The doctor will see you on screen, after math class

Texas is making access to health care much more convenient for the parents of children enrolled in the state’s Medicaid program. Through new legislation effective September 1, 2015, providers will be able to bill the program for telemedicine appointments after “seeing” the patients over video chats during school hours, with the help of the school nurse. If a diagnosis is made, parents will be able to pick up a prescription later that day.


State Representative Jodie Laubenberg (R-89) authored the legislation in an effort to increase access to health care while limiting work and school disruptions for parents and students. Laubenberg pointed to programs like the one organized by Children’s Health(SM), which provides 27 grade schools in the Dallas-Fort Worth area with electronic access to a doctor and two nurse practitioners. A local school nurse (who may or may not have a nursing degree) examines the child, and then schedules an appointment with Children’s if a problem is observed. Due to the success of the program, Children’s will deploy to an additional 30 schools. This program was limited to five years of funding through a Medicaid 1115 waiver, so the new law is vital to continuing to provide this type of access. The Texas program follows similar laws in Georgia and New Mexico.

Although some point out that the vast majority of things seen in a pediatric clinic, like sports injuries, strep throat, and mental illnesses, can be handled via telemedicine, others have raised concerns about these programs. Even those who find health intervention in school “effective” are concerned about equity and access for children who get sick in school but are not enrolled in Medicaid. Others pointed out that these busy doctors may not have a full picture of the child’s health, and children cannot be expected to understand risks and report allergies and medical histories appropriately.


The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) incorporates telemedicine in several sections, paving the way for the increased use of this method of providing care. For example, section 3021 of the ACA created the Center for Medicare and Medicaid Innovation (CMMI) in an effort to test new payment models, including ways of using telehealth services to treat behavioral health issues (see Are we there yet? Telehealth, telemedicine, and the ACA, Health Reform WK-EDGE, April 22, 2015). As states embrace new ways of delivering care and explore payment strategies, the ACA can serve as a guide for reform.

Community health in good shape all over; local Medicaid, behavioral health issues remain

State and federal governments must juggle many different responsibilities in their efforts to legislate and oversee health care concerns. Even as one area sees great strides, others clamor for attention. Although underserved areas will receive new health care centers through new funding made available from the community health program, many issues remain in North Dakota’s behavioral health and North Carolina’s Medicaid programs. These states’ legislators will have to work diligently in the coming months to ensure that their residents obtain proper care.

Community health centers, already doing well, get a boost

On August 11, 2015, HHS announced that more Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) funding would be available to create 266 community health centers (CHCs). These centers, which will be located in 46 states, D.C., and Puerto Rico, will receive a total of $169 million to enable them to offer care to the neediest communities. This follows a $101 million award announced in May 2015 for 164 new health centers.

The CHC program started under President Lyndon Johnson and grew at a slow pace over the next several years. President George W. Bush decided to double federal financing for the centers and created or expanded almost 1,300 clinics. The Obama Administration has already funded over 700 new health center sites through the ACA. In all, the national community health program serves nearly 23 million people. The program claims to save over $24 billion each year in health care costs due to early treatment of diseases and preventive care. The centers target low-income communities such as poor urban neighborhoods as well as isolated rural areas. The availability of these centers helps keep costs low, as patients would otherwise seek care in more expensive settings.

North Dakota’s behavioral health care has a long way to go

In contrast to the successful outreach of the community health program, states are struggling to properly meet their residents’ mental health needs. North Dakota is no exception. Although lawmakers have turned their focus to the matter and have been making strides to improve behavioral health services, the interim Human Services Committee said that the state still faces numerous hurdles. A final report from a consulting firm hired after the 2013 legislative session recommended changes in six areas: service shortages, workforce expansion, insurance coverage, communication, data collection, and the structure of the state agency.

Representative Kathy Hogan (D-Fargo) has been tasked with leading the interim committee. She feels that legislators are taking the problem more seriously, as 20 have asked for updates from the committee. The committee will study behavioral health needs and the best way to meet them. The members will develop recommendations and bill drafts for implementing the solutions, which Hogan admits is going to be a difficult process.

Last year, the legislature passed several behavioral health-related bills. One gave the Department of Human Services (DHS) $750,000 to address underserved areas as well as offer more addiction treatment services. Elizabeth Faust, Blue Cross Blue Shield of North Dakota’s senior medical director for behavioral health, said that throwing more money at the problem is not the answer. In her mind, the resources need to be spent more wisely. She told the committee that evidence-based, high-quality care must be consistently provided. Nancy Vogeltanz-Holm, director of the University of North Dakota School of Medicine’s Center for Health Promotion and Prevention Research, was encouraged to hear about the legislature’s awareness of  the workforce shortage. In 2013, North Dakota was ranked 43rd in mental health workforce availability.

North Carolina Medicaid reform forecast is stormy

The North Carolina House unanimously rejected the Senate’s Medicaid plan. The Senate bill would have changed the fee-for-service system and instead offered a per-member monthly allotment for in-state providers and commercial insurance. It also would have created a cabinet-level department of Medicaid. Following the rejection, the matter moved on to a committee of negotiators who already believe that a deal is in sight. House Republicans have tentatively agreed to a hybrid model that would involve both managed care companies and provider-led organizations. Patients would have the freedom to choose if their care will go through a large insurer or handled by a local provider-insurer combination.

Ryan White CARE Act celebrates 25 years

Many people who witnessed the early days of HIV/AIDS will never forget Ryan White, a young boy from Indiana who was diagnosed with AIDS and who brought much-needed attention to AIDS-related discrimination when he fought for the right to attend school. Twenty-five years after his death, Ryan White’s legacy lives on in the form of a comprehensive federal health program that bears his name.

Twenty-five years ago, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act (P.L. 101–381) funded the Ryan White HIV/AIDS Program, which is a federal program that provides services to low-income individuals living with HIV. In recognition of the 25th anniversary of the landmark law, the Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) is celebrating with the anniversary theme of “Moving Forward with CARE: Building on 25 Years of Passion, Purpose, and Excellence.”

Ryan White

Ryan White was a young man from Indiana who was diagnosed with AIDS at age 13 following a blood transfusion. Ryan and his mother, Jeanne White Ginder, fought to allow him to attend school and became international figures in the fight against AIDS-related discrimination. Ryan died at age 18 on April 8, 1990.

Ryan White HIV/AIDS Program

Just months after Ryan died, Congress, with bipartisan support, passed the Ryan White CARE Act, which was signed into law by President Bush on August 18, 1990. The Act provided for the creation of the Ryan White HIV/AIDS Program, which continues working to this day with various city and state governments and local, community-based organizations to provide a treatment system that is coordinated and comprehensive. The Act, which is now known as the Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87),  has been amended and reauthorized four times, the last time in 2009.

The program has provided service to more than 500,000 low-income individuals who lack sufficient health care coverage or financial resources to help manage their disease. In 2015, the program was funded at $2.32 billion.

Program Achievements

Over the past 25 years, 81 percent of the clients of the program are “retained in care,” meaning that they receive health care, with more than 78 percent of those being virally suppressed, which means that they have very low levels of the HIV in their bodies. The key treatment of HIV is viral suppression because it allows people to live healthier, longer lives and reduces the transmission rates.

HHS Secretary Sylvia M. Burwell stated, “Over the last quarter century, the Ryan White HIV/AIDS Program has contributed to remarkable progress for people living with HIV/AIDS.” Burwell further stated, “What was once a deadly disease, HIV/AIDS is now a manageable chronic condition because of access to high quality health care and appropriate treatment. Although we have more work to do, particularly in reaching the populations most at risk and disproportionately affected by HIV, we are committed to realizing the President’s vision of an AIDS-free generation.”

Updated National HIV/AIDS Strategy

The White House, citing the Ryan White HIV/AIDS Program as a critical source for HIV care and treatment, released the National HIV/AIDS Strategy: Updated to 2020. The program, which is administered by the HRSA, will focus on reducing new HIV infections while increasing access to care and improving health outcomes. It will also work toward reducing health inequities and HIV-related disparities while creating a national coordinated response.

President Obama issued a statement celebrating the CARE Act’s anniversary while detailing the national HIV/AIDS strategy going forward. He said, “By providing critical comprehensive care to so many Americans living with HIV, the Ryan White Program continues to be a cornerstone of our strategy to address HIV across America. It is part of our collective effort to ensure that every American has unfettered access to high-quality care—free from stigma and discrimination—and it helps us inch closer to a day when nobody has to know the pain caused by this devastating disease.”

GOP Senate bill to protect business, nonprofit conscience

Senate Republicans introduced new legislation to bar the federal government from requiring business to provide insurance for drugs and services that violate their moral beliefs. Sponsored by Sen. James Lankford (R-Okla), the bill, S. 1919, titled the Health Care Conscience Rights Act, would allow private businesses and religious nonprofits to negotiate health plans that do not cover abortion or forms of birth control they object to without risking heavy fines under the “contraception mandate” established under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The bill continues the renewed debates over religious liberty, abortion, and the legal fight over the availability of birth control benefits under health insurance plans post-ACA.

According to the GOP sponsors, the bill would prohibit any action by the federal government and any state or local government receiving federal financial assistance to subject a health professional, a hospital, a provider-sponsored organization, a health maintenance organization, an accountable care organization, a health insurance plan, or any other kind of health care facility, organization, or plan to discriminate on the basis that the entity refuses to participate in abortion-related activities. Democrats charge that the bill is one of many efforts to create obstacles for women’s health services.

Under current HHS policy, closely held corporations and religious nonprofits can notify either their insurers or the federal government of objections to insuring certain contraceptives, and the insurers or plan administrators would then step in and make sure employees can receive contraception coverage without the religious entity having to pay for it (see New government guidance clarifies and expands scope of ACA contraception coverage mandate, Health Reform WK-EDGE, May 27, 2015).