Vermont’s Reduction in Uninsured May Help Governor’s Reform Plan

The 2014 Vermont Household Health Insurance Survey indicates a significant drop in the number of uninsured Vermonters, which is welcomed news for Governor Peter Shumlin, who has been struggling to garner favor for his “Green Mountain Care” plan. The health plan seeks to change Vermont’s payment system from a premium-based model to one that is based on individuals’ ability to pay. The plan would be publically financed. Shumlin plans to outline his cost-focused, health care reform agenda in his annual budget address on January 15, 2015.

The Survey

Conducted between August and December 2014, the phone survey shows that the lowered number of uninsured Vermonters is a direct result of the expansion of Medicaid eligibility and some insurance coverage changes included in the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The governor noted, “With all the pains and struggle, it is clear that Medicaid expansion and the Affordable Care Act are benefiting Vermonters.” The last survey was taken in 2012.

2014 survey results reveal that approximately 19,000 of 43,000 Vermonters who had no health insurance in 2012 are now covered. This figure reflects a drop in the state’s uninsured rate from nearly 7 percent to 3.7 percent, which is the second lowest in America. Only 1 percent of Vermont’s children under age 18 are uninsured, which is also the lowest rate in the United States.

According to the survey, 310,000 Vermonters are privately insured, and 133,000 are now on Medicaid, with children under age 17 representing over 44 percent of that number.

The decrease in the uninsured rate spans across all income and age groups as well as geographic and demographic categories, although the survey reported that more men (almost 5 percent) are uninsured than women (2.5 percent). Nevertheless, both percentages show almost a 50 percent decline in the uninsured rate since 2012.

Every county in Vermont also experienced a reduction in the number of uninsured individuals. For instance, Essex County saw the largest drop from about 20 percent in 2012 to 10 percent in 2014.

For those who will remain without insurance, over 65 percent of uninsured Vermonters said the high cost of insurance is either the sole or main reason they do not have insurance coverage.

Budget Address

The cost of care is still a significant barrier in keeping Vermonters from obtaining insurance, the governor said. In his budget address, Shumlin will call for cost reforms such as:

  • health care payment structures that will shift to payments based upon quality rather than quantity;
  • a strengthened primary care system as part of Blueprint for Health, which has been proven to lower the cost curve while ensuring quality health care to Vermonters;
  • control over the cost shift that forces private insurance rates to cover inadequate reimbursements received for Medicaid care as Medicaid participation increases; and
  • the Green Mountain Care Board’s enhanced role in reducing health care costs with the long-term goal of lowering health care spending increases between 3 and 4 percent.

Perhaps the positive survey results will enable the enactment of the long-awaited Green Mountain Care plan.

Highlight on Alabama: ACA Grants to Reach Alabama Health Providers and Improve Patient Care

Alabama health providers will receive grant funding totalling $343,606 as part of a Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) initiative. Health and Human Services Secretary Sylvia M. Burwell announced $36.3 million in funding to 1,113 health centers in all 50 states, the District of Columbia, and seven U.S. Territories to recognize health center quality improvement achievements and invest in ongoing quality improvement activities. Thirteen Alabama health providers are set to receive the quality improvement grant funds to help with their ongoing efforts to improve patient care.

The funding rewards Alabama health centers that “have a proven track record in clinical quality improvement, which translates to better patient care, and it allows them to expand and improve their systems and infrastructure to bring the highest quality primary care services to the communities they serve,” Burwell said in a news release “With these funds, health centers in all 50 states will continue to provide access to high quality, comprehensive primary and preventive health care to the patients that need it the most.”

Alabama health centers receiving these funds are being recognized for high levels of quality performance. These providers have demonstrated their ability to focus on quality in all aspects of their clinical operations and the best overall clinical outcomes. They have exceeded national clinical benchmarks for quality, and demonstrated at least a 10 percent improvement in clinical quality measures between 2012 and 2013. Many of them have also used electronic health records (EHRs) to report quality measures. Alabama providers set to receive funding include:

  • Bayou La Batre Area Health Development Board, Inc., recognized as a clinical quality improver;
  • Birmingham Health Care, Inc., recognized as a clinical quality improver;
  • Cahaba Medical Care Foundation, recognized as an EHR health center and clinical quality improver;
  • Capstone Rural Health Center, recognized as a clinical quality improver;
  • Central North Alabama  Health Services, Inc., recognized as a clinical quality improver;
  • Franklin Primary Health Center, Inc., recognized as a clinical quality improver;
  • Health Services, Inc., recognized as a clinical quality improver;
  • County of Mobile, recognized as a clinical quality improver;
  • Northeast Alabama Health Services, Inc., recognized as an EHR health center and clinical quality improver;
  • Quality of Life Health Services, Inc., recognized as a clinical quality improver and a health center quality leader;
  • Rural Health Medical Program, Inc., recognized as an EHR health center and clinical quality improver;
  • Southeast Alabama Rural Health Associates, recognized as a clinical quality improver;
  • Whatley Health Services, Inc., recognized as a clinical quality improver.

“These funds reward and support those health centers that have taken steps to achieve the highest levels of clinical quality performance and improvement,” said Health and Resources Administration (HRSA) Administrator Mary K. Wakefield, Ph.D., R.N.

Leaving a Man Behind: Veteran Health Care

By Jennifer Chow, DePaul University College of Law-

Earlier in 2014, Cable News Network (“CNN”) issued a series of articles on the extended delays for United States veterans to be seen in the Veterans Affairs health care system. CNN boldly stated that hospital delays were “killing war veterans.” That following April, CNN broke the news that United States veterans were not only dying as they waited for health care appointments, but secret waiting lists and falsified records were also being utilized to hide the thousands of veterans forced to wait months to see a physician. The breaking news launched multiple federal investigations, including an internal investigation by Veterans Affairs (“VA”), as well as investigations by Veterans Affairs Office of the Inspector General, the Justice Department and the Federal Bureau of Investigations. As the year comes to a close, this article examines the progress, or lack thereof, of the Veterans Affairs Administration and addresses what the future of health care looks like for our war heroes.

A System on the Edge

 The Veterans Health Administration (“VHA”), a division of the United States Department of Veterans Affairs, is America’s largest integrated health care system, serving 8.76 million veterans each year. All those who served in active military, naval, or air service are eligible under the program. Nevertheless, even with the 150 medical centers, nearly 14,000 community-based outpatient clinics, and 53,000 licensed health care practitioners, the average wait time, in May 2014, for new primary care patients was 51 days.

Moreover, the cost of caring for veterans is on the rise, with no relief in sight. The aging members of World War II and the Vietnam War will continue to place stress on the VA as illnesses related to age become more prevalent. Additionally, servicemen and women from the wars in Iraq and Afghanistan will soon retire and seek medical attention, especially for chronic conditions such as post-traumatic stress disorder.

 

The Question of Progress

 In the aftermath of the scandal, Dr. Robert Pretzel retired as the VA Undersecretary for Health, followed closely by the resignation of Secretary of Veterans Affairs, Eric Shinseki. In his stead, President Obama appointed Robert McDonald, a United States Army veteran and formed Proctor and Gamble CEO, as the replacement Secretary of Veterans Affairs. Additionally, Congress passed the Veterans Access, Choice and Accountability Act of 2014 . The key features to the Act provided veterans the right to access private health care and established leases for 27 new VA facilities with the hope of reducing patient wait times and addressing the overflow of veterans in need of care.

On Thursday, November 6, Secretary of Veterans Affairs McDonald announced that average wait times have decreased to 42 days as of October 2014. While McDonald touted the decrease as “significant progress,” criticism still hails down on the new Secretary of Veterans Affairs.

McDonald is slowly, but surely, navigating through the legal minefield of firing executive members who were involved in the original cover up, yet commentators on the Hill continue to call into question McDonald’s tactics and expediency. After allegations surfaced, executive members were put on paid leave while further investigations were conducted. Until due process has been given to each individual, those responsible for the mismanagement of veteran care will continue to be bankrolled by the VA, draining an already faltering system.

About-Face, Private!

 It is clear that something has to change in the administration of health care under Veterans Affairs. On the surface, it is easy to throw money at the problem. In addition to the $16 billion in emergency funds approved by Congress, the VA’s budget, under the Obama Administration, has increased from $100 billion in 2009 to $154 billion in 2014. McDonald is also seeking an unspecified amount of additional funds, on top of the $16 billion to be allocated to the backlog of disability claims for veterans. However, even with this allocation of billions of dollars, there seems to be no significant change in the provision of health care for war veterans.

The system is clearly broken. No patient should be required to wait 42 days to see a primary care physician. This practice is unacceptable for any civilian in the United States, let alone those who fought for our country. The simplest solution for this problem is the administration of veteran care outside the VA system, in the private sector. Where the VA lacks the infrastructure and locations to support the needs of all veterans, private and public hospitals can ease the burden. Although the Veterans Access, Choice and Accountability Act takes steps in the right direction by allowing veterans to seek VA-paid health care from local health providers with “choice cards,” it is ultimately not enough. The anticipated roll out of the “choice cards” will most likely be slow and not reach the 9 million members for months, if not years.

Veterans need care now. Instead of allocating funds to bolster the existing infrastructure, the VA needs to take advantage of the multiple health care systems that are already established and more equipped to handle the volume of veterans that stream into VA hospitals every day.

Conclusion

 CNN was not wrong; wait times are killing war veterans. Despite the good intentions of the Obama Administration, Congress, and Veterans Affairs, money alone will not solve this problem. A fundamental change is necessary to heal those who fought so bravely for the United States. Until then, war heroes continue to suffer on American soil.

Jennifer Chow is a current student at DePaul University College of Law in Chicago. Ms. Chow is the current Editor-in-Chief of DePaul’s E-Pulse and Business & Managing Editor of the DePaul Journal of Health Care Law. She completed her undergraduate degree at the University of Southern California in psychology and advertising. Ms. Chow will complete her JD and LLM degree in health law in 2015.

To Expand or Not to Expand: Medicaid Under the Affordable Care Act

By Jaime Whitt, University of Kansas School of Law-

Famed US Supreme Court Justice Louis Brandeis wrote, in his dissent to the majority opinion in New State Ice Co v. Liebmann, 285 U.S. 262 (1932), that “It is one of the happy incidents of the federal system that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.” With these words Justice Brandeis generated one of the most prominent analogies of US Federalism—one that still holds true today: the States as the “laboratories of democracy.” This concept has seemingly come to life with the implementation of the ACA (P.L. 111-148) and its provisions. Though it is federal health care reform, there is considerable leeway for each State to individualize the legislation’s impact. From the choice between utilizing www.HealthCare.gov or creating its own state-based health insurance Exchange, to regulation of the health care Navigators and other ACA outreach programs, to whether or not to expand Medicaid and how, each State has several opportunities to either fully roll out the ACA and its initiatives or stifle the bill’s impact.

One of the mostly hotly debated issues of the ACA has been Medicaid Expansion. With 2012’s National Federation of Independent Business v. Sebelius, 132 S.Ct. 2566, the Supreme Court invalidated the federal Medicaid Expansion mandate as unlawfully coercive and left the Medicaid decision to the states. Since then, contentious arguments in favor of and against expansion abound. To exhaust the minutia surrounding this hotbed topic would arguably be fruitless in this context, but even a cursory review of the myriad issues involved reveals that the expansion decision is a complicated one.

To Expand

On the side in favor of Medicaid Expansion, the arguments typically stem from the vantage point of viewing expansion as a moral and fiscal imperative. States who choose to expand Medicaid get considerable financial support from the federal government in the form of 100% funding for the cost of newly enrolled Medicaid beneficiaries. In a December 2013 study of how states stand to gain or lose under Medicaid Expansion, the Commonwealth Fund found that expansion dollars would represent a major source of federal revenue to state enterprises—nearly 2.5 times the value of highly sought-after federal highway funds in some cases. These dollars are necessary, the argument often goes, to strengthen and protect state health care providers against uncompensated care and to expand health coverage and financial protection to a state’s neediest constituents. The Oregon Health Insurance Experiment (OHIE), which conducted a randomized clinical trial of the effects of expanded Medicaid coverage, found that expansion resulted in improvements in mental and physical well-being as well as protection from catastrophic medical expenses for those who previously had no such resources.

Not to Expand

On the other hand, many states have been leery that the federal government, whose ACA expansion funds match the states at 100% until 2019 when the rate levels out at 90%, will take back that funding, leaving state budgets strapped and on-the-hook to find a way to continue coverage. Recently, this argument has come under fire, as more states consider expansion and research into the history of federal Medicaid funding has revealed that once such funds become entrenched, they are rarely reversed. To that same point, however, many economic and health policy analysts have expressed concern that this massive expansion of public funds will further contribute to the already currently unsustainable growth of national health care expenditures. In support of this argument, results from the aforementioned Oregon study, as well as trends seen in Massachusetts after its 2006 health care reform, indicate that an (expensive) increase in ER utilization is a likely consequence of status-quo Medicaid expansion.

Conclusion

It seems clear, even after just a merely skin-deep examination of this issue and its many interrelated and dependent corollaries, that this debate may indeed be appropriate. Our federal government has the right and responsibility, many argue, to ensure health coverage and financial protection for its citizens to the extent that it can. Likewise, the States each have the right and responsibility to be concerned about their financial welfare when state budgets directly impact state citizens. This is US Federalism at its core.

And the debate is far from over. Certainly, the Republican routing in the November mid-term elections, given that party’s distaste for all things Obamacare, does not forecast a favorable future for the initiative. Having said that, it is no secret that Medicaid funds are generated by and distributed from general federal tax revenues. This means that even states that choose not to expand Medicaid are paying for it. How long will citizens in states that choose not to expand, such as Texas, be complacent with the denial of additional federal revenue, all the while knowing that their federal tax dollars are paying for benefits enjoyed by other states? Only time will tell.

Which brings me back to Justice Brandeis’ historic dissenting admonition. The States are the laboratories of democracy. No one would or could legitimately argue that either the Federal or State governments do not want to provide for and protect their citizens. The question comes down to who should do it and how. Overall, whether states choose new innovations designed to privatize and control Medicaid Expansion funds or choose to use increased funding to focus locally on educating beneficiaries on what resources are available and how to more efficiently use the system, choosing not to participate at all seems like a loser here. The States know their citizens and circumstances better than the Federal government and changes need to be made to the status-quo. The fallout is certainly not clear, but the “courageous” state that Brandeis highlighted will take the money and see what positive progress it can make.

Jaime Whitt is her fourth and final year of a joint-degree program at KU.  She will graduate in May 2015 with a Masters in Health Services Administration from the University of Kansas School of Medicine and a J.D. from the University of Kansas School of Law, with a focus in Healthcare and Health Law.  When she is not in school, Jaime is a Law Clerk at Simpson Logback Lynch Norris, P.A. in Overland Park, KS and is a Graduate Research Assistant in the Department of Health Policy & Management at the University of Kansas School of Medicine studying health policy and health reform.