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REFORM- Hospitals ask Congress (again) to delay ACA Medicaid funding cuts

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: LOL.

 
 

 
 

Clipped from: https://www.benefitspro.com/2023/07/26/hospitals-ask-congress-to-delay-aca-medicaid-funding-cuts-for-the-14th-time/?slreturn=20230627040946

Since 2013, Congress has voted 13 times to postpone billions in Medicaid funding cuts prescribed by the Affordable Care Act, siding with hospitals over their claims that losing the money would hinder the delivery of care.

 
 

It has become as familiar a sight in Washington as the cherry blossoms in spring: lobbyists from the nation’s hospitals descending on the Capitol to ask lawmakers to postpone billions in Medicaid funding cuts prescribed by the Affordable Care Act — cuts industry leaders agreed to years ago.

It is unlikely the reductions will occur this year, if history is any indication. Since 2013, Congress has voted 13 times to delay them, siding with hospitals over their claims that losing the money would hinder the delivery of care.

Unless Congress acts by October, the federal government will cut $8 billion from this year’s budgetthen make the same cut each year for the next three years — for a Medicaid program intended to help safety-net facilities that serve a large share of Medicaid and uninsured patients. The amount budgeted varies annually, though in 2021 the program’s spending totaled about $19 billion.

Known as the Medicaid Disproportionate Share Hospital (DSH) payments program, it has drawn criticism amid evidence that a substantial amount of its funding goes to hospitals that do not primarily cater to low-income patients. According to industry groups, more than 2,500 hospitals — about 40% of the total in the United States — get the payments.

The cuts are part of a deal brokered with the hospital industry 14 years ago, as the fate of the ACA dangled in the balance. At the time, hospitals agreed to accept $155 billion in Medicare and Medicaid funding cuts over 10 years, assuming the legislation’s promise to insure more patients would improve their bottom lines. A portion of those cuts were to Medicaid DSH payments.

Despite record-high hospital profits and record-low uninsured rates in recent years, the hospital industry again says this is not a good time for cuts, pointing to the COVID-19 pandemic and the millions of people losing Medicaid coverage as a result of pandemic-era protections ending.

Current Medicaid funding covers only about 81% of hospitals’ costs of caring for patients, said Jolene Calla, a vice president of The Hospital and Healthsystem Association of Pennsylvania.

Losing the Medicaid safety-net funding “would be devastating to hospitals,” she said.

bipartisan group of 231 members of the House of Representatives — a majority — have signed a letter to House leaders asking for another delay. Legislation is moving in the chamber that would delay any cuts to the Medicaid safety-net program until 2026.

The postponements show the political muscle of the hospital industry, strengthened by virtually every lawmaker’s district having at least one hospital that provides care and jobs.

Hospitals have been among the biggest donors to members of Congress and have a large lobbying force.

According to the watchdog group OpenSecrets, the Greater New York Hospital Association, which represents more than 160 hospitals, gave more than $11.8 million to congressional campaigns in the 2022 cycle. The American Hospital Association spent about $27 million on lobbying to influence lawmakers in 2022, more than nearly any other organization.

Critics say the hospital industry — which often increases prices, sues patients for lack of payment, and pays big-dollar salaries to top executives — should hold up its side of the deal it made with Democrats, particularly the Obama administration, in 2009.

“Too many hospitals have for years been trying to have it both ways, benefitting from the ACA while trying to escape responsibilities they have under the law,” said Daniel Skinner, an associate professor of health policy at Ohio University. “They constantly deploy their political power to wiggle out of these responsibilities while trying to maintain the generally good feeling they have within communities.”

Related: Profits over patients? States scrutinize nonprofit hospitals’ charity spending

On July 8, 2009, the nation’s top hospital leaders stood with then-Vice President Joe Biden at a White House press conference to announce their deal to keep national health reform legislation on track after a century of failed attempts, dating as far back as Theodore Roosevelt’s push for national insurance.

At the time, ACA reform efforts teetered as interest groups feuded and Democrats struggled to settle on a plan. The agreement, which followed a similar deal with the drug industry, was part of a plan by the Obama administration to preemptively negotiate with corporate interests that had blocked previous reform efforts.

The savings from the $155 billion in hospital funding cuts would “cover health care cost reform,” Biden said during the press conference. “As more people are insured, hospitals will bear less of the financial burden of caring for the uninsured and the underinsured, and we will reduce payments to cover those costs in tandem with that reduction.”

President Barack Obama signed the ACA into law in March 2010. The number of uninsured, which was 48 million in 2010, fell to 28 million by 2016. By 2021, the uninsured rate fell to record lows, with about 27 million uninsured.

Hospital lobbyists argue the industry has already absorbed cuts in Medicare funding under the ACA and that the Medicaid cuts should not be implemented because uninsured rates have not dropped as low as the 5% rate predicted before the law’s passage.

Though the health law has been a “godsend,” it also has not met its anticipated goal of universal coverage, said Chip Kahn, the president and CEO of the Federation of American Hospitals, which represents for-profit hospitals.

Kahn, who was involved in the agreement with the Obama White House, said the ACA has fallen short of universal coverage largely because 10 states, including more populous ones like Florida and Texas, have yet to adopt Medicaid expansion.

As a result, hospitals in these states have provided more unpaid care than anticipated and need the additional Medicaid payments to cover costs, he said.

Kahn said the extra Medicaid payments also help offset shortfalls caused by Medicare and Medicaid underpaying hospitals.

The ACA called for the DSH program’s cuts to be phased in, with less than $1 billion being cut in each of the first few years. But after hospitals lobbied Congress to postpone them, the revised budget deals meant future cuts would be deeper and immediate — leading to the $8 billion annual cuts currently slated for the coming years.

In fiscal year 2021, the most recent year for which data is available, DSH spending nationwide totaled $18.9 billion. While those payments represent 3% of overall Medicaid spending, they account for as much as 10% of some states’ Medicaid spending.

The program, intended for safety-net hospitals, has been the subject of controversy for decades.

One reason is that the money does not always go to safety-net hospitals.

A study published in Health Affairs last year found 57% of hospitals received the DSH payments in 2015. About 94% of these payments went to hospitals with either a high percentage of uninsured patients or Medicaid enrollees or higher-than-average uncompensated care.

But 6% of recipient hospitals did not meet these criteria, the study showed.

The researchers estimated that about a third of the payments went to hospitals not focused on caring for low-income populations.

Paula Chatterjee, the lead author on the study and the director of health equity research at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, said hospitals aren’t transparent about how they spend the extra money and that the states that receive the most money do not always have the highest rates of uninsured residents.

While the safety-net program is intended to help hospitals treating large numbers of Medicaid and uninsured patients, the formula determining how much money states get is based on historical Medicaid spending totals before limits were put in place in 1992, she said.

As a result, states like New York and New Jersey are among the largest recipients of the supplemental funding even though they have some of the lowest uninsured rates, she said.

Beth Feldpush, the senior vice president of policy and advocacy for America’s Essential Hospitals, which represents 300 safety-net hospitals, said these facilities’ 3% average operating margin would disappear if not for DSH money. “Members of Congress recognize there are pockets of underserved communities in most congressional districts,” she said.

Chatterjee said hospitals will likely argue there is never a good time to accept the cuts. She noted some rural and urban hospitals have closed in recent years even as other hospitals have made record profits.

“It’s always hard to take money away from hospitals because they hold such symbolic meaning, and legislators know that,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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REFORM (KY)- GOP nominee says he would renew push for Medicaid work requirement if elected governor in Kentucky

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Seems some in KY still are looking for more control over who gets Medicaid benefits.

 
 

Clipped from: https://apnews.com/article/kentucky-governor-medicaid-144cb682bdb502712239271f5ef568fb

 
 

LOUISVILLE, Ky. (AP) — Republican candidate Daniel Cameron said Wednesday that he would move quickly as Kentucky’s governor to revive a push to require some able-bodied adults to work in exchange for health care coverage through Medicaid.

If he succeeds in unseating Democratic Gov. Andy Beshear later this year, Cameron said his administration would seek federal permission to impose the Medicaid work requirement. The proposed rule would exclude able-bodied adults who are “truly vulnerable,” including those with children or who are pregnant, his campaign said in a follow-up statement. Cameron declared that connecting Medicaid coverage to work for some Kentuckians would raise workforce participation in the post-pandemic era.

“That will be one way in which we tackle the workforce issue,” Cameron said while attending a forum hosted by the Kentucky Farm Bureau, which Beshear did not attend.

The issue of imposing a Medicaid work requirement is yet another stark differences between Cameron and Beshear, who is seeking reelection to a second term in November. Beshear rescinded an attempt by the state’s previous GOP governor, Matt Bevin, to create a Medicaid work requirement that Beshear says would have stripped coverage from about 100,000 Kentuckians.

Cameron, the state’s attorney general, also used his time before the farm bureau officials to lay out his views on agriculture, taxes and spending. The Republican nominee is trying to cultivate strong support in GOP-leaning rural regions to offset Beshear’s expected strength in the metropolitan areas of Louisville and Lexington. Kentucky’s showdown for governor is one of the nation’s most closely watched campaigns this year.

Cameron said he supports policies promoting “generational farming,” enabling Kentuckians to keep farming operations within their families. He said he would “lean on” the GOP-led legislature and his running mate, state Sen. Robby Mills, on whether to pursue new tax exemptions to support agriculture.

Asked about his budget priorities, Cameron pointed to law enforcement. He recently unveiled a public safety plan that included awarding recruitment and retention bonuses to bolster police forces.

“We’re going to prioritize making sure that there is money within our budget to help our law enforcement community,” Cameron said Wednesday.

Beshear has touted his crime-fighting record by noting he pushed for large pay raises for state troopers, as well as increased training for police officers. The governor says he will seek additional funding for police training and body armor to protect law officers if he wins another term.

Cameron, answering a question about taxation, said he wants property taxes to be “as low as possible.”

“But I also recognize that our schools and a lot of local entities rely on some of those taxes,” Cameron added. “And so we’ll have to be smart and deliberative about how we approach this.”

Cameron’s pledge to seek a Medicaid work rule for some able-bodied adults would put an immediate Republican imprint on his administration if he wins in November. Cameron raised the issue during the GOP primary and vowed again Wednesday to make it “one of the first things I will do as governor.”

“If we want the plan and the coverage to exist and remain solvent for those that are means-tested and medically necessary, we need to make the program, as best as possible, transitory – something that folks will come off of if they are able-bodied individuals,” he said at the forum.

Medicaid is a joint federal and state health care program for poor and disabled people. Advocates have said work requirements would become one more hoop for low-income people to jump through, and many could be denied coverage because of technicalities and challenging new paperwork.

In Kentucky, hundreds of thousands were added to the Medicaid rolls when then-Gov. Steve Beshear, the current governor’s father, expanded the program to cover able-bodied adults. For many Kentuckians, it was their first time to have health coverage in a state plagued by high disease rates.

Bevin’s plan would have required that affected recipients either work, study, volunteer or perform other “community engagement” activities to qualify for Medicaid. A federal judge blocked the requirements before they took effect, but Bevin’s administration had appealed until Andy Beshear rescinded those efforts. At the time, Beshear referred to his action as the “moral, faith-driven thing to do.” Beshear, who calls health care a “basic human right,” narrowly defeated Bevin in the 2019 governor’s race.

Cameron’s campaign said Wednesday that his proposal would require affected adults to either work, be enrolled at least part-time in college or be involved in job training or community service to stay on Medicaid.

“We will protect the truly vulnerable but we will not allow able-bodied people to take advantage of taxpayer generosity,” Cameron said in the follow-up statement from his campaign.

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EXPANSION (GA)- Georgia Medicaid program aims to expand access to benefits for those in need

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: GA Medicaid expansion has started.

 
 

Clipped from: https://www.walb.com/2023/07/21/georgia-medicaid-program-aims-expand-access-benefits-those-need/

ALBANY, Ga. (WALB) – Medicaid is expanding to more Georgians.

WALB spoke to Georgia State Representative Penny Houston (R-Nashville) about a very important program starting up this month for the state of Georgia and people and people who may be challenged economically is called the Georgia Pathways to Coverage Expanding Medicaid.

“Well, there are many Georgians and citizens in Georgia who do not have access to coverage and don’t qualify for Medicaid,” Houston said. “And this is a program that the governor got a waiver for to include more people who do not qualify for Medicaid. And you have to be, within 10% —100% Of the poverty level. And are there other qualifications and it has most of the benefits that you get with Medicaid. There are future exclusions. One is transportation for a certain age group, but not to and from your doctor’s office. Of course, it does include transportation and ambulance services, but most of the things are already included: your doctor’s visits, your prescriptions, your emergency coverage for emergency rooms and those sort of things are already included. Your hospital stay. Your labs, your X-rays, all that are included in family planning.”

Another big part of this is preventative care: Wellness Care is also included in this, and that’s very much needed for people. And like you say, people who are working can qualify for this. It might lower their payments and their insurance. So it’s a very good thing and the application started in July.

“And July 1, and one other thing I’ve left out. That’s most important right now. And I would say, this does cover mental health services and mental health issues are something that have not been covered in a while. People are recognizing that so much mental health is really a disease,” Houston said.

To apply to the program online, click here. Georgians can also apply through the mail or in person at their local Division of Family and Children Services office. First applications can also be made by phone at 1-877-423-4746, or 711 for those that are deaf, hard of hearing or need extra assistance.

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EXPANSION (NC)- N.C. governor sets Medicaid expansion date, pressuring Republicans to act

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: In which the Good Guvnr needs to appear tough.

 
 

 
 

Clipped from: https://www.politico.com/news/2023/07/26/roy-cooper-north-carolina-medicaid-expansion-00108297

Medicaid expansion is set to begin October 1 if Republican lawmakers fund it.

 
 

The state’s plan gives lawmakers until Sept. 1 to fund the proposal. State health officials said that by starting their work now, they can reduce the lead time needed to implement the program from 90 or 120 days after the legislature gives its final approval to 30 days.

If, however, lawmakers miss the September deadline, Medicaid expansion would be delayed until Dec. 1, health officials said.

North Carolina became the 40th state to approve Medicaid expansion in March, with more than 600,000 people expected to be eligible for the program when it takes effect.

Implementing Medicaid expansion has been a top priority for the two-term governor, who will leave office in 2025.

Republican lawmakers overcame years of opposition to approve the proposal but declined to fund it separately, wanting some leverage over Cooper as they hashed out the budget. In August, Cooper railed against lawmakers for tying expansion to the budget.

“Making Medicaid Expansion contingent on passing the budget was and is unnecessary, and now the failure of Republican legislators to pass the budget is ripping health care away from thousands of real people and costing our state and our hospitals millions of dollars,” Cooper said in a statement.

Lawmakers have shown no signs of budging — even though negotiations between House and Senate Republicans are on other issues, such as tax cuts and pay raises for state employees.

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STATE NEWS (FL)- Judge rules against state on children in nursing homes

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: 140 kids stuck in 3 nursing homes in Florida should get to go home now that the judge has ruled in their favor.

 
 

 
 

Clipped from: https://news.wgcu.org/section/health/2023-07-17/judge-rules-against-state-on-children-in-nursing-homes

 
 

TALLAHASSEE — After a decade-long legal fight, a federal judge Friday ordered Florida to make changes to keep children with “complex” medical conditions out of nursing homes and help them receive care in their family homes or communities.

U.S. District Judge Donald Middlebrooks, siding with the U.S. Department of Justice, ruled that Florida has violated the Americans with Disabilities Act and the rights of children “who rely upon the provision of vital Medicaid services and are trying, in vain, to avoid growing up in nursing homes.”

“Unjustified institutionalization of individuals with disabilities is unacceptable, especially given the advances in technology and in the provision of home-based care,” Middlebrooks wrote in a 79-page decision. “Any family who wants to care for their child at home should be able to do so.”

Middlebrooks criticized the state for not doing more to ensure services such as private-duty nursing that could enable children to live outside of nursing homes and to help children who are at risk of being institutionalized. The case centers on children in the Medicaid program with conditions that often require round-the-clock care involving such needs as ventilators, feeding tubes and breathing tubes.

“Those who are institutionalized are spending months, and sometimes years of their youth isolated from family and the outside world,” Middlebrooks wrote. “They don’t need to be there. I am convinced of this after listening to the evidence, hearing from the experts, and touring one of these facilities myself. If provided adequate services, most of these children could thrive in their own homes, nurtured by their own families. Or if not at home, then in some other community-based setting that would support their psychological and emotional health, while also attending to their physical needs.”

The Justice Department filed the lawsuit in 2013, after conducting an investigation that concluded the state Medicaid program was unnecessarily institutionalizing children in nursing homes. The state has vehemently fought the allegations and the lawsuit, with the U.S. Supreme Court last year declining to take up a state appeal aimed at preventing the case from moving forward.

Friday’s ruling said about 140 children in the Medicaid program are in three nursing homes in Broward and Pinellas counties. It also said more than 1,800 children are considered at risk of being institutionalized.

Middlebrooks wrote that the Americans with Disabilities Act requires the state to provide services in the most “integrated setting appropriate” to meet the needs of people with disabilities. He also cited a major 1999 U.S. Supreme Court ruling that said “undue institutionalization” of people with disabilities is a form of discrimination.

Most beneficiaries in Florida’s Medicaid program receive services through managed-care organizations. A key part of Middlebrooks’ ruling was that the Medicaid program and managed-care organizations were not providing adequate private-duty nursing that could enable children to receive care in their family homes or communities.

“By the close of the evidence, I was convinced that the deficit of PDN (private-duty nursing) in Florida is causing systemic institutionalization,” wrote Middlebrooks, a South Florida-based judge who was appointed to the bench by former President Bill Clinton.

As part of the ruling and an accompanying injunction, Middlebrooks ordered that the Medicaid program provide 90 percent of the private-duty nursing hours that are authorized for the children. He also ordered the state to improve what are known as “care coordination” services and to take steps to improve the transition of children from nursing homes.

Middlebrooks, who held a two-week trial in May, also criticized the state’s oversight of managed-care organizations and ordered a monitor to help carry out the order.

“One of the most perplexing aspects of this case is the apparent unwillingness of the state to enforce its contracts,” he wrote. “The state has contracted with managed care organizations to establish complete medical provider networks to service the needs of children with medical complexity. Part of the required network is to provide home health care to eligible members in a clinically appropriate and timely manner. The managed care organizations have contracted to deliver, not endeavored to deliver, medical treatment to their members.”

In an April 28 court document, attorneys for the state disputed that the Medicaid program was not properly providing services to the children.

“The United States claims that parents are demanding the return of their children, but cannot take them home because Florida fails to deliver Medicaid services,” the state’s attorneys wrote. “That assertion finds no basis in the evidence. Each child’s circumstances are different and individualized, and each lives in a nursing home for reasons that seemed convincing to their parents. The ADA (Americans with Disabilities Act) does not entitle the court to second-guess those decisions — even if the United States disagrees with them.”

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STATE NEWS (NC)- NC House Democrats criticizes budget delay. Final plan may be weeks away.

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Reminder- NC did not expand Medicaid.

 
 

 
 

Clipped from: https://ncnewsline.com/2023/07/12/nc-house-democrats-criticizes-budget-delay-final-plan-may-be-weeks-away/

 
 

House Democratic Leader Robert Reives criticizes Republicans for the delayed state budget. (Photo: Lynn Bonner)

Republican legislators’ failure to agree on a state budget is delaying Medicaid expansion, teacher and state employee raises, and state retiree cost-of-living increases. 

House Democrats criticized the lack of a new spending plan at a news conference Wednesday. The new budget year started on July 1, but negotiations between legislative Republicans may drag on for another month. 

Republican leaders have said that they are working to negotiate a compromise on tax cuts. Potential expansion of casino and video gambling could also be in the mix. 

Rep. Jason Saine, senior chairman of the House budget committee said Wednesday it may be the middle of August before the state has a budget.

 
 

Rep. Jason Saine, senior chairman of the House budget committee (Photo: NCGA screen grab)

The Senate and House had different ideas on how big a boost employees should get, making raises one of the issues under negotiation. 

The Republican budget impasse has left school districts in limbo, Wake County Democratic Rep. Julie von Haefen said at the news conference. Year-round schools are already beginning and traditional schools are set to open in six weeks.

“How can we possibly ask our administrators to begin operating our schools when they don’t even know what the state appropriation is going to be to their districts,” she said.

The budget impasse adds to difficulties recruiting teachers because potential new hires won’t know how much they’ll earn. “Would you accept a contract to start a job with an undefined salary? That is exactly what Republicans are asking our teachers to do at this point. Accept jobs for uncertain pay,” she said. 

Once the budget passes, teacher and state employees’ raises will be retroactive, so state workers will eventually receive their money. At this point, they don’t know how much. 

Medicaid expansion remains on hold as unwinding begins

Last March, North Carolina became the 40th state to adopt Medicaid expansion, but Republicans made expansion contingent upon passing a budget. That means initiation of a plan that could offer up to 600,000 more North Carolinians health insurance is also delayed. 

Last week, Gov. Roy Cooper urged Republicans to decouple Medicaid and the budget. House Democratic leader Robert Reives repeated the call to separate expansion from the budget. 

In the meantime, states including North Carolina are dropping people from Medicaid programs. A federal mandate that prevented states from removing people from Medicaid has expired. Thousands of North Carolina residents who were able to remain insured during the pandemic are likely to lose their health insurance coverage.  Some of those people would be able to stay insured under Medicaid expansion. 

“This month alone, we have 9,000 people who will lose Medicaid coverage that would otherwise keep it,” Reives said. 

“I want to echo Governor Cooper’s urge to decouple Medicaid expansion from the budget, because we’re looking at a prolonged stand-off it seems,” Reives said. “We need to keep in mind that everybody in this state is waiting for something in this budget, especially state employees, and we owe it to them to provide the best that we can.”

 
 

Everybody in this state is waiting for something in this budget, especially state employees.

– House Democratic leader Robert Reives

Saine, a Lincoln County Republican, said Democrats were grandstanding, and most of them won’t vote for the budget anyway. Budgets have been late before, he said. 

“This is about us being very pragmatic and working through a very complicated multi-billion budget that sets our state on course,” he said. “These things do take time and being intentional and pragmatic means we get the best deal we can get. At this point, we’re not there yet.”

Saine said he understands that Senate Republicans want to include as part of the budget allowing more casinos, but he has not seen a final offer in writing. 

Western North Carolina has three casinos in its part of the state. Two are owned by the Eastern Band of Cherokee. The Catawba Nation owns one in Kings Mountain. 

Allowing casinos outside tribal lands was not in the House or Senate budget. House Speaker Tim Moore and Senate leader Phil Berger spoke to WRAL about a potential casino bill as  the legislature was approving online sports betting. 

The bigger issue holding up the budget are the accelerated tax cuts and “how quickly we get to a lower number on tax reform and whether there are going to be triggers,” Saine said Wednesday. Most House Republicans want tax-cut triggers based on state revenues, a plan where tax rates would drop if revenues reach certain targets. 

It’s harder to sell faster tax cuts without knowing if more money will be coming in, he said.  

“We could do tax reform, we could do casinos, we could do them both, but until we know exactly what they’re going to look like, it is a little difficult,” Saine said. 

Updated at 10:00 pm to correct spelling of Julie von Haefen. 

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STATE NEWS (NJ and DE) – N.J. giving Delaware hospital $20M to cover kids on Medicaid, but there’s no guarantee it will

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: One state funds Medicaid payments for a children’s hospital in another as part of a specific item in their own budget.

 
 

 
 

Clipped from: https://www.nj.com/politics/2023/07/nj-giving-delaware-hospital-20m-to-cover-kids-on-medicaid-but-theres-no-guarantee-it-will.html

 
 

Elias Del Collo of Upper Deerfield has been a patient of Nemours Children’s Hospital in Delaware since he was four days old. His family fears he will lose his treatment team in a dispute between the hospital and the Medicaid managed care carrier that covers his extensive treatment.

By

State lawmakers took the unprecedented step last month of earmarking $20 million in the new state budget for a pediatric hospital in Delaware, anticipating the cash infusion would halt the facility’s plans to leave New Jersey’s Medicaid managed care program on Aug. 1.

But it’s been nearly two weeks since Gov. Phil Murphy signed the $54.3 billion spending plan into law, and officials from Nemours Children’s Health have not announced whether the facility will remain an in-network hospital for families insured through NJ FamilyCare.

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PHE- Florida one of two states declining waivers to help with Medicaid unwinding

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Florida says no thank you, we are fine.

 
 

 
 

Clipped from: https://wusfnews.wusf.usf.edu/health-news-florida/2023-07-07/florida-declining-federal-waivers-help-medicaid

 
 

The waivers aim to reduce the risk of eligible families losing Medicaid coverage due to procedural errors.

Federal health officials are urging states like Florida to make it easier for people to renew their Medicaid coverage as a mass unwinding following the COVID-19 public health emergency continues.

Thousands of Floridians have been disenrolled from Medicaid since the state began redetermining eligibility in May, after a federal directive that states suspend such efforts during the pandemic was lifted. Florida began its process earlier than some others, but committed to spreading out renewals over the course of a year.

Health care advocates have been raising the alarm about large numbers of people in Florida and nationally who are losing coverage not because they no longer qualify but because of procedural issues, such as failing to respond to renewal notices or submitting information incorrectly. They say it suggests states are not doing enough to communicate with families about the renewal process and help them navigate it.

RELATED:
‘Trying to survive’: Families suddenly dropped from Medicaid seek reinstatement

Advocates and health officials say they are especially concerned about children, who are more likely to remain eligible for Medicaid than adults. Kids make up the majority of Florida’s Medicaid population, so coverage losses due to red tape could threaten their access to care.

The feds are offering help. Florida hasn’t taken it yet

The Centers for Medicare and Medicaid Services set minimum standards for states to follow to reduce the risk of people wrongfully losing coverage, but has also offered states some flexibilities to assist in the unwinding, including a series of policy waivers that Health and Human Services Secretary Xavier Becerra outlined in a June 12 letter to governors. But Florida is one of two states that has so far declined to take advantage, along with Montana.

“We really are at a moment here where we have the potential for millions of people to lose health care coverage,” CMS deputy administrator Dan Tsai said during a virtual meeting with reporters this week. “We need everybody, and that includes our state partners, to go far above and beyond the minimums and to do everything in their power to keep eligible people covered.”

The waivers allow states to do things such as automatically renew people who appear to have no or very little income, partner with Medicaid managed care plans to assist people with completing renewal forms, or delay administrative terminations for one month while the state conducts additional outreach.

This gives families more time to understand what steps they need to take to renew coverage, and also reduces the amount of resources states have to spend tracking down enrollees who are likely still eligible for coverage.

CMS has so far approved nearly 250 waivers for the remaining states and territories, and officials want to see Florida participate as well.

Some of the waivers allow for processes that Florida has already included in its state plan, according to Department of Children and Families spokesperson Tori Cuddy.

For example, some waivers let states use information about residents receiving benefits through the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) to determine Medicaid eligibility. Florida is already able to do this, Cuddy noted.

The state of Florida’s Medicaid unwinding

Medicaid enrollment reached record highs in Florida during the public health emergency, at more than 5 million people, but the state projected roughly 1 million were no longer eligible.

So far, the state has only been able to verify about 35% of the 303,000 Medicaid enrollees it’s estimated to have disenrolled during the process were ineligible, according to a Kaiser Family Foundation analysis of state unwinding dashboards and monthly reports submitted to CMS. The remaining 65% are due to procedural reasons.

That marks an improvement from the procedural termination rate during the first four weeks of redeterminations in Florida, which was closer to 80%. It is also lower than the current national average, which KFF lists as 71%, though the organization notes not all states have made data publicly available.

Calls for Florida to pause redeterminations

Still, the fact that the state has not been able to confirm ineligibility for a majority of enrollees that have lost coverage so far has CMS officials and other health care advocates concerned.

A coalition of 52 organizations sent a letter to Gov. Ron DeSantis and state health officials in late May asking them to pause the redetermination process, which in its first month resulted in a quarter-million Floridians losing Medicaid coverage.

In addition to the high rate of procedural terminations, advocates also cited long waits at state call centers as well as anecdotal reports of children with complex medical conditions, who were supposed to go last in Florida’s redetermination plan, experiencing disruptions in coverage as reasons to slow the process.

“As organizations that represent and advocate for the well-being of Florida’s families, we are deeply concerned about those with serious, acute and chronic conditions who will continue to lose access to their lifesaving treatments during this time, along with people who risk substantial medical debt, or even bankruptcy, as a result of coverage loss,” the groups, which include the Florida Policy Institute and Florida Health Justice Project, among others, wrote in the letter.

RELATED: About 250,000 Floridians were kicked off Medicaid. Experts say most were still eligible

CMS has asked some states to pause procedural terminations, Tsai said during Wednesday’s briefing, though he did not name which ones, nor did a CMS spokesperson upon follow-up inquiry.

“We are finishing discussions with states and will have more information to follow up with soon,” the CMS spokesperson said in an email.

There has been a “constant stream” of concerns that health providers and advocates have brought to CMS’ attention when it comes to challenges with renewals in Florida and other states, Tsai said. Staff are investigating individual cases and monitoring data.

But to take action against a state, CMS must find a “clear regulatory violation” occurred, which Tsai said is not always easy.

“Federal Medicaid regulations do not get very specific on some of the things including how understandable, say, a [renewal] notice is. That is an issue that we need to remedy, to be clear, but that is also why, in instances, we may not find a clear violation of a regulatory standard,” Tsai said.

The state touts its response

DCF officials tell Health News Florida that the state has implemented a variety of communication strategies to reduce the number of procedural terminations.

“The Department has implemented an extensive public outreach campaign, well exceeding federal requirements, including mail, email, texts, and call outs to Medicaid beneficiaries to encourage engagement in renewal,” said Cuddy.

More than 80% of recipients have responded to their redetermination requests compared to fewer than 50% pre-pandemic, she added. Recipients who don’t respond have 90 days to submit a late application and can get their coverage restored retroactively if determined eligible.

The department also notes thousands of residents who have been determined ineligible for Medicaid have been referred to other health insurance options, including Florida Healthy Kids, a program for children in families with low incomes, and plans available through the Affordable Care Act marketplace.

Posted on

PHE- This Little-Known Corporation Is Making a Fortune Kicking People Off Medicaid

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Somebody finally realized what the PHE means for Maximus.

 
 

 
 

Clipped from: https://jacobin.com/2023/07/medicaid-enrollment-maximus-contractor-profits

As more than 17 million people stand to lose health insurance in the unfolding Medicaid eligibility review disaster, a little-known company called Maximus is set to make massive profits off of helping the government deny people health insurance.

 
 

Dr Candice Jones attends to her patients Nihmaya Farrell, six, center, and Nichaya Simmons, thirteen, left, and mother Natasha James at the Edgewater Pediatrics in Orlando, Florida, on January 14, 2021. (Willie J. Allen Jr / Orlando Sentinel / Tribune News Service via Getty Images)

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As more than seventeen million people stand to lose health insurance in the unfolding Medicaid eligibility review disaster, there’s one company licking its lips: Maximus, a little-known federal contractor that is one of the biggest players in privatizing essential government services previously done by civil servants — in particular, taking over states’ capacity to determine who is eligible for Medicaid and who isn’t.

In a February earnings call for shareholders and Wall Street analysts, Maximus’s CEO Bruce Caswell announced that the current nationwide eligibility review of ninety million people on Medicaid and other government health insurance programs “is unprecedented in its scope,” and will allow Maximus “to gain traction in the market.” As a result of the deluge in Medicaid “redeterminations,” Caswell said, “we expect improvement to operating margin.”

The company has accordingly boosted its earnings estimate by $100 million. Maximus’s share price is closing on its all-time high, up nearly 50 percent since October. Caswell earned $6.3 million in 2022.

Outsourcing Medicaid eligibility reviews to Maximus has major implications beyond the company’s expanding bottom line. It also removes essential government services from the realm of public accountability, while draining resources from governments.

“One of the big concerns here is it’s a company that’s really making money coming and going from the county, state, and federal governments,” said Daniel Hatcher, a law professor at the University of Baltimore who has studied Maximus. “People who are benefiting the most are the company, occasionally governments, but not the people who are supposed to be benefiting from Medicaid services.”

Along with draining public finances, Maximus and other Medicaid redetermination contractors are incentivized to advocate for making Medicaid even more of a bureaucratic nightmare for recipients.

“If you look at the payment structure of these contracts, the more red tape, the more money Maximus makes,” Hatcher said. “The harder it is to get enrolled, the easier to get kicked off — the more money Maximus and contractors are making.”

Maximizing Profits

During the COVID-19 pandemic, lawmakers required states to stop removing people from Medicaid, the national health insurance program for low-income Americans. The move led to record enrollment in a strictly means-tested program designed to benefit only the very poor — one from which people are often arbitrarily removed.

Late last year, Congress passed and President Joe Biden signed a year-end spending bill directing states to resume annual redeterminations of Medicaid recipients’ eligibility for the program. Now, an estimated seventeen million people, and potentially up to twenty-four million, could lose their coverage.

Studies suggest that expanding Medicaid coverage substantially reduces deaths, and positively impacts people in poverty throughout their entire lives.

While there are significant reporting gaps as to where Maximus is doing redeterminations and how states are reporting eligibility reviews, Maximus dominates 60 percent of the Medicaid eligibility market, according to a recent report in Modern Healthcare.

While the final determinations for Medicaid eligibility must be completed by public employees, every other step of the process — from processing applications, to running call centers, to reaching out to people on the verge of losing benefits — can be done by private contractors.

In a recent investor presentation, Maximus wrote that it was boosting its “revenue and earnings guidance to account for Medicaid redeterminations,” and noted that “actual volume flow and beneficiary interaction will influence overall profitability.”

So far, more than 70 percent of those who have recently lost Medicaid coverage have been terminated for administrative reasons, such as not responding to a piece of mail or getting dropped from a call with a redetermination specialist, rather than because they were deemed ineligible due to their income and assets. Many of these people are likely still technically eligible for the program.

Maximus runs the call center for Medicaid eligibility in Indiana, where 85 percent of the 107,000 people kicked off Medicaid this year lost coverage because of procedural reasons. According to Maximus’s $400-million Indiana contract, up to seven percent of its eligibility calls in the state in a given week can be dropped before the company is penalized.

“We do not make Medicaid eligibility determinations,” Maximus said in a statement to the Lever:

Our job is to support the states’ responsibilities to ensure that everyone who is eligible for Medicaid remains covered. If they are no longer eligible for Medicaid, we work with the states to refer them to other health care options such as the insurance marketplace. We are not paid in any state on the basis of whether an individual is found eligible or ineligible.

Maximus did not answer follow-up questions about the scope of its work in various states and how much revenue the company expects to generate from its Medicaid redetermination business.

As Maximus seeks to expand its Medicaid redetermination work, the company has leaned into lobbying and political donations.

Maximus has donated $2.5 million to national political groups affiliated with state and local politicians since 2017. That includes $955,000 to the Republican Governors Association; $665,000 to the Democratic Governors Association; $450,000 to the Republican State Leadership Committee, which funnels money to GOP state legislative campaigns; $210,000 to the Republican Attorneys General Association; and $165,000 to the Democratic Attorneys General Association.

The company additionally donates to the National Governors Association, a nonpartisan group that represents governors from both parties.

Maximus spent $960,000 on federal lobbying alone in 2022, and its roster of lobbyists included former longtime representative Al Wynn (D-MD), who is now a senior director at the lobbying powerhouse Greenberg Traurig.

Wynn was one of just a handful of members of the Congressional Black Caucus to vote “yes” on the final vote on the 1996 welfare reform bill. The legislation, which led to a doubling of extreme poverty, provided an enormous boon to Maximus by incentivizing the outsourcing of welfare eligibility work.

Shar Habibi, the research director of In the Public Interest, which advocates against privatization, said that Maximus’s role in Medicaid redeterminations will hollow out the government’s ability to effectively provide public services.

“When governments contract with firms like Maximus to do essential public functions like determining who is or isn’t eligible for Medicaid, the question gets raised: Does outsourcing eligibility determination-related functions compromise the integrity of the program, especially when people’s lives are at stake?” she asked. “Using contractor staff does not promote an effective, efficient, and equitable delivery of Medicaid.”

Maximus also has major contracts with the federal government to provide assistance to those seeking to enroll in Medicare, the government health insurance program for seniors and those with disabilities, as well as those looking to sign up for individual health insurance plans offered on state marketplace exchanges created under Democrats’ 2010 health care law, the Affordable Care Act.

Some people formerly on Medicaid will move to exchange-based plans, which will almost certainly result in substantially higher out-of-pocket costs.

In May, Maximus laid off seven hundred workers from its Medicare and marketplace call centers where workers were seeking to unionize with the Communications Workers of America (CWA) union. The move led CWA to file an unfair labor practice charge with the National Labor Relations Board and launch a petition to pressure secretary of Health and Human Services Xavier Becerra to investigate Maximus’s labor practices.

Meanwhile, Maximus’s government contracts to do such work have continued to expand under the Biden administration, despite the fact that Joe Biden pledged in his 2020 campaign that “I intend to be the most pro-union president leading the most pro-union administration in American history.” In September 2022, Maximus was awarded a $6.6-billion contract from the Centers for Medicare and Medicaid Services (CMS).

Samira Burns, a spokesperson for the Health and Human Services Department (HHS) which includes CMS, told me that the department has initiated a request for information process with contractors like Maximus “to seek recommendations and remain in alignment with industry best practices to ensure we continue to meet national program missions and strategies. … In recent years, there has been increasing labor concerns at certain call center locations. HHS/CMS is looking to explore ways to prevent or mitigate ongoing and future concerns.”

Posted on

PHE- CMS: Marketplaces are ready to be ‘landing spot’ for those losing Medicaid coverage

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: In which CMS says- “come to the exchanges- we’ll pay 100% of the costs.”

 
 

 
 

Clipped from: https://www.beckerspayer.com/payer/cms-marketplaces-are-ready-to-be-landing-spot-for-those-losing-medicaid-coverage.html

CMS is ramping up efforts to connect over 2 million people who have been disenrolled from Medicaid coverage to ACA plans. 

“We’re in the execution phase to be the appropriate landing spot for many of the folks who are no longer eligible for Medicaid and CHIP,” Jeff Grant, deputy director for operations at CMS’ Center for Consumer Information and Insurance Oversight, said on a July 17 call with stakeholders. 

The agency is ramping up outreach to people who may be losing Medicaid coverage through text, email, phone calls and more mailers. 

“We’ve got to get outreach and communication in place to get people to our front door so that they actually do see the affordability options that are there for them and can make an appropriate choice,” Mr. Grant said. 

The agency is also funding navigator programs to connect people who may have lost coverage with community organizations that can provide them in-person help in choosing a new plan. 

“This is really the most exciting thing for us, to be able to create this new process that we’ve never done before for this group of consumers,” Mr. Grant said. 

As of July 18, at least 2.9 million people have been disenrolled from Medicaid as part of the redeterminations process, according to KFF. Of those disenrolled, 75 percent were for procedural reasons, rather than being deemed ineligible for the program. 

Daniel Tsai, CMS deputy administrator and director of the Center for Medicaid and CHIP services, said providers and health plans can make sure their beneficiaries know to respond to mail from their Medicaid provider and that they may qualify for coverage on individual marketplace. 

“I think we see low awareness among our Medicaid enrollees of what’s happening. So number one for health plans, providers, advocates is really making sure people are aware,” Mr. Tsai said. 

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