Tag: Medicaid Reform

MM Curator summary

 
 

Alabama will not take the federal expansion incentives, but is considering using gambling revenues to fund more rural healthcare.

 
 

 
 

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.

 
 

 
 

Brenda Smith of Selma urges Alabama Gov. Kay Ivey to expand Medicaid during a rally on the Capitol steps on April 14, 2020. (Mike Cason/mcason@al.com)

When it comes to expanding health care services for rural and poor people in Alabama, the Legislature is rolling the dice on gambling.

With few days left in the legislative session, the GOP-controlled Legislature’s answer to a possible health care expansion is wrapped into a legislative proposal to earmark new gambling revenues for “the provision of health care services, including rural health care services.” Lawmakers are set to debate and possibly vote on a historic gambling package by Thursday.

But any effort to fund a Medicaid expansion is on hold for the time being. An expansion plan was missing in the state’s $2.5 billion General Fund budget that is effective for the fiscal year starting on October 1 and was adopted by the Alabama Senate on Thursday.

“My personal position is when we have an answer on how to fund it, that’s when we’ll talk about it,” said State Sen. Greg Albritton, R-Atmore, chairman of the Senate budget committee on Thursday. “If you talk to the feds, it doesn’t cost us anything. But they are not looking at what we need to pay. They have never completely answered how much it will cost the state of Alabama to do it.”

Medicaid expansion

Advocates for expanding Medicaid say it could be done with a simple stroke of Alabama Gov. Kay Ivey’s pen, but the governor has been hesitant to do so since she took office in 2017. Ivey’s office says it’s up to the Legislature to agree upon a way to fully fund the expansion, which could affect up to 300,000 Alabamians. The costs to do so has varied; a 2019 University of Alabama at Birmingham study estimated it would be around $250 million per year.

It’s also unknown how the $2 trillion American Rescue Plan Act, signed into law in March, could lower Alabama’s obligation over time. New financial incentives were included within the coronavirus relief package for the states that have opted against Medicaid expansion. The incentives would provide a 5 percentage point increase on the federal match to cover the people already enrolled in Medicaid in Alabama as long as the state commits to expanding the program.

Alabama is one of 12 states that have not expanded Medicaid eligibility under the Affordable Care Act, the 2010 federal health care law that was a signature policy achievement for former President Barack Obama. Republican leaders have, for years, expressed political opposition to the program and concerns about its costs to state taxpayers.

“Ensuring every Alabamian has access to quality health care is important to the governor and always has been a priority of hers,” said Gina Maiola, the governor’s spokeswoman. “However, as she has made clear, the problem has always been how to pay for it. She is open to the discussion, but right now, we simply do not have all the facts. This is a massive package, and our Finance Department and Medicaid Agency will need to thoroughly review it before we can fully weigh in on the issue.”

State Rep. Barbara Drummond, D-Mobile, provides an update on Alabama House Democratic initiatives during a news conference on Wednesday, April 28, 2021, at the State House in Montgomery, Ala. Standing to her left is Rep. Jeremy Gray, D-Opelika, and Rep. Dexter Grimsley, D-Newville. (John Sharp/jsharp@al.com).

Democratic lawmakers have repeatedly called on their Republican colleagues to expand Medicaid, citing the American Rescue Plan Act as a rare opportunity for the state to reconsider its opposition.

State Rep. Barbara Drummond, D-Mobile, said the failure to expand the program is “costing lives” in addition to gaudy economic opportunity projections. An Alabama Hospital Association study says that expanding Medicaid to include over 300,000 new recipients would bring between $2.7 billion to $2.9 billion of annual economic activity into the state.

Medicaid expansion would provide insurance coverage to people making up to 138 percent of the federal poverty limit.

“It’s the right thing to do and we should do it right now,” said Drummond.

Robyn Hyden, executive director with Alabama Arise – a Montgomery-based non-profit agency that supports anti-poverty policies – said while the finances are complicated, she believes there is enough information for lawmakers to support the latest Medicaid expansion request. She said Alabama could save over $700 million over the next two years by accepting the deal offered in the coronavirus relief package.

“It yields a tremendous benefit in state savings and all of the immediate economic development impacts (that will help pay) for doctors and nurses,” said Hyden. “We think the math has never been better.”

Gambling uncertainty

She said what is less known is whether gambling is a stable bet for boosting financial support for health care. Lawmakers are set to debate that various parts of the wide-ranging and ever-changing gambling and lottery package during committee hearings on Tuesday. The main aspects of the package include authorizing a lottery, six new casinos, and sports betting and an encouragement for negotiations on a compact with the Poarch Band of Creek Indians.

Even if lawmakers support a gambling provision, it will have to go to the voters for final approval. The last time voters got to decide on a lottery plan was in 1999, when they defeated a ballot initiative by 8 percentage points.

“I’m not sure what will happen with gaming and the lottery,” said Hyden. “If it passes the Legislature, it takes a constitutional amendment and a statewide (referendum). But Arise will continue to lobby the governor (for the Medicaid expansion). The best thing we could do for our health care infrastructure, including rural health care, is expand Medicaid as much as possible.”

Danne Howard, executive vice president of the Alabama Hospital Association, said her organization is pleased that Alabama lawmakers are including a provision to fund rural health care within gambling legislation. SB310, which was approved out of the Alabama Senate last month, dedicates 25% of net gaming revenue toward rural health. Gambling legislation also includes significant money to fund broadband and mental health services in Alabama.

Substitute legislation, released on Monday, increases the percentage of gambling revenues to health care to 40%. The latest version does not specify an amount to rural health care or rural hospitals.

With state lawmakers negotiating a final version of the gambling package, Howard said she is unsure what it might ultimately mean for the rural hospitals.

“We are please they are dedicating some money for the ‘provision of health care services,'” said Howard, quoting the verbiage contained in SB310. “I can tell you that I don’t know what is meant by that. But we are happy health care and the provision of those services (are included).”

 
 

Alabama State Senator Greg Albritton takes questions from the media on Thursday, April 29, 2021, at the State House in Montgomery, Ala. (John Sharp/jsharp@al.com).

Albritton said the gambling legislation appears to be the only path forward for immediate health care expansion and addressing rural health deficiencies.

“That’s the only source we are going to have that is available to get the resources to deal with what we need to deal with,” he said.

Rural hospitals continue to be a concern for Alabama where seven have shut down since 2010. The percentage of rural hospitals operating in the red increased from 39 to 47 percent in the past five years leading up to the COVID-19 pandemic, which has only heightened the need for more doctors and nurses in small towns.

The Chartist Group, a healthcare analytics company, published research last year that indicated that 12 out of 45 rural hospitals in Alabama are most vulnerable to closure due to several factors that includes the lack of Medicaid expansion.

Said Drummond, “I think COVID has taken our skeletons and threw them out of the closet. It showed where our deficits are in health care. I think Republicans see the need and urgency as well. If we don’t fix health care, not only is there an economic disadvantage to do so but it will spiral in these other areas of education and jobs.”

This story was updated at 1:39 p.m. on May 4, 2021, to clarify how Medicaid expansion will work under the American Rescue Plan Act signed into law in March.

 
 

Clipped from: https://www.al.com/news/2021/05/gambling-in-medicaid-expansion-out-with-alabamas-latest-rural-health-care-approach.html

 
 

 
 

MM Curator summary

 
 

Nevada lawmakers are working on a revised approach to a public option that would require Medicaid plans to also offer public option plans.

 
 

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.

 
 

 
 

Nevada lawmakers are poised to once again debate creating a state public health insurance option.

Legislation expected to be introduced Wednesday would require insurers that bid to provide coverage to the state’s Medicaid population to also apply to offer a public option plan. 

The plans would resemble existing qualified health plans certified by the state health insurance exchange in many ways — for instance, covering a suite of essential health benefits — and would be available for purchase both on and off the exchange. The legislation would, however, require those plans to be offered, essentially, at a 5 percent markdown with the overall target of reducing average premium costs in the state by 15 percent over five years.

The bill also aims to align provider networks between Medicaid and public option plans in order to make access to care more seamless for people who, because of their income level, fluctuate between being covered by Medicaid and securing subsidized insurance on the state exchange.

The proposal, which is being spearheaded by Senate Majority Leader Nicole Cannizzaro, represents both an outgrowth of and a departure from other public option ideas lawmakers have considered in previous legislative sessions, including a 2017 bill that would have allowed Nevadans to buy into the state’s Medicaid program, which the Legislature approved but was vetoed by Gov. Brian Sandoval, and a 2019 study lawmakers approved to look into the possibility of allowing Nevadans to buy into the state’s Public Employee Benefits Program (PEBP) health plan.

The Medicaid buy-in proposal fell by the wayside during the 2019 session after its sponsor, Assemblyman Mike Sprinkle, resigned following accusations of sexual harassment. But Cannizzaro revived the public option conversation as a PEBP buy-in proposal in the final days of that session in the form of a resolution to study the concept.

“One of the top things that you will hear if you go and talk to people at the doors is the cost of health care here in the state,” Cannizzaro said. “When this idea of a public option came about, I immediately jumped on it because I think it is absolutely what folks are looking for and I think it’s a real solution to tackle this, ‘How do you make health care more accessible and more affordable?'”

Unlike the Medicaid and PEBP buy-in proposals, the public option that the new measure aims to establish would be overseen by the state but coverage would be directly provided by private health insurance companies, saving the state the overhead costs of administering a public health insurance program.

While the bill’s introduction will come a little less than five weeks before the end of the session, Cannizzaro said it took time after the release of the PEBP buy-in study in January to consult with state health officials on the legislation and work with the Legislative Counsel Bureau to draft it. The national nonprofit group United States of Care has also been involved with crafting the bill.

The legislation aims to leverage the state’s purchasing power with Medicaid managed care contracts with insurers — which were worth about $1.8 billion a year in fiscal year 2020, according to a memo from the bill’s proponents — to compel insurance companies to provide affordable public option plans as well. Under the legislation, all companies that bid to be a Medicaid managed care organization would also be required to submit a bid to be a public option plan.

Though all three of the state’s Medicaid managed care organizations offer plans on the exchange, the legislation would mandate that insurers that offer a public option plan do so in every county and both on and off the exchange — with the goal of providing additional coverage options to the state’s rural residents and preventing any future threat of bare counties, such as the one the state faced in 2017. Two of the Medicaid managed care organizations offer exchange plans in all 17 counties, while one offers plans in only three counties.

Insurers that don’t apply to be a Medicaid managed care organization would be able to bid to become a public option plan as well, and the legislation leaves to the state’s discretion how many public option plans it approves. Under the bill, development and implementation of the public option would ultimately fall to the director of the Department of Health and Human Services, in consultation with the head of the Silver State Health Insurance Exchange and the commissioner of the Division of Insurance, with the first coverage year slated for 2025.

Because the public option plans would be offered on the state’s health insurance exchange, people who are eligible for federal subsidies under the Affordable Care Act would be able to use those dollars to purchase a fully or partially subsidized public option plan. In addition to being offered both on and off exchange in the individual market, the plans would also be open to the state’s small group health insurance market.

All providers that contract with Medicaid, PEBP and workers’ compensation would be required to participate in at least one public option plan. The legislation would set the floor for contracted rates between providers and insurance companies for public option plans at Medicare rates, a move the bill’s proponents have framed as protecting providers from being negotiated down to Medicaid rates. Medicare generally pays more than Medicaid but is not as generous as private insurance.

“We want to make sure that providers can continue to negotiate,” Cannizzaro said. “We want to be able to reward providers and insurers when they can provide good value-based care that is actually improving the health care of Nevadans long term.”

It isn’t yet clear what kind of impact the legislation might have on reducing the number of uninsured people in Nevada, which, with about 350,000 uninsured residents, has one of the highest uninsured rates in the nation. A handful of states have explored establishing a public option — and only one, Washington, has been successful in implementing one — but none of them have an uninsured rate as high as Nevada’s.

An interim study into the feasibility of implementing a state-sponsored public option plan, commissioned by the Legislature and conducted by the health policy firm Manatt Health, estimated that a 10 percent reduction in premiums would translate to between zero and 1,500 uninsured individuals gaining coverage in the first year of the plan’s existence. A 20 percent reduction in premiums would reduce the state’s uninsured population between 300 and 4,800 people in the first year.

“These enrollment figures highlight that a 10 percent or 20 percent reduction in premiums may not be enough to substantially encourage the currently uninsured to enroll in coverage for the first time,” the study said.

By comparison, this bill requires at least a 5 percent reduction in premiums from a “reference premium” — defined as the second lowest cost silver plan offered on the exchange in any given ZIP code either in 2024, adjusted for inflation, or the previous year, whichever is lower — though the goal is to eventually achieve an overall 15 percent reduction in average premium costs over five years. To that end, the legislation gives the state the ability to approve premiums that exceed that 5 percent premium reduction threshold provided that the state is still on target to hit that five-year goal.

The legislation would also require the state to apply for a waiver to allow it to capture any federal dollars saved as a result of the public option program and then apply those dollars toward reducing premiums and out-of-pocket costs. Such waivers have been used under both the Obama and Trump administrations to help states implement reinsurance programs, a different kind of cost-reducing measure.

The bill also notes the state may apply for a waiver that would allow it to combine risk pools between Medicaid and the public option, if doing so would reduce the overall costs of Medicaid to the state and federal governments.

The legislation authorizes the state to contract with an actuary to assess the impact of a public option plan on the state’s health insurance markets in preparation for applying for any federal waivers. That, coupled with the long lead time until the public option goes into effect in 2025, Cannizzaro said, will give the state and lawmakers time to iron out any issues that may arise.

“We’re giving some additional time in the interim to continue with data analysis and an actuarial [study] to determine what the right points of this bill will be,” Cannizzaro said. “If this needs some tweaks along the way, we have the time and the ability to do that with giving flexibility to [the Department of Health and Human Services] and then also allowing for time, if the Legislature needs to make some adjustments before its actual implementation, we have some time to do that.”

Bill proponents hope the reductions in premiums and out-of-pocket costs will be attractive to the roughly 17 percent of uninsured Nevadans for whom insurance through the exchange is unaffordable and, potentially, some of the 27 percent of uninsured Nevadans who are undocumented and therefore aren’t eligible for exchange subsidies or Medicaid.

“If there are affordable health care plans, people are going to be incentivized and want to try to get health care coverage. So much of what plays into your decision to pay for health care coverage or not comes down to cost,” Cannizzaro said. “We have such a high and persistently high uninsured population that, again, doing nothing is not solving that problem.”

Cost, however, is only part of the battle in reducing Nevada’s uninsured rate. More than half of uninsured individuals in the state are already eligible for Medicaid or subsidized coverage through the exchange — programs that make health care affordable or even free to families — but still aren’t insured.

While affordability already shouldn’t be an issue for those uninsured individuals, the bill’s proponents hope that public awareness about a state public option plan might encourage Nevadans to seek out coverage, where they will find that low or no cost plans are already available to them.

The bill also proposes making changes to the state’s Medicaid program by increasing eligibility for coverage for pregnant women in Nevada up to 200 percent of the federal poverty level, expanding the definition of providers who can determine presumptive eligibility for pregnant women, covering lawfully present immigrants who are pregnant, adding coverage for doulas and community health workers and requiring payment parity between advanced nurse practitioners and physicians. 

“I bring a new perspective to this and realize how important it is to have access to this kind of care, especially for moms who can’t otherwise afford it,” said Cannizzaro, who is expecting her first child this summer. “If there’s a way that we can start to increase that here in the state, that is going to have long-term benefits for the health of Nevada families overall.”

Cannizzaro acknowledged there will be a cost to those Medicaid enhancements and said she is curious to see what fiscal notes state health officials put on the bill so lawmakers can start to figure out how to pay for them or whether they need to build more flexibility into the bill. There may be a cost, too, on the public option side of the bill, though it is not yet clear what that might be.

While health industry lobbyists have been receiving presentations on the bill over the last few days, Cannizzaro acknowledged there will likely be concerns with the legislation that will need to be discussed in the coming days and weeks.

“I’m hopeful that we’re going to come up with something that makes sense and that folks can get on board and in support of,” Cannizzaro said. “Do I think everyone is going to love this proposal from the get-go? No, but our job, and the reason why we’ve been having stakeholder meetings, is to talk to everyone who is at the table in this state so that we can hear their questions and concerns.”

Cannizzaro said that bill proponents have also been talking with the governor’s office about the bill.

“Obviously there is still work that needs to be done on this bill, but I know that the governor supports making sure that health care is accessible and affordable for Nevadans, and so we’re working with his office to make sure that we are getting this right as well,” Cannizzaro said. “He knows just as much as the rest of us that this pandemic has truly, I think, reiterated the need for something like this in Nevada.”

 
 

Clipped from: https://thenevadaindependent.com/article/four-years-after-passing-medicaid-buy-in-lawmakers-to-consider-public-option-proposal