care dollar Americans spend.
Site-of-care price differences: The prices providers charge for identical services and treatments vary wildly depending on location, ownership or provider market power. Medicare payment regulations vary reimbursement depending on location, often paying considerably more for the same outpatient services at certain locations such as hospital outpatient departments. Facility fees and ownership-driven billing by providers inflate costs, often without any corresponding increase in quality of care.
Prescription drug pricing: Drug spending is expected to be a key driver of premium growth in 2026, due to rising unit prices, costly new gene and cell therapies, and growing demand for weight-loss medications (GLP-1s). More than 24 cents of every premium dollar goes toward prescription drug costs – more than any other individual category. Prescription drug prices are set by pharmaceutical manufacturers. Yet brand drugmakers continue to raise prices on Americans multiple times a year – including increases already planned for 350 prescription drugs in 2026 with a median list-price hike of 4% – fueling premium increases and higher out-of-pocket costs for patients.
Private equity–driven billing practices: A fragmented health care system – combined with the rapid expansion of private equity ownership – has intensified out-of-network billing, balance billing and opaque pricing that harms consumers. Private equity-backed provider groups often rely on aggressive billing strategies, including remaining out-of-network or exploiting payment disputes, to maximize their revenue at the expense of American consumers. A recent analysis shows how implementation of the No Surprises Act – bipartisan legislation enacted to protect consumers – has been manipulated by private equity to drive $5 billion in wasteful spending. These practices contribute to surprise medical bills, medical debt and financial instability for individuals, families, and employers.

Common-sense, bipartisan solutions to improve patient affordability

Health plans are doing everything in their power to shield Americans from the high and rising costs of medical care, and we welcome any opportunity to discuss common-sense solutions to lower costs for everyone.

Health plans are the only part of the health care system whose profits and administrative costs are capped under federal law. Health plans' profit margin was 0.8% in 2024, NAIC data show. In 2023, the net income of health plans accounted for about 0.5% of U.S. health expenditures ($4.9 trillion that year, per CMS data). By comparison, the pharmaceutical industry averages 15-20% margins.

By focusing on addressing the root causes of higher health care costs and corresponding premiums, policymakers can take meaningful steps to make coverage and care more affordable for Americans.

From addressing brand drugmakers’ relentless abuse of the patent system to continue overcharging Americans, to enacting common-sense site-neutral reforms, to stopping private equity’s abuse of the No Surprises Act and other targeted policy changes, these solutions would address the market loopholes and misaligned incentives that lead to higher costs for every American. Learn more.

Steve Boucher of SCAHP Appointed to MAC by Eunice Medina

Addie Thompson — Fri, 02 May 2025 11:51:13 GMT

Steve Boucher, Director of Managed Care Services for the South Carolina Alliance of Health Plans (SCAHP) has accepted an invitation from Eunice Medina, Director of the South Carolina Department of Health & Human Services (SCDHHS,) to serve as a member of the South Carolina Medicaid Advisory Council (MAC) through 2026.In her invitation, Eunice commented that "my leadership and expertise would be invaluable in strengthening our collective efforts to ensure equitable access to high-quality health care for all Healthy Connections Medicaid members. We are committed to building an action-oriented council with a broad scope of backgrounds and expertise and I am confident your contributions will help shape the future of Medicaid in South Carolina."

The MAC has been established to advise SCDHHS on health and medical care services, with a focus on creating a consumer-driven approach that optimizes the efficiency and effectiveness of the South Carolina Healthy Connections Medicaid program. The council will help the agency address the health care needs of our state’s Medicaid population, which includes the state’s most vulnerable populations. The MAC will advise the Director of SCDHHS on matters of concern related to policy development and matters related to the effective administration of the Medicaid Program. The MAC replaces the former Medical Care Advisory Committee (MCAC). The MAC is required for all Medicaid programs effective July 9, 2025.

This appointment recognizes the quality of the expertise and leadership present in the SCAHP and recognizes the impact that we have in developing and furthering policies and practices that are creative and innovative to meet the needs of South Carolina's Medicaid population.

Statement from Gov. Henry McMaster on the Confirmation of Eunice Medina as SCDHHS Director

Addie Thompson — Fri, 28 Feb 2025 13:21:18 GMT

Statement from Gov. Henry McMaster on the Confirmation of Eunice Medina as SCDHHS Director

COLUMBIA, S.C. – Governor Henry McMaster today released the following statement on the confirmation of Eunice Medina as the next director of the South Carolina Department of Health and Human Services:

"Eunice Medina's expertise in Medicaid policy and her leadership within the Department of Health and Human Services make her exceptionally qualified to lead the agency," said Governor Henry McMaster. "Her experience at the executive level has prepared her to build on the agency's success, ensuring efficiency and accountability in South Carolina's healthcare system. I have full confidence in her leadership and look forward to working with her in this new role."

Governor Henry McMaster Requests the Reinstatement of Medicaid Work Requirements

Tue, 21 Jan 2025 20:15:12 GMT

COLUMBIA, S.C. – Governor Henry McMaster today formally requested the U.S. Department of Health and Human Services (HHS) work with the South Carolina Department of Health and Human Services (SCDHHS) to reinstate the state’s Healthy Connections Community Engagement Initiative, also known as Medicaid Work Requirements. The initiative promotes healthier outcomes and incentivizes financial independence by adding community engagement requirements for qualifying Medicaid members that would include 80 hours of monthly work, job training, education, or community service.

"Granting South Carolina the authorities necessary to reinstitute this initiative will strengthen the Medicaid program's dual missions of financing health services and improving opportunities for independence, self-reliance, and prosperity for the state's citizens," Governor McMaster wrote in the letter to Acting HHS Secretary Dorothy Fink.

The governor's letter added: "South Carolina pursued the Section 1115 waivers that made up its Healthy Connections Community Engagement Initiative to close the health care coverage gap created by the Patient Protection and Affordable Care Act (ACA) and incentivize employment among its citizens. Under the ACA, adults are eligible for subsidized health care coverage on the federal exchange when their earnings reach the federal poverty level. However, Medicaid coverage ends for many working parents at a threshold that is below the federal poverty level. This flawed structure created a health care coverage gap that disincentivizes many low-income families from earning additional income. This presents working families with an undesirable choice: earn additional income to support their family or lose their healthcare coverage."

In January 2018, Governor McMaster directed SCDHHS to seek federal waivers to establish work requirements for qualifying Medicaid recipients. South Carolina’s application was approved by the Trump Administration in December 2019 but it was paused during the COVID-19 pandemic to comply with federal requirements under the Families First Coronavirus Response Act. The Biden Administration then withdrew approval of the initiative in August 2021.

The governor's request for reinstatement is centered around restoring the New Coverage for Parents and Community Engagement components of the Palmetto Pathways to Independence section 1115 waiver that was approved by the Centers for Medicare and Medicaid Services in December 2019.

Director Kerr Honored by Governor McMaster

Addie Thompson — Mon, 18 Nov 2024 18:20:32 GMT

Last week, Governor Henry McMaster recognized Robby Kerr, the departing Director of SC DHHS, for his outstanding service to South Carolina. The ceremony at the State House drew over 300 attendees, reflecting the deep appreciation for his contributions to our state. Director Kerr received the Order of the Palmetto from the Governor, and a beautiful piece of art from the MCO plan presidents. SCAHP extends its heartfelt thanks to Robby for his years of dedicated leadership and commitment to South Carolina.

Governor Names Next SCDHHS Director

Addie Thompson — Thu, 07 Nov 2024 19:57:10 GMT

Governor Names Next SCDHHS Director

November 11, 2024. Governor Henry McMaster announced the retirement of South Carolina Department of Health and Human Services (SCDHHS) Director Robert Kerr, effective November 1, 2024. The SCDHHS administers Healthy Connections, the state’s Medicaid program. Director Kerr served in this leadership role for more than three years, following the governor’s 2021 nomination. Previously, Kerr served as SCDHHS Director from 2003 to 2007, and worked for the Department for 22 years.

The governor named Eunice Medina as Kerr’s successor as SCDHHS Director. Medina has been serving as the Chief of Staff and Deputy Director of Programs at the agency since June 2021. She has 20 years of experience in Medicaid policy and operations, and previously served as Bureau Chief with the Florida Agency for Health Care Administration, where she managed oversight of the state’s Medicaid MCOs. Medina’s appointment is now subject to confirmation by the state senate, and the Senate Medical Affairs Committee Chair stated that the confirmation process will be the committee’s first order of business.

Check out the announcement from the governor here.

SCAHP Q3 Meeting

Addie Thompson — Tue, 15 Oct 2024 14:22:12 GMT

The SCAHP Q3 Meeting was held at Wild Dunes Resort on October 9. Our featured speaker was Kobra Eghtedary, PhD. Dr. Eghtedary is the Director of the State Health Improvement Office at the S.C. Department of Public Health.

Will UnitedHealthcare’s gold card program benefit patients, physicians?

Fri, 30 Aug 2024 17:24:33 GMT

Prior authorizations are considered obstacles by many physicians and patients alike, with 9 in 10 physicians saying in an American Medical Association survey prior authorization has a negative effect on patient outcomes.

To combat that burden, UnitedHealthcare is rolling out a gold-card program that will reward contracted provider groups that "consistently adhere to evidence-based care guidelines" by allowing certain physicians to bypass the prior authorization process.

While some physicians and groups have expressed concern over the program, other physicians are optimistic it could help combat lengthy wait times and existing prior authorization requirements.

Joshua Rosenow, MD. Director of functional neurosurgery at Northwestern Medicine (Chicago): UHC has been the perpetrator of some of the most onerous prior authorization requirements. While the gold-card program does not solve all of the myriad issues with UHC prior authorization, it will hopefully reward practices for successfully navigating UHC's thicket of prior authorization requirements with a year of exemptions. However, this is renewable annually and it is unclear exactly how UHC will recertify practices' gold-card status if they are not submitting prior authorization requests. It is possible that submitting annual data and medical records to maintain gold-card status could be just as time consuming and frustrating as the prior authorization process itself. Moreover, the list of procedures that would be eligible for inclusion in the gold-card program won't be released until Sept. 1, so we don't yet know how applicable this will be to spine and pain practices.

Zeeshan Tayeb, MD. Owner and medical director of Pain Specialists of Cincinnati: The proposal behind the gold-card program from UHC is one that will work to help alleviate pre-certification requirements if the program works as designed. The qualifying criteria for provider enrollment is something that will help raise the standards of care for all patients receiving treatment. It would be an additional incentive if providers qualifying for the UHC gold card enrollment were provided an elevated fee schedule for services.

Specialty pharmacies’ role in gene therapy

Fri, 30 Aug 2024 17:19:53 GMT

Manufacturing of novel cell and gene therapy (CGT) products is extremely complex and patient-specific, so it can be a heavy lift to distribute these agents. However, several leading specialty pharmacies have developed dedicated programs focused on the unique financial, delivery, temperature control and patient support challenges associated with providing these therapies.

Orsini an Early Adopter

With three decades of experience in rare disease pharmacy, Illinois-based Orsini Specialty Pharmacy was well positioned to move into the CGT space in 2017, when it began supporting the cell therapy autologous cultured chondrocytes on a porcine collagen membrane (MACI, Vericel), used for the repair of full-thickness knee cartilage defects in adults. A year later, in 2018, Orsini entered the gene therapy channel with a program to support patients who are prescribed onasemnogene abeparvovec-xioi (Zolgensma, Novartis), an adeno-associated viral vector–based gene therapy for pediatric spinal muscular atrophy (SMA). Orsini currently supports six CGTs, including:

valoctocogene roxaparvovec-rvox (Roctavian, BioMarin), the first gene therapy for hemophilia A;
etranacogene dezaparvovec-drlb (Hemgenix, CSL Behring), the first gene therapy for hemophilia B; and
delandistrogene moxeparvovec-rokl (Elevidys, Sarepta), the first gene therapy for Duchenne muscular dystrophy.

“Taken together, we are managing or have managed around 6,500 patients receiving these cell and gene therapies,” said Allison Droba, Orsini’s gene therapy operations manager. Ms. Droba heads a small, tightly focused team that works directly with patients receiving CGT and with Orsini’s larger payor team and pharmacists and program managers who communicate with the manufacturers. “When a new referral comes in, everyone knows about it and it’s all hands on deck,” she said. On average, they can process any new cell and gene patient in five to seven business days and schedule shipment to the appropriate facility.

Rare disease specialty pharmacy programs often take a sequential approach to patient care, with different parts of the process moving from one functional team to another. Orsini’s care team, in contrast, “wraps around the case and the patient and monitors every step, sometimes hour by hour, to ensure the therapy gets to the patient on the time line we have established,” said Eyad Farah, the company’s chief operating officer.

With many CGTs, time is of the essence. Onasemnogene abeparvovec-xioi, for example, has completely transformed the prognosis for SMA, a rare genetic disease that causes progressive loss of muscle control and function. But time to treatment makes an enormous difference: Outcomes are better in infants who are treated before they begin to show symptoms. One real-world study found that the children with the best motor outcomes were those who had received gene therapy at a significantly younger age—a median of 1.7 versus 7.85 months in the overall group (Pediatr Neurol 2023;144:60-68).

“As soon as we get the referral for Zolgensma from the manufacturer hub, we stop everything we’re doing and work on that one first,” Ms. Droba said. “My team gets on the phone with the insurance company to verify benefits, determine whether it is covered under pharmacy or medical benefit and if prior authorization is needed, and immediately informs the physician’s office of what we need to submit. We follow up on that authorization at least two or three times a day; sometimes every hour on the hour.”

Accredo Focuses on Access

Accredo by Evernorth, part of Evernorth Health Services, is another leading specialty pharmacy with deep expertise in gene therapies, including several of the CGTs supported by Orsini as well as others such as lovotibeglogene autotemcel (Lyfgenia, Bluebird Bio) for the treatment of sickle cell disease and voretigene neparvovec-rzyl (Luxturna, Spark Therapeutics) for the treatment of inherited retinal disease.

Its GeneAXS team is solely dedicated to ensuring access to GCTs, which encompasses payor contracting, benefits investigation, fulfillment, patient services and clinical consultation. “This team regularly engages with patients, clinicians and their caregivers, as well as manufacturers, to ensure everyone is coordinated and in sync for each gene therapy order,” said Mark Jacob, the senior director of product management at Accredo. “Our team has expertise in navigating payor contracting, benefits investigation, fulfillment and patient services such as coordinating access to pharmacists, nurses, social workers, nutritionists and others as appropriate.”

Overcoming Payor Hurdles

Both specialty pharmacies stressed that complex insurance authorizations for costly rare disease therapies can be exponentially more challenging for CGTs costing more than $2 million or $3 million. “The approval pathway often has several extra steps for that high dollar amount, and every payor might have a different process,” Mr. Farah said. “Some may take each approval to the president of the business unit.”

The first approval of a new gene therapy with a specific payor is always the most challenging. “We have to learn how they want the drug billed, or if they have a specific letter of agreement designed,” Ms. Droba said. However, the process gets easier with time; the first approval may take a week, and the second several days, “because we know exactly what they’re looking for.

“Sometimes you get a rep on the phone who will rattle off a script and it could be wrong information,” she continued. “I have two benefit verifications done right off the bat for every patient, and if I don’t like what I’m hearing, if something doesn’t sound right, I’ll do a third and keep digging.”

Evernorth Health Services has a financial “benefit protection” platform called Embarc that covers certain gene therapy drugs. Participating health plans and clients pay a per-member, per-month fee to participate; the patient has no copay. “Many gene therapies can cost in the millions of dollars per patient, running the risk of bankrupting a small business with a single claim,” said Leslie Achter, the senior vice president of pharmacy benefit manager account management at Express Scripts by Evernorth. “For a small monthly fee per patient per month, Embarc offers significant protection, while ensuring access to these potentially lifesaving therapies.”

Pay-over-time contracts have been proposed as one model for helping payors manage the enormous up-front cost of gene therapy along with the attendant risk. (How long will the therapy’s benefits persist? What happens if a patient receives a gene therapy while covered by one health plan and then moves to another plan within a short time after Plan 1 has paid for therapy?)

But at this point, Orsini has no gene therapy contracts structured that way. “We have had several conversations on both the payor and manufacturer side, where everyone is thinking that it would make sense to think about pay-over-time or value-based contracts,” Mr. Farah said. “There are also several smaller companies trying to carve gene therapy out from the primary benefit and pooling it as a specific cell and gene benefit sold back to the employers. We haven’t yet had someone come to the table with a viable approach. As an industry we need all stakeholders to come together and agree about how we share the risk associated with these therapies in a way that will be transformative.”

‘Everything Is Personal for Us’

As soon as an approval is completed at Orsini, Ms. Droba’s team determines the delivery time and day and coordinates thawing time with this information, and monitors the therapy’s journey from the manufacturer to their pharmacy, using real-time tracking technology. Gene therapy manufacturers all have their own advanced high-tech systems for temperature control and monitoring of these gene therapies. For example, Novartis uses a system called evo to protect and track the journey of its SMA gene therapy, developed by New Mexico–based Savsu Technologies. “When we log into the portal, we can see not only exactly where the shipment is in real time, but whether the package was tilted and to what degree, and exactly what temperatures have been maintained throughout the shipment,” Ms. Droba said.

Gene therapy is not a nine-to-five job for the specialty pharmacy, she said. “We work on these day and night. Because we have such a dedicated team, all day long we are working on these specific patients, getting to know them and what they need, and building relationships with their families, doctors and care teams,” Ms. Droba said. “Everything is personal for us, and that’s why I feel like we can be as efficient as possible in getting the treatment they need in shortest time possible. [The patients] have enough problems and stress, and we do everything we can to make one part of their situation less stressful.”

Georgia’s state-based exchange and new Pathways program put more than 700K into private coverage, including 400K previously on Medicaid

Fri, 30 Aug 2024 17:16:32 GMT

Critics continue to say the Georgia Pathways to Coverage program falls short of expectations, but proponents say Georgia’s cumulative approach puts more people on private health insurance plans.

State officials initially indicated roughly 345,000 Georgians could qualify for the program. However, officials later said the estimated adoption rate would reach around 90,000 to 100,000 by 2025.

Less than 4,500 Georgians enrolled in Georgia Pathways to Coverage as of mid-June.

“Every Georgian deserves access to affordable health care,” Laura Colbert, executive director of Georgians for a Healthy Future, said in a recent announcement. “Unfortunately, the Pathways to Coverage program is falling far short of that vision for our state.

“Unfair paperwork requirements and other bureaucratic hurdles are keeping hard-working Georgians from getting covered,” Colbert added. “It’s time to remove these barriers to health coverage for uninsured Georgians, and to look at broader solutions to closing the coverage gap.”

In remarks this week, Republican Gov. Brian Kemp said Georgia Pathways and Georgia Access, a state-based exchange where Georgians can shop for health insurance, provide health coverage to more than 714,000 Georgians who earn less than 138% of the federal poverty level.

Georgia’s Office of the Insurance and Safety Fire Commissioner launched Georgia Access on Nov. 1, 2023, as a state-based exchange on the federal platform ahead of Open Enrollment 2024. Last week, state officials said the Centers for Medicare and Medicaid Services confirmed approval for Georgia to transition to a state-based exchange.

Citing September 2023 U.S. Census Bureau data, Georgia Access’ website indicates that 1.2 million Georgians do not have health insurance. According to remarks provided by his office, Kemp said that “through Georgia Access, 400,000 Georgians who were previously on Medicaid now have private sector insurance that provides better coverage, with more options, while saving taxpayer dollars.”

“To be clear, the rosiest projections for traditional Medicaid expansion estimate 500,000 people under 138 percent of the federal poverty limit would be eligible. Not actually enrolled – just eligible,” the governor added.

What’s more, analysts note that care and coverage are not the same.

“When we discuss Medicaid, it is important to remember that coverage does not mean care,” Chris Denson, Georgia Public Policy Foundation’s director of policy and research, recently told The Center Square via email. “Medicaid is a fundamentally flawed program. In Georgia, providers are paid, on average, 80 cents on the dollar for every Medicaid patient they see. As such, only 60% of Georgia physicians accept new Medicaid patients.

“The promise of Georgia Pathways comes from providing an opportunity for these enrollees to transition one day to commercial health insurance while receiving Medicaid coverage in the interim — by engaging in 80 hours each month of work, educational opportunities, or community service,” Denson added. “Even expanding Medicaid under the Affordable Care Act would only cover Georgians up to 138% of the federal poverty level.

“In Georgia, we provide fully subsidized coverage on the health insurance exchange for individuals up to 200% of the federal poverty level. Which provides a better deal for patients and providers alike.”

As Medicaid’s unwinding reduces roles, national coalition asks Congress to allow 12-month continuous eligibility for adults

Fri, 30 Aug 2024 17:15:17 GMT

With tens of millions of enrollees now dropped from the Medicaid rolls, a group of 189 health care organizations have taken another step they hope will add permanency to the program. The coalition, organized by the Association for Community Affiliated Plans (ACAP) and Families USA, sent a letter on Aug. 13 to congressional leaders calling for 12-month continuous enrollment for adults enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).

They asked for support of the Stabilize Medicaid and CHIP Coverage Act, which was introduced in the House by Rep. Debbie Dingell (D-Mich.) in September 2023 and in the Senate by Sen. Sherrod Brown (D-Ohio) the next month.

U.S. Office of Inspector General: South Carolina did not always invoice rebates to manufacturers for MCO members’ physician-administered drugs

Fri, 30 Aug 2024 17:11:08 GMT

Why OIG Did This Audit

For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program’s drug rebate requirements, manufacturers must pay rebates to the States for the drugs.
Prior OIG audits found that States did not always invoice and collect all rebates due for drugs administered to Medicaid managed-care organizations’ (MCOs’) enrollees.
This audit, one of a series of audits, determined whether South Carolina complied with Federal Medicaid requirements for invoicing manufacturers for physician-administered drugs dispensed to MCO enrollees.

What OIG Found

South Carolina did not always comply with Federal Medicaid requirements for invoicing manufacturers for rebates for physician-administered drugs dispensed to MCO enrollees. South Carolina did not invoice for, and collect from manufacturers, rebates totaling $14.2 million (Federal share).

Of this amount, $12.1 million (Federal share) was for single-source drugs and $65,691 (Federal share) was for top-20 multiple-source drugs.
We also identified rebates totaling $1.9 million (Federal share) for other multiple-source drugs for which we were unable to determine whether, in some cases, the State was required to invoice for rebates.

What OIG Recommends

We recommend that South Carolina:

invoice for and collect manufacturers’ rebates totaling $12.2 million (Federal share) for single-source and top-20 multiple-source physician-administered drugs and refund the Federal share;
work with CMS to determine whether the claims for other multiple-source physician-administered drugs, totaling $1.9 million (Federal share), were eligible for rebates and, if so, determine the rebates due for these drugs and, upon receipt of the rebates, refund the Federal share of the rebates collected;
ensure that all physician-administered drugs eligible for rebates after our audit period are processed for rebates; and
continue to review and strengthen its internal controls to ensure that, in line with South Carolina’s existing policies, all physician-administered drugs eligible for rebates are invoiced.

South Carolina generally concurred with all of our recommendations and described corrective actions it had taken or planned to take.

HRSA awards more than half a billion dollars to improve maternal and infant health, including $9.6M to Children’s Trust Fund of South Carolina

Fri, 30 Aug 2024 17:07:50 GMT

Today, the U.S. Department of Health and Human Services (HHS) announced more than $558 million in funding to improve maternal health, building on the Biden-Harris Administration’s commitment to reducing the nation’s high maternal mortality rate through the White House Blueprint for Addressing the Maternal Health Crisis. The Health Resources and Services Administration (HRSA), an agency of HHS, is awarding more than $440 million in funding to expand voluntary, evidence-based maternal, infant, and early childhood home visiting services for eligible families across the country. In addition, the Centers for Disease Control and Prevention (CDC) announced a new investment of $118.5 million, over five years, to 46 states, six territories, and freely associated states to continue building the public health infrastructure to better identify and prevent pregnancy-related deaths.

In 2022, President Biden signed bipartisan legislation that doubles funding for the Maternal, Infant, and Early Childhood Home Visiting program over five years – the first expansion of the federal home visiting program in nearly 10 years. Through this program, local organizations can provide home visits from nurses, social workers, and other trained health workers who work with families on early and ongoing engagement in prenatal care and postpartum support. They provide support on breastfeeding, safe sleep for babies, learning and communications practices that promote early language development, developmental screening, getting children ready to succeed in school, and connecting with key services and resources in the community – like affordable childcare or job and educational opportunities. The awards announced today reflect the first opportunity for states and jurisdictions to receive federal matching funds in addition to their base grants. Every single state and U.S. territory has seen an increase in funding to their home visiting program since the start of the Biden-Harris Administration.

“As someone who has spent my entire career fighting for the health and wellbeing of women and children, I am committed to addressing a maternal health crisis in which women across America are dying before, during, and after childbirth at higher rates than in any other developed nation. That is why I called on states to extend Medicaid postpartum coverage from two months to 12 months and announced the launch of the White House Blueprint for Addressing the Maternal Health Crisis, an unprecedented whole-of-government strategy to improving maternal care,” said Vice President Kamala Harris. “Today, we are building on this lifesaving work by awarding more than $558 million to improve maternal health across America. This includes a critical $440 million to support pregnant women, new mothers, and their children through home visiting programs that will improve health outcomes, child development, and access to resources for years to come.”

“Bringing home a baby can be stressful. Many new parents face additional challenges such as housing, or income insecurity, which can make the whole situation even more daunting. But we know from decades of research that home visits work – from helping with school readiness and achievement for children to improving health for women,” said HHS Secretary Xavier Becerra. “President Biden and Vice President Harris know how important it is to support children in their most crucial years of development so they can grow up to be healthy, happy adults. We will continue to make resources and support available, and elevate maternal health issues so that more women and families know that help is available.”

“At the Health Resources and Services Administration, we are deeply committed to removing barriers to care for expectant and new moms and babies who face too many hurdles getting the support that they need,” said HRSA Administrator Carole Johnson. “That’s why – thanks to the leadership of the President and Vice President – we were able to work closely with bipartisan leaders in Congress to grow the home visiting program to give more moms and babies a trusted home visiting partner to help their families in ways large and small to be healthy, feel supported, access health care services, nurture their child’s development, and give families every opportunity to thrive.”

HRSA Administrator Johnson announced the awards in conjunction with HRSA’s Enhancing Maternal Health Initiative convening at Wayne State University, in Detroit, Michigan. The Initiative is bringing together moms and babies served by HRSA programs with maternal and infant health community leaders, health officials, HRSA-supported community providers, and others to advance the goals of the White House Blueprint to Address the Maternal Health Crisis.

The home visiting program funds states, jurisdictions, and tribal entities to develop and implement evidence-based, voluntary programs that best meet the needs of their communities. Families choose to participate in home visiting programs from pregnancy up to kindergarten and partner with health, social services, and child development professionals who provide resources, support, and skills to help families and children be physically, socially, and emotionally healthy. The program has demonstrated significant benefits, including improved school readiness and achievement of children, improved health for women, increased health insurance coverage, and prevented child injuries, abuse, and neglect.

For a complete list of Maternal, Infant, and Early Childhood Home Visiting Program awardees, visit https://mchb.hrsa.gov/programs-impact/programs/home-visiting/maternal-infant-early-childhood-home-visiting-miechv-program/fy24-awards.

The CDC’s new $118.5 million five-year investment will continue building the public health infrastructure to better identify and prevent pregnancy-related deaths. This new investment expands support to Maternal Mortality Review Committees (MMRCs) from 46 to 52 states and U.S. territories and freely associated states. MRCs are state- and territory-based multidisciplinary groups that review deaths that have occurred within 1 year of the end of a pregnancy, determine if those pregnancy-related deaths were preventable, and recommend ways to prevent them in the future. This new investment in the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program also advances progress on implementing the White House Blueprint for Addressing the Maternal Health Crisis - PDF. CDC began the ERASE MM program in 2019 to invest in MMRCs and to strengthen and standardize their efforts to review deaths.

“Every pregnancy-related death is a tragedy for the family and the community,” said Wanda Barfield, MD, MPH, director of CDC’s Division of Reproductive Health. “Thanks to MMRCs, we know more about the causes and circumstances around pregnancy-related deaths, and we have actionable recommendations to prevent future deaths. This investment will support more jurisdictions in their critical work to save mothers’ lives.”

Together, these efforts build on both HHS’ and the broader Administration’s efforts to implement the White House Blueprint to Address the Maternal Health Crisis as described in the following Fact Sheet: https://www.whitehouse.gov/briefing-room/statements-releases/2024/07/10/the-white-house-blueprint-for-addressing-the-maternal-health-crisis-two-years-of-progress/.

Maternity wards closing throughout the U.S.

Fri, 30 Aug 2024 17:03:21 GMT

Michelle Cubbon had her first child, a boy, at St. Catherine of Siena Hospital in Smithtown, New York, a town of more than 100,000 in the middle of Long Island, where the median household income is $143,789 and many residents commute to white-collar jobs in Manhattan. She and her husband, who was also born at St. Catherine, are planning now for a second child. But when she tried to schedule an appointment with her obstetrician, she discovered that the hospital’s maternity unit — a cornerstone of their town for more than a half a century — was shutting down in February 2024.

“I’m back to square one,” said Cubbon.

The reason? High costs of running the maternity care unit and a nationwide staffing shortage left the hospital unable to hire obstetricians. Such closures have hit hardest in rural parts of the US, and are now menacing in politically conservative red states that are wrestling with abortion restrictions. But Cubbon’s experience shows how maternity ward closures can reach into other communities, even in comparatively wealthy, densely populated towns and suburbs outside major cities.

“If we don’t work to fix this broken system, we’re going to continue to see hospital and OB unit closures, which will have disastrous effects,” said Ndidiamaka Amutah-Onukagha, founder of the Center for Black Maternal Health and Reproductive Justice at Tufts University School of Medicine. “Limiting access to care and pushing people further out of their home communities are direct contributors to maternal morbidity. It’s that simple.”

The danger is well known in far-flung communities: 57% of rural hospitals don’t have maternity wards, and many more are in danger of losing their maternal care units. That translates into longer travel times for expectant mothers, who are likely to be 40 or more minutes away from labor and delivery services. In urban areas, by contrast, patients are typically able to get to reach care within 20 minutes.

But the overall proximity advantage enjoyed by city dwellers isn’t the whole story, as urban hospitals that predominantly serve women of color have been disproportionately affected by maternity ward closures. Amutah-Onukagha’s center found that not only are Black communities more likely to lose obstetric units, the racial makeup of patients at a hospital is an even larger determinant of closures than the number of low-income patients insured by Medicaid. The closures are one contributor to the much higher rates of maternal morbidity and mortality that Black women face.

"My hometown of Trenton, New Jersey, is a maternity care desert. The hospital where I and my siblings were born — there are no OB units there to service the residents,” said Amutah-Onukagha. “How is this possible? You can’t give birth in the capital city of one of the wealthiest states in the US?”

Rushing Delivery

A host of challenges, including staffing, costs and declining births, is putting access increasingly at risk. Obstetric units in suburban Cincinnati, Milwaukee and San Diego have already closed in 2024, according to Becker’s Hospital Review, an industry trade magazine. Many women were redirected to hospitals 30 minutes away. Studies have shown that having a drive of more than 30 minutes reduces prenatal visits, while increasing planned cesarean section rates and births that occur en route to the hospital.

While some laboring women, especially those having their first child, may have enough time to make the journey, extended travel can increase the risk, said Holly Meduri, a nurse who helped deliver babies at St. Catherine’s for 22 years before the unit shuttered in February.

“We all have our idealized version of how our labor and delivery is going to go, and then all of a sudden there are problems,” she said. “If you are bleeding or you’re having a real obstetric emergency like the baby’s cord prolapses, those are things that, within minutes, you need to be delivered.”

Prior to closing the maternity ward, the system that owns St. Catherine of Siena, Catholic Health, assessed the impact on medically underserved groups and worked to ensure care wouldn’t be compromised, a spokesperson said.

No Standards

It’s difficult to pinpoint the size of the problem or determine how quickly it’s growing. States don’t have a standard method to disclose changes, and US government data is often incomplete or inaccurate, said Harold Miller, chief executive officer for the Center for Healthcare Quality and Payment Reform, a nonprofit health policy organization.

“If there were a good source of information about labor and delivery service closures, we would be using it rather than trying to assemble the information ourselves,” Miller said. “It’s not even easy to find accurate information about which hospitals have labor and delivery services.”

Most of the available research, including from Miller’s group, focuses on rural areas. But less formal reporting, and a groundswell of attention on social media, shows a broader lens may be needed.

In the first five months of 2024, 19 US hospitals closed or paused their labor and delivery services, according to a list maintained by Becker’s Hospital Review. That compares with 29 for all of 2023. Nearly half of the 2024 closures were in non-rural areas, and six were in communities with household incomes that surpassed the nationwide median.

Maternity Ward Closures Ripple Beyond Rural Areas

The most recent data available, from the March of Dimes, found the loss of obstetric units led to decreased maternity care access in nearly one in 10 counties across the country between 2018 and 2022. There were 2,826 obstetric units in hospitals in 2020, according to research underway from Peiyin Hung at the University of South Carolina, and even those dated numbers may be inaccurate.

Staffing Shortages

Chief among the causes is the shortage of obstetricians and gynecologists, the doctors who focus on the reproductive health of women.

There were about 50,000 OB-GYNs in the US in 2018, about 1,000 fewer than needed, and the total has declined since then, according to the US Department of Health and Human Services. The agency projects the deficit will increase to 5,000 by 2030 as retirements pick up among the nation’s aging physician workforce.

New doctors are unlikely to fill the gap since the number of residency spots funded by the federal government has been largely frozen since 1997. That’s creating a bottleneck in addressing the shortage, said Atul Grover, executive director of the American Association of Medical Colleges Research and Action Institute.

The number of residency applications dipped temporarily after the Supreme Court’s Dobbs v. Jackson decision in June 2022, which rolled back federal abortion protections, Grover said. The ruling creates potential legal ramifications for doctors who perform the procedure on women in medical distress, which can require delicate decisions about when lives are on the line.

And yet the demand for these accredited specialists are among the highest for all physicians, according to AMN Healthcare, one of the nation’s largest health staffing agencies. More pregnancies are occurring in high-risk women, including those who are over age 35, obese or have hypertension, requiring greater expertise.

“Recruitment and retention of this highly trained, skilled workforce is further complicated as many rural and underserved areas do not present as an attractive option,” Amutah-Onukagha said in an email. “Conversely, major cities push talent away with exorbitant cost of living and astronomical insurance rates.”

High Costs

Just keeping the doctors can be difficult — and expensive. At St. Catherine’s, negotiations broke down between the hospital and the obstetricians who used to practice there, and the hospital wasn’t able to hire replacements.

“Despite our best efforts to find alternative options for coverage, as of February 1, there will be no OB-GYN physicians at St. Catherine of Siena to provide maternity services,” a spokesperson said.

Delivering babies is often a money loser, putting them at the top of the list for cuts when hospitals are struggling financially, said Erik Swanson, senior vice president of data and analytics at Kaufman Hall, a health care consulting firm that tracks hospital profit margins. Malpractice insurance rates alone can top $150,000 a year for a single OB-GYN, higher than most surgical specialties.

Maternity wards require specialists, including anesthesiologists and labor-and-delivery nurses, and must be staffed around the clock. Ideally, there should be a one-to-one nursing ratio, said Anne Banfield, a fellow at the American College of Obstetricians and Gynecologists.

The Supreme Court Dobbs decision on abortion can also give hospitals a different cost to weigh, raising legal, moral and ethical questions for doctors who have taken the Hippocratic Oath pledging to do no harm.

There are tight restrictions on the procedure in 14 states currently, and the question of whether it can be performed to protect the health of the woman has been hotly contested. The nation’s top court allowed Idaho to enforce its near-total ban even for women in medical distress for five months in early 2024, until issuing an about-face in June.

Declining Births

Spreading out those fixed costs is getting more difficult. There were 72,000 fewer births in 2023 than a year earlier, according to the Centers for Disease Control and Prevention, even as the number of women aged 15 to 44 grows.

The situation is exacerbated in areas where many patients have Medicaid, the US insurance program for the poor that covers about 40% of births nationwide. It typically only pays a fraction of the cost of care, Grover said.

“When hospitals look at the bottom line, if they’re talking about replacing joints versus delivering babies, they’re going to choose replacing joints all day long,” Banfield said.

Still, some communities have managed to rescue their imperiled obstetric units. In Troy, New York, for example, staffers and community members banded together to save the only maternity ward in Rensselaer County, just east of the capital Albany. Participants in the “Save Burdett Birth Center” campaign organized rallies, issued a community impact survey, and testified at a hearing with the New York Attorney General. As front yards in the region filled with pink lawn signs in support of the facility, the campaign gained the attention of the New York State Assembly, which allocated $5 million to keep the birth center open for another five years.

Nationwide, state and federal officials are taking proactive steps to help make labor and delivery wards viable. In the US Senate, a group of Democratic lawmakers introduced legislation to increase Medicaid reimbursement rates for births in rural hospitals, while California and Virginia have allocated state funds to create new OB-GYN residency spots.

When maternity wards close down, the effects aren’t limited to the communities nearby. Health care workers are forced to adjust, too. Meduri, the St. Catherine’s nurse, retrained to work in the operating room, but it’s not the same.

“I’ve gone from being an expert to the novice,” she said. “It’s a grieving process.”

Experts say managed care is still the best route to controlling costs for U.S. employers, healthcare system

Fri, 30 Aug 2024 17:01:59 GMT

With premiums for health maintenance organizations climbing faster than those for preferred provider organizations, employers are beginning to wonder what happened to the “management” in managed care.

While HMOs may still be less expensive than PPOs or indemnity plans, if they are doing their job in managing costs, why are their prices going up so much?

Industry observers blame three developments.

First, consumer backlash has forced plans to eliminate gatekeepers and specialist referrals and open drug formularies to include more choices-all once thought to be vital to controlling utilization and therefore costs.

Second, many plans are now for-profit entities that must respond to shareholder demands, which also is contributing to cost pressures.

And last but certainly not least, providers are becoming more aggressive in their negotiations with plans, scoffing at capitation and risk-sharing, and demanding more money and autonomy (see story, page 10).

Despite these setbacks, benefit consultants and employers believe managed care is still the best way to rein in health care costs. It’ll just have to do so a little bit differently in the future, they say.

“There is less management” in managed care as a result of “rebellion from both providers and employees,” observed Rich Ostuw, global health care practice director at Watson Wyatt Worldwide in Stamford, Conn.

“But, in many situations, even though the rate of increase in managed care is higher, nobody would say we want to go back to an indemnity system,” he said.

“What managed care has done best is in the areas of preventive care and reducing the cost and risk of unnecessary surgical procedures,” Mr. Ostuw pointed out.

“In many locations, and for many populations, there still is an important place for managed care plans,” he insisted. “We shouldn’t abandon it in the areas where it’s working.”

HMOs, once thought to be the panacea for rising health care costs, are beginning to look a lot more like PPOs, which many employers had hoped to use as steppingstones to move employees into the more-restrictive managed care plans.

“As you look at the distinction between (HMOs and PPOs), the differences are starting to blend,” said Brad Fluegel, health sector market leader for Tillinghast-Towers Perrin in New York.

HMOs have eliminated or curbed specialist referral requirements, expanded their drug formularies and are doing less capitation in their contracts with providers, industry observers say.

HMOs also experienced significant financial losses over the past few years and are now playing catch-up.

“The rate increases in prior years were well below medical trends,” Mr. Fluegel said. “Plans were more growth-oriented than profit-oriented and were aggressive on price in order to get the business.”

But that approach backfired. Lower premiums, coupled with higher prescription drug costs and less management, have put many HMOs in the hole, he said, and now they have to raise rates substantially to return to their former levels of profitability.

Furthermore, now the majority of plans are for-profit and have shareholders to answer to, said Blaine Bos, principal at William M. Mercer Inc. in Chicago.

As health plans consolidate and become publicly traded, “shareholders are demanding that more attention be paid to the bottom line,” Mr. Bos said. “Shareholders want better returns on their investment, so HMOs have to raise prices to improve profitability.”

Increased provider clout also is making it harder for HMOs to negotiate good discounts, which also is adding to the plans’ overhead, consultants point out, and the more they have to pay their doctors, the more they have to charge in premiums.

“The doctors are more sophisticated in how they negotiate contracts,” Mr. Bos said. “They’ve discovered how much power they have.”

But while managed care may be hitting some obstacles today, it did have a significant impact on health care costs over the past 10 years, almost everyone agrees.

“It has delivered on the cost promise,” said Ken Sperling, health care practice leader at Hewitt Associates L.L.C. in Norwalk, Conn.

“The discounts are real. It’s still cheaper to deliver care in an HMO with a $5 copayment than in an indemnity plan with a $400 deductible,” Mr. Sperling said.

“I think what happened is when companies changed to managed care plans, they had a one-time decline in their costs because of the discounts they were getting and case management and everything these managed care plans were doing to control costs,” said Mike Pikelny, corporate actuary and employee benefits consultant at Hartmarx Corp. in Chicago.

“But now that all those programs are in place, I think the increases for all the plans are going up at the same rate,” Mr. Pikelny said.

“It’s just that management care plans started from a lower level, and that one-time savings is gone,” he said.

Despite these trends, managed care plans will always cost less than indemnity plans will, Mr. Pikelny and others say.

“HMOs squeezed a lot of fat out of the system,” agreed Mr. Bos. “They’ve gotten rid of a lot of administrative inefficiencies, and now it’s getting hard.”

To survive, managed care will have to shift its focus, many say.

For example, rather than just offering discounts, plans will tout quality, use evidence-based medicine and institute new technology and procedures to eliminate medical errors, all of which have been shown to reduce cost over the long run, Mr. Bos said.

“But that’s a more-expensive and difficult proposition,” he acknowledged.

This is where the newest trend, the so-called “consumer-driven health care model,” will likely come into play, observers say.

“They say the way to focus on quality is to get the consumer involved,” Mr. Bos said. “But that’s a tough proposition too, because it means educating employees so they look at health care in a new way.”

And, “the return on investment will be much, much lower than in the beginning of managed care,” Mr. Bos predicted. He added that “the employer and the employee are going to pay for the transition.”

“I expect to see some pretty healthy increases for the next two to three years, as plans rebuild reserves and reinvent themselves,” Mr. Fluegel said.

And “there will be higher levels of cost-sharing with employees,” he said.

But “we’re certainly not going to go back to a world of fee-for-service medicine,” Mr. Fluegel said.

“It’s kind of like the stock market in a way,” he said. “We’ve been in a bull market for several years, and people have forgotten that the market goes up and it goes down-it vacillates. The same holds for health care premiums.”

“There used to be a five-year cycle, but that’s been moderated somewhat because of the advent of managed care,” Mr. Fluegel said. “But the underlying issues haven’t gone away.”

“Managed care in its current form has hit the wall,” said Hewitt’s Mr. Sperling.

“We’ve changed the intercept,” he said, “but not the slope.”

Future of Medicaid likely hinges on election but voters are not yet hearing about candidates’ views

Fri, 30 Aug 2024 16:57:19 GMT

We’ve worked on Medicaid policy and/or public opinion research for three decades now and have observed its growing importance as the backbone of our health care system – now covering approximately 80 million people — as well as its centrality to voters. Medicare and Social Security are often described as the third rail of politics and had many mentions at last week’s Democratic convention; Medicaid gets less attention; yet it consistently polls almost as well as Medicare.

As a very consequential election approaches, Medicaid should be added to the long list of issues whose future may hang in the balance. Medicaid remains squarely on the Republican agenda for caps and large cuts, including the Project 2025 plan, as Edwin Park has blogged about numerous times. Indeed, given candidate Trump’s promise not to cut Medicare, Social Security and the defense budget, Medicaid and the Affordable Care Act Marketplace subsidies are the two most likely single program major targets for severe cuts. Medicaid is now a household name like Medicare and Social Security, so if the winning candidate has plans for it, don’t voters deserve the opportunity to hear about those plans before they cast their votes?

First, a look at history. There have been four major attempts to cap Medicaid in the past forty years starting with former President Reagan’s push for a block grant in 1981, the former Speaker of the House Newt Gingrich’s budget bill in 1995 (which was vetoed by former President Clinton), a quickly abandoned effort in the early years of President George W. Bush, and the near-successful attempt to repeal the Affordable Care Act at the beginning of the Trump Presidency in 2017 when Republicans decided to cap Medicaid while they were in the neighborhood.

Medicaid is Popular with Voters

Two-thirds of Americans say they have a personal connection to Medicaid and most of these (59%) have actually been enrolled or had a family member or close friend covered by Medicaid at some point. Medicaid engenders positive views among the public across parties with higher favorability ratings for Democrats but a clear majority across parties. Interestingly, Republicans with a personal connection to the program value it more. The numbers of people with a personal connection to Medicaid is growing; Medicaid covers approximately half of all children, including a larger share of children of color, pays for 40-50 percent of births depending on the state, is the largest payer for behavioral health care services and long term services and supports, helps make Medicare affordable for low-income seniors, and covers many low-income parents and other adults.

A recent KFF poll found that seven in ten voters want Medicaid to largely continue as it is today, while only three in ten support changing Medicaid to cap federal funding and give states greater flexibility in designing their programs. While large shares of Democratic and independent voters prefer to keep Medicaid as it is today, Republican voters are evenly divided, with about half preferring to keep Medicaid as is and half supporting a cap on federal spending.

When thinking about voter concerns today as the election approaches, we thought it would be informative to look at key points that have been coming up in focus groups with voters. Here’s what’s on voters’ minds:

The unaffordability of heath care and health coverage in the US is increasing the value people place on Medicaid coverage in focus groups. This is the major change we have observed in recent years. There is real anger over health care costs that continue to rise along with food and other necessities. The ever-increasing costs of health care is making Medicaid desired health coverage. People want Medicaid coverage because it is an affordable option (and often the only affordable option) for lots of people.
Medicaid enrollees are the only group we speak to these days who are NOT skipping or delaying health care in order to avoid big costs. We are hearing about wide-scale avoidance of health care because it is just not affordable, and people are afraid of medical debt. Medicaid enrollees are the exception.
Those with Medicaid know it works and want to keep it. Those who lost Medicaid due to the “unwinding” want it back! More than 1 in 5 Americans have Medicaid and know its value. The testimonials we hear from Medicaid enrollees are overwhelmingly positive.
There is more intensity among those who have Medicaid – or had it in the past. They want to keep Medicaid coverage. They know the difference it makes in their lives. They do not take this program for granted.
Medicaid is particularly important during times of inflation and economic uncertainty. Medicaid protects families from medical debt and bankruptcy. It allows them to pay other bills and to save. It improves the emotional and mental health of those enrolled because they are less worried about falling behind on bills and going deeper into debt. This is what we hear from people with Medicaid.
Those in non-expansion states want to expand the program. KFF found 66% of adults in these states want the program expanded. Once again – the American public is clear about this – only a handful of politicians in a handful of states are stopping this from happening. Ballot initiatives in red states to enact expansion have won repeatedly.

At a time when the high cost of living is a key concern for many voters, Medicaid’s role is more important than ever. Medicaid has always been a popular program with the American public but it has never been more popular. There is ideological opposition to Medicaid among some politicians, but the American public has never been conflicted about Medicaid.

SC Alliance of Health Plans is now on LinkedIn!

Addie Thompson — Thu, 27 Jun 2024 14:50:09 GMT

We're excited to announce that the SC Alliance of Health Plans is now on LinkedIn. Follow SCAHP for the latest news, events, and more!

Follow SCAHP

How noncompete ban could shake up health care landscape

Sat, 01 Jun 2024 02:11:22 GMT

The Federal Trade Commission’s (FTC) vote to ban noncompete agreements is set to have an outsized impact on the health care sector, empowering clinicians and raising anxiety among private practices who worry it will compound staffing problems.

The FTC voted 3-2 last month to ban all current and future agreements preventing workers from going to competitors or starting a competing business after they leave a job. The rule is set to go into effect on Sep. 4, though the U.S. Chamber of Commerce has already sued to stop it.

Shortly before the rule came out, FTC Chair Lina Khan told reporters that of the 26,000 comments her agency received on the proposed rule, “a pretty significant chunk were from health care workers in particular.”

“Even for workers who, you know, make a decent living, their view was that at the point of signing these contracts, they did not actually have bargaining power,” she said.

In its announcement, the FTC said eliminating noncompete clauses is expected to lower health care costs by $194 billion over the next 10 years.

Lisa Stand, director of policy and regulatory advocacy at the American Nurses Association, said her group was pleased with the rule and surprised by “how strong it is.”

“It absolutely will make job mobility easier,” Stand said. “We’re nurses, and we think that ultimately this is good for patients as well, as there is more sort of robust competition for clinical talent and an expanded access to more choices of provider and provider setting.”

But some private practices worry not enough thought has been put into how a change like this will affect the care they provide to patients.

Jack Feltz is a practicing OB-GYN as well as president and CEO of Lifeline Medical Associates, a practice of roughly 200 physicians providing care to patients in New Jersey and Delaware.

Employees at Feltz’s practice, including himself, are asked to sign noncompete agreements. He acknowledges that noncompetes can be onerous on workers but argues that private practices will be less capable of competing with larger hospital systems without them.

“It truly unbalances the ability of those organizations, especially private practices which are already under siege and being decimated by hospital employment, for them to be able to maintain and be able to compete with hospitals that have no restriction on noncompetes,” said Feltz.

He warned that large health systems will soon be more able to poach not only physicians, but their private practice patients as well.

According to the American Medical Association, 37 percent to 45 percent of physicians are under noncompete agreements. While they are common, Feltz noted noncompete agreements aren’t always enforced. He said his own practice has let former employees out of their agreements due to external issues.

Lynn Rapsilber is co-founder and CEO of the National Nurse Practitioner Entrepreneur Network, a nonprofit that helps nurse practitioners start their own businesses. According to Rapsilber, everyone from large health systems to small practices is “competing for that patient” who she believes is the main beneficiary of this rule.

From a business perspective, Rapsilber agrees there is value in contractual agreements that former employees won’t take patients or mailing lists from a practice. The main “problematic” issue she sees in enforcing noncompete agreements is the geographic stipulations they place on health care workers, limiting where they can practice after leaving a job.

“For the consumer, this is great news because there’s going to be more opportunities for choice in their health care provider if there’s more opportunity for people to open up their own practices and to be able to serve the community,” she said. “That’s going to enhance competition, which will actually in the long run lower prices and increase quality.”

Labor experts argue that getting rid of noncompetes will also relieve physicians of an additional challenge amid an increasingly monopolized industry.

According to John August, director of health care and partner programs at Cornell University’s Scheinman Institute, noncompetes have become “a big issue” in health care as physicians’ practices are being taken over by large health systems.

“A lot of physicians are thinking of leaving their practices that they’ve spent many years building and then only to see them taken over by larger and larger corporations and feeling very, very dissatisfied in their employment situation and wanting to leave and finding these noncompete clauses,” August said.

The new rule would allow many of these physicians to leave after their practice is absorbed — with some caveats depending on what type of entity it is.

Some larger hospital systems may gain an advantage by being excluded from this rule. The FTC has limited jurisdiction over nonprofits, and about half of all community hospitals in the U.S. are nonprofits, according to the American Hospital Association.

As Fierce Healthcare recently reported, FTC Commissioner Rebecca Slaughter acknowledged there would be health care workers the rule would “struggle to reach” due to their employment at nonprofit hospitals.

How climate change will turn up the heat on healthcare payers

Sat, 01 Jun 2024 02:08:21 GMT

Climate change is bound to majorly impact every health plan on the planet, but payers don’t have to be left stranded. Getting an early start on climate change planning before it gravely threatens health plans is the best option for insurance businesses to not be left high and dry.

“The climate crisis is a health care crisis,” says Baylis Beard, director of sustainability for Blue Shield of California., “As insurers, we are part of the healthcare industry, which means we have a responsibility to decrease our emissions and use our voice to lead the way to a more sustainable, healthier future.”

Climate change will impact payers in three key ways: high utilization, high costs, and weather-related events that will affect healthcare workers.

HIGH UTILIZATION

Creating a Plan

Payers should develop climate change response plans to focus on their high-risk areas, the areas that will eventually cost them the most to cover. That might include implementing digital care and telehealth solutions. Payers can create ways for consumers to educate themselves about high-risk areas, possible health effects, precautions to take, and resources available to them if they are located in a high-risk area. By leveraging care-management platforms, payers can provide information like inclement weather alerts and educational content to allow their members to stay informed in an accessible way.

Keeping track of member health will play a greater role as climate change advances, particularly with seniors and the Medicare Advantage population. Studies show that seniors in particular will be greatly affected: “Among other alarming facts, heat-related mortality for people above age 65 has increased by more than 50% in just the past 20 years,” according to a report from the Patient Safety Network.

Research

High-risk areas might not always be easily identifiable, and this may take some research to create an accurate response plan.

For example, California experiences frequent wildfires, and long-term exposure to smoke inhalation kills thousands each year. However, according to one study , only about 1,700 of the 6,300 deaths that occurred each year from smoke inhalation between 2006 to 2018 occurred in the West. This study shows that wildfire smoke had the most prevalent effects in the East because of how fast the smoke traveled. The point: don’t make assumptions without looking at all the data.

“Much of the research on the effects of climate change on health has been done with clinical data to understand health outcomes,” said Blue Shield of California’s director of sustainability Baylis Beard, “but the impact on healthcare utilization and costs is less understood.”

In order to uncover the true cost of climate change for health insurance, payers should focus on using science and evidence-based strategies. An article by the Patient Safety Network states: “Evidence-based strategies are required to accelerate healthcare decarbonization and avert the worst predicted harms to health and healthcare systems.”

Further, insurers can collaborate with climate change researchers and weather institutions to create comprehensive plans that take into account a vast array of climate data.This avenue can ensure the most accurate results can be reflected when payers analyze the financial impacts.

HIGH COSTS

Perhaps the biggest and most obvious effect of climate change will be higher costs. High utilization leads to high costs for payers, but what will also step into the spotlight? Supply chain malfunctions.

The United States’ healthcare sector emits about a quarter of total global healthcare emissions. In other words, the U.S. healthcare industry uses a lot of energy, and transports a lot of supplies. Climate change will bring about disasters that are very difficult to prepare for in this sector.

For example, a tornado that ripped through a Pfizer drug warehouse in North Carolina in July of 2023 destroyed medications as well as pharmaceutical raw materials, exacerbating the shortage of drugs used in surgery and cancer treatment.

Payers can work with outside organizations to create communication plans on how they will handle these events. But they must make sure the select the right partners. “We play a role in creating the right incentives in the value chain and choosing sustainable partners,” said Beard.

CLIMATE CHANGE AFFECTING HEALTHCARE WORKERS

The biggest issue in healthcare is the labor shortage. Climate change will worsen this. Extreme heat and weather will affect certain occupations more than others.

For example, studies show that climate change will have a big effect on emergency response workers. The Journal of Emergency Medical Services published an article stating: “Prolonged heat waves strain EMS staff and resources, emphasizing the need for strategic planning and collaboration with other agencies.”

Payers should collaborate with their health systems to ensure there are resources for these workers when they feel strained. Along with EMS workers, doctors and nurses facing intense burnout from high volumes of patients after weather-related events will also increase. Implementing AI and automation to cover tedious tasks and mitigate stress is one tactic that can help.

VIRTUAL CARE

Virtual care is going to play an even bigger role as the climate crisis worsens. The healthcare industry has already gotten a jumpstart on this type of care because of the COVID-19 pandemic. Telehealth and virtual care have been shown to decrease emissions as well as water use. While virtual care can have its limitations, including broadband issues and limited access to technology, it can provide care when physical access to a health system is just not possible. Payers should look at updating their virtual care models and implementing new forms of virtual care. For example, Blue Shield of California has implemented a new virtual care platform that connects members with virtual primary care services for patients to access providers via mobile phone, tablet, or personal computer.

“This virtual care platform also helped provide critical health care services to a town badly damaged by the Camp Fire where many residents were forced to drive long distances to see a doctor,” Beard said.

THE OPPORTUNITY TO LEAD

Health insurers can take the lead on climate change in several ways.

For instance, the Boston Consulting Group suggests that “Insurers should collaborate with climate research and university institutions and should assist governmental and academic institutions in climate-health policymaking discussions.”

Health plans can look to create new insurance products and specified insurance models to address climate change health effects. Payers can explore implementing wider disease coverage and climate specific products. Looking to other countries may also help in generating new ideas. For example, Japan has implemented heatstroke insurance in response to climate change, costing members roughly 70 cents a day; in a single day they sold about 7,000 policies in June 2022.

Payers should also focus on underserved populations, as these groups often experience the worse climate change effects while contributing the least to pollution and carbon emissions. Collaborating with other institutions and agencies could be beneficial in this implementation.

Payers can also look to generate new opportunities by establishing health services that go beyond insurance. Climate change is already having an impact on payers’ portfolios, and this is a great way to diversify. Partnering with private equity firms to expand care delivery and creating tools for optimizing emergency-room triage and resource allocation are a couple of options that payers can explore.

U.S. health insurers see revenue growth but margins face pressure in 2024

Sat, 01 Jun 2024 02:07:04 GMT

In 2023, publicly traded health insurance companies in the US experienced continued growth, with total GAAP revenue increasing by 10.4% to $1.07 trillion. However, a new report from AM Best suggests that future profitability may face challenges as government programme returns to normal levels.

Titled “Revenue Grows but Margins Are Pressured for US Publicly Traded Health Insurers,” the report highlights that half of the 10 insurers studied reported double-digit premium growth in 2023, led by Oscar Health, Inc. with a 46.9% increase.

The overall population also saw a 28.5% rise in investment income. Net income reached $45.3 billion, marking a 6.8% increase from 2022, following a 12.5% surge the previous year.

The report attributes pressure on Medicare Advantage (MA) earnings to reduced reimbursement rates from the Centers for Medicare & Medicaid Services, alongside increased medical claims and utilisation. Medicaid managed care business is experiencing a significant decline in enrolment, potentially leading to a worsening risk pool as eligibility redeterminations are finalised.

Kaitlin Piasecki, Industry Research Analyst, AM Best, noted: “With medical costs continue to rise across the United States, insurers have been raising premium rates and are likely to continue doing so in 2024 to maintain favourable earnings.”

“Overall earnings for companies solely operating government programmes could be challenged in 2024, but these companies should remain profitable,” commented Jason Hopper, Associate Director, Industry Research and Analytics, AM Best.

“Medical management of those with chronic conditions, as well as quality programmes and related bonus payments, will be extremely important for sustained earnings for these health plans. For plans operating in all business segments, commercial business margins will become a greater focus given the likely earning declines in Medicare Advantage and Medicaid managed care,” further added Hopper.

AHA: High drug costs and shortages threaten care quality

Sat, 01 Jun 2024 02:05:53 GMT

Drugmaker price hikes that have occurred in tandem with ongoing drug shortages have not only created headaches for both hospitals and providers — but also jeopardized patient access to care, according to an analysis published May 22 by the American Hospital Association.

Inflation has not been the sole factor driving up prices, either. Between January 2022 and January 2023, the prices for about 2,000 drugs "increased faster than the rate of general inflation, with an average price hike of 15.2%," the report states.

The combination of drug shortages and price increases that outpace inflation led to around 85% of hospitals reporting to the AHA that their hospital has been critically or moderately affected, with 99% reporting that their hospital experienced a drug shortage in 2023.

In 2023, hospitals saw the highest number of drugs in shortages in 23 years, another report found.

Responding to the changing pharmaceutical supply landscape and either acquiring alternative medications, renegotiating contracts or identifying new suppliers raises what hospitals typically spend on drugs by about 20%, the AHA found.

"Though the problem of high drug prices is not a new issue for hospitals and health systems, the rate at which drug prices are increasing combined with the problem of drug shortages is becoming unsustainable for the field and having a direct impact on patient outcomes," the report reads. "Higher drug prices and increasing drug shortages mean more costs for hospitals and health systems to bear, further stretching their limited resources and ultimately jeopardizing patients' access to needed care."

Here are three more notable findings from the AHA:

Generic drugs account for around 83% of drug shortages.
The median annual price for new drugs went up 35% from the year before to $300,000 in 2023.
The 15.2% average increase in drug prices in 2023 was equivalent to an average increase of $590 per drug.

U.S. House committee hearing looks at health care monopolies, budgetary effects of health care consolidation

Sat, 01 Jun 2024 02:04:45 GMT

Breaking Up Health Care Monopolies: Examining the Budgetary Effects of Health Care Consolidation

View the video here: https://budget.house.gov/hearing/breaking-up-health-care-monopolies-examining-the-budgetary-effects-of-health-care-consolidation

The need for holistic policy thinking in Medicare

Thu, 30 May 2024 13:54:37 GMT

The Medicare program represents a sacred promise to America’s elderly and disabled citizens. The Medicare Fee-For-Service (FFS) program, introduced as part of the Great Society in 1965 to mirror a Blue Cross Blue Shield commercial market standard, covered hospital and physician benefits separately. As the private health care market evolved, policymakers introduced private plans into Medicare, followed by the Medicare Risk Program and the integration of health maintenance organizations, eventually leading to today’s Medicare Advantage (MA) program.

This article addresses the history of the Medicare program and the current debate around the recent MedPAC estimate of MA overpayments. We propose nuanced analytical considerations to ensure accurate coding, address favorable selection, and foster a holistic policy future for Medicare.

A Program In Evolution Since 1965

With the intent to create a program serving the changing needs of beneficiaries, various administrations and Congresses oversaw the design of benefits, addressing evolving medical practice and patient complexity. In the 1950s, hypertension was only newly being treated, with national treatment guidelines first issued in the 1970s. Powered by epidemiological research and pharmaceutical innovation, prescription drugs became a norm within medical practice, and, by 1986, 84.7 percent of Medicare HMO enrollees received prescription drug benefits. Driven by an increasingly diverse population, policymakers and analysts recognized the programmatic agility of MA, which, for example, allowed benefit design that better served beneficiaries in long-term care and provided home and team-based care for multi-morbid individuals.

Recognizing that customization—not standardization—coupled with plan quality transparency was critical to caring for an increasingly diverse population, policymakers created special needs plans and later added a quality star rating system to grade MA plans as part of the Patient Protection and Affordable Care Act. Subsequently, regulators have worked to improve ratings accuracy in response to analytical concerns. Given that the star rating quality bonus system does not apply to FFS Medicare, quality bonus incentives thus financially favor the MA program, the FFS Medicare plan lacks a quality rating, and beneficiaries cannot easily compare the two formulations of Medicare.

Simultaneous fiscal pressures drove commercial insurers to implement cost-control strategies via networks, utilization review, and employee cost shifting. States and the federal government faced similar pressures, motivating the evolution of FFS payment to risk-adjusted capitation as part of the volume-to-value transition supported across Democratic and Republican administrations.

Facing the pressures of fixed incomes and limited finances, just over half of all seniors today elect MA with its financial protections and enhanced benefits. The FFS program has become increasingly expensive for beneficiaries via premiums for Part B, Part D, and Medigap (exceeding $183 monthly); MA has become an appealing alternative by serving as an affordable Medigap plan coupled with no-cost or low-cost Part D coverage.

Recent Policy Questions And The Need For Analytical Rigor

With over 30 million elderly, disabled, and impoverished Americans turning to MA, analytical rigor in assessing MA’s value and performance compared to FFS Medicare is an absolute requirement. Analyses must integrate insights and data across academia, the policy community, government, and industry, all aimed at equalizing the evaluation and treatment of MA and FFS Medicare. This section responds to MedPAC’s recent analysis claiming $83 billion in MA overpayments as a result of greater coding intensity in, and favorable selection into, MA.

Coding Intensity Differences

While MA plans are likely overfunded, approaches to developing estimates of coding intensity and favorable selection must validate policy models by connecting them to real-world business and clinical operations. Coding intensity differences, a longstanding MedPAC concern, derive from different payment methodologies in FFS Medicare versus MA. In FFS Medicare, specific providers are paid based on relative value units while hospitals are paid based on diagnosis-related groups (DRGs). In FFS, providers are not incented to capture all diagnosis codes that accurately reflect a member’s health condition. In MA, health plans are paid on a per-member, per-month base capitation rate, risk-adjusted for health status. This incents MA plans to more accurately code disease prevalence, incidence, acuity, and complications.

Such differing incentives create problems when policy experts seek to do programmatic comparisons between FFS Medicare and MA. These coding intensity differentials stem from three potential components. First, outright fraudulent coding remains a concern given ongoing cases of plans adding diagnoses unsupported by medical documentation. A second, related concern is diagnostic upcoding, wherein complexity is falsely enhanced to drive payment. The third component is clinically appropriate diagnostic coding intensity, the reciprocal of FFS undercoding.

Regarding the third component, consider the case of a Medicare beneficiary with diabetes and cardiac, renal, and ophthalmic complications. In FFS Medicare, physicians and hospitals may capture only a portion of these diagnoses to justify the provision of a specific service. In contrast, an MA plan that bears full underwriting risk has an incentive to capture all of these diagnoses as a means of assessing the full cost to cover all beneficiary benefits. In this setting, policymakers must address chronic FFS undercoding, a problem acknowledged but not yet measured and accounted for in the MedPAC analysis of FFS versus MA spending.

While the first two examples of coding intensity differences represent MA plan “overpayment” in the sense that people normally use that word, the third—clinically appropriate coding—does not. Stringent CMS regulations and Medicare Risk Adjustment Data Validation (RADV) audits would greatly minimize the first two components. The recent MedPAC analysis of coding intensity in MA does not differentiate between, measure, or account for these three factors driving coding intensity. Thus, with FFS undercoding unaccounted for and the three components of coding intensity all lumped together as overpayment, the MedPAC analysis likely overestimates coding intensity effects.

With an eye towards solving problems and improving measurement, policymakers and regulators should measure all components of coding intensity via chart audits comparing large samples of FFS and MA beneficiaries, using them to address overpayment. Other drivers of policy consternation, like in-home health risk assessments, pose a regulatory opportunity to require two years of data as MedPAC recommended and go a step further by transforming what is functionally a data-harvesting visit into a meaningful, more convenient clinical encounter for elderly or disabled beneficiaries. CMS has begun to address challenges in MA coding through an appropriately muscular approach to implementing RADV audits, updating Medical Loss Ratio guidance, and attempting to target problematic coding practices.

Favorable Selection

Finally, favorable selection within the MA program has been a longstanding concern. Historically, bad actors have engaged in tactics ranging from deterring sicker beneficiaries through third-story sales seminars to targeted advertising designed to drive healthier enrollment. This has inspired enhanced oversight and a series of regulator- and policymaker-driven reforms: CMS designed policy interventions to address real-world market problems and now reviews all plan marketing materials, operationalizing existing regulations regularly updated through marketing guidelines.

MedPAC’s recent updated estimate of MA favorable selection violates several analytical norms, including the use of a non-peer-reviewed comparator model and the inclusion of beneficiaries enrolled in employer-group waiver plans (EGWPs). EGWPs are not available to the general public and are not subject to CMS plan bidding requirements for MA and prescription drug benefits.

In addition, for unclear reasons, MedPAC’s recent model excludes beneficiaries with end-stage renal disease (ESRD), despite MA penetration of ESRD Medicare beneficiaries rising from 27 percent in 2020 to 47 percent in 2022, nearly approaching the MA general market share of 51 percent. While there is undoubtedly health status variation among ESRD beneficiaries, caring for this population is generally costly, with evidence suggesting that the MA’s required maximum out-of-pocket benefit is highly attractive to many ESRD Medicare beneficiaries—resulting in likely negative selection for MA plans. Furthermore, growing MA enrollment in D-SNPs—special needs plans for beneficiaries who are dually eligible for Medicare and Medicaid, another high-cost population—and the Medicare trustees report denoting decreasing FFS costs per beneficiary due to this trend raise questions about the real-world validity of the recent MedPAC favorable selection model.

While invariably there is some favorable selection in MA, the program’s integrated benefits likely result in negative selection into the program. For example, a Wakely report concludes that, if the mandatory MA maximum out-of-pocket (MOOP) limit of $7,550 were included in FFS Medicare, FFS spending would be 2.8 percent higher. A desire for a MOOP limit likely drives some high-cost beneficiaries into MA, but this factor is unaccounted for in MedPAC’s recent program comparison methodologies, which thus likely overestimate the effect of favorable selection.

To ensure accurate measurement of favorable selection across FFS Medicare and MA, selection effects must be examined bidirectionally. As the example of ESRD beneficiaries demonstrates, models, including MedPAC’s, must undergo stress-testing with subsets of Medicare populations in order to ensure internal validity. Finally, MedPAC’s model and other models must be externally validated by connecting them to real-world business practices. As the historical and recent actions of CMS’ work to address favorable selection demonstrate, externally validating models in this fashion guides policymakers and regulators to focus regulatory policy on issues that harm Medicare beneficiaries.

Considerations For Future Analytical Work And Program Policy

While it is clear that MedPAC’s new model is incomplete and likely overestimates coding intensity and favorable selection effects through unaddressed analytical questions, the model also fails to distinguish overpayment from differential payment. Given a purported overpayment of $83 billion for beneficiaries enrolled in MA versus FFS, if that entire amount represented plan profit, UnitedHealthcare and Humana, representing nearly 47 percent of enrollees, would presumably reap $39 billion/year in excess spending. However, Humana reported $102.6 billion in annual revenues and $4.3 billion in earnings before interest, taxes, depreciation, and amortization (EBITDA) across all insurance lines for 2023; UnitedHealth Group reported annual revenue of $372 billion with $32 billion in EBITDA. Thus, the $39 billion in excess spending would represent more than the two companies’ combined pre-tax income across all lines of insurance business, suggesting that the health plans are losing money on their remaining lines of business—an unlikely scenario.

Just as not all differential payment is overpayment, neither is all differential payment contributing to plan profits. In fact, MA uses $2,328 in rebates per beneficiary annually to deliver additional benefits, meaning $69.8 billion (84 percent) of purported overpayments go toward reduced A/B cost-sharing, premium reductions, a prescription drug plan, and other supplemental benefits. MA thus attracts beneficiaries who are unwilling or, more worrisome, unable to purchase Medigap plans. Consequently, blind cuts in MA, versus targeted policy improvements that equalize the treatment of MA and FFS, would hurt the many poor and minority beneficiaries in the program and damage long-standing efforts to improve health equity.

Instead, future policy analyses of MA and FFS spending must be holistic. In addition to analyzing statutory program spending, analysts must consider component-by-component costs and the cost to both taxpayers and beneficiaries for the construction of a holistic health benefit package in both the FFS and MA programs. This could include analysis of taxpayer/beneficiary costs and induced demand as MA plans buy down Parts A and B beneficiary cost-sharing versus the much greater induced demand from FFS beneficiaries with Medigap, as nearly three-quarters of beneficiaries with Medigap are without any cost sharing.

Policymakers should also look to equalize the treatment of MA and FFS Medicare, promote value-based care, and differentiate between good and bad actors. If policymakers are concerned that MA is coded differently than FFS, regulators should look to improve coding accuracy for both programs. Solutions could include using artificial intelligence to crawl charts as a means of equalizing payment. In conjunction, policymakers could budget for thorough chart audits of FFS and MA populations to better measure differential coding. Other policies could include promoting site-neutral payments, competitive telehealth pricing, and tech-assisted and tech-driven solutions that reduce cost and expand access.

If MA program spending driven by inflated, formulaic benchmarks is a primary concern, policymakers could also consider staged reforms to Medigap plans, long a focus for programmatic reform; they could address the previously mentioned induced demand in FFS Medicare, driven by a lack of cost sharing created by Medigap, through the implementation of value-based insurance design in Medigap plans. Other policy alternatives worth exploring include larger geographies for plan bidding or benchmark reform through competitive bidding inclusive of FFS Medicare, with rigorous consumer protections such as grandfathering and risk corridors to protect vulnerable beneficiaries. To combat overpayments due to star ratings, policymakers and regulators could eliminate double-bonus counties (counties with high MA penetration and low FFS Medicare spending receive double bonuses) and steward the creation of a uniform quality ratings program for both FFS and MA.

To address high drug costs, regulators could mirror best practices in Medicaid and use managed care tools to implement value-based contracting for revolutionary new therapies. To better support consumers, regulators should improve the plan finder to help provide beneficiaries with more transparent cost and benefits information. Finally, with an increasingly complex Medicare population and changing delivery system, policymakers should support a diversity of beneficiaries through modernization and mass customization versus product or benefit standardization.

Indiscriminate, across-the-board program cuts would harm the millions of elderly and poor beneficiaries enrolled in MA. Policymakers should undertake a “measure twice, cut once” ethos, internalizing consumer protection as a core principle. Creative, contemporary policy solutions that preserve the strengths and minimize the weaknesses of the MA program should be coupled with simultaneous improvements to FFS Medicare, as the two programs are inextricably linked. While MA is imperfect, population-based payment provides the flexibility to meet the varying needs of America’s increasingly diverse population while creating a long-term framework for continuing the transition from volume to value.

Authors' Note

We would like to acknowledge the years of hard work on implementing and improving the Medicare Advantage and Part D Prescription drug programs by Jeffrey Kelman, MD, MMSc, the former Chief Medical Officer of CMS whose curiosity and skepticism inspired us all.

Kenny Kan is Chief Actuary of Horizon BCBS, which operates MA plans. The views expressed are the authors’ own and not necessarily those of their employers or affiliations.

U.S. Senate Finance Committee releases white paper on Medicare physician pay reform

Thu, 30 May 2024 13:52:49 GMT

Senate Finance Committee Chair Ron Wyden, D-Ore., and Ranking Member Mike Crapo, R-Idaho, released a white paper May 17 outlining policy concepts regarding pay reform for Medicare physicians. The paper highlights areas that could undergo reform, including: creating sustainable payment updates to ensure clinicians can own and operate their practices; incentivizing alternative payment models that reward better care provided at a lower cost; how Medicare measures quality care; improving primary care; supporting chronic care benefits in Medicare fee-for-service; and ensuring continued telehealth access.

Click here to view the white paper: https://www.finance.senate.gov/imo/media/doc/051723_phys_payment_cc_white_paper.pdf

10 questions facing Medicare Advantage

Thu, 30 May 2024 13:48:51 GMT

Medicare Advantage is the dominant form of Medicare, and questions loom for payers, providers and policymakers alike in the year ahead.

Enrollment in the program has doubled in the last 10 years, and over half of Medicare beneficiaries are enrolled in an MA plan in 2024. At the same time, a number of headwinds are converging on MA this year.

The public-private partnership is a major income generator for insurers, but as CMS tightens reimbursements, and audits and medical costs rise, it may not be the cash cow it once was. On top of this, many hospitals are fed up with Medicare Advantage. Several hospital executives have spoken out against delayed and denied payments from Medicare Advantage insurers, and some have even gone as far as to tell their patients to avoid the plans altogether.

Still, the program is as popular as it's ever been among beneficiaries. How the future shapes up for Medicare Advantage — and Medicare as a whole — depends on how providers, insurers and lawmakers act on key issues facing the program.

Here are 10 key questions for the future of Medicare Advantage:

1. How long will hospitals put up with denied payments?

A growing chorus of hospital leaders have criticized Medicare Advantage plans, often citing problems with denied care and delayed payments.

In September 2023, San Diego-based Scripps Health dropped all Medicare Advantage contracts, a move affecting 30,000 older adults. Scripps is one of the largest health systems to stop doing business with MA entirely.

"It's become a game of delay, deny and not pay,'' Scripps Health CEO Chris Van Gorder previously told Becker's. "Providers are going to have to get out of full-risk capitation because it just doesn't work — we're the bottom of the food chain, and the food chain is not being fed."

In the second half of 2023, at least 15 hospitals and health systems moved to drop some or all Medicare Advantage plans. Though a small portion of hospitals are done with MA altogether, many others are raising complaints, saying payment delays and denials from the plans are getting worse.

A survey published in April by the Healthcare Financial Management Association and Eliciting Insights found 62% of hospitals CFOs surveyed said collecting payments from MA plans is "significantly more difficult" than it was 2 years ago.

2. What other options do hospitals have?

While a few hospitals are dropping the program, Medicare Advantage enrollees now account for more than half of Medicare beneficiaries — meaning it's not feasible for most hospitals to cut ties with MA completely. Rates of Medicare Advantage enrollment vary widely by county and state, but for many hospitals, going out-of-network with all MA plans would mean losing a significant portion of patients.

Bristol (Conn.) Health CEO Kurt Barwis said delayed payments from Medicare Advantage plans were a major factor behind the system's workforce reduction. In March, Bristol Health announced it would cut 60 positions across departments, 21 of which were occupied. Over 60% of the system's Medicare patients are enrolled in MA, Mr. Barwis told Becker's, making it clear that dropping MA plans is not on the table.

"The reason it's not an option is I have an older community, and they need care," Mr. Barwis said. "If you look at the rules, and the disruption it would cause in the community, I'm not sure I can face the community if I was to use that as one of my approaches."

Hospitals have tried other approaches to address their Medicare Advantage pain points without cutting ties with plans completely. Some have opted to pare down the number of insurers they contract with to the ones that best align with their financial goals.

Will Bryant, CFO of Chapel Hill, N.C.-based UNC Health told Becker's the system will pick a few Medicare Advantage payers to work with moving forward, prioritizing "the partners who act like partners" and do not "deny care in order to bolster their billions of dollars of quarterly earnings." He said he expects many other health systems to do the same.

Some hospitals are opting to create their own Medicare Advantage plans. Morgantown, W.Va.-based WVU Medicine is a majority owner of Peak Advantage, a health plan that launched in 2021 with two other West Virginia health systems as co-owners and expanded into Medicare Advantage at the start of 2024.

WVU Medicine launched Peak Medicine in 2021, and began offering plans to its employees in 2023. It expanded to Medicare Advantage at the beginning of 2024.

Albert Wright Jr., president and CEO of West Virginia University Health System, told Becker's that ownership of the plan has resulted in a "true mindset change" for the organization.

"You start to think about everything you do as both the payer, provider," Mr. Wright said.

Peak Health should feel like the easiest Medicare Advantage plan for WVU physicians to work with, Mr. Wright said. The system has not dropped any external Medicare Advantage plans, but may pare back the number of plans it works with over time.

"We probably want to work with three or four that we have good, agreed-upon relationships with," Mr. Wright said.

3. What is the future of prior authorization?

As complaints about delayed and denied Medicare Advantage payments intensify, CMS has taken action on prior authorization.

In 2021, more than 35 million prior authorization requests were submitted on behalf of MA enrollees, according to KFF. Rates of prior authorization requests vary widely between insurers, from 2.9 requests per enrollees in Anthem plans, to 0.8 requests per enrollees in Kaiser Permanente plans. On average, 11% of prior authorization requests were denied by MA plans in 2023.

New regulations took effect at the start of 2024, clarifying MA plans must follow coverage guidelines set by traditional Medicare. If there are not clear guidelines for services covered by traditional Medicare, MA plans can develop their own internal guidelines, based on widely used clinical guidelines, that must be publicly accessible. The rule also prevents plans from imposing any prior authorization requirements in the first 90 days a member is enrolled.

In alignment with these regulations, CMS took further action in February and issued guidance to Medicare Advantage plans around the use of AI and prior authorization. MA plans can use algorithms to support coverage decisions, but any algorithm or AI-based tool must be compliant with the agency's coverage decision requirements. Algorithms can be used only to help predict length of stay for post-acute services and not as the basis for terminating coverage, CMS said.

The guidance follows controversy and questions about the adoption of AI in health insurance decision-making. In 2023, three major insurers — UnitedHealthcare, Humana and Cigna — faced lawsuits alleging they used AI or automated algorithms to wrongfully deny members care. At the time of this article's publication, the lawsuits are ongoing. Some lawmakers have expressed concern CMS's guidance around AI does not go far enough.

Even after enactment of the new prior authorization regulations at the start of 2024, hospitals have asked CMS to do more with health insurers that make it less cumbersome to collect payment for services. In March, over 100 hospitals and health systems signed onto a letter asking the agency to do more on Medicare Advantage denials. The providers requested CMS collect more data on claims denied by Medicare Advantage plans and take enforcement action against plans not following the coverage rules set out by Medicare. The systems also asked CMS to bar MA plans from delaying or denying claims approved through electronic prior authorization.

4. How will the two-midnight rule shake up hospitals' relationship with MA?

New regulations took effect at the beginning of 2024 that could increase the reimbursement hospitals receive from MA plans, but present challenges for how hospitals document inpatient care.

The rule specifies plans must provide coverage for an inpatient admission when the admitting physician expects the patient to require hospital care for at least two midnights. The rule means hospitals need to up their documentation of patient stays, Ronald Hirsch, MD, vice president of regulations and education group at R1 Physician Advisory Services, told Becker's in June.

"MA plans are theoretically going to have to pay for a lot more inpatient admissions, so they're going to audit a lot more," Dr. Hirsch said.

On an April 26 call with investors, HCA Healthcare CFO Bill Rutherford said the rule seems to be having a "moderate benefit" on the health system's inpatient volume. Other hospital executives have said the rule has had little effect on inpatient volumes or revenue.

5. Has MA lost its luster for insurers?

While hospitals' frustrations with MA grow, insurers are facing another set of challenges in the program, which no longer promises the same level of profitability it once did for for-profit insurers.

In January, Moody's analysts wrote that the program "seems to be losing some of its luster." According to Moody's, earnings in Medicare Advantage shrunk by 2.1% from 2019 to 2022, despite premiums and membership growing by 40% in the same time period.

In the second half of 2023 and early months of 2024, insurers warned of rapidly rising costs among the Medicare Advantage population, driven in part by pent-up demand from the COVID-19 pandemic. Humana, the second-largest Medicare Advantage insurer, reported a $541 million loss in the fourth quarter of 2023, driven by what executives called unprecedented increases in medical costs.

With headwinds in the Medicare Advantage market, Moody's noted Elevance Health and Cigna, which have a smaller portion of their business in Medicare Advantage, are becoming more attractive to investors. Cigna finalized a deal to sell its Medicare Advantage business to Health Care Service Corp. for $3.3 billion in January.

In May, CVS Health executives said they expected the MA business to lose money in 2024, and braced for a decline in members in 2025. Still, the company remains bullish on the long-term outlook for MA.

"The current environment does not diminish our opportunities, our enthusiasm, or the long-term earnings power of our company," CVS Health CEO Karen Lynch said in May. "We are confident that we have a pathway to address our near-term Medicare Advantage challenges."

6. Will MA benefits be cut back?

Though some challenges around costs appeared to abate in the early months of 2024, insurers are also facing a tougher rate environment from CMS. In April, the agency finalized rules that would trim benchmark payments.

Benchmark payments are the amounts CMS pays MA plans per beneficiary. In addition to the cut, the agency is phasing-in risk-adjustment coding changes from 2024 to 2026. Insurers have argued the changes amount to a cut in payments for Medicare Advantage.

In response to the government's rate changes, many major Medicare Advantage insurers have indicated they will cut supplemental benefits, increase premiums for Medicare Advantage beneficiaries, or pull back from certain markets to account for the tougher funding environment. Humana executives said in an April 24 call with investors that it is eyeing exiting certain markets in response to the CMS rates, for example.

Scott Ellsworth, founder and president at Ellsworth Consulting, told Becker's that 2024 marks a turning point, in that older adults have seen benefits in MA get better every year until now.

"Now we're at an inflection point and the free lunch is over," he said. "There is going to be a sharing of the pain. Providers have disproportionately shared the pain, and now you're seeing many of them say, 'Enough is enough, we're out.'"

7. Are supplemental benefits working?

Virtually all Medicare Advantage plans offer hearing, vision and dental benefits — coverage not included in traditional Medicare, according to KFF. Many also offer over-the-counter drug benefits, meal support and reduced cost-sharing compared to traditional Medicare plans.

While the offering of such benefits are widespread, utilization of them is less clear. CMS lacks data on how often supplemental benefits are used in the program, according to a 2023 report from the Government Accountability Office. In January, CMS issued a request for comments on improving transparency in the program, including greater data collection on supplemental benefit use.

Supplemental benefits are one draw for beneficiaries to join MA. Medicare Advantage may also cost less than other coverage options. Given that nearly all traditional Medicare beneficiaries rely on supplemental coverage to address out-of-pocket expenses not covered by the traditional Medicare program, the appeal of MA's supplemental benefits and cost-effectiveness becomes increasingly apparent.

One proposed solution to problems plaguing Medicare Advantage is to make traditional Medicare benefits on par with MA, Don Berwick, MD, who served as CMS administrator during the Obama administration and is a current health policy lecturer at Harvard Medical School in Boston, told Becker's.

The idea has gained and lost steam in Congress. Bipartisan legislation to add dental, vision and hearing benefits to original Medicare coverage was introduced in 2023, but stalled.

"It should be cost neutral to beneficiaries as to which they choose," Dr. Berwick said. "The money needed to improve traditional Medicare would be readily accessible by clawing back the excess subsidies that have accumulated for Medicare Advantage."

8. Can CMS curb overpayments?

The government spends more on Medicare Advantage beneficiaries than comparable enrollees in fee-for-service Medicare, according to the Medicare Payment and Advisory Commission.

Two factors account for this disparity, according to MedPAC, which advises the U.S. government on Medicare. The first is favorable selection. Medicare beneficiaries who use fewer healthcare services tend to self-select into MA plans. The second factor driving disparities is coding intensity. Medicare Advantage plans are paid based on beneficiaries' risk, so plans are incentivized to document more diagnoses in patients' records.

In 2024, the federal government will spend $83 billion more on Medicare Advantage beneficiaries than if they were enrolled in fee-for-service Medicare, according to MedPAC. The commission also estimated MA will increase Medicare premium costs by $13 billion in 2024.

Insurers decried MedPAC's estimate, which industry groups said did not account for differences between the fee-for-service and Medicare Advantage population. Mike Tuffin, CEO of industry group AHIP, said the estimates are based on "speculative assumptions" and "overlook basic facts about who Medicare Advantage serves and the value the program provides."

MedPAC also estimates that coding intensity will be 20% higher in Medicare Advantage than in fee-for-service in 2024.

An October 2022 report from The New York Times found nearly every major insurer has been accused of fraud by a whistleblower or by the federal government.

In addition to higher coding intensity, the federal government has investigated several payers for intentional upcoding — making patients appear sicker than they are on paper to receive more reimbursement from the government.

In October 2023, Cigna agreed to pay $172.3 million to resolve allegations it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher reimbursements.

Other insurers, including UnitedHealthcare and Elevance Health have faced similar allegations.

CMS is also toughening its audits of overpayments. In January 2023, the agency finalized a rule that will allow it to recoup more dollars from Medicare Advantage plans through audits. CMS estimates it could collect $650 million in clawbacks in the first three years the rule is in effect and $400 million each year after. The rule is being challenged in court.

9. Does MA deliver better outcomes?

Medicare Advantage has yet to deliver on yield savings for the government, and evidence is inconclusive as to whether the program is tied to superior outcomes and care.

Medicare Advantage and traditional Medicare are mostly the same when it comes to outcomes, according to a 2022 literature review from KFF. Neither program consistently outperformed the other on quality outcomes across 62 studies reviewed.

MA enrollees were more likely to report having a usual source of care and receive preventive wellness services. Traditional Medicare enrollees with supplemental coverage were the least likely to report cost-related problems, according to KFF, but traditional Medicare enrollees with no supplemental coverage were most likely to report an issue affording care.

Medicare Advantage beneficiaries may spend less overall on their healthcare costs than their counterparts in traditional Medicare. Fee-for-service Medicare members spend about 7% more on average for healthcare compared to Medicare Advantage members, according to a 2023 study published by AHIP.

10. What's the future of traditional Medicare?

Despite the challenges, Medicare Advantage is set to keep growing.

The Medicare Advantage program has ballooned from 14 million enrollees in 2013 to 31 million in 2023. Continued growth of the program is expected, according to estimates from KFF. Six in 10 Medicare beneficiaries are expected to be enrolled in an MA plan by 2030.

Medicare Advantage and traditional Medicare beneficiaries generally express high-levels of satisfaction with their care, with few major differences between the programs, according to KFF.

If Medicare Advantage keeps growing, and beneficiaries remain satisfied with their coverage, what's the future outlook for traditional Medicare?

CMS Administrator Chiquita Brooks-LaSure said it's "critical" that beneficiaries continue to have a choice between traditional Medicare and Medicare Advantage.

Michael Chernew, PhD, chair of the Medicare Payment Advisory Commission, said although MA was not designed to be the dominant form of Medicare, its growth reflects the value beneficiaries are getting from the program.

"That said, I think the trajectory of growing enrollment we're on is unstable, for a bunch of reasons that are sometimes mathematical, just the way that the benchmarks are set," Dr. Chernew said in January.

MedPAC has proposed several policy items the commission says will slow spending in Medicare Advantage, including overhauling the way CMS calculates its payments to MA plans to make them closer to fee-for-service rates.

One possibility is that, at this rate of enrollment, traditional Medicare could "be atrophied significantly," in the years ahead, Dr. Berwick told Becker's. In this scenario, only the patients most undesirable to MA insurers could be enrolled in traditional Medicare.

"The benchmarks for Medicare Advantage are basically based on the expense pattern of traditional Medicare, so the whole financing calculation system is put in jeopardy by the dominance of Medicare Advantage," he said. "I would like to see Medicare Advantage slowed or stopped right now, or at least forced to have better carriers."

Medicare Advantage plans are about to change

Thu, 30 May 2024 13:46:52 GMT

Medicare Advantage patients might be in for a rude awakening as CVS plans to get rid of 10 percent of its plans.

CVS Health made the decision to cut the Aetna health insurance plans in an effort to prioritize profit margins, company leaders revealed this week.

"The goal next year is margin over membership," CFO Thomas Cowhey said. "Could we lose up to 10% of our existing Medicare members? It's entirely possible. And that's okay, because we need to get this business back on track."

After releasing the company's first-quarter earnings, CVS was $900 million below its health care benefit predictions on medical costs, with $400 million lost due to heavy outpatient service utilization.

Currently, CVS is the third largest Medicare Advantage insurer in the country, with the company saying it had 4.2 million enrollees as of April. If 10 percent of its current plans are exited, that would leave 420,000 beneficiaries needing to switch to a different plan or go without coverage.

"With rising medical costs outpacing government reimbursement increases, CVS is prioritizing profit margins over membership growth for its Medicare Advantage plans. However, this strategy could impact benefits and plan availability for many retirees," Michael Ryan, a finance expert and founder of michaelryanmoney.com, told Newsweek.

Earlier this year, the Biden administration said it would be cutting next year's payments to Medicare Advantage plans by 0.16 percent, adding onto the financial pressure CVS and other insurers are feeling at the national level.

Ryan said the decision to cut plans is logical as medical costs keep climbing and seniors seek out more care than years previous as more Baby Boomers retire. At the same time, 2025 Medicare Advantage payment rates do not look like they will cover the increasing expenses.

"CVS has bluntly said the new rates are insufficient 'to cover overall cost trends,'" Ryan said. "So they're taking steps to recover profit margins, targeting a 4-5 percent margin for their Medicare plans by 2025."

Insurers often first target supplemental benefits like fitness memberships and over-the-counter medication allowances, so CVS is likely to look at those first. However, some counties might be axed altogether if they can't be profitable, Ryan said.

"And we can't rule out premium increases to make the numbers work," he said.

Still, if CVS wants to be sustainable in the long run, it will need to still be able to retain and attract new members.

"I don't think CVS wants to gut their Medicare Advantage plans to the point of being uncompetitive," Ryan said. "They're banking on efforts to better capture members' health conditions and boost risk-adjusted reimbursement rates down the line. Insurers have to continually re-evaluate and rebalance their models as medical inflation, regulations, and reimbursement rates shift."

HHS task force launches roadmap for improving maternal mental health

Thu, 30 May 2024 13:42:38 GMT

One in five women experience mental health and substance use problems during pregnancy and the postpartum period, a member of the Task Force on Maternal Mental Health said during a briefing hosted by HHS on Tuesday to mark the launch of the National Strategy to Improve Maternal Mental Health Care.opens in a new tab or window

Sharing her own story, Nicole Barnett, MSW, a member of the Task Force, said something felt different after the birth of her third and youngest child. When she described her symptoms to a nurse at her obstetrician's office and was told she might have postpartum depression, she said that she could not accept it.

"I did not want to hear the phrase 'postpartum depression,'" she said, noting that, for her, it meant failing at motherhood.

Barnett refused to seek help or take medication, and her symptoms worsened. Washing her face became a chore. Decisions as immaterial as what color folder to send her kindergartener to school with could trigger a full-blown panic attack.

At her worst, Barnett said she would fence herself off with her children behind a baby gate in a back room. "I'd give my older two something to play with, and just hold my baby in the rocking chair and just pray for my husband to get home."

Ultimately, the fear that she might be neglecting her children drove Barnett to seek help. Within weeks of starting on medication, she began to feel more like herself. She connected with a therapist and joined a support group for mothers, which she credits as most important to her recovery.

For the last 20 years, Barnett has worked in maternal mental health education and advocacy, including serving as a counselor for the Health Resources and Services Administration's National Maternal Mental Health Hotline.opens in a new tab or window

"Every day I get to help women just like me," she noted.

The Task Force on Maternal Mental Health, which is co-chaired by Admiral Rachel Levine, MD, the HHS Assistant Secretary for Health, and Miriam Delphin-Rittmon, PhD, the HHS Assistant Secretary for Mental Health and Substance Use, is a product of the TRIUMPH for New Moms Actopens in a new tab or window.

During the briefing, Levine said that maternal mental health issues and substance use disorders (SUDs) are the leading causes of pregnancy-related deaths in the U.S. Furthermore, pregnant women with mental health conditions are 50% more likely to experience severe maternal morbidity.

To address this crisis, the Task Force conducted a literature review, held listening sessions to gain input from stakeholders, and gathered public comments through a request for information. Five working groups met online dozens of times from November 2023 through April to gather their findings and develop the following five core recommendations:

Build a national infrastructure that prioritizes perinatal mental health and well-being: Develop and strengthen federal policies to promote perinatal mental health and well-being by reducing disparities and expanding care models in which perinatal care, mental health care, and SUD care are integrated.
Make care and services accessible, affordable, and equitable: Establish federal mechanisms to fund infrastructure to support new delivery models for mental health conditions, SUDs, and gender-based violence. Implement "culturally relevant and trauma-informed clinical screening" and focus on training, growing, and diversifying the perinatal mental health workforce.
Use data and research to improve outcomes and accountability: Fund and expand support for perinatal quality collaboratives (PQCs) in all 50 states, the District of Columbia, and U.S. territories. (The CDC currently supports PQCs in 36 states.) Establish a central clearinghouse of information to make it easier for providers and other stakeholders to locate resources for perinatal health data.
Promote prevention, and engage, educate, and partner with communities: Fund evidence-based best practices to support "person-centered, culturally relevant, and community-level detection and prevention of perinatal mental health conditions and SUDs," particularly in under-resourced communities.
Lift up lived experiences: Listen to the perspectives of people with lived experiences of maternal mental health problems and respond to their needs.

The Task Force's report explains how the lack of national infrastructure for maternal mental health care and other systemic barriers place unnecessary stress on pregnant and postpartum women. A shortage and "geographic maldistribution" of mental health and SUD providers compounds these problems.

Those most vulnerable to mental health problems and SUDs include those from under-resourced racial and ethnic groups; incarcerated persons; parents of children in the neonatal intensive care unit; those who have experienced pregnancy loss, forcible displacement, trafficking, and gender-based violence; veterans; and those with pre-existing mental or behavioral health conditions.

During interviews, women with lived experiences shared the changes that would have improved their situation during pregnancy, including opportunities to connect with experienced mothers, access to high-quality care, sleep strategies and support, information about available medications, and specialty training in perinatal mental health support for members of the workforce from under-resourced communities.

A key recommendation of the report was the call to enact paid family leave, specifically to support the House Bipartisan Paid Family Leave Working Groupopens in a new tab or window, which launched in January 2023 and calls for at least 6 months of guaranteed leave in every state, U.S. territory, and the District of Columbia.

In interviews, many mothers reported having to return to work after only a few weeks when their babies were still vulnerable and they were still healing, said Task Force member Maya Mechenbier, JD.

"The mental health impact of having to leave your baby and return to work before you're ready cannot be overstated," she said.

Link to task force website: https://www.womenshealth.gov/about-us/what-we-do/working-groups-and-committees/task-force-on-maternal-mental-health

States with the most substance use treatment centers that accept Medicaid and Medicare

Thu, 30 May 2024 13:38:44 GMT

Overdose deaths tragically rose during the COVID-19 pandemic, sparking renewed calls for awareness of substance use disorders and access to treatment.

The once-in-a-century global health crisis had widespread impacts on physical and mental health and coincided with America's worsening fentanyl epidemic. And though calls have been made to expand access to treatment, people with substance use disorders often face barriers to getting the help they need to survive addiction to deadly substances like opioids.

Stigmatization of these disorders, a lack of capacity at treatment centers where waitlists are common, and unaffordability of treatment present some of the most critical challenges to Americans' ability to get help, researchers have found.

And the population using Medicaid is more likely than those on commercial insurance to live with a substance use disorder: 21% of Medicaid users had some form of SUD compared to 16% of commercially insured Americans, according to KFF, the nonpartisan health research firm formerly known as Kaiser Health News.

In order to visualize how Medicaid acceptance rates can vary by state, Ophelia analyzed data collected by the Substance Abuse and Mental Health Services Administration in its survey of substance use disorder treatment centers nationwide. The data used in this analysis covers both public and private institutions in every state, totaling nearly 15,000 locations. The analysis did not include institutions that are funded by discretionary public dollars, such as from county health authorities.

American treatment centers do not universally accept Medicaid, and only 74% of them took it as payment in 2022, according to SAMHSA. Medicaid even covers methadone treatment for opioid use disorder, though the fraction of treatment centers offering opioid treatment programs also do not accept Medicaid universally. And when patients can't utilize insurance, their only option is to pay out of pocket.

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Texas, California, and Florida have the fewest treatment centers accessible by Americans dependent on Medicaid

Nationwide, the percentage of substance use disorder treatment centers that accepted Medicaid as payment hardly grew from 73% in 2021 to 74% in 2022, according to the latest data from SAMHSA.

The most populous states in the nation were more likely than others to have the lowest rates of Medicaid acceptance. Some of these states in the South, like Florida and Texas, are also controlled by elected officials who have blocked the expansion of Medicaid coverage under the Affordable Care Act, effectively reducing the population that could use it to pay for health care for conditions like substance use disorder.

But even in states where Medicaid is widely accepted, other issues block access to treatment for those with substance use disorders. In Montana, the state petitioned and received approval in 2022 to expand the number of beds centers could provide for Medicaid patients. To date, 36 other states have received waivers from Medicaid to expand benefits similarly, according to KFF.

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Treatment centers in some states make strides in expanding access to treatment for those on Medicaid in 2022

Missouri, Vermont, Colorado, and Mississippi all saw significant increases in the number of treatment centers accepting Medicaid in 2022 compared with the year before.

Each state that cracked the top 10 for Medicaid acceptance growth—except for Texas—has petitioned for and been granted Medicaid waivers to increase capacity to care for those using public insurance, suggesting that removing limitations on providers may make Medicaid acceptance more attractive.

But not every state saw Medicaid acceptance grow.

Twenty states had declining acceptance rates at treatment centers from 2021-2022. In Hawaii, Arkansas, South Dakota, and Nevada, the share of treatment centers accepting Medicaid as payment decreased at least 5 percentage points from the previous year.

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The importance of transparency requirements in the Medicaid managed care rule

Thu, 30 May 2024 13:35:17 GMT

The Medicaid Managed Care Rule published on May 10 has lots of moving parts. As my colleague Leo Cuello explains, the rule includes provisions to increase the transparency of state directed payments (SDPs). The rule also contains a number of other transparency requirements that are the focus of this blog, most of which are identical to those CMS proposed a year ago. If implemented, these new requirements have the potential for changing the culture of opacity that has long existed in Medicaid managed care and has long undermined its effectiveness. (Transparency requirements in the Medicaid Access rule relating to fee-for-service payment rates are summarized in this blog by my colleague Kelly Whitener).

Transparency matters. In the 42 states (including DC) that contract with managed care organizations (MCOs), Medicaid purchases billions of dollars of services on behalf of tens of millions of enrollees. Oversight of these arrangements is, to say the least, challenging for state Medicaid agencies and CMS. Transparency about the performance of individual MCOs for children and other enrollees is essential to accountability of MCOs, state Medicaid agencies, and CMS alike.

The rule builds upon transparency requirements in current regulations issued in 2016. These begin with the requirement that state Medicaid agencies contracting with MCOs operate a public website that provides content specified in the regulations. In some cases, the requirement could be met by linking to the public websites of individual MCOs. The requirement took effect in 2017. Table 1 below indicates the content that the state agencies were required to post on the website and the dates by which the agencies were required to post that information.

Table 1: 2016 Medicaid Managed Care Rule Transparency Requirements

A requirement that content be posted on a state agency website is one thing. Compliance with that requirement is quite another. As CMS notes in the preamble to the new rule:

“A State’s website may be the single most important resource for information about its Medicaid program and there are multiple requirements for information to be posted on a State’s website throughout 42 CFR part 438.…Despite these requirements, we have received input from numerous and varied interested parties since the 2016 final rule about how challenging it can be to locate regulatorily required information on some States’ websites. There is variation in how ‘‘user-friendly’’ States’ websites are, with some States making navigation on their website fairly easy and providing information and links that are readily available and presenting required information on one page. However, we have not found this to be the case for most States.”

As an interested party, we could not agree more.

To address this bureaucratic malpractice, the rule requires that state agency websites (1) place “clear and easy-to-understand labels” on documents and links and (2) include all content on one webpage, either directly or by link to individual MCO websites. The rule further requires that states verify the accurate function of the website and the timeliness of the information presented, at least quarterly. States have until the first rating period for contracts beginning on or after 2 years after July 9, 2024 to comply. For most states, that means 2027.

The rule reaffirms that all of the transparency requirements in Table 1 apply currently. Some of these requirements are already set forth in the section of the current regulations relating to transparency (42 CFR 438.602(g)(1)-(4)). To “help States verify their website’s compliance,” the rule adds the remaining current requirements to this checklist (438.602(g)(5)-(8), (12)-(13)), as well as references to the new information states are required to develop and post over the next five years (438.602(g)(9)-(11)). These additional requirements and their compliance dates are summarized in Table 2 below. The implementation runway is lengthy.

Table 2: 2024 Medicaid Managed Care Rule Additional Transparency Requirements

Going Forward

The Managed Care Rule presents advocates with a golden opportunity to use transparency to increase the accountability of individual MCOs (and the state agencies that contract with them) for their performance. Advocates could start by conducting an inventory of their state agency’s website to determine whether all of the information identified in Table 1 is posted as currently required and initiating a conversation with their state agency about any missing items. For extra credit, advocates could urge their state agencies to go beyond the federal minimum and post MCO-specific EPSDT participation data, as Minnesota has done, as well as the Annual Medical Loss Ratio reports that MCOs submit, as several states have done.

As noted, the rule requires that state websites be easily navigable, accurate, and up to date by 2027. Compliance with the current transparency requirements does not depend on whether a state complies with these new website requirements. Nor, for that matter, does the rule prohibit a state from making any necessary improvements to its website before 2027. But the fact is that, in many states, compliance will require a change of agency culture relating to transparency. One case in point: Illinois. And as the ongoing saga over the lack of transparency of Managed Care Program Annual Reports illustrates, that will not happen without sustained and effective state-level advocacy.

Click here to view the tables: https://ccf.georgetown.edu/2024/05/17/a-closer-look-at-transparency-in-the-medicaid-managed-care-rule/

Centene, America’s biggest Medicaid insurer, just pledged to help build nearly $1 billion in affordable housing

Thu, 30 May 2024 13:30:15 GMT

The nation’s largest Medicaid insurer is pledging to help build nearly $1 billion worth of affordable housing in eight states as it moves to address one of the biggest determinants of health.

Speaking at Fortune’s Brainstorm Health conference Monday, Centene CEO Sarah London said that the Centene Foundation—the insurer’s philanthropic arm—struck a multiyear partnership with affordable housing developer McCormack Baron Salazar to provide below-market loans for housing units.

The partnership will unlock $900 million in development funds and create thousands of housing units, said London. The issue of affordable housing is especially important to Centene’s members, London added.

“It’s about doing a lot with a little, which is something that our members are uniquely amazing at and I think speaks to our mission of transforming not just health care, but transforming the health of the communities that we serve,” London said.

It’s a reflection of the fact that, in America’s socially and economically stratified society, the health care system is only a small factor in what drives health care outcomes. These inequalities are evident in everything from the disparate impact of the coronavirus pandemic to the 15-year gap in life expectancy between the richest and the poorest Americans.

“We know 80% of what drives health is nonmedical. Eighty percent,” Dr. Michelle Gourdine, senior vice president at CVS Health, said earlier in the conference. “We could have the best doctors in the universe and it would only fix 20% of the problem.”

In recent years, the public health community has zeroed in on housing’s effects in particular, as costs have shot up and evidence has mounted about the destructive effects of housing instability. Last week, UnitedHealth Group announced that it had surpassed $1 billion in affordable housing over the last decade. In 2022, Kaiser Permanente also pledged $400 million to economic development and housing.

For the one in four Americans who were enrolled in Medicaid, getting access to affordable housing is especially important, and there was a shortage of 7.3 million affordable homes in the U.S. in 2023, according to the National Low Income Housing Coalition.

As London and other attendees said Monday, most of what drives health is nonmedical. London added that across demographic groups, some of the things that people recognize as important to health include housing, food, and access to childcare.

“We, of course, make sure that there is access to health care, but we also think about what are those things that are other drivers to health outcomes,” London said.

Medicaid holdout states see major ACA enrollment growth

Tue, 28 May 2024 14:16:19 GMT

In 2024, Affordable Care Act (ACA) Marketplace enrollment hit a new record high, reaching over 21 million people, almost double the 11 million people enrolled in 2020. This growth can be largely attributed to enhanced subsidies made available by the American Rescue Plan Act (ARPA) in 2021 and renewed under the 2022 Inflation Reduction Act (IRA). These enhanced subsidies significantly reduced premium payments across the board for ACA Marketplace enrollees – including providing 100% premium subsidies for the lowest-income enrollees – and made some middle-income people who had previously been priced out of coverage newly eligible for financial assistance.

Figure 1: 2024 ACA Open Enrollment Hits a New Record

Total ACA Marketplace Plan Selections During Open Enrollment, 2014-2024

Although the Inflation Reduction Act’s enhanced subsidies are available nationwide, some states have seen faster growth than others. In 15 states, ACA Marketplace enrollment has more than doubled since 2020 (Figure 2). One of these states is Texas, where ACA enrollment has more than tripled since 2020. Meanwhile, 3 states’ Marketplaces have seen enrollment fall since 2020.

Figure 2: In 15 States, Affordable Care Act (ACA) Marketplace Enrollment More than Doubled from 2020 to 2024

Change in Affordable Care Act (ACA) Marketplace Signups, 2020 - 2024

The five states with the fastest growth in Marketplace enrollment since 2020 – Texas (212%), Mississippi (190%), Georgia (181%), Tennessee (177%), and South Carolina (167%) – have certain characteristics in common: They all started off with high uninsured rates before the enhanced subsidies rolled out, they have not expanded Medicaid under the ACA, and they all use the Healthcare.gov enrollment platform.

It is difficult to disentangle the effect of each of these factors (uninsured rate, Medicaid expansion, and enrollment platform), as they are correlated and closely connected to one another. Nonetheless, the data suggest that a large number of uninsured people in these southern states with high uninsured rates wanted health insurance coverage, and the recently enhanced subsidies have made it possible for them to afford that coverage. However, these subsidies are temporary and will expire at the end of 2025 if not renewed by Congress.

Uninsured Rate

When considering the varying growth rates of Marketplace enrollment across states in recent years, it is important to keep in mind that states had different starting points before the enhanced subsidies in the ARPA and IRA were rolled out. The nonelderly uninsured rate in 2019 ranged from less than 5% in Massachusetts, the District of Columbia, and Hawaii to over 15% in Mississippi, Georgia, Florida, and Oklahoma, and over 20% in Texas. Generally speaking, states with higher uninsured rates in 2019 saw faster growth in ACA Marketplace enrollment from 2020 to 2024, while those with the lowest uninsured rates saw their market sizes generally grow less or even shrink a bit. On average, states that started out with nonelderly uninsured rates below 10 percent in 2019 saw an average of 31% growth in ACA Marketplace enrollment, while states with uninsured rates of 10 percent or more saw an average growth of 136% from 2020 to 2024.

Figure 3: Since 2020, ACA Marketplaces Have Generally Grown Faster in States that Started off with Higher Uninsured Rates

Weighted average percent change in ACA Marketplace Enrollment (2020-2024)

Medicaid Expansion

Another closely related factor that could explain why some states are seeing faster growth in their ACA markets is Medicaid expansion. On average, non-expansion states have seen their ACA Marketplaces grow by 152% since 2020, compared to 47% average growth in expansion states.

Figure 4: Affordable Care Act Marketplaces have Grown Faster in Medicaid Non-Expansion States

Weighted average percent change in ACA Marketplace Enrollment, 2020-2024

The Inflation Reduction Act subsidies bring premiums for ACA Marketplace silver plans down to as low as $0 per month for people with incomes between 100% and 150% of poverty. Meanwhile, in states that have expanded Medicaid, people with incomes up to 138% of poverty are eligible for Medicaid and are therefore ineligible to purchase ACA Marketplace plans. There are therefore relatively fewer people in Medicaid expansion states who would qualify for one of these “free” silver plans on the ACA Marketplaces. This could explain, in part, why there has been faster Marketplace growth in several non-expansion states. (With North Carolina recently expanding Medicaid, there are now 10 states, primarily in the South, that have chosen not to expand the program).

The unwinding of the pandemic-era Medicaid continuous enrollment policy, which led to millions of people losing Medicaid in 2023 after having their coverage maintained during the pandemic, likely contributed to the steeper increase in Marketplace enrollment during the 2024 open enrollment period. As states unwind the Medicaid continuous enrollment policy, these $0 premium, low-deductible ACA Marketplace plans may make the transition from Medicaid to Marketplace coverage easier, especially for people with incomes just above the poverty level in non-expansion states.

Enrollment Platforms

Growth in ACA Marketplace enrollment in recent years also correlates with enrollment platforms. The 23 states with the fastest growth in ACA Marketplace enrollment from 2020-2024 all use the Healthcare.gov enrollment platform. States using Healthcare.gov saw a weighted average growth of 126% in ACA Marketplace enrollment from 2020 to 2024, compared to 22% growth in states using state-run enrollment websites. All 10 states that have not expanded Medicaid use the Healthcare.gov platform.

Figure 5: States with the Most Growth in ACA Signups use the HealthCare.gov Platform

Change in Marketplace Plan Selections, 2020 and 2024

Another difference is that only Healthcare.gov states have Enhanced Direct Enrollment, which allows health plans and insurance brokers to directly enroll and provide customer service to enrollees throughout the year without the consumer needing to visit the Marketplace website (Healthcare.gov). In recent years, brokers have played a growing role in assisting Marketplace consumers.

However, states that use their own enrollment websites also had different starting points in 2020, ahead of the enhanced subsidies passing in 2021. Some state-based Marketplaces were already using state funds to offer additional health insurance subsidies beyond those offered by the federal government. Additionally, several states with their own Marketplaces had long embraced the ACA and have directed state resources toward outreach and marketing efforts for a decade. By contrast, states that rely on Healthcare.gov had significant cuts to outreach and marketing budgets during the Trump administration, with those investments renewed in 2021 under the Biden Administration.

Table 1: Marketplace Plan Selections, 2020 and 2024

View figures and tables here

Why Medicaid expansion in the South failed

Tue, 28 May 2024 14:11:29 GMT

AILSA CHANG, HOST:

Southern Republican-led states looked at expanding Medicaid this year to help cover more people who can't afford health insurance. And even though those efforts made some headway, they struggled to overcome the politics. Drew Hawkins of the Gulf States Newsroom reports.

DREW HAWKINS, BYLINE: Seven of the 10 states that have refused to adopt Medicaid expansion are in the South. Mississippi is one of them. This year, the state came so close, but in the end, expansion efforts fizzled and died in the legislature. So what's the deal? Why the hang-up? Well, one Mississippi doctor does not pull any punches with his answer.

ROGER GIVENS: It's called the stupidity of politics, period.

HAWKINS: Dr. Roger Givens is a radiation oncologist. He practices in rural Mississippi, in an area known as the Delta.

GIVENS: I mean, that's about as rural as it gets.

HAWKINS: He's also the board chair of the Mississippi State Medical Association, which wholeheartedly supports Medicaid expansion. Givens says it's long overdue, especially since most residents want it and other states in the South have already done it.

GIVENS: Look at Arkansas, which has a very similar population to us, and look at what has worked for them and what needs to be tweaked. For me, that's just common sense.

HAWKINS: Givens says people need health coverage. Because when they can't regularly see a doctor, bad things can happen.

GIVENS: I can't tell you the number of patients who come in with advanced disease who have full-time jobs. Plain and simple. That's the coverage gap.

HAWKINS: The coverage gap Givens is talking about only exists in states that haven't adopted Medicaid expansion. It's filled with thousands of people who make too much to qualify for Medicaid but too little to afford private insurance. But Mississippi lawmakers wanted this Medicaid coverage to come with a work requirement. Recipients would have to show they were working part time or in school.

JASON WHITE: That's just a place that I think you're going to see a conservative state come from.

HAWKINS: That's Mississippi Republican House Speaker Jason White. He supports expansion. And a work requirement makes it more palatable for Republicans because Medicaid expansion is part of the Affordable Care Act passed under President Obama.

WHITE: You know, no denying it's known as Obamacare.

HAWKINS: But work requirements weren't part of the original deal. And without a special waiver for that from the Biden administration, Mississippi can't get the money from the federal government. And that's why expansion failed. But White still thinks expanding Medicaid is the right thing to do because it would bring much-needed health care dollars to Mississippi. And that's been his message to his fellow Republicans.

WHITE: Come for the savings, if you will, and then you can stay for the salvation and the good things that it does to improve people's lives.

HAWKINS: Besides Mississippi, Alabama also tried to open the door to Medicaid expansion this year. The program would have focused narrowly on rural health, using casino gambling funds to pay for it, but it ultimately failed. And Republicans in Alabama remain wary of any new coverage that doesn't come with work requirements. Justin Bogie is with the Alabama Policy Institute, a conservative think tank.

JUSTIN BOGIE: So we think if you expand Medicaid and you open up this federal subsidized program for hundreds of thousands of people, then it could actually hurt that labor participation rate, give them another reason not to go to work, to stay at home.

HAWKINS: More and more holdout states in the South are adopting or warming up to expansion. North Carolina extended coverage to around 600,000 people this year. But there's still opposition. In Georgia, the governor wants to see if his own alternative program that allows people who work to join traditional Medicaid can succeed. It's about three times more expensive per person for the state and right now only has just over 2,300 participants, less than 1% of people Medicaid expansion would cover. For doctors like Givens, the debate around work requirements seems unnecessary. Sixty percent of the uninsured Mississippians already have a job.

GIVENS: I'm confused on this whole argument about why does there need to be a work requirement if we're talking about employees who are working who need coverage?

HAWKINS: Studies show the South has high rates of chronic disease and poor health, and it's especially difficult for patients in the rural South. And that's why some Mississippi Republicans in favor of expansion say they'll try again next year with the momentum they've already built. For NPR News, I'm Drew Hawkins. Transcript provided by NPR, Copyright NPR.

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Medicaid unwinding stressing rural families and clinics

Tue, 28 May 2024 14:08:55 GMT

Rural children and families are having to skip vital health treatments and even ending up in the emergency room, while already struggling rural clinics are losing more patients, as states cull their Medicaid rolls.

The process began in April 2023, when pandemic-era rules that prohibited kicking people off Medicaid coverage expired and states again began checking whether families met income restrictions. Nationally, nearly 70% of people who lost coverage did so for “procedural” reasons such as incomplete paperwork.

States with the largest drops in coverage also have large rural populations. The loss of coverage compounds struggles disproportionately experienced by rural children and families, experts say, including clinician shortages, long drives to care and poorer health outcomes.

Eight states — Alaska, Arkansas, Colorado, Idaho, Montana, New Hampshire, South Dakota and Utah — had fewer children enrolled at the end of last year than before the COVID-19 pandemic, according to a recent analysis by the Georgetown University Center for Children and Families.

“Medicaid is even more of a lifeline for rural communities than it is for urban ones,” said Joan Alker, the center’s executive director. “There are quite a number of states with large rural populations where things are not going well — so that’s very problematic.”

A year into the process, frequently referred to as Medicaid “unwinding,” South Dakota, Montana, Utah, Texas and Idaho have seen the largest plunges in rates of children losing coverage, with an average of 25% fewer children enrolled in those states since April 2023.

In rural areas, which on average have higher rates of poverty, children are less likely than their urban counterparts to have had a medical checkup or dentist visit in the past year, the center reported.

In Idaho, where 35 of 44 counties are considered rural, “a lot of this is attributed to the state rushing through the process to conduct [income eligibility] redeterminations in six months,” said Hillarie Hagen, health policy associate at Idaho Voices for Children, a group that advocates on policies affecting children. “The rush and arbitrary deadline resulted in an alarming number of children losing coverage.”

Hagen added that the change “is putting families in a very difficult position of having to choose to delay care or risk significant financial burden on their family.” Rural Idaho counties tend to be poorer than urban counties, and Hispanic and Native American state residents are more likely than white residents to be living in poverty.

Dr. Noreen Womack, a pediatrician at a mobile clinic for kids in Boise and nearby rural communities in Idaho, run by St. Luke’s Children’s Hospital, said not a week goes by that she doesn’t see a patient who has lost Medicaid coverage — and who is sometimes unaware they’re now uninsured.

When kids’ parents tell her they have Medicaid, she said, she’s learned to ask, “Are you sure?”

She said she regularly sees children and teens who are no longer covered and who stopped taking critical treatments, such as antidepressants and ADHD medications, harming their well-being and school performance.

Womack recalls one 7-year-old boy who was no longer enrolled in Medicaid and whose family couldn’t afford his ADHD medication. He was on the verge of being expelled from school.

He looked at Womack, scared and dispirited. “‘I’m having trouble staying on task again, and they’re going to kick me out,’” she recalled him saying.

“It’s so sad, because he’s only 7,” she said. “These families are already so much living on the edge, and it’s hard for them.”

Other young patients who have gone undiagnosed for asthma have ended up in the ER, she said. “One of the things we’re trying to do is decrease the amount of unnecessary emergency department visits.”

As in many states, patient navigators have been key to helping families work through the complex process of renewing Medicaid if they qualify, Womack said.

Idaho’s Department of Health and Welfare acknowledged the rapid pace of its redetermination process, but expects the number of enrollees to return to normal.

“Idaho was one of the very first states in the nation to start and finish unwinding activities while many other states are still in the process of completing all initial renewals,” spokesperson AJ McWhorter wrote in an email to Stateline. He added that the agency “early on identified and prioritized individuals who were likely no longer eligible for Medicaid. As other states continue to complete their unwinding activities, we expect these numbers to begin to normalize.”

Utah has seen the nation’s highest overall disenrollment rate at 56%, followed by Idaho and Montana at 55%, and Oklahoma, South Dakota and Georgia, which have each seen coverage loss rates of 50% or higher.

Utah’s state Medicaid office asserts that because states are at different stages in unwinding, disenrollment rates between states can’t be compared “apples to apples.” The state’s unemployment and poverty rates are lower than the national average, which means Utahns have fewer uninsured people and fewer Medicaid enrollees to begin with, said Kevin Burt, who oversees Utah’s Medicaid eligibility determinations at the state Department of Workforce Services.

“Having just finished unwinding, I don’t think the data is quite settled,” Burt added.

Jennifer Strohecker, Utah’s Medicaid director, said her office has been working with hospitals, clinics and nonprofits to help with redeterminations.

“It is our objective that if a person is eligible for Medicaid, we want them to have that coverage,” she said, adding that the state aimed to make sure the health centers “had the right resources and tools to meet the needs of the patient as they saw them, and help them with some of the [eligibility] questions.”

Families of color

Across small towns and rural areas nationwide, Medicaid covers 47% of children and 18% of adults, compared with about 40% of children and 15% of adults in urban counties, the Georgetown center found in an analysis of U.S. Census Bureau and Medicaid data.

Compared with urban residents, those in rural areas are more likely to have poorer overall health.

Many states with the highest rates of Medicaid disenrollments also have large American Indian and Alaska Native communities. Federal tribal affairs and Medicaid officials say the program plays a critical role in filling gaps in funding for tribal health care.

Chickasaw Nation member Dr. Jesicah Gilmore, a family medicine doctor and chief medical officer of the Indian Health Care Resource Center in Tulsa, Oklahoma, said the loss of Medicaid coverage has left many of her patients unable to obtain or pay for specialist care, such as cardiology or nephrology. While the center is in the city, it’s also a pillar for rural Native patients, who drive hours to the clinic for primary care and referrals.

“Part of what we’re seeing is that then they’re having difficulty accessing referral services or some of the specialty tests,” she said. “It’s provided quite a strain on our system.”

Many lost coverage because they no longer qualified or because they didn’t finish paperwork, leaving them to pay out of pocket — or forgo care if they can’t, she said.

“We have staff members here who specifically help patients with paperwork and can help navigate some of the online systems — many of our patients don’t necessarily have continuous access to the internet,” she said. “It does get worse when patients are uninsured, because they have no other recourse for care, other than going to the ER.”

She remembers one patient recently who lost Medicaid coverage two days before an orthopedic appointment for extreme knee pain. Gilmore estimates it could be another three months before her patient can get a knee replacement approved by a specialist and for the clinic to help her find and apply for another payor, such as the tribe, and up to six months until the actual surgery.

“It was affecting her ability to continue working, walking, standing,” she said. “Who’s going to pay for this appointment? This patient has been waiting to get this, hopeful. … Now, she’s kind of in a holding pattern.”

Loss of revenue for rural clinics, hospitals

Gilmore worries the longer-term fallout for her clinic will be a hit to revenue due to caring for uninsured rural patients. The clinic was planning to expand services “but might not be able to,” she said.

That concern is echoed in other rural health care settings.

Straddling the Utah-Arizona border is the Creek Valley Health Clinic, serving a rural area that the Utah Department of Health says is one of the most underserved regions in the state. The area lacked a primary care clinic for over a decade, and many patients would drive an hour or more to the nearest hospital before the clinic opened in 2019.

“We inherited such a sick patient population with really high rates of chronic disease and unhealthy habits,” said Hunter Adams, the clinic’s co-founder and CEO. Adams said the clinic had helped lower ER visits for primary care.

Since the clinic opened, Adams said, the patient base has seen improved rates of depression screening, diabetes control and childhood obesity.

But since the unwinding, the clinic saw an 8% drop in Medicaid patients. That, along with changes to pharmacy contract programs and expiring COVID-19 assistance grants, has put the nascent clinic in a bind, Adams said.

“It’s kind of a three-legged impact to our budget,” he said. “We’re in this kind of hard space where we’re not big enough to really contract and negotiate payment change, but we’re also big enough that we feel these budgetary changes … with the Medicaid unwinding.”

Alan Pruhs, executive director of the Association for Utah Community Health, which represents health centers across the state, estimated that those clinics have seen on average a 12% to 15% reduction in the Medicaid patient population, with some clinics losing up to 20% of Medicaid patients.

“Fiscal fragility just was ratcheted up a few more notches, because we’re now losing more revenue,” Pruhs said.

He’s hearing from clinics that serve particularly vulnerable clients, such as opioid patients, dropping out of rehabilitation programs because of losing Medicaid.

Pruhs said an increase in uninsured patients can further add financial pressure on already strapped rural community health clinics.

“From a health center perspective, your uninsured patient now comes in and it’s actually costing you money — it’s not generating revenue.”

How the PHE unwinding is affecting the Big 5 Medicaid managed care insurers

Tue, 28 May 2024 14:02:33 GMT

It’s now been four corporate reporting quarters since the start of the PHE unwinding on April 1, 2023. During that time, net national Medicaid enrollment—the combination of disenrollments from redeterminations, re-enrollment by some of those terminated, and new enrollments—has fallen by 13.1 million, including 5.0 million children. Of the disenrollments, 70 percent have been for procedural reasons, not the result of an actual determination of ineligibility. Three fourths of all Medicaid enrollees are covered through managed care organizations (MCOs) in 42 states (including the District of Columbia). Five national companies together dominate half of this market: Centene, CVSHealth/Aetna, Elevance Health, Molina Healthcare, and UnitedHealth Group. The “Big Five” have now reported their Q1 2024 financial results. How has the PHE unwinding affected them?

Figure 1 tells the enrollment tale for the Big Five as a group. When the PHE began in March 2020, their total Medicaid enrollment stood at 30.1 million. By the time the unwinding began, their total Medicaid enrollment had increased by 14.1 million, to 44.2 million. A year later, their total enrollment was 37.8 million, a drop of 6.4 million, or 14.4 percent. Despite this decline, total Medicaid enrollment for the “Big Five” in March 2024 is still 7.7 million higher than it was in March 2020.

Figure 1: "Big Five" Medicaid Enrollment During and After the COVID-19 Public Health Emergency

Table 1 tells the enrollment tale for each of the Big Five. Four of the companies reported Medicaid enrollment declines between the quarters ending March 31, 2023 and March 31, 2024. Centene, the company with the largest Medicaid enrollment, lost the largest number of enrollees, a little over 3 million, a drop of 18.5 percent. Aetna, now a business segment of CVSHealth, lost 375,000 Medicaid enrollees over that period, a decline of 13.4 percent. Elevance Health, formerly Anthem, had the largest Medicaid enrollment decrease in percentage terms: 21.5 percent, reflecting a decline of 2.6 million. UnitedHealth Group lost 700,000 Medicaid enrollees over the year, a decline of 8.3 percent.

Only Molina Healthcare, the smallest of the Big Five, reported an increase in Medicaid enrollment, from 4.8 million in Q1 2023 to 5.1 million in Q1 2024 (6.0 percent). How did a receding tide not lower all five boats? Management’s explanation: disenrollments due to unwinding redeterminations (50,000 in Q1 2024, 550,000 to date) have been offset by enrollment increases due to the start of new contracts in Iowa and Nebraska as well as an “expanded California Medicaid platform including Los Angeles County.”

Molina’s results underscore the point that enrollment data reported by each of the companies are net numbers, reflecting a combination of enrollment losses and gains. Enrollment losses could result not just from the unwinding, but also from the failure to keep Medicaid contracts in state procurements as well as current enrollees switching to a different MCO. Enrollment gains could come from the enrollment of newly eligible individuals, the award of new contracts in state procurements, the launch of new state Medicaid managed care programs (e.g., Oklahoma on April 1), and/or the acquisition of competitors.

Table 1: "Big Five" Medicaid Enrollment, Q1 2024

Table 2 tells the revenue tale, at least in part. (CVSHealth/Aetna and Elevance Health simply don’t report their Medicaid revenues; it’s unclear why investors would be uninterested in these payment streams). Between Q1 2023 and Q1 2024, Centene’s Medicaid revenues were down $767 million, or 3.5 percent; Molina’s were up $1.1 billion, or 18 percent; and UnitedHealth Group’s were up $1.7 billion, or 9.3 percent. Combined Medicaid revenues rose by $2.1 billion, or 4.5 percent.

Table 2: "Big Five" Medicaid Revenue Results, Q1 2024

This seems paradoxical. For all three companies, total Medicaid enrollment decreased by 3.4 million year-over-year, but total Medicaid revenues increased by $2.1 billion. At the individual company level, Centene’s Medicaid enrollment and revenues both decreased, while Molina’s both increased.

On the other hand, UnitedHealth Group’s Medicaid enrollment went down by 8.3 percent while its Medicaid revenues went up by 9.3 percent year-over-year. Can it be that every Medicaid enrollee United lost increased its revenues by $2,490? What kind of managerial magic produces that result? It’s a puzzlement. UnitedHealth Group’s 10-Q doesn’t give an explanation, and the financial analysts did not ask about it during the company’s earnings call (which is understandable given the Change Health debacle).

Only two of the Big Five disclosed medical loss ratios specific to their Medicaid lines of business for the quarter: Centene (90.9%) and Molina Health (89.7%). (The way in which these companies calculate MLR—costs of medical care as a percentage of premium revenue—differs somewhat from the way the federal regulations specify Medicaid MLRs should be determined).

While the financial analysts, as well as company managements, would prefer that these MLRs be lower, they nonetheless help to explain why the Medicaid managed care market continues to be attractive to the Big Five, among others. As Molina’s 10-Q report explains: “the underlying medical margin, or the amount earned by the Medicaid, Medicare, and Marketplace segments after medical costs are deducted from premium revenue, represents the most important measure of earnings reviewed by management….” Molina’s Medicaid margin in the quarter was $775 million.

And now for some forward-looking statements. Readers are advised that actual results may differ materially from these expectations.

We at CCF estimate that, by the end of June, the majority of states will have completed redeterminations of eligibility for all individuals enrolled in Medicaid at the time the unwinding began last year. There’s some uncertainty around this estimate, given the different cadences at which states have conducted and reported their redeterminations. Based on our analysis of CMS enrollment and unwinding data, we do know that as of February or March, 29 states had processed over 75 percent of their pre-unwinding caseload; another 19 states had processed between 50 and 75 percent; and one state (Alaska) had processed less than half. Some states have completed their unwinding redeterminations (e.g., Arizona, West Virginia) and some have begun conducting regular redeterminations at the same time as they continue their unwinding redeterminations.

The implications of the unwinding for each of the Big Five will continue to vary depending on the states in which they operate subsidiaries. Nonetheless, for the Big Five as a group, Medicaid enrollment is likely to continue to decline at least through Q2. Whether Medicaid revenues will continue to increase as Medicaid enrollment declines is anyone’s guess.

View figures and tables here

Four Spartanburg-based non profits come together to promote healthy birth outcomes

Tue, 28 May 2024 13:57:01 GMT

Three weeks ago, Cierra Clowney, 24, of Spartanburg, didn’t know how to swaddle a baby. Two and a half weeks ago, she became a mom.

Clowney is one of the 875 families Hello Family has helped provide free pre-natal and post-natal services, education, and pregnancy and childcare resources to specifically, since October 2021 as part of an initiative aimed to improve the outcomes of children and new mothers in Spartanburg.

Hello Family is comprised of four Spartanburg-based non-profits: Family Connects, BirthMatters, Triple P and Quality Counts. In total, Hello Family has helped more than 1,800 families

“I didn’t know hardly anything about raising a child and they can explain everything and help you with that whole process,” said Clowney. “They are there step-by-step. They will not leave you.”

Clowney relied on a Doula from the non-profit BirthMatters, a person experienced in the process of childbearing who coaches and mentors those experiencing pregnancy.

According to the results of a simulated study conducted by the Washington D.C.-based think-tank, Urban Institute, from Jan. 1 – Dec. 1 2022, Hello Family would have helped to decrease NICU admissions by 0.9% and low birth weights by 6.7%.

“What we have is without Hello Family, low birth weights would be almost double, it’s telling us that NICU admissions would be a little higher and it’s telling us there would be more avoidable emergency room visits,” said Kaitlin Watts, director of Center for Early Childhood Success at Spartanburg Academic Movement.

For Clowney, her nearly three-week-old baby boy, Kendrick Clowney, brings a smile to her face when she looks at him and also at times, stress.

“I definitely would be very stressed out [without BirthMatters], I don’t know how I would really make it honestly,” said Clowney. She said she still suffers from Postpartum Post-Traumatic Stress Disorder (PTSD) as a result of giving birth and regularly goes to therapy.

Clowney admitted for her to get the help she needed, she had to swallow her pride.

“I reached out because you need help,” said Clowney. “You do need help. It takes a lot for me to put things aside, and accept help and that’s what I had to learn to do.”

“We’re a community and a community helps one another,” said Watts. “We serve one another. So, these kids we’re talking about right now, one day, they’re going to be your neighbors. They might be the ones serving you in the stores. Our goal is to be the best we can be and have the strongest and healthiest community and that’s what this is doing.”

Another new mom who has utilized the services of Hello Family is Yasmin Wilson, 27. Her two-month-old daughter, Ysabella, was born in March. Before then, she said she had no idea how to feed a newborn baby.

“All the resources that [my Doula] gave me as far as being able to prepare myself and my body, and then having issues with [Ysabella] after she was born; having those resources has been so helpful,” said Wilson.

Wilson and Clowney say they relied on their Doulas from BirthMatters to get them through their pregnancy. But there are more services that Hello Family offers like having a registered nurse from Family Connects, a branch of Spartanburg Regional Healthcare System, make home visits to check up on the mother’s and baby’s health.

Anjonique Fernanders is one of those nurses who says she was initially surprised by the number of mothers who didn’t know much about raising a newborn child when she started working with Family Connects two years ago.

“Some moms may not be aware, ‘Well what should my baby be gaining?’ and ‘What should my baby be eating?’, so we want to relay that information to them,” said Fernanders.

Fernanders said one thing many new mothers should be looking for is high blood pressure. It’s something she checks when she makes home visits.

“Parenting is challenging,” said Fernanders. “Giving them the resources can help better support them.”

Watts said as of now Hello Family is only available to those in the City of Spartanburg’s limits but is in the process of expanding and will complete that process by 2030.

SC governor signs gender-affirming care ban

Tue, 28 May 2024 13:54:01 GMT

"I signed the Help Not Harm bill into law, which protects our state's children from irreversible gender transition procedures and bans public funds from being used for them," McMaster said in a post on the social platform X Tuesday. "I look forward to joining legislators and supporters at a ceremonial bill signing in the Upstate next week." The bill, House Bill 4264, states that a "physician, mental health provider, or other health care professional shall not knowingly provide gender transition procedures to a person under eighteen years of age" and that those who do so "shall, upon an adverse ruling by the appropriate licensing board, be considered unprofessional conduct and shall be subject to discipline by the licensing entity with jurisdiction over the physician, mental health provider, or other medical health care professional."

"Across the state, from the Lowcountry to the Upstate, South Carolinians are mourning the passage of H.4624, which will make it immeasurably harder for transgender youth and many adults to access the life-saving healthcare that they need and deserve," Chase Glenn, a leader in the LGBTQ advocacy group SC United for Justice & Equality, said in a statement in a Tuesday press release. "But let me be clear: This loss does not crumble a movement," Glenn continued. "Our movement supporting transgender people in South Carolina is louder and stronger than it's ever been. We've marched at the State House, we've told our stories, and we've made sure our lawmakers heard from us. Now, we will do everything in our power to support our community through this crisis." Jace Woodrum, the executive director of the American Civil Liberties Union (ACLU) of South Carolina, said in a press release Tuesday that the group stands "in grief and solidarity with LGBTQ South Carolinians, who are increasingly under attack by our own government."

"We can put to rest the notion that the governor cares about limited government and personal freedom," Woodrum's statement continues. "With the stroke of a pen, he has chosen to insert the will of politicians into healthcare decisions, trample on the liberties of trans South Carolinians, and deny the rights of the parents of trans minors."

History speaks clearly to SC health agency reforms

Tue, 28 May 2024 13:51:57 GMT

Looking back over South Carolina's civic life, most historians would agree that Carroll Campbell has been among our state’s most effective governors. It was Campbell, a Republican with a General Assembly that was 61% Democratic, who shepherded through a comprehensive restructuring of state government in 1993.

It is hard to imagine today, but before the former Greenville congressman’s reform plan was enacted, South Carolina’s governor was hands-down America’s weakest. State agencies were run by boards and commissions, some of which included legislators. There was no governor’s Cabinet, and executive authority was diffused so widely and thinly that citizens often wondered who was in charge.

There were a number of reasons for Campbell’s success, some of which seem almost paradoxical. He was clearly very conservative, but he believed passionately in reform. He was a fan of the “too conservative” Ronald Reagan, but he also decried “horse and buggy government.” He favored shrinking the size of government and knew well the balance that the framers sought to build into public policy: Power should be concentrated just enough to ensure effective governance, but not enough to open the door to tyranny.

Campbell’s conservative but reformist legacy and his understanding of the appropriate balancing of power speaks into the final stage of a current debate; following the division of DHEC into separate environmental and health agencies, the General Assembly is taking the next step by streamlining the health functions of six state agencies into the Executive Office of Health and Policy.

Unfortunately, even after the Senate passed S.915 by a vote of 44-1 and the House by a margin of 98-15, some concerns have prevented the enactment of the legislation to establish this new department from pieces of existing ones. But those concerns aren’t based in reality:

There is no South Carolina version of Anthony Fauci here. The governor can remove the executive secretary of Health and Policy at any time, and the General Assembly can still direct the governor to remove a Cabinet officer with a two-thirds vote in each chamber.
Some powers will move, but no new powers will be created. In at least one case, emergency powers on the books since 1908 were modified during the S.915 amendment process to clarify that only the governor can exercise them.
The governor’s choice for secretary will not be micromanaged with a long list of bureaucrat-friendly required qualifications in the enacting statute.
Employees of the consolidating agencies and offices will move to positions in the new component departments, but natural redundancies will create the opportunity for savings. The General Assembly can tighten the purse strings as well.
One of the remaining post-Campbell unelected and unaccountable governing boards, the DHEC board, is dissolving, and the health policy buck will finally stop with the governor.
There has been no unseemly rush. The massive restructuring legislation under Campbell was accomplished in about five months. This much-less-ambitious health restructuring will have taken about the same amount of time from beginning to end. Factoring in time spent on the legislation splitting the Department of Health and Environmental Control, the Office of Health and Policy timeline has been even longer than the 1993 restructuring.
Thanks to a subsequent reform, which established legislative oversight committees, the new agency will appear regularly before the Senate and House to answer for its actions. Citizens also have the ability to lodge a complaint about the agency with the oversight committees.

The establishment of the Executive Office of Health and Policy represents a significant opportunity — not only to save taxpayer dollars by eliminating duplication that went unaddressed in 1993 and 2014, but to serve our citizens more effectively, particularly those with complex health needs who have been underserved by the confusion that comes from existing unaligned agencies.

But the new agency will not have absolute power. The supreme authority of the governor, oversight and confirmation procedures already in place and additional safeguards built into the legislation are designed to protect the rights of citizens. There are additional political, legal and administrative remedies outside of these as well.

The Executive Office of Health and Policy is a reform whose time has come, a reform that I feel sure the Ronald Reagan Republican Carroll Campbell would have warmly embraced.

Oran Smith, senior fellow at Palmetto Promise Institute, served in the Campbell administration.

Will South Carolina expand Medicaid?

Tue, 28 May 2024 13:45:45 GMT

Video: Will South Carolina expand Medicaid?

Video: Could Medicaid expansion soon be on the table in South Carolina?

Medicaid disenrollment renews discussion on problem of uninsured

Wed, 22 May 2024 16:36:22 GMT

Strides have been made towards reducing the numbers of people without health insurance in the U.S. In August 2023 the Department of Health and Human Services announced that the national uninsured rate reached an all-time low of 7.7% during the first quarter of the year. The number of uninsured declined from 31.6 million to 25.3 million over the 2020–23 period.

Importantly, the largest drops in numbers of uninsured took place among lesser well off individuals whose household income was either below 100% or between 200% and 400% of the federal poverty level. But it’s millions of these folks, who have been disenrolled from Medicaid since the Covid-19 pandemic public health emergency ended in April of last year, who now find themselves uninsured. This harks back to the persistent issue of tens of millions of Americans lacking health insurance on any given day.

STAT News reported KFF data that roughly 21% of the people who were enrolled prior to the redeterminations, or almost 20 million, lost coverage at least temporarily. Meanwhile, 45%, or 42 million, were confirmed as Medicaid-eligible. However, for the remaining 31 million people, renewal of coverage is pending. Moreover, data show that approximately five of the more than 20 million who have been disenrolled during the post-pandemic eligibility reviews are still uninsured.

During the public health emergency caused by the Covid-19 pandemic, Medicaid’s annual (re)determinations of enrollee eligibility were paused as part of a continuous coverage provision included in the 2020 Families First Coronavirus Response Act. Through March of 2023, enrollment in Medicaid and the Children’s Health Insurance Program grew by more than 23 million people.

However, since last April Medicaid restarted the determination process to check to see if enrollees are still eligible. As a result, millions are no longer enrolled in Medicaid and have no other coverage. This has often been due to procedural and administrative reasons, meaning individuals did not complete the necessary paperwork, in part because former enrollees did not properly understand the process and specifically what was needed for them to retain coverage.

The impact on individuals varies enormously by state. For example, Utah disenrolled the highest percentage (60%) of its completed Medicaid redeterminations while Maine disenrolled the lowest (12%).

Disenrollment numbers have surpassed initial expectations set by the federal government. Last year the Biden Administration projected that 15 million in total would be removed from the rolls.

What’s concerning is that about 40% of the eligibility redetermination process remains to be completed, which implies there’s still a lot more disenrolling ahead which will result in more people added to the uninsured tally.

Many people who are no longer eligible for Medicaid can sign on to their employer’s health plan, should that be offered to them. Further, for some who must obtain their own health insurance, state marketplace exchange coverage is available. To illustrate, through November 2023, nearly 2.3 million people had transitioned from Medicaid to a private marketplace plan. This service is available in every state to help individuals, families and small businesses shop for and register with an affordable medical insurance plan. Some states have their own marketplace platforms. Other states use the federally run platforms. Created by the Affordable Care Act, these portals gives people access to health insurance plans of all types from a variety of insurers.

As the independent health insurance guide healthinsurance.org explains, in the majority of states people can sign up with a state marketplace plan at any time before July 31, 2024, as part of an extended “unwinding special enrollment period.” Also, individuals who no longer qualify for Medicaid based on their level of income may still be able to obtain subsidies to help offset the cost of their health insurance premiums.

Nevertheless, as Medicaid unwinding continues hundreds of thousands and perhaps millions more people will become uninsured. This calls to mind the longstanding discussion of both lack of health insurance for several tens of millions in America and the tenuous nature of medical coverage for many others.

States show significant variation in Medicaid redeterminations

Wed, 22 May 2024 16:34:14 GMT

There's significant variation among states when it comes to the ongoing Medicaid disenrollment process. A new Robert Wood Johnson Foundation analysis has found that while enrollment in Medicaid and the Children's Health Insurance Program (CHIP) declined by 9 million people from April to November 2023, eight states had Medicaid disenrollments surpassing 100% of projected net disenrollments.

Nationwide, aggregate net disenrollment as of November 2023 was at 60.5% of projected total disenrollment throughout the unwinding. The eight states exceeding 100% are Arkansas, Idaho, Iowa, Montana, New Hampshire, Oklahoma, South Dakota and Texas.

At the same time, 19 states had net disenrollment of 50% or less of the firm's projected total net disenrollment.

The net disenrollment rate was much higher for children than adults nationwide, largely because of exceptionally high child net disenrollment in some states. Total net disenrollment among children was 84.2% of the expected total, while total net disenrollment among adults was 50.7% of RWJ's estimates.

Seven states had adult net disenrollment greater than 100% of expected disenrollment, while 12 states had child net disenrollments that exceeded that threshold. This means current Medicaid enrollment levels in these states are below the historical trend, the report found.

States that publicized their intention to complete the unwinding in less than 12 months, states that obtained few federal waivers to streamline renewal, and states that prioritized the renewal of those likely to be ineligible all had notably higher overall net disenrollment rates relative to other states. States with any of these three characteristics had net child disenrollment over 120% of the projections, on average.

WHAT'S THE IMPACT?

In 2020, Congress passed the Families First Coronavirus Relief Act, which barred states from disenrolling people from Medicaid or child Medicaid coverage funded through CHIP during the pandemic unless they requested it. This led to record-high enrollment growth of more than 20 million Medicaid members than before the requirement.

Three years later, Congress passed legislation to end the continuous coverage requirement effective March 31, 2023, and allowed states to resume the Medicaid eligibility redetermination process, also known as Medicaid "unwinding."

Some are concerned that states are moving too fast and that many enrollees could lose coverage for procedural reasons even though they remain eligible. Others argue that slowing down the unwinding leaves ineligible people on the rolls at an unnecessary cost to both state and federal budgets.

The results from the analysis are likely to change when more recent data becomes available, particularly as more states complete the unwinding process, originally scheduled to end in June. Some variation between states may be because of their different start dates, authors said.

THE LARGER TREND

Data published by KFF in January showed an estimated 16 million beneficiaries had lost Medicaid coverage to that point.

There are reasons to expect disenrollment rates to moderate in the second half of the unwinding as states reduce procedural disenrollments and work through "likely ineligible" populations, the report said.

To date, 40 states and the District of Columbia have adopted Medicaid expansion, and 10 states have not adopted the expansion, according to a KFF report in December 2023. Originally a mandate of the ACA, Medicaid expansion was left to the determination of individual states following a ruling by the Supreme Court.

In the 10 states that have not adopted Medicaid expansion, nearly 1.5 million uninsured individuals fall into the "coverage gap," and are not eligible for Medicaid or ACA Marketplace subsidies, KFF said.

ACA Marketplace sign-ups among those losing Medicaid during unwinding slowed in last month of open enrollment

Wed, 22 May 2024 16:32:11 GMT

As readers of Say Ahhh! know, I have been tracking monthly data from the Centers for Medicare and Medicaid Services (CMS) on the number of people who were either previously enrolled in Medicaid or had experienced a denial or termination during unwinding who then selected a marketplace plan. At the end of April, CMS issued new data for January 2024, which was the last month of the 2024 Open Enrollment Period in nearly all states.

In January, another 1.15 million people lost their Medicaid coverage due to unwinding of the Medicaid continuous coverage protection, of which 67 percent were procedural disenrollments and 33 percent were due to a finding of ineligibility. Separately, CMS reported that nearly 484,000 people who were either previously enrolled in Medicaid in federal marketplace states or had experienced a denial or termination in state-based marketplace states selected a marketplace plan in the same month. That constituted about 42 percent.

Compared to total marketplace enrollment among those losing Medicaid in December, total January marketplace enrollment fell by 57 percent. As a result, the rate of marketplace enrollment among those disenrolled from Medicaid also decreased, compared to 83.9 percent in December — the second month of the 2024 Open Enrollment Period — and 54.2 percent in November, the first month of the Open Enrollment Period. (In addition, another 33,600 or 2.9 percent enrolled in a Basic Health Plan in New York and Minnesota in January, with nearly all of that BHP enrollment occurring in New York.) Cumulatively, through January 2024, compared to the 14.85 million people disenrolled from Medicaid, about 3.9 million or about 26.3 percent enrolled in marketplace plans. (The figure rises to 28.2 percent if including Basic Health Plan enrollment.)

As each of the blogs about previous CMS data releases noted, to provide context to these figures, federal researchers from the HHS Office of Assistant Secretary for Planning and Evaluation (ASPE) previously projected that of the 15 million people expected to lose Medicaid during the unwinding, nearly 2.7 million people — or about 18 percent —would be eligible for subsidized marketplace coverage. While this data represents only the outcome of unwinding through January, it indicates that the cumulative transition rate to marketplace coverage is significantly surpassing the expected pace, after many months of falling well short. What may have happened is that many people who were eligible for marketplace subsidies and who could have immediately enrolled in marketplace plans through a Special Enrollment Period after being disenrolled from Medicaid did not do so and became uninsured. However, after a gap in coverage, many eventually found their way to the marketplace during the 2024 Open Enrollment Period, which began on November 1, 2023. Marketplace enrollment soared to a historic high of 21.45 million during the 2024 Open Enrollment Period.

Notably, at the current pace of disenrollments, the total number of people disenrolled from Medicaid once unwinding is completed will well exceed the original 15 million projection from ASPE and the 17 million projection from other analysts such as KFF — with our latest data showing 18.8 million people have already been disenrolled. And the share of total disenrollments that are procedural terminations remains very high — 70 percent overall according to our latest data — with many of those losing coverage, especially children, likely remaining eligible. In comparison, ASPE estimated that 45 percent of those who would be disenrolled from Medicaid, including for procedural reasons, would remain eligible for Medicaid. Finally, while children’s enrollment in the marketplace rose to 2.16 million in the 2024 Open Enrollment Period, an increase of 611,000 — or about 39.5 percent — from the 2023 Open Enrollment Period, that increase offsets only a modest share of the 4.94 million in total net Medicaid enrollment losses among children (according to our latest data) since unwinding of the continuous coverage requirement began last year. Moreover, children still account for only about 10.1 percent of total marketplace enrollment in 2024.

Marketplace plans will be a valuable source of affordable, comprehensive health coverage but that will likely be the case for only several million people — and a relatively modest number of children —who lost their Medicaid coverage during unwinding, despite the large increases in transitions to marketplace plans during the Open Enrollment Period months of November, December and January. As our recent analysis of child Medicaid enrollment data shows, through December 2023, there was wide variation in Medicaid/CHIP child enrollment declines among states during unwinding of the continuous coverage requirement. Some states prioritized rapid disenrollment of children and adults, had high rates of procedural terminations and low rates of ex parte renewals and as a result, had larger child enrollment declines. But other states took a different approach. They strove to maximize successful renewal of eligible children and are adopting strategies moving forward to keep eligible children enrolled and avoid inappropriate coverage losses upon renewal.

For example, as they finish unwinding and post-unwinding, states should further improve their ex parte renewal rates, ensure full compliance with all federal requirements for Medicaid renewals, and continue the renewal flexibilities that were provided by CMS during the unwinding process. Moreover, to further increase child Medicaid enrollment to offset these large coverage losses from unwinding, states should also take up various actionable strategies to promote continuous coverage for children and families, as reinforced in a CMS Informational Bulletin issued in December. States should also take up multi-year continuous eligibility for children, which an increasing number of states are adopting, in addition to successfully implementing mandatory 12-months continuous eligibility for children which took effect on January 1, 2024. Finally, states and the federal government will need to work together on robust outreach and enrollment efforts in 2024, including back to school campaigns, to target eligible children, families and other adults who were disenrolled for procedural reasons so they can be reenrolled in Medicaid as quickly as possible.

Medicaid enrollment soars in North Carolina after expansion

Wed, 22 May 2024 16:28:46 GMT

We're nearing the six-month mark since North Carolina opened up enrollment to its expanded Medicaid program. Since December, 448,242 North Carolinians have been added to the rolls for full coverage, the state Department of Health and Human Services tells Axios.

Why it matters: The expansion meant that another 600,000 residents — nearly 6% of the state's population — became eligible for coverage they previously might not have been able to afford, from maternity care to prescription drugs.

Context: Gov. Roy Cooper has prioritized Medicaid expansion since he took office in 2017. Republicans had long been wary of expanding Medicaid benefits, initially citing financial concerns, the News & Observer reported.

Last year, lawmakers in Raleigh reached a bipartisan agreement to expand Medicaid once a state budget was passed.
North Carolina became the 41st state to adopt the Affordable Care Act Medicaid expansion when Cooper signed the legislation last year.

Between the lines: Medicaid signups are increasing in North Carolina's rural counties, including Edgecombe, Robeson, Swain and Graham, according to the state's Medicaid expansion dashboard.

"Relative to the size of [the] population, we are outpacing signups in our rural communities more than urban communities," N.C. Health and Human Services Secretary Kody Kinsley recently told WRAL.
A smaller share of the population is enrolled in large, urban counties. In Mecklenburg, for instance, 44,177 people are on the rolls — 6% of the adult population. In Wake County, the number is 27,480 people, representing 3.6% of the adult population.

Zoom out: Medicaid covers most health care services at little or no cost to patients, from emergency services to preventative care.

Most of the prescriptions being filled under the expansion are for seizures, asthma and other chronic conditions, NCDHHS officials say.
"Preventative, rehabilitative, services that people need and simply went without ... now will be able to benefit from," deputy secretary for NC Medicaid Jay Ludlam told Axios.
The expansion opened up enrollment to non-elderly adults with incomes up to 138% of the Federal Poverty Level (FPL) ($34,307 for a family of three in 2023), according to the nonprofit KFF.

What's next: State health officials are working to engage with communities to get residents in need to sign up for Medicaid through town halls, distributing bilingual material, and other outreach, Ludlam says.

What they're saying: "North Carolina serves as an example to other states who have yet to expand Medicaid health care coverage, because Medicaid expansion can and will save lives," U.S. Health and Human Services Secretary Xavier Becerra said in a recent statement.

States’ Medicaid costs expected to soar from pandemic lows

Wed, 22 May 2024 16:24:56 GMT

In fiscal year 2021—the first full budget year marred by the COVID-19 pandemic—states collectively spent 14.1 cents of every state-generated dollar to provide Medicaid coverage to low-income Americans; that was 1.5 cents lower than the 15-year average of 15.7 cents of every state dollar. A pandemic-related surge in tax revenue, coupled with temporary additional federal funding, contributed to the decrease in the share of state funds that were dedicated to Medicaid. But as federal pandemic aid concludes and Medicaid enrollment remains near historic highs, The Pew Charitable Trusts and other experts expect that share to rise by the end of the current budget year.

All but nine states spent a smaller share of their own dollars on Medicaid in fiscal 2021 than they had, on average, over the previous 15 years. Differences ranged from 4.5 percentage points in Tennessee to less than a tenth of a percentage point in Washington and Wisconsin.

States and the federal government share costs for Medicaid, which provides medical coverage for eligible groups of children, adults, people with disabilities, and the elderly. Medicaid is most states’ biggest expense after K-12 education.

Pew’s state Medicaid spending indicator excludes federal support, examining only the cost to states because that spending exerts pressure on their operating budgets, which rely on state-generated revenue.

Medicaid’s claim on each revenue dollar affects the share of state resources available for other priorities, such as education, transportation, and public safety. Federal law requires states to provide certain benefits for any eligible Medicaid enrollee, even during times of sluggish revenue growth. So policymakers have less control over growth in states’ Medicaid costs than they do with many other programs.

Most states posted a decrease in the share of state funds dedicated to Medicaid in fiscal 2021 compared with the previous year. Nationally, this share dropped by 1.7 percentage points—the most substantial annual drop since at least fiscal 2000. The extent of the declines ranged from 4.3 cents per state-generated dollar in California to a tenth of a percentage point in Arizona. A confluence of factors drove these significant declines, including a simultaneous increase in temporary federal Medicaid aid and higher-than-anticipated growth in tax revenue following the onset of the pandemic.

State Medicaid costs are expected to rise dramatically by the end of the current budget year. Survey data from the Kaiser Family Foundation shows that state costs rose by 13% in fiscal 2023 and are expected to increase by an additional 17.2% in fiscal 2024. In their survey responses, states identified the phaseout of enhanced federal Medicaid aid, provider rate increases, and slowing but still elevated enrollment levels as key drivers of these increased annual costs, which, coupled with weakening tax revenue collections, are likely to push up the share of state funds spent on Medicaid going forward.

State highlights

A comparison of the share of each state’s own-source revenue spent on Medicaid in fiscal 2021 with its average share over the previous 15 years shows that:

Alaska’s share rose the most. In fiscal 2021, the state spent 15.6% of its own revenue on Medicaid, 6.2 percentage points higher than its 15-year average—equivalent to 6.2 cents more of each state-generated dollar. It was the only state where Medicaid reached its highest percentage of own-source spending since 2007.
Besides Alaska, only North Dakota (1.4) and Kentucky (1.3) surpassed their 15-year average shares by more than 1 cent per state-generated dollar.
Only two states spent more than one-fifth of their own revenue on Medicaid in fiscal 2021: Pennsylvania (20.2) and New York (23.6), which contributed the largest share of any state.
The states that spent the smallest share of their own dollars on Medicaid in fiscal 2021 were Utah (4.4), Alabama (6.6), Oklahoma (7.2), Mississippi (7.7), and Hawaii and Idaho (both 8).

Trend drivers

In fiscal 2021, states collectively allocated $240.5 billion from their own resources to support health benefits for 86.3 million Medicaid recipients. This marked a 2.8% increase, or $6.6 billion in new spending, from fiscal 2020. But states’ own-source revenue grew even faster, leading to a drop in the portion of state funds dedicated to Medicaid coverage.

Higher enrollment is one of the major long-term drivers of growth in Medicaid spending; more than twice as many people were on Medicaid rolls in fiscal 2021 than in fiscal 2000. Until the onset of the COVID-19 pandemic, however, enrollment growth had been slowing. From 2000 to 2013, several factors fueled rising enrollment, including two economic downturns—which caused people to lose jobs and associated health insurance—and a gradual erosion of employer-sponsored insurance in general. From 2014 until the present day, millions more Americans joined Medicaid as most states implemented the optional expansion under the 2010 Affordable Care Act (ACA). But because the federal government absorbed the first three years of related expenses for those newly eligible enrollees, states only began picking up a portion of these costs in 2017.

Although the pandemic triggered a historic but temporary surge in Medicaid enrollment, states expect a decline in fiscal 2024 and 2025. This is largely because of the expiration of one-time federal pandemic aid and a related rule that prevented states from unenrolling individuals for the duration of the public health emergency from Jan. 31, 2020, to May 11, 2023. Strong economic conditions, including low unemployment, are also contributing to the downward trend in Medicaid enrollment, as more workers gain access to employer-provided health care.

Conversely, several factors are simultaneously exerting upward pressure on state Medicaid spending, including rising prescription drug prices and widespread increases in health care provider payment rates. Additionally, state policy choices, such as expanding coverage, or the potential impact of an economic slowdown could contribute to growth in Medicaid spending.

Medicaid spending by level of government

Medicaid is a state-administered program, but the federal government covered 60.3% to 83.5% of states’ bills for the program in federal fiscal 2021, for a total of 68% of costs. Federal spending on Medicaid grew by 12.5% that year, from $455 billion to $512 billion—the second consecutive double-digit annual increase since temporary enhanced federal aid was provided in early 2020.

The federal government covered the highest portion of state Medicaid costs in Mississippi (83.5%), New Mexico (82.6%), West Virginia (82.4%), Kentucky (81.4%), and Arizona (80.4%), and the lowest in New York (62.8%), New Hampshire (62.3%), Minnesota (60.9%), Wyoming (60.6%), and Massachusetts (60.3%).

Influence of federal policy changes

Recent changes in federal policies have significantly affected states’ financial responsibilities for Medicaid. In response to the economic challenges of the COVID-19 pandemic, the federal government increased the federal medical assistance percentage (FMAP) for Medicaid by 6.2 percentage points for the duration of the public health emergency. The enhanced FMAP, which was initially set to end on April 1, 2023, underwent a gradual phaseout throughout the 2023 calendar year, decreasing to 5% on April 1, 2.5% on July 1, 1.5% on Oct. 1, and concluding on Dec. 31.

As a condition of these enhanced federal funds, states were prohibited from removing individuals from their Medicaid programs, which lead to a surge in enrollment—from 71.1 million in February 2020 to 94.1 million by April 2023, a 32.4% increase.

The Consolidated Appropriations Act (CAA), which became effective March 31, 2023, marked the end of continuous Medicaid enrollment and allowed states to initiate unenrollment beginning in April 2023. At least 19.6 million Medicaid enrollees have been unenrolled as of April 4, 2024, according to the Kaiser Family Foundation. The CAA also initiated the phaseout of enhanced federal matching funds that concluded in December.

The federal government previously provided extra dollars to states to help cover the increased costs of higher Medicaid enrollment and declining state tax revenue associated with the 2001 and 2007-09 recessions. As the enhanced federal aid from the Great Recession tapered off between December 2010 and June 2011, states’ share of Medicaid costs spiked while their tax revenue was still recovering.

Since January 2014, the ACA has also provided an opportunity for states to expand their Medicaid programs with enhanced federal support. The law initially required states to expand Medicaid eligibility to all adults under age 65 who earn up to 138% of the federal poverty level, a change that the U.S. Supreme Court later ruled was optional for states. For states that chose to expand their coverage to this broader population, the federal government agreed to reimburse 100% of the expansion costs through 2016, then 95% of costs in 2017, and ultimately 90% from 2020 onward. As of the fiscal year that ended June 30, 2021, the time frame for this analysis, 36 states had expanded their programs in accordance with the ACA. Another four states had done so as of March 2024.

States that have expanded Medicaid coverage have typically drawn from their general funds to cover their share of the bill, and some have been able to offset the added costs with related budget savings, such as reductions in behavioral health spending. Several states also report using new or increased provider taxes and fees to help fund the expansion.

In 2006, the federal government began relieving states of prescription drug costs for “dual eligibles,” people who qualify for Medicaid and the federal Medicare program. In return, states must share some of their savings with the federal government through annual “clawback” payments, which are included in this analysis as part of state Medicaid spending.

However, the amount of federal reimbursement that states receive is just one of several factors that influence the wide range in the share of state’s own revenue spent on Medicaid. Among the other drivers are state Medicaid policy decisions—the breadth of health care services covered, eligible populations, and provider payment rates—and each state’s personal income levels. States with lower per capita income have higher federal reimbursement rates, and vice versa. The variation across states also is a function of tax and other policy decisions that determine state revenue and factors outside of policymakers’ direct control, such as state economic performance, demographics, resident health status, and regional differences in health care costs and practices. (For more information, see “State Health Care Spending on Medicaid.”)

Why Pew assesses state Medicaid spending

State Medicaid spending has a significant impact on state budgets. As the largest expense for most states after K-12 education, Medicaid's allocation from each revenue dollar directly influences the resources available for other key public services, such as education, transportation, and public safety. The federal government requires states to, among other things, provide matching funds to help cover the costs of Medicaid benefits for eligible enrollees, regardless of revenue conditions. This relative lack of state control over costs distinguishes Medicaid from many other programs and can be difficult for policymakers to navigate, especially when costs spike during economic downturns.

Justin Theal is an officer and Riley Judd is an associate on The Pew Charitable Trusts’ Fiscal 50 project.

Assaults on medical staff in SC hospitals are rising, and we’re trying to stop it

Mon, 20 May 2024 18:46:44 GMT

For more than 30 years, I’ve experienced the wide range of complex issues facing healthcare providers, and I can’t remember a time when we were more concerned about the safety and security of our workforce.

South Carolina’s hospitals and health systems represent more than $28 billion in state economic impact and 77,000 employees. Many of those employees have taken an oath to “Do No Harm,” and I’m sad to say that same courtesy is not being given to them.

Healthcare workers account for roughly three-fourths of all nonfatal workplace injuries and illnesses due to violence in the workplace. According to government data, that nurse getting ready for her shift is five times more likely to be assaulted at work than employees reporting to virtually every other job.

It’s been said that the true measure of a society is how it treats the most vulnerable among us — but what about how we treat those who care for us in our most vulnerable moments?

Until now, we’ve only been able to rely on anecdotal stories from front-line workers to express this problem, but thanks to an upcoming report from the South Carolina Hospital Association and Antum Risk, we finally have actionable data to illustrate the impact of workplace violence on the state’s hospital workforce.

The South Carolina Workplace Violence Collaborative was established in 2023 to address the increased incidence of violence against healthcare workers. The collective includes aggregate data submitted by 48 South Carolina healthcare facilities, including acute care hospitals, physician practices, outpatient clinics and rehabilitation centers, in 2023. For standardization purposes and to isolate these events, only incidents of physical violence are included in the report.

South Carolina’s hospitals and health systems have created a national model for enhancing hospital safety and security with a voluntary data collective actively sharing incidents of workplace violence in their facilities, and we’re already learning valuable lessons:

68% of health care assaults in the state were committed against bedside nurses and nursing support in 2023.
96% of these incidents were initiated by patients; however, we are seeing a growing trend of assaults by patients’ family members and visitors.
80% of these incidents occurred in the emergency department or the patient’s room or bathroom.

Our hope is that by focusing on building a data collective around outcomes for employees, as we do for patients through our Zero Harm program, we can learn more about the conditions to eliminate preventable harm in our facilities. If we can use data to improve surgical outcomes, we should be able to apply those same principles to bolster employee safety.

South Carolina’s hospitals and health systems are already using cutting-edge solutions to improve hospital safety and security, including enhanced surveillance, elevated training for security officers, first-alert badges for staff and trained K-9 units to uphold a more secure environment for everyone, including patients, employees and visitors.

Hospitals and health systems are also providing additional resources and support for employees who are affected by violent incidents. And, we are working closely with state and local law enforcement to help ensure we have strong partnerships for addressing incidents and maintaining a healing environment in our facilities.

It’s important to spotlight this issue and the amazing feats our healthcare heroes take on every day to lead South Carolina to a better state of health. So, the simplest way to celebrate nurses today when you need care is to be kind. Extend that kindness to everyone in the hospital, from the security guards to food services. Every day they suit up for work, our hospital employees make a commitment to Zero Harm. Let’s make that same commitment to them.

SC legislative session comes to a chaotic close as forces don’t get along

Mon, 20 May 2024 18:44:31 GMT

South Carolina’s legislative session came to a chaotic close following last-minute votes on a litany of bills, including a controversial ban on gender-affirming care for minors, a monument to a Black icon of the Civil War and limits on children’s ability to access pornographic material.

All of that was overshadowed by an eleventh hour vote by Republican hardliners to kill a top priority of legislative leadership and Gov. Henry McMaster.

With just several minutes left until the 5 p.m. hard deadline May 9, the conservative South Carolina House Freedom Caucus used a basic procedural maneuver to kill a sweeping state health agency restructuring bill that had been in the works for months — leaving members of the Senate incensed.

“Play stupid games, win stupid prizes,” Freedom Caucus chairman Rep. Adam Morgan, R-Taylors, told reporters afterward.

Plenty of other things did happen on the session’s final day.

The House and Senate struck a deal to form a committee to commemorate Robert Smalls, a South Carolina congressmen and a Civil War hero, with a memorial on the Statehouse grounds. They finalized legislation to prohibit minors from accessing pornographic content online. And they passed a controversial ban on gender-affirming care for transgender teenagers that the American Civil Liberties Union has described as “harmful and unconstitutional.”

But while the 2024 session is over on paper, state lawmakers leave Columbia with numerous major priorities still unresolved and the expectation they will find themselves back in the Statehouse within a month to finish up.

A proposal to reform the way South Carolina selects judges — lawmakers’ top priority this session — remains in purgatory after the House and Senate were unable to come to an agreement by the 5 p.m. deadline.

That bill will now go to a six-member conference committee consisting of three House members and three members of the Senate to rectify the differences between the two sides.

A sweeping energy reform package to expedite the conversion of a defunct Lowcountry coal-fired power plant to natural gas will also go to a conference committee after a reluctant Senate rewrote the proposal into a nonbinding resolution supporting new energy development.

And legislation banning the use of “prohibited concepts” in public school curriculum remains unresolved nearly a full year after a conference committee was appointed to debate it — leaving the fate of some of the most consequential bills discussed this year in the hands of a small group of lawmakers.

“I’m hopeful that once people sit down in the same room at the same table, that many of those differences can be worked out,” Sen. Shane Massey, R-Edgefield, told reporters after session.

The last-minute flurry of bills — and the lengthy post-session workload remaining — comes after weeks of questionable clock management from both chambers.

For several weeks, members of the House continually adjourned early amid an impasse over the energy bill, amassing a legislative backlog dozens of bills deep entering the session’s final days. Some bills, including a fentanyl bill favored by Senate President Thomas Alexander, R-Walhalla, died on the floor without a vote despite passing out of the Senate in February 2023.

Meanwhile, the Senate dedicated several days of its schedule in the session’s final week to debating legislation on topics like barring private businesses from mandating vaccinations to legalizing medical marijuana — discussions that ultimately went nowhere.

The penultimate day of session, which ran well into the night May 8, was also marked by chaos in the lower chamber of the Statehouse.

Over several hours, the House Freedom Caucus attempted to run several nongermane policy proposals as amendments to the state budget that sapped up several hours of lawmakers’ time.

Many were doomed to fail: Morgan, the group’s chair, attempted to run an amendment to the budget banning the distribution of forms mandated by the federal government to give individuals an option to register to vote.

Fellow Freedom Caucus member Jordan Pace, R-Goose Creek, attempted an amendment that would have required South Carolina to recognize all gold and silver currency — foreign or domestic — as legal tender, despite the fact it is the federal government that decides what currency is legal and what is not.

The latter effort elicited mockery from more moderate members like Rep. Micah Caskey, R-West Columbia, who donned a tinfoil hat to deliver remarks deriding Pace’s amendment from the dais.

“Everyone should point and laugh at the (SC Freedom Caucus),” he wrote on social media after the vote.

The group found other ways to be disruptive.

Later in the day March 8, Rep. April Cromer, R-Anderson, ground debate to a halt using an obscure procedural motion that would have forced House Reading Clerk Bubba Cromer to read every word of the nearly 300-page health department restructuring bill. It was a gambit Palmetto Promise Institute analyst Felicity Ropp estimated would have theoretically taken nearly 14 hours to complete.

The Anderson Republican eventually relented after nearly an hour of inactivity on the House floor. Her caucus would find another way to stall it.

With less than an hour left in session, Beaufort Republican Sen. Tom Davis — who led the bill — Sen. Margie Bright-Matthews, D-Walterboro, and Sen. Shane Martin, R-Pauline, ran more than half-dozen amendments to the bill, including several regarding vaccines that even some of Martin’s colleagues acknowledged could jeopardize the bill’s success in the House.

“Don’t push it too far now,” Sen. Nikki Setzler, D-Columbia, warned Martin 40 minutes before the deadline.

“I’m not trying to,” Martin replied.

Except he did.

When the bill came back to the more conservative House, members of the House Freedom Caucus objected to a motion to allow the bill to be heard within 24 hours of it crossing over — effectively killing it.

The architect of the bill-killing motion, Freedom Caucus member and Campobello Republican Rep. Josiah Magnuson, said the effort was personal.

All session, he said, House leadership had refused to weigh their policies seriously. Their members had been allowed to be openly mocked by colleagues on the House floor, he said, adding that someone had set up a red-haired puppet in the House chambers wearing a tinfoil hat; Magnuson has red hair.

“We’ve had bills for some of these issues filed since the beginning of last session,” Magnuson told reporters. “Some of them from the last session after COVID. A lot of this has been needed to be done for years, and it has never gotten any kind of attention until they got desperate.”

House Speaker Murrell Smith, R-Sumter, denied mismanagement of the legislation played any part in the bill’s failure, instead blaming the House Freedom Caucus for playing political games at the close of session.

“Holding hostage bills like that only harms South Carolinians,” said Smith. “It doesn’t harm the members that they feel weren’t nice to them. It doesn’t harm the institution. It harms real South Carolinians.

“We’ve got people with drug disorders with drug addictions,” he added. “We’ve got people with mental health issues. And because someone wants to have a bill that’s not related to health care restructuring and wants those bills enough, they will hold something hostage … that’s just a poor commentary on the state of affairs currently happening right now.”

Correction: A previous version of this article stated Robert Smalls was South Carolina's first Black Congressman. It was actually Joseph Hayne Rainey, who was elected to represent South Carolina's First Congressional District in 1870.

Gender transition bill among those headed to governor’s desk for signature

Mon, 20 May 2024 18:38:28 GMT

The Republican led South Carolina General Assembly agreed on several bills they say will protect children, including restrictions on transgender healthcare, age verification requirements for pornography websites and curbs to prevent child abductions.

Before ending its final day of session Thursday, the House concurred with the Senate’s changes to the Help not Harm bill, which requires schools to proactively notify parents of their child’s perceived gender identity while preventing gender transition procedures for minors by surgery or puberty-blocking drugs.

The measure is now headed to the governor.

I’ve talked to some some local teacher groups, and they felt like that, if they were, if they did encounter this situation, their number one priority is to simply say, ‘we believed this was what was happening’ and they’re out of it. That’s all they have to,” said House Majority Leader Davey Hiott on Thursday about any potential encounters with transgender students.

Hiott said the bill was important to pass for many in the legislature. “I’ve never had a perfect bill in my 20 years here. I believe that was good enough to where a teacher said look, as long as we’re not having to call parents,” he said. Hiott led the original effort in the House to eliminate the teacher’s responsibility to contact parents.

The House agreed with the Senate’s amendment to take the energy bill off a suicide prevention measure. The legislation would require and one hour of suicide prevention training as part of continuing education requirements and licenses for therapy workers. It was one of a half dozen bills the House had attached with the energy legislation. With the energy bill removed, they also passed a bill allowing for counselors licensed in other states to work in South Carolina.

Constitutional Carry was already passed and signed into law. The General Assembly revised the measure Thursday to dismiss pending illegal handgun possession charges.

Here are a few other measures, now awaiting Gov. Henry McMaster’s signature.

AMENDING CONSTITUTION ABOUT VOTING, U.S. CITIZENS

Both chambers passed a Senate measure changing one word in the state Constitution about voter qualifications. If the governor signs this bill, it would become a ballot measure for South Carolinians to vote on before becoming law.

State Sen. Josh Kimbrall, R-Spartanburg, told The State the measure is to prevent non U.S. citizens from voting in local elections. Other jurisdictions, such as California and New York, have allowed non-citizens to vote in municipal elections and school board races.

“Certain jurisdictions and courts have found that every citizen is a floor not a ceiling, so were just saying only citizens would be able to vote,” Kimbrell said.

NO TAX ON PERIOD PRODUCTS, ANTISEMITISM DEFINED

The General Assembly defined antisemitism, and added guidance on how it aligns with discrimination laws based on the International Holocaust Remembrance Alliance.

They passed tax exemptions for golf club dues and feminine menustral products. And, with the governor’s signature, people will be able to hunt feral hogs from helicopters, under certain conditions.

Other bills passed include:

allowing insurance providers to cover paid time off for family members
rules governing the name, image and likeness of college athletes
pay for inmates working outside prisons
creating an assessment fee for private ambulance services
allowing non S.C. residents to qualify for burial in the state’s veterans’ cemeteries
enabling deer processor’s to recover fee for donated does
prohibiting interference with farm animals being transported
allowing photographs to provided for handicap parking placards

Medicaid funding among unsettled issues in 2025 state budget

Mon, 20 May 2024 18:33:20 GMT

What type of tax cut to give South Carolinians and how big of a raise to give state employees are among the differences between the House and Senate budgets which will need to be reconciled in a conference committee.

House members Wednesday adopted their second version of the 2024-25 budget, pushing a $13.3 billion spending plan.

Even though both chambers have some agreements, including how much to pay teachers, differences will need to be worked out.

The two chambers agree on raising the starting teacher salary in the state to $47,000, but disagree on how much state aid to classrooms should be sent to school districts.

The House wants $229 million in state aid to classrooms, which give school district more flexibility than the Senate plan for $200 million in state aid.

Under the Senate plan, any state employee earning $50,000 or less would receive a $1,375 raise. Those earning more than $50,000 a year would receive a 2.75% pay increase.

The House plan calls for giving a $1,000 raise to any state employee earning $66,667 or less. Anyone earning more than $66,667 would receive a 1.5% raise.

For taxpayers, the House wants to stick with its plan for a property tax cut, but scaled back how large of a tax credit homeowners could expect.

The House plan now shrinks the property tax credit for owner-occupied houses from $500 million to $150 million in an effort to avoid the appearance of property taxes going up the following year.

Ways and Means staff estimates providing $150 million for property tax relief from surplus sales tax revenue would allow the relief to be in place for 10 years. The cut is smaller per year, but it’s larger over time.

About $100 million in surplus sales tax revenue is generated into the homestead exemption fund.

The homestead exemption fund was created in 2006 as part of Act 388 passed created a tax swap that increased the state sales tax in exchange for a reduction in property taxes on owner-occupied houses.

Senate budget writers want to use $100 million of the homestead exemption fund surplus to accelerate the planned income tax cut, with $500 million used for infrastructure projects in its $13.8 billion spending plan.

Gov. Henry McMaster suggested using $500 million of the $600 million to address bridge repairs in the state.

Lawmakers have less new money this year to allocate than in previous years as economic growth has returned normal levels.

How much to spend on the state’s Medicaid program also is different. The Senate only increased Medicaid spending by $56.1 million.

The House wants to spend $105.2 million more on Medicaid to keep up with the cost of rising inflation on health care costs.

Health and Human Services would not be able to do as many of its new initiatives it proposed, such as using more money for behavioral health, if the Senate figure is adopted.

“We will be able to do a few of those and the rest will have to wait until next year,” said HHS Secretary Robbie Kerr said.

In an effort to avoid the fight from last year when a budget deal was delayed over how much to spend on Clemson’s veterinary school, the Senate proposed $175 million for the vet school construction and $100 million for construction the University of South Carolina’s health campus. Those figures would allow the schools avoid borrowing money for the project.

The House, however, only proposed $47 million each for the vet school and health campus.

The amount on tuition mitigation also is different both budgets, with $57 million proposed by the House and $77 million by the Senate to give to universities on the condition they freeze tuition next year.

The House also included only set aside $1 for the required general reserve fund contribution. The Senate set aside $24 million.

Under the Department of Corrections, the Senate wanted to spend an additional $28.6 million on the state prison system which includes money for a cell phone interdiction project. The House budget only included an additional $15.3 million for the department of corrections

Senate budget writers also include $20 million for the Department of Juvenile Justice’s master facility plan, $1 million for IT application assessment, and $1 million for the agency’s cybersecurity remediation plan. The House only put $1 for each of those projects.

Only $645 million of new annual dollars is available for lawmakers to allocate and $1.06 billion of one-time money is available.

However, the Board of Economic Advisors is slated to meet on May 20 and may certify additional dollars for budget writers to use in final spending plan.

South Carolina’s bill to consolidate health agencies fails at last minute

Mon, 20 May 2024 18:29:09 GMT

A bill that would have consolidated six South Carolina heath care agencies and was overwhelmingly passed by both chambers of the General Assembly died on the session’s final day Thursday in a procedural move by a member angry he was mocked by his colleagues.

Republican Rep. Josiah Magnuson has been against the bill from the start, saying it would create a health care czar who could take over like a dictator if there was another pandemic emergency like COVID-19.

So when the House needed unanimous support to take up the bill one last time minutes before the 5 p.m. Thursday end-of-session deadline, Magnuson objected and stood his ground even as bill sponsor Republican Sen. Tom Davis came over and held a heated conversation with other party members that had many in the chamber stopping to watch and security sergeants hovering nearby.

After the session ended, Magnuson said he was offended that he and his fellow Freedom Caucus members — roughly 15 of the most conservative House members — had been mocked all week.

Magnuson said one colleague had a puppet with bright red hair, just like Magnuson, wearing a tin hat with a Freedom Caucus sticker.

He said Davis has had nothing but insulting things to say about the group that often tries to use obstructing tactics to stall bills and social media posts that other Republicans say are ambiguous or misleading to achieve goals outside of what most Republicans in the House want.

“They have basically ridiculed me,” Magnuson said. “They have completely eradicated any credibly they have with me.”

The bill follows up last year’s breakup of the state Department of Health and Environmental Control that spun off the environmental functions.

The 2024 proposal would have created a new Executive Office of Health and Policy. It would have combined separate agencies that currently oversee South Carolina’s Medicaid program, help for older people and those with mental health problems, public health and drug and alcohol abuse programs. The consolidated agency would have come under the governor’s cabinet.

Republican Gov. Henry McMaster supported the bill in his State of the State speech. It was a pet project of Republican Senate Finance Committee Chairman Harvey Peeler and backed by Republican House Speaker Murrell Smith It passed the Senate on a 44-1 vote and the House on a 98-15 vote.

A stunned Davis stormed back in the chamber after the gavel fell and told Peeler what happened. Staffers in both chambers shook their heads.

“I’m interested in delivering good health care options for the people of South Carolina,” Davis said. “And we had some people over in the House today that failed the people of South Carolina over petty political differences.”

The bill had a tough slog at times. More conservative senators tried to tack proposals on that would prevent businesses from requiring employees to get vaccines that had not been approved by the federal government — a holdover complaint from the COVID-19 pandemic.

Others didn’t like their interpretation that the new director of the bigger health care agency could get nearly unlimited powers to quarantine, require vaccines or arrest people who didn’t follow orders in a health care emergency. Supporters of the bill said that couldn’t happen.

The death of the health care bill was considered a win by the Freedom Caucus, which often feels shut out of the best committee assignments and that their ideas get no traction in committee or the House floor.

Caucus Chairman Republican Rep. Adam Morgan said it was a bad bill from the start.

“Sometimes your bills die,” Morgan said. “You play stupid games, win stupid prizes.”

Smith said this kind of move by the Freedom Caucus doesn’t help their cause in a chamber where almost all progress comes from working together. He said the bill will continue to be a priority and that the General Assembly returns sooner than some might realize.

“It will be a six-month delay, but I don’t think that disrupts anything we are doing,” Smith said.

Despite broad efforts, U.S. health equity gap continues to grow

Addie Thompson — Mon, 15 Apr 2024 14:29:39 GMT

Despite broad efforts since 2009 to increase the availability of health insurance and access to health care for underserved populations, low-income people are remaining sicker than higher-income people and that health inequity gap continues to grow. That’s according to José Escarce, MD, PhD, the guest speaker at the April 2 annual Leonard Davis Institute of Health Economics (LDI) Samuel P. Martin III Memorial Lecture.

A Penn alumnus, Escarce’s presentation was based on his study entitled, “Income-Related Inequity in Health Care Delivery: Concept, Measurement, and Recent Trends Among Working-Age Americans.” His Martin Lecture was simultaneously the second-day event in the four-day Penn Medicine Health Equity Week Conference, an annual event designed to facilitate discussions focused on advancing health equity. The LDI lecture was co-hosted by the Penn Division of General Internal Medicine and the National Clinician Scholars Program.

Denial of Care

“Disparity in health is increasing dramatically over a really brief period of time,” said Escarce, a Professor of Medicine in the David Geffen School of Medicine at UCLA, a Professor of Health Policy and Management in the UCLA Fielding School of Public Health, and a Senior Natural Scientist at RAND. “Why is this so? Well, the quality of insurance likely matters. Medicaid may fail to provide adequate access to costly services. The spread of Medicaid managed care in particular. Well over 70% or 80% of patients on Medicaid are in Medicaid managed care, a program that is notorious for denying access to expensive things. In fact, a recent Government Accountability Office (GAO) report explained how states have not implemented systems to monitor denials of care by Medicaid managed care organizations, whereas the federal government has done that for Medicare managed care organizations.”

“Additionally, there’s the spread of high deductible health plans, which are slightly more common among low-income people and are fighting against the reduction in health status inequity,” Escarce continued. “Beyond insurance it’s also about the social determinants — not of health but of health care. There are so many sociological barriers to getting health care, and those aren’t going to go away because you get people insurance. It’s also worth noting that the dramatic decline in health among low-income Americans, relative to their more affluent peers, speaks to the multifaceted crises that these Americans face, like in the labor market in earnings and stagnant wages, in health behaviors and other negative factors that are playing out in their health.”

Income Inequality Impact

“There’s also the effect of growth in income inequality which can worsen inequity in health care,” said Escarce. “Income inequality has grown in the United States over this period of time and is working against efforts to achieve reductions in health care inequity.”

“Focusing on Medicare expenditures, the 2019 observed concentration index (of our study) would imply that the high-income individuals would get $5,578 per person, and low-income people would get $5,468 per person,” Escarce said. “But if you look at the adjusted index, which is the one that accounts for health status, high-income individuals should get $4,584 per person, and the low-income people should get $6,462 per person. The difference between what they would get in this situation is almost $1,000. So, these small inequity indices translate to huge differences in the amount of care that people actually get.”

The Samuel P. Martin, III, MD Memorial Lecture series honors the legacy of a University of Pennsylvania physician and administrator who believed that American medicine had underachieved in harnessing its vast resources to serve the health care needs of the nation and who devoted his career to addressing the issue of how that could be changed.

Escarce is currently working on several projects that address socio-demographic barriers to access in managed care organizations and is the principal investigator of a program project entitled “Health Care Markets and Vulnerable Populations,” which uses the Medical Expenditure Panel Survey (MEPS) and is funded by the Agency for Healthcare Research and Quality (AHRQ). Among other issues, the program project addresses racial and ethnic differences in access to and quality of medical care.

Previous Day Health Equity Panel: Women of Color

The previous day’s Penn Medicine Health Equity Week event was a panel moderated by LDI Senior Fellow Jaya Aysola, MD, DTMH, MPH, Assistant Dean of Inclusion and Diversity and Associate Professor of Medicine and of Pediatrics at the Perelman School of Medicine. She is also the Founder and Executive Director of Penn Medicine’s Center for Health Equity Advancement (CHEA). The panelists included Penn Medicine nurses Larissa Morgan, MSN, RN-BC; Rebecca Trotta, PhD, RN; Felicia Morrison, MSN, MBA, RN; and Andrea Blount, MPH, BSN.

The panel marked the first collaboration between the Center for Health Equity Advancement and the Abramson Center for Nursing Excellence.

Entitled “The Path for Women of Color to Ascend in Health Care,” the session was focused on an underway study focused on defining the factors that impede advancement of female nurses of color to executive leadership. Launched in 2020, the pilot study’s goal is to produce recommendations to improve advancement of women of color (WOC), peer-reviewed publications on related themes, and a “playbook” for WOC advancement based on critical insights from the study’s analyses.

Over 53% of the women who held health care CEO roles had a clinical background, and 43.9% of them were nurses. However, Black, Indigenous, and People of Color who make up 23.6% of the nursing workforce account for only 19% of first- and mid-level managers, 14% of hospital board members, and 11% of executive leaders.

“The stats are clear,” said Aysola. “There is a gap that is important to highlight in terms of advancing women of color not only in our nursing workforce but all the way up into executive leadership. Nurses represent the backbone of most of our health care systems and it’s important to honor their voices as we make changes towards advancing equity.”

Change to Medicaid’s ‘best price’ rule may bring unintended consequences

Addie Thompson — Mon, 15 Apr 2024 14:27:47 GMT

More than one in five Americans rely on Medicaid, which is now the nation's largest health insurer.

Worryingly, these Americans may soon lose access to certain life-saving medicines because of a well-intentioned, but poorly designed, regulatory change that federal officials seem intent on advancing.

For more than 30 years, Medicaid's "best price" rule has made a simple and reasonable demand of drugmakers: Give Medicaid your lowest price or pay Medicaid a rebate of 23.1 percent of the "average manufacturer price" that's paid by retail pharmacies and wholesalers.

Especially for expensive drugs still under patent and less likely to be available at cut-rate prices, that minimum 23.1 percent discount helps poor Americans get the medications they need at a cost that's reasonable for taxpayers.

Sure, there are some technical aspects of all the definitions and procedures associated with the current rule that keep plenty of lawyers and accountants busy. But the basic idea is clear: Drugmakers don't get to excessively profit off the Medicaid population by charging the program more than they charge any other buyer.

Even though this formula is working reasonably well, officials now want to change it.

Instead of requiring drugmakers to offer Medicaid the best price available to any other single buyer—whether it's a commercial insurer, a hospital, a drug wholesaler, or a pharmacy benefit manager (PBM)—officials want the Medicaid price to reflect all the discounts given to those other entities combined.

The net effect would be lower Medicaid drug costs. In theory, that's a good thing. Who wouldn't want Medicaid to secure a better deal for beneficiaries and taxpayers?

But in practice, the proposed rule would prove almost impossible to implement and enforce—due, in part, to ongoing obfuscation by pharmacy benefit managers.

These secretive middlemen oversee the details of prescription drug benefits for most insurance plans, including the Medicaid "managed care" plans administered by private insurers. PBMs have deliberately made the drug supply chain as opaque and complex as possible in order to protect their tens of billions in annual profits.

There is currently no system in place to track the separate entities that handle a drug as it moves through the byzantine supply chain—and therefore no way to collect data on discounts at each "stop" (pharmacy benefit managers, insurers, wholesalers) along the way from manufacturer to patients. Drug companies often aren't even aware of the contract terms between retail pharmacies and PBMs.

Simply put, the numerous hurdles PBMs have introduced into the system of drug procurement—every one of which is also a tollbooth contributing to their bottom lines—have made it challenging to collect the information Medicaid wants.

A reform proposal worthy of consideration would start by asking PBMs what they do to actually benefit the Medicaid program as a whole and patients in particular. Spoiler alert: The answer is nothing.

Instead the proposal heaps the burden of demonstrating compliance on drugmakers and creates more paperwork for federal officials, further depleting essential resources that should be going to care for Medicaid beneficiaries.

A reform proposal worthy of consideration would start by asking PBMs what they do to actually benefit the Medicaid program as a whole and patients in particular. Spoiler alert: The answer is nothing.

Consider ailments like sickle-cell disease. Over 93 percent of patients hospitalized with the condition are Black. Just a few months ago, two biotech companies rolled out new gene therapies for sickle cell disease.

Would biotech companies research such conditions if the proposed rule were in effect? Or would firms instead opt to develop drugs for privately insured—and thus more lucrative—patient populations instead? The answer is obvious.

Medicaid is hardly perfect. Many doctors won't accept Medicaid patients, which leads to long wait times at the providers who do participate in the program. Enrolling, and staying enrolled, forces the poorest and most vulnerable Americans to navigate a considerable amount of red tape and paperwork.

But within the program, prescription drug coverage is a bright spot. By law, virtually every FDA-approved medicine is available to Medicaid enrollees at little to no cost. And the existing "best price" rule enables Medicaid to devote just 5.6 percent of its total spending towards prescription drugs—whereas in the health care system as a whole, prescription drugs account for about 11 percent of total spending.

When there are so many broken components of our health care system, and Medicaid specifically, that deserve attention, it's bizarre that federal officials are looking to overhaul the one piece of the program that's indisputably successful. Those officials would be wise to refocus their attention on rent-seeking middlemen—before their plan wreaks unintended consequences on the most vulnerable Americans.

One year after unwinding, community health centers struggle with Medicaid re-enrollment

Addie Thompson — Fri, 12 Apr 2024 17:57:56 GMT

Almost all community health centers (95%) are reporting Medicaid disenrollment, influencing the level of care provided to individuals that rely on these locations.

Three-quarters of people who have lost Medicaid coverage are still disenrolled, a new survey of national community health centers finds. Many of these individuals are likely unable to find commercial health insurance.

A breakdown of Medicaid disenrollees from community health centers shows the widespread impact. Of the affected individuals, 32% have chronic conditions, 24% are children, 12% were adults older than 65 years of age and 12% had disabilities.

The analysis was conducted by the National Association of Community Health Centers and the George Washington University's Geiger Gibson Program in Community Health from January to February 2024.

“Health centers are sounding the alarm on unwinding with nearly a quarter of their Medicaid patients, including children and older adults, losing coverage,” said Peter Shin, Ph.D., research director of the Geiger Gibson Program, in a news release. “The reported proportion of patients who are not seeking care or continuing treatment is also substantial and highly concerning.”

During the public health emergency, Medicaid enrollment increased more than 30% to over 23 million people. States began the unwinding process April 1, 2023, and enrollment now sits at 85 million people, said Jennifer Tolbert, director of state health reform for KFF, in a recent webinar on the unwinding's impact.

Enrollment has declined in all states except Hawaii, due to a procedural pause brought on by the Maui wildfires in August, but states are at different levels of processing renewals and enrollment varies greatly.

"We find mild, but positive, correlation between the number of e14 waivers a state has adopted and enrollment decline," she explained.

These waivers can increase ex parte (automatic) renewals, help enrollees submit renewal forms, update contact information or facilitate reenrollment for people affected by procedural terminations, KFF reported. Only Florida has not utilized any waivers.

She expects the Centers for Medicare & Medicaid Services to release a timeline showing each state's progress soon, though some states likely won't be done with the unwinding process until the fall.

North Carolina plans to expand Medicaid SDOH pilot statewide

Addie Thompson — Fri, 12 Apr 2024 17:57:12 GMT

After two years of experimentation with addressing people’s social needs with services like food, housing, and transportation through Medicaid, the North Carolina Department of Health and Human Services (NCDHHS) is planning to expand the services statewide.

More than 288,000 services have been delivered and more than 20,000 NC Medicaid beneficiaries have enrolled across 33 predominantly rural counties in North Carolina as part of the Healthy Opportunities Pilots since the program began providing services two years ago.

The Centers for Medicare and Medicaid Services (CMS) approved the Healthy Opportunities Pilots in 2018 as part of the state’s waiver to transition to Medicaid managed care. Also, North Carolina expanded who can get Medicaid starting Dec. 1, 2023. Enrollment has surpassed 400,000 in the expansion program’s first four months.

North Carolina says that preliminary research from the program’s independent evaluation shows the state is spending about $85 less in medical costs per Healthy Opportunities Pilots beneficiary per month.

Those findings also show participants avoided a significant number of emergency department visits, and research shows participants have a reduced risk of food insecurity, housing instability and lack of access to transportation. Further, the findings showed that the longer a person was enrolled in the pilots the greater reduction of risk.

"The Healthy Opportunity Pilots are having a tremendous impact on the lives of thousands of people in North Carolina by removing barriers for people, particularly in rural areas, to services that are critical to whole-person health," said State Health Director and NCDHHS Chief Medical Officer Elizabeth Cuervo Tilson, M.D., M.P.H., in a statement. "This collaborative effort is also investing in the economy of our local communities, which also promotes health.”

NCDHHS used the example of one member to describe how the program works. A single mother had been staying at a local shelter with her children but needed life-saving surgery. Her children couldn’t remain in the shelter without her, which left her in an impossible position. Mom had secured an emergency housing voucher, but it wasn’t enough to cover rent in the county where she would be receiving treatment.

Through the Healthy Opportunities Pilots, her care managers were able to help her transfer her housing voucher and secure income-based housing near the hospital. They also helped her access financial support for her security deposit and utility setup fees — all services that are covered for the Healthy Opportunities Pilots participants.

Now, mom is able to focus on her health, schedule needed medical care, and keep her family together under one roof with help from her friends and the Healthy Opportunities Pilots.

Encouraged by early success of the program, NCDHHS renewed a federal 1115 waiver in October 2023, which included a request to allow expansion of Healthy Opportunities services statewide. NCDHHS anticipates working in collaboration with federal partners to expand the program and ensure more people in North Carolina receive these services.

Right now, the Healthy Opportunities Pilots services are available to qualifying NC Medicaid Managed Care Standard Plan beneficiaries who live in a Pilot region and meet at least one qualifying physical or behavioral health criteria and one qualifying social risk factor. The program looks forward to further extending access to these services later this year for Medicaid Direct beneficiaries who are eligible for tailored care management in the Pilot regions.

‘Unsustainable’: Nation’s current 97% debt-to-GDP ratio to exceed 200% by 2047, 531% by 2098

Addie Thompson — Fri, 12 Apr 2024 17:54:34 GMT

An Unsustainable Fiscal Path

An important purpose of the Financial Report is to help citizens understand current fiscal policy and the importance and magnitude of policy reforms necessary to make it sustainable. This Financial Report includes the SLTFP and a related note disclosure (Note 24). The Statements display the PV of 75-year projections of the federal government’s receipts and non-interest spending17 for FY 2023 and FY 2022.

Fiscal Sustainability

A sustainable fiscal policy is defined as one where the debt-to-GDP ratio is stable or declining over the long term. The projections based on the assumptions in this Financial Report indicate that current policy is not sustainable. This Financial Report presents data, including debt, as a percent of GDP to help readers assess whether current fiscal policy is sustainable. The debt-to-GDP ratio was approximately 97 percent at the end of FY 2023, which is similar to (but slightly above) the debt to-GDP ratio at the end of FY 2022. The long-term fiscal projections in this Financial Report are based on the same economic and demographic assumptions that underlie the 2023 SOSI, which is as of January 1, 2023. As discussed below, if current policy is left unchanged and based on this Financial Report’s assumptions, the debt-to-GDP ratio is projected to exceed 200 percent by 2047 and reach 531 percent in 2098. By comparison, under the 2022 projections, the debt-to-GDP ratio exceeded 200 percent one year earlier in 2046 and reached 566 percent in 2097. Preventing the debt-to-GDP ratio from rising over the next 75 years is estimated to require some combination of spending reductions and revenue increases that amount to 4.5 percent PV of GDP over the period. While this estimate of the “75-year fiscal gap” is highly uncertain, it is nevertheless nearly certain that current fiscal policies cannot be sustained indefinitely.

Delaying action to reduce the fiscal gap increases the magnitude of spending and/or revenue changes necessary to stabilize the debt-to-GDP ratio as shown in Table 6 below.

The estimates of the cost of policy delay assume policy does not affect GDP or other economic variables. Delaying fiscal adjustments for too long raises the risk that growing federal debt would increase interest rates, which would, in turn, reduce investment and ultimately economic growth.

The projections discussed here assume current policy18 remains unchanged, and hence, are neither forecasts nor predictions. Nevertheless, the projections demonstrate that policy changes must be enacted to move towards fiscal sustainability.

The Primary Deficit, Interest, and Debt

The primary deficit – the difference between non-interest spending and receipts – is the determinant of the debt-to-GDP ratio over which the government has the greatest control (the other determinants include interest rates and growth in GDP). Chart 8 shows receipts, non-interest spending, and the difference – the primary deficit – expressed as a share of GDP. The primary deficit-to-GDP ratio spiked during 2009 through 2012 due to the 2008-09 financial crisis and the ensuing severe recession, as well as the effects of the government’s response thereto. These elevated primary deficits resulted in a sharp increase in the ratio of debt to GDP, which rose from 39 percent at the end of 2008 to 70 percent at the end of 2012. As an economic recovery took hold, the primary deficit ratio fell, averaging 2.1 percent of GDP over 2013 through 2019. The primary deficit-to-GDP ratio again spiked in 2020, rising to 13.3 percent of GDP in 2020, due to increased spending to address the COVID-19 pandemic and lessen the economic impacts of stay-at-home and social distancing orders on individuals, hard-hit industries, and small businesses. Spending remained elevated in 2021 due to additional funding to support economic recovery, but increased receipts reduced the primary deficit-to-GDP ratio to 10.8 percent.

The primary deficit-to-GDP ratio in 2023 was 3.8 percent, increasing by 0.2 percentage points from 2022 primarily due to lower receipts, partially offset by lower non-interest spending. The primary deficit-to-GDP ratio is projected to fall to 3.2 percent in 2024, based on the technical assumptions in this Financial Report, and projected changes in receipts and outlays, including an estimated decrease in Medicaid outlays as the expiration of temporary measures related to the COVID-19 pandemic winds down. After 2024, increased spending for Social Security and health programs due to the continued retirement of the baby boom generation, is projected to result in increasing primary deficit ratios that peak at 4.4 percent of GDP in 2043. Primary deficits as a share of GDP gradually decrease beyond that point, as aging of the population continues at a slower pace and reach 2.8 percent of GDP in 2098, the last year of the projection period.

Trends in the primary deficit are heavily influenced by tax receipts. The receipt share of GDP was markedly depressed in 2009 through 2012 because of the recession and tax reductions enacted as part of the ARRA and the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010. The share subsequently increased to nearly 18.0 percent of GDP by 2015, before falling to 16.3 percent in 2018, after enactment of the TCJA.

Receipts reached 19.6 percent of GDP in 2022, the highest share of GDP since 2000, then fell to 16.5 percent of GDP in 2023 due to a decrease in individual income tax receipts and lower deposits of earnings by the Federal Reserve. Receipts are projected to gradually increase to 18.1 percent of GDP in 2033 when corporation income tax and other receipts stabilize as a share of GDP. After 2033, receipts grow slightly more rapidly than GDP over the projection period as increases in real (i.e., inflation-adjusted) incomes cause more taxpayers and a larger share of income to fall into the higher individual income tax brackets. 19

On the spending side, the non-interest spending share of GDP was 20.3 percent in 2023, 2.9 percentage points below the share of GDP in 2022, which was 23.2 percent. The ratio of non-interest spending to GDP is projected to fall to 20.1 percent in 2024 and then rise gradually, reaching 23.3 percent of GDP in 2076. The ratio of non-interest spending to GDP then declines to 22.7 percent in 2098, the end of the projection period. These increases are principally due to faster growth in Social Security, Medicare, and Medicaid spending (see Chart 8). The aging of the baby boom generation, among other factors, is projected to increase the spending shares of GDP of Social Security and Medicare by about 0.7 and 1.7 percentage points, respectively, from 2024 to 2040. After 2040, the Social Security and Medicare spending shares of GDP continue to increase in most years, albeit at a slower rate, due to projected increases in health care costs and population aging, before declining toward the end of the projection period.

On a PV basis, deficit projections reported in the FY 2023 Financial Report decreased in both present-value terms and as a percent of the current 75-year PV of GDP. As shown in the SLTFP, this year’s estimate of the 75-year PV imbalance of receipts less non-interest spending is 3.8 percent of the current 75-year PV of GDP ($73.2 trillion), compared to 4.2 percent ($79.5 trillion) as was projected in last year’s Financial Report. As discussed in Note 24, these decreases are attributable to the net effect of the following factors:

Changes due to program-specific actuarial assumptions is the effect of new Social Security, Medicare, and Medicaid program-specific actuarial assumptions, which decrease the fiscal imbalance as a share of the 75-year PV of GDP by 0.6 percentage points ($10.6 trillion). This change is primarily attributable to near-term growth rate assumptions for Medicaid. In the 2022 projections, growth rates through 2027 followed projections in the 2018 Medicaid Actuarial Report. Growth rates for the 2023 projections are based on NHE data and reflect the expiration of temporary measures related to the COVID-19 pandemic.
Changes due to updated budget data increased the fiscal imbalance by 0.4 percentage points ($7.4 trillion). This change stems from actual budget results for FY 2023 and baseline estimates published in the FY 2024 President’s Budget, plus adjustments to discretionary spending and receipts from legislation enacted in the FRA (P.L. 118-5).20 This deterioration in the fiscal position is largely due to a higher 75-year PV of discretionary spending on defense programs and mandatory spending on programs other than Social Security, Medicare, and Medicaid, and lower individual income taxes as a share of wages and salaries. That deterioration is partially offset by a lower 75-year PV of spending on non-defense discretionary programs—attributable to the FRA caps—and higher other receipts.
Changes due to economic and demographic assumptions decreased the fiscal imbalance by 0.3 percentage points ($5.0 trillion). Contributing to this improvement in the imbalance are higher wages that increase receipts and GDP growth rates that lead to reduced spending as a percentage of GDP. The 75-year PV of GDP for this year’s projections is $1,919.1 trillion, greater than last year’s $1,872.9 trillion.
Change in reporting period is the effect of shifting calculations from 2023 through 2097 to 2024 through 2098 and increased the imbalance of the 75-year PV of receipts less non-interest spending by $1.9 trillion, which has a negligible effect on the 75-year PV of GDP.

The net effect of the changes in the table above, equal to the penultimate row in the SLTFP, shows that this year’s estimate of the overall 75-year PV of receipts less non-interest spending is negative 3.8 percent of the 75-year PV of GDP (negative $73.2 trillion, as compared to a GDP of $1,919.1 trillion).

One of the most important assumptions underlying the projections is that current federal policy does not change. The projections are therefore neither forecasts nor predictions, and do not consider large infrequent events such as natural disasters, military engagements, or economic crises. By definition, they do not build in future changes to policy. If policy changes are enacted, perhaps in response to projections like those presented here, then actual fiscal outcomes will be different than those projected.

Another important assumption is the future growth of health care costs. As discussed in Note 25, these future growth rates – both for health care costs in the economy generally and for federal health care programs such as Medicare, Medicaid, and PPACA exchange subsidies – are highly uncertain. In particular, enactment of the PPACA in 2010 and the MACRA in 2015 lowered payment rate updates for Medicare hospital and physician payments whose long-term effectiveness of which is not yet clear. The Medicare spending projections in the long-term fiscal projections are based on the projections in the 2023 Medicare Trustees Report, which assume the PPACA and MACRA cost control measures will be effective in producing a substantial slowdown in Medicare cost growth.

As discussed in Note 25, the Medicare projections are subject to much uncertainty about the ultimate effects of these provisions to reduce health care cost growth. Certain features of current law may result in some challenges for the Medicare program including physician payments, payment rate updates for most non-physician categories, and productivity adjustments. Payment rate updates for most non-physician categories of Medicare providers are reduced by the growth in economy-wide private nonfarm business total factor productivity although these health providers have historically achieved lower levels of productivity growth. Should payment rates prove to be inadequate for any service, beneficiaries’ access to and the quality of Medicare benefits would deteriorate over time, or future legislation would need to be enacted that would likely increase program costs beyond those projected under current law. For the long-term fiscal projections, that uncertainty also affects the projections for Medicaid and exchange subsidies, because the cost per beneficiary in these programs is assumed to grow at the same reduced rate as Medicare cost growth per beneficiary. Other key assumptions, as discussed in greater detail in Note 24—Long-Term Fiscal Projections, include the following:

Medicaid spending projections start with the NHE projections which are based on recent trends in Medicaid spending, as well as Trustees Report assumptions. NHE projections, which end in 2031, are adjusted to accord with the actual Medicaid spending in FY 2023. After 2031, the number of beneficiaries is projected to grow at the same rate as total population. Medicaid cost per beneficiary is assumed to grow at the same rate as Medicare benefits per beneficiary after 2034, after a three-year phase-in to the Medicare per beneficiary growth rate over the period 2032-2034. The most recent Social Security and Medicare Trustees Reports were released in March 2023.
Other mandatory spending includes federal employee retirement, veterans’ disability benefits, and means-tested entitlements other than Medicaid. Current mandatory spending components that are judged permanent under current policy are assumed to increase by the rate of growth in nominal GDP starting in 2024, implying that such spending will remain constant as a percent of GDP.
Defense and non-defense discretionary spending follows the FRA caps through 2025, then grows with GDP starting in 2026.
Debt and interest spending is determined by projected interest rates and the level of outstanding debt held by the public. The long-run interest rate assumptions accord with those in the 2023 Social Security Trustees Report. The average interest rate over this year’s projection period is 4.5 percent, approximately the same as the 2022 Financial Report. Debt at the end of each year is projected by adding that year’s deficit and other financing requirements to the debt at the end of the previous year.
Receipts (other than Social Security and Medicare payroll taxes) is comprised of individual income taxes, corporate income taxes and other receipts.
- Individual income taxes were based on the share of individual income taxes of salaries and wages in the current law baseline projection in the FY 2024 President’s Budget, and the salaries and wages projections from the Social Security 2023 Trustees Report. That baseline accords with the tendency of effective tax rates to increase as growth in income per capita outpaces inflation (also known as “bracket creep”) and the expiration dates of individual income and estate and gift tax provisions of the TCJA. Individual income taxes are projected to increase gradually from 19 percent of wages and salaries in 2024, to 29 percent of wages and salaries in 2098 as real taxable incomes rise over time and an increasing share of total income is taxed in the higher tax brackets.
- Corporation tax receipts as a percent of GDP reflect the economic and budget assumptions used in developing the FY 2024 President’s Budget ten-year baseline budgetary estimates through the first ten projection years, after which they are projected to grow at the same rate as nominal GDP. Corporation tax receipts fall from 1.7 percent of GDP in 2024 to 1.2 percent of GDP in 2033, where they stay for the remainder of the projection period.
- Other receipts, including excise taxes, estate and gift taxes, customs duties, and miscellaneous receipts, also reflect the FY 2024 President’s Budget baseline levels as a share of GDP throughout the budget window, and grow with GDP outside of the budget window. The ratio of other receipts, to GDP is estimated to increase from 1.1 percent in 2024 to 1.2 percent by 2027 where it remains through the projection period.
Projections for the other categories of receipts and spending are consistent with the economic and demographic assumptions in the Trustees Reports and include updates for actual budget results for FY 2023 or budgetary estimates from the FY 2024 President’s Budget.

The primary deficit-to-GDP projections in Chart 8, projections for interest rates, and projections for GDP together determine the debt-to-GDP ratio projections shown in Chart 9.That ratio was approximately 97 percent at the end of FY 2023 and under current policy is projected to exceed the historic high of 106 percent in 2028, rise to 200 percent by 2047 and reach 531 percent by 2098. The change in debt held by the public from one year to the next generally represents the budget deficit, the difference between total spending and total receipts. The debt-to-GDP ratio rises continually in great part because primary deficits lead to higher levels of debt, which lead to higher net interest expenditures, and higher net interest expenditures lead to higher debt.21 The continuous rise of the debt-to-GDP ratio indicates that current policy is unsustainable.

These debt-to-GDP projections are lower than the corresponding projections in both the 2022 and 2021 Financial Reports. For example, the last year of the 75-year projection period used in the FY 2021 Financial Report is 2096. In the FY 2023 Financial Report, the debt-to-GDP ratio for 2096 is projected to be 518 percent, which compares with 559 and 701 percent for the 2096 projection year in the FY 2022 Financial Report and the FY 2021 Financial Report, respectively.22

The Fiscal Gap and the Cost of Delaying Policy Reform

The 75-year fiscal gap is one measure of the degree to which current policy is unsustainable. It is the amount by which primary surpluses over the next 75 years must, on average, rise above current-policy levels in order for the debt-to-GDP ratio in 2098 to remain at its level in 2023. The projections show that projected primary deficits average 3.8 percent of GDP over the next 75 years under current policy. If policies were adopted to eliminate the fiscal gap, the average primary surplus over the next 75 years would be 0.6 percent of GDP, 4.5 percentage points higher than the projected PV of receipts less non-interest spending shown in the financial statements. Hence, the 75-year fiscal gap is estimated to equal to 4.5 percent of GDP. This amount is, in turn, equivalent to 23.8 percent of 75-year PV receipts and 19.8 percent of 75-year PV non-interest spending. This estimate of the fiscal gap is 0.4 percentage points smaller than was estimated in the FY 2022 Financial Report (4.9 percent of GDP).

In these projections, closing the fiscal gap requires running substantially positive primary surpluses, rather than simply eliminating the primary deficit. The primary reason is that the projections assume future interest rates will exceed the growth rate of GDP. Achieving primary balance (that is, running a primary surplus of zero) implies that the debt grows each year by the amount of interest spending, which under these assumptions would result in debt growing faster than GDP.

Medicare, Social Security will need $175 trillion more to cover today’s children

Addie Thompson — Fri, 12 Apr 2024 17:52:25 GMT

Topline: It will take an extra $175.3 trillion to keep Medicare and Social Security intact for when today’s children reach old age, according to OpenTheBooks’ analysis of the nation’s latest financial report.

Key facts: The Treasury Department projected spending over the “infinite horizon,” or the lifetime of everyone in the country today.

It projects that current participants in Medicare and Social Security will collect $105.4 trillion more in benefits from the programs than they contribute into them through payroll taxes.

Future participants, who are younger than 15 and even in the womb, will use up $69.9 trillion more than they pay in taxes.

Combined, that’s an unfathomable $175.3 trillion gap that can only be closed with “increased borrowing, higher taxes, reduced program spending or some combination,” according to the Treasury.

There’s no easy way to put that number in context. The national debt is “only” $34 trillion. The federal government has spent roughly $200 trillion on everything since the Constitution was written in 1787, even adjusted for inflation.

Medicare Part B, which covers doctor’s visits and medical equipment, is the largest liability. It’s expected to be underfunded by $99.5 trillion.

Social Security needs an extra $68.8 trillion to be solvent.

Background: Medicare and Social Security are supposed to fully fund themselves through payroll taxes, health care premiums and benefit taxes, a process that worked well until the 1980s.

Former President Ronald Reagan, among others, warned of the looming funding crisis and encouraged Congress to pass the Social Security Reform Act of 1983.

But since then, the system has remained largely untouched.

Medicare spending was equal to 2.9% of the U.S. GDP in 2022, but the Congressional Budget Office expects it to reach 5.9% of GDP by 2052. Social Security spending is projected to rise from 4.9% to 6.4%.

Medicare is expected to start cutting benefits in seven years, but the long-term implications are much more serious. The Treasury is required by U.S. law to borrow money if there is not enough to pay for Medicare and Social Security, which may soon be impossible without multiplying the federal debt.

Summary: There’s no realistic path toward generating the amount of money needed to avoid slashing Medicare and Social Security payments. Politicians have deferred having this difficult conversation for decades, but soon that will no longer be an option.

The #WasteOfTheDay is brought to you by the forensic auditors at OpenTheBooks.com

ACA Marketplace hits 10th birthday; 21 million enrolled

Addie Thompson — Sun, 31 Mar 2024 23:38:53 GMT

Today, the U.S. Department of Health and Human Services (HHS) issued four new reports showing that President Biden’s efforts to strengthen the Affordable Care Act (ACA) are linked to historic gains in Americans’ health insurance coverage. Today’s announcements include a report from the Centers for Medicare & Medicaid Services (CMS) showing that over 21 million consumers selected or were automatically re-enrolled in health insurance coverage through HealthCare.gov and State-based Marketplaces during 2024’s Open Enrollment Period (OEP). Three reports from HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) highlight current enrollment trends, enrollment trends broken down by race and ethnicity, and how the ACA Marketplaces have evolved and strengthened during the first ten years. ASPE analysis shows that today over 45 million people have coverage thanks to the Affordable Care Act’s Marketplaces and Medicaid expansion.

“On the ten-year anniversary of the ACA Marketplaces, HHS is releasing data that shows just how profoundly it has reshaped what health care looks like for so many Americans. The Marketplaces have become a pillar of American society, a guaranteed place where people can find affordable, quality coverage,” said HHS Secretary Xavier Becerra. “Thanks to President Biden’s leadership, more than 21 million Americans have health insurance through the Affordable Care Act Marketplaces, an all-time high, with millions of families saving hundreds of dollars every month. At HHS, we will keep doing everything we can to ensure more people have access to affordable, high-quality health care and the peace of mind that comes with it.”

“As we look back and celebrate the historic achievements of the Affordable Care Act, the law continues to live up to its purpose of providing affordable, quality health care coverage to Americans. Gone are the days when being a woman was considered a pre-existing condition or sick children could be denied health insurance. Today, over 100 million Americans have coverage through either Marketplace or Medicaid, thanks (in part) to increased affordability thanks to the Inflation Reduction Act,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure. “And we’re not stopping. Our commitment to strengthening the ACA and increasing access to affordable, comprehensive health care coverage has never been stronger.”

The Biden-Harris Administration has taken unprecedented action to make health insurance available and affordable to everyone. National estimates show that most consumers qualified for $0 premiums or are saving at least $800 a year on their premium, underscoring the importance of the American Rescue Plan and Inflation Reduction Act. Overall, four in five HealthCare.gov customers were able to select from health care coverage options that were $10 or less per month. Additionally, the Biden-Harris Administration issued almost $100 million for organizations to hire staff to help consumers find affordable, comprehensive health coverage. Navigators, as they are known, have been key to helping consumers in every state.

Key points from today’s reports include the following.

2024: Total Marketplace Plan Selections During 2024 Open Enrollment Period - PDF

During the 2024 Open Enrollment Period (OEP), over 21.4 million consumers selected or were automatically re-enrolled in health insurance coverage through HealthCare.gov Marketplaces and State-Based Marketplaces (SBMs).
5.1 million more consumers signed up for coverage during the 2024 OEP compared to the 2023 OEP, a 31% increase.
In HealthCare.gov Marketplaces, 16.4 million consumers selected plans during the 2024 OEP between November 1, 2023 and January 16, 2024.
Across the 19 SBMs, 5.1 million consumers selected plans during the 2024 OEP from November 1, 2023 through the end of their respective OEPs.
5.2 million people who signed up for coverage did so for the first time, a 41% increase from 3.7 million during the previous OEP.
Nationwide, 44% of consumers selected a plan for $10 or less per month after APTC during the 2024 OEP.

2024: Coverage Under the Affordable Care Act: Current Enrollment Trends and State Estimates

18.6 million people have coverage thanks to the ACA’s Medicaid expansion.
Across coverage groups, a total of 45 million Americans are enrolled in coverage related to the ACA, the highest total on record. This represents 14.1 million more people enrolled than in 2021 (a 46% increase) and 32.5 million more people enrolled than in 2014 (a 258% increase, or more than triple).
Survey results indicate that all 50 states and the District of Columbia have experienced substantial reductions in their uninsured rates since 2013, the last year before implementation of the ACA.

2015-2023: ASPE Marketplace Enrollment by Race and Ethnicity Issue Brief

Biden-Harris Administration policies – such as expanded and enhanced premium tax credits under the American Rescue Plan and the Inflation Reduction Act and increased Marketplace outreach and Navigator funding – likely contributed to gains in health coverage, particularly among low-income populations and communities of color.
Black Americans and Latinos continued to enroll in health coverage through the Marketplace at high rates. An estimated 1.7 million Black people and 3.4 million Latino people enrolled in Marketplace plans in HealthCare.gov states during the 2023 Open Enrollment Period, representing enrollment increases of 95% and 103% respectively since 2020.
The number of Asian-American, Native Hawaiian, and Pacific Islander (AANHPI) enrollees increased by 14 percent between 2020 and 2023.
Over half of Black, Latino, and Asian American enrollees select silver plans with cost sharing reductions, making it the most frequently selected plan. These plans with cost sharing reductions allow patients below a certain income to pay less out of pocket each time they receive medical services.

2014-2024: How the ACA Marketplaces have evolved in 10 years

The ACA substantially transformed health insurance by creating Health Insurance Marketplaces where consumers can shop for private comprehensive coverage that meets consumer protection and coverage standards
The number of issuers participating in Marketplaces has grown in recent years providing nearly all Marketplace consumers (96 percent) with a choice of plan offerings of at least three different issuers. This increase in market competition has contributed to premiums that are more affordable for both enrollees and taxpayers. In 2024, 210 health insurance issuers are participating in Marketplaces.
Between 2013 and the third quarter of 2023, the uninsured rate for all ages fell from 14.4 percent to 7.7 percent. Since 2013, the uninsured rate for children has decreased from 6.5 percent to 3.4 percent in 2023.
The ACA brought key consumer protections, such as preventing consumers from getting denied or charged more for coverage due to pre-existing conditions, age, and gender.
- For example, prior to the ACA, 92 percent of popular plans used gender rating. A woman could pay as much as 81 percent more for the same plan as a man of the same age, even without the plan covering maternity care
Prior to the ACA, health plans also often limited the benefits they covered. In 2011, 62 percent of individual market enrollees did not have coverage for maternity services, 34 percent did not have coverage for substance use disorder services, 18 percent did not have coverage for mental health services, and nine percent of enrollees did not have coverage for prescription drugs.

The Affordable Care Act has not been affordable for taxpayers

Addie Thompson — Sun, 31 Mar 2024 23:37:46 GMT

The Affordable Care Act (ACA), better known as Obamacare, turns 14 this Saturday. Its proponents claimed the ACA would lower costs and make health care more affordable. But after 14 years the data tell a different story.

Former President Barack Obama signed the ACA into law on March 23rd, 2010. His administration wanted to make health care “a right for every American”, and in typical government fashion that meant spending a lot of taxpayer money. The ACA’s subsidies have obscured the program’s true costs, and its impact on insurance coverage has fallen short of projections.

A study from Paragon Health Institute shows that while 19 million additional people got health insurance coverage after the ACA went into effect, only about 2 million got private insurance. The remaining 17 million were covered under the act’s Medicaid expansion provisions. The Congressional Budget Office (CBO) initially projected that the ACA would increase coverage by 25 million people, evenly split between private coverage and Medicaid expansion. However, as shown in the figure below, the percentage of people with private insurance coverage (blue line) has been flat.

One way to get private insurance is to buy a plan from an ACA exchange. The exchanges are websites operated by some states or the federal government where people can purchase ACA-compliant insurance plans. Competition was supposed to keep prices in check, but premiums continue to increase. The CBO estimated that exchange enrollees would cost federal taxpayers $6,850 each by 2021. In reality, each new enrollee cost taxpayers $20,739, or over three times as much. Given this high cost, perhaps taxpayers should be thankful enrollment has fallen short of expectations.

The ACA has cost taxpayers in other ways. It significantly expanded Medicaid, which provides health insurance to lower-income Americans, children, and disabled adults. Under the ACA, Medicaid eligibility was expanded to non-disabled, working-age adults earning up to 138% of the federal poverty line. To entice states to expand Medicaid, the ACA also increased the federal match given to states to offset the program’s cost, known as the federal medical assistance percentage (FMAP). The FMAP is typically based on a state’s per capita income, with wealthier states getting a smaller percentage than poorer states.

For people newly eligible under the Medicaid expansion the FMAP increased to 100% from 2014 to 2016 for all states, regardless of per capita income. After that, it declined until it hit 90% in 2020 for all states, where it remains. Forty states plus Washington, D.C., have expanded their Medicaid programs to take advantage of the federal subsidy.

Florida is one of the ten holdouts, and for good reason. In a recent study, Brian Blase and Drew Gonshorowski note that Medicaid is now the largest program in state budgets, exceeding spending on K-12 education. In 2022, Florida spent $38.3 billion on Medicaid but only $25 billion on education. Even without expansion, Medicaid spending drives most of the growth in government spending in Florida, as shown in the figure below. Expanding Medicaid would accelerate this trend.

Nation’s Medicaid disenrollments surpass 18M, exceeding HHS projections

Addie Thompson — Sun, 31 Mar 2024 23:36:55 GMT

March 25, 2024 - The Families First Coronavirus Response Act required Medicaid to provide continuous coverage for beneficiaries throughout the COVID-19 pandemic. With disenrollments paused, Medicaid and the Children’s Health Insurance Program (CHIP) enrollment grew by over 23 million beneficiaries.

The continuous coverage policy ended with the public health emergency, and states could begin coverage redeterminations on April 1, 2023. HHS had projected that 15 million beneficiaries would lose Medicaid coverage. However, as of March 20, 2024, more than 18 million people have been disenrolled. What’s more, 35 million beneficiaries’ eligibility redeterminations have either still not been completed or have not been reported.

Disenrollment numbers and processes have varied across states. Starting from April 2023, states have up to twelve months to initiate redeterminations. Some states began disenrollments in April, while others waited until May, June, or July. Oregon did not resume coverage determinations until October.

“Medicaid unwinding has been a massive undertaking for states,” Louise Norris, a health policy analyst for healthinsurance.org, said. “Not only do states have to redetermine eligibility for the record-high number of people enrolled in Medicaid, but they also have to continue to process new applications.”

Texas has disenrolled the most Medicaid beneficiaries so far at 2 million, while Wyoming has disenrolled the fewest number at 5,300 beneficiaries, according to KFF data. Utah has disenrolled the highest percentage of its completed Medicaid redeterminations (57 percent), and Maine has disenrolled the lowest percentage (12 percent).

Since the Medicaid unwinding started, coverage has been renewed for 40 million beneficiaries. Most renewals did not require beneficiaries to provide any information to confirm their eligibility, but 40 percent of cases required individuals to complete a renewal packet for confirmation.

The majority of disenrollments were due to procedural reasons, meaning beneficiaries did not complete the required renewal process to maintain coverage. These beneficiaries may have misunderstood the process, not had the resources to complete it, or may not even know they had to complete anything.

Many people who lost Medicaid eligibility are now eligible for an employer-sponsored health plan. Individuals have also transitioned to marketplace coverage. Through November 2023, nearly 2.3 million people moved from Medicaid to a marketplace plan, while 229,000 had transitioned to Basic Health Program coverage.

Disenrolled beneficiaries moving to a marketplace plan can enroll before July 31, 2024, as part of an extended unwinding special enrollment period. These individuals may qualify for premium subsidies to offset costs.

Congress tries again to increase Medicaid spending for behavioral health

Addie Thompson — Sun, 31 Mar 2024 23:34:33 GMT

Federal lawmakers are taking another stab at increasing funding for behavioral health expenditures in the Medicaid program.

A version of the Medicaid Bump Act was introduced in the U.S. Senate and Congress on March 12. The bill would create financial incentives for states to elevate spending on behavioral health beyond levels in 2019. Specifically, it would create an enhanced Federal Medical Assistance Percentage (FMAP) rate of 90% for mental health and substance use disorder (SUD) treatment.

States and their Medicaid programs would not be allowed to use the additional federal money to replace state funding levels. The new funds would be used to increase the capacity, efficiency and quality of behavioral health within Medicaid provider networks, according to a news release.

“Unfortunately, systemic underinvestment has left far too many out in the cold and without a place to seek these vital resources,” Rep. Paul Tonko (D-N.Y.) said in a news release. “Our Medicaid Bump Act begins to right that wrong, bolstering availability for providers by increasing the federal reimbursement rate for mental and behavioral health care services under Medicaid.”

About 40% of those on Medicaid have behavioral health conditions.

Sen. Tina Smith (D-Minn.) and Sen. Debbie Stabenow (D-Mich.) are the sponsors of the bill’s Senate version. Tonko filed an equivalent bill in the House in July 2023. He is joined by co-sponsors Rep. Brian Fitzpatrick (R-Penn.) and Rep. David Trone (D-Md.).

“As Co-Chair of the Bipartisan Mental Health and Substance Use Disorder Task Force, I’m proud to co-lead this bipartisan, bicameral legislation that will provide an incentive for states to increase their Medicaid spending on behavioral health services in order to expand access to care in areas where the demand outstrips the supply of service providers,” Fitzpatrick said in the release.

The bill would charge the Secretary of Health and Human Services (HHS) to define which services qualify as eligible behavioral health services for the enhanced FMAP. It would also enact an annual reporting requirement detailing the impact of the funding increase on behavioral health utilization.

Legislation that would have had a similar effect and used the same name first popped up in Congress in 2017, according to a cursory review of the legislative body’s website. At that time, then-Rep. Joe Kennedy III sponsored the bill. He filed it again in 2019. Tonko and Smith took up the legislation in 2021. Tonko refiled in 2023.

Medicaid has seen greater reform attention during the Biden administration. A recent funding bill made certified community behavioral health centers (CCBHCs) permanent by amending the Social Security Act. In February, The Centers for Medicare and Medicaid (CMS) released new guidance to state Medicaid directors on allowing master’s-level social workers, marriage and family therapists, and other master’s level behavioral health clinicians greater participation in Medicaid.

However, other analyses highlight gaps in the system. A review of the Medicaid program found that about 75% of states are missing “core” behavioral health crisis response services.

Medicaid, Medicare made $100B in improper payments in 2023

Addie Thompson — Sun, 31 Mar 2024 23:33:39 GMT

The federal government reported an estimated $235.8 billion in improper payments in fiscal year 2023, with more than $100 billion coming from Medicare and Medicaid, according to a March 26 report from the U.S. Government Accountability Office.

The $235.8 billion in improper payments reported by 14 agencies across 71 programs is a decrease from the $247 billion reported in 2022, but the figure remains higher than pre-pandemic levels, according to the report.

Of the total improper payments, $175 billion of the errors were overpayments, such as payments to deceased individuals or those longer eligible for the programs, according to the report. Underpayments comprised $11.5 billion of the payment errors, and $44.6 billion were unknown payments, meaning it is unclear whether a payment was an error.

Medicare payment errors decreased by $30 billion to $51.1 billion in 2023, according to the report. Medicaid payment errors totaled $50.3 billion in 2023.

The GAO said it has previously made recommendations to help reduce errors and "many of those recommendations still require action from agency leaders." Among those recommendations is that Medicare could improve communication around its prior authorization program, which could reduce expenses and improper payments. The GAO also said Medicaid could improve oversight to ensure claims aren't paid to ineligible providers, such as those who have suspended or revoked medical licenses.

Five things to know about Medicaid

Addie Thompson — Fri, 01 Mar 2024 19:51:44 GMT

You may know that while Medicare offers health insurance for older people, Medicaid offers health coverage for low-income folks. As you get older, you may occasionally run across information on Medicare and increasingly pay attention, as it will be important come age 65.

But it's worth learning more about Medicaid, too -- because it might be quite valuable to you right now, or to someone you care about. It's more interesting than you might have thought, as well.

1. Medicaid is different from Medicare in many ways

The two programs' names are similar, but they're actually quite different.

MEDICARE

One thing the two programs have in common is that they're rather critical for the people they serve. We all need healthcare, after all, and people with low incomes or retired people often wouldn't be able to secure it without Medicaid or Medicare.

2. Medicaid is a joint project of the federal government and the 50 states

As you might have deduced from the chart above, Medicaid is brought to you by the federal government and each of the 50 states. The federal government pays close to 70% of the total cost of the program, with states making up the difference from their own budgets.

Each state runs its own Medicaid program, often with its own unique name. Each state also sets its own eligibility requirements and determines what coverage it will offer -- but each state must also follow federal guidelines for minimum coverage and eligibility. Each state also sets payment rates. Medicaid programs are required to cover physician and hospital services, lab work and X-rays, nurse midwife services, home health services, and even transportation to medical care, among other things.

Interestingly, when Medicaid debuted in 1965, states were not required to provide it. But within its first few years, almost all states had signed on, and by the 1980s, all states were participating.

3. Medicaid costs a lot

We all know that healthcare in America is extremely costly. Indeed, in fiscal 2023, the federal government spent $6.4 trillion, and fully $1.9 trillion, or 29%, was for health programs and services. That's just government spending. In total, the U.S. was expected to lay out $4.7 trillion for healthcare in 2023, per the Peter G. Peterson Foundation.

Given all that, know that Medicaid represents $1 out of every $6 spent on healthcare in America. Yikes! Specifically, Medicaid cost a total of $824 billion in fiscal 2022.

The program costs each state a lot, too -- ranging from about 12% to 15% of the state budget (for, respectively, Wyoming and Hawaii) to 39% (Ohio) and 40% (Pennsylvania and Texas). The average percentage nationally was roughly 29%.

4. Medicaid is mostly free for participants

It makes sense that Medicaid is free or costs extremely little for the people it serves. After all, most have very low incomes, among other challenges. Specifically, most covered services cost enrollees nothing, with certain services or products costing a modest co-payment.

This low cost to enrollees partly explains the high cost to each state and the federal government.

5. Medicaid is a vital social safety net

Perhaps the best thing about Medicaid is that it's a social safety net -- and the "payer of last resort." If you fall on hard times and can't afford healthcare, at some point you will likely be eligible for Medicaid. That effect occurs nationally, too -- during a recession, for example, if millions lose jobs, then the ranks of Medicaid will grow as the program steps in to cover those folks.

Since it's a government program, it can also be used as a tool for promoting and protecting public health. For example, during the early years of the COVID-19 pandemic, Congress passed the Families First Coronavirus Response Act that boosted the Medicaid dollars available to states in exchange for the program not disenrolling enrollees during the Public Health Emergency phase of the crisis.

Keep this information in mind -- because at some point in your life, you might need Medicaid, and you should know that it exists for those in need. You might even know a loved one right now who isn't enrolled in, but could qualify for and greatly benefit from, Medicaid.

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One week after Senate approval, SC House passes bill to restructure health agencies

Addie Thompson — Fri, 01 Mar 2024 19:50:37 GMT

COLUMBIA, S.C. (WCSC) - A push to majorly restructure how health services are delivered to millions of South Carolinians cleared a big hurdle Wednesday at the State House.

After a five-plus-hour debate, the House of Representatives approved a bill, H.4927, to merge several state agencies into one, a week after the Senate passed similar legislation.

The bill is the second step in a massive reorganization that started last year, when the legislature passed a new law to split the Department of Health and Environmental Control, DHEC, into two new state agencies.

As part of that legislation, the state’s Department of Administration contracted with Boston Consulting Group last year to study whether more changes to agency structure would benefit South Carolinians.

Boston Consulting Group’s study of South Carolina’s healthcare delivery system found it is the most fragmented model in the country.

Lawmakers said that leads to people falling through the gaps when these agencies fail to coordinate as well as they could.

“They’ll come in with a mental health issue and a drug problem, and … it’s one of these where they’re sent somewhere else. So there’s no economy of scales right there, but also two, it’s the worst thing we can do for our constituents if we’re putting money in this to get them well,” Rep. Bill Herbkersman (R-Beaufort) and the sponsor of the House bill, said during Wednesday’s debate.

This bill is intended to streamline that by combining six separate state agencies into one, a new “Executive Office of Health and Policy.”

This office would merge the existing Departments of Alcohol and Other Drug Abuse Services, Disabilities and Special Needs, Health and Human Services, Mental Health, and Aging, plus the new Department of Public Health that will be created this summer when DHEC splits.

Under the bill, a new Secretary of Health and Policy would lead the new agency. That person would be a member of the governor’s cabinet and appointed by the governor, with senators’ approval.

“So that we can streamline the state agencies’ structure and roles,” Rep. Jay Jordan (R-Florence, said.) “This will hopefully allow to build a strategic plan and an operating approach so these healthcare services can be delivered in a more efficient manner.”

But members of the ultraconservative Freedom Caucus opposed the consolidation, saying it would give one person, the new agency’s secretary, too much power.

“What it’s going to end up being is centralization of power. It’s putting all the medical bureaucrats under one chief bureaucrat,” Rep. Josiah Magnuson, R – Spartanburg, said.

Many of their concerns focused on giving this new secretary the authority to command sheriffs and local law enforcement to enforce mandates during times of public health emergencies, an authority the director of DHEC has under the current structure.

Magnuson proposed an amendment that would allow the secretary to request law enforcement’s assistance but not compel it. That change was not adopted.

Rep. Micah Caskey, R – Lexington, noted law enforcement is not trained to determine what does and does not qualify as a public health emergency.

Caskey pointed to previous pandemics, epidemics, and outbreaks, when such enforcement has been needed to address these emergencies, including the 2013 tuberculosis outbreak in Greenwood County. During that period, DHEC issued a public health order that mandated people who tested positive for the disease comply with certain directives or else face arrest.

“Public health authorities need authority to act because they are not law enforcement officers themselves. They cannot take independent action to compel or restrict behaviors, which are subject to the public health directives that they have issued,” Caskey said.

The House ultimately approved the bill in a 100-17 vote, but the legislation must still clear a few more steps to reach the governor’s desk because the House and Senate passed separate bills, though they include similar language.

Gov. Henry McMaster has urged this consolidation, calling it one of the most important bills the legislature can take up this year.

SC lawmakers file bill to protect IVF services in state

Addie Thompson — Fri, 01 Mar 2024 19:49:30 GMT

COLUMBIA, S.C. (WCSC) - After a court ruling in Alabama left in vitro fertilization services there in limbo, other states, including South Carolina, are grappling with whether the same could happen to them.

Now lawmakers in Columbia are taking action.

On Thursday, legislators gathered to announce bills they have filed in light of the Alabama ruling, with some sharing their own experiences with what can be a challenging and expensive procedure that is ultimately worth it for so many families.

It’s why they said they filed bills to protect IVF across South Carolina.

“To rip away the ability of parenthood is heartless, cruel, and unacceptable. This is personal for me. But for IVF, my family would not have the opportunity to expand,” Rep. Kambrell Garvin (D-Richland) and the lead sponsor of the House bill, said during a news conference.

This week, bills have been filed in both the House and the Senate and referred to their respective judiciary committees.

The bills’ sponsors are predominantly Democrats, with some Republican support.

But one leading Republican lawmaker said this legislation is not needed.

“What played out in Alabama can’t play out in South Carolina,” Senate Majority Leader Shane Massey (R-Edgefield) told reporters Wednesday.

Massey said he was not concerned, pointing to how Alabama has enacted a ban on abortion from conception, while South Carolina has a ban from six weeks into a pregnancy.

“That is what was a big part of the Supreme Court opinion down there. That’s not what our law is,” Massey said. “I am confident that IVF is protected in South Carolina.”

But supporters of these bills point to South Carolina’s existing abortion law, the six-week ban, also known as the “Fetal Heartbeat Law.”

It defines “unborn child” as “an individual organism of the species homo sapiens from conception until live birth,” and “conception” as “fertilization of an ovum by sperm.”

They said by those definitions, conception is happening outside the uterus through IVF.

“If the court looked at our statutes the way that the Alabama Supreme Court looked at their statute, there is, in fact, an interpretation that would lead them to be able to say the very same thing, that IVF in this state would be wrong because they could consider an embryo to be a child,” House Minority Leader Todd Rutherford (D-Richland) said.

These bills aim to protect IVF by codifying in state law that any fertilized human egg or human embryo that exists in any form outside the uterus shall not be considered an unborn child.

Without this addition, they argued IVF could be threatened in South Carolina.

“Family matters. We need to protect a family’s right to have in vitro fertilization,” Sen. Margie Bright Matthews (D-Colleton) and the lead sponsor of the Senate bill, said during Thursday’s news conference.

Gov. Henry McMaster told reporters Thursday afternoon that he had not yet read the bills or the Alabama court’s decision.

“But I think anything to allow and protect the ability of parents, people who want to be parents, to be parents, to have beautiful babies is a good thing,” McMaster said.

Congratulations to SCAHP Board President Courtnay Thompson

Addie Thompson — Thu, 29 Feb 2024 18:51:01 GMT

COLUMBIA, SC, February 28, 2024 — The South Carolina Alliance of Health Plans is proud to announce that Board President, Courtnay Thompson, Market President at Select Health of South Carolina, has been selected to Modern Healthcare Magazine’s inaugural class of “40 Under 40” notable young executives who are influencing the future of healthcare. (https://www.modernhealthcare.com/awards/40-under-40-2024).

Ms.Thompson was Select Health’s youngest market president when she took the job in 2018. She has shown exceptional leadership in all of her roles at the company. Courtnay credits female colleagues with mentoring her, and she hopes to carry that forward for others. Her approach is often influenced by her background in nursing, as well, she said.

"We are very proud of Courtnay for receiving this national industry award. As the South Carolina Alliance of Health Plans' President, she provides excellent leadership and encourages strong collaboration among our members to advance the organization. We are pleased that Modern Healthcare recognized her early leadership on a national scale, and we are confident that Courtnay's impact will be even greater in the years to come." Jim Ritchie, Executive Director, SCAHP.

In the South, lawmakers rethink Medicaid expansion

Addie Thompson — Fri, 23 Feb 2024 19:37:23 GMT

By Daniel Chang and Andy Miller | KFF Health News

As a part-time customer service representative, Jolene Dybas earns less than $15,000 a year, which is below the federal poverty level and too low for her to be eligible for subsidized health insurance on the Obamacare marketplace.

Dybas, 53, also does not qualify for Medicaid in her home state of Alabama because she does not meet the program requirements. She instead falls into a coverage gap and faces hundreds of dollars a month in out-of-pocket payments, she said, to manage multiple chronic health conditions.

“I feel like I’m living in a state that doesn’t care for me,” said Dybas, a resident of Saraland, a suburb of Mobile.

Alabama is one of 10 states that have refused to adopt the Affordable Care Act’s expansion of Medicaid, the government health insurance program for people who are low-income or disabled.

But lawmakers in Alabama and some other Southern states are reconsidering their opposition in light of strong public support for Medicaid expansion and pleas from powerful sectors of the health care industry, especially hospitals.

Expansions are under consideration by Republican legislative leaders in Georgia and Mississippi, in addition to Alabama, raising the prospect that more than 600,000 low-income, uninsured people in those three states could gain coverage, according to KFF data.

Since a 2012 Supreme Court ruling rendered the ACA’s Medicaid expansion optional, it has remained a divisive issue along party lines in some states. Political opposition has softened, in part because North Carolina’s Republican-controlled legislature voted last year to expand the program. Already, more than 346,000 residents of the Tar Heel State have gained coverage.

And lawmakers in nearby states are taking notice.

“There has certainly been a lot of discussion of late about Medicaid expansion,” said Georgia House Speaker Jon Burns, a Republican, in a speech to the state chamber of commerce shortly after the legislative session began on Jan. 8.

“Expanding access to care for lower-income working families through a private option — in a fiscally responsible way that lowers premiums — is something we will continue to gather facts on in the House,” Burns said.

In addition to Georgia, state House speakers in Alabama and Mississippi have indicated a new willingness to consider coverage expansion. All three states have experienced a large number of hospital closures, particularly in rural areas.

Medicaid expansion has become “politically safer to consider,” said Frank Knapp, president of South Carolina’s Small Business Chamber of Commerce. In his state, Republican lawmakers are weighing whether to appoint a committee to study expansion.

It’s the kind of momentum some health policy analysts view as a favorable shift in the political discourse about expanding access to care. And it comes as a new crop of conservative leaders grapple with their states’ persistently high rates of poor, uninsured adults.

An additional incentive: Under President Joe Biden’s 2021 American Rescue Plan Act, the federal government pays newly expanded states an additional 5 percentage points in the matching rate for their regular Medicaid population for two years, which would more than offset the cost of expansion for that period.

But even as new discussions take place in legislatures that once froze out any talk of Medicaid expansion, considerable obstacles remain. Republican Mississippi Gov. Tate Reeves, for example, still opposes expansion. And several nonexpansion states appear to have little to no momentum.

“A lot of things need to come together in any given state to make things move,” said Robin Rudowitz, director of the Program on Medicaid and the Uninsured at KFF.

Under Medicaid expansion, adults earning up to 138% of the federal poverty level, or about $35,600 for a family of three, qualify for coverage.

Expansion has reduced uninsured rates in rural areas, improved access to care for low-income people, and lowered uncompensated care costs for hospitals and clinics, according to KFF analyses of studies from 2014 to 2021. In states that have refused to expand Medicaid, all of those challenges remain acute.

Alabama’s legislative session began Feb. 6. Republican House Speaker Nathaniel Ledbetter has suggested that he’s open to debating options for increased coverage. So many hospitals are in “dire straits,” he said at a Montgomery Area Chamber of Commerce meeting in January. “We’ve got to have the conversation.”

Expansion could make as many as 174,000 uninsured people in Alabama eligible for coverage, according to KFF data. Still, Ledbetter prefers a public-private partnership model, and has looked at Arkansas’ program, which uses federal and state money to pay for commercial insurance plans on the Obamacare marketplace for people who would be eligible for Medicaid under expansion.

In Alabama, lawmakers have introduced a plan that would levy a state tax on gaming revenue and could help fund health insurance coverage for adults with annual incomes up to 138% of the federal poverty level.

Robyn Hyden, executive director of advocacy group Alabama Arise, which supports Medicaid expansion, has seen progress on efforts to increase coverage. “The devil’s going to be in the details,” she said.

Mississippi’s new House speaker, Jason White, a Republican, has said he wants to protect hospitals and keep residents from seeking regular care through the emergency room. More than 120,000 uninsured people in Mississippi would become newly eligible for Medicaid under expansion, according to KFF data.

White told KFF Health News in a written statement that improving access to health care is a priority for business leaders, community officials, and voters.

“The desire to keep Mississippians in the workforce and out of the emergency room transcends any political party and is a vital component to a healthy workforce and a healthy economy,” he said. State legislators are determined to work with Reeves on the issue, he said.

Burns, the Georgia House speaker, has said that he’s open to a proposal for an Arkansas-style plan. Republican Gov. Brian Kemp said he would reserve comment until after the legislative process, according to spokesperson Carter Chapman.

He emphasized Kemp’s commitment to his recently launched plan requiring low-income adults to work, volunteer or receive schooling or vocational training for 80 hours a month in exchange for Medicaid coverage. As of mid-January, the cumulative enrollment was right around 3,000. Expansion could make at least 359,000 uninsured people in Georgia newly eligible for Medicaid, according to KFF data.

In South Carolina, Republican lawmakers are considering legislation that would allow them to form a committee to study expansion. State Sen. Tom Davis, a Republican from Beaufort who sponsored the bill and previously opposed expanding Medicaid, said he’s not endorsing or opposing Medicaid expansion at this time.

“We need to have a debate,” Davis said during a committee meeting in January.

The state legislature would likely have to work with Gov. Henry McMaster, a Republican, who, according to spokesperson Brandon Charochak, remains opposed to Medicaid expansion.

North Carolina started enrolling residents under its expansion Dec. 1. They included Patrick Dunnagan, 38, of Raleigh. The former outdoor guide said he hasn’t been able to work for years because of kidney disease and chronic pain.

He has relied on financial support from his family and said his medical debt stands at more than $5,000. Medicaid coverage will provide financial security.

Dunnagan said people with chronic health conditions in nonexpansion states “are accumulating medical debt and not getting the care they need.”

Bills proposed in Texas’ legislature didn’t get a vote last year. And the state doesn’t allow voter-initiated referendums, which have been a route to expansion in some Republican-led states. An estimated 1.2 million uninsured people would be eligible for coverage — more than in any other state still holding out — if Texas expanded.

Lowcountry healthcare system hopes SC passes bill to continue hospital care at home

Addie Thompson — Fri, 23 Feb 2024 19:36:06 GMT

CHARLESTON, S.C. (WCSC) - Hospital care at home could stay a reality in South Carolina thanks to a new bill working through the State Legislature, and one Lowcountry hospital is hoping for just that.

The bill’s sponsor, South Carolina Senator Tom Davis, says during the COVID-19 Pandemic, a lot of healthcare regulations were suspended, including the extent of care hospitals can offer at home.

“COVID was sort of a whole experimental process, it pushed the envelope as to how can we do things differently, are these rules and regulations really necessary, can we do things and provide more options?” Davis says.

Right now hospital care at home is still allowed, but Davis says they’re working against the clock to get Bill S.858 signed into law before the regulations come back.

Roper and Berkeley Hospitals Regional President Troy Powell says their Hospital at Home Program typically offers care to patients with chronic conditions, or to patients recovering from surgery.

A nurse or community paramedic will visit the patient’s home at least twice a day. The patient is also constantly monitored with a “biosticker,” which is a patch that collects data like blood pressure and oxygen saturation and feeds it back to a monitoring center, he says.

Powell is hoping the bill is signed into law because hospital-at-home care produces better outcomes for patients by lessening the risk of infection, delirium, and falls.

“Also, what the patients are reporting is much better. They’re much more comfortable being in their home, being able to eat their meals, not being woken up at all times of the night because we’re able to monitor it,” Powell says.

After getting part of her colon removed, Tracy Marley received hospital-at-home care from Roper. She says she felt safe and confident she was in good hands.

“It was tremendous, I got to sleep in my own bed, I wasn’t disturbed at night, I got to eat my own food,” she says.

Davis says they’re holding subcommittee hearings on the bill next week and will hopefully get it on the Senate floor in the next three weeks. He says he’s optimistic to get the bill passed before adjourning in May.

SC Senate passes sweeping health services restructuring bill

Addie Thompson — Fri, 23 Feb 2024 19:35:29 GMT

South Carolina lawmakers are taking sweeping action to consolidate, with the goal to hopefully improve the delivery of health care services in the state.

The SC Senate on Wednesday, Feb. 21, 2024 overwhelmingly gave final approval to a bill that restructures the giant Department of Health and Environmental Control, known as DHEC, by combining the state agency’s public health functions with those of five other health care agencies.

The bill also creates a separate environmental division, which currently is a part of DHEC.

“It’s all about improving healthcare outcomes for South Carolinians,” Sen. Tom Davis, R-Beaufort, told SC Public Radio.

“The bill brings South Carolina’s delivery of public health services from the 20^th century to the 21^st century,” David added.

If it becomes law, the measure calls for the following agencies to join with DHEC’s Division of Public Health: Commission on Aging, Alcohol and other Drug Abuse Services, Disability Services, Health and Human Services, and Mental Health.

A new cabinet-level secretary, appointed by the governor and confirmed by the Senate, would run the new Executive Office of Health and Policy.

For years, many state leaders have maintained that South Carolina’s delivery of health care and human services have been too fractured with little planning and cooperation among the involved agencies.

The Senate approved bill was two years in the making.

It followed dozens of public hearings and subcommittee meetings. It now goes to the S.C. House of Representatives where a similar bill is pending.

Restructuring DHEC and the state’s healthcare services is one of the top priorities in this year’s General Assembly session.

Medicare Advantage AI under more fire in D.C.

Addie Thompson — Thu, 22 Feb 2024 15:55:37 GMT

New guardrails for Medicare Advantage plans' use of AI may not be clear enough, experts told members of the Senate Finance Committee.

CMS sent a message to Medicare Advantage plans Feb. 6, clarifying how new prior authorization rules set forth by the agency apply to AI. The agency wrote that AI programs can be used to assist in coverage determinations, but it is the plans' responsibility to "ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made."

The agency will also up its auditing of denials in Medicare Advantage plans, according to the message.

Lawmakers have urged CMS to do more to regulate the use of AI by Medicare Advantage plans. The Senate Finance Committee held a hearing probing the use of AI in healthcare Feb. 8.

At the hearing, Michelle Mello, PhD, professor of health policy at Stanford University, told the committee CMS should implement more specific guidelines on requirements for meaningful human review of claims denied by algorithms.

"Audits by CMS need to look very closely, as I believe they intend to, at denials where algorithms were involved," Dr. Mello said.

UnitedHealthcare and Humana, the largest Medicare Advantage insurers, are facing lawsuits alleging they wrongfully denied members care using an AI-powered algorithm. A spokesperson for Optum, the UnitedHealth Group subsidiary that operates the algorithm, told Becker's the tool is not used to make coverage determinations.

A spokesperson for Humana told Becker's its augmented intelligence maintains a "human in the loop" whenever AI is used, and "adverse coverage decisions are only made by physician medical directors."

Ziad Obermeyer, MD, Blue Cross of California Distinguished Associate Professor of Health Policy and Management at the University of California Berkeley, told the committee AI learns from historical data and can reinforce existing trends rather than improve them.

"[AI] trolls through millions of records, and sees there are some privileged people with great insurance who stay in nursing homes longer than they should, and there are also vulnerable, underinsured people who are often kicked out too early," Dr. Obermeyer said. "Rather than undoing that problem, the AI reinforces it and encodes it as policy."

Well-designed AI programs could make these decisions better than humans, Dr. Obermeyer said.

"It could look at the patient's X-ray, it could look at the public transportation in their neighborhood, it could look at the layout of their house, and integrate all those things into a far better judgment than a doctor is able to make on who needs to be in that nursing home and who doesn't," he said.

Sen. Elizabeth Warren, a frequent critic of Medicare Advantage, said CMS should prevent MA plans from using AI in prior authorization until it can confirm algorithms do not result in wrongful denials of care.

"It takes the bad information and accelerates it, or [accelerates] the information that is bad practice," Ms. Warren said.

CMS issues AI guidance to Medicare Advantage plans

Addie Thompson — Thu, 22 Feb 2024 15:55:03 GMT

Algorithms and artificial intelligence-powered software tools can be used to support Medicare Advantage plans in making coverage decisions for members, but payers are still bound by CMS' internal benefits requirements and nondiscrimination rules under the ACA, the agency said in guidance to insurers regarding its final 2024 MA rule.

"We are concerned that algorithms and many new artificial intelligence technologies can exacerbate discrimination and bias," the agency wrote Feb. 6. "MA organizations should, prior to implementing an algorithm or software tool, ensure that the tool is not perpetuating or exacerbating existing bias, or introducing new biases."

The guidance comes as scrutiny of payers' use of AI increased in 2023. UnitedHealthcare, Humana and Cigna are facing lawsuits alleging they used AI tools or algorithms to wrongfully deny care to Medicare Advantage members.

Four key takeaways:

1. Because of how rapidly software technologies are evolving and overlapping definitions, CMS clarified its perspective on the difference between algorithms and artificial intelligence. Algorithms "can imply a decisional flow chart of a series of if-then statements," while AI is a "machine-based system that can — for a given set of human-defined objectives — make predictions, recommendations or decisions influencing real or virtual environments.

2. Payers can use algorithms to support coverage decisions, but it is their responsibility to ensure that an algorithm or an AI-based tool is compliant with the agency's coverage decision requirements. For example, MA carriers must base coverage decisions on an individual member's medical history, physician recommendations or clinical notes, not on a larger data set.

3. Algorithms can be used only to help predict length of stay for post-acute services and not as the basis for terminating coverage. Terminating coverage can be determined only by first reexamining a member prior to the termination notice. For inpatient admissions, algorithms and artificial intelligence alone cannot be used as the reason to deny admission or downgrade to an observation stay.

4. MA organizations may deny coverage for basic benefits only for reasons such as network limitations or noncompliance with prior authorization rules. Algorithms should be used only to ensure compliance with internal coverage criteria. AI cannot be used to shift coverage criteria over time, and predictive algorithms cannot apply internal coverage criteria that are not public.

Federal judge tosses PhRMA lawsuit challenging Medicare drug negotiations

Addie Thompson — Thu, 22 Feb 2024 15:54:23 GMT

A Texas federal judge on Monday dismissed a lawsuit challenging the Biden administration’s Medicare drug price negotiations filed by the pharmaceutical industry lobbying group Pharmaceutical Research and Manufacturers of America (PhRMA).

The decision marks a small victory for the Biden administration, as it’s the first time a court has outright dismissed a challenge to Medicare’s new price negotiation powers.

There are eight other lawsuits filed by drug companies and other plaintiffs, and the legal fight could stretch for years. The federal government sent out its initial offer to drug companies earlier this month, and while the negotiations will end in August, the prices won’t take effect until 2026.

Judge David Alan Ezra in the Western District of Texas granted the Biden administration’s request to dismiss the lawsuit, ruling that the plaintiffs lacked standing.

PhRMA was joined in the lawsuit by the National Infusion Center Association (NICA) and the Global Colon Cancer Association, but Ezra dismissed the NICA from the case because he said the court lacked jurisdiction.

As the NICA was the only plaintiff that resided in Texas, the entire case was dismissed. However, it was dismissed without prejudice and could be brought up again.

“We are disappointed with the court’s decision, which does not address the merits of our lawsuit, and we are weighing our next legal steps,” PhRMA spokesperson Nicole Longo said in a statement to The Hill.

PhRMA represents some of the largest drug companies in the world. The group sued the administration in June, arguing Medicare negotiation is unconstitutional and violated drug companies’ due process.

Pennsylvania officials release report, recommendations to improve care coordination and services for children and young adults with complex needs

Addie Thompson — Thu, 22 Feb 2024 15:53:08 GMT

Harrisburg, PA - The Pennsylvania Department of Human Services (DHS) today released recommendations from its Blueprint Workgroup, an interdisciplinary group comprised of representation from state and local governments, health care, education, service providers, managed care, and family advocates. The workgroup sought to evaluate challenges children and youth with complex, co-occurring physical and behavioral health care needs and their families experience like accessing care and services that adapt to a youth’s changing circumstances and needs, lessening the likelihood of child welfare system involvement, reducing trauma experienced by instability, prioritizing emotional wellbeing, and supporting family- and youth-driven care and choice.

“The detailed recommendations outlined by the Blueprint Workgroup set a course that now allows DHS and partners at the local level and systems of care to begin the work necessary to see how we make change happen so children with complex needs get the care that improves their quality of life, and the family is supported as they navigate these systems,” said Dr. Val Arkoosh, Secretary of DHS. “Systems of care should uplift those we seek to help, not create confusion and consequences from lack of coordination. The Blueprint Workgroup recommendation align our focus around the children and families we must always prioritize, and I am grateful for the work to this point and moving forward that will build a better future for children and families in Pennsylvania.”

One in six children have a diagnosed behavioral or developmental disorder, and rates of depression and anxiety are growing among children and young adults. Youth with co-occurring physical health, behavioral health, and/or intellectual disability or autism-related needs are considered complex cases because they require close coordination between multiple care and service providers in order to ensure the child and their family are receiving comprehensive supports and services that meet their unique and evolving needs.

Care coordination for these cases involve multiple county and state-level entities that coordinate health care, education, and disability services, and, at times, the child and their family may be involved with child welfare, foster care, and justice systems. Children and youth with complex needs are also more likely to have experienced abuse, neglect, and trauma, disruptions to their education, communications challenges, and a complex diagnostic history causing delayed or incorrect services. These circumstances create opportunities for confusion and lack of communication that can affect care.

Children and youth with complex needs deserve access to the care and supports they need without barriers, delays, or risks of new or additional trauma, and their families and guardians deserve support as they navigate systems of care for their child. The Blueprint Workgroup was established to help guide systems of care towards a renewed focus on youth and family engagement, respect for individual choice, support for the caring workforce, better collaboration and integrated planning between systems that serve youth with complex needs, and timely, accessible, and coordinated service delivery for youth that is responsive to their evolving needs.

Recommendations from the workgroup include:

Prioritizing prevention through early identification of needs, accurate and timely diagnosis, and prompt service intervention;
Improving information sharing and resource navigation among child-serving systems of care;
Developing clear and strong guidance to inform multi-system case planning and management that prioritizes family engagement, evidence-based practices, peer supports between families, streamlining processes for families, and avoids trauma or re-traumatization that can occur when a case information has to be presented by the youth or their family repeatedly;
Supporting a qualified, dedicated workforce, assessing payment models, and increasing efficiencies for people working in this system where appropriate;
Conducting a system needs and gaps analysis across child-serving systems to determine opportunities for improvement and establishing multidisciplinary care coordination teams where needed; and,
Building further understanding of trauma and embed trauma-informed care and principles across systems that serve and interact with children and youth with complex needs and their families.

Moving forward, DHS and Blueprint Workgroup members will begin work to determine work necessary to implement recommendations and identify barriers to implementation at the state and local level. The recommendations outlined in the workgroup’s report are a first step to strengthen supports for children and youth with complex needs and their families. Pennsylvania was also recently selected as one of eight states participating in a children’s behavioral health policy collaborative organized by Health Management Associates, the National Association of State Mental Health Program Directors, the National Association of Medicaid Directors, the Child Welfare League, and the American Public Human Services Association. The convening will build on this work by helping better align multi-system work to support youth with behavioral health needs.

To learn more about the Blueprint Workgroup and DHS’ work to support children and youth with complex needs, visit https://www.dhs.pa.gov/Services/Children/Pages/Complex-Case-Planning.aspx.

MEDIA CONTACT: Brandon Cwalina - ra-pwdhspressoffice@pa.gov

# # #

Medicaid expansion gains steam in states despite GOP opposition

Addie Thompson — Tue, 20 Feb 2024 15:28:34 GMT

Opposition to expanding Medicaid programs to cover more low-income individuals is becoming increasingly difficult to maintain amid growing public support for adoption across states, policy analysts say.

Ten years after the Affordable Care Act first allowed Medicaid programs to cover nearly all adults with incomes up to 138% of the federal poverty level—now roughly $15,000 for a single person in most states—all but 10 states have adopted the expansion. An estimated 1.9 million people in the states that haven’t expanded fall into what’s known as the Medicaid coverage gap, having incomes above their state’s eligibility for Medicaid but below the poverty level, according to KFF data.

North Carolina became the latest state to expand in 2023 with the help of Republicans who came on board after multiple unsuccessful attempts to overturn the ACA in the courts and the American Rescue Plan Act’s temporary fiscal incentive to states that haven’t yet expanded their Medicaid programs. The American Rescue Plan Act, signed into law in 2021, included $1.9 trillion in federal funding to respond to the public health and economic impacts of the Covid-19 pandemic.

Kansas Gov. Laura Kelly (D) introduced a proposal in January that would expand Medicaid to an additional 150,000 people in the state. But Republican leadership in the state legislature have vowed to block the legislation.

A vocal segment of Republicans across the country has long opposed Medicaid expansion over concerns about strains to state budgets, with many calling for requirements that individuals have a job to qualify for coverage.

While policy analysts predict a second Trump administration could lead to attempts to repeal or make cuts to Medicaid expansion, they say court wins supporting expansion, and voter demands for improved health access and affordability are likely to bring more bipartisan agreement on expanding Medicaid in the coming years.

“As long as the national situation stays status quo with the Affordable Care Act not being repealed or extensively trimmed or modified or reduced, I think it is very likely we will eventually get all 50 states on board,” said Patrick O’Mahen, an assistant professor of medicine at the Baylor College of Medicine.

Expansion Holdouts

Without more states adopting expansion, “there’s just these massive gaps in what Medicaid does in terms of health-care coverage for people,” said Matt Salo, founder and CEO of Salo Health Strategies and former executive director of the National Association of Medicaid Directors.

Coverage “can vary widely from state to state,” Salo said in an interview.

Medicaid expansion has succeeded in getting support when brought to voters via ballot initiatives in six states—Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah. But out of the 10 states that have yet to adopt expansion, only Florida and Wyoming have pathways for expanding Medicaid through ballot measures.

Elsewhere, “conservative Republican-controlled state legislatures seem to be the most common blocking mechanism,” said O’Mahen, whose research focuses on interactions between governments and health systems.

Kansas, Texas

Some Republicans have called for a hearing in Kansas on Kelly’s latest proposal. Last year, lawmakers left their legislative session without action on Kelly’s expansion proposal, despite the governor’s attempt to address Republican concerns by adding a work requirement, a tax on the Medicaid funding that hospitals receive to offset state costs, and allowing individuals to stay on private insurance while still receiving assistance from the state.

Kansas House Speaker Dan Hawkins (R) said in an emailed statement, “right now, the votes aren’t there to pass Medicaid expansion.” He added, though, there will be an opportunity to discuss the issue more when the House Health Committee holds a hearing on the proposal this legislative session.

“The facts remain though—Medicaid expansion siphons benefits away from the truly needy and disabled and gives them to a whole new population of able-bodied adults with other coverage options available … all on the backs of taxpayers,” Hawkins said.

A 2023 poll by the Texas Politics Project at the University of Texas at Austin found 76% of survey participants supported Medicaid expansion, with just 17% opposed.

But in the Lone Star State, where Republicans control both the governor’s office and legislature, the path toward expansion will likely be “longer given the depth of the ideological opposition,” said Jocelyn Guyer, senior managing director at Manatt Health.

For Tanner Aliff, policy director of the Right on Healthcare Initiative at the conservative Texas Public Policy Foundation, health workforce shortages and rural populations’ difficulty accessing hospital care are more important issues for the state of Texas to address. More than 20 rural hospitals have closed in Texas over the past decade, according to the Texas Hospital Association.

“What’s the point of putting a Medicaid card in the hands of somebody that still has to travel 80 miles to the nearest critical access hospital just to wait in the ER,” Aliff said in an interview.

‘Here to Stay’

Despite the opposition, policy analysts and proponents of Medicaid expansion say it’s possible these holdout states will eventually come on board.

Roughly 76% of US adults included in a March 2023 KFF Health Tracking Poll said they had either a “very favorable” or “somewhat favorable” view of the Medicaid program, and two-thirds of respondents living in the states that haven’t expanded their programs said they want their state to do so.

“The dominant sentiment, including among Republicans in places like North Carolina, is that the Affordable Care Act is here and it’s here to stay, and every single congressional effort to repeal, every single effort at litigation to get rid of it has failed,” Guyer said.

In North Carolina, Republicans like Senate President Pro Tempore Phil Berger, who referred to himself as “one of the staunchest opponents to expanding Medicaid in North Carolina” for more than a decade, eventually changed his position. In a March 2023 op-ed, Berger argued the ACA and Medicaid expansion are “not going away, and refusing to accept that reality hurts North Carolinians and the state’s finances.”

“Medicaid expansion if implemented in a reasonable, responsible manner is a positive for state fiscal and healthcare policy,” Berger wrote at the time, citing the fact that the federal government pays for 90% of Medicaid expansions in states.

With former President Donald Trump currently the front-runner for the 2024 Republican presidential nomination, O’Mahen said a second Trump term likely means “legislation repealing the ACA’s Medicaid expansion and making deeper cuts to the program is very much on the table.”

During the Trump administration, the Centers for Medicare & Medicaid Services broke from previous administrations by approving several Section 1115 waivers that conditioned Medicaid coverage on meeting work and reporting requirements—though courts later struck down many of these.

Despite some roadblocks to future efforts, universal expansion across the country is not an unlikely scenario, O’Mahen said.

“It becomes tougher and tougher for the holdouts to hang on because they can see that they’re leaving a lot of federal money on the table and everybody else is doing it,” he said.

SC Senate passes medical marijuana legalization bill, sending it to House

Addie Thompson — Tue, 20 Feb 2024 15:25:46 GMT

South Carolina’s Senate passed a medical marijuana legalization bill on Wednesday, sending it to the House of Representatives for consideration.

The vote on third reading passage was 24-19 and came one day after the body gave initial approval to the legislation from Sen. Tom Davis (R), which if enacted will allow medical cannabis access for patients with certain health conditions.

In order to get to the desk of Gov. Henry McMaster (R), the bill still needs to clear the House—a prospect that’s far from certain. The Senate had passed an earlier version of the legislation in 2022 but it stalled in the opposite body over a procedural hiccup.

Davis said during last week’s initial Senate debate on the current bill that his goal has always been to “come up with the most conservative medical cannabis bill in the country that empowered doctors to help patients—but at the same time tied itself to science, to addressing conditions for which there’s empirically based data saying that cannabis can be of medical benefit.”

“I think when this bill passes—and I hope it does pass—it’s going to be the template for any state that truly simply wants to empower doctors and empower patients and doesn’t want to go down the slippery slope” to adult-use legalization, he said. “I think it can actually be used by several states that maybe regret their decision to allow recreational use, or they may be looking to tighten up their medical laws so that it becomes something more stringent.”

Other changes that were adopted would prevent lawmakers and their immediate family members from owning or receiving compensation from medical marijuana businesses until 2029, ensure that vertically integrated businesses performing a certain function in the industry count against the total number of licenses allowed to be issued for that function, require dispensaries to have a pharmacist physically present on their premises during dispensing hours and further clarify that the definition of medical use does not include smoking.

The body had previously approved two amendments during second reading consideration on Tuesday.

One would make it so no more than three medical cannabis dispensaries could be located in any county. The other would clarify that regulators cannot prevent the “accurate listing of ingredients on a cannabis product that is a beverage,” with the sponsor of the amendment citing a recent letter from health officials that he said has “caused confusion” about the components of hemp-derived beverages.

The body had previously approved two amendments during second reading consideration on Tuesday.

Certain lawmakers have also raised concerns that medical cannabis legalization would lead to broader reform to allow adult-use marijuana, that it could put pharmacists with roles in dispensing cannabis in jeopardy and that federal law could preempt the state’s program, among other worries.

Here are the main provisions of the bill:

“Debilitating medical conditions” for which patients could receive a medical cannabis recommendation include cancer, multiple sclerosis, epilepsy, post-traumatic stress disorder (PTSD), Crohn’s disease, autism, a terminal illness where the patient is expected to live for less than one year and a chronic illness where opioids are the standard of care, among others.
The state Department of Health and Environmental Control (DHEC) and Board of Pharmacy would be responsible for promulgating rules and licensing cannabis businesses, including dispensaries that would need to have a pharmacist on-site at all times of operation.
In an effort to prevent excess market consolidation, the bill has been revised to include language requiring regulators to set limits on the number of businesses a person or entity could hold more than five percent interest in, at the state-level and regionally.
A “Medical Cannabis Advisory Board” would be established, tasked with adding or removing qualifying conditions for the program. The legislation was revised from its earlier form to make it so legislative leaders, in addition to the governor, would be making appointments for the board.
Importantly, the bill omits language prescribing a tax on medical cannabis sales, unlike the last version. The inclusion of tax provisions resulted in the House rejecting the earlier bill because of procedural rules in the South Carolina legislature that require legislation containing tax-related measures to originate in that body rather than the Senate.
Smoking marijuana and cultivating the plant for personal use would be prohibited.
The legislation would sunset five years after the first legal sale of medical cannabis by a licensed facility in order to allow lawmakers to revisit the efficacy of the regulations.
Doctors would be able to specify the amount of cannabis that a patient could purchase in a 14-day window, or they could recommend the default standard of 1,600 milligrams of THC for edibles, 8,200 milligrams for oils for vaporization and 4,000 milligrams for topics like lotions.
Edibles couldn’t contain more than 10 milligrams of THC per serving.
There would also be packaging and labeling requirements to provide consumers with warnings about possible health risks. Products couldn’t be packaged in a way that might appeal to children.
Patients could not use medical marijuana or receive a cannabis card if they work in public safety, commercial transportation or commercial machinery positions. That would include law enforcement, pilots and commercial drivers, for example.
Local governments would be able to ban marijuana businesses from operating in their area, or set rules on policies like the number of cannabis businesses that may be licensed and hours of operation. DHEC would need to take steps to prevent over-concentration of such businesses in a given area of the state.
Lawmakers and their immediate family members could not work for, or have a financial stake in, the marijuana industry until July 2029, unless they recuse themselves from voting on the reform legislation.
DHEC would be required to produce annual reports on the medical cannabis program, including information about the number of registered patients, types of conditions that qualified patients and the products they’re purchasing and an analysis of how independent businesses are serving patients compared to vertically integrated companies.

After Davis’s Senate-passed medical cannabis bill was blocked in the House in 2022, he tried another avenue for the reform proposal, but that similarly failed on procedural grounds.

The lawmaker has called the stance of his own party, particularly as it concerns medical marijuana, “an intellectually lazy position that doesn’t even try to present medical facts as they currently exist.”

Meanwhile, a poll released last year found that a strong majority of South Carolina adults support legalizing marijuana for both medical (76 percent) and recreational (56 percent) use—a finding that U.S. Rep. Nancy Mace (R-SC) has promoted.

NC Medicaid rolls grow by 1,000/day as smooth expansion rollout continues its third month

Addie Thompson — Tue, 20 Feb 2024 15:23:41 GMT

When North Carolina launched Medicaid expansion on Dec. 1, state officials said the measure would provide health insurance to an estimated 600,000 low-income adults over a span of two years.

It took just two months to reach 58 percent of that goal. More than 346,400 newly eligible beneficiaries have been approved for coverage as of Feb. 1, according to data from the N.C. Department of Health and Human Services.

The fast pace of enrollment was one of several expansion-related success stories that DHHS leaders shared with lawmakers during last week’s meeting of the monthly Joint Legislative Oversight Committee on Medicaid. It was the first formal report the department had presented to the 14-person committee since expansion took effect.

Expansion raised the state’s income limit for Medicaid, extending eligibility to people who make an annual income of up to 138 percent of the federal poverty level based on their household size ($25,820 for a family of three). The previous limit was 100 percent.

Jay Ludlam, the state’s deputy secretary for Medicaid, told the committee that DHHS launched expansion “in a way that was member-focused.” About 273,000 adults who had been enrolled in Family Planning Medicaid, a limited-coverage program for reproductive health services, were automatically upgraded to full Medicaid coverage when expansion went live in December.

“We ran the algorithm on the information that we had for that population,” Ludlam said. “We determined those individuals who would qualify for Medicaid expansion and those who wouldn’t, and we moved those individuals who [did] qualify onto expansion.”

That strategy, he said, allowed the department to hit the ground running. Most of the new beneficiaries gained Medicaid with little or no action needed on their end.

“Those individuals didn’t have to go into an office,” Ludlam said. “They didn’t have to call a DSS worker. They didn’t have to fill out a form. Effectively, they woke up on December 1st with a card in hand, and they were able to access the full Medicaid benefit on Day One.”

People who were not part of the initial wave of automatic enrollments have been signing up for Medicaid at a steady clip since expansion launched. Ludlam said DHHS is adding an average of 1,000 beneficiaries to the rolls each day — a number he believes will taper off in the coming weeks.

A disproportionate share of the state’s new enrollees are residents of rural, economically distressed counties. That isn’t entirely surprising, according to Ludlam. He said expansion was expected to have an outsize impact in rural areas.

“Broadly, in some of these communities, we would have anticipated high enrollment,” he said. “These are areas where individuals are working potentially more than one job to make ends meet.”

‘Knocking on death’s door’

For people like DeAnna Brandon, the value of Medicaid can be measured in days rather than dollars.

Diagnosed with a rare blood cancer in 2022, the Rowan County resident was told she had less than three years to live unless she received a stem cell transplant. Brandon, whose story was first reported by NC Health News, couldn’t afford the expensive procedure without health insurance — and her biological window of opportunity was growing smaller.

The chemotherapy that helped Brandon manage the symptoms of her cancer threatened to cause irreversible damage to her cells, undermining the effectiveness of the transplant. The physical toll of the treatment also left her unable to work.

North Carolina: Prison system works to combat health care coverage gap by enrolling people in Medicaid before release

Addie Thompson — Tue, 20 Feb 2024 15:22:24 GMT

Danay Burke, 43, was released from prison on Nov. 1. Among the many tasks on her to-do list for reestablishing her life was to figure out how to manage her health care needs. But she left prison without health insurance, making that a difficult and costly prospect.

“It’s slowing down the process of me helping myself,” Burke said.

She said she needs a drug assessment, medications for her anxiety and depression, birth control, a mammogram and a sleep study. However, Burke said she’s delayed all this care because she lacked medical coverage.

Burke, like many others released from incarceration, fell into a health insurance coverage gap. Historically, most people reentering society after incarceration were either uninsured or uninsurable.

But that’s poised to change in North Carolina with Medicaid expansion that took effect on Dec. 1.

The expanded eligibility rules allow people ages 19 to 64 whose incomes are up to 138 percent of the federal poverty level for their household size to gain coverage, allowing about 600,000 more low-income residents to join the state’s Medicaid rolls. Now, a single adult living in a one-person household is eligible if their annual income is $20,120 or less before taxes.

This criteria allows substantially more justice-involved individuals — people who often work in low-paying jobs or struggle to find work because of their criminal history — to enroll in Medicaid. The program can cover a variety of services, including doctor visits, behavioral health treatments and prescription drugs.

It’s a welcome change for Burke and others, who now have a path to getting health insurance that can pay for needed medical care — particularly as they shift out of a prison that was mandated to provide health care, to finding care in the community on their own.

Burke heard she newly qualified for Medicaid coverage from a staff member at Benevolence Farm — a reentry program in Alamance County offering housing and employment to women recently released from North Carolina prisons where she is staying — who helped her apply in December. Burke said she was approved for coverage, and she is eager to take advantage of the benefits to start taking care of her backlog of medical needs when she receives her Medicaid card in the mail.

However, Burke can’t help but think how much easier the path could have been without that disruption in care.

“A lot of people don’t have access,” Burke said. “They aren’t able to take care of themselves properly. Your mental health is a big thing because if you can’t take care of your mental health, a lot of people end up turning back to drugs and back to prison because we’re not able to take care of ourselves mentally and emotionally.

“It’s a big, big issue.”

The state prison system releases more than 15,000 people into the community each year, and prison officials estimate that 80 percent of them are now eligible for Medicaid.

They also recognize that inadequate access to health care can create a barrier to successful reentry into society. That’s why the N.C. Department of Adult Correction is working to ensure that fewer people are released into health care coverage gaps by helping people apply for Medicaid before they’re scheduled to leave prison.

“One of the key things with reentry is that break in service can really be detrimental,” said George Pettigrew, deputy secretary for rehabilitation and reentry at the N.C. Department of Adult Correction. “Somebody can decompensate real quick with mental health issues, substance use issues. If they don’t have that insurance ready to go where they can go and have these [health] services, that can be a problem.”

Gaining coverage

Mary Grillo, interim social work director and Medicaid expansion coordinator at the Department of Adult Correction, said the prison system has launched a department-wide effort to help people ages 19 to 64 who are within 90 days of their release date to apply for Medicaid coverage.

That effort is in line with one of the goals outlined in the state’s participation in Reentry2030, a national initiative that aims to dramatically improve reentry success. North Carolina joined the initiative through Gov. Roy Cooper’s January executive order seeking to boost reentry support.

Reaching people about 90 days ahead of time is important, Grillo said, because it can take up to 45 days for a Medicaid application to be processed and eligibility determined. The goal is to have as many people as possible covered before their release, she said.

“It’s one less thing that the individual has to do when they get out of prison,” Grillo said. “It’s one less thing to worry about.”

Grillo said prison staff, including three temporary workers hired in January to assist with the application process, are submitting about 100 Medicaid applications per week.

“The biggest challenge is getting the information out there and getting the education out there and letting people know that this is available,” Grillo said.

To spread the word about the new opportunity for Medicaid coverage upon release, the prison system has distributed a flyer through electronic tablets that are available to all incarcerated people and hung paper flyers on bulletin boards across prisons.

Groundswell of states pursue Medicaid for incarcerated people as they’re released

Addie Thompson — Mon, 19 Feb 2024 19:19:56 GMT

A slew of states are pursuing Medicaid coverage for incarcerated populations ahead of their release from prison as a means to address substance use disorders.

In Jan. of 2023, California received federal approval to provide people in correctional facilities with Medicaid services before their release.

One year later, a “groundswell” of other states seek to make similar strides in the hopes of reducing the rates of overdose-related death and other health care problems that are exacerbated in the weeks immediately after an incarcerated person’s release.

“There’s really a groundswell of state interest,” Vikki Wachino, founder and executive director of the Health and Reentry Project (HARP), told Addiction Treatment Business.

HARP is an initiative that seeks to advance policy and practices that improve the lives, health and safety of incarcerated people as they return to their communities.

“We see very poor health outcomes after people leave prison and jail,” she continued.
“We see it across a range of conditions … but the real standout is with respect to opioid overdoses, where the rate of opioid overdose deaths for people right after they leave prison or jail is significantly higher than it is for the population as a whole.”

More states are following the example set by California, which submitted an 1115 waiver petitioning the federal government to amend the federal law prohibiting Medicaid from covering most services when people are incarcerated.

Other states have followed suit. Washington’s waiver was already approved, and other states are awaiting CMS approval.

These waivers, or other legislature like them, will soon be all but universal, industry experts told Addiction Treatment Business.

“It’s about health care, but it’s also about giving people second chances and the difference that health care can make between life and death,” Wachino said.

The problem: heightened rates of overdose deaths

Mental illness and substance use disorders are disproportionately prevalent among incarcerated people.

Around 18% of the general population is estimated to have a mental illness, compared to 44% of people in jail and 37% of people in prison, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Among the general population, approximately 11% of people aged 18 to 25 have an SUD, as well as approximately 6% of people over 25 years old. The rates skyrocket among incarcerated people, with approximately 63% of people in jail and 58% of people in prison having an SUD.

“Because of the war on drugs, we’ve criminalized substance use,” Meghann Perry, a recovery coach professional educator and person with lived experience of substance addiction and incarceration, previously told Behavioral Health Business. “Therefore, the vast majority of people who are incarcerated, it’s related in some way to substance use.”

Incarceration can exacerbate symptoms of SUD and make it more challenging to get appropriate treatment. These problems, in turn, can lead to people staying incarcerated for more extended periods.

The transition from incarceration back into the general population can be perilous for those with SUD. People incarcerated in state prisons are 129 times more likely to die from an overdose compared to the general public, according to a study published in the New England Journal of Medicine.

The increased risk immediately post-release is due to the isolation of prison, according to Cooper Zelnick, chief revenue officer at Groups Recover Together.

“What we have observed, and we have data on this because we’ve been doing transitional care and reentry planning work with departments of corrections for years, is that if you can get an individual plugged into treatment within the first 24 to 48 hours after release,” Zelnick said, “you can massively reduce fatal overdose, relapse and recidivism, which of course has a significant benefit from a societal cost perspective.”

Woburn, Massachusetts-based Groups Recover Together provides SUD treatment using Suboxone, a brand name of buprenorphine, along with group therapy to promote members’ recovery through in-person or virtual care models.

“We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.

“The primary barrier,” Zelnick added, “Is that most treatment providers won’t provide treatment unless they’re reimbursed for it.”

The solution: passing 1115 waivers for incarcerated people

One method of breaking down that barrier is through an 1115 waiver designed to provide incarcerated people with Medicaid access prior to their release.

“The waivers basically build a bridge to help people access services right after release,” Wachino said.

The “bridge” covers a targeted set of services while still incarcerated, creating connections to community services.

California was the first state to receive federal approval to provide people in prisons, jails and youth correctional facilities with some Medicaid and Children’s Health Insurance Program (CHIP) services through an 11115 waiver called the California Advancing and Innovating Medi-Cal (CalAIM).

California’s waiver “blazed the path with CMS,” and now other states are following suit.

Two states, California and Washington, have approved waivers, and 16 other states have currently pending proposals.

“It’s really notable that a number of those states, like New Hampshire and West Virginia, have a specific focus on substance use or mental health services as part of their waiver,” Wachino said. “What we see here is governors and legislators of both parties looking to reentry waivers as a tool to address some of the national challenges that we face with respect to substance use overdoses and mental health.”

According to industry experts, both sides of the political aisle are supportive of addressing substance use disorders and related issues.

New Hampshire’s waiver, called ”Substance Use Disorder Serious Mental Illness and Serious Emotional Disturbance Treatment Recovery and Access,” would provide a limited package of care coordination services to incarcerated people in state prisons who are receiving treatment for SUD, opioid use disorder (OUD), serious mental illness (SMI) or serious emotional disturbance (SED).

West Virginia, Montana and Kentucky are also among the states with waivers that mention SUD.

Even among states that have not yet proposed similar waivers, the impact of California’s progress has sparked change.

“The state of Maine has, since 2018, received grants to serve the uninsured that are primarily designed to bridge that gap between incarceration and Medicaid coverage,” Zelnick said. “I imagine that this will be a thing that happens everywhere.”

States are motivated to follow in California’s footsteps partly because of potential cost savings.

“If you can give people access to benefits, they are much more likely to pursue care,” Zelnick said. “That care is likely to have a positive impact on recidivism, which massively reduces the cost center that is our criminal justice system, and on top [of that, you get positive] health outcomes, so it’s win-win.”

The waivers attract little criticism but have garnered questions on how the policies will be implemented.

“I think that’s a very valid question,” Wachino said.

To properly implement 1115 waivers, states must “set a big table” for the conversations to come, Wachino said, with place settings for correctional officials, health care providers, law enforcement officials, managed care plans and people who have themselves been incarcerated.

As California and Washington both work on implementing their approved waivers, more states will follow their examples.

“I imagine that this will be a thing that happens everywhere,” Zelnick said. “It’s still really tricky for a whole bunch of reasons. But the trend is moving in the right direction here.”

The waivers have the potential to be “groundbreaking,” Wachino said.

“It is a real opportunity to connect people to services and strengthen their health and the health of the communities that they live in,” she said. “This is a very substantial step forward, both by state and federal leaders.”

Study says doula care improves health for pregnant Medicaid patients

Addie Thompson — Mon, 19 Feb 2024 19:19:16 GMT

A new report by the Elevance Health Public Policy Institute underlines the positive health impacts of doula access on pregnant patients. Elevance Health provides Medicaid managed care plans nationally, including in Texas through Wellpoint.

The institute found that overall, patients had better birth and postpartum outcomes when accessing doula services. Researchers measured Medicaid patients across the health system’s locations and compared those who had a doula to those who did not.

Patients who used doula care were often Black and lived in communities with a shortage of OBGYN and maternal care. Jennifer Kowalski, the vice president of the public policy institute, said the organization intentionally did outreach to patients who were at higher risk for pregnancy complications.

She said even though these patients were at higher risk, the report still found “better outcomes among those [people]. That’s an important thing to underscore and perhaps somewhat surprising.”

The report found that people who worked with a doula had lower rates of C-sections and lower postpartum anxiety and depression. Patients were also more likely to attend their postpartum visits.

“I think doula services for folks who are pregnant is an important part of [a] whole health approach,” Kowalski said.

The report recommends states lower barriers for doula services to be covered by Medicaid. Midwives and free-standing birth centers are covered under Medicaid in Texas, but doulas are not.

Last year, Texas lawmakers introduced legislation to create a pilot program for doulas to be covered under Medicaid, but the bill stalled in committee.

“Expanding access to doula services more broadly is really the hope,” Kowalski said. “Over time, knowing that we’re seeing such positive results from our study…that this encourages investment in doula workforce and that [patients] who need these services can access them more widespread than they do today.”

Texas did pass and get federal approval for 12 months of postpartum coverage, which goes into effect March 1.

Advocates, birth workers and researchers have said this extended coverage will lower the rates of maternal mortality and morbidity in the state.

Got a tip? Email Elena Rivera at erivera@kera.org

Medicaid’s unwinding isn’t a crisis. It’s a chance to make coverage better

Addie Thompson — Mon, 19 Feb 2024 19:18:03 GMT

More than 16 million Americans have lost Medicaid coverage in recent months, according to data from the Kaiser Family Foundation. Two million Texans have rolled off Medicaid, newly released state data show. That’s good news, despite what the Biden administration would have us believe.

For decades, Medicaid has burdened taxpayers with billions of dollars in wrongly allocated payments while providing beneficiaries substandard care. Taxpayers and beneficiaries themselves would be well served by a swift process of redetermining whether those currently enrolled in the program are actually eligible — and reforms that make private insurance more affordable.

The size of Medicaid has swelled in recent years. During the pandemic, the federal government restricted states’ ability to “disenroll” people who no longer qualified, often because they’d moved up to a higher income level.

As a result, Medicaid enrollment increased by more than 23 million people between February 2020 and April 2023. Total enrollment was nearly 95 million at its peak.

Even in Texas, which did not expand Medicaid under the terms of the Affordable Care Act and has some of the tightest criteria for eligibility in the country, enrollment surged during the pandemic. Nearly 6 million people — about one in five Texans — had coverage through Medicaid and the state Children’s Health Insurance Program in May 2023.

After the COVID public health emergency ended last spring, states resumed “redetermination” procedures to establish Medicaid eligibility. Progressives are warning that millions of low-income Americans could end up losing Medicaid by mistake — say, by failing to respond to a letter requesting that they prove they’re eligible.

Such scaremongering is unwarranted. Anyone wrongfully disenrolled can sign up again. And in most states, including Texas, those folks can also get several months’ worth of retroactive coverage.

It’s far likelier that those being disenrolled shouldn’t be on the program at all.

According to the Congressional Budget Office, nearly 13 million Medicaid enrollees in 2022 weren’t eligible and had simply been kept on due to pandemic rules. Payments for these extra enrollees amount to waste.

And Medicaid’s issues with waste, fraud, and abuse run deep. In 2023, it distributed more than $50 billion in “improper payments” — expenditures for the wrong people or at the wrong amount.

Things were worse before redetermination. In 2021, Medicaid’s improper payments reached nearly $100 billion. That year, the program spent a staggering one in every five dollars incorrectly.

Even Medicaid’s proper payments are inefficient. The program, which now costs taxpayers north of $800 billion annually, spends nearly three times more per patient than employer-sponsored plans.

Many state officials are rightly trying to stop this waste through redetermination. Government shouldn’t squander money earmarked for the vulnerable on those who qualify for cheaper care elsewhere.

The Urban Institute estimates that most of the 18 million Americans projected to lose Medicaid during redetermination will get comparable coverage through the Children’s Health Insurance Program, the individual market, or some kind of employer-sponsored insurance.

Of the 3.8 million projected to become temporarily uninsured, roughly half will “have access to subsidized coverage, principally a subsidized exchange plan,” according to Brian Blase of the Paragon Health Institute.

There’s plenty the government could do to help disenrolled beneficiaries obtain quality coverage.

To start, the federal government could give low-income Americans vouchers to spend on employer-sponsored or other private health plans in lieu of the federal subsidies they’re already entitled to. Those funds could go into health savings accounts, or HSAs, where people can stow money tax-free for future health needs. Patients could access the money using a bank-issued debit card reserved for medical bills, as a paper published by the Paragon Health Institute recently proposed.

Incentivizing people to use HSAs would save money for virtually all taxpayers and prove especially valuable for lower-income Americans. According to one estimate, nearly seven in 10 Obamacare enrollees below 200% of the federal poverty line would benefit from an HSA option, with the average beneficiary saving around $1,500 per year.

Lawmakers should also expand ways for employers to offer coverage. That means loosening regulations so it’s easier for companies to purchase association health plans. These group plans cover multiple businesses, making insurance more affordable for startups and entrepreneurs with tight budgets.

Congress should also enshrine a Trump-era executive order that lets employers reimburse their employees for qualified health expenses, including Obamacare premiums. That way, employers can offer health benefits without purchasing a company-wide plan.

Medicaid should not be the largest health insurer in the country. The program exists to serve those who truly can’t afford care. States are rightly pushing a return to that original purpose by disenrolling those who don’t qualify.

The shifting budgetary sands of Medicaid: Less federal funding, more state dollars

Addie Thompson — Mon, 19 Feb 2024 19:17:23 GMT

By far the biggest thing about the great Medicaid unwinding of 2023 is the number of low-income people who have been disenrolled, and we have been tracking that relentlessly at KFF. More than 16 million people have been disenrolled so far, as continuous Medicaid coverage provided during the pandemic ended, based on the most current data from all 50 states and the District of Columbia. About 70% of the disenrollments were for procedural reasons. Many people dropped will get coverage elsewhere, through an employer or the Affordable Care Act marketplace, and some who are still eligible will make their way back to Medicaid. The big question is how many will end up uninsured. The picture will vary across states, as it always does when it comes to covering the low-income population.

But there is another story in the data that goes with the unwinding that has mostly escaped notice. We are seeing a decline in federal Medicaid funding as fiscal relief to states in the form of higher matching funds is withdrawn, and an increase in state Medicaid spending, despite lower enrollment. And it’s happening when revenues in most states are weakening. That can be expected to put pressure on state budgets, rekindle on again off again conflict in states about the share of the budget consumed by Medicaid, and make it tougher for states to continue current efforts to strengthen their Medicaid programs.

A few numbers:

The Congressional Budget Office projects that states will receive $58 billion less in federal Medicaid outlays in FY 2024 than they did in 2023. As a consequence, states report that their Medicaid spending will increase by 17.2% in FY 2024.
State revenue collections have started to slow down or decline, and some states may have to face budget gaps in the coming years. States have recently experienced an overall 2% decline in inflation adjusted revenues.
Most of the state numbers are estimates and projections. They are often the product both of best estimates and political calculus, but over the years, they’ve generally been in the ballpark.
States are spending to address rising costs in Medicaid and health care, but also long overdue needs, such as increasing some providers payment rates or putting more resources into home and community-based services or mental health and behavioral health services. States like California and North Carolina are making big plays to address the social determinants of health outcomes for targeted populations. These are some of, if not the most innovative programs in health care.

Medicaid will face blowback in state budget wars in many states as it eats up a larger share of the new funds available in state budgets that legislatures, cabinet agencies, and governors will want to direct to other priorities. When I was Human Services Commissioner in New Jersey, I had eight divisions and a third of the state budget and workforce in NJ HHS (the department has long since been reorganized and reduced in size). One division was Medicaid. The competition for new funds was fierce even within my own department when times were good. In state budget politics, only so much of the annual increase in a state budget will go to one department, no matter the need.

As always there will be variation among states. Where governors have made Medicaid initiatives a personal priority, they may sustain them despite revenue and budget challenges, even cutting elsewhere in Medicaid and social services to continue favored projects.

In our large survey of consumers, Medicaid generally competed well with Medicare, Marketplace and employer coverage, with each type of coverage presenting consumers with the kinds of barriers to care and frustrations common to health insurance today. But Medicaid programs face their own challenges, including access to many specialists.

The question for the next several years is whether states will be able to continue to make targeted new commitments to strengthen Medicaid and mount innovative new programs in an environment of declining federal matching funds, weakening state revenues and competing state priorities. Medicaid is a counter-cyclical program and these are far from the worst circumstance states have faced. The election obviously can have significant additional consequences for Medicaid, especially if Republicans control the White House and Congress, and return to proposals to block grant Medicaid and make significant cuts in federal funding. But that’s only a possibility, while these changes are already in the works, bringing with them shifting sands for Medicaid.

View all of Drew’s Beyond the Data Columns

Highest-paying cities for nurses, by state (SC = Spartanburg)

Addie Thompson — Thu, 15 Feb 2024 19:15:18 GMT

Nurses in Santa Cruz, Calif., make more money on average than nurses in any other metro area, a Vivian Health ranking found.

Vivian Health used Bureau of Labor Statistics data to find the metro area in each state that paid nurses the highest wages. Rankings of metro areas were based on the dollar difference between a registered nurse's median annual salary and the median salary of all occupations in the area.

The ranking showed that nurses earn some of the highest wages relative to other occupations in the area. California had the highest wage among all states, while Iowa had the lowest.

Here is the top metro area in every state with the median annual wage for nurses:

Alabama — Daphne: $64,700

Alaska — Fairbanks: $107,880

Arizona — Yuma: $82,290

Arkansas — Little Rock: $71,460

California — Santa Cruz: $175,350

Colorado — Pueblo: $82,780

Connecticut — Danbury: $105,370

Delaware — Dover: $78,320

Florida — Sebastian: $79,190

Georgia — Rome: $81,320

Hawaii — Urban Honolulu: $127,020

Idaho — Coeur d'Alene: $83,730

Illinois — Kankakee: $80,470

Indiana — Michigan City: $72,720

Iowa — Sioux City: $62,860

Kansas — Lawrence: $67,150

Kentucky — Owensboro: $78,040

Louisiana — Shreveport: $77,790

Maine — Bangor: $83,750

Maryland — Salisbury: $79,210

Massachusetts — Leominster: $96,410

Michigan — Flint: $86,210

Minnesota — St. Cloud: $85,730

Mississippi — Hattiesburg: $59,910

Missouri — St. Louis: $77,390

Montana — Missoula: $76,550

Nebraska — Grand Island: $74,290

Nevada — Las Vegas: $95,770

New Hampshire — Manchester: $80,560

New Jersey — Ocean City: $85,490

New Mexico — Las Cruces: $78,270

New York — New York City: $103,540

North Carolina — Fayetteville: $82,390

North Dakota — Fargo: $75,710

Ohio — Canton: $74,950

Oklahoma — Lawton: $77,070

Oregon — Bend: $108,310

Pennsylvania — Chambersburg: $84,090

Rhode Island — Providence: $84,770

South Carolina — Spartanburg: $81,520

South Dakota — Rapid City: $62,920

Tennessee — Cleveland: $76,620

Texas — Wichita Falls: $79,800

Utah — Provo: $75,090

Vermont — Burlington: $77,230

Virginia — Winchester: $81,940

Washington — Spokane: $100,280

West Virginia — Huntington: $77,240

Wisconsin — Racine: $77,960

Wyoming — Cheyenne: $81,680

Prescription drug costs much higher in U.S. than other countries

Addie Thompson — Thu, 15 Feb 2024 19:14:03 GMT

Feb. 1 (UPI) -- A RAND Corporation report released Thursday found that U.S. prescription drug prices are much higher than in other nations.

The report is out on the same day that Medicare sent initial price negotiating offers on 10 drugs for seniors.

According to the study, U.S. drug prices average 2.78 times the prices charged in 33 other countries studied.

For brand name drugs, it's even more pronounced, with U.S. prices for those kinds of drugs being 4.22 times higher than drug prices in other countries.

For insulin, RAND found U.S. prices ranged from 457% higher than Mexico to 3,799% higher than prices in Turkey.

"These findings provide further evidence that manufacturers' gross prices for prescription drugs are higher in the U.S. than in comparison countries," said report lead author Andrew Mulcahy in a statement. "We find that the gap is widening for name-brand drugs, while U.S. prices for generic drugs are now proportionally lower than our earlier analysis found."

Medicare on Thursday sent initial pricing offers to U.S. drug manufacturers aiming to lower medicine costs for families.

The White House said in a statement that Big Pharma is using nine lawsuits against the Medicare Drug Price Negotiation that was in the Biden Administration's Inflation Reduction Act.

According to the RAND report, U.S. prescription drug prices are 1.72 times higher than in Mexico while they are 10.28 times more expensive than prescription drugs in Turkey.

The U.S accounts for 62% of the total drug spending in the nations RAND studied while it accounts for just 24% the drug volume sold.

The study was sponsored by the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services.

The study looked at pricing in the Organization for Economic Cooperation and Development countries.

According to RAND, estimates are that prescription drug spending in the United States accounts for more than 10% of all health care spending.

Retail prices for prescription drugs in the United States rose by 91% between 2000 and 2020. It's expected to go up 5% a year annually through 2030.

The RAND report "International Prescription Drug Price Comparisons Estimates: Using 2022 Data" is available at www.rand.org.

Marketplace enrollment surges among those losing Medicaid coverage during unwinding

Addie Thompson — Thu, 15 Feb 2024 19:13:32 GMT

As readers of Say Ahhh! know, I have been tracking monthly data (here, here, here, here, here and here) from the Centers for Medicare and Medicaid Services (CMS) on the number of people who were either previously enrolled in Medicaid or had experienced a denial or termination during unwinding who then selected a marketplace plan. At the end of January, CMS issued new data for October 2023. (For an overall status update on Medicaid unwinding, see this blog from my CCF colleague Joan Alker.)

In September, another 1.62 million people lost their Medicaid coverage due to unwinding of the Medicaid continuous coverage protection, of which 68.9 percent were procedural disenrollments and 31.1 percent were due to a finding of ineligibility. Separately, CMS reported that nearly 393,000 people who were either previously enrolled in Medicaid in federal marketplace states or had experienced a denial or termination in state-based marketplace states selected a marketplace plan in the same month. That constituted about 24.3 percent.

Compared to total marketplace enrollment among those losing Medicaid in September, October marketplace enrollment was nearly 77 percent higher. (Virtually all of this marketplace enrollment increase occurred in federal marketplace states.) As a result, the rate of marketplace enrollment among those disenrolled from Medicaid increased substantially, compared to only 13.4 percent in September. (In addition, another 36,000 or 2.2 percent enrolled in a Basic Health Plan in New York and Minnesota in September, with nearly all of that BHP enrollment occurring in New York.) Cumulatively, through October 2023, compared to the 10.8 million people disenrolled from Medicaid, about 1.4 million or still only 13.3 percent enrolled in marketplace plans. (The figure rises to 15.1 percent if including Basic Health Plan enrollment.)

As each of the blogs about previous CMS data releases noted, to provide context to these figures, last year, federal researchers from the HHS Office of Assistant Secretary for Planning and Evaluation (ASPE) projected that of the 15 million people expected to lose Medicaid during the unwinding, nearly 2.7 million people — or about 18 percent —would be eligible for subsidized marketplace coverage. While this data represents only the outcome of unwinding through October, it indicates that overall transitions to marketplace coverage is still falling short of the expected pace. This is despite overall marketplace enrollment soaring to a historic high of 21.3 million during the 2024 Open Enrollment Period and the welcome surge in successful marketplace transitions for those disenrolled from Medicaid in October.

Moreover, at the current pace of disenrollments, the total number of people disenrolled from Medicaid once unwinding is completed is highly likely to far exceed the original 15 million projection from ASPE, and even the 17 million projection from other analysts such as KFF. And the share of total disenrollments that are procedural terminations — 71 percent according to our latest data — is well above the 45 percent estimate from the ASPE projections of the number of eligible people disenrolled for procedural reasons. Finally, for children losing Medicaid, even with the enhanced marketplace subsidies, children accounted for only about 9 percent — or 1.55 million — of total marketplace enrollees during the 2023 Open Enrollment Period. (Data on the child share of marketplace enrollees during the 2024 Open Enrollment Period is not yet available.)

Marketplace plans will be a valuable source of affordable, comprehensive health coverage but only for a relatively modest number of people, especially children, who lose their Medicaid coverage during unwinding. Instead, it’s critical for state Medicaid programs, as they complete the unwinding process in coming months, to reduce the persistently high rates of procedural terminations for children, parents and other adults, many of whom, especially children, are likely to remain eligible for Medicaid. This includes states continuing to increase ex parte renewal rates, ensuring full compliance with all federal requirements for Medicaid renewals and taking up more of the renewal flexibilities provided by CMS, such as pausing all Medicaid renewals for children for one year as Kentucky and North Carolina have recently done.

At the same time, to increase child Medicaid enrollment to offset these large coverage losses from unwinding, states should also take up various actionable strategies to promote continuous coverage for children and families, as recently reinforced in a CMS Informational Bulletin issued in December. States should also take up multi-year continuous eligibility for children, which an increasing number of states are adopting, in addition to successfully implementing mandatory 12-months continuous eligibility for children which took effect on January 1, 2024. Finally, states and the federal government will need to work together on robust outreach and enrollment efforts in 2024 to target eligible children, families and other adults who were disenrolled for procedural reasons so they can be reenrolled in Medicaid as quickly as possible.

Halfway through Medicaid unwinding, nation’s rolls down about 10 million

Addie Thompson — Thu, 15 Feb 2024 19:12:26 GMT

We’re halfway through the Medicaid “unwinding,” in which states are dropping people from the government health insurance program for the first time since the pandemic began.

Millions of people have been dumped from the rolls since April, often for procedural issues like failing to respond to notices or return paperwork. But at the same time, millions have been re-enrolled or signed up for the first time.

The net result: Enrollment has fallen by about 9.5 million people from the record high reached last April, according to the latest estimates by KFF, based on state data. That leaves Medicaid on track to look, by the end of the unwinding, a lot like it did at the start of the coronavirus pandemic: covering about 71 million people.

“What we are seeing is not dissimilar to what we saw before the pandemic — it is just happening on a bigger scale and more quickly,” said Larry Levitt, executive vice president for health policy at KFF.

Enrollment churn has always been a feature of Medicaid, which covers low-income and disabled Americans. Even before the pandemic, about 1 million to 1.5 million people fell off the Medicaid rolls each month — including many who still qualified but failed to renew their coverage, Levitt said.

In the unwinding, a lot of people have been disenrolled in a shorter period of time. In some ways — and in some states — it’s been worse than expected.

The Biden administration predicted about 15 million people would lose coverage under Medicaid or the related Children’s Health Insurance Program during the unwinding period, nearly half due to procedural issues. Both predictions were low. Based on data reported so far, disenrollments are likely to exceed 17 million, according to the KFF report, 70 percent of them due to procedural reasons.

But about two-thirds of the 48 million Medicaid beneficiaries who have had their eligibility reviewed so far got their coverage renewed. About one-third lost it.

Timothy McBride, a health economist at Washington University in St. Louis, said the nation’s historically low unemployment rate means people who lose Medicaid coverage are more likely to find job-based coverage or better able to afford plans on Obamacare marketplaces. “That is one reason why the drop in Medicaid is not a lot worse,” he said.

There are big differences between states. Oregon, for example, has disenrolled just 12 percent of its beneficiaries. Seventy-five percent were renewed, according to KFF. The rest are pending.

At the other end of the spectrum, Oklahoma’s dumped 43 percent of its Medicaid beneficiaries in the unwinding, renewing coverage for just 34 percent. About 24 percent are pending.

States have varying eligibility rules, and some make it easier to keep people enrolled. For instance, Oregon allows children to stay on Medicaid until age 6 without having to reapply. Everyone else gets up to two years of coverage regardless of changes in income.

Joan Alker, executive director of the Georgetown University Center for Children and Families, said she remains worried the drop in Medicaid enrollment among children is steeper than typical. That’s particularly bothersome because children usually qualify for Medicaid at higher household income levels than their parents or other adults.

More than 3.7 million children have lost Medicaid coverage during the unwinding, according to the center’s latest data. “Many more kids are falling off now than prior to the pandemic,” Alker said.

And when they’re dropped, many families struggle to get them back on, she said. “The whole system is backlogged and the ability of people to get back on in a timely fashion is more limited,” she said.

The big question, Levitt said, is how many of the millions of people dropped from Medicaid are now uninsured.

The only state to survey those disenrolled — Utah — discovered about 30 percent were uninsured. Many of the rest found employer health coverage or signed up for subsidized coverage through the Affordable Care Act marketplace.

What’s happened nationwide remains unclear.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

SC senators square off over medical marijuana legalization

Addie Thompson — Thu, 15 Feb 2024 19:10:37 GMT

South Carolina’s Senate convened for an initial debate on Wednesday about a bill that would allow medical cannabis access for patients with certain health conditions. It’s a renewed push by lawmakers after the body passed an earlier version of the legislation in 2022 that went on to stall in the House over a procedural hiccup.

During the floor debate on the measure from Sen. Tom Davis (R), members held a lengthy discussion on the merits of the reform proposal and also adopted an amendment on vaping. It’s expected to receive an initial vote on second reading, possibly as soon as Thursday, before a third and final reading that could send it over to the House.

Senators last week had failed to advance the measure to floor debate, falling short on a vote that required two-thirds support. But on Tuesday, lawmakers voted again and came up 23–13 to give the bill a special order slot and keep it in play for the 2024 session.

Davis said during Wednesday’s floor session that his goal has always been to “come up with the most conservative medical cannabis bill in the country that empowered doctors to help patients—but at the same time tied itself to science, to addressing conditions for which there’s empirically based data saying that cannabis can be of medical benefit.”

“I think when this bill passes—and I hope it does pass—it’s going to be the template for any state that truly simply wants to empower doctors and power patients and doesn’t want to go down the slippery slope” to adult-use legalization, he said. “I think it can actually be used by several states that maybe regret their decision to allow recreational use, or they may be looking to tighten up their medical laws so that it becomes something more stringent.”

Overall, the bill would allow patients to access cannabis from licensed dispensaries if they receive a doctor’s recommendation for the treatment of qualifying conditions, which include several specific ailments as well as terminal illnesses and chronic diseases where opioids are the standard of care.

On Wednesday, members adopted an amendment that clarifies the bill does not require landlords or people who control property to allow vaporization of cannabis products.

Certain lawmakers raised concerns during the hearing that medical cannabis legalization would lend to broader reform to allow adult-use marijuana, that it could put pharmacists with roles in dispensing cannabis in jeopardy and that federal law could preempt the state’s program, among other worries.

Here are the main provisions of the proposal:

“Debilitating medical conditions” for which patients could receive a medical cannabis recommendation include cancer, multiple sclerosis, epilepsy, post-traumatic stress disorder (PTSD), Crohn’s disease, autism, a terminal illness where the patient is expected to live for less than one year and a chronic illness where opioids are the standard of care, among others.
The state Department of Health and Environmental Control (DHEC) and Board of Pharmacy would be responsible for promulgating rules and licensing cannabis businesses, including dispensaries that would need to have a pharmacist on-site at all times of operation.
In an effort to prevent excess market consolidation, the bill has been revised to include language requiring regulators to set limits on the number of businesses a person or entity could hold more than five percent interest in, at the state-level and regionally.
A “Medical Cannabis Advisory Board” would be established, tasked with adding or removing qualifying conditions for the program. The legislation was revised from its earlier form to make it so legislative leaders, in addition to the governor, would be making appointments for the board.
Importantly, the bill omits language prescribing a tax on medical cannabis sales, unlike the last version. The inclusion of tax provisions resulted in the House rejecting the earlier bill because of procedural rules in the South Carolina legislature that require legislation containing tax-related measures to originate in that body rather than the Senate.
Smoking marijuana and cultivating the plant for personal use would be prohibited.
The legislation would sunset eight years after the first legal sale of medical cannabis by a licensed facility in order to allow lawmakers to revisit the efficacy of the regulations.
Doctors would be able to specify the amount of cannabis that a patient could purchase in a 14-day window, or they could recommend the default standard of 1,600 milligrams of THC for edibles, 8,200 milligrams for oils for vaporization and 4,000 milligrams for topics like lotions.
Edibles couldn’t contain more than 10 milligrams of THC per serving.
There would also be packaging and labeling requirements to provide consumers with warnings about possible health risks. Products couldn’t be packaged in a way that might appeal to children.
Patients could not use medical marijuana or receive a cannabis card if they work in public safety, commercial transportation or commercial machinery positions. That would include law enforcement, pilots and commercial drivers, for example.
Local governments would be able to ban marijuana businesses from operating in their area, or set rules on policies like the number of cannabis businesses that may be licensed and hours of operation. DHEC would need to take steps to prevent over-concentration of such businesses in a given area of the state.
Lawmakers and their immediate family members could not work for, or have a financial stake in, the marijuana industry until July 2029, unless they recuse themselves from voting on the reform legislation.
DHEC would be required to produce annual reports on the medical cannabis program, including information about the number of registered patients, types of conditions that qualified patients and the products they’re purchasing and an analysis of how independent businesses are serving patients compared to vertically integrated companies.

Kevin Caldwell, southeast legislative manager for the Marijuana Policy Project, praised Davis’s multi-year effort to advance medical cannabis legislation.

“He has listened to patients as well as fellow senators who have opposed this type of legislation in the past. He has been masterful in making strategic compromises to satisfy both groups,” Caldwell told Marijuana Moment. “We certainly hope that this is the year that his colleagues in the Senate and the House pass this legislation. The long-suffering patients of the Palmetto State deserve the same safe access that residents of 38 other states and the District of Columbia currently have. ”

After Davis’s Senate-passed medical cannabis bill was blocked in the House in 2022, he tried another avenue for the reform proposal, but that similarly failed on procedural grounds.

New SC company uses telemedicine to offer health care to restaurant, hospitality workers

Addie Thompson — Wed, 14 Feb 2024 14:56:28 GMT

Neel Ghoshal was 13 years old when his life changed.

Born in 1978 to Sam and Pritha Ghoshal, who immigrated from India eight years prior in pursuit of the American dream, Neel grew up in the Northeast.

There were moments of struggle but life was good in the New York City area, where his father worked at the World Trade Center.

In November 1991, Ghoshal’s mother went back to India to visit her father. She never made it home.

His mother had been managing a kidney issue, Ghoshal said, but a disconnect between doctors and a lack of access to health care led to a misdiagnosis. For reasons unbeknownst to him, the family and doctors in India did not contact medical professionals back in the United States. She died a few weeks later in 1992.

Ghoshal recalls feeling angry at the systems that were designed to protect people like his mother.

“There was no reason she had to pass,” he said. “She did because of this lack of access.”

Though he has worked in multiple industries during his professional career, Ghoshal’s desire to help fill the gaps in the health care system has always stuck with him. That, plus a family connection to the hospitality industry, is driving his new business venture, Healthpitality.

The memory of his mother is directly tied to the “why” behind Healthpitality, Ghoshal said. Many U.S. citizens, including the majority of hospitality workers, struggle to access affordable health care. For those who do have traditional health care, long wait times and pricey copays can make it hard to see a primary care physician regularly.

Set to launch in January, Healthpitality is being marketed as a membership-based alternative to traditional health insurance. It will rely heavily on telehealth services to treat the many hospitality employees — more than 50 percent nationally — who do not receive health insurance from the restaurant or hotel that employs them. At Healthpitality, Ghoshal wants to create an environment where members of the hospitality industry “are partners in their care and are treated with the same VIP treatment that they provide for their guests night after night.”

Hospitality industry workers can become Healthpitality members individually, but Ghoshal envisions restaurants making this membership an employee benefit. The monthly subscription will cost employers $38 to $55 dollars per month per employee, plus a $250 onboarding fee, and includes unlimited telehealth visits.

Restaurants will be billed monthly per employee, meaning restaurants will not be left with footing the bill of someone who leaves the staff, Ghoshal said. On the flip side, workers will not be dropped when they switch jobs.

Subscriptions for individual employees purchasing their own Healthpitality package are $65 per month. Hospitality workers who want to sign up individually will be asked to provide proof of employment, such as a recent paycheck.

‘Telehealth first’

Ghoshal, who moved to Charleston in 2018, describes Healthpitality as a “virtual-first” health care provider. His experience with telehealth includes working as a consultant for Doxy.me, a telemedicine business that got its start as a tool for health care providers to bring prenatal care to women who normally would have to travel long distances for well-checks and weigh-ins.

Though he understands the benefits of telehealth, Ghoshal also recognizes that it cannot cover every health care need. It simply is not possible to do every type of visit remotely, meaning Healthpitality members will still have to schedule appointments for imaging tests, blood work and other visits that require in-person interaction.

In-person visits, recommended by the doctors and nurse practitioners employed by Healthpitality, will incur an out-of-pocket expense for either the restaurant or the employee.

“Our providers are adept at leveraging telehealth’s best practices to serve our members. However, when necessary, they are also skilled at identifying situations where in-person care is essential, and will accordingly refer members to external providers,” Ghoshal said.

Telemedicine has been more widely adopted since the pandemic, said Medical University of South Carolina Director of Primary Care Telemedicine Dr. Marty Player. It has been especially effective in treating mental health disorders, Player said.

Telemedicine’s limitations include the inability to conduct testing and exams that must be done in person. South Carolina law also prohibits doctors from prescribing certain “controlled” medications without establishing care with a patient in person.

Early research prior to the pandemic suggested that telemedicine provided more access to people who already had access to health care, Player said. Developments in the field suggest that, moving forward, telemedicine could increase access for more vulnerable populations, he said.

“Access to primary care is still limited in this country in general,” Player said. “I think there’s a benefit to having the telehealth option.”

Healthpitality currently has six employees and plans to have three doctors and six to nine nurse practitioners by its January launch in South Carolina and Florida. The primary focus at the onset will be on acute care. As Healthpitality sees a growth in demand, the plan is to broaden services to encompass primary care and preventive medicine, said Ghoshal, whose brother is a certified master chef, a designation given by the American Culinary Federation.

The eventual goal is to create a “comprehensive health and wellness ecosystem” where members can manage most of their health needs. They will do so by working with Healthpitality’s concierge team, who will be trained to understand the realities of working in the restaurant industry.

“Their deep understanding of the unique challenges faced by those in hospitality ensures that every interaction is not only helpful, but also empathetic and tailored,” Ghoshal said.

Ambitious future goals include the creation of “healthpitals,” units that would bring health care services directly to members for seasonal needs like flu shots and physical exams. The overarching goal, Ghoshal said, is to make health care accessible and convenient for all Healthpitality members.

For more information, visit healthpitality.life.

SC telehealth bill on way to Governor’s desk

Addie Thompson — Wed, 14 Feb 2024 14:55:45 GMT

We have another Freedom Agenda healthcare win to report! Healthcare in South Carolina just got a little freer and more accessible for South Carolinians on January 31 with the passage of H. 4159, the Telehealth and Telemedicine Modernization Act!

The bill was first filed last year and passed by the House in May 2023. At the beginning of the 2024 legislative session, the Senate fast-tracked the bill unanimously with an expansive amendment, and on January 31, the House concurred with the amendment, officially sending the Telehealth and Telemedicine Modernization Act to the Governor’s desk! We urge Governor McMaster to sign this outstanding legislation as soon as possible.

Palmetto Promise has supported the expansion of telemedicine for years. In fact, it was item #9 in our 2023 Palmetto Freedom Agenda. Telehealth allows patients to access medical care more efficiently, flexibly, and cost-effectively than going in-person for every appointment, and we fully support the reduction of regulations that allow consumers the ability to choose the best care for them. This is particularly beneficial for rural South Carolinians, where in-person medical providers are fewer and further between.

Back in 2022, PPI Senior Fellow Dr. Oran Smith testified in support of S. 1179, which allowed social workers, professional counselors, and other mental health professionals to practice via telehealth. The bill was ultimately passed in both chambers and signed into law in May 2022. According to the South Carolina Telehealth Alliance, South Carolina’s telehealth scene has grown rapidly, with over 1.2 million telehealth interactions between patients and medical professionals in the year 2022. A few months ago, we discussed the next steps for telehealth and other essential healthcare reforms in our Beyond Policy podcast here.

Now this session, we are pleased to see the General Assembly take that next step with the passage of H. 4159!

Representative Sylleste Davis, chair of the House’s Medical Committee, put it best in her post on X (formerly known as Twitter):

The repeal of Certificate of Need laws in South Carolina opened the door to greater advancements in healthcare freedom and a medical system that is free of burdensome, costly regulations. Now, that momentum continues with telehealth expansion, another Freedom Agenda win that every South Carolinian should celebrate.

Pandemic-fueled changes open up virtual care to SC patients

Addie Thompson — Wed, 14 Feb 2024 14:48:58 GMT

The COVID-19 pandemic created a sudden need for virtual health care for patients and prompted regulators to drop stricter regulation of what could be provided.

Now, four years later, giant retailers are offering consumers direct access to services while traditional providers adapt and partner to meet patient needs, particularly for rural patients like many across South Carolina.

The future of health care for many patients and providers could be a mix of both virtual and face-to-face care, experts said.

Telemedicine, providing an exam via an interactive video system, has been around for decades, but it was limited by acceptance, traditional regulation and reimbursement to limited uses, such as in a stroke. Hooking up a rural emergency room that lacked specialists to a larger medical center meant patients with a suspected stroke could be evaluated remotely, and after a neurologist read a CT scan of their brains, offered clot-busting drugs that improved outcomes and survival.

Stroke was one of the first ways the technology showed it was better than the traditional approach, said Brandon Welch, CEO of telemedicine company Doxy.me and author of “Telehealth Success: How to Thrive in the New Age of Remote Care.”

“Telemedicine really proved itself in the stroke use case because it was a very clear path to success,” he said. But outside of that, and some limited use in psychiatry, the industry “was kind of treading water,” Welch said.

That is until COVID-19 hit in early 2020. Suddenly, hospitals and clinics were limiting who could be seen, while many patients feared leaving the safety of their homes, even when sick. Federal regulators like the Centers for Medicare and Medicaid Services quickly loosened the reins on what care could be provided virtually and also reimbursed, and many others followed suit.

Those flexibilities were meant to be temporary, and technically still are, with the latest expiration on Dec. 31. But most believe they will be made permanent soon. Congress has been trying in various bills, and the South Carolina Legislature recently passed new regulations codifying remote care standards.

The changes are here to stay, Welch said.

“They’ve been threatening to end it for the last four years, and every time the time comes, they extend it for another year or two,” he said. Members of Congress don’t agree on much, but “what they can agree on is telemedicine should be here to stay,” Welch said.

Big companies already believe that. Amazon purchased virtual-care provider One Medical; Costco members in South Carolina can use its provider, Sesame; and other big retailers have followed suit or soon will.

That kind of access is what many patients want, said Kaitlyn Torrence, executive director of MUSC Health Solutions. She gets it — she uses One Medical herself at times.

“I demand access. I want it quickly,” Torrence said. “And yet, I still want that continuum of care when I need to go to a higher level (of treatment).”

It poses a dilemma for MUSC Health and other providers in South Carolina and across the country: How do you compete with that? Or do you even try?

It’s something MUSC Health is thinking a lot about, whether to continue building its own or partner with a provider like One Medical to provide care that it can’t, Torrence said. For instance, one of those quick-access providers might be the first to see a patient, but MUSC Health becomes the provider for more acute care or for patient management.

One Medical is already a provider for 8,500 employers and partners with 18 health systems across the country, the American Hospital Association noted.

Steve Boucher Presents to Genentech Carolinas Field Reimbursement Team

Addie Thompson — Tue, 16 Jan 2024 18:43:13 GMT

Steve Boucher, the Director of Managed Care Services for the SC Alliance of Health Plans, presented to the Genentech Carolinas Field Reimbursement Team on January 9, 2024. The presentation was designed to elevate the group's fundamental knowledge and included an overview of Medicaid and Medicare, the status of the Medicaid members redetermination project, and an overview of emerging projects and trends within the Medicaid program.

The presentation provided insights to the Genentech field reimbursement leaders that attended both in-person and virtually that will enable Genentech to continue their mission to "do now what patients need next.

Southern Legislative Conference Reception

Addie Thompson — Thu, 20 Jul 2023 13:20:53 GMT

On Sunday, July 9, SCAHP hosted a reception for SC Legislators in Charleston at the Dewberry, during the 2023 SLC Conference.

Below are some photos from the event.

Jim Ritchie pictured with Senator Alexander.

States ranked by total Medicare Advantage members (SC is 25th)

(Past member) — Tue, 06 Jun 2023 15:19:38 GMT

Jakob Emerson - Friday, May 26th, 2023

Eight states have at least 1 million residents enrolled in Medicare Advantage plans, according to a health coverage report published by insurance trade group AHIP in April.

States ranked by total Medicare Advantage members:

California: 3.1 million
Florida: 2.6 million
Texas: 2.2 million
New York: 1.8 million
Pennsylvania: 1.4 million
Michigan: 1.2 million
Ohio: 1.2 million
North Carolina: 1 million
Georgia: 947,000
Illinois: 794,000
Tennessee: 696,000
Arizona: 682,500
New Jersey: 634,000
Washington: 627,000
Wisconsin: 619,100
Missouri: 619,000
Alabama: 595,000
Indiana: 584,000
Minnesota: 551,000
Virginia: 541,000
Colorado: 479,000
Oregon: 474,000
Kentucky: 466,200
Louisiana: 466,000
South Carolina: 465,000
Massachusetts: 406,000
Connecticut: 377,000
Oklahoma: 273,000
Nevada: 271,000
Arkansas: 250,000
Mississippi: 222,000
Maryland: 211,000
New Mexico: 207,000
Utah: 206,000
Iowa: 197,000
West Virginia: 194,000
Maine: 193,000
Idaho: 164,000
Kansas: 163,000
Hawaii: 154,000
Rhode Island: 116,000
Nebraska: 98,000
New Hampshire: 97,000
Montana: 64,000
Delaware: 63,000
Vermont: 44,000
Washington, D.C.: 27,000
South Dakota: 24,000
North Dakota: 14,000
Wyoming: 9,000
Alaska: 2,000

What do the early Medicaid unwinding data tell us?

(Past member) — Tue, 06 Jun 2023 15:18:48 GMT

What do the early data show?

As states begin to unwind the COVID emergency continuous enrollment provision and resume Medicaid disenrollments, early data from a handful of states – highlighted on KFF’s regularly-updated Medicaid Enrollment and Unwinding Tracker

– reveal wide variation in disenrollment rates. While not all states that have resumed disenrollments have publicly posted their numbers, data from 12 states show that over half a million enrollees have already been disenrolled, nearly 250,000 in Florida alone (Figure 1). In nine states that reported both total completed renewals and total disenrollments, the disenrollment rate ranges from 54% in Florida to just 10% Virginia. Among these states, the median disenrollment rate is 34.5%.

Click here to continue reading.

CMS urges states to stem Medicaid losses during redeterminations

(Past member) — Tue, 06 Jun 2023 15:17:23 GMT

States must take better care not to expel eligible Medicaid enrollees from the program during the re-determinations process, a senior Centers for Medicare and Medicaid Services official said Tuesday.

Click to continue reading.

SC Medicaid terminations are underway – What to know and where to turn.

(Past member) — Tue, 06 Jun 2023 15:14:20 GMT

Scores of Medicaid recipients will begin to lose their insurance next week as states continue to review whether residents still qualify.

The South Carolina Department of Health and Human Services anticipates close to 250-300,000 members will be dis-enrolled by 2024. That will roll back enrollment numbers from 1.3 million to pre-pandemic levels at just over 1 million.

KFF, a non-partisan health research organization, estimated close to 214,300 Medicaid losses, including over 86,000 children.

Click here to continue reading.

Overview of the Medicaid Annual Review Process

(Past member) — Wed, 10 May 2023 13:42:55 GMT

Steve Boucher, Director of Managed Care Services for the South Carolina Alliance of Health Plans presented both in-person and virtual overviews of the Medicaid Annual Review process to hundreds of health insurance professionals. These presentations leveraged Steve’s extensive knowledge of the Medicaid Annual Review process as well as his understanding of the health insurance industry and identified him as a key leadership resource in the Medicaid sector. The presentations provided the health insurance professionals with trusted information that will enable strategic decisions within their organizations.

Half of all Medicare members are now in a Medicare Advantage plan

(Past member) — Wed, 10 May 2023 13:39:42 GMT

Dive Brief:

Half of eligible Medicare beneficiaries are now enrolling in private Medicare Advantage coverage, according to recently released data from the CMS.
Of the 59.82 million people who qualify for a Medicare Part A and Medicare B private plan, 30.19 million, or over half of those who qualify, enrolled in January 2023, according to a Monday report from the Kaiser Family Foundation.
Plan A and Plan B enrollment increased by two percentage points from 48% in 2022, according to the nonprofit’s analysis. That means MA now has more enrollees than original Medicaid, a report from Barrons noted.

Read Article!

SC’s CON bill passes final hurdles in House and Senate

(Past member) — Wed, 10 May 2023 13:37:19 GMT

COLUMBIA, S.C. (WPSA) -The South Carolina House of Representatives unanimously approved a bill that would repeal the state’s Certificate of Need program.

The Senate had passed the bill earlier this year with a 30-6 vote.

‘Certificate of Need’ regulations were put into place by the federal government in the 1970s. According to DHEC, the purpose of CON laws is to promote cost containment and prevent unnecessary duplication of healthcare facilities and services.

Right now, if a healthcare provider in South Carolina wants to add beds, build a new facility or purchase expensive medical equipment, they need to go state health officials for approval.

Competitors can appeal these requests, slowing down the process.

House members made a change to the bill on the floor before passing it. The bill would repeal nearly all parts of ‘Certificate of Need’ regulations almost immediately.

Health providers looking to build a new hospital must go through the ‘Certificate of Need’ process up until January 2027. After that date, the regulations would be repealed.

The bill received a third reading from the House Wednesday and was sent back to the Senate. There are now four days left in this year’s legislative session.

Long-term care facilities would still need to go through the Certificate of Need process.

View Article

Website offers SC parents single application for dozens of early childhood programs and services, including Medicaid

(Past member) — Wed, 10 May 2023 13:34:03 GMT

COLUMBIA — Parents of children 5 and younger in South Carolina can fill out a new online application to simultaneously check their eligibility for taxpayer-funded child care assistance, preschool and other government programs.

The May 1 launch of the common application on first5sc.org was celebrated by state agency leaders and early childhood advocates as providing families an easier, quicker way to access services that enable parents to work and children to succeed.

Instead of filling out separate, often lengthy forms — sometimes needing to do so in person during business hours — parents can securely submit information once that will automatically fill out applications across state government.

Governor McMaster Nominates Michael Wise to be the Director of the South Carolina Department of Insurance (DOI)

(Past member) — Tue, 02 May 2023 16:53:42 GMT

Gov. Henry McMaster Announces Michael Wise as Next Director of the S.C. Department of Insurance

What’s Driving Your Employer-Provided Health Coverage Premiums?

(Past member) — Thu, 20 Apr 2023 18:14:35 GMT

Health Coverage Premiums - View Document.pdf

Preference for telehealth use does not exceed that of in-person care

(Past member) — Thu, 20 Apr 2023 18:14:23 GMT

https://mhealthintelligence.com/news/preference-for-future-telehealth-use-does-not-exceed-that-of-in-person-care

Medicare Advantage final rule addresses prior auths, health equity

(Past member) — Thu, 20 Apr 2023 18:14:05 GMT

https://healthpayerintelligence.com/news/medicare-advantage-final-rule-addresses-prior-authorization-health-equity

Medicare Advantage associated with reduced hospital readmission, mortality rankings

(Past member) — Thu, 20 Apr 2023 18:13:47 GMT

https://www.2minutemedicine.com/medicare-advantage-associated-with-reduced-hospital-readmissions-and-mortality-rankings/

Medicare Advantage has lower healthcare use, higher clinical quality

(Past member) — Thu, 20 Apr 2023 18:13:30 GMT

https://healthpayerintelligence.com/news/medicare-advantage-has-lower-healthcare-use-higher-clinical-quality

Medicaid payments to psychiatrists falls short; varies greatly by state

(Past member) — Thu, 20 Apr 2023 18:13:19 GMT

https://www.fiercehealthcare.com/payers/medicaid-payment-mental-health-services-shortchanges-psychiatrists-many-states-study

Resumption of Medicaid annual reviews to hit hospitals, insurers, states

(Past member) — Thu, 20 Apr 2023 18:13:06 GMT

https://www.wsj.com/articles/medicaid-eligibility-changes-set-to-hit-hospitals-insurers-states-5d0a6070

National ‘unwinding tracker’ looks at states’ planning and publicity of Medicaid annual review processes

(Past member) — Thu, 20 Apr 2023 18:12:47 GMT

https://ccf.georgetown.edu/2023/04/01/state-unwinding-tracker/

U.S. health spending to top $6 trillion in 2027; managed care $4 trillion of that

(Past member) — Thu, 20 Apr 2023 18:12:27 GMT

https://www.businesswire.com/news/home/20230331005195/en/U.S.-Managed-Care-Market-Report-2023-Rise-in-Healthcare-Expenditure-and-Growing-Adoption-of-Healthcare-Insurance-Fuel-the-Sector---ResearchAndMarkets.com

Four SC cities among top 25 obese/overweight cities in U.S. (Columbia, Greenville, Myrtle Beach, Charleston)

(Past member) — Thu, 20 Apr 2023 18:12:07 GMT

https://wallethub.com/edu/fattest-cities-in-america/10532

Poll: Affordable health care, drug use among Americans’ top concerns

(Past member) — Thu, 20 Apr 2023 18:10:55 GMT

https://thehill.com/policy/healthcare/3937415-affordable-health-care-drug-use-grow-as-top-american-concerns-gallup/

Rates & Forms Filing Timeline for Plan & Policy Years Beginning in 2024

(Past member) — Thu, 20 Apr 2023 14:06:57 GMT

I.PURPOSE

This memorandum details the filing timelines for issuers offering:

individual or small group1non-grandfathered health insurance coverage2; or

coverage of pediatric dental services under Exchange-certified Stand-Alone Dental Plans (SADPs).

It applies to coverage with plan or policy years beginning in calendar year 2024. Hereafter, these policies are referred to as 2024 Plans and 2024 SADPs, respectively.

II.FILING TIMELINES FOR 2024 PLANS AND 2024 SADPs

South Carolina has a Federally Facilitated Marketplace (FFM). However, this Department retains responsibility for the review and approval of forms and rates for 2024 Plans and 2024 SADPs sold on and off the FFM.

The Center for Consumer Information and Insurance Oversight (CCIIO) sets QHP application and single risk pool rate submission timelines annually, which are summarized in the Key Dates for Calendar Year 2023: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (posted by CMS on March 28, 2023).

These federally imposed deadlines are the basis for the filing timeline summarized in this Memorandum. We are requesting that issuers submit filings for 2024 Plans and 2024 SADPs by the following dates:

Health Insurance Issuers Seeking QHP Certification (excluding SADPs)

QHP Application Deadline: June 14, 2023

Submit Rate/ Form Filing in SERFF by: June 9, 2023

Submit Binder in SERFF Plan Management by: June 9, 2023

Submit Rate Filing Justification in URR Module5by:          June 9, 2023
SERFF/ URR5System Dispositions Deadline:                August 16, 2023
State QHP Certification Recommendations Due:     September 20, 2023

Dental Issuers Seeking SADP Certification (including SADPs that will be offered strictly outside of the FFM and/or FF-SHOP)
QHP Application Deadline:                                                 June 14, 2023
Submit Rate/ Form Filing in SERFF by:                                June 9, 2023
Submit Binder in SERFF Plan Management by:                   June 9, 2023
SERFF Dispositions Deadline:                                         August 16, 2023
State QHP Certification Recommendations Due:      September 20, 2023

Health Insurance Issuers Writing Solely Outside of the FFM
Submit Rate/ Form Filing in SERFF by:                                  July 7, 2023
Submit Binder in SERFF Plan Management by:                     July 7, 2023
Submit Rate Filing Justification in URR Module by:                July 7, 2023
SERFF/ URR5System Dispositions Deadline:                October 16, 2023

Open Enrollment for 2024 Plans begins: November 1, 2023

III.FILING REQUIREMENTS FOR 2024 PLANS & 2024 SADPs

Our continued goal is to provide issuers with the maximum amount of time possible to develop their filings to get better quality, more complete submissions at the beginning of the process.

With that in mind, we ask that issuers be mindful of the following items relative to the upcoming filing period:

Filings cannot be reviewed until the associated binder is also submitted.

The Department will only accept one filing per 2024 Plan/SADP issuer per market segment.

The Department will provide two weeks for issuers to respond to initial objections on rate objections and one week on form objections. Approximately 30 days prior to the federally imposed disposition deadlines, response time frames will be limited to one week or less in some cases. Extensions will not be granted unless there is an extraordinary circumstance.

Prior to filing, issuers should review all objections and requests from prior years.The current filing should be amended accordingly to expedite the review of the filing.

When the final guidance is released, we will post the 2023 Filing Requirements (for 2024 Plans) chart on our website.Changes, updates, and new requirements for PY 2024 will be outlined in this document.It is imperative that the most recent guidelines are followed to maintain accuracy and completeness of the filing.

The Department will publish additional guidance as necessary on its LA&H webpage under the PPACA Resources heading, which may be accessed at doi.sc.gov/lah.

The information in this Memorandum is based on the Final Key Dates for Calendar Year 2023. Please check our website often for the latest updates

IV.QUESTIONS

Issuers should regularly check the LA&H webpage (doi.sc.gov/lah) for additional materials relative to the filing and review process.Please note that all materials will be listed under the PPACA Resources heading.

Questions should be submitted via email to lahmail@doi.sc.gov and include the company name and primary point of contact (with phone number and email address).

A progress check on hospital price transparency

Addie Thompson — Fri, 07 Apr 2023 13:03:39 GMT

For decades, U.S. hospitals have generally stonewalled patients who wanted to know ahead of time how much their care would cost. Now that’s changing — but there’s a vigorous debate over what hospitals are disclosing.

Under a federal rule in effect since 2021, hospitals nationwide have been laboring to post a mountain of data online that spells out their prices for every service, drug, and item they provide, including the actual prices they’ve negotiated with insurers and the amounts that cash-paying patients would be charged. They’ve done so begrudgingly and only after losing a lawsuit that challenged the federal rule.

How well they’re doing depends on whom you ask.

The rule aims to pull back the curtain on opaque hospital prices that may vary widely by hospital for the same service or even within the same hospital. The expectation is that price transparency will boost competition, giving consumers and employers a way to compare prices and make informed choices, ultimately driving down the cost of care. Whether that will happen is not yet clear.

Insurers and large employers are also required to post their negotiated prices with all their providers, under separate rules that took effect last summer.

Hospitals have made “substantial progress,” according to an analysis by the federal Centers for Medicare & Medicaid Services of 600 randomly selected hospitals that was published in the journal Health Affairs last month. The agency looked at whether hospitals had met their obligation to post price information online in two key formats: a “shoppable” list of at least 300 services for consumers, and a comprehensive machine-readable file that incorporates all the services for which the hospital has standard charges. This file should be in a format that allows researchers, regulators, and others to analyze the data.

CMS found that 70% of hospitals published both lists in 2022. An additional 12% published one or the other. By contrast, the agency’s previous progress assessment in 2021 found that just 27% of 235 hospitals had both types of lists.

The 2022 analysis “represents a marked improvement,” said Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at CMS, in a statement. But she also said the advances are still “not sufficient” and CMS will continue to use “technical assistance and enforcement activity” so that all hospitals “fully comply with the law.”

The American Hospital Association said the CMS assessment demonstrated the progress hospitals had made under very challenging circumstances as they grappled with the covid-19 pandemic.

“These are complicated policies that went into effect in the most complicated time in hospitals’ history,” said Molly Smith, group vice president for policy at the trade association. “And we have seen increases in compliance over the past 18 months.”

Some groups that have looked at the hospitals’ posted price data, though, were less upbeat. In an analysis published last month, Patient Rights Advocate examined 2,000 hospitals’ listings and found that only 489 of them, 24.5% of the total, were compliant with all the requirements of the rule. An earlier analysis in August 2022 found that 16% met all the requirements.

The advocacy group’s analysis covered not only the two types of lists that CMS looked for but also checked whether the hospitals included required data on specific types of standard charges for every service offered, such as the gross or “chargemaster” charge before any discounts are applied, the discounted cash price, and the negotiated charge by insurer.

Although most hospitals have published files online, too often the data is incomplete, illegible, or not clearly associated with specific health plans or insurers, said Cynthia Fisher, founder and chair of Patient Rights Advocate, which promotes health care price transparency.

“As hospitals continue to post incomplete files with swaths of missing prices, patients are unable to accurately compare prices across hospitals and across plans to make the best health care decisions and protect themselves from overcharges,” Fisher said. Such hospitals were considered noncompliant in the PRA analysis.

The hospital association faulted PRA’s analysis. The contracts that hospitals have with health plans vary substantially from one to the next, and prices are not always based on a simple dollar amount, said Terry Cunningham, AHA’s director of policy. They might be based on a bundle of services or on volume, for example, he said.

“It’s both frustrating and problematic for these other organizations to be weighing in, saying, ‘This cell shouldn’t be blank,’” Cunningham said.

In their 2020 lawsuit, hospitals argued that they should not be required to disclose privately negotiated prices, and maintained that doing so would confuse patients and lead to anti-competitive behavior by insurers.

Last summer, price transparency requirements took effect in the health insurance industry as well, complementing and providing a cross-reference tool for what hospitals have posted. The insurer transparency requirements are even broader than those for hospitals: Insurers and self-funded employers must list every negotiated rate they have with every doctor, hospital, and other health care providers.

Some critics charge that data isn’t user-friendly either. Sens. Maggie Hassan (D-N.H.) and Mike Braun (R-Ind.) sent a letter March 6 to CMS Administrator Chiquita Brooks-LaSure encouraging the agency to take steps to close “technical loopholes” such as large files and a lack of standardization that make it difficult to use the data they’re reporting.

That’s where pricing platforms like Turquoise Health come in. The data becoming available from hospitals and insurers is a vast treasure trove the company is mining to devise user-friendly tools that consumers and businesses can use to discover and compare prices.

In its own analysis of how effective hospital price transparency efforts were in 2022’s third quarter, Turquoise Health found that 55% of the more than 4,900 acute care hospitals that posted machine-readable files were “complete,” meaning they posted the cash, list, and negotiated rates for a “significant quantity” of items and services. Twenty-four percent of hospitals were judged to be “mostly complete.” (The analysis didn’t evaluate the second type of posting, the list of shoppable services.)

According to Chris Severn, Turquoise Health co-founder and CEO, the company uses a scoring algorithm of 60 variables to assess how complete a hospital’s file is.

“What you end up with is a more nuanced look at these files that hopefully takes into consideration shades of gray,” Severn said, rather than a simple pass-fail rating.

Regardless of the differences in how the hospital disclosures are evaluated, experts generally agree that CMS should require data be reported in a standardized format for ease of comparison and enforcement. CMS has developed a template, but hospitals aren’t required to use it.

For price transparency to work, enforcement also needs consistent attention, experts say. The Biden administration increased the maximum potential penalty to more than $2 million annually per hospital for 2022. Still, last year CMS penalized just two hospitals for noncompliance even though 30% of hospitals didn’t meet the requirement to post both a machine-readable file of prices as well as a shoppable list.

CMS provided technical assistance to many hospitals to help them come into compliance, said Seshamani, and it also plans stronger enforcement actions.

She said the agency will “continue to expedite” the time frame hospitals have to reach full compliance after submitting a corrective action plan, which indicates they have fallen short on some posting requirements. “CMS also plans to take aggressive additional steps to identify and prioritize action against hospitals that have failed entirely to post files,” she said.

UHC Unit to reduce use of Prior Authorizations

Addie Thompson — Fri, 07 Apr 2023 13:02:44 GMT

March 29 (Reuters) - UnitedHealth Group Inc (UNH.N) said on Wednesday its insurance unit will reduce the use of prior authorization process by 20% for some non-urgent surgeries and procedures.

Under this process, Healthcare providers get coverage approval for certain non-emergency procedures.

The reductions will begin in the third quarter and will continue through the rest of the year for most commercial and Medicare Advantage as well as Medicaid businesses.

The company will implement in early next year a national Gold Card Program for care providers that meet eligibility norms, ending the need for prior authorization for most procedures. It would apply for most UnitedHealthcare members.

"We will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure," said Anne Docimo, chief medical officer of UnitedHealthcare.

The company said it plans to remove prior authorization requirements in certain types of medical equipment like orthopedic support devices and some genetic tests used for diagnosis.

The U.S. Centers for Medicare & Medicaid Services had last year issued a proposed rule to simplify the process, which doctors said causes administrative burden to patients and doctors.

Google plans to boost Medicaid information as annual reviews resume

Addie Thompson — Wed, 05 Apr 2023 16:30:00 GMT

During the tech giant’s annual healthcare event on Tuesday, Google also shared an a updated version of its medical artificial intelligence that can answer clinical questions at an “expert” level.

Google announced slew of new health initiatives on Tuesday, including bolstering Search to help Medicaid enrollees during redeterminations, an updated version of its medical artificial intelligence that can answer clinical questions and a digital health app development infrastructure.

Among the other announcements during the tech giant’s annual healthcare event, Google said it will make Medicaid information easier to find on Search for people looking to re-enroll once states resume their eligibility checks. The checks, which were paused during the COVID-19 public health emergency, will resume in April and could cause some 18 million Americans to lose Medicaid coverage.

When consumers search for a Medicaid-related term on Google, they’ll see a new Renewal tab which will include results on the renewal guidelines in their state, and other information on Medicaid like contact information or the log-in to their state portal. The update will roll out it in the coming weeks, according to a spokesperson.

Google also plans to highlight providers that are community health centers offering free or low-cost care on search, building on a search engine feature that shows consumers available appointment times for select providers.

Google frequently cites data that most people use the internet first when checking symptoms or researching medical information. In late 2021, the company wove additional information into practices’ business profiles, including whether they accept Medicare and what languages they offer services in.

Google launched the booking functionality last year. It shows appointments for CVS MinuteClinics and links with scheduling tools like Kyruus and Stericycle so their provider users can integrate their appointment times into the search engine.

The bookings functionality only shows appointments at specific practices and does not aggregate across providers.

On Tuesday, Google said it was expanding the network of qualified partners in the U.S. who can show their appointment availability directly on Search, and make it simpler for them to self-onboard, in the coming months.

AI and app development

Google also announced a number of updates to AI projects.

In partnership with Mayo Clinic, Google has been testing how AI can support planning for radiotherapy, a common cancer treatment. Google said it will soon publish research on the findings of a study into AI’s efficacy in “contouring,” a process where clinicians draw lines on a CT scan to separate healthy tissue from areas of cancer that can take up to seven hours for one patient.

Google and Mayo Clinic are also formalizing their partnership to explore further research, along with model development and commercialization, according to Greg Corrado, who leads health AI at Google.

Also on the AI front, Google has invested in medical large language model research to develop AI tools that can retrieve medical information and accurately answer medical questions. Its model, called Med-PaLM, recently performed at an “expert” doctor level on medical exam questions, scoring 85%. That’s an 18% improvement from Med-PALM’s previous performance and a result that “far surpasses similar AI models,” Corrado wrote in a blog post on the news.

However, there’s more work to be done to ensure Med-PaLM will work in real-world settings, said Alan Karthikesalingam, a research lead at Google. An evaluation of the AI found significant gaps when it comes to the complexity of medical questions answered and meeting product excellence standards.

Google also announced a number of new partners for AI research, including Kenya-based nonprofit Jacaranda Health on ultrasound delivery for expectant mothers, Chang Gung Memorial Hospital in Taiwan on ultrasound for breast cancer detection and nonprofit Right to Care on AI-powered chest x-ray screening to help with tuberculosis in Africa.

The tech giant introduced a suite of open-source infrastructure built on an interoperable data standard to make it easier for developers to quickly build healthcare apps.

Despite disbanding its health-specific unit in 2021, Google has remained active in the healthcare industry, launching tools to help healthcare companies make their medical images more actionable through AI and machine learning and inking a deal with major EHR vendor Meditech to embed its clinical software tools into the records of U.S. hospitals.

CDC: U.S. maternal death rate rose sharply in 2021; experts worry it is getting worse

Addie Thompson — Tue, 04 Apr 2023 18:22:48 GMT

As women continue to die due to pregnancy or childbirth each year in the United States, new federal data shows that the nation’s maternal death rate rose significantly yet again in 2021, with the rates among Black women more than twice as high as those of White women.

Experts said the United States’ ongoing maternal mortality crisis was compounded by Covid-19, which led to a “dramatic” increase in deaths.

The number of women who died of maternal causes in the United States rose to 1,205 in 2021, according to a report from the National Center for Health Statistics, released Thursday by the US Centers for Disease Control and Prevention. That’s a sharp increase from years earlier: 658 in 2018, 754 in 2019 and 861 in 2020.

That means the US maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births, compared with rates of 20.1 in 2019 and 23.8 in 2020.

The new report also notes significant racial disparities in the nation’s maternal death rate. In 2021, the rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for White women, at 26.6 per 100,000.

The data showed that rates increased with the mother’s age. In 2021, the maternal death rate was 20.4 deaths per 100,000 live births for women under 25 and 31.3 for those 25 to 39, but it was 138.5 for those 40 and older. That means the rate for women 40 and older was 6.8 times higher than the rate for women under age 25, according to the report.

The maternal death rate in the United States has been steadily climbing over the past three decades, and these increases continued through the Covid-19 pandemic.

Questions remain about how the pandemic may have affected maternal mortality in the United States, according to Dr. Elizabeth Cherot, chief medical and health officer for the infant and maternal health nonprofit March of Dimes, who was not involved in the new report.

“What happened in 2020 and 2021 compared with 2019 is Covid,” Cherot said. “This is sort of my reflection on this time period, Covid-19 and pregnancy. Women were at increased risk for morbidity and mortality from Covid. And that actually has been well-proven in some studies, showing increased risks of death, but also being ventilated in the intensive care unit, preeclampsia and blood clots, all of those things increasing a risk of morbidity and mortality.”

The American College of Obstetricians and Gynecologists previously expressed “great concern” that the pandemic would worsen the US maternal mortality crisis, ACOG President Dr. Iffath Abbasi Hoskins said in a statement Thursday.

“Provisional data released in late 2022 in a U.S. Government Accountability Office report indicated that maternal death rates in 2021 had spiked—in large part due to COVID-19. Still, confirmation of a roughly 40% increase in preventable deaths compared to a year prior is stunning new,” Hoskins said.

“The new data from the NCHS also show a nearly 60% percent increase in maternal mortality rates in 2021 from 2019, just before the start of the pandemic. The COVID-19 pandemic had a dramatic and tragic effect on maternal death rates, but we cannot let that fact obscure that there was—and still is—already a maternal mortality crisis to compound.”

During the early days of the pandemic, in 2020, there was limited information about the vaccine’s risks and benefits during pregnancy, prompting some women to hold off on getting vaccinated. But now, there is mounting evidence of the importance of getting vaccinated for protection against serious illness and the risks of Covid-19 during pregnancy.

The Covid-19 pandemic also may have exacerbated existing racial disparities in the maternal death rate among Black women compared with White women, said Dr. Chasity Jennings-Nuñez, a California-based site director with Ob Hospitalist Group and chair of the perinatal/gynecology department at Adventist Health-Glendale, who was not involved in the new report.

“In terms of maternal mortality, it continues to highlight those structural and systemic problems that we saw so clearly during the Covid-19 pandemic,” Jennings-Nuñez said.

“So in terms of issues of racial health inequities, of structural racism and bias, of access to health care, all of those factors that we know have played a role in terms of maternal mortality in the past continue to play a role in maternal mortality,” she said. “Until we begin to address those issues, even without a pandemic, we’re going to continue to see numbers go in the wrong direction.”

‘This is a problem in our country’

Some policies have been introduced to tackle the United States’ maternal health crisis, including the Black Maternal “Momnibus” Act of 2021, a sweeping bipartisan package of bills that aim to provide pre- and post-natal support for Black mothers, including extending eligibility for certain benefits postpartum.

As part of the Momnibus, President Biden signed the bipartisan Protecting Moms Who Served Act in 2021, and other provisions have passed in the House.

In the United States, about 6.9 million women have little or no access to maternal health care, according to March of Dimes, which has been advocating in support of the Momnibus.

The US has the highest maternal death rate of any developed nation, according to the Commonwealth Fund and the latest data from the World Health Organization. While maternal death rates have been either stable or rising across the United States, they are declining in most countries.

“A high rate of cesarean sections, inadequate prenatal care, and elevated rates of chronic illnesses like obesity, diabetes, and heart disease may be factors contributing to the high U.S. maternal mortality rate. Many maternal deaths result from missed or delayed opportunities for treatment,” researchers from the Commonwealth Fund wrote in a report last year.

The ongoing rise in maternal deaths in the United States is “disappointing,” said Dr. Elizabeth Langen, a high-risk maternal-fetal medicine physician at the University of Michigan Health Von Voigtlander Women’s Hospital. She was not involved in the latest report but cares for people who have had serious complications during pregnancy or childbirth.

“Those of us who work in the maternity care space have known that this is a problem in our country for quite a long time. And each time the new statistics come out, we’re hopeful that some of the efforts that have been going on are going to shift the direction of this trend. It’s really disappointing to see that the trend is not going in the right direction but, at some level, is going in the worst direction and at a little bit of a faster rate,” Langen said.

“In the health care system, we need to accept ultimate responsibility for the women who die in our care,” she added. “But as a nation, we also need to accept some responsibility. We need to think about: How do we provide appropriate maternity care for people? How do we let people have time off of work to see their midwife or physician so that they get the care that they need? How do all of us make it possible to live a healthy life while you’re pregnant so that you have the opportunity to have the best possible outcome?”

Americans who lose Medicaid may choose employer-sponsored coverage

Addie Thompson — Tue, 04 Apr 2023 18:22:09 GMT

In most states, beneficiaries who lose Medicaid coverage when the public health emergency ends are likely to transition into employer-sponsored health plans, according to a study funded by AHIP from NORC at the University of Chicago (NORC).

NORC used the Urban Institute’s public health emergency Medicaid coverage loss estimates and historic data from the Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC).

The researchers recategorized the data, taking into account respondents’ coverage type in year one and year two of the transition, supplementing data for smaller states, and applying a hierarchy of coverage types to distribute respondents with multiple coverage sources. When respondents had multiple coverage types, the researchers prioritized first employer-sponsored coverage, then uninsurance, CHIP, nongroup coverage, and other public coverage, respectively.

Dig Deeper

When the researchers blended these two data sources, the study found that individuals who lose their Medicaid coverage after the end of the public health emergency will transition into employer-sponsored health plans in most states.

More than half of the beneficiaries who lose Medicaid coverage will transition to employer-sponsored health plan coverage in every state except for Georgia (48.9 percent), according to the dashboard associated with the report. The state with the highest share of beneficiaries going into employer-sponsored health plans after the public health emergency was Delaware (57.1 percent).

Overall, more than one in five beneficiaries who lose Medicaid coverage will become uninsured. Seven states had a 23.1 percent expected uninsurance rate or higher: Arizona (23.5 percent), Florida (23.1 percent), Maine (23.3 percent), New Mexico (23.1 percent), North Carolina (23.2 percent), South Carolina (26.2 percent), and Texas (24.5).

Delaware had the lowest uninsurance rate projection, but it was still above 15 percent. The First State may see 17.7 percent of its beneficiaries become uninsured after the public health emergency.

Altogether, 54 percent of beneficiaries will end up in employer-sponsored health plans, 21 percent will become uninsured, 15 percent will gain CHIP coverage, seven percent will join nongroup coverage, and three percent will get other public payer coverage.

These estimates were close to the Urban Institute estimates except for the CHIP and other public payer coverage projections. Urban Institute expected that 18 percent of beneficiaries would turn to CHIP coverage and only one percent would fall under other public coverage.

Around 18 million Medicaid beneficiaries will lose their coverage in the first 14 months after the public health emergency ends, according to the Urban Institute.

In response to the threat of coverage loss after the public health emergency ends, AHIP has partnered with numerous organizations to introduce a new coalition. The coalition’s website consolidates CMS guidance around the redetermination process. The coalition itself encourages information-sharing between stakeholders.

A separate, state-based analysis from the Kaiser Family Foundation found that states that saw significant Medicaid enrollment gains during the coronavirus pandemic could experience the biggest drop in enrollment after the public health emergency ends.

Resumption of Medicaid annual reviews and the impact on employer medical plans

Addie Thompson — Tue, 04 Apr 2023 18:21:22 GMT

In case you haven't heard, COVID-19’s public health emergency (PHE) and national emergency (NE) are coming to a close. The Biden administration announced that both emergencies will terminate on May 11, 2023. In addition to the cessation of various group health plan obligations to provide certain COVID-19-related items/services without cost-sharing under the PHE and the end to the extended deadlines under the NE’s “outbreak period,” the PHE’s expiration will also lead to the unwinding of Medicaid continuous coverage protection.

Starting as early as February 2023, state agencies in charge of Medicaid may begin the process of redetermining which Medicaid participants may no longer be eligible and, consequently, dropped from Medicaid starting April 1, 2023. The exact timing will vary by state. More information regarding when a particular state will begin this re-evaluation process may be found here(opens a new window).

Key Takeaways

The Medicaid redetermination process will result in numerous individuals losing their current Medicaid coverage.
Loss of Medicaid coverage is a HIPAA special enrollment right, allowing individuals to return to employer-sponsored coverage mid-year if they provide notice within 60 days.
Bottom line: Employers may see a significant uptick in covered employees and family members in the coming months.

Background

The Families First Coronavirus Response Act, passed in early 2020, increased federal Medicaid funding for states that agreed to allow anyone already enrolled or who became enrolled in Medicaid during the PHE to remain enrolled throughout the PHE, even if their eligibility status changed. This continuous coverage rule increased Medicaid enrollment by roughly 30% to approximately an additional 18 million participants. Legislation passed late last year allows states to redetermine eligibility and begin involuntary terminations. It is estimated that roughly 6 million individuals who lose Medicaid coverage will be eligible for coverage under an employer-sponsored health plan.

Effect on Employer-Sponsored Medical Plans

Losing Medicaid triggers a HIPAA special enrollment right in employer-sponsored medical plans. And, for many employers who allow employees to pay medical premiums on a pre-tax basis through a cafeteria plan, it is also a qualifying election change event. Generally, the window for notifying the plan of losing Medicaid eligibility is 60 days. However, keep in mind that we are still in the Outbreak Period (think NE) through July 10, 2023, so the 60-day window is temporarily extended for anyone losing Medicaid before that date.

Lockton Comment: For example, if an employee were to lose Medicaid eligibility effective April 1, they would (under pre-covid rules) have until May 30th to enroll in their employer-provided medical plan, assuming they are otherwise eligible. This year, however, with the extra padding of time under the NE, their 60-day clock to exercise the HIPAA special enrollment right will not start ticking until the end of the Outbreak Period on July 10, 2023, bringing their deadline to Sept. 8, 2023 (July 10 plus 60 days).

Bring In the Actuaries

From an actuarial perspective, Lockton’s Actuarial Practice anticipates the impact will likely vary greatly from employer to employer, depending on the employer’s situation. The Medicaid redetermination process would be a non-event for some employers, while others could see a significant impact. Here are points that Lockton’s actuaries recommend employers consider:

New members joining a plan due to no longer being eligible for Medicaid could be spread over the next 12 to 18 months.
Federal regulators estimate that 5-6 million people who lose Medicaid coverage will seek enrollment in employer-sponsored health plans. This concurs with other CMS data stating that 15-18 million will lose coverage, and 30-40% will seek coverage through employer-sponsored plans. This represents a potential increase of approximately 3% to the total amount of people currently participating in private insurance (~160M).
- Using this as a starting point, we could expect nationwide employer-sponsored plan membership to increase by 3%.
- The members coming on to the plan would be expected to have similar costs as those currently on the plan unless other information is available from the client about these members. Thus, the additional members would be expected to result in an increase of 3% cost for employer-sponsored plans.
Based on an employer’s specific situation, the impact could be very close to zero (not noticeable among other changes in membership throughout the year); the impact could also be much higher than 3% for employers that were more affected by the pandemic.
It is believed that those people impacted by the end of the PHE and NE are more likely those whose employment was also impacted during the pandemic (food service, hospitality, service industries).
Employers that were able to move employees to remote working situations during the pandemic and/or didn’t experience a significant loss of workers are not likely to be impacted by this redetermination. These will typically be white-collar industries and those with higher compensated employees.

Lockton Comment: We recommend that employers review historical waiver percentages pre-pandemic and currently. If the percentage of employees that waived coverage pre- to post-pandemic increased, it is an indicator that an influx of new enrollees could impact the plan. Consideration should also be given to additional dependents being added to the plan for employees currently enrolled.

There is no information available to help determine how many of an employer’s employees are currently on Medicaid. If somehow an employer had that information, it is expected that about 13% of Medicaid enrollees will be disenrolled, and only about 26% of those will enroll in private insurance (with the rest either re-enrolling in Medicaid based on qualifications or going uninsured).

Again, for most employers, we do not expect this to be an event to cause any noticeable increase in cost or enrollment; however, for specific employers in certain industries, there could be a cost increase due to the number of new enrollees that should be considered in financials on top of the standard trend.

How Aetna is using CVS stores to warn members about upcoming annual reviews

Addie Thompson — Tue, 21 Mar 2023 15:22:10 GMT

Aetna is leveraging its parent company's retail stores to let Medicaid members know they may need to renew their coverage.

Kelly Munson, president of Aetna Medicaid, a CVS Health company, told Becker's CVS retail stores have a chance to reach all Medicaid members when they walk into a store, regardless of if they are members of Aetna or another managed care plan.

"Regardless of payer, CVS can be supportive of all the Medicaid members that are walking in the door," Ms. Munson said. "We have messaging in the stores that plays over the sound system, videos that remind members they need to be looking for redeterminations, and we have QR codes they can scan so they can know and understand what their next move is."

Up to 18 million people nationwide could lose their Medicaid coverage beginning April 1, according to estimates from the Robert Wood Johnson Foundation. Some Medicaid members will lose coverage because they make too much income to qualify for the program, while others may be dropped for administrative reasons.

Read more about how Aetna is reaching members ahead of redeterminations here.

15 million Americans could lose coverage as pandemic-era enrollment unwinds

Addie Thompson — Fri, 17 Mar 2023 13:51:57 GMT

About 15 million Americans could lose Medicaid health insurance coverage as states unwind the “continuous coverage requirement” implemented at the beginning of the COVID-19 pandemic to ensure people retained health benefits, a new analysis from the Kaiser Family Foundation shows.

The federal government has called the expiration of the coverage requirement, first authorized by the Families First Coronavirus Response Act, the “the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act.” The move paused disenrollment from Medicaid in February 2020 at the pandemic’s beginning and has contributed to a boom in growth of health insurance for low income Americans to nearly 95 million by the end of this month when the continuous enrollment provision ends.

“Millions of beneficiaries are expected to be disenrolled over the next year, including some who are no longer eligible for Medicaid and others who still qualify but lose coverage due to administrative paperwork problems,” the Kaiser Family Foundation, which worked with the Georgetown University Center for Children and Families, to survey states on how they would disenroll people from Medicaid, as part of the 21st annual KFF survey of state Medicaid and Children’s Health Insurance Program (CHIP) report, which was issued Thursday.

“One-third of states that were able to report projected coverage losses estimate that about 18% of Medicaid enrollees will be disenrolled after the continuous enrollment provision ends,” Kaiser said. “The estimates range from 7% to 33% of total enrollees and are consistent with other estimates that about 15 million people may lose Medicaid coverage over the coming year.”

Aside from Americans including children and families who could lose coverage, the coming loss of Medicaid recipients is on the minds of health insurance companies across the country that could lose business. Executives from UnitedHealth Group, Centene, Elevance Health, CVS Health’s Aetna health insurance unit and a host of other companies are regularly peppered with questions from Wall Street analysts about the coming end to the continuous coverage provision.

But it’s difficult to know exactly how many Americans will lose Medicaid coverage and when because states, which administer such health benefits, have different plans and strategies, the Kaiser analysis shows. Meanwhile, some states are making it easier for people remain eligible to keep their coverage while others are making it more difficult, the Kaiser analysis showed.

The process will be slow with 43 states “taking 12-14 months to complete renewals following the end of the continuous enrollment provision,” the Kaiser analysis said.

Here’s a link to the entire Kaiser 50-state Medicaid survey.

Medicare Advantage is good policy for SC seniors

Addie Thompson — Fri, 17 Mar 2023 13:43:18 GMT

I am continually proud of South Carolina’s senators for the leadership they show in Washington on issues that are important to their constituents. Through my work as a national committeeman, I have had the opportunity to get to know these gentlemen and see their work firsthand.

That is why I am thankful to Sens. Tim Scott and Lindsay Graham for leading on issues surrounding senior health care and pushing policies that offer affordable, accessible options to our aging community. Last month, Scott emerged as a lead signer on a bipartisan senate letter calling on the Biden Administration to continue supporting Medicare Advantage. Graham also supported and signed this same letter. This is exactly the kind of leadership that our senators should be focused on.

Medicare Advantage is an increasingly popular program for seniors, offering them health care coverage that is tailored to their needs at a low cost. Nationwide, over 30 million Americans choose to be enrolled in a Medicare Advantage plan, including over 450,000 South Carolinians. The program gives seniors access to a variety of great benefits, including capping out-of-pocket costs and expanded in-home care coverage, all under one plan.

NAIC’s President’s Award Renamed to Honor South Carolina Insurance Director Ray Farmer

Addie Thompson — Tue, 21 Dec 2021 19:29:23 GMT

During the National Association of Insurance Commissioners’ (NAIC) opening session to its 233rd National Meeting, NAIC President and Commissioner of Florida’s Department of Insurance, David Altmaier, recognized South Carolina Department of Insurance Director, and NAIC Immediate Past President, Ray Farmer, with the NAIC President’s Award for Distinguished NAIC Leadership (President’s Award).

The President’s Award is given at the discretion of the current NAIC President and honors an NAIC member who has shown exemplary leadership; has a sustained length of industry service; and who has contributed to advancing the mission of the NAIC.

“Director Farmer has displayed exceptional leadership at the NAIC as he navigated the organization through a global pandemic, spearheaded the Special Committee on Race and Insurance, and served on the leadership teams for climate and resiliency, technology, data, privacy and cybersecurity task forces, as well as several other priority initiatives,” said NAIC President and Florida Insurance Commissioner, David Altmaier.

Following the presentation of the President’s Award, NAIC President Altmaier, announced that the NAIC President’s Award would be renamed in Director Farmer’s honor.

“It was the unanimous opinion of the NAIC officers that leadership examples such as the ones Director Farmer set for all of us and has displayed during his 53 years of industry service, are truly profiles in courage that should be memorialized well beyond handing out this award. Today, I proclaimed that the President’s Award be renamed the Raymond G. Farmer Award for Exceptional Leadership, and it is the award to be presented for exceptional NAIC Leadership from this day forward,” said Altmaier.

The NAIC President’s Award was first awarded at the 2008 Fall National Meeting to Commissioner, Jim Long. Other recipients include Commissioner Alfred Gross (2010); Commissioner, Sandy Praeger (2014); Superintendent, Joseph Torti III (2015); and Commissioner, Roger Sevigny (2017).

About the National Association of Insurance Commissioners

As part of our state-based system of insurance regulation in the United States, the National Association of Insurance Commissioners (NAIC) provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers. The U.S. standard-setting organization is governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer reviews, and coordinate regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally.