Welcome back! We’ve gotten through the general reforms and are ready to tackle the exchange. As always, you can follow along at congress.gov, which offers a (very dry) summary and a (even drier) full text version.
We’re on Title II finally: “Title II: Role of Public Programs“. This is talking about things like medicare and how it’s impacted (or not) by the new act.
Medicaid and CHIP expansion
We start off with “Subtitle A: Improved Access to Medicaid“. The first thing this does is expand who has access to Medicaid. If you’re like me and always get confused, here’s the quick lowdown: Medicare is a program designed to help senior citizens who are retired still get the health care they need, while Medicaid is more like welfare in that it’s meant as a stopgap to help poor people. Under the ACA, anyone who is under 65 (because people over 65 get medicare instead), not pregnant (I think because CHIP helps pregnant women), and have incomes below 133% of the federal poverty line can sign up for Medicaid. In the ACA, this is clearly intended to be national, and in fact, is paid for by the federal government until 2016 to help bolster the costs. However, a Supreme Court ruling gave states the chance to opt-out, and many did.
The next provision expands the Federal Medical Assistance Program starting this year. I believe the result of this is that more money goes to the states, depending on whether they provide insurance to people at 100% of the FPL or not. Again, remember that under the ACA, having coverage means free basic health care: preventative visits of all kinds are covered 100% by the insurer.
This section also requires states to use the gross income to determine eligibility, as opposed to evaluating assets (like owning your own home) or anything like that. It requires medicaid to cover prescriptions and mental health coverage; I don’t know much about prescription coverage on medicaid, but mental health coverage has historically been very spotty and expensive. A lot of people can’t work because of mental health issues, and getting them help goes a long way toward reducing unemployment.
It also extends medicaid to cover foster care graduates until they are 26, the same as how a parent’s insurance can cover a child until 26. Foster care ends at 18; often, after “aging out”, the teens end up homeless,and only 6% attend college. Colleges are building programs to help improve that, but asking them to pay for health insurance on top of everything else would limit their usefulness. So medicaid steps in to cover at least that much.
(An aside: many people believe the church should be in charge of supporting the poor and needy. If you’re one of those people, I have to ask: what is your church doing to support the mentally ill, foster children, and others who traditionally fall through the cracks? The ACA doesn’t stop you from helping out. If it wasn’t necessary, I wouldn’t be as much in favor of it as I am.)
The rest of this covers more about how the federal government will reimburse the states: a credit for states going through a disaster, revisions on limits of the federal payout, and so on.
Having covered Medicaid, we move on to CHIP: “Subtitle B: Enhanced Support for the Children’s Health Insurance Program“. If you haven’t heard of it, CHIP is a program by which the states can cover children’s health insurance and the federal government reimburses them. The ACA isn’t the first time a democratic president has tried to tackle the health care crisis; in 1993, President Clinton and the First Lady made it a priority, but they were never able to get their reforms passed. The major thing that did get passed is this CHIP program, intended to cover children of parents who are working (and thus, under the old rules, ineligible for medicaid) but not making enough to buy health insurance. In 2007, it was discovered that many children were being dropped from their parents insurance because the employers stopped covering dependents, and the parents made too much to qualify for CHIP.
The ACA prohibits states from enacting more restrictive eligibility requirements than the ACA outlines. It offers money to states who enroll more children in CHIP, and it seems to be moving more children from CHIP to Medicaid. This is another section that’s difficult for me to parse, mostly because a lot of it’s corrections to other acts rather than explaining what it’s doing. You can read more about CHIP and Medicaid and the ACA in the Kaiser Family Foundation’s excellent summary.
Finally, in “Subtitle C: Medicaid and CHIP Enrollment Simplification“, we see reforms meant to make applying to these programs easier. It requires the states to maintain a website where you can apply for both medicaid and CHIP, and requires states to check if you qualify for any other assistance if they deny you the assistance you applied for, just in case you filled out the wrong form.The states are also mandated to do outreach to homeless youth, children with special needs, pregnant women, racial minorities, folks in rural areas, and people with HIV to inform them about the programs and help them get signed up. These are all groups with either a dire need for health care or who have been historically disadvantaged in purchasing it, so this is again meant to move toward a goal of 100% coverage.
Furthermore, if a hospital has a patient who cannot pay but who is probably eligible for one of these programs, they can treat them now and talk to Medicaid about paying for it after. That way if someone shows up at a hospital, they can walk away with a shiny new Medicaid card when they’re better.
Now that more people are on Medicaid (and CHIP, and other programs like it), what can we do for them as far as covering more services? Turns out, a lot. “Subtitle D: Improvements to Medicaid Services” focuses on just that: offering more services under Medicaid.
The first thing that it covers is “freestanding birth centers” (and the ambulance ride to get to one if needed). This is defined as a non-hospital facility where someone has planned to give birth, so long as it’s licensed by the state and meets whatever requirements the state has for this sort of thing. This basically gives women on Medicaid the freedom to choose a midwife over a hospital birth and still have everything covered. It’s all about choices here.
The next thing covers children in hospice care. It requires that, if the parents choose to continue treating the illness while the child is in hospice, that Medicaid cover both. Typically hospice care is reserved for those for whom no treatment is possible; however, under a new model called “concurrent care“, hospice-like services are provided to help ease the burden of care during treatment and improve treatment outcomes. This isn’t an area I have much experience or expertise with, but it seems like it’s a valid model of care here, so it’s nice to see more coverage options.
Finally, the controversial part: family planning services. This isn’t a mandate, but an option: states may choose to allow medicaid to cover family planning services. It’s pretty vague as to what that entails, punting the definition to the Social Security Act which just reads “family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who are eligible under the State plan and who desire such services and supplies”. I suppose therefore it’s up to the states to determine what to cover. If you’re curious, here’s a report on which states have chosen to enact this. I feel like we really ought to be holding states more responsible for their choices, rather than letting them point the finger at the feds, ya know?
The next section is “Subtitle E: New Options for States to Provide Long-Term Services and Supports“. These are all optional reforms, so it’s up to the states to decide if they want them or not.
The first expansion is home-based (or community-based) care for those who need assistance with their daily life. Previously, to get medicaid to pay for it, you’d have to move the individual to a nursing home; now, if expanded, it could cover someone to stop by every day (or week or whatever) and help out in the person’s own home. This also covers training on how to pick a good attendant, things like beepers so you can summon them when they’re not around and you need help, and transition assistance for moving out of a nursing home (first month’s rent, transportation, et cetera). It does not cover the attendant’s room and board, or any special education services. All 50 states offer some sort of home-based care assistance, but not all offer it through medicaid.
The act also expands and extends an existing program that was about to expire: the Money Follows The Person plan. This is a plan intended to help move people out of full-time care and integrate them back into the community, because full-time homes for the mentally ill and disabled are expensive, and much of the time the person would rather be integrated anyway. Why force people into care facilities to get treatment? For those who are staying in facilities, however, the act provides for the Secretary to come up with a plan to expand these centers.
Finally, we have another of those opinion bits where the Senate lectures about its findings to help express their intent. They point out that it’s been almost 2 decades since Congress looked into nursing homes, and that Congress never did act on the Pepper Comission’s report. They point out a Supreme Court decision that people with disabilities have a right to seek treatment in the community rather than going to separate facilities, and that since 1990 our nursing homes for elderly and disabled people have only gotten worse. 69% of Medicare funding for elderly and disabled people goes to these nursing homes, with half of states spending less than 25% of the funds for those groups on home care. They feel that Congress should address long-term support services for disabled and elderly people, and that services should be made available in the community as well.
Next we cover prescription drugs, in “Subtitle F: Medicaid Prescription Drug Coverage“. First, this makes certain drugs cheaper: drugs that induce clotting, and drugs formulated especially for children. It then amends previous acts to increase the rebate on…. something that I don’t know what it is, because this is another part that just amends a previous act without explaining what it’s doing. More importantly, it requires Medicaid programs to cover prescription drugs, and provide data about how they’re being used for future study.
It also appears to expand coverage to new formulations of existing drugs, such as an extended-release formula, and something called an “innovator multiple source drug”. I don’t know what multiple-source means, but an innovator drug is the opposite of a generic drug; usually, pharmacies call them “brand name” drugs. So this covers more of them.
Some drugs that were previously excluded from Medicaid are now covered: drugs to allow you to stop smoking, like the nicotine patch or the gum; Barbiturates, which are important for epileptics but are also addictive; and Benzodiazepines, which basically means Valium and Xanax and stuff like that. The reforms also allow the programs to pay out more for pharmacies that charge more than average, up to 175% of the average price of the drug.
The next subtitle helps pay for all this; “Subtitle G: Medicaid Disproportionate Share Hospital (DSH) Payments” reduces the amount available to DSH programs. Basically, when someone without insurance goes to the hospital on an emergency, can’t pay for their treatment, and gets to walk away without paying, this is the program that reimburses the hospital. With more people insured, the plan was to cut this spending in half, but it’s graduated based on how much coverage a state has achieved so that nobody gets left high and dry.
The next subtitle, “Subtitle H: Improved Coordination for Dual Eligible Beneficiaries“, creates a new government office: the Federal Coordinated Health Care Office. This office is meant to oversee the weird edge cases where someone is eligible for both Medicare and Medicaid, to make sure that people are still getting the care they need and not ending up in limbo.
Next up is the quality of Medicaid in general: “Subtitle I: Improving the Quality of Medicaid for Patients and Providers“. Previously, the Secretary was commanded to produce a report on recommendations to improve the health care of children; under this act, a new report is commissioned along the same lines but focusing on adults. $60 million is set aside to pay for this report.
The Secretary is also asked to review practices the states have enacted that prevent Medicaid from paying for conditions that someone picked up while in the hospital, such as a UTI that was transmitted via catheter. They are asked to turn the best practices into regulation for all the other states to use. More about this later, because this is the stick to a carrot established later in the act.
States are given the option of working with providers to establish health homes for individuals with chronic conditions, which Medicaid would then cover. This is for people with two chronic conditions, or one and the high risk of developing another, or serious mental illness requiring constant care. Asthma, substance abuse, diabetes, heart disease, and being fat are specifically called out as chronic conditions. 20 states have enacted this policy.
The Secretary is asked to put together a “demonstration program” in not more than 8 states to show how states can bundle payments for people who are in the hospital and also receiving care from another provider. The goal is to reduce cost while improving the care for the patient. A second demo was requested to show how moving to a system where the payments for multiple patients are bundled together is more cost-effective than issuing single payments for each service. These reforms are just about reducing the overhead costs of Medicaid to be more efficient.
Another demo is aimed at giving some existing incentives to certain pediatric providers who were not previously eligible. Another is aimed at providing coverage for psychiatric emergencies handled at private institutions (rather than hospitals). We have a long way to go as far as effective psychiatric care, so this bit is more of an experiment to see if private treatment centers are effective in handling psychiatric episodes.
Another subsection we’re mostly going to gloss through: “Subtitle J: Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC)“. This commission, as well as MEDPAC for Medicare, is intended to study the ongoing programs and suggest improvements. This section of the ACA gives them some specific topics to study, such as enrollment and retention, quality of care, and regulations. They’re instructed to work with the states and MEDPAC, and to recruit people with experience as enrollees, caregivers, parents, and providers, as well as people recognised as experts in health finance, actuarial science, technology, and so on. The goal is to get a diverse team representing everyone from pregnant women to caregivers for disabled people, across all geographies, to generate recommendations.
“Subtitle K: Protections for American Indians and Alaska Natives” is pretty much what it says on the tin.
Medicaid is usually the “Payer of last resort“, meaning that any other insurance an individual has pays out before Medicaid does; in this act, an exception is made for tribal insurance, making that the payer of last resort after government programs.
The “Express Lane” program allows Medicaid to let another organization such as SNAP, WIC, or Head Start to determine if you’re eligible for Medicaid; basically, if you qualify for food stamps, you qualify for Medicaid, in some states. The ACA allows Tribal Organizations and the Indian Health Service to count as Express Lane providers and tell Medicaid when someone in their tribe qualifies.
There was a previous requirement that the Secretary reimburse certain Indian hospitals for Medicare services; the ACA removes the expiration date on that requirement to make it permanent.
The last Subtitle in this section is “Subtitle L: Maternal and Child Health Services“. The first thing this subtitle does is concerned with early childhood visitation programs. It directs the states to assess the risks they face and identify what types of people are at risk for premature birth, low birth weight, infant mortality, and poor infant health. They are also asked to find communities that are impoverished, with high crime, high domestic violence, high rates of school dropouts, high substance abuse rates, and high risk of child maltreatment. They are then required to assess existing programs for early childhood visitation to determine who is getting visited, what gaps exist, and how well they provide for substance abuse treatment. They then have to turn in a report identifying the risks as well as a plan to fix them. I feel like this is a giant finger-waggle to the states, like the teacher’s upset nobody did the reading so they’re all expected to do a book report now. The upside is that there’s then grants made available to help pay for carrying out these plans.The rate of visiting drastically improved under this plan, so assuming that’s an effective way to prevent infant mortality, we should see good results.
The next topic covered is postpartum depression. The Secretary’s job is expanded to support basic research into the topic, as well as clinical trials for drugs treating postpartum depression and education campaigns to help people recognize it. This is a topic you don’t necessarily hear a lot about compared to all the joys of motherhood being discussed by new parents, but it affects up to 1 in 5 women, and only 15% of those women get treatment for it. Congress commissioned a specific report on the ways in which a pregnancy’s end (birth, birth plus adoption, abortion, miscarriage, stillbirth) affects postpartum depression; currently, the statistics gathered only count women who are depressed after a live birth. Grants are also made available for the states to enact programs to combat postpartum depression, but no specific programs are enacted in the ACA. A 2015 act follows up on this to provide more specific funding.
Next, grants are made available for personal responsibility education. This covers sex ed programs; it specifically calls out programs that teach both abstinence and basic contraceptive use, and programs must use evidence-based medicine, be medically accurate and complete, and emphasize both abstinence and contraception. In addition, to receive a grant, a program must also cover three of the following:
- healthy relationships, such as positive self esteem, friendships, dating, marriage, and family interactions,
- healthy attitudes toward body development, diversity, body image, and so on,
- financial literacy,
- parent-child communication,
- educational and career success, such as how to job interview, live alone, and be productive in the workplace,
- life skills such as negotiating, making decisions, setting goals, and managing stress
A separate, existing grant covering abstinence education is also extended, to pay for those programs.
Finally, for people aging out of foster care programs, the states are now required to educate them about the importance of having someone with health care power of attorney to make decisions if they were in a catastrophic health situation. Typically this would be your parents, but for people aging out of foster care, they might not have anyone legally capable of making those kinds of decisions.
And that’s it! That’s public programs. We still have quite a ways to go, however; next up is Title III, improving quality and efficiency of health care.