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. 


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. 

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. 

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. 



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. 

NPR--Addressing the Wrong Question About Disabilities

Several recent NPR stories reported by Chana Joffe-Walt that originated on This American Life perpetuate stereotypes and misconceptions about disability and the country’s main safety net programs that support people with disabilities. Many of these stories’ mistakes and insinuations have been pointed out and refuted in other blogs this week. These include comprehensive facts from the Center on Budget and Policy Priorities, a Media Matters fact check, strong protest from the Paralyzed Veterans of America to the stories’ skepticism about mental and other disabilities that cannot be seen, and a letter from over 100 groups that work on behalf of people with disabilities.

Ira Glass of This American Life issued a statement defending the reporter’s fact-checking of the piece, denying factual errors, and standing by the story. That statement, in turn, was rebutted by Shawn Fremstad of the Center for Economic Policy Research.

Although the blogs convincingly establish that the NPR stories make a number of errors about the disability programs, what is more disturbing to me is the tone of the reporting and the reporter’s cynical message that something is fishy with these programs. Joffe-Walt never outright claims that a significant number of the people who receive disability benefits are not in fact disabled, but reading and especially listening to the This American Life piece make it unmistakable that this is what she wishes to convey. Her stated “news” from her research is that the growth in disability benefits recipients reveals a hidden feature of our economy—that there are no jobs for lots of people with less than high school education in our economy. That’s a fair and useful point. But she clearly also conveys that she thinks there is something wrong with the disability programs, because people who tell her they would try to work if they could find a job instead are able to qualify for disability. 

Joffe-Walt says the disability definition is “squishy,” especially with respect to impairments that are not readily visible, because “you can end up with one person with high blood pressure who is labeled disabled and another who is not.” She apparently did not dig enough to find out that core inquiries in the disability determination process, which may be answered only by medical experts, are about the “severity” of impairments and the impact they have, when combined with all of the person’s impairments, on his or her ability to function in the workplace. High blood pressure, in particular, is explicitly blocked from being the basis for disability all by itself. Thus, two people with high blood pressure of different severity, in the presence of different additional medical impairments, can easily fall on different sides of the disability line. Nothing “squishy” about it, once you understand it.

Joffe-Walt questions the good faith of all 14 million Americans “on disability.” She never notes how stringent the disability requirements are, or that only 40% of applicants succeed in establishing disability. Although at times she concedes that many people getting disability benefits are actually medically unable to work, she also says that “going on disability,” which offers recipients small cash benefits and health coverage but also keeps them poor for the rest of their lives, is a “deal 14 million Americans have signed up for.” That conclusion assumes that, for most of recipients, “going on disability” was some sort of choice. But people who are disabled do not have a real choice. Their only “choice” is whether to apply for available subsistence income or to have no income at all.

The main problem I have with the piece is its paper-thin penetration of a deep problem. Joffe-Walt never examines the issues through what should be an obvious lens—what if virtually all of the people receiving disability benefits are actually disabled or medically unable to work? The real problem is not why so many people get disability benefits, but why so many people are disabled. If you spend any length of time in low-income communities, it becomes increasingly clear that there are lots of walking wounded, a reservoir of people who medically qualify for disability benefits but who have not been able to apply or navigate the system to get assistance.

Examining the issues through that lens gives rise to important questions about our health system and the healthiness of our workplaces (in addition to Joffe-Walt’s good point about the changing nature of the American job market). The one doctor Joffe-Walt could find in the Alabama county she visited apparently carries on a heroic practice. Yet one wonders how much preventive care, how much early diagnosis and treatment of conditions to keep them from becoming acute, how much well-child care, how much prenatal care is going on in that crowded practice, where so much of interaction involves assessing the disabling impact of impairments people already have. In the larger picture, there are important questions about the impact that a lack of health insurance, and its attendant lack of a regular relationship with a doctor, have on the working ability of the 50 million uninsured Americans.  

There is a huge debate raging in this country about vigorously implementing the Affordable Care Act, which has aggressive strategies to reform the health care system and insure most of the uninsured, all of which can bring down the number of people with disabilities. And we have the spectacle—in Alabama and elsewhere—of governors and legislators rejecting those reforms on ideological and political grounds. Joffe-Walt’s piece, unbeknownst to her, is a very poignant reminder of who and what those politicians are sacrificing on the altar of their political ambitions. 


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. 


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.


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.



The Debt Collector Will See You Now

Medical debtWhen patients seek emergency medical treatment, they expect to speak to doctors and nurses—not debt collectors. But hundreds of documents released last week by the Minnesota Attorney General reveal that at least one medical debt collector, Accretive Health, has been working on the front lines in hospitals, often demanding that patients pay before receiving medical treatment.

According to the New York Times, the documents show that the embedded debt collectors may appear to be hospital employees and may even discourage patients from seeking emergency care. They follow scripts, just like debt collectors on the telephone, only they speak to patients in person at a time when they have immediate medical needs.

In addition to its scrutinized work at Fairview Health Services in Minnesota, Accretive Health holds contracts for “revenue cycle operations” with Henry Ford Health System in Michigan, Intermountain Healthcare in Utah, and Catholic Health East, which runs hospitals in eleven states. All of these hospital systems are nonprofit corporations, meaning that the Internal Revenue Service allows them to operate tax-free in exchange for providing certain benefits to the communities they serve. The tax savings realized by nonprofit hospitals aren’t peanuts—$4.3 billion in 2002 alone. Nonprofit hospitals make up less than 2 percent of nonprofit organizations, but they receive 41 percent of federal nonprofit tax benefits.

Many nonprofit hospitals meet their “community benefit” obligations by providing charity care, also known as “financial assistance,” which helps fill a gap in health coverage for many uninsured and underinsured Americans. But measuring and monitoring hospitals’ community benefit efforts has been a challenge. In fact, in 2005, the IRS noted the prevalence of abuse of the amorphous “community benefit” standard, saying it had difficulty distinguishing between nonprofit and for-profit hospitals in their operations.

As Corey Davis of the National Health Law Program and Jessica Curtis and Anna Dunbar-Hester of Community Catalyst explain in their recent article in Clearinghouse Review, Congress responded to this abuse by including in the Patient Protection and Affordable Care Act amendments to sections of the tax code that govern nonprofit hospitals. These changes protect low-income and self-pay patients through new billing and collection standards that nonprofit hospitals must follow to maintain their tax-exempt status. Unlike some parts of the new health care law, these changes went into effect immediately. According to Section 9007(a) of the Patient Protection and Affordable Care Act, nonprofit hospitals now must:

  • refrain from engaging in “extraordinary collection actions” unless and until they have made “reasonable efforts” to determine if a patient is eligible for financial assistance,
  • limit charges for emergency or other medically necessary care for patients qualifying for financial assistance to the lowest amount charged to insured patients, 
  • refrain from applying “gross charges” to patients who qualify for financial assistance, 
  • have a written policy to provide emergency medical care regardless of a patient’s ability to pay, and
  • have a written financial assistance policy describing eligibility criteria, whether free or discounted care is available to low-income patients, how the hospital calculates charges, how it will publicize financial assistance, and how patients can apply for financial assistance.

To monitor and enforce compliance with the new law, the IRS recently revised the Schedule H form that nonprofit hospitals must file with their Form 990 tax returns. Schedule H, the vehicle for reporting community benefit activities, now includes questions reflecting the new requirements from the Patient Protection and Affordable Care Act.

But the IRS isn’t the only one paying attention to this issue. After the Minnesota Attorney General’s report, a California congressman asked for an investigation of Accretive Health to probe whether its practices violated other federal laws. Last week a North Carolina newspaper ran a weeklong series highlighting questions around hospital profits, and NPR’s All Things Considered featured a story on nonprofit hospitals’ “stinginess” with charity care.

Whether the new health care law will prevent scenes such as those described in the New York Times article from recurring in nonprofit hospitals remains to be seen. Davis, Curtis, and Dunbar-Hester note in their Clearinghouse Review article that the Treasury Department is developing regulations that should define exactly what constitutes an “extraordinary collection action” and will elaborate on other sections of the health care law that could curb such behavior. By anyone’s definition, embedding debt collectors among medical staff seems, at a minimum, “uncharitable.”


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.

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: 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 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: 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: 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.      


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.


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.


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.


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.


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?