Friday, August 29, 2014

Feds approve PA Medicaid expansion plan

The federal government has given its approval to a revised version of Governor Corbett’s Healthy Pennsylvania plan. The approval could mean that Medicaid health insurance coverage becomes available to over half a million currently uninsured adults beginning January 1, 2015.
Medicaid is the main public health insurance program for people with low income. It is the largest source of health insurance in the United States with coverage provided to more than 66 million Americans (1 in 5). The Medicaid program is administered by the states but most of the financing comes from the federal government. To get the federal funds, states must comply with federal rules.  
In the past, Medicaid was not available to many low income adults. The Affordable Care Act (ACA - commonly referred to as “Obamacare”) expanded the Medicaid program to cover millions of previously uninsured adults. However, a Supreme Court ruling effectively made the Medicaid expansion portion of the ACA optional for states.
In Pennsylvania, Governor Corbett initially declined to expand Medicaid. However, he changed his mind and earlier this year submitted his Medicaid expansion plan, called Healthy Pennsylvania, to the federal government for approval. After months of negotiation, during which many aspects of the Governor’s original plan were dropped, the state and federal governments came to agreement.
The newly approved Pennsylvania plan involves two parts: (1) changes to Pennsylvania’s current rules for regular (state plan) Medicaid (“Reformed Medicaid”); and (2) a demonstration project (Healthy PA PCO demonstration) that waives of normal Medicaid rules. “PCO” stands for “Private Care Option” and means the state will be utilizing private managed care health plans.
More information on the changes is available in a press release from the Governor’s office here, on the Healthy PA website, and in the federal government’s final approval letter, and special terms and conditions.
The Healthy PA PCO part is classified as a demonstration project (under Section 1115 of the Social Security Act) with federal approval given through December 31, 2019. The demonstration authorizes the state to require that a portion of the new adult coverage group receive benefits through private managed care health plans and provides authority for the charging of premiums and the implementation of healthy behavior incentives.  
Assuming the plan is implemented, Medicaid coverage will be available for Pennsylvania adults earning below 133 percent of the federal poverty level ($15,521 in 2014). In 2016, participating adults whose earnings are above the federal poverty line (currently $11,670) may have to pay premiums of up to 2 percent of household income. Healthy behaviors can reduce the cost sharing.
According to the Associated Press, the expansion is expected to save Pennsylvania billions of dollars over the coming years. The federal government will pay the cost of the state’s Medicaid expansion through 2016. The federal government’s match rate gradually drops beginning in 2017, decreasing to 90 percent in 2020 and after.
Expanded Medicaid coverage under the Healthy PA PCO demonstration may be particularly important to individuals who are over age 50 but not yet eligible for Medicare. As they reach age 50-64 people become more susceptible to health problems but private health insurance may be too expensive or difficult to obtain. As a result many in this age group go uninsured until they are eligible for Medicare. 

Some individuals are specifically excluded from coverage under the demonstration, including:
  • Pregnant women, with the exception that a woman who becomes pregnant while in PCO coverage may elect to stay in PCO coverage.
  • Individuals who are institutionalized.
  • Individuals who are dually eligible for Medicaid and Medicare
  • Individuals 65 years of age and older.
  • Individuals under 21 years of age.   
It is unclear how the election of Tom Wolfe as Governor this November might impact the implementation of the plan. Wolfe has proposed following the more traditional ACA approach to expanding Medicaid.    
Note: Since January of 2014 some non-Medicaid eligible individuals have been able to purchase health insurance coverage through the ACA’s health insurance exchange. But gaps exist and insurance through the exchange has been unavailable or unaffordable for many lower income Pennsylvania residents. The new Healthy PA PCO demonstration program should help fill those gaps.
Further Reading:
CMS Final Approval Letter, August 28, 2014
Corbett Announces Historic Approval of New Healthy Pennsylvania Program, Office of the Governor Press Release, August 28, 2014)
Pennsylvania’s Healthy PA website:
U.S. approves Pennsylvania Medicaid-expansion plan, Associated Press via York Daily News, August 28, 2014
Medicaid Moving Forward, Henry J. Kaiser Foundation, June 2014

Monday, August 25, 2014

Report: Fragmented Long Term Care System Needs Reforms

Older adults have difficulty navigating a long term care services and support system that is characterized by loose coordination, inconsistent communication, fragmented delivery and navigation difficulty by consumers and providers alike. There are multiple entry points for services, multiple services with differing levels of qualification and approvals, county-by-county variations, duplicative regulations, and paperwork that characterize a disjointed and confusing system. (p19).

Family caregivers, independent and care dependent older adults, and middle income seniors are most likely to fall between the gaps, and may be unable to afford self-pay but do not qualify for many services. (p16)
These are some of the conclusions contained in a newly issued Joint State Government report on long term care issues in Pennsylvania. The report includes 37 specific policy findings and/or recommendations. (Note: I have italicized direct quotations from the report. Page numbers refer to the online version available at
The Joint State Government Commission (JSGC) is a non-partisan research organization serving the Pennsylvania Legislature. It provides lawmakers with a means for conducting interdisciplinary studies. The JSGC Long Term Care report was written in response to a legislative request for a study of the Commonwealth’s delivery system of long-term care services and supports for independent and care-dependent older adults.
To conduct its study the JSGC formed an advisory committee of 29 experts. The goal of this advisory committee and JSGC staff was to objectively review the issues relating to long term care, establish the current state of services and supports, and analyze the needs of the growing population of seniors. (p4)
In addition, the JSGC staff did background research and traveled throughout the state to speak with stakeholders, visit nursing homes, assisted living residences, personal care homes, continuing care retirement communities, adult day services, and senior centers, and hold information sessions.
The recommendations of the advisory committee are contained within the Findings & Recommendations chapter, which includes several proposed statutory and regulatory changes. The recommendations propose policy and legislative changes that focus on more efficiently and effectively meeting the needs of consumers. (p4)
The amount of consensus achieved by the advisory committee is remarkable given its diverse membership and the reality that long term care stakeholders have very strong and defined special interests with huge dollar implications based on policies adopted. (p2). If this group could agree on 37 points, state government should take heed. 

Here is a sampling of the recommendations:
System Structure and Organization
1. Redesign and enhance the long term care system in Pennsylvania
4. Develop a standardized assessment tool which can be used to for all individuals needing long term care services to determine needs and measure outcomes
Long Term Care Services and Supports
10. Expand home and community based services
12. Need for expanded respite care and adult day services
Payment for Services
22. Reduce waiting for long term care and support services
23. Eliminate hard caps for benefits
27. Conduct a study on the feasibility of including personal care and assisted living homes under waiver
30. Permit HCBS providers to allow presumptive eligibility
Regulatory and Statutory Reforms
37. Change Medicaid rules around long term care support services make them consistent with nursing homes
In addition to its Findings and Recommendations the report contains useful background information on the long term care system in Pennsylvania. 
The authors recognize that Pennsylvania is facing a “silver tsunami” at its doorstep as the baby boomers increase the need for aging services. The graying of this state has increased demand on both services and funding. (p13).  
We cannot meet this rising tide solely by increasing efficiency or prevention.
Efficiencies in operations and delivery, along with healthy living initiatives by government and private insurers, will only go so far to divert people from needing LTC and it is inevitable that more services will be needed to serve a growing aging demographic. (p15)
Given the growing need for more long term care services, the JSGC report asks fundamental policy questions:  
How can the state deliver more services to more people given budgetary constraints? How can those services be safeguard without the unintended impact of regulations on providers, making them spend more time on compliance paperwork than delivery of care? How can true consumer choice be promoted when there may not be the money to support those choices? There is no one solution and the complexity of the combined funding, delivery, and support systems will keep this issue on the front burner for families, consumers, and policy makers in the decades to come. (p1)
According to the report [t]his state needs a consumer friendly approach that provides greater availability of and access to services. The primary focus should be to reduce barriers and provide a seamless system across the continuum of care, including medical care, safe and affordable housing, supportive and supervisory services.... The ultimate goal is to sustain coordination of care in a consumer directed model that connects people with the right services when they are needed. (p20)
The report contains some errors that reflect the immense complexity of the laws and regulations involved in our current health and long term care delivery system. But, overall its description of the dysfunction in the system is accurate, and its findings and recommendations provide an excellent resource for policy makers who have the responsibility of protecting our frail and vulnerable elderly.  
Long term care is not an investment in the future for the state’s children, it does not maintain the infrastructure in roads or bridges, but it serves an important government function to help its most vulnerable citizens. That function may be as critical as the constitutional duty to protect the health, safety and welfare of all Pennsylvanians. The aged represent some of the most vulnerable of those citizens, a generation that has paid its dues and should receive a level of programs and services to its benefit. Policy makers often focus on getting the youngest citizens off to a great start in life, but the oldest citizens need the opportunity to end their days with choice, dignity, and respect. (p3)  
More reading:

Thursday, August 21, 2014

Down Syndrome Education Act Becomes Law

Pennsylvania has enacted a new law that requires health care practitioners to provide educational information to parents who receive a test result that is positive for Down syndrome. Dubbed “Chloe’s law” by its sponsors, the Down Syndrome Prenatal and Postnatal Education Act (Act 130 of 2014) was signed by Governor Corbett on July 18th.
Act 130 requires that, upon receiving a test result that is positive for Down syndrome, health care practitioners must provide the expectant or new parent with educational information made available by the Pennsylvania Department of Health (DOH).
The information to be developed by DOH will include evidence-based information about Down syndrome that has been reviewed by medical experts and national Down syndrome organizations. Included will be information about: 

  • Physical, developmental, educational, and psychosocial outcomes

  • Life expectancy

  • Clinical course

  • Intellectual and functional development

  • Treatment options

The information must also include contact information for first call programs and support services, hotlines specific to Down Syndrome, relevant resource centers, clearinghouses and national and local Down Syndrome organizations.
The law has created some controversy. Marie McCullough reports in the Philadelphia Inquirer that the law is opposed by the American College of Obstetricians and Gynecologists on the grounds that it interferes with the physician-patient relationship. The law is also opposed by the Pennsylvania Medical Society.  
Although its sponsors argue that it is an information law rather than a pro-choice or pro-life law, some pro-choice advocates disagree. And Ms. McCullough notes in the Inquirer that advocates for the law “hope the information will discourage women from aborting affected fetuses now that noninvasive genetic testing is making diagnosis easier, earlier and more accurate.”
Despite any controversy, Act 130 passed by the State House by a vote of 196 to 4, and the State Senate by a vote of 50 to 0.
Further Reading: