The Truth About Marketplace Health Plan Rates

You may have heard stories about dramatic increases in private health insurance rates since the implementation of health reform. Although Illinois insurance carriers recently sent preliminary 2017 rates to regulatory authorities, we likely won’t know what the final prices and plans for next year look like until closer to the beginning of open enrollment. But we already know that misinformation about increased rates is being hyped by the media.

Fingers crossed behind backThis is a lie about Obamacare plans that we’ve heard before. What stories about these proposed rate filings often miss is that, even if premiums go up, financial assistance (through tax credits) to help pay for those premium increases as well. Simply put, the majority of consumers in the Marketplace won’t feel the premium price increases that the media often focuses on.

A new report from the U.S. Department of Health and Human Services (HHS) proves the point. The report found that, last year, the average cost of Marketplace coverage for people getting tax credits went from $102 to $106 per month—a modest increase, especially when you think about how costs for everything tend to rise.

In Illinois, 75% of Marketplace consumers receive tax credits based on their income. By design, tax credits increase if the cost of the benchmark plan (the second lowest-cost silver plan) goes up. So if all premiums in a market go up by similar amounts, consumers who get tax credits will not necessarily pay more, because their tax credits will go up to compensate.

In addition, if a Marketplace consumer isn’t happy with his or her current plan—either because the premium went up or for another reason—the consumer has the ability to, and in fact is encouraged to, come back and shop around. According to HHS, nearly 50% of returning consumers selected a new plan for 2016. In Illinois, that number was greater than 50%, and those consumers saved an average of $636 annually.

The stories we keep seeing about big rate increases happen only in a world that doesn’t exist. As the HHS report notes, “the average premium changes reported in insurers’ rate announcements assume a scenario in which no consumer leaves the Marketplace, no new consumers enroll, nobody switches plans, no new plans are offered, and no one receives tax credits.” We know from the past three years of Marketplace experience, these assumptions do not reflect reality. Beyond the fact that the majority of Marketplace customers receive tax credits, we know that consumers whose income or job situation changes will move between the Marketplace and employer-subsidized plans or Medicaid. Moreover, for better or for worse, the Marketplace is robust with choices (the number of plans in Illinois increased from 410 choices in 2015 to 480 choices in 2016) so people will often “vote with their pocketbook” and switch plans.

Of course any increase in premium prices for Marketplace consumers will be a hardship to many. Moreover, out-of-pocket costs (like high deductibles) continue to concern Illinois consumers. However, it’s important to step back and remember that before the Affordable Care Act, affordable, quality health care was completely out of reach for many consumers—for example the millions of people with pre-existing conditions. And for many more, health care plans excluded important services like maternity care or mental health treatment.

Now, Illinois consumers have the option to purchase quality health plans and have the financial assistance to help pay for them. The media need to acknowledge the immense benefits of these tax credits, if they are going to responsibly report on premiums.

Ask the Assisters: Three Secrets to Health Care Outreach and Enrollment Success

As Year 3 of Affordable Care Act (ACA) enrollment quickly approaches, we can look to experienced assisters to figure out how to best plan for a successful year. During the first two years of open enrollment, Illinois had a large cadre of in-person assisters: hundreds of federally funded navigators, state-funded In Person Counselors (IPCs), and Certified Application Counselors were spread out across the state from Moline to Chicago and Waukegan to East St. Louis. These assisters were located in diverse communities from Polish, Latino, and Chinese urban immigrant enclaves to communities of young invincibles in college towns to farming communities mid-state. Over the past two years they reached many hard-to-serve populations, such as limited English speakers and homeless populations that may never have gotten coverage without in-person assistance.

Yet, even with their different backgrounds and experiences, the enrollment specialists we interviewed this summer about “best practices” in outreach and enrollment all had similar things to say. When it comes to a successful outreach plan , three strategies were key:  Partnerships, Meeting People Where They Are, and Building Trust.


Partnerships of all kinds – with the state, with other community-based organizations, and with other enrollment entities – made all the difference to Illinois enrollment assisters in their ability to increase their impact.

Martin Logo of the Project of the Quad Cities said that their collaboration with Get Covered Illinois helped them provide staff trainings and logistical support to enrollment assisters. In addition, the Project of the Quad Cities worked with local job training sites that provide literacy services, job skills, and counseling to unemployed and low-income individuals. The partnership included staffing information tables at events, weekly presentations, and one-on-one enrollment sessions. The Project of the Quad Cities was invited to speak during various job information classes and reached a large number of uninsured, unemployed residents who previously had minimal information about the ACA.  

Bill Green of United Way of Metropolitan Chicago stressed the importance of working with existing organizations that have a wealth of knowledge about their local community and its needs that assisters do not always recognize. For example, an agency in Chicago’s Chinatown knew that many community members commute via bus to work every morning. Assisters working with the organization decided to go to the bus stop in the early mornings to hand out flyers and make enrollment appointments. Without input from the local organization, the assisters would not have known how to reach the population in effective ways.

In another example of collaboration, navigators working within the Chicago Northwest and Southwest Consortium formed a tight collaborative of over 25 partnering enrollment organizations in highly uninsured neighborhoods in Chicago. Representatives from all enrollment organizations hold bi-weekly meetings, share their best practices and challenges, and work together toward a common goal of cultivating community enrollment opportunities. This consortium is also working together to develop and pilot a sustainable model for enrollment assistance.

Graciela Guzman, a Navigator with PrimeCare Community Health, described the enormous power of the consortium. Guzman notes that the highest number of enrollments in Chicago came out of this region because of the enrollment organizations’ high-level of coordination and resource sharing. The consortium model benefits assisters as well, giving them a place to share their frustrations and successes with others in their same positions. It also allows a forum for ongoing training, including specialized training beyond what the state can provide.

HelpHub, a technical assistance center for enrollment specialists in Illinois, and the Shriver Center provided ongoing trainings for the Chicago Northwest and Southwest Consortium. These trainings were offered at quarterly meetings on subjects such as Medicaid redeterminations and renewals, the TANF/SNAP online system integration with Medicaid, and immigrant eligibility trouble-shooting.

Building a consortium of small, regional groups of assisters can be helpful because members of the individual groups know their particular neighborhoods or communities well or can address specific needs together like outreach to new immigrants.

Meeting People Where They Are

To be effective, assisters must go to the people. As Bill Green stated, “You have to go inside the community itself.” According to Green, the most effective enrollment events by far were ones that “piggybacked on existing community events. Creating our own events didn’t work very well.”

Every interviewee mentioned the ongoing necessity of expanding enrollment assistance and health literacy by providing language access in multiple languages. A large proportion of the uninsured do not speak English, and it is important to be able to educate them about their healthcare options in languages that they can understand. For example, Martin Logo said that his organization gave educational presentations at community meetings in English, French, and four different African languages. Graciela Guzman says that a third of her clients self-reported having difficulty reading and writing in their native languages or in English, and 90% needed email accounts created because they did not previously have one and were not familiar with computers.

Megan Davy, of Peer Services in Evanston, had a particularly adventurous take on meeting people where they are. Davy knew from a long career in advertising that “word of mouth is the best advertising.” She took to the streets, walking into every business and speaking to every owner about his/her employees’ health insurance coverage. She spoke to many employees who were unaware of their need for health insurance, and even more who were unsure of how to get it. By doing this, Davy reached a large population of young invincibles. Moreover, by getting out into the neighborhood and especially meeting people where they are most often (such as at work), Peer Services was successful in getting more people educated and enrolled.

Building Trust

The best practice cited by our interviewees most often was a simple concept but one that takes time to develop. Janice Parker, a Navigator at Navicore Solutions summed it up well: “It’s not just as easy as ‘You want healthcare? Enroll!’ It’s also a matter of trust.” In most cases, this refers to the trust of community members, who aren’t inclined to put their lives in the hands of just anybody.

It takes time to invest in the relationship building. One way to build trust more quickly is for the state, medical centers, or contracted organizations to make a concerted effort to hire from the communities they serve so that they have culturally competent, linguistically expert, trusted partners from the beginning. Sometimes, building trust is as simple as speaking and distributing educational materials in the native language of a client. Graciela Guzman professed that there is “so much trust involved… They believe in your ability to get you through the process. I don’t take that lightly.” Janice Parker stressed the importance of integrating family members into the enrollment process in order to build trust. The individualistic nature of enrollment may alienate some clients, but Navigators have the unique ability to transform it into a much kinder process.

Interviewees spoke about the deep ties they developed with clients. The emotional impact of the job is huge, and assisters’ effect on the lives of their clients is tangible. Megan Davy went on to explain: “Every day, somebody hugged me and said thank you. People share their [specific individual] information. To help somebody feel safe – what’s more important than their health?” It takes skill and trust to reassure someone about privacy concerns and give them individualized assistance in the same manner that financial counselors, insurance brokers, and credit managers do.

Final Thoughts About the Upcoming Open Enrollment Period

Faced with reductions of Get Covered Illinois staff and a much smaller funded network of in-person help across the state, the coming year will bring challenges in Illinois. As Bill Green puts it, year three is certainly a “make or break year.”  Many organizations will no longer have the dedicated full-time staff to work on outreach and enrollment. In the face of these upcoming challenges, building partnerships, building trust and going to where the people are will be more important than ever.

It will also now mean that consumers may turn more to Certified Application Counselors (CACs) at health centers for help enrolling. In turn, CACs may have to do more outreach at health fairs or homeless shelters in the community and other places where uninsured populations who may have been “missed” the first and second time around can be found. Fortunately, the Illinois Primary Healthcare Association, which represents community health centers around the state was chosen as one of the sites around the country to participate in the inaugural Get Covered Academy Endowment, focused on outreach training this year. We are excited about this new partnership and the learnings they can share with the rest of the enrollment community.

As Graciela Guzman puts it. “We’ve enrolled individuals more likely and wanting to enroll in the process. We’re going to have to start thinking outside of the box to reach consumers that may not have heard the message yet or are hesitant about the process.”

From what we’ve seen of these incredibly talented, passionate assisters, they will do just that to enroll the remaining uninsured in Illinois.


This blog post was co-authored by Anna Kanter, intern, and Stephanie Altman, Assistant Director of Health Care Justice at the Sargent Shriver National Center on Poverty Law.

The Shriver Center’s health team trains extensively on ACA implementation in Illinois and runs HelpHub, an online technical assistance center for enrollment specialists in Illinois.

Cross posted on Enroll America's blog here.

50 Years of Medicaid and Medicare

This blog was co-authored by Janine Hill, Executive Director, EverThrive, and Congresswoman Jan Schakowsky (Ill.–09).

When President Johnson outlined his vision in the 1960s to achieve a Great Society, he mapped out a long “to do” list. Central to his mission to eliminate poverty, end racial disparities, and improve the quality of life of millions of Americans was the creation of the Medicaid and Medicare public health insurance programs. 

Yet, even as we celebrate the 50th anniversary of the Medicaid program this week, we are reminded of the constant need to protect it.  Republican leaders in Washington, D.C. continue to propose policies aimed at rolling back key elements of the Medicaid program. And in Illinois, Governor Bruce Rauner had to be ordered by a federal court last week to continue making Medicaid payments to health care providers so that children can receive the care they need during the state's budget crisis.  

Medicaid has played a critical role for the past five decades in the health and economy of our state. After Medicaid was enacted in 1965, Illinois wisely accepted the federal government’s offer to help finance a public health insurance program for select groups of low-income individuals, including children, persons with disabilities and older adults. By enrolling in the Medicaid program, these individuals gained access to the comprehensive health services, like doctor’s visits and medications, they needed, but otherwise could not afford.

Today, the Illinois Medicaid program continues to operate as a joint venture with costs shared between our state and the federal government.  Illinois has designed our program to meet the health needs of our state’s most vulnerable residents. Low income pregnant women, children, and, thanks to the Affordable Care Act, adults without minor children, are also eligible for Medicaid coverage.  Of the three million Illinoisans currently enrolled in Medicaid, about half are children.  Furthermore, Medicaid provides critical health coverage to more than 15 percent of Illinois older adults and more than a quarter of individuals with disabilities living in our state.

There is no other healthcare program that serves so many Illinois residents throughout their lifetime, when they need it.  Similarly, no other health insurance program provides the same comprehensive—and in some cases—life-saving package of health benefits. Research indicates that the maternity and prenatal services available to eligible pregnant women and infants through Medicaid improve birth outcomes and lower infant mortality rates, offering our youngest residents a healthy start. Children enrolled in Medicaid have access to essential preventive and comprehensive health services, including vaccinations and dental benefits. Medicaid fills important gaps in insurance and Medicare coverage—like adult dental services—helps low-income seniors and people with disabilities with cost-sharing and, nationally, pays for one-quarter of all behavioral health services. Medicaid is the single largest payer of long-term care, providing critical home- and community-based services as well as nursing home coverage—helping seniors and people with disabilities get the care they need.

Medicaid benefits extend far beyond doctors’ visits and medication. Medicaid has been proven to reduce health disparities by providing a pathway to health care for scores of individuals who are at a disproportionate risk of being uninsured. A growing body of research shows that Medicaid has been a powerful factor in closing the achievement gap, as children who are covered by Medicaid are more likely to graduate high school, attend college, and have increased future earnings as adults. The National Bureau of Economic Research estimates that, with these increased earnings, the government will recoup 56 cents of each dollar spent on childhood Medicaid.

As the major payer of health care in Illinois, Medicaid should, and does, attract the close attention of our top decision makers. However, cuts to Medicaid, the backbone of our health care safety net in Illinois, will reverse course on half a century of progress towards a better Illinois. We should reject cuts to Medicaid at the state or federal level. On the 50th anniversary of Medicaid, let’s renew our call to policy makers to enhance and improve, not undermine, Medicaid coverage for Illinoisans. It will not only strengthen millions of families in our state, it will also help build up our economy.

Millions Can Keep Health Coverage Because of the Supreme Court's Decision in King v. Burwell

Yesterday’s U.S. Supreme Court’s decision in King v. Burwell, which upheld tax credits for 6.4 million Americans, is a big story. It has implications for health care policy, tax policy, even presidential politics. But the most important story is about the individuals who count on the Affordable Care Act (ACA) for medical and financial security.

Take John, a 61-year-old industrial electrician, who was recently laid off from his job due to early onset Parkinson’s disease. His family now survives on income from retirement savings of about $30,000 a year. Although he always had health insurance through his job, John is now unable to work, and he and his wife obtain health coverage through the federal Marketplace. John receives a tax credit of $800 a month, leaving him with a monthly health insurance premium of $240. His health plan provides good coverage, which is important to John, because his treatment for Parkinson’s disease without health insurance would be extremely expensive.

The ACA is working for John and people like him. In fact, more than 10 million people now have quality, affordable health coverage through the Marketplaces who didn’t have it before. That includes 294,000 people who selected a plan and have paid their premiums in the Illinois Marketplace. Moreover, fewer Americans are uninsured: Gallup polls show a national uninsured rate of 11.9%, which is a 5.3% drop from 2013.

Because of the Supreme Court’s decision today in King, John and others like him can keep the tax credits that subsidize their health insurance coverage. In Illinois—one of the 34 states impacted by this decision—over 232,000 Marketplace enrollees (almost 80% of all enrollees) will now be able to keep their premium tax credits. Since each Illinois Marketplace enrollee receives an average tax credit of $211 per month, that totals $49 million in tax credits in the state.

This decision is a significant victory for millions of Americans working hard to join or remain in the middle class. Most of those who use the premium tax credits are in working families, either employees or entrepreneurs. Now, with tax credits intact, these families, many of whom earn less than $25,000, can continue to access the health care services that they need. In addition, this decision ensures a more certain future for the Affordable Care Act, which has brought health care coverage to millions of previously uninsured Americans. 

The Shriver Center will continue to monitor the impact of the Supreme Court's decision in King and will continue to work with our state and federal partners to advocate for high-quality and affordable healthcare for all Americans. We will be hosting a webinar with EverThrive Illinois on June 30 at 2:00 pm to discuss the implications of momentous decision. Please join us then!


Health Coverage at Risk for Illinois Children and Families in King v. Burwell

This blog post was coauthored by the Center for Children and Families of the Georgetown University Health Policy Institute.

In the coming weeks, the Supreme Court will rule on King v. Burwell (King), a case that could have far-reaching effects on health coverage in Illinois and across the country. The court will rule on whether the Affordable Care Act (ACA) allows consumers to receive tax credits to help pay for insurance in the states like Illinois that did not set up their own health insurance marketplaces. When Congress wrote and passed the ACA, drafters agreed that the tax credits would be available in all states. However, opponents of the law have latched onto their own interpretation and are seeking to undermine the ACA by denying tax credits to those who sign up for coverage through In Illinois, families and individuals sign up for private coverage and obtain their tax credits through because the state did not set up its own state-based marketplace.

According to the Department of Heath and Human Services, about 7% of Illinois’s marketplace enrollees are children, meaning more than 20,000 Illinois kids could be among those who lose coverage. And even more children would be put at risk when their parents lose health coverage, as that impacts the health and financial security of the whole family.

In addition, as many as 408,000 Illinoisans could go uninsured if the court rules for King, according to The Urban Institute. Illinois’s uninsurance rate has dipped to 11% due to tax credits and the Medicaid expansion. A ruling that takes tax credits away from those enrolled through would reverse the positive trend and add to the ranks of the uninsured by pricing more Illinoisans out of the health insurance market.

If that wasn’t bad enough, things could get even worse. Experts predict that a bad ruling will cause health insurance premiums to spike for millions of Americans who have health insurance in the individual market, including those who currently receive premium tax credits and those who would not receive premium tax credits regardless of King. Legal experts also suggest that a favorable ruling for King could have implications for Medicaid funding in states that did not set up their own state-based marketplace.

Everyone involved in the health care system, including hospitals, providers and insurance companies, strongly disagrees with the challengers’ position. This is a political tactic from opponents of the ACA to dismantle the law.

With so much at stake, we’ll be following the case closely and will let you know about the ruling and its implications for Illinois’s children and families shortly after the Court issues its decision. 


Thanks to the Senate for Renewing Children's Health Coverage

We applaud the U.S. Senate for passing a bill last night, 92-8, that extends funding for the Children’s Health Insurance Program (CHIP). The vote follows passage of identical legislation in the House and demonstrates that members of Congress overwhelmingly support the CHIP program and understand it is vital to keeping kids across the country healthy. The legislation also allocates $7.2 billion in additional funding for community health centers.

When children’s health was on the line, the U.S. Senate stepped up for millions of kids. Last night’s vote demonstrates the overwhelming popularity of CHIP and support for getting kids the health care coverage they need to succeed.

CHIP has a long history of bipartisan support, providing coverage for children in families that earn too much to qualify for Medicaid but don’t have access to affordable health care. As a result of CHIP’s implementation, coverage rates for kids across the country are at a historic high of close to 93 percent. 

CHIP funding makes it possible for Illinois to offer children of families up to 300 percent of the Federal Poverty Level (FPL) access to affordable and comprehensive All Kids coverage. Both Illinois Senators Durbin and Kirk voted in support of this legislation. CHIP is life changer for 174,000 Illinois children. This vote demonstrates that Congress understand the impact this critical program has on millions of families and we will look to lawmakers to continue to demonstrate their support in 2017 when the program is up for renewal.


Good News: House Votes to Extend CHIP Funding

 In an overwhelming 392-37 bipartisan votethe U.S. House of Representatives has voted to ensure children in Illinois and across the nation continue to get the quality health care coverage they need to succeed. Today’s bipartisan House vote to renew funding for the highly successful Children’s Health Insurance Program (CHIP) will help ensure that kids from low- and moderate-income working families continue to receive the care they need to reach their full potential.

CHIP has a long history of bipartisan support, providing coverage for children in families that earn too much to qualify for Medicaid but don’t have access to affordable health care. As a result of CHIP’s implementation, coverage rates for kids across the country are at a historic high of close to 93 percent.

We thank the members of the Illinois delegation that voted to stand up for Illinois’s kids and support this vital program. Their actions will help make sure more than 174,000 Illinois kids keep the coverage and quality care families depend on.

As the Senate takes up legislation to renew CHIP, we strongly urge them to build on the House bill by quickly passing a four-year extension of this critical program. By ensuring funding stays intact, Congress can provide the stability families and state officials need to plan without worrying that the promises Congress made for the future of CHIP won’t be kept.

Forty-two governors of both parties called on Congress to move quickly to fully fund CHIP. Most states are planning on finalizing their budgets now, and many have already factored the amount of promised federal CHIP funding into their plans. In Illinois, this means Congress must take action to pass this legislation orIllinois will have to cut at least $454 million from its 2016 budget

The message is loud and clear – CHIP is an important lifeline for Illinois children. Congress has taken an important step today and we urge members to finalize legislation quickly to provide families and states the stability they need to plan for the next four years.

Congress Must Act to Extend Funding for the CHIP Program

More than 174,000 Illinois children could lose their current health coverage if Congress does not act now to extend funding for the Children’s Health Insurance Program (CHIP).     

In Illinois, CHIP federal dollars provide significant support to the All Kids program, which gives low-income children access to comprehensive health coverage, including screening, prevention, medically necessary diagnostic and treatment services, and vision, mental health, and hearing services.  Federal CHIP dollars also help sustain All Kids’ oral health safety net, covering services such as teeth cleanings, check-ups, x-rays, and fluoride treatments.  

CHIP has also helped Illinois emerge as a national leader of children’s health coverage.  In the past five years, Illinois has received more than $60 million in bonus payments under CHIP—and Illinois is one of only nine states to receive bonus payments for five consecutive years.  Federal CHIP funding has helped bring Illinois’s children’s coverage rate up to more than 95 percent, one of the highest rates in the country.

Without continued CHIP funding, Illinois would lose access to significant federal dollars—as much as $454 million in 2016 alone—at a time when our state has never been more budget-strapped. And failing to meet children’s health needs today prevents Illinois from reaping the long-term social and economic benefits associated with children’s health coverage, including increased educational attainment and higher future earning potential.

Extending CHIP funding through 2019 would accomplish dual goals. It would limit disruptions in medical and oral health care for children currently enrolled in the CHIP-funded Illinois All Kids program. It would also provide our state with the stability it needs to effectively plan a budget. Congress needs to pass a four-year extension of CHIP funding that maintains the current elements of the program already in place.


Invest in Children's Health Today to Reap Benefits Tomorrow: Renew the Children's Health Insurance Program

Editor's Note: This blog post was coauthored by Janine H. Lewis, MPH, Executive Director of EverThrive Illinois.

Ben Franklin was right when it comes to health coverage for kids. An ounce of prevention is worth a pound of cure. New research shows that investments in children produce long-lasting returns by preparing children for success in school and life. Especially in difficult economic times, Illinois must continue to invest in children’s health insurance programs that are proven to improve health and educational outcomes for children, and even increase college attendance, and boost future income. The Children’s Health Insurance Program (CHIP) is one important and proven investment. Federal CHIP funding of the All Kids program has been successful in providing high-quality, cost- effective health insurance for hundreds of thousands of children—which has helped to bring Illinois’s children’s coverage rate up to more than 95 percent, one of the highest rates in the country. When children’s health needs are met, they are better able to learn in school, and parents have less medical debt and miss fewer days of work. By ensuring our kids have the health care they need, we can create a stronger future for Illinois.

Federal CHIP funding of the All Kids program has been successful in providing high-quality, cost- effective health insurance for hundreds of thousands of children—helping to bring Illinois’s children’s coverage rate up to more than 95 percent, one of the highest rates in the country. Unfortunately, no new CHIP funding will be available after September 2015 without congressional action. Without federal CHIP funding to support the All Kids program, Illinois may lose as much as $454 million in federal funds in 2016 alone, and thousands of Illinois households are unlikely to have an affordable, comprehensive health insurance coverage option for their children. The President recognizes CHIP’s importance and included it in his proposed budget. Now, we need to work to ensure that Congress recognizes CHIP’s importance and success and passes legislation as soon as possible to renew funding for this crucial health safety net for kids.

What is the Children’s Health Insurance Program (CHIP)? In Illinois, CHIP is a federal funding stream that strengthens the All Kids program to cover the cost of nearly 175,000 Illinois families eligible at All Kids' “higher” income levels who otherwise would lack affordable health insurance coverage. CHIP funding makes it possible for Illinois to cover children with family income up to 318% of the federal poverty level (FPL) (about $6,320/month for a family of four); CHIP also provides federal funding for Illinois to provide health insurance coverage to pregnant women and their babies—all of whom live in families with income no greater than 213% of the FPL (about $4,360/month for a family of four). For children in All Kids whose services are funded with CHIP dollars, monthly premiums range from $0-40 per child with a maximum of $80 per month for two or more children, and cost sharing for office visits ranges from $3.90 - $15 per visit. Thanks to CHIP funding, these children receive pediatrician-recommended services that children need to reach important developmental milestones, such as screening, prevention, and medically necessary diagnostic and treatment services and dental, vision, mental health, and hearing services. Any gap in funding will leave kids without critical medicines and treatments they need and also cause them to miss wellness visits that can cause small problems to balloon into lifelong issues. When children’s health needs are met, they are better able to learn in school and parents have less medical debt and miss fewer days of work.  By ensuring our kids have the health care they need, we can create a stronger future for Illinois. Continued CHIP funding will give hardworking families the peace of mind of not being one accident or illness away from financial disaster due to their kids’ unpaid medical bills.

CHIP gives Illinois the flexibility to run programs that work best for them.  CHIP allows states to experiment with different program designs that work best for their state. CHIP also allows states to earn extra state funding for simplifying their enrollment and renewal processes and for increasing enrollment of uninsured children in their Medicaid program. In the past five years Illinois has received more than $60 million in bonus payments under CHIP—and Illinois is one of only nine states to receive bonus payments for five consecutive years.

CHIP is the most effective way to cover kids at the lowest cost.  CHIP is the most effective way to cover kids at the lowest cost. In Illinois, children ages zero to eighteen comprise 57% of the overall Medicaid program enrollment but account for just 26% of the total cost. A recent study of the long-term effects of kids on Medicaid confirmed that giving kids health coverage may boost their future earnings for decades. And the taxes they pay on those higher incomes may just help pay Illinois back for some of its investment.

CHIP delivers coverage through private insurance companies. CHIP is a public-private partnership, and private partners can’t sign contracts when the funding source is in doubt. Pursuant to state statute, Illinois will enroll more than half of its Medicaid consumersincluding children—into managed care. These managed care companies rely on CHIP dollars. Renewing CHIP funding for at least another five years gives these private insurance partners and Illinois the ability to better plan their budgets.

CHIP is a proven program with a history of bipartisan support that provides kids with the health care they need to stay healthy and succeed. Governors and state legislatures are planning their state budgets now, and any uncertainty leaves their bottom line in jeopardy. Governors from 39 states—such as our neighbors in Michigan, Pennsylvania, and Wisconsin--have weighed in on the importance of CHIP, with Republicans and Democrats alike calling on Congress to move quickly to renew federal funding for CHIP so they can continue to provide struggling families with vital health coverage for their kids. 

Without federal action, we stand to undo nearly 20 years of progress connecting kids to the health coverage they need to develop and thrive. If CHIP funding is not renewed, Illinois may lose as much as $454 million in federal funds in 2016 alone. By renewing this proven, bipartisan program, we can protect and build on our progress for the nation’s children, help Illinois as it plans its budget, and provide Illinois’s kids with the coverage and quality care they need to reach their full potential.




Could the U.S. Supreme Court Take Away a Financial Lifeline for Health Care Consumers?

Meet John, a 53-year-old self-employed contractor in Southern Illinois who works construction jobs and earns about $23,000/year. Up until January 2014, when health insurance coverage under the Affordable Care Act (ACA) began, he had never had health insurance because it had never been affordable. John has suffered three heart attacks and a broken femur, and his hospital and doctor bills for these illnesses have been a heavy financial burden. 

In October 2013, an in-person assister in Illinois helped John to complete a Marketplace application for health insurance through John was pleased to be offered many options for affordable, quality coverage, ranging from paying $0 per month for a Bronze or low-end Silver plan to only $180 per month for a high-end Silver plan, because he was eligible for premium tax credits, which reduced his premium costs dramatically. John ended up selecting a Silver Multi-State plan that cost less than $15/month. It has a $250 deductible and an out-of-pocket maximum of only $2,000 for the year.  John is relieved that he now has affordable health insurance and can receive the cardiac care he needs to stay healthy and continue working.     

This is a great example of what the Affordable Health Care Act was meant to do—and what is at risk in the U.S. Supreme Court’s decision to review King v. Burwell.

On November 7, the Supreme Court announced it would review King v. Burwell, the Fourth Circuit’s decision upholding an Internal Revenue Service (IRS) rule extending tax credits to federally established marketplaces. The parties appealing the Fourth Circuit decision claim that tax credits should be available only to consumers purchasing insurance in a marketplace operated by a state, and not to consumers purchasing in a marketplace operated by the federal government. If successful, this case would remove the ability of health care consumers in about three dozen states, including Illinois, who use the federally facilitated marketplace to access premium tax credits to reduce the cost of private, quality health plans. In other words, the majority of low- to moderate-income health care consumers (those who earn up to $47,000 a year for one person and up to $95,000 a year for a family of four) would have to pay full price for health insurance in the individual marketplace, making it out of reach—again.

To put this into context, 77% of Illinois consumers and an overwhelming 87% of consumers across the nation accessed financial assistance to purchase plans in the federal Marketplace. If those tax credits were stripped away, not only would this have a devastating impact on the health and lives of millions of people like John, but it would create what economists call a “death spiral” in the health insurance market. Without financial assistance, healthy people would leave the Marketplace, making the premiums go up for those who remain, which would cause them to leave as well.

The implications of such a potential decision are severe. However, it’s critical to remember 3 things:

  1. Open enrollment—which starts on November 15—will not be affected in any way by the Supreme Court’s announcement.  Health care consumers should review plans, enroll in coverage, and feel confident that their tax credits are safe and can be used to help lower the cost of their coverage.
  2. In the unlikely event the Court rules against providing tax credits to millions of Americans, consumers will not be required to pay back those tax credits.
  3. Premium tax credits have helped over 168,000 people in Illinois and over 4 million people across the nation access health care that they can afford, and the Shriver Center will continue to inform consumers about their health insurance options through the Affordable Care Act.

John and millions of other consumers relied on the promise of the Affordable Care Act (ACA) to provide affordable, guaranteed health care coverage. Over two thirds of states including Illinois relied on the intent of Congress in creating the ACA to provide financial assistance to consumers nationwide, regardless of whether the state or federal government administers the marketplace website. Now the focus turns to the Supreme Court to ensure that those promises are kept. Consumers and states will be watching the Court’s decision closely to ensure that healthcare stability and equality across the nation is maintained. 

Burwell v. Hobby Lobby and the Civil Rights Act of 1964

Fifty years ago yesterday President Lyndon Johnson signed the landmark Civil Rights Act of 1964  into law, outlawing discrimination based on race, color, religion, sex, or national origin in voter registration, in employment, in schools, and by facilities that serve the public.   We should be dancing in the streets.

Instead of rejoicing, we are worried. We think all Americans should be worried. Why? Because just days before, on June 30, the United States Supreme Court’s majority decision in Burwell v. Hobby Lobby Store, Inc, potentially drove a truck through the protections of the 1964 law as well as any number of other federal laws, such as the Americans with Disabilities Act, the Pregnancy Discrimination Act, and the Age Discrimination Act.

Right now, the Hobby Lobby decision does substantial damage to the health of women and girls who are employees, spouses, or dependent daughters of the over 14,000 employees of the three plaintiff businesses.  The Court held that the federal Religious Freedom Restoration Act (RFRA) of 1993 protects the free exercise of religion rights of the three for-profit, closely controlled corporations that brought the lawsuits and that the businesses do not have to comply with the federal law and regulations requiring employer group health plans to cover the 20 contraceptive methods approved by the Food and Drug Administration as preventive services without cost to the patient.  The companies objected to covering four of those 20 methods in their health plans, claiming those four may interfere with a fertilized egg’s attaching to the uterus and the corporations’ owners have sincerely held religious beliefs that life begins at conception.    With the Court’s decision, thousands of women who work at these companies or who are the company-insured wives or daughters of company employees will have to pay 100% of the cost if they need one of the four excluded contraceptives.   Many will not have the funds to pay these costs and will go without or use second or third choice contraceptive methods which may not be the optimal medical choice. (NOTE: Extending RFRA’s protections to for-profit corporations was a huge leap that the majority of the Court was willing to take; This “startling breadth” is discussed by Justice Ginsberg in her dissent.)

In the future, closely held for-profit corporations and perhaps all for-profit corporations that can claim they have sincerely held religious beliefs can demand to opt out of federal laws they judge incompatible with their beliefs. Hence our worry. The majority decision tries to tell us this is not a big deal, that the decision is only about contraceptive health care coverage. We can only say “Really?” Since when do American courts make decisions whose holdings are not used by other litigants to support their positions in future, not identical cases?   

It does not take much imagination to come up with claims companies might make in the name of their sincerely held religious beliefs that would strip employees and customers of rights protected by the laws of the United States. Without pointing fingers at specific religions, we’ll just say that in the past, and sometimes into the present, main line religions have claimed that slavery was okay;  that interracial marriage was sinful; that a woman’s place was in the home not in the workplace; that unmarried women should not be sexually active and should be punished if they are; that gays and lesbians are sinners; and that a long list of well-established medical procedures (vaccinations, anesthesia, for example) are against their religious tenets.    In the present day there are serious disagreements among established religions over many issues and even more disagreements among smaller groups and individuals—but all have the “sincerely held religious beliefs” that the Hobby Lobby majority opinion potentially allows to trump third parties federally protected established rights. The result could be that for-profit corporations claiming these beliefs could refuse to employ people, fire people, turn away customers, and otherwise not follow generally applicable federal laws because following them would violate their beliefs. 

The Hobby Lobby decision is slightly over 72 hours old. Already, there is much commentary and speculation about it. We suggest you look at the Center for American Progress’ thoughtful historical and legal analysis, A Blueprint for Reclaiming Religious Liberty Post-Hobby Lobbyfor a better understanding of how we got to this point and how we can move forward, undo Hobby Lobby’s damage, and continue to foster the free exercise of religion.



Medicaid Is Still Open for Business

The big news in Illinois this month is that enrollments into new health care options under the Affordable Care Act from October 1, 2013 – April 15, 2014, topped the half million mark.  More than 217,000 people enrolled in the Illinois Health Insurance Marketplace and even more – 287,000 enrolled into the new Medicaid expansion. The latest Gallup poll is shoring up these enrollment numbers with related data: the U.S. uninsured rate continued to drop to its lowest monthly rate since January 2008.

This is exciting news for all of us involved in the Affordable Care Act rollout. At the Shriver Center, we help run a technical assistance center for Illinois enrollment specialists (e.g., Navigators and Certified Application Counselors). We get to hear stories every day from enrollment specialists around the state who worked hard over the past six months to get their clients connected to benefits, tax credits, and cost sharing reductions, and who are now are working hard to help customers understand and use their health care benefits – some for the very first time.

The half million mark is definitely worth celebrating; however, our enrollment work is not done. Unlike the Health Insurance Marketplace, which isn’t officially open again until November 2015 (except for those eligible for a Special Enrollment Period), Medicaid is always open for business. There is no start or end date for submitting online, phone or in person applications for Medicaid.

Illinois is one of the 26 states to have passed the Medicaid expansion under the Affordable Care Act, so now all low-income individuals, children, and families are eligible for Medicaid.  It’s vital to get the word out -- people denied Medicaid in the past may now qualify.

Medicaid, like the Qualified Health Plans on the Marketplace, must cover Essential Health Benefits, including pediatric dental and vision care. That means low-income children, individuals, and families will have access to preventive care, emergency room care, behavioral health care services, doctors’ visits and other critical services. In addition, as the state’s coordinated care efforts continue to roll out, each Medicaid recipient will be connected to a primary care provider to help monitor and coordinate his or her care.

Please help spread the word that Medicaid enrollment is open all year round. If someone you know is eligible and needs health insurance, they have not missed out. You can help them enroll online themselves or connect them with a certified enrollment specialist.

Let’s continue to push Illinois past the half million mark! 


Illinois Keeps Its Eye on the Back Door: Medicaid Renewals

In Illinois, we’ve been busy enrolling more than 260,000 newly eligible adults through Medicaid’s front door. But we’ve also had our eye on Medicaid’s back door to make sure we don’t lose Medicaid-eligibles through the annual renewal process.

The state has been working with us at the Shriver Center and other stakeholders on a “Medicaid Redetermination Project” to streamline the process for Medicaid renewals (sometimes called “redeterminations” or “REDEs"). This includes work on the regular annual renewals and new MAGI-based renewals. Some key practices that are already helping to facilitate renewals in Illinois include:

  • using electronic data from verification databases to pre-populate forms with updated information prior to sending them by mail to recipients;
  • providing different forms (scroll down to “client redetermination notices” to see the different forms in English and Spanish) for the MAGI and non-MAGI populations to eliminate confusion and reduce the need for recipients to answer questions that are not relevant to their eligibility;
  • shortening the renewal forms to under 3 pages;
  • the ability to reinstate cases—if the case is cancelled for non-compliance with the renewal process—without the need to re-apply or appeal.

We still have work to do to improve the Illinois renewal process both in policy and in practice. We are monitoring the initial mailing of renewal forms to assess whether there is a high percentage of non-response or terminations. We are also trying to collect more information and clarification on the Illinois renewal process through the Medicaid Advisory Committee. We are also working to ensure that Illinois allows at least 30 days to respond to renewal requests and at least 90 days to reinstate cancelled cases.

We hope that other states will also keep their eye on the back door and share strategies about what is working for them with Medicaid renewals.

Four Gifts the Affordable Care Act Has Given Americans by Its Fourth Birthday

Birthday cakeOn March 23, 2014, the Affordable Care Act (ACA) turned four. In its relatively short life, the ACA has already accomplished a great deal. To celebrate, here’s a list of the top four gifts that the ACA has given to the American people:

1. No More Pre-existing Condition Exclusions

Before the ACA was law, insurance companies routinely denied people health coverage due to “pre-existing conditions,” which could range from common chronic conditions such as asthma and arthritis to diseases such as cancer or mental illness. However, as of September 2010, children could no longer be denied coverage due to a pre-existing condition, and as of January 2014, adults are now enjoying that same right.

By way of example, on
HelpHub, the Illinois site that provides technical assistance to enrollment specialists, we have heard many stories about people who are beginning to obtain insurance after being told for years that they are were “uninsurable.” Families USA estimates that 64.8 million non-elderly Americans—or 1 in 4 people—have been diagnosed with pre-existing conditions that could have led to denials of coverage in the past. That’s over 5.6 million people in Illinois alone who can no longer be turned down or charged more for health insurance.

Though over half of the public know about this “gift” from the ACA, according to a January 2014 Kaiser Family Foundation tracking poll,
53% of the uninsured remain unaware of this provision. We need to continue to publicize this incredible benefit of the law.

2. Financial Help to Obtain Insurance

Aside from pre-existing condition exclusions, another major barrier to accessing health insurance has been cost. Since employers have not been required to offer coverage, many low-wage workers never received an offer of coverage and were priced out of the individual insurance market.

Through the new Health Insurance Marketplaces, the ACA created three new ways to make health insurance more affordable. The first is premium tax credits, which can be taken by Marketplace consumers in advance to lower the amount of premium the individual or family must pay for their coverage. Consumers with incomes under $45,960 for a single individual and $94,200 for a family of four are eligible for these credits. The Department of Health and Human Services reports, for example, that nearly 5 in 10 uninsured single young adults eligible for the Marketplace could pay $50 or less per month after tax credits for coverage in 2014.

The second form of financial help provided by the ACA is cost-sharing reductions. These reduce the out-of-pocket costs, such as deductibles, copays, and co-insurance, that health care consumers can expect. Cost sharing reductions are available to health insurance Marketplace consumers who make between 100% and 250% of the federal poverty level who purchase a Silver plan. Why does this matter? It means lower prices for doctors’ visits, prescription drugs, and other care that people need—which is particularly important for people who utilize a high amount of services.

Recent enrollment numbers indicate that people are signing up for these subsidies, too. As of February 2014, 85% of enrollees qualified for premium tax credits, while 67% consumers chose Silver plans, indicating that they may also qualify for cost sharing reductions.

3. Medicaid Expansion

The ACA mandated a Medicaid expansion to all qualified adults below 138% of the federal poverty level (about $15,800/year for a single individual); this mandate filled a huge coverage gap in Medicaid eligibility for low-income adults. In June 2012, however, the United States Supreme Court made this expansion optional, and currently just half the states and Washington, D.C., have expanded Medicaid. Illinois is one of those states; last July, Governor Quinn signed the Medicaid Expansion (SB 26) into law, and according to reports at the recent Illinois Health Reform Implementation Council meeting enrollment into Medicaid has already exceeded expectations.

The number of Illinois residents enrolled in ACA Adult Medicaid is now at 200,000. This includes all Supplemental Nutrition Assistance Program (SNAP) auto-enrollment and enrollment in CountyCare, the early expansion of Medicaid in Cook County, the largest county in Illinois )which includes Chicago and some of its collar suburbs). Of pending applications, the state expects another 150,000 will be eligible for ACA Adult Medicaid. Overall for 2014, it is anticipated that Illinois will enroll over 400,000 adults into the new Medicaid program. 

Together, the Premium Tax Credits, Cost Sharing Reductions and the ACA Medicaid Expansion provide low-income families with the gift of affordable health care.

4. Essential Health Benefits

The ACA gift that people probably know the least about is the
10 Essential Health Benefits (EHB) that must be included in Medicaid and health plans in the individual and small group markets. Under EHB, not only must plans now include a range of free preventive services and screenings, but also prescription drugs, lab tests, dental and vision care for children, and mental health and substance use disorder services, among other critical services. The Essential Health Benefits package ensures comprehensive services are included in your policy so you aren’t left paying premiums for shoddy coverage.

These gifts have already started to make a huge difference to the American people. The uninsured rate is decreasing; and stories from around the country are streaming in about people who are able to see a doctor when they hadn’t for years, families who are able to afford their premiums every month, and individuals who finally have peace of mind because they have a good health insurance policy when they need it.

We can’t wait to see what the next four years of the ACA brings.


New Resources to Help Smooth the Path to Health Insurance Coverage for Immigrants

Last fall we blogged about how the Affordable Care Act (ACA) helps immigrants by providing new and strengthening current health insurance coverage opportunities. Unfortunately, some immigrants have encountered problems in accessing these coverage opportunities. Advocates have been working with the federal government to fix these problems. Below are some new resources that may help smooth the path for immigrants to health insurance coverage.

Lawfully present immigrants are eligible to purchase private health insurance plans in the health insurance marketplaces. This checklist and fact sheet on immigration document types can assist in preparing to complete the application. Applicants need to prove or verify their identity as part of the application process. This fact sheet from the federal government offers information for applicants in answering the identity verification questions. Also, when immigrants are completing an application on the federal marketplace, they may be asked about their immigration status. This new fact sheet from the federal government provides information on how to answer these questions. Open enrollment for 2014 coverage ends March 31, 2014. If an applicant has not enrolled in coverage by then and he or she does not qualify for a special enrollment period, then he or she generally cannot enroll in 2014 coverage until the next open enrollment period, which begins November 15, 2014. If the applicant enrolls in a plan by March 31, 2014, he or she will not have to pay any penalty.

Lawfully present immigrants may qualify for federal financial help to lower the cost of their monthly premiums and cost-sharing (e.g., co-payments, deductible, co-insurance) to help them afford a private insurance plan through the Marketplaces. Lawfully present immigrants with household income between 100% and 400% of the federal poverty level (FPL) are eligible for premium tax credits; lawfully present immigrants with income between 100% and 250% FPL are eligible for the cost-sharing reduction subsidies. To qualify for this federal financial help, applicants cannot be offered affordable health insurance through their job or be eligible for Medicaid. This website (also available in Spanish) helps people find out if they qualify for the financial help.

Most lawfully present immigrants who meet Medicaid program requirements, such as income and state residency, can enroll in Medicaid after they have been in the United States for five years or more. Some groups of lawfully present immigrants (including refugees, asylees, and pregnant women and children in some states) do not have to wait five years before they may enroll in Medicaid. Immigrants will benefit greatly in states that choose to add the ACA’s new Medicaid eligibility category, which will expand that program to all adults under age 65 with household income of less than 138% of the FPL. Use of Medicaid does not affect one’s immigration status (public charge decision) unless the Medicaid use is for long-term care, such as nursing home care.

Lawfully present immigrants with household incomes of less than 100% of the FPL are also eligible for the private Marketplace coverage and can get help paying premiums and cost sharing if they are ineligible for Medicaid (either because they are not lawful permanent residents (LPRs) or because they are LPRs with less than five years of residency). For instance, if a lawfully present immigrant who has a household income of 90% FPL has been in the United States just two years, he or she should qualify for a private plan on the Marketplace and receive both premium tax credits and cost sharing reduction subsidies. If the applicant is mistakenly told by the Marketplace that he or she does not qualify, the applicant should file an appeal. If the Marketplace mistakenly informs the applicant that he or she is Medicaid eligible, the applicant could choose to apply to Medicaid and receive a Medicaid denial before attempting again to enroll in Marketplace coverage. Applicants can now report a Medicaid denial on the Marketplace application. Many organizations are working to to help individuals experiencing difficulties in enrolling eligible immigrants in ACA’s coverage, including the National Immigration Law Center (NILC), Community Catalyst’s In The Loop, and the Sargent Shriver National Center on Poverty Law, to name just a few. 

Undocumented immigrants may not buy health insurance through the Marketplaces, even at full cost. However, until this is remedied, undocumented immigrants need to know that:

  • Community health centers, strengthened by ACA funding, will still accept patients regardless of immigration status.
  • Emergency rooms will continue to treat undocumented immigrants for free or at very low cost.
  • Many hospitals have charity care obligations that essentially provide free care to low-income patients, regardless of immigration status.
  • Undocumented immigrants may purchase health coverage through an employer or a spouse’s employer.
  • Undocumented immigrants may purchase private health insurance off of the Marketplace.
  • And some state-funded Medicaid programs are open to immigrants regardless of immigration status.

Undocumented immigrants also need to understand that, if they have family members who are U.S. citizens or lawfully present, these family members are required to have health insurance under the law starting in 2014, or face a penalty at tax time, unless they qualify for some exemption. (If you are undocumented, you don’t need to apply for an exemption to the penalty because this will be handled when you file your taxes in 2015.) This means that undocumented parents who have lawfully present or U.S. citizen children must ensure that their children have health insurance (through a child-only private Marketplace plan or through Medicaid, for instance). It’s important to remember that only those individuals in a family who are applying for health insurance are required to provide citizenship and immigration status. So undocumented parents applying through the Marketplace for private or Medicaid coverage for their eligible family members will not be asked for a Social Security Number for themselves (only for the applicants).

Many groups of immigrants are eligible to enroll in the Marketplace plans, and they should be encouraged to do so. The information they provide in their Marketplace applications is NOT shared with immigration authorities. Since October 2013, Immigration and Customs Enforcement (ICE) has had a policy that the information provided in Marketplace application will not be the basis for carrying out immigration enforcement action. Simply put, this information will not be used for immigration enforcement purposes. 

There is no charge to individuals who receive in-person help in enrolling in Medicaid or Marketplace coverage. The ACA provides federal funding to train and certify in-person consumer assisters to walk individuals through all of their health insurance coverage options. You can find an in-person assister by going to your Marketplace’s website. These assisters cannot and will not charge individuals for this enrollment assistance, including answering questions post-enrollment. The Ms. Foundation for Women recently published a series of fact sheets in English and Spanish describing ACA health coverage options; these fact sheets include links for help in obtaining coverage and also feature information for consumer assisters who work with immigrant populations. 

The road to coverage has had a few bumps for applicants in general, and immigrant applicants have encountered more than most. We will continue to work with the Marketplace to highlight and fix these bumps so that eligible individuals and families can get the coverage they need.

The Affordable Care Act Can Reduce Poverty, Just as Medicare Did for Older Adults in the 1960s

Home health care visitAs we continue to implement the Affordable Care Act, we should be mindful of the lessons of the War on Poverty and how the creation of programs like Medicare were effective at reducing poverty.

By opening up access to care through the desegregation of hospitals, the War on Poverty made significant improvements in measures like health care outcomes and reductions in infant mortality. However, the “opening” of hospital doors doesn’t help much if people cannot pay for their care and fear accessing care because they will not be able to afford it.

Since the 1960s, Medicare and Medicaid have gone a long way towards reducing poverty in many populations, especially among the elderly. Medicaid is a joint federal and state program that provides health insurance for adults and children who are below or just above the federal poverty line. Medicare is a federal insurance program that generally provides health insurance to people over age 65 and people with disabilities below age 65.  Recent studies have shown that both Medicare and Medicaid reduce out-of-pocket health spending, and therefore increase income available to older adults people with disabilities and families.

Most people don’t think of health care as a poverty issue, an economic justice issue, or even a civil rights issue. Yet, medical debt and the inability to pay for medical care is one of the major reasons that people in the United States file for bankruptcy. People fall into poverty because they do not have health insurance and cannot pay for medical care in the event of a catastrophic medical issue. Also, people without health insurance who cannot get preventative care or routine sick care may have a more difficult time staying on the job if they cannot afford to go to the doctor for a minor illness or to pay for maintenance medications.

The Affordable Care Act (ACA) is the next step in the fight to provide health care coverage and improve health care outcomes not only for individuals in poverty but also for those who are in danger of slipping into poverty. And, importantly, the opportunity to expand Medicaid presented by the ACA can take this even further by providing coverage to even more low-income Americans.

During the recession, many middle class people with pre-existing health care conditions have either lost their jobs or been in danger of losing their jobs and having their hours cut. Before January 1st (when the ACA major provisions went into effect), unemployed workers were at risk of never being insured again if they could not get private insurance or could not get another job with group health insurance. After 63 days out of work and without health insurance, a person would lose all protection against being denied for pre-existing health conditions.

The ACA will reduce the numbers of the uninsured by providing Medicaid coverage for working age adults with income under $15,000 per year; providing financial assistance for families of four with income up to $95,000 to buy insurance through state Marketplaces; and guaranteeing everyone the right to get insurance regardless of previous health problems.

However, the Medicaid expansion for working age adults was made optional for states, and many states with very high poverty rates in their populations have decided not to expand the Medicaid program. This choice has left millions of people with income under the poverty level without access to health coverage. We should remember the lessons of the Medicare program and the War on Poverty and ensure the expansion of Medicaid nationwide. Providing health care coverage to everyone is one of the most important ways that we can bring people out of poverty while improving their health and population health at the same time. 

Get Covered--An Easy Resolution to Keep

Editor's Note: A Spanish-language translation of this blog post appears below. Una traducción al español de esta entrada de blog se encuentra más abajo.


If you make any New Year’s resolutions this year, one of them should be to take advantage of the Affordable Care Act (ACA)’s new coverage opportunities and get yourself and your family enrolled in a health insurance plan in 2014. Almost all of the 1.7 million people uninsured in Illinois last year are now newly eligible for either Medicaid or private coverage (1.5 million).

Thanks to the Affordable Care Act (ACA), more than 6 million people have enrolled in health insurance nationally since October 1, 2013, and nearly 2.2 million of those people have enrolled in private plans through the federal and state health insurance marketplaces. Not only has the law improved access to health insurance for young adults and people with pre-existing conditions, but the law has also improved coverage for millions of people with employer-sponsored health insurance and has allowed for states to expand their Medicaid programs. In the states that have expanded their Medicaid programs, now adults between 19-64 years old who have a household income of less than 138% FPL and meet certain citizenship and residency requirements may be eligible for the public Medicaid health insurance program. Not all states have expanded Medicaid, so check if your state is expanding.

If you didn’t enroll in a health insurance plan by the December 24, 2013, deadline (for coverage that took effect on January 1, 2014), don’t fret because you still have until March 31, 2014, to enroll and avoid the penalty. Penalty? Yes, penalty. The ACA requires that all U.S. citizens and lawfully present immigrants who can afford health insurance to enroll in a health plan or else pay a fee. As long as you are enrolled in a health plan (such as Medicaid, Medicare, employer-sponsored coverage, or a private plan purchased through the Marketplace, among others) that meets minimum essential coverage by March 31, 2014, you do not have to pay the penalty. Certain people will be exempt from the penalty, including undocumented immigrants, members of a federally-recognized tribe, incarcerated individuals, and those for whom health insurance is still unaffordable even after consideration for financial assistance. These individuals, excluding undocumented immigrants, may need to complete an application for an exemption. For more information on exemptions and exemption application deadlines, visit

Be aware that not only must you choose a plan by March 31, 2014, but for private insurance coverage, you must pay your first month’s premium by your plan’s payment due date in order for your coverage to officially take into effect. Every insurer sets a different due date for premium payments, so be sure to check with your insurance company to find out when your first payment is due. For example, Blue Cross Blue Shield extended the payment deadline for some customers to January 30, 2014, as long as they enrolled in a plan by December 24, 2013, for the January 1 effective date. There are multiple ways individuals can make their premium payments, such as through electronic fund transfer from a bank account; sending a personal check, money order or cashier’s check; or making payments with a prepaid card. Some insurance companies will accept wire transfers or debit and credit card payments as well, so check with your insurance company to find out their acceptable methods of payment. For more information on the various acceptable payment methods for health insurance premiums, check out this guide in English and Spanish.

After you’ve enrolled in a plan and made your first premium payment, be sure to call your insurance company to verify that your enrollment has, in fact, taken place. If you need help finding your health plan’s customer service phone number, follow these instructions from the Health Insurance Marketplace.

Make getting health insurance coverage your resolution this year. Choose and enroll in a plan by January 15 and you can have a February 1st effective date; enroll in a plan on or before March 31, 2014 and you can avoid a fee. Remember that Medicaid is always open for enrollment if you are eligible, but you still should enroll by March 31, 2014 to avoid the penalty. In special circumstances, people will be able to enroll in a plan through the Marketplace after March 31, 2014, but only certain people will be eligible for a special enrollment period. Thanks to the Affordable Care Act, a new year’s resolution for health insurance coverage should be easier to keep.

Obtenga Cobertura—Un Propósito de Año Nuevo que Es Fácil Cumplir

Si hace algún propósito de Año Nuevo, uno debe ser a aprovechar las nuevas oportunidades de cobertura médica de la Ley de Cuidado de Salud e inscribirse en un plan de seguro de salud en 2014. Casi todo de las 1,7 millones de personas sin seguro de salud en Illinois el año pasado ya son elegibles para Medicaid o seguro de salud privado a través del mercado de seguros médicos (1,5 millón). 

Gracias a la Ley de Cuidado de Salud (ACA en inglés), más de 6 millones de personas han inscrito en un plan del seguro médico a nivel nacional desde el 1º de octubre de 2013, y casi 2,2 millones de personas han inscrito en planes privados de seguro de salud a través de los mercados de seguros médicos federal y estatal. La Ley de Cuidado de Salud no sólo ha mejorado el acceso a seguro médico para los jóvenes y personas con condiciones pre-existentes, pero la ley también ha mejorado la cobertura médica para millones de personas con seguro médico patrocinado por su empleador y ha permitido que los estados expandan sus programas de Medicaid.  En los estados que han expandido sus programas de Medicaid, ahora los adultos que tienen 19 a 64 años de edad, con ingresos familiares por debajo del 138% del nivel federal de pobreza (FPL en ingles), y que son ciudadanos de los EE.UU o ciertos inmigrantes calificados pueden ser elegibles para el programa de seguros médicos públicos de Medicaid.  No todos los estados han expandido su programa de Medicaid, entonces verifique si su estado lo va a expandir.  Para obtener más información acerca de la ley y cómo están los inmigrantes incluidos en la ley de cuidado médico, échale un vistazo a esta guía.

Si no se inscribió en un plan de seguro de salud para la fecha límite del 24 de diciembre de 2013 (para la entrada en vigor el 1º de enero de 2014), no se preocupe porque usted todavía tiene hasta el 31 de marzo de 2014, para inscribirse y evitar la multa. ¿Multa? Sí, una multa. La Ley de Cuidado de Salud requiere que todos los ciudadanos y residentes permanentes legales se inscriban en un plan de seguro médico, si está a su alcance, o pagar una multa. Siempre y cuando usted tiene un plan de salud (como Medicaid, Medicare, la cobertura patrocinada por el empleador, o un plan comprado a través del Mercado, entre otros) que cumple con la cobertura mínima esencial antes del 31 de marzo 2014, no tiene que pagar la multa. Ciertas personas estarán exentas de la multa, incluidos los inmigrantes indocumentados, los miembros de una tribu indígena, personas encarceladas, y aquellos para los que el seguro médico está todavía inalcanzable ni siquiera después de la consideración para ayuda financiera. Puede ser que estos individuos, no incluso los inmigrantes indocumentados, necesitan completar una solicitud para una exención. Para obtener más información acerca de las exenciones y la fecha límite de la solicitud de la exención, visite

Ten en cuenta que no sólo hay que elegir un plan para el 31 de marzo de 2014, pero para el seguro médico privado, usted debe de hacer el primer pago de la prima (premium en inglés) para la fecha límite del pago de su plan para que su cobertura médica tenga vigencia oficialmente. Todas las compañías de seguros médicos fijan una fecha límite del pago de la prima diferente, entonces consulte con su compañía de seguros médicos para averiguar cuando tiene que hacer su primer pago de la prima. Por ejemplo, Blue Cross Blue Shield ha extendido la fecha límite del primer pago de la prima para algunos clientes hasta el 30 de enero de 2014. Siempre que hayan inscrito en un plan de seguro médico antes del 24 de diciembre de 2013 para la entrada en vigor el 1º de enero de 2014, tienen hasta el 30 de enero de 2014 para hacer el primer pago de la prima. Hay varias maneras en que una persona puede pagar sus primas, como a través de la transferencia electrónica de fondos de su cuenta bancaria; el envío de un cheque personal, giro postal o cheque de caja; o con una tarjeta prepagada. Algunas compañías de seguros médicos aceptan envíos de dinero electrónicos o pagos de tarjeta de crédito o débito también, entonces consulte con su compañía de seguros médicos para averiguar sus métodos de pago aceptables. Para obtener más información acerca de los métodos diferentes de pago de la prima de seguro médico, refiera a esta guía en español e inglés.

Después de que se haya inscrito en un plan e haya hecho su primer pago de la prima, llame a su compañía de seguros médicos para verificar que su inscripción, de hecho, ha llevado a cabo. Si necesita ayuda para encontrar el número telefónico de servicio al cliente de su plan de salud, puede navegar por esta lista para encontrar el número telefónico de su compañía de seguros médicos. La lista está organizada por estado, condado, y nombre de su plan de salud.

Propóngase este año a conseguir un seguro médico. Elija e inscríbase en un plan antes del 15 de enero y usted puede tener una fecha de entrada en vigor el 1º de febrero; inscríbase en un plan antes del 31 de marzo de 2014, y se puede evitar la multa. Recuerde que la inscripción de Medicaid siempre está abierta (no hay fecha límite de inscripción) si usted es elegible, pero todavía debe inscribirse antes del 31 de marzo de 2014 para evitar la multa. En algunas circunstancias especiales, individuos pueden inscribirse en un plan a través del Mercado de Seguros Médicos después del 31 de marzo de 2014, pero solamente ciertas personas serán elegibles para un período de inscripción especial.  Gracias a la Ley de Cuidado de Salud debería ser más fácil cumplir el propósito de Año Nuevo de tener la cobertura de un seguro médico.

Lindsey Croasdale contributed to this blog post.



Illinois is a National Leader in Children's Health Insurance Coverage

Child with stethoscopeWhen Illinois invests in its families, our state grows and thrives. A new report from Georgetown University Center for Children and Families shows that our state’s commitment to children and families is paying off--and making Illinois a national leader in children’s coverage. 

The report shows that Illinois reduced its number of uninsured kids from 140,105 to 101,466 children between 2010 and 2012. In just two years, almost 40,000 kids gained health insurance. This puts Illinois children’s uninsurance rate at 3.3 percent, the fourth lowest rate in the country.   

When we help Illinois families grow and thrive, we are creating a healthy and productive workforce. Investing in our families means investing in their health through All Kids--Illinois’s health insurance program, and through, the online marketplace that connects individuals and parents to public and private health insurance options with financial help for lower income households.

Investing in our children’s health today helps create a strong workforce tomorrow. Children are the least expensive population to insure, and the investment now in their health will pay back in dividends later. Research shows that individuals with access to health care as children are less likely to have chronic health problems as adults. Children in All Kids are able to receive annual checkups and visit the dentist, which means that they receive necessary vaccinations and that illness can be caught early to allow for more time in the classroom. Children in All Kids have a “medical home,” which means that the state of Illinois has been successful in connecting individual All Kids enrollees to a provider who knows the child's health history and can provide health care on a regular basis. These investments ensure Illinois kids show up at school ready to learn and are on the right track to become healthy, productive young adults.

We are proud of this progress, but we need to keep working to make sure no child is left uninsured. When 100 percent of our state’s children have coverage, every child, from every background and all areas in Illinois, will have the care they need to ensure a healthy start. 


The Affordable Care Act: Covering More Americans AND Saving Money

You have probably heard a lot of negativity recently about the Affordable Care Act (also known as the ACA or Obamacare). Website glitches, trouble registering, cancelled policies, OH MY!

In this negativity cloud, it’s easy to miss really big, good news. In very important ways, the Affordable Care Act is working better than expected. You heard me right. The ACA is offering millions of uninsured Americans with premium costs below projected estimates.

So, let’s not be blinded by the “could have” and “should have” political debates surrounding or concerns over cancellations—the Affordable Care Act is a much needed, long-awaited positive development that, in ways too numerous to mention in a blog, restructures the way our health care system works.

And, on top of everything else, health care reform will actually save us money.

Critics claim we can’t afford Obamacare, and that it’s going to put us further in debt. In fact, the Congressional Budget Office (CBO) projected the Affordable Care Act would lower the deficit by $109 billion over the next 10 years. From the outset, comprehensive health care reform legislation was projected to save us money. With the increase in savings from lower-than-expected premiums, the Center for American Progress is projecting an additional $190 billion in savings to the federal government.

In outlining the effect the ACA would have on premiums, the CBO noted the effect of competition on premiums, stating the competition created amongst insurers with a centralized marketplace (the exchanges) would work to reduce premium rates because insurers would lower the cost of premiums to attract new people signing up. They were right, but actually underestimated the effect of this competition.

Premiums are 16% lower than anticipated. In 2012, the CBO estimated that an average individual premium for the second-lowest-cost silver plan in 2014 would be $4,700; however, actual numbers for 2014 show the individual premium for the second-lowest-cost silver plan is $3,936—or 16% lower than was originally predicted. A recent report from the Kaiser Family Foundation corroborates these findings. Of the 18 areas that published information regarding premiums for 2014 at the time of the report, 15 had premiums below those CBO estimates for a 40 year old in the second-lowest-cost silver plan. According to the United States Department of Health and Human Services (HHS), in 48 states (including the District of Columbia), the average premium for the second-lowest-cost silver plan is 16% lower than CBO estimates.

Why all this hype about the “second-lowest-cost silver plan”? It’s considered a benchmark plan by which to base premium tax credits. The Affordable Care Act gives premium tax credits to individuals between 100-400% of the federal poverty line. At different income levels within this income range, the percentage an individual is required to contribute to his or her premium varies. The lower an individual’s income, the less he or she is required to contribute.

Government spending on tax credits for these individuals, then, is based on the cost of this “second-lowest-cost silver plan.” In other words, an individual’s premium tax credit will be the cost of the second-lowest-cost silver plan minus the individual’s contribution based on income level. Therefore, if the cost of the second-lowest-cost silver plan is less than the CBO’s original estimates, the government will spend less on the premium tax credits, decreasing the deficit by more than projected!

All of this is to say the Affordable Care Act is working better than predicted on the cost side. So, next time you hear someone focused only on website glitches, trouble registering, and cancelled policies, gently remind them of these better-than-expected cost and plan outcomes, and encourage patience with the rest.

Jamie Feldman contributed to this blog post. 



How the Affordable Care Act Helps Immigrants

Immigrant family

There are at least 40 million immigrants in the United States, accounting for about 13% of our country’s total population. The Affordable Care Act (ACA, also known as ObamaCare) helps immigrants by providing new and strengthening current health insurance coverage opportunities. Below are six important points about the ACA that all immigrants need to understand.

Lawfully present immigrants are eligible to purchase private health insurance plans in the health insurance marketplaces. Every state has made available to its residents access to a state or federal online marketplace where applicants will be provided a range of affordable private qualified health plans for them to enroll in. Essential health benefits, pre-existing conditions, and preventive care will all be covered under these qualified health plans. Open enrollment in these plans is from October 1, 2013, until March 31, 2014. Applicants must have enrolled in and purchased coverage by December 15, 2013, for coverage to start on its earliest date: January 1, 2014.

Lawfully present immigrants may qualify for federal financial help to lower the cost of their monthly premiums and cost-sharing (e.g., co-payments, deductible, co-insurance) to help them afford a private insurance plan through the Marketplaces. Lawfully present immigrants with household income between 100% and 400% of the federal poverty level (FPL) ($45,960 for an individual or $94,200 for a family of four) are eligible for premium tax credits and between 100% and 250% of the FPL ($28,725 for an individual and $58,875 for a family of four) are eligible for the cost-sharing reduction subsidies. The tax credit alone is estimated to provide $2,700 per family that purchases coverage on the Marketplace, reducing premium cost by an average of 32%. To qualify for this federal financial help, applicants cannot be offered affordable health insurance through their job or be eligible for Medicaid.

Most lawfully present immigrants who meet Medicaid program requirements, such as income and state residency, can enroll in Medicaid after they have been in the United States for 5 years or more. Some groups of lawfully present immigrants do not have to wait five years before they may enroll in Medicaid, including refugees, asylees, and pregnant women and children in some states. Immigrants will benefit greatly in states that choose to add the ACA’S new Medicaid eligibility category, which will expand that program to all adults under age 65 with household income of less than 138% of the FPL (about $15,800 for an individual and $32,500 for a family of four). In fact, more than half (52%) of uninsured Hispanics with incomes below this limit reside in states adding the new Medicaid eligibility category. Use of Medicaid does not affect one’s immigration status (public charge decision) unless the Medicaid use is for long-term care such as nursing home care.

Lawfully present immigrants with household incomes of less than 100% of the federal poverty level are also eligible for the private Marketplace coverage and can get help paying premiums and cost sharing if they are ineligible for Medicaid (either because they are not LPRs or because they are LPRs with less than five years of residency).

Undocumented immigrants may not buy health insurance through the Marketplaces, even at full cost. However, until this is remedied, undocumented immigrants need to know that

  • community health centers, strengthened by ACA funding, will still accept patients regardless of immigration status, 
  • emergency rooms will continue to treat undocumented immigrants for free or at very low cost, 
  • many hospitals have charity care obligations that essentially provide free care to low-income patients, regardless of immigration status, 
  • undocumented immigrants may purchase health coverage through an employer or a spouse’s employer,
  • undocumented immigrants may purchase private health insurance off of the Marketplace, and 
  • some state-funded Medicaid programs are open to them regardless of immigration status. 

Undocumented immigrants also need to understand that, if they have family members who are U.S. citizens or lawfully present, these family members are required to have health insurance under the law starting in 2014, or face a penalty at tax time, unless they qualify for some exemption. This means that undocumented parents who have lawfully present or U.S. citizen children must ensure that their children have health insurance (through a child-only private Marketplace plan or through Medicaid, for instance). It’s important to remember that only those individuals in a family who are applying for health insurance are required to provide citizenship and immigration status. So undocumented parents applying through the Marketplace for private or Medicaid coverage for their eligible family members will not be asked for a Social Security Number for themselves (only for the applicants).

There is no charge to individuals who receive in-person help in enrolling in Medicaid or Marketplace coverage. The ACA provides federal funding to train and certify in-person consumer assisters to walk individuals through all of their health insurance coverage options. You can find an in-person assister by going to your Marketplace’s website. These assisters cannot and will not charge individuals for this enrollment assistance, including answering questions post-enrollment. Lastly, enrollment information is not shared with immigration agencies for the purpose of enforcement.


Happy T-Day

StethoscopeIt’s October 1, 2013. Lots going on—or not, since many parts of the federal government are shut down.

But it is a very big day for the 48 million uninsured Americans who need health insurance coverage. It’s opening day for the health insurance marketplaces where uninsured Americans can explore their options for public or private health coverage. 

And I’m calling it “T-Day.” That’s my shorthand for Truth Day. Why?  Because today is the day many Americans will, one by one, family by family, begin to sort out the truth from the lies about the Affordable Care Act (ACA), also known, both affectionately and pejoratively as “Obamacare.”

Congress passed the ACA in 2010 to reform America’s health care system, tamp down its costs, improve its quality, and give all Americans quality, affordable, comprehensive health coverage. Today and in the coming days, weeks, and months, Americans without health insurance (and by “health insurance” I mean coverage by either public insurance, like Medicare, Medicaid, or the Children’s Health Insurance Program [CHIP] or private insurance) can examine the range of new options open to them, find coverage that best suits their health needs and their budgets, and sign up.     

However, what in a less fraught world would have been a win-win for the American people has become extremely contentious. Case in point—after losing in their efforts to repeal the ACA in Congress, to have it declared unconstitutional in the Supreme Court, and to defeat President Obama in the 2012 election, one wing of the Republican party is shutting down much of the federal government today in an attempt to delay the ACA. Rather than allowing the law to go into effect, they want to stop their fellow Americans from seeing the kind of health coverage they will get under the Affordable Care Act and making up their own minds about what it offers.

Hence “T-Day.” I’m betting that, once uninsured Americans actually see the options for public or private coverage available to them, people will realize that “Obamacare” is good for them and their families and that the hysteria around it was, well, unfortunate. Here’s some unsolicited advice for those uninsured Americans willing to approach the ACA with an open mind. 

First, try to clear your head of much of the rhetoric about Obamacare and resolve to rely on information sources you really trust going forward.

Second, put aside your ideas about how health insurance works or does not work, based on bad experiences you or your family have had trying to buy and use health insurance in the past.

  • The ACA has prohibited many insurance company practices that made health coverage unavailable, unhelpful, or too expensive.
  • These insurance reforms have been phasing in since the ACA was passed in 2010, but many of the most significant ones will go into effect on January 1, 2014, and will apply to the insurance plans offered on the online marketplaces opening today. Plans must: not deny coverage based on pre-existing health conditions); base their cost on the purchaser’s age, location, and whether he or she smokes (not on gender or health status); and assure that patients covered by the plan have access to services in a timely manner.

Third, if you are between 19 and 65 and your income is under roughly 138% of the Federal Poverty Limit, you may be “newly eligible” for Medicaid, even though you may have been denied in the past. And FYI, Medicaid coverage is good health coverage; states are constantly improving it with care coordination and other smart measures.

Fourth, accept the fact that having health insurance is far better for you and your family than not having it, and be willing to pay something for it if you are over the Medicaid or CHIP income ceilings. Like buying car insurance, buying health insurance protects you, your family, and society.

Fifth, take your time. Today you can begin to look at and sign up for coverage under public or private insurance, but you have lots of time to figure it out and lots of people to help you. To be covered on January 1, you need to be signed up and pay your first month’s premium by December 15. Start the learning process soon, give yourself time to think about your needs and what works for you, and then sign up. And be aware that when you sign up for an insurance plan, it’s not a lifetime commitment. There will be a chance to change every year during the “open enrollment” period and even before then if your circumstances change, for example, through marriage, divorce, adoption, or the birth of a child. 

Finally, be patient with the whole enrollment process. Lots of new websites and software and staff are starting up today. No one doubts that there will be glitches, but these will be sorted out in due time and should not prevent individuals and families from signing up to take advantage of the Affordable Care Act.

The pursuit of truth always leads us in the right direction. Investigate the facts about ACA and don’t be fooled by the rhetoric.


Consumers Need Protection from Health Insurance Company Plan Year Manipulation

It was disappointing—infuriating actually—to learn that some of the nation’s health insurance companies are trying to take advantage of their current customers by manipulating plan years. They are doing so to avoid having to pass on to these customers the benefits of national health reform.

These insurers are reaching out to current customers, taking advantage of their uncertainties, and luring them to switch to health plan years that begin in 2013. By substituting 2013 plans for their current plans that run through early 2014, customers will lose important Affordable Care Act (ACA) protections that must apply to plans issued on or after January 1, 2014. For example, plans issued in 2014 must offer a comprehensive range of benefits and have rates based only on the customer’s age, geographic location, number in family, and tobacco usage. Discrimination based on gender or preexisting conditions is banned by federal law in 2014 plans. Health insurance insider turned critic, Wendell Potter, recently wrote in detail about this outrage in the Huffington Post

So insurers are trying to have the best of both worlds. They want all the goodies the ACA offers them, including hundreds of millions of new customers (many of whom will only be able to afford coverage because they qualify for the federal financial help in the form of advance premium tax credits and cost sharing subsidies available under the ACA), but they also want to deprive their existing customers of the benefit of ACA reforms. 

Fortunately, insurance regulators can and are protecting customers from such manipulation. Illinois Department of Insurance Director Andrew Boron issued Bulletin 2013-07 on April 29, 2013, telling Illinois health insurers that they won’t get away with such manipulation. “The Department will not approve . . . filings for such arrangements,” the bulletin says. That should bring these threatened manipulations to an end in Illinois, and we hope regulators in other states take similar actions. 

Health insurance has been baffling to most individuals and small businesses. The federal government, many states, and many non-profit organizations are working hard to inform citizens of the reforms, benefits, and opportunities the Affordable Care Act has already brought and the major improvements coming in 2014. Actions like these plan date manipulations simply have no place in the picture. Thank goodness regulators can and are stepping it to ensure a happy ending. 

Reposted from Illinois Health Matters.


Illinois Extends Medicaid to Low-Income Adults--a Very Big Deal

Girl at the doctorIllinois took a big step on the road toward all Illinoisans having quality, affordable health care this past week. On July 22, 2013, Illinois Governor Pat Quinn signed into law Senate Bill 26, as Public Act 98-0104. The new law extends Medicaid eligibility to nearly all low-income Illinois residents effective January 1, 2014. Until now, low-income adults, ages 19 through 65, the great majority of whom are working at lower wage/no benefits jobs, have not been eligible for Medicaid. These people qualified only if they were totally disabled or caring for minor children. The federal Affordable Care Act allows states to cover this long left-out group in their Medicaid programs and receive 100% federal funding for the costs. With Public Act 98-0104, Illinois wisely is doing so.   

With the other ACA reforms also set to go into effect January 1, 2014, nearly all uninsured Illinois residents now will have access to public or private health coverage and health care. Those under 138% of the Federal Poverty Level (FPL) ($15,415 for an individual) will be eligible for public coverage in Medicaid. (The income limits are higher for children in Illinois's All Kids program.) Those over 138% of the FPL will be able to purchase health insurance on the Illinois Health Insurance Marketplace. Illinoisans finally will have peace of mind knowing that:

  • they can get comprehensive, affordable private insurance if their income is over Medicaid’s limits;
  • they can get Medicaid if their income is lower;
  • they can move from public to private health coverage and vice-versa as their income changes; and
  • both the private insurance plans and Medicaid will cover comprehensive, quality care. 

The insurance sold on the Marketplace starting October 1, 2013, will be better in coverage and cost than the individually purchased health insurance now being sold. ACA reforms eliminate insurance companies' ability to deny or price coverage based on one’s preexisting medical condition or gender. Instead, health insurance policies will be priced on the basis of the customer's age, geography, number in family, and tobacco usage. Additionally, policies must cover a broad range of needed health services and not charge any copayments or deductibles for preventive care.

Medicaid, too, will offer comprehensive, quality coverage. Skeptics (and there are a lot of them) who disparage Medicaid coverage should take another look. The Illinois Medicaid program has been reforming itself for several years now. It was ahead of the curve on requiring Medicaid patients to have a "medical home," that is, a primary care doctor who manages their care and refers them for specialty care as needed. It also is testing a variety of "care coordination" models that take the medical home concepts farther and, through provider payment methods aimed at improving quality and decreasing costs, encourage preventive care, discourage unnecessary emergency room use, and support patient follow up and follow through on treatment.

With the enactment of Public Act 98-0104, Illinois is a lot closer to coverage for all. On January 1, 2014 (with enrollment starting October 1, 2013), Illinois residents at all income levels will have access to quality, affordable health insurance coverage. Of course, neither Medicaid coverage nor insurance coverage will drop from the sky. People need to apply. They can do that starting October 1. Between now and then the Illinois government, the federal government, and hundreds of Illinois community groups will be offering information about public and private coverage and the application process. And after October 1, they'll be there to help us apply and walk us through the enrollment process.  

Unbanked and Uninsured: Implications for ACA Enrollment

Description: the countdown to full Affordable Care Act insurance coverage on January 1, 2014, proceeds and details get filled in, smart folks in government and the private sector are analyzing those details and catching potential problems. Case in point--a recent report by Jackson Hewitt raised concerns that nearly 8 million of those uninsured Americans eligible for premium assistance to help them purchase insurance and meet the mandate under the Affordable Care Act (ACA) will not be able to buy insurance and utilize such assistance. According to the report, more than 25% of Americans who are eligible for tax credits to help them purchase health care insurance are unbanked. Among African Americans and Hispanics the prospects are even worse, as they are 40% more likely than whites to be unbanked. The concern was that for these uninsured Americans health care coverage would remain unattainable because insurance companies might not allow consumers to pay premiums through methods other than through a checking account, whether by check or electronically. Turns out the Centers for Medicare and Medicaid (CMS) and the Department of Health and Human Services (HHS) had this potential problem on their radar screen, too. They included provisions requiring insurance companies to accept premium payments in many forms in proposed rules released on June 14 and published in the Federal Register on June 19.  

The Jackson Hewitt report, which was released last month, raised significant concerns that the very people who most need the assistance in purchasing health insurance provided by the ACA would not benefit from it. As the report noted, more than 1 in 4 uninsured Americans eligible for the new premium assistance tax credits under the ACA do not have a checking account. Thus, limiting premium payments to only checks or electronic transfers from checking accounts would have prevented these individuals, who are also heavily African American and Hispanic American, from accessing health insurance. 

While the report noted that HHS issued guidance in April to issuers on federally-facilitated and state partnership exchanges that included a statement that “issuers must be able to accept payment in ways that are non discriminatory,” it did not specifically state what alternative methods of payment should be accepted. The proposed rules spell out those methods.

Although the Jackson Hewitt report suggested that allowing unbanked Americans to make their health insurance premium payments using prepaid cards would be the best option, this suggestion also raised some concerns. Consumer advocates have warned that prepaid cards are risky and have high fees, and they are likely to weigh in with their concerns in commenting on CMS’s proposed rules.

Clearly in order to ensure that the benefits the ACA was meant to confer were in fact conferred, further guidance was needed, and CMS and HHS have provided just this. Under the proposed rules, qualified health plan issuers must, at a minimum, accept a variety of payment formats, including, but not limited to, paper checks, cashier’s checks, money orders, and replenishable prepaid debit cards, so that individuals without a bank account will have readily available options for making monthly premium payments. As HHS noted, this will allow unbanked individuals to be able to access coverage through an exchange on the same basis as those with a bank account or credit card and ensure that they are not unable to access coverage merely due to the inability to pay their share of the premium by means of a check. The proposed rule also permits issuers to offer electronic funds transfer from a bank account and automatic deduction from a credit or debit card as payment options. HHS also specifically asked for the public to submit comments on this proposal and whether other payment methods should be included during the 30-day comment period.

While we are pleased with the CMS/HHS proposed rules, the issue that millions of Americans are unbanked remains. According to the FDIC, 10 million American households are unbanked, and another 24 million households are underbanked. Thus, the long-term solution to this issue must be to continue to offer banking opportunities to the unbanked and provide greater access to mainstream financial services. As detailed in our recent Clearinghouse Review article, The Affordable Care Act: An Effective Asset-Building Policy” and related webinar, being uninsured hinders a person’s ability to build assets. Extensive research shows that poverty and poor health outcomes go hand in hand. Sometimes poverty leads to negative health outcomes, and sometimes negative health outcomes lead to poverty. While the directionality of this relationship is not consistent, poor health is known to place additional burdens on low-income people and acts as a barrier against moving out of poverty. Improving health outcomes is, therefore, not only an important asset-building tool, but another reason why banking the unbanked is paramount. 

Illinois General Assembly Extends Medicaid Coverage to Low-Income Residents

Time: 4:30 p.m Central, Tuesday, May 28, 2013. "Mr. Clerk, take the record." With those words the President of the Illinois Senate asked the clerk of the chamber to record the votes on Senate Bill 26, as amended, the bill which would  put Illinois in the column of states that will, come January 1, 2014, offer Medicaid coverage to all low-income state residents. The Senate passed the bill by a vote of 39 to 20, concurring with the House, which passed the same bill the previous day (63 to 55). Thus, pending Governor Quinn’s signature, which he has promised, President Obama's home state will extend Medicaid to all previously ineligible low-income adults under the Affordable Care Act.

As Shriver Center President John Bouman stated:

Passage of this measure helps everyone in the state because it is a key part of the overall reform of the health care system and controlling its costs. But make no mistake: it is also the single most significant blow against poverty struck in Illinois in the last 50 years.

It was clear from the floor debates that these thoughts, as well as the moral conviction that health care should be for all, were prevalent among the supporters of the bill. Opponents of the bill largely cited unsubstantiated fears about future costs and the speculation that the federal government might someday renege on the funding promises in the Affordable Care Act. In fact, however, the opposition was partisan. The Republican caucuses took “caucus positions,” meaning that individual members were not free to vote their consciences or their opinions about wise public policy. 

Enacting this legislation means Medicaid coverage and increased access to quality and affordable health care to those who are uninsured with incomes under 138% of the federal poverty level (roughly $15,856 for an individual). This would make an exponential improvement in their quality of life and economic opportunity. This measure is a crucial part of the overall health reform taking effect since March of 2010. With passage of this law, Illinois joins 28 other states that have supported extending Medicaid to those newly eligible under the Affordable Care Act.

The Affordable Care Act provides that the Federal Medical Assistance Percentage (FMAP) rates for newly eligible individuals are 100% for calendar years 2014 through 2016. Federal financial support will then phase down slightly over the following several years so that, by 2020 and for all subsequent years, the federal government will pay 90% of the costs of covering these individuals (meaning that Illinois will pay just 10% of the cost of care for this new population). Medicaid coverage for the newly eligible group will start statewide January 1, 2014, with enrollment starting in October 2013. (The new coverage took effect January 1, 2012, for Cook County, Illinois, residents.).

 In addition to health improvements for the newly eligible, the law’s implementation will also:

  • Ease the financial burden on health care providers. Through 2016, this legislation will bring an estimated $4.6 billion into Illinois in the form of Medicaid provider payments for newly eligible adults, with no net state costs for the care.
  • Help stabilize Illinois’s state budget. The Illinois State Budget, Townships, and General Assistance providers will be relieved from paying for coverage of those who are uninsured and are currently ineligible for Medicaid.
  • Benefit family economic well-being. New Medicaid will help reduce the financial burden that those who have private insurance pay towards the cost of uncompensated care. According to a report from Families USA, the average family with private health insurance pays an annual “hidden tax” of over $1,000 annually to offset the cost of uncompensated care.
  • Create new jobs in Illinois. Adding the new eligibility category to Illinois’s Medicaid program will bring in a large amount of federal funds, which will result in more economic growth and jobs. In Illinois, the total amount of federal Medicaid funding anticipated to accompany the expansion is over $21 billion dollars from 2013 to 2022, which could finance hundreds of thousands of new health care jobs.
  • Provide health insurance coverage to veterans. About 13,000 of the newly eligible for the Medicaid Expansion are returning veterans who will not be helped by the U.S. Department of Veterans Affairs.

This new adult coverage legislation, Senate Bill 26, sponsored by Senator Heather Steans and Representative Sara Feigenholtz, was supported by hundreds of business, health care, faith-based, community-based, and patient/consumer advocacy organizations. These supporters conducted public outreach, wrote articles and blogs, and attended the legislative sessions. Thank you to all of the legislators who voted yes on a bill that tackles one of the most fundamental justice issues of our time: access to health care. 

Obamacare Enters Its Big Year for Fighting Poverty

Birthday cakeObamacare, the Affordable Care Act (ACA), had its third birthday over this past weekend. So this is its first work week in its most important year. This is the year for the ACA’s heavy lifting, bringing affordable health coverage to 36 million uninsured Americans and ending discrimination against adults with pre-existing conditions, all effective as of January 2014. This is the year that the ACA becomes the biggest single measure in the fight against poverty in the last 50 years.

The ACA, of course, is usually discussed in terms of its impact on the health care system. And it is already doing a significant job on that front. In its birthday editorial, the New York Times aptly summarized the important contributions to reform of the health care system that the ACA has already produced:

That is a substantial list of accomplishments; moreover, the health care system is due for its most important improvements in the coming year. The upcoming big changes, however, will have an impact that should be understood in more than just health care terms. The progress that will be made in the fight against poverty will be truly remarkable. 

Half of the gain in covering the uninsured will be directed at people in the deepest poverty in our country. Since Medicaid began in 1965, it has had a gap. It never offered coverage to people aged 19-64 who are not officially disabled and not caring for a child in their home. These are young adults leaving high school or college (whose parents do not have employer-supported coverage); empty nest parents whose children are over 18; tens of thousands of veterans not covered by VA health programs (over 12,000 would gain Medicaid coverage just in my home state of Illinois); chronically unemployed people with serious mental and physical impairments who are not officially disabled; many of the homeless; and others. The ACA will fill that gap in Medicaid , providing coverage to all with income under 138% of the Federal Poverty Line ($15,415 per year for an individual and $26,344 for a family of three) in the states that choose to take the federal money that the ACA offers them to pay for it.

For many people in poverty, health coverage not only means health, reduction in pain, and expansion of life expectancy, it also means employability and productivity and upward mobility. It can improve learning capacity. It reduces family stress. It can be a major factor in reducing family and community violence. It is a vast improvement in quality of life and quality of opportunity.

The ACA also ends the high cost for Medicaid beneficiaries of making more money. Currently, when a Medicaid beneficiary succeeds in the workplace and escapes poverty, there is a penalty: the loss of health coverage when earnings exceed allowed Medicaid levels. Starting in January, though, the Healthcare Marketplaces in every state will offer affordable private insurance coverage to replace Medicaid when earnings call for termination of Medicaid eligibility. This private coverage removes a barrier to upward mobility. It also acts as a net to keep workers in the middle class if they lose employer-supported insurance, when a health emergency might otherwise mean a free-fall into poverty. And it is there to provide coverage for budding entrepreneurs who want to try for the American Dream and start their own businesses, but who currently are blocked because they cannot risk losing either Medicaid or employer-supported coverage.    

Obamacare already fights poverty by helping seniors on Medicare make ends meet and by helping young adults make their way in the workforce by staying on their parents’ insurance. And in the coming year, at least in the states that implement it thoroughly, Obamacare will make its biggest inroads against poverty.  

The Affordable Care Act: Saving Prescription Drug Costs for Medicare Beneficiaries

Prescription drug bottleIn February, the Centers for Medicare and Medicaid Services (CMS) released the second annual report on the impact of the Affordable Care Act (ACA) on Medicare drug spending. This report revealed that 6.1 million Americans with Medicare saved $5.7 billion on their prescription drugs—money that otherwise would have fallen into the “donut hole” prescription drug coverage gap that forces beneficiaries to pay for 100 percent of their drug costs once they have reached their prescription drug plan limit.

Since 2010, the ACA has started to gradually close the “donut hole” or Medicare prescription drug coverage gap. More than three million Medicare beneficiaries in the “donut hole” received a 50% discount on covered brand name drugs and a 14% discount on generic drugs. These reductions will continue to increase until the gap is completely closed by 2020. On average, a Medicare beneficiary will save about $5,000 on prescription drug spending by 2022.

When the ACA was signed into a law it outlined ways to improve Medicare by saving money for its beneficiaries, removing unnecessary barriers, and lengthening the life of the program. Under the law, the cost of Medicare premiums remained moderately low. In fact, some individuals paid lower premiums in 2012 compared to what they paid in 2010. For Medicare beneficiaries, these savings meant lower prescription drugs costs and improved access to benefits.

Furthermore, the ACA focuses on efficient long-term cost containment strategies. One way it does this is by increasing access to preventive health services. Last year, through an ACA provision, Medicare beneficiaries accessed preventive services with no deductibles or co-pays. Vaccinations, screenings, and other preventive service are important because they help identify diseases, detect illnesses in their most treatable stages, and allow for the best chance of recovery. This provision removed the out–of-pocket cost barrier to preventive services, thus encouraging seniors to take a proactive approach to their health.

The Medicare program is working and it is becoming stronger, thanks to the Affordable Care Act. You can read the full CMS report here

This blog post was coauthored by Viviane Clement.


The Affordable Care Act and You: Closing the Medicaid Coverage Gap

Nurse with infantWelcome to the second blog in our series “The Affordable Care Act and You.” Our last blog highlighted some of the consumer benefits that were made possible by the Affordable Care Act (ACA). We discussed how the ACA banned insurance industry practices like lifetime dollar limits and gender rating. We also noted how the ACA increased access to health care through provisions that expanded dependent coverage and provided consumers with preventive services without cost sharing.

This blog will focus on the ACA’s changes to the Medicaid program, which has the potential to extend coverage to more than 16 million low-income individuals across the nation. Medicaid is a state and federal health insurance program that provides coverage to certain categories of low-income individuals and families—namely, children, their parents, pregnant women, people who are disabled, and the elderly. Currently, Medicaid provides health insurance to about 60 million low-income Americans. However, there are millions of individuals who do not qualify for Medicaid no matter how poor they are because they don’t fit into one of these specified categories. This coverage gap causes millions of low-income individuals to postpone necessary care and prescriptions, over-rely on emergency rooms, and lack any relationship with a primary care provider to obtain preventive care and health care screenings.

The ACA offers states the opportunity to close this Medicaid gap starting in 2014 by offering insurance to persons age 19 through 65 who have household incomes less than 133% of the federal poverty level (which is $14,856 for an individual or $20,123 for a couple). Moreover, the cost of covering them will be 100% paid for by federal funds for the first three years. This 100% federal match rate will gradually decrease to 90% by 2020. With this enhanced federal match rate, Illinois, for example, can expect over $21 billion in federal funds over the next 10 years

States that have already committed to closing the Medicaid coverage gap have realized that it is a great deal. The significant federal funding will enable states and local governments to support programs delivered to the newly eligible population, and thereby saving states an estimated $92 to $129 billion over the next five years. Covering the Medicaid gap in states will help pay for hospitals’ uncompensated care costs, which translates to an estimated $1.5 billion in savings in one state. Medicaid coverage would make it possible for individuals to have a relationship with a primary care provider. This will result in a healthier population and lower mortality rates.  For more reasons of why states should opt in to the Medicaid expansion, read the National Health Law Program’s fifty reasons why Medicaid is good for your state

This blog post was coauthored by Viviane Clement.


The Affordable Care Act and You: The New Consumer Benefits

Doctor and patietThe election is over, and the Affordable Care Act (ACA) is here to stay. The Shriver Center, along with numerous national and local advocacy organizations, has been active in getting the word out about what is in the ACA. Surveys show that many people are unaware of the benefits that are available to them because of the ACA and that most Americans approve of the consumer benefits offered by the Act. And so, we are launching a biweekly blog series called “The Affordable Care Act and You” because it is time to get to know the ACA.

Let’s start with the basics. What is the Affordable Care Act? Signed on March 23, 2010, the Affordable Care Act sets forth provisions and regulations to reform our health care system in a way that offers more people access to health care. It is important to know that not all insurance plans are subject to the consumer protections rules of the ACA. Employer-sponsored health insurance plans that existed before March 23, 2010, are granted a “grandfather status,” which basically means that they have to abide only by some of the rules of the ACA. However, insurance plans created after that date must abide by all of the ACA’s regulations.

The ACA has decreased the number of uninsured individuals in the U.S., ensured that insurance companies spend at least 80% of your premium dollars on your medical needs, and has made it easier for small businesses to offer health insurance to their employees. These are just some of the existing reforms made by the ACA; in this first blog in the series we will talk about several more consumer benefits provided for in the Act.

1.     The ACA makes preventive services free of cost-sharing.

Too many Americans refrain from getting needed preventive care because of the expenses they must pay out-of-pocket. Preventive care is crucial for the simple fact that it helps individuals to avoid costly and deadly illness by detecting health issues early. The ACA requires health plans, excluding grandfathered plans, to offer you preventive services at no additional cost. This means that your immunizations, screenings, and checkups are covered—no out-of-pocket expenses. And for women, well-woman visits, mammograms, contraceptives, and other services are also free of cost-sharing. You can find the full list of preventive services that are now free of cost-sharing here.

2.     The ACA bans lifetime dollar limits.

Medical expenses are costly for a healthy individual; for millions of Americans living with a chronic medical condition, health care costs can lead to financial ruin and loss of health insurance. For years, it has been perfectly legal for insurance companies to impose a lifetime dollar limit on your health coverage. And once you reach that amount, they can stop paying for your health expenses. Now, because of the ACA, if you or someone you know has a medical condition, there is no longer a need to worry about losing insurance coverage because of lifetime dollar limit.  Because of the ACA, insurance companies are banned from imposing a lifetime dollar limit on your coverage. In addition, the use of annual dollar limits will be phased out over the next two years and banned entirely in 2014.

3.     The ACA provides for dependent coverage for young adults up to the age of 26.

The ACA’s dependent coverage provision allows young adults up to the age of 26, to stay or be added to their parents’ health insurance. The young adult population, or so-called “young invincibles,” often struggle to afford health insurance, and many just go without. Since the dependent coverage provision went into effect in 2010, 13.7 million young adults were able to remain or rejoin their parents’ health insurance. If you are under the age of 26, or a parent of a young adult under the under this age, check to see if your insurance plan offers dependent coverage up to the age of 26.

4.     The ACA will assure that pre-existing conditions will no longer be a barrier to coverage.

Several common health conditions—asthma, high blood pressure, arthritis—can be considered pre-existing conditions. Insurance companies, if they choose to, can refuse to cover you because of a pre-existing condition. Since the passage of the ACA, children can no longer be denied health insurance because of a pre-existing condition. Adults, on the other hand, must wait until 2014 to receive the same benefit. Luckily, the federal government, under the ACA, provided funding to the states for temporary high-risk pools. This funding provides health insurance for adults with pre-existing conditions who are unable to find coverage because of their conditions. In Illinois, this program is called the Illinois Pre-existing Condition Plan (IPXP), and you can enroll by contacting the Department of Insurance.

5.     The ACA will end gender rating.

In many states, women can be charged more for health insurance than men—as much $391 more annually! This surprisingly common practice—where insurance company charge more based on gender—is called gender rating. In states that do not already prohibit gender rating, 95% of the best-selling health insurance plans practice it. In Illinois, 100% of the best-selling health insurance plans practice gender rating. Starting in 2014, the ACA will ban gender rating in all states.

These five patient consumer benefits are only the tip of the iceberg. Once the ACA is fully implemented, Americans can expect health insurance to be more accessible, affordable, and comprehensive. Now you know some of the consumer benefits that may benefit you or your family and friends. So spread the word!

The next blog in this series will be about the changes in the Medicaid program that will offer health insurance to low-income single adults with no dependent children. So stay tuned!

This blog post was coauthored by Viviane Clement. 


Affordable Care Act Trumps Recession's Impact on Health Insurance Coverage

Child with doctorAmidst the mixed news about poverty and income in the Census Bureau’s data released earlier this week, came some positive news about health coverage and the impact of the Affordable Care Act’s (ACA) provisions that are already in effect.

Overall, the rate and number of people without insurance coverage dropped in 2011 for the first time since 2007, in spite of the recession, contrary to most expert predictions (which were based on the assumption that loss of employer supported insurance due to job loss might increase the rate of uninsurance). 

The largest drop in the uninsured was among the 19-25 age group, clearly fueled by the ACA provision allowing young adults to stay on their parents’ health insurance as dependents up to age 26. The Obama Administration estimates that three million people have gained coverage through this provision.

While private and employer-based insurance did not decline for the first time in 10 years (due in large part to the impact of the young adult provision), it was an increase in public insurance enrollment that fueled the overall drop in the uninsured. Both Medicaid and Medicare enrollments increased, and children’s insurance held steady. The Medicaid and children’s insurance results can be attributed to the “stability provisions” in the ACA, which require states to hold the line on Medicaid and State Children’s Health Insurance Program eligibility (“maintenance of effort”). Medicaid and Medicare combined cover about one third of the country’s population.

On another front, one of the main messages of the Census Report was the ongoing exacerbation of income inequality in the U.S. (with the bottom four-fifths of the population losing ground, and the top fifth gaining). There is a health insurance side to that story. In 2011, the uninsured rate grew the lower a family’s income was: 25.4% of those with household income less than $25,000 were uninsured, compared to 7.8% of those in households with income over $75,000.

Thanks to the ACA, the country’s performance on health coverage improved in 2011, when it otherwise could have been dragged down by the recession. But there is a long way to go, with over 15% of the population and 9.7% of children still uninsured. Addressing income inequality will have a positive impact on insurance coverage. The ACA’s largest impact on coverage will come in 2014 and beyond, with implementation of the health insurance exchanges and the completion of Medicaid’s coverage of the poor. Faithful and vigorous implementation of those changes will make this story even brighter.

The Check Is Actually in the Mail

MailboxThis month, about 163,000 families in Illinois are expected to receive a rebate check in the mail. No, it’s not a refund on your federal taxes and it’s probably not the hundred dollars your cousin Sam owes you—it’s actually money back from their health insurance company. Due to a provision of the Affordable Care Act (ACA) called the 80/20 Rule or the Medical Loss Ratio Rule, insurers are mandated to spend at least 80% (85% for the large group market) of the premium dollars they receive from clients on actual health care expenses, and not items like CEO bonuses, marketing, and other overhead. When insurers don’t meet that threshold, they have to issue refund checks to their clients. These clients will be getting a health insurance rebate check with money that their insurance company owes them for not spending at least 80% of their premium dollars on medical care.

In Illinois alone, health insurance carriers have to pay back about $62 million to their clients—the fifth highest amount in the nation—for not meeting the medical loss ratio in 2011. UnitedHealthCare, the second largest health insurance company in the state of Illinois, paid back $13.1 million to policyholders. Nationwide, there are estimates that at least $1.1 billion in rebates will be paid back to the consumers. The average rebate amount to a family that purchases their own insurance is $151—that’s a nice chunk of their own money they will be getting back! Insurers who failed to meet the requirements had to sent out their rebates by August 1, so the checks should have already arrived in many mailboxes. 

So, just who is receiving a check? To be clear, not everyone will actually receive a physical check—their refund could be issued to their employer if that employer pays for their health care, or it could be used to credit their account in the future or returned to their credit cards. Even if consumers do not actually receive the check in the mail, this is still money that goes back into the consumer’s pocket, thanks to the Affordable Care Act.

This blog post was coauthored by Viviane Clement.


The Affordable Care Act: Helping the "Young Invincibles"

Just who are these “young invincibles”?  The term describes young adults between the ages of 18-29 who may seem uninterested in health insurance and believe they can afford to go without coverage— and are therefore, “invincible”. Unfortunately, this belief is false. Of course, not all young adults think they are invincible and none of them actually are. While this is a mostly healthy demographic, many of them desperately need health insurance to obtain necessary health care, and many more of them know that they should have it in case of emergency.  In addition, the parents of many of these young adults are keenly aware that if their son or daughter experiences a significant medical need, it is they who will be paying for it, one way or another. These parents want coverage for their child, even if it is not a priority for the young adult.  If given the chance to have affordable health insurance, many young adults leap at the opportunity. And thanks to the Affordable Care Act (ACA), as of November 2011, 13.7 million young adults aged 19-25  did just that, by either staying on their parents’ health insurance or rejoining it. 

These not-so-invincible young invincibles often struggle with obtaining, navigating, and affording health insurance. The uninsured rate among this group in 2009 was 14.8 million, an increase of 4 million from the past decade. This group is a large part of the 50 million people in 2010 living in the United States without health insurance and the ACA addresses their coverage directly. The dependent coverage provision encompassed in this law permits young adults under the age of 26 to remain on their parents’ private health insurance plan, even if the adult child lives in a different house in a different state, or even if the child is married. This policy went into effect on September 23, 2010; six months after President Obama signed the ACA into law. Since then, millions of young adults have gained or retained health insurance through their parents.

But young people must confront more than misconceptions about their own mortality—there are other reasons this group lacks health insurance. One unfortunate practice that serves as a barrier for young women’s access to health care is the practice of gender rating. Women are routinely charged more than double the premium compared to the amount men pay for the same health insurance coverage. This existing practice causes young adult women to delay getting needed health care because of the cost. Some states banned this practice, but in states where gender rating is not prohibited, 95% of bestselling health insurance plans charge women more for the same exact plan. The ACA makes it against the law in 2014 in all states for health insurance companies to charge women higher premiums solely based on gender. This provision reflects the ACA’s mission to make quality health insurance accessible and affordable.

Another reason this group often lacks coverage is simply the high cost of insurance. A national survey reported 40% of young adults had outstanding medical bills and were in medical debt. Often falling through the cracks of our healthcare system, there are many uninsured young adults in this country who lack reliable, affordable access to basic medical care. This is also a group that is likely to just be starting out in their careers, and making difficult choices about whether to pay for health insurance or rent. Luckily the ACA provides a new category of Medicaid eligibility for single, childless adults who have a household income at or below the 133% Federal Poverty Level (FPL) — or about $14,800 annual income for a single individual.  Currently, the eligibility criteria for Medicaid excludes low-income young adults from Medicaid if they do not have a disability or a child, thus leaving many young adults uninsured. For example, a 19-year-old who has just lost their AllKids insurance—Illinois public health insurance for children—may likely join the uninsured population. Under this ACA provision, however, the Medicaid program will change its eligibility criteria in 2014 to include single, childless adults.

Changing the Medicaid eligibility will finally allow many low-income young adults to receive much needed health care. Individuals who will be insured in 2014 because of the Medicaid changes will be called the newly eligibles, and the cost of their care is covered at 100% by federal funding until 2020, and after that, it will be covered at least at 90%.  This provision has the potential of covering 429,300 residents in Illinois

While many young adults will be newly eligible for Medicaid or eligible to remain on their parent’s insurance, not everyone will be. For young adults for whom neither Medicaid nor the dependant coverage provision is available, there is an alternative of signing up to buy health insurance from their state’s Exchange in 2014.   An Exchange is an online site that will offer many comprehensive health insurance plans. It will allow the consumer to shop and compare plans so that they can ultimately find the one that best suits their needs and budget. Through the Exchange, there will be a variety of private health insurance plans available in a central online location that is both easy to navigate and written in plain English to allow for full transparency. There will also be financial assistance in the form of subsidies and tax credits available for those who qualify. The financial assistance will be available for individuals who make an income of up to 400% of the FPL – that’s a monthly income of $3,723 for a young single person.  An Exchange can be created by the state, the federal government, or in collaboration by both state and federal governments to offer quality and affordable health plans.  Through the Exchanges, young people will have affordable and quality health insurance options to choose from.

Given the benefits and protection that it provides to young adults, we can see that the Affordable Care Act is working to help them access affordable and quality healthcare. By 2014 when the Exchanges are launched, the Medicaid expansion is in place, and all the other provisions are fully implemented, many more young adults will be able to take care of their health easily, affordably and efficiently. Unfortunately none of us are invincible, but the Affordable Care Act is a great tool in helping young adults (and everyone else) control their own healthcare.

This blog post was co-authored by Viviane Clement.


A Push Toward Smarter Health Care Policy

Welcome to the third in our series of blogs in which we examine the SMART Act’s changes to the Illinois Medicaid system. As a quick reminder, we think that truly smart health care policy has three components:

  1. Providing great outcomes and preventing bad ones.
  2. Caring for the whole person.
  3. Fiscal sustainability.

Newborn babyThis blog will focus on a change we think does achieve smart health care policy—Illinois Medicaid will now no longer pay an extra amount for medically unnecessary, or elective, Cesarean (C-section) births, but instead will cover them only at the normal vaginal delivery rate. Hopefully, this change will decrease the number of parents choosing C-sections for non-medical reasons by creating impetus for parents and health care providers to have a serious talk about why they would like to schedule a medically unnecessary C-section. Even though C-sections are very common and comprise about one third of all births in the United States and a similar percentage in Illinois, a Cesarean birth is still a major abdominal surgery. This means that a C-section comes with all of the risks associated with other common surgeries, including adverse reactions to medications and increased risk of infection for the mother, along with health risks for the baby. To top it off, billing for an uncomplicated C-section birth is almost double that of a vaginal birth. The State of Illinois estimates that eliminating medically unnecessary C-sections will save about close to $3 million in the next year. All those health risks and more expensive, too?  Sounds like a good place to start improving Medicaid. 

So why are medically unnecessary C-sections a choice for some people? Parents and doctors might schedule medically unnecessary C-sections for a variety of reasons, including wanting to deliver with a particular doctor or on a particular day, desire to avoid prolonged labor pains, or desire to avoid the uncomfortable last few weeks of a pregnancy.

However, the World Health Organization strongly cautions against medically unnecessary C-sections. Medical professionals say that medically unnecessary C-sections are more likely to cause problems for both the mother and the baby. Scheduling C-sections for reasons of convenience often result in the surgeries occurring prior to the 39th week. Babies do better when their C-sections come no sooner than one week before their due date, if at all possible. This wait allows their lungs, brains and kidneys to finish developing. Babies born by C-section have, on average, more difficulty breathing after birth and have lower Apgar scores. Particularly at risk are those infants delivered before 39 weeks, a segment which includes one in three C-sections.  These infants are at risk for eating and breathing problems, jaundice, and temperature instability and are at greater risk of being re-hospitalized for poor weight gain or failure to thrive. Mothers have a longer recovery time and a higher risk of complications from C-sections than from vaginal births. Complications can include blood clots, excessive bleeding, infections, and injury to the bladder, uterus, or bowel. Of course, all of these avoidable but serious complications cost the Medicaid program more money. 

Some hospitals are already implementing procedures to cut down on their numbers of medically unnecessary C-sections. In Salt Lake City, Intermountain Hospital has implemented a program to encourage parents and health care providers to carefully consider the rationale for C-sections.  This successful program has kept their C-section rate below the national average, thereby   decreasing patient costs by more than $270 million over a 10-year period. The hospital states that $3.5 billion could be saved in annual medical charges if the national rate of C-section births was comparable to their own. In addition to saving money, Intermountain accomplished an even greater goal—better medical outcomes

Of course, some situations will call for a Cesarean section for reasons of medical safety, like some births involving multiple children, risky situations or older mothers. Medically necessary C-sections will still be covered at the higher rate under Medicaid; it’s only the elective C-sections that will be covered at the less expensive vaginal birth rate. This should cut down on the numbers of elective C-sections, saving money and improving health outcomes at the same time.  Healthier outcomes for moms and babies from a less expensive procedure?  Sounds like it fulfils all the prongs of our test! 

Expanding Medicaid: The Choice is Clear

The Supreme Court on June 28th ruled that while the federal Affordable Care Act’s (ACA) Medicaid expansion is constitutional, in the event that a state does not implement the expansion, it would be unconstitutional to withdraw all Medicaid funding from that state. The ruling appears to leave intact both the mandatory nature of the expansion and the other remedies that the federal Medicaid authorities might use to enforce it. The states, however, might view the removal of the most aggressive remedy (full Medicaid defunding) as opening up some additional degree of choice about whether to forego the expansion and risk whatever lesser penalties federal authorities may impose (such as a partial withholding of funds). In Illinois, as in any other state, it is clear that expanding the Medicaid program on schedule in 2014 is by far the smart and right thing to do, regardless of the potential federal penalties for not expanding.

1.  The ACA’s expansion is aimed at covering some of the most vulnerable low-income adults who are otherwise unable to afford private insurance. Not all low-income Illinoisans are currently eligible for Medicaid. Instead, right now, to qualify for Medicaid, a low-income person must fit into a “category,” such as being 65 or over, or totally and permanently disabled, or pregnant, or a child under age 19, or a parent or caretaker relative of a child under age 19. But if you are a single, childless, non-disabled adult without a penny to your name, you do not qualify for Medicaid. This expansion adds another category—having household income less than 138% of the Federal Poverty Level (FPL), which would apply to an estimated 500,000 individuals in Illinois. People in a wide range of circumstances will belong to the “newly eligible” group. Many will be low-wage, part-time workers. Some will be unemployed, either recent or long term. Some will have health conditions that, if addressed by consistent medical care, could and would allow them to get jobs. Some are really destitute, even homeless. Some are young adults, perhaps having aged off Medicaid, which they received as children, but are not fortunate enough to have parents with insurance that would cover them until they turn 26. Others are middle-aged or close to 65. Some are people who had insurance coverage, but lost it through changes in circumstances such as job loss or divorce. 

Of the newly eligible population in Illinois, an estimated 431,000 Illinoisans with household incomes less than 100% FPL will be left in the cold without the Medicaid expansion. The ACA envisioned that these folks would qualify for Medicaid. That’s why the federal subsidy to help pay for private insurance premiums starts at 100% FPL and goes to 400% FPL. So, without the Medicaid expansion, these folks will likely be priced out of affordable health insurance through the Exchange because they won’t qualify for the federal financial help (unless they are lawfully residing residents ineligible for Medicaid). They will have to continue to access safety-net providers and emergency rooms for care, driving up costs for these providers and showing up sicker. And, these folks are still held responsible under the individual mandate to prove insurance coverage or why they are exempt.

2.  Minimal state investment will reap overwhelming benefit. The ACA increased the Federal Medical Assistance Percentage (FMAP) rates for the newly eligible individuals under the expansion to 100 percent for calendar years 2014 through 2016, and then gradually declining to 90 percent in 2020 where it remains indefinitely. By 2020, when Illinois will pay just 10 percent of the cost of care for this new population, the annual state cost is estimated at $157 million. (This is 10% of the current cost per adult beneficiary in Illinois, $3,157, times 500,000 new beneficiaries). But even as this cost will rise due to inflation, it will also be offset by benefits such as larger state tax revenues from increased employment and provider income and an increased insured population. It will also be offset by increased efficiencies due to the new system to simplify and coordinate eligibility and enrollment for Medicaid and the Exchange, which is nearly entirely paid for by the federal government. It may also be offset by the stabilization of the health of almost half of the newly eligible population in the event that the federal government gives permission for Cook County to expand Medicaid early, this year or next. If Cook County is allowed to expand Medicaid early, an estimated 250,000 folks will have medical homes and coordinated care, which would likely stabilize chronic conditions, prevent disabilities, and therefore reduce future Medicaid costs. Finally, state costs can be further minimized by increasing efficiency through care coordination initiatives, especially for persons with chronic conditions and for dual eligibles (persons eligible for both Medicaid and Medicare). The Lewin Group estimates that the ACA will increase Illinois’s Medicaid spending by just 2.8% between 2014 and 2019. The Congressional Budget Office has estimated that the ACA would impose less than a 1% increase in state Medicaid costs.  Moreover, these high federal matching rates are highly likely to stay. In Medicaid’s close to 50-year history, Congress has never decreased FMAP levels in Medicaid other than to allow the expiration of temporary FMAP increases enacted as parts of stimulus packages in recessions. The more states that adopt the “newly eligibles” expansion, the more members of Congress who will resist any reduction below 90% down the line. In fact, with sufficient support, Congress could amend the matching rate, keeping it at 100% indefinitely.

3. Expanding Medicaid creates jobs. We know from our recent past that an increased federal matching rate in the Medicaid program has an enormously significant economic impact—called a multiplier effect—throughout the economy and positively impacts jobs. When Congress included an increase in the federal Medicaid matching rate in the American Recovery and Reinvestment Act from 50% to 61.88% from October 2008 through December 2010, $1.2 billion per year for that period flowed into Illinois. For FY 2009, one estimate places the value of the wages generated from the Medicaid program that included the enhanced match as high as $15.8 billion, supporting as many as 385,742 jobs. The job growth and wages generated are likely to be much more substantial under the ACA’s Medicaid expansion, since the federal matching rate under the ACA is 100% from 2014 through 2016 and an additional roughly 500,000 newly eligible Medicaid patients are expected to enroll. State and local revenue increases when Illinois residents pay income, sales, and other taxes generated by the federal funding for the Medicaid expansion; this revenue would offset much, perhaps all, of the additional costs.

4. Participating in the Medicaid expansion will help stabilize the state budget. The budget is critically dependent on federal Medicaid funding. The Illinois Medicaid program is by far the largest source of federal revenues to the state. Federal funds also support the Department of Human Services, Department on Aging, Department of Children and Family Services, local public health departments, Cook County Health and Hospitals Systems, Illinois’s state universities, and local school districts’ special education programs, among others. The Medicaid expansion will provide crucial federal funds across the state and local governments to support programs now being delivered to the expansion population with no federal funds, or being withheld from that population due to lack of funds.

5. We pay for the health care for the uninsured in any event, so let’s use federal dollars to pay for their current uncompensated care. A Kaiser and Urban Institute report on state spending under the expansion found that under the expansion, by 2019, Illinois would have reduced its number of uninsured adults in this newly eligible population by over 42% with the federal government paying for over 94% of the cost. This could translate into a decrease in Illinois’s uncompensated care spending of as much as $1.5 billion. And any cost to the state will be there, whether or not Illinois takes the money provided for the expansion. Working Illinoisans in low-wage jobs without insurance still get sick, still get injured. But without the federal dollars from the Medicaid expansion, other Illinoisans with insurance will still have to pick up the cost of their care, to the tune of $1,000 per year in increased annual premiums. And local property taxes are strained to support the township medical assistance programs and safety net health systems that provide care for low-income uninsured people now. In fact, currently over $400 million in services for uncompensated care is being provided annually by just one hospital: Cook County’s Stroger Hospital. 

6. Illinois hospitals need the Medicaid payments to offset reductions in federal funds in other areas. Targeted hospital subsidies, known as disproportionate share hospital (DSH) payments, will decline under the Affordable Care Act. The reduction was justified on the theory that the Medicaid expansion will eliminate the need for DSH subsidies by greatly reducing the burden of uncompensated care. If hospitals lose those payments, and the loss is not made up by the expansion of Medicaid, it will devastate not only hospitals, but entire communities. Many Illinois hospitals, especially in rural areas, simply are not viable if their DSH subsidies decline without being replaced by expanded Medicaid. Hospitals are among the largest employers in their communities. When a hospital closes, the community not only loses a major employer, but providers leave too, and then the community has great difficulty recruiting new industry. Additionally, expanding Medicaid will ensure that Illinois’s medical providers will have the financial support coming from the Medicaid expansion to offset the ACA’s Medicare payment reductions. Doctors and hospitals are counting on the Medicaid expansion (which will bring in revenue for services to the newly eligible and reduce the need for uncompensated care) to be in place as the Medicare payment changes are phased in.

7. Expanded coverage is the linchpin for the big picture reforms that will deliver both better health outcomes and lower costs. Coverage requires an investment (which the federal government virtually entirely funds under the ACA). But the investment will yield returns. Coverage makes possible a relationship with a regular medical provider. That, in turn, facilitates prevention, wellness advice, early detection of conditions, maintenance care (avoiding acute care), a platform for the full use of health information technology that avoids duplication and mistakes and spreads best practices, and care coordination. Coverage thus addresses the cost of health care by improving health outcomes across the system. This overall downward bending of the cost curve helps all of us, not just the newly insured. 

8. Federal Medicaid dollars will finally be paying for behavioral and mental health services for Medicaid enrollees. Under the ACA, the newly eligible population will have a benefit package that includes mental health and behavioral health services. These are costs now being borne by state and local funds, or else the services are simply not being provided—with impact on emergency rooms, state institutions and the criminal justice system. These state and local costs will be replaced with federally funded Medicaid.

9. Illinois’s veterans deserve health insurance. Not all veterans are able to get care at a Veterans Affairs hospital. And, in fact, roughly 43,000 Illinois veterans are uninsured (along with 25,000 of their family members). Illinois needs to take care of veterans, and the ACA’s Medicaid expansion will do just that. At implementation in 2014, nearly half of uninsured veterans will likely qualify for expanded Medicaid coverage. Illinois should serve these veterans, just like they served its citizens.

10. Does Illinois really want to subsidize health care in other states? As Justice Scalia stated in his dissent, “Those States that decline the Medicaid Expansion must subsidize, by the federal tax dollars taken from their citizens, vast grants to the States that accept the Medicaid Expansion.” So if Illinois does not take advantage of the federal 100%/90% funding for the Medicaid expansion, other states that chose to expand will get the benefit of Illinoisans’ federal tax dollars.

11. Expanding Medicaid coverage helps the financial viability of community clinics. Clinics are our best—really only—strategy for providing health care to the uninsured outside of emergency rooms. There will still be plenty of uninsured after the ACA is implemented, plus many of the newly insured Medicaid beneficiaries will get their care from clinics. The only way that clinics can serve the uninsured is by serving a critical percentage of patients who have coverage. The Medicaid reimbursement for covered patients allows the clinic to also serve the uninsured. With a high percentage of patients covered, the clinics will be able to expand capacity to serve the uninsured as well as those newly coverage by Medicaid.   

12. The Medicaid expansion is simply the right thing to do. We have a chance, through the incredible leveraging of federal funds, to provide health coverage—and the chance for better health and upward mobility—to hundreds of thousands of our state’s most vulnerable, needy residents. We can create a system that expands its circle of moral concern to include the uninsured, recognizing as Justice Ruth Bader Ginsburg wrote in N.F.I.B. v. Sebelius, that “[v]irtually everyone … consumes health care at some point in his or her life.”

The Affordable Care Act Upheld: Addressing America's Health Care Crisis

Today’s Supreme Court decision in National Federation of Independent Business v. Sebelius means that the Affordable Care Act remains the law of the land. As Chief Justice Roberts said in the majority opinion, Congress has the power to enact the individual mandate and the Medicaid expansion, the two provisions challenged in the case. 

People with insurance and people without insurance should be relieved that the process of reform can now move forward and make health care more secure. All of them have spent sleepless hours worried about the cost, lack of control, lack of choice, and absence of peace of mind associated with our current system. The Affordable Care Act (ACA) has tools to address all of these issues, although much still depends on decisions made at the state and local level, where officials must now continue implementing this important work.

The Court’s decision means that the benefits of the Affordable Care Act that are already in place will not have to be reversed.

Looking down the road a bit, the Court’s decision means that the full benefits of the law will be implemented on schedule:

Starting in 2014, the Affordable Care Act expands Medicaid to cover all 16 million Americans with incomes under 138% of the federal poverty level who are not currently eligible for Medicaid. The Act provides 100% federal funding to cover the costs of this expansion for the first years, and then settles in at 90% funding after five years. The Supreme Court’s decision today upholds Congress’s power to enact this expansion, and we encourage all the states to take full advantage of this wonderful opportunity.  

The decision, however, also says that the federal government may not take away all of a state's existing Medicaid funding if it decides not to participate in the expansion. Medicaid law has always provided that, if states disobey the conditions Congress has imposed on the receipt of Medicaid funding, the federal government has several different remedies, one of which is to withdraw all federal funds. That remedy has never actually been used by the federal government, even though there have been many disputes involving state noncompliance with Medicaid conditions. So the threat that the federal government might deploy that remedy if a state failed to carry out the ACA's Medicaid expansion was highly theoretical. In today's decision, however, the Court ruled that a state's refusal to adopt the ACA's Medicaid expansion cannot trigger the removal from a state of all of its existing Medicaid funding. The ruling is unclear about exactly what the states' options are and what other remedies the federal government may have in those circumstances. As we study the decision further, we will address these Medicaid issues more in depth in future blogs. Of course, we urge all states to take advantage of the federally funded Medicaid expansion to bring coverage to their lowest income uninsured.

Tonight, people all over the country, men and women, of all ages, socioeconomic statuses, and political beliefs, can breathe a bit easier knowing that the reforms launched in March 2010 will continue and that America is moving toward quality, affordable, comprehensive health care for all.

This blog was coauthored by Caitlin Padula.



Good Health Care Doesn't Have to Feel like Pulling Teeth

DentistIn early June, Illinois governor Pat Quinn signed a package of cuts to the Medicaid program that was designed to save the state money and “save” the Medicaid program.

Last week, we examined the three components of a good health care program:

  1. Providing great outcomes and
    preventing bad ones.
  2. Caring for the whole person.
  3. Fiscal sustainability.

This is the second in an ongoing blog series in which we examine the Medicaid cuts from the SMART Act, recently signed by Governor Quinn, and measure them against the standard we have set for good health care. Some of the changes measure up, while others fall short. One of the cuts we think falls woefully short is the near elimination of dental care for adults on Medicaid. 

According to the federal Medicaid rule, adult dental services are in the “optional” service group; this means that states aren’t required to provide these services for their Medicaid-eligible populations. Under the SMART Act, Illinois’s Medicaid program will no longer pay for preventative services for adults on the program; emergency extractions will still be provided. 

These cuts mean that preventive services, like cleanings and even fillings, are not covered by the Medicaid program; sadly, this change means the cut obviously fails our first component—providing great outcomes and avoiding bad ones. Ideally, we would like all Illinois residents to be in good oral health, which is impossible to maintain without a regimen of regular visits and cleanings. These preventive visits are when we catch the little problems, like cavities, before they become big problems, such as completely unsalvageable teeth that need to be pulled, or dangerous infections

We also want to have a holistic approach to health care. It’s always been confusing to me why dental coverage is singled out as an optional piece. When any preschooler can tell you that your mouth is a part of your body, why can’t our Medicaid program accept this simple fact? Oral health is obviously a part of your overall physical health, and any distinctions we draw between the two are illusory. Poor oral health care is related to other adverse physical conditions, including low birthweights, coronary heart disease, strokes, and even cancer. That’s right—by refusing to cover one part of the body now, we could be setting up other parts of the body for (expensive) future problems. This is an obvious failure on our second component of providing holistic health care.

Our third component is fiscal sustainability. At first blush, it looks like eliminating adult dental will save the state around $35 million,  but let’s think about that number for a second. People with severe dental issues that cause pain or infections won’t all give up on relief—they will look for it. Emergency room treatment is a mandatory Medicaid category for states, so if individuals seeks dental care there, they cannot be turned away. A new report entitled “A Costly Dental Destination” from the Pew Center on the States estimates that preventable dental conditions were the primary reason for 830,590 ER visits by Americans in 2009, which is a 16% increase from 2006. The same report noted that from 2008-11, hospitals in the Chicago area alone saw nearly 77,000 visits for dental-related issues.

According to the Pew report, the average cost of a Medicaid enrollee's hospital treatment for dental issues is approximately 10 times more than the cost of preventive care from a dentist. Dr. Frank Catalanotto, professor of dentistry, noted that “Preventive dental care such as routine teeth cleaning can cost $50 to $100, versus $1,000 for emergency room treatment that may include painkillers for aching cavities and antibiotics from resulting infections.” That’s simply not cost-effective. These visits cost the Medicaid program millions of dollars each year, but they result in very little actual improvement for the patients. That’s because emergency rooms generally don’t have dentists on staff—so doctors can’t get to the root of the problem to fix it, but usually can prescribe nothing more than antibiotics and painkillers. Since the underlying problem continues, patients must return to the emergency room when their symptoms return. So, sadly, this change fails our third component of fiscal responsibility by a wide margin.

However, dental organizations are already speaking out against the cuts. Dave Marsh of the Illinois State Dental Society noted that these cuts are really just shifting the cost of the problem elsewhere: “You're going to see a lot of people waiting when they have tooth decay, toothaches, waiting until it gets to a point where they're going to go to the emergency rooms. And the cost of emergency care, as you're well aware, skyrockets over the cost of dental care."

Sorry, Illinois. This change to “save” the Medicaid program simply doesn’t measure up to the standard of good healthcare. Be sure to check back in with us as we examine other cuts in S.B. 2840 and measure them against our three-part standard.  

Changes in Illinois's Medicaid Program--Smart Health Care Policy?

Today, Illinois Governor Pat Quinn signed into law S.B. 2840, which carves $1.6 billion out of the Medicaid program, claiming that it represents a bold plan to save Medicaid. Since the new law cuts the program so deeply and in so many different ways, it is legitimate to ask if these cuts really do improve the program, in terms of policy and long-term financial sustainability, or if they are actually merely expedient and short-sighted. To answer this question, we need to step back and really think about what makes effective and efficient health care policy. It’s a difficult question, and we’ve heard a lot of different answers, but I think we can boil it down to some broad categories. 

  1. Good health care policy obviously needs to be focused on providing the best outcomes possible immediately and later. Preventive services are key for this kind of health care; for example, check out the U.S. Preventive Service Task Force’s recommendations of effective and recommended services for adults. But not all procedures are necessary; some may not have any effect or even be harmful. For example, this year the U.S. Preventative Service Task Force issued advice counseling healthy women to undergo Pap tests only every three years instead of yearly. A representative for the task force noted, “We achieve essentially the same effectiveness in the reduction of cancer deaths, but we reduce potential harm of false positive tests […] It’s a win-win […].” We can prevent big problems from occurring tomorrow if we take some reasonable, manageable steps today. Preventing those big problems (obesity, heart disease, diabetes, etc.)  can also save big money, in addition to improving people’s quality of life.
  2. Good health care policy also takes care of the whole person, from head to toe. The Medicaid program contains “optional” categories that states don’t have to cover, like prescription drug coverage and adult dental care, but are these categories really optional?  At first glance, dental care might seem like an oft-dreaded luxury, but it is critical to good overall health. Cavities and gum disease contribute to wide-ranging health issues including low birthweights,  coronary heart disease, strokes, and even cancer. As states cut dental coverage, more people are turning to emergency rooms to take care of dental issues (hospital coverage is a mandatory Medicaid category), but that’s a terribly inefficient way to deal with the problem. Emergency rooms usually don’t have a dentist on staff, so all they can do is prescribe pain medications or antibiotics, not treat the root of the problem. The problem is similar with prescription drugs—if people cannot afford their medications, they usually need other medical intervention. Treating people holistically, instead of with a narrow focus on certain aspects, is cost-effective and health-effective.  
  3. Good health care policy needs to be fiscally sound not just now, but in the future, too.  We don’t want penny-wise cuts today that are pound-foolish down the line, since Illinois will pay for pieces of the Medicaid program that are mandatory, like emergency room visits and hospital coverage. While some services, like prescription drugs and adult dental care are technically optional, dropping this coverage may cause higher utilization of the mandatory categories, resulting in unforeseen high costs.

Senate Bill 2840 makes dramatic cuts to the Medicaid program.  Some of them are consistent with the above hallmarks of good policy, but more of them simply don’t make for good health care. 

So let’s start on a positive note—some of the bill’s provisions are solid choices that will save money and improve the health of our Medicaid system and our people. For example, one section of the bill deals with increasing the state’s ability to ferret out fraud in the program. There will be increased effort to make sure only eligible people receive Medicaid, including electronically examining residency and income to verify that they meet program requirements. It is estimated that this increased effort will save the state $350 million. We are strongly behind the effort to make sure that Illinois Medicaid uses its resources wisely by only enrolling those eligible for the program and reimbursing vendors fairly. However, it’s worth noting that the intent of the law appears to be that the state use a private company to provide computerized eligibility verifications. This bears close watching because, in the past, private companies have been guilty of inaccurate and profit-motivated caseload reduction. The determinations need to be accurate and procedurally fair. The law also contains welcome measures for finding and preventing fraud on the vendor side of the equation. 

Another provision we’re wholeheartedly behind ensures that Medicaid will no longer pay for medically unnecessary, or elective, cesarean births. A cesarean birth is a major abdominal surgery and comes with all of the risks associated with other common surgeries, including adverse reactions to medications and increased risk of infection. Babies born by c-section have, on average, more difficulty breathing after birth and have lower Apgar scores. Mothers have a longer recovery time and a higher risk of complications from c-sections than from vaginal births. Of course, some situations call for a cesarean section—medically necessary c-sections will still be covered under Medicaid, but elective c-sections will be covered only at the vaginal birth rate. This should cut down on the numbers of elective c-sections, saving money and improving health outcomes at the same time!   

However, there are other cuts in S.B. 2840 that are clearly not good policy and not fiscally sound, or that depend heavily on implementation decisions before they can be judged one way or the other. Among these, the law slashes the Illinois Cares Rx program, the FamilyCare program, and dental coverage for adults, and it applies utilization controls on many services, including especially prescriptions. We’ve already written a blog about the cuts to the Illinois Cares Rx program and you can find that here. Of course, S.B. 2840 wasn’t the only health care related bill this session. There were also changes in the laws regarding hospital charity care obligations and the expansion of Cook County’s Medicaid system. We’re planning blogs on these and other provisions of the law to explain them and examine how they fall short or could be implemented without measuring up to good policy, so please keep us bookmarked and return for an update.   

With the Loss of Illinois Cares Rx, Where Can People Turn?

Prescription drugsPrescription drugsLast week, the Illinois General Assembly overwhelmingly voted to end Illinois Cares Rx, which is a state prescription assistance program that helps more than 150,000 Illinois citizens afford prescription drugs. Illinois Cares Rx was designed to help truly needy Illinois seniors and persons with disabilities obtain the prescription drugs necessary to maintain their health and combat illness. To be eligible, individuals had to be at or below $22,340 in yearly income. If Governor Quinn signs the bill into law, their coverage will end July 1 of this year. While losing Illinois Care Rx assistance is going to be a serious blow, Illinois low-income seniors and person with disabilities may be eligible for other programs, such as Medicaid spenddown, Medicare Part D, or the AIDS Drug Assistance Program, all of which are described below.

The Medicaid spenddown is still an option for many of the Illinois seniors who will be forced off Illinois Cares Rx. Medicaid spenddown can help individuals afford health care that would otherwise be unobtainable due to cost. The spenddown program is designed to help people who are ineligible for regular Medicaid because their incomes are too high or they have too many assets, as long as those people have significant monthly health costs. 

Who is eligible for spenddown and how can you estimate the spenddown amount? Almost anyone who is eligible for Medicare is eligible for spenddown, as long as they have medical expenses that are high enough to meet their “spenddown amount.” Spenddown is a little bit like having a health insurance deductible. Based on your income and your assets, you are assigned a monthly spenddown amount. For an individual, the income dividing line between regular Medicare eligibility and Medicaid spenddown eligibility is $956 per month (not counting SSI income), or $11,472 a year. That means that an individual whose income is over that amount must spend down to that amount in order to receive a monthly Medicaid medical card. In other words, if your income is $1,000 per month, the spenddown amount is $44, and if monthly income is $1,500, the spenddown amount is $544. An individual will also have a spenddown if their assets are over $2,000 (although some assets, like one’s home, are exempt from this limit).      

Once you are assigned a spenddown amount, you are responsible for showing that you have either paid or unpaid medical bills; once the bills equal the spenddown amount, you are eligible for a Medicaid card and assistance paying for your health care expenses for a month. So, if your spenddown amount is $100, you are eligible for Medicaid assistance after you show that you have monthly medical bills equal to that amount. You can submit expenses monthly or, if you have large bills for something like a hospitalization or expensive testing, you can use those bills to satisfy several months of your spenddown amount.

Paid or unpaid bills for the following can count towards meeting your spenddown limits:

  • doctor services;
  • hospital services;
  • nursing home services;
  • clinic services;
  • dentist services;
  • podiatrist services;
  • chiropractor services;
  • medicines, medical supplies and equipment that are prescribed by your doctor;
  • eyeglasses;
  • medical or personal care in your home;
  • health insurance premiums, including Medicare premiums;
  • speech, occupational and physical therapy;
  • transportation to and from medical care; and
  • co-payments or deductibles you pay for medical care.

To apply for the Medicaid spenddown program, contact your local Department of Human Services (DHS). Use this locator to find the office closest to you. The Department of Human Services will decide if you are eligible for Medicaid without a spenddown, or, if you are ineligible, will assign you a spenddown amount.

There may also be another option for seniors losing their prescription coverage. It appears there will be an open enrollment period for individuals to change their plan choice in Medicare Part D after Illinois Cares Rx ends. (We’ll keep you updated when we get more facts on this). Medicare Part D is available to anyone who is eligible for regular Medicare, but it is offered through private insurance companies that contract with Medicare to offer this additional coverage. Typically, you pay a monthly premium, deductible and co-pays, depending on which plan you choose. After you satisfy your deductible, you will be responsible for a co-pay for each prescription up until you reach the “donut hole,” when you will pay the full cost of the prescription until you have spent about $3,600, after which the insurance kicks in again. (The Affordable Care Act is working to close this “donut hole” over several years.) All Part D plans will include their own formulary, or list of covered drugs, so you should confirm which ones cover your particular prescriptions. Because of the existence of Illinois Cares Rx, many people chose cheaper and less comprehensive plans, or perhaps did not enroll in Part D at all. However, it appears that they will be allowed to enroll in a Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan that will replace some of the coverage lost with the ending of Illinois Cares Rx. This chance to join lasts for two full months after the month in which coverage is lost.  

Additionally, some Illinois Cares Rx enrollees are AIDS patients. AIDS treatments are notoriously expensive, with some treatments topping over $25,000 a year. Those individuals may be eligible for the AIDS Drug Assistance Program (ADAP). Individuals whose incomes are less than 300% of the federal poverty level (about $33,500) are eligible for the program. ADAP provides 81 different drugs on its formulary, including all anti-retroviral therapies approved by the U.S. Food and Drug Administration. Clients do have a benefit cap of $2,000 per month (except for a few Category V drugs), which is sufficient to support triple and quadruple combination therapies. You can apply for ADAP online.

The elimination of Illinois Cares RX is effective on July 1, if the Governor signs the bill as is. As you can tell from this blog, that leaves precious little time for seniors to make the complicated choices and actions necessary to rearrange their drug purchasing and transition to the new system. Advocates have asked that Governor Quinn amendatorily veto the bill to keep Illinois Cares Rx on the books, or, at a minimum, to delay the effective date to January 1, 2013, to allow for a smoother transition—let’s keep our fingers crossed. Of course, we will keep you updated on any developments.   

The Affordable Care Act: Protecting America's Protectors


In 2010, over 22 million men and women who have served our country in the Armed Forces were still alive. That’s a sizeable chunk of the population and those veterans have served in every conflict from World War II through the ongoing War on Terror. Veterans are a vital part of America and this weekend is a special time to think about their contributions and thank them for their service. 

However, we could be doing more to help our veterans. According to a new report by the Urban Institute and the Robert Wood Johnson Foundation, there are an estimated 1.3 million uninsured veterans between ages 19 and 64 nationwide – more than 10% of all veterans. These uninsured veterans make up about 5% of the total uninsured population.    Veterans as a group are more likely to be insured than the rest of the population, but these numbers are still shocking. The report also finds that 41 percent of uninsured veterans report unmet medical needs, while 34 percent report having delayed care due to cost. That’s right—2 out of every 5 veterans need medical attention and are not getting it.  

But wait a second—can’t veterans all get care at their local Veterans Affairs (V.A.) Hospital? Not necessarily. The pool of money provided by Congress to the V.A. hospitals is a set amount and can provide care for a set number of veterans; priority groups have been established make sure that certain veterans, such as those with a significant injury, Medal of Honor or Purple Heart, definitely receive healthcare. Thankfully, not everyone in the armed services is injured in combat, but that does mean that some veterans fall lower on the priority list. Other veterans have to pay co-pays to be seen at the VA Hospitals, which may be financially difficult.   So who are these uninsured veterans? They are more likely to be younger, have served recently, overall have less education, and are more often unmarried and unemployed.   In Illinois, 43,000 veterans don’t have health insurance and 25,000 of their family members are similarly uninsured.  

Americans need to take care of veterans and the Affordable Care Act will do just that. When the ACA is implemented, nearly nine in 10 uninsured veterans will have improved access to affordable coverage. At implementation in 2014, nearly half of the uninsured veterans will likely qualify for expanded Medicaid coverage. This provision will expand Medicaid coverage to adults with incomes under about $15,000 a year. Another 40 percent of uninsured veterans have incomes that would allow them to qualify for subsidized coverage through state health insurance exchanges, in which they will receive subsidies to help pay for private health insurance coverage.

The Affordable Care Act is around to serve these veterans, just like they served their country. Take a few minutes this holiday weekend to think about veterans and their service. Don’t they deserve affordable healthcare for themselves and their families?   

If you or someone you know is a veteran, check out this benefits calculator and this financial calculator to see if you are eligible for VA health benefits!

On Memorial Day at 3 p.m., local time around the nation, Americans will pause for the annual Moment of Remembrance to pause and reflect on the sacrifice of America’s fallen warriors and the freedoms that unite Americans. 


Check Out How Far We've Come--and How Far We Have to Go

Girl getting a checkupLast week, the  Centers for Disease Control (CDC) released their annual health report for 2011, and I highly recommend you check it out—some pieces are encouraging and other parts indicate that we need to continue our efforts to improve the health of our nation. The report contains dozens of tables with information on Americans’ health, with a special focus on socio-economic status. There are a number of bright spots, alongside areas we need to work on. Luckily, the Affordable Care Act (ACA) is already in place and at work improving America’s health in exactly these areas.

For example, the CDC noted the following:

We don’t have enough primary care doctors.  The report notes that the South and Rocky Mountain areas of the country have about 85% of the doctors that the rest of the country has. The ACA is addressing this crucial problem through providing training and financial support to thousands of new primary care  doctors, nurses, nurse practitioners, and physician’s assistants. Primary care providers paid by Medicare will also get 10% “bonus” payments and the number of community health centers will grow, increasing access to affordable primary care. In 2013, primary care providers paid by Medicaid will see an increase to the higher Medicare rates, making it fiscally easier for doctors to see Medicaid patients.

Obesity is still a major problem.  Although childhood obesity rates are leveling off, they are still troublingly high. The CDC report also shows that childhood obesity is strongly correlated to the level of parental education. Luckily, the ACA has allocated funds to fight childhood obesity through teaching kids to improve their nutrition choices and encouraging more physical activity. 

We’re getting better at keeping ourselves well. In 2010, almost 60% of the recommended adults had a colorectal screening, compared to 34% in 2000. The ACA is seriously working to change the culture of health care from caring for people after they’re sick to prevention and screenings. The ACA requires that health insurers, including Medicare, offer certain preventative care and screenings free of charge. Check out the list here!

Racial health disparities are narrowing. The difference between life expectancy for Caucasians and African-Americans is closing, although Hispanics still have the longest lifespans. Other health disparities include higher rates of obesity, asthma, flu, infant mortality, cancer, and heart disease in minority communities. The Affordable Care Act recognizes these disparities and is working to close the gap and make all Americans healthier through numerous advances, including increasing cultural competency among providers, adding more health care providers to underserved communities, and coordinated care organizations that will help manage chronic diseases.

The percentage of uninsured people has grown from 13% in 2000 to 16% in 2010. Nearly 1 in 6 Americans lacks health coverage—an indication of how badly this country needs the ACA. The Affordable Care Act is designed to hugely increase the number of people who are covered, both through tax subsidies for Americans under 400% of the federal poverty level to purchase private insurance and through expanding Medicaid to cover all individuals under 133% of the federal poverty level.

The CDC report contains many more charts and data on Americans’ health. Overall, the report is an excellent reminder of how far we’ve come and how far we still have to go in our work to improve the health of our people.  I encourage everyone to page through the list and take a look at the reality of health in America today.  The Affordable Care Act is vital to improving that reality and is already at work doing so!

When Cutting Illinois's Medicaid Program, First, Do No Harm

SurgeryThe Illinois General Assembly is currently debating where to cut $2.7 billion dollars (roughly 18 percent of spending) from the state’s health insurance program for certain low-income populations. The thinking is that these “savings” will Band-Aid the hemorrhaging state budget deficit and root out fraud. If the Medicaid program were a patient, it would be on the surgery table preparing for amputation of a few healthy limbs.

And while this might prevent some problems, it is much more likely to cause larger, more serious ones. Of course we need to manage Medicaid spending so that the program is working efficiently. But cutting almost 18 percent of the program in just one year is not the way to do it.

Why should you care that these low-income folks may be cut from the Medicaid program or have severely reduced access to medical services? Because every dollar Illinois cuts means a little more than a dollar in federal funding is lost from Illinois’s economy, creating a negative ripple effect of economic harm. The proposed 18-percent cut to Medicaid would put 25,600 Illinois jobs at risk and reduce business activity by roughly $3.3 billion

And you should care because medical needs and costs don’t disappear when Medicaid is cut. The people who lose coverage or vital services like dental care still get sick, and then forgo or delay necessary medical care, and eventually end up in the emergency room. And by that time, they are often more expensive to treat. For those who lose coverage, manageable health conditions, such as high blood pressure and diabetes, may deteriorate and lead to hospitalizations. And a portion of these costs go unpaid and are eventually passed on to all of us--consumers, employers, and businesses--in the form of higher insurance premiums.

Rather than imposing such drastic cuts on the Medicaid program, let’s instead look at thoughtful alternatives to closing the budget gap. First, the state needs to raise revenue. The cigarette tax is an important and necessary step in that direction. Second, there are already processes in the works that promise to produce sustainable savings and improve care in the Medicaid program. For instance, let’s allow the state’s new Medicaid reform plan, which includes increased care innovation for high-cost enrollees, to take effect. And new care coordination entities, such as the Medical Home Network, show great promise for increased efficiencies for Medicaid enrollees.

Let’s remember that quick fixes sound good but often have long-term negative impacts. And like an amputation, they can be both irreversible and regrettable.

Healthy Mother's Day

MomIf your mom is anything like mine, she’s part doctor, part cheerleader, part chef, part justice of the peace, and all-knowing. Being a mother is a tough job (and one we can’t outsource).  However, things are starting to get a little better for mothers across the country. The United States just moved up six places in the annual Save the Children State of the World’s Mothers report – to the 25th best country in which to be a mother.  Norway, Iceland, and Sweden take the top three spots, while Yemen, Afghanistan and Niger rank at the bottom. Our leap in the rankings was mostly due to educational improvements for mothers, but we still have improvements to make in many policy areas, especially health. For instance, we must face the sobering reality that a mother in the United States is fifteen times more likely to die of pregnancy-related causes than a Greek mother, and a child in the United States is four times more likely to die than a child in Iceland. We also lag behind in maternity leave policies, since the United States is the only developed country that does not guarantee paid maternity leave.  

Luckily for mothers, the Affordable Care Act is at work to improve maternal health! The Affordable Care Act cares for moms many ways, with more improvements on the way. 

Some provisions of the law are already helping mothers.

  • Right now, the ACA mandates that most companies provide nursing mothers time and a private place to express milk, allowing mothers to return to work and still ensure their children enjoy the benefits of breast milk. While the benefits to the baby are numerous, mothers also benefit from breastfeeding, with decreased sick days and lower incidences of postpartum depression, obesity, and breast and ovarian cancers.        
  • Children up to age 26 can now be covered on their parents’ insurance plans, creating peace of mind for parents of young adults. 
  • Currently, free preventative services, like mammograms and cervical cancer screenings, help moms stay healthy for their families. Pregnant women can now also receive a screening for gestational diabetes.  

And there will be major improvements in August of this year!

  • Beginning August 1 of this yearmost women will have access to the full-range of FDA-approved contraceptives without co-pays or deductibles.  Contraception obviously allows women to choose when to become mothers, resulting in healthier parents, children and communities. Other benefits include a reduced risk of ovarian cancer, endometrial cancer, and osteoporosis. 
  • Also beginning this August, nursing mothers will also receive nursing support, supplies, and counseling from their insurance companies when they give birth.

And looking to the future, 2014 will also bring great things for mothers!

Mothers do so much work that goes unrecognized and un-thanked, so let’s make sure we do right by our 85.4 million mothers. The Affordable Care Act recognizes that healthy mothers are essential to raising the next generation of healthy Americans and works hard at providing them with the resources they need to do so.    

Watch out Norway—with the Affordable Care Act, we are coming for your title!

Happy Mother’s Day, Mom!


Don't Be Led Ashtray--Raise the Cigarette Tax!

AshtrayIllinois Governor Pat Quinn recently offered a proposal to increase the cigarette tax by one dollar. This proposal is a triple win for the state−the tax would be a budget win, a health win, and a political win. Research shows that cigarette taxes raise revenues, decrease the negative health effects associated with smoking, and are widely supported by voters across the spectrum. 

Illinois’s Medicaid program is facing deep and painful cuts, and raising the cigarette tax to help pay for Medicaid seems like a no-brainer. The U.S. Centers for Disease Control and Prevention estimate that smoking-caused health costs total $10.47 per pack sold and consumed in the U.S.  $10.47 a pack! For a pack-a-day smoker, that adds up fast. In fact, it adds up to $3,811 in yearly health costs for that smoker. Illinois spends nearly $5 billion treating smoking-related illness, and $1.8 billion of that is paid for by the Medicaid program. 

This tax will incentivize people to quit smoking or not to start at all, but the decrease in consumer numbers will be more than offset by the dollar tax increase. From 2002-09, twelve states increased their cigarette taxes by one dollar or more. Every single one of these states saw both a decline in sales (indicating fewer consumers were smoking) but also a spike in revenue ranging from 36% to 193%. There will certainly be people on the margins who can evade the tax by purchasing outside of Illinois, but most smokers will either quit or pay the increased costs of smoking. Currently, Illinois’s cigarette tax rate is only 98 cents a pack—the 18th lowest state cigarette tax, with Massachusetts being the highest at $2.51 per pack. Professor Frank Chaloupka of the University of Illinois estimates that a $1 per pack cigarette tax increase in Illinois would raise $377 million.  

Although opponents of the law claim that it will decrease overall revenue as people decrease their purchases, Illinois has enjoyed substantial revenue increases every time it has raised the tax on cigarettes. Nor will Illinoisans simply leave the state in droves to purchase their cigarettes.  Professor Chaloupka notes that when Illinois last increased its cigarette tax rates, the state’s cigarette revenues increased over 38%, while increases in neighboring low-tax state of Missouri were only 6.4%.  

But the benefits of the tax include more than just the money. Tobacco’s burden on statewide health and budget concerns is widespread: in addition to costs for ailments directly attributable to tobacco use, like lung cancer or emphysema, tobacco use also increases state expenditures via decreased productivity and premature deaths. 

A $1 per pack tax increase would actually increase the health of Illinoisans by changing people’s smoking habits. The tax is expected to prevent 78,000 young Illinoisans from taking up the habit, encourage almost 60,000 Illinoisans to quit, and prevent up to 59,000 deaths caused by smoking. Young people in particular are very price sensitive; an extra dollar is expected to prevent thousands of young people from paying the price to get hooked in the first place.

Plus, this tax has amazingly high support from Illinoisans. Seventy-four percent of Illinois voters support a $1 increase per pack to pay for the associated health costs and to reduce the budget deficit. Without the revenue raised from the cigarette tax, the State of Illinois would have to look to other areas in the budget to make up the shortfall. Governor Quinn stated "[I]f we don't succeed in the area of raising the price of cigarettes, then there will be pressure on cutting reimbursements or, perish the thought, trying to reduce education. I think that would be a very bad way to go."   

I agree with the Governor and I bet you do, too. Taxing cigarettes to help pay for the health consequences they cause or cutting important services? This triple-win seems like a clear-cut choice to me.  


The Affordable Care Act: Dollars Flowing into Illinois

Doctor visitThere’s no debating that Illinois could use some healthcare help. The state is ranked the 29th healthiest state—not the absolute bottom, but nowhere near the top. A recent poll also listed Illinois as the 31st most obese state and 25th for diabetes—not exactly stellar statistics. The same source noted that ,while Illinoisans benefit from high usage of early prenatal care and a comparative availability of primary care doctors, the state faces severe challenges, including prevalent binge drinking, high pollution levels, and a high rate of preventable hospitalizations. 

These problems are not insurmountable. However, we all know the state is in a budget crisis.  Governor Quinn has announced a plan to drastically reduce spending and raise revenues for Medicaid. We understand the state budget crisis, but obviously, people in Illinois need medical services, and the state is currently struggling to provide them.  

Luckily, the Affordable Care Act is there to throw a lifeline out to health service providers and state agencies and especially to the real people who need healthcare. Thanks to the ACA, the states will spend about $90 billion less on healthcare with the implementation of the law than they would have spent without it. Thousands of people will still be getting the increased services mandated by the Act, but much of the funding will be federal rather than state. 

It’s important to note that these benefits are not in the distant future; Illinoisans from birth to retirement are already benefitting from the Affordable Care Act.  

Assistance from the ACA starts when kids are young; the ACA has already provided:

  • $10.3 million for Maternal, Infant, and Early Childhood Home Visiting Programs. These programs bring health professionals into individual homes to connect families to the services they need to raise happy and healthy kids. These services include prenatal care, pediatric care, education, and parenting skills.   
  • $191,000 for Family-to-Family Health Information Centers, organizations run by and for families with children with special health care needs.
  • $4.9 million for expanding and improving school-based health centers. Illinois funds 38 school-based clinics that provide screenings, physicals, exams, and more to students.
  • $555,000 to support the Personal Responsibility Education Program, which educates youth on abstinence and contraception to prevent teen pregnancy and sexually transmitted infections, including HIV/AIDS.

The ACA is also spending money putting people to work at improving healthcare! Illinois has received:

  • $400,000 to support the National Health Service Corps, by assisting Illinois in repaying educational loans of health care professionals in return for their practice in health professional shortage areas. This program is designed to help medical, dental, and mental health providers who choose to work in needy communities to repay their student loans. This is a particularly critical program because these professionals provide medical and dental care that individuals desperately need; the program allows professionals to provide care to needy individuals without worrying about their reimbursement rates or their ability to pay back debt.
  • $5.1 million for health professions workforce demonstration projects. This program is designed to supplement the workforce in areas that are either already short-staffed or expected to be in the future. The Illinois Workforce Investment Board’s report noted  shortages of both registered nurses and licensed practical nurses in Illinois. 

And the ACA helps elderly Illinoisans, too!

So far, Illinois has received $170.7 million in grants due to the Affordable Care Act.  These grants are creating tangible improvements to the physical and fiscal health of our state.  Thanks, Affordable Care Act!

The Affordable Care Act: Caring for Our Most Vulnerable

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Did you know that the Affordable Care Act contains preventive health provisions that will improve the health of Medicaid recipients and help control costs?

If you’ve been tuning in to our weekly blog series on preventive health measures in the Affordable Care Act, you are well-aware of the many wonderful preventative care provisions that the national health reform law has set in motion. These measures range from community and nationwide preventive and public health programs to timely reforms in the private health insurance market and Medicare that are increasing access to affordable coverage and preventive health care services. What you may not know about are the many important initiatives the ACA is putting to work to prevent chronic diseases among the Medicaid population. These programs are improving the health of vulnerable populations and saving money for the Medicaid program. 

Today, chronic health conditions like Type 2 diabetes, heart disease, stroke, and cancer combine to cost our nation billions of dollars in health care expenditures annually and account for 70 percent of all American deaths each year. Medicaid, the second largest health insurer in the United States, insures one-fifth of Illinois residents. The program covers a population that is disproportionately affected by chronic health conditions, and is certainly picking up its share of the costs for treating and managing preventable chronic diseases. Treatment and management of chronic diseases are crucial to controlling Medicaid costs and health, an important point to remember as budget cuts loom in SpringfieldIt has been proven that for every dollar spent on effective preventive and public health initiatives, $5.60 is saved.

Take a look at just some of the several steps the ACA is taking to cut unnecessary health care costs for the Medicaid program and help low-income individuals and families stay ahead of costly chronic health conditions:

  • The Affordable Care Act is increasing access to preventive health care services for Medicaid recipients at no extra cost to recipients or the states. Access to basic preventive health care services is critical for preventing chronic health conditions, and will save individuals as well as the Medicaid program a lot of money if states choose to provide these services. Starting on January 1, 2013, the federal government will provide states with a one-percent increase in federal matching rates for the specified expanded set of preventive health services.
  • The ACA is increasing access to primary care physicians by boosting Medicaid payments to primary care providers from January 1, 2013, to the end of the 2014, with the increase paid for by the federal government. Payment rates will rise to match Medicare rates during this time period, incentivizing primary care physicians to take on Medicaid patients and, in the end, getting more Medicaid recipients the basic preventive health care they need.
  • Among many other wonderful things the ACA is doing is the effort to help people quit smoking and live healthier lives. The health reform law is requiring states’ Medicaid programs to fully cover counseling and pharmacotherapy services for tobacco cessation for pregnant women. Healthy pregnancies lead to healthy babies and a head start for preventing costly chronic health conditions down the road.
  • The ACA is providing grant money for states that participate in the Medicaid Incentives for Prevention of Chronic Diseases Program, which began in January of 2011. States receiving grants must develop initiatives that provide incentives to Medicaid recipients who participate in a healthy lifestyle program that addresses chronic disease prevention goals. The Medicaid Incentives Program will evaluate the effectiveness of the states’ initiatives and analyze the changes in health risk and outcomes, with the goal of improving health and lowering health care costs.
  • Finally, effective January 1, 2014, the Affordable Care Act is expanding the Medicaid program to cover an additional 16 million people (700,000 of them in Illinois) who are uninsured today by changing the standards for eligibility to include almost all persons living at or below 138 percent of the federal poverty level. The states will not have to foot any part of the initial bill for the “newly eligible” Medicaid population; the federal government is covering 100 percent of the cost until 2017; after that, federal payments will slowly decrease to 90% of the cost by 2022. Recent research shows that newly covered individuals seek cost-effective primary care more often, use emergency room and in-hospital admissions less, and, in effect, cut health care costs for everyone.

By putting effective preventive health initiatives to work for the Medicaid program, the Affordable Care Act is making the second largest health insurer in the United States more cost-effective, saving taxpayers money, and improving the health and well-being of millions of Medicaid recipients. For more on what the ACA is doing for preventive health, check out the Shriver Center’s “Did You Know” blog series online, or visit

This blog post was coauthored by Rachel Gielau.

Proposed Illinois Medicaid Cuts--A Delicate Balance

Baby looking at mobileIllinois Governor Quinn and the state General Assembly are proceeding on a track to make $2.7 billion in cuts to the Medicaid program in the state’s budget for July 2012 thru June 2013. That’s a huge percentage of the Medicaid budget, and Medicaid is nearly 1/3 of the state budget. As Governor Quinn’s Senior Health Advisor Michael Gelder said of the budget crisis: “I'd say 'inconceivable,' but we have to begin to conceive this.”

Not everything about Medicaid is on the table. Under the Affordable Care Act’s “Maintenance of Effort” requirements, Illinois cannot alter the eligibility requirements for Medicaid and CHIP by changing who is eligible or by making it more difficult for those people to apply and be approved. The state is also not allowed to touch the mandatory services set out by the federal government, which include services like outpatient care, X-rays, children’s vaccinations, and pediatrician visits. 

Of course, there are some reductions still available to the states. States are permitted to reduce optional benefits. The Illinois Department of Health and Human Services (IDHHS) has issued a list of legally possible cuts to the program. Although items like fraud reduction and correcting clerical errors may save the state millions, the real money is to be found in cutting other pieces of the Medicaid program. Or is it?

Cuts are not easy to make, and making cuts in something as complex as Medicaid is not quite the same as cuts to the Department of Natural Resources (although for the record, I love the DNR!). But when the DNR’s funding is cut, the beavers and deer don’t show up at the hospitals as emergency patients and incur huge bills.  

As legislators examine the Medicaid program, they need to be aware that health care hangs in a delicate balance, like a mobile dangling over a child’s crib. When you pull on one string, the whole system wobbles.   

For example, eliminating dental coverage for adults would save $51 million initially. Great news for Illinois, right? Of course, adults with severe dental issues usually end up in the emergency room, costing the state much more money than preventative care would have cost. In fact, a presentation to Illinois legislators by Joy Wilson of the National Conference of State Legislatures noted: “Most states that cut adult dental care — a Medicaid option — quickly reinstate the program, because untreated dental problems too often lead to more costly hospitalization, boosting states’ Medicaid costs.”

Another example would be eliminating pharmaceutical benefits from Medicaid. The program spends more than $1 billion annually covering prescriptions for 2.7 million Illinois residents. Seems like an easy place to trim some fat, right? Wrong. Look a little farther down the line and think about what happens when people don’t get vital medications like blood thinners, asthma inhalers, and antipsychotics. Those people end up extremely ill and with nowhere to turn except the already overcrowded emergency rooms. 

The state also spends $100 million on hospice care, and we could cut that. Of course, hospice is a program for individuals who have significant medical issues and are approaching the end of their lives. If these individuals can’t be cared for at home (and remember, they are in severely declining health), they will end up in hospitals. Since hospital care is a mandatory service, the Medicaid program will still be responsible for these patients, just in a less comforting and cost-effective setting.  

Another option is cutting the rates paid to providers. According to IDHHS’s list, a 6% rate cut would save the state $550 million. But some hospitals say a 6% rate cut would push them out of business. We also need to consider the fact that the federal government matches certain Medicaid expenditures. Cutting spending in these areas is a double whammy, as it may not only increase spending down the line, it will actually cut the funds coming into Illinois right now.     

When Ms. Wilson recently addressed the Illinois Senate, she told them that the desired quick reduction in Medicaid costs was a daunting task. She explained that other states have taken two years to make similarly substantial reductions. Wilson also told the Senate Committee of the Whole: "Over a year or over two years, those are hard numbers to get out of the Medicaid program as it's currently constituted. It is very hard to get savings in the Medicaid program in real time. It just is.”  

Significant reforms in the Medicaid program were enacted last year, but it takes time to improve such a complex system. Preventative care programs and coordinated care programs will save the state money, but they are slower to create savings than the quick fix of cutting a few million dollars from programs that provide medical care to torture victims and hemophiliacs. It’s wrong to look at cuts in the Medicaid program as the solution to Illinois’ budget woes—Medicaid improves health, creates jobs, and brings federal dollars into the state

Ultimately, legislators should consider slowing down in their rush to squeeze all the possible “savings” (many of which may in fact cost more in both dollars and suffering) from the Medicaid program this year. This debt was certainly not created in a year, and it’s only logical that it might take more than one year to dig our way out from underneath it. Reductions in spending are certainly possible, but the Illinois legislature needs to proceed with caution to ensure that the Medicaid program is balanced, or it risks bringing the whole mobile crashing down on the baby.  

Future blogs will offer a more detailed picture of Illinois medical assistance program and cover developments in the General Assembly on funding it. 

The Affordable Care Act at Two

Birthday cupcakeTwo years ago, President Obama joined a long line of American leaders like Franklin Delano Roosevelt and Bill Clinton in working to pass comprehensive health reform. Well, today we are grateful that those efforts paid off and all Americans can enjoy the benefits of a bouncing, baby (health care) bill!

The Affordable Care Act turns two years old today and, like all toddlers, it’s been very busy!  While other toddlers can go through a “terrible twos” stage, the ACA is just embarking on its “terrific twos.” All children are wonderful, but I can’t think of another two-year-old that has so dramatically changed American’s lives.  

In fact, other youngsters already are benefitting dramatically from the ACA’s provision that prohibits health insurance companies from denying coverage to children on the basis of pre-existing conditions.  Before the passage of the ACA, health insurance companies could refuse to insure children with pre-existing conditions as common as an ear infection, leaving parents to pay out of pocket for all medical care or to forgo it all together. Now, children with pre-existing conditions like ear infections or asthma cannot be denied coverage, which allows their parents to rest easier knowing that their children have access to affordable care when they need it.

Although even healthy births and healthy children can be costly medical events, children born with severe medical issues in the past have often come close to or surpassed their insurance’s lifetime (or annual) limit on coverage when they are quite young.  The ACA has now eliminated the lifetime caps on insurance (and put restrictions on annual limits).  Almost 28 million children will benefit from this change.    

Of course, that’s not all the law has already done. We’ve done some significant blogging on the steps that ACA is making in the area of preventative care, explaining how the law is working to control and reduce the epidemic of chronic diseases like diabetes, heart disease and obesity in order to improve health and reduce spending.  The law has also set in place a significant measure for the health of low-income families by requiring states to maintain their current CHIP and Medicaid eligibility requirements, which is keeping kids covered and healthy until the ACA kicks in completely in 2014. Additionally, the ACA allows children to remain on their parent’s health insurance until age 26,  is reducing the cost of seniors’ medications, and has made insurance companies responsible for justifying premium increases to their clients, among other fantastic reforms.

So, what should we expect as the ACA matures?  We have a lot to look forward to!  In 2014, all health insurance plans will cover pregnancy and prenatal care, resulting in healthier moms and babies. Also that year, children’s vision and dental services will be covered by all policies. Covering children’s oral care is a multi-faceted issue that affects academic performance and self-image, as well as preventing expensive emergency care.  

Of course, the benefits are not just for children.  Subsidies that will make insurance much more affordable for working people will also become available in 2014.  More affordable insurance equals more insured people and greater access to care. Also in 2014, Medicaid will be expanded to everyone under 133% of the Federal Poverty Level.  

So take a moment today to enjoy a piece of birthday cake and this short ACA birthday song!  After your cake, you can check out more milestone developments in the ACA here!     

Protect Women's Health Care

I Will Not Be Denied: Protect Women's Health CareThe Sargent Shriver National Center on Poverty Law is proud to join the National Women’s Law Center’s I Will NOT Be Denied™ campaign to educate the public about the benefits of the health care law and what is at risk if it is repealed. The American public has so much to gain from the Affordable Care Act (ACA), both in improvements to overall health and budgeting.

As we have been noting in our blogs, the ACA is making an enormous impact in people’s lives. 

These and so many other fantastic provisions in the ACA are worth fighting for. Take a stand and get informed about the new health care bill. Join the campaign, learn the facts about healthcare reform, share the video and tell opponents of affordable care “I Will NOT Be Denied.”™ !

Join the #NotDenied conversation on Twitter, or visit the National Women's Law Center on Facebook.

The Affordable Care Act: Preventing Childhood Obesity

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Obese ChildDid you know that the Affordable Care Act contains measures that are designed to reverse the childhood obesity epidemic?

Today, one third of America’s youth is overweight or obese. Childhood obesity is becoming a serious threat to the health and well being of our  youth, as well as the nation’s health care spending and overall economy. Some experts are saying that today’s kids could be the first generation to not outlive their parents. This shocking news is directly related to the alarming, growing prevalence of obesity in American children and the associated severe health risks. Fortunately, the Affordable Care Act (ACA) is taking the lead to combat this problem so that our country can raise a healthy children and rein in the costs associated with preventable, weight-related health conditions.

Rates of childhood obesity have tripled in the last three decades. According to the Centers for Disease Control (CDC), total annual costs for childhood obesity amount to $3 billion. Overweight and obese children are 70 to 80 percent more likely to become overweight or obese adults, and the total annual cost of obesity in America, including expenditures like hospital bills, prescription drugs, and lost productivity in the workplace, is up to $147 billion. The cost of hospitalization alone related to childhood obesity grew from $125.9 million in 2001 to $237.6 million in 2005

Overweight and obese children have a higher risk of developing costly chronic health conditions like high cholesterol, heart disease, Type 2 diabetes and depression. Developing weight-related chronic health conditions at a young age can cause a lifetime of health complications and result in a shorter life span. In fact, research shows that children with Type 2 diabetes are less likely to graduate high school and attend college than their healthy counterparts, earn less in wages throughout their lives, and have shorter life spans.

Because obesity and the health risks associated with it are largely preventable, health reform is consistently focused on cost-effective, preventive health interventions. Currently, the Obesity Demonstration Project, created by the ACA, is funding community-based efforts that employ proven, effective health care and community strategies aimed preventing childhood obesity.  

Thanks to the health reform law, insurance companies are required to cover a set of preventive health care services specific to children’s health needs without charging a co-payment or deductible. This access to free, preventive children’s health care is available to any person with a new or non-grandfathered health plan, and is making it affordable for millions of parents to ensure their children are avoiding weight-related health problems and other preventable chronic health conditions. Services like blood pressure screening, depression and obesity screening and counseling, and height, weight and body mass index measurements, among others, are included in this significant ACA mandate.

Additionally, First Lady Michelle Obama created the Let’s Move! campaign, based on her goals of reversing the obesity trend in one generation and giving parents and children the tools they need to stay active and healthy. Let’s Move! is an initiative that is bringing healthy living awareness and education to parents, creating opportunities for children to become more physically active, and bringing healthy foods into schools across the country.

The Obama Administration’s work through the Affordable Care Act and the Let’s Move! campaign is already helping America raise a healthier generation of children and bring down the costs of health care at the individual and the national level. For more on what the Affordable Care Act is doing in the name of preventive health, see online. For more on childhood obesity, including the causes, risks, remedies, and how you can get involved, visit the Centers for Disease Control and Prevention and the Robert Woods Johnson Foundation online.

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization! 

This blog post was coauthored by Rachel Gielau.

Medicaid Expansion: The "Other Issue" in the Supreme Court's Health Reform Case Is a Big Deal, Too

Supreme CourtThe United States Supreme Court will hear arguments later this month on constitutional challenges to aspects of the nation’s health reform law, the Patient Protection and Affordable Care Act (ACA). The issue that gets the most attention concerns the “individual mandate,” which involves whether the Constitution allows the federal government to impose a tax penalty on people who fail to buy affordable health insurance. 

But there is another issue of immense importance that the justices will decide. They will rule on the constitutionality of the ACA’s expansion of Medicaid to cover all of the country’s lowest income people. Half of the 32-million-person reduction in the uninsured promised by the ACA will come from this guarantee of coverage for the poor under Medicaid.

Medicaid is a cooperative federal-state program. The federal government offers significant funding to the states to cover low income people—no less than half the cost, and much more than that in many states. States that opt into the program must comply with the federal rules about who gets covered. States know in advance that Congress may expand Medicaid, and Congress has done so many times since 1965. However, Medicaid has never covered all poor people. Instead it specifies coverage only for certain categories of poor people: children, parents, people over 65, and disabled people.

Under the ACA, Congress expanded Medicaid to cover everyone with incomes under 133% of the federal poverty level. It provides 100% federal funding for this expansion for several years, and permanently provides 90% funding for the expansion into the future. This simple step will cover 16 million Americans. It is a part of the overall strategy of the ACA to bring down the cost of the health care system by featuring prevention, early detection, wellness, care coordination, health information technology, and avoidance of unnecessary emergency room visits and acute care episodes. All of these benefits are fostered when people have a relationship with a regular doctor, which is made possible by insurance coverage.

The briefs have been filed in the Supreme Court on the challenge to the Medicaid expansion. The states that oppose the expansion of the Medicaid program under the ACA lost on this issue in the Eleventh Circuit federal appeals court, so they are the petitioners in the Supreme Court. Their claim is that the ACA gives the states no choice but to implement the Medicaid expansion and that this violates Congress’s power under the Constitution’s “Spending Clause” (Article I, Section 8) to attach strings to the money that the federal government offers to states by effectively depriving the states of any choice to turn it down. The petitioners make this claim with two main arguments.

First, they contend that Congress knows of the immense importance of Medicaid funds to the states and, even though Congress will fully fund the Medicaid expansion, it has effectively deprived states of any choice to decline to expand the program. They argue that their states would have to decline to participate in Medicaid altogether in order to decline the expansion. This cannot be a “voluntary acceptance,” the argument goes, and this imbalance of power is an impermissible coercion of the states into an “all-or-nothing choice”: abide by the federal requirements and expand Medicaid, or lose all Medicaid funding.

Second, the petitioners construe the ACA to impose a “universal mandate” that everyone have health insurance. They reason that, since the ACA does not provide the states with another federal mechanism to cover the health insurance of the state’s neediest citizens, the ACA forces the states to participate in Medicaid in order for their citizens to comply with the “mandate.”

The government, in its brief defending the ACA and the lower court ruling upholding the Medicaid expansion, points out that the Supreme Court has already decided that Congress has the power to attach strings to the money it offers to the states; this is well-settled law.

Further, the strings attached to the expansion are not onerous, since the federal government will ultimately assume 90% of the cost of the Medicaid expansion under the ACA (starting with 100% for the first few years). All of the states accepted the Medicaid deal knowing that the average federal contribution to Medicaid is 57%, and knowing that Congress reserved the right to change or expand the program, which it has done repeatedly since 1965. By assuming a higher funding burden for the expansion, which the federal government was not required to do under the terms of the Medicaid deal that all the states accepted, Congress avoided any sense of taking unfair advantage of the deal.

Second, in the government’s view, the states seem to be arguing that the more money that Congress provides to the states, the less say that Congress should have over how the states may use those funds; this is contrary to common sense.

Finally, in response to the argument that Medicaid is necessary to fulfill the ACA individual mandate, the government notes that the ACA has exceptions from the individual mandate for certain low-income individuals (including those who would be eligible for Medicaid under the ACA expanded criteria). Therefore, it is simply not true that Medicaid is “required” to comply with the individual mandate; the people who are covered under the ACA-Medicaid expansion would most likely qualify for waivers from the individual mandate, if necessary.

The Shriver Center is an amicus curiae in this case and supported a “friend of the court” brief written for the Center and other amici by the National Health Law Program. The brief goes into greater detail about the history of the Medicaid program, stressing that the ACA’s Medicaid expansion is well within the arrangement that all states have accepted in choosing to participate in the program.

The outcome of this case will affect millions of uninsured people and impact the ACA’s overall strategy to improve the nation’s health and bring down the cost of the health care system. Moreover, it could significantly alter the power of the federal government to attach strings to federal money that it offers to states in many varieties of programs beyond Medicaid, such as transportation, education, social services, and many more.

The Court will hear arguments on this issue later in March and will rule by mid-summer.

This blog post was co-authored by Brandon Jordan.


The Affordable Care Act: Fulfilling Promises, Cutting Costs

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

StethoscopeDid you know that the Affordable Care Act has already expanded affordable preventive health coverage to 54 million Americans?

If you’ve been following the Shriver Brief health care blogs, you probably remember reading about the Affordable Care Act mandate that insurance companies provide a specified list of preventive health care services to policy holders without charging a co-payment or deductible. Services like screenings for blood pressure and cholesterol; testing for Type 2 diabetes, obesity, and colorectal cancer; and alcohol and tobacco cessation counseling, among others are included in the mandate. Additional preventive health services like childhood immunizations; screenings for hearing, vision, and oral health; as well as testing for autism, HIV, and obesity, among others must be provided free of co-payment for children’s care. And starting in August of this year, insured women will be able to receive a set of women’s preventive health benefits like well-woman visits, FDA-approved contraception, mammograms, breastfeeding support and supplies, and domestic violence screening and counseling, also without cost-sharing. The health reform law requires that all of these free preventive health services are provided by insurance companies for anybody with a new or a so-called “non-grandfathered” insurance plan. And the most recent research shows that people—tens of millions of people—are already receiving these preventive services, for free!

According to a study conducted by the Kaiser Family Foundation, “31% of all workers were covered by plans that expanded their list of covered preventive services due to the Affordable Care Act.” Using this data, the Department of Health and Human Services (HHS) was able to calculate just how many people are benefiting from expanded preventive health coverage across the country. HHS estimates that 54 million Americans—and counting—have received one or more of the Affordable Care Act’s mandated preventive health services free of co-payment or cost-sharing. This number breaks down to over 20 million women, 14 million children, and 19.5 million men making use of their increased access to affordable and essential preventive health care. Illinois was among the top five states to benefit the most, with almost 2.4 million Illinois residents receiving free preventive health care services! And this number will only continue to grow as more and more people choose to enroll in new or “non-grandfathered” health plans, and as the health reform law rolls out its final stages in 2014, adding 16 million individuals to the private health insurance market.

These kinds of meaningful, money-saving provisions in the Health Reform law are making a real impact at a time of need, when many individuals and families affected by the recession have been resorting to cutting back on basic medical care to make ends meet. A Kaiser Family Foundation study conducted in 2009 found that 53 percent of American families were cutting back on medical care because of the cost. In 2010, the Commonwealth Fund reported that 25 percent of Americans were cutting back on recommended tests like blood pressure tests, colonoscopies, mammograms, and other potentially life-saving cancer screenings. And just recently, a study from the University of North Carolina’s medical school found that, during the height of the recession, adults between the ages of 50 and 64 received 500,000 fewer colonoscopies compared to the couple of years before the economy turned, even though the colonoscopies can cut the risk of dying from colon cancer in half. The good news is the Affordable Care Act is increasing access to many of these preventive health tests and screenings at a price Americans can afford.

Households all over the country are pinching pennies trying to stay afloat during hard economic times. Thank you, Affordable Care Act, for working diligently to make sure that nobody’s health is sacrificed because of the cost of care.

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!

This blog post was coauthored by Rachel Gielau.


The Affordable Care Act: Helping Consumers Make Healthier Choices

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Nutrition LabelDid you know that the Affordable Care Act requires large-scale restaurants and vending machines to display nutritional information at the point of purchase for consumers?

An important but mostly overlooked measure in the Affordable Care Act’s effort to combat obesity rates and bring down health care costs in the United States is likely to be noticed by consumers all over the country when it goes into effect later this year. The health reform law mandates chain restaurants with 20 or more locations to display the calorie content of standard items sold on the menu board or table menus, and to make other nutritional information, like fat, cholesterol, and fiber content, available in written form upon request. This new rule also pertains to vendors with at least 20 vending machines across the country. These vendors will have to make the calorie content of the foods sold visible to consumers at the point of purchase. Because this rule applies only to large-scale restaurants and vendors, small business owners with fewer than 20 locations will not be affected.

The goal is to make information available to consumers so they can make healthier choices when eating away from home. Studies show that consumers are increasingly getting more and more of their diets from food outside the home, from restaurants, fast food chains, and vending machines. Americans report spending almost half of their food budgets on away-from-home foods, and most parents report feeding their families restaurant-prepared meals at least once or twice a week. But American consumers know little about the nutritional value of the food they are consuming when eating out, and most tend to underestimate the number of calories and fat content in away-from-home foods. I like to think of myself as a fairly knowledgeable consumer, but I was shocked last week when I discovered that the sandwich I had ordered had over 1,000 calories—had I known the nutritional facts when I ordered, I definitely would have changed my dinner plans!

With obesity and other diet-related chronic health conditions like Type 2 diabetes and heart disease at alarming levels and on the rise in our country (two out of every three adults and one out of every three children in the U.S. are overweight or obese), nutrition and public health advocates believe that disclosing the caloric and nutritional value of foods served at restaurants and available in vending machines will help consumers make better choices about the food they eat away from home. Experts say that it is hard to tell how much nutrition labeling will affect individual consumer choice, and that more research needs to be done on this topic. However, studies show that, after nutrition labeling became mandatory for packaged foods sold in grocery stores, the demand for healthier cheeses tripled and the demand for fat-modified cookies increased 15 percent. The American Dietetic Association agrees, even small individual changes in food choice multiplied by millions of consumers can make a significant impact on public health and help improve the food supply by consumer demand. And it can bring down health care costs, both at the individual and national level, by preventing unnecessary and costly chronic health conditions often exacerbated by obesity.

While the impact of this legislation seems difficult to predict, who can argue with the notion that knowledge is power for American consumers?

For more information about the importance of nutrition in your diet and educational resources, visit the American Dietetic Association online.

For more on how the Affordable Care Act is working to combat obesity and other chronic health conditions, visit 

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!

This blog post was coauthored by Rachel Gielau.



The Affordable Care Act: Heart Healthy Reform

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

HeartsDid you know that February is American Heart Month, and that the Affordable Care Act is already working to save lives and save money by improving our heart health?

With an emphasis on effective preventive health measures, the Affordable Care Act has set in motion a comprehensive strategy to improve health and cut costs of treating chronic disease. Part of that strategy includes a targeted effort towards reducing the prevalence, severity, and costs of heart disease.

Heart disease, like other chronic diseases plaguing our country, is costly, life threatening, and often preventable. And, heart disease is increasingly prevalent and expensive to treat. According to the Million Hearts initiative, one out of every three people in the United States suffers from some form of heart disease, which includes severe chest pain, heart attacks, heart failure, and stroke. Heart disease claims more lives yearly than all forms of cancer, lower respiratory diseases, and accidents combined. This devastating chronic health condition kills 2,200 people every day in the U.S., and costs our country $444 billion every year in health care costs and lost economic productivity.

Fortunately, as we celebrate American Heart Month this year, we have some compelling reasons to be optimistic about the health of our hearts. One reason for optimism is that heart disease is largely preventable. By shifting our focus to preventing diseases before they occur, we save money and, more importantly, save lives. For many, it can be as easy as talking to your doctor yearly, keeping your blood pressure and cholesterol levels under control, and living a healthy lifestyle. However, we recognize there are barriers to this kind of healthy living for some. After all, if people don’t have access to things like basic medical care or healthy foods, knowing how to prevent heart disease may not be enough. These barriers need to be addressed in tandem with education efforts about preventive health

And this is where another reason for optimism comes in—the Affordable Care Act. The ACA is effectively shifting the focus in the United States from treating costly diseases to preventing them. The ACA is also changing the way health insurance companies do business so that obtaining coverage is fair and affordable for everybody. The ACA requires insurers to provide a number of preventive services free of cost sharing for many consumers, including screenings for obesity, blood pressure, and cholesterol levels; counseling on the use of daily aspirin to reduce the risk of stroke; and counseling on weight loss and a healthy diet, among others.  

The health reform law also increases access to affordable and fair health coverage by expanding the Medicaid program to include an additional 16 million people, and by providing tax credits and subsidies to eligible families to offset the cost of health insurance. In addition, the ACA bans many bad practices that kept many people with chronic illnesses uninsured and without access to necessary medical care. For example, insurance companies are no longer allowed to place lifetime or annual limits on coverage or deny people health insurance based on a preexisting condition

Finally, in a bold and unprecedented effort to prevent one million heart attacks and strokes in five years, the ACA put in motion the Million Hearts initiative. The Million Hearts initiative will focus on “improving access to effective care; improving the quality of care for the ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation); focusing clinical attention on the prevention of heart attack and stroke; activating the public to lead a heart-healthy lifestyle; and improving the prescription of and adherence to appropriate medications for the ABCS. To learn more, visit Million Hearts online.

And this isn’t all that the ACA does to help people with heart disease get access to the medical care they need. To learn about other ways the Affordable Care Act is making a positive impact on the lives of people living with heart disease, visit the American Heart Association on the web

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!

This blog post was coauthored by Rachel Gielau.


The Affordable Care Act: Knowledge is Power

Confused consumerGreat news for anyone who has ever struggled to understand exactly what their health insurance covers, what conditions apply, and how much they will owe for medical care! (And isn’t that everyone?)

Health insurance is notoriously difficult to comprehend. Luckily, one of the many positive benefits of the Affordable Care Act is the requirement that insurers disclose certain facts in easily comprehensible language. Consumers overwhelmingly like this component of the law. In fact, this provision is the most popular piece of the entire ACA.

Starting in September of this year, insurance companies will be required to provide easily understandable summaries of the coverage they issue and the terms they use, making shopping for and using your insurance much easier. They will also have to use uniform language in describing their plans, making it easier for consumers to compare the benefits offered by each plan. “All consumers, for the first time, will really be able to clearly comprehend the sometimes confusing language insurance plans often use in marketing,” said HHS Secretary Kathleen Sebelius. “This will give them a new edge in deciding which plan will best suit their needs and those of their families or employees.” Of course, the “edge” is that it actually levels the playing field between consumers and insurers by putting everyone on the same page. 

This aspect of the ACA ensures that consumers will be able to better understand their coverage and compare plans. Insurers will have to issue a six-page document that discloses what benefits are actually provided by the insurance; additionally, the document will provide examples of common medical situations (childbirth, chronic disease management, outpatient surgery, etc.) and explain how much coverage the insurance provides in each example. Insurers will also provide a dictionary of common insurance lingo, such as “deductible” and “co-insurance.” Worried you’ll miss something in the fine print? No more tiny restrictions and warnings at the bottom of the last page—the law literally bans fine print by mandating all writing must be in at least 12-point font! 

While information about insurance coverage was difficult to find in the past, the new law will mandate that it is available before purchase to allow comparisons when the coverage is up for renewal, if the policy changes, or any other time the consumer wants. In addition, the glossary will be publicly displayed on,, and

This piece of the ACA will increase consumer knowledge and allow consumers to efficiently and effectively compare coverage from different insurers. Providing the facts about insurance policies will let consumers avoid surprises in coverage gaps and pick coverage that works best for them.  


The Affordable Care Act: Significant Progress Made for Diabetics and the Fight Against the Disease

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Blood sugar testingThe Affordable Care Act (ACA) will bring down the cost of health care by improving peoples’ health. A prime example is the ACA’s comprehensive approach to diabetes.

According to the National Diabetes Information Clearinghouse, diabetes affects around 25.8 million people today, which is 8.3 percent of our population. If left untreated, diabetes can spiral into a long list of serious complications. It is the leading cause of kidney failure, responsible for most new cases of blindness for people under 75 years old, and the number one reason for non-accident-related foot and leg amputations for adults. In 2007, diabetes claimed enough lives to rank as the seventh leading cause of death in America.

Diabetes is an expensive disease to treat. Diabetics spend, on average, 2.3 times more than their healthy counterparts do on medical care each year. The United States spends $116 billion every year in direct medical care to treat diabetes and loses $58 billion in lost productivity, disability, and premature mortality due to the chronic illness, a whopping total of $174 billion annually. If trends continue, the United States could see the incidence of diabetes go from 1 in 10 adults today to 1 in 3 adults by year 2050. And the cost for treating diabetes is predicted to increase by 100 percent as soon as 2025, reaching $514 billion. But it doesn’t have to come to that. Type 2 diabetes is the most common form of the disease and is known to be triggered by obesity and lifestyle, rendering it largely preventable through healthy diet and regular exercise.

The cost of care over a lifetime for a diabetic and the risk of developing expensive complications help to explain why insurance companies have found diabetics unfavorable to insure. Yet quality health insurance is what permits sustained relationships with primary care doctors, which facilitates prevention and health maintenance. 

The ACA helps people with diabetes get the care they need at a price they can afford. For example:

Here are a few other ways the ACA is working to prevent diabetes and the serious and costly complications that go with it:

The ACA’s strategies for handling diabetes are a strong example of the cost-saving, health-improving measures available under the act across the spectrum of health conditions.

For more diabetes-related information and resources, see the American Diabetes Association online. And go online to learn about how the Affordable Care Act is working to prevent the many other costly chronic health conditions prevalent in the United States.

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!

This blog post was coauthored by Rachel Gielau.


The Affordable Care Act: Dollars in Your Pocket

Pocket moneyNew data show that the Affordable Care Act has already saved $2.1 billion for the 3.6 million Americans with Medicare! That comes out to be over $600 per person for Medicare beneficiaries, who are either elderly or disabled. And the savings are growing—by 2021, the average Medicare beneficiary will have saved about $4,200. People with particularly expensive prescription needs will save about $16,000 in the same 10-year period. The particular provisions at work here involve closing the prescription drug donut hole through discounts on generic and brand-name prescriptions. Medicare beneficiaries are saving on all kinds of prescriptions, with diabetes, cholesterol, asthma, and blood pressure drugs as some of the biggest categories. These drugs treat chronic conditions—making these prescriptions affordable helps people treat ongoing conditions and prevents the costly care associated with not treating chronic conditions.

Illinoisans have received higher than average benefits from the new law. Last year, over 144,000 Illinois Medicare beneficiaries saved over $96 million. That is an average saving of $667 dollars per person in 2011. That would pay more than nineteen months of CTA passes or ten months of electric bills—a significant savings. The Affordable Care Act is already making a difference in people’s lives.


The Affordable Care Act: Preventing Chronic Diseases

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Did you know that switching the focus from treating chronic illnesses to preventing the diseases will not only improve the health of individuals and families all over the country, but will also rein in health care costs and strengthen the economy?

The Affordable Care Act (ACA) is applying this logic in its fight to lower the rate of preventable chronic illnesses, produce real savings in the health care sector, and recover lost economic activity at the local, state, and national levels. And it’s doing it in the name of prevention through effective public health initiatives.

The prevalence of chronic health conditions in the United States is taking a huge toll on our citizens, our nation’s health care spending, and our workforce. More than half of the people living in the United States have at least one chronic health condition, such as heart disease, stroke, diabetes, obesity, and cancer. Chronic health conditions account for 7 out of 10 deaths in America and rack up 75% of our nation’s health care spending. The cost for treating people with type 2 diabetes, heart disease, hypertension, and stroke, alone, amounts to $238 billion each year. In 2010, the United States spent almost $2.6 trillion on health care, meaning we spent around $1.9 trillion just last year on treating and managing chronic illnesses, most of which are largely preventable. Here in Illinois, more than 6.7 million people have reported being diagnosed with a chronic health condition, costing the state $12.5 billion in annual health care expenses.

What’s more is that the cost of chronic health conditions goes beyond the money spent on health care services. The toll these illnesses take on our workforce productivity is telling. According to the Gallup Poll, 7 out of 8, or 83 percent of American workers either have a chronic health condition or are obese. The poll estimates that this prevalence of chronic illness and obesity in our workers could be costing our economy $153 billion a year in lost productivity due to increased sick days. Other reports that take into account other chronic conditions and factors like lost productivity from workers who show up on the job while sick estimate that chronic health conditions are costing the United States more than $1 trillion each year in lost economic activity. To bring these statistics home, chronic disease plaguing Illinois’s workforce cost the state $14.3 billion in lost productivity. And the commonality of chronic disease is rapidly increasing. It is estimated that the number of Americans living with a chronic health condition will increase by 36%, or 46 million people by the year 2030, and that we could be spending $685 billion a year on medical treatment for chronic disease by 2020. Other sources estimate the total economic toll of chronic health conditions to reach $6 trillion a year by the middle of the century.

But it doesn’t have to be this way. As the CDC states, “Access to high-quality and affordable prevention measures (including screening and appropriate follow-up) are essential steps in saving lives, reducing disability and lowering costs for medical care.” And research has proven that for every dollar invested in effective prevention and public health initiatives, $5.60 is saved. The same study reveals that, if we invest $10 per person every year in effective community-based public health programs, we could save the United States more than $16 billion in just five years. 

Fortunately, the Affordable Care Act recognizes the benefits to be had from investing in smart and effective preventive and public health efforts. The ACA established the National Prevention, Health Promotion and Public Health Council within the Department of Health and Human Services (HHS), made up of secretaries from various federal departments and chaired by the Surgeon General. The Council is responsible for developing our first ever National Prevention and Health Promotion Strategy, which was released in June of 2011 and identifies four strategic directions for preventing disease and improving health nationwide. The four strategic directions are: creating healthy and safe community environments; expanding access to quality clinical and community preventive health service; empowering people to make healthy choices; and eliminating health disparities. The Council is charged with providing leadership moving forward with the National Prevention and Health Promotion Strategy.

The ACA also established a Prevention and Public Health Fund, which is administered by the Secretary of HHS, Kathleen Sebelius, and provides financial support for state and community-wide efforts to prevent disease and promote healthy lifestylesThe Fund is a 10-year, $15 billion commitment to support prevention and public health programs across the country, like the Community Transformation Grants, which fund community-level programs geared towards reducing the prevalence of chronic disease and promoting healthy lifestyles.   Already, $103 million in grant money has been issued to 61 different state and community programs across the country, reaching 120 million people.

So what does all of this mean for chronic disease in Illinois? Already, the State of Illinois has received $17.14 million out of the Prevention and Public Health Fund to support community- and state-level wellness and prevention programs aimed at preventing chronic disease and raising awareness about healthy living. For a breakdown of what programs received funding and for how much, visit online.

The Secretary of HHS will continue to issue funds for prevention and public health programs across the country to reverse the trend of chronic disease, so stay tuned as health reform continues to make a positive impact in our communities. To find out what other kinds of initiatives the Affordable Care Act has taken to increase access to preventive health measures and decrease illness in America, visit the Shriver Brief online.


Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!

This blog post was coauthored by Rachel Gielau.



A Report Card for Health Reform

Report CardThe White House issued a new report recently on the states’ progress in implementing health reform. The Affordable Care Act is an extensive, complex piece of legislation; the states must complete many steps on the way to full implementation of the law. Since the process is by no means over, think of this information as a progress report like you got in grade school. It highlights strengths and reveals areas where states need to work harder before the final exam (full exchange implementation will be January 1, 2014). Naturally, states are at different places on the timeline but the overall trends are very encouraging.

Forty-four states are participating in premium rate review, which forces insurers to justify any double-digit increases in premium costs. This review process has already protected purchasers. For example, in South Carolina, state review saved consumers up to $15 million total. (To the six states not doing premium reviews—Alabama, Arizona, Louisiana, Missouri, Montana and Wyoming—what are you waiting for? Your citizens need your help.)

Even more encouraging, 28 states and Washington, D.C., are well on their way toward establishing the Affordable Insurance Exchanges. These states and D.C. have already been awarded federal establishment grants. These exchanges will function to connect consumers to insurers; through a web portal, consumers will be able to enter a few simple pieces of information and then compare different insurance plans to decide what will work best for their situation. The exchanges will select qualified insurance plans, assist consumers, and coordinate eligibility standards for the exchange and premium assistance. Another round of grants will be awarded in mid-February.

The White House report also included a snapshot of ten states’ progress toward implementing the law. The profiled states are not necessarily the farthest along in implementing the law; instead they are used to highlight the diversity of approaches and political orientations of the states. These examples work to underscore the fact that health care truly is a bipartisan issue. As the Mississippi Commissioner of Insurance aptly noted, “A healthcare exchange is not a partisan political issue. Across this nation, Republicans and Democrats alike have embraced the concept of health exchanges as a way to help individuals and small businesses more easily obtain health insurance.”

However, just because it is a bipartisan issue doesn’t mean that everyone agrees on the best way to implement the exchanges. Many stakeholders are convinced that state-run exchanges are more ideal than the federal exchange. The Boise Chamber of Commerce stated that it supported a state-based exchange “[s]o that Idaho can maintain authority over the state’s private health market.” This concern was echoed by the Pennsylvania Department of Insurance, which noted that “Pennsylvania has determined that developing a state-based health insurance exchange will work best for Pennsylvania residents.” However, some states may feel unprepared or unwilling to run their own exchanges. Those states have several choices. There will be Partnership Exchanges, which will allow states to run certain elements of the exchange while the federal government runs the other functions. Arkansas plans to pursue this option. And even though many states are making progress on their own exchanges, there is a federal exchange in the works for those states that cannot or do not want to establish and run their own exchanges. 

Just like students in a classroom, the states’ progress varies widely. However, overall the states are progressing towards implementation of the Affordable Care Act. Certain states are farther along in the process, but no one wants to be left behind!


A Follow-Up on Women's Preventive Health Services Guaranteed by the Obama Administration

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health.   

WomanDid you know that, in an HHS ruling last week, the Obama administration reaffirmed the Affordable Care Act’s commitment to improving the health and well-being of America’s women?

If you’ve been tuning in to our weekly “Did You Know” blog series on preventive health and the Affordable Care Act, you might remember that last summer the U.S. Department of Health and Human Services (HHS) required health insurance companies to cover a set of women’s preventive health services without charging a co-payment (effective August 2012). The comprehensive set of free women’s preventive health services recommended by the Institute of Medicine includes, among many other necessary services, Food and Drug Administration-approved contraceptives, or birth control. This issue affects millions of Americans. There are approximately 43 million sexually active women who do not want to become pregnant in the United States; 89% of them use contraception. 

Last summer’s interim rule allowed certain nonprofit religious employers offering health insurance to their employees to qualify for a religious exemption and therefore be able to decide for themselves whether or not to cover contraceptive services in their employer-sponsored coverage. This religious exemption was narrowly defined, pertaining only to those religious institutions that employ and serve people of the same religious beliefs, like churches or synagogues. The exemption did not include religiously affiliated institutions, like hospitals and schools. When HHS asked for public comment on this part of the rule, it received an outpouring of input from groups supporting the narrow exception and groups wanting it expanded.

On Friday of last week, HHS announced its final ruling on this issue, concluding that the narrow definition of the religious exemption will stand. Religious places of worship like churches will be exempt from the rule, but institutions with religious affiliations like hospitals and schools will not. This means, for example, that churches will not have to cover contraceptive health for their employees, but religiously affiliated hospitals will have to offer that coverage to their doctors, nurses, and other employees. The only change to the rule from last August is the decision to give employers who don’t currently offer contraceptives in their employer-sponsored health coverage because of a religious belief an extra year (until 2013) to comply with the mandate. The Secretary of HHS, Kathleen Sebelius, said that she believes this proposal “strikes the appropriate balance between respecting religious freedom and increasing access to important preventive services.”

This blog post was coauthored by Rachel Gielau.


Friends of the Court (and the Affordable Care Act)

Supreme CourtThe Affordable Care Act (ACA) has friends in high places, and they are letting the world know it. “Amicus Curiae” means “friend of the court” and is the name for a person or group who is not officially the plaintiff or defendant in a lawsuit, but who has good reason to be concerned about the case and offers an opinion based on special experience or expertise to the court regarding the case. Now pending in the Supreme Court is a case challenging the validity of portions of the ACA. Friends of the court are now submitting “amicus curia” briefs to the Supreme Court defending the ACA.

One important friend on the ACA’s side is Illinois Attorney General Lisa Madigan. Recently, she and twelve other attorneys general filed briefs before the Supreme Court arguing that the individual mandate is constitutional as a valid exercise of the constitution’s Commerce Clause. The opponents have argued that the ACA’s “individual mandate” (imposing a tax penalty on anyone who remains uninsured after the ACA is implemented) is beyond the scope of Congress’s power to act under the Commerce Clause. As one of the amici notes, "The healthcare industry takes up at least one-sixth of our economy. If anything is interstate commerce, it's healthcare.”

We say “thanks” to these Attorneys General, including our own Lisa Madigan, for supporting this monumental legislation—they are truly looking out for all of their constituents.

However, it’s not just lawyers who are lining up to support the ACA. Many friends of the law have significant medical expertise, including the American Academy of Pediatrics, the American Nurses Association, the American Cancer Association, and the American Diabetes Association. Other amici are familiar with the intricacies of running health systems, including the American Hospital Association and the Catholic Health Association of the United States, as well as the National Association of Children’s Hospitals. Other friends include Nobel Prize winning economists, the AARP, small business groups and numerous academics. The Shriver Center has joined as “amicus curiae” in two briefs in support of the ACA: one led by the National Women’s Law Center pointing out the tremendous positive impact of the law on women’s health; and the other led by the National Health Law Program that defends the Act’s Medicaid expansion as a valid exercise of congressional authority.

Having experts support the ACA in the Supreme Court is important, but it is also important that everyone who will be affected by this law take a stand in support of it. This law will affect all Americans—whether it is by providing affordable coverage, allowing young adults to stay on their parents insurance, or any of the myriad other benefits the law offers. Share this information with people—research shows many people don’t know how the ACA can help them. Let your friends, neighbors and co-workers in on the good news.  .

The Affordable Care Act: Helping Women Prevent Cervical Cancer

This post is part of a weekly “Did You Know” blog series that highlights important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

January is National Cervical Cancer Health Awareness month. One goal this month is to bring awareness to the preventative role that routine Pap tests play. The American Cancer Society states that Pap tests can actually prevent the disease and that early detection allows for more successful treatment, making it a matter of life and death for some women. Unfortunately, this does not bring peace of mind to the millions of uninsured women who lack access to primary care doctors and OB-GYNs.

Almost 1 in 5, or 19 million women in America reported being uninsured in 2010; more than 17 million, almost 1 in 6, fell victim to poverty. These women are your neighbors, your co-workers, your loved ones and your community members, and they are at a heightened risk of developing serious illnesses like cervical cancer simply because they cannot afford basic and necessary preventive health care. Dr. Martin Luther King Jr., whose legacy we recently celebrated, once said, “Of all the forms of injustice, inequality in health care is the most shocking and inhumane.” This is an injustice that the Affordable Care Act—commonly referred to as “Obamacare”—is working diligently to fix.

In 2014, the Affordable Care Act will expand the Medicaid program to cover all Americans living at or below 133% of the federal poverty level ($14,483.70 a year for a single person). This expansion will bring comprehensive health care, including primary care providers, to an estimated 16 million people nationwide. Here in Illinois, 700,000 people, including many low-income women will gain access to basic and effective preventive health services like routine Pap tests.

The Affordable Care Act recognizes that the cost of insurance policies and medical bills are not just problems for those living in poverty; they are also significant sources of stress for middle-class families. Fortunately, in 2014, the health reform law will provide tax credits and cost-sharing subsidies for individuals and families living below 400 percent of the federal poverty level ($89,400 for a family of four) to offset the cost of obtaining health coverage and maintaining a healthy lifestyle. This kind of financial relief is estimated to make a huge impact on women’s access to health care and greatly decrease the number of women who are uninsured or “underinsured” (women who have health insurance but don’t get medical care because they cannot afford their policies’ big deductibles or co-payments or because the services they need are not covered by their policies).

A 2009 study reported that seven out of ten women are uninsured or underinsured, have trouble paying for medical bills, or avoid seeking health care because of the cost. With record breaking numbers of women living in poverty and the fact that women have historically been charged higher premiums than men simply for being women—a discriminatory practice that health reform has banned—this should come as no surprise. Women need access to basic preventive health care now in order to prevent life-threatening diseases like cervical cancer in the future. That’s why, right now, the Affordable Care Act is helping insured women gain access to affordable health care by mandating that insurance companies provide preventive services free of cost-sharing to anybody with a new or “non-grandfathered” plan. Furthermore, in August of this year, a significant number of women’s preventive health services, including annual well-woman visits and Food and Drug Administration-approved contraceptives, will be free of co-payment for women who have insurance policies that are considered to be “non-grandfathered” status.

Finally, health reform is effectively eliminating barriers between women and OB-GYNs by banning the old, status-quo requirement that women must get a referral from a primary care physician before seeing a gynecologist. This consumer protection has been in effect since the fall of 2010 so women all over the United States are already finding it easier and more affordable to get the necessary preventive care they need as a result of health reform.

On behalf of women everywhere, thank you, Affordable Care Act, for increasing access to affordable health care and for helping women stay ahead of cervical cancer.

For information on what the government is already doing to help women prevent cervical cancer, check out the National Breast and Cervical Cancer Detection Program online. This program provides access to free breast and cervical cancer screening and treatment for millions of uninsured women.

 Also, see the American Cancer Society for in-depth information on what cervical cancer is, the risks and treatment options, as well as support.  

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!

This blog post was coauthored by Rachel Gielau.


The Affordable Care Act: A New Tool in the Fight Against Breast Cancer

This post is part of a weekly "Did You Know?" blog series that highlights important, but not well known, features of the health reform law about prevention, wellness, and personal responsibility for our health.

Did you know that the Affordable Care Act is upping the ante on breast cancer awareness and prevention efforts?

Mammogram machineAccording to, about one in eight U.S. women (just under 12%) will develop invasive breast cancer over the course of their lifetimes. In 2011 alone, it was estimated that nearly 230,000 women were diagnosed with some form of the disease, and tens of thousands of women lost their lives to it. Breast cancer is the second most common type of cancer in women and one of the most deadly cancers among our mothers, sisters, and grandmothers. But it doesn’t have to be. Raising awareness about breast cancer, educating women about effective preventive health practices and increasing access to doctors and routine mammograms can reduce the cost, hardship, and lives lost to this all-too-common form of cancer. And this is precisely what the Affordable Care Act is doing for women all across the country.

The Affordable Care Act (ACA) authorizes the Centers for Disease Control and Prevention (CDC) to award grants to fund breast cancer education and awareness campaigns across the country. The Act also directs the Secretary of Health and Human Services, along with the CDC, to establish an advisory committee on breast cancer and to launch a breast cancer awareness and education campaign, targeting young women with information about prevention and early detection. The law also authorizes the CDC to conduct research to better understand the disease, as well as the most effective prevention and awareness-raising efforts.

The CDC states that mammograms can detect breast cancer up to three years before it can be felt. And according to Health and Human Services, 3,700 lives would be saved every year if 90 percent of women 40 years old and up received routine breast cancer screenings. It is no secret that educating women about the importance and effectiveness of early detection is crucial to reducing the prevalence and mortality rates of breast cancer. 

However, this isn’t just an awareness issue. Especially in today’s economy, the financial cost of a routine mammogram—let alone making a visit to the doctor—is high enough to deter women from getting their necessary check-ups. The Affordable Care Act works to solve this problem for many American women. The health reform law is making women’s preventive health care affordable by requiring health insurance companies to cover certain preventive health services, like routine mammograms, free of co-pay for individuals with new or “non-grandfathered” plans. This means that any woman with a health insurance plan that is new or has changed significantly since March 23, 2010, can receive necessary routine mammograms without having to pay any money out of pocket for the procedure. Yearly well-woman check-ups will soon be free, too, giving women a chance to speak to their doctors about their health without worrying about their bank accounts.

The Affordable Care Act, referred to in the media by “Obamacare”, is also making strides for women who currently battling breast cancer and those who are survivors. Thanks to “Obamacare’s” many new consumer protections, insurance companies are no longer able to place lifetime limits on insurance policies, and in 2014, they will no longer be able to place annual limits on coverage, meaning people everywhere can rest easy knowing that the health insurance they pay for will be there for them when they need it most. Also in 2014, insurance companies will no longer be able to discriminate against anybody for having a pre-existing condition, like breast cancer, which means that women will no longer be denied coverage or charged a higher rate because they’ve fallen victim to cancer.

Breast cancer affects women and men of all races and ethnicities, but did you know that African American women are at a greater risk than any other race of dying from breast cancer in America? Find information on how the Affordable Care Act is working to reduce health disparities like this one across the country online.

For information on what you can do to stay ahead of breast cancer and on top of your health, visit the American Cancer Society online. For more in-depth information about breast cancer, like risks, treatments, and support, visit the National Breast Cancer Foundation website.

This post was coauthored by Rachel Gielau.

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!


The Affordable Care Act: Supporting Working Mothers

Coauthored by Rachel Gielau

Did You Know that the Affordable Care Act requires employers to provide a designated breastfeeding station and allowbreak time for women to breastfeed or pump during the workday? 

That’s right! Employers with at least 50 employees must allow for reasonable break times during the workday for working mothers to nurse or pump, and must also provide a breastfeeding station other than the bathroom. According to the law, working mothers must have access to these breastfeeding accommodations for one year after their child is born. 

This is a wonderful achievement for women’s rights and women’s health, not to mention the health of our nation’s children who benefit immensely from being breastfed during infancy. Breastfeeding gives children a kickstart to preventing chronic illnesses like asthma, lower respiratory infections, type 2 diabetes, and obesity, and building healthy immune systems. And it’s great for mothers too. Breastfeeding is linked to a lower risk of women developing breast & ovarian cancer, type 2 diabetes, and postpartum depression. By preventing short and long term health complications for mother and child, this healthy practice is also good for the economy, business, and the environment, and it saves families money too! Recent research shows that the United States could save an aggregate of 13 billion dollars per year if 90 percent of our nation’s mothers breastfed their newborns for the first 6 months due to reduced medical expenses. It is also been shown that women and their partners miss fewer work days due to sick children when their babies are breastfed during infancy, which fosters productivity in the workplace. Breastfeeding also avoids the environmental cost and waste associated with producing and using formula and plastic bottles.

In this effort to ensure that our nation’s women have the tools they need to successfully breastfeed their newborns, the Affordable Care Act is working to break down barriers for women in the doctor’s office. Starting in August of this year, women with non-grandfathered health insurance plans will be able to receive breastfeeding support and counseling, and access to breastfeeding supplies without having to pay money out-of-pocket. This is part of the excellent list of women’s preventive health services that were passed down by HHS last summer. 

Learn even more about the Affordable Care Act’s many achievements for women’s health onlineFor breastfeeding support and helpful resources, go here.

As we wrap up this holiday season, thank you, Affordable Care Act,for being an advocate for the health and wellbeing of our nation’s women and children.

The Affordable Care Act: A Champion for Women's Preventive Health

This is the second post in a weekly “Did You Know” blog series that will highlight important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Did you know that insurance companies will soon be required to cover women’s preventive health services like birth control and annual gynecological visits free of co-pay?

The Department of Health and Human Services (HHS), under the guidelines of the Affordable Care Act, announced this summer that starting in August, 2012 (for new or “non-grandfathered” plans), insurance companies will have to cover a set of women’s preventive health services free of cost-sharing (i.e., co-payments, deductibles, or the use of co-insurance). These services are in addition to the set of preventive benefits for all adults that health insurance companies are already required to cover without cost-sharing in the private market (at least those with “non-grandfathered” plans), all thanks to the Affordable Care Act.

The women’s preventive health services included in the rule are:

  • Well-woman visits
  • Screening for gestational diabetes
  • HPV DNA testing for women 30 years and older
  • STI counseling
  • HIV screening and counseling
  • FDA-approved contraceptives and contraceptive counseling
  • Breastfeeding support, supplies, and counseling
  • Domestic violence screening and counseling

There are a couple of important exemptions that come with this new rule. Insurance plans with “grandfathered” status will not be required to cover these benefits free of co-pay in 2012. The rule only applies to new plans, or those that have lost their “grandfathered” status. If you are unsure whether or not your plan is new or grandfathered, ask your insurer or your employer if you have coverage through work. You can find more information on grandfathered vs. non-grandfathered plans online.

The other exemption to this new rule, which is still being considered by HHS, involves religiously affiliated places of work and the mandate to provide coverage for birth control. Controversial in nature, the proposed religious exemption has recently become the center of debate. The exemption would allow religiously affiliated institutions that oppose birth control and offer employer coverage to refrain from providing contraceptive benefits. This means that millions of women working for religiously affiliated institutions, including places of work like hospitals and schools, may face barriers to accessing affordable FDA-approved family planning methods, which is a concern for women’s rights advocates across the country.  

Quick Fact: Speaking of women’s preventive health, did you know that health reform is already working to increase women’s access to ob-gyns?  Thanks to the Affordable Care Act, women no longer have to get a referral from their doctor before seeing a gynecologist no matter what kind of insurance they have! This consumer protection applies to all women and has been in effect since September 23, 2010.

This blog post was coauthored by Rachel Gielau.                                      

Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals?  Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve?  Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel Gielau at 312-368-1154 to set up a presentation for your organization!



How to Talk to Your Family about the Affordable Care Act over the Holidays

Family dinnerFamily holiday dinners can be wonderful, warm times to bond, or they can devolve into intense full-contact debates. We’ve all been at the table when Uncle Steve wants to debate politics or Cousin Liz is in the mood to talk about religion. A little friendly debate over crescent rolls can bring a family closer together and enlighten people, or it can make for a really uncomfortable holiday. 

This year, I’m predicting the federal Affordable Care Act (ACA) to be a hot-button topic as relatives spar over the universal mandate, death panels, and whether or not Grandma’s Medicare will be rationed. (Hint: it won’t be.) Research shows that about half of uninsured people who will benefit from the ACA are really in the dark about healthcare reform; some of them are probably going to be sitting around the table with you. We would like to remind our readers to take advantage of this great opportunity to enlighten (in a positive, respectful way) family and friends on the many ways the ACA is helping Americans get affordable healthcare. Once people know about the many benefits of the ACA, they are far more likely to support it.  

Here are a few tips to make sure this holiday season doesn’t end in frustration for anyone.

1.     Most importantly, take ownership of the ACA. You like this legislation—tell people why!

I know I’ll be telling my own family how thrilled I was that my young adult sisters and I could remain on my parents’ very good insurance (along with 2.5 million other young Americans) rather than purchase overpriced, low-quality plans on our own before being eligible for employer-provided insurance.  

Or maybe you have diabetes and are looking forward to the day (January 1, 2014) you won’t be denied the ability to purchase insurance for your preexisting condition, or you would like to provide health insurance to maintain your best employees and are excited about the tax credits you will receive. Whatever part of the ACA you are excited about, share it with your family over dinner. Positive stories create positive impressions of the law.

2.     Know what you’re talking about. Have reliable information ready to refute your dad’s claim that small businesses will be going under in droves or your sister’s statement that sick people won’t be readmitted to the hospital. We suggest using the official website, The Kaiser Family Foundation, and the new interactive game “Thanks Obamacare!”  for helpful facts. Misinformation absolutely will not help the cause of broadening public support for the ACA. 

3.     Mention the most popular provisions of the ACA, like closing the Medicare donut hole and requiring health insurance companies to sell policies to all people (even people with preexisting conditions); research shows that most Americans feel “very favorable” about these provisions.

4.     Don’t be insulting. Your aunt’s unwavering stance on death panels may make you twitch with anger, but don’t ever attack her personally. She’s still your family and you still have to finish the evening with her. Address her misinformation calmly and with facts rather than focusing on her propensity for exaggeration or gullibility.      

5.     Call a truce if the discussion gets intense. Don’t make discussing the ACA a battle during your dinner. Agree to continue the discussion via an email chain, where you can include citations to reliable information, and then everyone can focus on enjoying dessert and family. 

Of course, this advice doesn’t just apply to holiday dinners—everyone who supports the ACA has an important job to do in confronting misinformation that they hear about the law and in spreading the word about its positive aspects. As you do this, keep a mental note of the most outrageous or most prevalent misinformation you hear and share it with us via blog comments or email. We would love to know more about what we are up against!


Save Current Medicaid and CHIP Requirements
to Protect Kids!

We have good news and some bad news. The good news is that, in 2010, the number of uninsured children in the United States was one of the lowest in over a decade—about 7.3 million children were uninsured. Of course, Illinois’s rates of child uninsurance are even lower, thanks to the All Kids program. The Affordable Care Act has the potential to cut the number of uninsured children even further to 4.2 million (still too many uninsured children, but improving!). The expected decreases in uninsured children depend significantly on the states’ continuation of Medicaid and Children’s Health Insurance Programs (CHIP) coverage. 

The bad news is that some lawmakers are proposing legislation that will eliminate or greatly reduce Medicaid and CHIP. Without this coverage,  the level of uninsured children might actually rise—the exact opposite of what the Affordable Care Act is intended to accomplish. Eliminating Medicaid and CHIP for families above 138% of the federal poverty level would gut the Affordable Care Act’s goal of insuring our nation’s children—these programs must continue in full force in order to offer affordable insurance to young Americans. 

Under the Affordable Care Act, children and families with incomes under 138% of the federal poverty level will be covered under expanded Medicaid eligibility provisions. dults over the Medicaid threshold will be expected to obtain coverage for themselves through either the benefits exchanges or traditional employer-provided coverage and will be provided tax credits to make coverage more affordable. 

However, as the law currently stands, children in families between 138% and 400% of federal poverty level will continue to be eligible for Medicaid and CHIP due to congressionally mandated “maintenance-of-effort” (MOE) requirements. These requirements dictate that states maintain their existing eligibility, application, and renewal procedures requirements for children until October 1, 2019. his means that states cannot scale back coverage in order to save money, nor can they enact more onerous enrollment procedures.

Unfortunately, some lawmakers are calling on Congress to roll back those MOE requirements. If they are successful, states looking to balance their budgets will surely be tempted to make cuts in this area and force vulnerable children off Medicaid and CHIP. This would be a disaster for the health of our nation’s children. If states are allowed to discontinue their MOE requirements, an estimated 7.9 to 9.1 million children would be uninsured.      

If this happens, some families without employer-provided coverage will be eligible for tax credits and purchase coverage for the children on the benefits exchanges. Others will be able to obtain affordable employer-provided coverage.

However, not all families will be able to take advantage of these options. Children of all ages and races will experience higher rates of uninsurance without CHIP and Medicaid, despite the availability of exchange or employer-based coverage intended to replace those programs. For various reasons, the exchanges may be too expensive or unavailable to these families, leaving children without options for insurance.

The Affordable Care Act is a vital piece of legislation that has the potential to cut the number of uninsured parents and children by millions if it is implemented properly. We cannot skimp on providing coverage for children. Although the government could save some money by eliminating Medicaid and CHIP coverage for families over 138% of the federal poverty level, a decision to do so could leave millions of our most vulnerable uninsured. Medicaid and CHIP must continue at full strength, since these are vital lifelines for millions of uninsured children and high-quality and affordable coverage for our nation’s youth.


The Affordable Care Act: Making Preventive Health Care Affordable for You!

Editor's Note: This is the first of a weekly “Did You Know” blog series that will highlight important, but not well known features of the health reform law about prevention, wellness, and personal responsibility for our health. 

Did you know that you can receive preventive health services at your doctor’s office free of co-pay?

That’s right! The Affordable Care Act is serious about changing the culture of our health care system from treating disease after we get sick to preventing disease so that we don’t fall ill in the first place. From free preventive medical services and personalized wellness plans to community transformation grants and nationwide health education campaigns, the Affordable Care Act can help Americans raise a healthy generation of kids, build a healthier workforce, and reduce the overall cost of health care. 

One of the many ways the Affordable Care Act is working already to help individuals stay ahead of chronic illnesses is by requiring health insurers, including Medicare, to offer certain preventive health services free of co-pays. This new rule has been in effect since September 23, 2010, so you may already be reaping the benefits! For private insurance, the rule applies only to new plans, or those that have lost their “grandfathered” status, meaning, if you enrolled in a new plan at work or your employer significantly changed its health plan since March 23, 2010, you can receive the following preventive services without paying a deductible or co-payment:

  • Blood pressure screening
  • Cholesterol screening for certain aged and high-risk adults
  • Colorectal cancer screening for adults over 50
  • Type 2 diabetes screening for adults with high blood pressure
  • HIV screenings for people at high risk
  • Depression screening
  • Alcohol abuse screening and counseling
  • Aspirin use for men and women of certain ages
  • Immunization for adults and children (see full lists here)
  • Abdominal aortic aneurysm screening for men who have smoked
  • Diet counseling for adults at higher risk for chronic disease
  • Obesity screening and counseling
  • Sexually transmitted infection prevention counseling and screening for people at high risk
  • Tobacco use screening and cessation interventions for tobacco users
  • Syphilis screening for adults with high risk

There are additional preventive health services available specifically for women and for children that are also free of co-pays. Comprehensive lists of available services can be found online. Information about each of these preventive services, along with tips and resources to help you and your loved ones stay healthy, is also available.

Unsure whether or not your plan is grandfathered or if you will be able to get these services at no cost to you? Ask your insurer! They will know. You can also learn more about grandfathered plans online.

This post was coauthored by Rachel Gielau.


Interested in an in-person presentation on how health reform is rolling out in Illinois and what it means for individuals? Are you a direct service provider or advocate for vulnerable populations and interested in how the Affordable Care Act will impact the population you serve? Rachel Gielau, health policy expert at the Shriver Center, is giving free in-person presentations to Illinois audiences on how health reform is affecting individual and families in Illinois. Contact Rachel at 312-368-1154 to set up a presentation for your organization.


Affordable Care Act--Some Myths and Facts

Photo credit: Ann FisherThe Affordable Care Act (ACA) is the name of the national health reform law, which has also become known as “Obamacare.” The ACA creates a set of tools that can significantly address the health coverage crisis now and especially over the next few years as the law phases in

Here are some of myths spread by opponents of the law, and the facts that refute them:

Myth: The ACA is a government takeover of health care. 

Fact: The ACA keeps the private insurance system, but strengthens the watchdog role of government to ensure that consumers get choice, control, and peace of mind. Health care itself is still private, and most individuals under 65 will continue to get insurance from their employers and private insurance companies. 

Myth: The ACA replaces Medicare or cuts basic Medicare benefits. 

Fact: False. In fact, 18.9 million Medicare recipients have received free annual checkups and preventative services, and 4 million have received Medicare prescription discounts. The ACA will eliminate the notorious Part D “donut hole” entirely.

Myth: The ACA hurts small businesses. 

Fact: Small businesses do very well under the ACA. Employers will be able to purchase insurance with large-pool savings and bargaining power. They will also receive tax credits to offset the cost of their employee premiums. Only larger companies will be fined for failure to offer coverage.

Myth: The ACA adds to the federal deficit. 

Fact: The nonpartisan Congressional Budget Office has scored the ACA to reduce the deficit

Myth: The ACA does not actually insure anyone.

Fact: Already a million young Americans are covered under their parents’ plans because the ACA raised the age limit to 26 for dependent coverage. After the phase-in period, well over 30 million Americans now uninsured will be covered by affordable, comprehensive private insurance or (for lowest income people) a Medicaid expansion.

The ACA contains strategies to improve the health insurance worries that afflict every American household, regardless of income. It is also a smart and crucial strategy to fight poverty, by improving lives and upward mobility.      


Maternal Health Care is a Human Right in Brazil and the U.S.

Midwife visitThe United Nations (UN) has affirmed that maternal health care is an international human right – a right of all women, regardless of their race, ethnicity, income, or citizenship status. In its landmark decision on the case Alyne da Silva Pimentel v. Brazil, the United Nations Committee on the Elimination of Discrimination Against Women established that governments have an obligation to guarantee that all women in their country have access to adequate and timely maternal health care, including emergency services, even if the government outsources health care to private institutions.

The 1979 Convention on the Elimination of All Forms of Discrimination Against Women established that governments must ensure that women receive appropriate prenatal and postnatal services (Article 12), but a maternal death case had never been brought before the UN. In 2007, the Center for Reproductive Rights brought a case against Brazil before the UN committee, and this month this first ever case involving maternal death was decided by an international human rights body. The case involved the 2002 death of a 28-year-old Afro-Brazilian woman who died in her sixth month of pregnancy from preventable complications because of misdiagnosis and delayed treatment. The UN Committee concluded that Brazil had violated the international human rights of women through discriminatory maternal health practices made clear by its history of inequitably distributing maternal health care facilities across regions, a practice that ultimately resulted in Ms. Pimentel’s untimely and preventable death. The decision signals a commitment by the UN to uphold women’s rights to maternal health services and reaffirmed that it is a human right to receive appropriate, adequate, and timely maternal health care.

The case laid bare the stark injustice women and girls face in seeking quality health care in Brazil and around the world. The inequitable distribution of maternal health care facilities in Brazil led to disproportionately low concentrations of adequate maternal health in low-income areas and areas with high concentrations of people of color. Although Brazil’s overall maternal death rate has decreased – recent numbers place it at 58 per 100,000 live births – significant disparities remain along the lines of race, economic status, and region.  

Unfortunately, Brazil is not alone in having starkly disparate maternal death rates based on race. In the United States, African American women, regardless of income, are four times more likely than white women to die of pregnancy-related complications (page 1). This has resulted in an overall maternal death rate for African American women of 26.5 per 100,000 live births (table 34) and rates as high as 83.6 per 100,000 live births in New York City (page 4). Indeed, the U.S. women most likely to die of pregnancy-related complications are low-income women of color.  

Compared to other industrialized countries, however, all women in America have high maternal death rates. With an overall maternal death rate of 12.7 per 100,000 live births (table 34), the United States ranks 50th in the world. This is an embarrassingly low rank for a country that spends the most money on health care in the world and the largest percentage of its health care costs on maternal health. To put this in perspective, a woman in the United States, regardless of race or income, is three times more likely to die in childbirth than a woman in Spain, and five times more likely to die in childbirth than a woman in Greece (page 1).

For the United States, the problem is not necessarily quality of health care, but rather access to it. Federal and state governments have programs in place to serve pregnant women and provide them with appropriate care. Many low-income pregnant women, regardless of race, age, or citizenship status are eligible for Medicaid, which allows women to receive health coverage for pre-natal and post-natal medical treatment. Indeed 42 percent of all births are covered by Medicaid, and no woman in active labor can be turned away from a hospital because of her ability to pay. Many women, however still face barriers to receiving adequate health care under Medicaid, such as transportation concerns, inflexible appointment hours, and difficulty taking time off work. Doctors, too, may be unwilling or unable to take Medicaid because of the low fees and high costs involved (page 5).    

The Patient Protection and Affordable Care Act moves the right to health care forward by requiring insurers to provide some preventive services for women at no cost, such as well-women visits, and expanding Medicaid coverage. These provisions will mean that thousands more pregnant women will receive the health care they need. But estimates indicate that thousands more women will still be in need. Many women who will now qualify for Medicaid will still face barriers in receiving quality maternal care. With the Alyne da Silva Pimentel v. Brazil decision, the UN has reinforced that maternal health care is a fundamental human right. The United States must reaffirm its commitment to women and help lead the way to lower the unacceptably high rate of preventable maternal deaths within its own borders by ending discriminatory practices and ensuring quality maternal health care for all women.

This post was coauthored by Hannah Green.



Dear Medicaid: Happy 46th Birthday!


Coauthored by Rachel Gielau

On July 30th, 1965, President Johnson signed Medicaid into law. Its mission, then and now, is access to quality, affordable health care. For 46 years, Medicaid has been a lifeline to millions of America’s most vulnerable people, including low-income seniors, people with disabilities, children and their parents, and pregnant women. Today, the public health insurance program is the second largest health insurer in the United States, providing quality coverage and peace of mind to one out of five Americans.

Unfortunately, in the midst of the budget battles being fought in Washington Medicaid is under attack. Right-wing proposals like the U.S. House-passed Republican budget plan calls for debilitating cuts that would end the Medicaid program as we know it, slashing the program by about one-third and shifting costs onto states, beneficiaries and providers.

But individuals and families in Illinois depend on Medicaid!

  • For 46 years, Medicaid has been the foundation of health coverage for Illinois’ most vulnerable populations. Today, more than 2.5 million Illinoisans (60 percent are children; 20 percent are elderly, blind, or disabled adults) rely on Medicaid.  
  • Children depend on Medicaid! Almost 1.5 million children, or 43 percent of all kids in Illinois, rely on Medicaid for their well-child doctor visits and other health care needs. For most low-income children, Medicaid is the only source of affordable coverage available. 
  • Medicaid is a lifeline! For more than 559,000 Illinois seniors and people with disabilities Medicaid provides affordable long-term and specialty care. Access to these services helps avoid the use of institutionalized care, keeping costs down and families together.

And we know that Medicaid works!

  • Medicaid makes Illinoisans healthier! Medicaid has been proven to increase access to affordable health care for low-income people, which improves the health and financial stability for families everywhere.
  • Because of Medicaid, low-income children in Illinois are able to get a healthy start in life. Medicaid helps Illinois children be better students and develop healthy living habits early in life. With access to well-child care, our children get the primary care they need to avoid absences from school and prevent costly chronic health conditions later in life.
  • The success of public health insurance programs like Medicaid and the Children’s Health Insurance Program (CHIP—called All Kids in Illinois) has kept uninsured rates for children from spiking due to the economic recession.  
  • Medicaid is more cost-effective than private health insurance! Medicaid spending per enrollee has increased at a slower rate than that of private insurance. Also, Medicaid spends less per enrollee than private insurance does. In fact, “Medicaid costs 27% less for children and 20% less for adults than private insurance.”
  • Medicaid stimulates the economy and supports jobs in Illinois. Every dollar spent on Medicaid in Illinois generates matching federal funds that come back to the state, increasing economic activity and creating jobs. In 2009, Medicaid funding brought an additional $46 billion in business activity, $15.8 billion in wages, and support for 385,742 jobs to local economies in Illinois.
  • While America and Illinois can take pride in Medicaid as it turns 46, the program needs and is getting 21st Century improvements.   Primary care case management, medical homes, electronic medical records, disease management, coordinated care and other initiatives aimed at improving the quality of care for Medicaid patients and controlling costs are all in effect or on the drawing board in Illinois and elsewhere. 

Medicaid just marked its 46th birthday. We think it has improved with age. And as we sing at the end of the birthday song, “Happy birthday to you—and many more.”



Illinois General Assembly Taking on Immensely Important Task: Creating Competitive Health Insurance Marketplace

Hospital sighnThe stage is set for the Illinois General Assembly to complete one of the most important tasks of its members’ legislative lifetimes: creating the competitive health insurance marketplace (officially called the Illinois Health Benefits Exchange) to begin operations in January 2014.

Recently enacted Illinois Public Act 97-0142 calls for the creation of a 12-member Legislative Study Committee tasked with reporting to the General Assembly and the Governor by September 30, 2011, on implementation and establishment of a centralized marketplace where individuals and small businesses can shop for affordable health insurance, qualify for public subsidies to purchase insurance, or be enrolled in public programs (Medicaid or All Kids). The full General Assembly will take up the Exchange legislation during the fall veto session, which begins October 26. 

The leaders of the General Assembly should immediately appoint members to the Study Committee—legislators who understand that establishing this marketplace is extremely important to millions of Illinois residents (including the 1.7 million currently without insurance) and small businesses.

Once appointed, the Study Committee members need to educate themselves on what the different and better world of health insurance will be like in 2014. For starters, they need to recognize that by 2014 (sooner in some cases) due to insurance market reforms required by the federal Affordable Care Act, all health insurance companies must:

  • offer insurance to all applicants (no rejections  due to health status or pre-existing health conditions),
  • set rates based on applicants’ age, geographic location, and smoking status (no charging women or sick people more),
  • spend most of the premiums they collect on health care, not on administration, and
  • cover preventive health services with no deductible or co-payments, cover care in approved clinical trials, and have no lifetime or annual limits on coverage.

Come 2014, most Americans will be required to have health insurance; that means some 25 million new customers for insurers. The federal government will subsidize the purchase of insurance by people under 400% of the Federal Poverty Level (that’s $43,560 per year for one person and $89,400 for a family of four), and all citizens (and some non-citizens) with incomes under 133% of the Federal Poverty Level will be eligible for Medicaid. Insurers will be able to put their energies into competing by offering the best value and highest quality to customers rather than into avoiding insuring people with health problems, rescinding coverage, or not renewing policies when people file insurance claims.

Study Committee members also need to recognize that the Exchange is about both private health insurance and public health insurance programs. On the private insurance side, the Exchange needs to make it easy for individuals and small businesses to compare health plans, find out if they are eligible for subsidies, and enroll in a health plan that meets their needs. On the public side, the exchange needs to screen people seeking health coverage for eligibility for Illinois public health programs (Medicaid and All Kids), verify their eligibility, and enroll them and reach out to those newly eligible for Medicaid.

Committee members need to understand what the U.S. Department of Health and Human Services (HHS) expects from and offers to the states regarding exchanges, most of which is set out in the newly issued proposed rules announced by HHS head, Kathleen Sebelius, on July 11, 2011.

The Study Committee members also need to get up to speed on the substantial work already done or in progress in Illinois.

First, they need to review the Illinois Health Care Reform Implementation Council Initial Report (March 2011). The Implementation Council, established by Governor Quinn, was comprised of the heads of the several Illinois state agencies responsible for various aspects of federal health reform. In 2010 and early 2011, it held meetings around the state to hear from legislators, medical providers, individuals, and organizations on how to best implement the federal reforms, including the Exchange. The report contains detailed recommendations regarding the Exchange (most importantly, that Illinois establish its own Exchange as a quasi-governmental agency with power to negotiate with insurers and require them to compete on price and quality to sell on the Exchange), with accompanying discussion and summaries of the positions of various interests.

Second, they need to examine carefully Illinois Senate Bill 1729, the Illinois Health Coverage Exchange Act. It was the product of months of Department of Insurance-convened open meetings of five stakeholder working groups (patient and family advocates, employers, insurers, providers, and insurance agents). These groups met separately and then together on the key issues of Exchange governance options, operating models, and financing options. S.B. 1729 was based on all that thoughtful input. Study Committee members should also visit the Illinois Department of Insurance’s website pages on Health Insurance Reform, where they will find much important background information on Exchanges and statutes from other states.

Third, on the public programs side, the Department of Healthcare and Family Services (HFS) is moving ahead in developing the automated processes for screening people for eligibility for Medicaid and All Kids, verifying their eligibility, and enrolling them in the appropriate program via the Exchange. The Study Committee needs to invite HFS Director Julie Hamos to give a detailed briefing on those activities.

Finally, the Study Committee can learn from other states that are going down the same road—some far ahead of Illinois.

The Study Committee should take advantage of all these existing reports and resources and should use its approximately 10 weeks to drill down into the issues, perhaps by inviting recognized experts to meet with it to answer questions members may have and debate various options. And, of course, it should allow the public to describe their needs and express their opinions. 

What it should not do is start from scratch, ignoring the work of the Council, the state agencies, and the input of the hundreds of individuals and organizations who already have participated in good faith in earlier processes.

Its September 30 report should aim to educate the entire General Assembly about the importance of this competitive health insurance marketplace. It should be based on facts and sound economic and policy analysis, should explain the reasons for the policy choices that underlie its recommendations, and should include any substantial conflicting evidence, so that General Assembly members can have a full and fair understanding of the choices they will be making in passing Exchange legislation.


Unwise Illinois Policy Proposals Blocked - Little or No Impact on Illinois Budget

Doctor VisitTwo minor features of the Illinois Medicaid Reform law that passed last January required approval from the federal Medicaid agency, Centers for Medicare and Medicaid Services (CMS), before they could be implemented. They were to be effective on July 1, but on June 24, CMS denied permission for Illinois to implement the changes. The proposed changes would have called upon applicants for the program to provide pay stubs for a whole month’s income instead of just one paystub (the current policy), and it would have required cumulative paper evidence of Illinois residence in addition to the applicant’s sworn statement under penalty of perjury (the current policy). Current policy also calls for rigorous electronic monitoring of both income and residence and full authority to demand additional proofs if any questions arise. 

While there is anecdotal evidence that there are instances of beneficiaries receiving Medicaid coverage based on incorrect income or residence information, there was never any evidence that significant savings would be gained by implementing the proposed changes. Indeed, there was never any evidence that savings, if any, would exceed the undeniable cost of administering the new policies. Implementation would have demanded new document-processing capacities, changes in notices and computer settings, and more staff.

In fact, the Illinois General Assembly, perhaps forgetting that it had previously mandated these new staff and operations-intensive Medicaid policies, slashed funding for staff and operations in the recently enacted budget. That budget decision would have made successful implementation of these new policies very difficult, if not impossible. The CMS denial of permission to implement the changes relieves Illinois Medicaid officials of having to launch a futile and distracting attempt to implement with no resources.

For several reasons, the proposed policies are counter to the smart trends in Medicaid policy indicated by research, best practices, experience in the leading states, and policy directions in the reform law. It is not cost-effective to administer the program through staff-heavy, old fashioned welfare bureaucracy. There are excellent electronic tools that accomplish good accountability and fraud prevention. Indeed, this is one of the main reforms in the Illinois Medicaid Reform law and a much more promising direction than the old-fashioned measures that CMS prohibited.

What policies like those CMS prohibited accomplish in terms of “savings” is mostly the denial or delay of coverage to eligible people, through red tape, understaffing, and mistakes. This blocks a major cost-saving theme of both the federal and state reforms–primary care, prevention, and early diagnosis. Those are the types of care facilitated by insurance coverage. Without coverage, people must wait for care until their conditions are acute, and they must go to the emergency room or be hospitalized. That is a bad health outcome, and it costs money. Senator Kirk has been quoted claiming that CMS’s action will cost Illinois $800 million over six years. That is clearly not the case. CMS’s action is likely to save Illinois money.

 Finally, this is not a story of “Washington bureaucrats”. CMS was not making a judgment call, but carrying out the will of Congress. In the health reform law, Congress placed a high value on stability in the Medicaid program during the reform process, and provided that states may not cut back the eligibility and services features of their Medicaid programs during reform (which will see a massive infusion of federal funds for Medicaid in the coming years).

The two provisions that Congress blocked in this instance were very minor details in the Illinois Medicaid reform law. The three major themes of that law–care coordination, long-term care rebalancing, and expansion of information technology to improve and streamline the eligibility process and prevent fraud–are proceeding steadily towards implementation.


Study Highlights Importance of Improved Medicaid Program

Child visiting the doctorOn June 17, Dr. Karin Rhodes and her colleague Joanna Bisgaier of the University of Pennsylvania released a report on access to subspecialty doctors by children covered by Medicaid in Cook County, Illinois. The authors also published an article about the study underlying the report in the New England Journal of Medicine

Dr. Rhodes undertook and was paid for the study pursuant to a contract with the Illinois Department of Healthcare and Family Services, the state’s Medicaid agency. The study was part of the department’s compliance with a 2005 consent decree in the case of Memisovski v. Maram, which followed a 2004 federal district court ruling that the state was not in compliance with Medicaid Act requirements that children receive recommended levels of preventive care and treatment of diagnosed conditions, and that they receive care at least to the same extent as children covered by other forms of insurance. 

Following the consent decree in Memisovski, Illiniois has undertaken very significant reforms of the primary and preventive care system for children on Medicaid. It improved the rates paid for office visits to primary care doctors and dentists, and it held the processing time for those services to a reasonable level, even during the recession (when all other state bills were being delayed for many months). It launched a statewide “medical home” initiative designed to match children up with primary care doctors, which has had considerable success. Other strategies to improve primary care have been launched, and the overall effort continues.

The consent decree was less specific with respect to access to specialty care to diagnose conditions or especially to treat diagnosed conditions. It provided that the department undertake a study to examine the extent of access problems, and it left the remedies for any such problems to be determined after the study was completed. However, Illinois was not idle on this front. It enacted a round of rate increases for some pediatric specialists, and it included children in a disease management program for people with chronic illness. 

The study released last Friday, however, shows that there is a very serious problem with access to specialty care for children covered by Medicaid and other public insurance, particularly as compared to children covered by other forms of insurance (mostly employer-based private insurance). Using a “secret shopper” methodology, the investigators posed as parents seeking care for a child, saying in one call that the child’s coverage was Medicaid and in the next call that the same child’s coverage was Blue Cross Blue Shield PPO (which dominates the market in Illinois). The Medicaid-covered children had very significant disadvantages for almost all sub-specialties in both the ability to get an appointment and in the waiting time for the appointment if it was granted. The one exception was psychiatric care, where there was a severe access problem regardless of type of insurance. 

At the time of the original court order and consent decree, Illinois authorities were dealing with an inherited problem resulting from decades of underfunding and neglect of access issues in the state’s Medicaid program. They have been working to comply with the decree and improve the program, in spite of the grinding recession-driven budget crisis in the state. Representatives of the children in the case look forward to working in cooperation with state authorities to find and implement solutions to these newly documented problems with specialty access. 

Meanwhile, the study has resulted in media coverage, and some commentators are attempting to use it to bolster current attempts by conservatives to cut spending on Medicaid or relieve states of the duty to comply with Medicaid’s federal rules guaranteeing children access to all needed care. Medicaid is not “broke”; it is underfunded. The underfunding causes it to fall short on its ability to deliver the kinds of quality health care that, over the long term, would save money by supporting healthier people. And Medicaid is not “broken”; it is falling short of its full potential. It provides plenty of essential health care to millions of children, working adults, people with disabilities and seniors. Cutting them off of Medicaid would hurt them immeasurably. And starving the program of funds would only exacerbate the problems with access and the efforts to expand the health care workforce needed to provide adequate care to all beneficiaries. Just because there are flaws in the program does not mean the program must end for millions of beneficiaries. If we scrapped every governmental program that has flaws that need fixing, where would the armed forces, roads, or schools be? Medicaid is essential, but it can and should improve, especially on this issue of access to needed care.   


Affordable Health Insurance Is On Its Way

StethoscopeIn 2014, health insurance marketplace exchanges will be up and running in every state across the United States. As a major part of the Affordable Care Act (ACA), these exchanges will provide an easy and consumer-friendly place for people to find and buy affordable health insurance. Perhaps the best feature of the health insurance exchanges is the federal assistance that will be offered through tax-subsidies and cost-sharing to individuals and families to help pay for insurance premiums and out-of-pocket expenses. People with household incomes less than 400 percent of the federal poverty level, or $74,124 for a family of three, will qualify for the subsidies and out-of-pocket help in the exchanges.

Looking ahead to 2014, authors of a recent study released by The Commonwealth Fund set out to see just how affordable health insurance might really be once these insurance marketplace exchanges are up and running. Using survey data, the authors determined how much “room” people have in their budgets, after covering costs of household necessities, to determine whether the federal tax-subsidies and cost-sharing offered in the exchanges will actually create affordable coverage options for most Americans. The results were cause for cautious optimism.

According to the study, an overwhelming majority of individuals and families will be able to find affordable health insurance in the 2014 exchanges. Thanks to those premium tax subsidies and help with out-of-pocket costs, around 90 percent of households will have enough room in their budgets to pay for the health insurance they need. This is promising news for folks struggling with the burden of run-away health care costs and a private insurance market too expensive to enter.

As to the remaining 10 percent who may not be able to find affordable health insurance, the study’s authors point out three major factors worth addressing: out-of-pocket health care costs, family structure, and place of residence.

The authors predict that high out-of-pocket costs will be the most common reason why some people will run out of money to pay for their medical bills. High out-of-pocket costs double and sometimes nearly triple the percentage of households that can’t afford to meet their health care needs. Because of the way the cost-sharing structure is set up in the exchanges, the financial burden of high out-of-pocket costs will hit individuals and families with household incomes from two to three times the federal poverty level the hardest. These are households with $37,060 to $55,590 annual income for a family of three. Unless states address this when creating their exchanges, one in four families in this income range with high out-of-pocket costs will not have enough money left in their budget to cover their health care expenses.

Family structure is also a significant factor in determining affordability of health insurance on the exchanges. When looking at family size, the study reveals that single individuals, compared to childless couples and families, have less room in their budgets to pay for health care. Regardless of income level, single individuals may find themselves unable to pay for their health care more often than childless couples and families in the 2014 exchanges.

Geography plays a role as well. The study’s authors pooled the states into three different categories: high cost of living, middle cost of living, and low cost of living. It turns out that households in higher-cost states have less room in their budgets for health care than households in lower-cost states.  So, for instance, a family of two making $22,068 a year will find health insurance less affordable in a high-cost state like California when compared to a low-cost state like Oklahoma.

States can address all of these factors when setting up their exchanges. They can give exchanges an active role in finding and negotiating health plans with insurance companies so that the coverage options offered are of the highest quality and at the lowest prices. They can create strong conflict-of-interest rules so that the decision-makers in the exchanges have the public interest at heart rather than profit. They can pass laws making the rules for insurance companies inside and outside of the exchanges the same so that the exchange marketplaces can attract enough insurers and consumers to offer competitive and affordable insurance plans. With rules like these in place, most people will be able to find affordable health insurance, giving our families and our children a real chance for healthy futures.

This blog post was coauthored by Rachel Gielau.



Medicare Improving Fast

Helping Senior Citizen WalkThere is an intense debate over Rep. Paul Ryan’s (R. WI) proposal to scrap Medicare and turn it into a voucher program shifting costs to seniors, a debate that became even more intense when it was passed by the Republican-controlled House of Representatives. The Senate has not passed it, and the President has registered his opposition. The American people are also firmly opposed

But that debate has taken news focus away from the substantial improvements to the Medicare program that have been accomplished in just the last year under the Affordable Care Act, with more improvements soon to come. Costs are lower and care is better for seniors all over the country.

Here is what happened in 2010 and is about to happen in 2011 in Medicare under the Affordable Care Act. The numbers apply to Illinois, but the same impact is happening everywhere in America.

  1. Prescription drugs are more affordable. In 2010, 152,170 Illinois residents hit the Medicare prescription drug “donut hole” and received at $250 rebate check to defray their costs. Across the state, this came to $38 million in savings for seniors. In 2011, everyone in Illinois who hits the donut hole will receive a 50% discount on their brand name and generic prescription drugs. As of March, Illinois Medicare beneficiaries who had triggered into this benefit were getting about $800 a month in savings.
  2. Preventive services are free. In 2010, when this section of the new law had not yet taken effect, Medicare charged co-pays for preventive services like mammograms and other cancer screenings. In 2011 all of the 1.9 million Medicare beneficiaries in Illinois now get all recommended preventive services with no out-of-pocket costs.
  3. The annual checkup is free. In 2010, when this section of the new law had not yet taken effect, Medicare charged a co-payment for the annual checkup. Starting in 2011, Medicare beneficiaries can go to an annual wellness visit with no out-of-pocket cost. As of April 20, 17,508 Illinoisans have had a free wellness visit. 
  4. Premiums are lower. Under the new law, in 2010 Medicare Part B premiums were nearly $8 less per month than projected by the Medicare trustees. In 2011, the premiums are almost $5 less per month than projected by the Medicare trustees. The lower premium translates to $107 million in savings for Illinois Medicare beneficiaries in 2011.
  5. Medicare Advantage. In 2010 and 2011 all beneficiaries still retain the option of joining a Medicare Advantage plan if they so desire.

This is a story typical of many things in the Affordable Care Act. Improvements to the system are constantly rolling out, but the general public remains unaware of them. In part, this is because the subject matter is complex and hard to absorb unless you are directly affected. And in part it is a deliberate strategy of the opponents to keep the focus elsewhere and downplay the accomplishments of the law as they endeavor to repeal it and roll back its benefits. The intense reaction to Rep. Ryan’s proposal shows that at least the people directly affected – seniors who depend on Medicare – are well aware of the increasing quality of their program. 

An earlier version of this blog post inadvertently referred to Rep. Paul Ryan as "Jack" Ryan.  This has been corrected, and we apologize for the mistake.


Proposed Rule Would Ensure Access to Medical Care While Preserving States' Flexibility to Set Rates

For decades, the federal Medicaid law has provided that the states, in return for the billions of federal dollars they get for the program, must arrange the program in a way that ensures that Medicaid beneficiaries will be able to gain access to the medical care they need. This includes the issue of the rates that the program will pay to providers of healthcare services (doctors, hospitals, pharmacies, etc). States have great flexibility to set rates, but they must also pay attention to the impact that the rates have on access to care. 
In the budget crisis prevailing in virtually every state, many states have begun to look to rate-cutting in their Medicaid programs. The federal Medicaid agency, noticing this trend, has issued proposed regulations reminding states that they continue to be responsible for assuring access to care, and that they must consider this obligation in their rate-setting decisions. As part of their overall assault on Medicaid, Republican governors and members of Congress plan to fight these proposed regulations, claiming (wrongly) that they represent a new federal assault on state "flexibility". 
In fact, states have ample flexibility under Medicaid, including the flexibility to cut rates under some circumstances. But they also have a decades-long responsibility to assure access to care. There is nothing new in the proposed regulations--every state knew about this responsibility before it accepted billions of federal Medicaid dollars. What is new is the assertion that governors who accept billions in Medicaid dollars should the have "flexibility" to arrange the program so that people are denied healthcare and end up in more expensive emergency rooms. 
The drive for Medicaid "flexibility" is in fact a drive to provide less health care to fewer people. You save money by providing less care--not rocket science, but not good policy either. It is also not much of a rallying cry, hence the paper-thin coat of "flexibility" paint that is being applied to it.   

Experts from the National Senior Citizens' Law Center exposed the flimsiness of this argument in a blog for the American Constitution Society yesterday.

Illinois Needs a Competitive Health Insurance Marketplace--SB 1729 Will Establish One

Health Care for AllThe Illinois General Assembly has a lot of contentious, difficult, and time-consuming items on its 2011 agenda—the state budget, pensions, workers compensation to name a few.

But one item—passage of legislation establishing a competitive marketplace for health insurance where everyone will be able to find comprehensive coverage that is affordable—has already been researched and debated and is ready for a quick decision.

SB 1729, the Illinois Health Coverage Exchange Establishment Act of 2011, is the product of months of work by the Illinois Health Care Reform Implementation Council followed by open and robust discussions about the bill’s components and language in stakeholder working groups of patient and family advocates, employers, insurers, providers, and insurance producers convened by the Illinois Department of Insurance. SB 1729 is s sponsored by Senator David Koehler and, as of April 11, 2011, 13 other senators.

SB 1729 creates a marketplace in which individuals and small businesses can shop for high-quality, affordable health plans and individuals and families of modest means can enroll in public programs, such as Medicaid or All Kids, or obtain federal subsidies to purchase private health plans. Under the bill, this marketplace, officially called the Illinois Health Benefits Exchange, will be an independent body, governed by a nine-member board representing health care consumers, providers, small businesses, employees, labor, and insurance producers, who are appointed by the Governor and Attorney General, subject to confirmation by the Senate. Strong conflict-of-interest rules will keep board members focused on the public good, not narrow interests.

The Illinois marketplace needs to be up and running by January 1, 2014, when many of the federal Affordable Care Act insurance reforms (including no denials for pre-existing conditions and premium prices based only on age, geography, and smoking status and not on health condition) and expansions of coverage for lower income individuals go into effect. Illinois needs to have made substantial progress toward establishment of its marketplace by January 1, 2013, or the federal government will run it for Illinois.

SB 1729 will put Illinois on the road to having an effective exchange operational by 2014 and will allow Illinois to receive $150-200 million in federal funds for implementation. A competing bill, HB 1577, was drafted without any public input, lacks a governance plan, totally ignores the public program side of an exchange, makes preemptive decisions on insurance offerings, and delays Illinois’s progress toward establishing a health insurance marketplace that truly serves Illinois’s small businesses, employees, individuals, and families well.

Those interested in the future of affordable, comprehensive health coverage in Illinois should call their state senator and ask him or her to support SB 1729 and even become a sponsor. Call 1.888.616.3322 (AARP’s health line) to reach your senator.


Happy Birthday Affordable Care Act

Happy BirthdayAmerica’s health care law, the Affordable Care Act, turns one year old on March 23rd. That’s good news for Illinois’s four-year-olds—and forty-four-year-olds, and lots of other Illinoisans too. That’s because the law imposes consumer protections on the hugely unregulated health insurance industry, and promises to cover over half of the uninsured by allowing states to create insurance marketplaces that provide transparent, comprehensive, affordable health plan choices, makes federal subsidies available to ensure middle-class families won’t break the bank to pay for their plans, and expands Medicaid to low-income adults.

Illinois’s leaders have worked hard to build a track record of success on access to health insurance coverage. Democrats and Republicans have put partisan politics aside and worked together to reform Medicaid and to enact consumer protections in the private insurance industry, such as dependent care coverage for young adults. Now it’s time for our leaders in Springfield to again make some critical decisions—this time about how the Affordable Care Act works in Illinois. And we all have a role in ensuring that the law works for Illinois’s families and individuals.

The Affordable Care Act has already delivered important wins for Illinois’s residents. Illinoisans diagnosed with cancer or other serious conditions can no longer be denied care because of annual or lifetime insurance limits and insurers cannot deny coverage outright for children. Parents can keep their college-age children on their family health insurance policies. And Illinoisans with private insurance can get the screenings and check-ups they need to stay healthy, without the out-of-pocket costs that encourage fix-it care instead of health care.

And the Affordable Care Act can deliver even bigger wins for Illinois in the coming years. It authorizes new insurance marketplaces or “exchanges,” to make private insurance work better. Exchange subsidies can make care more affordable for middle-class families. The law authorizes improvements to Medicaid that can make health care a reality hundreds of thousands more Illinoisans who are uninsured today.

But these gains for Illinois’s families and individuals are not automatic. Our leaders in Springfield will make decisions over the next few years that will have consequences for decades to come. They will decide whether Illinois’s exchange provides adequate access to health care for patients, families, and employers in Illinois in a manner that is in the best interest of such individuals, and they’ll decide whether the exchange offers coverage parents can afford.

They’ll decide whether insurance consumer protections actually work and whether Medicaid reaches more uninsured Illinoisans, or whether these individuals will be left behind. And they’ll make dozens of other decisions that will determine how—or even if—the Affordable Care Act works for Illinois.

Every Illinois resident who cares about access to health care can help our leaders in Springfield make the right choices. Policymakers need to hear that it’s time to embrace Illinois’s long-standing tradition of putting access to health care ahead of partisan politics. They need to hear that the cost of failure is too high. They need to hear that they must keep implementation moving forward, and that making the right choices for Illinoisans is the best way to define success.

The Affordable Care Act’s first birthday is the perfect time to send a strong message to Illinois’s leaders. If we get off the sidelines and into the game today, Illinois will be the big winner.


Class Action Challenging Medicare Improvement Standard Moves Patients Closer to a Civil Right to Live at Home

Elderly ManMost of us hope that if we become injured, disabled, or too old to care for ourselves, we will be cared for at home. Many studies suggest that it is more cost-effective to care for people who are disabled and elderly in their homes rather than in nursing homes, and advocates for these populations often discuss an emerging civil right to remain at home. Unfortunately, as a class action filed in the District of Vermont on January 18, 2011, by the Medicare Advocacy Project of Vermont Legal Aid and the Center for Medicare Advocacy makes clear, false hurdles are erected throughout the Medicare system that make it difficult for patients to receive care in their homes.

Under the United States Supreme Court’s 1999 ruling in Olmstead v. L.C., patients in nursing homes and other institutions who can safely and appropriately live in their communities are entitled to do so. Finding appropriate service providers and obtaining Medicare coverage remain challenging for many patients, however, and one of the main impediments standing between patients and living at home is the Medicare improvement standard.

As Gill Deford, Margaret Murphy, and Judith Stein of the Center for Medicare Advocacy discussed in their January-February 2010 Clearinghouse Review: Journal of Law and Policy article, How the “Improvement Standard” Improperly Denies Coverage to Medicare Patients with Chronic Conditions, Medicare beneficiaries with chronic conditions who need skilled care—including home health care—are often improperly denied care because of the myth “that coverage of skilled care requires a beneficiary to be improving.” Under this “phony coverage standard” that appears nowhere in the Medicare statute or its implementing regulations, Medicare recipients suffering from a wide array of physical and mental impairments are denied the nursing care, physical therapy, occupational therapy, and speech therapy that they need to remain stable and avoid further deterioration. This standard is routinely applied to Medicare recipients living in hospitals and nursing homes, as well as those who live independently, even when their doctors make it clear that skilled care is necessary to keep the patients from deteriorating. The problem stems, in large part, from unclear Medicare manual provisions that are sometimes more restrictive than the actual regulations, as well as from ongoing confusion regarding the difference between “skilled care,” which is covered by Medicare, and “custodial care,” which is not.

A new class action, Jimmo v. Sibelius, was filed against the U.S. Secretary of Health and Human Services on January 18 by five individual plaintiffs and five national organizations, including the National Multiple Sclerosis Society and Paralyzed Veterans of America. The plaintiffs brought the suit on behalf of a nationwide class of Medicare beneficiaries who have been or will be harmed by the improvement standard. The suit challenges Medicare’s continued use of the improvement standard to deny benefits to Medicare recipients with chronic conditions. The plaintiffs specifically argue that the improvement standard is not included in Medicare law and regulations and, therefore, should not be a consideration when decisions are made about patients’ benefits. (An amended complaint, adding the Alzheimer’s Association, United Cerebral Palsy, and a sixth individual beneficiary as plaintiffs, was filed on March 3).

Jimmo v. Sibelius follows a recent flurry of legal and regulatory activity around the Medicare improvement standard. First, in the fall of 2010, two federal courts examined and rejected the improvement standard. As Robert Pear wrote in the New York Times, federal judges in Pennsylvania and Vermont held that “skilled care may be reasonable and necessary and covered by Medicare even if the person’s condition is stable and unlikely to improve.” The plaintiff in the Pennsylvania case, Papciak v. Sebelius, resided in a nursing home, where she received skilled nursing care, physical therapy, and occupational therapy following hip replacement surgery. Medicare eventually denied coverage for these services, however, because she had “made only minimal progress in some areas, had regressed in other areas, and had been determined to have met her maximum potential for her physical and occupational therapy.” According to Medicare, plaintiff’s lack of improvement meant that plaintiff was receiving “custodial care,” not “skilled care.” By contrast, in Anderson v. Sebelius, the plaintiff was receiving home health services to stay stable after her second stroke and address a variety of other health problems, including hypertension, slurred speech, and type II diabetes. Medicare ultimately denied her coverage as well, claiming the services did not meet Medicare’s coverage criteria. In both cases, albeit in slightly different language, the judges held that Medicare improperly relied upon whether or not the plaintiffs had the potential to improve when denying them coverage. (Coincidentally, the same judge who issued the Anderson decision will preside over Jimmo.) 

Next, on January 1, 2011, new Medicare regulations promulgated by the Centers for Medicare and Medicaid Services became effective. As the Center for Medicare Advocacy announced, the new rules make it clear that “skilled care does include services that are intended to maintain a person’s condition and that no ‘rules of thumb’ should be used to deny care—including rules that require restoration potential.” The new regulations state that decision-makers should review “accepted standards of clinical practice and . . . consider whether a professional is needed for the service to be safe and effective for the particular beneficiary.” Patients and their advocates should not be overly optimistic about the new regulations, however. As Gill Deford noted in a press release about the Jimmo class action, the new regulations are meaningless if service providers ignore them. Deford said “[w]hile we thank CMS for their recent clarification of Medicare coverage for home health services—including physical therapy, occupational therapy and speech-language pathology services—the clarification does not undo conflicting policies and practices.”

Ironically, as Dr. Nicholas LaRocca of the National Multiple Sclerosis Society stated in the Center for Medicare Advocacy press release about the Jimmo case, Medicare’s denial of benefits for services such as home health care and physical therapy can end up being more expensive for the government than providing appropriate therapeutic care. These types of services “help avert physical and cognitive deterioration or maintain optimal functioning,” Dr. LaRocca said. “This deterioration often leads to more intense, more expensive services, hospitalization or nursing care.”

Hopefully, the Jimmo class action will put an end to the use of the improvement standard and move America’s elderly and disabled one step closer to a civil right to live at home. If you, a family member, or a client has been denied Medicare coverage because your health condition is not improving, you may have been denied coverage unfairly. For information about your Medicare rights, contact the Center for Medicare Advocacy at:


A Birthday for America's Children's Health Law, With the Gift of Health for Illinois's Kids

Kid and doctorIt’s been two years since Congress and President Obama enacted legislation to strengthen the Children’s Health Insurance Program, known here in Illinois as All Kids. And at this birthday party, Illinois’s families no longer have to wish and hold their breath when they blow out the candles. 

The children’s health law has helped Illinois cover more uninsured children through All Kids. As a result, 1.6 million children can get the checkups and preventive care they need to stay healthy and see the doctor when they get sick or injured.

That means parents struggling to keep their families afloat during tough economic times can have peace of mind that a playground injury or flu outbreak won’t drive the family deeper into debt. It means Illinois uses health dollars wisely – keeping kids healthy, rather than spending more on emergency room care for problems we should have prevented. And it means Illinois’s federal tax dollars come back into our economy, to protect local health care jobs.

Help us to celebrate this important anniversary. Thank your representatives in the General Assembly in Springfield for their continued support of All Kids and let them know that maintaining coverage for children should continue to be a top priority this year. Spread the word to parents and others in your community about All Kids, so we can help even more uninsured children to get the care they need to grow and thrive.


Extremist Florida Judge Rules Against Affordable Care Act

GavelThe Social Security Act, the Voting Rights Act, the Civil Rights Act and the Minimum Wage Act were all landmark laws that changed our country for the better. They secured essential freedoms for all Americans and improved our quality of life. All were initially struck down by lower court judges unwilling politically or unable intellectually to embrace the fact that our Constitution permits that kind of progress. An activist conservative lower court federal judge in Pensacola, Florida, has now made his contribution to this history.   

U.S. District Judge Roger Vinson ruled this week that the Affordable Care Act’s (ACA’s) provision requiring most Americans to obtain private health insurance, or else face a modest tax penalty, was unconstitutional. He is the only judge who has adjudicated challenges to the law to be so aggressively activist as to strike down the whole law. Unlike the other judges who have ruled the “individual mandate” to be unconstitutional, Judge Vinson went further and held that the individual mandate was so intertwined with the rest of the law that it could not be “severed” from it, and so he invalidated the whole law.

The Justice Department immediately announced that it plans to appeal the decision to the U.S. Court of Appeals for the 11th Circuit. The score in the cases now stands as follows: 13 challenges have been filed in federal courts since March 23, 2010; ten suits have upheld the law, and three rulings have found all or part of the ACA unconstitutional. So far, judges appointed by Republican presidents have ruled consistently against the ACA, while Democratic judicial appointees have ruled for it. And in the most recent case, all but one of the state officials who filed suit are Republican. 

At the heart of these lawsuits is the individual responsibility provision. This part of the ACA says that most individuals who can afford it will be required to obtain basic health insurance coverage or else pay a fee to help offset the cost of providing medical care to uninsured individuals. If affordable coverage is not available to an individual, he or she will be eligible for an exemption. The individual responsibility provision is an extremely important tool to help ensure that healthy people have health insurance policies, too; otherwise, only the sick or old may choose to have coverage, which would drive up costs for consumers and insurers alike. Every insured family pays an average of $1,000 more a year in premiums to cover the care of those who have no insurance, and the cost of uncompensated care was an estimated $43 billion in 2008.

Like the Virginia judge, Judge Vinson did not issue an injunction against the ACA’s implementation. Indeed, Judge Vinson rejected a constitutional challenge to the part of the ACA that will expand Medicaid in 2014 to individuals with household incomes under 133 percent of the poverty level. The plaintiff state officials had argued that this expansion unlawfully imposes on their sovereignty; however the Judge Vincent held that there is no infringement because a state can choose whether to participate in the Medicaid program.

Nevertheless, Judge Vinson’s ruling invalidating the whole law (as “un-severable” from the individual mandate provision) means that the 26 state officials who are plaintiffs in the case are in an ambiguous position as to whether they will continue implementation activities in their states. They might gamble on the ruling of this fringe judge holding up on appeal. Wisconsin’s governor, a highly partisan Republican, has said he will stop implementing the law. That is unfortunate for the people who live in Wisconsin and in any other state where a governor decides to exalt his or her ideology over the needs of the citizens that are being addressed by the ACA.

Americans—including lots of them who live in Wisconsin—cannot afford to lose the benefits already flowing from provisions of the Affordable Care Act that have nothing to do with the individual mandate, including discounts for seniors struggling with the cost of lifesaving prescriptions, tax credits for small businesses struggling to provide coverage for employees, protections for children who have pre-existing conditions, and coverage for young adults up to age 26.

In the midst of our nation’s jobs crisis, Americans are counting on the Affordable Care Act to put them back in control of their own healthcare, stop insurance company abuses, and lower escalating healthcare costs. Judge Vinson and at least some of the state officials in the case have other priorities.


Progress Made with Illinois Medicaid Reforms, But Policy Concerns Remain

Kid playing doctorIllinois’s legislators were hard at work this winter discussing ways to make changes to Illinois’s Medicaid program that would result in short-term savings. Members of Illinois House and Senate’s Special Committees on Medicaid Reform held hearings where representatives from the Governor’s office, the Illinois Department of Healthcare and Family Services (HFS), advocates, providers, and others offered ideas on how to save money by reforming the Medicaid program. Afterwards, the Governor’s office, HFS, and co-chairs of these committees drafted amendment 2 of H.B. 5420, which passed with bipartisan support and was signed into law January 25, 2011. The reforms contained in the new law are expected to save the state hundreds of millions of dollars. Some of these reforms are discussed below.

A few provisions of the new law make changes to the All Kids children’s health insurance program. Starting July 1, 2011, children in households with incomes over 300% of the poverty level (about $66,150/year for a family of four) will no longer be eligible for All Kids. If these children are already enrolled, they will be allowed to stay in the program for one year. Also, starting July 1, 2011, new applicants to the All Kids program will need to provide proof of one-month of income and to verify their Illinois residency. Enrollees in the All Kids and FamilyCare programs will need to recertify their coverage with HFS—to verify income and other eligibility information—in order to stay in the program. HFS will notify current enrollees of these changes within 90 days of the bill becoming law. These provisions changing the All Kids program may not align with national health reform, and it is not yet clear whether they will be approved by federal authorities, since they may implicate the maintenance of effort provision in that law, which applies to procedural changes. 

The new law also requires HFS to conduct an analysis of how All Kids determines eligibility and to submit reports in 2011 and 2012. The law also institutes a two-year moratorium on medical assistance program expansions beyond anything in place on January 1, 2011, with the exception of anything that would jeopardize the federal Medicaid match if it wasn’t implemented. Further, the law extends the sunset date of the bipartisan Covering All Kids Health Insurance Act —which authorized coverage for undocumented children and for those in households with incomes greater than 200% of the poverty level—by five years to July 1, 2016. The extension of the sunset is immensely important to promote the health and well being of Illinois’s children and will help Illinois to maintain its position as a national leader in covering kids.

Other provisions in the new law will improve upon Illinois’s existing information technology infrastructure to allow for data sharing among government agencies. For instance, these provisions will allow HFS and the Department of Human Services (DHS) to access records of other governmental agencies, such as the Social Security Administration, Illinois Secretary of State, Illinois Department of Insurance, and the Illinois Department of Employment Security, to verify eligibility information. These steps will help build a foundation for the enormous information technology infrastructure requirements necessary for the successful working of a state-based health insurance exchange marketplace. The eventual goal is a streamlined and simplified Eligibility, Verification, and Enrollment (EVE) electronic data-sharing system that will fully comply with the Affordable Care Act.

The new law also provides that by 2015, at least half of all Medicaid enrollees will be in a care coordination program—an integrated delivery system with providers that furnish or arrange for the majority of care, including primary care and referrals from those providers, hospital services, dental services, etc. Illinois Health Connect—Illinois’s existing primary care case management (PCCM) program—does not, in its current form, qualify. However, it may qualify at a later date if the PCCM program makes changes that define its services more comprehensively and assumes more risk on behalf of its enrollees. HFS will be required to report to the General Assembly from April 2012 until April 2016 on the progress and implementation of the coordinated care program initiatives.

Medicaid is the primary payer for long-term care, which covers a variety of services needed by people to live independently in the community, such as home health and personal care, as well as services provided in institutional settings, such as nursing homes. The new law makes changes to Illinois’s existing long-term care system to allow for the state to shift Medicaid long‐term services budgets to noninstitutional, community-based settings. The law provides the governor with the authority to redesignate a portion of funds set aside for institutional services to be transferred to community-based, long-term care programs. This reform represents an opportunity for Illinois to address the long‐term care needs of low‐income individuals with chronic and disabling conditions. The law’s provisions affecting long-term care rebalancing, enhancing care coordination delivery systems, and EVE can all be implemented in a way that aligns with parts of the national health reform law, and that they should be done that way.

The law will also make many changes to the way government monitors and enforces Medicaid fraud. It provides for a civil remedy to combat Medicaid fraud, which includes a financial penalty of up to $2,000 for each fraudulent claim for benefits or payments. Illinois will also be repaid 5% interest per annum on the value of benefits fraudulently received.  HFS’s Inspector General’s office will be required to report to the General Assembly 12 months after the law’s effective date on the number of fraud cases identified and pursued and the fines assessed and collected.

In sum, the new law makes progress in necessary areas, especially in implementing national health reform, but may not be best policy in others. The Shriver Center is supportive of many of the measures in the law, including the ones that have the most potential to reduce health care costs in constructive ways, such as long-term care rebalancing. We regret the changes to the All Kids program narrowing eligibility and increasing red tape. We urge the General Assembly to fully fund the staff needed to competently manage the increased bureaucracy. We are hopeful that when EVE is fully implemented, the red tape can be removed.


The Affordable Care Act Is Working! Turning Back the Clock Would Hurt Millions of Americans

Health Care for AllThe House of Representatives is going to vote on H.R. 2 and H. Res. 9, which would repeal the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as “the Affordable Care Act”). These two laws are already providing critically important benefits and protections for individuals and families across the country. Turning back the clock by repealing these vitally important laws would harm millions of Americans, and would once again allow insurance companies to put profits first

Repeal would allow unfair and discriminatory insurance practices to continue. Repeal would eliminate important measures that hold insurance companies accountable. Repeal would once again impose lifetime or annual dollar limits on covered services, or rescind insurance coverage when an individual gets sick. Repeal would allow insurers to deny women coverage if they’ve had a Cesarean section, breast or cervical cancer, or received medical treatment for domestic or sexual violence.

Repeal would allow insurance companies to continue to deny coverage to those with pre-existing conditions. Members of Congress are guaranteed access to health coverage even if they or family members have a pre-existing condition. The Affordable Care Act provides this protection for America's families. The ACA is already working to provide children with pre-existing conditions the coverage they need to grow up healthy. The repeal bill would take this right away from America's families--as many as 129 million Americans under age 65--while members of Congress keep it for themselves.

Repeal would make obtaining insurance more difficult and more expensive. The new law would give individuals and families the ability to find more affordable insurance options through the new exchanges to be established in 2014. Repeal would eliminate those opportunities for an estimated 54 million Americans, including the 15.9 million who are expected to enroll in Medicaid by 2019, and the families who would be eligible for tax credit subsidies to help with the cost of premiums and out-of-pocket costs. Members of Congress receive subsidies of almost three-quarters of their health insurance premiums--all paid by taxpayers. 

Repeal will make finding comprehensive health insurance more difficult. Too many Americans struggle to find health insurance that covers important health care services they need, like maternity and mental health care as well as prescription drugs. Repeal of the Affordable Care Act will eliminate the requirement that all plans sold to individuals and small employers cover these critically essential health benefits. Under repeal, adults would also lose free access to recommended preventive screenings. 

Repeal will eliminate critical tax credits for small employers, making it harder for them to provide insurance coverage for their employees. The Affordable Care Act provides critical tax credits to small employers that help them provide health insurance to their employees. And, the ACA will offer small employers new options to find affordable coverage when the exchanges are operational in 2014. 

Repeal will eliminate many additional provisions providing important benefits to families, including extending dependent coverage to children up to age 26 and prohibiting insurers from requiring pre-authorization for emergency room care or for women to get a referral to see their ob/gyn.

The Affordable Care Act is working! The law preserves what works while giving Americans the freedom to change jobs and the security of knowing they won't lose their homes because someone in the family got sick. Repeal will turn back the clock on important progress and cause real harm to real families struggling everyday to ensure comprehensive affordable health care coverage. Repeal would destroy 250,000 to 400,000 jobs annually over the next decade by reducing the share of workers who start new businesses, move to new jobs, or otherwise invest in themselves and the economy. And the Congressional Budget Office’s preliminary analysis of the effects of the bill estimated that repeal would increase the deficit by $230 billion from 2012 to 2021. 

Call your congressperson today to urge them to vote against repeal! Call toll free: 1-866-922-4970


Illinois Wins Millions in Federal Performance Bonus to Reward Cutting Red Tape in Connecting Children to Health Care

This week, Illinois received national recognition from the U.S. Department of Health and Human Services for the exceptional strides it has made in covering children. As part of this recognition, Illinois was rewarded a $15 million performance bonus. Illinois is one of the top 15 states in the country at cutting government waste and making taxpayer dollars go further to protect the health of Illinois children.

Research shows that the best results for children’s health and for the most efficient use of public funds are accomplished by quickly connecting children to preventive health care and then making sure that care is not interrupted. The Illinois performance bonus is a tribute to the public servants in our state who work every day to make the Illinois All Kids program function in this smart and effective way for Illinois children. In so doing, they make government work better and more efficiently for all Illinoisans.  

All Kids has had bi-partisan support from its beginning in Illinois, including the minimizing of bureaucratic red tape. Until now, leaders on both sides of the aisle have been committed to the effort to help families get the best kind of health care for their children, through coverage, quick connection to preventive care, and continuity of care. This is not only the best way to achieve good health outcomes for the children and to accomplish short- and long-term savings on their health care, but it has now also generated two years of federal performance bonuses (Illinois received $9 million last year). 

We urge Illinois leaders to continue this successful course for All Kids use these well-deserved performance bonus funds to maintain this commitment and sustain this progress in securing Illinois children’s health. This is especially important during challenging economic times as families need the security of knowing that programs like All Kids are there for their children.

Andrea Kovach coauthored this article.



Three Studies Indicate That Health Reform Will Reduce State Budgets

States can relax a little about the impact health care reform will have on their budgets, particularly the large expansion of Medicaid. States have been made skittish about their state budgets because of structural deficits and recession-driven shortfalls. Thus, even the fact that the Medicaid expansion will be 100% federally funded for the first few years, and ultimately 90% federally funded from 2020 onward, has not been completely comforting. The states are nervous about predictions that some analysts have made that the implementation of national health reform will add difficult levels of new spending to their budgets. This has the potential to dampen states’ willingness and confidence to embark on aggressive implementation efforts. 

But the predictions of dire impact on state budgets are not accurate. At least three studies now estimate that health care reform will have a positive impact on state budgets, reducing spending in an array of areas to more than offset the marginal increase in state funds spent on Medicaid.

First, there is a very recent report issued by the Urban Institute (commissioned by First Focus), “Net Effect of the Affordable Care Act on State Budgets.” The report compares the increased costs states will experience due to the expansion of Medicaid coverage for low-income adults in 2014 with the savings states will realize from the law. The report takes into account savings that will come when states move people currently covered by Medicaid at income levels above 133% of the poverty level into the private insurance exchange, where the subsidies for premiums and co-pays are entirely federally financed. In Illinois, the FamilyCare program currently covers adults up to 185% of the poverty level with a 50% federal match. The Urban Institute’s report also takes into account the savings states will realize when new Medicaid beneficiaries no longer use uncompensated health care (mostly emergency room care) and state-funded mental health services.

The study does not take into account significant scheduled increases in the federal matching rate for Children’s Health Insurance or a variety of other health care cost savings that will be brought about under the reform law, but nevertheless it finds that state savings under the Affordable Care Act will exceed state costs by between $40.6 and $131.9 billion during 2014-19.

The Urban Institute study is consistent with earlier findings by the Council of Economic Advisers (CEA) and the Lewin Group that, on balance, states will realize significant net budgetary gains from the legislation. The contrary analyses, among other flaws, recognize or describe only state costs and not potential state gains.

The CEA report profiled 16 states, finding that each would experience net fiscal gains from the Affordable Care Act, totaling between $3 billion and $4 billion a year for all 16 states combined. The states were Arkansas, California, Florida, Idaho, Indiana, Iowa, Maine, Michigan, Minnesota, Nebraska, Montana, North Carolina, Oregon, Pennsylvania, Vermont and Wyoming.

The Lewin report found that, on balance, the Affordable Care Act will save states $106.8 billion during 2010-19, including $100.6 billion in 2014-19.


Americans Want Health Care Reform to Go Forward

StethoscopeSome people are spinning hard about the outcome of the recent mid-term elections. They are trying to say that the changes in Congress were a “mandate” to repeal health care reform. As usual, most of those spinners have little to say about how to resolve health care issues--for them health care is an ideological or political issue, not an issue of importance in everyday lives. It is a tactical issue in the beltway game, a ploy in the never-ending struggle for power and for special interest money.

But out here, when the issue is reduced to kitchen-table reality, people don’t think ideologically or politically. They think about their own health care, their families’ health care, and their own financial circumstances. 

Here are some numbers about health coverage and the election. 

Even on the ideological level on which they choose to operate, the spinners are wrong. The election result was driven by concern about the economy and jobs, not health care. According to a CNN exit poll, only 19% of voters named health care reform as their top concern--a distant second to the 61% of voters most concerned with the economy.

On the big abstract ideological question about support for the health reform law, the voters split down the middle: 48% say they support repeal and 47% say they want the reform law to stay the same or be expanded. Some mandate. 

Polls consistently confirm that, when the public hears truthful facts (as opposed to the other kind of “facts”) about the health reform law, they want the benefits and support health reform. The specifics of health care reform already help people in ways that matter deeply to them. Undoing health care reform would mean:

  • People would continue to be denied coverage or charged more for it due to pre-existing conditions.
  • People diagnosed with the particular pre-existing condition of being female would continue to be discriminated against in the cost of their coverage. The spinners would continue that outrageous discrimination. 
  • People would continue to have coverage dropped when they get sick.
  • People would continue to have lifetime caps on their insurance coverage.
  • Small businesses would continue to have to pay higher rates for health insurance than big corporations.
  • There will be no smart investment in prevention as the focus of our healthcare system--clearly the way to get both lower cost and better patient outcomes.
  • People would lose the comfort of knowing that, no matter what happens to their job, their health, or their family, there will always be access to affordable, decent coverage.  
  • Entrepreneurs would continue to experience the drag on their creativity and chances for success caused by the health coverage problems. And health coverage issues would continue to prevent would-be entrepreneurs from even getting started, stuck in their current jobs in order to retain insurance.

The post-election spinners stay far away from these real problems. The new law leaves the private insurance sector in place (a single-payer system would have ended it), but imposes fair boundaries on it. The spinners, scrupulously avoiding anything specific about how to address health coverage issues, instead simply call the new law names: “takeover,” “socialism.” But calling something a name is not the same as talking about it honestly--indeed, it’s a time-honored way to stifle full discussion. The health reform law is in fact a very promising public-private effort to address a problem that plagues American households everywhere. The spinners are wrong about the importance to real people of health care reform. When the focus is on the actual health coverage problems that plague American households, most Americans want their federal and state officials to get on with implementation--and do a good job of it.


Not Anymore! Consumers Can Have a Voice in Health Insurance Rates

StethoscopeMany Illinois consumers might be surprised to learn that health insurance rates are regulated (or not) on the state level. This was the case before the federal health reform law was passed earlier this year and, by and large, remains the case. Federal rate regulation was included in some early drafts of the law, but not in the final version. 

Over the next few years, Illinois consumers will benefit from many reforms enacted in the federal law that will bring to an end to some of the unfairness and excessive cost of the until-now unregulated Illinois insurance market. Illinois is the national leader in the number of rescissions—or retroactive cancellations of an insurance policy. Illinois companies can and do charge identically situated women more than men--as much as 57% more. Illinois law allows for individuals and families to be denied health insurance for any reason other than “race, color, religion or national origin.” Case in point: a widow was denied health insurance for herself and her three children because she attended grief counseling to help cope with her young husband’s death. Apparently grief is a pre-existing condition. All of these practices have changed or will change soon under the reform law.

The unchecked state health insurance market in Illinois will not change with respect to rates, however. Insurance companies have been able to increase health insurance premiums with little oversight, transparency, or public accountability because current Illinois law does not restrict health insurance rate increases. In contrast, residents of over half the states and the District of Columbia are protected, because their states have the statutory authority to reject a proposed increase that is excessive, lacks justification, or exceeds certain standards. 

This lack of authority has contributed to unfettered and unjustified premium increases. Health insurance premiums have doubled on average over the last decade, much faster than wages and inflation, putting coverage out of reach for millions of consumers and business owners.  Next year, Chicago workers can expect to pay 12.4 percent more in health insurance premiums and out-of-pocket costs for their health insurance, according to a recent study. And for Chicago employers, the average cost per worker will rise 8.7 percent, including employee contributions to premiums—the highest increase since 2006 and about the same as the national average of 8.8 percent. And if a small employer in Illinois has even just one injured or sick employee, the business can experience rate increases of greater than 50 percent when it’s time to renew. 

Further, a recent report from the Illinois Department of Insurance revealed that Illinois families and individuals have experienced striking base rate increases in their health insurance coverage, often greater than 30 percent since at least January 2005. How can these unchecked rate increases be stopped? Rate approval authority, through the Department of Insurance, has the potential to improve the performance, transparency and accountability of the health insurance market for employers and families. Illinois families trying to obtain financial security and peace of mind in their purchase of health insurance are entitled to have reasonable and fair premiums.

While federal regulation of health insurance rates was not part of the national health reform law, that law does provide a strong foundation for Illinois to start passing necessary insurance reforms at the state level for the almost seven out of ten Illinoisans (69%) who have private insurance policies. The Affordable Care Act provided Illinois a one million dollar grant to help Illinois set up a system of review and public information about rate increases, requiring the companies at least to publicly reveal their justifications for rate increases. Beyond improving public information, however, national reform did not give Illinois the power to deny or reduce rate increases (like it does for public utilities); only Illinois can do that. 

The Illinois Department of Insurance intends to pursue rate review authority, and consumers can and should help in this effort to put the breaks on unfair health insurance premium increases. Illinois consumers of health insurance, be they individuals and families buying their own coverage, employers buying coverage for their employees, or people covered through their work policies, need to start speaking up about the need for rate review authority in Illinois. They should tell their representatives in the Illinois House and Senate to pass strong rate review legislation now. And they also should speak out to the other interests involved here--their insurance brokers and the insurance companies, too. The message to all is the same: the time for rate review is now.


Health Care Reform Is Here!

Child Playing DoctorIt’s finally here.

Families across the country can breathe a sigh of relief now that we have reached a major milestone of the new health care law. Starting today, many of the provisions of the new health reform law go into effect! Because of the new law, families will no longer have to worry about their children being denied coverage because of a pre-existing condition (and starting in 2014, no one will have that worry), being dropped from insurance, or facing bankruptcy because of reaching the “lifetime limit” on insurance coverage and still needing expensive health care. Health plans don't have to implement the provisions until their next annual renewal date (so for plans that begin their coverage year on Jan. 1, 2011, that's when the changes will start). Thanks to the Affordable Care Act, the law is finally on our side!

However, some people have spread confusion about the new law. That’s why it’s so important that all of us to get the facts out about our new health care rights under this new law. We need to make sure our families, friends and neighbors understand how the new law will help them.

Take a look at the health care changes going into effect on September 23, 2010, and then send them along to your friends and family:

And if you want more information, visit or Families USA's summary of the new health reform law.

No More Getting Dropped After You Get Sick:  You can no longer be cut after the fact.

Free Preventive Care: New health insurance plans must provide preventive services such as mammograms and immunizations without patients paying deductibles or co-payments.

Expanded Coverage to Young Adults:  Young adults can stay on their parents’ health plan until age 26. See Young Invincible website for more information.

Immediate Access for Children, Even If They Have Pre-Existing Conditions: Children under 19 can no longer be rejected from health care plans due to pre-existing conditions or have their health condition be uncovered. New plans cannot exclude children from coverage for a pre-existing condition. And in 2014, adults cannot be denied coverage due to a pre-existing condition. (Uninsured adults with a pre-existing condition may qualify for Illinois’ Pre-existing Condition Insurance Plan (IPXP).)

No More “Lifetime Limits”:  Insurers can no longer stop your benefits because you have “maxed out.”

Tax Credits for Small Businesses Providing Coverage to Workers:  Already effective, qualified small businesses get tax credit for up to 35% of their premiums for covering their workers.

Medicare Prescription Drugs Rebates for Seniors: Medicare Part D enrollees who hit the Medicare prescription drug benefit gap in 2010 will automatically receive a $250 rebate check.

Direct access to OB/GYNs: The new health reform law provides direct access to in-network OB/GYNs for women in health plans that require them to designate primary care providers. This means that, if you are a female, you can see an OB/GYN without prior authorization from the health plan or referral from another doctor, such as your primary care provider.

Access to out-of-network emergency room services: The new law prevents health plans from requiring higher copayments or co-insurance) for out-of-network emergency room services. The new law also prohibits health plans from requiring you to get prior approval before seeking emergency room services from a provider or hospital outside your plan’s network.

We need your help to set the record straight about these changes – share them with your friends and family now!

And there is more to come! Here are some other changes coming in the next year:

Insurers Must Spend More of Your Premium Dollars on Medical Care: Starting in January 2011, your health insurer must spend 80 to 85 cents of your premium dollar on actual health care and quality improvement, or you get a rebate.

Cost-savings to Seniors on Medicare: Effective January 1, 2011, seniors who reach the coverage gap will receive a 50-percent discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020.

Free Preventive Services for Seniors on Medicare: Effective January 1, 2011, the law provides certain free preventive services, such as annual wellness visits and personalized prevention plans, for seniors on Medicare. 

Reducing Health Disparities: Effective March 2012, to help understand and reduce persistent health disparities, the law requires any ongoing or new federal health program to collect and report racial, ethnic, and language data. The Secretary of Health and Human Services will use this data to help identify and reduce disparities.

Increasing Medicaid Payments for Primary Care Doctors: Effective January 1, 2013, As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government.

Increasing Access to Medicaid: Effective January 1, 2014, Americans who earn less than 133 percent of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing to 90 percent federal funding in subsequent years.

Access to Insurance Options, Subsides, and Public Programs on the Exchange: Effective January 1, 2014, Starting in 2014 if your employer doesn’t offer insurance, you will be able to buy insurance directly in an Exchange -- a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans.  Exchanges will offer you a choice of health plans that meet certain benefits and cost standards.  Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges, and you will be able buy your insurance through Exchanges too.

Help with Purchasing Private Insurance: If you can’t find affordable, quality coverage, you’ll have new options and help purchasing insurance.  Starting in 2014, people will be able to buy cheaper coverage through the “exchange”—one-stop shopping access point for insurance. Exchanges will also set standards to keep insurers honest and provide value for premium dollars. If you earn up to roughly $88,000 a year (family of four), you’ll be eligible for new premium tax credits to help you afford coverage.

And much, much more!


Let's Enroll Eligible Kids in All Kids Now

KidsThe Affordable Care Act, signed into law in March, is already protecting families from some of the abusive practices of the insurance industry. When the new law is fully phased in by 2014, it will help families secure affordable health coverage that can’t be taken away when they become sick or lose their job. In the meantime, most uninsured children in Illinois don’t have to wait until 2014 as they are already eligible for stable, affordable health coverage through the All Kids health insurance program.

Illinoisans should be proud that our state ranks as one of the top in the nation at getting our children into health care coverage many of them qualify for. Now let’s finish the job and enroll the remaining children! To accomplish this, we must answer:

  • Why are there still eligible but unenrolled children in Illinois?
  • What can we do about it?

To address the “why” question, let’s look at a Kaiser survey that found parents often lack accurate information about Medicaid/CHIP programs, don't know how to enroll their children, or find the enrollment process difficult. But it doesn’t have to be that way. There are All Kids Application Agents across Illinois ready to answer questions and enroll children.

To address the “what can we do” question, the Georgetown University Center for Children and Families (CCF)—an independent research organization—has extensive experience in this area. Georgetown CCF has identified numerous strategies states can take to enroll and retain more eligible children such as:

  • streamlining the application process,
  • making it easier for families to keep their children enrolled as long as they are eligible,
  • linking with other public programs in which children may be enrolled, and
  • expanding outreach and educational efforts to inform more parents about All Kids. 

And the Shriver Center has created a toolkit to make it easier to plan and implement an All Kids enrollment event.  Let’s finish the job and enroll the remaining kids!  

Families interested in more information on enrolling their children in All Kids should contact 1-866-ALL-KIDS or go to

Women Will Benefit from Health Care Reform

Mother at the doctor's officeWomen are the most likely to have the greatest contact with the health care system, as they often coordinate health care for themselves and their families. Yet women face unique barriers to obtaining and paying for health care. Nearly half of all low-income women are uninsured, and those who are insured are less likely to visit the doctor because of unaffordable out-of-pocket costs. However, things are changing for the better. Thanks to health care reform, low-income women now will face dramatically fewer cost barriers to access health care. The newly passed health care reform law, the Patient Protection and Affordable Care Act of 2010, will make health care more affordable, easier to obtain and provide more comprehensive services, ensuring women receive the care they need. 

Starting January 1, 2014, 8.2 million women whose incomes are at or below 133% of the federal poverty level will now be eligible for health coverage through the expansion of the Medicaid program. According to the National Women’s Law Center, up to 154,300 uninsured, low-income women in Illinois will gain health care coverage through the Medicaid expansion.  Another benefit, this coverage will be more comprehensive and include family planning and contraceptive services that are, without a doubt, a plus for women.

Moderate-income women and their families will also reap the benefits from health care reform with the creation of health insurance exchanges. Women with incomes up to 400% of federal poverty level can receive tax-credits that effectively lower out-of-pocket costs and help pay for health insurance coverage. Up to 7 million uninsured women nationwide and 471,000 women in Illinois will benefit from health insurance exchanges and tax-credits.

All women will benefit from the provision that requires all new individual and small business health plans to carry an “essential benefits package”, which provides coverage for essential services such as maternity care, prescription drug coverage, and mental health services.  Because of the difficulty women have finding these services in the individual market, this coverage marks a vital improvement in providing fundamental services women need.

Women stand to gain greatly from health care reform. In fact, women across socioeconomic levels have already started benefiting from health care reform. The National Women’s Law Center and the Commonwealth Fund have done extensive work to make clear what health care reform means for women. For more information on how health care reform benefits all women, read or subscribe to the latest issue of WomanView, entitled “30 Million Women Will Benefit from Health Care Reform.”

Heidy Robertson coauthored this article.


Investing in Our Children by Supporting the All Kids Program

Investing in our children is investing in Illinois. When we help children grow and thrive, we are paving the way for our state’s next generation of healthy workers and leaders. Investing in our children means investing in their health through All Kids--Illinois’ nationally renowned health insurance program. Ensuring that every Illinois child has access to health insurance allows children to grow into healthy, productive adults. And we know that our investment is paying off because of the “All Kids Final Report”--a recently released study of the All Kids program. The Covering All Kids Health Insurance Act mandated the study, and it was conducted by the Health Evaluation Collaborative and Institute for Health Research and Policy at University of Illinois at Chicago School of Public Health. 

The study aimed to measure the progress of the All Kids program in insuring children as well as examine areas for improvement. The study showed that the All Kids program has been hugely successful in helping to cover Illinois’ uninsured children: more than nine out of every ten Illinois children have health insurance coverage—many through the All Kids program or a parent’s workplace. While an overwhelming majority of the children who are eligible for employer-sponsored coverage were enrolled in that coverage, that is not an option afforded to all. Luckily, All Kids is there to catch those kids whose families cannot afford or do not have the choice of employer-sponsored coverage so their families have one less thing to worry about during these difficult economic times.

Since All Kids was first offered, the rate of uninsured children has dropped dramatically. At the beginning of the All Kids program, one out of every five low-income children were uninsured, but today, that number is down to approximately one in twenty low-income children. The majority of this enrollment growth since All Kids became available to all uninsured children is among children who were already eligible before the program was expanded. Children are the least expensive population to insure, and the investment now in their health will pay back in dividends later. Research shows that individuals with access to health care as children are less likely to have chronic health problems as adults.  

The recently released study also showed that children in All Kids were significantly more likely to have received an annual check-up and to have seen a dentist in the last 12 months than uninsured children, which means that they received necessary vaccinations and illnesses could be caught early to allow for more time in the classroom. Parents of All Kids’ enrollees were also more likely to report that their child had a “medical home” than both parents of uninsured children and privately insured children, which means that the state of Illinois has been successful in connecting All Kids’ enrollees to a provider who knows the child's health history and can provide health care on a regular basis. These investments are crucial to ensure Illinois kids are ready to learn and on the right track to become healthy, productive young adults.

The study also highlighted areas for improvement, including connecting All Kids’ enrollees to the care they need. We need to ensure that All Kids enrollees can get appointments with specialty doctors when they need them and that providers and clinics offer expanded hours for working parents to take their children to their primary care provider. Overall, the study findings show that there is much to be proud of with the All Kids program: It is leading the way in covering kids, which benefits our entire state. Every child should be able to count on access to affordable, quality health insurance and care, and supporting the All Kids’ program isn’t just the right thing to do. It’s one of the best investments we can make as a state.

This article was co-authored by Kathy Chan, Associate Director, Illinois Maternal and Child Health Coalition.

Putting Children's Health First

Healthy schoolkidEvery time you see a healthy, happy child this fall, there’s a good chance we’ve got Congress to thank for it. If you’ve never heard of the Federal Medical Assistance Percentage (FMAP), doesn’t worry – almost no one has. But FMAP – the share of Medicaid costs covered by the federal government – is a lifeline for the 1.6 Illinois children who depend upon Medicaid for the health care they need to grow and thrive. FMAP helps seniors, people with disabilities, and parents stay healthy, too. This week, as part of its response to the recession, Congress extended a temporary FMAP increase that will provide $545 million dollars to help Illinois avoid drastic cuts that would have put children’s health at risk and cost state employees and local health care providers their jobs. And these funds will generate additional economic activity in Illinois. Every $1 million in federal funds generates $1.7 million in business activity on average, 17.1 new jobs, and $600,000 in wages and salaries.

Keeping kids covered is a win for our state. Kids get the checkups and preventive care they need to stay healthy, so they miss less school and so problems like nearsightedness and hearing trouble don’t hold them back. Parents get the peace of mind of knowing that a playground mishap or flu outbreak won’t drive the family deeper into debt. And we all get more value from every health dollar, by focusing on prevention instead of letting today’s minor problems become tomorrow’s costly burdens.

Among our leaders in Washington, Senators Durbin and Burris along with the entire Democratic Congressional delegation voted to keep Illinois kids healthy by keeping FMAP strong. Every late summer picnic, every high school football game, and every afternoon at the park – everywhere we see happy, healthy kids is a reminder to thank our leaders for standing up for families struggling through the recession and putting the health of Illinois children first.

Back-to-School Is a Great Time to Enroll Children in All Kids

Back to SchoolIn the next several weeks kids throughout the state will head back to school. As summer vacation comes to a close, annual vaccinations and check-ups are often on the back-to-school to-do list of Illinois families. But for the estimated 148,000 uninsured children in Illinois, accessing these services can be a challenge. Fortunately, in Illinois this is a problem we can solve. In Illinois every uninsured child qualifies for Illinois’ public health insurance program: All Kids. For kids whose families cannot afford or do not have the choice of employer-sponsored coverage, All Kids is there to catch them so their families have one less thing to worry about during these difficult economic times.

Health insurance coverage allows children to get the care they need so they can spend more days in the classroom. Healthy children can grow and thrive. And children who have access to care now are much more likely to grow into healthy, productive adults. In fact, a recent study found that children enrolled in All Kids were significantly more likely to have had a well-child visit in the last year than uninsured children. And parents of children enrolled in All Kids were significantly more likely to report that their children had a usual source of care than did parents of uninsured children. Enrolling every uninsured child in All Kids health insurance can ensure that children have access to care so they are ready for the first day of school, have eyeglasses so they can see the chalkboard, dental exams so they are not distracted by a toothache, and medications for childhood illnesses like asthma so they can run and play.

Check out the Shriver Center’s All Kids Enrollment Event Toolkit for resources and best practices for enrolling eligible children in All Kids. And be sure to take a look at the new resources from Cover the Uninsured on back-to-school efforts. Parents can enroll their children in All Kids online or find an All Kids Application Agent in their area who can assist with the application process. 

This article was coauthored by Carrie Gilbert.



Questions About the Illinois Auditor General's Program Audit of the Covering All Kids Health Insurance Program

Kid and DoctorThis May, the Illinois Auditor General released an audit of the Covering All Kids Insurance Act expansion population of the All Kids program, Illinois’ comprehensive and affordable health insurance program for all uninsured children, which benefited over 1.67 million kids in 2009 and has garnered bi-partisan support in the state General Assembly over the last several years. The Sargent Shriver National Center on Poverty Law recently released a brief examining the scope of the audit and the conclusions made by the Auditor General. Instead of providing helpful information to Illinois legislators and citizens on the program’s expenditures of money and awards of contracts, as directed by the law authorizing the audit, it overreaches into policy issues beyond its legislative authority and unwisely recommends changes to the All Kids program that, if implemented, would contradict health policy experts and jeopardize billions of federal Medicaid match dollars. 

The legislative purpose of the audit was to monitor expenditures of money and awards of contracts under the program, not to evaluate public policy. However, the Auditor General chose to focus the overwhelming majority of his attention on the public policy behind the Covering All Kids Insurance Act (to cover all children) and the carefully researched administrative policies regarding enrollment and retention in the program that have been adopted by the Department of Healthcare and Family Services (DHFS). It is unclear why the Auditor General assumes that the General Assembly was inviting an audit of its own public policy choices, and by doing so, second guesses the implementation choices made by DHFS experts on these matters. Moreover, the requirement of an annual audit for a subset of a state Medicaid program is unusual, administratively costly, and not supported by any data or legislative finding. The Covering All Kids Insurance Act—which provides coverage to less than 6% of the total All Kids population—was unjustifiably singled out for this scrutiny.

The Auditor General’s critique of Illinois’ use of passive renewal and 12-month continuous eligibility, and his other recommended changes to the enrollment procedures contradict national health policy experts and federal health leaders. If implemented, these recommendations could result in eligible kids being dropped from coverage, leaving them less likely to receive treatment for chronic conditions such as diabetes and asthma, and more likely to have poorer health, greater rates of avoidable hospitalizations, higher mortality rates, delays in necessary care, and unfilled prescriptions. At the same time, many of these recommendations, if implemented, could jeopardize federal Medicaid match money under the maintenance of efforts requirements of the stimulus law and federal health reform--at a loss of billions of dollars for Illinois.

The audit spends much time complaining about the lack of documentation in case files differentiating the types of immigrant children covered by the program, because, according to the audit, the correct documentation would entitle the state to federal matching funds that Illinois would otherwise forego. However, the difference in documentation among immigrant children did not become relevant to federal financing until Congress passed CHIPRA in January 2009 allowing federal matching funds for certain immigrant children for the first time. The Auditor General paid insufficient attention to the fact that DHFS can retroactively obtain the documentation needed to maximize and claim these federal funds for the time period in question. Similarly, the Auditor General failed to mention that the expansion population of the Covering All Kids Insurance Act has been entirely paid for by offsetting spending reductions elsewhere in the state’s medical assistance programs, as intended by the General Assembly when it passed the law.

Hard working Illinois families know far too well today’s economic reality and the importance of their children’s health insurance. We owe Illinois families a complete, accurate picture of the All Kids program, including a thoughtful real-world analysis of how over 1.6 million Illinois children and their families would be affected by implementation of the auditor’s recommendations. The full brief on the All Kids program is available on the Shriver Center's website.


Community-Based Outreach Proves Successful for Enrolling Kids in All Kids

Healthy KidsEvery day organizations throughout the state of Illinois are actively enrolling children in the state’s comprehensive health insurance program called All Kids.  According to the All Kids website, All Kids Application Agents (AKAAs) are faith-based organizations, medical providers, unions, day care centers, local governments, and other community-based organizations that help families enroll in the state’s public health insurance programs. AKAAs provide families with the support and assistance they need to enroll in the state’s public health insurance programs. AKAAs are organizations and individuals that families trust, which is crucial in a process that asks families to provide personal information. 

Imagine how many kids AKAAs could enroll if brought together for a single, community-wide, well-publicized event. This was the thinking behind the 1,000 Healthy Kids Campaign undertaken by Resurrection Health Care in the summer of 2008. Families are often unaware of the state’s option for uninsured children. By partnering with organizations that families trust and getting the word out about the program and the event, the 1,000 Healthy Kids Campaign was able to enroll over 1,000 kids in All Kids in one day. 

The 1,000 Healthy Kids Campaign enlisted the help of community leaders to ensure that their event was a success. Involving people in the community who families already know and trust is a crucial part of a successful event. Rosemary Kaminski and Andrea Hernandez at the Laboure Outpatient Center at St. Joseph Hospital, which is part of the Resurrection Health Care network, enroll children everyday at the clinic, hold an annual health fair, and were a pivotal part of the 1,000 Healthy Kids Campaign. Kaminski says that the trust and reputation the clinic has goes a long way in getting families enrolled in All Kids, “We get referrals from our patients and they know we’re here…There is a big trust there.”

Those involved in the planning, preparation, and execution of the event said that seeing their hard work come to fruition on the day of the event made their work worth it. Julie Derrig, who was part of the team that planned the event and served as a field captain on the day of the event, recounts that by 8:30 a.m. families were already lining up to enroll their kids in All Kids. 

The 1,000 Healthy Kids Campaign event successfully enrolled over 1,000 kids, but equally important the campaign made the people of the City of Chicago aware of a wonderful program available to families. The effort equipped families with the information and tools to enroll their children in health insurance, even if they were not able to enroll on the day of the event. Although the event was Chicago-based, the event headquarters received phone calls from families in Lake County looking for information. Outreach and education around All Kids can be as important as enrolling people in the program

The success of the 1,000 Healthy Kids Campaign can serve as inspiration for other enrollment events. However, organizations and communities should not feel like an effort is futile unless they can enroll 1,000 kids. Every kid enrolled in All Kids is another kid who will have access to the health care they need and another kid who will be connected to a primary care doctor. Check out the Shriver Center’s All Kids Enrollment Event Toolkit for more information on executing an enrollment or outreach event in your community.

This post was coauthored by Carrie Gilbert.



How Does Health Care Reform Help Older Americans?

Senior CitizensThroughout the debate on health care reform, the focus on changes for older Americans was largely prescription drugs and closing the drug coverage "doughnut hole." These changes are extremely important for many senior citizens who hit their drug coverage limit and are forced to pay high out-of-pocket costs. In fact, there is a $250 payment to seniors who reach the doughnut hole--a down payment until the eventual full elimination of the doughnut hole that will happen later this year.

However, the new law also includes several other provisions that will greatly assist older Americans, particularly low-income senior citizens, which the National Senior Citizens Law Center details in several recent reports.

  • For older Americans who rely on long-term services, the new law will create financial incentives for states to shift Medicaid spending toward community-based services, including a six-percentage point increase in federal Medicaid reimbursement for community-based care initiatives.
  • The law establishes several pilot programs to study and improve coordination of care for Americans who receive coverage through both Medicare and Medicaid, otherwise known as "dual eligibles."
  • The law strengthens medical assistance programs to ensure beneficiaries promptly receive covered services.
  • The law eliminated co-payments for prescription drugs for individuals receiving long-term care services in the home and in an institutional setting. Under current law, individuals living in an institutional setting do not have co-payments, while those receiving services in the home do have co-payments.
  • For Americans who are too young to qualify for Medicare but who retire early, a temporary "reinsurance" program will reduce the cost burden on employers.

According to the National Senior Citizen Law Center, the most significant new provision in the new law is the extension of coverage for 32 million Americans, which includes millions of people aged 50-64, through a Medicaid expansion, new state-based Exchanges with subsidies for low- and middle-income Americans, and regulation of the worst practices of insurance companies. Finally, millions of low-income older Americans will have access to the care that they need, and important improvements will be made to programs that contribute to the health and well-being of older Americans.

Check out the NSCLC reports for details on how reform benefits older Americans!

Carrie Gilbert co-authored this post.


Let's Get Health Coverage for All Kids in Illinois

The United States Department of Health and Human Services and the states have already begun to implement the health reform law, which will finally provide health insurance coverage to low-income childless adults and individuals with preexisting conditions. Ultimately, health reform will insure an additional 32 million people. In Illinois, we do not need to wait to cover all uninsured children. Thanks to Illinois' All Kids program, we have the opportunity to provide kids with the health coverage and care they need right now. Illinois has led the way in health coverage for children, and was the first state in the country to offer comprehensive, affordable coverage to every uninsured child.

Happy children

Kids who have health insurance are more likely to receive the preventive care, treatment for chronic conditions and vaccines that they need. Children with health insurance are generally healthier throughout their childhood and adolescence. Good health in childhood has been linked to a more productive and lucrative adulthood. 2008 Census data revealed the lowest uninsured rates for children in over 20 years, largely because public programs like All Kids serve as a vital safety net for children whose families lose or cannot afford health coverage.

While Illinois has made immense progress in the effort to cover uninsured children since the inception of All Kids, there are still approximately 235,400 uninsured Illinois children. Because of the All Kids program, however, this is a problem we can solve: we must find and enroll these uninsured kids. One of the best ways to find and enroll uninsured kids is to host a one-day enrollment event in your community. An enrollment event provides families with answers to their questions about the All Kids program as well as the resources and support they need to enroll their kids. The Shriver Center has assembled a toolkit with information, sample materials, and support and advice for hosting a successful enrollment event that you can check out here. Now is the time to enroll Illinois kids in health coverage in provide them with the access to health care they deserve.

This post was coauthored by Carrie Gilbert.

It's Safe to Start Dreaming Again

For any Illinoisan who may have put aside their dream of starting a small business for fear of losing or not being able to afford health insurance coverage, it’s safe to start dreaming again. Illinois small businesses are getting some financial relief from the recently enacted health insurance reform signed into law by President Obama on March 23, 2010. This will be of great help as small businesses’ health care costs have grown 129% since 2000. Luckily, President Obama had small business owners in mind when he signed the health insurance reform bill into law. He said, “I’m signing it for Ryan Smith, who’s here today. He runs a small business with five employees. He’s trying to do the right thing, paying half the cost of coverage for his workers. This bill will help him afford that coverage.”  And the thousands of Ryan Smiths in Illinois will see many benefits from the new law. Here are some of the main benefits:

Right away many Illinois small businesses—and an estimated 3.6 million total small businesses nationwidewill get a tax cut this year to help them pay for health insurance for their employees. This tax credit starts at up to 35% of the money the small business owner spends on premiums for employees and increases over time, eventually reaching 50% when the Insurance Exchanges go into effect in 2014. Nonprofit organizations also qualify, starting at 25% and increasing to 35% of the employer contribution. In this way, small business owners who choose to provide health insurance to their employees will be able to do so more affordably and can stop worrying about rate hikes. 

By 2014, small business owners will also have access to the new Small Business Health Options Program (SHOP) Exchanges so they can find the best deal through a simple and efficient process. Funding will be given to the states through January 1, 2015 to establish these Exchanges within one year of enactment. In the Exchange, small businesses with up to 100 employees (states can limit to 50 employees) can purchase qualified coverage. 

This Exchange will greatly assist small businesses, which have been paying up to 18 percent more than large companies for the same health insurance policy. The independent and non-partisan Congressional Budget Office found that premiums for small businesses will go down. The larger pool leads to more insurer competition and lower administration costs, thereby increasing affordable insurance options. And the larger pooling structure will protect small businesses from sudden, arbitrary rate hikes because a worker gets sick. For those small business employees and self-employed who are currently excluded from coverage due to a pre-existing condition (and who have been uninsured for at least six months), right away there will be a temporary high risk pool established to guarantee coverage.

Small business owners will benefit greatly from the new law. With dollars freeing up due to the tax credit, new competitive insurance marketplace and other health cost savings, small business owners will be able to reinvest in and grow their organizations, offer increased salaries to employees, hire new employees and retain quality employees.  

Historic Social Change

I'm not a health care expert, just a spectator like most of America. It's been said that watching legislation being made is like watching sausage being made. Thanks to the 24-hour news cycle, blogs, etc., we've all just been treated to 14 months of the stomach-turning process of watching legislation being made. This may account for the less-than-jubilant reaction to the enactment of health care reform into law.

Make no mistake, however. This is real, lasting, fundamental, historic social change, on a par with the creation of Social Security in the 1930s and Medicare in the 1960s. It ends the national shame of more than 40 million people without health insurance. It creates a system where everyone must play and everyone has a stake.

Health care reform is not a traditional safety net program. You don't get a card. But we live in a much more complicated world than we did in the 1930s or the 1960s. This reform had to be a accomplished within the confines and constraints of two of the most powerful industries in America--the pharmaceutical industry and the insurance industry. Health care reform succeeded because it builds on the existing health care structure to accomplish at least nine extraordinary goals:

  1. First and foremost, it creates a system of subsidies that will allow all people--adults, children, working, not working--to access affordable health insurance.
  2. It will protect people from financial ruin if they contract a disabling disease.
  3. It will prevent insurance companies from canceling insurance policies when the policyholder gets sick.
  4. It will provide workers with job mobility since insurance companies will no longer be permitted to deny coverage based on a preexisting condition.
  5. It will make insurance affordable for middle-income people through a system of subsidies.
  6. It will provide very low-income single adults with access to Medicaid.
  7. It will make it affordable for small businesses to provide health insurance to their workers.
  8. The doughnut hole will be eliminated and seniors will be able to afford their prescriptions.
  9. Young adults--an age group that is particularly likely to be uninsured--will be able to remain on their parents' insurance policies until they turn 26.


Healthcare -- A Lot Happens Right Away

Many Americans will feel the effect of health reform this year, as significant changes start to go into effect. During 2010:

Child with Doctor

  • Children will not be denied coverage due to a preexisting condition.
  • Young adults will be able to stay on their parents' health plans to age 26.
  • Insurance companies will be prohibited from revoking coverage when people become ill, and from setting lifetime limits on benefits.
  • Small businesses will be eligible for new tax credits to offset their premium costs.
  • People with preexisting conditions will be eligible for subsidized coverage through a national, high-risk pool.
  • New limits will be set for the percent of premiums that insurers can spend on nonmedical costs, e.g., administrative or profit, and, beginning in 2011, carriers that exceed those limits will be required to offer rebates to enrollees.
  • Medicare will provide $250 rebates to beneficiaries to help with prescription drug costs (with greater help coming in future years).
  • Medicare will eliminate cost-sharing for preventive services in Medicare and private plans so they are free.

Much more follows in later years.

Congress Makes History

On March 21, the House of Representatives passed historic health insurance reform legislation. The House passed the reform bill previously passed by the Senate, which now becomes law upon the President’s signature (expected as early as March 23).  The House also passed a package of changes to the Senate bill that have been negotiated with the Senate, and which the Senate is expected to pass very soon (using the “reconciliation” procedure that requires a simple majority vote).

The package of reforms is a major step forward to provide Americans more security, more choices, and better cost control for their health care.  See the impact in your legislative district.

This is the end of the worst practices of the insurance industry—no more denials due to pre-existing conditions or dropping coverage for people who get sick, or hidden ceilings on your coverage.

We will all get the same insurance choices that Members of Congress have. What is good for them will be good for everyone.

We have kept what is good in our health system and added oversight of insurance practices, control of insurance rate increases, choice of plan and doctor, more competition, and expanded prevention.

Medicare will be strengthened—reform will cut waste and fraud in Medicare, improve solvency and close the gap in prescription drug coverage for seniors.

There will be access to affordable health care for 3.6 million small businesses and 32 million Americans who have been left out – until now.

The first order of business is to thank your House member, if he or she voted “yes”. 
Here is the roll call.  This is VERY important – these are leaders who deserve thanks and support.

"Let's Make a Deal" Reruns

Remember the show, Let’s Make a Deal, with Monty Hall? Well, it's back--sort of. For more than a year, Congress has been saying that it’s close to making a deal on legislation to overhaul America’s health care and financial systems. 

The original Let’s Make a Deal show was based on the show’s host, Monty Hall, offering deals to members of the audience. The contestants usually had to weigh the possibility of an offer being for a valuable prize, or an undesirable item. In its simplest format, a contestant was given a prize of medium value (such as a television set), and the host offered the contestant the opportunity to trade for another prize. However, the offered prize was unknown. It might be concealed on the stage behind one of three curtains, or behind "boxes" onstage, or within smaller boxes brought out to the audience.

Congress seems to have brought this classic TV game show back. “We’re close to a deal,” on health care legislation. “We’re close to a deal,” on financial reform legislation. 

Health Care Reform

The need across the country for health insurance reform has not abated. Americans agree that the nation's health insurance system is broken, but Congress still hasn’t sent a bill to President Obama to fix it. The current deal on the table is for the House to pass the Senate’s bill and then for both chambers to pass a budget reconciliation bill that resolves their differences. The proposed deal would ban insurance companies forever from denying coverage to children with preexisting conditions and from dropping coverage when an individual becomes sick. Insurance companies would no longer be able to randomly hike premiums or to impose lifetime or annual limits on the amount of care someone can receive. All new insurance plans would be required to offer free preventive care so that illnesses may be caught early. Young adults will be able to stay on their parents’ insurance policies until they are 26 years old. Uninsured individuals and small business owners would have the same kind of choice of private health insurance that members of Congress get for themselves. And individuals who do not have insurance coverage through a large group could be part of a bargaining pool that negotiates lower rates. Also, if an individual is ineligible for Medicaid but still can’t afford the insurance offered through the pool, she or he would receive a tax credit to assist with this cost. Finally, this deal would provide a new, independent appeals process if a claim has been unfairly denied.

It’s time for Congress to take the deal and make health insurance available and affordable for all.

Financial Regulation Reform

After the catastrophic financial crisis, President Obama called for the creation of an independent Consumer Financial Protection Agency, which would have as its sole mission the protection of consumers. It would create and enforce clear rules to ensure fairness of credit card terms and conditions, overdraft loan programs, payday and car title loans, and mortgages. In the fall, the House of Representatives passed legislation creating such a new Consumer Financial Protection Agency, which would provide the type of consumer protections that should have been in place all along. The Senate, however, has been debating the issue for months.

Specifically, Senate Republicans and the financial-services industry have opposed the creation of such an entity. Instead they would prefer that the Federal Reserve continue to be responsible for consumer protection as part of its regulation of nationally chartered banks. The central bank has always been responsible for the health of the nation's largest banks and the safety of American borrowers; however, its failures in both roles have been well documented. For years, the Federal Reserve primarily focused on monetary policy over bank supervision and often made consumer protection an afterthought. As a result, millions of American families have been left unprotected and financially unstable.

Additionally, the Federal Reserve only regulates banks, which would mean that the so-called shadow banking system of payday lenders, debt collectors, and loan originators and servicers would remain unregulated. The power of these entities has been demonstrated by the huge role they had in the current economic crisis. Allowing them to continue their predatory practices without being regulated would not be a deal on reform but rather a continuation of the status quo. Lawmakers have repeatedly said that they are close to a deal on this very divisive issue. Yet, proposals to let the Federal Reserve remain the primary regulator of consumer protection laws, is not a deal, it’s just the status quo. 

Well Monty, Where’s the Deal?

Congress seems to be weighing the possibility of whether reforming health care and financial systems will ultimately be valuable prizes, or undesirable items. Yet, rather than holding onto its existing undesirable prizes, Congress should choose Door #1, quality, affordable health insurance reform NOW and a dedicated agency to monitor and rein in the reckless behavior of financial institutions. 

Well Congress, where’s the deal?

The Health Insurance Reform Finish Line:

Co-authored by Carrie Gilbert

Over the last several weeks, we have looked at the different proposals coming through Congress to achieve comprehensive health insurance reform. Congress is now modifying two versions – one in each – the House and the Senate. We have come quite a long way since the beginning of this series, however before health reform is signed into law, there are several more important steps. The Senate has officially begun debate. In order, to take a final vote and pass health reform, they will need 60 votes to end debate on the floor. Then they need a simple majority to pass it out of the Senate. Once each house has a passed a version, it will go to conference committee so that the differences can be resolved and a final bill written.   Your Senators and Representatives will need to hear from you every step of the way. Reassure those that support health reform that they are doing the right thing and let the fence-sitters and naysayers know that as their constituent you would like to see them support health reform. Here is the number to call 1-800-828-0498 to let your representatives know how you feel. 

Here is our final installment of the homestretch series: The Finish Line.  We wrap up the previous issues we have looked at and offer insight into unresolved issues.   

Children’s coverage:

House bill
H.R. 3692 would ultimately dissolve the Children’s Health Insurance Program (CHIP) as of December 31, 2013. Children below 150% of the federal poverty level (FPL) would then move into Medicaid and those above would be moved into the new Health Insurance Exchange or employer-based insurance.   While CHIP is still in place, HR 3692 eliminates waiting periods for children who were previously covered by employer sponsored insurance.  By the end of 2011, the Secretary of HHS will have to conduct a study for what the Exchange will look like and make recommendations to Congress for improving the Exchange for children’s coverage.

Senate bill
H.R. 3590 maintains CHIP for children above 133% FPL through
2019. However, it does not allocate funding past its current renewal date of September 30, 2013. If Congress does not fund CHIP after 2013 then families may enroll in the Exchange and may qualify for subsidies. 

Some advocates fear that moving children out of CHIP without first ensuring that the Exchange is comparable in price and benefits, would harm families and children. They fear that CHIP goes well beyond what private plans in the Exchange would offer in terms of benefits and covered
services. However, others argue that moving entire families into the Exchange would simplify the process and increase the likelihood that children get coverage. Studies have found that when the parents are covered, the children are more likely to be covered and receive necessary benefits. Additionally, there would be an “essential benefits package” requirement in the Exchange that would serve as a benefits floor for private plans. Finally, in the Exchange all families up to 400% FPL would qualify for subsidies, whereas one state has CHIP eligibility to 400% FPL, thereby covering more families. On the Senate side, Senator Bob Casey (D-PA) introduced an amendment to protect and ensure health care coverage for low-income children, including continued full funding for CHIP through 2019. 

Medicaid Expansion:
House bill
The House bill expands Medicaid to 150% FPL in January 2013 with 100% federal financing for 2 years and 91% federal financing beginning in year 2015 for new eligibles (such as childless adults) and some current eligibles covered by a waiver. States with Medicaid levels above 150% will be required to maintain their current levels. The House bill’s additional funding is geared towards helping states transition to the expanded Medicaid program.   Additionally, the House bill would increase Medicaid payment rates to primary care providers to 100% of Medicare rates by 2012. 

Senate bill
The senate bill expands Medicaid to 133% FPL and includes childless adults. The bill requires that the expansion occurs by 2014, but states could begin expanding as early as
2011. Some individuals who qualify for Medicaid could also receive subsidies in the Exchange, although people below 100% FPL could only receive subsidies if they do not qualify for Medicaid. 

Health Affairsdid a study about a year ago, which found that average medical expenses are lower per person under public programs than under private insurance. When controlling for demographics and income, the medical expenditures for the same adult would be 26% higher under private insurance than Medicaid. Additionally, out-of-pocket costs are vastly higher under private insurance than under Medicaid. A Medicaid enrollee would spend 6 to 7 times more on out-of-pocket costs under private insurance than under Medicaid. The CBO estimates that Medicaid expansion to 150% FPL will cover 15 million people. This is not to say that we should balk at the Senate’s Medicaid expansion to 133%, and both bills expand Medicaid to previously ineligible childless adults, which finally addresses a longstanding gap in public coverage for those who often do not qualify or cannot afford private insurance. 


House bill
HR 3692 requires all individuals to purchase coverage, but provides tax credits to individuals and families with incomes above Medicaid eligibility but below 400% FPL. A family of four headed by a 45-year-old making $44,000 a year would pay roughly $2,400 in premiums, or $200 a month, according to the Kaiser Family Foundation. The tax credits are awarded on a sliding scale based on income to limit premium contributions to an affordable percentage of income, starting at 1.5% of income for 133% FPL to 12% of income for 400% FPL. The House bill requires employers to provide health insurance or pay a tax on their total payroll. However, for businesses with annual payrolls less than $750,000 the tax is assessed on a sliding scale, and businesses with annual payrolls under $500,000 are exempt from the tax entirely. 

Senate bill
Similarly, in the Senate bill individuals will receive affordability credits to pay for premiums. The credits would start at 4% of income for households at 134% of FPL and increase to 9.8% of income for households at 300%-400% FPL. The Senate bill also includes employer mandates and penalties, but exempts employers with 50 or fewer employees.

The Senate bill is more affordable for households between 250-400% FPL, but the House bill is more affordable for households under 250% of FPL. In the case of those at the bottom of the subsidy scale, under the Senate bill they could end up paying at least twice as much as what they would pay under the House bill. However, a recent analysis by MIT economist, Jonathan Gruber, found that the Senate bill makes health insurance for individuals purchasing in non-group market much more affordable. The same plan that would cost $5500 without reform would cost $4600 with reform. Gruber also found that the House bill would deliver a savings ranging from $200 for individuals to $500 for families, even without subsidies. The nonpartisan CBO and the Joint Committee on Taxation analysis of how the Senate bill might affect health insurance premiums concluded that the Senate bill will reduce premium costs for 57% of Americans who will receive subsidies by as much as 59%, and rates in large group market by as much as 3%.   Rates may rise for individuals who have to purchase coverage on their own but do not qualify for subsidies, but this is mostly because the plans offered in the Exchange will be better plans than those currently offered and therefore slightly more expensive. 

Public Option
House bill:
HR 3692 creates a National Health Insurance Exchange, where individuals and employers (employers would be phased-in beginning with the smallest employers) can purchase plans that meet certain qualifications in order to be considered an adequate plan. A public option would be included in the Exchange. The public option would follow the same insurance industry guidelines as private plans. The public option would negotiate rates with providers so that they are not below Medicare rates but not above the average rates for comparable private plans. 

Senate bill:
HR 3590 creates a state-based Exchange for individuals and businesses with fewer than 100 employees. States can allow bigger businesses to buy insurance in the Exchange beginning in 2017. The Exchange would include a public option, which must comply with insurance industry regulations for private plans. The Senate bill permits states to choose not to offer the public option, but they would have to pass legislation to do so. The Senate bill would also create a program to foster the development of CO-OPS or non-profit health insurance companies. 

According to the CBO, the House bill’s public option would enroll less than 2% of the population (about 6 million customers over the next 10 years) and probably have higher premiums than private plans. The Senate’s bill would attract about 4 million customers. Nevertheless, the
public option has become a heated topic. If Senator Reid can find a public option compromise that pleases all 60 democratic votes, then he can close debate and move toward the final vote. Republicans want six weeks of debate, but as soon as Democrats come to an agreement on the public option they can shut down the debate and avoid the Republican arsenal of stalling and bill-killing tactics. Finding this magical compromise is much easier said than done. Senator Joe Lieberman (I-CT) and other conservative Democrats, most notably Ben Nelson (D-NE), Mary Landrieu (D-LA) and Blanche Lincoln (D-AR) have voiced opposition to the opt-out public option. Landrieu has said that she would support the “trigger” option, which would activate the public option if the private industry does expand coverage fast enough.   Sen. Olympia Snow (R-VT), the only Senate Republican to vote for health reform this year, has also voiced support for the “trigger”. Sen. Nelson supports an opt-in option for states, while Lieberman and Lincoln are going to be much harder to bring to the table on the public option. Meanwhile, Democrats on both the House and Senate side can be lost if there is not a public option. However, a potential compromise is beginning to emerge from negotiations between five liberal and five moderate Democratic Senators. The compromise would remove the public option and replace it with a network of non-profit health insurance plans, which the Office of Personnel Management would administer. The Office of Personnel Management currently administers the Federal Employee Benefits Program. In exchange for removing the public option, moderate Democrats would agree to expanded Medicare and Medicaid.  Getting the 60 votes necessary to close debate involve negotiation on several issues, but the public option balancing act may be the single most important issue for getting to 60. 

Insurance Market Reforms
House bill:
HR 3692 would require private insurers within the Exchange to guarantee coverage regardless of the policyholder’s health and renew the coverage each year, and insurance companies could not rescind a policyholder’s plan. Insurance companies would be required to issue plans despite pre-existing conditions. Variation in premium rates would be illegal based on gender and geography. Premiums can vary based on age but limited to a ratio of 2 to 1. Insurance companies could not impose annual or lifetime caps for medical care.  

Senate bill
The Senate bill also guarantees issue and renewability. As in the House legislation, companies could not rescind coverage or refuse coverage based on a pre-existing condition. Premium variation is allowed based only on age and tobacco use within ratios of 3 to 1 and 1.5 to 1 respectively. 

Insurance market reforms are some of the most needed and least debated aspects of health reform. Countless people have been denied coverage or had their coverage rescinded due to pre-existing conditions or post claims underwriting and rescission practices. These insurance reform changes are significant change to current insurance company business practices. However, even if one issue causes health reform to fail then even these widely agreed upon changes will get thrown out. These changes would mean significant improvements in care for lots of Americans who currently struggle to find adequate coverage.    However, since insurance companies currently charge the young and healthy much less than middle-age people who are more likely to get sick, the young may pay more under both bills than they currently do, if their income is too high for them to qualify for public coverage or subsidies. 

Impact on the deficits and paying for reform:
House bill:
The House bill uses a combination of penalties for lack of coverage, taxes on wealthy Americans and changes to Medicare payment to pay for reform. It is expected to reduce deficit by $109 billion over ten years. 

Senate bill:
The Senate bill uses a combination of taxes on high cost insurance plans, increases to the Medicare payroll tax and a 5% tax on non-medically necessary cosmetic surgery. The Senate bill is expected to reduce the deficit by $130 billion over the first ten years and by more than half a trillion dollars in the following decade. 

Both bills offer positive elements to craft an affordable bill that curbs the cost of health insurance over time. The tax on wealthy individuals will raise considerable revenue, while the tax on high-cost insurance plans will slow health care growth over time. 

Other Hot Issues:

Abortion: Federal funding for abortions became a contentious issue at the last minute in the House debate. The House passed their bill with language which makes it illegal for the public plan to cover elective abortions, and for individuals receiving subsidies to purchase plans which cover elective abortions. The Senate bill, on the other hand, allows individuals who receive federal subsidies to purchase plans which cover abortions, but insurance companies would have to segregate federal funds to ensure that only the policyholder’s money is used to pay for the procedure. It is expected that early this week Senator Bill Nelson (D-NE) will introduce an amendment to make the language in the Senate bill more like that in the House bill. Some House Democrats have said that while they voted for the amendment once, they will not do it again, and their votes could be lost if the language remains as restrictive as it now is. Speaker Pelosi has stated, however, that health reform will not fail on account of the abortion debate. 

Immigration: The House bill allows undocumented immigrants to buy insurance in the Exchange; however they would have to use their own money to do so. The Senate bill, on the other hand, restricts access to the Exchange completely. Some Congressional Democrats, in particular the Hispanic Caucus, are disappointed with the language regarding immigrants, particularly in the Senate bill. 

Homestretch 6: Paying for it and the impact on the deficit

Co-Authored by Carrie Gilbert

[This is the sixth in a series of six articles summarizing the leading categories of issues at stake in the final stages -- the homestretch -- of the debate on national health insurance and health care reform.]

Last week the Senate released their combined bill which has been sent to the floor for debate. Many of the basic principles of the Senate and House bills are similar; however there are still major differences, including the method for paying for reform. For our final installment in our homestretch series we will compare these two proposals on how they will pay for reform and their impact on the budget deficit. 

Covering millions of previously uninsured Americans obviously has an upfront cost; however given the current state of our broken health insurance system, the proposed reforms will actually reduce the deficit. Both bills have received deficit neutral scores from the Congressional Budget Office (CBO), despite having different methods for reducing the budget.

The House bill, called the Affordable Health Care for America Act or HR 3962, proposes a combination of mandate penalties, reforms to Medicare and Medicaid and a tax on wealthy individuals to raise revenue to pay for reform.   The House bill is projected to save $426 billion over ten years by reforming Medicare and Medicaid. The federal government currently pays about $1,100 more per person to cover the same beneficiaries through Medicare Advantage, private Medicare plans, than through traditional Medicare. HR 3962 will reduce overpayments to Medicare Advantage plans.   Overall, the bill attempts to reduce fraud and waste in both the Medicaid and Medicare systems. 

In addition to extensive reforms to Medicare and Medicaid, H.R. 3962 includes a 5.4% surcharge on couples with incomes over $1 million, which would affect less than 1% of taxpayers, and amount to a moderate tax burden for these households. Some people fear that this new tax would harm small businesses that file taxes as individuals. However, the Tax Policy Center calculates that just 1.6% of taxpayers in this group would face the surcharge, and that many in this group are actually wealthy investors and not true small business owners. Ultimately, only 0.6% of taxpayers who derive more than half of their income from business sources would face this surcharge

The newly released Senate bill, The Patient Protection and Affordable Care Act or HR 3590, may slow the growth of health care costs over time by, for instance, imposing an excise tax on high-cost health insurance plans, decreasing overpayments that private insurers receive through Medicare Advantage, and reducing the cost of prescription drugs in Medicaid.   The new tax on high-priced health insurance policies (or Cadillac plans with yearly premiums of $8,500 for individuals and $23,000 for families) applies to self-insured plans and plans sold in the group market, and not to plans sold in the individual market (except for coverage eligible for the deduction for self-employed individuals). HR 3590 would also increase the Medicare payroll tax from 1.45 to 1.95% on individuals earning $200,000 per year and couples earning $250,000 per year. Both of these new taxes will yield considerable revenue.   

HR 3590 imposes many fees to pay for the bill, including on pharmaceutical manufacturers, medical device manufacturers and the health insurance sector. Many of these fees do not apply to companies whose sales are below $5 million and the fees are allocated across the industry based on market share. Moreover, HR 3590 mandates that non-profit Blue Cross Blue Shield (BCBS) organizations have a medical loss ratio of 85% or higher to receive the special tax benefits provided to them. This means that they have to spend at least 85% of profits on their beneficiaries’ medical care. 

Ultimately, the House bill will reduce deficits by $109 billion over the next ten years. The Senate bill will reduce deficits by $130 billion over the next ten years, and by about one-quarter of one percent of GDP in the decade thereafter, which amounts to about $55 billion in 2020 and several hundred billion dollars over the 2020-2029 period. The bill finances its expanded health coverage by redirecting existing spending and tax subsidies from less productive uses elsewhere in the health sector. Therefore, the Center for Budget and Policy Priorities’  and CBO report that the Senate Bill extends health coverage to 31 million more Americans, while keeping the total federal cost for all health care spending and tax subsidies in the decade after 2019 essentially where it would be under current law. Additionally, a group of economists sent a letter to President Obama last month advocating for many of the reforms in the Senate bill as a way to stem the costs of the health care industry. 

This does not mean that the Senate bill is the better bill. There are provisions in both bills which are worth preserving the in the final bill. Over the next several weeks, as the Senate works to pass their version of the bill and then the two bills go to conference committee, there will be several opportunities for improving the bills and producing a superior final bill. Both bills contain key provisions for slowing the growth of health care costs and paying to insure more Americans. As always, the ultimate goal is affordable quality health insurance for all Americans.

Homestretch 5: Health insurance market reform

[This is the fifth in a series of six articles summarizing the leading categories of issues at stake in the final stages -- the homestretch -- of the debate on national health insurance and health care reform.]

 A recent Congressional Report initiated by Senator Jay Rockefeller found that while the insurance industry has long claimed that 87% of premium dollars go to pay for medical care, in fact, the average is 82% for the top six insurers. This five point difference equates to billions of dollars not being spent on hardworking families’ medical care. And these findings underscore the need for meaningful reform of the insurance industry. The three bills in Congress (H.R. 3962, Senate HELP and Senate Finance) include major reform to the private health insurance companies. These reforms will vastly change the way in which companies decide who qualifies for insurance and who does not. In a historic vote this past weekend, the House passed H.R. 3962, including many changes to the health insurance market.   Senator majority leader Harry Reid (D-NV) has combined the two Senate proposals and sent a couple of different versions to the Congressional Budget Office (CBO) for consideration. He is waiting on the report from the CBO before releasing a final Senate bill, which will be the version sent to the Senate floor for debate. Until the final Senate bill is released we will offer comparison and analysis on the two Senate bills (HELP and Finance).

The three bills provide for significant reform to the health insurance industry, which would greatly expand access to health insurance. As discussed in Homestretch part 4, all three proposals create a health insurance Exchange, which would regulate the individual and small group insurance plans available in the Exchange.   Benefit plans in the Exchange would be standardized. Plans would vary on the level of cost-sharing of co-pays and deductibles. Private insurance companies participating in the Exchange could not deny coverage based on pre-existing conditions. Additionally, premiums could not vary because of gender or pre-existing conditions. 

The only characteristics that are permitted to factor into premiums are age, tobacco use, family composition and geography. The three proposals set ratios for premium variation based on age and tobacco use. The Senate Finance bill limits age variation to a 4 to 1 ratio and tobacco use to a 1.5 to 1 ratio. For example, a company can only charge its oldest customers four times that of its youngest customers.   The Senate HELP bill limits age variation to a 2 to 1 ratio and tobacco use to a 1.5 to 1 ratio. H.R. 3962 limits age variation to a 2 to 1 ratio, but does not allow insurance companies to vary premiums based on tobacco use.   The insurance companies indicated they will fight the limiting ratios, because they argue that they will raise costs to younger and healthier individuals

The Exchange contained in the three bills would also require that insurance companies issue insurance to a consumer regardless of their health status. Additionally, an insurance company could not sell a consumer a plan that explicitly does not cover their pre-existing medical condition. Companies would have to guarantee that they will renew an individual’s policy each year.   Additionally, each proposal sets limits for annual out-of-pocket costs to policy holders.   Insurance companies would not be able to limit the amount of claims a policy holder makes either annually or in a lifetime. In other words, an insurance company could not suddenly tell a policyholder that they will no longer cover that policyholder’s claims. 

Senator Rockefeller faced significant difficulties in getting the insurance companies to voluntarily divulge what portion of the premiums goes to medical care versus profit, administration, etc. This would change under all proposals. Both of the Senate proposals require insurance companies to report how much of the revenue from premiums goes toward paying for medical services. The House proposal requires that the Secretary of Health and Human Services sets a minimum percentage of revenue that must pay for medical services.   If the companies do not meet this minimum then they must provide rebates to their customers. 

The aforementioned reform is quite similar among the three proposals, but to whom they would apply differs. Senate Finance would apply these changes to the individual and small group market (businesses with fewer than 50 employees). Senate HELP and the House bill would apply reforms to all private insurance markets, including businesses of all sizes. And the Senate Finance bill would, however, require that all new policies, both inside and outside of the Exchange, meet the standards of one of four benefit levels set forth in the proposal. 

These reforms will offer greater consumer protections and decrease insurance companies’ discriminatory practices. Some of these measures may face fierce debate an opposition in the coming weeks as the Senate sends a final bill to the floor for debate and final bill is composed for President Obama’s consideration.   These reforms will mean containing costs, creating choices, upgrading care and ultimately covering all

Homestretch 4 - The Exchange, public option and CO-OPs

[This is the fourth in a series of six articles summarizing the leading categories of issues at stake in the final stages -- the homestretch -- of the debate on national health insurance and health care reform.]

55% of Americans who favor a government insurance plan and health reform advocates are rejoicing over yesterday’s news from Senate Majority Leader Harry Reid (D, NV). Yesterday, Reid stated that the bill he intends to send to the Senate floor next month will include a "public option" – a federal government created insurance plan offered to Americans who do not get medical coverage through their employers -- with the condition that states could opt out of the program. Reid’s move is being hailed as a bold and vital move by health reform supporters throughout the country and a major milestone for health insurance reform as it moves forward in both houses. This is not to say that Reid’s model of the public option is a definite or that amendments will not attempt to eliminate or alter the public option in the Senate bill.  

Majority Leader Reid and House Speaker Nancy Pelosi (D-San Francisco) are advancing separate healthcare bills, each containing different provisions for the public option. House Democrats may have the support to pass a bill that would create a nationwide government plan without any option for states not to offer the plan; however Speaker Pelosi has stated that the opt-out alternative could be included in a reconciled bill. Both the Senate bill and the House bill will need to be reconciled later this year before final legislation could be sent to the White House for President Obama's signature.

All three of the current versions of the bill in Congress (Senate HELP, Senate Finance and the House Tri-committee bill--H.R. 3200) include a health insurance Exchange, which would serve as the marketplace for qualified plans that follow new insurance provisions. The Exchange would create a competitive marketplace that offered choices of plans, which would have to follow a common set of regulations. The Exchange has several advantages including choice, price competition and portability if you choose to change jobs. In all three proposals, the Exchange would be a place where individuals without access to employer-sponsored coverage could purchase insurance. Small employers could also purchase plans for their employees through the Exchange. In both the Senate Finance bill and H.R. 3200, eligibility for employers would be phased in starting with smaller employers. 

Conservative Democrats and some Republicans supported a Consumer Operated and Oriented Plan (CO-OPs) program. The Senate Finance bill included a CO-OP program, which would encourage the creation of non-profit health insurance companies run by the members. Members would be required to use the profits to lower premiums, improve benefits or improve the quality of the care consumers receive. In order to be included in the Exchange, CO-OPs would have to follow the same regulations as the private plans. Many health reform advocates maintain that CO-OPs have failed in the past and will fail this time too. Additionally, the Congressional Budget Office does not find significant savings in the CO-OP model, whereas it does with the public option planSenate Finance Committee Chairman Baucus has said that he chose to include the CO-OP over the public option in the Finance bill because he felt it would garner greater support, but he is still open to the public option

Despite the disagreement among policy makers regarding the potential success of CO-OPs, much of the debate has now turned to the
public option.  With Reid’s announcement, the question seems to have become not if there will be a public option, but what form the public option will take. Reid’s opt-out model allows states to withdraw from the public plan in 2014, a year after the public plan goes into effect. Senator Olympia Snowe (R-ME), the only Republican on the Senate Finance committee to vote for the Finance committee version of the bill, supports the “trigger” model of the public option. The trigger would only put a public option into effect in states that do not meet standards of affordability. Snowe stated yesterday that she was disappointed with Reid’s decision to go with the opt-out model over the trigger model.   

The Insurance industry has released a report which argues that the public option will raise costs to those people with private insurance plans, in order to offset the reduced cost of the public plan. In fact, public health insurance actually costs less than private insurance. However, the public option as proposed by Reid would be offered through the Exchange, which would only be available to those individuals without employer sponsored insurance. And only a fraction of people would choose the public option, according to the Congressional Budget Office. Moreover, the Exchange would serve as a regulator of benefit plans, and Reid’s proposal also requires the government plan to negotiate provider rates, instead of relying on Medicare rates, which are often lower than private reimbursement rates. 

Congress must produce a bill that creates competition in the health insurance market, in order to successfully lower costs and provide quality choices to consumers. A majority of Americans, policy makers and advocates see the public option as the best way of doing this. H.R. 3200 and Reid’s proposal can achieve this but we cannot lose focus on the overall goal of passing health insurance reform this year. If an opt-out or trigger can create competition while lowering costs and providing quality care, then they should be considered to keep the momentum going. The ultimate goal is quality affordable health insurance for all Americans.

Homestretch Part 3: Affordability Measures

[This is the third in a series of six articles summarizing the leading categories of issues at stake in the final stages -- the homestretch -- of the debate on national health insurance and health care reform.]

Health insurance reform is crucial for the success and prosperity of American families. However it will only succeed if there are affordability measures in place for families, individuals and small business owners.   Congress now has three bills that have passed out of committee and must be reconciled to create the final bill. The key will be to take the best elements of each bill to ensure Americans adequate and affordable health insurance.   In all three bills, almost all individuals are required to carry health insurance. The goal of the individual mandate is to encourage the use of primary care providers and preventive care, while reducing the use of emergency rooms for non-emergency care. This could prove problematic for individuals who do not qualify for subsidies but cannot find an affordable plan, and for low-income individuals. However, with adequate subsidies and affordability measures, Congress can ensure that health insurance is affordable for everyone.

Individual and Employer mandate
All three bills require that almost all individuals have health insurance and those who do not will be required to pay a penalty. However, each of the bills has a different method of penalizing certain individuals. Both Senate bills (Health, Education, Labor and Pensions (HELP) and Finance) impose a tax penalty of $750 per individual per year and per adult per year, respectively. The Senate HELP bill exempts people whose incomes are below 150% of the Federal Poverty Level (FPL), people without coverage for fewer than 90 days, members of Indian tribes, and residents of states without an Exchange in place. The Senate Finance Committee exempts certain individuals as well, including, individuals with incomes below 133% FPL, individuals with religious objections, individuals who can prove financial hardship, American Indians, and if the lowest cost plan exceeds 8% of an individual’s income. 

The House Tri-Committee bill (H.R. 3200) imposes a penalty of 2.5% of income up to the cost of the Exchange’s national average premium. The House bill exempts dependents, individuals with religious objections or financial hardship. 

The three bills also include employer mandates which require employers to contribute to their employees’ cost of insurance. An employer mandate is necessary to ensure that costs do not get passed to employees and that employers do not drop employee insurance with the adoption of the Exchange. However, these mandates must be carefully designed as not to impose higher costs on small business owners or discourage the hiring of low-income individuals.

The Senate Finance bill would impose a tax on employers with more than 50 employees that do not offer coverage. They would be taxed for each employee that receives a tax credit through the Exchange. This provision may discourage employers to hire low-income individuals who would be more likely to receive credits in the Exchange. Additionally, the Finance bill would require an employer with more than 200 employees to automatically enroll employees into the employer’s health insurance plan. Employees may choose to receive coverage from another source. 

The Senate HELP bill requires employers to offer health insurance and pay 60% of the premium cost. Under this bill, employers will be subject to a $750 penalty for each full-time employee and $375 for each part-time employee who is uninsured and not offered insurance. The provision exempts employers with 25 or fewer employees. 

H.R. 3200 requires employers to offer coverage and pay at least 72.5% of premium for an individual and 65% of premium for a family. The penalty for not following this requirement is to pay 8% of the employer’s total payroll into the Health Insurance Exchange Trust Fund. Certain employers would receive exemptions from the penalty. For small employers with a payroll of less than $750,000 a year, the penalty would be imposed on a sliding scale instead of the flat assessment rate of 8%. 

The key to successfully mandating health insurance without creating a financial imposition on low and middle income families, is implementing adequate
subsidies for people to buy insurance through the Exchange. The goal of the subsidies is to limit the premium cost to individuals based on a sliding scale. The House bill does the best job of limiting the percentage of an individual’s income that goes toward premiums. However, the Senate HELP bill provides the best subsidies or individuals below 150% FPL. The Senate Finance bill has improved their subsidies substantially; however more could still be done.   It is also important to keep in mind that Medicaid eligible individuals, non-citizens and non-Legal Permanent Residents will not qualify for the subsidies, with the exception of some Medicaid eligible individuals under the Senate Finance bill. Here is a table of the subsidies for income tiers under each bill:


Senate Finance Committee

Senate HELP Committee

H.R. 3200**