Data Note: Medicaid’s Role in Providing Access to Preventive Care for Adults
Medicaid has played a large role in the life of many Americans. By using federal money low-income Americans are able to receive healthcare. Take a look at this article by Kaiser Family Foundation and see how Medicaid's dollars are spent to help provide low-income Americans with healthcare.
Medicaid, the nation’s public health insurance program for people with low income, covers 74 million Americans today, including millions of low-income adults. The Affordable Care Act (ACA) expanded Medicaid to nonelderly adults with income up to 138% of the federal poverty level (FPL), and, in the 32 states (including DC) that implemented the expansion, more than 11 million adults have gained Medicaid as a result. Chronic illness is prevalent in the adult Medicaid population. Preventive care, including immunizations and regular screenings that permit early detection and treatment of chronic conditions, improves the prospects for better health outcomes. This Data Note focuses on Medicaid’s role in providing access to preventive care for low-income adults.
WHY IS PREVENTIVE CARE FOR ADULT MEDICAID ENROLLEES IMPORTANT?
Adults in Medicaid have high rates of preventable and controllable conditions. Nearly one-third (30%) of non-elderly adult Medicaid beneficiaries report that they are in only fair or poor health – roughly double the percentage of low-income privately insured and uninsured adults who report fair or poor health (Figure 1). Medicaid adults also have significantly higher rates of chronic conditions and risky health behaviors that may be amenable to preventive care. One in 10 adult enrollees has a diagnosed mental illness; 7 in 10 are overweight or obese, and almost 1 in 3 smoke tobacco.
Preventive care can reduce disease and avoidable use of high-cost services. Increased access to screening for diabetes, cancer, depression, and o ther chronic conditions, and counseling to address behavioral risk factors, have the potential to reduce disease and prevent exacerbations of conditions that can be medically managed. Improved health may reduce the use of avoidable hospital and other high-cost care, and reduce Medicaid spending. For example, smoking can cause heart disease and other chronic illnesses that one study estimated may be responsible for more than $75 billion in Medicaid costs. Medicaid coverage of smoking cessation services, including quit lines and medications, has the potential to mitigate both the health and cost impacts of smoking. Obesity, a major driver of preventable chronic illness and health care costs, affects about two-thirds of low-income adults. Findings from one study indicate that severe obesity in adults cost state Medicaid programs almost $8 billion in 2013, suggesting that “effective treatment for severe obesity should be part of each state’s strategy to mitigate rising obesity-related costs.”
WHAT PREVENTIVE SERVICES DOES MEDICAID COVER FOR ADULTS?
Coverage of most adult preventive services has historically been optional for states. Medicaid coverage of preventive services for children has long been strong, as states must cover comprehensive preventive services at no cost for children in Medicaid under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. In contrast, historically, coverage of adult preventive care has been largely optional for states, with some exceptions – states must cover pregnancy-related care and family planning services without cost-sharing. In addition, within federal guidelines, states can charge adults cost-sharing for preventive services.
The ACA expanded coverage of adult preventive care. An important thrust of the ACA was an emphasis on preventive care. In particular, the ACA included recommended preventive services without patient cost-sharing as one of the 10 “essential health benefits” (EHBs) that most health plans are now required to cover. The required preventive services are based on the recommendations of independent, expert clinical panels and include, for adults: 1) screening and counseling services (e.g., cancer screening, diet counseling); 2) routine immunizations; and 3) preventive services for women. The EHB requirement applies to Medicaid benefits for adults who are newly eligible due to the ACA expansion, but not “traditional” Medicaid adults, for whom most preventive services are optional for states and can require cost-sharing within federal guidelines. To incentivize states to cover the EHB preventive services for all Medicaid adults, the ACA provided for a one percentage point increase in the federal Medicaid match rate for these services in states that opt to cover all of them without cost-sharing.
Selected EHB-required preventive services for adults:
All adults
- Immunizations
- Cancer screening
- Diabetes screening
- Depression screening
- Obesity screening and counseling
- Tobacco screening and smoking cessation services
Women
- Well-woman visits to get recommended services for women
- Breast and cervical cancer screening
- Domestic and interpersonal violence screening and counseling
- Osteoporosis screening
- Breastfeeding support, counseling, and supplies for pregnant and nursing women
- Expanded tobacco intervention for pregnant women
Most state Medicaid programs covered many adult preventive services before the ACA took effect. A 2014 study found that most state Medicaid programs covered all EHB-required adult preventive services in 2013, although some had cost-sharing charges. At the same time, another study found that documented state coverage policies in effect prior to the ACA did not always correspond precisely with the EHB requirements for preventive care, indicating there was room for improvement. Eight states – California, Minnesota, Nevada, New Hampshire, New Jersey, New York, Oklahoma, and West Virginia – have opted to cover the recommended adult preventive services without cost-sharing for all Medicaid adults. Seven of these states implemented the Medicaid expansion to low-income adults.
HOW DO ADULTS WITH MEDICAID FARE IN ACCESSING PREVENTIVE CARE?
Nearly all adults with Medicaid have a usual place where they get routine or preventive care. One measure of Medicaid’s effectiveness is the extent to which beneficiaries have a usual source of care, which opens the door to the health care system, including preventive care. Over 90% of adults with Medicaid report having a usual place of care – the same as the percentage of low-income privately insured adults with a usual place, and significantly exceeding the share of low-income uninsured adults who do (Figure 2). Adults with Medicaid are also significantly more likely than adults in the other two groups to have had a primary care visit and a mental health visit in the past year. Research shows that people with a usual source of care have better outcomes and that having a primary care physician as the usual source of care increases the likelihood of receiving appropriate care.
Medicaid is as effective as private insurance at connecting low-income adults with recommended clinical preventive services. The percentage of Medicaid adults who report receiving recommended clinical preventive services is at least as high as the percentage of low-income privately insured adults receiving these services (Figure 3). In fact, Medicaid adults are significantly more likely than the privately insured to report a blood pressure check (84% versus 79%) and a cholesterol check (60% versus 56%). Medicaid adults do significantly better than the uninsured on every measure of preventive care. Notably, the share of low-income adults who report receiving recommended cancer screenings is no more than about half, pointing to a need for increased investment and effort to improve access to these services as well as public education about their importance.
The major health risks and costs posed by overweight/obesity and smoking point to a need for more focus on patient counseling, including in Medicaid. As mentioned earlier, 70% of Medicaid adults are overweight or obese and nearly one-third smoke, somewhat higher rates than those for low-income privately insured adults (65% and 18% respectively). Both obesity and smoking are risk factors for preventable chronic diseases, including cancer, that increase morbidity and mortality as well as health care costs. The share of overweight/obese adults and adult smokers in Medicaid who report being counseled by their provider on diet (38%) or smoking (63%), while similar to the share for privately insured adults, highlights an important gap in preventive care and a need for more investment and effort (Figure 4).
WHAT IMPACT HAS THE MEDICAID EXPANSION HAD ON ACCESS TO PREVENTIVE CARE FOR LOW-INCOME ADULTS?
A large and growing body of studies demonstrate that Medicaid eligibility expansions can improve access to primary and preventive care. Research shows that Medicaid expansion is associated with increased visits to primary care providers and increased diagnosis of diabetes and high cholesterol, as well as increased screening for diabetes, and reduced rates of skipped medication due to cost. The Oregon Health Insurance Experiment provides strong evidence of increases in screening and medication use for depression and declines in self-reported and clinically observed depression among previously uninsured adults who randomly won a limited number of Medicaid “slots” through a state lottery. The expansion also led to increases in diabetes screening and medication use among the adults who gained Medicaid compared to those who remained uninsured. A focused study of health center patients in Oregon found increases in screening for obesity, blood pressure, smoking, and chlamydia, as well as increased rates of mammograms, Pap tests, and lipid testing for adults in the Medicaid group. The pre-ACA expansion of Medicaid in Massachusetts was associated with an increase in hospital utilization, as would be expected, but hospitalizations for preventable conditions fell.
LOOKING AHEAD
Because Medicaid plays a large role in covering low-income adults and adult Medicaid enrollees are at elevated risk for preventable or treatable chronic conditions, ensuring access to preventive care and boosting utilization of these services among Medicaid adults is important to the national goal of improving population health while lowering health care costs. Medicaid expansion states have put preventive care within affordable reach of millions of previously low-income adults. State coverage of recommended preventive services without cost-sharing for all Medicaid adults would lower financial barriers to these services for many more of the nation’s poorest and sickest adults, increasing early detection and treatment of health conditions and risky behaviors, a necessary step to improve health outcomes and long-term trends in Medicaid costs. The House-passed American Health Care Act (AHCA) would both terminate enhanced federal funding for the Medicaid expansion to low-income adults and repeal the federal EHB requirements for Medicaid adults, threatening large losses of Medicaid coverage for adults as well as retrenchment in covered benefits, including preventive care for adults.
See the original article Here.
Source:
Ku L., Paradise J., Thompson V. (2017 May 17). Data note: medicaid's role in providing access to preventive care for adults [Web blog post]. Retrieved from address https://www.kff.org/medicaid/issue-brief/data-note-medicaids-role-in-providing-access-to-preventive-care-for-adults/?utm_campaign=KFF-2016-The-Latest&utm_source=hs_email&utm_medium=email&utm_content=52163695&_hsenc=p2ANqtz-_gq9UyDH_SyF_QUp6ExHuNpYp6ykLD7jGDmfelAPRlt4oaEFavzA8qUl9kjpfPDmmJd0VguBWPyhfkRGAzAiJl9iQmcA&_hsmi=52163695
Workers Might See Employer Health Coverage Disappear Under New GOP AHCA
Do you receive your healthcare through an employer? Then take a look at this article from Benefits Pro about how the passing of the AHCA will affect employees who get their healthcare through an employer by Marlene Y. Satter.
It’s not just individuals without employer health coverage who could lose big under the newly revised version of the Republicans’ American Health Care Act.
People who get health coverage from their jobs could be left swinging in the wind, too—in fact, as many as half of all such employees could be affected.
That’s according to an Alternet report that says an amendment added to the bill currently being considered by the House of Representatives would allow insurers in states that get waivers from regulations put in place by the Affordable Care Act to deny coverage for 10 types of health services—including maternity care, prescription drugs, mental health treatment and hospitalization.
An MSNBC report points out that “because the Republican-led House is scrambling to pass a bill without scrutiny or serious consideration,” the last-minute amendment’s full effects aren’t even known, since “[t]his is precisely the sort of detail that would’ve come to light much sooner if Republicans were following the American legislative process. In fact, this may not even be the intended goal of the GOP policy.”
While the ACA prohibits employer-based plans from imposing annual limits on coverage and bare lifetime caps on 10 essential benefits, the Obama administration did loosen those restrictions back in 2011, saying that employers could instead choose to follow another state’s required benefits.
What the new Republican take on the AHCA does is push that further—a lot further—by allowing large employers to pick the benefit requirements for any state. That would let them limit coverage on such costly types of care as mental health and substance abuse services.
In a Wall Street Journal report, Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services under President Barack Obama, is quoted saying, “It’s huge. They’re creating a backdoor way to gut employer plans, too.”
The changes to employer-based plans would hit anyone not insured by Medicare or by small-business plans, because the bill includes cuts to Medicaid and changes to the individual market as well.
A report from the Brookings Institution points out that “One of the core functions of health insurance is to protect people against financial ruin and ensure that they get the care they need if they get seriously ill.” The ACA pushed insurance plans to meet that standard, it says, by requiring them to “limit enrollees’ annual out-of-pocket spending and [bar] plans from placing annual or lifetime limits on the total amount of care they would cover.”
However, while those protections against catastrophic costs “apply to almost all private insurance plans, including the plans held by the roughly 156 million people who get their coverage through an employer,” the Brookings report says, the amendment to the Republican bill “could jeopardize those protections—not just for people with individual market plans, but also for those with employer coverage.”
How? By modifying “the ‘essential health benefit’ standards that govern what types of services must be covered by individual and small group market insurance plans. The intent of the amendment is reportedly to eliminate the federal benefit standards that currently exist and instead allow each state to define its own list of essential health benefits.”
And then, with employers allowed to pick and choose which state’s regulations they’d like to follow, a loophole the size of the Capitol building would not only allow “states will set essential health benefit standards that are considerably laxer than those that are in place under the ACA,” says the report, but “large employers may have the option to pick which state’s essential health benefits requirements they wish to abide by for the purposes of these provisions.”
The result? “[T]his would likely have the effect of virtually eliminating the catastrophic protections with respect to large employers since employers could choose to pick whichever state set the laxest standards. The same outcome would be likely to occur for all private insurance policies,” the report continues, “if insurers were permitted to sell plans across state lines, as the Administration has suggested enacting through separate legislation.”
While the actual effect of the amendment is unclear, the Brookings report concludes, “there is strong reason to believe that, in practice, the definition of essential health benefits that applied to the catastrophic protections would be far weaker under the House proposal than under current law, seriously undermining these protections. These potential adverse effects on people with employer coverage, in addition to the potentially damaging effects of such changes on the individual health insurance market, are thus an important reason that policymakers should be wary of the House proposal with respect to essential health benefits.”
See the original article Here.
Source:
Satter M. (2017 May 4). Workers might see employer health coverage disappear under new GOP AHCA [Web blog post]. Retrieved from address https://www.benefitspro.com/2017/05/04/workers-might-see-employer-health-coverage-disappe?page_all=1
3 Aspects of the GOP Healthcare Plan that Demand Employers’ Attention
The House of Representatives last week passed the American Health Care Act (AHCA) bill to begin the process of repealing the ACA. Find out what this new legislation means for employers in the great article from Employee Benefits Adviser by Daniel N. Kuperstein.
The extremely emotional journey to repeal (more appropriately, to “change”) the Affordable Care Act reached a significant milestone this week: The Republican-led House of Representatives passed an updated version of the American Health Care Act. While more than 75% of the provisions of the ACA remain intact, the AHCA gutted or delayed several of the ACA’s taxes on employers, insurers and individuals.
So what does this mean for employers?
First off, it’s important to remember that this new bill is not law just yet. The House version of the bill now heads to the Senate, where there’s no guarantee that it will pass in its current form; the margin for victory is much slimmer there. Only three “no” votes by Senate Republicans could defeat the bill, and both moderate and conservative Republican lawmakers in the Senate have expressed concerns about the bill. In other words, employers don’t have to do anything just yet, but it’s still beneficial to understand the major changes that could be coming down the pike.
As employers know from working over the last seven years to implement provisions of the ACA, there will be a million tiny details to work through if the AHCA becomes law.
But for now, we see three major aspects that demand employers’ attention.
There will be more emphasis on health savings accounts
Under the AHCA, health savings accounts will likely become far more popular — and more useful. The HSA contribution limits for employers and individuals are essentially doubled. Additionally, HSAs will be able to reimburse over-the-counter medications and allow spouses to make catch-up contributions to the same HSA. Of course, with this added flexibility comes increased responsibility — there will be a greater need for employees to understand their insurance.
There will be more flexibility in choosing a benchmark plan
For larger employers not in the small group market, the AHCA creates an opportunity to choose a benchmark plan that offers a significantly lower level of benefits to employees.
Currently, the ACA provides that employer-sponsored self-insured health plans, fully-insured large group health plans, and grandfathered health plans are not required to offer EHBs. However, these plans are prohibited from imposing annual and lifetime dollar limits on any EHBs they do offer. For purposes of determining which benefits are EHBs subject to the annual and lifetime dollar limits, the ACA currently permits employers sponsoring these types of plans to define their EHBs using any state benchmark plan. In other words, employers are not bound by the essential health benefits mandated by their state and can pick from another state’s list of required benefits.
Under the AHCA, we may see a big change to how the rules on annual and lifetime limits work. Notably, nothing in the AHCA would prohibit employers from choosing a state benchmark plan from a state that had obtained an AHCA waiver, which would allow the state to put annual and lifetime limits on its EHBs. This means that, if one state decides to waive these EHB requirements, many employers could decide to use that lower-standard plan as their benchmark plan. Of course, while choosing such a benchmark plan may benefit an organization by lowering its costs, such a move may have a negative impact on its ability to recruit and retain the best talent.
There will be a greater need to help employees make smart benefits decisions
The most important aspect of this for employers is to understand the trend in health insurance, which is undeniably moving in the direction of consumerism.
The driving philosophy behind this new Republican plan is to place more responsibility on individuals. However, this doesn’t mean employers can throw a party and simply wish their workers “good luck” — employers need to think at a macro level about what’s good for business. In a tightening labor market in which so many talented people consider themselves free agents, smart employers will focus on helping employees to make smart decisions about their health insurance.
See the original article Here.
Source:
Kuperstein D. (2017 May 5). 3 aspects of the GOP healthcare plan that demand employers attention [Web blog post]. Retrieved from address https://www.employeebenefitadviser.com/opinion/3-aspects-of-the-gop-healthcare-plan-that-demand-employers-attention
Medicaid Family Planning and Maternity Care Services: The Current Landscape
Find out about the current landscape of Medicaid and how the repeal ACA will impact certain aspects of Medicaid in this great article by Kaiser Family Foundation.
As the Trump Administration and Congress weigh major changes to Medicaid and programs that fund reproductive health care, new analyses from the Kaiser Family Foundation highlight the current state of coverage and challenges for family planning, pregnancy, and perinatal services in the Medicaid program that provides coverage for millions of low-income women across the nation.
- The inclusion of maternity care as an essential health benefit has been the focus of a recent policy debate over the future of the Affordable Care Act. For nearly half of births in the U.S., Medicaid picks up the tab. A new survey of state-level maternity care policies under Medicaid finds that all surveyed states covered prenatal visits, but benefits such as genetic counseling, parenting and newborn education services, and home visits were not covered in some states. Similarly, all states included hospitalization benefits, but not all paid for deliveries in birth centers or at home.
- Over half of states have established limited scope family planning programs under Medicaid. A case study analysis of Medicaid family planning programs in six states (AL, CA, CN, IL, MO, and VA) conducted in the summer of 2016 uncovered opportunities to improve enrollment in family planning programs; identified the importance of these programs for women who have difficulty affording premiums; and documented challenges faced by family planning clinics under Medicaid. Some ACA Medicaid expansion states are reconsidering the need for a separate family planning program under Medicaid, but most have maintained them.
- Three quarters of reproductive age women on Medicaid are enrolled in managed care arrangements. A new analysis explores the experiences and perspectives of leaders of Medicaid Managed Care Organizations (MCOs) and finds that MCOs rely heavily on safety net clinics including community health centers and family planning clinics such as Planned Parenthood to provide in-network family planning services to their members. MCO leaders identified churning in enrollment, the high costs of stocking IUDs and implants, and global hospital payment methodologies for maternity care as potential barriers to certain family planning services.
See the original article Here.
Source:
Author (2017 April 27). Medicaid family planning and maternity care services: the current landscape [Web blog post]. Retrieved from address https://www.kff.org/womens-health-policy/press-release/medicaid-family-planning-and-maternity-care-services-the-current-landscape/
House Passes Obamacare Repeal
Find out more about the passing of the AHCA in this article from The Hill by Peter Sullivan.
House Republicans on Thursday passed legislation aimed at repealing and replacing ObamaCare, taking a major step toward a long-held goal and setting in motion an overhaul of the nation’s health system.
The narrow 217-213 vote is a victory for GOP leaders, who faced a tumultuous path to getting the bill to the floor. The measure had to be pulled in March because of a lack of votes, but a series of deals since then brought on board the conservative Freedom Caucus and then wavering moderates.
The bill, known as the American Health Care Act, repeals the core elements of ObamaCare, including its subsidies to help people get coverage, expansion of Medicaid, taxes and mandates for people to get coverage.
In its place, the bill provides a new tax credit aimed at helping people buy insurance, though it would provide less help than ObamaCare to low-income people.
The Congressional Budget Office found that 24 million more people will become uninsured over the next decade because of the bill. While some of that loss is because of people choosing not to get coverage when the mandate is repealed, much of it would come from Medicaid cuts and the smaller tax credit as well.
Republicans brought the measure to a vote without an analysis from the Congressional Budget Office on the updated bill, meaning lawmakers did not have the full nonpartisan analysis of what the bill would do.
In addition, while Republicans have long argued that Democrats rammed through ObamaCare in 2010, the final changes to the Republican bill were only released the night before the vote.
Republicans’ main argument is that ObamaCare is failing and needs to be replaced. They point to insurers pulling out of certain markets, while Democrats counter that uncertainty from Republican efforts to weaken the law are to blame.
“It’s been a winding road to this point but we’re here today to fulfill the promise that we made to the American people,” said Rep. Diane Black (R-Tenn.) who led GOP floor debate on the measure.
“Under ObamaCare, the situation is getting worse every day,” she said. “We can’t wait a moment longer than necessary to provide relief for the American people by repealing and replacing ObamaCare.”
House Democratic Leader Nancy Pelosi (Calif.), meanwhile, called the measure a “very sad, deadly joke.”
Pointing to the hundreds of billions of dollars in tax cuts, she said the bill “will have the biggest transfer of wealth in the history of our country — Robin Hood in reverse.”
The measure has deep cuts to Medicaid, the government healthcare program for low income people, including putting a new cap on payments and ending ObamaCare’s expansion of the program after 2020.
The bill was a tough vote for some electorally vulnerable members of Congress. Many remained publicly undecided until the last moment as leaders furiously whipped lawmakers over the last several days.
Rep. Mike Coffman (R-Colo.), for example, came out as a “no” hours before the vote. He cited the lack of a CBO analysis as well as weakening protections for people with pre-existing conditions.
The key move to bring the Freedom Caucus on board was an amendment that allows states to repeal one of ObamaCare’s key protections for people with pre-existing conditions, known as community rating. If that were repealed in a state, insurers could go back to charging exorbitant premiums to sick people, which could put coverage out of reach for many.
Republicans counter by pointing to money for high risk pools. A last-minute addition of $8 billion more in funding for people with pre-existing conditions was key to winning over several wavering moderates, though many experts doubt whether that will be close to enough funding.
The measure is expected to undergo a major overhaul in the Senate, especially on the Medicaid front, where several Republican senators from states that accepted the expansion are wary of cutting it off.
The path in the Senate is also even tougher, given that Republicans can lose only two votes and still pass the bill.
See the original article Here.
Source:
Sullivan P. (2017 May 4). House passes obamacare repeal [Web blog post]. Retrieved from address https://thehill.com/policy/healthcare/331937-house-passes-obamacare-repeal
Employers Want Lawmakers to Curb Rising Pharma Costs
Has the cost of pharmaceuticals caused an increase in your health care costs? Find out how other employers are trying to combat rising costs in the great article from Employee Benefits News by Nick Otto.
A majority of employers say they were relieved to see the GOP’s repeal and replace plan fizzle out last month, and instead have their own ideas on how to best reform healthcare and how to rein in costs.
In a poll conducted by Mercer days following the crumbling of the American Health Care Act, more than half who invest in employer-sponsored healthcare said they were happy to see the GOP plan fail.
Nearly a quarter (24%) of employers told the consulting firm they “very relieved” of the legislation’s failure, while 32% said they were “relieved.”
Meanwhile, 16% said they were disappointed the legislation didn’t pass, 5% were “very disappointed” it didn’t pass, and the remainder of employers had no opinion. A planned vote on the ACHA was scrapped in late March at President Donald Trump’s request after a number of Republicans said they opposed the bill.
With more than 61% of covered Americans getting health coverage through employer plans, Mercer says businesses should help play a key role in recognizing and addressing the underlying cost concerns plaguing the healthcare market.
“Cost-shifting does not address the underlying causes of healthcare cost growth, and increasing burdens on employers will simply make it harder for them to provide affordable coverage to their employees,” Mercer says.
So what do employers say are the top issues lawmakers should address?
Topping the employer wish list, according to the Mercer poll, is help with controlling the climbing cost of pharmaceuticals with a score of 4.4/5 (employers ranked policymaker priorities 1-5, 5 being “top priority).
The following improvements also made the list of employer desires: improving price transparency (4.1), stabilizing the individual markets (4), maintaining Medicaid funding (4) and investing more in population health and education (3.7).
While neither the ACA nor the AHCA had any significant impact to how employers offer healthcare, there are aspects of both legislations that would still influence some employer plans.
Maintaining Medicaid funding and having a stabilized individual market will lower hikes to private payers by allowing people not in employer-sponsored plans have access to affordable coverage and avoid a rise in the number of uninsured.
See the original article Here.
Source:
Otto N. (2017 April 9). Employers want lawmakers to curb rising pharma costs [Web blog post]. Retrieved from address https://www.benefitnews.com/news/employers-want-lawmakers-to-curb-rising-pharma-costs?brief=00000152-14a7-d1cc-a5fa-7cffccf00000
Understanding the Evolution of Health Insurance in a Post-ACA World
With the fall of the AHCA, are you wondering where you are left standing with healthcare? Check out this great article from Benefits Pro on what the fall of the AHCA means for employers and how to proceed with healthcare from here by Eric Helman.
While much has been written about specific aspects of the ACA and how repeal, replace and repair will affect certain populations, the impact on employer-sponsored benefits is more convoluted.
In the world of employee benefits, to properly understand the post ACA world, we must reflect on the confluence of how five separate constituents react to the new health insurance landscape.
The issues and priorities of these five groups: government, carriers, employers, employees, and brokers/consultants, and how they relate to each other will dictate the evolution of health insurance in the post-ACA world.
These insights will illuminate what to expect in a post-ACA climate as the health insurance landscape continues to evolve under President Trump.
Government compliance issues ease
While we all may be a bit weary from the focus on Washington, the fact remains the federal government continues to be the single biggest catalyst for changes in the health insurance and benefits landscape.
For benefits professionals, it is important to recognize that for all the politicization around ACA, there is very little focus on the employer-provided benefits space, especially outside of the realm of small employers. The priority for government involvement in repeal-replace-repair is the individual market and Medicaid expansion.
Having said this, if the Republicans choose to use reconciliation to repeal the ACA with a simple majority, many aspects of the employer-provided system will be affected. Unfortunately, this will perpetuate the preoccupation with compliance in the employer space, continuing the trend of non-value add expenditure of resources that has plagued the industry for the last five years.
Carrier mandates relax
Perhaps surprisingly, the second area of significant change in the post-ACA era will be in the domain of the carriers. Against the backdrop of the Department of Justice opinions on the two proposed mega-mergers, we expect the greatest impact of repeal-replace-repair will manifest itself in the proliferation of new products which were “non-compliant” under the ACA.
Whether correct or not, one of the indictments of the ACA is increased mandates do more to destroy markets in terms of access and affordability than they do to advance these objectives.
Look for the relaxation of these mandates and the commensurate acceleration of new product development which will inevitably follow. Combined with the return of premium reimbursement plans in the small market, we expect the further commoditization of major medical insurance as low risk consumers choose less coverage for less premium.
Employers reallocate benefits compensation
Second only to the carriers, the employers have been the biggest victims of the ACA era. While many have applauded the decline in the rate of health care inflation, the reality is that benefits costs continue to grow more than inflation, placing an ever-increasing burden on total compensation planning.
Add to this the increased cost of compliance in an environment where employers are trying to reduce administrative costs in the face of a slow growth economy and you can understand the “ACA fatigue” many employers report.
Repeal-replace-repair, while it will bring uncertainty in the near term, is likely to lower the burden on employers and allow more strategic thinking about how they allocate compensation to benefits.
The increasing age diversity of their employees will force them to consider altering this allocation in favor of financial wellness (retirement and student debt) perhaps at the expense of traditional health benefits. The war for new talent precipitated by near full employment in skilled professions will only exacerbate this tension.
Employees wise up on benefit choices
For employees, the impact of the politicization of health care will continue to cloud their perception of their role in choosing and consuming the benefit programs offered by their employers.
While much has been written about the promise of “consumerism” to change the hyper-inflationary nature of fee-for-service health care, it is apparent that the deadly combination of employee illiteracy and entitlement about employer-provided health insurance is a greater impediment to real reform in the way health care is consumed in this country.
With the potential deregulation on mandated benefits and the increasing availability of retail health care alternatives, it will be incumbent on all the constituents to accelerate the employees’ education and appreciation for employee benefit choices customized to their informed perception of need and risk mitigation.
Brokers/consultants rise to the challenges
And now, the elephant in the room, the impact on brokers and consultants. One of my early mentors said, “There is profit in confusion.” For the skilled practitioners, I think they would agree that the net effect of the ACA was increased opportunity. It is important to note however, that this opportunity required focus on new disciplines.
No longer were the skills of customer relationship management, procurement management and vendor management sufficient to satisfy the needs of their clients. The best players were forced to develop expertise in compliance, regulatory impact, benefits technology and internal human resources processes that their predecessors could ignore. This, the low cost of money and the aging workforce of benefit producers has contributed to the continued wave of firm consolidation which changes the nature of competition.
Additionally, the widely publicized fall of market disruptors will have a chilling effect on innovation for the near term. In the post-ACA era, benefits professionals will be challenged to balance revenue, client retention and cost-of-service pressures in an environment where the future is uncertain.
The post-ACA era promises to be as exciting as the last five years. To paraphrase Richard Epstein on a separate topic, the real dilemma is that the people working on the problem lack the technical expertise and the political agnostic orientation necessary for real change.
In the meantime, successful participants in this marketplace will be forced to be both diplomats and opportunists, acutely aware of the issues and priorities facing all of the important constituents and balancing these to the most optimum outcome. I, personally, am comforted that we have some of the most creative people I know working on this challenge.
See the original article Here.
Source:
Helman E. (2017 April 7). Understanding the evolution of health insurance in a post-ACA world [Web blog post]. Retrieved from address https://www.benefitspro.com/2017/04/07/understanding-the-evolution-of-health-insurance-in?t=core-group&page_all=1
What Marketplace Health Insurance Plans Cover
Do you know what is covered in your marketplace health insurance plan? Find out more about your health insurance plan and everything it covers in this article by HealthCare.Gov.
All plans offered in the Marketplace cover the same set of essential health benefits.
Every health plan must cover the following services:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Additional benefits
Plans must also include the following benefits:
Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on your state’s requirements. Plans may offer additional benefits, including:
- Dental coverage
- Vision coverage
- Medical management programs (for specific needs like weight management, back pain, and diabetes)
When comparing plans, you’ll see exactly what each plan offers.
See the original article Here.
Source:
Author (Date). What marketplace health insurance plans cover [Web blog post]. Retrieved from address https://www.healthcare.gov/coverage/what-marketplace-plans-cover/
Are Healthcare Cost-Shifting Efforts at a Tipping Point?
Are you having trouble controlling your healthcare cost? Take a look at this interesting article from Employee Benefits Advisor on how rising healthcare costs are affecting employers by Bruce Shutan.
With the fate of healthcare reform in limbo, new research suggests employers are moving forward with a host of incremental changes to their health and wellness plans in hopes of curtailing costs on their own.
Kim Buckey, VP of client services at DirectPath, an employee engagement and healthcare compliance technology company, has noticed a slowdown in adoption of high-deductible health plans and cost-shifting strategies that aren’t quite living up to expectations. DirectPath’s 2017 Medical Plan Trends and Observations Report, based on an analysis of about 975 employee benefit health plans, found employers applying creative methods for cost control.
Buckey noted greater use of health savings accounts, wellness incentives, price transparency tools and alternative care options.
Slightly more than half of the employers studied by DirectPath offer a price transparency tool, while another 18% plan to do so in the next three years. Price-comparison services were found to save employees and employers alike an average of $173 and $409, respectively, per procedure.
In an effort to reduce costs and the administrative burden of tracking coverage for dependents, surcharges on spouses who can elect coverage elsewhere soared more than 40% within the past year to $152 per month.
The number of plans that offer wellness incentives rose to 58% from 50% between 2016 and 2017. Rewards included paycheck contributions, plan premium discounts, contributions to HSAs and health reimbursement arrangements and reduced co-pays for office visits. HSAs were far more popular than employee-funded HRAs (67% vs. 15% of employers examined), while employer contributions to HSAs increased nearly 10%.
Barriers to care and cost containment
A separate survey conducted by CEB, a technology company that monitors corporate performance, noted that although as many as one-third of organizations offer telemedicine, more than 55% of employees aren’t even aware of their availability and nearly 60% believe they’re difficult to access.
DirectPath and CEB both found that the average cost of specialty drugs increased by more than 30%. This reflects research conducted by the National Business Group on Health. Nearly one-third of NBGH members said the category was their highest driver of healthcare costs last year.
The pursuit of a panacea for rising group health costs has been meandering. When Buckey’s career began, she recalls how indemnity plans gave way to HMOs and managed care, then HDHPs, consumer-directed plans and private exchanges. “There is no one silver bullet that’s going to solve this problem,” she explains, “and I think employers and their advisers are starting to understand that it’s got to be a combination of things.”
More employers are now realizing that cost-shifting isn’t a viable long-term solution and that “whatever changes are put in place will require a well thought-out, year-round and robust communication plan,” she says.
There’s also a serious need to improve healthcare literacy, with Buckey noting that many employees still struggle to understand basic concepts such as co-pays, deductibles and HSAs. Consequently, she says it’s no wonder why they often “just shut down and do whatever their doctor tells them.
“So I think anything that advisers and brokers can do to support their employers in explaining these plans, or whatever changes they choose to implement,” she continues, will help raise understanding and eventually have a positive influence on behavior change. This, in turn, will help lower employee healthcare costs.”
See the original article Here.
Source:
Shutan B. (2017 April 5). Are healthcare cost-shifting efforts at a tipping point? [Web blog post]. Retrieved from address https://www.employeebenefitadviser.com/news/are-healthcare-cost-shifting-efforts-at-a-tipping-point
How Employers Should Proceed After the AHCA’s Collapse
Take a look at the great article from Employee Benefits Advisor on what employers need to know about healthcare with the collapse of the AHCA by Alden J. Bianchi and Edward A. Lenz.
The stunning failure of the U.S. House of Representatives to pass the American Health Care Act has political and policy implications that cannot be forecasted. Nor is it clear whether or when the Trump administration and Congress will make another effort to repeal and replace, or whether Republicans will seek Democratic support in an effort to “repair,” the Affordable Care Act. Similarly, we were unable to predict whether and to what extent the AHCA’s provisions can be achieved through executive rulemaking or policy guidance.
Here are some ways the AHCA’s failure could impact employers in the near term.
Immediate impact on employers
Employers were not a major focus of the architects of the ACA, nor were they a major focus of those who crafted the AHCA. This is not surprising. These laws address healthcare systems and structures, especially healthcare financing. Rightly or wrongly, employers have not been viewed by policymakers as major stakeholders on those issues.
In a blog post published at the end of 2014, we made the following observations:
The ACA sits atop a major tectonic plate of the U.S. economy, nearly 18% of which is healthcare-related. Healthcare providers, commercial insurance carriers, and the vast Medicare/Medicaid complex are the law’s primary stakeholders. They, and their local communities, have much to lose or gain depending on how healthcare financing is regulated. The ACA is the way it is largely because of them. Far more than any other circumstance, including which political party controls which branch of government, it is the interests of the ACA’s major stakeholders that determine the law’s future. And there is no indication whatsoever that, from the perspective of these entities, the calculus that drove the ACA’s enactment has changed. U.S. employers, even the largest employers among them, are bit players in this drama. They have little leverage, so they are relegated to complying and grumbling (not necessarily in that order).
With the AHCA’s collapse, the ACA remains the law of the land for the foreseeable future. The AHCA would have zeroed out the penalties on “applicable large” employers that fail to make qualified offers of health coverage, but the bill’s failure leaves the ACA’s “play or pay” rules in full force and effect. The ACA’s reporting rules, which the AHCA would not have changed, also remain in effect. This means, among other things, that many employers, especially those with large numbers of part-time, seasonal, and temporary workers that face unique compliance challenges, will continue to be in the position of “complying and grumbling.”
This does not mean that nothing has changed. The leadership of the Departments of Health and Human Services, Labor and Treasury has changed, and these agencies are now likely to be more employer-friendly. Thus, even though the ACA is still the law, the regulatory tone and tenor may well be different. For example, although the current complex employer reporting rules will remain in effect, the Treasury and IRS might find administrative ways to simplify them. Similarly, any regulations issued under the ACA’s non-discrimination provisions applicable to insured health plans (assuming they are issued at all) likely will be more favorable to employers than those issued under the previous administration.
There are also unanticipated consequences of the AHCA’s failure that employers might applaud. We can think of at least two.
1. Stemming the anticipated tide of new state “play or pay” laws
The continuation of the ACA’s employer mandate likely will put on hold consideration by state and local governments of their own “play or pay” laws.
In anticipation of the repeal of the ACA’s employer mandate, the Governor of Massachusetts recently introduced a budget proposal that would reinstate mandated employer contributions to help cover the costs of increased enrollment in the Medicaid and Children’s Health Insurance Program, known as MassHealth. Under the proposal, employers with 11 or more full-time equivalent employees would have to offer full-time employees a minimum of $4,950 toward the cost of an employer group health plan, or make an annual contribution in lieu of coverage of $2,000 per full-time equivalent employee. While the Governor’s proposal is not explicitly conditioned on repeal of the ACA’s employer mandate, the ACA’s survival may prompt a reconsideration of that approach.
California lawmakers were also considering ACA replacement proposals, including a single-payer bill introduced last month by Democratic state senators Ricardo Lara and Toni Atkins. Had the ACA’s employer mandate been repealed, those proposals were likely just the tip of an iceberg. When the ACA was enacted in 2010, Hawaii, Massachusetts, and San Francisco were the only jurisdictions with their own healthcare mandates on the books. But in the prior two-year period, before President Obama was elected and made healthcare reform his top domestic priority, more than two dozen states had introduced various “fair share” health care reform bills aimed at employers.
Most of the state and local “play or pay” proposals would have required employers to pay a specified percentage of their payroll, or a specified dollar amount, for health care coverage. Some required employers to pay employees a supplemental hourly “health care” wage in addition to their regular wages or provide health benefits of at least equal value. California, Illinois, Pennsylvania, and Wisconsin considered single-payer proposals.
To be sure, any state or local “play or pay” mandates would be subject to challenge based on Federal preemption under the Employee Retirement Income Security Act (ERISA). While some previous “play or pay” laws were invalidated under ERISA (e.g., Maryland), others (i.e., San Francisco) were not. In sum, given the failure of the AHCA, there would appear to be no rationale, at least for now, for any new state or local “play or pay” laws to go forward.
2. Avoiding upward pressure on employer premiums as a result of Medicaid reforms
The AHCA proposed to reform Medicaid by giving greater power to the states to administer the Medicaid program. Under an approach that caps Medicaid spending, the law would have provided for “per capita allotments” and “block grants.” Under either approach, the Congressional Budget Office, in its scoring of the AHCA, predicted that far fewer individuals would be eligible for Medicaid.
According to the CBO: CBO and JCT estimate that enacting the legislation would reduce federal deficits by $337 billion over the 2017 to 2026 periods. That total consists of $323 billion in on-budget savings and $13 billion in off-budget savings. Outlays would be reduced by $1.2 trillion over the period, and revenues would be reduced by $0.9 trillion. The largest savings would come from reductions in outlays for Medicaid and from the elimination of the ACA’s subsidies for non-group health insurance.
While employers rarely pay attention to Medicaid, the AHCA gave them a reason to do so. Fewer Medicaid-eligible individuals would mean more uncompensated care — a significant portion of the costs of which would likely be passed on to employers in the form of higher premiums. As long as the ACA’s expanded Medicaid coverage provisions remain in place, premium pressure on employers will to that extent be avoided.
Long-term impact on employers
As we conceded at the beginning, it’s not clear how the Republican Congress and the Administration will react to the AHCA’s failure. If the elected representatives of both political parties are inclined to try to make the current system work, however, we can think of no better place that the prescriptions contained in a report by the American Academy of Actuaries, entitled “An Evaluation of the Individual Health Insurance Market and Implications of Potential Changes.”
The actuaries’ report does not address, much less resolve, the major policy differences between the ACA and the AHCA over the role of government — in particular, the extent to which taxpayers should be called on to fund the health care costs of low-and moderate-income individuals, and whether U.S. citizens should be required to maintain health coverage or pay a penalty. And even if lawmakers can reach consensus on those contentious issues, they still would have to agree on the proper implementing mechanisms.
But whatever the outcome, employers are unlikely to play a major role.
See the original article Here.
Source:
Bianchi A. & Lenz E. (2017 April 6). How employers should proceed after the AHCA's collapse [Web blog post]. Retrieved from address https://www.employeebenefitadviser.com/opinion/how-employers-should-proceed-after-the-ahcas-collapse