Stand Up for Health Care Blog

On May 17, the Centers for Medicare and Medicaid Services released a list of five great options states can use to ensure that low-income people get and keep Medicaid coverage when the new simplified, streamlined enrollment system opens in October 2013. (It’s important to note that those determined eligible for Medicaid before the end of the year won’t receive benefits until January 2014, unless they are currently eligible for Medicaid.) As states attempt to enroll millions of new applicants in coverage, the following options will make it easier for them to ensure people get covered:

1. Make an early switch to the new way of determining eligibility. The Affordable Care Act calls for a new eligibility determination system and one streamlined application for Medicaid, CHIP, and the premium tax credits available to help people purchase coverage in state health insurance marketplaces. This application process will be available for states to use in October 2013 to start signing people up for coverage that will start in January. However, some of those who apply for coverage from October through December will already be eligible for Medicaid and do not need to wait until January to get covered. Previously, states would have needed to keep using their old applications to determine eligibility for this group of applicants. This option allows states to make an early switch to exclusively using the new application. 
2. Push back Medicaid renewals. As the word gets out about new coverage options under the Affordable Care Act at the end of this year and beginning of next year, states can expect a flood of new applications. This will be on top of the work states already do helping those who currently receive Medicaid renew their coverage once a year. States can push the requiredrenewal dates for those already enrolled in Medicaid coverage until after the extremely busy open enrollment period is over on March 31, 2014, so that they can focus on new applicants at the very beginning of the year.
3. Enroll people in Medicaid using SNAP information. SNAP (Supplemental Nutrition Assistance Program, formerly called food stamps) benefits are available to people with incomes below 130 percent of the federal poverty level ($30,600 for a family of four). Because the Medicaid eligibility level is 138 percent of poverty ($32,500 for a family of four) for all children and for adults in states that expand Medicaid, most people receiving SNAP will also be eligible for Medicaid. States can use the information they already have for SNAP recipients to enroll eligible people in Medicaid. Using the SNAP information, states could, for example, send an eligible SNAP participant a Medicaid card and ask her to activate it if she’d like to receive Medicaid.
4. Use information on children’s eligibility to enroll parents. The majority of states already offer Medicaid coverage for kids in families with incomes of up to 133 percent of poverty ($31,300 for a family of four). States can use the information they already have about a child’s family income to determine the eligibility of parents and provide them with an easy way to enroll.
5. Provide 12-month continuous eligibility for adults. Since eligibility for coverage in Medicaid depends on a person’s income, changes in income throughout the year can mean that people are eligible for Medicaid in some months but not in others. This is sometimes referred to as “churning.” Churning can disrupt the care people receive by requiring them to switch coverage and change providers. It also raises administrative costs for states that have to disenroll and re-enroll people when changes in their income cause changes in eligibility. Continuous eligibility ensures a full year of coverage even with income changes. Most states already use continuous eligibility to keep some or all kids enrolled in Medicaid or CHIP. States can do the same for adults enrolled in Medicaid.

Millions of Americans will be newly eligible for coverage starting on January 1, 2014. States can use these exciting new options to make sure enrollment goes smoothly and maximize the number of Americans who are able to get and keep coverage.

How the Law Has Already Helped

More young adults have coverage thanks to the Affordable Care Act. As of September 2010, young adults have been able to stay on their parents’ health insurance plans until they turn 26. The rate of those aged 19 to 25 with insurance increased by 10 percent between 2010 and 2012, with 3.4 million young adults gaining health coverage. This provision reversed a decade-long trend of increasing rates of uninsurance among young adults.

The Commonwealth Fund recently released the results of their 2012 national health insurance survey. The survey shows how many people stand to benefit from provisions in the Affordable Care Act starting January 2014 and highlights the progress that has already been made in expanding coverage.

How the Law Will Help Starting January 2014

• Three in 10 adults were uninsured for at least part of 2012. That’s 55 million people who had a period where they went without coverage.

Starting in 2014…

These adults will have better access to affordable coverage through Medicaid and the new state health insurance marketplaces.

•  Many Americans currently face high costs due to “underinsurance.” Nearly 16 percent of adults had coverage that did so little to protect them from health care costs that they were defined as underinsured. Those surveyed were considered underinsured if they had health insurance all year but spent 10 percent or more of their incomes, or 5 percent or more of their incomes for those with incomes below 200 percent of poverty ($46,100 for a family of four), on out-of-pocket costs for health care. People with deductibles that were more than 5 percent of their incomes were also counted as underinsured. Underinsurance was particularly common for those who bought coverage on the individual market: Almost half of this group was underinsured.

Starting in 2014…

The Affordable Care Act will improve coverage and protect consumers from high costs when they buy their own plans. Under the law, plans will be required to cover a set of essential benefits, insurers will be prohibited from setting annual or lifetime limits on the costs that they will pay, and insurers will no longer be able to deny coverage to people with pre-existing conditions or charge them more to cover those conditions.

• Low-income populations are even more likely to be uninsured or underinsured. Three-quarters of adults with incomes below 133 percent of the federal poverty level ($30,700 for a family of four) were uninsured or underinsured at some point in 2012, as were 59 percent of those with incomes below 250 percent of the federal poverty level ($57,600 for a family of four).

Starting in 2014…

Low-income individuals and families will be able to get coverage or help paying for coverage. An estimated nearly 90 percent of adults who were uninsured at some point in 2012 and 85 percent of those who were underinsured had incomes below 400 percent of the poverty level ($92,200 for a family of four). This means that they would qualify to get help paying for coverage in the state insurance marketplaces or may be eligible for Medicaid in their state.

These numbers confirm what we know already—the Affordable Care Act is helping some Americans get affordable health coverage already, and will help many millions more starting 2014. 

Young adult photo by Shutterstock.com

Last week, the Kaiser Commission on Medicaid and the Uninsured released a study suggesting that people with Medicaid enjoy similar access to health care at lower cost than they would experience if they had job-based coverage.

Here’s a detailed breakdown of the study’s findings:

If Medicaid beneficiaries had job-based coverage instead, their access to care would not be significantly different. 83.9 percent of Medicaid beneficiaries reported having a usual source of care other than the emergency department. If these beneficiaries had job-based coverage instead, the percentage is projected to be 84.6 percent. Similarly, they would be no more or less likely to have unmet medical care or prescription drug needs.

Average health care costs for low-income adults would be significantly higher if they had job-based coverage instead of Medicaid coverage. Not only does Medicaid offer comparable access to services, but it also provides that access at significantly lower costs than job-based coverage. In short, Medicaid is a good deal.

Additionally, if Medicaid beneficiaries were uninsured, they would be significantly less likely to have a usual source of care and more likely to have unmet health care needs. While 83.9 percent of Medicaid beneficiaries reported having a usual source of care, projections show that this percentage would drop to 60.4 percent if these beneficiaries were uninsured. The share of people reporting unmet needs for medical care and prescription drugs would be more than four times higher if these Medicaid beneficiaries did not have insurance.

Furthermore, if Medicaid beneficiaries were uninsured, the study suggests that their out-of-pocket spending costs would rise, on average, from $257 to $993. That’s an increase of nearly 400 percent in out-of-pocket spending! And those high out-of-pocket costs still would not cover the total cost of care. The bulk of health care costs would likely be uncompensated and therefore passed on to privately insured individuals in the form of a hidden health tax.

All in all, these results indicate that Medicaid coverage not only provides access to care that is comparable to what job-based coverage provides, but it is also a cost-effective program that protects low-income adults from undue financial burden. 

New findings from the Oregon Health Study reaffirm that Medicaid is good health coverage: The study showed that Medicaid beneficiaries were more likely than the uninsured to receive needed health care services (including preventive care), they experienced improved mental health as a result of coverage, and they were more financially secure. These findings, published last week in the New England Journal of Medicine, are part of an ongoing study of Oregon’s state Medicaid program.

In 2008, Oregon, facing budgetary constraints, created a lottery to give uninsured, low-income adults the chance to apply for Medicaid. Nearly 90,000 people signed up, and approximately 30,000 were selected for the lottery. This lottery presented an opportunity to study the effects of Medicaid coverage in a randomized, controlled study. Here is a summary of what the findings show:

Medicaid coverage improves access to needed health care services. Medicaid beneficiaries were more likely to report having obtained health care services. They were also more likely to report having access to a regular source of care.

Medicaid coverage encourages use of preventive services. Medicaid beneficiaries in the study were more likely than the uninsured to get preventive care, such as cholesterol screenings and mammograms. Obtaining these preventive services will result in better health outcomes for these individuals and lower costs to the health care system in the long run. 

Medicaid coverage improves mental health. In the Oregon study, Medicaid coverage reduced the rate of depression among study participants by 30%. It also resulted in an increase in the mental health component of the quality of life measure.

Medicaid coverage provides financial security and peace of mind. Medicaid coverage was shown to significantly reduce financial strain from high medical costs on a number of measures. Most significantly, Medicaid almost completely eliminated catastrophic out-of-pocket medical expenditures (defined as expenses that exceeded 30% of their household income).

All in all, the preliminary findings from the Oregon Health Study reaffirm what we already know: Medicaid coverage provides American families with better access to care, economic security, and peace of mind. Medicaid matters.

This post was originally a guest blog for the Abandoned Infants Assistance National Resource Center.

Elaine Saly is a health policy analyst at Families USA and developer of the Navigators and In-Person Assisters Resource Center.  She recently composed a toolkit and presentation on the navigator program, a new grant opportunity for existing organizations to expand their services by conducting outreach and assisting individuals with enrolling in health care coverage through the insurance exchanges.  She discussed the program and this exciting opportunity with us.

Can you briefly describe the role of navigators and the navigator program?

The Affordable Care Act provides for the establishment of navigator programs to conduct outreach and provide assistance with enrollment in coverage through new health insurance marketplaces or “exchanges.” The navigator programs will be established in each state, whether the state is operating its own marketplace, partnering with the federal government to operate the marketplace, or having the federal government operate the marketplace to ensure access to affordable coverage for state residents.

Navigators are individuals or organizations that will help consumers and small employers learn about and enroll in coverage and qualify for assistance with the cost of coverage through the marketplace. Many consumers and small businesses enrolling in new coverage will need assistance understanding their coverage options and completing the enrollment process. A majority of those who will gain coverage will be uninsured and have limited experience with health coverage. This population will also be more racially and ethnically diverse, typically have lower incomes, have lower literacy levels and be more likely to speak a non-English language in their household as compared to those who currently have private insurance. The role of navigators will be to leverage existing relationships with populations that are likely to be eligible for new coverage options and help address personal barriers to ensure successful enrollment and retention of coverage.

How can current case management support services modify their programs to fit criteria for navigators?

Navigators must have existing relationships, or be able to easily establish relationships, with populations likely to be eligible to enroll in new coverage options through the health insurance marketplace. Case management support programs will need to demonstrate that they can reach individuals who are currently uninsured, or only have access to coverage that is not considered comprehensive or affordable, and will need to dedicate staff to conducting outreach and providing enrollment assistance. Navigators can focus on reaching particular populations or serving specific geographic areas, but they must establish procedures for serving any individual or small employer requesting assistance. Programs that become navigators must also be able to record information about their outreach activities and the assistance they provide to consumers and small employers to help marketplaces monitor these programs. In order to be eligible to serve as a navigator, programs also have to demonstrate that they do not have a conflict of interest, that is, they do not have relationships or funding that would incentivize them to enroll an individual or small employer in a particular health insurance plan.

 Where can one find information about applying to become a navigator?

If your program is situated in a state that is operating its own marketplace or exchange, visit your state’s exchange website to find out about how to apply for a navigator grant. States running their own exchanges will have already released information about how to apply for this funding. If your program is in a state for which the federal government will operate the marketplace, the Department of Health and Human Services has released a funding opportunity to apply for navigator grants for which proposals are due on June 7th.

Comprehensive care coordination promises to be a key strategy in new care delivery models that aim to improve patient health and reduce waste in the health care system. The Affordable Care Act has made it easier for states to address our country’s rising health care costs by investing in care coordination. States can now design and test new models of care delivery and payment that improve health outcomes and patient experience while also reducing health care spending.

What is care coordination? At its core, care coordination is just what the name implies: a mechanism through which teams of health care professionals work together to ensure that their patients’ health needs are being met and that the right care is being delivered at the right place, at the right time, and by the right person. It also means that your doctors work with you and your family to identify your needs, priorities, and goals for different treatment plans. Your health care providers will help you figure out what's preventing you from following a course of treatment and help you find a way around those barriers. All of your doctors will know if you are admitted to the hospital or if another doctor changes one of your medications. Overall, care coordination means fewer unnecessary services, more comprehensive care, and, ultimately, better health.

When doctors prescribe lots of different medications or tests, it can be difficult to keep track of it all, especially since doctors rarely talk to each other or work together. Failing to coordinate care often results in medication errors, unnecessary or repetitive diagnostic tests, and preventable emergency room visits. These errors and unnecessary tests don't just hurt patients and their loved ones. They also contribute to unnecessary health spending. Some researchers have estimated that inadequate care coordination resulted in $25-40 billion in wasteful spending in 2011 due to complications and hospital readmissions that could have been avoided.

Some care coordination programs have already seen savings. Vermont’s Blueprint for Health, a statewide, public-private partnership that provides physician practices with insurer-funded community health teams and access to real-time electronic information, is just one example. Between 2007 and 2010, annual expenditures per person for Blueprint participants increased at a lower rate than controls, and the annual rate of hospital inpatient stays decreased by 6 percent, compared to 1 percent in the control group.

Replicating these results will require a long-term investment from community leaders, and it will take time. But if there is a commitment from key stakeholders to make and sustain necessary changes to improve the health of the community, then care coordination will pay off.

To read more about care coordination, check out our new brief, The Promise of Care Coordination: Transforming Health Care Delivery.

On Tuesday, the Department of Health and Human Services released three new application forms that consumers will be able to use to sign up for coverage beginning on October 1. These consumer-friendly applications ask for all the information needed to see if an individual or family will qualify for free coverage from Medicaid or CHIP, or if they qualify to buy a plan in the new health insurance marketplace, and if so, whether they will get premium tax credits to help pay for this coverage. These three forms are tailored to meet the needs of different types of applicants:

• Single adults who don’t have any dependents and can’t get coverage through a job can use the short form.
• Couples, families, and those who can get health coverage through a job can use the family application.
• People with incomes over 400 percent of the poverty level ($94,200 for a family of four in 2013) who do not want to apply for assistance paying for coverage can use the non-financial assistance application.

In addition to these forms, the Department of Health and Human Services is developing an online application that will make applying for coverage even easier. The online application will be dynamic, meaning it will learn from the questions an applicant has already answered and ask her only the questions that apply to her situation. For example, if it appears that an applicant will be eligible for free coverage in Medicaid, the application will not ask questions about health coverage available through the applicant’s job, since this information is only needed to determine eligibility for marketplace coverage. This means that most people applying online will have to answer less than a third of the possible questions!

These three new forms, along with the online application and counselors who are trained to help with the application process, will enable millions of Americans to sign up for affordable, high-quality health coverage for 2014.

This post is a guest blog by Staurt Berlow, Public Policy Manager, at The DC Cancer Consortium.

The DC Cancer Consortium and our 75 organizational members are committed to reducing the toll of cancer in the District of Columbia, particularly among low-income and underserved populations. That is why we so strongly oppose tobacco “rating.” And that is why we are so appreciative to the District of Columbia Health Benefit Exchange (HBX) Executive Board for prohibiting this practice.

Tobacco rating is the practice of charging tobacco users higher health insurance premiums than non-users. Although the federal health care law prohibits rating based on gender and health status, it authorizes insurers to raise premiums by up to 50% for smokers and other tobacco users. Makes sense, right? Of course we want to incentivize smokers to quit such an unhealthy and costly addiction. But, we also know that quitting is not easy, and smokers require support and access to evidence-based cessation programs to reduce their tobacco use.

If the District of Columbia permitted the practice of tobacco rating, it would end up pricing people who most require tobacco cessation services and programs—low- and middle-income residents—out of the insurance market. Imagine, for example, earning only $17,000 per year and seeing your insurance costs increase from around $60 a month with Affordable Care Act tax credit subsidies to more than $350 monthly because you’re a smoker. Clearly that presents a financial pressure to forego insurance…and the coverage for cessation programs that come along with it. Suddenly, quitting smoking becomes a lot more difficult.

Had the tobacco rating proposal gone forward, health insurance would have become unaffordable for many DC residents, and they would have lacked much of the support necessary to attempt quitting. Quitting smoking is not easy, and no evidence exists to support the contention that financial incentives alone increase quit rates. Though the Consortium passionately seeks to reduce tobacco use in the District, tobacco rating would not accomplish that.

Currently, 700 District residents die each year from tobacco use, and total direct and indirect costs attributable to tobacco in DC reach almost $500 million annually. Additionally, more than 30% of African Americans in DC use tobacco, compared with less than 10% of the white population. Making cessation programs available through affordable health plans is especially important since the District has not invested in public cessation programs in recent years and our jurisdiction’s Tobacco Quitline has faced ongoing budget challenges. Tobacco rating would have led to further degradation of available cessation initiatives—accompanied by increased illness and expense.

Tobacco rating would increase insurance premiums, pricing many residents out of coverage, and thereby eliminating cessation options for DC’s low- and middle-income population. This would have led to very real health impacts for our neighbors, and continued escalating costs for the District. We thank the HBX Board for recognizing the critical need for access to cessation programs in DC.  

We will continue to urge the District government to strengthen legislative and regulatory restrictions on tobacco use, sale, and marketing. However, as we do, we are gratified that current smokers will receive the cessation services and support they need to quit through their insurance coverage. Tobacco rating would simply limit or completely prevent this necessary option for too many District residents. Thank you to the DC HBX Board for wisely voting to preserve cessation options for smokers and making it easier for them to quit such a deadly and costly addiction. 

Recently, despite initial opposition, significant pressure from political interest groups, and the daunting task of getting support from the required 75 percent of legislators, the Arkansas legislature voted “yes” on the Medicaid expansion. This victory was made possible by an effective advocacy campaign that mobilized the people of Arkansas to call upon their elected leaders to do the right thing—an ideal strategy in a state where the motto is, “The People Rule.”

Looking purely at the math, the Medicaid expansion will provide Arkansas with more than $800 million in federal funding each year. This funding will assure that 250,000 people who are currently uninsured can go to the doctor, buy medications, and get preventive care. Based on these numbers, you might think that moving forward with the Medicaid expansion was a no-brainer. But the votes in Arkansas involved much more than math.

With the help of organizations such as the Chamber of Commerce, the Municipal League, and the Hospital Association, Arkansas Advocates for Children and Families led a winning campaign that reached and mobilized Arkansans who will be helped by the Medicaid expansion. Across the state, dozens of small business owners and parents took the time to contact their representatives and tell their stories. These efforts helped legislators get to know the people behind the numbers. For a sense of how successful this strategy was, just take a look at Rep. Sue Scott’s impassioned explanation of why she changed her vote from “no” to “yes.”

Powerful political interest groups who oppose all provisions of the Affordable Care Act had urged the Arkansas legislature to refuse the Medicaid expansion. Fortunately, the people of Arkansas successfully convinced the legislature that using Medicaid expansion dollars to purchase private health coverage was good for businesses, families, and children. As implementation moves forward, consumer advocates will continue to work with both the state and the federal governments to protect the interests of low-income people who will rely on Medicaid as a lifeline. This victory in Arkansas makes “The People Rule” ring ever more true. 

Some lawmakers see the one-year delay in scheduled cuts to the Medicaid Disproportionate Share Hospital Program (DSH) in the President’s recently released budget proposal as a reason to delay the Medicaid expansion in their states. They claim that hospitals won’t be hurt if Medicaid isn’t expanded because DSH, which helps hospitals offset the cost of treating people who can’t afford to pay for their care, will still help hospitals continue to provide care to the uninsured.

But they’re wrong—not expanding Medicaid will not only hurt hospitals, it will hurt the uninsured as well.

The scheduled cuts to DSH were included in the Affordable Care Act because it was believed that, starting in 2014, more low-income people would get health coverage through the Medicaid expansion, and, as a result, hospitals wouldn’t need as much DSH support for unpaid care. However, last June’s Supreme Court decision made the Medicaid expansion an option for states. Hospitals in states that don’t expand Medicaid will still have considerable unpaid care, so the President’s budget tried to account for these continuing costs by delaying the DSH payment cuts.

While this delay in cuts would allow these hospitals to continue to be compensated for providing health care for the uninsured, lawmakers should not use this as a reason to avoid expanding Medicaid.

Here’s why:

First, this is a proposal. The President’s budget proposal to delay DSH payment cuts is just that—a proposal. It hasn’t been adopted. It isn’t law. Under what is the law right now, the DSH payment cuts will still start in 2014.

The President’s budget proposal will not be adopted as it is. The President’s budget proposal is one step in a process that requires negotiation between the President and members of Congress. In Congress, the House and Senate have both passed non-binding budget resolutions for 2014. However, there are vast differences between the House, the Senate, and the President’s budgets. A lot of negotiation is needed before a budget passes, so there is no guarantee that these cuts will be delayed in the final budget.

The Medicaid DSH cuts are only delayed for one year. Under the President’s proposal, the DSH payment cuts will still happen, they are just put off for a year. Come 2015, DSH payments will be cut. Not only that, but under the President’s proposal, to make up for the delay, the payment cuts scheduled for 2016 and 2017 would be larger.

States that delay expansion are losing full federal funding. From 2014 through 2016, the federal government will pay 100 percent of a state’s cost for expanding Medicaid. The federal share starts declining in 2017 until it reaches 90 percent in 2020. If a state doesn’t expand Medicaid until 2015, it loses a year of full federal funding. The President’s budget proposal did not change that.  

The Medicaid expansion does a lot more than help hospitals. There’s no question that expanding Medicaid will reduce the amount of unpaid care hospitals provide, and that will help hospitals’ bottom line. But it will do a lot more than that. It will allow states to reduce what they pay other programs to help low-income residents without health coverage. And, the added federal funds will stimulate state economies and create jobs.

Oh, and expanding Medicaid will mean that millions of Americans will have access to doctors, nurses, and hospitals—they’ll be able to get the health care they can’t afford now. That makes for healthier communities.

A proposal to delay cuts in hospital payments for a year is a foolish reason for states to reject millions in federal funding and the opportunity to provide health coverage to their lowest-income uninsured residents. 

This blog was originally posted on HuffingtonPost.com

Obamacare was designed to give peace of mind to hard-working American families. And starting in January, it will do just that for millions of Americans. In fact, according to "Help Is at Hand: New Health Insurance Tax Credits for Americans," Families USA's latest report on nearly 26 million Americans becoming eligible for new premium tax credits, this new help will soon make private health insurance much more affordable.

Premium tax credits will be available to individuals and families with incomes up to 400 percent of poverty, which translates to $45,960 for an individual and $94,200 for a family of four. The tax credits will ensure that moderate-and middle-income individuals and families will not have to spend more than a set percentage of their incomes on health insurance.

The size of the credits will be determined on a sliding scale based on income, so those who have lower incomes will receive a more substantial benefit than those with higher incomes. The tax credit will be used to purchase health coverage from a range of plans in new health insurance marketplaces, otherwise known as "exchanges."

The tax credits will act like subsidies, in that individuals and families will receive help as they buy insurance, rather than having to wait until they file taxes to receive reimbursement through a tax refund. And the help is available to individuals and families even if they don't owe any taxes. The size of the tax credit is calculated based on one plan offered in the new state marketplaces -- the so-called "silver reference plan." However, once the size of the credit is determined, it can be used toward the purchase of any private plan in the marketplace that the individual or family chooses to purchase.

Here is an example of how the tax credit size is calculated (view the infographic).

The Johnsons, a family of four (two adults, two children under age 18), with an annual income of $35,300 (about 150 percent of poverty): If the annual premium for the silver reference plan for family coverage in the state marketplace in the Johnsons' zip code is $12,500, the family's out-of- pocket contribution for premiums for a silver reference plan would be about $1,410 (about $118 a month). The remainder of the family's premium for the silver reference plan would be covered in the form of a tax credit of $11,090. (That amount could also be credited toward premiums for a more or less expensive plan of the family's choice).

Taking a deeper look at the people who will be eligible for the premium tax credit, our report estimates that, in 2014, a large majority of those eligible for these new premium tax credits -- about 88 percent -- will be in working families. All age groups will benefit from the tax-credit premium subsidies, from hard-working Americans supporting their families to young adults who are just starting their careers.

The tax-credit subsidies have become a health care game changer. These tax credits will help make health coverage affordable for a huge number of uninsured families. Moderate- and middle-income families won't have to worry about being priced out of the health coverage and care they need. This assistance will also bring peace of mind to individuals and families who may have a pre-existing condition or who change jobs and experience a subsequent drop in income.

As we draw closer to the start of the open enrollment period in October, it is essential that states across the country work to inform their residents of this opportunity for assistance. Come January 2014, comprehensive, affordable health coverage will finally become a reality for millions of Americans.

If you would like more information on national, state, or county-level estimates of the number of people eligible for the new premium tax credits, I invite you to read Families USA's Help is At Hand report.

This post was originally from Georgetown Center for Children and Families' Say Ahhh! blog

By Maureen Hensley-Quinn, National Academy for State Health Policy

As state and federal government officials race to meet Affordable Care Act (ACA) implementation deadlines much of their attention has been focused on adults who will be newly eligible for health coverage.  Health insurance exchanges (exchanges) or marketplaces need to be prepared to serve children’s needs as well.  The Children’s Health Insurance Program (CHIP), an already established and tested program, could be used to help states meet ACA requirements for exchanges while establishing good coverage for children.  A recent issue brief and compendium released by the National Academy for State Health Policy (NASHP) explores how CHIP could inform children’s coverage provided through exchanges.

Children have specific health care needs related to their growth and development that are distinct from those of adults.  Health benefits that support a child from infancy through adolescence and appropriate, available providers are essential.  Children are recognized in the ACA as a “diverse segment of the population” whose health care needs should be taken into account in defining the Essential Health Benefit (EHB) package.

There are a number of ACA exchange provisions that aim to support children’s health needs.  Exchanges are required to offer child-only plans that are available only to children up to age 21 at the same level (silver, gold, etc.) as other Qualified Health Plans (QHPs).  Child-only plans will be important in providing coverage options for millions of families where parents and children have different coverage situations.  Catherine Hess, Managing Director at NASHP outlines this and other issues for children that states should consider as ACA implemented in a previous NASHP blog post.

The ACA also explicitly includes “pediatric benefits” and “habilitative services” within the EHB package that must be offered in individual and small group markets inside and outside the exchanges.  States are afforded a lot of flexibility in defining each of these benefit categories.  While benchmark benefit plans serve as a “reference plan” that reflects a “typical employer plan”, HHS recognizes states may need to define and supplement benefits to ensure all 10 EHB categories are covered.  Habilitative services, which are critical to children with special health needs, will likely need to be supplemented, as most benchmark plans do not include such services.

The Children’s Health Insurance Program has been providing coverage designed for children for over 15 years and can inform or serve as a model to meet the ACA’s child specific requirements in the exchange.  Separate CHIP programs, which generally tend to be more like plans offered in the private market than through Medicaid, may be more easily aligned with exchange requirements.  For instance, separate CHIP programs offer federally identified benchmark benefit plans or approved alternatives and are usually delivered by managed care organizations.  A recent study commissioned by the American Academy of Pediatrics that compared benefit packages in five states found CHIP covers the 10 EHB categories more completely than the benchmark plan options.

Considering the ACA’s requirements as well as the flexibility afforded to states, exchanges could use CHIP as a tool in the following ways:

• Use the separate CHIP benefit package to define the “pediatric services” category within the EHB
• Engage health plans and their provider networks that are contracted to deliver CHIP services to participate as QHPs in the exchange
• Implement premium assistance by using CHIP funds to purchase coverage in the exchange
• Use CHIP to guide development of wrap-around for QHP coverage to ensure there is a comprehensive benefit package for children in the exchange.

Although many assume children are taken care of as a result of steady progress to reduce the number of uninsured low-income children, many children will gain coverage through the exchange.  According to the Urban Institute, nearly 4 million children will enroll in Qualified Health Plans (QHPs) through exchanges in 2014.

If federal funding for CHIP is not renewed after October 2015, there will be millions more children that will likely turn to exchanges for their health coverage.  ACA requires that before children eligible for CHIP can be transitioned to an exchange, the U. S. HHS Secretary must certify there is exchange coverage comparable to CHIP in both benefits and cost sharing.  While federal guidance related to the comparability study has not yet been released, states may want to consider ways to incorporate CHIP features into exchange coverage to provide child specific coverage now and in the future.

How will your state ensure children’s coverage needs are met in the exchange?

New health coverage options under the Affordable Care Act promise to help millions of uninsured Americans. Currently, 48.6 million Americans are uninsured. But under the Affordable Care Act, 25.7 million Americans will qualify for new tax credits to help pay for health coverage and millions more will be eligible for coverage as states expand Medicaid in 2014.

Using data from the Department of Health and Human Services, Enroll America has released new interactive state maps that show just how many people will be eligible for these options in each community, as well as important information about the uninsured, such as income, age, and race and ethnicity. Each state map shows the number of uninsured in each community, highlighting the areas with the highest numbers of uninsured in dark red.

Income information is broken down according to the different types of help that people in the community can get to help them pay for health coverage starting in 2014. In most states that expand Medicaid, those with incomes at or below 138 percent of poverty ($32,500 for a family of four in 2013) will qualify for free coverage from Medicaid. Those who have incomes between 138 percent of poverty and 400 percent of poverty ($94,200 for a family of four in 2013) will qualify for tax credits to help them buy coverage in their new state health insurance marketplace.

This new tool is a great way to find out where the uninsured live in your area so that you can join the effort to help them enroll in new affordable health coverage options. To learn more or to volunteer, check out Enroll America’s nationwide campaign: Get Covered America. 

Tax time has just passed. For many people, that’s a time to take stock of finances and to start planning for the future. That should include plans in case you or a family member needs long-term care. It’s a tough topic. But if you plan ahead, you’re more likely to get the kind of care you want. Here are some questions and answers to help you jump-start the process.

If you need long-term care, what are your preferences?

Once, long-term care meant staying in a nursing home. Not anymore. Today, there are assisted living facilities, retirement communities with many levels of care, and devices that can help you stay in your home longer.  Think about what you want, and then do as much as you can in advance to plan for it. For example, if you want to stay in your home, make modifications like adding grab bars and accessible entryways.

Should you consider buying long-term care insurance?

Planning is a good idea, but you may end up needing more care than you anticipated. That’s where long-term care insurance may help. Long-term care is expensive: The average cost for a year in a nursing home is $84,000, and it is not covered by Medicare. Evaluate your finances and see what you can afford. You might consider buying long-term care insurance, but it doesn’t make sense for everyone. Policies are expensive, what they cover varies, and you’ll have to be able to keep up with premium payments for years or even decades. Talk to a financial planner or an elder care attorney to help you evaluate what’s best for you. The website www.eldercare.gov, operated by the U.S. Administration on Aging, can help you find an elder care attorney.

When should you start thinking about buying long-term care insurance?

Financial advisors suggest that it is best to purchase long-term care insurance when you are in your 50s. You can still get a policy if you are older, but the longer you wait, the more a policy will cost.

What should you look for in a long-term care insurance policy?

Policies vary a lot. Here are some things you’ll need to understand before you sign up. First, make sure the policy includes inflation protection. Policies usually pay up to a certain amount per day and have a lifetime maximum. You might not need care for decades after you buy the policy, so you need to make sure that the amount it will pay keeps up with inflation. Most policies don’t start paying until after you need care for a certain period of time, which is known as the elimination period. You need to know how long that is. Also ask how disabled you’ll need to be before coverage begins: Policies require different levels of disability before they start to pay. Finally, make sure the policy covers both home care and nursing home care, and check to see if it excludes coverage for certain conditions. In the end, you need to balance what a policy costs and covers with what you’re able to pay. Some experts recommend that you spend no more than 5 percent of your income on long-term care insurance.

What if you can’t afford long-term care insurance and end up needing expensive long-term care?

If you don’t have insurance and need care, you generally have to pay for it yourself, which can eat up your assets. But if that happens, there is a safety net: Every state’s Medicaid program pays for long-term care. While it’s best to not have to qualify for Medicaid, it’s there if you need it. It’s the only reliable long-term care insurance we have right now.

Are there other options or resources?

Some states have what’s called “long-term care partnership programs.” If you buy an approved insurance policy through such a program, you can qualify for Medicaid when you run out of insurance coverage, instead of when you use up your assets. Check if your state has a program. Also visit www.longtermcare.gov, a resource clearinghouse for senior services that includes information on long-term care options.

Are there any policy changes on the horizon that might help?

Unfortunately, we don’t have anything like Medicare for long-term care—a national insurance program for everyone. But there is hope for progress. President Obama and congressional leaders recently appointed members to a Long-Term Care Commission. Over the next six months, they’ll be developing a plan to improve consumers’ long-term care choices. Hopefully, you’ll be reading about their recommendations soon.

With spring comes another crop of college graduates. For many, graduation can bring a flood of widely varying emotions. On one hand, there’s the fist-pumping, cap-in-the-air celebration of a diploma in hand: Four years of long nights of study, heavy class loads, and numerous deadlines for papers are now left behind. On the other hand, the day can also bring a gut-wrenching uncertainly about job prospects. There are few other milestones in life where emotions can run the gamut from one end of the continuum to the other.

Fortunately for graduates and their families, the Affordable Care Act has wiped away one of the big concerns young people have historically faced as they entered the working world. The class of 2013 will be the third spring graduating class that will be allowed to remain on their parents’ health insurance plans until they are 26.

Before the health care law was enacted, losing access to parental coverage meant that many young adults ended up being uninsured. For those who were lucky enough to find a job in this economy, those jobs often didn’t come with health insurance. Young people who tried instead to purchase coverage directly from an insurance company learned the cost of that coverage could be prohibitively high. Others who did buy such coverage sometimes found that the only policies they could afford didn’t cover the services they needed—services that had been covered under their parents’ health plan.

Now young adults can stay on their parents’ health insurance plans whether or not they are still students, and whether their parents’ insurance comes from a job or directly from an insurance company. This holds true even if young adults are married, live in a different state than their parents, or are no longer financially dependent on their parents (although if young adults are offered coverage through their job, they might not be able to stay on their parents’ plans).

So why does this matter to you? Well, it’s been three years, but there is still an education process going on about the benefits of the health care law. As your grandkids celebrate their graduations, you can help make sure they know about this option.

In addition, if your grandkids are still in college but need better health insurance than what is offered through their school, you can encourage them to look into their parents’ plans. During busy and exciting times, young adults may not make health coverage a high priority, so having a grandparent or parent looking out for them can make a big difference.

Also, it’s important to remember that we all benefit when more people have health insurance. That’s because, when people don’t have insurance, we all pay the price: The costs of providing care to people without insurance are passed on to those of us who do have insurance in the form of higher premiums. Getting everyone covered keeps those costs down.

There are big changes coming in 2013 and 2014 that will provide access to quality health coverage for millions of Americans—but for students, the benefits of the health care law have been in place for several years. In its own way, the law has given college graduates one less thing to worry about—which is a big plus for graduates and their families. 

Today, members of Congress in both the House and the Senate introduced the Medicare Drug Savings Act of 2013, which would restore drug rebates for low-income people with Medicare. President Obama included a similar proposal in his budget last week, and for good reason. Getting Medicare a better price on prescription drugs would save the federal government more than $140 billion without shifting costs to low- and middle-income seniors.

Drug rebates (often referred to as discounts or subsidies) are not as complicated as they may sound. It simply means that the federal government gets a better price on drugs, saving Medicare money without shifting costs to health care consumers.

Drug rebates are not new. Prior to 2003, the federal government received rebates from pharmaceutical manufacturers for drugs provided to people who were eligible for both Medicare and Medicaid. Drug rebates in Medicare is a common sense way to reduce federal health care costs. This proposal is attractive because:

• Medicare drug rebates would not shift costs to seniors. Remember, of the 50 million people who rely on Medicare for health care, half live on annual incomes of $22,500 or less.  Furthermore, Medicare beneficiaries already spend about 15 percent of their incomes on health care expenses—three times more than people without Medicare.
• Drug rebates have been proven to save money. The Medicaid program already benefits from lower drug prices thanks to federal rebates on prescription drugs. A study by the Department of Health and Human Services found that in 2011, Medicaid saved an average of 45 percent on leading brand-name drugs, while Medicare Part D’s average savings was only 19 percent.
• Several studies show that pharmaceutical spending on research and development is not at risk, so rebates would not threaten pharmaceutical innovation.
• A recent national poll found that 68 percent of Americans are in favor of restoring drug rebates in Medicare.

Are you interested in seeing drug rebates in Medicare come to fruition? Do you want to avoid forcing seniors and people with disabilities to pay more for their health care?  Contact your members of Congress today and ask that they cosponsor the Medicare Drug Savings Act of 2013.

Last month, President Obama appointed the final members of the Commission on Long-Term Care. The purpose of this commission is to improve consumer choice and access to home- and community-based services (HCBS) for those who need long-term services and supports.

While nursing homes provide quality care for many people, low-income older adults and people with disabilities should have a choice about where and how they receive care. Unfortunately, Medicaid, the nation’s largest payer of long-term care services, continues to give preference to institutional care and nursing homes over home- and community-based care. With the creation of this new commission, we now have an important opportunity to change the way long-term care in Medicaid is paid for and delivered, which could improve the lives of millions of people who depend on these services.

The National Senior Citizen’s Law Center recently released an issue brief on this topic that gives the new commission seven recommendations:

1. Every Medicaid program should be required to cover home- and community-based services. 
2. The ability to receive financial assistance should be the same for institutional and home- and community-based services.
3. Spouses of people receiving Medicaid assistance for long-term care should be allowed to keep the same level of assets, regardless of whether the spouse needing care is living in a nursing home or in the community.
4. Medicaid’s financial eligibility requirements must allow people to keep enough money to pay for food and housing to allow them to take advantage of home- and community-based services. Therefore, Medicaid’s financial eligibility requirements should be adjusted to reflect the added costs of living in the community.
5. The Centers for Medicare and Medicaid Services (CMS) should adequately fund activities to develop and enforce quality standards for home- and community-based services.
6. Congress should prioritize home- and community-based services in the next reauthorization of the Older Americans Act (OAA).
7. Adequate and sustainable funding should be secured to develop and support Aging and Disability Resource Centers, which provide care coordination for those who need long-term services and supports.

These recommendations are critical steps toward improving choice and access for people who need long-term services and supports. It is vital that these services be offered in a way that does not limit people’s independence, choice, or connection with their community. 

Today President Obama released his proposed budget for the 2014 fiscal year. Unlike the austerity budget passed by House Republicans last month, his proposal protects and strengthens our nation’s health care priorities, including Medicaid, the Affordable Care Act, and Medicare.

Here’s what stands out immediately: the President’s budget protects Medicaid--a critical safety net for seniors, children, people with disabilities, and their families—from reductions in funding.

The President is demonstrating the federal government’s intention to fully fund Medicaid’s expansion under the Affordable Care Act. Budgets are statements of priorities, and this is the Administration’s strongest commitment yet to protecting Medicaid. Compared to the House budget, which cuts Medicaid by a third and eliminates consumer protections, the President’s budget makes clear that it is not okay to further burden our most vulnerable citizens. 

President Obama’s signature accomplishment, the Affordable Care Act, will continue to be implemented under his budget. In less than a year, consumers without insurance will be able to buy affordable health coverage in online marketplaces with new tax credits. And yet, the House budget continues its dogged resistance to much-needed health care reform, offering Americans no new ideas in return.

By proposing a Medicare voucher system, House Republicans also chose to shift health care costs to consumers, half of whom live on less than $22,500 a year. The President takes a more sensible approach. He keeps the promise of guaranteed, affordable Medicare coverage while strengthening Medicare’s finances for the future. Unlike that of the House, the President’s budget significantly reduces health costs without hurting beneficiaries. The budget proposes saving $123 billion by securing the same discounts for pharmaceuticals that the government was receiving prior to 2006. The budget demonstrates that other changes to Medicare must be considered carefully, remembering that most people with Medicare cannot afford to pay more for their health care.

Taken as a whole, since spending changes cannot be considered without balanced tax increases for the wealthy, the budget provides a feasible endpoint for a deficit reduction compromise. House Republicans offered a severe vision of spending cuts for the poor and tax cuts for the rich. The President, however,  offers a path that both protects our health care and gets the country past this budget quagmire and on to more important challenges. 

Families USA and the National Health Law Program worked together to develop a checklist to help advocates ensure that their states implement health insurance exchanges that meet the needs of people with limited proficiency in English. Addressing this issue will be incredibly important as research shows that adults and children with limited English proficiency are significantly more likely to be uninsured than those who speak and understand English fluently.

Language could create a barrier for consumers with limited proficiency in the English, preventing them from applying and enrolling in health coverage through the new health insurance marketplaces. Because one in four consumers who will be eligible to enroll in coverage through the marketplaces speaks a language other than English at home, marketplaces must tackle language barriers head on to ensure equitable access to coverage. Terms such as “individual mandate” and “premium tax credits” are prime examples of language that these consumers may struggle to interpret. 

• Translate the paper and online applications that consumers will use to apply for coverage into the most common languages in the state.
• Include taglines on the application and marketplace website in at least 15 languages to inform consumers where they can get assistance and interpretation services.
• Select partner organizations in their state that currently provide bicultural and bilingual assistance to limited English proficiency populations to serve as navigators, in-person assisters, and certified application counselors that will help people learn about and enroll in coverage.
• Work with partner organizations to conduct targeted outreach to populations with limited proficiency in English that are likely to be eligible for coverage.

Some states, like Oregon, are already leading the charge in addressing language barriers. Oregon’s health insurance marketplace will have staff who speak Spanish, Russian, and Vietnamese. In addition, Oregon’s health insurance marketplace website will provide translated information for consumers, including the application for health insurance, in these languages.

Providing adequate and appropriate language services will be essential to successfully implementing health insurance marketplaces and to ensuring equitable access for consumers with limited English proficiency.

The Department of Health and Human Services announced late last week that 6.3 million Medicare beneficiaries have saved a total of $6.1 billion on their prescription drug coverage since the enactment of Affordable Care Act in 2010. On average, this equates to $706 in savings per person in 2012.

Seniors saw these savings because the Affordable Care Act is gradually closing the gap in prescription drug coverage in Medicare Part D. This gap is known as the doughnut hole. When beneficiaries reach a certain limit of covered prescription drug costs, they are required to pay thousands of dollars out of pocket for prescriptions until they reach a catastrophic spending limit and their coverage resumes. (Check out our blog post on the doughnut hole and the Affordable Care Act to learn more.)

The Affordable Care Act calls for the doughnut hole to be closed by 2020. This process started in 2010, when beneficiaries received a $250 rebate check. Then, in 2011, beneficiaries began receiving discounts on prescriptions drugs while they were in the doughnut hole. These discounts are increasing every year until the doughnut hole is completely phased out.

These are big savings for seniors who depend on their prescriptions to keep them healthy. And this is only the beginning—these savings will continue to grow in the years to come.

For more information on the donut hole being phased out, visit: http://www.healthcare.gov/law/features/65-older/drug-discounts/