[MarignyBywater] Concept....Obama.....Louisiana Health

[nolarussell at bellsouth.net]

Seems that Louisiana could do some of these things....a concept



With the fed offering 1.6 bil, for Health, we should redo the healthcare system in Louisiana. DHH Levine has made a convincing case that we need to change the way we are doing things. My understanding from DHH is their needs assessment may be helpful. Single payer; parish or regional system of care  Yes we can.

Russell Henderson
Organizing for Louisiana





IMPROVING MEDICAID AS PART OF BUILDING ON THE CURRENT SYSTEM TO ACHIEVE UNIVERSAL COVERAGE
by January Angeles
The U.S. health care system suffers froma number of problems.  Almost 46 million individuals were uninsured in2007, an increase of 6 million people since 2001.  Employer-basedcoverage, the primary source of health insurance across the nation,continues to erode.  Costs continue to rise and bear primaryresponsibility for the nation’s bleak long-term fiscal outlook.  Whilethe United States spends more on health care than any other country, itfalls short of other industrialized nations on key dimensions of caresuch as quality, access, and efficiency.[1]
Against this backdrop, there is broadagreement that comprehensive health care reform is essential and thatensuring access to affordable health insurance for all Americans, whilecontaining costs and improving quality, is a top priority.  But thereis less agreement about the appropriate path to universal coverage. Some have suggested replacing the current mix of employer-sponsoredinsurance and public programs with a universal public health insurancesystem (a “single-payer” system).  Others would rely heavily on thenon-group private insurance market.[2]  
Alternatively, several leading proposalsfavor building on the strengths of the current system — preserving whatworks and improving the current framework of employer-sponsoredinsurance and public programs in an attempt to achieve a seamless,integrated health care system.  Senator Max Baucus, Chairman of theSenate Finance Committee, has proposed extending Medicaid to covereveryone below a certain income level, noting that those with lowincomes are least likely to be able to afford and purchase coverage ontheir own.  President Obama’s health care reform proposal during thepresidential campaign would expand eligibility for Medicaid and theChildren’s Health Insurance Program (CHIP).  Similarly, researchersfrom the Commonwealth Fund argue that Medicaid should be one of the“building blocks” in developing a system that provides seamlesscoverage to all Americans.[3] 
Currently, Medicaid covers manylow-income individuals but leaves many others out.  It does not coverchildless adults unless they are pregnant, over the age of 65, or haveserious disabilities.[4] While it covers all children up to age six with family incomes below133 percent of the poverty line, and all poor children aged six to 19,the income eligibility standards for parents are much lower, leavingmany families with only partial coverage.[5]  
In a reformed system that builds onemployer-sponsored and public programs to achieve universal coverage,Medicaid should be expanded so that any American below a certain incomelevel can qualify for benefits regardless of age or disability status. Since Medicaid provides more comprehensive and affordable coverage thanother insurance options, it is an attractive vehicle for extendingcoverage to low-income Americans who cannot afford to pay premiums,cost-sharing, or deductibles.  For Medicaid to serve as a base forexpanding coverage, however, it needs to be strengthened and integratedinto a broader system of coverage. 
 
Expanding Medicaid an Effective Way to Cover Low-Income, Uninsured Americans
Medicaid’s proven success at providingcomprehensive, affordable coverage to tens of millions of low-incomechildren, parents, seniors, and people with disabilities makes it anexcellent option for expanding coverage to a broader group oflow-income, uninsured Americans.  A substantial portion of uninsuredpeople have characteristics that are similar to current Medicaidbeneficiaries:  two-thirds of them are poor or near-poor, 10 percentare in fair or poor health, and almost half suffer from a chroniccondition.[6]  Medicaid’s benefit package and cost-sharing structure are well-matched to this population’s needs.
 
Medicaid’s Benefits Are Suited to the Needs of Low-Income Populations
Medicaid provides an array of servicesand supports that private health insurance generally does not.  Becausemany Medicaid beneficiaries have disabilities or chronic healthconditions, these services are critical to maintaining and improvingtheir health.  For example, Medicaid’s Early Periodic Screening,Diagnostic and Treatment (EPSDT) benefit guarantees low-income childrencoverage for any service needed to treat any diagnosed health conditionthey have, even if it is not otherwise covered by a state’s Medicaidprogram.  These include, among other things, physical and speechtherapies, hearing services, and vision exams and eyeglasses.  TheEPSDT benefit is more comprehensive than the comparable children’sbenefit under most private insurance plans.[7] This is especially important, since poor families whose children arecovered through Medicaid generally would not be able to afford topurchase health care services that their children needed but theirinsurance did not cover.
Medicaid also provides a number ofhealth services not offered by private insurance that are tailored tomeet the particular needs of low-income people who have seriousdisabilities, chronic illnesses, or other complex health conditions. For beneficiaries with serious disabilities, for example, Medicaidcovers services and supports to facilitate independent living and tohelp them function at the highest level possible.  In contrast, privateinsurance tends either to cover services such as physical therapy onlyto the extent that they meet a narrow definition of medical necessity —when a condition can actually be ameliorated and normal functioningrestored — or not to cover such services at all.[8]
The Kaiser Commission on Medicaid andthe Uninsured has noted, “Medicaid plays a critical role in providinghealth care services to people with disabilities — both filling in thegaps in Medicare and in private health insurance and . . . offer[ing]the broad array of services needed by people with severe disablingconditions.”[9]
 
Medicaid Improves Beneficiaries’ Health 
Almost all children in Medicaid and CHIPhave a usual source of care, i.e., a regular place where they receivepreventive care or treatment when they are sick.  Having a usual sourceof care generally increases the quality of care a person receives. Children served by Medicaid and CHIP are much more likely thanuninsured children to obtain important preventive services, forexample, and they have checkups at rates similar to privately insuredchildren.[10]
Better health care, in turn, contributesto better health.  Studies have shown that low-income children’s healthstatus improved after one year of enrollment in Medicaid or CHIP.  InCalifornia, children in poor health showed improvements both in theirhealth and in their ability to function socially after two years ofcoverage through CHIP.[11]  Children with chronic illnesses showed similar kinds of improvements after enrolling in CHIP.[12]
 
Medicaid Is Affordable for Beneficiaries
Medicaid’s premiums and cost-sharing arewell below those that private insurance plans charge.  Medicaidgenerally does not charge premiums and requires only small co-paymentsof approximately $3 per service.[13] In contrast, many private plans charge co-payments of $15 to $25 peroffice visit to primary care physicians, and $20 to $30 for specialtycare physicians within the plan network.[14]
For low-income populations, thisprotection against high out-of-pocket costs is essential.  Researchshows that even modest premiums can make it difficult for low-incomepeople to enroll in Medicaid and keep their coverage.  Higherco-payments also tend to cause low-income individuals to use lessprimary and preventive care.[15] Low-income people may not seek care they need if they are charged thehigh co-payments that are typical in most private plans.  This couldlead to complications that eventually require more expensive forms ofcare, such as emergency room treatment or hospitalization.  
 
A Stronger Medicaid Could Play an Essential Role in a Reformed Health System
For Medicaid to serve effectively as thefoundation for expanding coverage to low-income Americans, however, itneeds to be strengthened as part of a comprehensive reform that buildson the current system of private insurance and public programs.  Fourparticularly important steps are outlined below.
 
1.  Modernizing Eligibility Rules and Processes 
An estimated one-quarter of alluninsured individuals, and about three-quarters of uninsured children,are eligible for public programs like Medicaid and CHIP but remainunenrolled.[16] Many low-income parents are unaware that they qualify for theseprograms due to complicated eligibility rules.  (Some working-poorparents mistakenly assume that these programs are not for workingfamilies and that their earnings are too high to qualify for benefits,for example.)  In addition, administrative barriers such as burdensomedocumentation and face-to-face interview requirements have sometimesprevented eligible families from completing the eligibility process.[17]  
Moreover, Medicaid and CHIPbeneficiaries often have difficulty retaining coverage.  Many of thebeneficiaries who are “disenrolled” during the renewal period losecoverage because of procedural problems, such as failing to renew theireligibility within a certain timeframe or not having completedocumentation.  Only a small portion of disenrollments are actually theresult of changes in eligibility.  As a result, many families end uplosing coverage at renewal, subsequently reapplying for benefits, andgetting re-enrolled a few months later.[18] This “churning” unnecessarily increases administrative costs, leads todisruptions in coverage, and adds to the ranks of the uninsured.  
Making Medicaid available to everyonebelow a certain income threshold would go a long way toward simplifyingand increasing the effectiveness of outreach and enrollment efforts. It would eliminate much of the uncertainty about who is eligible andwould allow all members of a family to be covered under the sameprogram, a particularly important reform.  Research has shown thatexpanding Medicaid and CHIP to cover low-income parents raisesparticipation rates among eligible children significantly and improvescontinuity of coverage.  Family coverage also increases the likelihoodthat enrolled children actually receive health care services they need.[19]
More uniform eligibility standardsshould be accompanied by measures to simplify enrollment and renewalprocesses.  Since CHIP was established in 1997, states have madesignificant strides in enrolling eligible children in both CHIP andMedicaid; most states have eliminated the asset test and done away withface-to-face interviews, for example.  Many states, however, have notapplied these same simplification measures to parents who apply forMedicaid.  Aligning the rules and procedures for children and parentswould represent a significant first step in reducing barriers toenrollment.
More progress also is needed in otherareas.  For example, fewer than half of the states provide 12 months of“continuous eligibility” for children, which allows them to retaincoverage for a full year regardless of changes in family income orcircumstances during that period.[20] Continuous eligibility prevents disruptions in care and the negativehealth consequences these disruptions can cause.  In addition, bymodernizing state Medicaid eligibility systems (such as by using datafrom other public programs to verify family income and otherinformation), states could make it easier for families to obtaincoverage.[21]  Measures like these would improve efficiency and decrease administrative costs.  
Finally, since Medicaid would only beone component of a broader system of universal coverage, it isimportant to coordinate the eligibility rules for Medicaid and othersubsidy programs so that people can easily move from one program toanother if their circumstances change.  One strategy for doing soinvolves using the same rules across all of the programs for countingincome and verifying eligibility. 
 
2.  Increasing Provider Payments
Medicaid beneficiaries are more likelythan other individuals to need services because of difficult health andsocial problems, but the program generally pays health care providersat much lower rates than private insurance or Medicare.[22]  In addition, Medicaid provider payments are often the first to be cut when states reduce spending due to an economic downturn.[23]
In a reformed system where Medicaidserves as a foundation for universal coverage, it is essential thatpayment rates be brought up to levels sufficient to encourage moreproviders to participate in the program.[24] This is critical to ensuring access to necessary services, since in asystem of universal coverage, Medicaid will cover more people than itdoes now.  The Children’s Health Insurance Program Reauthorization Actof 2009 established the Medicaid and CHIP Payment Access Commission(MACPAC) to review policies affecting children’s access to services andother issues affecting Medicaid and CHIP.  MACPAC can be set up tooperate like the Medicare Payment Advisory Commission, an independententity that advises Congress on payment and related Medicare issues,and to make recommendations on provider payment rates in Medicaid.  
 
3.  Strengthening Medicaid Financing 
Medicaid needs a reliable and adequatesource of funds if it is to serve as a base for a reformed health caresystem.  The financing mechanism must allow Medicaid to adapt tochanging needs and economic circumstances without putting beneficiariesor services at risk.  
In a reformed health care system,Medicaid would play a larger role in covering the uninsured.  Newfederal resources would be needed to ensure that states have thecapacity to cover those who enter the program as a result ofeligibility expansions and improved enrollment and renewal procedures. States would also need financial assistance to raise payment rates forproviders. 
There are a number of ways to provideadditional federal support.  One option is to increase the Medicaidfederal matching rate for all states to help offset costs stemming fromincreased enrollment.  Another is to shift more of Medicaid’s financialresponsibilities for “dual eligibles” — individuals who are eligiblefor both Medicaid and Medicare — to the federal government.[25]
In addition, to ensure that Medicaid isstable and secure during bad economic times as well as good ones,federal support should increase automatically during recessions.  In arecession, Medicaid enrollment increases as people lose their jobs andjob-based health coverage; at the same time, rising unemploymentshrinks state tax revenues, limiting the state’s ability to finance theprogram just when it is most needed.[26] These pressures place Medicaid at risk for significant cuts,particularly because states are required to balance their budgets eachyear, even in recessions.  
The recent economic stimulus packagetemporarily increases the percentage of state Medicaid costs that thefederal government pays, in order to help states maintain theirMedicaid programs during the current downturn.  Such adjustments shouldbe made automatic in recessions, through the creation of a trigger thatincreases federal matching rates during economic downturns, based onchanges in a combination of economic indicators at both the nationaland state levels.  
 
4.  Integrating Medicaid into Broader Efforts to Improve the Quality and Efficiency of Care 
Health reform needs not only to expandcoverage; it also must address the quality and costs of health care. It is evident that the current health care delivery system containsinefficiencies and excesses and does not always lead to appropriatecare.  Moreover, without fundamental changes in the way care isprovided, health care costs will rise to unsustainable levels.
Medicaid has strong incentives to “bendthe trend” in health care spending by improving the quality andefficiency of care.  Fewer than one-quarter of all Medicaidbeneficiaries account for 70 percent of program spending; thesebeneficiaries, many of whom have chronic conditions and disabilitiesand require social supports to help them deal with their health orother issues, are also the patients who would benefit most from careand disease management programs and other efforts to improve servicedelivery. [27] Focusing on improving care for this segment of the Medicaid populationmay allow states and the federal government ultimately to containcosts. 
Medicaid should be an integral part ofbroader efforts to improve the quality and efficiency of health care,such as initiatives that promote access to appropriate care, advancethe use of information technology, and emphasize prevention and diseasemanagement.  Many states are already engaged in these activities;Medicaid can be a leader in these efforts.  For example, NorthCarolina’s Medicaid program is a pioneer in implementing the “medicalhome” concept:  Medicaid patients in the state have a usual source ofcare, and primary care physicians manage patient care on an ongoingbasis.  As a result, the state has demonstrated savings by preventinghospitalizations and reducing unnecessary care.[28]  
 
Conclusion
Medicaid plays a critical role inproviding needed and affordable health care to tens of millions oflow-income Americans, particularly those with disabilities and specialhealth care needs.  It is difficult to imagine how a reformed systemwould function without it.  
If Medicaid is to serve as a foundationfor a reformed health care system that builds on the existing base ofemployer-sponsored insurance and public programs, it will need to bestrengthened so it can work effectively in concert with other parts ofthe reformed system to ensure seamless coverage.  By streamliningMedicaid enrollment, enhancing beneficiaries’ access to providers,putting the program on a sounder financial footing, and improving thequality and efficiency of health care services, policymakers can helpMedicaid fulfill this essential task.
End Notes:
[1]Karen Davis, “Closing the Quality Chasm: Opportunities and Strategiesfor Moving Toward a High Performing Health System,” testimony beforethe Senate Committee on Health, Education, Labor and Pensions, January29, 2009.
[2]For example, some have proposed eliminating the tax exclusion foremployee health care benefits and replacing it with tax credits forindividuals to secure private health coverage on their own in theindividual health insurance market.  See Nina Owcharenko, “Health CareTax Credits: Designing an Alternative to Employer-Based Coverage,”Backgrounder #1895, The Heritage Foundation, November 8, 2005.
[3]Senator Max Baucus has proposed broadening Medicaid so it coverseveryone living below the poverty line.  Researchers from TheCommonwealth Fund propose using a threshold of 150 percent of poverty. See Max Baucus, “Call to Action: Health Reform 2009,” November 2008,available athttp://finance.senate.gov/healthreform2009/finalwhitepaper.pdf.  Seealso and Cathy Schoen, Karen Davis and Sara Collins, “Building Blocksfor Reform:  Achieving Universal Coverage with Private and Public GroupHealth Insurance,” Health Affairs, Vol 27, No 3, May/June 2008. 
[4] Some states have expanded Medicaid to cover low-income childless adults through Section 1115 waivers.
[5]Donna Cohen Ross and Caryn Marks, “Challenges of Providing HealthCoverage for Parents and Children in a Recession: A 50 State Update onEligibility Rules, Enrollment and Renewal Procedures, and Cost-SharingPractices in Medicaid and SCHIP in 2009,” Kaiser Commission on Medicaidand the Uninsured, January 2009.
[6] Henry J. Kaiser Family Foundation, “The Uninsured: A Primer, Key Facts About Americans Without Health Insurance,” October 2008.
[7] “Comparing EPSDT and Commercial Insurance Benefits,” The Commonwealth Fund, September 2005.
[8]See, for example, “Comparing EPSDT and Commercial Insurance Benefits,”The Commonwealth Fund and George Washington University, September 2005.
[9]Diane Rowland, “Medicaid’s Role for People with Disabilities,”testimony before the House Energy and Commerce Committee, KaiserCommission on Medicaid and the Uninsured, January 16, 2008.
[10]Leighton Ku, Mark Lin and Matthew Broaddus, “Improving Children’sHealth: A Chartbook about the Roles of Medicaid and SCHIP,” Center onBudget and Policy Priorities, January 2007.
[11]“The Healthy Families Program: Health Status Assessment (PedsQL) FinalReport,” California Managed Risk Medical Insurance Board, 2004.  
[12]Amy Davidoff et al, “Effects of the State Children’s Health InsuranceProgram Expansions on Children With Chronic Health Conditions,”Pediatrics, 2005.
[13]The Deficit Reduction Act of 2005 gave states greater flexibility tocharge certain Medicaid populations higher premiums and cost-sharing,as long as aggregate premiums and cost-sharing do not exceed 5 percentof a family’s income.
[14]“Employer Health Benefits: 2008 Annual Survey,” Kaiser FamilyFoundation and Health Research Educational Trust, September 2008.  
[15]The research on cost-sharing and premiums is summarized by Julie Hudmanand Molly O’Malley, “Health Insurance Premiums and Cost-Sharing: Findings from the Research on Low-Income Populations,” KaiserCommission on Medicaid and The Uninsured, March 2003.
[16]Kaiser Commission on Medicaid and the Uninsured, “Characteristics ofthe Uninsured:  Who is Eligible for Public Coverage and Who Needs HelpAffording Coverage?” February 2007.
[17] Michael Perry and Julia Paradise, “Enrolling Children in Medicaidand SCHIP:  Insights from Focus Groups with Low-Income Parents,” KaiserCommission on Medicaid and the Uninsured, May 2007.
[18]Victoria Wachino and Alice Weiss, “Maximizing Kids Enrollment inMedicaid and SCHIP: What Works in Reaching, Enrolling, and RetainingEligible Children,” the Robert Wood Johnson Foundation and NationalAcademy for State Health Policy, February 2009.
[19]Leighton Ku and Matthew Broaddus, “Coverage of Parents Helps ChildrenToo,” Center on Budget and Policy Priorities, October 2006.
[20] Donna Cohen Ross and Caryn Marks, op cit.
[21]The new Express Lane Eligibility option under CHIP, enacted as part ofCHIP legislation that became law on February 4, will allow states torely on information previously collected by public agencies thatdetermine eligibility for other public programs, such as the schoollunch program, in order to facilitate enrollment in Medicaid and CHIP.
[22]Will Fox and John Pickering, “Hospital and Physician Cost Shift:Payment Level Comparison of Medicare, Medicaid, and Commercial Payers,”Milliman, December 2008.
[23]Vern Smith et al., “States Respond to Fiscal Pressure: State MedicaidSpending Growth and Cost Containment in Fiscal Years 2003 and 2004:Results from a Fifty-State Survey,” Kaiser Commission on Medicaid andthe Uninsured, September 2003.
[24]Studies have shown greater Medicaid participation among physicians instates where fee levels are higher.  See Stephen Zuckerman et al.,“Changes in Medicaid Physician Fees, 1998-2003,” Health Affairs (WebExclusive), June 23, 2004.
[25]See, for example, John Holahan and Alan Weil, “Toward Real MedicaidReform,” Health Affairs (Web Exclusive), February 23, 2007. 
[26]A one percentage point increase in the national unemployment rateresults in 1 million new Medicaid enrollees and a 3 to 4 percentdecline in state revenues.  See “Impact of Unemployment Growth onMedicaid and SCHIP and the Number Uninsured,” Henry J. Kaiser FamilyFoundation, April 2008.
[27]“Medicaid Enrollees and Expenditures by Enrollment Group, 2005,” KaiserCommission on Medicaid and the Uninsured and the Urban Institute, May19, 2008.
[28]Thomas Ricketts et al., “Evaluation of Community Care of North CarolinaAsthma and Diabetes Management Initiatives: January 2000 – December2002,” The Cecil G. Sheps Center for Health Services Research, April15, 2004.
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://marigny.org/pipermail/marignybywater_marigny.org/attachments/20090225/954a9842/attachment-0001.html>