Medicaid vs Education

In The Hill yesterday, Dick Morris, one-time Republican strategist and advisor to President Clinton beginning with the 1994 midterm elections, wrote about the looming social battle between state funding of Medicaid v. Education

Even in those states that have chosen not to expand Medicaid through the Affordable Care Act’s benefit opportunity Morris believes they will be, “unable to provide decently for education without cutting back on the ambitious Medicaid expansion” as insurance exchanges provide coverage to individuals already eligible for Medicaid without the ACA.

He points out that Medicaid’s recently modest spending trajectory is set to increase substantially with increases in enrollment (spending is projected to rise 12.2 percent in 2014, 7.9 percent in 2015 and 2016, and 6.6 percent per year thereafter). But with state budgets overall not increasing commensurately, that means Medicaid spending must take a bigger share of the budget pie – and something else must get less.

Morris believes that will be education and has issued this dire warning: “we cannot afford both [education and Medicaid]. Of course, states can still raise taxes and join jurisdictions like Detroit into their slow spiral to oblivion.”

What really puts this suggested tradeoff on the razor’s edge is the evidence of failure that Medicaid expansion efforts have generated. Of course the Oregon Health Insurance Experiment is both timely and top of mind here. If you haven’t already, I encourage you to take the time to at least survey that research. In a nutshell, the experiment found that expanding Medicaid resulted, “in no measurable health benefits in the Medicaid group for several chronic conditions, including hypertension, high cholesterol and diabetes.” It did result, however, in a significant increase in ER utilization, where relative costs are substantially higher than primary care settings.

Expanding healthcare coverage to those who cannot otherwise afford it is both a noble and moral obligation of a progressive society. But making choices to pursue noble pursuits with limited resources is a reality that becomes more urgent every day in the face of what we have seen  happen in other countries due the lack of fiscal responsibility.

Mr. Morris has pointed out an important and challenging debate that states will have to wrestle with in the years ahead. It’s hard to make the argument for defunding children’s educations to support a program that has so far not achieved the desired ROI. But while we’re focused on relative social ROI we might also want to look critically at the success of state investments into educational programs.


Blog image from The Hill ~ Jenny Francis

Turning Up the Heat on Medicaid Expansion

There was a study published last week in the New England Journal of Medicine that is getting a lot play in the popular media – which as I have written before is the sharpest of double-edged swords where issues of truth and reality are concerned. Nonetheless, the timing of the research reported is well done in light of a number of states still wrestling with whether or not to accept the Affordable Care Act’s Medicaid expansion.

The Oregon Experiment — Effects of Medicaid on Clinical Outcomes

Back in 2008 approximately 90,000 individuals in Oregon signed up for a lottery that would subsequently provide Medicaid coverage to approximately 30,000. In doing so, Oregon created two randomly selected groups that could be analyzed to determine the comparative effects of having access to health insurance via the state Medicaid program there.

Two years later the relative impact of being insured through Medicaid produced what on the surface appears to many as conflicting results. Use of medical services (i.e., physician services, medications and hospital services) by those covered by Medicaid increased 35%, while access to preventative services and screenings increased by 50% or more. The rate of depression incidence in the Medicaid covered population was reduced by 30% compared to the control group. In addition, the financial impact on families was dramatic – e.g., it was reported the probability of having to endure financial hardship to pay medical bills was reduced by more than 50%.

On the other hand, the health impact in terms of outcomes for those individuals covered by Medicaid was less impressive. In fact, while those receiving the Medicaid benefit were more likely to be diagnosed with diabetes as compared to the control group, their blood sugar levels were not markedly impacted. And the same held true for blood pressure and cholesterol levels.

So in a nutshell, what the research shows is that having health insurance can drive higher access and utilization of available medical services. If you provide it, they will use it – a good thing. But it very well may not have a significant impact on health outcomes – particularly outcomes that are largely influenced by chronic conditions such as obesity, diabetes and hyperlipidemia (high cholesterol). Providing it won’t change lifestyle behaviors – a bad thing.

As this research demonstrates, addressing the behavioral elements that impact health outcomes is far more difficult and far more complex than just an access issue. But I think it is certainly shortsighted and faulty logic to fail Medicaid based on health outcome data alone. Improving access and utilization of medical services by the un- and underinsured population is a progressive advancement that has merits independent of outcomes, which is further reinforced when considering the relatively short time period covered by this research.

But the more salient if not subtle point of these results is that chronic disease management requires a coordinated effort of social, educational and medical influences that clearly place expectations of behavior modification beyond the sole responsibility of healthcare practitioners. That reality neither bolsters nor detracts from the arguments being made in support of state Medicaid expansion under the Affordable Care Act despite what you may read or hear otherwise.


Medicaid Coverage of Nursing Care in Tennessee: Prudent, Rationing or Inevitable Reality?

In an article published yesterday in the Washington Post, Guy Gugliotta writes about a new Medicaid policy in Tennessee, which seeks more efficient alignment between reimbursement and cost settings (my interpretation). 

This is very likely an important bellwether of state Medicaid policy that will be repeated in some fashion or other in other states, and it has unsurprisingly been met with a fair amount of controversy and concern.

Operating under a Section 1115 waiver from CMS, TennCare is the State of Tennessee’s Medicaid program, providing health care for 1.2 million with an annual budget of $8 billion. TennCare utilizes a managed care model that extends coverage to additional populations who would not otherwise be Medicaid eligible, while seeking to maintain a consistent level of quality care.  Tennessee has one of the oldest Medicaid managed care programs in the country, having begun on January 1, 1994. It is the only program in the nation to enroll the entire state Medicaid population in managed care.

On June 20th of this year TennCare released a new Nursing Facility Level of Care Guide outlining programmatic changes to its CHOICES program, which, “are designed to target Nursing Facility services to persons with higher acuity of need, while simultaneously making Home and Community Based Services more broadly available.”  This is the subject of the above-referenced article.

With this initiative TennCare seeks to increase the Nursing Facility Level of Care criteria necessary for Medicaid eligibility to a level it believes to be more in line with criteria used in other states while providing a less costly benefit for those individuals who will no longer qualify under the new criteria.  The new criteria are being applied prospectively, so no one currently qualifying for nursing care will be affected.

Under the new eligibility criteria three groups are established:
Group 1: Individuals eligible to receive care in a nursing
facility (NF) and requesting care in a NF;
Group 2: Individuals eligible to receive care in a NF but
                   requesting home and community-based services
                   (HCBS) in lieu of receiving care in a NF; and
Group 3: Individuals not eligible to receive care in a NF,
                   but “at risk” of NF placement and requesting
                   HCBS in the TennCare CHOICES program.

Group 3 is the population of concern and being debated from a policy perspective.  These are individuals that may have qualified for nursing care coverage under previous criteria and been eligible for HCBS cost coverage at a level commensurate with the cost of coverage in a NF.  Now the annual benefits available to this population will be $15,000.

From a consumer advocacy perspective the concern is that many individuals in Group 3 will not receive adequate services and care because the $15,000 benefit is not sufficient.  From a state policy perspective the concern is trying to allocate finite resources in a fashion where those individuals with the greatest need are afforded the ability to receive care that meets those needs.  In short, pub patrons, welcome to Healthcare Public Policy in the 21st Century.

From a pragmatic vantage, the initiative in Tennessee has very important ramifications for providers of community-based services and post-acute/long-term care.  This is an initiative that is certain to hasten the trend toward HCBS and away from care in institutional settings.  It is a threat to projected demand for long-term care in NF settings – and it is a threat to projected reimbursement levels available to HCBS providers under Medicaid.

It seems to me that any healthcare provider wishing to include the Medicaid population in its targeted market in the future look now at how to integrate BOTH NF-based care AND HCBS in its care continuum if it wishes to be economically viable and sustainable.  What do you think?

~ Sparky

Managed Care for Dually Eligible

On another discussion venue in which I participate, a very learned and esteemed physician colleague in the San Francisco area shared with our group a recent brief from the California Medical Association (CMA Alert) regarding that state’s pilot project to move dually eligible individuals in Los Angeles, Orange, San Diego and San Mateo counties into a managed care plan.

Under the Medi-Cal 1115 Waiver, California is pursuing four pilot projects to redesign care for dually eligible seniors.  Similar pilot projects are being pursued in a number of other states as part of a national effort under the direction of the Center for Medicare & Medicaid Services’ (CMS) Center for Medicare and Medicaid Innovation (CMMI).  Of significance for this post, it was noted in the CMA Alert that, “if dual eligibles (sic) wish to remain in fee-for-service Medicare, they will have to actively choose to do so.”

In other words, they will be assigned to the new managed care pilot project by default.  Given what is the reasonably perceived inability of this aging population to necessarily advocate for themselves, at issue is whether such default can be interpreted as a back door mandate.  Are these individuals being deprived of their right to choose their healthcare provider? And who, by right, assumes the responsibility of advocating on their behalf?

This is certainly a moral dilemma, and I can appreciate CMA physician members’ concerns.  We are a nation and society with deep roots and political sensibilities to individual rights.  We are also a society, however, that is facing a potential national calamity in being unable to provide basic housing, services and care for an aging population that cannot afford to pay for such necessities.  From that vantage, I think an effective argument can be made that the potential to infringe upon such rights is outweighed by the urgent need to proactively develop innovative public policy solutions to address the aging tsunami that is building every day.

But setting aside for the moment the issue of the means by which the dual eligible population is enrolled, according to a Kaiser Family Foundation research paper, when compared to the non-dual eligible population dually eligible individuals are more likely to have chronic care needs, have a higher incidence of ADL needs, and be more than twice as likely to be both in fair or poor health – and suffer from a cognitive or mental impairment. This is a population for which the right to choose their own doctor is often not high on their list of priorities. This is also the very population where coordination of services and care across community-based programs, acute care, post-acute/long-term care and behavioral health services has the most promise of being beneficial to the individual because of the huge communication gaps that now exist between those areas.

So we are looking at a frail elderly population that isn’t able to pay for their own care – and likely in need of a host of complimentary/supplementary assistance (housing, ADL assistance, private duty, medication management, behavioral health – addiction in this population is scarily on the rise).  I do not wish to be ignorant of those individuals’ rights – but we are standing on the beach looking into the abyss of the looming demographic tsunami and understanding before a lot of others that such tradeoffs will have to be made.  They will be made.  The only thing at issue is when and how.  Wouldn’t it be better to plan for the flooding after the age wave hits?

These are the types of critically important public policy issues that senior housing, aging services and PA/LTC organizations should be aware of – and have active participation in their advocacy – whatever your views.

So, what do you think?

  ~ Sparky