Showing posts with label Medicare/Medicaid. Show all posts
Showing posts with label Medicare/Medicaid. Show all posts

August 2, 2018

Puerto Rico's Bleeding Out Medicaid Program Faces New Cuts from Trump

Blue tarps still dot rooftops, homes lack electricity needed to refrigerate medicines, and clinics chip away at debts incurred from running generators. Yet despite these residual effects from last year's devastating hurricanes, Puerto Rico is moving ahead with major cuts to its health care safety net that will affect more than a million of its poorest residents.
The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory's agreement with the federal government, as the island claws its way back from fiscal oblivion.
Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory's large Medicaid expenses. That's on an island where the average household earns $20,000 annually and diabetes and hypertension are widespread.
But physicians, health insurers and former government officials say the drastic cuts demanded provide far too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks do nothing to address the underlying fiscal imbalance at the root of Puerto Rico's health care woes, which stem from the fact that the federal government already contributes a much smaller fraction of the U.S. territory's Medicaid budget, compared to what it contributes to the 50 U.S. states.
"We are rearranging the chairs on the Titanic," says Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.
Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.
"These people who have been under our service for the last four or five years — all of a sudden I have to abandon them," says Dr. José Joaquín Vargaspresident and chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.
Health care crippled by debt
If Puerto Rico were a state, the federal government would pay 83 percent of its Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according to a formula that takes a state's economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent of Puerto Rico's Medicaid costs, and as a fixed annual payment, or block grant.
In February, Congress approved $4.8 billion in additional funds to help pay the island's Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory's fiscal oversight board. That's a federal control board established by Congress in 2016 to oversee Puerto Rico's budget, negotiate with its creditors and help restructure at least some of the island's debt.
Gov. Ricardo Rosselló's administration aims to reduce Puerto Rico's Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló's plan, the companies will be forced to offer island-wide insurance plans and compete for customers.
"We do not have the luxury" of continuing to spend inefficiently, says Ángela Ávila Marrero, executive director of Puerto Rico's Health Insurance Administration.
If Rosselló's overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Among those cuts: Some 1.1 million of the 1.6 million Puerto Rico residents on Medicaid are at risk of losing coverage next fall, their health held hostage to the island's need to pay back its crippling debt.
Puerto Rico's government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession, a corporate tax break that ended in 2006,and reckless spending by a bloated government.
But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico's staggering Medicaid burden.
Poverty is so pervasive here that nearly 50 percent of residents qualify for public health insurance; Medicaid expenses in 2016 totaled $2.4 billion.
Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.
Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island's fiscal health, health economists say.
Researchers of health care say that, putting aside interest on Puerto Rico's debt, the territory's primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.
"The main issue is that we are not yet a state," says Rep. Jenniffer González-Colón, the territory's nonvoting member of Congress. The island must pay for Medicaid, she adds, "with local funds that we don't have."
Battered even before the storm
Puerto Rico's health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act, and that 900,000 Puerto Rican residents would lose coverage.
Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology, and fueled the exodus of thousands of physiciansto the mainland in search of better incomes.
Today, Medicaid patients face long waits to see doctors on the island.
"If your kid needs a neurologist, for example, the waiting period is around six to 12 months," says Dr. Jorge Rosado, a pediatrician in San Juan. "For a genetics specialty, it's two to three years."
The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.
There is little time to waste
Barring the unlikely passage of bills that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out in the fall. González-Colón also has authored a bill calling for statehood, which would eliminate the federal government's unequal treatment toward the island's Medicaid program.
The fiscal control board established by Congress openly acknowledges the impending disaster. In an April 19 report (p. 97 of "New Fiscal Plan For Puerto Rico: Restoring Growth and Prosperity") the board projects monthly costs per Medicaid patient will rise nearly 40 percent over the next six years, barring any changes, and that Puerto Rico "will hit a 'Medicaid cliff.' "
Beginning this fall, Medicaid patients in Puerto Rico will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.
Puerto Rico has long capped the monthly payments insurers receive for Medicaid patients regardless of how many medical services they use — a form of managed care. But the government in San Juan believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.
The island's government has vowed to pay private insurers extra money to care for those patients that have expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.
"I support the government on what they're trying to do, but they didn't price it properly," says Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.
"The oversight board is fixated on cuts," he says, "but we're never going to improve health care unless more money is put into the system."
Government health officials argue that their changes mean Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But staff at the island's clinics and hospitals fear they will be squeezed by insurers seeking to reduce costs, even as the clinics are still reeling from hurricane-related expenses.
For example, Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.  
Many experts are skeptical that managed-care companies will hire the army of social workers and nurses needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty.Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.
Many people displaced by the storm haven't yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.
"The managed-care companies need to produce revenue," says Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. "That's a setup for concern."
Bottom line? The economic overhaul doesn't rectify Puerto Rico's fundamental problem — it can't sustain its Medicaid program so long as Congress treats the territory differently than it treats states.
"Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens," says Torres. But, he adds, "it's time the local government started thinking about a Plan B."
Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation, and not affiliated with Kaiser Permanente.

March 27, 2018

Medicaid Could Be Another Promise Like The LGBT-Q Promise Trump Ripped To Pieces But Backfires

Since the day Donald Trump took office, he and Republicans in Congress have had government health care programs like Medicaid in their sights. And reactions across the country, highlighted by recent special elections in Pennsylvania and Alabama, suggest this is backfiring in a spectacular way. Their policies are so out of line with public thinking that the more they push them, the higher the likelihood that they put the country on an inevitable path to Medicaid, Medicare or some other health care plan that is ubiquitous and available to all.
Take Medicaid. Since Trump’s election, Congress has relentlessly attempted to slash the program, which covers one in five Americans. After failing to cap it and cut its funding by one-fifth over the next decade, Trump again called for cuts in his State of the Union address. The Trump administration has also given states the green light to impose work requirements on Medicaid recipients, which the Center on Budget and Policy Priorities says will result in “less access to care, worse health outcomes, and less financial security.” 
So far, three states — Kentucky, Indiana and Arkansas — have won approval for their work requirements and seven more have pending requests with the Trump administration. Nearly 640,000 people would be vulnerable to losing their health coverage if all 10 states go ahead with work requirements. 
While these efforts will hurt many families, the real story of the impact of this continued assault has been to significantly increase Medicaid’s popularity and cause Americans in large numbers to press for expanding its availability. According to the latest Kaiser Health Tracking Poll, 84% of Americans now want to continue the Affordable Care Act's Medicaid expansion to people slightly above the poverty line. 
For good reason. States that expanded Medicaid have seen their citizens’ health and financial outcomes improve and have helped rural hospitals and the economy, while providing a lifeline for single mothers and helping states combat the opioid epidemic.
Perhaps the most significant response is that in many parts of the country, citizens are turning to local ballot initiatives to deliver the changes they want but aren’t getting from political leaders. In the reliably red states of Utah and Idaho, for example, initiatives to expand Medicaid coverage are making their way to the November ballot. Polling shows the efforts to be highly popular, with support across the political spectrum.
The Utah Decides Health Care Act would expand Medicaid and maintain Children’s Health Insurance Program funding for tens of thousands of vulnerable Utahns. A December poll of registered voters found 59% backed the initiative.
Reclaim Idaho has filed a similar proposal, aiming to close the “Medicaid gap” for 78,000 Idahoans who lack access to affordable health care because they are too poor to qualify for Obamacare subsidies but not poor enough to qualify for Medicaid (which in Idaho means earning just $24,000). While elected officials in Idaho have failed to address the issue, a poll late last year showed 76% of Idahoans favor expanding Medicaid.
And last month, in Nebraska, a coalition of local organizations and political leaders announced that they too are filing an initiative for the November ballot to expand Medicaid in the state and bring health care to some 90,000 people
Momentum is growing elsewhere. Groups in Montana are taking steps to add a Medicaid expansion initiative to the state ballot this November, with the aim of making the expansion permanent instead of allowing it to sunset as scheduled next year. And the Fairness Project is in early talks with several states about ballot initiatives in 2020.
If there is any doubt that ballot initiatives can bring major change where elected officials fail, look back just a few months to November when Maine voters, by nearly 18 percentage points, used a ballot measure to bring Medicaid coverage to 70,000. Prior to the vote, Maine Gov. Paul LePage had vetoed expansion five times.
All this momentum shows that when under threat, Americans act not just to protect their rights, but go further.
This Pac-man politics, where the chased become the chasers, was on vivid display six years ago when states like Washington, Maryland and Maine, after being besieged by efforts to outlaw marriage between same sex couples, used the ballot to ensure its legality. Along with a number of other efforts, this ultimately led to the Supreme Court decision to make same-sex marriage legal across the country.
We may be at the beginning of a similar cycle now in health care. Trump and Congress have Americans concerned that their access to care is at risk to the point where many are taking action. The response isn’t ending with the defeat of repeal, and may not stop until health care is expanded to all Americans. 

By Andy Slavitt and Jonathan Schleifer
Andy Slavitt, board chairman of United States of Care, ran Medicare, Medicaid and the Affordable Care Act during the Obama administration. Jonathan Schleifer is executive director of The Fairness Project. Follow them on Twitter: @aslavitt and @Jonathanchad
You can read diverse opinions from our Board of Contributors and other writers on the Opinion front page, on Twitter @usatodayopinion and in our daily Opinion newsletter. To respond to a column, submit a comment to

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April 24, 2015

The Plan in NY to END AIDS will Save $4.5B by 2020 in Medicaid Alone

$4.5 Billions  $4.5 Billions

NY Plan to End AIDS Will Save $4.5B in Medicaid by 2020, Says Report

If New York State implements all the recommendations of a blueprint created to end the AIDS epidemic, it will save a net $4.5 billion in Medicaid costs by 2020 and an additional $120 million through improving the lives of HIV-positive New Yorkers who are homeless or in unstable housing, according to a press release and report by the Treatment Action Group (TAG) and Housing Works.

Last year, Governor Andrew Cuomo formed the Ending the Epidemic (ETE) Task Force, which was made of HIV/AIDS experts, including members of TAG and Housing Works. The group’s goal was to create a blueprint to end the epidemic in the Empire State by 2020. Specifically, this meant reducing new infections from the 3,200 cases in 2013 to fewer than 750 a year by 2020. It included the goals of identifying undiagnosed people and linking more HIV-positive New Yorkers to care and helping them remain undetectable, as well as providing more access to pre-exposure prophylaxis (PrEP) to HIV-negative people.

This January, the task force completed its blueprint to attain these goals. According to the press release, the plan requires the state to invest an additional $2.5 billion in Medicaid spending between now and 2020—but that investment will result in a net savings of $4.5 billion for that program alone.

The fiscal report released this week from Housing Works and TAG focuses on the costs and savings of the plan, specifically in terms of the New York State Medicaid program, because it covers half of people with HIV in the Empire State.

“[The blueprint] will pay for itself because the number of averted infections will be so great it will save billions of dollars,” Mark Harrington, TAG’s executive director, told The Associated Press. “Which then can be spent on treatment, and on housing, and on many other services we need for people living with HIV.”

January 4, 2013

Over Cliff Cut Delays Saved Medicare a 26.5 % Cut and Medicaid Raise

    The fiscal cliff deal that a contentious Congress passed yesterday postpones a 26.5% Medicare pay cut for physicians for 1 year and preserves a hefty Medicaid raise for those in primary care. 

 The massive Medicare cut, triggered by the program's sustainable growth rate formula and set for January 1, was a minor component of the fiscal cliff. What made the precipice so dangerous was the combination of Bush-era tax cuts set to expire this month and $109 billion worth of automatic, across-the-board cuts — called sequestration — in domestic and military spending that also were to take effect this year. Some economists said this one-two punch could have knocked the nation into another recession.
The fiscal cliff bill, called the American Taxpayer Relief Act (ATRA) of 2012, preserves the tax cuts for individuals earning no more than $400,000 and couples earning no more than $450,000. Americans earning above these thresholds will see their tax rate rise from the current top rate of 35% to 39.6%. ATRA delays sequestration until March 1, giving lawmakers 2 months to replace it with a more discriminating deficit reduction plan. The measure also extends unemployment insurance benefits and numerous tax credits and reduces tax breaks for high-income households.
When President Barack Obama signs the bill, which has his support, it will be an anticlimax to a torturous, sleep-deprived episode of New Year's Day legislating. The Democrat-controlled Senate approved ATRA at roughly 2 am January 1, with the House following suit late last night. Many Congressional Republicans fumed that the deal lacked major spending cuts, but in the end, bipartisanship prevailed. The measure easily passed 89-8 in the Senate and 257-167 in the House, where 85 Republicans, including House Speaker John Boehner (R-OH), said aye.
However, Congressional head-butting is sure to quickly resume as lawmakers grapple with how to reduce the federal deficit to defuse sequestration, which was triggered by Congress' failure to reach a deficit reduction deal in 2011. Republicans seek deep budget cuts, but Democrats want them balanced with revenue hikes.
At stake for physicians in this debate is a 2% cut in Medicare reimbursement written into sequestration. ATRA puts this off until March 1.
The New Year's Day bill freezes Medicare rates for 1 year, which is not exactly good news for physicians whose practice expenses continue to climb. On a more positive note, ATRA does not offset the $25 billion cost of this "doc fix" by cancelling a Medicaid pay hike for primary care physicians authorized by the Affordable Care Act. The act raises Medicaid rates to Medicare levels for evaluation and management services and vaccine administration. Family physicians, general internists, pediatricians, and subspecialists related to these fields (eg, pediatric cardiologists) are eligible for the increase. At one time, some House Republicans favored eliminating the Medicaid raise to fund a 1-year doc fix, an idea that provoked strong opposition from organized medicine.
Instead, ATRA pays for the doc fix largely by reducing Medicare outlays to hospitals. The American Hospital Association and other hospital umbrella groups denounce this approach as harmful to their institutions and the patients they serve.If it was up to the present GOP you will never get that card at any age.

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